Osteochondral Lesion of the Talus 2026 | Podiatrist

Classification	Grade	Description	MRI Finding	Treatment
Berndt-Harty (X-ray)	I	Subchondral compression; no fragment	Bone marrow edema; intact cartilage	Conservative; protected WB 6–8 weeks
Berndt-Harty	II	Partially detached fragment	Fluid partially surrounding fragment	Arthroscopic fixation if in situ; excision if displaced
Berndt-Harty	III	Completely detached but non-displaced	Full fluid rim around fragment; intact overlying cartilage	Arthroscopic excision + marrow stimulation; fixation if large
Berndt-Harty	IV	Displaced osteochondral fragment	Fragment displaced into joint space; loose body	Fragment excision; microfracture or cartilage restoration
Hepple MRI	V	Subchondral cyst (±stable fragment)	Subchondral cyst; viable-appearing cartilage above	Retrograde drilling + bone grafting; or osteochondral transfer (OATS)

Cartilage Repair Technique	Lesion Size	Mechanism	Success Rate	Recovery
Microfracture (marrow stimulation)	<150 mm² (<1.5cm²)	Perforates subchondral plate; allows marrow cells to form fibrocartilage repair tissue	75–85% at 5 years; fibrocartilage (inferior to hyaline)	6–8 weeks NWB; 4–6 months sport
OATS (Osteochondral Autograft Transfer)	150–400 mm²	Harvests cylindrical hyaline cartilage + bone plug from non-weight-bearing knee; press-fit into talar defect	80–90% at 5 years; true hyaline repair tissue	6–8 weeks NWB; 6 months sport
MACI (Matrix-Induced ACI)	>250 mm²; failed microfracture	Autologous chondrocytes grown on collagen scaffold; implanted into defect	75–85%; hyaline-like repair; better for large lesions	6–8 weeks NWB; 12 months sport
Retrograde Drilling + Bone Graft	Subchondral cyst (Hepple V)	Drill through intact cartilage from distal tibia; fill cyst with bone graft; preserve overlying cartilage	80–90% if cartilage intact above cyst	6–8 weeks NWB; 4–5 months sport

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Osteochondral Lesions of the Talus: Ankle Cartilage Injuries

The talus — the weight-bearing dome of the ankle joint — is covered by hyaline articular cartilage that allows smooth, low-friction ankle motion. Osteochondral lesions (OLTs) represent focal areas of damage to this cartilage and its underlying subchondral bone, creating a defect that disrupts the articular surface. OLTs are classified by their anatomical location on the talar dome (medial versus lateral), the stability of the fragment (stable versus unstable/displaced), and the depth of involvement. Unstable or displaced fragments — loose bodies within the joint — cause mechanical clicking, catching, and locking that significantly impairs ankle function.

Causes and Presentation

Lateral talar dome OLTs are almost universally post-traumatic, typically resulting from acute inversion ankle sprain with concurrent talar dome impaction against the fibula. Medial OLTs have a more complex etiology — some are post-traumatic, others represent osteochondrosis (vascular compromise of the subchondral bone) — and tend to be deeper, more cystic, and more challenging to treat. Patients present with persistent deep ankle pain and swelling following an ankle sprain that “won’t heal normally,” often accompanied by mechanical symptoms (clicking, giving way) and pain with prolonged activity. The diagnosis is frequently delayed because initial ankle X-rays after sprains may not reveal the lesion — OLTs are visible on X-ray only when the defect is large or the fragment is displaced.

Diagnostic Imaging

MRI is the gold standard for OLT diagnosis and classification — it visualizes the cartilage surface, subchondral bone edema, cyst formation, and fragment stability with excellent sensitivity. The Hepple MRI classification guides treatment decision-making: Stages 1–2 (cartilage signal abnormality without fragmentation) may be treated conservatively; Stages 3–5 (displaced fragments, subchondral cysts, loose bodies) typically require surgical intervention. CT scan provides superior detail of subchondral bone cyst size and morphology — essential for pre-surgical planning in medial cystic lesions requiring bone grafting.

Treatment

Conservative treatment is appropriate for small, stable, asymptomatic or minimally symptomatic Stage 1–2 lesions — particularly in skeletally immature patients where healing potential is higher. Six to twelve weeks of non-weight-bearing or protected weight-bearing in a CAM boot, combined with physical therapy for periarticular strengthening, allows some lesions to heal or become asymptomatic. Surgical treatment is indicated for unstable or displaced lesions, large cystic lesions, persistent symptoms despite conservative care, and loose bodies causing mechanical symptoms. Arthroscopic debridement and microfracture — creating channels in the subchondral bone to stimulate fibrocartilage repair — is the most common first-line surgical procedure for lesions smaller than 1.5cm. Larger defects may benefit from osteochondral autograft transplantation (OATS), allograft transplantation, or matrix-induced autologous chondrocyte implantation (MACI) — procedures Dr. Biernacki coordinates with orthopedic ankle specialists for definitive surgical care.

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