Posteromedial Talus Research Articles

Access to the talar dome through the medial posterolateral approach: an anatomical study.

Background: The osteochondral grafting has become a popular procedure for treating challenging talar dome lesions. However, the vast majority are treated through medial malleolus osteotomy. The aim of this study was to determine the posteromedial area of the talus that can be reached without malleolar osteotomy through the posteromedial approach.
 Study Design: Descriptive laboratory study. Evidence Level 4
 Methods: Fifteen human cadaveric ankles were dissected in a standard fashion to expose the posteromedial talar dome. Seven approaches were used on the cadaver's left limb (46.7%). We did not observe any significant difference between the evaluated sides (chi-square test, p = 0.715).
 Results: On average, 2,09 cm2 (range, 1,72-2,69) of the posteromedial talus dome or 15,27 % (range 12-20) of total talus dome can be accessed without osteotomy.
 Conclusion: If the osteochondral lesion is within the area accessible through PM approach (mean 2 cm2), as seen on magnetic resonance imaging, it is possible that it can be treated without a medial malleolus osteotomy.
 Keywords: talus; osteochondral lesions; osteotomy; arthrotomy; surgery

Osteochondral Lesions of the Talus: Factors Predictive of Cartilage Integrity

Objectives:The integrity of articular cartilage in patients with osteochondral lesions of the talus (OLTs) guides treatment. The ability to predict cartilage integrity in OLTs, as previously published for OCD of the knee, would be beneficial. The purpose of this study is to evaluate the association of radiographic and MRI findings and articular cartilage integrity at the time of ankle arthroscopy for OLTs.Methods:A single-institution retrospective review identified patients 19 years of age and younger with operative treatment of OLTs from 2010 – 2017. Demographics and intra-operative findings at the time of ankle arthroscopy were identified by chart review. Radiographs were assessed for physeal status, OLT location, and Berndt and Hardy grade. MRIs were reviewed for OLT size and location, modified Kramer grade, and cartilage status.Results:53 patients with 54 OLTs and a mean age of 13.6 years (range 7 – 19 years) were included. Radiographic details are listed in Table 1. OLTs were located in the posteromedial talus in 39 patients (72%). Physeal status was closed/closing in 32 patients (59%) and open in 22 patients (41%). On MRI, the cartilage was predicted to be disrupted in 40 patients (74%) and intact in 14 patients (26%). At the time of ankle arthroscopy, the cartilage was found to be disrupted in 38 OLTs (70%) and intact in 16 OLTs (30%). Table 1 lists variables predictive of cartilage integrity.MRI classification of cartilage integrity was 95% sensitive and 75% specific for arthroscopic integrity, with 11% misclassification. In the 16 patients less than 13 years, MRI perfectly predicted arthroscopic cartilage integrity. In patients with open physes, MRI sensitivity was 92% and specificity 100%. In patients with closing/closed physes, MRI sensitivity was 89% and specificity 50%.Receiver operator curve characteristics of a model to predict arthroscopic cartilage integrity combining MRI cartilage integrity, physeal status, and radiographic grade has an AUC of 0.955.Conclusions:Physeal status, radiographic grade, MRI grade, and cartilage integrity on MRI are independent predictors of cartilage integrity at the time of ankle arthroscopy for patients with OLTs. Overall, MRI has 95% sensitivity and 75% specificity for cartilage integrity at the time of arthroscopy, which improves to near 100% sensitivity and specificity in patients with open physes. A model combining MRI cartilage integrity, physeal status, and radiographic grade has the highest predictability of intra-operative cartilage integrity.

Mapping of Posterior Talar Dome Access Through Posteromedial Versus Posterolateral Approaches.

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.

OSTEOCHONDRAL LESIONS OF THE TALUS: FACTORS PREDICTIVE OF CARTILAGE INTEGRITY

Background:The integrity of articular cartilage in patients with osteochondral lesions of the talus (OLTs) guides treatment. The ability to predict cartilage integrity in OLTs, as previously published for OCD of the knee1, would be beneficial. The purpose of this study is to evaluate the association of radiographic and MRI findings and articular cartilage integrity at the time of ankle arthroscopy for OLTs.Methods:A single-institution retrospective review identified patients 19 years of age and younger with operative treatment of OLTs from 2010 – 2017. Demographics and intra-operative findings at the time of ankle arthroscopy were identified by chart review. Radiographs were assessed for physeal status, OLT location, and Berndt and Hardy grade. MRIs were reviewed for OLT size and location, modified Kramer grade, and cartilage status.Results:53 patients with 54 OLTs and a mean age of 13.6 years (range 7 – 19 years) were included. OLTs were located in the posteromedial talus in 39 patients (72%). Physeal status was closed/closing in 32 patients (59%) and open in 22 patients (41%). On MRI, the cartilage was predicted to be disrupted in 40 patients (74%) and intact in 14 patients (26%). At the time of ankle arthroscopy, the cartilage was found to be disrupted in 38 OLTs (70%) and intact in 16 OLTs (30%). Table 1 lists variables predictive of cartilage integrity.Table 1.Summary of Cohort: Overall and by Cartilage Integrity Determined by ArthroscopyVariableLevelNOverallDisruptedIntactP-ValueN=54N=38N=16Physeal Statusclosed5427 (50%)22 (57.89%)5 (31.25%) 0.018 closing5 (9.26%)5 (13.16%)0 (0.00%)open22 (40.74%)11 (28.95%)11 (68.75%)Radiographic Grade15414 (25.93%)4 (10.53%)10 (62.5%) <.001 2 16 (29.63%)11 (28.95%)5 (31.25%) 3 20 (37.04%)19 (50%)1 (6.25%) 4 4 (7.41%)4 (10.53%)0 (0.00%) MRI Grade15414 (25.93%)2 (5.26%)12 (75%) <.001 2 25 (46.3%)22 (57.89%)3 (18.75%) 3 14 (25.93%)13 (34.21%)1 (6.25%) 4 1 (1.85%)1 (2.63%)0 (0.00%) Cartilage on MRIDisrupted5440 (74.07%)36 (94.74%)4 (25%) <.001 Intact 14 (25.93%)2 (5.26%)12 (75%) MRI classification of cartilage integrity was 95% sensitive and 75% specific for arthroscopic integrity, with 11% misclassification. In the 16 patients less than 13 years, MRI perfectly predicted arthroscopic cartilage integrity. In patients with open physes, MRI sensitivity was 92% and specificity 100%. In patients with closing/closed physes, MRI sensitivity was 89% and specificity 50%.Receiver operator curve characteristics of a model to predict arthroscopic cartilage integrity combining MRI cartilage integrity, physeal status, and radiographic grade has an AUC of 0.955.Conclusions:Physeal status, radiographic grade, MRI grade, and cartilage integrity on MRI are independent predictors of cartilage integrity at the time of ankle arthroscopy for patients with OLTs. Overall, MRI has 95% sensitivity and 75% specificity for cartilage integrity at the time of arthroscopy, which improves to near 100% sensitivity and specificity in patients with open physes. A model combining MRI cartilage integrity, physeal status, and radiographic grade has the highest predictability of intra-operative cartilage integrity.SIegaSll E, Faust JR, Herzog MM, Marshall KW, Willimon SC, Busch MT. Age predicts disruption of the articular surface of femoral condyles in knee OCD: can we reduce usage of arthroscopy and MRI? J Pediatr Orthop 2018;38:176-180.

Surgical Treatment of Posteromedial Talus Fractures: Technique Description and Results of 10 Cases.

Background:The aim of this study is to describe a surgical technique for successful treatment of posteromedial talar body fractures and establish treatment recommendations for fractures of the posterior aspect of the talus.Materials and Methods:Ten patients treated operatively for a posteromedial talar body fractures entering both the subtalar and ankle articulations with a minimum of 1-year followup were identified from a trauma database. Age, mechanism of injury, associated injuries, time to surgery, complications, the range of motion, secondary procedures, and need for arthrodesis were evaluated.Results:Followup averaged 4.8 years (1–10). Eight of ten patients had high-energy mechanisms of injury. Six patients had associated medial subtalar dislocations with two open. Associated injuries were common. No surgical complications occurred. The range of motion was present but decreased. No arthrodesis procedures were performed.Conclusions:Operative fixation of posteromedial talus fractures with the described surgical technique resulted in acceptable outcomes in this series of patients with improved outcomes when compared to prior reports in the literature.

Arthroscopic Treatment of a Malunion of a Posteromedial Tubercle Fracture of the Talus

Posteromedial ankle impingement is rare and uncommonly associated with a fracture. Bone resection of the fragment is the recommended treatment. In this report, we describe the step-by-step surgical technique of arthroscopic resection of a malunion of a posteromedial talus fracture to correct the impingement.

Plantar talar head contusions and osteochondral fractures: associated findings on ankle MRI and proposed mechanism of injury

To evaluate the significance of plantar talar head injury (PTHI) in predicting osseous and soft tissue injuries on ankle MRI. The IRB approved this HIPAA-compliant retrospective study. The study group consisted of 41 ankle MRIs with PTHI that occurred at our institution over a 5 ½ year period. Eighty MRIs with bone injuries in other locations matched for age, time interval since injury, and gender formed a control group. Injuries to the following structures were recorded: medial malleolus, lateral malleolus/distal fibula, posterior malleolus, talus, calcaneus, navicular, cuboid, lateral, medial and syndesmotic ligaments, spring ligament complex, and extensor digitorum brevis (EDB) muscle. Twenty separate logistic regressions determined which injuries PTHI predicted, using the Holm procedure to control for family-wise alpha at 0.05. PTHI strongly predicted the occurrence of injuries involving the anterior process of the calcaneus [24% of cases, odds ratio (OR) 12.66], plantar components of the spring ligament (27%, OR 9.43), calcaneal origin of the EDB and attachment of the dorsolateral calcaneocuboid ligament (22%, OR 7.22), cuboid (51%, OR 6.58), EDB (27%, OR 5.49), anteromedial talus (66%, OR 4.78), and posteromedial talus (49%, OR 4.48). PTHI strongly predicted lack of occurrence of syndesmotic ligament injury (OR 19.6). The PTHI group had a high incidence of lateral ligamentous injury (78%), but not significantly different from the control group (53%). PTHI is strongly associated with injury involving the transverse tarsal joint complex. We hypothesize it results from talo-cuboid and/or talo-calcaneal impaction from a supination injury of the foot and ankle.

Trabecular bone anisotropy and orientation in an Early Pleistocene hominin talus from East Turkana, Kenya

Among the structural properties of trabecular bone, the degree of anisotropy is most often found to separate taxa with different habitual locomotor modes. This study examined the degree of anisotropy, the elongation, and primary orientation of trabecular bone in the KNM-ER 1464 Early Pleistocene hominin talus as compared with extant hominoid taxa. Modern human tali were found to have a pattern of relatively anisotropic and elongated trabeculae on the lateral aspect, which was not found in Pan, Gorilla, Pongo, or KNM-ER 1464. Trabecular anisotropy in the fossil talus most closely resembled that of the African apes except for a region of high anisotropy in the posteromedial talus. The primary orientation of trabeculae in the anteromedial region of KNM-ER 1464 was strikingly different from that of the great apes and very similar to that of modern humans in being directed parallel to the talar neck. These results suggest that, relative to that of modern humans, the anteromedial region of the KNM-ER 1464 talus may have transmitted body weight to the midfoot in a similar manner while the lateral aspect may have been subjected to more variable loading conditions.

Fixation of a Posteromedial Osteochondral Lesion of the Talus Using a Three-Portal Posterior Arthroscopic Technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.

Medial approaches to osteochondral lesion of the talus without medial malleolar osteotomy

The purpose of this study was to determine the area of the talus that can be reached through combined anterior and posterior arthrotomy without medial malleolar osteotomy. Five fresh-frozen cadaver foot-ankle specimens were examined using posteromedial approach and anteromedial approach. We calculated the size of the marked area beginning from the posteromedial corner of the talus in the posteromedial approach and beginning from the anteromedial corner in the anteromedial approach. From the posteromedial talus, we can access 33% of the talus' AP length and 30% of its medial to lateral length through a posteromedial approach. From the anteromedial arthrotomy, 50% of the AP length and 31% of the medial to lateral length can be reached. This leaves approximately 20% that is not accessible. If the osteochondral lesion is within the accessible area through either a posteromedial or anteromedial approach as viewed on MRI/CT, it can be safely reached without a medial malleolar osteotomy.

V 46 CT-guided robotically-assisted retrograde drilling of osteochondral lesions of the ankle joint

Introduction Disadvantages of arthroscopically guided surgical techniques for treatment of osteochondral lesions (OCL) of the ankle joint are disruption of viable articular cartilage and insufficient addressing of the subchondral bone. For certain lesion locations, like the posteromedial talus, feasibility is often compromised. The INNOMOTION robotic assistance device proved its value for precise musculoskeletal interventions, such as facet joint and sacroiliac joint infiltrations. We present our first experience with CT-guided robotically-assisted retrograde drilling of osteochondral lesions of the ankle joint and evaluate its feasibility, precision and potential use as a routine operative treatment. Methods 8 patients diagnosed with OCL of the talus (4) and the distal tibia (4) were included. MRI revealed an intact cartilaginous cover in all cases. Surgery was performed with the INNOMOTION robotic assistance device (Innomedic, Herxheim, Germany) mounted on the table of a CT scanner. The robot-device was referenced to the coordinate system of the CT-scanner. Drill trajectory and depth were planned within acquired CT images. A guiding sleeve for the Kirschner-Wire (K-Wire) was attached to the holding device on the application module and positioned automatically according to the planned trajectory. A 2.5 mm K-Wire was advanced through the guiding-sleeve up to the calculated drilling depth. A cannulated drill was placed over the wire and advanced into the lesion. The lesion was curetted and filled with DBM-paste and patient spongiosa. CT-control scans were performed to determine the position of the instruments and to document the exact localization of the deposit. Results Technically successful CT-guided robot-assisted retrograde drilling was performed in all cases without intra- and postoperative complications. No intervention abort or conversion to arthroscopically guided technique or arthrotomy was necessary. CT-control scans confirmed exact initial placement of the guiding wire within the centre of the OCL, precise drill bit positioning and successful retrograde filling of the bored cavity. Discussion The first clinical cases demonstrated CT-guided robot-assisted intervention to be a feasible and safe method for retrograde drilling of OCL of the ankle. Precise assistance by the INNOMOTION-robot combined with the superior ability of the CT to visualize skeletal anatomy greatly improves the accuracy of drilling with exact and reliable addressing of OCL without damage to overlying cartilage. Further studies need to evaluate the outcome of this new operative technique and to compare it to conventional retrograde drilling.

A computer assisted surgical technique for retrograde autologous osteochondral grafting in talar osteochondritis dissecans (OCD): a cadaveric study.

This study describes a new method for the treatment of osteochondritis dissecans (OCD) in the medial talar dome. Ten cadaveric lower extremities were used to develop and evaluate a retrograde osteochondral grafting technique applying computer-assisted surgery. With the help of a computed tomography (CT)-based navigation system, a guide wire was placed from the lateral talar process into the posteromedial talar trochlea where OCD lesions are predominantly located. Cannulated reamers and arthroscopic shavers were used for the preparation of the recipient hole. The grafts, with diameters of 4.5 mm, 6.5 mm or 8.5 mm were harvested from the lateral femoral trochlea and inserted in a retrograde fashion. The last five cadavers were analyzed for accuracy of surface reconstruction and graft stability. For this purpose a medial malleolar osteotomy and a CT scan was performed. We found steps in the joint surface to range from 0.5 mm to 1.5 mm (mean 0.9 mm, SD 0.4) with the graft always below the surrounding cartilage. Graft subsidence occurred at an applied force of 26.4 +/- 4.6 N. This study indicates that osteochondral cylinders can be inserted in a retrograde fashion to reconstruct the posteromedial talus. Good surface congruency and sufficient graft stability can be achieved.

ANKLE PAIN - BASKETBALL 1053

HISTORY - A 12-year-old white female basketball player presented for evaluation of left ankle pain which had been present for approximately 2 years. The patient and her mother recalled symptoms dating back to the fifth grade. She recently participated in a basketball camp and developed a recurrence of left ankle pain. She was diagnosed with Sever's disease and was treated with a heel cup. Left ankle pain continued despite this treatment. She stated the pain was mostly on the inside of her left ankle. She reported no history of trauma to her left ankle. Pain was present with running and was relieved with rest. The patient further denied swelling, catching, or locking symptoms. PHYSICAL EXAMINATION - The left ankle was free of swelling or ecchymosis. There was tenderness over the medial aspect of the left ankle in the vicinity of the sinus tarsi. There was no tenderness directly over the medial or lateral malleoli. Full range of motion with dorsiflexion/plantarflexion and eversion/inversion without discomfort. There was some medial pain with resisted internal rotation. Anterior drawer revealed no laxity. Talar tilt was negative. Neurovascular exam was normal. DIFFERENTIAL DIAGNOSIS: Left ankle sprain (deltoid ligament) Sinus tarsi syndrome Syndesmosis sprain JRA Epiphyseal injury Stress fracture TEST AND RESULTS: X-ray: Plain film x-ray revealed lytic lesion involving medial aspect of left talus MRI: Revealed a confirmed osteochondritis dissecans, left posteromedial talus, and indicated that the fragment was nondisplaced FINAL/WORKING DIAGNOSIS: Osteochondritis dissecans of the left posteromedial talus, Stage II TREATMENT: Short leg walking cast to the left lower extremity for 6 weeks. After 6 weeks, the cast was removed. Follow-up x-rays were taken, revealing a well-healed posteromedial aspect, left talus. The patient was started in physical therapy to increase ankle strength and range of motion. She was also started on the BAPS board to increase proprioception. The patient will be followed to monitor progress.

Insufficiency fracture of the talus: diagnosis with MR imaging.

To describe the clinical setting and pattern of talar insufficiency stress fractures as diagnosed with magnetic resonance (MR) imaging. The authors retrospectively reviewed the clinical history and MR images from four patients with five talar insufficiency fractures. All patients were women (age range, 30-70 years). Images were evaluated for the location and orientation of fractures and the presence of concomitant osseous and soft-tissue injury. Concomitant fractures were identified in two patients. Only two fractures were typical in location and orientation at the talar neck. Three fractures were atypical in location and orientation. One occurred horizontally in the talar body and two occurred in the posteromedial talus (one was oriented vertically and one horizontally). Two patients had associated concomitant stress fractures--one in the distal tibia and one in the calcaneus. The location and orientation of talar insufficiency fractures is more variable than previously recognized. Specific diagnoses and coexisting fractures can be determined with MR imaging.