Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects

Abstract

Objective Provision of a natural scaffold, good quality cells, and growth factors in order to facilitate the replacement of the complete osteochondral unit with matching talar curvature for large medial primary and secondary osteochondral defects of the talus. Indications Symptomatic primary and secondary medial osteochondral defects of the talus not responding to conservative treatment; anterior–posterior or medial–lateral diameter >10 mm on computed tomography (CT); closed distal tibial physis in young patients. Contraindications Tibiotalar osteoarthritis grade III; multiple osteochondral defects on the medial, central, and lateral talar dome; malignancy; active infectious ankle joint pathology. Surgical technique A medial distal tibial osteotomy is performed, after which the osteochondral defect is excised in toto from the talar dome. The recipient site is microdrilled in order to disrupt subchondral bone vessels. Then, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exact fitting shape to match the extracted osteochondral defect and the talar morphology as well as curvature. The graft is implanted with a press-fit technique after which the osteotomy is reduced with two 3.5 mm lag screws and the incision layers are closed. In cases of a large osteotomy, an additional third tubular buttress plate is added, or a third screw at the apex of the osteotomy. Postoperative management Non-weight bearing cast for 6 weeks, followed by another 6 weeks with a walking boot. After 12 weeks, a CT scan is performed to assess consolidation of the osteotomy and the inserted autograft. The patient is referred to a physiotherapist. Results Ten cases underwent the TOPIC procedure, and at 1 year follow-up all clinical scores improved. Radiological outcomes showed consolidation of all osteotomies and all inserted grafts showed consolidation. Complications included one spina iliaca anterior avulsion and one hypaesthesia of the saphenous nerve; in two patients the fixation screws of the medial malleolar osteotomy were removed.

Comparison of Autologous Osteoperiosteal and Osteochondral Transplantation for the Treatment of Large, Medial Cystic Osteochondral Lesions of the Talus

“…Of the 23 patients, 1 patient (4.3%) had persistent iliac pain without numbness or swelling in the AOPT group at the final follow-up. One patient with donor-site morbidity and iliac avulsion was reported in Kerkhoffs et al, 15 while no cases of donor-site morbidity were reported in Hu et al 14 The above results indicate that AOPT is associated with very low rates of donor-site morbidity. Although no differences in pain morbidity were observed between the AOPT and AOCT groups, the rates of total donor-site morbidity and discomfort morbidity in the AOPT group were lower compared with those in the AOCT group.…”

“…2,20,33 Nonoperative management is the primary strategy for OLTs, and surgical treatments are considered in patients with persistent symptoms. 15,24 Arthroscopic bone marrow stimulation is the common first-line surgical treatment for small and noncystic defects. 13,22 However, several studies have reported inferior outcomes of bone marrow stimulation in patients with large cystic OLTs.…”

Unorganized fibrocartilage and osseous proliferation after bone marrow stimulation for an osteochondral lesion of the talus

“…17,18 Restorative techniques -such as the TOPIC technique -can be considered more appropriate for facilitating native hyaline cartilage regeneration on the transplanted periosteal membrane 'scaffold' and restoration of healthy subchondral bone. 12,19,20 These techniques have been shown to be effective in the treatment of secondary OLTs and to result in superior outcomes when compared to BMS. 20,21 Another point of interest is the clinical correlation of the fibrocartilaginous flap and the persistent instability of the affected ankle experienced by the patient.…”

“…Based on the clinical presentation, radiological lesion characteristics, and previous failed surgery with the concomitantly present lateral ankle instability, the patient and treating team elected to perform a restorative procedure in the form of a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) combined with a lateral ligament Duquennoy plasty with non-absorbable suture augmentation (InternalBrace™, Arthrex USA) through a direct anterolateral approach. 11,12 Through an anterolateral arthrotomy access to the lateral ankle joint was acquired. The anterior talofibular ligament (ATFL) showed 1+ laxity and was detached from the fibula in order to facilitate exposure of the lateral talus.…”

“…Hereafter, the OLT was addressed through the restorative lateral TOPIC procedure, analogous to the procedure described in an earlier report 12 . After the TOPIC procedure, a lateral ligament reconstruction was performed.…”