Oblique medial malleolar osteotomy for the management of talar dome lesions

Comparison of two versus three-screw fixation for biplanar chevron medial malleolar osteotomy

PURPOSE

This study was designed to compare the clinical outcomes and complications of using two versus three screws to fix the biplanar chevron medial malleolar osteotomy (MMO).

PATIENTS AND METHODS

A retrospective review was conducted on 43 patients (46 ankles) who underwent biplanar chevron MMO to treat talus osteochondral lesions. Of these, MMO was fixed with two parallel screws placed perpendicular to the osteotomy plane in 16 ankles, while in the remaining 30 ankles, MMO was secured with two parallel screws plus an additional third screw inserted parallel to the tibial plafond. Patients were divided into two groups based on the fixation method and clinical outcomes, union and malunion rates, and complications were compared.

RESULTS

Demographic and clinical characteristics such as age (p: 0.411), gender distribution (p: 0.119), affected side (p: 0.126), lesion grades (p: 0.056), and lesion sizes (p: 0.310), immobilization (p: 0.119) and weight-bearing periods (p: 0.252) were statistically similar across both groups. Initial malreduction were observed in five cases within the three-screw group and one case in the two-screw group (p: 0.307). However, neither group exhibited any progressive step-off or gap in the follow-up radiographs, and osteotomy union was achieved in all patients. Delayed union was observed in one patient from the three-screw group. Significant improvements in American Orthopedic Foot and Ankle Society scores were observed in both groups, with no functional discrepancies evident at the final follow-up (p: 0.488).

CONCLUSIONS

The study found no significant differences in union rates, complications, or clinical outcomes between two and three-screw fixation methods for medial malleolar osteotomies (MMO). Both methods allowed for effective MMO fixation without loss or displacement post-surgery, suggesting their safety and efficacy.

LEVEL OF EVIDENCE

Level III, retrospective comparison.

The role of the oblique medial osteotomy angle during osteochondral fragment fixation in patients with a posteromedial osteochondral lesion of the talus

BACKGROUND

Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy.

METHODS

Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed.

RESULTS

There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°).

CONCLUSIONS

This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.

Dual Approach to Talar Dome Increases Access for Fracture Care Without Osteotomy

BACKGROUND

There is no consensus surgical treatment algorithm for talar body fractures, with authors recommending both soft tissue-only and osteotomy-based approaches. This study evaluates talar dome access via dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches.

METHODS

Ten cadaveric legs (5 matched pairs) were included. An mPM approach, between flexor hallucis longus and Achilles tendon, and an ATL approach, utilizing the anterolateral interval with transection of anterior talofibular ligament and calcaneofibular ligament, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4 mm of tibiotalar distraction using an external fixator. Specimens were analyzed by computed tomography (CT). Primary outcome was accessible DSA. Student t tests compared DSA accessed by different exposure methods.

RESULTS

An initial mPM approach exposed 25.6% and 33.6% of DSA without and with distraction (P = .002). An initial ATL approach accessed 47.0% and 58.1% of DSA without and with distraction, respectively (P = .003). Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach (P = .96 and .37, respectively). The central talar dome was inaccessible in an almond-shaped area, tapered at the medial and lateral ends. Anterior, lateral, and posterior articular margins were able to be fully exposed, often with overlapping exposure between posterior and anterior approaches, with distraction reliably improving lateral visualization.

CONCLUSION

Dual approaches provided access to greater than 70% and 85% of talar DSA without and with distraction, respectively. Order of approach did not significantly affect exposure and thus should be determined by surgeon discretion. These results may promote soft tissue-only treatment strategies in talar body fracture care with an extensile exposure of the talar dome surface. Careful preoperative planning optimizes the advantages of this approach.

LEVEL OF EVIDENCE

Level IV, case series.

Comparison of Fixation Techniques in Oblique and Biplanar Chevron Medial Malleolar Osteotomies; a Finite Element Analysis

This study aimed to evaluate different fixation techniques and implants in oblique and biplanar chevron medial malleolar osteotomies using finite element analysis. Both oblique and biplanar chevron osteotomy models were created, and each osteotomy was fixed with 2 different screws (3.5 mm cortical screw and 4.0 mm malleolar screw) in 2 different configurations; (1) 2 perpendicular screws, and (2) an additional third transverse screw. Nine simulation scenarios were set up, including 8 osteotomy fixations and the intact ankle. A bodyweight of 810.44 N vertical loading was applied to simulate a single leg stand on a fixed ankle. Sliding, separation, frictional stress, contact pressures between the fragments were analyzed. Maximum sliding (58.347µm) was seen in oblique osteotomy fixed with 2 malleolar screws, and the minimum sliding (17.272 µm) was seen in chevron osteotomy fixed with 3 cortical screws. The maximum separation was seen in chevron osteotomy fixed with 2 malleolar screws, and the minimum separation was seen in oblique osteotomy fixed with 3 cortical screws. Maximum contact pressure and the frictional stress at the osteotomy plane were obtained in chevron osteotomy fixed with 3 cortical screws. The closest value to normal tibiotalar contact pressures was obtained in chevron osteotomy fixed with 3 cortical screws. This study revealed that cortical screws provided better stability compared to malleolar screws in each tested osteotomy and fixation configuration. The insertion of the third transverse screw decreased both sliding and separation. Biplanar chevron osteotomy fixed with 3 cortical screws was the most stable model.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs.

HYPOTHESIS

The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol.

MATERIALS AND METHOD

This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated.

RESULTS

No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series.

DISCUSSION

There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded.

LEVEL OF EVIDENCE

IV.

Long-term results of osteochondral autograft transplantation of the talus with a novel groove malleolar osteotomy technique

Objectives

This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique.

Patients and methods

This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients’ clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity.

Results

The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.23 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three patients (14%).

Conclusion

In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Comparison of magnesium versus titanium screw fixation for biplane chevron medial malleolar osteotomy in the treatment of osteochondral lesions of the talus

PURPOSE

This retrospective study aimed to compare the clinical and radiological outcomes of patients who underwent biplane chevron medial malleolar osteotomy (MMO) for osteochondral lesions of the talus (OLT), fixed with either magnesium (Mg) or titanium (Ti) screws.

METHODS

A total of 22 patients (12 male and 10 female) with a mean age of 40.6 ± 12.5 years (range 18-56 years) who underwent MMO for OLT treatment were included in this retrospective study. Of the 22 patients, MMO was fixed with bioabsorbable Mg screws (Alloy: MgYREZr) in 11 patients, and in the remaining 11 patients (one bilateral) MMO was fixed with Ti screws. All patients were followed up for at least 1 year with a mean of 20.7 ± 8.9 months (range 12-49 months). The American Orthopedic Foot and Ankle Society (AOFAS) scale and the visual analog scale (VAS) were used to evaluate the clinical results. Union of the osteotomy, postoperative displacement and all other complications were followed and analyzed.

RESULTS

An improvement in the AOFAS scale and VAS points were recorded in both groups with no statistically significant difference between the groups (p 0.079 and 0.107, respectively). Complete union of the osteotomy was obtained in all patients. One patient in the Ti group required implant removal due to pain and irritation. There were no other significant complications in either group.

CONCLUSIONS

The results of this study showed that bioabsorbable Mg compression screws have similar therapeutic efficacy to Ti screws in respect of functional and radiological outcomes in MMO fixation. Bioabsorbable Mg screw is an alternative fixation material which can be safely used for MMO in ankle surgery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Large Osteochondral Lesions of the Talus Treated With Autologous Bone Graft and Periosteum Transfer

Background:

The treatment of large osteochondral lesions of the talus (OLTs) is challenging due to the poor intrinsic reparative capability of the damaged articular cartilage. Autologous transfer of bone and periosteum has been used successfully in the treatment of large defects in animals, and therefore it was believed that this technique might show similar results in humans. The purpose of this study was to assess the outcome of an innovative technique for autologous transplantation of cancellous tibial graft with periosteal transfer in large OLTs.

Methods:

Forty-one patients (22 females, 19 males), with a mean age of 34.9 years (range, 18-72 years), with a large OLT (>200 mm²) were treated with autologous bone graft and periosteum transfer. OLTs averaging 310 mm² were identified on a preoperative computed tomography scan. The procedure consisted of malleolar osteotomy, curettage of sclerotic bone, autologous bone graft from the proximal tibia, and transfixion of periosteum over the graft. Outcome measures, including the pain visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Foot & Ankle Disability Index (FADI), were compared between preoperative and 1 and 2 years following surgery.

Results:

There were significant improvements in VAS pain score from 7.7 before surgery to 1.1 at 1 year after surgery and 0.4 at 2 years or more after surgery. The AOFAS and FADI scores were also significantly improved from 40.3 and 53.3 preoperatively to 95 and 93.2 postoperatively at 1 year and 95 and 93.2 at 2 or more years postoperatively, respectively. Postoperative complications included 2 patients who required removal of medial malleolar osteotomy tension bands due to symptomatic hardware. There were no nonunions or malunions of the osteotomies and no donor site complications.

Conclusion:

Autologous bone graft and periosteum transfer was an effective treatment for large OLTs leading to significant decreases in pain and improvement in functional scores at more than 2 years after surgery.

Level of Evidence:

Level IV, retrospective case series.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

Osteochondral autograft transplantation with biplanar distal tibial osteotomy for patients with concomitant large osteochondral lesion of the talus and varus ankle malalignment

Background

Osteochondral lesions of the talus (OLTs) are amongst the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (>10 mm), Osteochondral autograft transplantation is usually recommended. This article highlights biplanar distal tibial osteotomy as an approach and management for patients with concomitant large OLTs and varus ankle malalignment.

Methods

From January 2012 to July 2014, 13 patients (6 male and 7 female) underwent surgery in our faculty and their average age was 55.4 (ranging from 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, followed by an osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight-bearing X-rays were conducted and used for the measurement of radiographic parameters such as the tibial articular surface (TAS) and tibial lateral surface (TLS) angles. Ankle function of the subjects was evaluated according to the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot score (AOFAS-AH) questionnaires and Visual Analog Scale (VAS).

Results

11 patients completed the follow-up over a mean period of 21.2 months. The average area of talar lesion was 135.9 mm² while the average depth was 11.4 mm. The mean time for osseous union was 8.5 weeks. Donor site morbidity was not recorded in any of the cases. The mean AOFAS-AH and VAS improved from 53 to 90 points (p < 0.05) and 6.7 to 1.9 points (p < 0.05) respectively. The mean TAS angle improved from 83.1 to 90.3° (p < 0.05).

Conclusions

Biplanar distal tibial osteotomy with the combination of osteochondral autograft transplantation could be used to address patients with concomitant large OLTs and varus ankle malalignment as this technique provides excellent visualization of the talar defect, favorable biomechanical environment for the ankle joint with high rate of good and excellent results.

Osteochondral transplantation of autologous graft for the treatment of osteochondral lesions of talus: 5- to 7-year follow-up

PURPOSE

Bone marrow stimulation procedures (microfractures/drilling) are considered the gold standard for the primary treatment of osteochondral talar lesions. In the literature, there is lack of evidence about the appropriate treatment in cases of failure of these procedures. A technique of osteochondral autologous transplantation of talar graft was used. It was hypothesized that this is a successful method with good results and low complication rates. Additionally, a technique of anterior ankle approach with temporary removal of a bone block from the distal tibia that gives adequate access to posterior talar dome lesions is demonstrated.

METHODS

Between 2004 and 2007, 46 patients (37 males, 9 females), with OLT for which arthroscopic treatment with curettage and drilling or microfracture had failed, underwent osteochondral transplantation with an osteochondral graft harvested from the ipsilateral talar articular facet. A medial malleolar osteotomy or a distal tibial wedge osteotomy was used to access the talar dome defect.

RESULTS

The median follow-up time was 5.5 years (range 52-75 m). Thirty-four lesions (70.8 %) were located in the central talar dome in the coronal plane, while 26 (54.1 %) and 19 (39.5 %) lesions were located in the lateral and medial aspect of talar dome in saggital plane, respectively. The overall improvement between the preoperative and post-operative AOFAS and VAS FA score was 35 points (p < 0.001) and 39 points (p < 0.001), respectively. Clinical results were considered as good in 43 patients (93.4 %) and fair in three patients (6.5 %). All the transplanted grafts were observed to incorporate fully into the recipient bed. No complications occurred at the site of the malleolus osteotomy or tibial osteotomy and the donor site at the talus.

CONCLUSIONS

The midterm results suggest that the technique of osteochondral transplantation of autologous talar graft for osteochondral lesions of talus after failure of primary treatment with bone marrow stimulation can be safely and successfully used. It demonstrates excellent post-operative scores including improvement of pain and function. This procedure is combined with removal of a tibial bone block and its subsequent replacement and does not yield complications experienced with other procedures.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Medial malleolar osteotomy for the treatment of talar osteochondral lesions: anatomical and morbidity considerations

PURPOSE

Osteochondral lesions of the talus are often located posteromedially requiring open surgery to facilitate solid and complete osteochondral reconstruction. The aim of the study was to identify the optimal anatomical site for medial malleolar osteotomy based on the criteria of minimal cartilage damage (Study I) and to report on the morbidity in patients receiving osteotomy performed at the previously identified site (Study II).

METHODS

For Study I, cartilage coverage of the tibiofibular ankle joint facet was measured in 40 cadaveric ankles (20 cadaver specimens). In Study II, we assessed clinical (VAS pain score, AOFAS score, range of motion) and radiological outcome measures (SPECT-CT) in 17 patients (mean age, 36.8 ± 10.8 years) undergoing medial malleolar osteotomy.

RESULTS

The medial edge in the transition zone of the tibial plafond to the medial malleolus showed less than 75 % of cartilage coverage in 62.5 % of cadavers (Study I). Surgery resulted in lower pain levels (2.4 ± 2.6 compared with 6.3 ± 1.8 points; p < 0.001) and greater AOFAS scores (82.9 ± 14.1 compared with 43.5 ± 10.8 to points; p < 0.001) compared with baseline (Study II). No signs of intra-operative damage or mal- or non-union were found. Long-term morbidity was found in one patient. Implant removal was necessary in 12 of 17 patients (71 %).

CONCLUSION

Anatomically, there is an optimal location for the medial malleolar osteotomy at the medial ankle edge involving minimal cartilage damage. Clinical results using this location showed no short- or mid-term morbidity and little long-term morbidity. However, many patients required re-intervention for implant removal.

LEVEL OF EVIDENCE

IV.

Rate of Malunion Following Bi-plane Chevron Medial Malleolar Osteotomy

BACKGROUND

Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy.

METHODS

A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications.

RESULTS

At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation.

CONCLUSION

Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Low Level of Evidence and Methodologic Quality of Clinical Outcome Studies on Cartilage Repair of the Ankle

PURPOSE

To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle.

METHODS

A search was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery. Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest.

RESULTS

Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique (P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence (r = -0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type (r = 0.05, P = .6480) or financial conflict of interest (r = -0.16, P = .1256).

CONCLUSIONS

Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Medial Malleolar Osteotomy and Osteochondral Autograft Transfer for Osteochondritis Dissecans of the Distal Tibial Plafond

The literature on the surgical treatment of osteochondritis dissecans of the distal tibial plafond is significantly limited. The purpose of this case study is to present a novel surgical technique to repair osteochondritis dissecans of the distal medial tibial plafond. A retrospective chart and radiographic review of a 15-year-old male was performed with a 24-month follow-up along with a review of the literature. A right angled medial malleolar osteotomy provides adequate exposure, width, and depth of the medial distal tibial plafond allowing for the successful transfer of osteochondral autograft plugs.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Magnetic resonance imaging, computed tomography, and radiographic correlation of nonunion of the posteromedial tubercle of the talus: a case report

Fracture of the posteromedial tubercle of the talus is an uncommon injury that is often missed on plain radiographs. In the present report, we describe the case of an adult male with a chronic nonunited fracture of the medial tubercle of the posterior process of the talus after having undergone clinical and radiographic evaluation in a community hospital emergency department. A review of the computed tomographic, magnetic resonance imaging, and plain film radiographic findings associated with nonunion of the posteromedial tubercle of the talus is also presented.

An anterior ankle arthroscopic technique for retrograde osteochondral autograft transplantation of posteromedial and central talar dome cartilage defects

PURPOSE

The purpose of this study was to present an arthroscopic technique for the treatment for posteromedial and central cartilage defects of the talus using anterior arthroscopic portals and without performing a medial malleolar osteotomy.

METHODS

Nine fresh cadavers were dissected. Autografts were implanted under arthroscopy using a retrograde osteochondral transplantation system, and their position was estimated using specific angular calibrators and later confirmed by software analysis of two photographs of the disarticulated ankle joint.

RESULTS

In eight cases, the congruence between the surrounding articular cartilage and the cartilage of the graft was high, with differences measuring <1 mm. There were no iatrogenic cartilage lesions of the tibial plafond and no fractures of the talus. All the autografts remained stable during full range of motion cycles of the ankle joint. One failure was reported.

CONCLUSION

This cadaveric study showed that the retrograde osteochondral autograft transplantation technique in the talus is feasible. It can be used to restore the posteromedial and central talar articular surfaces using conventional ankle arthroscopic instrumentation and anterior arthroscopic portals without resorting to a medial malleolar osteotomy. Further clinical and biomechanical studies are required to prove the efficacy of this technique and its reproducibility in routine clinical practice.

[Malleolar osteotomy--osteotomy as approach]

Both arthroscopic and open surgical techniques may be used for treatment of osteochondral lesions of the ankle joint. Osteotomy around the ankle joint is a well established technique to extend the approach in cases where the osteochondral lesions are located more posteriorly. Medial, oblique, monoplanar malleolar osteotomy should be used in patients with lesions of the medial talus shoulder. The posterolateral ostechondral lesions are less frequent and in such cases distal fibular osteotomy is recommended. In this study the indications for different forms of osteotomy are discussed and the surgical techniques are described.

Microfracture for osteochondral lesions of the talus: a systematic review of reporting of outcome data

BACKGROUND

Microfracture is recognized as a primary treatment strategy for osteochondral lesions of the talus up to 15 mm in size. The ability of fibrocartilage to withstand the mechanical loading of the joint over time is unknown.

PURPOSE

The purpose of this study was to systematically review studies of microfracture for OLT and descriptively analyze the outcome data reported to determine whether it is consistent from one study to another and able to be pooled for systematic review.

METHODS

A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published between January 1966 and June 2011 were included in the review. Only studies that reported data specifically on microfracture for treatment of osteochondral lesions of the talus and written in English were included in this review.

RESULTS

Twenty-four studies were included in this systematic review. The categories of general demographics and study design were generally well reported (each over 80% of studies). Patient history and patient-reported outcome data were reported less (55%-66%). Clinical variables (48%) and imaging data (39%) were the least reported in studies.

CONCLUSION

There were gross inconsistencies and an underreporting of data between studies such that pooling was deemed impossible. A concerted effort must be made by investigators to ensure that there is adequate reporting of data in studies of microfracture treatment for OLT. A set of guidelines to assist surgeons in reporting data may be useful for future research.

Exposure of the medial talar dome: bi-plane chevron medial malleolus osteotomy

Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.

Clinical tip: aiming probe for a precise medial malleolar osteotomy

Level of Evidence: V, Expert Opinion

Direction of the oblique medial malleolar osteotomy for exposure of the talus

INTRODUCTION

A medial malleolar osteotomy is often indicated for operative exposure of posteromedial osteochondral defects and fractures of the talus. To obtain a congruent joint surface after refixation, the oblique osteotomy should be directed perpendicularly to the articular surface of the tibia at the intersection between the tibial plafond and medial malleolus. The purpose of this study was to determine this perpendicular direction in relation to the longitudinal tibial axis for use during surgery.

MATERIALS AND METHODS

Using anteroposterior mortise radiographs and coronal computed tomography (CT) scans of 46 ankles (45 patients) with an osteochondral lesion of the talus, two observers independently measured the intersection angle between the tibial plafond and medial malleolus. The bisector of this angle indicated the osteotomy perpendicular to the tibial articular surface. This osteotomy was measured relative to the longitudinal tibial axis on radiographs. Intraclass correlation coefficients (ICC) were calculated to assess reliability.

RESULTS

The mean osteotomy was 57.2 ± 3.2° relative to the tibial plafond on radiographs and 56.5 ± 2.8 on CT scans. This osteotomy corresponded to 30.4 ± 3.7° relative to the longitudinal tibial axis. The intraobserver (ICC, 0.90-0.93) and interobserver (ICC, 0.65-0.91) reliability of these measurements were good to excellent.

CONCLUSION

A medial malleolar osteotomy directed at a mean 30° relative to the tibial axis enters the joint perpendicularly to the tibial cartilage, and will likely result in a congruent joint surface after reduction.

Treatment of osteochondral lesions of the talus: a systematic review

The aim of this study was to summarize all eligible studies to compare the effectiveness of treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from January 1966 to December 2006 were systematically screened. The proportion of the patient population treated successfully was noted, and percentages were calculated. For each treatment strategy, study size weighted success rates were calculated. Fifty-two studies described the results of 65 treatment groups of treatment strategies for OCD of the talus. One randomized clinical trial was identified. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. Retrograde drilling and fixation scored 88 and 89%, respectively. Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of surgical strategies for OCD of the talus.

Treatment of osteochondral defects of the talus

This review article provides a current concepts overview of osteochondral defects of the talus, with special emphasis on treatment options, their indications and future developments. Osteochondral defects of the talar dome are mostly caused by a traumatic event. They may lead to deep ankle pain on weight-bearing, prolonged swelling, diminished range of motion and synovitis. Plain radiographs may disclose the lesion. For further diagnostic evaluation, computed tomography (CT) and magnetic resonance imaging (MRI) have demonstrated similar accuracy. Computed tomography is preferred for preoperative planning. Treatment options are diverse and up to the present there is no consensus. Based on the current literature, we present a treatment algorithm that is mainly guided by the size of the lesion. Asymptomatic or low-symptomatic lesions are treated nonoperatively. The primary surgical treatment of defects up to 15 mm in diameter consists of arthroscopic debridement and bone marrow stimulation. For large cystic talar lesions, retrograde drilling combined with a bone graft is an important alternative. In adolescents or in (sub)acute situations, in which the fragment is 15 mm or larger, fixation of the fragment is preferred. Osteochondral autograft transfer and autologous chondrocyte implantation (ACI), with or without a cancellous bone graft, are recommended for secondary cases as well as large lesions.

Talonavicular joint approach to the talar body: a cadaver study

BACKGROUND

Lesions of the talar dome or tumors within the talar body may require an open approach with medial or lateral malleolar osteotomies. The aim of this study was to evaluate the possibility and feasibility of a new minimally invasive approach without osteotomy, using the talonavicular joint (TJ) as the entry portal for lesions of the talar body.

MATERIALS AND METHODS

Nine cadaveric feet were used for this study. Using the TJ and a 5-mm skin incision we aimed to reach the superolateral, superomedial, inferolateral and inferomedial corners of the talar body under fluoroscopy. A 2-mm Kirshner wire and a 4-mm cannulated drill bit were used to reach the desired target area and an angled curette was used for curettage after reaching the target. The proximity of vascular structures to the entry portal was noted. The talar and navicular joint surfaces were checked for any damage. The articular areas of the talar heads and the defect areas were measured.

RESULTS

All 4 targets and even the posterior talus could be reached by this approach. The nearest neurovascular structures were the saphenous vein and the saphenous nerve. The navicular cartilage was not damaged in any specimen. The talar defect area corresponded to only 3.3% of the talar head cartilaginous area.

CONCLUSION

The TJ approach can be used to reach lesions in all regions of the talar body without the need for an osteotomy. A mini-incision may be used to retract the saphenous nerve and vein. Damage to the talar head cartilage is minimal with this approach which requires no special equipments.

CLINICAL RELEVANCE

This study shows that talar dome lesions can be reached with a minimally invasive method.

The anterior approach for the treatment of posterior osteochondral lesions of the talus: comparison of different surgical techniques

INTRODUCTION

Most of all osteochondral talar lesions are located in the middle and posterior area of the talar surface. Malleolar osteotomy is often used to access the defect but may be associated with malunion or secondary osteoarthritis. We present an alternative approach to the talus with temporary removal and replacement of a tibial bone block and compare it with other anterior approaches described in the literature.

PATIENTS AND METHODS

Thirteen patients (5 males, 8 females) with an average age of 27.2 years and an osteochondral talar lesion were included in our study. All patients were previously operated on the same ankle. Ten lesions were caused by a sports injury. The average follow up was 45 months. The patients were evaluated before and after surgery using the ankle and hindfood score (AOFAS). For the analyses baseline clinical data were compared with follow up data using the Wilcoxon test.

RESULTS

The overall improvement between the preoperative and postoperative AOFAS scores was an average of 34.9 points (P=0.0002). No complications occurred at the site of the tibial bone block and the donor site at the talus. There were no patients with recurrence or an ankle osteoarthrosis in the follow up period.

CONCLUSION

The removal of a tibial bone block and its subsequent replacement is a useful technique to access osteochondral talar lesions for osteochondral transplantation for which arthroscopic interventions have failed. The results are comparable to other anterior approaches described in the literature.

Mosaicplasty with autogenous talar autograft for osteochondral lesions of the talus after failed primary arthroscopic management: a prospective study with a 4-year follow-up

BACKGROUND

There have been limited data in the literature reporting the results of osteochondral autografting for osteochondral lesions of the talus that have failed arthroscopic treatment.

HYPOTHESIS

Osteochondral autografting can produce significant clinical improvement and a high rate of healing of osteochondral defects of the talus that have failed arthroscopic treatment.

STUDY DESIGN

Cohort study; Level of evidence, 4.

METHODS

Between 1998 and 2003, 35 patients (18 men, 17 women) with osteochondral talar lesions for which arthroscopic excision, curettage, and drilling had failed, underwent mosaicplasty with an osteochondral graft harvested from the ipsilateral talar articular facet. A malleolar osteotomy or a tibial wedge osteotomy was used for central or posterior lesions that could not otherwise be reached. The mean age of the patients was 30.9 years, and the mean follow-up was 48.9 months.

RESULTS

The American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale score in patients without osteotomy rose by 39 points (P = .0001); with malleolar osteotomy, by 30.1 points (P = .017); with tibial wedge osteotomy, by 34.9 points (P = .0002); and with the posterolateral approach, by 32 points. The Wilcoxon test revealed a significant difference between patients without and with osteotomy (P <or= .027) and between patients with malleolar and tibial wedge osteotomies (P = .046). There were no patients with nonunion or malunion in the osteotomy groups. The score values corresponded with the subjective patient evaluation. The Spearman coefficient of correlation was .89.

CONCLUSION

Osteochondral autografting with tibial wedge osteotomy is a good alternative to malleolar osteotomy in osteochondral talar lesions that have failed arthroscopic treatment and that cannot be reached in spite of a forced plantar flexion of the ankle. Patients with small osteochondral lesions accessible through an anterior approach without additional osteotomy have the best prognostic factors.

Use of the noninvasive ankle distractor with talar dome osteochondral graft transplantation

Talar dome lesions greater than 1 cm in diameter are often treated with ankle joint mosaicplasty. The purpose of this article is to present the use of a noninvasive ankle distractor that can improve access to the talus when used with a malleolar osteotomy. The use of the distractor allows for graft insertion at a more appropriate angle in relationship to the talar cartilage, avoidance of invasive distractor usage, and potential use of a smaller osteotomy.

Osteochondral autografts for osteochondritis dissecans of the talus

Eighteen symptomatic advanced-stage osteochondritis dissecans (OCD) of the talus (Berndt and Harty stages III 7 and IV 11) in 17 patients were treated with multiple autogenous osteochondral cylindrical grafts. The mean time of follow-up was 36 months (range, 25-49). The average age at surgery was 22.7 years (range, 19-34). The mean size of defect of OCD was 13.6 mm x 7.2 mm. Two or three osteochondral grafts (6 or 7 mm in diameter and 15-20 mm in length) were harvested from the superomedial margin of the ipsilateral knee. A partial osteotomy of the medial malleolus or osteotomy of the distal lateral tibia was performed for all cases. Being evaluated by the Freiburg ankle score, 16 of 18 ankles (88.8%) had excellent and two (11.8%) had good results. "Second-look" arthroscopy of 16 ankles revealed consistency of the osteochondral grafts and congruity between grafts and native cartilage in 14 (87.5%), and a softening or fissuring of the osteochondral graft in two. Our results showed that this procedure provided an effective treatment for a symptomatic advanced-stage OCD of the talus.

Systematic review of treatment strategies for osteochondral defects of the talar dome

The aim of this study was to summarize all eligible studies to compare the effectiveness of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from January 1966 to June 2000 were systematically screened. Based on our inclusion criteria, 39 studies describing the results of treatment strategies for OCD of the talus were included. No randomized clinical trials (RCT) were identified. Fourteen studies described the results of nonoperative treatment (NT); 4: the results of excision alone; 10: the results of excision and curettage (EC); 21: the results of excision, curettage, and drilling (ECD); 2: the results of cancellous bone grafting after EC; 1: the results of osteorchondral transplantation; 3: the results of fixation; and 1: the results of retrograde drilling. The average success rate of NT was 45%. Comparison of different surgical procedures showed that the highest average success rate is reached by excision, curettage, and drilling (ECD; 86%), followed by excision and curettage (EC; 78%) and excision alone (38%). On the basis of this systematic review, we conclude that NT and excision alone are not to be recommended in treating talar OCD. Both EC and ECD have been shown to lead to a high percentage good/excellent results. At the present time, ECD seems to be the most effective treatment strategy for osteochondral defect of the talus. Due to great diversity in the articles and variability in treatment results, however, no definitive conclusions can be drawn. Sufficiently powered randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of surgical strategies for OCD of the talus.

The posteromedial process fracture of the talus: a case report

Injuries to the ankle tend to be some of the most common injuries seen in practice. Of these ankle injuries, fractures of the posteromedial process of the talus are often misdiagnosed as ankle sprains because of poor visualization on routine ankle radiographs. The examining physician must have a heightened awareness of this injury to accurately diagnose and treat this fracture. Proper treatment could help to lessen the possibility of post-traumatic arthritis to the ankle and subtalar joints. The authors present a case of a fracture of the posteromedial process of the talus, after a medial subtalar dislocation, treated with open reduction and internal fixation with bioabsorbable pins.

Medial malleolar osteotomy for exposure of complex talar body fractures

Traditional surgical approaches to the talus often fail to afford adequate exposure of the talar body, especially in the case of complex talar body fractures. Preservation of the remaining blood supply to the talus is a main concern during operative repair and can be difficult to accomplish when multiple approaches and forceful manipulations are required to gain satisfactory exposure. A medial malleolar osteotomy was used to gain access to the talar body in situations in which the traditional approaches did not provide adequate exposure. We describe our technique in a small series of patients.