Avascular necrosis of the talus: current treatment options

Influence of Talar and Calcaneal Morphology on Subtalar Kinematics During Walking

BACKGROUND

Cadaver biomechanical testing suggests that the morphology of articulating bones contributes to the stability of the joints and determines their kinematics; however, there are no studies examining the correlation between bone morphology and kinematics of the subtalar joint. The purpose of this study was to investigate the influence of talar and calcaneal morphology on subtalar kinematics during walking in healthy individuals.

METHODS

Forty ankles (20 healthy subjects, 10 women/10 men) were included. Participants walked at a self-selected pace while synchronized biplane radiographs of the hindfoot were acquired at 100 images per second during stance. Motion of the talus and calcaneus was tracked using a validated volumetric model-based tracking process, and subtalar kinematics were calculated. Talar and calcaneal morphology were evaluated using statistical shape modeling. Pearson correlation coefficients were used to assess the relationship between subtalar kinematics and the morphology features of the talus and calcaneus.

RESULTS

This study found that a shallower posterior facet of the talus was correlated with the subtalar joint being in more dorsiflexion, more inversion, and more internal rotation, and higher curvature in the posterior facet was correlated with more inversion and eversion range of motion during stance. In the calcaneus, a gentler slope of the middle facet was correlated with greater subtalar inversion.

CONCLUSION

The morphology of the posterior facet of the talus was found to a primary factor driving multiplanar subtalar joint kinematics during the stance phase of gait.

CLINICAL RELEVANCE

This new knowledge relating form and function in the hindfoot may assist in identifying individuals susceptible to subtalar instability and in improving implant design to achieve desired kinematics after surgery.

Total Talus Replacements

Background

Total talus replacements are a surgical treatment for talar avascular necrosis (AVN) replacing the entire talus. The potential for total talus replacements has increased with the advent of patient-specific implants using 3D printing based on computed tomographic scanning of the ipsilateral or contralateral talus. The primary aim of this review is to summarize the literature on total talus replacements, providing a historical survey, indications, controversies, complications, survival, and functional outcomes.

Methods

A systematic review was performed. Articles with survival of total talus replacements were included. Basic percentages and a critical review of the literature was performed.

Results

Nine articles with 115 patients were included. The mean age ranged from 27.6 to 72 years, but with 5 studies having a mean age of <50 years. Mean follow-up ranged from 12.8 to 152 months. The most common indication was avascular necrosis in 67 patients (58%). Five studies used customized implants and 4 studies used 3D printing. Four studies used ceramic prostheses, 3 cobalt chromium, 1 stainless steel, and 1 titanium with ceramic surface. Three studies involved a talus replacement in conjunction with an ankle replacement. Postoperative complications ranged from 0% to 33%. Of 24 functional outcomes scores, 66.7% demonstrated significant improvement.

Conclusion

Total talus replacements are a promising alternative to tibiotalocalcaneal fusion for patients with avascular necrosis of the talus; however, further studies are required to ensure reliable outcomes prior to widespread adoption of this technology.

Level of Evidence

Level IV, review of case series.

The stability of total talar prosthesis-How stable to dislocation? Cadaveric study

The aim of this study was to characterize ankle stability of total talar prosthesis (TTP) and to determine the effect of implant sizes on stability as well as the resistance to TTP dislocation. Twelve below-knee cadaveric specimens were divided into two groups. Group 1 received a size matched implant and Group 2 received downsized implant by 5%. The stability assessment under fluoroscopy was performed for each cadaver in its native state. Following TTP insertion process, each then underwent evaluation of the TTP ankle stability. The stability of pre- and post-TTP was compared. (1) Anterior drawer distance. (2) Talar tilt angle under varus and valgus stress. (3) Subtalar tilt angle under varus stress was measured. Finally, the dislocation test was performed using the aforementioned testing conditions, then the stress force was slowly increased from 0 to 350 N, during which time it was observed on fluoroscopy all the time. Compared to pre TTP ankles, varus and anterior drawer stress showed significant instability (p < 0.001-0.031). Only anterior drawer stress in smaller sized implants showed significant instability when compared to identical sized implants (p = 0.008). No dislocation was seen under varus, valgus, and subtalar stress. However, anterior dislocation was observed in all cases of smaller size implant group (p = 0.045). TTP implant was stable under valgus and subtalar stress. However, clinicians should pay attention to anterior instability. Notably, downsized implants should be considered carefully to minimize the chance of anterior dislocation.

Avascular Osteonecrosis of the Talus: Current Treatment Strategies

Avascular osteonecrosis (AVN) of the talus (AVNT) is a painful and challenging clinical diagnosis. AVNT has multiple known risk factors and etiologies and presents at different stages in severity. Given these unique factors, the optimal treatment solution has yet to be determined. Both joint-preserving and joint-sacrificing procedures are available, including core decompression and arthrodeses. Recently, new salvage and replacement techniques have been described including vascularized pedicle bone grafts and total talus replacement using patient-specific prosthesis; however, evidence remains limited. This review examines the current trends AVNT treatment and the emerging data behind these novel techniques.

The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects-Results of a New Technique in Tibiotalocalcaneal Arthrodesis

Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m². All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.

Anatomical basis of a pedicled cuboid bone graft based on the lateral tarsal artery for talar avascular necrosis

PURPOSE

Vascularized pedicled bone-grafting from the cuboid to the talus provides low donor site morbidity and satisfactory outcomes in patients with early-stage talar avascular necrosis. We investigated the anatomy of the rotational vascularized pedicled bone graft from the cuboid.

METHODS

15 embalmed cadaver specimens were perfused with red latex via the popliteal artery. The lateral malleolus was dissected. The course of the lateral tarsal artery and the vascular territory in the cuboid supplied by the lateral tarsal artery were observed. Vessel diameters were measured.

RESULTS

The course of the lateral tarsal artery to the cuboid was consistent, and a vascularized pedicle of the lateral tarsal artery was present in all specimens. Mean diameter of the lateral tarsal artery was 1.40 ± 0.12 mm (range 1.67-1.25). Mean length of the vascularized pedicle was 67.15 ± 3.18 mm (range 62.43-74.36). The pedicle bone graft was long enough to reach the bony border of both the lateral and medial malleolus.

CONCLUSION

A vascularized pedicled cuboid bone graft based on the lateral tarsal artery has clinical utility for early-stage talar avascular necrosis.

Early Outcomes of 3D Printed Total Talus Arthroplasty

BACKGROUND

Patients with talar avascular necrosis (AVN) have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTRs) has arisen as a treatment option for these patients, possibly allowing better preservation of hindfoot motion. We hypothesized that patients undergoing TTR will demonstrate a statistically significant improvement in Foot and Ankle Outcome Score (FAOS) at 1 year after surgery.

METHODS

We retrospectively reviewed 15 patients who underwent a TTR over a 2-year period. Patient outcomes were reviewed, including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, radiographic alignment, FAOS and Visual Analog Scale (VAS) score, and range of motion. Data analysis was performed with Student t-tests and multivariate regression.

RESULTS

FAOSs and VAS scores showed statistically significant improvements postoperatively as compared with preoperative scores. There was a statistically significant decrease in VAS pain scores from 7.0 preoperatively to 3.6 (P < .001). Average follow-up was 12.8 months. With the number of patients available, there was no statistically significant change in radiographic alignment parameters postoperatively as compared with preoperatively (P values ranged from .225 to .617).

CONCLUSION

Our hypothesis that these patients show statistically significant improvements in FAOSs at 1 year was confirmed. TTR represents an exciting treatment option for patients with talar AVN, though longer-term follow-up is needed.Level of Evidence: Level IV: Case series.

The role of external fixation in the management of infected avascular necrosis after traumatic talus fractures

PURPOSE

Avascular necrosis (AVN) after fractures of the talus is a distinct and challenging clinical entity that is associated with poor outcomes. Although several articles are published on the management of posttraumatic AVN of the talus, very little is known about the management of infected AVN after talus fractures. Therefore, three cases of infected AVN were treated successfully by extensive debridement, external fixation and arthrodesis.

METHODS

Three cases of infected AVN of the talus were encountered after a mean of 3 months (range 2-6 months) after initial reconstructive surgery. Suspected infection was confirmed by positron emission tomography scan (PET-CT). Management involved extensive debridement, PMMA cement if necessary and final fusion using medial external fixator, accompanied by culture guided antibiotics. Functional outcome was assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot and Ankle Society hindfoot score (AOFAS). Quality of life (QOL) was measured by the EuroQol-5D (EQ-5D).

RESULTS

After a mean follow up of 24 months (range 13-29), FFI index scores ranged from poor to good (23, 50, 56) with similar AOFAS scores indicating poor to fair functional outcome (38, 41, 71). The EQ-5D score was 0.78. Overall patient satisfaction was high with a mean VAS of 8.3 (range 8-9).

CONCLUSION

Infected talar AVN is a rare condition associated with severe long-term morbidity in term of joint function. The authors recommend extensive debridement and arthrodesis by means of external fixation, followed by post-operative culture-guided antibiotics for the treatment of infected avascular necrosis of traumatic talar fractures. Shared decision-making and expectation management are of crucial importance and may lead to high patient satisfaction despite low functional outcomes.

LEVEL OF EVIDENCE

IV, Retrospective case series.

Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology

Background:

Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone.

Methods:

A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months).

Results:

The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 ( P = .017) and prior arthrodesis ( P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively ( P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 ( P < .001).

Conclusion:

The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes.

Level of Evidence:

Level IV, retrospective case series.

Avascular Necrosis of the Tibial Plafond Following Rotational Ankle Fractures

Avascular necrosis (AVN) following rotational ankle fractures is most commonly described in the talus; however, it can also occur in the tibial plafond. These sequelae of ankle fractures are rarely described in the literature. Diagnosis of AVN is best confirmed with MRI of the involved extremity. Treatment options range from conservative treatments such as observation and limited weight-bearing to surgical management including percutaneous drilling, ankle arthrodesis, and total ankle arthroplasty. More research is needed to further identify patients at high risk for developing these sequelae of ankle fractures and to aid in the treatment and surgical decision-making process.

Core Decompression and Bone Grafting for Osteonecrosis of the Talus: A Critical Analysis of the Current Evidence

Several operative treatments have been explored to treat patients with progressive or symptomatic osteonecrosis of the talus, aiming to alleviate pain and restore mobility. Because most affected patients are typically younger and more active individuals, joint preservation techniques have received increasing attention. Core decompression, either through an open or percutaneous drilling approach has been used. Similarly, nonvascularized and vascularized bone grafts have been used in clinical practice with varying results. Owing to the relative paucity of studies, in this review we aimed to investigate the use of (1) core decompression and (2) bone grafting for treating osteonecrosis of the talus.

Ankle Arthrodesis for Talar Avascular Necrosis and Arthrodesis Nonunion

This article reviews the surgical treatment of talar avascular necrosis. Specifically, arthrodesis for this complex entity and potential treatment of nonunions are discussed. The hallmarks of treatment are evolving and can range from nonoperative measures to amputations. Nonoperative treatment and the results of current arthrodesis techniques for late-stage avascular necrosis are reviewed. Surgical correction requires an understanding of the condition's natural history, utilization of structural and nonstructural bone grafting techniques, and stable fixation. Although the methods described follow standard orthopedic principles, high-quality evidence and outcome studies are limited for treatment of this challenging and often disabling condition.

Tibiotalocalcaneal Arthrodesis for Severe Talar Avascular Necrosis

Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.

An Alumina Ceramic Total Talar Prosthesis for Avascular Necrosis of the Talus

Avascular necrosis tends to occur in the talus because of poor blood supply caused by the extended coverage to the articular cartilage on its surface. Treatment is conservative in the earlier stage of this disease; however, surgical treatment is usually indicated in the advanced stage. Nonunion, leg length discrepancy, or hindfoot instability may occur in patients treated with ankle or tibio-talo-calcaneal fusion. Arthroplasty using a customized total talar prosthesis designed using the computed tomography image of contralateral talus has the potential advantages of weightbearing in the earlier postoperative phase, prevention of lower extremity discrepancy, and maintenance of joint function.

Custom 3D-Printed Total Talar Prostheses Restore Normal Joint Anatomy Throughout the Hindfoot

BACKGROUND:

Third generation total talar prostheses (TTPs) are viable options for talar avascular necrosis (AVN) in the absence of neighboring joint pathology. The use of modern three-dimensional (3D) printing allows the production of custom implants that exactly mimic the patient's anatomy. The aim of this study is to determine the accuracy of 3D printing in reproducing a synthetic talus and, in doing so, restoring more normal anatomical relationships. We hypothesize that this mode of replication will restore and maintain normal radiographic alignment of the ankle, subtalar, and forefoot joints in the setting of talar AVN.

METHODS:

A retrospective analysis was performed on all patients undergoing TTP implantation for the treatment of talar AVN between 2016 and 2017. Radiographic measurements were taken preoperatively and postoperatively to determine native talar dimensions, TTP implant dimensions, and the corresponding radiographic alignment about the forefoot, hindfoot, and ankle.

RESULTS:

A total of 14 patients were identified in our cohort. Talar arc length and width were not found to be significantly changed; however, talar height was significantly increased with use of TTP. Five alignment dimensions were measured, of which, only talar tilt angle was significantly changed. Instances of Meary's angle correction were observed in cavus and planus foot deformity.

CONCLUSION:

As a proof of concept, 3D-printed TTP was successful in restoring talar height and talar tilt in the setting of AVN. Additionally, the procedure maintained normal alignment in nonpathological joints. TTPs, based on our cohort, are a viable option to restore more normal anatomical alignment.

LEVELS OF EVIDENCE:

Level IV: Case series.

Management of Nonunited Talar Fractures With Avascular Necrosis by Resection of Necrotic Bone, Bone Grafting, and Fusion With an Intramedullary Nail

BACKGROUND

The presence of nonunion of a talar fracture with displacement, together with complete avascular necrosis, is a challenging entity to treat.

METHODS

Twelve patients, 8 men (66.7%) and 4 women (33.3%), with nonunited talar fractures and extensive avascular necrosis of the talus were included. The average age was 27.7 years (range, 19-38 years). After exclusion of infection, the patients underwent resection of necrotic bone, bulk autograft, and fusion using an intramedullary nail. The posterior approach was used in 11 patients and the anterior approach in 1 patient. The primary outcome was solid osseous union at the ankle and subtalar level and between the talar head anteriorly and the posterior construct, as evidenced by computed tomographic examination. Functional assessment was performed with the American Orthopaedic Foot & Ankle Society score and subjective patient satisfaction Results: After a mean follow-up duration of 23 months (range, 12-60 months), solid osseous union was achieved in 8 patients (66.7%). Stable fibrous union was seen in 1 patient (8.3%). Three patients (25%) required reoperation, and osseous fusion was finally achieved. American Orthopaedic Foot & Ankle Society score improved from a mean of 39.3 (range, 12-56) preoperatively to 76.6 (range, 62-86) at last follow-up. Subjective patient satisfaction was graded good or excellent in all cases.

CONCLUSION

Resection of necrotic talar body and bulk autograft with tibiotalocalcaneal fusion by an intramedullary nail through a posterior approach was a reasonable option for the management of type IV posttraumatic talar deformity.

LEVEL OF EVIDENCE

Level IV, case series.

Vascularized Pedicle Bone-Grafting from the Cuboid for Talar Osteonecrosis: Results of a Novel Salvage Procedure

BACKGROUND

Osteonecrosis of the talar body represents a complex clinical challenge with treatment options currently limited to core decompression, vascularized and nonvascularized bone-grafting, total talar replacement, and hindfoot arthrodesis. Vascularized pedicle bone-grafting from the cuboid to the talus is a potential alternative to contemporary operative options for replacement of necrotic talar tissue with viable bone. We aimed to analyze functional and radiographic outcomes of vascularized pedicle bone-grafting from the cuboid for the treatment of talar osteonecrosis in a consecutive series of patients spanning a 12-year period.

METHODS

Patients with osteonecrosis of the talar body and dome who underwent vascularized pedicle bone-grafting from the cuboid to the talus at our institution between 2003 and 2014 were retrospectively identified. All patients had preoperative radiographs and magnetic resonance imaging (MRI) scans and were monitored postoperatively with serial radiographs and MRI. For generic health-related quality-of-life (HRQoL) assessment, patients were given the preoperative Medical Outcomes Study Short Form-12 (SF-12) and postoperative 36-Item Short Form (SF-36) from which Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were derived and compared before and after surgery.

RESULTS

Thirteen patients were identified and sequentially followed for 2 to 12 years (mean, 6 years). Two patients had failure of treatment and subsequently underwent total ankle replacement, 1 patient had arthroscopic debridement for soft-tissue impingement, and no other patient required secondary surgery. The average PCS score (and standard deviation) significantly improved by 23.3 ± 18.9 points with surgery (p = 0.006), and the average MCS score significantly increased by 39.4 ± 10.1 points (p < 0.001).

CONCLUSIONS

HRQoL outcomes suggest that vascularized pedicle bone-grafting from the cuboid combined with bracing for 1 year may be a viable treatment option for osteonecrosis of the talus that provides good pain relief and improved physical function without necessitating a secondary procedure for the majority of patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Talar Osteonecrosis Related to Adult Sickle Cell Disease: Natural Evolution from Early to Late Stages

BACKGROUND

Little is known about the rate of, and factors affecting, progression of talar osteonecrosis related to sickle cell disease. Adult patients with sickle cell disease who presented with hip osteonecrosis were evaluated for talar osteonecrosis with radiographs and magnetic resonance imaging (MRI). Forty-five of them (75 tali) were diagnosed with talar osteonecrosis, and this group was evaluated for factors influencing the progression of the disease.

METHODS

Forty-five patients with sickle cell disease and osteonecrosis of the talus were identified with radiographs and MRI between 1985 and 1995. Seven of these patients were homozygous for hemoglobin S (S/S genotype), 26 had hemoglobin S/hemoglobin C, and 12 had hemoglobin S/beta-thalassemia. The talar osteonecrosis was graded with radiographs and MRI. The patients were followed with clinical examination and radiographs every 6 months until talar collapse and every year after the collapse.

RESULTS

The osteonecrosis was unilateral in 15 patients and bilateral in 30 at the time of the initial examination. Forty-five ankles were asymptomatic and 30 were symptomatic at the initial evaluation. MRI performed at the time of the most recent follow-up, and compared with MRI performed at diagnosis, did not show partial or total regression of the osteonecrosis in any of the patients, even those with asymptomatic stage-I osteonecrosis. At the time of the most recent follow-up (mean, 20 years; range, 15 to 25 years), pain and collapse had developed in all except 12 ankles. The stage of the osteonecrosis at the initial visit, pain, the genotype of the sickle cell disease, and the extent and location of the lesion in the talus were risk factors for progression of the disease.

CONCLUSIONS

In the majority of the patients with sickle cell disease, osteonecrosis of the talus should be expected to show relevant clinical and radiographic evidence of progression over a long period.

LEVEL OF EVIDENCE

Prospective Level II. See Instructions for Authors for a complete description of levels of evidence.

Arthrodesis of the ankle using an anterior sliding tibial graft for osteoarthritis secondary to osteonecrosis of the talus

Aims

This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus.

Patients and Methods

We reviewed the clinical and radiological outcomes of 27 patients who underwent arthrodesis with either vascularised or non-vascularised (conventional) grafts, comparing the outcomes (clinical scores, proportion with successful union and time to union) between the two groups. The clinical outcome was assessed using the Mazur and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. The mean follow-up was 35 months (24 to 68).

Results

The mean outcome scores increased significantly in both groups. In the vascularised graft group, the mean Mazur score improved from 36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. In the conventional arthrodesis group, the mean Mazur score improved from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. Complete fusion was achieved in 13 patients (76%) in the vascularised group, but only four (40%) in the conventional group. The clinical outcomes and proportion achieving union were significantly better in the vascularised group compared with the conventional arthrodesis group, although time to union was similar in the two groups. Take home message: Vascularised sliding tibial grafts may be used to achieve arthrodesis in patients with OA of the ankle secondary to osteonecrosis of the talus. Cite this article: Bone Joint J 2016;98-B:359–64.

Treatment of extended osteochondral lesions of the talus with a free vascularised bone graft from the medial condyle of the femur

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle. Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration. At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle. Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term.

A new form of surgical treatment for patients with avascular necrosis of the talus and secondary osteoarthritis of the ankle

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.

Arthroscopic ankle fusion for avascular necrosis of the talus

BACKGROUND

Avascular necrosis (AVN) of the talus is a painful condition leading to destruction of the ankle-hindfoot complex. Moderate outcomes and high complication rates are reported in small numbers of advanced disease treated with tibiotalocalcaneal fusion, which has the additional disadvantage of sacrificing both the ankle and subtalar joints. The blood supply of the talus is tenuous, and open procedures risk further talar collapse by disrupting extraosseous vessels. This article reports the outcome of arthroscopic ankle fusion for late-stage AVN of the talus. Our hypothesis was that arthroscopic ankle fusion would relieve symptoms of advanced talar AVN, prevent collapse of the talus, and preserve the subtalar joint.

METHODS

A cohort study was performed on 16 patients with talar AVN treated with arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included perioperative complications, ongoing pain, and further operative intervention. All radiologic investigations were reported independently by a senior radiologist. The average age of the patients was 53.5 years. The presumed causes of talar AVN were steroids, trauma, hematologic disorders, and alcoholism. The etiology was unknown in 7 patients. One patient was lost to follow-up.

RESULTS

Clinical and radiologic fusion at the ankle joint was confirmed in 15 of 15 available patients. Thirteen patients reported resolution of pain at follow-up. Three patients had ongoing pain and underwent a subsequent successful subtalar fusion.

CONCLUSIONS

Arthroscopic ankle fusion was a safe and reliable treatment of symptomatic advanced talar AVN. It was a minimally invasive procedure with minimal complication rate, preserving the talus and sparing the subtalar joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft

BACKGROUND

Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis.

METHODS

Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire.

RESULTS

Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection.

CONCLUSION

Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.

The prognostic value of the hawkins sign and diagnostic value of MRI after talar neck fractures

BACKGROUND

The early diagnosis of avascular necrosis of the talus (AVN) and prediction of ankle function for talar fractures are important. The Hawkins sign, as a radiographic predictor, could exclude the possibility of developing ischemic bone necrosis after talar neck fractures, but its relationship with ankle function remains unclear. The purpose of this study was to illustrate the prognostic effect of the Hawkins sign on ankle function after talar neck fractures and to study the value of early MRI in detecting the AVN changes after talus fractures.

METHODS

Cases of talar neck fractures between November 2008 and November 2013 were evaluated. The occurrences of the Hawkins sign and AVN were studied. X-ray imaging was performed at multiple time points from the 4th to the 12th week after the fractures, and MRI examinations were used in the Hawkins sign negative group, with the time span ranging from 1.5 to 12 months. AOFAS scores of the Hawkins sign positive and negative groups were compared during the follow-up. Forty-four cases (48 feet) were evaluated.

RESULTS

The occurrence of positive Hawkins sign was 50%, 30%, and 33.3%, the incidence of AVN was 0%, 10%, and 50%, respectively, in type I, type II, and type III and IV talus fractures, respectively. The AOFAS scores showed no statistically significant difference between Hawkins sign positive group and negative group in type I and II fractures. The Hawkins sign positive group had better AOFAS scores than the negative group in type III and IV fractures. However, there was no statistically significant difference between Hawkins sign positive and negative groups when AVN cases were excluded in type III and IV fractures.

CONCLUSION

The Hawkins sign was a reliable predictor excluding the possibility of AVN. It did not have predictive value on the ankle function in low-energy fractures and may predict better ankle function in high-energy fractures. MRI can diagnose AVN during an earlier period, and we believe Hawkins sign negative patients should undergo MRI examinations 12 weeks after the fractures, especially in high-energy traumatic cases.

LEVEL OF EVIDENCE

Level III, comparative case series.

Functional and clinical assessment of two ankle arthrodesis techniques

Isolated tibiotalar fusion is the preferred choice for isolated end-stage arthritis, joint destruction after infection, talar avascular necrosis, Charcot neuroarthropathy, and joint replacement failure. Combined tibiotalar and subtalar joint fusion with an intramedullary nail can achieve better alignment and save patients from prolonged non-weightbearing. The purpose of the present study was to functionally assess using instrumental gait analysis and clinically assess the effect of these 2 surgical techniques. Twelve patients with a mean follow-up duration of 70 (range 55 to 89) months after successful ankle fusion were analyzed, 6 isolated and 6 combined. The main outcome measure was the functional assessment performed using a stereophotogrammetric system and an established multisegment foot kinematics protocol. Standard clinical, imaging, and score systems were also assessed in the 2 groups, including radiographic-based classification of arthritic degeneration at the neighboring foot joints. No significant differences were found between the 2 groups using the scoring systems. Severe arthritic degeneration was found at the subtalar joint in the isolated fusion group and at the talonavicular and Lisfranc joints in the combined fusion group. From the gait analysis, no differences were found in the time-distance parameters; however, significant differences were observed in several joint rotations and planar angles. Isolated tibiotalar fusion allows for motion, however small, at the subtalar joint but can result in severe degeneration. Good clinical and functional results can also be obtained with combined tibiotalar and subtalar fusion, although this can result in degeneration of the adjacent joints of the foot.

Percutaneous Drilling for Early-Stage Osteonecrosis About the Ankle

Introduction

The mid-term clinical, patient-reported, and radiographic outcomes of percutaneous drilling to treat early-stage osteonecrosis (without joint collapse) of the distal part of the tibia or of the talus are promising.

Step 1 Preoperative Planning for a Lateral Talar Lesion

Obtain anteroposterior and lateral ankle radiographs as well as magnetic resonance imaging (MRI) studies of the ankle to evaluate the stage of the osteonecrotic disease.

Step 2 Percutaneous Pin Insertion Lateral Talar Lesion

Insert a 1.8-mm Steinmann pin or Ilizarov wire percutaneously under biplanar fluoroscopic visualization.

Step 3 Percutaneous Drilling

Make one, two, or three passes with a 3.2-mm cannulated drill bit over the pin into the lesion(s).

Step 4 Backfilling the Bone Tunnel Optional

Infiltrate the defect with demineralized bone matrix to backfill the drill track and the deep necrotic bone defect.

Step 5 Postoperative Management

The patient bears weight as tolerated in a removable short leg rigid boot for the first four weeks and avoids high-impact activities for at least ten months.

Results

In our study, there were significant improvements in the mean American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score (p = 0.001), University of California Los Angeles (UCLA) activity score (p = 0.025), and visual analog scale (VAS) pain score (p = 0.001) at a mean of five years (range, two to nine years) postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Clinical characteristics of early-stage osteonecrosis of the ankle and treatment outcomes

BACKGROUND

The purposes of this study were to describe the clinical manifestations of osteonecrosis involving the distal tibia and talus, to identify risk factors associated with the disease, and to evaluate the efficacy of percutaneous drilling for the treatment of ankles with early-stage symptomatic osteonecrosis.

METHODS

One hundred and one ankles in seventy-three patients with symptomatic osteonecrosis of the talus and/or distal tibia treated with percutaneous drilling were identified. There were eighty-one ankles in fifty-nine patients treated only at our institution and twenty ankles in fourteen patients with a failed prior core decompression at outside institutions. The parameters evaluated included demographics, disease characteristics, clinical outcomes including the American Orthopaedic Foot & Ankle Society score, Short-Form-36 scores, University of California Los Angeles activity scores, and visual analog scale pain scores, and radiographic outcomes at a mean follow-up duration of five years (range, two to nine years).

RESULTS

Eighty-five ankles had isolated talus osteonecrosis, eleven ankles had involvement of the distal tibia and talus, and five ankles had isolated distal tibial disease. Twenty-nine patients (40%) had initially presented with symptomatic osteonecrosis of another joint, most commonly the knee (37%), the hip (29%), and the shoulder (25%). The most common identifiable risk factors included chronic corticosteroid use (49.3%), alcohol abuse (35.6%), tobacco use (29%), and hypertension (20.5%). Overall, 83% of ankles did not demonstrate further disease progression after the procedure. There were significant improvements (p < 0.05) in clinical and patient-reported outcomes after surgical treatment. The presence of human immunodeficiency virus and sickle cell disease was associated with a higher odds ratio of disease progression to joint collapse.

CONCLUSIONS

Osteonecrosis of the distal tibia and talus was usually part of multifocal disease, and concurrent knee osteonecrosis was more common than hip osteonecrosis. The results of the present study suggest that early-stage ankle osteonecrosis can be treated successfully with percutaneous drilling.

Applications of the medial femoral condyle free flap for foot and ankle reconstruction

BACKGROUND

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology.

METHODS

A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months).

RESULTS

There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively.

CONCLUSIONS

Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Autologous matrix-induced chondrogenesis aided reconstruction of a large focal osteochondral lesion of the talus

The aim of this case report is to describe a novel technique for treatment of large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III membrane.

Avascular necrosis of the talus in a HIV-infected patient

Level of Evidence: V, Expert Opinion

Retrograde intramedullary nail arthrodesis for avascular necrosis of the talus

BACKGROUND

Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail.

MATERIALS AND METHODS

A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint.

RESULTS

Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup.

CONCLUSION

Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

Posttraumatic avascular necrosis of the talus

Avascular necrosis of the talus is one the most challenging problems encountered in posttraumatic reconstruction of the hindfoot. Since the first description of the talus injury in 1608 by Fabricius of Hilden, our knowledge of the talar anatomy, injuries, sequelae, and management has increased significantly. Adequate knowledge of the etiology, the extent of the disease, and the degree of patient symptoms are required to determine optimal treatment.

Ankle arthrodesis: the simple and the complex

Ankle arthrodesis is by no means a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of ankle positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to recognize important patient factors and to determine which type of ankle arthrodesis is most appropriate for that specific patient.

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.