To investigate knowledge, attitude and practice (KAP) of patients with ankle injury regarding osteochondral lesions of the talus (OLT).

A cross-sectional study.

Between March and September 2023, at the Ninth People’s Hospital of Wuxi, affiliated with Soochow University.

Among patients with OLT.

KAP scores and associated factors.

Data were collected through a researcher-designed, validated questionnaire with four dimensions (sociodemographic characteristics, knowledge, attitude and practice). Structural equation modelling (SEM) was applied to explore associations among variables.

A total of 537 valid (valid rate: 78.85%) questionnaires were obtained from the responders who were aged 27.18±11.01 years, with 151 (28.12) males. The mean KAP scores were 17.28±4.84 (possible range: 0–28), 29.44±4.21 (possible range: 9–45) and 18.01±5.39 (possible range: 6–30), respectively. SEM revealed that employment (employed vs unemployed, β=1.33, p=0.002), had medical insurance (β=1.19, p=0.019) and with a history of ankle sprains (β=1.08, p=0.009) exhibited positive direct effects, while whether with cartilage injury of the talus (no vs yes, β=−0.73, p=0.001) had negative direct effect on knowledge. Additionally, knowledge (β=0.08, p=0.032) showed positive direct effects, while gender (males vs females, β=−1.81, p<0.001) showed negative direct effects on attitude. Furthermore, knowledge (β=0.38, p<0.001), attitude (β=0.18, p<0.001), had medical insurance (β=1.05, p=0.045) and had recovered from an ankle injury (β=1.38, p=0.025) exhibited positive direct effects on practice.

Patients with ankle injury had inadequate knowledge, negative attitude and inactive practice toward OLT. Gender, job, medical insurance, cartilage injury of the talus, history of ankle sprains and recovery from ankle injury influenced their KAP.

All data relevant to the study are included in the article or uploaded as supplementary information.

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Osteochondral lesions of the talus (OLT), recognised as an increasingly common injury, are one of the major challenges in orthopaedic surgery, often resulting from acute ankle trauma.1 2 These lesions involve the articular cartilage of the talus and associated subchondral bone, and they occur in up to 73% of all ankle fractures, 50% of ankle sprains and 41% of ankles with lateral instability.3 4 The talus’s small articular surface, combined with its exposure to high loads, makes it particularly susceptible to such degenerative lesions.5 These injuries, characterised by cartilage degeneration, lead to joint pain and destruction, presenting a significant hurdle in orthopaedic care.6 Additionally, OLT remains a common and challenging issue in the field, often encountered in the context of ankle injuries, particularly in sports medicine.7 8 Effective management and treatment strategies for these lesions are vital in providing the best possible care and outcomes for patients with OLT.

A knowledge, attitude and practice (KAP) survey is a valuable tool for assessing patients’ understanding, beliefs and behaviours regarding health conditions.9–11 Given that OLT can result in significant discomfort and negative impact on quality of life, understanding patients’ KAP is critical for improving clinical communication, addressing misconceptions and refining treatment strategies.12

However, limited studies have explored patients’ KAP regarding OLT, leaving a gap in understanding how knowledge and attitudes influence their behaviours toward diagnosis and treatment. This study aimed to investigate the KAP of patients with ankle injuries regarding OLT and identify factors influencing these dimensions.

Initially, a total of 648 questionnaires were collected. After data cleaning, the following questionnaires were excluded: (1) 58 questionnaires with response time less than 90 s; (2) 48 questionnaires with logical errors, such as abnormal age, height and weight value, and for multiple choice questions, such as ‘Do you have any underlying or chronic medical conditions?’, while selecting ‘none’ and any other disease option; (3) 5 questionnaires from respondents under 18 years old. Finally, 537 valid (valid rate: 82.87%) questionnaires remained. Respondents’ average age was 27.18±11.01 years, with 151 (28.12) males. Their mean KAP scores were 17.28±4.84 (possible range: 0–28), 29.44±4.21 (possible range: 9–45) and 18.01±5.39 (possible range: 6–30), respectively (table 1). Moreover, the knowledge and practice scores varied from patients with medical insurance states (p=0.005 and p=0.033), history of ankle sprains (p=0.026 and p=0.001), with diffuse tender points around the ankle joint (p=0.020 and p=0.002), with an injury to the calcaneal cartilage (both p<0.001) and whether recovered (p=0.025 and p=0.005). Meanwhile, the knowledge score varied from patients with different employment (p<0.001), monthly per capita income (p<0.001) and alcohol consumption (p=0.047). Attitude scores were more likely to differ by gender (p<0.001). Practice scores differed by gender (p=0.010), education (p=0.028), employment (p=0.033), monthly per capita income (p<0.001) and smoking states (p=0.028) (online supplemental table S1).

The distribution of knowledge dimensions revealed that the question with the highest number of participants choosing the ‘Correct’ option (K5: ‘Understanding that OLT requires early medical intervention to prevent progression’) was 48.23%. On the contrary, the question with the highest number of participants choosing the ‘Unclear’ option (K7: ‘Awareness of the potential for cartilage regeneration in OLT’) was 60.89% (online supplemental table S2). Regarding attitudes, a significant portion (56.43%) of respondents recognised the significance of ankle sprains, emphasising that they should not be taken lightly (A1). Acceptance of minimally invasive arthroscopic treatment was shown by 38.36% of respondents, perceiving it as having minimal trauma and low risk (A7). Nearly half (45.81%) strongly agreed or agreed that it is necessary to visit the hospital for potential OLT after an ankle sprain (A8). A substantial majority (49.54%) expressed their willingness to gain a comprehensive understanding of the emergency treatment and daily management of OLT (A9) (online supplemental table S3). Participants demonstrated varied behavioural practices; 39.11% of the participants mentioned prioritising rest to alleviate strain on the ankle and reduce the risk of calcaneal cartilage injury (P3). A substantial 56.61% of respondents reported their inclination to base their treatment decisions on medical advice (P5). Interestingly, 31.48% of participants expressed their openness to considering minimally invasive surgery as a treatment option (P6), while only 5.77% stated they would never consider it (online supplemental table S4).

Pearson’s correlation analysis showed that the correlation between knowledge and attitude (r=0.076, p=0.077) was not statistically significant, while significant positive correlations were observed between knowledge and practice (r=0.382, p<0.001) and between attitude and practice (r=0.220, p<0.001) (online supplemental table S5). The SEM analysis indicated a highly favourable model fit, affirming a well-fitting model (online supplemental table S6). It revealed that employment (employed vs unemployed, β=1.33, p=0.002), had medical insurance (β=1.19, p=0.019) and with a history of ankle sprains (β=1.08, p=0.009) exhibited positive direct effects, while whether with cartilage injury of the talus (no vs yes, β=−0.73, p=0.001) had a negative direct effect on knowledge. Additionally, knowledge (β=0.08, p=0.032) showed positive direct effects, while gender (males vs females, β=−1.81, p<0.001) showed negative direct effects on attitude. Furthermore, knowledge (β=0.38, p<0.001), attitude (β=0.18, p<0.001), had medical insurance (β=1.05, p=0.045) and had recovered from ankle injury (β=1.38, p=0.025) exhibited positive direct effects on practice (table 2 and figure 1). In addition, multivariate logistic regression showed that employed (OR=1.667, 95% CI: 1.100 to 2.528, p=0.016), history of ankle sprains (OR=1.603, 95% CI: 1.057 to 2.434, p=0.026) and diffuse tender points around the ankle joint (OR=1.713, 95% CI: 1.009 to 2.911, p=0.046) were independently associated with knowledge (online supplemental table S7 and table 3). Knowledge (OR=1.050, 95% CI: 1.007 to 1.094, p=0.022) and age (OR=0.974, 95% CI: 0.947 to 0.999, p=0.048) were independently associated with attitude (online supplemental table S7 and table 4). Furthermore, knowledge (OR=1.114, 95% CI: 1.060 to 1.171, p<0.001), attitude (OR=1.114, 95% CI: 1.085 to 1.209, p<0.001) and with cartilage injury of the talus (OR=5.584, 95% CI: 1.991 to 15.813, p=0.001) were independently associated with practice (online supplemental table S7 and table 5).

This study highlights that patients with ankle injuries demonstrated limited knowledge, negative attitudes and insufficient proactive behaviours toward OLT. These findings suggest that addressing knowledge deficits and misconceptions is crucial for improving patient outcomes. To our knowledge, this is the first study to comprehensively explore the interrelationship between KAP of patients with ankle injury towards OLT and associated influencing factors using SEM. This study suggests our findings support implementing educational programmes to improve patient knowledge, addressing misconceptions and encouraging early intervention and active participation in treatment.

Our study highlights that prior ankle injuries and exposure to related conditions were associated with higher knowledge levels. However, misconceptions about the regenerative capacity of cartilage and the perceived insignificance of ankle sprains remain prevalent. Tailored educational initiatives addressing these gaps could enhance patient understanding and early intervention.14 Moreover, efforts should focus on dispelling misconceptions and fostering more positive attitudes toward treatment and rehabilitation.15 Additionally, ensuring access to adequate medical insurance coverage can mitigate financial barriers that might otherwise hinder patients’ access to necessary care.16–18

Our findings highlight several key factors that influenced patient outcomes, including employment status, history of ankle sprains, presence of cartilage injury and medical insurance coverage. Specifically, employed patients showed better knowledge scores, those with prior ankle sprains demonstrated higher awareness, while patients with cartilage injury had different practice patterns. Additionally, patients with medical insurance (defined as having active health insurance coverage vs paying out-of-pocket) showed more proactive behaviours in seeking care. Key factors such as employment, financial status and prior injury history were found to influence patients’ knowledge, attitudes and practices. Previous studies have also highlighted the impact of BMI, age, lesion size and anatomical location on patient-reported outcomes and quality of life in symptomatic OLT cases.19 Notably, patients with medical insurance demonstrated more proactive behaviours, underscoring the importance of addressing financial barriers to ensure equitable access to care. These results emphasise the importance of tailoring patient education and awareness campaigns to specific demographic and health-related factors to bridge the knowledge gap.14 20 The association between medical insurance coverage and practice scores underlines the significance of ensuring financial accessibility to medical care for patients.21 22

This study adds to the literature by identifying specific misconceptions and uncertainties regarding OLT among patients. For example, patients often underestimated the chronic nature of the condition or delayed seeking professional care. While some respondents demonstrated a basic awareness of the term ‘OLT’, the specific details regarding the location, function, symptoms and treatment of OLT were less clear to many. Several misconceptions and uncertainties were evident, such as the misconception that calcaneal cartilage can regenerate and the underestimation of the chronic nature of these injuries. This limited knowledge underscores the need for comprehensive patient education initiatives, emphasising accurate information about OLT, their management and potential long-term consequences.16 23 24 Ensuring that patients have a correct understanding of this topic is essential for improving clinical practice, enabling early recognition, prompt intervention and better long-term outcomes for patients with OLT.25 26

Attitudes toward OLT were influenced by demographic factors, with certain groups more likely to perceive ankle injuries as minor and self-healing. Such perceptions may delay necessary interventions. Encouraging evidence-based treatment choices and addressing these attitudes through patient education is essential for improving clinical outcomes. For example, a significant proportion of respondents consider ankle sprains as minor injuries, potentially leading to a lack of attention and delayed intervention when OLT are associated with such sprains. The belief that OLT can heal on their own and that self-medication can expedite recovery might discourage patients from seeking professional medical care promptly. On the positive side, a considerable number of respondents seem to be open to minimally invasive arthroscopic treatment, indicating potential acceptability of this approach in clinical practice. These findings underscore the importance of addressing and redirecting potentially detrimental attitudes through patient education and awareness campaigns. Encouraging a more informed, proactive and open-minded approach to OLT is essential for improving clinical practice and ultimately patient outcomes.27–29

Patient practices revealed room for improvement, particularly in seeking timely medical care and adhering to professional treatment advice. While intentions to learn about OLT were evident, translating these intentions into effective actions remains a challenge. Educational efforts should focus on bridging this gap to foster evidence-based management practices. Notably, there is room for improvement in several areas to enhance clinical practice. While a substantial percentage of respondents express their intention to proactively learn about OLT, it is crucial to ensure that these intentions translate into informed actions.30 31 Going to the hospital for a check after an ankle injury is a positive practice, but more patients could adopt this approach. However, there is still room for improvement, especially in ensuring that patients choose treatment plans based on medical advice. Overall, these results emphasise the need for patient education that fosters informed decision-making, promotes best practices in the management of OLT and encourages patients to follow medical recommendations, ultimately contributing to improved clinical outcomes.32 33

The observed associations between knowledge, attitudes and practices reaffirm the interconnected nature of these dimensions. Enhancing patient knowledge may lead to improved perceptions and more proactive behaviours, which are critical for effective management of OLT. Our findings further suggest that interventions addressing knowledge gaps could have a cascading positive impact on attitudes and practices.34 Similarly, the correlation between attitude and practice highlights the interconnected nature of these aspects. The SEM analysis reveals that employment, medical insurance, a history of ankle sprains and the presence of a calcaneal cartilage injury directly impact knowledge. Moreover, knowledge and gender directly affect attitude, and knowledge, attitude, medical insurance and recovery from ankle injury directly influence practice. These understandings can inform tailored interventions aimed at enhancing clinical practice by addressing these influential factors and fostering more informed, positive and proactive patient engagement in the management of OLT.35 36

This study had limitations, including its single-centre, regional focus, potentially limiting the generalisability of findings; the cross-sectional design’s inability to establish causality or track changes over time; reliance on self-administered questionnaires, which may introduce response bias and interpretation inaccuracies; the possibility of social desirability bias in participant responses; limited demographic information, hindering the exploration of influential factors; the complexity of interpreting SEM results; and the absence of long-term follow-up, which could provide insights into changes in patients’ KAP.

In conclusion, this study identifies significant gaps in knowledge, attitudes and practices related to OLT. By highlighting the role of demographic and clinical factors, such as prior injury history and medical insurance, this study underscores the need for targeted interventions to address misconceptions, improve patient education and promote timely care. Knowledge, attitude, gender, employment, medical insurance, cartilage injury of the talus, history of ankle sprains and recovery from ankle injury might have an effect on their KAP. To improve patient outcomes and care in this context, targeted interventions are warranted. Healthcare providers should focus on increasing patients’ knowledge about OLT, potentially through educational programmes and materials. Moreover, efforts should be made to foster a more positive attitude among patients by addressing their concerns and misconceptions. Encouraging early intervention and active participation in treatment and rehabilitation should be a key objective. Lastly, it is crucial to emphasise the significance of medical insurance coverage for these injuries, ensuring that financial barriers do not hinder access to appropriate care.

All data relevant to the study are included in the article or uploaded as supplementary information.