Avascular Necrosis of the Tibial Plafond Following Rotational Ankle Fractures

Treatment of Post-traumatic Osteonecrosis in the Distal Tibia With Autologous Bone Grafting: A Case Report

Osteonecrosis is a disruption of blood supply to the bone which results in bone cell death. Post-traumatic osteonecrosis of distal tibia rarely happens as compared to osteonecrosis which affects other parts of the musculoskeletal system. We report a case of osteonecrosis of distal tibia in an adult male following an open fracture dislocation of the right ankle. Initial surgery of wound debridement with a temporary external fixator was performed for ankle stabilization. The patient underwent internal fixation once the subcutaneous tissue was deemed suitable. A year later, he had worsening ankle pain which affected his daily activities. Magnetic resonance imaging showed osteonecrosis of the distal tibia, osteochondral injury of the medial tibial plafond, and medial talus with lateral ligament complex injuries. Autologous iliac bone grafting was applied to the distal tibia and a cell-free hyaluronic acid-based scaffold (Hyalofast®) was used to address the bone osteonecrosis and osteochondral injury respectively. Visual analog score (VAS), AOFAS hindfoot score, and ankle range of motion improved at three months and significantly increased after six months and one year post-operatively.

ACR Appropriateness Criteria® Osteonecrosis: 2022 Update

Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.