SLR - July 2017 - Vilayvanh Saysoukha
Reference: Nunley JA., Hamid KS. Vascularized Pedicle Bone-Grafting from the Cuboid for Talar Osteonecrosis: Results of a Novel Salvage Procedure. J Bone Joint Surg Am. 2017 May 17; 99(10):848–854.Scientific Literature Review
Reviewed By: Vilayvanh Saysoukha, DPM, MS
Residency Program: Northwest Medical Center, Margate, FL
Podiatric Relevance: Avascular necrosis of the talus often presents as a challenge for foot and ankle surgeons. Surgical options are limited, and most often involve joint destructive procedures, such as rearfoot arthrodesis, talar replacement, core decompression and bone grafting. One novel surgical technique involves core decompression with revascularization of the necrotic talus by using a vascularized pedicle bone graft from the cuboid. Vascularized pedicle bone grafts avoid the need for microvascular anastomosis as well as donor site morbidities associated with free vascularized bone grafts. Combined with bracing, this surgical technique may salvage the talus by revascularization, as well as prevent further progression of the disease, thereby improving pain and function of the affected limb.
Methods: A level IV retrospective study was performed on 13 patients who underwent vascularized pedicle bone grafting from the cuboid to the talus with a diagnosis of osteonecrosis of the talar body and dome. Inclusion criteria were less than 60 percent involvement of the talus and an articular collapse of less than 1 mm. Patients received the preoperative Medical Outcomes Study Short Form-12 (SF-12) and postoperative Short Form (SF-36) in order for the authors to assess generic health-related quality of life (HRQoL) measures in which Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were compared. Serial radiographs and magnetic resonance imaging (MRI) scans were performed on all patients before and after surgery.
Results: The mean follow-up after surgery was six years. Two of the 13 patients in this study underwent total ankle replacement due to persistent pain at the four- to five-year mark and were excluded from the analysis. There was statistical significance noted in the average PCS and MCS scores after surgery, which improved by 23.3 ± 18.9 points and 39.4 ± 10.1 points, respectively. All postoperative MRI scans displayed partial return of marrow signaling in the necrotic talus, signifying revascularization to the operative site and confirming that there was no evidence of articular surface collapse. One of the patients required ankle arthroscopy due to soft-tissue impingement.
Conclusions: The outcome measures suggest that using a vascularized pedicle bone graft from the cuboid is a viable surgical option to treat avascular necrosis of the talus. This novel approach is joint sparing and provides pain relief and improved function in a majority of patients. The authors also initiated restricted weightbearing for three months with the use of a patellar tendon bearing brace for one year. Limitations of the study include no control group to examine nonoperative treatment or the different types of surgical treatment, a small sample size, low statistical power and possible detection bias of the senior author when reviewing the radiographs and MRI scans. Adding this joint-sparing technique to the foot and ankle surgeon’s armamentarium can provide another viable alternative in the treatment approach of a challenging disease.