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Mazli N, Bajuri MY, Nik Abdullah NA. Treatment of Post-traumatic Osteonecrosis in the Distal Tibia With Autologous Bone Grafting: A Case Report. Cureus 2023; 15:e48214. [PMID: 38050520 PMCID: PMC10693789 DOI: 10.7759/cureus.48214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
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.
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Affiliation(s)
- Norliyana Mazli
- Orthopedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
| | - Mohd Yazid Bajuri
- Orthopedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
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Madi NS, Chopra A, Fletcher AN, Mithani S, Parekh SG. 3D-Printed Total Talus Replacement After Free Vascularized Medial Femoral Condyle Osteocutaneous Flap for Avascular Necrosis of the Talus Leads to Poor Clinical Outcomes: A Case Series. Foot Ankle Spec 2022:19386400221138640. [PMID: 36482676 DOI: 10.1177/19386400221138640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Avascular necrosis (AVN) of the talus is 1 of the most difficult foot and ankle pathologies to diagnose and manage. The purpose of this study was to report on the functional outcomes of 3D-printed total talus replacement (TTR) in 2 patients with talar AVN who both underwent a failed revascularization. METHODS This is a case series of 2 patients with TTR after a failed revascularization and a comparison group of 25 patients with primary TTR. Clinical and functional outcomes are used to compare both groups. RESULTS Patient 1 had a postrevascularization Visual Analogue Scale (VAS) pain score of 9. Imaging showed failure of the medial femoral condyle to incorporate with talar fragmentation. Patient underwent TTR at 5 months postoperatively. At 2 years postoperatively, the patient underwent a cavovarus foot reconstruction; however, patient continued to suffer from ankle pain (VAS 6) and ultimately underwent below knee amputation at 3 years after the TTR. Patient 2 initially underwent a core decompression for a talar bone infarct followed by revascularization procedure at 6 months postoperatively due to persistent pain and bony infarcts. At 18 months postrevascularization, the patient had a VAS pain score of 9 and progression of the AVN. She underwent a TTR. At 1-year follow-up, the VAS pain score was 8. Both patients had an ankle plantarflexion of 30° at their last TTR follow-up. The comparison group consisted of 25 patients who underwent 3D-printed TTR with mean postoperative VAS score and ankle plantarflexion of 3.7° and 41.8°. CONCLUSION Patients 1 and 2 demonstrated reduced plantarflexion and ankle motion after TTR relative to the comparison group which improved in both physical assessments. The first patient needed a below knee amputation for persistent pain. Patient 2 showed less improvement in all the foot and ankle outcome scores as compared with the primary TTR group. LEVEL OF EVIDENCE Level V: Retrospective case series.
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Affiliation(s)
- Naji S Madi
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Aman Chopra
- School of Medicine, Georgetown University, Washington, DC
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Suhail Mithani
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Ha AS, Chang EY, Bartolotta RJ, Bucknor MD, Chen KC, Ellis HB, Flug J, Leschied JR, Ross AB, Sharma A, Thomas JM, Beaman FD. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022; 19:S409-S416. [PMID: 36436966 DOI: 10.1016/j.jacr.2022.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Roger J Bartolotta
- Division Chief, Musculoskeletal Imaging, Weill Cornell Medical College, New York, New York
| | - Matthew D Bucknor
- Associate Chair, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Karen C Chen
- Musculoskeletal Radiology Section Chief, VA San Diego Healthcare System, San Diego, California
| | - Henry B Ellis
- Medical Director, Clinical Research, Texas Scottish Rite Hospital for Children, Dallas, Texas; American Academy of Orthopaedic Surgeons; Board of Directors, Pediatric Research in Sports Medicine; Board of Directors, Texas Orthopaedic Association; Council of Delegates, Texas Representative, AAOS
| | - Jonathan Flug
- Committee Chair, Radiology Quality Oversight, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jessica R Leschied
- Committee on Emergency Radiology-GSER, Henry Ford Health System, Detroit, Michigan
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Akash Sharma
- Chair, Research Committee, Radiology and Chair, PET-MRI Workgroup, Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | - Jonelle M Thomas
- Vice-Chair, Clinical Affairs and Director, Radiology Informatics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Zhang H, Fletcher AN, Scott DJ, Nunley J. Avascular Osteonecrosis of the Talus: Current Treatment Strategies. Foot Ankle Int 2022; 43:291-302. [PMID: 34753345 DOI: 10.1177/10711007211051013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Hanci Zhang
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel J Scott
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
Talar osteonecrosis results from trauma to the fragile blood supply to the talus. Many etiologies exist that can cause talar osteonecrosis, with the most common being talar neck fractures. Patients with talar osteonecrosis frequently present with progressive ankle pain and limited range of motion. Treatment strategy depends primarily on the stage of disease. Conservative care in the form of medications and bracing treatment can be beneficial for patients with low functional status and early disease stages. Surgical options also exist for early disease without talar collapse that can potentially preserve the tibiotalar joint. Once talar collapse develops, surgical treatment is move invasive and typically involves an arthrodesis or talus arthroplasty. Although some treatment guidelines exist based on the disease stage, talar osteonecrosis is a complex problem, and treatment strategy should always be determined on a case-by-case basis carefully examining all clinical aspects.
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Han Q, Liu Y, Chang F, Chen B, Zhong L, Wang J. Measurement of talar morphology in northeast Chinese population based on three-dimensional computed tomography. Medicine (Baltimore) 2019; 98:e17142. [PMID: 31517856 PMCID: PMC6750351 DOI: 10.1097/md.0000000000017142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Morphological data of talus are important for the design of talar prostheses. The talar morphology of Chinese population has been rarely reported. This study adopted a three-dimensional (3D) measurement approach to provide accurate data for the anatomical morphology of talus in Northeast Chinese population and compared it with that of foreigners.One hundred forty-six healthy subjects form Northeast China underwent computed tomography (CT) arthrography. 3D digital talar model was reconstructed and thirteen morphological parameters were measured through Mimics and Magics software. Length and breadth indexes of total talus, trochlea, medial and lateral malleolus articular surface were mainly selected. Statistical analysis was conducted by independent-samples and paired-samples t test through SPSS software.All the indexes were normally distributed. No significant difference between left and right talus was identified in either males or females (P > .05). Most of the indexes showed significant sexual differences except the radian of lateral malleolus articular surface and the posterior breadth of trochlea (P < .05). The talar anatomy of Chinese subjects is different from the published data in other populations.The promising approach adopted in this study addresses some inconvenience with previous conventional methods on cadaver specimens. The geometric parameters of talus in Chinese population differ from those in other populations. The talar measurements and morphology analysis in this study suggest that population characteristics should be taken into account. This study will provide references for the design of talar prostheses in Chinese population.
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Abstract
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.
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Affiliation(s)
- Angela K Heinen
- Foot and Ankle Surgery, UCLA Harbor Medical Center, 1000 W. Carson Street, Torrance, CA 90502, USA.
| | - Thomas G Harris
- Foot and Ankle Surgery, UCLA Harbor Medical Center, 1000 W. Carson Street, Torrance, CA 90502, USA; Foot and Ankle Department, Congress Medical Associates, 800 South Raymond, 2nd Floor, Pasadena, CA 91105, USA
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Sultan AA, Mont MA. Core Decompression and Bone Grafting for Osteonecrosis of the Talus: A Critical Analysis of the Current Evidence. Foot Ankle Clin 2019; 24:107-112. [PMID: 30685004 DOI: 10.1016/j.fcl.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Strategic Initiatives, Lenox Hill Hospital, 100 E 77th Street, New York, NY 10075, USA.
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Abstract
Osteonecrosis arises throughout the foot and ankle in various forms and due to numerous causes, with a thousand US cases per year estimated for the ankle alone. Although research continues to elucidate specific mechanisms at work, the pathophysiology remains poorly understood. Nevertheless, the various osteonecrosis pathways converge on osteocyte death, and bony lesions follow a pattern of progression. Understanding the specific anatomy and biomechanics associated with common forms of foot and ankle osteonecrosis should help guide diagnosis and interventions, particularly at earlier stages of disease where etiology-specific approaches might become optimal.
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Affiliation(s)
- Daniel K Moon
- Department of Orthopedic Surgery, University of Colorado, 12631 East 17th Avenue, Mail Stop B202, Room 4602, Aurora, CO 80045, USA.
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Chang SM, Chen PY, Tsai MS, Shee BW. Light Bulb Procedure for the Treatment of Tarsal Navicular Osteonecrosis After Failed Percutaneous Decompression: A Case Report. J Foot Ankle Surg 2019; 58:187-191. [PMID: 30448372 DOI: 10.1053/j.jfas.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Indexed: 02/06/2023]
Abstract
Tarsal navicular osteonecrosis in adults is a rare condition with unclear etiology, and the optimal treatment has not been established. Here we report a case of tarsal navicular osteonecrosis with a complete course of treatment and comprehensive imaging studies starting at an early stage. A 37-year-old female diagnosed with tarsal navicular osteonecrosis was first treated with percutaneous decompression, but her symptoms persisted postoperatively. The tarsal navicular showed no further collapse, but follow-up magnetic resonance imaging (MRI) at 6 months postoperatively revealed persistent osteonecrotic changes. Debridement of the necrotic bone with preservation of the cortical shell and bone substitute packing for the defect (light bulb procedure) were performed. The symptoms resolved by 3 months postoperatively, and the patient could return to work. At a 6-year follow-up visit, the patient was free of symptoms, and MRI showed remodeling of the tarsal navicular without further collapse.
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Affiliation(s)
- Shun-Min Chang
- Surgeon, Department of Orthopedics, Taiwan Landseed Hospital, Tao-Yuan City, Taiwan.
| | - Pei-Yu Chen
- Surgeon, Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mu-Shiun Tsai
- Pathologist, Department of Pathology, Taiwan Landseed Hospital, Tao-Yuan City, Taiwan
| | - Bing-Wu Shee
- Surgeon, Department of Orthopedics, Taiwan Landseed Hospital, Tao-Yuan City, Taiwan
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The use of non-vascularized bone grafts to treat osteonecrosis of the femoral head: indications, techniques, and outcomes. INTERNATIONAL ORTHOPAEDICS 2018; 43:1315-1320. [DOI: 10.1007/s00264-018-4056-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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Nevalainen MT, Repo JP, Pesola M, Nyrhinen JP. Successful Treatment of Early Talar Osteonecrosis by Core Decompression Combined with Intraosseous Stem Cell Injection: A Case Report. J Orthop Case Rep 2018; 8:23-26. [PMID: 29854687 PMCID: PMC5974671 DOI: 10.13107/jocr.2250-0685.982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Osteonecrosis of the talus is a fairly rare condition. Many predisposing factors have been identified including previous trauma, use of corticosteroids, alcoholism, and smoking. As a gold standard, magnetic resonance imaging (MRI) is the most sensitive and specific diagnostic examination to detect osteonecrosis. While many treatment options for talar osteonecrosis exist, core decompression is suggested on young patients with good outcome results. More recently, intraosseous stem cell and platelet-rich plasma (PRP) injection has been added to the core decompression procedure. Case Report: We report a successful treatment of early talar osteonecrosis ARCO I (Association Research Circulation Osseous) by core decompression combined with stem cell and PRP injection. On 3-month and 15-month follow-up, MRI showed complete resolution of the osteonecrotic changes together with clinical improvement. Conclusion: This modified technique is a viable treatment option for early talar osteonecrosis. Nevertheless, future prospects should include a study comparing this combined technique with plain core decompression.
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Affiliation(s)
- Mika T Nevalainen
- Department of Radiology, Central Finland Central Hospital, Keskussairaalantie 19 Jyväskylä, 40620 Finland.,Medical Research Center, University of Oulu and Oulu University Hospital, P.O. Box 10, OYS 90029 Finland
| | - Jussi P Repo
- Department of Orthopedics and Traumatology, Central Finland Central Hospital Keskussairaalantie 19, Jyväskylä, 40620 Finland
| | - Maija Pesola
- Department of Orthopedics and Traumatology, Central Finland Central Hospital Keskussairaalantie 19, Jyväskylä, 40620 Finland
| | - Jukka P Nyrhinen
- Department of Orthopedics and Traumatology, Central Finland Central Hospital Keskussairaalantie 19, Jyväskylä, 40620 Finland
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Abstract
Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.
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Affiliation(s)
- Mandeep S Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Balvinder Rana
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Inayat Panda
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Sandeep Patel
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Sandeep Patel, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail:
| | - Prasoon Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hernigou P, Flouzat-Lachaniette CH, Daltro G, Galacteros F. Talar Osteonecrosis Related to Adult Sickle Cell Disease: Natural Evolution from Early to Late Stages. J Bone Joint Surg Am 2016; 98:1113-21. [PMID: 27385685 DOI: 10.2106/jbjs.15.01074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Callachand F, Milligan D, Wilson A. Atraumatic Pantalar Avascular Necrosis in a Patient With Alcohol Dependence. J Foot Ankle Surg 2015; 55:207-8. [PMID: 26387059 DOI: 10.1053/j.jfas.2015.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Indexed: 02/03/2023]
Abstract
In the United States, an estimated 10,000 to 20,000 new cases of avascular necrosis are diagnosed each year. We present an unusual case of atraumatic avascular necrosis with widespread hindfoot and midfoot involvement. A 62-year-old female with a history of alcohol dependence and smoking, who had previously been treated for avascular necrosis of the knee, presented with right-sided foot pain and difficulty weightbearing. Imaging studies revealed extensive avascular necrosis of the hindfoot and midfoot, which precluded simple surgical intervention. The patient was followed up for 18 months. In the last 8 months of the 18-month period, the patient managed her symptoms using an ankle-foot orthosis. A diagnosis of avascular necrosis should be considered in patients with atraumatic foot and ankle pain, especially in the presence of risk factors such as alcohol excess and smoking.
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Affiliation(s)
- Fayaz Callachand
- Orthopaedic Surgeon, Musgrave Park Hospital, Belfast, Northern Ireland.
| | | | - Alistair Wilson
- Orthopaedic Surgeon, Musgrave Park Hospital, Belfast, Northern Ireland
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Abstract
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.
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Affiliation(s)
- Adrian R Kendal
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Paul Cooke
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Robert Sharp
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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Lamm BM, Issa K, Kapadia BH, Naziri Q, Jones LC, Mont MA. Percutaneous Drilling for Early-Stage Osteonecrosis About the Ankle. JBJS Essent Surg Tech 2014; 4:e21. [PMID: 30775128 DOI: 10.2106/jbjs.st.m.00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Bradley M Lamm
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Kimona Issa
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Qais Naziri
- SUNY Downstate Medical Center, Department of Orthopaedic Surgery and Rehabilitation, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203
| | - Lynne C Jones
- The Johns Hopkins Medical Institution, 733 North Broadway, Baltimore, MD 21287
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
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