|Year : 2017 | Volume
| Issue : 2 | Page : 119-122
Reconstruction of osteochondral defect of the talus with ankle distraction frame
Taylor James Reif1, Mitchell A Bernstein2
1 Loyola University Medical Center, Maywood, IL, USA
2 Department of Orthopaedic Surgery and Rehabilitation, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
|Date of Web Publication||22-Aug-2017|
Mitchell A Bernstein
Department of Orthopaedic Surgery and Rehabilitation, Stritch School of Medicine, Loyola University Medical Center, 2160 South First Ave., Maywood, IL
Source of Support: None, Conflict of Interest: None
A 23-year-old male sustained a gunshot to the right foot with resultant talar body fracture and a 1 cm2 osteochondral defect of the talus. The patient was treated acutely with ankle arthrodiastasis using an external circular frame allowing ankle range of motion and full weight bearing while the fracture healed and the bone and cartilage graft incorporated. The circular frame was utilized for 4 months. At follow up, the patient was able to walk pain-free, the bone graft had incorporated on radiographs, and there were no signs of joint degeneration. We were unable to find any similar reports in the English literature of a young patient with a traumatic injury treated with ankle arthrodiastasis. This technique allows more normal function during the healing period than traditional techniques to reconstruct osteochondral lesions of the talus which require prolonged nonweight bearing. While primarily used for ankle osteoarthritis to date, ankle arthrodiastasis should be investigated for other indications to determine its utility in complex injuries.
Keywords: Ankle distraction, bone loss talus, osteochondral defect, talus fracture
|How to cite this article:|
Reif TJ, Bernstein MA. Reconstruction of osteochondral defect of the talus with ankle distraction frame. J Limb Lengthen Reconstr 2017;3:119-22
| Introduction|| |
Large osteochondral lesions of the talus present a challenge to the clinician. The bone and cartilage selected to reconstruct the defect require time to heal before being able to sustain the high loads experienced by the talar dome. Keeping the patient off weight bearing is an option, but ankle arthrodiastasis using an external distraction frame allows ankle range of motion and weight bearing while the underlying graft incorporates. Two case reports and one case series of six patients have been published which detail treatment of posttraumatic osteochondral talar defects with ankle arthrodiastasis.,, The following case is unlike previous reports because the patient presented acutely with a fracture of the talar body sustained from gunshot. On removal of the missile, the patient remained with a talar body defect and associated cartilage loss.
| Case Report|| |
A 23-year-old male patient presented with an isolated gunshot wound to the right foot with retained bullet fragment in the lateral tibiotalar joint [Figure 1]. He was taken to the operating room (OR) for debridement where an open talar body fracture and 9 mm × 9 mm osteochondral defect of the lateral talar dome were seen. He underwent open reduction and internal fixation of the fracture and insertion of antibiotic beads into the defect [Figure 2]. We brought the patient back to the OR two days later for repeat debridement of the defect and ankle distraction arthroplasty using a two ring hinged circular fixator applied to the distal tibia and foot. The proximal tibial ring was circular and fixed to bone with three 6 mm half pins in two planes separated by approximately 30°. The distal ring was a foot ring fixed to the foot with three 1.8 mm trans-calcaneal wires. Uniform ankle distraction and ankle motion was achieved through medial and lateral threaded rods ending in Ilizarov hinges which connect the rings. The hinges are fluoroscopically placed along the Inman axis of ankle motion to allow balanced dorsiflexion and plantarflexon. Ankle motion could be locked/unlocked using another threaded rod connecting the anterior proximal ring to the distal crossbar of the distal ring. A square nut along the anterior rod twists against a plate attached to the tibial ring to lock and unlock motion. The ankle was acutely distracted 6 mm before leaving the OR [Figure 3]. Postoperatively, we allowed the patient to bear weight to tolerance and began range of motion exercises when his surgical wounds healed at 2 weeks.
|Figure 1: (a) Anterior-posterior and (b) lateral radiographs of right ankle from initial presentation to emergency department. Bullet shrapnel is evident lodged in the lateral talar dome|
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|Figure 2: (a) Mortise and (b) lateral radiographs of right ankle following open reduction internal fixation of the talus fracture|
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|Figure 3: (a) Anterior-posterior and (b) lateral radiographs of the right ankle following ankle distraction with external fixator|
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Approximately 1 month later, the patient was taken to the OR to reconstruct the osteochondral talar defect. The procedure began with iliac crest bone harvest using an acetabular reamer along the gluteal column to obtain corticocancellous autograft. The talus was then exposed, the antibiotic beads removed, and the osteochondral defect was debrided a final time [Figure 4]a. The autograft bone was then packed into the talar defect to the level of the surrounding subchondral bone. The cartilage defect was then reconstructed with Biocartilage® Cartilage Extracellular Matrix (Arthrex, Naples, FL, USA) mixed with 1 ml of pelvic bone marrow aspirate and sealed with fibrin glue [Figure 4]b and [Figure 4]c. Postoperatively, the patient continued to weight bear as tolerated and began ankle range of motion after 4 days. The patient's treatment was complicated by a wound infection 1 month later which was successfully treated with irrigation and debridement and oral antibiotics.
|Figure 4: (a) Photograph of talar defect taken before insertion of bone graft. (b) Anterior-posterior and (c) lateral radiographs of right ankle following osteochondral reconstruction|
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Four months after initial application of the external fixator, the frame was removed under light sedation. He underwent an outpatient course of physical therapy postoperatively. At 10 months follow up, the patient was walking without an aid and without pain except with terminal inversion of his ankle. His ankle was stable in all directions with a range of motion of five degrees dorsiflexion to 30 plantarflexion. This was consistent with an American Orthopedic Foot and Ankle Score (AOFAS) of 90 out of 100. His radiographs showed incorporation of the bone graft, maintained joint space, intact hardware and no signs of avascular necrosis or degenerative changes of the ankle or subtalar joints [Figure 5]. On a phone interview at 33 months postinjury, the patient was working full time without foot or ankle pain.
|Figure 5: (a) Anterior-posterior and (b) lateral radiographs of right ankle 10 months postoperatively|
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| Discussion|| |
Large osteochondral defects of the talus are a difficult orthopedic problem. While small chondral defects can be managed with microfracture alone with good results, larger chondral lesions associated with the loss of subchondral bone require either osteochondral autograft transplantation or bulk allograft implantation. While both procedures have studies that support good to excellent long-term results,, these procedures have their limitations including extended periods of ankle immobilization and nonweight bearing during the healing phase.
Conversely, arthrodiastasis allows immediate full weight bearing and ankle range of motion once the wound heals. This motion creates intermittent fluid pressure of low physiologic magnitude which is potentially beneficial to cartilage matrix synthesis. While not fully understood, ankle distraction may also lead to improved cartilage repair by decreasing shear forces, normalizing proteoglycan synthesis, decreasing inflammation, and optimizing the mechanical environment for healing.
Arthrodiastasis of the ankle is a relatively new procedure investigated predominantly for ankle osteoarthritis as an alternative to total ankle arthroplasty or arthrodesis. With this indication studies have consistently shown reduction in pain and disability with short-term follow up. Other authors have used the technique to offload osteochondral reconstructions. Rodriguez et al. published the first series of patients with osteochondral lesions of the talus treated with ankle distraction and cryopreserved talar dome allograft. External fixation was used for 8 weeks followed by 8 weeks of partial weight bearing. Of the six patients in the study, five had excellent or good outcomes using the Maryland foot score, and there were no major complications. Belczyk et al. used the osteochondral autograft transplantation system (OATS, Arthrex, Naples, FL, USA) and 8 weeks of ankle arthrodiastasis to reconstruct a 20 mm × 5 mm × 8 mm talar defect. Radiographs showed incorporation of the graft at 6 months, but no patient reported outcomes. In another case study, D'Angelantonio and Schickused juvenile hyaline cartilage graft (DeNovo NT, Zimmer, Warsaw, IN, USA) to cover a 6 mm × 9 mm talar defect protected with 12 weeks of ankle arthrodiastasis. At 1 year, the patient was working with painless ankle motion. Beyond these studies, there is a lack of other evidence to guide the appropriate use of ankle distraction arthroplasty.
The patient presented here differs from the other published reports because he presented with an acute osteochondral defect of his talus with an associated fracture. The talar body fracture fixation did not make the defect amenable to osteochondral autograft plugs or additional allograft fixation. After thorough debridement, iliac crest corticocancellous autograft was chosen given its ability to completely fill the bone defect. This was covered with commercially available cartilage substitute, which was able to uniformly fill the chondral defect without step-off to normal cartilage. Ankle distraction allowed the patient to weight bear on both the talus fracture and osteochondral defect, versus the alternative of 12 weeks of nonweight bearing in a cast or fracture boot.
The limitations of this study include a single case example, short-term follow up in a circumstance where longer follow up could reveal posttraumatic cartilage degeneration, and lack of advanced imaging (e.g., cartilage sensitive MRI) or arthroscopic follow up to investigate cartilage viability/incorporation. Implants with less MRI distortion like titanium may be warranted in these situations. It is unknown whether the cartilage adjunct was necessary as part of treatment, as theoretically anatomic reduction of the fracture, stable fixation, early ROM and the mechanical unloading provided by the fixator should allow the cartilage to heal.
In conclusion, the patient presented had an excellent clinical result per his AOFAS score, and was able to resume work with no pain. This report provides further evidence that ankle arthrodiastasis should continue to be investigated for indications beyond osteoarthritis.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]