2018 AWARD WINNER

Background: Osteochondral lesions of the talus (OLTs) involve various regions of the talar dome articular cartilage and underlying subchondral bone. Large OLTs include substantial portions of the weight-bearing dome and may be encountered medially and laterally. These lesions are associated with poor healing potential, largely because of tenuous vascular supply, and may lead to progressive degenerative joint disease. For patients with a large, expansive OLT or an OLT involving the shoulder region of the talus, cartilage restoration procedures, including microfracture, osteochondral autograft transplantation, and juvenile chondrocyte implantation may be inadequate and lead to failure. Osteochondral allograft transplantation has emerged as a promising treatment option for the management of large OLTs because it affords structural support and self-sustaining viable chondrocytes. However, adequate access to the talar dome is critical for allograft transplantation. Medial malleolar osteotomy has emerged as a reliable and safe method for exposure of the talar dome and shoulder region. Careful technique is essential to avoid poor outcomes and ensure consistent results.

Purpose: This video and case presentation demonstrate fresh osteochondral allograft transplantation for the management of a large OLT of the talus through a medial malleolar osteotomy.

Methods: The video provides an overview of the pathogenesis, diagnosis, and management of OLTs followed by a discussion of the indications for osteochondral allograft transplantation for the management of talar dome osteochondral defects. The video discusses the case presentation of a 16-year-old boy with a large, traumatic OLT. The patient previously underwent ankle arthroscopy with autologous stem cell and extracellular matrix implantation but has persistent, recalcitrant symptoms. Advanced imaging studies revealed an incompletely healed, large OLT of the medial talar dome. Fresh osteochondral allograft transplantation was performed through a medial malleolar osteotomy.

Results: Excellent restoration of the talar articular surface was achieved intraoperatively. The patient advanced through a standardized rehabilitation protocol with gradual relief of his symptoms.

Conclusion: Osteochondral allograft transplantation is a reliable treatment option for the management of large or refractory OLTs. Transplantation often requires adequate exposure, which is afforded by a medial malleolar osteotomy. Although studies have demonstrated good outcomes, results are contingent on careful and consistent technique.