Osteochondral Lesions of the Talus

Osteochondral lesions of the talus (OLTs) are defects of cartilage and subchondral bone in the talar dome. More sophisticated imaging techniques allow for precise diagnosis of OLTs, and advanced arthroscopic and open methods are available to treat this difficult problem. Pathogenesis OLTs, also known as osteochondritis dissecans lesions, are generally located in one of two areas on the talar dome: either posteromedial or anterolateral. The more common posteromedial lesions are usually deeper lesions involving subchondral bone. Their origin is thought to involve ischemia, often with an episode of trauma exacerbating the underlying condition. Anterolateral lesions are a result of a single traumatic episode or repetitive trauma from lateral ankle sprains. These lesions tend to be purely cartilaginous. Clinical Findings Symptoms and Signs Patients usually present with several months of ankle pain following a routine ankle sprain. Sometimes they recount a history of recurrent sprains to the ankle. The pain is usually located over the anterior aspect of the ankle on the side of the lesion, but it may be diffuse. Occasionally, there is a sensation of locking in the ankle when a loose flap of cartilage is present. A high index of suspicion is necessary because OLTs can be misdiagnosed as a chronic ankle sprain, as discussed in the section on ligamentous injuries about the ankle joint. Imaging Studies Radiographs are often normal in OLTs. MRI scan is the imaging procedure of choice for determining the size, location, and extent of bony or cartilaginous involvement (Figure 962). Treatment Nonsurgical A 6-week trial of cast immobilization is warranted if the MRI scan shows no evidence of a displaced bone or cartilage fragment. Surgical The surgical treatment method depends on the type of lesion. Acutely displaced lesions can be reduced and pinned with an absorbable pin by either open or arthroscopic methods. Purely cartilaginous lesions are curetted to a stable rim and drilled to stimulate vascular ingrowth and fibrocartilage formation. OLTs with significant bony involvement require bone grafting in addition to drilling and curettage. A medial malleolar osteotomy is required to access a posteromedial lesion. If a bony lesion has intact overlying cartilage, drilling and bone grafting

can be performed under radiographic guidance through the talus, thereby sparing the overlying cartilage. Postoperatively, patients are kept nonweight bearing for 4 weeks, but early ROM is encouraged. New techniques were developed for larger lesions or ones that fail curettage and drilling. Osteochondral autograft or allograft plugs can be used to replace bone and cartilage defects. Autograft plugs are generally harvested from the ipsilateral knee. Intermediate-term follow-up data shows good results in most patients following this technique. Autologous chondrocyte implantation is also used to a limited extent for OLTs.

Anterior Tibial Tendon Rupture Pathogenesis Rupture of the anterior tibial tendon occurs infrequently, and most often in patients older than 60. The mechanism is either chronic rubbing against the inferior edge of the extensor retinaculum or rubbing against an exostosis at the first metatarsocuneiform joint. The rupture usually occurs at the distal 23 cm of tendon. Nondegenerative traumatic ruptures of the anterior tibial tendon are rare. Clinical Findings Symptoms and Signs Patients with a degenerative rupture present with complaints of pain and swelling over the anterior ankle. They sense the foot slapping down, or they may be catching their toes on the ground when they walk. Patients frequently present after the symptoms have been bothersome for several months. Physical exam is notable for weakness of ankle dorsiflexion, often with a palpable mass over the anterior ankle joint. Imaging Studies If the diagnosis is in doubt, MRI scan can accurately determine if the tendon is ruptured. Treatment Nonsurgical In the case of a less active patient, nonsurgical treatment appears to give equal functional results to surgical repair. Cast immobilization is followed by long-term use of an AFO. Surgical

Acute tendon rupture in an active individual should be surgically repaired. Chronic ruptures that are symptomatic usually require reconstruction using an extensor tendon graft or tendon transfer because the distal stump is usually too degenerated to perform a primary repair.

Peroneal Tendon Subluxation and Dislocation Pathogenesis Peroneal tendon dislocation is caused by a sudden forceful dorsiflexion motion of the ankle combined with a simultaneous strong contraction of the peroneal musculature. This mechanism injures the superior peroneal retinaculum, which holds the peroneal tendons in place along the posterior border of the distal fibula. The retinaculum is either stripped off the fibular periosteum or avulsed with a small piece of fibular cortex. This permits the creation of a false pouch and laxity of the retinaculum, allowing the peroneal tendons to dislocate anteriorly. If this condition goes unrecognized, either the tendons remain dislocated, or they relocate with the propensity for recurrent subluxation or dislocation. Clinical Findings Symptoms and Signs The patient usually recalls an acute episode of trauma and frequently the sensation of the tendon dislocating. Pain and swelling is localized to the peroneal tendon sheath around the tip of the fibula. With recurrent subluxation or dislocation, the tendons are felt to pop out of place. On examination, resisted eversion of the ankle elicits pain and may cause the tendons to subluxate. Unfortunately, many acute peroneal tendon dislocations go unrecognized as lateral ankle sprains. Imaging Studies Radiographs may show a small piece of bone lateral to the distal fibula, indicative of avulsion of the retinaculum. MRI scan usually details the injury well if careful attention is paid to this area. Treatment Nonsurgical Treatment of acute peroneal tendon dislocations consists of casting in plantarflexion and inversion for 4 weeks, followed by a walking cast for an additional 2 weeks. Cast treatment has at least a 50% failure rate. Once a tendon is chronically dislocated or recurrently subluxates, only surgical treatment will keep it in position. Surgical

Surgical repair is recommended for an athletic individual following an acute dislocation of the peroneal tendons. It is also recommended for patients with recurrent dislocation if their physical activities are significantly restricted. The procedure consists of repairing the superior peroneal retinaculum to the fibula, either through drill holes or with suture anchors. In the case of attenuated retinaculum caused by chronic dislocations, the repair can be reinforced with a strip of Achilles or by rerouting the calcaneofibular ligament over the tendons. At the time of surgical repair, the tendons are inspected for tears and the contour of the posterior fibular groove is evaluated. If a shallow groove is noted, a bony procedure to deepen the groove is necessary to prevent recurrent dislocations. Postoperatively, the patient is immobilized in a cast for 6 weeks.

Treatment

Methods for treating Achilles tendon rupture include primary repair, using open or percutaneous techniques, or cast immobilization. Surgical repair is recommended for active individuals, in the case of a rerupture, or if the injury is older than 2 weeks.

Cast treatment for Achilles tendon ruptures is recommended for more sedentary individuals, patients who are at increased risk of developing wound problems, or high-risk surgical patients. The primary risk of cast immobilization is a higher chance of rerupture. For the vast majority of patients, either treatment method results in a good outcome.

Nonsurgical Treatment

Once an acute rupture is diagnosed, the patient should be placed in a gravity equinus cast. A below-knee cast is adequate in a reliable patient. If there is a question of whether the tendon edges are properly apposed in the cast, an MRI scan be done, although this is not routine. After 4 weeks, the cast is changed, with correction of approximately half of the previous equinus. Over the next 4 weeks, the patient is brought down to neutral with serial casts. Once at neutral, the patient is given a removable walking cast for 4 weeks. Supervised strengthening activities then begin.

Surgical Treatment

The surgical approach is on the medial side of the Achilles tendon sheath. The frayed edges of the tendon are debrided. The foot is positioned in equinus position equal to the resting equinus of the opposite ankle. Two heavy nonabsorbable sutures are woven through 34 cm of each tendon edge using

a Bunnell or Kessler stitch (Figure 959). The repair can be reinforced with lighter, absorbable sutures at the site of the tear. If the plantaris tendon is intact, it can be harvested and used to reinforce the repair. Postoperatively, a hard cast is used for 3 weeks, followed by a removable cast with adjustable ankle motion. Over the next 23 weeks, the joint should be gradually brought out of equinus. Weight bearing is then allowed, and ROM exercises are begun. The cast is discontinued at 68 weeks, and supervised strengthening exercises are performed.

The primary risk of surgical repair is wound healing problems, which occur in approximately 5% of patients. A percutaneous method of Achilles tendon repair is listed in the references.

Treatment of Chronic Ruptures or Reruptures

Chronic Achilles tendon ruptures, more than 6 weeks old, or reruptures of previously treated injuries can be challenging reconstruction problems because of retraction and degeneration of the tendon ends. A number of different procedures are described to address this problem, including a variety of synthetic and interpositional grafts (Figure 960). Small defects can be bridged by turning down a strip of gastrocnemius fascia, which is sutured into the distal tendon stump. Larger defects can be treated by using a V-Y lengthening of the gastrocnemius aponeurosis. If the deficit is too large for V-Y lengthening, transfer of the flexor hallucis longus tendon can be performed. The tendon of the flexor hallucis longus is transected distally in the foot, and the distal segment is tenodesed to the flexor digitorum longus to maintain flexion of the great toe. The proximal tendon is secured to the calcaneus through a drill hole or by using an absorbable anchor or screw. A central slip of the Achilles tendon is advanced to bridge the gap, and then the repair is reinforced by securing it to the flexor hallucis (Figure 961).