Cartilage injuries in the ankle have a way of lingering. A twisted ankle that “never feels right” after the swelling subsides, a soccer player who cannot pivot without a sharp catch deep in the joint, a runner whose pain flares every time mileage climbs past ten. As an orthopedic foot and ankle surgeon, I see these patterns often. The common thread is damage to the smooth cartilage that coats the talus and tibia where they meet. When that surface breaks down or pulls away with a wafer of bone, the joint loses its low-friction glide and starts to grind.
Cartilage in the ankle is thin, roughly 1 to 2 millimeters, but it is dense and durable under normal loads. It does not heal well on its own. Blood supply is limited, and the cells that maintain it do not readily migrate or regenerate. The earlier we identify the size, location, and nature of an osteochondral defect on the talus or tibial plafond, the more precisely we can match the right operation to the right patient. That is where microfracture, grafts, and implants each have a place.
How ankle cartilage gets injured
Most symptomatic lesions start with trauma. A classic mechanism is an inversion injury with axial load, where the talus impacts the tibia and shears cartilage. The lateral talar dome takes a brunt of these injuries, though medial lesions appear with twisting or chronic instability. Recurrent sprains stretch the ligaments and let the talus shift fractionally, concentrating force on a small area and wearing it down. Less commonly, a lesion follows an ankle fracture, a penetrating injury, or an inflammatory process. In children and adolescents, a similar problem can present as osteochondritis dissecans.
Patients describe deep, poorly localized pain inside the joint, worse with impact, stairs, or pivoting. Catching, locking, and a sense of giving way point toward a loose flap or fragment. Some present late with swelling that seems to settle in the front of the ankle after activity, then disappears overnight. Exam may be unremarkable between flares. When I palpate the joint line and put the ankle through loaded motion, the patient will often wince at a certain arc. Mechanical symptoms are real clues here.
Getting the diagnosis right
Plain X‑rays are a start. I look for a lucency or a small crater on the talar dome, or a bony fragment that has migrated. A standard mortise view can miss small defects, so I add plantarflexion dorsiflexion stress views if suspicion is high. Even so, X‑rays underestimate cartilage involvement.
MRI remains the workhorse. It shows the defect’s width and depth, whether cartilage is thinned, delaminated, or missing, and whether there is bone marrow edema in the talus. Subchondral cysts hint that the lesion has been there a while and that fluid has pumped into the bone with each step. When I am planning a graft or implant, I add a CT scan. CT defines the bony contours and cysts with millimeter precision, which helps avoid surprises in the operating room.
Not every lesion needs surgery. If symptoms are mild and mechanical catching is absent, targeted physical therapy to restore heel cord length and peroneal strength, bracing to control inversion, and a period of reduced impact can calm the joint. I am candid, though, about the limits of rest for a true cartilage crater. Symptom improvement does not necessarily mean structural healing. If a patient’s quality of life remains curtailed after three to six months, especially in athletes or active professionals, an operative conversation makes sense.
Matching the operation to the defect
The size and character of the lesion, the patient’s age and goals, and the condition of the surrounding joint dictate the plan. A 24‑year‑old midfielder with a 7 by 9 millimeter lesion calls for something different than a 52‑year‑old hiker with a 15 by 15 millimeter crater and subchondral cysts. We also factor in alignment, ligament stability, and any coexisting issues such as ankle impingement or peroneal tendon tears.
Broadly, the surgical tools fall into three buckets: marrow stimulation like microfracture, cartilage and bone grafts, and implants. Many operations combine them with adjuncts such as biologic scaffolds, bone grafting of cysts, and realignment or ligament repair to protect the repair.
Microfracture, done well
Microfracture is a straightforward idea. After arthroscopic debridement of unstable cartilage and feathering of the edges to a stable rim, we puncture the exposed subchondral bone with a small awl to create channels. Marrow elements bleed into the defect and form a clot rich in stem cells. Over months, that clot matures into fibrocartilage. Fibrocartilage is not identical to the native hyaline cartilage, but in small, contained ankle lesions, it can be durable and pain relieving.
Technique matters. The holes should be perpendicular to the surface, spaced a few millimeters apart, and penetrate just enough to trigger bleeding without crushing bone. If I see a hard, sclerotic base or subchondral plate thickening, I first remove that to let marrow participate. I pay attention to the edges; a smooth transition distributes load.
Patient selection matters more. Microfracture performs best for defects under roughly 1 to 1.5 centimeters in greatest dimension, contained by healthy cartilage, and without large cysts. Younger patients tend to form more robust fibrocartilage. If the lesion is on the shoulder where shear is high, or if the ankle is unstable, the failure rate climbs.
Rehabilitation after microfracture is not optional. The first six weeks are protected. I allow toe‑touch or partial weight bearing in a boot, immediately start gentle range of motion, and use a continuous passive motion machine when feasible. The idea is to nourish the clot with synovial fluid and avoid crushing it. By eight to ten weeks, most patients have weaned out of the boot and started low‑impact strengthening. Running usually resumes around 4 to 5 months. Cutting sports and heavy pivots often wait 6 to 8 months. Honest timelines keep expectations aligned.
What does success look like? In my practice, roughly 70 to 85 percent of carefully selected patients report meaningful pain relief and improved function for several years, sometimes a decade. The failures either never settle, or they flare when activity increases. When microfracture fails, it does not burn bridges. We can still step up to a graft or implant later.
Cartilage grafts when the crater is bigger or cystic
When the defect is larger, uncontained, or associated with bone cysts, a graft approach tends to serve better. Here we replace like with like, bringing hyaline‑like cartilage and fresh bone to recreate a congruent surface. There are several ways to do this, each with trade‑offs.
Osteochondral autograft transplantation uses the patient’s own cartilage and bone harvested as cylindrical plugs, typically from the knee’s non‑weightbearing area. For the ankle, we size and press‑fit one or more plugs into the talar defect after preparing it to accept them. These autografts integrate reliably because the bone sees the patient’s own biology. The downside is donor site morbidity in the knee. Most handle a small harvest well, but a subset will feel anterior knee pain with kneeling or squatting. For a single plug under 10 millimeters diameter, I find autograft attractive in a young athlete who wants their own tissue.
Fresh osteochondral allograft transplantation uses a graft from a donor. The benefit is obvious. We can match size to a larger or irregular talar lesion without touching the knee. Viable chondrocytes in a fresh allograft can produce the extracellular matrix that gives hyaline cartilage its glide. The challenges are availability, cost, and the logistics of timing surgery when a properly sized graft arrives. With fresh grafts processed under strict standards, the risk of disease transmission is extremely low. Graft incorporation in the bone is good in most cases. The cartilage itself lives if handled gently and implanted within an optimal window from procurement.
Particulate juvenile cartilage allograft is another option. During arthroscopy, we debride the lesion, pack small cartilage particles mixed with a biologic glue into the defect, and cap them with a membrane. The premise is that juvenile chondrocytes have higher anabolic potential. Early results in the ankle are promising in select cases, but head‑to‑head comparisons with osteochondral plugs are still maturing. I consider this in medium‑sized, contained lesions where a single‑stage arthroscopic solution is preferred and bone cysts are absent or small.
Matrix‑assisted chondral repair and scaffold techniques occupy a middle ground. A collagen or hyaluronic acid scaffold can be used with microfracture to corral the clot and support chondrocyte organization. It makes sense mechanically, and some series show better fill and quality. Insurance coverage and cost can be hurdles. When I deploy it, I do so in patients who understand the rationale and who will commit to the same meticulous rehabilitation.
A word about the bone under the cartilage: if MRI or CT shows sizable subchondral cysts, I plan to address them. That might involve curettage of the cyst through a small cortical window and filling with bone graft before cartilage repair. Ignoring a large cyst is an invitation for the surface to collapse later.
Implants and resurfacing
Implants come into play when cartilage loss is focal but too large or irregular for microfracture alone, and when grafting options are constrained or have failed. There are metallic focal resurfacing implants designed to sit flush with the talar dome and restore contour over a contained defect. The goal is to offload the crater with a congruent surface while preserving the rest of the joint. Patient selection matters here, as does alignment. If the implant protrudes even half a millimeter, patients feel it. If it sits low, load concentrates on the rim.
Biologic implants such as cell‑seeded matrices or newer synthetic scaffolds with bioactive surfaces are developing rapidly. For the ankle, regulatory pathways and long‑term data lag behind the knee. I have used them selectively in revision settings where previous surgery left a mixed picture of scar cartilage and bone loss, and where the patient wants to delay or avoid an ankle fusion or total ankle replacement. The conversation in those cases is frank: expectation management, the possibility of another operation, and the need to optimize everything around the joint including alignment and ligament stability.
If the cartilage damage is diffuse or combined with arthritis, focal implants are not the answer. That is the realm of joint preservation with realignment osteotomy, or joint replacement and fusion. A board‑certified foot and ankle surgeon will distinguish these paths early to avoid chasing the wrong solution.
Arthroscopy as the workhorse
Most cartilage procedures in the ankle use arthroscopy. Small incisions, a camera the size of a pencil, and specialized tools let us see the defect, debride frayed edges, and work at precise angles. An arthroscopic approach respects the soft tissues. It allows treatment of associated problems in the same sitting, such as removing loose bodies or trimming anterior bone spurs that block dorsiflexion.
Certain lesions on the medial shoulder of the talus require a small medial malleolar osteotomy to expose the area safely. I plan those carefully to ensure stable fixation and a reliable healing trajectory. This is where experience as an arthroscopic ankle surgeon and trauma ankle surgeon overlaps. Bone cuts and hardware should be minimalist and biomechanically sound.
Rehabilitation details that matter
The most common mistakes after cartilage surgery in the ankle are loading too much too soon, and not moving enough early on. Both sabotage healing. The sweet spot is protected weight bearing with early motion. In microfracture, I typically recommend 6 weeks of protected weight bearing, 8 to 10 weeks for grafts or implants that need bone integration. I start closed‑chain strengthening when the joint can tolerate it without swelling. Stationary bike before elliptical, pool before treadmill.
Return to running comes only after swelling is predictable and the calf has nearly symmetric strength. When the ankle stays quiet after a brisk 30‑minute walk on varied terrain, we take the next step. Cutting sports come last. Soccer, basketball, and tennis ask a lot of the talus. A foot and ankle specialist who sees athletes will set phased goals with the therapist and coach. This avoids the loop of progress, premature stress, flare, rest, then lost confidence.
I also address the kinetic chain. If the heel cord is tight, dorsiflexion is limited, or the first ray is weak, the ankle pays. A plantar fasciitis surgeon or Achilles tendon surgeon might sound like a different hat, but in practice, these tissues all influence load at the talar dome. Orthoses, calf flexibility, hip abductor strength, and foot intrinsic training matter as much as any implant.
When to choose surgery, and when to wait
I do not rush the knife for every MRI lesion. A middle‑aged hiker with a 6 millimeter contained defect and tolerable symptoms deserves a chance to adapt with sleeves, activity modification, and targeted therapy. On the other hand, a 19‑year‑old collegiate sprinter with a 12 millimeter posterior medial lesion and catching every time she pushes off is not going to “rehab it away.” The sport, the lesion, and the season all weigh in. I tell patients that time is a resource, and we should invest it where it yields.
For workers who climb ladders or stand on concrete all day, the calculus respects livelihood. A foot and ankle consultant will map a rehab plan around job demands and discuss temporary duty or staged return. For diabetics or smokers, wound and bone healing become central considerations. Tight glucose control, nicotine cessation, and nutritional optimization are not side notes, they are main act. A diabetic foot surgeon learns to screen and prepare carefully.
Edge cases and judgment calls
Multifocal lesions present a dilemma. Two small lesions on opposing sides can act like one large problem. I handle each surface based on size and containment, but I warn that outcomes are less predictable. Very large lesions over 2 centimeters with broad cystic change push me toward fresh allograft or staged approaches. If the ankle is globally arthritic, focal repair fails more often, and planning shifts to joint preservation strategies or replacement.
Chronic ankle instability amplifies focal cartilage damage. I frequently combine a Broström type ligament repair with cartilage work in the same setting. I have had patients who finally turned the corner only after the instability was addressed, even though their lesion was technically “fixed” months earlier.
Revision cases need humility. Scar tissue, previous microfracture, and altered subchondral bone change the biology. A second microfracture rarely outperforms a step up to grafting. When prior allograft collapsed due to malalignment, a calcaneal osteotomy or distal tibial realignment to offload the medial or lateral dome might be the key to making the next graft succeed.
Outcomes, numbers, and honest probabilities
If you ask ten orthopedic foot and ankle surgeons for a number, you will hear ranges, and for good reason. Variability in lesions and patients defies a single percentage. Still, experience and published data point in consistent directions. Microfracture in small, contained ankle lesions shows good to excellent outcomes in roughly 70 to 85 percent at midterm follow‑up, with some decline after 5 to 10 years as fibrocartilage deteriorates under load. Osteochondral autograft in appropriately sized lesions reports success rates in the 80 to 90 percent range, with low revision rates, and knee donor site symptoms in a minority. Fresh osteochondral allograft for larger lesions can deliver similar satisfaction when the graft integrates, although graft survival is sensitive to alignment and cyst burden. Focal metallic implants help select patients who have failed prior biologic attempts, but long‑term durability data in the ankle are still evolving.
These numbers are guideposts, not guarantees. I make a point of discussing what success means day to day. Can you play with your kids without paying the price that night? Can you return to your job without swelling by noon? Can you go back to your sport at a level that feels like you? A surgeon for complex foot and ankle surgery keeps those markers in mind rather than chasing perfect MRI images.
Who should do the surgery
Cartilage work in the ankle is technical, and the margin for error is narrow. A foot and ankle fellowship trained surgeon who performs arthroscopic ankle surgery weekly will be attuned to details that matter. A podiatric surgeon with extensive arthroscopic experience can be equally skilled. Ask about volume, outcomes, and how often they use each technique. If you have coexisting deformity or old fractures, a foot reconstruction surgeon or ankle reconstruction surgeon with trauma experience may be the best fit. Board‑certification is one marker. More important is thoughtful planning and a rehabilitation program that feels tailored, not templated.
Keywords like foot and ankle specialist, orthopedic foot and ankle surgeon, and ankle surgery specialist can blur in online searches. You will find orthopedic surgeons for ankle, podiatric surgeons, and hybrid practices. Focus on the surgeon’s case mix and comfort with microfracture, grafting, and implants, not just the title. Patients with ligament laxity benefit from someone who is also an ankle ligament surgeon. Those with previous fractures or alignment issues should see a surgeon who handles ankle trauma and corrective osteotomies.
The role of alignment, footwear, and everyday choices
Even the best cartilage repair struggles under a tilted load. A subtle cavus foot that overloads the lateral talar dome, or a valgus hindfoot that drives the medial dome, can sabotage an Jersey City, New Jersey foot and ankle surgeon otherwise sound operation. I examine standing alignment carefully. A simple heel lift or lateral wedge in a flexible cavus foot can redistribute load instantly. Stiffer deformities may need surgical correction by a flatfoot surgeon or high arch foot surgeon to protect the joint. Shoes matter. A stable heel counter, a slight rocker sole, and cushioning that matches body weight are not fashion notes, they are engineering.
Daily habits count. Uneven trails and repetitive cutting movements make an early comeback riskier. Cycling, swimming, rowing, and strength training maintain fitness without punishing the talus during the healing phase. Patients who buy into this philosophy do better, not just at six months, but at two years when they have layered durable patterns over their operation.
A brief look at costs and logistics
Patients often ask about costs and insurance coverage. Microfracture and standard arthroscopy are generally covered with predictable facility and professional fees. Osteochondral autograft adds operative time and potentially a knee harvest, but not implant costs. Fresh allografts and certain implants introduce graft costs and vendor coordination. Lead time for an allograft can vary from a week to several months depending on size. I start that process early if it is on the table so we do not waste valuable training time waiting for a call.
Time away from work depends on job demands. Desk work can resume within one to two weeks for many. Standing occupations need accommodations until protected weight bearing ends. Heavy labor waits longer. A foot and ankle surgery consultant can help with paperwork and realistic timelines to avoid friction with employers.
What fails, and what we do then
Persistent pain after microfracture in a well selected lesion usually falls into one of a few buckets. The lesion was bigger or uncontained, the subchondral bone was not addressed, the ankle remained unstable, or the rehab timeline collapsed under life demands. Imaging guides the next step. For a small unhealed lesion without cysts, an augment with scaffold or a switch to osteochondral plug often solves it. For a cystic, large or shoulder lesion, fresh allograft or a focal implant takes the lead. If arthritis has developed, we talk frankly about joint‑level solutions, including ankle fusion or replacement with an ankle replacement surgeon.
Graft failures are less common but more consequential. A graft that never integrates shows pain with weight bearing, persistent bone edema on MRI, and a Additional resources lack of bony bridging on CT. Tobacco, poor vitamin D, or early overload are usual suspects. Sometimes we revise with bone grafting and protected weight bearing. If the cartilage cap remains viable, salvaging is possible. If not, a staged approach or implant enters the discussion.
Final thoughts from the clinic room
Cartilage surgery in the ankle is not a one‑size decision. It is a careful match of defect biology, patient goals, and surgeon skill. Microfracture is a workhorse for small, contained lesions when rehab is respected. Grafts are powerful for larger or cystic craters, with choices between using your own tissue or a carefully matched donor. Implants fill gaps in revision and large focal defects when grafts are not practical or have failed. The rest of the plan, from ligament stability to alignment to footwear, matters just as much.
The best outcomes I see come from patients who partner fully in the process. They do the small boring things that protect the big surgical moves. They ask good questions, keep appointments, and tell me when something does not feel right. With that collaboration, an ankle that once punished every step can find its glide again, not with a miracle, but with a series of right calls made at the right time by an experienced foot and ankle doctor.