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Category: Arthroscopy; Ankle Introduction/Purpose: The long-term sustainability of arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT) remains a matter of debate. The primary aim of the present study is to assess the 10-year survival following arthroscopic BMS for OLT. The secondary aim is to evaluate the influence of baseline patient- and lesion characteristics on survival. Methods: Patients who underwent arthroscopic BMS for a symptomatic OLT with a minimum follow-up of 10-years were included to assess procedure survival. The primary outcome, the 10-year cumulative survival rate, was analysed with a Kaplan-Meier survival analysis. Secondary outcomes concerned the median time to survival and the effect of baseline factors (i.e., lesion size, primary or non-primary lesion type, preoperative cysts, and obesity (body mass index ≥30 kg/m²) on survival and was analysed with a cox-regression model and reported with hazard ratios (HR). Results: From the 262 patients included at a mean 15.3 ± 4.8 years follow-up, the 10-year cumulative survival rate of arthroscopic BMS was 82% [95%-CI: 77% - 87%]. At 15-years follow-up the cumulative survival rate was 82% [95%-CI: 76% - 86%]. The median time to revision was 2.4 (interquartile range: 1.3 – 5.1) years. Of the baseline factors, obesity (HR: 3.0 [95%-CI: 1.44 – 6.43], p= < 0.01) was associated with decreased survival. Lesion size (HR: 0.9 [95%-CI: 0.5– 1.8] p= 0.8), non-primary lesion type (HR: 1.8 [95%-CI: 0.9 – 3.4] p= 0.1), and the presence of preoperative cysts (HR: 1.0 [95%-CI: 0.6 – 1.9] p= 0.9) were not significantly associated with survival. Conclusion: At a minimum follow-up of 10-years, the survival rate of arthroscopic BMS for OLT was 82%. At 15- and 20-years follow-up survival seems to remain stable. Obesity (BMI ≥30 kg/m 2 ) was associated with a higher likelihood of revision surgery. This risk factor should be incorporated into the treatment algorithm for OLT when counselling patients for surgery.

Category: Ankle Introduction/Purpose: Osteochondral lesions of the talus (OLT) are often caused by sports. The Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) is an autologous press-fit bone grafting technique for large (cystic) primary- and non-primary OLT. The purpose of this study was to prospectively evaluate sport outcomes after the TOPIC surgery. The purpose of this study was to prospectively evaluate sports outcomes for patients with OLT who were treated with the TOPIC procedure. Methods: 61 patients who underwent the TOPIC procedure for a symptomatic OLT were prospectively included up-to 24 months follow-up. Using digital questionnaires, an in-depth telephone interview, and electronic patient files, the return to any level of sport (primary outcome), the return to preoperative level of sport, the return to preinjury level of sport, the return to performance, the participation in improved preoperative level of sport and participation in desired level of sport rates were determined 1- and 2-years after TOPIC. On top of that the Ankle Activity Scale (AAS), Numeric Rating Scale (NRS) for pain while running preoperatively, 1- and 2-years after TOPIC were assessed. Lastly complication and reoperation types and rates were presente Results: 2 years after TOPIC surgery, 98% of patients returned to any level of sport. Of the 61 participants, 90% participated in an improved level of sports compared to pre-operatively, 59% returned to their preinjury level of sports and 3% returned to perform on a higher level of sports than preinjury. The AAS increased significantly from 2 to 5 out of 10 (p < 0.01) both 5 points both 1- and 2-years post-TOPIC. The NRS for pain during running improved from 9 to 5 out of 10 (p < 0.01) 5 points both 1- and 2-years post-TOPIC. Any complication occurred in 3% of cases and in 31% of cases a reoperation was conducted, primarily due to hardware removal. Conclusion: The TOPIC procedure for large OLT results in high return to sport and participation in sport rates 1- and 2-years postoperatively making it a suitable treatment option for the athletic population suffering from OLT.

Category: Ankle Introduction/Purpose: The aim of this study is to assess the return to sports rate and times after treatment of osteochondral lesions of the ankle in elite level athletes. Methods: All elite level athletes treated for an OLT(P) were selected from a cross-sectional database consisting of consecutive patients with cartilage injuries of the ankle and subsequently underwent prospective follow-up. Outcomes included return to sports outcomes, patient reported outcomes and a qualitative assessment regarding mental health Results: 26 patients with a median age of 22 years (IQR: 19.0 – 24.5) were included with a median follow-up time of 48 months (IQR: 34.5 – 71.0). Seven patients (27%) underwent conservative treatment and 19 patient (73%) operative treatment. Conservative treatment yielded a return to sport rate at any level of 86%, return to pre-injury and return to performance level of both 57%. For operative treatment these rates were 100%, 74% and 63% respectively. Mean time to return to pre-injury level overall was 8.3 months. At latest follow-up only 11 patients (44%) were still active at an elite level of sport. Conclusion: Both conservative and surgical treatment for osteochondral lesions of the ankle yielded return to sport rates above 86% in elite level athletes. The results of this study can be used in the decision-making process between the physician and the elite athlete to inform them about the expected return to sport rates and times for the different treatment options for OLT(P)s. As most athletes at the time of injury and treatment are still highly motivated and disciplined to return to their sport at the same level and be able to compete at the highest level available in their sport.

Category: Ankle; Other Introduction/Purpose: WBCT enables the creation of a three-dimensional model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating OLT, allowing for the quantification of its surface area, volume, and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth, and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention Methods: This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface, and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis, and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured. Results: Interclass correlation of the lesion's depth surface produced an excellent interrater and intrareader agreement of 0.90 -0.94 p-value < 0.001. Cohen's Kappa agreement analysis of the preferable preoperative plan produced a Kappa = 0.834 P-value< 0.001, indicating a near-perfect agreement Conclusion: WBCT-based 3D modules and DM can be used to measure the OLT surface and depth and to calculate the lesion volume with excellent interrater and interrater reliability; using the OLT measurement and a predetermined treatment algorithm, a near-perfect interrater agreement for the preoperative planning was reached. WBCT in conjunction could help determine the type of surgery needed preoperatively and assess if additional surgeries are needed.

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: An osteochondral lesion of the talus (OLT) is a defect of talar cartilage and subchondral bone, primarily linked to a history of ankle trauma. Mechanical overload is considered one of the reasons for the development of osteochondral lesions of the talus. However, no gait analysis of this patient group exists to date. We hypothesize that altered gait patterns lead to increased load at the side of the lesion compared to healthy controls. The primary aim of the study was to compare the foot and ankle biomechanics during gait between individuals with OLT and healthy controls. The secondary aim was to compare these parameters between individuals with a medial and lateral OLT. Methods: Ten patients diagnosed with symptomatic OLT (5 medial and 5 lateral lesions) underwent gait analysis. 3D kinematics according to the Amsterdam Foot Model, ground reaction force, and plantar pressure data were collected to quantify the motions and forces within the foot. OLT data were compared to a reference dataset of healthy controls (n=13) using statistical parametric mapping and one-way ANOVA. Results: The ankle joint was significantly rotated towards valgus in both the OLT groups compared to the control group during most of the gait cycle. Moreover, the medial OLT group showed decreased plantarflexion in the Lisfranc joint, and lateral OLT group showed higher peak pressures in the midfoot zone compared to the control group. Conclusion: The valgus rotation reduces medial loading, but was present in both OLT groups. Decreased Lisfranc plantarflexion and increased midfoot pressures indicate a tendency towards flat feet. The observed alterations in the OLT group could be adaptations to, or causes of, osteochondral damage in the ankle joint.

Category: Ankle Introduction/Purpose: Outcomes after fixation of osteochondral lesions of the talus (OLTs) are currently underreported in literature. Clinical and radiological outcomes after the open fixation procedure ‘lift-drill-fill-fix’ (LDFF) for OLT with an osteochondral fragment are unknown. The advantages of fixation over other surgical techniques is the preservation of the native hyaline cartilage, immediate stabilization of the fragment and restoration of the talar dome congruency, as well as facilitating subchondral bone healing. Methods: This study describes the results of open LDFF treatment in a prospective, multicentre, nonrandomized, noncomparative clinical trial of 42 ankles in 40 patients with a 2-year follow-up period. The primary outcome measure in this study was the numeric rating scale (NRS) of pain during walking. Secondary outcome measures included the NRS of pain during rest, running and stairclimbing, the foot and ankle outcome sore (FAOS), and the mental component scale (MCS) and physical component scale (PCS) of the short form 36 (SF-36), and the radiological union rate as well as the level of the subchondral bone layer as measured on 1-year postoperative CT. Results: A total of 40 ankles which underwent fixation of an OLT with a fragment were prospectively included with 2-years follow-up. The primary outcome, pain during walking, significantly improved with 3.5 (95% CI 2.4-4.6) points on the NRS (p=< 0.001). Significant improvement was also seen for the NRS of pain during rest (p=< 0.001), pain during running (p=< 0.001) and pain during stair climbing (p=< 0.001). Additionally, all subscales of the FAOS, and the MCS and PCS significantly improved as well. Postoperative CT-scans showed union in 88% of the lesions 1-year after the procedure, a flush subchondral bone layer in 88%, and a depressed subchondral bone layer in 12%. Conclusion: Open fixation by means of LDFF for OLT results in a significant improvement of clinical outcomes up-to mid-term follow-up. Radiological follow-up shows a union rate and a flush subchondral bone layer in 88% of lesions. These results indicate that open fixation should always be considered when an osteochondral fragment is present as it leads to an excellent improvement in PROMs.

Category: Ankle Introduction/Purpose: The primary aim of the present study is to assess the clinical success rate of fixation for osteochondral lesions of the talus (OLT). The secondary outcomes concern the union rate and adverse events. Methods: A systematic literature search of PubMed, Embase (Ovid), and Cochrane Library was performed up to December 2023. The primary outcome was the pooled clinical success rate following fixation with 95% confidence interval (95%-CI). Secondary outcomes concerned the union rate, complication rate, and revision rate. Results: A total of 10 studies with 241 ankles were included at a mean follow-up of 40 months. The pooled clinical success rate was 92% [95%-CI: 87% – 95%]. The pooled union rate was 91% [95%-CI: 87% - 94%]. A sub-analysis found superior success rate for patients treated with bone-peg (98% [95%-CI: 89 – 100] compared to non-metal screw and pin (84% [95%-CI: 68 – 93]), P=0.03. The pooled complication and revision rate were 1% [95%-CI: 0 - 4] and 6% [95%-CI: 0 - 4], respectively. Conclusion: Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients. Moreover, fragment union is achieved in 9 out of 10 cases, with a low reported complication rate. These findings show that when a symptomatic OLT is fixable physicians should always consider fixation.

Category: Ankle; Sports Introduction/Purpose: The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up. Methods: Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures. Results: Thirty-nine patients with a mean lesion size was 122.3±64.1 mm 2 and mean follow-up time of 138.9±16.9months were included. The mean FAOS scores improved from a preoperative score of 51.9±16.0 to 75.3±21.9 (p < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R2=0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9±5.2ms) compared to the superficial layer of the adjacent native cartilage (35.8±3.8ms) (p < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI. Conclusion: This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs.

Category: Ankle; Sports Introduction/Purpose: The purpose of this prospective study was to evaluate the quality of the reparative cartilage during second-look needle arthroscopy following talar osteoperiostic grafting from the iliac crest (TOPIC) and autologous osteochondral transplantation (AOT) procedures for the management of large osteochondral lesions (OCLs) of the talus. Methods: Patients who underwent second-look needle arthroscopy following either TOPIC or AOT procedure were prospectively recruited. The primary outcome was the assessment of the quality of the reparative cartilage via second-look needle arthroscopy scored by the International Cartilage Repair Society (ICRS) score. The secondary outcomes were the number and nature of ad-hoc needle arthroscopy interventions and complications associated with these interventions. Results: Five patients underwent second-look needle arthroscopy following TOPIC procedure and 11 patients underwent second-look in-office needle arthroscopy following AOT. The mean ICRS in the TOPIC cohort was 9.4 ± 1.0 at a mean time of 24.4 months following the index procedure. The mean ICRS in the AOT cohort was 10.6 ± 1.3 at a mean time of 58.8 months following the index procedure. No complications were observed in either cohort. Conclusion: This study demonstrated that AOT and TOPIC lead to high-quality reparative cartilage at short-term to mid-term follow-ups, but further studies with larger patient cohorts and longer follow-ups are warranted. Furthermore, second-look needle arthroscopy is a safe and viable minimally invasive procedure that can effectively evaluate the quality of reparative cartilage following surgical intervention for OCLs of the talus. In addition to arthroscopic evaluation of the reparative cartilage, this procedure has therapeutic capabilities and can resect bony and soft tissue sources of anterior ankle impingement.

Category: Ankle; Sports Introduction/Purpose: The purpose of this study was to present the surgical technique and to evaluate the clinical and radiological outcomes of a new press-fit transplantation technique for large talar osteochondral lesions of the talus (OLTs), Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC). Methods: 60 patients, mean age 38 years, underwent a press-fit TOPIC procedure. Clinical assessment at 12- and 24-months follow-up included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the Short-Form 36 (SF-36) Mental Component Scale (MCS) and Physical Component Scale (PCS), the Numeric Rating Scales (NRS) of pain at rest, during walking and stairclimbing, and the Foot and Ankle Outcome Score (FAOS). Remodeling of the contour of the talus, bone ingrowth and consolidation of the implanted graft were assessed on computed tomography (CT) one year post-operatively. Results: All patients were available for two-year follow-up. The AOFAS improved from 48 to 90 (p< 0.05). All NRS scores improved: during rest from 3 to 0 (p< 0.05), during walking from 5 to 1 p< 0.05), and stairclimbing from 5 to 1 (p< 0.05). Both SF-36 components improved. The PCS from 34 to 47 (p< 0.05) and the MCS from 37 to 66 (p< 0.05). All FAOS subscales significantly improved. All patients showed remodeling of the talus and all grafts showed bone ingrowth on the CT scans. Conclusion: The TOPIC procedure for large osteochondral lesions of the medial talar dome is an effective technique resulting in significant improvement in pain, as well as other outcomes, with 100% consolidation of the grafts.

Category: Ankle; Other Introduction/Purpose: This study aims to evaluate the clinical outcomes of arthroscopic autologous matrix-induced (A-AMIC) chondrogenesis for osteochondral lesions of the talus (OLT) at 24 months and 60 months of follow-up. The secondary aim was to assess whether age, body mass index (BMI), and lesion surface affect outcomes. Methods: Sixty-three patients (32 males, 31 females) with a median age of 37 years [IQR 25-48] were included. Preoperative and postoperative (24 months and 60 months) clinical outcomes were evaluated using a Visual Analog Score (VAS) for pain during walking, the American Orthopedic Foot and Ankle Society (AOFAS), Short-Form Survey (SF-12), the Halasi, and the University of California (UCLA) scores. Patients were categorized according to age, BMI, and lesion surface (1-1.5 cm 2 and over 1.5 cm 2 ). The effect of each category was evaluated. Results: There were significant improvements in the VAS, AOFAS, SF12, and UCLA, comparing the preoperative scores to the 60-month follow-up scores (p < 0.001). There were no significant differences in the above-mentioned outcomes between the follow-up periods. Patients older than 33 had lower SF-12, Halasi, and UCLA scores (p-value = 0.005, 0.004, and < 0.001, respectively). Overweight patients had lower VAS, SF-12, Halasi, and UCLA scores (p-value = 0.006, 0.002, 0.024, and 0.007). Lesion size was uninfluential. Conclusion: A-AMIC yielded clinical improvements at a minimum follow-up of 60 months in patients with symptomatic OLTs, with clinical improvement peaking in the first two years, followed by a plateau period. Increased age and BMI were significantly associated with inferior outcomes.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Osteochondral lesions of the talus (OLT) are lesions that affect both the articular cartilage and underlying subchondral bone that often arise after trauma. Large OLTs may be treated using osteochondral autografts, for example from the ipsilateral knee. This, however, often results in donor site morbidity. Moreover, the cylindric nature of the osteochondral grafts does not allow for a perfect fit for the defect. The novel technique Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) overcomes these challenges by using an osteoperiosteal autograft of the ipsilateral iliac crest. The aim of the present study is to prospectively evaluate the clinical, radiological and safety outcomes after 5 years of follow-up for patients who underwent the new TOPIC procedure for an OLT. Methods: A prospective cohort study of patients who underwent the TOPIC procedure was conducted. The primary outcome was the Numeric Rating Scale (NRS) of pain during walking. Other clinical outcomes included the NRS during rest and stair climbing, the Foot and Ankle Outcome Score (FAOS) and the Mental Component Score (MCS) and Physical Component Score (PCS) of the Short Form-36 (SF-36). In addition, the AOFAS ankle-hindfoot score was measured. All clinical outcomes were measured preoperatively and after 6 months, 1 year, 2 years and 5 years of follow-up. Computed tomography (CT) scans were performed preoperatively and postoperatively at 12 weeks, 1 year, 2 years and 5 years to assess osteotomy union, graft consolidation and graft cyst development. In addition, complications and hardware removal were evaluated. Results: 36 patients (current data is 29pt; expected to be complete at congress) were assessed, and no patient were lost to follow-up. The NRS of pain during walking improved from 6.5 [5-8] preoperatively to 2 [1-3] at 5-year follow-up (p < 0.001). The NRS during rest and stair climbing improved with 2 (p = 0.002) and 4 points (p < 0.001), respectively. All FAOS subscales improved significantly. The SF-36 PCS improved (32 to 35; p = 0.059) and the MCS improved (39 to 47; p < 0.001). The AOFAS improved from 52 to 90 (p < 0.001). There was 100% union at the osteotomy site after 12 weeks and 100% of the graft showed consolidation at 1, 2 and 5 years postoperatively. No major complications occurred. Conclusion: The TOPIC procedure is an effective treatment option for large osteochondral lesions of the talus, with durable results after 5 years of follow-up. A significant improvement in clinical outcomes was observed, with excellent radiological results. No major complications were recorded.

Category: Sports; Ankle Introduction/Purpose: Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) is a novel technique for the treatment of large osteochondral lesions of the talus. It is the purpose of the present study to assess the gender-specific differences in the presentation and outcomes following TOPIC between male and female patients. Methods: A prospective comparative analysis was performed comparing consecutive female and male patients having been treated by the press-fit TOPIC procedure. Clinical comparative assessment pre-operatively and at 12 months of follow-up included determination of the Numeric Rating Scale (NRS) scores for pain during walking (primary outcome), at rest, and during stair-climbing. The Foot and Ankle Outcome Score (FAOS) was also assessed. A computed tomography (CT) scan was performed for lesion size, morphology and localization determination pre-operatively as well as 10-12 weeks postoperatively to assess union of the distal tibial osteotomy site and at 1 years postoperatively to assess consolidation of the graft as well as cyst development in the graft. Results: A total of 48 patients (30 women, 18 men) were eligible for inclusion. Both men and women demonstrated significant functional improvements post-operatively concerning the clinical outcomes with no significant differences between men and women (n.s.) except for a significantly greater improvement in postoperative FAOS pain scores in women. Men presented with OLTs significantly larger in both surface area (208 mm 2 for males versus 155 mm 2 for females, p< 0,05) as well as lesion volume (3.0 cm 3 for males versus 1.8 cm 3 for females, p< 0.05). At 1-year post-operatively, all patients with a CT scan (n=47) showed graft consolidation. Cyst formation was present in 11 females (37% of the group) and 10 males (59% of the group), respectively (p=0.24). There were no statistical differences in complication rates following the TOPIC procedure. Conclusion: Both male and female patients showed clinically relevant improvements in the clinical outcomes after undergoing the TOPIC procedure, with significant differences in pre-operative size. There were no statistical differences in complication rates following the TOPIC procedure, although a higher proportion of women did require hardware removal. TOPIC procedure is a good treatment strategy for large OLTs in both men and women.

Category: Sports; Arthroscopy Introduction/Purpose: Graft transplantation is a widely used treatment for large osteochondral lesions of the talus. However, cyst formation surrounding the graft is of concern. The primary purpose was to assess and compare cystic occurrence after autografting, allografting and osteoperiosteal grafting for osteochondral lesions of the talus. Our secondary aim was to assess correlation of clinical outcomes with the presence of postoperative cysts. Methods: A literature search was performed up to October 2023 through PubMed, Embase (Ovid), and Cochrane Library. The primary outcome was the postoperative cystic occurrence rate. A random effects model with moderator analysis was used to calculate differences in occurrence rates between treatment groups. The relationship between the presence of cysts and clinical outcomes was additionally described. Results: Thirteen studies were included with 382 ankles that were radiologically assessed at follow-up after osteochondral autograft, allograft, and osteoperiosteal transplantation. The rates of cystic occurrence for the osteochondral autograft transplantation group, the allograft transplantation group, and the osteoperiosteal transplantation group were 42% (95% CI 24-61), 58% (95% CI 40-74), and 34% (95% CI 12-67), respectively, without any significant differences noted between these treatment groups. Six studies studied the relationship between the presence of cysts and clinical outcomes: none of these studies found a significant relationship between these two variables. Conclusion: Postoperative cystic occurrence is common after osteochondral autograft transplantation (42%), allograft transplantation (58%), and osteoperiosteal transplantation (34%) in osteochondral lesions of the talus – without significant intertreatment differences. The postoperative presence of cysts was not correlated with clinical outcomes.

Category: Ankle Introduction/Purpose: Symptomatic primary (large) cystic and non-primary osteochondral lesions of the medial and central tibial plafond are challenging entities to treat. These lesions may benefit from a lesion specific treatment approach. In the present manuscript we describe the novel surgical technique by means of an osteotomy of the distal tibia and cancellous bone graft filling. The procedure involves an oblique distal tibia osteotomy which is made directly over the lesion. Hereafter, the defective lesion tissue is curetted and filled with autologous cancellous bone from the ipsilateral iliac crest, and compression by means of refixation of the osteotomy. The procedure provides provide surgeons an alternative option for OLTP. Methods: Indications: Symptomatic primary cystic and non-primary (i.e., failed prior surgical treatment for the OLTP) osteochondral lesions of the medial and central tibial plafond which failed to respond to a minimum 6 months of nonoperative treatment. Results: Surgical Technique: The procedure is started by means of a curved incision over the medial malleolus, and careful dissection until adequate visualization of the medial malleolus and anteromedial ankle joint is achieved. Hereafter, the screws for the fixation of the osteotomy are predrilled. Then, the OLTP is directly approached with an osteotomy using an oscillating saw directly through the lesion. The lesion is thereafter debrided with a curette until healthy bleeding bone is observed. Subsequently, microfracturing may be performed. Then, autologous cancellous bone is harvested from the ipsilateral iliac crest (or from the osteotomy site in small cysts) and the cyst is filled. Finally, the osteotomy is closed and fixated with two diverging 3.5mm cortical lag screws. Conclusion: Postoperative Management: Post-operatively, there is a period of 5-6 weeks in short leg cast non-weight bearing and 5-6 weeks of short leg cast with weightbearing as tolerated. Hereafter, a CT-scan is made to confirm osteotomy union and patients start a personalized rehabilitation under the guidance of a physical therapist.