Background:
The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm2 in area or 15 mm in diameter. However, recent ...investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs.
Purpose:
To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs.
Study Design:
Systematic review.
Methods:
A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes.
Results:
Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm2 in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm2, while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm2. The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies.
Conclusion:
An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm2 in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.
Fractures of the talus: where are we now? Kelleher, Joshua Francis; Patel, Riana; Bua, Nelson ...
Orthopaedics and trauma,
February 2023, 2023-02-00, Volume:
37, Issue:
1
Journal Article
Peer reviewed
The talus provides a crucial role in ankle stability and joint movement. If the talus is damaged, the collective motion of the foot and ankle becomes compromised, and significant disability or ...chronic pain can result secondary to complications including post-traumatic osteoarthritis, infection, and avascular necrosis. Talus fractures are challenging to treat due to their multiple articulations, precarious vascularity, and confined anatomical location. Long-term outcomes after talar fractures have historically been poor. Surgical management is advised for most displaced fractures of the talus in suitable patients. Goals of surgical treatment focus on meticulous anatomic reconstruction, preservation of blood supply, and stable fixation to encourage fracture union. This review summarizes the literature findings to provide a clearer view of the recommended management for each type of talus fracture. This article addresses individual talus fracture subtypes, including lateral process, posterior process, head, body, neck, and extrusion of the talus. In each section, we address assessment, management options, and known outcomes. The reader is also reminded of how to assess the commonly missed talus subtype fractures, particularly lateral process, posterior process and the talar head, where high index of suspicion is paramount even following a low-energy injury mechanism. Appropriate counselling is recommended to inform and educate patient about the long-term morbidity associated with talar fractures.
Background:
Autologous osteoperiosteal transplantation (AOPT) using graft harvested from the iliac crest is used to treat large cystic osteochondral lesions of the talus (OLTs). However, no studies ...have compared clinical and radiologic outcomes between AOPT and autologous osteochondral transplantation (AOCT) using graft harvested from the nonweightbearing zone of the femoral condyle of the ipsilateral knee in patients with large cystic OLTs.
Purpose:
To compare clinical and radiologic outcomes between patients undergoing AOPT and those undergoing AOCT for large cystic OLTs.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Between March 2015 and March 2018, patients who underwent AOCT and AOPT to treat medial large cystic OLTs (>10 mm) were retrospectively evaluated. For comparability, the 2 groups were matched 1:1 based on their characteristics, including sex, age, body mass index, side of injury, follow-up period, and the preoperative cyst volume. After propensity score matching, 23 patients were enrolled in each group for the analysis. Clinical outcomes were assessed using the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) score, and the Tegner score. Donor-site morbidity was recorded according to the symptoms, including pain, stiffness, swelling, and discomfort. In addition, the Lysholm score was used to assess the most common knee donor-site morbidity. Radiologic outcomes were evaluated using the magnetic resonance observation of cartilage repair tissue (MOCART) score, and the International Cartilage Regeneration & Joint Preservation Society (ICRS) score was obtained during second-look surgery.
Results:
The mean follow-up period was about 48 months. There were no significant differences in patient characteristics and lesion volumes between groups. Postoperative ankle pain VAS score, AOFAS score, and Tegner score were not significantly different between groups at final follow-up. Total donor-site morbidity (P = .004) and discomfort morbidity (P = .009) were significantly lower in the AOPT group than in the AOCT group. However, the Lysholm score showed no significant difference between the donor knee and the opposite knee (P = .503) in the AOCT group. The MOCART and ICRS scores were not significantly different between groups.
Conclusion:
Clinical and radiologic outcomes of patients who underwent AOPT from the iliac crest were found to be comparable with those of patients who underwent AOCT from the ipsilateral knee for the treatment of medial large cystic OLTs. These results may be helpful for orthopaedic surgeons to decide appropriate treatments for patients with large cystic OLTs.
Osteochondral lesions of the talus (OLT) represent an abnormality of the articular cartilage and sub-chondral bone. The abnormality is typically associated with trauma though the exact aetiology ...remains unknown. Multiple staging systems have been developed to classify the abnormality and management can vary from conservative treatment to different surgical options. Early diagnosis is essential for optimal outcome and all imaging modalities have a role to play in patient management. The aim of this article is to review the pathology, classification, multimodality imaging appearances of OLT, and how the imaging affects patient management.
Purpose
Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This ...study aimed to assess how OLT are managed worldwide by foot and ankle surgeons.
Methods
A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a “main tendency”, whereas where prevalence exceeded 50% of respondents they were considered a “tendency”.
Results
A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10–15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm.
Conclusion
The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options.
Level of evidence
Level IV.
Background:
Large cystic osteochondral defects of the talus can be challenging to treat. This retrospective control study looked at the use of osteochondral autograft transfer combined with ...cancellous allograft in patients with advanced cartilage and subchondral bone damage of the talus.
Methods:
Thirteen patients were treated with large cystic osteochondral defect of the talus between February 2010 and July 2013. All of these cystic osteochondral defects were larger than 15 mm in diameter. The subchondral defects were filled with cancellous allograft and the center of the lesions were sealed with an osteochondral cylinder autograft that was harvested from the ipsilateral medial femoral condyle. The visual analog scale (VAS) score for pain during daily activities, American Orthopaedic Foot & Ankle Society Ankle and Hindfoot (AOFAS-AH) scores and subjective satisfaction survey rating were obtained. Plain radiographs and magnetic resonance imaging of the ankle were obtained before and after surgery. In 5 cases, arthroscopy was performed 12 months postoperatively, and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society. Twelve patients were available for follow-up at a mean of 25.4 months (range, 18 to 48 months).
Results:
Average postoperative AOFAS-AH score 12 months after surgery was 88±7 compared with 64±10 preoperatively. The mean VAS score decreased from 6±1 preoperatively to 1±1 at the latest follow-up. Seven patients rated their result as excellent, 5 as good and none as fair. The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean International Cartilage Repair Society arthroscopic score from follow-up arthroscopy was 9±1 points.
Conclusions:
The use of osteochondral autograft transfer combined with cancellous allograft was an effective option for the treatment of large cystic talar osteochondral lesions.
Level of Evidence:
Level IV, retrospective case series.
Literature describes different patterns of calcaneal facets for the talus in terms of whether some calcaneal facets are connected or separated from each other or completely absent. The aim of this ...study was to establish the patterns of calcaneal facets for the talus, to calculate their total area, and to analyse the data with respect to gender. The study involved 59 calcanei which were photographed. The patterns of calcaneal facets noted in this study were compared with the patterns from the literature. ImageJ program was used to measure different parameters on calcanei. The pattern 1 was the most commonly found in the study sample (45.76%), then the pattern 2 (40.68%), and finally the pattern 3 (13.56%). That order of frequencies is the same in both sexes. The patterns 1 and 2 have a larger contact surface for the talus in comparison to the pattern 3. Male bones have a larger contact surface for the talus than female bones. The sum of the pattern 1 and pattern 3 frequencies was high. Knowing the frequency of different patterns of calcaneal facets for the talus in a certain population is important for orthopaedic surgeons when performing foot osteotomy.
This article reviews the etiology, clinical presentation, classification schemes, and treatment options for osteochondral lesions of the talus. These lesions typically occur after a traumatic injury ...and are best diagnosed on MRI. Asymptomatic lesions and incidentally found lesions are best treated conservatively; however, acute displaced osteochondral fragments may require surgical treatment. Lesion characteristics may dictate surgical technique. Outcomes following surgical treatment may be impacted by patient age, BMI, and lesion characteristics.
The treatment of talus avascular necrosis (AVN) is challenging owing to its unique anatomical features. Despite decades of studies, till date, there is no appropriate treatment for talus AVN. ...Therefore, surgeons need to develop newer surgical methods. In the present study we introduce a new surgical method, 3D printed partial talus replacement (PTR), to treat partial talus necrosis and collapse (TNC).
A male patient with talus AVN underwent PTR in our hospital. The morphology of the talus was quantified using 3D computed tomography (CT) imaging. A novel 3D printed titanium prothesis was designed and manufactured according to the findings of the CT imaging. The prosthesis was applied during talus replantation surgery to reconstruct the anatomical structure of the ankle. The follow-up period for this patient was 24 months. The visual analog scale (VAS) scores before and after surgery, American Orthopedic Foot and Ankle Score (AOFAS), ankle range of motion, and postoperative complications were recorded to evaluate the prognosis.
The anatomical structure of the talus was reconstructed. The patient was satisfied with the effects of treatment, recovery, and function. The VAS score decreased from 5 to 1. The AOFAS improved from 70 to 93. The range of motion remained the same as that during the pre-operation. The patient returned to a normal life.
3D printed PTR is a new surgical method for talus AVN that can provide satisfactory outcomes. In future, PTR might be an effective and preferential treatment for the treatment of partial talus AVN and collapse.
To evaluate the accessible area of the talar dome through 2 standard posterior approaches posteromedial (PM) and posterolateral (PL) with and without distraction.
A standard PM or PL approach was ...performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals.
The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach.
The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.
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