Free vascularised osteochondral flap for the treatment of osteochondritis dissecans of the talus
- 1 Orthopaedics and Traumatology, Klinik Diakonissen Schladming, Schladming, Austria
- 2 Privat Hospital Maria Hilf, Klagenfurt, Austria
- 3 AUVA Unfallkrankenhaus Graz, Graz, Austria
- Correspondence to Dr Georg Mattiassich; georg.mattiassich@diakonissen.at
Abstract
We present a case report of a man in his 20s with osteochondritis dissecans of the talus, treated with autologous transplantation of a vascularised osteochondral flap. The patient with high level of activity presented to our orthopaedic outpatient department for progressive limping and pain, mainly related to sports. An osteochondritis dissecans grade IV of the medial talus was identified by MRI. A microvascular transfer of osteochondral tissue was performed successfully. At follow-up 1 year after surgery, the MRI examination revealed vital cartilage; the patient was free of pain and had returned to his previous level of activity.
Background
Osteochondritis dissecans (OD) is an aseptic necrosis of the subchondral bone of multifactorial origin.1 In 1558, Ambroise Paré was the first to write about ‘loose bodies removed from the inside of a joint cavity’ during a surgical intervention.2 The term OD was introduced in 1888 by Konig3 but the disease still remains a therapeutic challenge. The most frequently affected joint is the knee, followed by ankle and elbow,4 and OD is mainly diagnosed in adolescents and young adults in the second decade.5 The treatment is guided by the patient’s age, the clinical presentation and the stage of the disease6 following the radiographic classification system by Berndt and Harty7 or Kramer and Scheurecker.8 Beside a conservative approach for lower grade OD, several techniques for surgical repair with limited success rates have been described in the recent literature.1 The use of microvascular osteochondral flaps is an advanced procedure for resurfacing of damaged cartilage. We present a case report of a young adult with OD of the talus, treated with autologous transplantation of a vascularised osteochondral flap.
Case presentation
A man in his 20s with high level of activity presented to our orthopaedic outpatient department for progressive limping and pain, mainly related to sports. He reported two episodes of acute lateral ankle sprain more than 6 months ago; initially he had immediate pain, swelling and was unable to weight bear. He did not seek medical attention, therefore radiographs or MRI was not performed at the time of injury. The symptoms have improved after temporary immobilisation and 2 weeks after initial trauma, the patient was able to walk almost normally but he reported about continuous pain during sports. Based on the clinical symptoms and the long history, we requested an MRI scan to identify possible lesions of cartilage or bone and identified an OD grade IV of the medial talus (figures 1–3).
Preoperative performed scans show the lesion of the cartilage of the medial talus.
Preoperative performed scans show the lesion of the cartilage of the medial talus.
Preoperative performed scans show the lesion of the cartilage of the medial talus.
Treatment
A microvascular transfer of osteochondral tissue was suggested. Intraoperatively, a detached, non-displaced osteochondral fragment with the size of 2×1 cm was obvious (figure 4). After forming a wax model of the defect, a vascularised osteochondral flap was removed from the medial femoral condyle (figures 5 and 6). The vessels of the articular branch of the descending genicular artery were identified by preparation along the main vessel and anastomosed end to side to the tibialis posterior vessels (figure 7). The blood flow was monitored using ultrasound. The corticocancellous block with cartilage was then fitted into the lesion of the talus with the cartilage replacing the medial aspect of the talus trochlea. The pedicle of the graft was directed behind the medial malleolus and caused no compression of the vessels. The bone block was then stabilised with screws (figures 8 and 9). The vascularisation was checked with Doppler ultrasound.
Dimensions of the defect.
Picture of the donor zone.
Dimensions of the graft.
Picture of the anastomosis.
Interoperative picture of the fixation of the block.
Interoperative picture of the fixation of the block.
Outcome and follow-up
The patient was mobilised on day 4 and dismissed on day 7. Postoperatively, limited weight-bearing with 20 kg was allowed followed by full weight-bearing after 6 weeks (figures 10 and 11). Follow-up investigations were performed 6 weeks and 6 months after surgery; the clinical course was uneventful. An MRI and CT scan 1 year after surgery showed good fracture alignment, vital cartilage and the restoration of the joint surface (figure 12). The patient is able to perform sports free of pain.
Postoperation CT scan.
Postoperation CT scan.
MRI scan performed 1 year after operation.
Discussion
Low-grade osteochondral lesions are mainly located on the medial talus and preferably treated with cast immobilisation between 6 weeks and 6 months (up to 1 year); a good functional outcome may be achieved but radiographic changes (irregular ossification) will persist in approximately half of the case.9 It is known that conservative treatment has an average success rate of 45%10 and juvenile OD has a better healing potential compared with adult-onset OD; in symptomatic grade II or III lesions, failure of conservative treatment, older patients and in all cases with grade IV lesions, a surgical approach is recommended.11 There are several techniques described in the literature which may be an indicator that the best treatment modality has not been identified yet. Popular techniques are excision of the fragment, fixation of the fragment, bone marrow stimulation, microfracture, autograft or allograft transplantation of osteochondral tissue and chondrocyte implantation.12 However, in all these techniques, avascular tissue is used to repair an avascular necrosis, thereby resulting in a significant number of complications. In addition, the number of long-term studies is low.13 The initial success rate of standard surgical procedures is highest with excision, curettage and drilling (85%) followed by excision and curettage (78%) and isolated excision without replacement (38%).10 A reoperation rate of almost one-third of these cases has been described 1.7 years mean after initial surgery.14 Therefore, advanced surgical techniques are required to improve outcome in OD of the talus. The vascularised osteochondral flap transplantation has been first described by Hintermann et al in 201515 and requires a skilful surgical team, an expert in microvascular anastomosis and a long operation time. Therefore, the technique of using a free vascularised osteochondral flap for the treatment of OD of the talus may be restricted to selected cases of revision surgery and patients with very high levels of activity and large osteochondral defects.
Learning points
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A vascularised osteochondral flap can be used successfully for replacement of higher-grade osteochondritis dissecans lesions.
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Other popular techniques use avascular tissue to repair an avascular necrosis, thereby resulting in a significant number of complications.
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The technique of transferring a vascularised osteochondral flap is advanced and requires an experienced, skilful surgical team.
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Therefore, the described method should be restricted to selected cases of revision surgery and patients with very high levels of activity.
Ethics statements
Patient consent for publication
Footnotes
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Contributors Supervised by GM. The patient was under the care of HB, MA, GM and GS. Report was written by GS.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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