SLR - April 2023 - Jaclyn D. Wessinger, DPM
Title: Triplane osteotomy combined with talar non-weight-bearing area autologous osteochondral transplantation for osteochondral lesions of the talusReference: Triplane osteotomy combined with talar non-weight-bearing area autologous osteochondral transplantation for osteochondral lesions of the talus. Zhang Y, Liang JQ, Wen XD, Liu PL, Lu J, Zhao HM. BMC Musculoskelet Disord. 2022;23:79
Level of Evidence: 2
Reviewed By: Jaclyn D. Wessinger, DPM
Residency Program: Geisinger Community Medical Center, Scranton, PA
Podiatric Relevance: Treatment of talar osteochondral lesions proves taxing secondary to limited vascularity in accordance with lower success rates of conservative management. Furthermore, 78% of osteochondral lesions occur within the posteromedial aspect of the talar dome requiring a medial malleolar osteotomy for visualization. Consequently, literature reports a malunion rate of 30% following traditional oblique medial malleolar osteotomies with 60% of patients admitting residual pain. The current authors have devised a triplane medial malleolar osteotomy which appears to expedite return to weightbearing as well as improvement of mean Visual Analog (VAS) and American Orthopedic Foot and Ankle Hindfoot (AOFAS-AH) scores.
Methods: Inclusion criteria included patients aged >18 years with an osteochondral defect to the posteromedial talus measuring a confirmed cystic depth greater than 6 mm on CT. Patients exhibited approximately 6 months of ineffective conservative management combined with 22 months of follow-up. Ultimately, 23 patients were included. According to the “9-zone anatomic grid system” for classifying anatomic locations of osteochondral talar lesions, 100% of lesions were found within the posteromedial portion. Clinical outcomes were assessed utilizing AOFAS-AH scores as well as VAS scores.
Triplane osteotomy technique: The first osteotomy was completed in a transverse fashion within the anteromedial tibia 2 cm above the tibial distal surface. Secondarily, a coronal osteotomy was performed along the midline of the medial malleolus. Tertiarily, a sagittal osteotomy was performed following the midline of the anterior tibia. A cylindrical portion of autologous talar graft was taken from a non-weight bearing portion of the medial ipsilateral talus and inserted into the defect. Osteotomy sites were fixated with three screws. CT studies were employed at the three-month mark.
Results: All osteotomy sites healed within 5-12 weeks. Neither malunion nor nonunion were recorded. All autologous grafts were found to be sufficiently fused on CT scan. All patients reported satisfactory pain relief. Mean VAS scores improved from 5.6 to 0.7. Mean AOFAS-AH scores improved from 56.0 to 93.8. Average return to full weightbearing was 8.1 weeks.
Conclusions: Advantages of a triplane osteotomy include addition of a coronal osteotomy site thereby reducing adhesion of posteromedial soft tissue. The integrity of the posterior medial malleolus is preserved, reducing risk to neurovascular structures coursing within this area. The final osteotomy is a three-dimensional concave shape which achieves anastomosis of three planes, exhibiting higher stability upon reduction. Finally, the use of autologous hyaline talar cartilage imparts a graft that is similar in both mechanical and biological properties to native cartilage. This technique appears to be a viable alternative to reduction of postoperative pain and malunion however prospective comparative analyses are necessary to advocate for use of such approaches in the future.