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Fracture of posterior process of talus is quite rare, but is associated with significant morbidity as it involves two articular surfaces. We report two such cases in which open reduction and internal fixation were done with good functional results. One of the cases had a concomitant medial malleolus fracture which to the best of our knowledge has not been reported so far.
We present a retrospective clinical and radiological study of eight patients who underwent primary Blair tibiotalar arthrodesis for Hawkins' grade III fractures of the neck of talus. The average age of the patients was 23 years and the average follow-up, was 2 years. Results were good in six patients, fair in one and poor in one. It is concluded that the displaced talar fractures with late presentation are challenging to treat and Blair fusion is a reasonable procedure.
Although if fractures of the lateral process of the talus (LPT) have been considered rare the widespread diffusion in snowboard practice has resulted in a dramatic increase in their frequency. If unrecognized they can result in secondary osteoarthritis of the ankle and/or talo-calcaneal joints and chronic pain and stiffness. Due to the complex anatomy of the region, these fractures are difficult to detect by standard radiographs. A high degree of suspicion is then necessary to diagnose them. Once suspected on the basis of physical examination and/or non concluding radiographs, computed tomography (CT) is the best modality to confirm the diagnosis and accurately appreciate the number of the fragments and their position which have therapeutic consequences (medical vs. surgical treatment). A better knowledge of these lesions seems necessary to the general radiologist to allow an early diagnosis in order to avoid chronic sequel. The purpose of this article is to report three additional cases of LPT fractures and discuss their pathogenesis, diagnosis and treatment.
We report on 9 patients with persistent ankle pain and radiographic evidence of a cystic lesion on the talus. All had a history of an inversion-type of ankle injury. Radiographs were initially negative, but a cyst developed about 6 months after the injury. Arthroscopic debridement revealed extrusion of viscid gelatinous material from the cyst. The cavity was arthroscopically abraded to bleeding base. Follow-up of these patients at an average of 26 months showed statistically significant improvement in terms of pain, swelling, stiffness, limp, and activity level. Bone grafting may not be necessary in the treatment of post-traumatic cysts.
Ankle arthroscopy is an effective procedure for the evaluation and management of osteochondritis dissecans of the talus. For active individuals with detached lesions, excision, curettage, and drilling are an effective treatment. The ability to drill arthroscopically significantly reduces the morbidity associated with open procedures. The use of an anterior cruciate ligament guide and the transmalleolar approach are techniques that have been advocated for the drilling of defects on the posteromedial aspect of the talar dome. However, we describe a new technique using the meniscal repair instrumentation that permits accurate arthroscopic localization and drilling of osteochondral lesions; no transmalleolar portal is required.
A fracture of the entire posterior process of talus is rare. In this case report, the authors present a case of isolated displaced fracture of the entire posterior process, which was treated by early open reduction and internal fixation through a posterolateral approach. The fracture healed without evidence of avascular necrosis of either the posterior fragment or the talar body. The aim of this article is to highlight the importance of early internal fixation of this uncommon type of fracture.
Treating large osteochondral defects of the talar dome is a challenging problem for the foot and ankle surgeon. The purpose of this study was to determine if ankle joint surface mechanics can be restored by repairing large osteochondral defects with multiple osteochondral cylinder grafts. Pressure-sensitive film was used to measure total contact area and mean contact pressure of the ankle joint using a cadaver foot model. Specimens were sequentially tested evaluating the following conditions: 1) intact ankle, 2) with osteochondral defect, and 3) after mosaicplasty. An ovoid chondral defect measuring 8 x 12 mm for each specimen was consistently placed within the center of the contact zone. Multiple osteochondral grafts were harvested from donor tali and placed in the defect. Two graft arrays arranged in either a cluster of four 4 x 10 mm or two 6 x 10 mm plugs were inserted sequentially to fill the defect and were tested separately. Specimens were positioned in a neutral alignment on a custom load frame and axially loaded to 560 N with the pressure transducer in place. The transducers were then digitized and analyzed with an imaging software program. Data for total contact area and mean contact pressures for all conditions of each specimen were collected and statistically analyzed. Results demonstrated that the 6-mm grafts were less than optimal in fully restoring the defect in the contact zone of the talus. There was significant decrease in mean total contact area and increase in contact zone mean pressure compared to the intact condition (p < .05). Whereas, 4-mm plugs nearly restored joint contact area and pressure to normal levels. These findings suggest that focal talar dome defects can be repaired to restore normal ankle contact characteristics via the placement of small, osteochondral cylindrical grafts of talar origin.
Avascular necrosis (AVN) of the talus is a controversial complication of trauma in children. A case of AVN is presented with a 2-year follow-up. More aggressive initial treatment may be indicated to avoid this complication. Close follow-up and suspicion are recommended.
Chondroblastomas are rare cartilaginous tumors that are found in the foot or ankle. They are usually located in portions of the humerus, tibia, or femur, and comprise approximately 1 to 3% of all osseous tumors. This is a unique case report of a chondroblastoma involving the talus of a young individual.
Osteochondral fracture of the dome of the talus is a well known complication of an inversion injury of the ankle. Recently the authors encountered a patient having a talar dome fracture associated with intra-articular fracture of the medial facet after inversion injury of the ankle. The authors have been unable to find a medial facet intra-articular fracture reported in the English literature. The talar dome fragment was removed arthroscopically and the medial facet fragment was removed using an open surgical approach. The mechanism of injury and the operative approach are discussed.
The following is a case report detailing what appears to be a previously unreported and unclassified osteochondral fracture of the posterior talar facet. This case report will detail the diagnosis and treatment of the fracture, as well as provide a brief history of previously reported osteochondral lesions involving the talus. The authors suggest a new classification method for these types of fractures.
Intraosseous cystic formation in the talus is a complication of subtalar joint arthroereisis which has not been previously reported. The authors present a case whereby STA-peg implants were utilized to correct a bilateral flatfoot deformity in an adolescent girl. The surgical procedure was successful in treating the structural deformity of the foot; however, the formation of talar cysts occurred. A review of the literature and the treatment of this previously undescribed complication is presented.
Osteochondral lesions of the talus are common injuries, especially in the athletic population. Although multiple etiologies exist, lateral lesions have a higher incidence of association with a specific traumatic event. It has been postulated that lateral lesions are produced when the anterolateral aspect of the talar dome impacts the fibula on application of an inversion or dorsiflexion stress to the ankle [2]. There is general agreement that surgery should be performed only in symptomatic cases, as osteochondral lesions of the talar dome show little tendency to progression and do not seem to lead to osteoarthritis [10,42]. Appropriate preoperative imaging is extremely important. Standard radiographs of the ankle supplemented with lateral plantar flexion and dorsiflexion views and CT or Mr imaging can be helpful in evaluating the size, depth, and exact location of the lesion. This information is essential in planning the appropriate surgical procedure. Although many stage I and II lesions respond well to conservative therapy and a period of immobilization, some higher-grade lesions (stage III and IV) eventually require surgical intervention. Most lesions can be approached arthroscopically. Many arthroscopic procedures have been shown to be successful, including debridement with abrasion chondroplasty, subchondral drilling, and microfracture [18-20]. But certain larger or refractory lesions may require an open approach to the ankle joint to restore the articular cartilage. Most lateral lesions have an anterior location and are easily accessible through a standard anterolateral approach. Most medial lesions are located on the posterior talar dome, and a medial malleolar osteotomy is usually required. Osteotomies, in particular of the medial malleolus, should be approached carefully. The possible complications of nonunion and malunion can lead to progressive arthritis of the ankle joint.
Osteochondral lesions of the talus can be difficult to diagnose and can result in a significant functional limitation in young, active patients. New imaging modalities have improved the diagnosis and staging of these lesions. In general, nonoperative treatment results in poorer outcomes compared with operative treatment, and arthroscopic treatment has results similar to open treatment. Although the literature is limited, the treatment of adolescents results in outcomes similar to the adult population.
For years, OCD of the talus has been known as a symptomatic lesion that causes pain, recurrent synovitis, altered joint mechanism, and obstruction from loose bodies. It is a probable precursor of ankle osteoarthritis because of altered joint mechanics and recurrent synovitis. With the notable advance of diagnostic imaging and the advent of ankle arthroscopy, classification of the lesion has become standardized, which allowed for the comparison of treatment options. Arthroscopic procedures (eg, debridement, retrograde drilling, bone grafting, by nature of their minimally invasive approach, have a great advantage in treating small defects and stable OCD lesions compared with open methods. For larger osteochondral defects and unstable OCD lesions, the optimal treatment is the long-term replacement and integration of type-specific hyaline cartilage. In principle, mosaicplasty autogenous osteochondral transplantation fills these criteria. The early- and medium-term results are encouraging, complete with confirmatory radiographs and histology, and hold promise for this procedure to provide lasting relief of symptoms and the prevention of ankle arthrosis. Under the current dichotomy of nonoperative and operative treatments giving satisfactory results, and few comparative studies, there is a need for a randomized, prospective study in the treatment of talar OCD to define a reproducible treatment algorithm.
The cause of a typical osteochondral lesion of the talus is traumatic; if symptomatic, several options exist. Because nonoperative treatment results in no more than 50% good to excellent results, the following types of surgery are in clinical use: (1) debridement and drilling, (2) osteochondral transfer, and (3) autologous chondrocyte transplantation. Reported good to excellent results are at least 80% in the short term. Currently available data allow no recommendation of a specific therapy for a specific lesion. Advocates of drilling and debridement accept that the repair tissue is fibrocartilage; osteochondral transfer includes a donor side morbidity. We are still at the beginning of cartilage repair; it will take time before a certain type of lesion can be treated with the best modality because that requires comparative randomized prospective studies with a long follow-up. All modern cartilage repair techniques, that were initially investigated at the knee joint, are now in use for ankle osteochondral lesions. Reported short-term success rates are greater than 80%. Further improvements will depend on the understanding of the pathogenesis and the role of contributing factors (eg, instability).
We report on a retrospective study of 33 patients who underwent arthroscopic treatment for osteochondritis dissecans of the talus. Twenty-eight of the patients (85%) had a history of mild to moderate trauma. Arthroscopic treatment consisted of removal of the osteocartilaginous fragments, debridement of disrupted cartilage, and abrasion of the base to bleeding subchondral bone. The average duration of follow-up was 7.4 years with a range of 2 to 18.3 years. Follow-up showed statistically significant improvement in terms of pain, swelling, stiffness, limp, and activity level.
SUMMARY: We report on 8 patients with persistent ankle pain after open surgery for osteochondritis dissecans of the talus. At an average of 35 months after initial surgery, arthroscopic treatment was performed in these patients. The patients had residual loose chondral and osteochondral debris at the site of the original lesion. The remaining loose cartilage was removed and abrasion of the defect to a bleeding base was performed. Follow-up of these patients at an average of 38 months showed statistically significant improvement in terms of pain, swelling stiffness, limp, and activity level.