Utilizing Fresh Talar Allograft For An Osteochondral Defect In An Ex-Football Player

Lisa Thatcher, DPM, coauthored this DPM Blog

A 33-year-old obese ex-football player, who sustained multiple ankle sprains to his left ankle in his youth, presented to the office with continued left ankle pain.

The patient reports having two previous surgical interventions on a diagnosed osteochondral defect: arthroscopy with microfracture (2011) and synthetic cartilage transplantation (2012). The patient stated that after the second procedure, he had pain relief for approximately seven weeks into physical therapy. Then the pain returned, causing him to continue the use of an ankle brace as well as miss work. He presented to our office for a second opinion in October of 2013.

We attempted all appropriate conservative treatment options that failed over an 18-month period prior to implementing surgery. Conservative treatments included bracing, injections, rest, activity modifications, non-steroidal anti-inflammatory drugs (NSAIDs), immobilization in a controlled ankle motion (CAM) walker and weight loss. Initial computed tomography (CT) imaging (11/1/13) and repeat imaging (11/17/14) revealed an osteochondral defect to the medial third of the talar dome with a few small loose bodies, no cyst formation and no progression when comparing studies. After the failure of all previous conservative treatments, we decided upon surgical intervention consisting of fresh talar allograft transplantation and performed the procedure on 2/25/15.

Surgery consisted of a medial approach with a medial malleolar takedown osteotomy to allow for fresh talar allograft transplantation. After resection of the lesion, measuring 2.0 x 1 x 0.8 cm, and preparation of the defect for graft transplantation, we shaped and press fit the allograft into the defect. Metallic fixation consisted of two 3.0 mm headless, cannulated, partially threaded stainless steel screws. We fixated the medial malleolar osteotomy with two 4.0 mm headed, cannulated, partially threaded stainless steel screws. We closed the joint capsule, superficial fascia, subcutaneous tissue and skin in the usual fashion.

The patient was non-weightbearing with the left lower extremity for a total of 12 weeks postoperatively. He proceeded to protected full weightbearing in a walking boot at 16 weeks and was fully weightbearing in regular shoe gear at 30 weeks. The patient started utilizing an ultrasound bone growth stimulator the third week after the procedure and used it for a total of nine weeks. This was a preventative measure due to the amount of prior surgeries to the talus. A new CT, obtained at 12 weeks, revealed about 55 percent graft incorporation with bony coaptation across the osteotomy site as well as intact hardware, and no graft subsidence. Radiographs revealed routine healing at all postoperative visits and final films revealed 100 percent graft incorporation, no subsidence and no hardware failure at 32 months. The patient remained pain-free at 32 months post-op.

The above case summarizes an option for larger osteochondral defect lesions recalcitrant to previous surgical intervention. Please provide your thoughts on this surgical option or if you have any experience with similar or other approaches.