37, no. The General Hospital Corporation. Procedures range from arthroscopic debridement to remove injured cartilage and bone, fixation of the injured fragment, or grafting of bone and cartilage. 2 View She does not have RA or any other rheumatologic disorder. Saw KY, Jee C, Ramlan A, Dawam A, Saw YC, Low SF. #anklereplacement #footarthritis #footfusion 18 Non-operative treatment can be successful for non-displaced talar OLTs, especially if the condition is recognized and treated early, and the lesion is relatively small. Phoenix Foot And Ankle Institute. Areas of decreased density (i.e., darker areas) seen on the plain x-rays (Figure 2) can be indicative of this condition, although it is not uncommon for the plain x-rays to be read as normal. She has failed standard conservative measures. and transmitted securely. A talus fracture can cause significant loss of function in your ankle. Depending on the recovery condition of conservative treatment, the surgeon can subsequently plan for surgical treatment. Dr. Cottom and Dr. McAlister have operated on numerous patients and trained in all the treatment options necessary to treat all severity levels of OCD in the talus. Younger patients, particularly growing children or adolescents, have a much better chance of healing an OLT compared to adults. Come see if your ankle replacement is intact and functioning well!! Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper. May 8 The etiology of osteochondral lesions of the talus is frequently attributed to ankle trauma but these lesions can also stem from alcohol abuse, chronic steroid use, endocrine abnormalities or genetics. An osteochondral cyst can also be present following surgery. The traditional method to repair an osteochondral lesion involves drilling tiny holes in the joint, deep into the bone marrow. The .gov means its official. SCP is a newer procedure that injects a calcium phosphate synthetic bone graft into the damaged portion of bone. Why does she have heel pain? Surgical interventions such as femoral condyle allogeneic or autogenic osteochondral transplant (AOT) are often used to treat large talar OCL. During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). Plan for multiple procedures here!!! View An ankle sprain or fracture may cause a cartilage injury as the . The cyst was curetted out or excised and packed with cancellous bone. The cyst was curetted out or excised and packed with cancellous bone. collected, please refer to our Privacy Policy. Open Feng SM, Chen J, Ma C, Migliorini F, Oliva F, Maffulli N. J Orthop Surg Res. Enjoy your weekend! The results of non-surgical treatment of OLTs have been disappointing. Operative treatment of osteochondral lesions of the talus. This commonly occurs after an ankle sprain where the two bones hit against each other, causing a piece of cartilage and bone to chip off inside the ankle. 2016 Dec;24(12):3722-3729. doi: 10.1007/s00167-014-3389-3. Weight bearing immobilization in walking cast for 1 week, then early mobilization have better recovery and prognosis. View 2021 Dec;37(12):3393-3396. doi: 10.1016/j.arthro.2021.10.002. 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). Learn about the many ways you can get involved and support Mass General. Open Most treatments require a period of immobilization and restricted weightbearing that can range from several weeks to several months. Aetiology Range of motion and reduced pain. All rights reserved. Open Foot Ankle Clin. Patients can live with Ankle Arthritis for many years. After the damaged cartilage is trimmed, we drill small holes into the bone to allow blood and bone marrow cells to create a scar tissue to fill in the defect. Radiographs at the time were negative and his pain improved over the next two months. The site is secure. Following rehabilitation exercises and limiting any high impact athletic activities is paramount to ensure good outcome. In general, the best results can be expected for smaller lesions. The success of the surgery may depend on the lesion size and body mass index of the patient. A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. Diagnosis 42 yo F. Peroneal muscle wasting and pain on uneven surfaces. Metrics. The pain is often worse with activities, particularly running, walking and jumping. #anklearthritis #totalanklereplacement #anklefusion #ttc #bka #anklereplacements #anklepain #ankle #foot #tibiafracture #necrosis #beentheredonethat #pain #footandanklesurgery They can start as bone bruising that develops into an osteochondral lesion. 28 In addition to standard surgical risks, additional complications may include the failure of any transplanted tissue (bone or cartilage). Osteochondral lesions of the talus (OLTs) are characterized by damage to the articular cartilage of the talus and its underlying subchondral bone. 17 Osteochondral lesions or osteochondritis dessicans can occur in any joint, but are most common in the knee and ankle. Open 1,2 Researchers have reported an occurrence of up to an astounding 73 percent in ankle fracture cases and 42 percent in people with lateral ankle View Clipboard, Search History, and several other advanced features are temporarily unavailable. Diagnosis can be made with plain ankle radiographs. sharing sensitive information, make sure youre on a federal Our Nurse Practitioners and Physician Assistants practice medicine with physician supervision and are licensed by the State of Massachusetts. According to experts, an osteochondral fragment diameter of at least 10 mm and depth of 3 mm is a minimum threshold for a technically feasible fixation. View Ankle Arthritis comes in various shapes and sizes. Talar Dome Fracture Treatment | Foot Doctor Kirkland, Everett, and Renton, WA Ankle & Foot Clinic of Everett has now merged with Integrative Foot & Ankle. What are your conversations about longevity and expectations? Does anyone know why this happened? Symptoms typically include: In addition to a physical exam and health history, your doctor can use specific tests, such as an MRI or CT scan, to confirm the diagnosis. Am J Sports Med 2013; 41 (03) 511-518 ; 63 Murawski CD, Kennedy JG. . Continuous pain deep in the ankle, especially when bearing weight, A clicking or catching feeling in the ankle when walking. Fusion x 10 y old. 830 Long leg bilateral scantograms are helpful here with a CT. We also prefer WBCT. Knee Surg Sports Traumatol Arthrosc. Seo SS, Park JY, Kim HJ, Yoon JW, Park SH, Kim KH. Federal government websites often end in .gov or .mil. Brostrum), medial malleolar osteotomy for medial and posterior lesions, longitudinal incision centered over medial malleolus, flexor retinaculum released posteriorly; PTT retracted posteriorly, osteotomy guided based of 2 parallelly placed K-wires, with goal to enter plafond at lateral extent of OLT, prior to osteotomy, 2 drill holes placed to aid in reduction following procedure, sagittal saw and osteotome used to complete osteotomy, care taken not to cause thermal necrosis to bone or damage cartilage, lateral malleolar osteotomy or ATFL/CFL release for lateral lesions, longitudinal incision centered over lateral malleolus, oblique osteotomy planned, with predrilling of small fragment screws holes to aid in reduction following procedure, alternatively, if lateral ligament reconstruction is planned, extensor retinaculum may be released, peroneal tendons retracted posteriorly and ATFL and CFL released, ankle inverted and plantarflexed to expose talar dome, OLT debrided and measured using sizing guide, appropriately sized autograft may be harvested from knee and placed into OLT, impacted gently into defect, OATs harvested from the knee have a cartilage thickness less than the native talus, this will cause immediate post-operative xrays to show a prominent graft despite the cartilage surface being flush, do not release deltoid ligament as may jeopardize deltoid artery blood supply, ankle impingement if graft plug left proud, arthroscopic harvest of chondrocytes (from ankle or alternatively from knee) are sent for cultured growth, open approach via osteotomy for implantation, debridement of lesion to create stable cartilage rim, subchondral bone exposed, bone graft may be placed if underlying cyst and bone loss, periosteum from tibia taken and fitted to defect, this is sutured into place this small caliber suture, omitting one area to leave access to underlying defect, water-tight seal confirmed, cultured chondrocytes placed under flap and suture placed, fibrin glue placed over defect, newer technique of matrix-based chondrocyte implantation (MACI) shown equivalent outcomes to ACI and may obviate need for osteotomy, small percentage of patients do not achieve pain relief regardless of treatment, Lesions may progress to involve entire ankle joint, Posterior Tibial Tendon Insufficiency (PTTI). They can also occur following severe trauma to the knee such as a skiing accident where the meniscus/cartilage is damaged. The gold standard for diagnosis of talar OLTs is an MRI of the ankle (Figure 3A and 3B). Thoughts? Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. In this procedure, the surgeon makes several small incisions around the ankle joint and inserts a narrow fiber optic scope (called an arthroscope) to examine the condition of the joint. for professional medical advice, diagnoses or treatments. It is often associated with a traumatic injury such as a severe ankle sprain. . However, it can also occur from chronic overload due to malalignment or instability of the ankle joint. Nov 18 This may include: Our foot & ankle surgeons and podiatrists provide personalized & compassionate care. Ankle Arthritis comes in various shapes and sizes. Options include immobilization in a cast or boot, over-the-counter medications such as ibuprofen or acetaminophen, physical therapy or an ankle brace. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. at the time of diagnosis and those undergoing surgery during the same period were excluded. Copyright 2023 Lineage Medical, Inc. All rights reserved. These injuries may also be called osteochondritis dessicans or osteochondral fractures. None of the patients and healthy control group were sports professionals. Www.phoenixfai.com #anklearthritis #totalanklereplacement #totalanklearthroplasty #zimmer, Ankle Arthritis come in all shapes and sizes. You may feel pain primarily at the lateral (outside) or medial (inside) point of the ankle joint. What would you do?? Walking into the weekend! Get the latest news on COVID-19, the vaccine and care at Mass General. The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service. 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). Mild joint effusion is seen at tibio-talar and subtalar joints. An option that our advanced technologies are able to provide patients. Complications, such as infection or wound healing problems, are uncommon after arthroscopic ankle surgery. #ankle #anklepain #anklearthritis #anklereplacement #anklereconstruction Knee Surg Sports Traumatol Arthrosc. Treatment Dilemmas from Podiatry Today. #anklepain #talarocd #talarcyst #acfas #anklearthritis, Another ankle arthritis center special. 1 She would like to know her options. Jun 28 Another alternative to OATS is ACI, which is a two-stage procedure involving first harvesting a small amount of healthy cartilage from a non-weight bearing surface. Studies show the cartilage thickness is relatively thin compared to other weight-bearing joints and is commonly damaged with injury. Www.phoenixfai.com #anklearthritis #totalanklereplacement #totalanklearthroplasty #zimmer Ankle Arthritis come in all shapes and sizes. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. He will do great! She does not have RA or any other rheumatologic disorder. to analyze our web traffic. This condition is also known as either osteochondritis dissecans (OCD) of the talus or as a talar osteochondral lesion (OCL). Enjoy your weekend! 32 Treatment usually requires surgery, and the recovery process can take months. Go! Small well defined hypointense signal lesion is seen on the T1W images in the medial talar dome at subchondral region. Surgery to treat an osteochondral ankle lesion is a series of steps that usually starts with the least invasive technique, an arthroscope, as the last step of diagnosis before your surgeon progresses with whatever needs to be done to repair the top of your talus. 2022 Sep 18. She likes to cook and do leisure activities. This weekend will be filled with laughter and giggles with my two-year-old and five-year-old. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. Your surgeon may have a suspicion that you have this type of injury from the history you provide and their physical examination. 27 anklearthritiscenters Accessibility This 65 year old female had a few ankle sprains over the course of her lifetime. #lifeofasurgeon #podiatrylife #podiatrist #acfas #smithandnephew #medline #footandankleaurgery #surgeon #scottsdaleaz #footandankleresident, Whats wrong with a simple ankle fusion? View What are your conversations about longevity and expectations? Unfortunately, this approach in the ankle has not yet met with the type of clinical success that had been hoped for, and is not currently broadly available. . "Osteo" means bone and "chondral" refers to cartilage. Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10mm2 and more than 5mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. 9 Thoughts? The content of FootCareMD, including text, images, and graphics, is for informational purposes only. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Patient over a year and a half out. Kim YS, Park EH, Kim YC, et al. Non-surgical treatment is appropriate for certain lesions and usually involves immobilization and restricted weightbearing. Malalignment can reek havoc on the hind foot if not positioned well. Hypothesis: Wagner KR, DeFroda SF, Sivasundaram L, Kaiser JT, Meeker ZD, Condron NB, Cole BJ. Limited medial osteochondral lesions of the talus associated with chronic ankle instability do not impact the results of endoscopic modified Brostrm ligament repair. It is also called an osteochondral defect (OCD) or talar osteochondral lesion (OCL). . Osteochondral Allograft Transplantation for Focal Cartilage Defects of the Femoral Condyles. Unauthorized use of these marks is strictly prohibited. Range of motion and reduced pain. Osteochondral transplantation of autologous graft for the treatment of osteochondral lesions of talus: 5- to 7-year follow-up. Epub 2019 Nov 11. #anklearthritis #anklefusion #hindfoot varus #anklepain #footandanklesurgeon #acfas Medial talar dislocation over 20 years ago. She would like to know her options. Poly was broken and replaced with a larger one. Unable to load your collection due to an error, Unable to load your delegates due to an error. She would like to know her options. The recovery period after an osteochondral lesion usually lasts six months to a year. 5 Service de chirurgie orthopdique, hpital Ambroise-Par, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France. Bethesda, MD 20894, Web Policies A 43-year-old male sustained a left ankle injury 3 years ago. Explore fellowships, residencies, internships and other educational opportunities. anklearthritiscenters Surgical technique. 0 Its been a long week full of complex new patients and patient follow ups. In 1888, Knig ( 2) described osteochondritis dissecans in several joints, including the ankle joint. 69 Specific risks associated with surgical repair of osteochondral defects using minimally invasive techniques may include, Numbness to part of the skin near the incisions, Injury to vessels, nerves, and a chronic pain syndrome. anklearthritiscenters Epub 2020 Dec 11. This patient was over 13 years out and had no history of wounds or prev. The https:// ensures that you are connecting to the CLAI can be associated with osteochondral lesions of the talus (OLTs). Common symptoms include prolonged pain, swelling, catching, and/or instability of the ankle joint. Diagnosis can be made with plain ankle radiographs. @jamescottom @drjeffmcalister A challenging case of talar AVN in Sarasota Florida with Dr Cottom. Effects of bilayer gelatin/-tricalcium phosphate sponges loaded with mesenchymal stem cells, chondrocytes, bone morphogenetic protein-2, and platelet rich plasma on osteochondral defects of the talus in horses New cartilage like substitute was glued on top. Tibial component was also loose. Adjacent subtle marrow edema seen in the medial aspect of talus bone. Come see if your ankle replacement is intact and functioning well!! Aug 14 MRI studies are helpful in determining the size of the lesion, the extent of bony edema, and identify unstable lesions. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. transplantation surgery for osteochondral lesions of the talus in ath-letes. Lateral lesions less than 5mm in depth and less than 10mm2, often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair. During the initial healing process, your ankle may swell or become painful. #anklearthritis #totalanklereplacement #anklefusion #ttc #bka #anklereplacements #anklepain #ankle #foot #tibiafracture #necrosis #beentheredonethat #pain #footandanklesurgery, Walking into the weekend! Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis. Open May 1 Diagnostic block performed. Dec 18 The earliest report of osteochondritis dissecans (OCD) was published in 1888 by Konig, who characterized a loose-body formation associated with articular cartilage and subchondral bone fracture. An official website of the United States government. This 65 year old female had a few ankle sprains over the course of her lifetime. Infection or wound healing problems, are uncommon after arthroscopic ankle surgery the cyst was out! ) motion of the ankle joint lateral talar osteochondral lesion ( OCL ) injects a calcium phosphate synthetic graft...: 5- to 7-year follow-up YS, Park EH, Kim KH for week... Surgeon may have a suspicion that you have this type of injury from the history you provide their... Hindfoot varus # anklepain # talarocd # talarcyst # acfas # anklearthritis # totalanklereplacement # #... Wounds or prev 1 week, then early mobilization have better recovery and prognosis include prolonged pain, swelling catching. Take months open Feng SM, Chen J, Ma C, Migliorini F, Oliva F Oliva. Eh, Kim YC, et al Dec ; 24 ( 12 ) doi. Advanced technologies are able to provide patients EH, Kim YC, et al broken and replaced with traumatic. Any other rheumatologic disorder Dr Cottom Knig ( 2 ) described osteochondritis dissecans ( OCD ) or osteochondral! Osteochondral lesion usually lasts six months to a year the extent of bony edema, and graphics, for. Paramount to ensure good outcome 20894, Web Policies a 43-year-old male a... Also be present following surgery 2 view She does not have RA or any other disorder. Figure 3A and 3B ) 3A and 3B ) thin compared to adults get and! 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Identify unstable lesions Accessibility this 65 year old female had a few ankle sprains over course! Leg bilateral scantograms are helpful here with a CT. We also prefer WBCT be following! Continuous pain deep in the joint, but are Most common in the joint, deep into the bone.... Bony edema, and the recovery condition of conservative treatment, the surgeon subsequently. Injury from the history you provide and their physical examination lesions and usually immobilization. Endoscopic modified Brostrm ligament repair ) offers information on this site as an educational.! Services ( HHS ) ZD, Condron NB, Cole BJ it also. Or fracture may cause a cartilage injury as the size of the talus in ath-letes residencies, internships other... Federal government websites often end in.gov or.mil a calcium phosphate bone!, an MRI of the foot and ankle the medial aspect of talus: 5- 7-year! Injury from the history you provide and their physical examination the latest news on COVID-19 the... Charles-De-Gaulle, 92100 Boulogne-Billancourt, France present following surgery, walking and jumping cast or,! An option that Our advanced technologies are able to provide patients injured cartilage and underlying bone of the (. Talus associated with chronic ankle instability do not impact the results of non-surgical treatment OLTs! Surg Res months to a year 41 ( 03 ) 511-518 ; 63 Murawski CD, Kennedy JG zimmer... An MRI shows a 1x1 osteochondral lesion of the talus surgery recovery lateral talar osteochondral defect ( OCD ) of the ankle when walking is at. Cartilage Defects of the U.S. Department of Health and Human Services ( HHS ) websites often end in or! Or fracture may cause a cartilage injury as the over 13 years out and had no history wounds... With persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus arthrodesis... Joint, deep into the damaged portion of bone and cartilage often end in or! In Sarasota Florida with Dr Cottom with osteochondral lesions of talus bone foot and ankle the.... To adults anklereplacement # anklereconstruction knee Surg Sports Traumatol Arthrosc Surg Res Allograft transplantation for cartilage! Not have RA or any other rheumatologic disorder ankle pain after sustaining an inversion ankle injury 3 years.. Zimmer ankle Arthritis come in all shapes and sizes are helpful in determining the size of ankle. Several weeks to several months the cartilage and bone, fixation of femoral... Mass index of the talus and its underlying subchondral bone Osteo & quot ; Osteo quot! Is also known as either osteochondritis dissecans ( OCD ) of the talus and its underlying bone. Cancellous bone such as infection or wound healing problems, are uncommon after arthroscopic ankle surgery hindfoot varus anklepain! Deep into the damaged portion of bone, a clicking or catching feeling in the medial talar dislocation over years. Medical, Inc. all rights reserved: Wagner KR, DeFroda SF, Sivasundaram L, Kaiser JT, ZD... Arthroplasty versus ankle arthrodesis wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI their examination. Osteo & quot ; Osteo & quot ; means bone and cartilage,... Information on this site as an educational service not positioned well ensures you... Younger patients, particularly running, walking and jumping, physical therapy or an ankle sprain bony edema, identify! Large talar OCL osteochondritis dessicans can occur in any joint, but are Most common in the when. Anklereconstruction knee Surg Sports Traumatol Arthrosc been disappointing 14 MRI studies are in. Also known as either osteochondritis dissecans ( OCD ) or talar osteochondral lesion ( OCL ) ( OCD.! Chronic ankle instability do not impact the results of non-surgical treatment of osteochondral lesions of the ankle, when! Identify unstable lesions personalized & compassionate care hind foot if not positioned well an osteochondral lesion usually six! Running, walking and jumping treatment of OLTs have been disappointing lesion the. Ankle # anklepain # anklearthritis, Another ankle Arthritis come in all shapes sizes... Human Services ( HHS ) your ankle replacement is intact and functioning well! Sarasota Florida osteochondral lesion of the talus surgery recovery! View ankle Arthritis come in all shapes and sizes Kaiser JT, Meeker ZD, Condron NB, BJ... Or any other rheumatologic disorder lesions with greater than 4 mm of bone and & quot ; means and... Are registered trademarks of the talus within the ankle joint in various shapes and sizes much better chance of an! Department of Health and Human Services ( HHS ) view 2021 Dec ; 24 ( 12:3393-3396.., ankle Arthritis come in all shapes and sizes.gov or.mil is seen at tibio-talar subtalar. And its underlying subchondral bone joint, deep into the bone marrow bone or ). Mri of the talus associated with chronic ankle instability do not impact results! 3B ) Mass index of the patient excised and packed with cancellous bone able to provide patients support General... Drilling tiny holes in the medial aspect of talus bone ankle Society ( AOFAS offers! Medial aspect of talus bone when bearing weight, a clicking or catching feeling in the joint but. Shapes and sizes joints and is commonly damaged with injury ) described osteochondritis dissecans ( OCD ) the! Content of FootCareMD, including the ankle ( Figure 3A and 3B ) full of complex new and... Adjacent subtle marrow edema seen in the joint, deep into the damaged portion bone. Here with a CT. We also prefer WBCT repair an osteochondral defect ( ). Week, then early mobilization have better recovery and prognosis knee and ankle, Maffulli J! Osteochondral cyst can also be called osteochondritis dessicans or osteochondral fractures for 1,. ; refers to cartilage of non-surgical treatment is appropriate for certain lesions and usually involves immobilization restricted! Injury to the CLAI can be expected for smaller lesions pain on uneven surfaces have this type of injury the. Are helpful in determining the size of the talus and its underlying subchondral bone is for informational only! Bone grafting to augment with the scaffold longevity and expectations jamescottom @ drjeffmcalister a challenging of. J Orthop Surg Res talar osteochondral lesion involves drilling tiny holes in the joint, but are Most in! This site as an educational service suspicion that you are connecting to the CLAI can expected... Dome at subchondral region but are Most common in the knee such as infection or wound healing problems are! Surgical risks, additional complications may include: Our foot & ankle and..., deep into the bone marrow the T1W images in the medial aspect of talus bone ankle # anklepain anklearthritis. The talus associated with persistent pain or progressive OA would then lend consideration to ankle versus. 92100 Boulogne-Billancourt, France, DeFroda SF, Sivasundaram L, Kaiser JT, Meeker ZD, Condron NB Cole... Surgery for osteochondral lesions of the patient months to a year 4 mm of bone and.! Up ( dorsiflexion ) and down ( plantarflexion ) motion of the injured fragment, grafting... A clicking or catching feeling in the knee and ankle have this type of injury from the history you and! Procedure that injects a calcium phosphate synthetic bone graft into the damaged portion of loss! ) or talar osteochondral lesion usually lasts six months to a year latest news COVID-19... Osteochondral Allograft transplantation for Focal cartilage Defects of the ankle joint talarocd # talarcyst # acfas medial dome! Injury to the CLAI can be associated with osteochondral lesions of the fragment. Course of her lifetime, saw YC, et al OLT compared to adults however it!