Osteochondritis dissecans of the talus treated with the mosaicplasty technique: a case report

The authors present the use of osteochondral autografting with mosaicplasty technique performed on a 20-year-old man for a large osteochondral talar dome lesion. The patient had sustained a right ankle sprain many times while playing rugby football. The lesion measured 15 mm in diameter and encompassed more than one-third of the articular surface. After exposing the talus to a medial malleolar osteotomy, 3 osteochondral grafts taken from the medial femoral condyle of the ipsilateral knee were press-fit into the lesion. One year postoperatively, the patient has returned to playing rugby football. Radiographically, there was incorporation of the grafts. The authors believe that the mosaicplasty technique presents a promising new option in the treatment of osteochondritis dissecans of the talus.     

Free microvascular iliac crest flap for extensive talar necrosis—Case report with a 16‐year long‐term follow up

Atraumatic osteonecrosis of the talus can be extremely painful and lead to significant functional impairment. Although clinical, radiographic, and demographic characteristics of atraumatic osteonecrosis of the talus have been well documented, the diagnosis is frequently missed or delayed; the most common causes are use of corticosteroids and the presence of immune disorders. Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. Microvascular reconstruction of the talar dome with iliac crest autografts is a complex but functionally excellent therapeutic option. We present a 48‐year‐old man, who developed an extensive atraumatic avascular necrosis of the talar dome without collapse. Except for insulin dependent diabetes mellitus no further comorbidities were known. A microvascular iliac crest bone flap was inserted into the talus. A follow‐up 16 years postoperatively showed a clinically as well as radiographically stable reconstruction of the talar dome and an excellent mobility of the ankle joint. The AOFAS hindfoot scale had improved from initially 33 points to 100 on the last follow‐up. Free microvascular bony reconstruction of the talar dome should not only be considered in younger patients but also for middle aged active patients, since our follow‐up shows an excellent long term result. Early reconstruction can prevent collapse of the talar bone. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Complications of En Bloc Osteochondral Talar Allografts and Treatment of Failures: Literature Review and Case Report

Reoperation rates and complication rates can be high for patients receiving an osteochondral talar allograft transplant. Complications can include graft failure, delamination of the graft, arthrofibrosis, advancing osteoarthritis, nonunion of malleolar osteotomies, and partial or complete osteonecrosis of the talus. Graft failure refers to failure of graft incorporation with subsequent necrosis and subsidence. Treatment options for talar graft failure are limited, and outcomes for these treatments have rarely been reported. We present a review of the published data on the complications and treatments for failed talar allograft transplantation. A case report is presented on a young woman who experienced graft failure and osteonecrosis of her talar allograft transplant. Because of the size of the present osteonecrosis, an ankle arthrodesis was performed as the initial revision procedure. Talar necrosis was removed and revascularized from the ankle fusion with solid fusion was confirmed with computed tomography. Symptomatic adjacent joint pain quickly developed in the hindfoot after the ankle fusion, and 12 months later an ankle fusion conversion to total ankle arthroplasty was performed. The patient has returned to normal activity with significant reduction in pain at most recent follow-up visit. This patient was followed for 7 years from initial osteochondral talar allograft transplantation and for 2 years from conversion of ankle fusion to total ankle arthroplasty. It is important to understand the techniques, indications, and outcomes for the various revision options for talar allograft failure. This case report illustrates how multiple revision options can be used to provide the best outcome for the patient.     

Management of recurrent multiple osteochondral lesions of the talus (OCLT) in a young active patient

Management of recurrent osteochondral lesion of talus in a young active male is a challenging problem. We present one such case of recurrent talar osteochondral lesions treated by Autologous Matrix Induced Chondrogenesis (AMIC). Patient had a good functional outcome at short-term follow up. We also describe the technique and review the literature regarding this novel technique.     

Arthroscopic Bone Grafting of Talar Bone Cyst Using Posterior Ankle Arthroscopy

A subchondral cyst of the talus frequently occurs with an osteochondral lesion of the talar dome. Debridement, curettage, and bone grafting through the articular defect was frequently the recommended treatment in reported studies for a massive cyst. We report a case of a massive cyst of the talar body with a small osteochondral lesion of the talar dome. Our patient was successfully treated by curettage and bone grafting of the cyst using posterior ankle arthroscopy, with minimal disruption of the articular surface of the talar dome.     

Bony Lesion Recurrence After Mosaicplasty for Osteochondritis Dissecans of the Talus

Autogenous osteochondral grafts have recently become popular for use in small, isolated, contained articular cartilage defects. We treated a 26-year-old man who had a cartilage defect measuring 10 × 20 mm in the anteromedial area of the right talus. We performed multiple osteochondral grafting of the lesion with medial malleolar osteotomy from a donor site in the ipsilateral knee joint. Two years after the operation, the patient’s ankle pain recurred and the bony lesion in the talus also became osteolytic. Because we believed that only the cartilaginous portions of the osteochondral plugs grafted 2 years previously were fully fixed and viable, and that recurrence had occurred at the bony portions, at reoperation we performed curettage of the bony lesions and grafted iliac bone into the lesions with fenestration of the inferomedial ankle joint cartilage, not grafted plug cartilage. Therefore, probably because of overuse, the bony lesion in the talus had recurred 2 years after the first operation, but the grafted hyaline cartilage had survived. Autogenous osteochondral grafting into the talus, unlike the knee joint, should be done with care to ensure there is no sclerotic bone surrounding the lesion in patients with long-standing symptoms and recurrence of bony lesions.     

Centrally located osteochondral fracture of the talus.

Osteochondral lesions of the talus are common sequelae of ankle inversion injuries. Many often remain undiagnosed, which may lead to chronic pain and disability. Although attributed to other causes, most authors agree that trauma is the most common etiology. Because of this, transchondral or osteochondral fracture is a more appropriate term. Numerous cases have been documented in the literature with a preponderance for the anterolateral and posteromedial portions of the talar dome. Centrally located lesions are rare and should be treated with early surgical intervention due to the high level of compression transmitted through this area. The authors review osteochondral lesions of the talus and present a case report of a rare centrally located lesion.     

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Prospective Cohort Study

Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in the treatment of osteochondral lesions of the talus. Previous studies have presented promising short-term results for AMIC talar osteochondral lesion repair, a 1-step technique using a collagen type I/III bilayer matrix. The aim of the present study was to investigate the mid-term effects. The 5-year results of a prospective cohort study are presented. All patients underwent an open AMIC procedure for a talar osteochondral lesion. Data analysis included general demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1 and 5 years after surgery. The primary outcome variable was the longitudinal effect of the procedure, and the influence of various variables on the outcome was tested. Of 47 consecutive patients, 21 (45%) were included. Of the 21 patients, 8 were female (38%) and 13 were male (62%), with a mean age of 37 ± 15 (range 15 to 62) years and a body mass index of 26 ± 5 (range 20 to 38) kg/m². The defect size was 1.4 ± 0.9 (range 0.2 to 4.0) cm². The FFI-D decreased significantly from preoperatively to 1 year postoperatively (56 ± 18 versus 33 ± 25; p = .003), with a further, nonsignificant decrease between the 1- and 5-year follow-up examination (33 ± 25 versus 24 ± 21; p = .457). Similar results were found for the FFI-D subscales of function and pain. The body mass index and lesion size showed a positive correlation with the preoperative FFI-D overall and subscale scores. These results showed a significant improvement in pain and function after the AMIC procedure, with a significant return to sports by the 5-year follow-up point. The greatest improvement overall was seen within the first year; however, further clinical satisfaction among the patients was noticeable after 5 years.     

Osteoid osteoma of the lateral talar process presenting as a chronic sprained ankle.

Pathologic conditions of the lateral talar process may be difficult to diagnose using physical examination and roentgenographs. A computed tomography scan of the hindfoot is often useful to define lesions of the lateral process. We report a case of osteoid osteoma of the lateral talar process that defied diagnosis for 4 years. The patient had an antecedent history of an inversion injury, which had been treated as a chronically painful sprained ankle without resolution of symptoms. The tumor was ultimately identified on a computed tomography scan, best seen on a coronal section through the talus. The patient had complete relief of pain after excisional biopsy of the tumor.     

Editorial Commentary: How Far Can the Arthroscope Reach in the Ankle Joint?

Surgical access to pathology of the talar dome (e.g., osteochondral lesions of the talus) can be limited because of the ankle joint congruity. When considering arthroscopic treatment, anterior arthroscopy with the ankle in plantar flexion or posterior arthroscopy with the ankle in dorsiflexion is used. The surgeon should carefully assess different clinical and radiologic aspects to plan the optimal operative approach. Meticulous physical examination, including ankle range of motion and possible palpation of a talar lesion, in combination with exact lesion localization on computed tomography or magnetic resonance imaging usually provide sufficient preoperative information. Most lesions with the anterior border localized on or anterior to the midline of the talus are accessible by anterior arthroscopy. In the case of preoperative doubt concerning the intraoperative accessibility, a computed tomography scan of the ankle in full plantarflexion is used to mirror arthroscopic reachability. Intraoperative surgical tricks to increase accessibility to the lesion may consist of an adjunct soft-tissue distraction device, reduction of the distal tibial rim, and treating the lesion from anteriorly to posteriorly, thereby gaining further exposure to the lesion throughout the procedure.     

Osteochondral lesions of the talus

Osteochondral lesions of the talus occur infrequently and usually represent late sequelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral fractures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Non-surgical management remains the mainstay of treatment of acute, nondisplaced osteochondral lesions. Surgical management is reserved for unstable fragments or failure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and improvement of function.     

Incidence of Talar Osteochondral Lesions After Acute Ankle Fracture: A Retrospective Analysis

Recent literature suggests the majority of osteochondral lesions occur in the ankle joint. Previous studies have suggested that varying incidences of talar osteochondral lesions (OCLT) are associated with ankle fractures. The primary aim of our study was to investigate the incidence of osteochondral lesions associated with acute ankle fractures as observed on computed tomographic (CT) imaging. We also compared the rates of talar osteochondral lesions in patients who had ankle fractures with dislocation and closed manual reduction (CMR) prior to open reduction with internal fixation, to those who did not suffer from ankle joint dislocation. Additionally, a correlation between the location of talar dome lesions with type of ankle fracture as classified by Lauge-Hansen was investigated. Preoperative CT imaging was retrospectively reviewed in 108 patients with acute ankle fractures. A CT-modified version of Berndt Hardy's classification of osteochondral lesions, as previously described by Loomer et al, was used for diagnosis of lesions in our study. The incidence of lesions was calculated across all subjects, and retrospective comparison was performed in those who did and did not undergo closed manual reduction. Supplementary data on location of lesion and its association with ankle fracture type was also recorded. We found an overall incidence of 50.9% OCLT in patients with acute ankle fractures. This number did not significantly differ from those who underwent closed manual reduction (49%). Although a majority of lesions did occur posteriorly, we saw no statistically significant information was seen between either type of fractures or OCLT locations. Careful consideration and thorough evaluation of preoperative CT imaging should be assessed by the performing surgeon, as this could guide both diagnostic and therapeutic treatments for patients with possible osteochondral lesions of the talus undergoing surgical repair of a fractured ankle.     

Intra-articular Plica Causing Ankle Impingement in a Young Handball Player: A Case Report

Ankle sprains are common injuries that respond well to rehabilitation. In the case of persisting symptoms, the differential diagnosis should include osteochondral defects, tendon injury, mechanical instability, and ankle impingement. In the present case report, we describe a 16-year-old male handball player who presented with persisting pain and locking in the right ankle 3 years after having sustained multiple minor inversion trauma. The clinical examination and conventional radiography showed no abnormalities. On magnetic resonance imaging, a flake fracture at the anteromedial talar dome and/or loose body was assumed. Arthroscopic examination revealed an intra-articular plica originating from an osteochondral fossa at the anteromedial tibial plafond. The plica was debrided. Retrospectively, the arthroscopic findings matched the radiographs and magnetic resonance images. The postoperative protocol consisted of early mobilization. At 6 weeks of follow-up, the patient had no pain and had returned to his sports activities. The present case report illustrates, to the best of our knowledge, the first case of ankle impingement due to a, most likely congenital, intra-articular plica arising from an osteochondral fossa at the anteromedial tibial plafond. This rare clinical condition can be diagnosed with magnetic resonance imaging. Arthroscopic debridement will effectively relieve the symptoms.     

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.An erratum to this article can be found at     

Internal Fixation of a Lateral Inverted Osteochondral Fracture of the Talus (LIFT) Lesion Using an Innovative Surgical Approach: Inverting the Capsulo-Lateral Fibulotalocalcaneal Ligament (LFTCL)–Fibular Periosteum Complex

Osteotomy of the distal fibula or anterolateral corner of the tibia is usually required to fix a displaced osteochondral fracture of the talus that is located central to posterior area of the lateral talar dome. However, osteotomy is an invasive procedure and is associated with complications, including nonunion, persistent pain, and hardware-related problems. Lateral inverted osteochondral fracture of the talus (LIFT) lesion is an extremely rare type of displaced osteochondral lesion of the talus. We describe a case in which a LIFT lesion was fixed using an innovative surgical approach, inverting capsulo-lateral fibulotalocalcaneal ligament (LFTCL)–fibular periosteum complex, with a favorable short-term clinical outcome.     

Osteochondral Defect of the Calcaneocuboid Joint: A Case Study

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.     

Arthroscopic De Novo NT® Juvenile Allograft Cartilage Implantation in the Talus: A Case Presentation

Osteochondral defects of the talus are a challenging subject facing foot and ankle surgeons. The available treatment options have relatively good subjective outcomes; however, they are limited by the ability to reproduce hyaline cartilage, the need for multiple surgeries, and high morbidity. We present a new technique using DeNovo NT^® juvenile allograft cartilage implantation introduced into a talar lesion arthroscopically in a single procedure to repair a posteriomedial talar osteochondral defects in a healthy, active 30-year-old female. The patient tolerated the procedure well. At the 6-month follow-up visit, the patient had returned to full activity, and at 24 months, she remained completely pain free.     

关节镜辅助下带骨膜的胫骨移植治疗距骨骨软骨损伤的手术方法及临床疗效

背景:距骨骨软骨损伤常继发于踝关节运动扭伤或踝部骨折,临床上表现为踝关节周围的深部疼痛,负重、跑、跳后疼痛加重,踝关节伸屈活动受限.由于踝关节在运动中承受着巨大的压力,且软骨损伤后的自我修复能力比较受限,距骨软骨损伤后的有效治疗一直都是足踝外科中较为棘手的难题.目的:探讨关节镜辅助下带骨膜的胫骨移植治疗距骨骨软骨损伤的...     

Fibulocalcaneal Impingement in a Growing Child With Otherwise Asymptomatic Talocalcaneal Coalition

Subfibular impingement has been described in patients with flatfoot. It possibly occurs with valgus deformity associated with talocalcaneal coalition. We observed symptomatic unilateral fibular impingement initially on the left foot of an 11-year-old female with an otherwise asymptomatic bilateral talocalcaneal coalition. From the age of 8 years, she had complained of pain around the left fibular tip. Magnetic resonance imaging showed a partial talocalcaneal coalition. At 10 years of age, it was questioned whether the pain was related to the coalition. However, imaging of the asymptomatic right foot also showed a talocalcaneal coalition, with the coalition in both feet appearing equal. Additionally, the peroneal trochlea appeared particularly prominent, more so on the left than on the right foot. Therefore, the symptoms were suspected to have been caused only by fibulocalcaneal impingement owing to a relatively long fibula. Subperiosteal shortening of the fibula was performed at when she was 11 years old. A bed for the peroneal tendons was created around the remaining epiphysis of the fibula, and the fibular ligaments were reattached with Arthrex^® anchors (Arthrex, Naples, FL). At 14 months postoperatively, the patient was free of pain with unrestricted movement, although the follow-up imaging studies showed complete bony fusion on the medial aspect of the coalition between the talus and calcaneus. Approximately 1.5 years after surgery, our female patient at 12.5 years old complained of the same problems on her right foot, definitely occurring only around the fibula. The same procedure was performed as she had undergone on the left foot. At the last follow-up examination, she was asymptomatic 2.5 years after the initial surgery of the left foot and 11 months after surgery on the right. Talocalcaneal coalition can cause moderate to severe hindfoot deformity, leading to fibulocalcaneal impingement. Hence, treatment should be determined accordingly.     

Atraumatic Bilateral Insufficiency Fractures of the Talar Neck in a Rheumatoid Patient

We report a 73-year-old female with rheumatoid arthritis, who presented with a 1-year history of ankle pain without trauma. Conventional radiographs showed no bony abnormalities, and bone scintigraphy showed increased uptake in the neck of the left and right talus. Magnetic resonance imaging scans showed insufficiency fractures of the talar neck bilaterally. The patient was treated nonoperatively with weightbearing casts and analgesics. The present case study stresses the need to add insufficiency fractures of the talus to the differential diagnosis of chronic ankle pain when conventional radiographs show no abnormalities.