Surgical Treatment of Symptomatic Osteochondral Lesions of the Foot: A Contemporary Review

Introduction

An osteochondral lesion (OCL) is a focal disruption of joint cartilage that also affects the subchondral bone. Multiple causes of OCLs have been hypothesized. These include ischemia, repetitive microtrauma, injury, and genetics. ² OCLs can be found in any joint, but the majority of studies discuss treatment of the most frequent locations of these lesions: the elbow, knee, and ankle. ¹¹

OCLs are uncommonly found in the joints of the hindfoot, midfoot, and forefoot. With the current literature mainly consisting of case reports or small case studies on a single joint, there is no consensus on the optimal treatment method for these lesions. In their recent systematic review, Shimozono et al ²⁷ discussed treatment strategies for OCLs of the hindfoot. Similarly, Artioli et al ¹ limited their review to only surgical management of osteochondral lesions in the first metatarsal head.

This contemporary review aims to provide a comprehensive summary of the current literature on OCLs of the hindfoot, midfoot, and forefoot, excluding the talar dome. A full summary of the studies reviewed in this article are included in Table 1.

Table 1.

Overview of Osteochondral Lesion Studies by Joint Treated.

Joints	Studies	Design	Unique Surgical Cases, n	Follow-up Duration
First metatarsophalangeal (n = 92)	Artioli et al 1	Systematic review	26	mean = 29.2 mo
	Bartlett 3	Case report	1	1 y
	Bojanic et al 5	Case series	2	1 y
	Bruno et al 6	Case report	1	1 y
	Delniotis and Leidinger 10	Case report	1	1 y
	Kim et al 16	Retrospective cohort study	24	mean = 25.1 mo, range 22-36 mo
	Kuyucu et al 17	Prospective cohort study	14	mean = 16.4 mo, range 13-18 mo
	Saxena and Shou 25	Prospective cohort study	12	mean = 52.3 mo, minimum follow-up of 2 y
	Van Dyke et al 30	Case series	9	mean = 39.6 mo
	Wunschel and Bohringer 31	Case report	1	3 mo
	Zelent and Neese 33	Case report	1	1 y
Subtalar (n = 17)	Buck et al 7	Case series	11	median = 15 mo, range 13.5-100 mo
	Cugat et al 9	Case report	1	2 y
	Kadakia and Sarkar 13	Case report	1	1 y
	Moonot and Sharma 20	Case report	1	1 y
	Nafei et al 21	Case report	1	3 y
	Shimozono et al 27	Systematic review	1	2 y
	Yanagisawa et al 32	Case report	1	4 y
Talonavicular (n = 19)	Beil et al 4	Case report	1	N/A
	Corominas et al 8	Case report	1	5 y
	Kanazawa et al 14	Case report	1	14 mo
	Keller et al 15	Case report	1	16 mo
	Nunag et al 22	Case report	1	7 mo
	Ross et al 23	Case series	3	range 16-22 mo
	Saxena and Fullem 24	Case series	3	range 2-4 y
	Togher et al 29	Case report	1	13 mo
	Lehman and Gregg 18	Case series	1	5 y
	Honle and Schuh 12	Case report	1	N/A
	Shimozono et al 27	Systematic review	5	range 2-7 y
Naviculocuneiform (n = 1)	Lehman and Gregg 18	Case series	1	4 y
Calcaneocuboid (n = 1)	So et al 28	Case report	1	8 mo

Presentation

The primary presenting symptom for patients with symptomatic OCLs is chronic pain. OCLs were associated with a traumatic event in 69% of reported cases (75/108) we reviewed. Stratified by joint, the association of antecedent trauma with OCLs was highest at the subtalar joint at 87% (33/38), followed by the talonavicular joint at 73% (11/15) and the metatarsophalangeal joint at 60% (31/52). The only reported OCL of the calcaneocuboid joint was also associated with trauma.

Participation in sports involving pivoting, planting, or high-volume running was commonly reported among patients with an OCL. Cross-country running, volleyball, soccer, and basketball were the most frequently reported sports.

All the cases discussed in this review underwent surgical intervention due to failure of appropriate conservative management, including nonsteroidal antiinflammatory drugs, immobilization, shoe modification, physical therapy, or activity modification.

Treatment

Nonoperative treatment was attempted prior to surgical intervention for symptomatic OCLs in all the reported cases. This included nonsteroidal antiinflammatory drugs, immobilization, and activity modification. Patients underwent roughly 3 to 6 months of conservative management prior to surgical consideration.

For those lesions that failed nonoperative management, an array of surgical options was used, including curettage, loose fragment excision, microfracture or drilling, bone grafting, internal fixation, osteochondral autograft transfer, and cartilage matrix with platelet-rich plasma (PRP). The selected option, or combination of options, depended on the location of the lesion and associated conditions. Surgical interventions reported are summarized in Table 2.

Table 2.

Breakdown of Symptomatic OCLs by Surgical Treatment.

Joint Affected (n)	Open or Arthroscopic Surgical Excision Alone	Supplementation With Debridement, Drilling, or Microfracture	Supplementation With Bone Graft			Other
			OATS	Autograft	Allograft
Metatarsophalangeal (92)	1	43	37	1	8	2 a
Subtalar (17)	2	7	0	1	0	7 b
Talonavicular (14)	0	5	0	6	1	3 c
Naviculocuneiform (1)	0	1	0	0	0	0
Calcaneocuboid (1)	0	0	0	0	1	0
Total (123)	3	57	55			11

Abbreviations: OCLs, osteochondral lesions; OATS, osteochondral autograft transfer system.

^aMoberg Osteotomy; first metatarsophalangeal cheilectomy.

^bFurther supplementation with concentrated bone marrow aspirate (cBMA) or platelet-rich plasma (PRP).

^cPercutaneous subchondral drilling; rigid fixation with screw or plate.

First Metatarsophalangeal Joint

The metatarsophalangeal (MTP) joints, and primarily the first metatarsal head, are the most common sites for symptomatic OCLs in the foot. Of 92 cases, 43 were treated through an arthroscopic approach with a combination of curettage and microfracture or drilling. Bone grafting with autograft or allograft was used as an adjunct in 46 cases whereas a bony osteotomy to address hallux valgus was reported in 2 cases.

Kim et al ¹⁶ conducted a retrospective study of 24 OCLs of the first metatarsal head caused by sports injuries and compared cases treated with subchondral drilling to patients treated with osteochondral autograft transfer system (OATS) from the lateral trochlea of the knee. Although both treatment options were shown to improve pain and function scores, their findings suggest OATS to be the preferred treatment for OCLs greater than 50 mm² in size or OCLs in the presence of a subchondral cyst. ¹⁶ In this series, the authors also investigated the presence of radiographic degenerative changes. Arthritis was noted in 6 of 14 cases who underwent subchondral drilling and 1 of 10 cases treated with OATS. Large defect size and the existence of a subchondral cyst were significantly associated with the development of degenerative arthritis in patients who underwent subchondral drilling. The effect of these radiographic changes on clinical outcomes was not reported.

Other transplant options have been reported in the literature for the treatment of symptomatic, first metatarsal head OCLs. For example, Zelent and Neese ³³ described a case of osteochondral autograft harvested from the talar head, which resulted in the patient being pain-free at a 12-month follow-up with graft incorporation and joint restoration on imaging. Intraoperative images of their described technique, originally presented in their 2005 publication in the Journal of Foot and Ankle Surgery, are included in Figure 1.

Figure 1.

Intraoperative image depicting osteochondral autograft transfer (OATS) from the talar head after open excision of the 6-mm first metatarsophalangeal osteochondral lesion. From the 2005 publication in Journal of Foot & Ankle Surgery by Zelent and Neese. ³³

In their series of 3 cases, Bojanić et al described the use of arthroscopic debridement and microfracture alone of the first metatarsal head. In all three cases, successful restoration of painless active motion was gained by 12 months postoperatively. ⁵ Given the smaller diameter of the MTP joints, Sherman et al ²⁶ suggest using K-wires for arthroscopic microfracture, taking advantage of their small diameter. Drilling follows a similar principle to microfracture, and some reports indicate it may produce cartilage with superior thickness and quality when compared to microfracture. ¹⁷ The durability of this new cartilage, however, may decrease with time as fibrocartilage is inferior to hyaline cartilage. ¹⁶

Arthroscopic treatment for the first metatarsal head OCLs is a particularly viable treatment option in young athletes. In our review, all athletes were able to return to sport within 3-6 months postoperatively. Aside from 6 patients who developed arthritis of the first MTP, all other reported patients gained full, painless active range of motion by 1 year postoperatively or reported significant improvement in patient-reported outcomes by their final follow-up.^3,10,16,31

The addition of bone graft using alternative methods to OATs has been described in the literature. An alternative reported harvest site for autograft was the dorsal portion of the first metatarsal head, performed in the case of a 45-year-old man who sustained a first-MTP OCL during a traumatic soccer injury. The authors also performed a Moberg osteotomy to improve hallux dorsiflexion. ⁶ Delniotis et al ¹⁰ and Saxena et al ²⁵ similarly described their use of autograft harvested from the dorsal MTP metaphysis or the dorsal exostosis of the first MTP, respectively. The metaphyseal bone graft was affixed using the chondral flap and fibrin glue, whereas the dorsal exostosis graft required a bioabsorbable pin if the lesion was greater than 10 mm. Delniotis et al ¹⁰ allowed partial weightbearing for 6 weeks with gradual progression to full weightbearing. At 1-year follow-up, they showed radiographic integration of the graft and improved pain and range of motion of the first MTP. Saxena et al, ²⁵ in contrast, did not allow weightbearing for the first 4 weeks. Eleven of 12 patients had returned to preoperative activity level by 4.7 months postoperative and 1 required first MTP arthroplasty 6 years postoperative.

If a surgeon prefers to use allograft, Van Dyke et al published a case series of 9 patients with OCLs of the first metatarsal head treated with juvenile particulated cartilage allograft secured with fibrin glue. Four of the patients had a history of traumatic injury, and 3 had previously failed drilling procedures. The average follow-up was 3.3 years, and 7 of the 9 patients reported no limitation in their daily and recreational activities at the final follow-up. ³⁰

In summary, the current literature supports the use of arthroscopic curettage with microfracture or drilling to improve pain and function for patients with small, sports-related OCLs of the first metatarsal head. A large defect size may be better treated with OATS. Alternative autograft or allograft options have also been described. The benefit of osteochondral autografts is excellent integration and clinical results, but at the risk of donor site morbidity and graft size mismatch.^16,29,33 Osteochondral allografts may also be used for large defects, with potentially more ease in matching the lesion’s shape and site while eliminating donor site morbidity. Potential risks of allograft include reaction to the graft and reduced viability compared to autograft. ³³ Particulated cartilage allograft is a relatively new alternative that may improve integration at the recipient site as the matrix produces hyaline cartilage that potentially integrates with the surrounding host tissue to restore the contour of the joint surface.^6,28

Subtalar Joint

Most OCLs involving the subtalar joint followed a traumatic injury. A retrospective case series on subtalar OCLs by Buck et al ⁷ observed a high failure rate of conservative treatment, with 9 of 11 patients eventually requiring surgery. We identified a total of 14 cases undergoing surgery after failed conservative management with improved symptomatic outcomes at long-term follow-up.

Several surgical techniques were reported for the treatment of subtalar OCLs: debridement with bone marrow stimulation via arthroscopic microfracture, arthroscopic debridement/microfracture, curettage followed by bone graft with screw fixation, and surgical excision alone.

Arthroscopic bone marrow stimulation (BMS) via microfracture following debridement was the technique described in the initial surgical management of talar-sided osteochondral lesions of the subtalar joint. Seven of the 9 surgical patients in the 2023 retrospective case series by Buck et al ⁷ underwent arthroscopic debridement with the addition of BMS, while the other 2 underwent debridement alone. Three of those 7 patients receiving BMS were further augmented with the use of concentrated bone marrow aspirate (cBMA). Within their full cohort, the median postoperative Foot and Ankle Outcome Scores (FAOS) was 80, which was identical to the mean score for the 3 patients receiving cBMA. The median NRS at rest was 2 (interquartile range [IQR]: 0-2), 3 when walking (IQR: 1-3), 4 when stair-climbing (IQR: 1-5), and 3 when running (IQR: 2-5). The median follow-up time was 15 months. The authors noted that nonoperative care failed in most cases.

Kadakia and Sarkar ¹³ and Cugat et al ⁹ described 2 nontraumatic subtalar OCLs treated successfully with arthroscopic debridement and microfracture in a female adolescent and a 37-year-old man, respectively. Moonot and Sharma ²⁰ described a case of a nontraumatic lateral talar-sided OCL in a 37-year-old male laborer surgically treated with curettage and cancellous autograft with screw fixation. This is depicted in Figure 2, which was originally published in a 2021 case report by Moonot et al in the Journal of Foot and Ankle Surgery. The decision by Moonot and Sharma ²⁰ to pursue bone grafting and screw fixation was due to the larger size of the OCL, which measured 12 × 10 × 15 mm.

Figure 2.

Intraoperative photographs of an OCL on the lateral aspect of the talus in the subtalar joint: (A) OCL visualized, (B) curettage performed, and (C) bone grafting and screw fixation. From the 2021 publication in Journal of Foot and Ankle Surgery by Moonot and Sharma. ²⁰

There are also 2 reported cases involving surgical excision of osteochondral fragments alone, and these were localized to the posterior calcaneal articular surface of the joint.^21,32 Limited information about one of these cases was available other than symptom-free status at 3 years postoperatively. ²¹ Yanagisawa et al ³² described a unique case of a professional soccer player involving bilateral posterior calcaneal subtalar OCLs. Surgical excision of a loose fragment was chosen for only the right subtalar joint because of the presence of 2 associated displaced fragments. Conservative management, on the other hand, was sufficient for the left side as it did not have any fragments. ³² This study used the progression in stages of the Berndt and Harty classification of talar osteochondral lesions to help inform management.

Because of the limited number of subtalar OCLs treated with surgical management, it is difficult to compare the outcomes of the various options available. Arthroscopic procedures seem attractive because of their minimally invasive nature, but open surgical excision approaches may still have utility in cases where arthroscopic visualization of the OCL is hindered by its location or the presence of multiple fragments. Bone grafting may be necessary in cases with larger OCLs that leave a larger void, but there are no clear objective size parameters to inform implementation. Bone marrow stimulation, injection with PRP, and cBMA hold promise as surgical adjuncts based on their proposed physiologic mechanisms of promoting bone growth and having chondroprotective qualities. ¹⁹ However, more studies are needed to compare their effects to arthroscopic debridement and microfracture alone.

Talonavicular Joint

Our review of the current literature regarding OCLs of the talonavicular joint revealed 19 cases. All cases were initially treated conservatively; however, 15 required surgical intervention.

Of the patients who underwent surgery, 7 were treated with microfracture or subchondral drilling after removal of the osteochondral fragment.^8,12,18,23 Although most often completed through an open approach, Ross et al ²³ described the use of an arthroscopic technique in 3 patients with curettage, fragment excision, and microfracture. Corominas et al ⁸ similarly described a minimally invasive, percutaneous approach to subchondral drilling of talar-sided OCLs of the talonavicular joint. All cases showed improvement of pain, no noted complications of surgery, and return to sport.^8,12,18,23

Supplementation with bone grafting was reported in the treatment of 7 other talonavicular OCLs with the goal of filling the underlying bone void to provide a congruent articular surface. All procedures were performed through an open approach.^{4,14,15,22,24} Donor sites for autologous bone graft differed from OCLs of the first MTP joint and were reported to be the proximal tibia by Nunag et al ²² and Beil et al, ⁴ and the iliac crest by Kanazawa et al ¹⁴ and Keller et al. ¹⁵ No studies provided criteria for selecting one donor site over the other.

A unique concomitant finding, specifically in young athletes, was an associated navicular stress fracture. This occurred in 3 cases and was treated with rigid fixation. Fixation was accomplished with percutaneous screw fixation in 2 cases or a navicular plate in 1 case. The use of a navicular plate as used by Nunag et al is shown in Figure 3. Although the combination of talonavicular OCL and navicular stress fracture could theoretically be treated with fusion, the decision was made to pursue joint-sparing surgery because of the patients’ high activity levels.^14,22,24

Figure 3.

Postoperative radiographs 6 months status post curettage, bone grafting, and plate stabilization of 3-mm navicular-sided talonavicular osteochondral lesion with associated oblique subacute stress fracture. From the 2014 publication in Foot by Nunag et al. ²²

Aside from one patient who required screw removal at 6 months postoperatively, all patients treated with fragment excision/curettage, microfracture/drilling, and supplementation with autologous bone grafting and rigid fixation, if indicated, returned to full activity without pain or limitations.^{4,14,15,22,24} The patient who required screw removal returned to professional soccer by 2 years postoperatively. ²⁴

One case report described the use of allograft derived from microionized cartilage matrix and platelet-rich plasma instead of an autologous source as described above. ²⁹ The 22-year-old competitive dancer was able to return to full competition by 3 months postoperatively. She had mild pain posterior to the medial malleolus noted at the 13-month mark that resolved with antiinflammatory medication, ice, and elevation. ²⁹

Although the literature regarding the treatment of talonavicular OCLs is limited, surgical management appears to be a viable treatment option in patients who have failed conservative management. A common theme of surgical management of these cases is the concept of joint debridement with removal of loose fragments combined with marrow stimulation. Underlying bony defects can be treated with bone grafting, and navicular stress fractures can be stabilized with internal fixation. Because of the small number of cases in the literature, further studies are necessary to determine the optimal treatment of these lesions.

Naviculocuneiform Joint

We could only identify a single case of an osteochondral lesion at this joint, which was due to repetitive microtrauma in a young male cross-country runner. Symptoms were refractory to conservative management with nonsteroidal antiinflammatory drugs and low-dye taping. ¹⁸ However, surgical excision of the fragment and drilling followed by appropriate rehabilitation resulted in complete resolution of symptoms and absence of degenerative imaging changes at 5 years of follow-up. ¹⁸

Calcaneocuboid Joint

The calcaneocuboid joint is another location in which the literature is limited to 1 case report involving surgical management. So et al ²⁸ report a case of a traumatic bipolar OCL involving the calcaneocuboid joint. After failing conservative management, the lesion was treated with drilling and juvenile particulate cartilage. Intraoperative photographs, originally presented in their 2019 report from the Journal of Foot and Ankle Surgery, are shown in Figure 4. The patient ambulated 8 weeks after surgery and was pain-free at 8-month follow-up, with radiographs showing no degenerative changes. This technique is similar to that used by Van Dyke et al ³⁰ in the first MTP joint. In those few patients in whom it has been used, it seems to be a viable method for treating OCLs, although cost and the remote risk of rejection must be considered.

Figure 4.

Intraoperative images depicting a 1-cm bipolar osteochondral lesion of calcaneocuboid joint, surgically treated with open curettage and particulate juvenile cartilage allograft implant. (A) Cuboid aspect of osteochondral lesion. (B) Calcaneal aspect of osteochondral lesion. From the 2019 publication in Journal of Foot and Ankle Surgery by So et al. ²⁸

Complications

Most published studies reported no complications, specifically no chronic stiffness or persistent pain. However, 2 case series did report postoperative complications after surgical intervention for OCLs of the first MTP joint.

As noted, the study conducted by Kim et al ¹⁶ reported postoperative osteoarthritic changes in 7 of 24 MTP joints. Their study had an average follow-up of 25.1 months, and they noted arthritic changes including loss of joint space and joint line sclerosis as early as 9 months postoperatively on plain radiographs. The authors attributed the increased risk of osteoarthritic changes to the presence of large (>50 mm²) defects or subchondral cysts and recommended considering osteochondral autograft transfer for these cases, as discussed above.

Meanwhile, Saxena and Shou reported persistent pain in 2 of 12 MTP joints. One of these did not require subsequent surgery, but the patient was unable to return to full activity. The other had progressive postoperative arthritis resulting in metatarsophalangeal arthroplasty 6 years later. ²⁵

Summary

OCLs are uncommonly found in the joints of the foot outside of the talar dome, with the recent literature regarding surgical management mainly composed of case reports, small case series, and 2 systematic reviews focused on the hindfoot and first MTP joint, respectively. OCLs can occur in any population but most commonly affect athletes. For the adolescent and adult athletes with symptomatic OCLs, surgical intervention is often required and, in the literature we reviewed, is most often successful.

The most common treatment reported was curettage with microfracture or drilling of the lesion. This was often supplemented with either autograft or allograft bone application for OCLs larger than 50 mm². Although there is no consensus on the treatment of OLCs of the foot, most patients can return to their desired activity level and report satisfactory recovery within 1 year postoperatively.

Future literature should focus on evaluating the advantages and disadvantages of available surgical options, including comparative studies if possible.