Ankle Cartilage Surgery

Ankle Joint Cartilage and Osteochondral Lesions (OCL/OCD)

Among the bones forming the ankle joint, the upper surface of the talus (the talar dome) and the lower surface of the tibia (the plafond) are covered with a smooth, white, slippery, shock-absorbing tissue called hyaline cartilage. This cartilage allows the joint to move with minimal friction.

Osteochondral Lesion (OCL) / Osteochondral Defect (OCD): This is a condition in which the articular cartilage of the ankle and the subchondral bone tissue just beneath it are damaged together. The damage can range from a simple crack or softening of the cartilage alone to complete separation of a cartilage-and-bone fragment that falls into the joint (a loose body). It is most commonly seen on the dome of the talus bone (Talus OCL/OCD).

This condition differs from ankle osteoarthritis, which involves widespread cartilage wear on the joint surface; OCL/OCD refers more to damage confined to a limited area.

The Goal of Ankle Cartilage Surgery:

• To repair or restore the damaged cartilage and bone area.
• To relieve pain and mechanical symptoms such as catching and locking.
• To improve ankle function.
• To restore congruity of the joint surface, thereby reducing or delaying the future risk of developing osteoarthritis.

What Causes Ankle Cartilage Damage? Risk Factors

The most common causes of osteochondral lesions (OCL/OCD) in the ankle are as follows:

• Trauma: Trauma is the cause in the vast majority of cases (70-85%). Particularly during moderate or severe ankle sprains (forceful inward or outward twisting of the ankle), the talar dome may strike against the tibia or fibula, causing bruising or fracture of the cartilage and the underlying bone. Ankle fractures can also lead to OCL.
• Repetitive Microtrauma: In individuals with chronic ankle instability (a persistent sense of giving way or repeated sprains), repeated abnormal loading can damage the cartilage over time.
• Vascular Causes: Rarely, OCL can also develop as a result of impaired blood supply to a specific area of the talus bone (similar to Avascular Necrosis).
• Idiopathic / Developmental (Osteochondritis Dissecans – OCD): Seen especially in young people, this is a condition of unknown exact cause in which a fragment of the bone beneath the cartilage separates due to impaired blood supply.

What Are the Symptoms of Ankle Cartilage Damage?

Symptoms vary depending on the size, location, and stability of the lesion (whether the fragment has separated) and the patient’s activity level. Common symptoms include:

• Deep Ankle Pain: Pain felt inside the ankle that usually increases with activity, particularly weight-bearing movements such as walking, running, and jumping, and decreases with rest.
• Mechanical Symptoms: Catching, locking, popping, or a clicking sound in the ankle during movement. These symptoms particularly suggest a separated or loose cartilage/bone fragment.
• Swelling: Recurrent swelling (effusion) in the joint, especially after activity.
• A Sense of Insecurity: A feeling of the ankle giving way or sudden weakness (can mimic a ligament injury).
• Limited Range of Motion: Restriction of joint movement may rarely occur.
• Persistent Sprain Pain: OCL should be suspected when pain following an ankle sprain lasts longer than expected and does not resolve.

How Is Ankle Cartilage Damage Diagnosed?

An accurate diagnosis and detailed evaluation of the lesion are essential for treatment planning.

• Detailed History: A history of prior ankle sprain or trauma (very important!), the nature of the pain, mechanical symptoms, and activity limitations are all reviewed.
• Physical Examination: Tender points in the ankle (usually along the joint line), swelling, and range of motion are assessed. The examiner checks for catching or a clicking sound and evaluates for accompanying ligament laxity or impingement findings.
• Imaging Methods:
  
  • X-ray: This is the first-line imaging study. AP, lateral, and especially mortise views are obtained. It can show large, bony lesions, loose bodies, joint space narrowing (osteoarthritis?), or fractures. However, x-rays can appear completely normal in early-stage lesions or those involving only the cartilage.
  • Computed Tomography (CT): Especially useful for detailed assessment of the size and location of the bony component of the lesion, the presence of cysts, and any separated bone fragments. It is used for surgical planning.
  • Magnetic Resonance Imaging (MRI): This is the gold-standard method for diagnosing OCL/OCD. It provides detailed information on both the cartilage damage and changes in the underlying bone such as edema, cysts, and necrosis, as well as the size, depth, and stability of the lesion (whether the fragment has separated). It also detects any accompanying ligament or tendon injuries.
• Diagnostic Arthroscopy: When imaging findings remain inconclusive, or when surgery is already planned, direct examination of the joint with a camera provides a definitive diagnosis and allows treatment to be performed at the same time.

Ankle Cartilage Surgery Options (Arthroscopic Approach)

The choice of treatment is based on the size, location, depth, and stability of the lesion (separated/non-separated), the patient’s age, activity level, and the severity of symptoms. Small, stable, and asymptomatic lesions can sometimes be monitored. However, symptomatic or large/unstable lesions generally require surgical treatment, which is most often performed using an arthroscopic (closed) technique.

1. Arthroscopic Debridement / Chondroplasty: Shaving and removing small, unstable cartilage flaps or frayed edges. It provides temporary relief but does not repair the cartilage.
2. Bone Marrow Stimulation Techniques (Microfracture / Drilling): One of the most commonly used methods. Particularly for full-thickness cartilage and bone defects smaller than 1.0-1.5 cm², small holes are made arthroscopically in the bone beneath the damaged area. Blood and bone marrow cells seeping from these holes form a repair tissue (fibrocartilage). This technique can give good results in young patients and small lesions.
3. AMIC (Autologous Matrix-Induced Chondrogenesis): Covering the defect with a collagen membrane to enhance the effectiveness of the microfracture procedure. It can help keep cells within the defect. It is an option for defects slightly larger than those suited to microfracture alone.
4. Osteochondral Autograft Transplantation (Mosaicplasty / OAT): Transplanting cartilage-bone cylinders taken from the patient’s own knee (usually from a non-weight-bearing area) into the defect site in the ankle. It restores the defect with original hyaline cartilage in small-to-medium sized defects. It can create donor-site problems in the knee and is technically demanding. It can be performed arthroscopically or through a mini-open approach.
5. Osteochondral Allograft Transplantation: The use of cadaveric cartilage-bone grafts obtained from a tissue bank. It is preferred especially for large OCLs (>1.5-2.0 cm²) or when other methods have failed. It has the advantage of filling large defects with a single piece of hyaline cartilage. It involves challenges related to graft availability, cost, and technical difficulty. It generally requires open or mini-open surgery.
6. Autologous Chondrocyte Implantation / Transplantation (ACI / MACI): A two-stage procedure (biopsy, cell culture, and implantation). It is an option for large defects but is less commonly performed in the ankle than in the knee, is technically demanding, and requires a very long rehabilitation.
7. Other New Techniques: New methods such as particulated juvenile cartilage allograft are also being developed.

Prof. Dr. Murat Bozkurt is experienced in ankle arthroscopy and cartilage restoration techniques and determines the surgical method best suited to each patient’s lesion.

Choice of Surgery, Risks, Benefits, and the Long Recovery Process

• Factors Affecting the Choice of Surgery: The size, location, depth, and stability of the lesion, the patient’s age, activity level, accompanying pathologies (instability, impingement), prior treatments, and the surgeon’s experience.
• Benefits: Relief of pain and mechanical symptoms such as catching and locking, improved ankle function, the ability to return to activity and sport, and the potential to delay osteoarthritis.
• Risks: General surgical risks (infection, DVT, nerve injury, anesthesia). Specific risks include failure of the repair or graft (nonunion, insufficient cartilage formation), persistent pain, joint stiffness, donor-site pain in the knee after mosaicplasty, progression of osteoarthritis, and the need for further surgery (such as ankle replacement or fusion surgery in the future).
• Recovery Process: Recovery after ankle cartilage surgery is a long process that requires patience and in which rehabilitation is critical.
  
  • Non-Weight-Bearing / Protected Weight-Bearing: This is very important. Depending on the procedure performed, it is generally necessary to avoid bearing any weight on the leg, or to bear only very little weight, using crutches for 6 to 8 weeks or longer after surgery. This is essential for protecting and allowing healing of the repaired or transplanted cartilage.
  • Immobilization: Initially, the ankle may be kept immobile with a cast or a special walking boot.
  • Gradual Physical Therapy: The rehabilitation program begins right away and continues for months. It starts with passive movements, progressing to active movements as weight-bearing increases, followed by strengthening (particularly of the calf and peroneal muscles), balance, and proprioception exercises.
  • Timeline: Return to normal daily activities takes a few months. Return to high-impact activities such as running and jumping, or to sport, generally takes 6 to 12 months or longer.

Ankle Cartilage Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Osteochondral lesions (OCL/OCD) of the ankle are a significant cause of persistent pain following trauma, and their diagnosis and treatment require specialized expertise. In Ankara, Prof. Dr. Murat Bozkurt offers patients modern treatment options for this condition:

• Accurate Diagnosis: He accurately determines the type, size, and severity of the lesion using advanced imaging methods (especially MRI) and clinical evaluation. He also thoroughly assesses accompanying issues such as ligament injuries or impingement.
• Personalized Treatment: He determines the most suitable treatment method (conservative follow-up, arthroscopic debridement, microfracture, AMIC, OAT, allograft, etc.) based on the characteristics of the lesion and the patient’s expectations.
• Advanced Arthroscopic Techniques: When surgery is needed, he draws on his experience in ankle arthroscopy to treat the cartilage lesion using minimally invasive methods, and addresses any other intra-articular problems in the same session.
• Comprehensive Rehabilitation Management: He plans the long, structured rehabilitation program that is the cornerstone of post-operative success and closely monitors the patient throughout this process.