Tibial Wedge Osteotomy for Osteochondral Transplantation in Talar Lesions

Abstract

Between 1999 and 2002, 16 patients with osteochondral lesions on the central and posterior talar dome underwent osteochondral autografting. A new approach with temporary removal and replacement of a tibial bone block from the anterior tibial plafond was adopted. Inclusion criteria were joint stability, an age between 18 and 50 years, and osteochondral lesions stages 3 and 4 according to the radiological classification of Loomer, for which previous arthroscopic treatment was not successful. All patients underwent clinical and MRI evaluation after 12, 35 and 59 months. The AOFAS Ankle Hindfoot score improved significantly between the preoperative period and 1 year (p < 0.001), between 1 and 3 years (p < 0.001), but not between 3 and 5 years postoperative (p = 0.37). The score was independent from patients gender (p = 0.44) and age. The Spearman coefficient of correlation between clinical outcome and defect size was - 0.79 (p = 0.01), indicating that patients with small lesions had the best results. Control radiographs and MRIs showed no reduced joint space and good integration of the tibial bone block without incongruency. Osteochondral grafting with temporary removal of a tibial bone block is a successful technique with good midterm results in osteochondral talar lesions for which arthroscopic excision, curettage and drilling has failed.

Key words

osteochondral lesion - osteochondral autograft - tibial wedge osteotomy - malleolar osteotomy - talus

References

• 1 Assenmacher J A, Kelikian A S, Gottlob C, Kodros S. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: an MRI and clinical follow-up study.  Foot Ankle Int. 2001;  22 544-551
• 2 Baltzer A W, Arnold J P. Bone-cartilage transplantation from the ipsilateral knee for chondral lesions of the talus.  Arthroscopy. 2005;  21 159-166
• 3 Berndt A L, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus.  J Bone Joint Surg [Am]. 1959;  41 988-1020
• 4 Brittberg M, Aglietti P, Gambardella R. et al .The ICRS clinical cartilage injury evaluation system - 2000. 3rd ICRS meeting in Göteborg, Sweden, April 28 - 29, 2000. 2000
• 5 Bruns J, Behrens P. Osteocondrosis dissecans tali - Ätiologische und pathophysiologische Aspekte.  Arthroskopie. 1998;  11 166-176
• 6 Campbell C J, Ranawat C S. Osteochondritis dissecans: the question of the etiology.  J Trauma. 1996;  6 201-221
• 7 Canale S T, Belding R H. Osteochondral lesions of the talus.  J Bone Joint Surg [Am]. 1980;  62 97-102
• 8 Coltart W D. Aviators astragalus.  J Bone Joint Surg [Br]. 1952;  34 545-566
• 9 Dann K, Wahler G, Neubauer N, Steiner R, Titze W, Wagner M. Concomitant injuries after upper ankle joint dislocations.  Sportverletz Sportschaden. 1996;  10 67-69
• 10 Flick A B, Gould N. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions.  Foot Ankle. 1985;  5 165-185
• 11 Gaulrapp H, Hagena F W, Wasmer G. Postoperative evaluation of osteochondrosis dissecans of the talus with special reference to medial malleolar osteotomy.  Z Orthop Grenzgeb. 1996;  134 346-353
• 12 Hangody L, Feczko P, Kish G. Mosaicplasty for the treatment of articular defects of the knee and ankle.  Clin Orthop. 2001;  391 (Suppl) 328-336
• 13 Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints. Ten years experimental and clinical experience.  J Bone Joint Surg [Am]. 2003;  85 25-32
• 14 Kitaoka H B, Alexander I J, Adelaar R S, Nunley J A, Myerson M S, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes.  Foot Ankle Int. 1994;  15 349-353
• 15 Kreuz P C, Steinwachs M R, Edlich M, Kaiser T, Mika J, Lahm A, Südkamp N P. The anterior approach for the treatment of posterior osteochondral lesions of the talus: comparison of different surgical techniques.  Arch Orthop Trauma Surg. 2006;  126 241-246
• 16 Kreuz P C, Steinwachs M R, Erggelet C, Lahm A, Henle P, Niemeyer P. Mosaicplasty with autogenous talar autograft for osteochondral lesions of the talus following failed primary arthroscopic management. A prospective study with a 4 year follow-up.  Am J Sports Med. 2006;  34 55-63
• 17 Lahm A, Erggelet C, Steinwachs M R, Reichelt A. Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefullness of magnetic resonance imaging before and after treatment.  Arthroscopy. 2000;  16 299-304
• 18 Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus.  Am J Sports Med. 1993;  21 13-19
• 19 O'Farrell T A, Costello B G. Osteochondritis dissecans of the talus. The late results of surgical treatment.  J Bone Joint Surg [Br]. 1982;  64 494-497
• 20 Ogilvie-Harris D J, Sarrosa E A. Arthroscopic treatment of osteochondritis dissecans of the talus.  Arthroscopy. 1999;  15 805-808
• 21 Pettine K A, Morrey B F. Osteochondral fractures of the talus. A long term follow-up.  J Bone Joint Surg [Br]. 1987;  69 89-92
• 22 Ritzler T, Van Dijk C N. Arthroskopische Behandlung der Osteochondrosis dissecans der Talusrolle.  Arthroskopie. 1998;  11 187-192
• 23 Sammarco G J, Makwana N K. Treatment of talar osteochondral lesions using local osteochondral graft.  Foot Ankle Int. 2002;  22 693-698
• 24 Schenck R C, Goodnight J M. Current concepts review - osteochondritis dissecans.  J Bone Joint Surg [Am]. 1996;  78 439-456
• 25 Schöttle P B, Oettl G M, Agneskirchner J D, Imhoff A B. Operative therapy of osteochondral lesions of the talus with autologous cartilage-bone transplantation.  Orthopäde. 2001;  30 53-58
• 26 Seil R, Rupp S, Pape D, Dienst M, Kohn D. Approach to open treatment of osteochondral lesions of the talus.  Orthopäde. 2001;  30 47-52
• 27 Steinhagen J, Bruns J. Ätiologie und Pathogenese der Osteochondrosis dissecans tali.  Orthopäde. 2001;  20 20-27
• 28 Steinwachs M R, Kreuz P C. Access to posterior osteochondral defects of the talus through a tibial wedge osteotomy.  Operat Orthop Traumatol. 2004;  16 300-319
• 29 Struijs P AA, Tol J L. Behandlungsstrategien bei osteochondralen Läsionen des Talus.  Orthopäde. 2001;  30 28-36
• 30 Thompson J P, Loomer R L. Osteochondral lesions of the talus in a sports medicine clinic. A new radiographic technique and surgical approach.  Am J Sports Med. 1984;  12 460-463
• 31 Ziran B H, Abidi N A, Scheel M J. Medial malleolar osteotomy for exposure of complex talar body fractures.  J Orthop Trauma. 2001;  15 513-518