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This article addresses very large osteochondral lesions of the talus with an osteonecrosis overlap. Six cases are discussed where lesions were deemed too large for osteochondral autograft transfer (OATS) or autologous chondrocyte transplant (ACT). These cases were treated with bulk fresh or fresh frozen matched talus allograft transplantation. The associated literature is reviewed.
AVN of the talus is a challenging disease process with respect to patho-physiology and treatment. We believe that our algorithm is a legitimate approach to aid the orthopedic surgeon in initiating a promising treatment. It is divided into different levels and allows to change between some. This is not the only way to proceed but it seems promising, especially if the long-term results with the vascularized bone grafts show revascularization of the talus. As always in medicine, the treatment needs to be individualized. Arthrodesis always should be the last option and is a challenging procedure.
Several studies have demonstrated that discriminant function equations used to determine the sex of a skeleton are population-specific. The purpose of the present research was to develop discriminant function equations for sex determination on the basis of 18 variables on the right and left talus and calcaneus in a modern northern Italian sample. The sample consisted of 118 skeletons (62 males and 56 females) from the Frassetto Collection (University of Bologna). The ages of the individuals ranged from 19 to 70 years. The results indicated that metric traits of the talus (in particular) and calcaneus are good indicators of sexual dimorphism. The percentage of correct classification was high (87.9-95.7%). In view of the differences among current Italian populations, we tested the validity of the discriminant function equations in an independent sample of individuals of different origin (northern and southern Italy). The accuracy of classification was high only for the northern Italians. Most southern Italian males were misclassified as females, confirming the population-specificity of discriminant function equations.
We report three patients with subperiosteal osteoid osteoma of the talus. All showed an erosion of the dorsal surface of the talus with medullary bone sclerosis. Adjacent paraosseous soft tissue calcification was seen in two lesions. Computed tomography demonstrated the nidus of the osteoid osteoma in two cases.
Knee dislocation is defined as a radiographically confirmed total loss of the tibiofemoral articulation. This rare injury is believed to be the result of a high-impact trauma. Knee dislocations are classified according the direction of tibial displacement with respect to the femur. Subtalar dislocation is the simultaneous dislocation of the distal articulations of the talus at both the talocalcaneal and talonavicular joints. These injuries are also quite rare and are mostly (80%-85%) classified as medial subtalar dislocations with the calcaneus lying medially, the head of the talus being prominent dorsolaterally and the navicular located medial and dorsal to the talar head. The authors report the case of an elderly patient who suffered ipsilateral anterior dislocation of his left knee and medial subtalar dislocation of his left foot. The authors believe this to be the first presentation in the English literature of an ipsilateral combination of these two injuries on the same limb.
Injuries to the ankle tend to be some of the most common injuries seen in practice. Of these ankle injuries, fractures of the posteromedial process of the talus are often misdiagnosed as ankle sprains because of poor visualization on routine ankle radiographs. The examining physician must have a heightened awareness of this injury to accurately diagnose and treat this fracture. Proper treatment could help to lessen the possibility of post-traumatic arthritis to the ankle and subtalar joints. The authors present a case of a fracture of the posteromedial process of the talus, after a medial subtalar dislocation, treated with open reduction and internal fixation with bioabsorbable pins.
Chondroblastoma of bone is an uncommon condition that has a predilection for secondary ossification centers, particularly of the humerus, tibia, and femur. Treatment usually involves surgical curettage and autogenous bone graft. This article reports the case of a chondroblastoma affecting the talus of a young man and a minimally invasive surgical approach for the treatment of this lesion. The patient presented with an 18-month history of right ankle pain and swelling. The lesion involved most of the talar body, with 2.5-cm cortical erosion inferiorly at the posterior talocalcaneal facet. A lateral approach was made to the talus and a window was fashioned at the distal end of the sinus tarsi under fluoroscopic guidance to allow access to the lesion. This was curetted and the defect was filled with autogenous bone graft taken from the ipsilateral iliac crest. The patient underwent an uneventful recovery, and was asymptomatic at follow-up 24 months postsurgery. He had 75% movement at the subtalar joint, when compared with the contralateral foot.
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.
PURPOSE: The purpose of this study was to show that magnetic resonance imaging (MRI) can accurately and noninvasively evaluate the articular cartilage overlying osteochondral lesions of the talus, using arthroscopy as the standard, and provide information about lesion stability. A classification system applicable to both MRI and arthroscopy is proposed. TYPE OF STUDY: Retrospective review with MRI and arthroscopy correlation. METHODS: A retrospective analysis involving 26 men and 28 women who underwent MRI of the ankle and in whom arthroscopy had been performed. The talar dome cartilage was evaluated using the following grading system: 0, normal cartilage; 1, abnormal signal but intact; 2, fibrillation or fissures not extending to bone; 3, flap present or bone exposed; 4, loose undisplaced fragment; 5, displaced fragment. There was a history of trauma in 80% of cases. RESULTS: At surgery, 14 ankle joints had intact cartilage and 40 showed osteochondral lesions. MRI correctly identified all 40 osteochondral lesions and all 14 normal ankles. MRI correctly graded 33 of 40 (83%) of the osteochondral lesions using the described 5-point scale. Of the remaining 7 lesions, all were identified within 1 grade. Collapsing all grades into disease-negative status (grades 0 and 1) and disease-positive status (grades 2, 3, 4, and 5) yielded sensitivity of 95%, specificity of 100%, negative predictive value of 88%, and positive predictive value of 100%. CONCLUSIONS: This study shows that MRI can be used to evaluate the articular cartilage covering osteochondral lesions of the talus with a high degree of accuracy and thus may aid in identifying patients who would benefit from definitive arthroscopic treatment.
PURPOSE: The goal of this study was to perform a retrospective review of arthroscopically treated osteochondral lesions of the talus (OCLTs) to determine their outcome and to analyze the correlation of 3 subjective outcome scoring systems for the ankle. METHODS: Between 1985 and 1999, 37 arthroscopic debridement or subchondral drilling procedures were performed on 33 ankles to treat OCLTs. The charts of these patients were reviewed for general demographic, preoperative, surgical, and postoperative information. Patients were sent a questionnaire that included 3 subjective outcome scoring systems: the Martin Score questionnaire; the Berndt and Harty scale; and the Single Assessment Numeric Evaluation (SANE) question. Twenty-eight people responded to the questionnaire. Twenty-four patients reported a history of trauma. There were 17 lesions on the medial aspect of the talus, 10 laterally, and 1 centrally. The lesions were classified according to their arthroscopic appearance. There were 7 stage I, 2 stage II, 10 stage III, and 9 stage IV lesions. After all data were analyzed, the Pearson product-moment correlation coefficient (r) and correlation of determination (r2) were performed among the 3 outcome scales. RESULTS: The mean follow-up time was 66 months (range, 6-169 months). Outcome results varied according to the scoring system. Using the Berndt and Harty scale, 13 (46%) patients had good, 13 (46%) fair, and 2 (8%) poor results. According to the Martin Score, 1 patient (4%) had excellent, 10 (35%) good, 9 (32%) fair, and 8 (29%) had poor results. According to the SANE score, 5 patients (18%) had excellent, 8 (29%) good, 9 (32%) fair, and 6 (21%) had poor results. Seventeen patients reported some form of pain at follow-up examination. Analysis of variables, including age at operation, stage of the lesion, length of follow-up, and previous surgery revealed no statistical significance. All 3 scales showed positive correlations. Based on these outcome data, the Berndt and Harty scale showed good correlation with both the SANE and the Martin outcome systems (r =.81 and r =.69, respectively). The Martin Score showed moderate correlation with the SANE outcome system (r =.57). CONCLUSIONS: The outcome results for our patient population were not as successful as has been previously reported. Our analysis showed positive correlation among the 3 subjective outcome systems. However, it remains difficult to compare these data with previous results secondary to the variety of outcome measures employed by previous reports in the literature.
PURPOSE: To evaluate the clinical value of sagittal 2D- and 3D-reformations of the talus with and without electronic disarticulation compared to axial slices. MATERIAL AND METHODS: 23 patients with suspected traumatic lesions of the talus underwent 26 diagnostic CT examinations. Axial slices, sagittal reformations, and 3D-reformations without and with electronic disarticulation were performed. The sagittal 2D- and both types of 3D-reformations were compared to the axial slices with regard to their diagnostic information. RESULTS: Axial slices showed involvement of articular facets in 25 cases. Sagittal and 3D-reformations after electronic disarticulation depicted 23 fractures (23/25), 3D-reformations without electronic disarticulation showed none (0/23). Subluxation of the talocalcaneal joint was only visualised on axial slices three times. One complete luxation of this joint was shown on axial slices, sagittal and 3D-reformations without disarticulation. It was not visualised on 3D-reformations after disarticulation. CONCLUSION: The diagnosis must be made based on the axial slices, supported by sagittal reconstructions. 3D-reformations after electronic disarticulation provide a graphic, detailed and readily recognised image of the anatomy of transchondral fractures, and are very helpful in preoperative planning.
The collective consists of 11 patients with a "ball and socket"-anomaly of the talus with a mean age of 13.7 years. All patients demonstrated typical symptoms of the FFU-syndrome with a leg length discrepancy of 4.3 cm (2-20). In 6 patients a close follow-up was done in the early development of the talus form. In the metacarpal region also synostosis of some bones were seen at a mean age of 4.8 years (3.2-5.9). No clinical complaints but a slight reduction of hind foot mobility could been registered. Ball and socket deformity can not been seen as congenital, but as a subsequent deformity after congenital fusions in the metatarsal bones.
Congenital vertical talus (CVT), also known as "rocker-bottom foot" deformity, is a dislocation of the talonavicular joint, with rigid dorsal dislocation of the navicular over the neck of the talus. This condition is usually associated with multiple other congenital deformities and only rarely is an isolated deformity. The reported familial cases are consistent with an autosomal dominant mode of inheritance with incomplete penetrance. In contrast, Charcot-Marie-Tooth disease (CMT) is thought to be a completely distinct heterogeneous group of disorders, with foot abnormalities that typically develop a high-arched "claw foot" appearance later in life. In the present study, DNA was isolated from 36 members of a single upstate (northern) New York white family of Italian descent in which both CVT and CMT were segregating. Whole-genome linkage analysis with Affymetrix GeneChip Mapping 10K Array defined a 7-Mb critical region on chromosome 2q31, which led to candidate-gene sequencing of six HOX genes and detection of a single missense mutation, M319K (956T-->A), in the HOXD10 gene. In the study family, this mutation was fully penetrant and exhibited significant evidence of linkage (LOD 6.33; theta =0), and it very likely accounts for both CVT and CMT in heterozygotes.
Displaced fractures of the ankle are a common component of current orthopaedic practice, whereas displaced fractures of the talus are unusual. Ankle fractures generally are produced by indirectly applied, relatively low energy forces, whereas talus fractures are created by higher energy axial loading. Despite these inherent differences, the end result of either injury can be avascular necrosis, posttraumatic arthritis, or soft tissue loss. Complications and poor results can arise from the inherent characteristics of the injury, from failure to accomplish appropriate treatment objectives, from overzealous treatment goals, or from overlooking subtle clinical or radiographic signs. The goal of the current study is to provide a method of evaluating the characteristics of these injuries to optimize functional outcomes and avoid morbidity.
Ten patients with osteochondral lesions of the talus had magnetic resonance (MR) imaging to determine if this modality could accurately characterize the bone lesion and overlying articular cartilage. Eight patients had arthroscopy, five of whom also had arthrotomy. Magnetic resonance detected abnormal cartilage in all eight patients and disruption of cartilage in four of five, proven at surgery. One patient had disrupted cartilage at surgery not diagnosed by MR. Four patients had excision of the osteochondral fragment and curettage of the talar defect and in these patients MR accurately characterized the bony lesion. Three patients had conservative surgical procedures (drilling) and the extent of the bony lesion could not be determined at surgery. Magnetic resonance can accurately characterize the osteocartilaginous components of talus lesions and even though it should not replace plain radiography for diagnosis, it is ideally suited for evaluation of the articular cartilage and has proven to be useful in planning surgical procedures.
A rare case of a fracture through the neck of the talus with a trimalleolar ankle fracture and ruptured tibialis posterior tendon is presented and the literature reviewed. Management consisted of open-reduction internal fixation of the fractures and repair of the tibialis posterior tendon. At 40 months after injury, the patient had tibiotalar range of motion at 5 degrees of dorsiflexion and 38 degrees of plantar flexion. While avascular necrosis of the talus did not occur, significant degenerative arthritis of the ankle was noted.
Coronal computed tomography (CT) scan was used in the evaluation of a fractured process of the talus in 10 patients. Because routine radiographs failed to determine either the size or comminution of the fractured process, CT imaging was used to accurately assess the size, displacement, and comminution of the fractured process. CT scans also showed the extent of subtalar joint involvement, any associated tendon pathology, or additional fractures. In two patients the nature of the injury was initially missed, and CT scan diagnosed a nonunion of the lateral process. In all patients, CT scan altered the management of the fracture or helped in selecting the surgical approach. The authors recommend that coronal CT scans be used in the evaluation of a fractured process of the talus.
Treatment goals in the operative management of talus fractures include prompt, anatomic, open reduction with rigid internal fixation; functional outcome is measured by degree of arthrosis, pain, range of motion, limb length, cosmesis, and return to premorbid activities. If restoration of the articular surfaces is precluded secondary to comminution, immediate and/or staged reconstructive salvage procedures must be considered. This report describes an immediate reconstructive procedure for salvage after a comminuted talus fracture with an ipsilateral tibia fracture. A standard antegrade tibial nail extending into the calcaneus was selected to stabilize both fracture sites. The technique of tibiocalcaneal arthrodesis using interposition fibular autograft and intramedullary fixation is presented as a unique treatment option.