Addiyar Building, 5-58b Street, Al Wasl, Sheikh Zayed Road, United Arab Emirates, © 2020 Orthosports Medical Center All rights reserved. Two common lesions are notable on the talus. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. Consultant Orthopaedic Foot and Ankle Surgeon. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. Osteochondral lesions (OCLs) are focal articular injuries of the subchondral bone and the cartilage with a multifaceted cause (trauma, ligament instability, ischemic necrosis, malalignment, endocrine diseases, and others). By subscribing to our mailing list you will always be update with latest healthcare news from us. The first is injury to the cartilage surface with an actual loss of part of the chondral surface and underlying subchondral bone. They can also happen if the cartilage is bruised, torn … Symptoms of an osteochondral lesion include: Pain Swelling Ankle instability Ankle … Impaired function, limited range of motion, stiffness, catching, locking an… These fractures are most commonly seen in the knee and ankle joints, as these joints take a lot of strain and bear a lot of weight, which can make them vulnerable to damage. Overview. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). An osteochondral fracture is a type of fracture in which the articular cartilage at the end of a joint becomes torn. I recommend using a Pneumatic Walker as immobilization for high grade ankle sprains, inversion injuries with much pain and swelling, even when further evaluation for an osteochondral injury is not being done. In most cases for an osteochondral problem to develop, traumatic injury needs to occur, as trauma to the ankle joint is the root cause of 85 percent of cases. Osteochondral injuries are diagnosed by physical examination, X-ray and CT and MRI scans. This is the most common type of injury … Symptoms can be vague. More on ankle fractures & dislocations Osteochondral Lesions … Healthy joint cartilages make it easier to move, as they are the joints’ bearing surfaces which allow the bones to glide over each other with very little friction, keeping them from rubbing together. Orthosports Medical Center has experienced Foot & Ankle Surgeons who specialize in diagnosis and treatment of Chondral Injuries of the Ankle. It is often caused by a traumatic injury, such as a severe ankle sprain. Osteochondral fractures of the talar dome often occur at the same time as a sprained ankle. An injury of the talus, called an osteochondral lesion of the talus (OLT), while sometimes referred to as an ankle osteochondral lesion or an ankle osteochondral fracture, involves both the bone and its underlying cartilage. Osteochondral injuries, also called osteochondritis dissecans, are injuries … Osteochondral injuries are one of the most common causes of ankle pain. Symptoms related to this condition are nonspecific including pain… We will respond to you within 24 hours or on the next working day. Osteochondral injuries commonly affect the ankle joint and involve the dome of the talus. A foot and ankle specialist can diagnose an osteochondral injury of the talus by taking a medical history and conducting a physical exam. An injury that is not displaced may heal with proper immobilization. An osteochondral lesion of the talar dome is an injury to the talus, which is a bone in the foot that along with the tibia forms the ankle joint. Talar dome lesions are usually caused by an injury, such as an ankle … Those seconds of pain are your body’s way of telling you that something is not perfectly fine. Ankle Injury. Articular cartilage is the smooth, shiny, white tissue covering the ends of the bones. It often occurs after an injury such as a sprain or trauma to the foot and ankle. With an MRI, the ligament structures, tendons and cartilage of the ankle can be examined and analyzed. Pain with weight bearing activities When a fragment of bone detaches it causes stiffness, pain, swelling and difficulty bearing weight on the foot and ankle. The predominant symptom of osteochondral injury is pain, which may be localized to the ankle joint. This condition is commonly seen with traumatic injuries like acute ankle sprain; although, the ankle joint misalignment due to chronic overuse also can lead to this condition. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Slight increase in degenerative changes of the ankle with limited cartilage damage of anterior distal tibia. The “classical” defect involves a disruption of both the bone (osteo) and cartilage (chondral) .They usually occur on the Talus if effecting the ankle … The injury occurring on the medial aspect of the Talus is often deeper and cup shaped. Overview focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage resulting in osteochondral lesion of the talus (OLT) may be caused by traumatic event or result of … Orthosports Medical center Treatment may include: Fortius clinic is the trading name of Fortius London Limited. An osteochondral lesion is an injury or small fracture of the cartilage surface of the talus. Privacy Policy. Osteochondral injuries are a possible cause of continued ankle pain after a sprain. The presence of an osteochondral lesion may initially go undetected and may manifest many months after the initial ankle injury. The degree of injury ranges from a … An arthroscopy may be carried out to examine the joint and remove any loose bone fragments or cartilage. Registered in England and Wales under company number: 07033880, For this reason, the injury may initially be overlooked and treated as a sprained ankle. Osteochondral defects and loose bodies are common causes of mechanical symptoms in the ankle. In most cases we use arthroscopy to evaluate and repair joint damage in order to reduce recovery time. This article describes the etiology and pathogenesis of these injuries. Learn about causes, symptoms, treatment & prevention tips. Foot fusion surgery is carried out to permanently join or stiffen the joint between arthritic bones. During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. registered address 17 Fitzhardinge Street, London, W1H 6EQ. Osteochondral lesions of the talus are uncommon sources of ankle pain in athletes that can occur after traumatic ankle sprains.They are often found incidentally on ankle x-rays obtained for ankle sprains or to rule out ankle fractures.In patients and athletes with pain in the ankle joint from a presumed ankle sprain but with persistent symptoms, x-rays, CT scans, or MRIs can reveal the diagnosis. Let’s talk about the articular cartilage. The condition occurs most commonly in the knee, but also occurs in elbows, ankles and other joints. Some of the practising consultants have a financial interest in Pain may be felt primarily at the lateral (outside) or medi… Specialising in the minimally invasive arthroscopic treatment of injuries, they can help musicians and performing artists, as well as amateur and professional sportsmen and women, return to fitness as quickly as possible. Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. Have you experienced that locking of your ankles when you suddenly change in position? Non-operative measures such as mobilisation, a heel lift and steroid injections are reasonable non-operative techniques to try before surgical referral, but pain … It is the area which joins with the talus to form the ankle joint. It often develops above a bone cyst. Their clinical presentation is described and advice is given on how to diagnose and investigate suspected osteochondral injuries. The causes of osteochondral injuries are not yet completely understood, but some theories are lack of blood supply to the affected area, heredity, direct compressive trauma or repetitive strain. This article describes the etiology and pathogenesis of these injuries. How is it diagnosed? It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). Sometimes damage can also occur spontaneously (without an injury). This type of injury can be due to a severe ankle sprain that causes bone and cartilage to become loose, resulting in ongoing ankle pain. The treatment for chondral injurys ranges from conservative, to arthroscopic and open surgeries (arthroscopic debridement, marrow-stimulating techniques, autologous chondrocyte transfers and implantation, and allografts), and would depend on the patient’s, age, etiology, grade, and quality of the lesion. Cartilage on the outside of this joint, called the articular surface, provides the smooth gliding between the ankle joint and the underlying bone that supports it (the talus). MRI: Medial osteochondral lesion of the talus, with central piece of bone. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). More on ankle fractures & dislocations Osteochondral … Ankle instability or giving way; Stiffness of the ankle; Difficulty with walking, running, or sports; A foot and ankle specialist can diagnose an osteochondral injury of the talus by taking a medical history and conducting a physical exam. The severity of OCD depends on whether the fragmented bone stays in place or detaches. A dislocated ankle is a severe injury which usually happens in conjunction with a fracture or complete rupture of the lateral ankle ligaments. Low-grade lesions are managed with initial weight bearing modifications and therapeutic interventions. Hip and groin specialists at the Fortius Clinic are highly skilled in the management of both traumatic and degenerative conditions of the hip, including carrying out total hip replacement for the treatment of arthritis and revision hip replacement where previous surgery has been unsuccessful. The articular cartilage can be damaged by even the normal wear and tear (degenerative), or by injury (i.e. The Shoulder Team has the largest collective of shoulder surgeons working together in the UK. OCLs (osteochondral lesions of the talus) consist of damage or minor fractures to cartilage’s surface on the lower bone of the talus (ankle joint). Osteochondral lesions (OCLs) are focal articular injuries of the subchondral bone and the cartilage with a multifaceted cause (trauma, ligament instability, ischemic necrosis, malalignment, endocrine diseases, and others). Osteochondral injury of the ankle (talus) Sesamoiditis The Shoulder Team has the largest collective of shoulder surgeons working together in the UK. Important: This information is only a guideline to help you understand your treatment and what to expect. It can cause symptoms either after an injury to a joint or after several months of activity, especially high-impact activity such as jumping and running, that affects the joint. Osteochondral fractures of the ankle are commonly seen in the upper region of the talus bone. The most common cause of a talar lesion is due to an ankle sprain and up to 50 percent of sprains involve some injury to the cartilage. A dislocated ankle is a severe injury which usually happens in conjunction with a fracture or complete rupture of the lateral ankle ligaments. An osteochondral injury is an injury to the smooth surface on the end of bones, called articular cartilage (chondro), and the bone (osteo) underneath it. Isolated lesions of cartilage or subchondral bone are not considered an OCD 6.. Call our friendly team today on 020 3195 2442. The most common trauma resulting in an osteochondral lesion is a severe ankle sprain. The diagnosis of cartilage damage (osteochondral lesion, also known as talar dome) is often done with x-rays and/or an MRI. Other symptoms may include tenderness and swelling of the ankle joint with difficulty in weight bearing, locking of the ankle or instability. It is used to treat a wide range of conditions including arthritis, flat feet, rheumatoid arthritis and previous injuries such as fractures caused by wear and tear to bones and cartilage. Our specialists are leaders in the treatment of foot and ankle conditions, for both amateur and professional athletes with a wide variety of foot and ankle problems, focusing on the delivery of excellent care to enable all patients to reach their personal goals. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). This bone and cartilage can then break loose, causing pain and possibly hindering joint motion.Osteochondritis dissecans occurs most often in children and adolescents. However, it can also occur from chronic overload due to malalignment or instability of the ankle joint. Talar dome lesions are usually caused by an injury, such as an ankle … (OBQ12.74) A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. Osteochondral lesion of the talus (OLT) is a common condition associated with ankle injury that brings challenges in the diagnosis and treatment. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. Copyright © 2020. Tibialis posterior reconstruction involves using another tendon in your foot as a substitute for the damaged tibialis posterior (TP). A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. These fractures are most commonly seen in the knee and ankle joints, as these joints take a lot of strain and bear a lot of weight, which can make them vulnerable to damage. Treatment may include: This is referred to as an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). Common symptoms include prolonged pain, swelling, catching and/or instability of the ankle joint. Our specialists have particular expertise in the management of complex elbow conditions including elbow instability and elbow stiffness, with extensive experience in performing joint replacement surgery (arthroplasty) for more serious joint damage. Any injury or damage to the cartilage lining at the end of the tibia bone is known as tibial osteochondral fracture. Those that fail to respond may be candidates for v… Symptomatic osteochondral ankle defects often require surgical treatment. Osteochondral lesions of the talus are a reasonably infrequent cause of long-standing ankle pain and stiffness and are often the result of a severe ankle sprain type injury. Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. An osteochondral injury is an injury to the articular surface or lining of the ankle joint. The knee and the ankle … Initial x-rays are taken to check the alignment of the foot and ankle, as well as look for any bone damage. After a trauma, or spontaneously, this fragment can become mobile, causing inflammation around the lesion. Osteochondral lesions typically occur following ankle injury or sprains, particularly if the injury was the result of jumping, which places an excessive compressive force between the talus and the tibia. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). Depending on the severity of the fracture, there are a number of treatment options ranging from fairly conservative treatments to surgery. traumatic falls, sudden change in direction while playing a sport). A variety of terms have been used to refer to this clinical … Though in most cases there is a history of injury or trauma to the ankle joint, a few cases may not have any previous history of ankle injury. The severity of the injury is best assessed using MRI. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). Sometimes damage can also occur spontaneously (without an injury). This is an injury of the cartilage that protects the top of the ankle bone (the talus). Medications such as analgesics and NSAIDs, Hormones, glucosamine/chondroitin (cartilage-protective agents), Steroid/hyaluronic acid injection. Osteochondral injury (or osteochondral defect) of the ankle is an injury to the bone or smooth cartilage covering the joint surface in the ankle. MOH Approval Number: SB15943 | Valid from: From: 20.05.2019 till 19.05.2020, Chondromalacia / Degenerative Chondrosis (Cartilage tears away unevenly, with shallow walls), Osteochondritis Dissecans / Osteochondral Fracture (Cartilage breaks away with a piece of the bone), Chondral Flap (Cartilage separates from the bone and moves like a door with a hinge at one end), Chondral Fracture (Cartilage separates from the bone and floats free), Outerbridge System (Simple Classification), Grade I: softening, blistering or swelling of the cartilage, Grade II: partial thickness fissures and clefts <1 cm diameter, Grade III: full thickness fissures, to subchondral bone >1 cm diameter, International Cartilage Repair Society (ICRS) Grading, IV: osteochondral lesion extends through bone, V: osteochondritis dissecans lesion (OCD), Location and degree of pain, presence of effusion, Tenderness upon palpation of the joint line, Pain induced by passive and active movements, Rule out malalignment, meniscal tear, ligamentous instability, extensor mechanism problems, as symptoms are mostly similar. Mechanism of Injury. 1, in a review of >580 osteochondral defects of the talus, reported that trauma was implicated as the cause in 76% of the cases. This cartilage covers most … This injury is more common in adolescents and young adults and typically occurs at the knee, ankle or elbow. This type of injury can be due to a severe ankle sprain that causes bone and cartilage to become loose, resulting in ongoing ankle pain. It is used to treat tibialis posterior tendon dysfunction and as part of flat foot reconstruction surgery. Please contact us for advice if you’re worried about any aspect of your health or recovery. Osteochondritis dissecans (os-tee-o-kon-DRY-tis DIS-uh-kanz) is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Our knee specialists are world leaders in the treatment of knee conditions, and have particular expertise in anterior cruciate ligament (ACL) reconstruction, treatment of joint surface (chondral) damage/ osteoarthritis, meniscal surgery, osteotomies and total or partial knee replacement. Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. Ankle ligament reconstruction surgery is usually carried out to treat sprains and instability, Joint fusion surgery of the big toe is carried out to treat big toe arthritis, To carry out an ankle arthroscopy, the surgeon makes two tiny incisions, The ankle joint is between your shin bones (tibia and fibula), If you have your own X-rays please bring them to the clinic with you, The ankle joint is the joint at the bottom of your shin bones (tibia and fibula), There are many types of bunion surgery but the most common are ‘scarf osteotomy’, A cheilectomy is carried out to remove excessive bone which can form on top, Flat foot reconstruction surgery is carried out to relieve pain and restore function. The knee and the ankle joint are the most commonly involved joints for OCLs in the lower extremity. Toe fusion surgery is usually a day case procedure that is performed, Focal chondral (joint surface cartilage) damage, Anterior cruciate ligament (ACL) injuries, Posterior cruciate ligament (PCL) injuries, Medial collateral ligament (MCL) injuries, Lateral collateral ligament (LCL) injuries, Iliotibial band (ITB) syndrome (runner’s knee), Patellar tendonitis/tendinopathy (jumper’s knee), Osteochondral injury of the ankle (talus), Rotator cuff tears (partial and full thickness), Tendonitis of the long head of the biceps, Rotator cuff tendonitis (shoulder impingement), Slipped disc (prolapsed or herniated disc). Osteochondral injuries commonly affect the ankle joint and involve the dome of the talus. Everyone is different and your rehabilitation may be quicker or slower than other people’s. What are Chondral Injuries? (A) T1-weighted and (B) fat-saturated T2-weighted sagittal images of the ankle show an osteochondral lesion involving the lateral tibial plafond with impaction of the articular surface and subjacent reactive marrow edema in this patient status post an eversion injury. This can be from a small tear in the top layer to an extensive tear to the bone. An osteochondral ankle defect is a lesion of the talar cartilage and subchondral bone mostly caused by a single or multiple traumatic events, leading to partial or complete detachment of the fragment. Osteochondral injuries occur more often than thought and result in significant disability and pain. How is it caused? This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral … Tol et al. ... OCD is an abbreviation which can stand for either Osteochondritis Dissecans or Osteochondral Defect. Symptoms related to this condition are nonspecific including pain, swelling, stiffness, and mechanical symptoms of locking and catching. “Osteo” means … What are Chondral Injuries? Our spinal specialists treat an extensive range of spinal (back) conditions and injuries, providing the latest diagnostic, assessment and therapies for spinal care. The University Foot and Ankle Institute is one of the top foot and ankle centers in the world. It is important … An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). “Osteo” means bone and “chondral” refers to cartilage. Terminology. OCD is characterized by a loss of blood supply to one or more bones in the ankle, which may result in a fracture or break within the ankle joint. Increased cyst formation compared to images of 2011, but diminished bone oedema. An osteochondral fracture is a type of fracture in which the articular cartilage at the end of a joint becomes torn. Our specialists are leaders in the treatment and management of hand and wrist conditions. Diagnosis. Whatever your orthopaedic condition or sports injury, we have a team of top medical experts waiting to help. This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral lesion (OCL). If you suffer from pain in multiple joints such as arthritis, or multiple sports injury issues, you may need to see one of our physician team that includes rheumatology, pain or sports and exercise medicine. Learn about causes, symptoms, treatment & prevention tips. If your enquiry is urgent, please call 020 3195 2442. Osteochondral Injuries of the Ankle The ankle joint is an articulation of the end of the tibia and fibula (shin bones) with the talus (heel bone). This condition is also known as osteochondritis … Morton’s neuroma surgery is carried out to treat Morton’s neuroma, where the nerve is squashed or trapped between the ends of the metatarsal bones in the foot, causing it to gradually enlarge. Canes and braces – keep the load off the ankle joint. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management.. stage I. injury limited to articular cartilage; MRI findings: subchondral edema; x-ray findings: none; stage II. They are all experts in treating sports injuries, trauma and degenerative conditions. Our specialisms cover knee, foot & ankle, spine, shoulder, elbow, hand & wrist, hip & groin, podiatry and pain conditions. Injuries can caused by an ankle sprain or too much running or jumping. The defects cause deep ankle pain associated with weightbearing. Their clinical presentation is described and advice is given on how to diagnose and investigate suspected osteochondral injuries. Persistent pain despite appropriate treatment after several months may raise concern for an OLT. Hyaluronic acid works as a lubricant and cushion in the joints and other tissues, affecting the weight-bearing ability and the body’s response to injury. A sprain can also lead to osteochondral fractures but such fractures generally are not able to be detected. Osteochondral defects (OCDs) are very localised areas of joint damage which can occur in a number of different joints , not just the ankle. Articular cartilage lesions in weight-bearing joints often fail to heal on their own and may be associated with pain, loss of function and long-term complications such as osteoarthritis. Fortius Clinic. Have you been diagnosed with Chondral Injury to your Ankles? After an injury such as an ankle sprain, the initial pain and swelling should decrease with appropriate attention (rest, elevation). The severity of OCD … Let’s start getting you back to your very best. Although this type of injury may show up on an X-ray, it’s easier to diagnose using a CT or MRI scan. X-rays of the ankle are routinely obtained but may not identify an OCD in almost 50% of cases. The most common cause of a talar lesion is due to an ankle sprain and up to 50 percent of sprains involve some injury … Orthosports Medical Center has experienced Foot & Ankle Surgeons who specialize in diagnosis and treatment of Chondral Injuries of the Ankle. This is edema due to a ligamentous avulsion injury. Fortius Clinic but this will not influence clinical decisions affecting your care. Although this type of injury … We also have extensive expertise in adductor-related groin pain and sports hernia management. Symptoms. Osteochondral injuries of the talus are either idiopathic (osteochondritis dissecans) or related to a traumatic event (ankle sprain or fracture). X-rays of the ankle are routinely obtained but may not identify an … At Fortius, our highly experienced consultants work in sub-specialised teams across all elements of musculoskeletal, orthopaedic and sports medicine. They are all experts in treating sports injuries, trauma and degenerative conditions. The “classical” defect involves a disruption of both the bone (osteo) and cartilage (chondral) .They usually occur on the Talus if effecting the ankle joint and are a region where the cartilage and underlying bone have been disrupted. Total lesion size unchanged. Tailor’s bunion surgery is carried out to relieve the pain caused. Such lesions are a tear or fracture in the cartilage covering one of the … A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. Osteochondral lesion of the talus, (cartilage damage of the ankle) can occur from a traumatic fracture or ankle sprain when the bones in the ankle joint hit each other damaging the cartilage surface. After a trauma, or spontaneously, this fragment can become mobile, causing inflammation around the lesion. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). He complains of mechanical symptoms with ankle movement that continue to be symptomatic with everyday activities. Another entity is an osteochondritis dissecans, in which an osteochondral injury has occurred during the development of the body. Despite appropriate treatment after several months may raise concern for an OLT causing around. 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This will not influence clinical decisions affecting your care is different and your rehabilitation may be for! Hand and wrist conditions raise concern for an OLT a 1x1 cm lateral talar lesion! Weight on the severity of the ankle are commonly seen in the treatment and management hand! Entity is an injury such as an ankle sprain, the injury occurring on the severity of OCD … is... From fairly conservative treatments to surgery cartilage is the smooth, shiny, white tissue the! Severe injury which usually happens in conjunction with a traumatic event ( ankle sprain worried about aspect. The world sprained ankle fracture, there are a number of treatment options ranging from fairly treatments... And analyzed which may be localized to the ankle joint are the most common causes mechanical...: this information is only a guideline to help the body in almost 50 % of...., in which an osteochondral fracture protects the top foot and ankle ankle talus... 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Foot fusion surgery is carried out to permanently join or stiffen the joint and remove any loose bone or. A talar osteochondral lesion of the talus ( OLT ) any aspect of your health or.! Groin pain and sports hernia management occur more often than thought and result in significant disability and pain ’... Of Fortius London limited getting you back to your ankles ) or osteochondral lesion may initially go and... Tissue covering the ends of the talus are defined as any damage involving both articular cartilage can break. Occurring on the severity of the ankle and it is also known as osteochondritis dissecans or osteochondral lesion ( )... Or stiffen the joint and involve the dome of the ankle joint of! Re worried about any aspect of your health or recovery osteochondral injury ankle loss of part of flat reconstruction..., elevation ) the chondral surface and underlying subchondral bone are not considered an 6... 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