Case Presentation:
Fresh Osteochondral Allografting in the Treatment
of Osteochondritis Dissecans of the Talus

By Ali Abadi, DPM & Raymond Ferrara, DPM
West Jersey Virtua Hospital, New Jersey

A 42 year old female with persistent ankle pain secondary to trauma to the right ankle is presented. Magnetic resonance imaging (MRI) revealed an osteochondral lesion of the medial equatorial aspect of the talar bone. MRI also revealed a mass located at the posterior tibial neurovascular bundle. This benign mass (17x13x12 mm ) was excised two month prior to osteochondral allografting surgery. Based on the pathology report this benign mass was a  posterior tibial schwannoma tumor.

 After exhausting several type of conservative treatments, such as pain management, icing, NSAID,  injection and immobilization, surgical intervention was necessary to treat the osteochondral dissecans.

The condition was initially described by Alexander Monro (primus) in 1738.¹ In 1870, James Paget described the disease process for the first time, but it was not until 1887 that Franz König published a paper on the cause of loose bodies in the joint.²  König named the disease "osteochondritis dissecans",³ describing it as a subchondral inflammatory process of the knee, resulting in a loose fragment of cartilage from the femoral condyle. In 1922, Kappis described this process in the ankle joint.⁴ On review of all literature describing transchondral fractures of the talus, Berndt and Harty developed a classification system for staging of osteochondral lesions of the talus (OLTs).⁵ In 2001, Scranton and McDermott added a fifth stage to the Berndt and Harty classification system in order to describe the cases of patients in whom the cartilage cap is intact with the lesion involving a subchondral cyst within the talar dome.⁶ The term osteochondritis dissecans has persisted, and has since been broadened to describe a similar process occurring in many other joints, including the knee, hip, elbow, and metatarsophalangeal joints.

Case report: A 42  years-old female  presented with  history of severe right ankle pain. Patient stated that she has deep ankle pain and she “twists her ankle” repeatedly. On physical examination the region of pain was localized to the anteromedial  aspect of the right talus, the area was tender to direct pressure. There was evidence of swelling at the right medial malleolar, no evidence of acute trauma, or bruising noted. The ankle range of motion is preserved. Weight bearing radiographs of the ankle revealed  osteochondral lesions.

Magnetic resonance imaging of the right ankle revealed a osteochondral defect involving the medial talar dome, without associated subchondral collapse. There is a T2 hyperintense and T1 hypointense osteochondral defect. measuring 5 mm in transverse extent x 6 mm in cranicaudal extent. (figures  1a-c). The ankle mortis is symmetric. There is a surrounding bone marrow edema along the superomedial talar dome. It also revealed mild fluid within the retrocalcaneal burs and minor tenosynovitis of the medial and lateral ankle tendons. Laboratory examination included corpuscular blood count with differential count,white blood cell count, rheumatoid factor, C-reactive protein, erythrocyte sedimentation rate, and serum uric acid are all unremarkable. Osteochondral allograft was obtained from a thirteen year old fresh cadaver and supplied by Arthrex  Inc.⁷

Figure 1a

Figure 1b

Figure 1c

The surgical procedure was performed under Monitored anesthesia care (MAC)  combined with local infiltrative nerve block. Patient is supine on operating table. Preoperative antibiotic ( 2 grams Cefazolin ) was given at the beginning of the case. A pneumatic ankle tourniquet is placed on the mid-calf. The skin was prepped and draped from toes to mid calf . Tourniquet was inflated to 250 mmHg. (fig 2).

A 6 cm longitudinal incision was made directly over the medial malleolar (fig 3).

The incision was then carried down through the subcutaneous tissue using sharp and blunt dissection. Care was taken to avoid all vital neurovascular structures. The Talus dome and tibial plafond was located and marked on the skin utilizing the intro-operative fluoroscopy  (fig 4-5).

The medial malleolus is predrilled with two 0.045 pins at a slightly divergent angles to help prevent proximal slippage of the medial malleolus during screw insertion. These pins are overdrilled with Arthrex 3.4 mm cannulated Trim-It Drill Bit across the medial malleolus and into the tibial plafond. The holes are then tapped (fig 6 ).

A V-shaped osteotomy  was performed and medial malleolar carefully pulled inferiorly to expose the talus (fig 7-8).

The posterior tibialis and the flexor hallucis longus tendons are protected with small senns. The talar lesion is drilled perpendicularly and centrally with the 2.4 mm guide pin. The guide pin is advanced to a depth of 15-20mm.(fig 9 ).

The guide pin is then overdrilled with the appropriate size cannulated Headed Reamer to a depth of at least 12 mm. (fig 10).

The cannulated  OATS Alignment Rod is introduced over the guide pin, which measures the diameter and depth of the taral hole. At this point we covered the surgical site with  saline soaked gauze and directed our attention to the Allograft bone. ( fig 11).

After matching the defected cartilage site to the donor site, we utilized the Arthrex OATS 6 mm donor harvester.(fig12)

We drove the harvester into to the donor talus, at 90 degrees, and twisted it clockwise 90 degrees under pressure  and then full counter clockwise revolution (fig 13-14).

The tube and the raft were then withdrawn. (Fig15).

Then we inserted the graft into the recipient hole in the talus. We utilized the large end of the tamp for tapping the graft into the hole and made sure there is no protrusion. (fig16-17).

The medial malleolus is replaced back to its anatomical position. The Arthrex 0.045 pins re-inserted back into the cannulated holes. Two 4.5mm cannulated, screws were driven up the holes while the medial malleolus is held in a position of anatomic reduction.(fig18).

Articular cartilage disease can eventually lead to debilitating injury because of the body’s inability to repair this important tissue. Osteochondritis dissecans (OCD) is a pathologic process in which a fragment of subchondral bone becomes avascular and can separate from the surrounding tissue. Although most lesions are thought to have a traumatic origin, other possible causes include defect of ossification, repetitive mechanical stress, and ischemia.^8,9  The main indication for allografting includes talar defects that are 10 mm or greater. The lesions are often missing articular cartilage, or the remaining cartilage is soft and fibrillated. In the Brendt and Harty classification, these are usually stage III or IV leisons.¹⁰ Surgery is offered when the pain is unresponsive to nonoperative treatment that includes medication, cast immobilization, bracing and physiotherapy. Contraindications to allografting are few in number. The major reasons are osteoarthritis of tibiotalar joint, reflex sympathetic dystrophy and avascular necrosis of the talus.¹¹

There is extensive evidence in support of Autograph and allograft treatment of osteochondritis dissecans. Hangody et al were the first to report their early and intermediate results.They used the ipsilateral knee as a donor site and found good to excellent long term success in 34 out of 36 patients at an average of 4.2 years.¹² Al-Shaikh et al reports their results using the OATS procedure for treatment of the large OCD lesions of talus. 17 out of 19 patients (89%) were satisfied with their results.¹³

Gross et al were the first to use fresh osteochondral allografts in the treatment of large OCD lesions of talus. They had nine patients, who underwent fresh osteochondral allograft transplantions, from the tali of fresh human cadaver. Six grafts remain in situ with a mean survival of 11 years.¹⁴  According to Gross et al, the most common complication of fresh osteochondral allografting is resorption and failure of the graft to incorporate, which results in subchondral collap and fragmentation of the graft.

Post operative management includes non-weight bearing for period of 12 weeks, but range of motion excercises are started once the incision is healed. At three months, patients begin protected weight bearing in a cam boot for one month. Full activity is allowed after six months.

References:

1. Munro A (1738). "Part of the cartilage of the joint separated and ossified". Medical Essays and Observations 4: 19. cited in Burns RC (September 1939). "Osteochondritis dissecans". CMAJ 41 (3): 232–5.
2. Garrett JC (July 1991). "Osteochondritis dissecans". Clinical Journal of Sports Medicine 10 (3): 569–93. PMID 1868560.
3. Barrie HJ (November 1987). "Osteochondritis dissecans 1887-1987. A centennial look at König's memorable phrase". Journal of Bone and Joint Surgery (British) 69 (5): 693–5. PMID 3316236
4. Kappis M (1922). "Weitere beitrage zur traumatisch-mechanischen entstehung der "spontanen" knorpela biosungen" (in German). Deutsche Zeitschrift für Chirurgie 171: 13–29.
5. Berndt AL, Harty M (June 2004). "Transchondral fractures (osteochondritis dissecans) of the talus". Journal of Bone and Joint Surgery (American) 86 (6): 1336. PMID 15173311
6. Scranton PE Jr, McDermott JE, Treatment of type V osteochondral leisons of the talus with ipsilateral knee osteochondral autograft. Foot ankle intl. 2001;22:380-4.
7. Arthrex Med. Inst. GmbH,  Single use osteochondral Autograft Transfer System (OATS) and Small Joint OATS Sets, www.arthrex.com
8. Obedian RS, Grelsamer RP. Osteochondritis dissecans of the distal femur and patella. Clin Sports Med. 1997;16:157-174.
9. Steadman JR, Rodkey WG,Rodrigo JJ. Microfracture :surgical technique and rehabilitation to treat chondral defects. Clin Ortho Relat Res. 2001; 391:362-36
10. Brendt AL, Harry M. Transchondral fractures of the talus. J Bone Joint Surg Am.1959; 41A :988-1018.
11.  Meehan R.E, Brage M.E .Fresh Osteochondral Allografting for Osteochondral Defect of the Talus : Techniques in Foot and Ankle Surgery 2004, 54: 53-61.
12.  Hangody L. Kish G, Karpati Z, et al. Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique. Foot Ankle Int. 1997;18: 628-634.
13.  Al-sheikh RA, Chou LB, Mann JA et al. Autologous osteochondral grafting for talar cartilage defect. Foot Ankle Int. 2002;23:381-389.
14. Gross AE, Agnidis Z, Hutchinson CR. Osteochondral defect of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. 2001;22:385-391.
    

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