The Foot 16 (2006) 103–106

Case report

Osteochondral lesion of the central talar dome: A case report

Kazuya Sugimoto a,∗, Kohjirou Okahashi a, Manabu Oshima a,Yoshinori Takakura b, Ryoji Kasanami b

a Department of Orthopaedic Surgery, Saiseikai Nara Hospital, 4-643 Hachijo, Nara-shi, Nara 6308145 Japanb Department of Orthopaedic Surgery, Nara Medical University, 840 Kashihara-shi, Nara 6348522, Japan

Abstract

A 33-year-old male patient with an osteochondral lesion of the central talar dome is reported. Operative treatment with perpendicularaccess to this area was impossible without an osteotomy of the tibial plafond. Pie-wedge osteotomy of the tibial plafond with on pediclecapsule-periosteal flap enabled us to treat the lesion by mosaicplasty.© 2006 Elsevier Ltd. All rights reserved.

Keywords: Talus; Osteochondral lesion; Osteotomy; Mosaicplasty

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. Introduction

Most osteochondral lesions of the talus are located in theedial or lateral portion of the talar dome, and rarely in the

entral portion [1–7]. When the lesion is located in the cen-ral area, the operative approaches reported in the literaturere not practical. The lesion in this area requires osteotomyf the tibial plafond including an extensive portion of theoint surface. The major problem associated with osteotomyncluding the joint surface is the risk of avascular bone necro-is, which leads to degeneration of the cartilage in the area ofsteotomy. We report a case treated by a unique technique toccess the lesion without any risk of avascular bone necrosis.

. Case report

A 33-year-old man fell under the influence of alcohol inpril 1998. The next day, he felt pain in his right ankle andas unable to walk. He was referred to us because of annusual finding in the ankle on plain radiographs.

At the first examination, he complained of pain in the

moderately restricted, but with no crepitus. Plain radiographyshowed a small area indicating an impacted fracture of thecentral talar dome. The ankle was immobilized in the neutralposition for a month in a below knee cast. Weight bearingwas not allowed for 6 weeks. After removal of the cast, ahard brace was applied for 2 months. He returned to work inSeptember 1998.

The patient complained of pain again in May 2000 aftera recreational baseball game. Plain radiographs did notshow any improvement compared with those at the time ofinjury. MRI showed an area of high intensity in T1-weightedsequence and a low intensity in T2-weighted sequence, whichindicated osteochondritis dissecans in the central talar dome.Plain CT of the ankle showed two cystic subchondral lesionsin the central and centromedial talar dome (Fig. 1).

Arthroscopy was performed on June 13th 2000 andshowed an area of chondral softening and fibrillation inthe central talar dome and moderate synovitis. They wereassessed as Berndt and Harty stage II osteochondral lesionswith subchondral cysts. Mosaicplasty was performed dur-ing the approach described below under general anaesthesiawith tourniquet control in June 2000. A 6 cm long longitudi-

ight ankle on weight bearing. Physical examination revealedild swelling of the ankle and tenderness, which was mostarked at the anterior joint. Ankle and hindfoot motion were

nal incision was made on the anterior aspect of the ankle. Anantero-distal part of the tibia was cut in a pie-wedge shape3 cm height, on pedicle flap consisting of its periosteum andthe capsule of the ankle (Fig. 2). Cartilage and bone plugci

∗ Corresponding author. Tel.: +81 742 36 1881; fax: +81 742 36 1880.E-mail address: kzort@m3.kcn.ne.jp (K. Sugimoto).

958-2592/$ – see front matter © 2006 Elsevier Ltd. All rights reserved.oi:10.1016/j.foot.2005.12.001

omplexes were harvested from the lateral femoral condylen the ipsilateral knee joint and mosaicplasty was performed.

104 K. Sugimoto et al. / The Foot 16 (2006) 103–106

Fig. 1. Plain CT of the left ankle showed two cystic subchondral lesions in the central (A) and centromedial (B) talar dome.

Fig. 2. On pedicle pie-wedge osteotomy of the anterior tibial plafond.

Three plugs 12 mm in depth and 3.5 mm in diameter and twoof 10 mm in depth and 2.7 mm in diameter were transplanted(Fig. 3). The tourniquet was released before reduction of thepie-wedged bone. Then the pie-wedge bone was repositionedto the tibial plafond and fixed using two screws.

The operated ankle was immobilized in a below knee castwith the ankle in a neutral position for 4 weeks. After removalof the cast, a patella tendon bearing brace was applied, andsupervised physical therapy commenced. Full weight bearingwas not allowed for 3 months after the operation. The patientreturned to his original work 5 months after the operation.The repositioned pie-wedged bone united rapidly without anyevidence of avascular bone necrosis (Fig. 4).

The patient complained of no pain 2 years and 7 monthsafter the operation, but mild restriction of the sagittal motionpersisted (range of dorsiflexion and plantarflexion were 15◦and 40◦ in the operated ankle compared with 18◦ and 45◦ inthe contralateral ankle).

3. Discussion

Arthroscopic drilling is indicated for the early stage(Berndt and Harty [8] stage II) in osteochondral lesion of thetalus and works well in patients under 15 years old [9–12].Open procedures are indicated for advanced lesions (BerndtawB

nd Harty stage III and IV) [13,14]. The patient in this caseas a 33-year-old man who had double lesions assessed aserndt and Harty stage II with degenerative cartilage and

K. Sugimoto et al. / The Foot 16 (2006) 103–106 105

Fig. 3. Mosaicplasty was performed with perpendicular access.

subchondral cysts. An open procedure was employed in thiscase, because the indication for arthroscopic drilling of theselesions were not established and drilling of central talar domewas technically hard to perform.

Open procedures such as mosaicplasty or bone peg tech-nique with perpendicular access to the lesions often requireosteotomy of the tibia or fibula. Osteotomy of the medialmalleolus is used to access the lesions located medially, whilea variety of tibial or fibular osteotomies are reported forlesions located laterally [15–17].

When the lesion is located in the central area, osteotomy ofthe tibial plafond including an extensive area of the joint sur-face is required. This leads to a risk of avascular bone necrosisand degeneration of the cartilage. In the current case, a pie-wedge shape osteotomy on a pedicle flap was used to treatthe lesions located in the central or postero-lateral portionof the talar dome. This technique is easy to perform withoutany risk of avascular necrosis. The repositioned pie-wedgeshaped bone united rapidly without any evidence of avas-cular necrosis. The periosteal membrane and joint capsuleare rich in capillaries and microcirculation, which are veryimportant for keeping the pie-wedge shaped bone alive andthereby preventing the effect of degenerative change in car-tilage on the bone.

Fig. 4. Repositioned pie-wedged bone block united rapidly without any evi-dence of avascular bone necrosis.

Tochigi et al. [17] introduced a technique of anterolat-eral osteotomy of the tibia preserving the attachment of theanteroinferior tibiofibular ligament. This technique allows aperpendicular approach to osteochondral lesions located inthe lateral or centrolateral portion of the talar dome. However,the use of their technique for lesions located in the central orcentromedial talar dome is not established.

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