Autologous Osteochondral Transplantation

Indications

Large osteochondral lesions of the talus (OLTs), generally considered as lesion size >150 mm² in area or 15 mm in diameter.¹^,² Recently, smaller lesions >100 mm are regarded as the optimal size.³
Secondary procedure for failed arthroscopic bone marrow stimulation technique⁴
OLTs with large cystic subchondral defects (Berndt and Harty stage 5)⁵

Positioning

The patient is positioned in the supine position. The level of the heel is set around the edge of the table.

Operative Technique

The surgical approach is determined by the location of the OLT. If the lesions are located in the anterior aspect of the talar dome, a mini-open arthrotomy can be applied. However, if the lesions are located in the central or posterior position, the osteotomy is required to expose the lesions because a perpendicular approach to the lesions is important for implantation.

Tibial Osteotomy

Medial Malleolar Osteotomy

As most of the medial OLT are located in the center of the posterior position, a medial malleolar osteotomy is usually required for medial lesions.
A skin incision is made over the medial malleolus after palpation of the medial corner of the joint line (Figure 20-1).

Expose medial corner of anterior aspect of tibia to prepare a chevron-type osteotomy. A provisional K-wire is inserted to visualize the osteotomy site under the guidance of fluoroscopy (Figure 20-2).

Figure 20-1. A longitudinal incision centered over the medial malleolus.

Figure 20-2. A provisional K-wire is drilled to visualize the osteotomy site fluoroscopically. A chevron-type osteotomy is then made in the medial malleolus. Illustrations copyright of and reproduced with permission from J. G. Kennedy, MD. Reproduction without express written consent is prohibited.

Before performing the osteotomy, two parallel fixation holes are predrilled in the medial malleolus for a later anatomic screw fixation (Figure 20-3).
A chevron-type osteotomy is performed using a bone saw and an osteotome. This type of osteotomy provides appropriate alignment, stability after fixation, and large surface area for healing. Cold saline should be used to prevent thermal necrosis at the osteotomy site. The bone saw is stopped at the subchondral bone, and the osteotomy is completed by an osteotome to protect the posterior tibial tendon and minimize the articular cartilage damage (Figure 20-4).
The malleolar fragment is retracted in the plantar direction to allow adequate visualization and access to the medial talar dome (Figure 20-5).

Figure 20-3. The osteotomy site is determined under the guidance of fluoroscopy (left). Predrilling the medial malleolus with two parallel fixation holes crossing the proposed osteotomy (right).

Figure 20-4. Medial malleolar osteotomy started with bone saw parallel to the K-wire (left). The remainder of osteotomy is completed with a sharp osteotome (right). Illustrations copyright of and reproduced with permission from J. G. Kennedy, MD. Reproduction without express written consent is prohibited.

Figure 20-5. Plantar displacement of the osteotomized medial malleolus allows exposure of the medial aspect of the talar dome. Illustrations copyright of and reproduced with permission from J. G. Kennedy, MD. Reproduction without express written consent is prohibited.

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