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Osteochondral Repair of Talus: The Basic Anatomy & Pathology Of The Talus
The Basic Anatomy
The ankle joint is the meeting point of the bottom of tibia and the top of the talus. The talus is the second largest tarsal bone and is comprised of three major parts including the head, neck, and body. The dome of the talus, trapezoid in shape, is two thirds covered by the trochlear articular surface, which supports the weight of the body. The top of the talus is coated with cartilage – the tough, flexible connective tissue that absorbs shock and facilitates motion in the joints. The talus does not bear any muscular or tendinous attachments. Most of the blood supply of the talus enters through the neck via the sinus tarsi.
The Basic Pathology
The latest research has shown that most osteochondral lesions are central medial and central lateral lesions. Both types of lesions present with the following features:
- Medial osteochondral lesions are more common than lateral osteochondral lesions.
- Medial lesions have been observed as deeper and larger, extending into subchondral bone and often developing into cystic lesions.
- Lateral lesions are usually associated with a traumatic injury and are observed as shallow with a greater tendency to become displaced.
Despite significant recent advances in the treatment of symptomatic osteochondral lesions of the talus (OLTs), appropriate selection of the most suitable treatment plan still remains a complex and challenging prospect.
Osteochondral Repair of Talus: Causes Leading To Osteochondral Lesions
The causes of an OLT can be classified into traumatic and non-traumatic defects.
The Traumatic Defects
Most researchers believe that a traumatic cause plays a pivotal role in the development of a vast majority of OLTs. An acute ankle injury is associated with chronic ankle pain that develops after the traumatic incident. The mishap is commonly an inversion injury to the lateral ligamentous complex. The symptoms associated with this type of an OLT are:
- Prolonged, Deep Pain In The Ankle
- Recurrent Ankle Swelling
- Weakness In The Joint
- Subjective Instability
- Mechanical Symptoms Like Catching, Clicking & Locking
The Non-traumatic Defects
The causative factors of this type of a defect can be attributed to:
- Endocrine Problems
- Metabolic Abnormalities
- Avascular Necrosis
Osteochondral Repair of Talus: Diagnosis Of The OLT
The diagnosis of an OLT is rarely made immediately after an acute ankle injury. In most cases the condition is associated with chronic ankle pain that develops gradually after a traumatic mishap. A high level of suspicion for an OLT must always be maintained when evaluating patients with chronic ankle pain and arriving at some definite conclusion. The diagnostic procedure proceeds as follows:
- Physical Examination usually presents the following traits:
- Swelling And Tenderness at the level of the ankle mortise anteriorly or posteriorly
- Ligamentous Insufficiency Or Laxity that should always be evaluated
- A Benign Examination Process where patient’s history happens to be the best assessment source for determining an OLT
- Staging Via MRI is most commonly used modality to evaluate the OLT. The following staging systems are employed to measure the extent of deterioration of the condition.
- Berndt & Harty staging system based on plain radiographic findings
- Ferkel & Sgaglione staging system based on CT findings
- Cheng & Ferkel’s grading system based on arthroscopic findings, later explained on MRI grading system
MRI offers improved three-dimensional localization and sizing of the lesion. It also aids in the assessment of stability and determination of the presence of a cystic component. CT is predominately utilized as an adjunct for a more comprehensive evaluation and pre-surgical planning of visualized lesions.
Osteochondral Repair of Talus: The Course Of Treatment
The Conservative Treatment Approach
Conservative management of OLTs should always be attempted before surgical management is proceeded with.
- Complete Immobilization
- Regular Physiotherapy
- Staying Non-weight Bearing
- Remaining In A Cast Or Walking Boot
- Applying Bracing
- Usage Of NSAIDs
The Non-conservative Treatment Approach
Once a symptomatic OLT has been diagnosed, the orthopedic physician must confirm that conservative management has failed before considering operative interventions.
In both the diagnosis and treatment of the OTL, ankle arthroscopy has successfully established itself as a useful tool. Arthroscopy has proven to provide superior visualization of the talar dome along with improved access to the lesion, compared to an extensive open procedure. Owing to recent surgical advances, arthroscopic management of the OLT is now the preferred technique whenever possible.
Factors For Invasive Intervention
Surgical treatment relies upon a variety of factors, including:
- Activity Level of the patient
- Age at the time of surgery
- Degenerative Changes faced by the sufferer
- Location of the lesion
- Size of the lesion
- Containment of the lesion
- Severity Or Chronicity of the lesion
Aims Of Invasive Intervention
Surgical treatment generally follows one of the three principles stated beneath:
- Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation
- Loose-body removal with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling)
- Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system, mosaicplasty), allografts (particulated juvenile cartilage), or cell culture
The Surgical Process
After deciding that surgery is indicated and inevitable, the physician faces a plethora of choices from which to select the most appropriate procedure for treating an OLT. The approach and objectives of the operative procedure are variable and depend upon the type of lesion that is faced. The aims may range from removal of a loose fragment to securing a larger fragment anatomically.
- Treatment Of Intact Lesions
- Treatment Of Completely Detached Lesions
- Internal Fixation
- Bone Grafting
- Autologous Osteochondral Grafting
- Autologous Chondrocyte Transplantation
- Particulated Juvenile Cartilage Allograft
- Treatment Of Coexisting OLT And Ligamentous Instability
Osteochondral Repair of Talus: The Postoperative Care & Precautions
- Non-weight Bearing for at least 7 to 8 weeks
- Active & Passive Motion Workout for attaining full-range ankle motion
- Edema Control through ice massage & foot elevation
- Usage Of NSAIDs for effective pain management
Osteochondral Repair of Talus: The Risks & Complications Involved
- The adjacent tendons and neurovascular structures may get severed in an event of improper osteotomy placement.
- The Tibial Plafond at the malleolar osteotomy site may remain uneven.
- Hyperesthesia Around The Portal Incision may arise owing to arthroscopy.
- Neuralgia Of The Superficial Peroneal Nerves may develop occasionally.
- Allograft Implant may become resorbed over time and fragment.