Osteochondral lesions of the talar dome in the athlete: what evidence leads to which treatment

Osteochondral lesions of the talar dome (OLT) are common injuries that involve cartilage and subchondral bone. These injuries appear in up to 42% of professional soccer players on magnetic resonance imaging (MRI). Typically, patients are 20 35-yearold male athletes experiencing chronic ankle pain, decreased range of motion, and joint effusion, especially during or after sports activities, and compromised quality of life. The low regeneration potential of chondrocytes and the recent findings revealing subchondral bone architecture's role in cartilage homeostasis, repair durability, and overall clinical outcomes make OLT treatment a challenging topic in orthopedics. The aim of this narrative review was to outline a surgical treatment algorithm for OLT management in the athlete. Debridement and bone marrow stimulation techniques remain the first-line treatment of OLT with satisfactory short- to long-term outcomes, a high return to sports (RTS) rate, and a rapid RTS, with improved results when augmented with PRP. Still, considering the controversy of its potential disadvantages, debridement should be limited to the International Cartilage Repair Society (ICRS) grade I-II injuries regardless of its size and with or without additional bone marrow stimulation (BMS)in ICRS III < 1.0 cm2 injuries. In the presence of larger lesions and subchondral plate and bone involvement, the benefits and disadvantages of osteochondral autologous transplantation system (OATS)/mosaicplasty and scaffold-based techniques should be considered for a tailored treatment approach either as a primary procedure or as an off-season procedure for better cartilage tissue quality, functional outcomes, and potentially increasing the player's professional career length.