Osteochondral lesions of the talus

When nonsurgical measures fail, OLTs can be managed effectively in most cases with arthroscopic debridement and drilling/microfracture. Preopera-tively, it is important to verify the OLT as the source of pain and to stage the lesion with CT. Small-joint instruments combined with proper setup and technique afford access to most lesions. When the articular surface is disrupted, favorable results are achieved by de-briding the lesion to a stable rim, followed by penetration of the subchondral plate to stimulate the formation of fibrocartilage to fill the defect. When the articular surface is intact, retrograde drilling, with or without bone grafting, is effective at restoring subchondral support and relieving pain. Despite proper technique, some patients with OLTs fail to improve. Larger-diameter lesions, those as-sociated with subchondral cysts, and those that have failed arthroscopic treatment are candidates for OAT or ACI. These techniques have the po-tential to restore hyaline cartilage in the OLT. Perpendicular access to the talar dome is needed, which often necessitates ligament release or an osteotomy. Graft harvest from the knee may lead to persistent knee symptoms. OLTs that have failed OAT or ACI or that involve the talar shoulder or a significant portion of the talus may be treated with structural allograft reconstruction as an alternative to ankle arthrodesis.