43: Arthroscopic Management for Juvenile Osteochondritis Dissecans of the Talus

Arthroscopic Management for Juvenile Osteochondritis Dissecans of the Talus

Craig J. Spurdle and Michael Busch

Indications

Failed conservative treatment for 6 months, including casting and weight-bearing restriction

Unstable osteochondritis dissecans (OCD) lesions at presentation

• All Berndt and Harty stage 4 and anterolateral stage 3 lesions (Canale and Belding, 1980; Pettine and Morrey, 1987)

Relative indications

• Early surgery for symptomatic stage 3 (posteromedial and central) and all stage 4 lesions

• Early surgery for symptomatic stage 2, 3, and 4 in patients nearing skeletal maturity (age > 12) (Letts et al., 2003; Perumal et al., 2007; Pettine and Morrey, 1987)

Pitfalls

• Any underlying ankle instability must be addressed prior to surgical treatment of OCD lesions. Untreated instability can be a cause of recurrence for OCD lesions.

Controversies

• There is increasing evidence that older children (>12 years) may have a poorer response to conservative management. Therefore, it has been suggested that surgery be performed earlier in older children, while younger children may benefit from a course of nonoperative treatment (Letts et al., 2003; Perumal et al., 2007; Pettine and Morrey, 1987).

Examination/Imaging

Ankle pain and swelling are the most common complaints with OCDs.

A standard ankle examination should be performed, including a thorough neurovascular and motor examination, and a range-of-motion examination with comparison to the opposite side.

Lateral ankle instability should be assessed with the anterior drawer test and the talar tilt test. These tests examine the anterior talofibular ligament and calcaneofibular ligaments, respectively.

Medially, the deltoid ligament should also be examined for tenderness and laxity.

Other sources of ankle pain should be excluded: peroneal tendon pathology, flexor hallucis longus pathology, and os trigonum pain.

Plain radiographs

• Anteroposterior (AP), lateral, and mortise views are obtained.

• OCD lesions are usually diagnosed by radiographs (Fig. 1).

FIGURE 1

Magnetic resonance imaging (MRI)

• MRI provides valuable information regarding the stability of the lesion.

• The size, location (posteromedial, anterolateral, or central), and stability can be evaluated.

• The arthroscopic surgical approach (anterior vs. posterior portals) is chosen from the location of the OCD on MRI (Fig. 2).

FIGURE 2

Pearls

• We typically perform arthroscopy on all surgical patients to visually evaluate the integrity of the articular surface of the OCD with a probe. This provides the most valuable information regarding OCD stability and finalizes our treatment plan. MRI and radiographs are not always adequate to determine OCD stability (Lahm et al., 2000; Pritsch et al., 1986).

Treatment Options

• OCDs with arthroscopically determined intact articular cartilage (stable) and less than 1 cm in size are treated with extra-articular drilling.

• OCDs with arthroscopically determined intact articular cartilage (stable) and greater than 1 cm in size are treated by extra-articular drilling and placement of autograft.

• OCDs with disrupted articular cartilage (unstable) are treated by débridement and marrow perforation.

• Alternatives for rare large lesions of the talus (2 cm or greater) include internal fixation, osteoarticular allograft/autograft, and autologous chondrocyte implantation.

Note: Medial malleolar osteotomy is contraindicated in the skeletally immature patient.

Surgical Anatomy

Anterior structures at risk (Fig. 3)

FIGURE 3

• Lateral portal: The intermediate branch of the superficial peroneal nerve is at risk.

• Medial portal: This portal is near the saphenous vein and nerve.

Posterior structures at risk using the coaxial posterior portals (Fig. 4)

FIGURE 4

• Medial portal: The posterior tibial artery and nerve are near this portal.

• Lateral portal: This portal is located just posterior to the peroneal tendons. The sural nerve is near this portal.

Positioning

We position all patients supine, and our table setup is the same as for a standard knee arthoscopy (Fig. 5).

FIGURE 5

The foot is placed on the surgeon’s thigh during the surgery, and we do not use traction (Fig. 6).

FIGURE 6

Pitfalls

• Use of a long surgical gown can avoid contamination of the limb while the surgeon is in the seated position (Fig. 7).

FIGURE 7

Equipment

• A mini C-arm is used for this procedure.

• An arthroscopy leg holder is used on the surgical side and an Allen stirrup is used for the well leg.

Controversies

• Using coaxial posterior portals for the ankle allows us the use of one position for both anterior and posterior ankle arthroscopy. Any intraoperative change using conventional posterior portals requires repositioning of the patient.

Portals/Exposures

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Tags: Operative Techniques Pediatric Orthopaedic Surgery

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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