Dome Lesions Research Articles

Talar Dome Fracture Repaired Using Bioabsorbable Fixation

We describe a man with an acute osteochondral defect in the lateral talar dome associated with a supination-adduction-type ankle fracture. The osteochondral defect was readily visible on plain film radiographs, and magnetic resonance imaging was ordered to determine the full extent of soft-tissue and articular injury. It was discovered that the patient had a stage IV lesion of the talar dome, with complete inversion of the fragment, and rupture of the anterior talofibular and calcaneofibular lateral ankle ligaments. Furthermore, the patient experienced an oblique fracture of the medial malleolus with comminution. The talar dome lesion was surgically reduced and fixated using bioabsorbable pins. Nine months after surgery, the patient was fully recovered from his injury and had no functional limitations.

Use of the Noninvasive Ankle Distractor With Talar Dome Osteochondral Graft Transplantation

Talar dome lesions greater than 1 cm in diameter are often treated with ankle joint mosaicplasty. The purpose of this article is to present the use of a noninvasive ankle distractor that can improve access to the talus when used with a malleolar osteotomy. The use of the distractor allows for graft insertion at a more appropriate angle in relationship to the talar cartilage, avoidance of invasive distractor usage, and potential use of a smaller osteotomy.

Long-term follow-up after conservative surgery for bladder endometriosis

To describe the long-term outcome of surgical conservative treatment of bladder endometriosis. Descriptive study. Tertiary referral center for the treatment of endometriosis. Forty-seven patients with symptomatic bladder endometriosis. Partial cystectomy by laparoscopy or laparotomy. Rates of recurrence at a 36-month follow-up. All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively). Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality.

LAPAROSCOPIC EVALUATION OF MASSES IN END STAGE LIVER DISEASE PATIENTS

P592 The Model of End-Stage Liver Disease (MELD) scoring system is the current standard for determining recipient priority for liver transplantation. Under this scoring system, a patient diagnosed with hepatocellular carcinoma (HCC) receives a considerable increase in their priority score. As a result, multiple programs have adopted an aggressive surveillance program, which frequently utilizes surgical exploration, to confirm the presence of and provide treatment for tumors. Methods: All potential liver transplant candidates who were explored for a radiographic mass were identified, and patient demographics, tumor characteristics and patient survivals were examined. All patients with tumors identified by intra-operative ultrasound underwent radiofrequency ablation (RFA). Results: Sixty-four patients were explored for undiagnosed liver masses. Three (7%) patients were managed via an open incision; one laparoscopic patient required conversion to improve access to safely ablate a dome lesion. Fourteen (21%) patients underwent laparoscopy without ablation: absence of diagnostic lesions (n=7), metastatic disease (n=5), or benign tumor biopsy (n=2). Mean hospital stay for the series was 36 hours (range 20 to 50 hrs). Complications included new onset of ascites (n=5), worsening of ascites (n=23), and wound infection (n=4). No treatment related mortality was incurred. Of the 46 patients who received RFA, 16 (34%) were excluded from transplantation: newly diagnosed pulmonary hypertension (n=2), unabated alcohol usage (n=2), poor physiologic age (n=2), lack of social support (n=5), morbid obesity (n=2), metastatic disease (n=1), and death [variceal bleed, recurrent HCC] (n=2). Twenty-seven (42%) explored patients were transplanted, while 9 (14%) patients were excluded from transplantation based on findings identified during the procedure. With the diagnosis of HCC, 24 patients in need of therapeutic transplantation had their MELD scores increased from 14 to 22 points. Six patients are currently awaiting either completion of their evaluations or transplantation. Time from RFA to transplant ranged from 2 weeks to 1 year. Examination of explants identified one (2%) liver in which HCC was missed. Of the 24 patients who underwent RFA, all had evidence of necrosis, which varied from 30 to 99%. While those with RFA-to-transplant intervals greater than 3 months had the highest percentages of necrosis, those with shorter intervals, though demonstrating lower percentages of necrosis, displayed extensive apoptotic tumors. Conclusion: Laparoscopic evaluation and RFA of hepatic tumors in cirrhotic transplant candidates is both safe and efficacious. With continued changes in the MELD scoring system, laparoscopy can provide both accurate staging and interventional therapy for candidates awaiting transplantation. In this series, laparoscopic findings saved 14% of patients from an unnecessary open exploration at the time of organ availability. The findings of this series also indicate there is a linear rate of necrosis found in cirrhotic livers after ablation.

Osteochondritis dissecans of the talus treated with the mosaicplasty technique: a case report

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.

Percutaneous ethanol injection via an artificially induced right hydrothorax for hepatocellular carcinoma in the hepatic dome.

To evaluate the efficacy of sonographically (US) guided percutaneous ethanol injection (PEI) via an artificially induced right hydrothorax (transthoracic PEI) to treat US-invisible hepatocellular carcinoma (HCC) in the hepatic dome. Five cirrhotic patients with US-invisible HCC in the hepatic dome, who were poor surgical candidates, underwent transthoracic PEI. An artificial right hydrothorax was created by instilling 500 ml saline, and absolute ethanol was injected transhydrothoracically into the hepatic dome lesion under local anesthesia. The success and complications were assessed radiologically. The patients were followed up serologically and radiologically for 12-44 (mean 28.4) months. Twenty-five hydrothoraces were induced. All hydrothoraces enabled US visualization of the entire hepatic dome. Eight of the nine small lesions were treated successfully by the treatment. Two of the three local recurrences were eradicated by repeat transthoracic PEI. One large lesion was treated by a combination of transthoracic and regular PEI. The only complication was one clinically insignificant pneumothorax. Induction of a right hydrothorax is feasible and safe. The hydrothorax enables US visualization of the entire hepatic dome and permits US-guided PEI for HCC in the hepatic dome that otherwise would not be possible.

Paper #118 Autologous osteochondral grafting for cartilage defects of the talar dome

We present a follow-up study including a standardized outcome analysis of both the recipient and donor sites to help further develop our understanding of both the management and prognosis of osteochondral defects of the talus treated with the use of autologous osteochondral grafting. The cases of twenty-one patients surgically treated with open talar autologous osteochondral grafting for symptomatic focal cartilage defects of the talar dome between 1998 and 2000 were retrospectively reviewed. The mean age of men and women was 31.3 and 33.7 years, respectively, with a mean time to follow-up of 20.5 months. The talar lesions were preoperatively evaluated using plain radiographs, computerized tomography (CT), magnetic resonance imaging (MRI), and arthroscopy. The surgical management for all patients consisted of open debridement of the talar dome defect approached using either an oblique medial malleolar osteotomy for the medial talar dome lesion or a soft tissue takedown of the syndesmotic ligaments via an anterolateral approach for the lateral talar dome lesion. The donor osteochondral cylindrical grafts were then harvested using an open arthrotomy from the nonweightbearing trochlear border of the ipsilateral knee and consequently press-fitted into the respective sized recipient talar site to fill the defect. The medial malleolar osteotomy site was then rigidly internally fixed using two screws for the medial lesion or a modified Brostrom repair was performed to reconstruct the lateral ligaments for the lateral talar lesion. The postoperative regimen included an eight week course of nonweightbearing in a short leg cast with early range of motion of the knee followed by a foot and ankle and knee rehabilitation program. The mean size of the talar dome defects was 10mm x 15mm (range 70mm2 to 350mm2). Functional outcome results were prospectively obtained, for both the ankle and the knee, using the MODEMS AAOS Foot and Ankle Follow-up questionnaire, the AOFAS (American Orthopedic Foot and Ankle Society) ankle-hindfoot scale and Hannover scores for the ankle, and the International Knee Documentation Committee (IKDC) subjective knee evaluation form (a modification of the MODEMS Knee follow-up questionnaire), the IKDC objective knee examination form, and the Hospital for Special Surgery (HSS) score for the knee. The mean AOFAS ankle-hindfoot score was 60.6 (range 42 to 72) preoperatively, 83.5 (range 60 to 100) at twelve months postoperatively (in nineteen patients), and 89 (range 65 to 100) at final follow-up. The Hannover ankle assessment revealed a mean score of 93.3 (range 73 to 104) at final follow-up, and the mean score for the MODEMS AAOS Foot and Ankle Follow-up questionnaire was 93.2 (range 77.5 to 100). Regarding donor site pathology, the IKDC subjective knee evaluation form revealed a mean score of 87.4 (range 61.4 to 100) at final follow-up. Using the IKDC objective evaluation form, the mean postoperative score for the knee was grade A (normal) in 14 (67%) and grade B (nearly normal) in seven (33%). Using the HSS score, the mean score was 95.3 (range 85 to 100). There was 90.5% overall patient satisfaction. Additionally, there was a statistically significant association between the presence of a bipolar ankle lesion (with a focal cartilage defect of the distal tibial plafond opposite the corresponding talar lesion) and less than excellent outcome results (p < 0.05). We believe that the technique of autologous osteochondral grafting presented is valuable and should be considered an option for the patient with a symptomatic focal osteochondral defect of the talus.

Chevron-type Transmalleolar Osteotomy: An Approach to Medial Talar Dome Lesions

ABSTRACTOperative treatment of lesions of the medial talar dome can be very challenging. An osteotomy of the medial malleolus can provide adequate access for posteromedial talar dome lesions. The authors describe the technique of a chevron-type medial malleolar osteotomy. This particular osteotomy p

Computer-assisted retrograde drilling of osteochondral lesions of the talus

Treatment principles of osteochondral lesions of the talus usually consist of debridement of the chondral part and methods that attempt to stimulate revascularization of the necrotic bony part of the lesion. The latter is mostly achieved through multiple drilling of the subchondral zone. Dorsomedial talar dome lesions are frequently inaccessible with antegrade drilling techniques. In addition, if the cartilage surface over the bony lesion is still intact, it can be injured by antegrade drilling. To overcome these potential problems, retrograde drilling techniques have been developed using drill guides or intraoperative fluoroscopy. Our proposed method of computer-assisted retrograde drilling is an advancement of these techniques. The use of 3D navigation provides the possibility for placing a guide wire exactly in the center of the lesion defined on preoperative MRI or CT scans. This guide wire can then be overreamed with cannulated reamers followed by retrograde bone grafting of the lesion or allows multiple retrograde drilling of the subchondral plate using a parallel drill guide. We found that computer-assisted retrograde drilling could improve precision, avoid misplacement of guide wires, and reduce the time of surgery and intraoperative fluoroscopy.

Incidence of lateral talar dome lesions in SER IV ankle fractures

Osteochondral lesions of the talar dome are commonly the result of ankle trauma. While the technique of surgical repair of ankle fractures has been well reported, there are no studies that correlate the presence or absence of talar dome lesions. A possible explanation for this may be lack of intraoperative inspection of the talar articular surface. This retrospective study evaluates the incidence of lateral talar dome lesions in 50 supination-external rotation stage IV ankle fractures. Specifically, operative reports were reviewed for the presence of lateral talar dome lesions documented through intraoperative inspection. Overall, 19 of 50 fractures, or 38%, were found to have a lateral talar dome lesion. While the bimalleolar and deltoid ligament tear type fractures exhibited more talar dome lesions, there was no significant difference between these two fracture types (p = .1111). There was no statistically significant difference among the three types (unimalleolar, bimalleolar, and trimalleolar) of supination-external rotation ankle fractures (p = .0804). The authors conclude that intraoperative inspection of the lateral talar dome should be a routine part of ankle fracture repair.

Autogenous bone grafting for the treatment of talar dome lesions

This study evaluated a surgical bone grafting technique, which restores the talar dome weightbearing articular surface for the repair of a transchondral lesion. An autogenous bone graft combined with viable cartilage is used to recreate a normal talar articular surface. In a retrospective analysis of talar dome lesions, 14 patients surgically treated with bone grafts were compared to 17 patients treated with curettage and subchondral drilling. Post surgical follow-up was collected at 71.5 +/- 21.1 months (mean +/- SD). Age, lesion stage, and gender did not differ between the groups, but the mean fracture area was selectively smaller in the curettage and drilling group (85.2 +/- 58.7 mm2 vs. 156.4 +/- 69.4 mm2). Clinical evaluation consisted of an 8-point scale which took into account range of motion, the presence of pain and crepitus, and radiographic assessment. Significantly better overall clinical scores were observed for the bone graft group (graft, 6.9 +/- 1.6, curettage plus drilling, 4.5 +/- 1.9; p = .001), due to better results for range of motion (1.6 degrees +/- 0.5 degrees; 1.1 degrees +/- 0.4 degrees), less pain (2.7 +/- 0.50; 2.0 +/- 0.7), and presence of subchondral bone on x-ray (0.9 +/- 0.4; 0.2 +/- 0.4). Patients were also asked their perception of their own surgical outcome (considering pain frequency and ability to participate in sporting activities or walk at a similar level compared to before the surgery), and if they would have the surgery again. No differences in the patients' preoperative symptoms or their subjective assessment post surgery were detected between the groups. While curettage plus drilling is the most common surgical procedure for chronic symptomatic talar dome lesion, our results suggest that bone grafting of the lesion yields better long-term clinical results.

Nuclear medicine teleradiology in regional and rural centres of Western Australia

We have established a nuclear medicine teleradiology service for rural and regional areas of south-west Western Australia. This study aimed to evaluate whether existing treatment models had altered in ways which were directly related to improved medical outcomes and reduced cost. Preliminary observation into musculoskeletal injury of the ankle joint included diagnosis of 10 radio-occult talar dome lesions which in some cases had not been identified until six months after the trauma. Several cases suggest that nuclear medicine provided a more timely diagnosis and actively altered treatment. Further, the potential role of radiologists as primary-care extenders in guiding appropriate investigations and defining the nature of the illness before specialist consultation may lessen the economic burden on public health care while creating economies of scale by expanding the clinical usefulness of the nuclear physician over a large rural area.

Oblique medial malleolar osteotomy for the management of talar dome lesions

The purpose of this retrospective study was to determine the efficacy of the oblique medial malleolar osteotomy for the management of medial talar dome lesions. Arthroscopy remains a viable option for the management of these lesions; however, the central and posteromedial lesions are often difficult to gain access to with arthroscopy and may require open arthrotomy. Fourteen oblique medial malleolar osteotomies were performed for the surgical management of medial talar dome lesions. Subjective data were collected through the process of questionnaire. Objective criteria consisted of radiographic evaluation and retrospective medical record review. Seven of the 14 patients related a history of trauma preoperatively. The oblique medial malleolar osteotomy demonstrated osseous union at an average of 6.6 weeks. There were no delayed unions or nonunions. None of the patients required a second operative procedure. Nine patients reported excellent postoperative results, two patients had good results, two had fair results, and one patient related a poor postoperative outcome with only 50% relief of pain. Patients greater than the age of 30 were found to have less favorable results. Follow-up ranged from 6 to 72 months, with a mean follow-up of 34 months.

Biopsy of hepatic dome lesions: semi-real-time coronal MR guidance technique.

MR imaging, with its coronal imaging capability, may be ideally suited for biopsies of hepatic dome lesions. We are reporting on the successful semi-real-time biopsy of such lesions using a 0.2-T open-configuration MR scanner in five patients. MR guidance holds promise for facilitating biopsies of hepatic dome masses.

Recognizing Talar Dome Lesions.

In brief People who sprain their ankles brief may sustain osteochondral fractures of the talar dome. If unrecognized, these fractures can cause chronic pain and disability. The history and physical examination may be nonspecific, but a physician who has a high index of suspicion can identify these lesions with targeted imaging procedures. Identifying the stage of the lesion will suggest a conservative or surgical treatment approach. Prognosis for either option is generally good; however, osteoarthrosis may develop.

Osteochondritis Dissecans of the Talus (Transchondral Fractures of the Talus): Review of the Literature and New Surgical Approach for Medial Dome Lesions

A retrospective study of 22 ankles in 22 patients with osteochondral talar dome lesions between 1975 and 1983 has indicated that surgical treatment yields superior results to conservative therapy. Thirteen male and 9 female patients, ages 9 to 72 years, average age 28 years, showed 10 medical lesions (Berndt and Harty classification (stage I (one); stage II/III (nine)) and 12 lateral lesions (stage II/III (5), stage IV (7)). Examination follow-up on 19 patients (86%) has averaged 24 months. The initial diagnosis seen retrospectively on x-rays was missed 43% of the time by emergency room physicians. A history of trauma was verified in 100% of the lateral lesions and 80% of the medial talar dome lesions. Of the 22 ankles, 14 lesions were isolated injuries, while 8 had concomitant fractures, lateral ligament, or peroneal tendon damage. Surgical treatment consisted of removal of the osteochondral fragment, curettage, and drilling of its bed. Two distinct surgical approaches were utilized. Lateral dome lesions were approached through the standard anterolateral incision, while medial dome lesions were approached through the anterior tibial tendon sheath with grooving of the anteromedial distal tibia articular surface. The medial approach allowed the somewhat posteriorly placed medial lesions to be reached, negating the need for a medial malleolar osteotomy and postoperative immobilization. On follow-up, no untoward ankle arthrosis was noted as a result of the grooving of the anteromedial distal tibia. Nineteen of the 22 patients had surgical therapy with 79% excellent or good, 21% fair, and no poor results. Five of the eight patients who elected prolonged conservative therapy finally had surgery. Of the three remaining patients conservatively treated, there were two fair results and one poor result.

Osteochondral lesions of the talus in a sports medicine clinic. A new radiographic technique and surgical approach.

A retrospective review of 11 patients seen at the University of British Columbia Sports Medicine Clinic with osteochondral lesions of the talus was undertaken. From our data, a number of points became apparent. There was a predominance of posteromedial talar dome lesions. A flexion-inversion ankle injury could be documented in the majority of cases. There was frequently a long delay in diagnosing these ankle sprain mimics. Historical details which should raise one's index of suspicion include: (1) history of flexion-inversion injury; (2) exercise-related ankle pain; (3) sensations of "clicking and catching"; and (4) persistent swelling. Surgery produced consistently good early results in these active patients without osteotomizing the medial malleolus. Experimental analysis and clinical experience suggest that the optimal radiographic technique for identifying the posteromedial osteochondral lesion consists of an anteroposterior view of the ankle in maximum plantar flexion with the kilovoltage set at 70.

Prognostic significance of a polypoid configuration in malignant melanoma.

In a review of 2296 patients with malignant melanoma, the overall incidence of a polypoid configuration was 21.5%. A markedly higher proportion of patients with polypoid melanoma than with dome-shaped melanoma first presented for melanoma treatment already with metastases (i.e. clinical stage II or III). In patients with localized disease, more men than women tended to present with polypoid lesions. The majority of these lesions were of the nodular histogenetic type, greater than 3.0 mm thick and ulcerated. When patients with polypoid and dome lesions were matched according to three known important prognostic determinants: sex of patient, the thickness of their primary lesion and whether their lesion showed microscopic evidence of ulceration, no consistent differences in prognosis were detected between patients with polypoid and dome lesions. Thus it appeared that the poor prognosis for patients with polypoid lesions was not attributable to the configuration of their lesion per se but primarily due to the fact that they were typically thick, ulcerated lesions.