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Answer

University of Wisconsin Clinical Science Center Madison, WI 53792-3252

(In response to Question from pg. 867.)

The natural history of a medical condition can refer to the outcome of either patients who are not treated at all or those who are treated with conservative measures. Most commonly, patients with talar osteochondritis dissecans (OCD) present with an ankle injury or ankle pain. Because treatment normally consists of either surgical débridement or casting, there are no reports giving the natural history of patients with untreated talar OCD.

However, there are many reports of the short-term results of casting. Flick and Gould [1] treated eight patients with talar OCD using 6-12 weeks of casting and limited weight-bearing. Six patients had a poor result and required surgery, whereas the remaining two patients did not require surgery but had persistent pain. However, in their review of the literature, they noted that cast treatment of patients with talar OCD gave good to excellent results in 68-69% of patients in two studies, but only 17-22% of patients had good results with casting in two other studies [1]. Thus, it is not known if a minority or majority of patients with talar OCD will have a good outcome with conservative treatment.

The studies in the literature do not provide details on the frequency of radiographic healing of talar OCD when no surgery is performed. In my experience, the lesions may completely heal when patients are treated either conservatively or with débridement. However, new fragments or displacement of the fragments may develop after either type of treatment.

The important clinical issue is the long-term outcome of conservative management of OCD. Here, clinical series have also reported widely varying findings. In the study by Canale and Belding [2], 50% of the patients treated conservatively developed degenerative joint disease in the ankle. However, Bauer et al. [3] reported their 21-year average follow-up assessment of 30 patients who were treated conservatively [3]. Only two of the 30 ankles showed radiographic findings of degenerative joint disease. Presumably the difference in patient outcomes reflects differences between the two studies in case selection.

In summary, patients with talar OCD may develop fragmentation and progression of their lesions despite conservative or surgical treatment. It is not clear from the literature whether the short-term and long-term results are generally favorable or poor. In my own practice, the orthopedic surgeons initially treat patients with talar OCD by casting and limited weight-bearing of the involved ankle. Curettage and fixation are then recommended for patients who have persistent pain and nonunion.

References

1. Flick AB, Gould N. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. Foot Ankle 1985;5:165-185[Medline]
2. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg 1980;62-A:97-102[Abstract/Free Full Text]
3. Bauer M, Jonsson K, Linden B. Osteochondritis dissecans of the ankle. J Bone Joint Surg 1987;69-B:93-96

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by De Smet, A. A. Search for Related Content PubMed Articles by De Smet, A. A. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?