SLR - September 2023 - Azar
Title: Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus.Reference: Meisterhans, M., Valderrabano, V. & Wiewiorski, M. Medial oblique malleolar osteotomy for approach of medial osteochondral lesion of the talus. Arch Orthop Trauma Surg 143, 3767–3778 (2023). https://doi.org/10.1007/s00402-022-04598-9
Level of evidence: Level III, retrospective cohort study
Reviewed By: Maureen Azar, DPM
Residency Program: SSM Health DePaul Hospital, Bridgeton, MO
Podiatric Relevance: Osteochondral defects of the talus present in different age groups and bring forth various challenges to both the treatment and post-recovery phase. Some of these include secondary osteoarthritis, return to sports, or revision surgery. Moreover, the harder locations to access intra-operatively, such as the medial talar dome, tend to constitute the most common talar lesions. This article presents an interesting perspective to the podiatric surgeon and an alternative procedure for lesions that are difficult to access arthroscopically. Modified techniques led to the utilization of the medial malleolar osteotomy, which provides superior exposure to the talar area with attention to protecting the deltoid ligament. In an aim to assess the consolidation rates and postoperative complications, this osteotomy was further analyzed. The authors hypothesized a higher fusion rate, lower percentage of revision and malreduction, and the decrease of malreduction with the utilization of a third screw parallel to the tibial articular surface.
Methods: A level III retrospective cohort study was performed on 67 patients between October of 2007 and July of 2014 who underwent the medial malleolar osteotomy for a medial osteochondral lesion. Fixation was achieved with three fully-threaded 3.5 cortical screws. Factors assessed were perioperative and postoperative complications, consolidation, hardware removal, and malunion or non-union rate, which was a primary outcome measure that was evaluated with the utilization of post-operative radiographs.
Results: Consolidation of the osteotomy was highly achieved with a 98.5% success rate where only one patient required revision surgery due to non-union. Malreduction was noted with 23.9% of patients. When two screws were utilized, there was a 32% malreduction rate as opposed to 16.7% with three screws. Malreduction was noted in the form of joint incongruity assessed by a malreduction ratio and other variables including a mean medial malleolus osteotomy angle and mean screw to osteotomy angle. Hardware removal was conducted in 83.6% of patients. In 59.7% of those cases, pain was involved while in 23.9% of the cases medial impingement was the cause.
Conclusions: The oblique medial malleolar osteotomy achieves the necessary factors to treat medial lesions, such as surface perpendicularity, good exposure, and osteotomy stability. The main benefit is outcome predictability considering the high consolidation and low revision rate. However, as with any invasive procedure, it is not free of risk. A key risk to consider is malreduction as this may be related to secondary osteoarthritis in the long term. Nonetheless, it is important to note that perfect reduction is not achievable since the blade itself cuts down from the osseous surface depending on its size. The articular surface recovery is also non-linear and multifactorial. For instance, it may be that the chondral lesions noted are a part of the healing process rather than a consequence of the procedure. As a result, longer follow-up times are necessary in future research. Another limitation to the postoperative radiographic assessment is that only an AP mortise view was obtained to evaluate the consolidation. Finally, an interesting finding is that a greater number of patients underwent hardware removal when two screws were used compared to three screws. Since the third screw is parallel to the tibia, headless compression may help reduce hardware removal rate and is potentially the next research step.