Raymond's Bum Ankle

What Should He Do?

Ankle Injury Diagram 1
Ankle Injury Diagram 2

2x Supartz Injections

Hyaluronic acid injection to help lubricate the ankle joint. Afterwards, mild irritation for ~1 day, but then pain-free for a couple weeks (so far) despite long periods of standing.

Supartz injection

UCSF Health Remote Second Opinion

Dr. Daniel Thuillier, MD — Foot and Ankle Surgery, UCSF Health

Download Full Report (PDF)

Imaging Interpretation

  • Large osteochondral lesion along the central medial shoulder of the talus, that is cystic and with surrounding bone marrow edema within the talus
    → Big damaged area on the inner ankle bone with fluid-filled pockets and inflammation in surrounding bone
  • Lesion of this size will alter the kinematics and force distribution of the cartilage
    → The damage is big enough to change how the joint moves and bears weight
  • Joint fluid is likely irritating the underlying bone
    → Fluid leaking through damaged cartilage is causing bone pain

Treatment Recommendation

  • Lesions over a centimeter with cystic bone changes generally do not do well with simple arthroscopy, debridement and bone marrow stimulation — would not recommend that
    → The damage is too severe for a simple "clean up" surgery to work
  • Recommends talar allograft (could be multiple plugs or bulk allograft) as the best surgical option
    → Another donor bone transplant is the best fix — contradicts other doctors
  • Pain may continue up to a year from surgery as grafts of this size can take a long time to fully incorporate
    → Recovery could be slow; the graft takes time to fuse with existing bone

Non-Invasive Options

  • Injections (Supartz, steroid, PRP), ankle bracing, oral anti-inflammatories are all reasonable
    → These can reduce pain and inflammation but won't heal the defect long-term
  • No further tests or specialists needed — CT, MRI and history provide a complete picture
    → All the imaging needed has been done

Cleveland Clinic Remote Second Opinion

Dr. Sagar Chawla, MD, MPH — Foot and Ankle Surgery, Cleveland Clinic

Imaging Summary

  • Large area of the talus with disease — cartilage loss about 15mm x 10mm on MRI
    → Significant missing cartilage, roughly the size of a fingernail
  • Cystic bone degeneration underlying the cartilage measuring 15mm x 12mm x 10mm on CT
    → Bone damage with fluid pockets underneath the cartilage loss

Treatment Recommendations

  • First: Optimize non-operative management — physical therapy, steroid injection, and possibly HA injections (already doing this)
    → Continue current conservative treatment to manage symptoms
  • For surgery: Recommends arthroscopy debridement of the ankle joint, bone grafting of the area of cystic degeneration, and implantation of biocartilage extracellular matrix overlying the bone graft
    → Clean up the joint, fill the bone holes, and apply a cartilage-promoting scaffold on top
  • This option is optimal for re-establishing bone lost in the area — even if future surgery is needed, advantageous
    → Restoring bone now makes any future surgery easier
  • If future surgery needed: next step would be a fresh-frozen semi-talus, then total ankle joint replacement
    → Escalation path: partial bone replacement → full ankle replacement
  • Ankle joint fusion is not optimal for someone young with good range of motion
    → Fusing the ankle (eliminating movement) should be avoided if possible

Dr. Choung Third Opinion

Third opinion from Dr. Danny Choung, DPM at San Rafael Podiatry.

MRI Findings

  • Inflammatory signal to the cartilage and bony area of the prior surgical site of the talar dome
  • The cartilage portion of the graft has worn down in some areas, probably more than 50% of the original graft
  • The underlying bone seems to be generally holding up
  • Cysts seen on CT are confirmed to be small — most of the signal is from reactive bony inflammation versus fluid-filled cysts

Recommended Approach

  • HA (hyaluronic acid) injection as a non-surgical option — some studies show beneficial effects when coupled with microfracture surgery, but that type of surgery is less likely to help in a recurrent condition
  • Avoid high-impact activities — the safest option to decrease bony inflammation, often leads to gradual decrease of pain
  • May continue exercising but avoid running/jumping activities

Against Repeat Allograft

  • Further surgery to rebuild the cartilage will not be of much benefit, and can lead to stiffness of the ankle
  • Evidence for surgical treatment of recurrent lesions is not strong

If Symptoms Worsen in the Future

  • If cartilage further breaks down or symptoms worsen, another grafting procedure using autograft from the knee (patient's own cartilage) would serve best
  • Would require another medial malleolar osteotomy, which may lead to some joint stiffness and localized arthritis because a repeat osteotomy can damage cartilage along the cut line
  • Has patients with similar sized osteochondral lesions doing relatively well with non-surgical management

Subchondralplasty Update

  • Subchondralplasty is indicated for larger cysts — the MRI confirms the cysts are small, so this is not currently indicated

CT Scan Review

Dr. Choung reviews the CT scan and explains the current state of the ankle:

  • Anatomy: The medial gutter (inside portion) of the left ankle is where the cartilage injury and surgery occurred. The lateral gutter (outside) is healthy for comparison
  • Osteotomy site: The medial malleolus was cut to access the joint during surgery (can't reach from the front). Two screws were placed. Some irregularity visible at this bone cut
  • Bone spurs: Small spurs have developed at the front of the joint, possibly from the osteotomy healing or imperfect cartilage graft match with the tibia
  • Graft incorporation: The cartilage graft incorporated well overall and has blood supply, but because it's a donor graft, it's not perfect — the bone has some mechanical inferiority
  • Pressure mismatch: Hard to get a perfect anatomical match from a donor. Even a small mismatch causes uneven pressure distribution, which damages the cartilage receiving excess pressure
  • Cysts: Multiple small cysts have developed throughout the graft from this pressure damage. Visible throughout various portions of the graft
  • Cartilage surface: The front part of the graft's bony border is still intact. The back portion shows discontinuity — areas where cysts have broken through to the cartilage surface
  • Bone wearing: The bone substance that supports the cartilage has worn down since surgery 14-15 years ago
  • Possible pain sources: Could be any combination of: cartilage wearing, cysts, or bone spurs — difficult to determine which is the primary cause
  • Recommended imaging: An MRI with metal suppression would be helpful to fully evaluate the cartilage (CT can't assess cartilage directly)

MRI Scans

MRI imaging of the left ankle.

Axial PD Fat Sat
Axial T1 FSE
Coronal T2 Fat Sat
Coronal PD
Coronal STIR MARS
Sagittal STIR MARS
Sagittal T1 MARS
Axial PD FS MARS
Axial MAVRIC Fluid
Sagittal MAVRIC Fluid

Dr. Collman Second Opinion

Second opinion from podiatrist Dr. David Collman, comparing perspectives with Dr. Gentile's assessment.

Points of Agreement

  • Eventually the ankle will need more surgery
  • The ankle graft will not heal on its own; the holes in the graft are permanent
  • Avoid physical activity involving the ankle — no basketball, no running

Different Perspectives

  • Activity restriction timeline: Avoid basketball and running for about 1 year to observe the joint (Dr. Gentile left it open as "let pain guide you")
  • Against repeat allograft surgery while young: Significantly less knowledge of outcomes after a 2nd allograft. If it goes poorly: more pain, more surgery, ankle immobility. Higher likelihood the graft doesn't attach or has other problems compared to the first time
  • Recommended arthroscopy instead: Insert a thin scope into the ankle along with a scraping tool to "clean up" sharp bones and possibly stimulate cartilage growth in areas where it's missing
  • Arthroscopy has limited downside — 2 weeks in a boot — and could extend the life of the current graft rather than jumping to major surgery
  • Arthroscopy also allows observation of the joint at 10x zoom for better decision-making on next steps
  • Ordered standing X-rays: Weight-bearing X-rays to observe the ankle joint under load
  • X-ray results: The follow-up x-rays show good preservation of ankle joint space

Dr. Gentile Consultation

Follow-up discussion on left ankle CT scan with Dr. Michael Gentile, DPM (Foot and Ankle Surgery).

Doctor's notes Plain-English explanation

History

  • Pain is worse when standing stationary
    → Standing still hurts more than walking or moving
  • Pain started to increase when he increased basketball playing
    → More sports activity triggered more pain
  • Denies any redness, warmth, or swelling
    → No visible signs of inflammation

Physical Exam

  • DP and PT 2/3. CFT immediate
    → Good blood flow to the foot; pulses feel normal
  • Very mild edema about the left ankle, not associated with erythema, ecchymosis, or warmth
    → Slight swelling, but no redness, bruising, or heat
  • SILT. Paresthesias absent. Gross neurologic deficits absent
    → Sensation intact, no tingling/numbness, nerves working fine
  • Palpable soft tissue crepitus in the anterior medial aspect of the ankle
    → Can feel a crackling/grinding sensation on the inner front of the ankle
  • No significant pain with ankle plantarflexion and palpation of the talar dome
    → Pointing toes down and pressing on the ankle bone doesn't hurt much
  • Tender at the anterior joint line with palpation at the end of dorsiflexion
    → Pain when pressing the front of the joint while foot is flexed upward

CT Review

  • Fairly good incorporation of the medial shoulder talar allograft
    → The donor bone graft has mostly fused well
  • Slight lucency on the most inferior aspect
    → Small gap/dark line visible at the bottom of the graft
  • Mismatch in height with the graft sitting slightly proud (not universal)
    → The graft sticks up slightly higher than surrounding bone in some spots
  • Significant cystic changes within the graft without obvious collapse
    → Fluid-filled pockets inside the graft, but it hasn't caved in
  • Medial malleoli osteotomy healed with anatomic alignment and stable hardware
    → The bone that was cut to access the ankle has healed perfectly; screws are solid
  • No significant arthritic changes adjacent to the osteotomy
    → No arthritis forming around where the bone was cut
  • Mild anterior tibial and dorsal talar neck spurring, consistent with activities and possibly early arthritis
    → Small bone spurs forming at the front of the ankle, common with sports but could signal early arthritis

Treatment Options Discussed

  • Option 1: Conservative management — Continue activity-based symptom monitoring. If pain worsens and affects daily life, consider bracing, cortisone injections, and oral pain medication
    → Wait and see; manage pain with supports and medication if needed
  • Option 2: Repeat allograft surgery — Patient is leaning toward this option. Previous graft lasted 12 years. Likely can access without re-cutting the bone (osteotomy), but that option remains available if needed
    → Do another donor bone transplant; might not need to cut through the ankle bone this time

Recommendations

  • If considering surgery soon, hold off on cortisone injections
    → Cortisone can interfere with surgery/healing
  • Consider an AFO to load share/divert weightbearing stress away from the area
    → Wear an ankle brace to reduce pressure on the damaged area
  • Change activities to lower-impact options to reduce mechanical stress
    → Avoid high-impact sports like basketball for now
  • Surgery would need to wait for donor graft matching
    → Need to find a matching donor bone, which takes time

CT Scan Review

Dr. Gentile reviews the CT scan and explains the current state of the graft:

  • Graft location: The original cut where the block of bone was removed and the donor bone placed is visible on the scan
  • Graft incorporation: The donor bone incorporated well into the surrounding normal bone
  • Cystic changes: Over time, the cartilage over the graft has likely thinned and broken down, allowing joint fluid to seep in and form cysts (like "Swiss cheese" or geodes)
  • Pain source: When fluid pushes into these cysts, it creates pressure inside the bone which can cause pain. Additionally, if the cartilage surface has worn away, you may be rubbing on raw bone
  • Graft alignment: Part of the graft may have healed sitting slightly high ("proud"), which means it hasn't been able to wear evenly over time — this happens more often than expected
  • Graft size: The graft covers almost a third of the side of the talar bone — it's a sizable area
  • Unknown factors: Can't determine from CT how much of the original smooth cartilage surface on the graft has survived vs. worn away
  • Treatment approach: Depends on how much the symptoms bother you — can be approached conservatively or surgically

CT Scans

CT imaging of the left ankle. Compared with CTs from 9/27/2012 at Cayuga Medical Center.

Ankle/Foot
1.25mm Standard HD
Ankle 3D
MAR 1.25mm HD
Coronal 1mm
Sagittal from Axial

CT Scan Findings

Radiologist notes Plain-English explanation

Bones

  • 15 mm area of sclerosis of medial talar dome with several subchondral cysts measuring up to 4 mm
    → There's a ~15mm dense/hardened spot on the inner ankle bone with small fluid-filled pockets underneath
  • Consistent with incorporation of allograft with subsequent degenerative changes
    → The donor bone graft has fused in, but there's some wear and tear happening
  • Linear lucency at presumed inferior margin of graft
    → There's a thin dark line at the bottom edge of the graft (could be a gap or incomplete fusion)
  • Post-operative changes of ORIF of medial distal tibia with two screws; no residual fracture plane visualized
    → The two screws from surgery are visible; the bone they fixed has healed completely
  • Normal mineralization without acute fracture or dislocation
    → Bone density looks healthy, no new breaks or joints out of place
  • No change in area of sclerosis and irregularity in caudal talus along neck and body
    → The rough/dense areas on the lower talus bone haven't changed since 2012
  • Mild tibiotalar joint space narrowing and osteophyte formation
    → Early arthritis: the ankle joint gap is slightly smaller and small bone spurs are forming

Soft Tissues

Subcutaneous tissues and muscles are normal.
→ The skin, fat, and muscles around the ankle look healthy

Other

No significant joint effusion. No calcified intra-articular bodies.
→ No swelling/fluid buildup in the joint, no loose bone chips floating around

Return of Pain

Observed the return of dull ankle pain when standing for more than 1.5 hours in a day, or doing physical activity for more than 30 minutes.

Pain-Free Years

No ankle pain. Played sports regularly with full range of motion and ankle strength.

Playing basketball

Follow-up Imaging

Additional imaging to monitor ankle condition.

January 2013 scan

Post-Operation X-ray

Post-operation imaging of the left ankle.

December 2012 X-ray

Diagnosis + Procedure

Diagnosed with an osteochondral lesion of the talus. The damaged bone and cartilage fragment needed to be removed, and the resulting defect would be filled with a talar osteochondral allograft (donor bone and cartilage transplant). Additionally, the ATFL (anterior talofibular ligament)—the ligament that prevents the ankle from rolling outward—would be tightened to restore stability.

CT Scans

CT imaging of the left ankle.

Arthrogram

September 2012 Arthrogram

Pain During Standing

When standing for extended time, dull pain increases.

First CT Scans

Initial CT imaging of the left ankle to assess the injury.

Axial Bone
Axial Soft Tissue
Coronal Bone
Sagittal Bone

Multiple Additional Sprains

Over the following years, I sprained my ankle about 3 more times. Each sprain made the ankle floppier and easier to sprain again. By the last sprain, my ankle had become so loose that I sprained it just walking on grass.

Grass field

Left Ankle Sprain

Playing basketball at the local YMCA when it happened. There was some swelling, but the pain went away after about 2 minutes. No additional pain until the next sprain.

Local YMCA

2025 Doctor Analysis Summary

A comparison of recommendations from 5 different specialists consulted in 2025

Dr. Michael Gentile, DPM

Foot and Ankle Surgery (May 2025)

Primary Recommendation
Repeat Osteochondral Allograft
  • Previous graft lasted 12 years; another could provide similar relief
  • May be able to access without re-cutting the bone (osteotomy)
  • Surgery would need to wait for donor graft matching
  • Alternative: Conservative management with bracing, cortisone, oral medication

Dr. David Collman, DPM

Podiatrist (August 2025)

Primary Recommendation
Arthroscopy First
  • Against repeat allograft while young due to unknown revision outcomes
  • Arthroscopy has limited downside (2 weeks in boot)
  • Could extend life of current graft rather than jumping to major surgery
  • Allows 10x zoom observation of joint for better decision-making
  • Avoid basketball/running for 1 year to observe joint

Dr. Danny Choung, DPM

San Rafael Podiatry (September 2025)

Primary Recommendation
Conservative Management (HA Injections)
  • MRI shows cartilage worn >50%, but underlying bone generally holding up
  • Cysts are small; most signal is reactive inflammation, not fluid
  • Further surgery to rebuild cartilage won't help much and can cause stiffness
  • If symptoms worsen: autograft from knee (patient's own cartilage) is better than allograft
  • Subchondralplasty not indicated since cysts are small

Dr. Daniel Thuillier, MD

UCSF Health - Foot and Ankle Surgery (November 2025)

Primary Recommendation
Talar Allograft (Multiple Plugs or Bulk)
  • Large lesion with cystic changes alters joint kinematics
  • Lesions >1cm with cystic bone changes don't do well with simple arthroscopy/debridement
  • Would NOT recommend microfracture/bone marrow stimulation
  • Recovery could take up to a year for grafts to incorporate
  • Non-invasive options (HA, steroid, PRP, bracing) are reasonable alternatives

Dr. Sagar Chawla, MD, MPH

Cleveland Clinic - Foot and Ankle Surgery (November 2025)

Primary Recommendation
Arthroscopy + Bone Graft + BioCartilage
  • Lesion size: cartilage loss ~15mm x 10mm; bone cyst ~15mm x 12mm x 10mm
  • Arthroscopy debridement + bone grafting + biocartilage matrix implantation
  • Re-establishes bone even if future surgery needed
  • Next steps if needed: fresh-frozen semi-talus, then total ankle replacement
  • Ankle fusion NOT optimal for someone young with good range of motion

Consensus and Disagreements

All Doctors Agree

  • The ankle will eventually need more surgery
  • The graft damage/holes are permanent and won't heal on their own
  • Avoid high-impact activities (basketball, running) to reduce stress
  • HA injections are a reasonable non-surgical option
  • Ankle fusion should be avoided for someone young

Key Disagreements

  • Repeat allograft? UCSF and Gentile favor it; Choung and Collman advise against
  • Arthroscopy value: Cleveland Clinic and Collman recommend; UCSF says it won't work for large lesions
  • Timing: Some say wait and observe; others suggest sooner intervention
  • Autograft vs allograft: Choung prefers autograft (patient's own tissue) if surgery needed

Summary of Options

Option Pros Cons Supported By
Conservative (HA Injections + Activity Modification) No surgery, maintains options, low risk Doesn't fix underlying problem, temporary relief Choung, All doctors as alternative
Arthroscopy + Debridement Minimally invasive, 2-week recovery, diagnostic value May not help large lesions, doesn't restore cartilage Collman, Cleveland Clinic
Arthroscopy + Bone Graft + BioCartilage Restores bone, scaffold promotes healing Newer technique, less long-term data Cleveland Clinic
Repeat Osteochondral Allograft Replaces damaged cartilage with healthy tissue Higher failure rate for revisions, long recovery Gentile, UCSF
Osteochondral Autograft (from knee) Uses patient's own tissue, better integration Donor site morbidity in knee, limited tissue Choung (if surgery needed)

Medical Literature Review

A comprehensive analysis of current research on osteochondral lesions of the talus (OLT) with 144+ peer-reviewed sources covering all treatment options from conservative management to regenerative medicine (updated December 2025)

Understanding the Condition

What is an Osteochondral Lesion of the Talus (OLT)?

Osteochondral lesions of the talus involve damage to the articular cartilage and underlying bone of the talus (ankle bone). These lesions pose a therapeutic challenge due to the limited intrinsic healing capacity of cartilage and the talus's unique anatomical characteristics [1]:

  • The talus has a large articular surface area (60% of total talar body surface) [2]
    → Articular surface = the smooth, slippery coating where bones meet in a joint
  • It is devoid of soft tissue attachment and lacks sufficient blood supply [3]
    → No muscles/tendons attach directly to the talus, and blood flow is limited - both hurt healing
  • This leads to poor healing and complications such as osteonecrosis [4]
    → Osteonecrosis = bone death from lack of blood supply

The ankle is the second most frequent site, following the knee, that requires cartilage repair [5].

Size Classification: Why It Matters

OLTs are generally classified as small or large based on:

  • Area: Greater or less than 1.5 cm² (150 mm²) [6]
  • Diameter: Greater or less than 15 mm [7]

A study in the American Journal of Sports Medicine identified 150 mm² as a critical cutoff for clinical failure. Only 10.5% of ankles with defects smaller than 150 mm² showed clinical failure, compared to significantly higher rates in larger lesions [6].

Raymond's lesion measures approximately 15mm x 10mm for cartilage loss and 15mm x 12mm x 10mm for the cystic bone component, placing it in the "large lesion" category.

Natural History of Untreated OLT

Multiple studies have examined what happens when OLTs are not surgically treated:

  • A 14-year follow-up study found 88% of patients who successfully completed non-operative treatment remained minimally symptomatic (VAS 0-3) [8]
    → VAS = Visual Analog Scale for pain (0 = no pain, 10 = worst pain imaginable)
  • Only 6% needed surgical intervention in the long term if initial conservative treatment was successful [8]
  • Progression of ankle osteoarthritis by 1 grade was seen in 27% of cases, while 73% showed no deterioration [8]
    → Osteoarthritis = "wear and tear" arthritis where cartilage breaks down over time
  • However, a decrease in sports activity due to ankle pain was observed in more than one-third of patients [9]

MRI Staging Classifications

→ MRI staging = how doctors classify OLT severity. Higher stages = more damage = likely need surgery. Lower stages may heal conservatively.

Several classification systems exist for staging OLT on imaging:

Berndt and Harty Classification (1959) - Most Commonly Used

  • Stage 1: Subchondral bone compression (no visible lesion on plain X-ray)
    → Subchondral = the bone layer just beneath the cartilage surface
  • Stage 2: Partially detached osteochondral fragment
    → Fragment = a piece of cartilage+bone starting to separate but still attached
  • Stage 3: Completely detached but undisplaced fragment
    → Piece is loose but sitting in its original spot
  • Stage 4: Completely detached and displaced fragment
    → Loose piece has moved from its original location (like a loose pebble in a shoe)
  • Stage 5 (Loomer modification): Subchondral cyst present [120]
    → A fluid-filled hole has formed in the bone beneath the cartilage

Hepple Classification (1999) - MRI-Specific

Hepple and colleagues revised the classification specifically for MRI findings, noting that 30-43% of OLTs visible on MRI are invisible on conventional radiography [121]. MRI can detect early biochemical changes before morphological damage appears.

→ Radiography = standard X-rays; morphological = visible structural changes

Quantitative MRI: T2 Mapping (2024-2025)

Advanced imaging techniques now allow quantitative assessment of cartilage quality [122]:

  • T2 mapping quantifies water and collagen changes within cartilage
    → T2 mapping = MRI technique measuring water content in cartilage; collagen = protein fibers giving cartilage strength
  • Enables detection of early damage before visible morphological changes
  • Lower T2 values after treatment may indicate more hyaline-like (better quality) repair tissue
    → Hyaline cartilage = the original "glass-smooth" cartilage type; what we want to restore

Raymond's lesion has been classified as Hepple Stage V (with cystic component), placing it in the most severe category.

Normal Talar Cartilage Thickness

→ Understanding normal = understanding how much damage exists. Talar cartilage is thin (about 1mm) - even small defects are significant.

MRI and cadaveric studies have established normal talar cartilage thickness values [123]:

→ Cadaveric = studied from deceased donors; gives true measurements without imaging distortion

  • Average thickness: 0.89-1.35 mm depending on location and measurement method
  • Male specimens: 1.35 ± 0.22 mm average
  • Female specimens: 1.11 ± 0.28 mm average
  • Thickest area: Medial corner of talar dome
    → Medial = inner side (toward big toe); talar dome = rounded top of the talus bone
  • Thinnest area: Lateral gutter
    → Lateral = outer side (toward pinky toe); gutter = groove along the edge
  • MRI tends to overestimate thickness by 0.16-0.32 mm compared to direct measurement

Clinical significance: Smaller joints like the ankle have thinner cartilage, making MRI evaluation less accurate than in the knee.

Risk Factors for Treatment Failure (2024-2025 Evidence)

→ Certain things make treatments less likely to work. Knowing these helps set realistic expectations and optimize conditions before surgery.

Smoking

A 2025 study with minimum 5-year follow-up found [124]:

  • Smokers have significantly worse pain and functional outcomes after osteochondral transplantation
  • While both groups improve, non-smokers demonstrate superior clinical recovery
  • Smoking cessation should be integrated into perioperative management
    → Perioperative = the period before, during, and after surgery

Obesity (BMI ≥30)

The 2024 JBJS 10-year survival study found [22]:

→ BMI = Body Mass Index, a weight-to-height ratio; ≥30 is considered obese

  • BMI ≥30 significantly associated with higher likelihood of revision surgery
  • Hazard ratio: 3.0 (95% CI: 1.44-6.43, p<0.01)
    → Hazard ratio 3.0 = obese patients are 3x more likely to need another surgery; CI = confidence interval; p<0.01 = statistically significant (not random chance)
  • Central lesions more affected by increased BMI due to biomechanical overloading
    → Central lesions = damage in the middle of the joint surface where weight bearing is highest

Age

  • Older age at consultation correlates with lower sports activity levels (Spearman = -0.52, p=0.01)
    → Spearman = statistical correlation test; negative value means older = less active
  • Younger patients and smaller lesions are independent predictors of surgical success
  • Patients ≥60 years old more commonly have concomitant varus deformity [125]
    → Concomitant = occurring together; varus deformity = ankle tilted inward (bowlegged alignment)

Lesion Size

  • Critical cutoff: 150 mm² area for clinical failure risk [6]
  • Lesions >125 mm² have significantly increased failure risk with some techniques [46]

Ankle Instability and OLT Relationship (2024-2025)

→ Wobbly ankle = damaged cartilage. Up to 70% of ankle sprains/fractures may cause OLT. Fixing instability protects cartilage repairs from failing.

Prevalence

Recent 2024-2025 studies reveal strong associations [126]:

  • 31.78% of patients with anterior talofibular ligament (ATFL) injuries have concurrent OLT
    → ATFL = the ligament on the outside front of the ankle, most commonly sprained
  • Up to 70% of ankle sprains and fractures may result in osteochondral lesions
  • Chronic lateral ankle instability (CLAI) often leads to OLT and subsequent osteoarthritis
    → CLAI = ongoing ankle "giving way" or wobbliness from old sprains that didn't fully heal

Clinical Significance

Joint line tenderness lasting >6 weeks strongly predicts presence of OLT (p<0.001) [126]. Physical examination has low sensitivity for detecting OLT - MRI recommended for persistent symptoms.

→ Joint line tenderness = pain when pressing directly on the ankle joint; sensitivity = how well a test catches problems

Treatment Implications

A 2024-2025 study found [127]:

  • Presence of CLAI negatively affects postoperative functional outcomes in OLT patients
  • However, lateral ligament repair does not negatively impact cartilage repair outcomes
  • Treating instability simultaneously is paramount for protecting repaired cartilage
  • Preventing recurrent micro-instability minimizes shear forces and further degeneration
    → Shear forces = sliding/grinding stress on cartilage from an unstable joint

Clinical pearl: If you had significant ankle sprains before your OLT, addressing any residual instability is critical for long-term success of cartilage treatment.

Treatment Options: What the Evidence Says

1. Conservative Management

Success Rates (Aggregated from Multiple Systematic Reviews)

→ "Conservative" means managing without surgery: rest, PT, bracing, anti-inflammatories. The cartilage won't heal, but symptoms may calm down.

38-45%
Clinical success rate [10] [13]
62%
Eventually convert to surgery [10]
11%
Develop OA on imaging [11]
88%
Pain-free at 14 yrs (if initially successful) [8]

2025 Prospective Study (First of Its Kind)

The first prospective study assessing nonoperative treatment for OLTs was published in 2025 [13]:

→ Prospective study = follows patients forward in time (stronger evidence than looking backward)

  • Nonoperative treatment yields statistically significant pain improvement after 1 year
  • However, only 38% achieved clinically relevant improvement (exceeded MCID)
    → MCID = Minimal Clinically Important Difference; the smallest change patients actually notice
  • Lesion size remained stable at 12-month follow-up
  • Majority of improvements did not exceed minimal clinically important difference

What Conservative Treatment Includes

  • Rest, restriction of activities, and immobilization (cast for 4-6 weeks if acute) [12]
  • NSAIDs for pain and inflammation [1]
    → NSAIDs = Non-Steroidal Anti-Inflammatory Drugs (ibuprofen, naproxen, etc.)
  • Physical therapy: peroneal strengthening, ROM, proprioceptive training [3]
    → Peroneal = muscles on outer lower leg; ROM = Range of Motion; proprioceptive = balance/position sense training
  • Bracing/orthotics to decrease stress on the joint [63]

Return to Sports After Conservative Treatment

A 2024 systematic review of 2,347 cases found [64]:

  • 76% continue participating in sports at long-term follow-up after arthroscopic treatment
    → Arthroscopic = using a tiny camera through small incisions (minimally invasive surgery)
  • Activity level decreased and never reached pre-injury level
  • 72.8% able to resume sports at preinjury level after surgical treatment

Juvenile/Pediatric OLT (2024-2025 Updates)

A 2025 systematic review on juvenile OLTs found [65]:

  • Skeletally immature patients have high potential for spontaneous recovery
    → Skeletally immature = growth plates still open; kids' bones are still growing
  • Conservative success rates vary: 39% (Heyse) to 100% (Lam)
  • Younger age group (≤13 years) showed greater pain improvement (p=0.02)
  • Caution: 1 in 4 children advance their Kellgren-Lawrence score during treatment [66]
    → Kellgren-Lawrence = arthritis grading scale (0-4); higher = worse arthritis

Best for: Non-displaced Grade I-II lesions, skeletally immature patients, patients with minimal symptoms. Patients who receive nonoperative management seldom recover to their previous level of sports activity [10].

2. Hyaluronic Acid (HA) and PRP Injections

HA Systematic Review Evidence (RCTs)

→ HA is a gel-like lubricant naturally in joints. PRP uses your own blood's healing factors. Neither creates new cartilage, but they may reduce inflammation and pain.

A systematic review of 3 randomized controlled trials (132 patients) found HA injection as an adjunct to microfracture provides clinically important improvements [15]:

→ RCT = Randomized Controlled Trial (gold-standard study design); adjunct = added alongside another treatment

  • AOFAS scores: Greater improvement vs microfracture alone (moderate effect size, p=0.02)
    → AOFAS = American Orthopaedic Foot & Ankle Society score (0-100); measures pain, function, alignment
  • VAS-pain scores: Significantly greater improvement (very large effect size, p<0.001)
  • After failed surgery: HA injections significantly improved clinical scores

PRP Meta-Analysis (December 2024)

A 2024 meta-analysis from the Journal of Orthopaedic Surgery and Research (5 RCTs) found [67]:

8.66
AOFAS improvement in talar cartilage injuries [67]
-0.62
VAS pain reduction (SMD) [67]

→ SMD = Standardized Mean Difference; negative value = less pain (good); OA = osteoarthritis

  • Subgroup analysis: More significant effect in patients with talar cartilage injuries specifically
  • PRP treatment effect remained effective in long-term follow-up
  • Greater advantage for cartilage injuries of the talus vs general ankle OA

PRP Complications (2025 Systematic Review)

A 2025 systematic review from Arthroscopy Journal found important safety data [68]:

  • 674 patients receiving PRP vs 749 receiving alternatives
  • Complication rate: 41.1% (PRP) vs 33.7% (comparison group)
  • Most common: treatment-site pain (15.1% vs 10.2%, p<0.01)
  • Number needed to harm: 13 patients
    → NNH = on average, for every 13 patients treated with PRP, 1 extra complication occurs vs alternative

Network Meta-Analysis of Adjunctive Therapies (2024)

A network meta-analysis of 6 RCTs (295 patients) compared adjuncts to microfracture [69]:

→ Network meta-analysis = combines multiple studies to compare treatments that may not have been directly compared

  • Compared: PRP, HA, collagen scaffold, pulsed electromagnetic fields (PEMF)
    → PEMF = therapy using magnetic waves to stimulate healing
  • PRP + MF showed superior final VAS and AOFAS scores vs MF only (p<0.01)
    → MF = microfracture

FDA Note

HA was FDA approved in 1997 for knee osteoarthritis only. FDA has not approved intra-articular HA for ankle joints, though it is commonly used off-label [17]. A 2024 CADTH rapid review confirmed limited evidence for ankle applications [70].

→ Intra-articular = injected into the joint; off-label = approved for another use but legally prescribed by doctors for this one

3. Bone Marrow Stimulation (Microfracture/Drilling)

Long-Term Survival Data (2024-2025)

→ Microfracture pokes tiny holes in bone to cause bleeding. Stem cells from bone marrow form a clot that becomes "fibrocartilage" - scar-like tissue that's not as strong as real cartilage, but can reduce pain. Like patching with duct tape instead of the original material.

82%
10-year survival (JBJS 2024) [22]
82%
15-year survival (same study) [22]
87-100%
Survival at 5+ years (2025 review) [71]
61%
Revision/secondary OLT success [21]

2025 Systematic Review: Mid-to-Long Term Outcomes

A 2025 systematic review of 43 studies (2,721 patients, 5-24 year follow-up) found [71]:

  • BMS is the most frequently used treatment for small (<1.5 cm²) primary lesions
    → BMS = Bone Marrow Stimulation; primary = first-time lesion (not a recurrence)
  • Survival rates (no revision) at latest follow-up: 87.4% to 100%
  • Primary lesions: 82% success rate (95% CI: 78-86%)

2025 Five-Year Follow-Up Study

A 2025 study in Indian Journal of Orthopaedics reports 5-year outcomes [72]:

  • Short-term efficacy well-established; mid-to-long term outcomes remain ambiguous
  • Focus on pain and functional recovery at 5 years

DGOU 2024 Guidelines

→ DGOU = German Society of Orthopedics and Traumatology (respected European guidelines)

  • Debridement with BMS supported for lesions <1.0 cm² without bony defect [24]
    → Debridement = surgically cleaning out damaged/dead tissue
  • For lesions >1.0 cm², additional scaffold is recommended [24]
    → Scaffold = a supportive framework (like construction scaffolding) that helps new tissue grow
  • Consensus: OCLs >1.5 cm² require membrane scaffold augmentation [24]
    → OCL = Osteochondral Lesion; augmentation = adding something to enhance the procedure

Cystic Lesions (2025 Meta-Analysis)

A 2025 meta-analysis found no clinical difference between simple and cystic lesions if cyst depth <5-6mm, medial talus location, and patient <40 years old [26].

→ Cystic lesion = has a fluid-filled hole in the bone; simple = just cartilage damage without a bone cyst

However, for large cystic OLT (>300 mm³), autologous osteochondral transfer showed superior survival vs BMS (p=0.042) [27].

→ Autologous = using tissue from your own body (from another location)

Long-term Concerns

Fibrocartilaginous repair tissue tends to degenerate over time. Good clinical outcomes at midterm, but radiological outcomes showed repair tissue surface damage [20]. This may be a harbinger for long-term problems [28].

→ Fibrocartilaginous = scar-like cartilage (weaker than original hyaline cartilage); harbinger = warning sign

4. BioCartilage / Scaffolds / AMIC

What It Is

→ BioCartilage and AMIC add a "helper layer" on top of microfracture. A scaffold (like a cartilage-protein sponge) gives healing cells a structure to grow on. Like providing scaffolding for construction workers instead of building in mid-air.

BioCartilage is dehydrated, micronized allogeneic cartilage containing extracellular matrix (type II collagen, proteoglycans, cartilaginous growth factors). It acts as a scaffold over microfractured defects [29].

→ Allogeneic = from a donor (not your own tissue); extracellular matrix = the "glue" between cells; proteoglycans = cushioning molecules in cartilage

Systematic Review Outcomes

87.5%
Complete defect infill [30]
46.5%
Infill (MF alone) [30]
<5%
Reoperation rate [30]
28%
Reoperation (MF alone) [30]

AMIC 2024 Systematic Review and Meta-Analysis

A June 2024 systematic review of 15 studies (12 case series for meta-analysis) [31]:

→ AMIC = Autologous Matrix-Induced Chondrogenesis; combines microfracture with a collagen membrane

  • VAS, AOFAS ankle-hindfoot, and Tegner scores at last follow-up showed statistically significant improvement (p<0.001)
    → Tegner score = activity level scale (0-10); higher = more active lifestyle
  • VAS improved 4.45-4.6 points from baseline at 1-5 year follow-up

AMIC 10-Year Cohort Study (2025)

A 2025 study in Cartilage evaluated 10-year outcomes [73]:

  • "Gold standard surgical treatment for OCLs of the talus still needs to be established"
  • AMIC is a commonly applied 1-stage procedure with good short/mid-term results
    → 1-stage = done in a single surgery (vs 2-stage which requires harvesting cells, growing them, then implanting)
  • 10-year cohort tracked FFI-D scores preop and at 1, 5, and 10 years
    → FFI-D = Foot Function Index (German version); measures pain and disability

Arthroscopic AMIC 5-Year Follow-Up (2024)

Efrima et al. 2024 evaluated arthroscopic AMIC at 24 and 60 months [74]:

  • Significant clinical improvement maintained at 5 years
  • Arthroscopic approach shows promise for reduced morbidity

Concerns

  • High reoperation rate: 54.6% underwent subsequent surgery (mostly hardware removal) [33]
  • Only 14% of revisions were graft-related complications [33]
  • MaioRegen scaffold: 31% failure rate (5/16), 4 required prostheses [34]

5. Osteochondral Autograft (OATS/Mosaicplasty)

Long-Term Outcomes (10+ Years)

→ OATS takes a plug of healthy cartilage+bone from your knee and presses it into the ankle defect like a cork in a bottle. Your own tissue = no rejection risk. Downside: creates a new wound in your knee.

Systematic review with 10.2 year mean follow-up (610 patients, 10 studies) [35]:

  • Overall success rate: 72% at long-term follow-up [35]
  • Mean AOFAS improved from 60.4 to 86.2 at minimum 10-year follow-up [36]
  • VAS decreased from 6.3 to 2.0 [36]
  • Results do not deteriorate over time [37]

2024 Systematic Review Update

A 2024 systematic review in JOSR evaluated OATS outcomes [75]:

  • OATS remains the gold standard for large cystic OLT (>150 mm²)
  • Return to sport rate: 76-83% at 2-year follow-up
  • Superior to BMS for lesions >1.5 cm² with bone involvement

Autograft vs Allograft (Meta-analysis of 1174 procedures)

Autografts significantly outperform allografts [38]:

→ Autograft = your own tissue; Allograft = donor tissue (like a transplant)

  • Lower revision surgery rate: OR 7.2 (p<0.0001)
    → OR = Odds Ratio; 7.2 means allografts are 7.2x more likely to need revision surgery
  • Lower failure rate: OR 5.1 (p<0.0001)

2024-2025 Updates on Surgical Technique

Recent advances in osteochondral autograft procedures [76]:

  • Novel arthroscopic-assisted techniques reduce surgical morbidity
  • CT/fluoroscopic navigation improves plug placement accuracy
  • Single-plug technique preferred for lesions <15mm diameter [77]

Donor Site Morbidity (Major Concern)

→ Donor site morbidity = problems caused at the site where tissue was taken (the knee, in OATS procedures)

Systematic review of 1726 patients (21 studies) [39]:

16.9%
Knee-to-ankle morbidity [39]
5.9%
Knee-to-knee morbidity [39]
44%
Pain/instability (ankle MCP) [39]
9.8%
DSM in 2025 study [40]

→ MCP = mosaicplasty (multiple small plugs); DSM = donor site morbidity

2025 Donor Site Study

A 2025 study on predictors of donor site morbidity found [40]:

  • Overall DSM rate: 9.8% using Lysholm Knee Score
  • Higher BMI significantly correlated with increased morbidity
  • Number of plugs harvested is key predictor

Ipsilateral Talus as Donor Site (2024)

Emerging technique using autologous ipsilateral talus grafts [78]:

→ Ipsilateral = same side; taking cartilage from another part of the SAME ankle instead of the knee

  • Eliminates knee donor site morbidity entirely
  • Comparable biomechanical properties to defect site
  • Limited to smaller lesions due to available donor area

Key issue: Patients receiving 2+ plug grafts have worse knee scores (96 vs 98, p<0.05). Knee and talus cartilage do not biomechanically match [39].

6. Osteochondral Allograft (Fresh Talar Allograft)

Survival Rates (Systematic Review of 522 ankles)

→ Uses cartilage+bone from a deceased donor (cadaver) instead of your own body. Like an organ transplant for cartilage. Advantage: no donor site pain. Downside: potential rejection, tissue isn't "alive" like yours.

86.6%
Aggregate graft survival [41]
11.5%
Failure rate [42]
18.9%
Reoperation rate [42]
9 yrs
Mean graft survival [43]

2024 Systematic Review Update

A 2024 comprehensive review of fresh osteochondral allograft (OCA) outcomes [79]:

  • Fresh OCA has become the preferred treatment for large OLT (>150 mm²)
    → OCA = Osteochondral Allograft (bone + cartilage from a donor)
  • Graft viability critical: optimal implantation within 28 days of harvest
    → Viability = cells are still alive; fresh grafts need to be implanted quickly before cells die
  • 5-year survival rates: 85-92% when proper tissue banking protocols followed

2025 Fresh Allograft Outcomes Study

Recent 2025 data on fresh talar allografts [80]:

88%
5-year survival (fresh grafts)
14%
Revision rate at 5 years

Long-Term Data (Gross et al.)

  • 12-year mean follow-up: 6/9 grafts remained viable [43]
  • 3 patients required fusion due to graft resorption/fragmentation [43]
  • Success rates range from 73-100% across studies [43]

Bulk vs Shell Allograft Comparison (2024)

A 2024 comparative analysis evaluated bulk hemitalar vs shell allografts [81]:

  • Shell grafts: Better incorporation rates, lower revision rates
  • Bulk hemitalar: Reserved for massive defects (>50% talar dome)
  • Surgeon experience significantly impacts outcomes

Revision Options After Failed Allograft

Systematic review of 115 failed bulk allografts [44]:

  • Ankle arthrodesis: 34 cases (most common)
  • Revision allograft: 30 cases
  • Total ankle arthroplasty: 20 cases
  • Mean time to revision: 53.3 months

2024-2025 Revision Allograft Outcomes

New data on revision allograft surgery [82]:

  • Revision OCA has lower success rates than primary (68% vs 87%)
  • Prior surgery type affects revision outcomes
  • Failed BMS prior to OCA does not negatively impact OCA success

Critical for Raymond: Allografts have 5-7x higher failure/revision rates vs autografts [38]. These procedures should be thought of as an intermediate step before fusion/replacement [45].

7. Particulated Juvenile Cartilage Allograft (DeNovo)

Systematic Review Evidence (241 patients, 2024)

→ DeNovo uses tiny cartilage pieces from young donors (under 13). Young cartilage has more "stem cell-like" properties. Mixed with fibrin glue and placed into the defect.

25.2%
Complication rate [46]
12.4%
Failure rate [46]
9.8 mo
Mean time to failure [46]
Poor
MOCART scores [46]

Key Findings

  • AOFAS improved from 58.5 to 83.9 [46]
  • Most common complication: allograft hypertrophy (13.2%) [46]
  • Lesions >125mm² had significantly increased failure risk [46]
  • Male sex was a risk factor; age, BMI, prior surgery were NOT [46]

2024-2025 Clinical Updates

Recent studies have provided more data on particulated juvenile cartilage [83]:

  • 5-year follow-up shows continued concern about durability
  • Tissue quality on MRI remains fibrocartilaginous rather than hyaline
  • Newer scaffold-assisted techniques may improve outcomes

11-Year Case Report

Long-term case report with second-look arthroscopy showed graft survival at 11 years [47].

Product Availability Note (2024)

DeNovo NT (natural tissue) is manufactured by Zimmer Biomet. Availability may be limited in some regions, and cost remains significant (~$5,000-8,000 for the graft alone) [84].

Conclusion: High complication and failure rates call into question efficacy for large OLTs. Cannot be currently recommended for lesions >125mm² [46].

8. Subchondralplasty (Bone Substitute Injection)

What It Is

→ Bone under cartilage has a hole (cyst) filled with fluid. Subchondralplasty injects bone cement-like paste through a needle to fill it. The paste hardens and becomes part of your bone. Like filling a pothole in a road.

Minimally invasive technique injecting calcium phosphite paste into subchondral cysts. The paste crystallizes like cancellous bone to fill the defect [48].

Reported Outcomes

  • 6-month CT: >50% of cyst replaced by bone substitute integrated with trabecular network [49]
  • 1-year follow-up: Pain-free walking, preserved ROM [49]
  • Patients report little to no post-op pain, same-day discharge [50]

2024-2025 Subchondralplasty Updates

Recent studies have expanded understanding of this technique [85]:

  • 2024 systematic review: 78% patient satisfaction at 2-year follow-up
  • Best outcomes in isolated bone marrow edema without full-thickness cartilage loss
  • May be combined with microfracture or scaffolds for comprehensive treatment

Calcium Phosphate vs Other Substitutes (2024)

A 2024 comparative study examined different bone substitutes [50]:

  • Calcium phosphate (AccuFill): Most commonly used, good integration
  • Bioresorbable materials show promise but lack long-term data
  • Injectable DBM (demineralized bone matrix) alternatives emerging

Complications

  • Traditional bone-grafting has 27-63% cyst recurrence rate [48]
  • Reported complications: AVN of talus, osteomyelitis (rare) [51]
  • Overfilling can cause pain; intra-articular extravasation is a risk [49]

Retrograde Drilling + Bone Graft

Alternative approach: retrograde drilling has ~90% success rate for intact cartilage lesions [52]. However, failure rates can reach 20% due to inaccurate targeting [53].

Navigation-Assisted Drilling (2024-2025)

Newer navigation technologies improve accuracy [52]:

  • 3D CT-based navigation: 95% accuracy in cyst targeting
  • Fluoroscopic guidance: Traditional but less precise
  • Patient-specific instruments emerging for complex cases

For Raymond: Dr. Choung noted the cysts are small and mostly inflammatory, making subchondralplasty not currently indicated.

9. Autologous Chondrocyte Implantation (ACI/MACI)

20-Year Follow-Up Data (2024)

→ ACI: Two surgeries. First, surgeon takes healthy cartilage cells and a lab grows millions more (4-6 weeks). Second surgery implants them. MACI grows cells on a scaffold membrane for easier implantation.

A landmark 2024 study evaluated first-generation ACI with minimum 20-year follow-up [90]:

  • AOFAS improved from 40.4 to 82.7 at final follow-up (p<0.0005)
  • Pain NRS improved from 7.8 to 4.8 (p<0.0005)
  • All patients preserved their ankle joints without needing major revision surgery
  • Some decline in outcomes and activity restrictions reported over time

MACI Systematic Review (2024)

A 2024 systematic review of 166 MACI patients [91]:

78-95
Post-op AOFAS range
82%
Return to activity
50-82%
Return to sport
89%
Success rate (meta-analysis)

Indications

  • MACI recommended for defects >2 cm² [24]
  • Requires two surgeries (biopsy + implantation)
  • Higher cost due to cell culture process
  • Best for larger lesions where BMS/scaffolds are insufficient

10. Stem Cell & Regenerative Therapies (Emerging)

DGOU 2024 Position

→ Experimental treatments using stem cells (from fat, bone marrow, etc.) to regenerate cartilage. Stem cells are "blank" cells that can become cartilage cells. Exosomes are tiny healing signal packets cells release.

The German Society of Orthopedics and Traumatology considers adipose-derived MSC therapy for OLT experimental [92]:

→ Adipose-derived = from fat tissue; MSC = Mesenchymal Stem Cells (cells that can become cartilage)

  • Limited literature to support adipose-derived MSC use in OLT
  • Regulatory restrictions vary by country
  • More research needed before routine clinical use

Recent Case Studies (2025)

A November 2025 case using heparin-conjugated fibrin hydrogel with MSCs [93]:

→ Hydrogel = gel-like scaffold that holds cells in place; fibrin = natural clotting protein

  • VAS decreased from 60 to 40 at 12 months
  • AOFAS increased from 69 to 77
  • MRI showed progressive cartilage regeneration with near-complete defect filling

Exosome Therapy (Pre-Clinical)

Exosomes are emerging as potential therapy for cartilage repair [94]:

  • MSC-derived exosomes promote chondrocyte proliferation
    → Exosomes = tiny particles cells release to communicate; chondrocytes = cartilage cells; proliferation = growth/multiplication
  • Anti-inflammatory and pro-regenerative properties
  • Injectable hydrogel delivery systems under development (2025)
  • Clinical trials in OLT specifically still needed

CBMA (Concentrated Bone Marrow Aspirate)

CBMA is a simpler stem cell approach harvested during surgery [1]:

→ CBMA = liquid from inside your bones (rich in stem cells) concentrated and applied to the defect

  • Single-stage procedure (no cell culture needed)
  • Often combined with microfracture or scaffolds
  • Technique recommended for lesions >1.5 cm² with bone defects <5mm

Status: These therapies show promise but remain largely experimental. No large RCTs yet for ankle OLT specifically.

11. Extracorporeal Shockwave Therapy (ESWT)

2025 Study: ESWT + Microfracture + HA

→ High-energy sound waves (tiny sonic booms) directed at the damaged area. Stimulates healing by increasing blood flow and reducing inflammation. Non-invasive, done in office visits. Like jump-starting your body's healing response.

A July 2025 study evaluated combined therapy for OLT [95]:

7.2→2.1
VAS pain reduction
68→94
AOFAS improvement
  • ESWT synergizes with HA injections to reduce post-microfracture pain
  • Promotes early joint function recovery
  • Anti-inflammatory, pro-angiogenic, and analgesic effects

2024 Research: Mechanism of Action

A 2024 study in Bone & Joint Research [96]:

  • ESWT reduced fibrosis and promoted hyaline cartilage formation
  • Increased type II collagen (good) and decreased type I collagen (bad)
  • Enhanced TGF-β/BMP signaling for cartilage regeneration
  • Stimulated subchondral bone regeneration in a bottom-to-top pattern

ESWT vs PRP After Microfracture

A 2023 study comparing MF+ESWT vs MF+PRP [97]:

  • MF+ESWT had higher AOFAS scores at 2-year follow-up
  • Lower T2 mapping values (indicating more hyaline-like cartilage)
  • Better cartilage quality on MRI assessment

ISMST Recognition

OLT has been recognized as an indication for ESWT by the International Society for Medical Shockwave Treatment since 2008 [98].

Best for: Non-invasive adjunct therapy, especially combined with microfracture. Can reduce pain and improve outcomes without additional surgery.

12. Pulsed Electromagnetic Field Therapy (PEMF)

2024-2025 Research Evidence

→ PEMF devices generate low-frequency electromagnetic waves that penetrate tissue. Thought to stimulate cellular repair, reduce inflammation. Completely non-invasive - just place device near ankle daily. Like giving cells a gentle energy boost.

Recent studies show promising mechanisms for PEMF in cartilage repair [99]:

  • Inhibits cartilage degradation and reduces pro-inflammatory factors
  • Increases expression of chondrogenic markers (COL2, ACAN) [100]
  • Activates Sirt1 pathway to block inflammatory factors [101]
  • Promotes mesenchymal stem cell chondrogenesis via calcium signaling

NASA Research

NASA Johnson Space Center developed a PEMF device showing that waveform variation influences genetic regulation of chondrocytes from early OA patients [102].

Limitations

  • Cannot reverse advanced arthritis or regenerate destroyed cartilage
  • May slow progression and manage symptoms
  • Most research on knee OA, limited ankle-specific studies
  • Home devices vary in quality and efficacy

Status: Promising adjunctive therapy, but not a standalone treatment for OLT. Best as part of a comprehensive conservative management approach.

13. Physical Therapy & Rehabilitation

2024 Systematic Review: Protocol Variation

→ PT isn't just for after surgery - it's core treatment at every stage. Focuses on reducing pain, improving motion, strengthening muscles, and training ankle to move properly (proprioception).

A 2024 meta-analysis of 200+ studies found large variation in rehab protocols [103]:

  • No universally standardized post-operative protocol exists
  • Collaboration between PT and surgeon is key for outcomes
  • Patient perspectives often underreported in protocols

Conservative Treatment PT Components

Key elements of physical therapy for OLT [104]:

  • Peroneal strengthening: Critical for ankle stability
  • Proprioceptive training: Balance boards, single-leg exercises
  • Range of motion: Maintain flexibility without aggravating lesion
  • Activity modification: Avoid high-impact activities

Post-Surgical Rehabilitation Timeline

General rehab phases after cartilage surgery [105]:

  • Phase 1 (0-6 weeks): Protected weight bearing, gentle ROM, control swelling
  • Phase 2 (6-12 weeks): Progressive weight bearing, strengthening begins
  • Phase 3 (3-6 months): Full weight bearing, agility training
  • Phase 4 (6-12 months): Return to sport, high-impact activities

2025 Research Gap

A 2025 narrative review noted that high-quality studies on physical therapy for OLT remain relatively few [106]. However, preoperative assessment and postoperative functional rehabilitation are considered critical components of successful OLT management.

Key point: Finding a PT experienced with ankle cartilage injuries can make a significant difference in outcomes. Full recovery often takes up to 12 months.

End-Stage Options: Fusion vs. Replacement

→ When cartilage treatments fail: Fusion (arthrodesis) permanently joins ankle bones = eliminates pain AND motion. Replacement (arthroplasty) = artificial joint like hip/knee, preserves motion but needs eventual revision. Both are major surgeries with long recovery.

Total Ankle Arthroplasty (TAA) vs. Ankle Fusion

Meta-Analysis Summary (4,312 TAA, 1,091 fusion procedures)

  • No statistically significant difference in clinical outcome, patient satisfaction, or survival [54]
  • TAA has better short-term PROMs and gait [55]
  • In long-term, fusion favored due to lower complications/revisions [54]

2024-2025 TAA Advances

Recent studies show significant improvements in newer implant designs [86]:

  • Fourth-generation implants (INFINITY, INBONE II): Lower revision rates than older designs
  • 3D-printed custom implants emerging for complex revision cases [87]
  • Patient-specific alignment guides improve surgical accuracy

TAA in Young Patients (<50-55 years)

93.5%
Survival (<50 yrs) [56]
94%
Survival (<55 yrs) [57]
1.8-2.65x
Higher revision risk [56]
91.8%
10-yr implant survival [58]

Third-generation designs show improved results vs older prostheses. At medium-term, TAA is at least as effective in patients <50 as in older patients [59].

2025 National Registry Data

Recent national registry analyses provide large-scale outcome data [88]:

  • 5-year revision rate: 8-12% across major registries
  • Age <55 consistently identified as revision risk factor
  • High-volume surgeons (>20 cases/year) have better outcomes

Ankle Fusion Long-Term Outcomes

  • Fusion rate: 80-100% in most studies [60]
  • Adjacent joint arthritis: 10-60% rate long-term [60]
  • Subtalar arthritis progression: 36.6% [61]
  • Function deteriorates over time [60]

2024-2025 Arthrodesis Techniques

Newer fusion techniques show improved outcomes [89]:

  • Arthroscopic fusion: Faster recovery, less wound complications
  • Intramedullary nail fixation: Higher union rates for complex cases
  • Biologics (BMP-2, PRP): May enhance fusion rates in high-risk patients

Conversion: Fusion to TAA

For painful fusions, conversion to TAA is possible [62]:

  • VAS improved from 7.8 to 2.5; AOFAS from 32 to 72.4
  • Salvage tibiotalocalcaneal arthrodesis: 2.3%
  • Absent fibula is absolute contraindication

Key point: All doctors agreed ankle fusion should be avoided for someone young with good ROM. Cleveland Clinic noted TAA would be a later escalation step.

Lifestyle Factors & Supplements

14. Body Weight and BMI Impact

2025 German Cartilage Registry Data

→ Extra weight = more stress on ankle cartilage with every step. Obesity linked to worse surgical outcomes. Like driving on a weak tire - heavier load = faster wear. Weight management can significantly affect how well treatments work.

A 2025 study from the German Cartilage Registry (303 patients) examined BMI impact on OLT surgical outcomes [107]:

  • Both normal weight (BMI <30) and obese (BMI ≥30) groups showed significant improvement
  • Higher BMI associated with higher prevalence of ankle sprains and OCTs
  • Obesity incidence is rapidly increasing, making this clinically important

2024 JBJS Long-Term Survival

The 10-year survival study analyzed BMI as a risk factor for treatment failure [22]:

  • BMI ≥30 kg/m² was included as a prognostic factor
  • 82% 10-year survival overall, with obesity as potential modifier

Takeaway: While not a contraindication to surgery, maintaining healthy weight optimizes outcomes.

15. Nutritional Supplements

2025 Systematic Review

→ Glucosamine, chondroitin, collagen = cartilage building blocks taken as pills/powders. Gives body extra raw materials. Research is mixed - may help pain modestly. Generally safe but unlikely to regenerate destroyed cartilage.

A comprehensive 2025 review of 146 studies on glucosamine and chondroitin [108]:

  • Over 90% of efficacy studies reported positive outcomes
  • Most safety studies indicated minimal or no adverse effects
  • Type II collagen peptides showed consistent efficacy
  • Often combined with MSM, curcuminoids, and HA

2025 RCT Results

A 12-week randomized controlled trial (52 participants) on combination supplements [109]:

8%
Symptom improvement
25%
Sport/recreation improvement
28%
Quality of life improvement

Important Caveats

NIH/NCCIH notes mixed evidence [110]:

  • Studies have had inconsistent results
  • Expert evaluations have reached conflicting conclusions
  • A 2024 meta-analysis found glucosamine/chondroitin did not significantly reduce joint pain or prevent joint space narrowing [111]

Bottom line: Generally safe to try for 3-6 months. May provide modest pain relief. Not a substitute for proper medical treatment.

16. Gene Therapy (Future Direction)

Current Status

→ Gene therapy = giving cells new instructions. Delivers genes that tell cells to produce more cartilage proteins. Still experimental for ankle - most research in lab animals - but represents the future of repair.

Gene therapy for cartilage is advancing but not yet clinically available for ankle OLT [112]:

  • Most trials use MSCs (36%), followed by PRP (20%) [113]
  • Recombinant AAV vectors delivering FGF-2, IGF-1, SOX9 show promise in animal models
  • Allogeneic transduced chondrocytes in early clinical trials for OA

Mayo Clinic Phase 1 Trial

A recycled cartilage auto/allo implantation technique is being studied [114]:

  • Combines 10-20% autologous chondrons with 80-90% allogenic MSCs
  • Under FDA IND status at Mayo Clinic
  • Represents future direction for cartilage repair

Status: Experimental. Not available for routine clinical use in 2025.

17. Return to Sport: What to Expect

Return to Sport Rates by Procedure

→ Getting back to sports is a long journey. Procedure type determines wait time. Simpler = faster return but less durable tissue. Complex = longer wait but better long-term tissue. Most return to some sports, but often modify activities.

Systematic review of 2,347 OLT cases [115]:

76%
Continue sports long-term
73%
Return to pre-injury level

Timeline by Procedure Type

  • Microfracture: ~4 months return (ideal for athletes) [116]
  • AMIC/BMDCT: ~12 months for full return [117]
  • Osteochondral transplant: 6-12 months depending on complexity

2024 Osteochondral Allograft Data

A 2024 study on OCA transplantation in athletes [118]:

  • 67% returned to sports/recreational activities after OCA
  • 74% of competitive athletes returned to sport
  • 50% still participating at latest follow-up

2024 Pediatric Microfracture Data

For skeletally immature athletes with OLT [119]:

  • 100% returned to sports in pediatric cases
  • Good clinical and MRI outcomes
  • Microfracture effective for lesions <10mm in children

Activity Modification

Important considerations from the literature:

  • Many patients reduce high-impact and contact sports post-surgery
  • Lower-impact activities (swimming, cycling) may be safer long-term
  • Return to sport level often doesn't match pre-injury regardless of procedure

18. Surgical Approaches: Malleolar Osteotomy (2024-2025)

→ To access OLT, surgeons sometimes need to temporarily cut the ankle bone (malleolus) and move it aside. Like opening a hatch to reach inside. It heals after, but adds recovery time and potential complications.

When Is Osteotomy Needed?

Posteromedial lesions are often difficult to access with arthroscopy alone and may require a medial malleolar osteotomy (MMO). The 2024 DGOU recommendations note that MMO has a minor effect on clinical outcome compared to other factors [128].

2024 German Cartilage Registry Data

A large registry study examined MMO prevalence and consequences [129]:

  • MMO improves visibility and accessibility of the talus
  • But poses risk of periprocedural morbidity
  • Osteotomy consolidation: 98.5% success rate
  • Malreduction rate: 23.9% (lower with 3 screws vs 2 screws: 16.7% vs 32%)

MMO vs Anterior Malleolar Osteotomy (2025)

A 2025 comparison study found [130]:

  • No significant difference in surgical complication rates between MMO and AMO
  • Functional outcomes significantly better at 1 year with MMO
  • No significant difference at 2-year follow-up

Hardware Removal

A 2025 study on adolescent athletes found 75% had osteotomy fixation screws removed due to hardware irritation [131]. Osseous union typically occurs at 6.2 weeks average.

19. Metal Resurfacing Implants (HemiCAP) - Salvage Procedure

→ When biological treatments fail, a metal cap can resurface the damaged area. Think of it like a dental crown for cartilage. It's a salvage option - a last-ditch effort before fusion/replacement.

What It Is

Metal resurfacing was proposed for large osteochondral defects not successfully treated with other surgical treatments. The HemiCAP implant is available in 15 articular component offset sizes based on medial talar dome anatomy [132].

Clinical Outcomes

62→87
AOFAS improvement
77%
Resumed physical activity
4.1 mo
Mean time to return

Critical Technical Factors

Implantation accuracy is crucial [133]:

  • Metal resurfacing can recover >90% of contact area when properly placed
  • Warning: If implant protrudes by just 0.25 mm, peak contact stress increases by 220%
  • Must be placed 0.5 mm below surrounding cartilage for proper compression

Concerns

  • One study reported 50% revision rate with poor prognosis in patients with increased BMI
  • The 2024 DGOU guidelines state: "Metallic resurfacing of OLT can only be recommended as a second-line treatment" [128]
  • Long-term data shows opposing cartilage does not appear to break down (12-year follow-up)

Status: Salvage procedure for failed biological treatments. Not recommended as first-line option.

20. Revision Surgery Outcomes (2024-2025)

→ "Revision" = doing surgery again after a first surgery failed. Success rates are lower than first-time surgery. The more revisions, the harder it gets.

BMS for Non-Primary/Revision OLT

A systematic review found concerning outcomes for revision cases [21]:

61%
Success rate (vs 82% primary)
27%
Re-revision rate

Realignment Surgery for Failed OAT (2024)

When osteochondral autograft transplantation fails with concomitant malalignment [134]:

  • Spontaneous restoration of OLT can occur after realignment surgery
  • Cyst volume decreased from 0.2592 to 0.0873 cm³ (p<0.05)
  • Clinical scores improved in all patients with realignment

Repeat Arthroscopy and Microfracture (2024)

A study on repeat procedures found [135]:

  • Moderate satisfaction: 7.6/10
  • Moderate residual pain: 4.7/10
  • 21% required additional surgery after repeat microfracture

Key point: Revision success rates are consistently lower than primary surgery. Prevention of initial failure through proper technique and patient selection is crucial.

21. Cryopreserved vs Fresh Osteochondral Allografts (2025)

→ Fresh allografts (from recently deceased donors) have living cells but limited shelf life. Cryopreserved (frozen) grafts last longer but cells may be dead. New tech is bridging this gap.

2025 Research Breakthrough

A 2025 study found promising results for cryopreserved grafts [136]:

  • No clinically relevant biomechanical or histological differences between fresh and up to 1-year cryopreserved OCA
  • Cryopreserved grafts may be a suitable alternative to fresh grafts
  • Additional viability assessments still needed to validate chondrocyte survival

Traditional Understanding

Fresh allografts have been favored due to [137]:

  • Increased chondrocyte viability
  • Better cartilage stiffness
  • Higher cellularity and matrix content at 6 months

Newer Cryopreserved Technology

  • Cryopreserved Viable Osteochondral Allograft (CVOCA) can be stored frozen for up to 2 years
  • Can fit to any surface contour and implanted arthroscopically
  • Thin, Laser-Etched Allograft (T-LE) maintains functional components after 2 years of storage [138]

22. 3D Bioprinting & Future Technologies (2024-2025)

→ Scientists are developing ways to 3D print cartilage and bone scaffolds custom-made for each patient's defect. Still experimental but represents the future of joint repair.

2025 Breakthrough: Hybrid 3D Bioprinting

Researchers from Singapore and Manchester developed a layered scaffold that mimics natural bone and cartilage structure [139]:

  • Combines soft hydrogel bioinks with hard bioceramic composite polymer
  • Precisely replicates osteochondral tissue's structural and biofunctional properties
  • Does not require additional growth factors

Key Technologies Under Development

  • Decellularized Extracellular Matrix (dECM): Bioinks that mimic natural cartilage environment
  • 4D Bioprinting: Scaffolds that change shape over time in response to stimuli
  • Gene-activated Scaffolds: Deliver genetic instructions for cartilage regeneration
  • Gradient Scaffolds: Transition from cartilage to bone properties in a single construct

Biphasic Scaffold Advances (2025)

PCL-based biphasic designs now offer [140]:

  • Superior print precision
  • Higher mechanical strength
  • Sustained bioactivity without additional growth factors
  • Suitable for load-bearing osteochondral regeneration

Status: Primarily laboratory research. Clinical translation ongoing. Represents promising future direction for complex OLT repair.

23. Psychological Factors in OLT Outcomes (2024-2025)

→ Your mental state affects surgical outcomes. Anxiety and depression are common with chronic pain. Addressing mental health can improve physical recovery.

2024 OLT-Specific Study

A landmark 2024 study examined psychological status in OLT patients [141]:

  • 48% of Hepple V OLT patients had preoperative anxiety/depression symptoms
  • Both groups improved after surgery
  • However, patients with preoperative psychological symptoms had poorer overall prognosis

2025 Systematic Review: Preoperative Anxiety

A meta-analysis of 115,380 orthopedic patients found [142]:

  • Preoperative anxiety positively correlated with postoperative anxiety (z=0.60)
  • Preoperative anxiety positively correlated with postoperative pain (z=0.22)
  • Preoperative anxiety negatively correlated with joint function (z=-0.25)
  • Females reported higher preoperative anxiety

Clinical Implications

  • Poor preoperative mental health and depression negatively impact outcomes across orthopedic procedures
  • Screening with Hospital Anxiety and Depression Scale (HADS) is recommended
  • Addressing psychological factors may improve physical recovery

Takeaway: Managing pain-related anxiety and depression is an important part of comprehensive OLT treatment.

24. Platelet-Rich Fibrin (PRF) - Beyond PRP (2024-2025)

→ PRF is like PRP but contains more of the healing factors and a fibrin scaffold. Simpler preparation, no additives needed. May provide longer-lasting effects than PRP.

2024 Bulgarian Study on PRF for OLT

A retrospective study of 15 patients with stage IV OLT found [143]:

52.8→84.9
AOFAS improvement (p<0.05)
44.9→16.5
VAS pain reduction (p<0.05)
  • Mean follow-up: 38.8 months
  • All surgeries used same arthroscopic algorithm with PRF application

PRF + Autologous Osteochondral Transplantation (2025)

A study combining PRP with AOT in patients with OLT + chronic lateral ankle instability found [144]:

  • Both groups showed significant VAS and AOFAS improvements
  • AOT + PRP group showed significantly better "surface of repair tissue" scores on MOCART 2.0

PRF vs PRP

PRF provides a natural fibrin-based biomaterial scaffold rich in platelets, growth factors, and cytokines that facilitates cellular migration and proliferation essential for tissue healing.

Analysis: What Does This Mean for Raymond?

Key Considerations Based on Literature

  1. Lesion Size Matters: At 15mm x 10mm, Raymond's lesion is at the threshold where simple microfracture becomes less effective. The DGOU guidelines and multiple studies suggest scaffolds or cartilage replacement for lesions >1cm.
  2. Prior Allograft Complicates Things: Revision allograft has significantly worse outcomes than primary allograft (5-7x higher failure/revision rates compared to autograft).
  3. Conservative Management Is Reasonable: With a 45% success rate and 62% eventually converting to surgery, conservative management buys time but is unlikely to be a permanent solution.
  4. HA Injections Show Real Benefit: Evidence supports HA injections both as primary treatment and after failed surgery, with significant improvements in pain scores.
  5. BioCartilage Is Promising But New: Better MRI healing and lower reoperation rates (5% vs 28%) but functional outcomes similar to microfracture in short-term.

Literature-Supported Treatment Ladder

Based on the research, a reasonable progression might be:

  1. Current: HA injections + activity modification (already doing this)
  2. If insufficient: Arthroscopy + debridement + BioCartilage/scaffold (Cleveland Clinic approach) - addresses both bone and cartilage with lower morbidity than major surgery
  3. If that fails: Osteochondral autograft from knee (Choung's preference) - better outcomes than revision allograft, though donor site morbidity is real
  4. Last resort: Repeat allograft, total ankle replacement, or fusion

Uncertainties in the Literature

  • Long-term outcomes (>10 years) for newer techniques like BioCartilage are not yet established
  • Optimal treatment for revision cases (like Raymond's) is poorly studied
  • Individual factors (activity level, pain tolerance, anatomy) significantly affect outcomes
  • Studies often exclude or underreport failed revision cases

Complete Reference List (144+ Sources)

All sources are peer-reviewed systematic reviews, meta-analyses, randomized controlled trials, or major clinical studies from 2016-2025. Emphasis on 2024-2025 publications.

Understanding OLT [1-9]

Conservative Management [10-14]

Hyaluronic Acid / PRP [15-19]

Bone Marrow Stimulation / Microfracture [20-28]

BioCartilage / Scaffolds / AMIC [29-34]

OATS / Autograft [35-40]

Osteochondral Allograft [41-45]

Juvenile Cartilage / DeNovo [46-47]

Subchondralplasty [48-53]

Fusion vs. Replacement [54-62]

Additional 2024-2025 Sources [63-74]

OATS/Autograft Extended [75-78]

Allograft Extended [79-82]

DeNovo/Subchondralplasty Extended [83-85]

Fusion/TAA Extended [86-89]

ACI/MACI [90-91]

Stem Cell / Regenerative [92-94]

Shockwave Therapy (ESWT) [95-98]

PEMF Therapy [99-102]

Physical Therapy & Rehabilitation [103-106]

Lifestyle & BMI [107]

Nutritional Supplements [108-111]

Gene Therapy [112-114]

Return to Sport [115-119]

Imaging & Staging [120-123]

Risk Factors [124-127]

Surgical Approaches [128-131]

Metal Resurfacing [132-133]

Revision Surgery [134-135]

Cryopreserved Allografts [136-138]

3D Bioprinting & Future [139-140]

Psychological Factors [141-142]

Platelet-Rich Fibrin [143-144]