Chondropathy surgery
At The Foot Clinic, we specialize in the treatment of cartilage lesions, also known as chondropathies, affecting the ankle and foot. These lesions, caused by trauma, microtrauma, or conditions such as osteoarthritis, can cause pain and limit mobility.
Thanks to innovative surgical techniques, such as arthroscopy or targeted cartilage repair, our specialists offer personalized care to preserve or restore joint function. Our goal: to relieve your symptoms while optimizing your recovery for a quick return to your activities.
What is chondropathy and its stages?
Chondropathy is the pathology of cartilage. Cartilage lesions can be focal, more or less extensive, or affect all the articular cartilage in the case of osteoarthritis.
For focal lesions, there is a gradation of severity:
Chondropathy stage 1
Chondromalacia corresponds to the softening of the cartilage surface and the loss of adhesion of the cartilage to the subchondral bone. Chondromalacia is a cartilage lesion known as stage 1 or grade 1.
Chondropathy stage 2
Cartilage lesions known as stage 2 (or grade 2) involve less than 50 % of the thickness of the articular cartilage.
Chondropathy stage 3
Cartilage lesions known as stage 3 (or grade 3) involve more than 50 % of the cartilage thickness.
Chondropathy stage 4
Cartilage lesions of stage 4 (or grade 4) involve the entire thickness of the cartilage; these correspond to more or less extensive cartilage ulcerations, with exposure of the subchondral bone.
Osteoarthritis corresponds to diffuse cartilage damage of the joint, on both articular surfaces.
The diagnosis of osteochondral lesion is suspected during the clinical examination. It is necessary to characterize the chondropathies using imaging. The weight-bearing X-ray assessment of the ankles and feet is the first step. For the ankle, a CT scan is performed to characterize the extent of the bony involvement of the osteochondral lesion. MRI tends to overestimate the size of the osteochondral lesion in the ankle or foot, due to associated bone edema.
The causes of chondropathy
Cartilage lesions can be traumatic, microtraumatic, or result from a lack of bone arterial perfusion or from incomplete fusion of ossification centers during childhood in cases of osteochondritis.
Any ankle fracture involving a joint by definition causes cartilage lesions that can potentially lead to osteoarthritis.
In the case of a severe ankle sprain, ligament injuries can cause articular shearing that may be responsible for acute cartilage lesions. In some cases, a post-traumatic osteochondral lesion can appear on the dome of the talus, most often on the external side.
In cases of chronic ankle instability, articular shearing increases with ligament laxity, then there is a risk of ankle osteoarthritis following medium-term ligament laxity.
Microtrauma are impacts or repeated shocks over a long period of time at the joint level. Microtrauma can cause cartilage lesions, particularly in the metatarsophalangeal joint of the big toe, or hallux (hallux rigidus, hallux valgus). Microtrauma and trauma to the big toe lead to cartilage lesions evolving towards osteoarthritis, especially when the first metatarsal is long.
Osteochondritis is a particular case of cartilage lesions. Osteochondritis may be related to incomplete fusion of ossification centers. It may also be caused by insufficient arterial perfusion leading to the lesion. Osteochondritis is a mixed lesion, both bone and cartilage. These lesions are not necessarily symptomatic. In the ankle, the symptoms of these lesions very likely depend on the patients' lifestyle, their sports activities, their footwear habits, the alignment of the lower limbs, and the morphology of their foot.
The symptoms of chondropathy
The main symptoms of chondropathy are pain, episodes of joint swelling, and sensations of joint locking.
The pain is generally mechanical. It appears and increases with physical activity, then decreases and disappears at rest. Cartilage is a substance that is not innervated, unlike the subchondral bone. This means that in the case of cartilage lesions, traction forces at the level of the subchondral bone are responsible for the pain. This pain is generally difficult for patients to locate, as it is within the joint. It is typically described as deep pain that is hard to pinpoint.
An unstable cartilage lesion causes intra-articular inflammatory reactions with episodes of joint swelling or effusion.
Unstable cartilage lesions can take the form of a flap. Depending on the position of the flap, joint locking may be felt by the patient. Some patients may feel as though something is moving around in the ankle.
What treatments are available for chondropathies?
Medical treatment
An asymptomatic cartilage lesion does not require any treatment.
Functional treatment should initially be undertaken in the case of a symptomatic cartilage lesion. This treatment involves stretching the posterior muscle chains in case of stiffness, correcting joint pressures using orthopedic insoles for example, modifying footwear habits, or changing sports habits in case of microtraumatic pathology.
If functional treatment fails, medical treatment may be initiated. In case of joint pain with episodes of swelling, cortisone injections may be offered. In case of joint pain without effusion, hyaluronic acid injections, called viscosupplementation, may be proposed.
In our opinion, intra-articular platelet injections, PRP, cannot achieve healing of the lesions.
If both functional and medical treatment fail, surgical treatment may be considered.
Surgical treatment
Surgical treatment is tailored to the cartilage lesion.
For small, localized cartilage lesions on one side of the joint, surgical treatment by arthroscopy can be performed, involving debridement of the cartilage lesion, curettage of the underlying fragile bone, and drilling into healthy bone. This is called the microfracture technique, which stimulates bone reconstruction.
Surgical treatment of more extensive lesions, or deep cystic lesions, consists of performing an osteocartilaginous autograft. This involves taking a bone and cartilage graft, usually from the knee on the same side, to transplant it into the damaged area. This is called a mosaicplasty. This technique can be performed arthroscopically depending on the accessibility of the lesion. It can also be performed via open surgery, sometimes combining with a malleolar osteotomy if access to the osteochondral lesion is difficult.
If both sides of the joint are diffusely affected, this is osteoarthritis. Several surgical interventions are possible depending on the deformation of the lower limbs, joint stiffness, and foot morphology.
Axis defects can be corrected by corrective osteotomies. Correction of a high-arched foot or a flat foot may also be considered. If a conservative treatment of the joint is no longer possible, joint replacement or fusion may be proposed.
FAQ
In the case of a small symptomatic osteochondral lesion, arthroscopic treatment with debridement and microfractures may be considered. Arthroscopy presents a notable advantage in terms of postoperative recovery: it does not require a plaster cast and allows for early resumption of walking.
When the osteochondral lesion is more extensive, surgical management becomes more intensive. It may involve osteochondral autograft, joint replacement, or fusion of the joint by ankle arthrodesis. Postoperative recovery is more restrictive and involves a period of immobilization with a cast.
The duration of postoperative care after surgical treatment of chondropathy varies depending on the treatment, the technique used, and whether the joint is preserved or not.
After conservative surgical treatment of an osteochondral lesion, functional recovery is generally achieved about one year after the procedure. In the case of prosthetic replacement, inflammatory reactions may persist for up to a year or even a year and a half after the procedure. After fusion of a joint, that is, after arthrodesis, functional recovery is generally achieved one year after surgery, as it is necessary for the surrounding joints to adapt to the immobilization of the affected joint.
Medical management of an osteochondral lesion is indicated in case of pain. Medical treatment is always necessary as a first-line approach, especially when it involves rebalancing intra-articular pressures. If medical treatment fails, surgical treatment may be proposed; the therapeutic strategy will depend on the type of lesion, its extent, and its location.