SLR - June 2011 - Namjong Lee

Midterm Results of Osteochondral Lesions of the Talar Shoulder Treated with Fresh Osteochondral Allograft Transplantation

Reference:  Adams SB, Viens NA, Easley ME, Stinnett SS, Nunley JA.  (2011). Midterm Results of Osteochondral Lesions of the Talar Shoulder Treated with Fresh Osteochondral Allograft Transplantation.    J Bone Joint Surg Am. 93A: 684-654.

Scientific Literature Review

Reviewed by: Namjong Lee, DPM
Residency Program:  DVA New Mexico, Albuquerque, New Mexico.

Podiatric Relevance: 
There is no current consensus in the literature with respect to the best surgical option for treatment of talar dome lesions. Many times the procedure selected is based on the diameter, the depth or the location of the lesion.  The loss of the medial or lateral articular buttress can also have an impact when choosing osteochondral autograft transfer system or mosaicplasty.   This study reviews the outcome of treating talar dome lesions using fresh talar allografts. 

Methods: 
Eight patients with history of talar shoulder osteochondral lesions (mean age of 31 years) were retrospectively studied for mean follow-up of 48 months after the use of a fresh osteochondral allograft transplantation.   Patients were assessed based on clinical examination, imaging studies (CT and/or MRI), visual analog pain scale and the Lower Extremity Functional Scale. 

Patient underwent open arthrotomy using a medial or lateral malleolar osteotomy.  The lesion on the talar shoulder was identified and debrided.  The edges of the lesion were cut square with a fine saw. The fresh allograft was then fashioned to match the area of the lesion. The allograft was stabilized with one or two titanium 2.0 mm cancellous screw.   Postoperatively, the surgical site was immobilized for 8-10 weeks in NWB cast.  The patient was then transferred into a walking boot until the surgical site was fully healed. 

Results: 
In the small group of eight patients, significant pain relief was noted post application of fresh allograft to replace the talar osteochondral lesions.    The visual analog pain scale was reported to decrease from a mean of 6 points preoperatively down to a mean of 1 point  postoperatively.  There was a significant improvement in the mean of Lower Extremity Functional Scale from 37 to 65 within 48 months.  The mean postoperative AOFAS ankle-hindfoot score was 84 points.  Three patients with medial talar dome grafts had partial lucency along the lateral border of the allograft-host bone.  However, all these three patients were reported to be asymptomatic.  One patient was noted to have superior graft lucency along the lateral border of the graft-host bone, however, this patient was also noted to have significant symptom improvement with a stable graft as per follow-up CT scan.  One patient had continued pain and “clicking” sensation. A CT scan revealed possible nonunion of the allograft requiring further surgery.  Three other patients required additional surgeries for removal of painful medial malleolar hardware (n=1), revision of an ununited medial malleolar osteotomy (n=1), and a supramalleolar and calcaneal osteotomies for a varus malalignment of the ankle (n=1). 

Conclusions: 
Treatment of large talar osteochondral lesions can be challenging for the surgeon and the patient.  There are many surgical approaches for treatment of talar dome lesions.  To this date, there is no consensus on the best surgical procedure when treating OCD lesions of the talus. The authors present a retrospective study of 8 patients who underwent a fresh osteochondral allograft transplantion. Although, this study represents a small number of patients, the reported results in this study demonstrate successful use of the fresh allografts in treatment of talar OCD lesions. Perhaps most importantly, there was significant amount of pain relief among all studied patients in this study.

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