Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm. 2. ) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm. 2. or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm. 2. 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested

Introduction. Talus fractures have traditionally been reported as having poor outcomes with rates of avascular necrosis in excess of 80% in some studies. It was noted by the senior author that this was not his experience in a tertiary institution with many patients having good to excellent outcomes and lower rates of avascular necrosis than anticipated despite high-energy trauma. The aim of this paper is to review all talus fractures that have been fixed internally at our institution to determine whether current surgical techniques have improved traditionally poor outcomes. This could result in improved outlook for patients on initial presentation and improved ability to manage the long-term consequences of the multiply-injured patient. Method. A review of all lower limb trauma cases from 2012–2015 was made. This yielded 28 talus fractures that had been internally fixed at Southmead hospital. Patients were contacted using telephone and letters. The AAOS Foot and Ankle Outcome Questionnaire, patient satisfaction surveys and analysis of radiographs were made. Results. Our preliminary results suggest avascular necrosis rates of less than 10% despite the high energy, sometimes open nature of these injuries. We also report that patients are returning to work and are reasonably satisfied following their injury. Fixation methods varied between cases but generally good outcomes were reported amongst most patients. We summarise the demographics of patients presenting with talus fractures and classify their initial injury according to the Hawkins talus fracture classification. Conclusion. Our results were surprising. They suggest that modern surgical techniques may be improving outcomes for patients with talus fractures. It was previously thought that these injuries can be career-ending for some patients but we would suggest that there is hope for good outcomes in this patient group

Introduction

Large osteochondral defects (OCD) of the talus present a difficult management conundrum. We present a series of Maioregen xenograft patches applied through an open approach, early lessons from the technique and good early outcomes, in patients who are otherwise looking at ankle salvage techniques.

Introduction

Autologous Matrix Induced Chondrogenesis (AMIC) for surgical treatment of osteochondral lesions of the talus (OCLT) has shown excellent clinical and radiological results at short term follow up two years after surgery. However, no mid-term follow up data is available.

Introduction

The purpose of this study was to examine trends in patient characteristics and clinical outcomes that occur with age as a statistical variable when performing autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT).

Introduction

Fibula shortening with an intact anterior tibiofibular ligament (ATFL) and medial ligament instability causes lateral translation of the talus. Our hypothesis was that the interaction of the AITFL tubercle of the fibular with the tibial incisura would propagate lateral translation due to the size differential.

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Aims

The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

Bipartite talus is a rare condition of uncertain aetiology, possibly congenital, with only six reported cases in the literature. Previously, these lesions have been successfully managed either conservatively, by excision of the posterior fragment, arthrodesis or one case by internal stabilisation using a postero-anterior screw which failed to lead to bony healing.

We report a series of four symptomatic cases of talus partitus in three patients, with a mean follow-up of 47 months (range 25-66 months). All patients had significant pain on presentation warranting surgical management. All three patients were male, with a mean age of 26 years (range 13-55 years) at surgery. Plain radiographs and computed tomography scans were obtained pre-operatively. All patients were reviewed at follow-up by an independent assessor.

The youngest patient presented aged 13 with a lesion without sub-talar arthrosis. He represented two years later with a similar lesion on the contralateral side. He was treated twice by internal fixation with two postero-anterior cannulated screws augmented with bone graft following preparation of the bone surfaces. The second patient presented with symptoms of isolated sub-talar osteoarthritis. He was treated with a sub-talar arthrodesis augmented with bone graft through a postero-lateral approach. The final patient presented late (age 55) with severe hind-foot osteoarthritis. His symptoms required treatment with tibio-talar-calcaneal fusion and a hind-foot nail. All patients reported a resolution of their symptoms post-operatively. Evidence of was seen radiographically in all cases.

We report the largest series to date of bipartite talus. All four cases were successfully treated surgically with three differing techniques, all of which utilised bone graft and internal fixation to achieve bony healing. We suggest treatment by a fusion of the talar fragments with associated limited fusion if the adjacent joints are markedly degenerate.

The arterial supply of the talus has been studied extensively in the past. These have been used to improve the understanding of the risk of avascular necrosis in traumatic injuries of the talus. There is, however, poor understanding of the intra-osseous arterial supply of the talus, important in scenarios such as osteochondral lesions of the dome. Previous studies have identified primary sources of arterial supply into the bone, but have not defined distribution of these sources to the subchondral regions.

This study aims to map the arterial supply to the surface of the talus. Cadaveric limbs (n=10) were dissected to identify source vessels for each talus. The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be visualised. Each talus was then reconstructed using a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be determined.

This study will provide quantifiable evidence of areas consistently restricted to single-vessel supply, and those consistently supplied by multiple vessels. These data may help to explain the distribution and mechanisms behind the development of the subchondral cysts of the talus.

There is no optimal treatment for osteochondral defects of the talus after failed primary surgical treatment. To treat these patients, a 15-mm diameter metal implant was developed for the medial talar dome. The present study was undertaken to evaluate the clinical effectiveness of the metal implantation technique for osteochondral lesions of the medial talar dome.

This is a prospective case series. The inclusion criteria were the combination of a large OCD (ϕ >12 mm) of the medial talar dome, persistent complaints >1 year after treatment, and clinically relevant pain levels. The exclusion criteria were: age <18 years, OCD size >20 mm, ankle osteoarthritis grade 2 or 3, concomitant ankle pathology, and diabetes. The primary outcome measure was the Numeric Rating Scale pain (NRS) rest, walking, running, and stair climbing. Secondary outcome measures were: Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. The Wilcoxon signed ranks test was used to calculate p-values.

Between October 2007 and March 2009 10 patients were included. The median follow-up was 2 years (range, 2–3 years). On preoperative CT scanning, the median lesion size was 15 (range, 12–20) × 11 (range, 8–14) mm. The NRS rest improved from a median of 3 (0–7) preoperatively to 0.5 (0–2) at final follow-up (p = 0.017), NRS walking from 6.5 (4–8) to 1 (0–4) (p = 0.005), NRS running from 9 (6–10) to 3 (0–10) (p = 0.024), and NRS stair climbing from 6 (4–8) to 1 (0–7) (p = 0.012). The FAOS improved significantly on four of five subscales. The AOFAS improved from a median of 70 (47–75) before surgery to 89 (69–100) at final follow-up (p = 0.008). There were three temporary complications: hyposensibility about the scar in two and a superficial wound infection in one. There were no radiographic complications.

Introduction

Osteochondral defects of the talus are usually a consequence of trauma. They can cause chronic pain and serious disability. Various interventions, non-surgical and surgical, have been used for treating these defects. The objective of this Cochrane systematic review of randomised control trials is to determine the benefits and harms of the interventions used for treating osteochondral defects of the talus in adults.

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients.

We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.

Cite this article: Bone Joint J 2015; 97-B:802–8.

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation.

Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Cite this article: Bone Joint J 2014;96-B:164–71.

We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.

Cite this article: Bone Joint J 2013;95-B:1650–5.

The purpose of this study was to evaluate the clinical results of a newly designed prosthesis to replace the body of the talus in patients with aseptic necrosis. Between 1999 and 2006, 22 tali in 22 patients were replaced with a ceramic prosthesis. A total of eight patients were treated with the first-generation prosthesis, incorporating a peg to fix into the retained neck and head of the talus, and the remaining 14 were treated with the second-generation prosthesis, which does not have the peg. The clinical results were assessed by the American Orthopaedic Foot and Ankle Society ankle/hindfoot scale.

The mean follow-up was 98 months (18 to 174). The clinical results of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. There were, however, radiological signs of loosening, prompting a change in design. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favourable radiological appearances. Revision was required using a total talar implant in four patients, two in each group.

Although the second-generation prosthesis produced better results, we cannot recommend the use of a talar body prosthesis. We now recommend the use of a total talar implant in these patients.

Aims

The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Introduction. The Mobility™ prosthesis [Depuy] is the most extensively used TAR in the UK, though there are few published results. We present our complete experience of the Mobility prosthesis in a diverse population. Methods. From March 2005 to December 2009, 84 consecutive Mobility ankle replacements were performed by the senior author, in 79 patients (28 female, 51 male) with mean age 64.5 years (43–80). This complete cohort included the first and last cases with this implant. Mean follow-up was 50.1±18.2 months (range 14–86). Patients with ankle replacements in situ, were reviewed clinically and radiologically. Clinical outcome measures were: AOFAS score, MOXFQ (adapted for the ankle), and VAS for pain. Post-operative radiographs were reviewed to assess component position and examine for zones of lucency. Results. At final review, 1 patient had died (unrelated), 13 had been revised as follows: . Arthrodesis 7. Further TAR 2. Talus only revised 1. Tibia only revised 1. Amputation 2 (one for an unrelated problem). Exchange of bearing had been carried out in 4. Intra-operative malleolar fractures occurred in 4.8% and were internally fixed. 62 patients attended for clinical review and 8 completed postal questionnaires. At follow up:. Mean AOFAS hindfoot score was 72.4±17.5 (0–100). Mean MOXFQ scores were:. Walking/Standing 40.8±28.4. Pain 31.6±20.8. Social 23.1±23.0. Mean VAS 2.7±2.3. Survival of the implant was:. 91.7 (CI 83.4–96.0) at 2 years. 89.2 (CI 80.2–94.2) at 3 years. 84.1 (CI 73.4–90.8) at 4 years. 84.1 (CI 73.4–90.8) at 5 years. 78.9 (CI 62.6–88.7) at 6 years. Conclusion. This study is a complete review and our failure rate is comparable to other publications. Early failures included some poor case selections with large pre-operative deformity and reflects the initial period of the learning curve of TAR. Longer term follow up is needed to evaluate for ongoing failures and monitor progressive radiolucency

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

Aims

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.