avascular necrosis of the talus current treatment options (2)

9 (2004) 757–773

Avascular necrosis of the talus:

current treatment options

Frank Horst, MDa,*, Brett J. Gilbert, MDb,

James A. Nunley, MDb

aDepartment of Orthopaedic Surgery, St. Josef-Stift Sendenhorst, Westtor 7,

48324 Sendenhorst, GermanybDepartment of Orthopaedic Surgery, Duke University Medical Center, Erwin Road,

Durham, NC 27710, USA

When considering osteonecrosis of the talus, it is convenient to classify the

amount of bone that is involved by distinguishing small (osteochondral lesions),

partial, and total involvement of the talus. The osteochondral lesion of the talus

can be considered to be a partial osteonecrosis; its treatment options have been

covered in other issues.

A fracture of the talar neck can heal in the presence of avascular necrosis

(AVN) of the talus [1,2]. This leads to a treatment algorithm (Fig. 1) that seems to

be reasonable and practical and is based on what we know about the natural

history of AVN of the talus.

It makes sense to distinguish between early- and late-stage AVN—‘‘late’’ is

more than 9 to 12 months after injury. In the late stages only a few options

remain; one is arthrodesis and the other is talectomy.

In the early stages it is important to notice whether the AVN developed

secondary to a fracture. The Hawkins’ sign is the most helpful radiographic sign

[1,3–5]; the MRI also is useful, but may be too sensitive to offer any prognostic

value or assist in algorithms that are used for treatment. If subchondral atrophy

in the talar dome is not present at 6 or more weeks after fracture (absent Hawkins’

sign) and the fracture has healed radiographically, the concern shifts to avoiding

late segmental collapse of the talus. Creeping substitution of the talar body can

take up to 36 months to complete [6]. Controversy exists concerning the best way

Foot Ankle Clin N Am

1083-7515/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.fcl.2004.08.001 foot.theclinics.com

* Corresponding author.

E-mail address: [email protected] (F. Horst).

AVN

Progressive wb

PTB brace Core decompression

Resolution

ProgressionNonvascularizedAllo or Auto Vascularized

Arthrodesis

lateearlyWith fx Without fx

Talectomy

Arthrodesis

P/Nwb until union

bonegraft

Fig. 1. Treatment algorithm for AVN of the Talus. fx, fracture; PTB, patellar tendon–bearing brace;

wb, weight bearing; P/Nwb, partial or no weight bearing.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773758

to treat patients who have a healed fracture and an absent Hawkins’ sign that

indicates AVN of the talar body. Penny and Davis [2] concluded that weight

bearing on a sclerotic and avascular talus poses no real danger for dome collapse,

especially when the subsequent revascularization occurs slowly. If, however,

revascularization occurs rapidly, it will proceed to a profound structural weakness

within the trabecular bone and result in gross collapse of the talar dome. There is

Fig. 2. (A,B) PTB brace.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 759

no way to determine the period and speed with which the talus will revascularize;

it has not been proven that nonweight bearing prevents talar collapse.

Therefore, some investigators suggest nonweight bearing until fracture healing

and until revascularization is complete [7–9], whereas others propose protected

weight bearing in a patellar tendon–bearing brace (PTB) (Fig. 2A and B) until

revascularization has occurred [10–12]. A third group believes that it is impos-

sible to keep the patients non- or partially weight bearing sufficiently; they

concentrate instead on treating the sequelae symptomatically [1,2,13]. Poor re-

sults with AVN of the talus could not be correlated with the methods of treatment

or time off from weight bearing [2].

Therefore, the only symptom that helps us to move on in the algorithm is pain.

If the fracture is healed and there is no pain, progressive weight bearing is

accepted and is recommended (also for bone remodeling) [14]. The two best

courses of the disease are spontaneous resolution or the wearing of a PTB (see

Fig. 2A and B) and continuing to a complete resolution. If that does not occur, the

orthopedic surgeon has two options—core decompression and bone grafting.

Fig. 3. Preoperative and postoperative radiographs of a patient who was treated with core decom-

pression for AVN of the talus. (A,B) preop. (C) postop.


Technique of core decompression

The theory behind core decompression—to decrease intraosseous pressure and

to enhance revascularization—is well-known and will not be discussed in this

article. It is only recommended in stages I and II AVN of the talus. The surgeon

will either use a small, 1.5- to 2-mm drill or a 4.0-mm drill to perforate the area of

AVN. With the small drill we prefer several holes (8–10), whereas with the

4.0-mm drill we use 2 to 4 holes (Fig 3). It is easy to use the posterolateral

approach between the peroneal tendons and the Achilles tendon. Rarely, other

approaches are used (eg, a lateral or medial one, through small incisions with a

little dissection). Typically, 70% of patients have reduced pain and increased

motion and would be considered to have a good result.

Core decompression techniques are used with pressure sensors in the humerus

(C. Basamania, MD, personal communication, July 2003). This could be trans-

ferred to the talus easily and a pressure-guided and more focused decompression

could be possible.

Postoperatively, the patients are put in a short leg cast for 2 weeks and start

range of motion (ROM) exercises after wound healing. Most patients are treated

with a PTB brace. After 6 weeks, partial weight bearing is allowed and is

increased individually to full weight bearing.

Results of core decompression

Mont et al [15] reviewed 11 patients (17 ankles) who had had core

decompression for symptomatic AVN of the talus before collapse. The Mazur

grading system was used to assess function preoperatively and at final follow-up;

radiographs were graded according to the Ficat and Arlet classification that

was modified for the ankle. At a mean follow-up of 7 years (range, 2 to 14 years)

14 ankles (82%) had an excellent or good outcome (Mazur scores N80 points;

pain scores N40 points [range, 41 to 50]). The other three ankles required tibio-

talar fusion at a mean of 13 months (range, 5 to 20) after core decompression.

The investigators concluded that core decompression is a viable method of treat-

ment for symptomatic AVN of the talus before collapse.

In 1998, Delanois et al [16] reviewed 37 ankles in 24 patients that were treated

at their institution between July 1, 1974, and December 31, 1996 for atraumatic

osteonecrosis of the talus. The mean duration of symptoms before the patients

were seen was 5.4 months (range, 2 months to 2 years). The mean ankle score at

the time of presentation was 34 points (range, 2 to 75 points), according to the

system of Mazur et al [17]. A radiographic review revealed—according to the

system of Ficat and Arlet— that 8 ankles had stages III or IV disease of the talus

at presentation. The remaining 29 ankles had stage II disease.

Thirty-two ankles that remained severely symptomatic were treated with core

decompression, which was useful in the treatment of precollapse (stage II)

disease. Twenty-nine of these ankles had a fair to excellent clinical outcome at a

Fig. 4. Sagittal (A) and axial (B) MRI 1 year after core decompression for AVN of the talus.


mean of 7 years (range, 2 to 15 years) postoperatively; the remaining 3 ankles had

an arthrodesis after the core decompression failed. Three ankles were treated

initially with an arthrodesis for postcollapse (stages III or IV) disease. All 6 of the

ankles that had an arthrodesis fused at a mean of 7 months (range, 5 to 9 months)

postoperatively. When patients who have a history of osteonecrosis are seen

because of pain in the ankle, the diagnosis of osteonecrosis of the talus should be

considered. Early detection may allow the ankle to be treated nonoperatively or

with core decompression, and thus, reduce the need for arthrodesis.

If the pain resolves after core decompression and the patient is full weight

bearing, they are scheduled for reassessment every 3 months (Fig. 4). If there is

no segmental collapse and no pain, it is considered to be resolved. In cases of

increasing pain when weight bearing is progressed, bone grafting is the next

reasonable option. Four types of bone graft generally are available for these

cases—nonvascularized auto- or allograft and vascularized pedicle or free

autograft. There are no long-term results with large bone substitutes and no

personal experience.

Nonvascularized autograft

The nonvascularized autograft from the iliac crest probably is the most widely

used bone graft, followed by the allograft (eg, talus, femoral head).

Fig. 5 is taken from a 48-year-old male smoker who had no significant past

medical history and presented with left ankle pain. His radiologic studies revealed

subtotal AVN of the talus. He had been treated nonoperatively for 6 months.

Because of his increasing symptoms we decided to treat him surgically. We used

a tricortical iliac crest bone graft as a scaffold and cancellous bone graft after

excising the necrosis (Fig. 6A–C). The approach was a lateral one with a fibula

osteotomy (Fig. 7). Postoperatively, the rest was filled with cancellous bone graft.

Postoperatively, the patient was nonweight bearing for 6 weeks and then started

Fig. 5 (continued).


protected partial weight bearing in a Controlled Ankle Motion (CAM) walker

with ROM exercises.

Two years later we performed an MRI (Fig. 8). The patient mostly was pain-

free, although he had intermittent painful episodes, especially after exercising. At

first glance, the MRI is disappointing because it seems that large areas of

osteonecrosis remain and revascularization is incomplete; however, creeping

substitution may take up to 36 months. So far there had been a reduction in pain,

slight improvement of ROM, and no segmental collapse.

Nonvascularized allograft

If smaller parts of the talus are necrotic and mainly involve the articular

surface, a talar allograft may be the only option. This requires the availability of a

fresh tissue lab or the surgeon is forced to buy an allograft, that is very expensive.

The following case is a 34-year-old basketball player who presented with a

large Osteochondral Defect (OCD) of the talus that was considered to be partial

necrosis. Initial treatment consisted of arthroscopic debridement and refixation

with a small screw. After 4 months, the screw was removed. The patient pre-

sented with persistent severe pain to his left ankle 1 year later.

It was decided to proceed with a talar allograft from the Duke University

Medical Center Fresh Tissue Laboratory; it was placed exactly into the defect

after fibula osteotomy and open debridement. The allograft was fixed with two

screws that were placed subchondrally (Fig. 9). Two years later the patient

returned to the office with a reduced pain level and no segmental collapse.

The option of taking an allograft is not available to every surgeon or patient,

based on availability and cost. In addition, there are no long-term results for talar

Fig. 5. Anteroposterior radiograph (A) and coronal MRI (B) of subtotal AVN of the talus. Sagittal

radiograph (C) and MRI (D) of subtotal AVN of the talus.

Fig. 6. (A,B,C) Insertion of tricortical bone graft into necrotic defect in the talus through a lat-

eral window.


Fig. 7. Final intraoperative situs after closing the window (A) and postoperative radiograph (B).


allograft survival rates in larger numbers of patients. There are no data on

revascularization, which is considered to be the most important factor for re-

modeling of the talus.

Vascularized bone graft

Mulfinger and Trueta [18] published a complete analysis of the talar

circulation in 1970. Gelberman and Mortensen [19] studied the extraosseous

and intraosseous blood supply of the talus in 1983, with a new chemical

debridement technique.

To improve operative incisions for talar fracture treatment, Giebel et al [20]

looked at the extraosseous blood supply to the tibia, fibula, and talus. Further

Fig. 8. Coronal (A) and sagittal (B) MRI 2 years after scaffolding.


studies looked at the blood vessels in the sinus tarsi [21], the blood supply to the

calcaneus [22,23]. In 1989, Hussl et al [24] reported a vascularized bone graft

from the iliac crest that was used for revascularization of the talus in

posttraumatic AVN in a 16 year-old patient. In 2001, Gilbert et al [25] studied

14 fresh-frozen cadaver lower extremities with injection of Batson’s compound

and bone clearing with a modified Spalteholz technique. A second group of

specimens was injected with Ward’s red latex to dissect potential new rotational

vascularized pedicle bone grafts. Through this study, they were able to identify a

Fig. 9. (A,B) Postoperative radiographs after talar allograft.


consistent blood supply to the distal fibula, cuboid, and cuneiform I and III with

reliable nutrient arteries. The transverse pedicle branch of the proximal lateral

tarsal artery reached and supplied the cuboid in every specimen. The proximal

lateral tarsal artery with the cuboid pedicle is approximately 4.1 cm long and can

be rotated even to the medial malleolus (Fig. 10).

The first cuneiform was found to be supplied by the middle pedicle branch of

the distal medial tarsal artery. This is a short pedicle that can be used for navicular

pseudarthrosis but is too short for the talus. Basically, the same is true for the next

pedicle of the transverse branch to the third cuneiform off the distal lateral tarsal

artery (Fig. 11). The fourth potential vascular pedicle was a transverse segment of

the anterior lateral malleolar artery to the lateral malleolus. The pedicle also is

approximately 4 cm long but usually is an extremely small vessel.

The identification of these new rotational vascular pedicle bone grafts could

help the foot and ankle surgeon to treat some patients who have AVN of the talus.

A few patients who had AVN of the talus were treated with a vascularized bone

Fig. 10. (A,B) Proximal lateral tarsal artery with the cuboid pedicle and its range.

Fig. 11. Vascularized pedicles of the distal lateral and medial tarsal artery to the first and

third cuneiforms.


graft by James A. Nunley, MD, at the Duke University Medical Center. There are

no long-term results yet, but the surgeries were promising.

Salvage procedures/arthrodeses

What are the options if the aforementioned methods do not work? There are

several salvage possibilities (eg, ankle arthrodesis, subtalar arthrodesis, tibio-

talocalcaneal arthrodesis). All of these arthrodeses are disabling to the patient.

Although they may revascularize the body of the talus to some extent, the patient

is left with a pronounced gait abnormality and the expectation for arthritis in the

surrounding joints over time.

It is recommended to place the ankle in neutral dorsiflexion/plantarflexion,

08 to 58 of hindfoot valgus, and 58 to 108 of external rotation with the talus

translated posteriorly [26–29]. If possible, the talus should be positioned exactly

under the tibia. The surgeon always should examine the contralateral side for

individual modifications in position; generally, the hindfoot is realigned with the

leg and the foot is positioned plantigrade. Many techniques can be used that

combine a preferred approach with a preferred method of arthrodesis and

fixation. Special circumstances, however, might necessitate alteration of a

preferred approach or require the use of different fixation techniques. In general,

there are surgical principles to be followed (eg, creating broad, congruent

cancellous bone surfaces and stabilizing with rigid internal fixation).

If there is no or little malalignment of the ankle joint, it is possible to perform

an arthroscopic ankle arthrodesis [30]. Using the anterolateral, medial, and

posterolateral portals, the surgeon performs an anterior synovectomy and

debridement of the ankle with a full radius shaver. Then the articular surfaces

are denuded of cartilage with the periosteal elevator followed by a power burr.

The medial and lateral gutter also are denuded to expose bleeding subchondral


bone, while maintaining the contour of the bony surfaces. Internal or external

fixation in situ is accomplished by two or three percutaneous, cannulated, or

noncannulated, cancellous screws that are parallel or converging.

The advantages of this method are less blood loss, a shorter time to union, and

an increased union rate because of the minimal interruption of the surrounding

soft tissue with subsequent better blood supply. Furthermore, there are fewer

complications in patients who have compromised healing potential (eg, vascular

disease, diabetes, rheumatoid arthritis, history of corticosteroid use, previous

skin or soft tissue flaps). The main disadvantages are that deformities cannot be

corrected if they are more than a few degrees and severe bone deficiencies cannot

be addressed well [31].

The mini-open technique is similar to the arthroscopic technique but the

portals are extended to an anterolateral and anteromedial 1.5- to 2-cm incision.

The advantages and disadvantages correspond with the ones of the arthroscopic

technique. It is important to close the anterior capsule meticulously. With this

technique it is possible to perform additional iliac crest grafting.

Several investigators have offered modifications of the open technique. Simin

et al [32] described a technique with a distal tibial inlay graft without fixation that

may be used as a primary or secondary salvage procedure. Lionberger et al [33]

reported a 28% pseudarthrosis rate and fibrous ankylosis secondary to prolonged

immobilization. They developed a modified Blair fusion and suggested using a

pediatric hip compression screw and a modified Stone staple for fixation.

Morris [34] modified Blair’s technique by placing a screw in the tibial inlay

and using a longitudinal Steinmann pin. Patterson et al [35] described a technique

with an anterior sliding graft to provide fixation and fusion. They used an

anterolateral approach and limited the periosteal elevation to the anterior aspect

of tibia in the region of the graft site. The joint is debrided of cartilage and fibrous

tissue while maintaining its shape. The anterior tibial graft (1.2 cm wide, 1.5 cm

depth, 5 cm long) is cut out with a saw and removed. After positioning the ankle

in the desired position, the quadrilateral area in the talar dome is marked through

the tibial defect with the talus positioned posterior in the tibia plafond. The bone

is removed from the talus in a plantarflexed position. One 6.5-mm screw is

inserted from the posterior medial malleolus directed anteriorly and one 6.5-mm

screw is inserted from the anterior lateral tibia into the posterior talus. The tibial

graft is implanted and fixed with two 4.5-mm screws. The postoperative

treatment includes 6 weeks of nonweight bearing and 6 weeks in a short leg cast

with weight bearing as tolerated. There is a moderate risk of an anterior stress

fracture of the tibia.

The technique that was proposed by Mann and Rongstad [36] in 1998 includes

a transfibular approach with resection of the distal fibula; this allows good joint

visualization. They did not propose to maintain joint shape but preferred two

matched parallel cuts on the distal tibia and the talar dome. This is especially

necessary to correct massive malalignment or angular deformities. Two parallel

interfragmentary compression screws are inserted from the sinus tarsi into the

tibia with the screw tip engaging the medial tibial cortex. The screw heads are


buried in the sinus tarsi. A partial or total resection of the medial malleolus may

be necessary. In cases of total resection, an additional screw or another fixation

device should be considered. Rarely does the surgeon need to augment with

medial staples.

This technique results in slight limb shortening of approximately 4 mm to

9 mm but rarely are there any problems with the peroneal tendons. The deltoid

arterial blood supply to the medial talus is preserved. The arthrodesis usually does

not require bone grafting. The disadvantages include disruption of the sinus tarsi

and difficult placement of the screws; two parallel screws provide less stability

than crossed screws [37]. With flat surfaces it can be difficult to align the joint

properly. Resection of the fibula allegedly interferes with proper blood supply

and subluxation of the peroneal tendons. This technique usually results in greater

shortening and the lack of the medial and lateral malleolus provides less stability

than with other techniques; however, it allows for the greatest correction of

angular deformities [31].

Our preferred open method includes a lateral approach with subperiosteal

dissection of the tibia and talus from the lateral side. The cartilage is removed

from all surfaces of the tibia and talus. After drilling all surfaces to enhance

osteoblast/cyte ingrowth, the ankle is positioned correctly and fixed with three

6.5-mm screws, starting with the posterolateral one. At the end we insert the

autologous bone graft from the excised medial one half of fibula to front and back

and fix the lateral part of the fibula onto the fusion site with one or two 4.0-mm

cancellous screws. It is important to check the peroneal tendons so that they do

not sublux.

Another described technique is the ‘‘Insitu dowel grafting’’ method, which

consists of using a rotated bone plug in patients who have rheumatoid arthritis or

painful, nondeformed ankles. This technique includes using a hollow trocar to

create a plug of bone that is approximately 8 mm in diameter and is cut across the

ankle parallel to the joint surface. The plug is then rotated 908.Besides fixing the arthrodesis site with screws, the surgeon can use different

external fixators (eg, monoplanar, multi-planar) or plate fixation. If using a lateral

plate, a large or small fragment T-plate is applied to the lateral side (compression

type) or a pediatric 908 osteotomy compression plate can be used [38]. The other

possibility is to use a double T-plate fixation—that is stronger than the fibular

strut fixation (lateral fibular strut fixed is with two 4.5-mm screws in tibia)—with

the crossed screw fixation (6.5 mm) [39].

In certain cases of severe osteoarthritis or joint destruction or in salvage

procedures it may be necessary to use an anterior plate that is bent accordingly to

hold the joint in the desired position. Screw purchase is obtained in the tibia and

the dorsal foot (talus, navicular, cuboid, cuneiforms, or metatarsals). This fixation

method often includes bone grafting, either with allograft or the iliac crest. The

posterior plate requires a posterior approach; the arthrodesis is fixed with a 908osteotomy plate and the blade is in the talus. Kirschner wires or vertical

Steinmann pins do not provide compression. Staples only should be used as a

supplement [31].


The patient is usually kept nonweight bearing for 12 weeks and then is

allowed to increase weight bearing with a removable upright walking boot [36].

Some investigators advocate 4 to 6 weeks of nonweight bearing and then weight

bearing is progressed. In any case, an individual postoperative treatment is

necessary according to the patient’s habits, occupation, social integration, and

compliance. Unprotected weight bearing is allowed only after bone trabeculation

is seen across the arthrodesis site.

After ankle arthrodesis, the foot is allowed dorsiflexion/plantarflexion of 108to 268 [40,41]. It is important to address postoperatively a possible leg length

discrepancy and the tendency to rotate the hip externally, even with proper

positioning of the fusion. Patients compensate and try to facilitate the stance

phase of their gait with external rotation of their ipsilateral hip.

In cases of fusion with bone graft after failed Total Ankle Replacement (TAR),

the patient will be kept nonweight bearing for 4 to 6 months until there is evi-

dence of bone union through the massive bone graft. For a limited time after sur-

gery, some patients may benefit from an orthotic or even a double-upright brace

with a locked ankle and solid ankle cushion heel to compensate for heel–ground

contact. A rocker-bottom sole helps to translate the tibia over the foot [31].

Complications in ankle arthrodesis

Complications are not rare. Besides wound problems that are due to hema-

toma, dehiscence, and soft tissue irritation during surgery, the complication that is

noted most often is the literature is nonunion, which may occur in up to 40% of

cases. Other complications include overresection of subchondral joint surfaces

with excessive shortening of the leg and delayed union that may require the use

of an internal or external bone stimulator. If an arthrodesis malunion occurs,

several sequelae can follow, including increased stress on other structures in the

foot, knee, hip, and spine.

Increased stress in adjacent joints could lead to the need for extension of the

arthrodesis in the long-term. As with every surgical procedure there can be an

infection (eg, wound, pin tract, osteomyelitis, sepsis) or a talar or tibial fracture

(eg, distal anterior tibial stress fracture after anterior sliding graft technique). The

need for a Below the Knee Amputation (BKA) is rare [26].

In the case of large bony defects in failed arthroplasty, large slabs of iliac crest

graft usually are needed for reconstruction. The plastic surgeon may need to be

involved to cover larger skin defects with musculocutaneous flaps (local or free).

Nonunions might cause subtalar involvement so that in revision surgery that

joint has to be addressed additionally and also be fused with screws, an

intramedullary nail, an external fixator, or even a plate. The ideal position for

pantalar arthrodesis is approximately 58 of valgus. A double plate fixation or

anterior plate, in cases with bone loss with fibular bone graft or iliac crest, are

possible. Revision arthrodesis for tibiotalar pseudarthrosis is a worthwhile pro-

cedure [42,43].


Summary

AVN of the talus is a challenging disease process with respect to patho-

physiology and treatment. We believe that our algorithm is a legitimate approach

to aid the orthopedic surgeon in initiating a promising treatment. It is divided into

different levels and allows to change between some. This is not the only way to

proceed but it seems promising, especially if the long-term results with the

vascularized bone grafts show revascularization of the talus. As always in

medicine, the treatment needs to be individualized. Arthrodesis always should be

the last option and is a challenging procedure.

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avascular necrosis of the talus current treatment options (2)

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