Avascular Osteonecrosis of the Talus: Current Treatment Strategies

Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study

BACKGROUND

Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT.

METHODS

A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant.

RESULTS

The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023.

CONCLUSION

Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT.

LEVEL OF EVIDENCE

Level III, retrospective cohort comparative study.

Talus Avascular Necrosis as a Rare Complication of Cushing's Disease: A Case Report

Avascular necrosis (AVN), also called osteonecrosis, stems from blood supply interruption to the bone and is often idiopathic. It has risk factors like trauma, alcohol, and corticosteroids. AVN in the talus (AVNT) is less common than in the femoral head. Most cases of talar osteonecrosis are associated with trauma, while a smaller proportion is linked to systemic conditions such as sickle cell disease or prolonged prednisone use. Glucocorticoids are a key nontraumatic cause. We report a middle-aged woman with Cushing's syndrome symptoms, such as hypertension and moon face, since her youth. A few years ago, she experienced pain and swelling in her ankle, which was diagnosed as atraumatic AVNT and treated with hindfoot fusion. Years later, she was diagnosed with Cushing's disease caused by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in laboratory tests and imaging, which was resected in 2020. She experienced significant weight loss, and her Cushing's syndrome symptoms were relieved after tumor resection. Mechanisms behind AVN in hypercortisolism involve fat cell hypertrophy, fat embolization, osteocyte apoptosis, and glucocorticoid-induced hypertension. Traditional X-rays may miss early AVN changes; MRI is preferred for early detection. Although there are some cases of femoral AVN caused by endogenous hypercortisolism in the literature, as far as we know, this is the first case of AVNT due to Cushing's disease. AVNT treatment includes conservative approaches, hindfoot fusion, and core decompression. Cushing's disease is a rare cause of AVNT, and a multidisciplinary approach aids in the rapid diagnosis of elusive symptoms.

A chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to reconstruct partial necrosis of talar body: A case report

Total talar extrusion is a rare complication of high-energy traumas. A consequence of this injury can be avascular necrosis (AVN) of the talus. Patients are confronted with pain, limited range of motion and post-traumatic arthritis. As AVN progresses the talus is gradually destroyed. This report presents the use of a chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to increase vascular supply to the traumatized area, accelerate bone formation, flap integration, and restore articular surfaces in a patient with partial necrosis of talar body. The patient was a 26-year-old female with open left lateral talar extrusion after a motor-vehicle accident that developed a partial avascular necrosis, at the level of the subtalar and ankle joint with altered talar dome surface with partial depression of 2 cm. The patient was in pain and not able to walk. The medial femoral condyle chondro-osseus portion was placed in the talar dome depression to restore the subtalar joint, the periosteal flaps were placed on top to reconstruct the ankle joint restoring the articular surfaces and the correct weight-bearing distribution. No complications or morbidity of donor site were observed. One year after the operation, the patient walks free, without pain. Post-operatory x-ray performed, evidenced progressive bone healing and reduction of the AVN. In the intent of performing a joint-saving procedure, the presented chimeric flap might be effective in the short-term with excellent clinical and radiographic outcomes.

Talus Idiopathic Versus Stress-Injury-Related Osteonecrosis and Its Resolution: A Case Report

A 34-year-old healthy long-distance runner sustained a possible stress injury to the talus. This injury progressed into osteonecrosis (ON) or might have presented idiopathically. This patient had a complete normal metabolic workup. Non-surgical management, including resting, activity modification, and bone stimulators, led to resolution. Serial exams and magnetic resonance imaging demonstrated gradual resolution of the ON. At two years old, she was pain-free and had returned to running. Talus ON is uncommon and even more so in the absence of metabolic disorders or precipitating trauma. This case presents a debatable stress injury, an overuse injury, or even an idiopathic ON. It healed with non-surgical management. Serial, advanced imaging surveillance was implemented. There is a lack of impactful literature regarding the management of early ON and a paucity of strong recommendations to guide non-surgical treatment options in the early stages. This presentation is quite debatable as to whether there was a stress fracture leading to ON or if it was idiopathic ON. Yet, these entities could easily overlap, and physicians and orthopedists should be aware.

A Novel Technique for Lateral Ankle Ligament Reconstruction with Total Ankle Total Talus Replacement: A Case Report

CASE

A 65-year-old man with severe left talar avascular necrosis, arthritis, and chronic lateral ankle instability underwent total ankle total talus replacement (TATTR) with lateral ligament reconstruction. Tibial component placement was performed using preoperative computed tomography navigation and patient-specific guides. A custom, total talus replacement to mate with the fixed-bearing tibial component was implanted. Last, a modified Brostrom procedure was performed to restore lateral ankle stability. The patient has performed well through 1 year with improved pain-free function.

CONCLUSION

This case report details a novel technique for performing a modified Brostrom procedure in conjunction with TATTR to restore lateral ankle stability.