Several authors describe more extensive tibial osteotomies to access the posterior ankle, including the posterolateral talar dome [45, 46, 63, 74]. Sammarco and coworkers describe an anterior tibial wedge osteotomy that corresponds to the coronal plane position of the OLT, allowing perpendicular access to the posterior talar dome, including the posterolateral aspect of the talus [63]. Kreuz and coworkers modified this technique to take less bone but afford the same access to the posterior talus; however, these authors only described their technique for the posteromedial talar dome [45, 46]. Tochigi and coworkers, in a technique tip article, suggested that access to the centrolateral talar dome may be improved with an anterolateral tibial plafond osteotomy, where an osteochondral block resembling that of a juvenile Tillaux fragment is reflected via an anterolateral ankle arthrotomy [74]. Through an anterior or anterolateral approach, a 1 × 1.5 cm anterolateral fragment of the distal tibial plafond (at Chaput’s tubercle) is mobilized using a combination of reciprocating saw and osteotome and reflected on the anterior inferior syndesmotic ligament. After the posterolateral OLT has been managed, the anterolateral bone block is reduced and secured with screw fixation. Al-Shaikh and coworkers described using an anterolateral arthrotomy in 5 of 6 patients with lateral OLTs to gain satisfactory perpendicular access for osteochondral transfer; in the sixth patient, the authors report using a lateral malleolar osteotomy to gain perpendicular access [4]. Little detail was provided with respect to how the lateral malleolar osteotomy was performed.

Perpendicular access has been the focus of several recent investigations, including ones dedicated to the lateral talar dome [25, 53, 62]. Muir and coworkers suggested that an average of 80 % of lateral OLTs may have perpendicular access without osteotomy [53]. Via a 6 mm anterolateral arthrotomy lateral to the peroneus tertius, 36 % of the lateral talar dome in the sagittal plane, 54 % of the talar dome in the coronal plane, and 28 % of the entire talar dome are exposed for perpendicular access, respectively. These authors observed that an anterolateral osteotomy [74] adds a mean 22 % to sagittal plane exposure via an anterolateral arthrotomy, with 62 % of the talar dome in the sagittal plane, 36 % in the coronal plane, and 35 % of the entire talar dome accessible for perpendicular access. A posterolateral arthrotomy affords 37 % of the talar dome in the sagittal plane, 37 % in the coronal plane, and 12 % of the entire talar dome, respectively. A fibular osteotomy, performed after repair of the anterolateral tibial osteotomy in the cadaveric model, afforded 100 % access to the talar dome in the sagittal plane, 52 % in the coronal plane, and 43 % of the entire talar dome, respectively.

Whereas Muir and coworkers’ study comprehensively analyzed access to the entire talar dome, Garras and coworkers’ investigation focused on the perpendicular access to the posterolateral talar dome [25]. These authors observed in their cadaver model that sagittal plane exposure to the lateral talar dome averaged: 43 % with anterolateral arthrotomy and ATFL release, 68.5 % with anterolateral tibial osteotomy, 88 % with fibular osteotomy, 91 % with fibular osteotomy and ATFL release, and 95 % with fibular osteotomy and combined ATFL and CFL release [25]. Rush and coworkers, also using a cadaveric model, observed that temporary invasive distraction with an external fixator afforded greater sagittal plane/posterior access to the lateral talar dome than anterolateral arthrotomy or anterolateral tibial osteotomy alone and afforded greatest posterolateral talar dome perpendicular access when combined with the anterolateral tibial osteotomy [62]. In an attempt to limit vascular compromise to the lateral ankle, Ove and coworkers demonstrated that the posterolateral talar dome may be fully accessed via a medial malleolar osteotomy; however, this was without consideration for perpendicular access [57].

Ray and Coughlin [61] reported using Gatellier’s description of a distal fibular osteotomy [26] to access a posterolateral OLT. Ly and Fallat [51] and Draper and Fallat [18] also described this technique for improving access for surgical treatment of posterolateral talar OLTs. These authors describe an oblique fibular osteotomy that resembles the fracture pattern of a Weber B ankle fracture (Fig. 7.2a, b). With the osteotomy originating from the joint line and directed laterally and superiorly to exit in the lateral fibular cortex approximately 2–3 cm proximal to the joint line, the syndesmotic ligaments are preserved. The osteotomy is secured with lag screw(s) if possible and stabilized with a lateral neutralization plate; the screw holes may be predrilled prior to the osteotomy to facilitate anatomic reduction. Hansen [41] and Allen and DiGiovanni [6] described a fibular window to access the lateral talar dome. With this technique a 3 cm intercalated segment of fibula is osteotomized and reflected posteriorly on a soft tissue pedicle, thereby creating perpendicular access to the lateral talar dome, including the posterolateral articular surface. The anterior aspect of the interosseous membrane and anterior inferior tibiofibular ligaments need to be released to reflect the intercalated fibular segment. Upon completion of the cartilage procedure, the ligaments are repaired, and the osteotomy is stabilized with lateral plate fixation; the fibula may be predrilled prior to osteotomy to facilitate anatomic reduction, and a syndesmotic screw fixation may be considered to optimize stabilization.

Autologous chondrocyte implantation (ACI) traditionally requires an extensile exposure, occasionally necessitating lateral distal tibial or distal fibular osteotomy [27, 29, 32, 65]. Giannini and coworkers reported favorable outcomes using ACI for OLTs with long-term follow-up [27, 29]. The authors reported performing ACI for lateral OLTs through a lateral arthrotomy with fibular osteotomy but offer no detail of where on the talar dome the lateral lesion was located in the sagittal plane and provide little detail of the surgical exposure. Likewise, Schneider and coworkers accessed five lateral OLTs with fibular osteotomy to perform MACI but provided no specifics regarding exact location of the OLT in the sagittal plane or how the osteotomy was performed [65].

Structural allograft reconstruction generally requires extensile exposure. Several authors have published results of talar allograft reconstructions for voluminous OLTs [2, 35, 37, 38, 60]. Gross and coworkers’ series of nine patients only included medial talar allograft reconstructions [37]. Hahn and coworkers’ series included three lateral talar structural allograft reconstructions, including one posterolateral OLT reconstruction [38]. These authors reported using the fibular window technique described by Hansen and Allen and DiGiovanni [6, 41]. Raikin described three cases of lateral talar dome structural allograft reconstruction, exposing the lateral talar dome via an extensile anterior approach in two cases and a lateralized ankle arthrotomy with distal fibular osteotomy in the third case [60]. He used the anterior extensile approach to perform a hemi-talus reconstruction (entire replacement of talar dome in the sagittal plane) and the fibular osteotomy for a location-specific OLT to preserve uninvolved cartilage. Raikin did not provide detail of the specific technique for fibular osteotomy and did not define if the location-specific lateral OLT was posterolateral on the talar dome. Adams and coworkers reported using a distal fibular osteotomy for structural allograft reconstruction of a lateral OLT and also did not provide detail of the sagittal plane position of the lateral OLT or the specific technique used for fibular osteotomy [2]. Gortz and coworkers reported 6 of 11 structural allograft reconstructions being for lateral OLTs [35]. These authors performed all shell allograft reconstructions through an extensile anterior ankle approach, with joint distraction but without malleolar osteotomy (Fig. 7.3a, b). No specific detail was provided with respect to sagittal plane position of the lateral OLTs.

Giza and coworkers described performing matrix-induced ACI (MACI) for OLTs [33]. The investigators harvested cartilage from the margin of the OLT at the time of initial arthroscopic inspection/debridement, culturing the chondrocytes, imbedding the cells in a collagen membrane, and then implanting this graft into the prepared OLT via an arthrotomy at a second surgery. The authors enhanced exposure with ankle plantar flexion and a limited plafondplasty originally described by Assenmacher and coworkers [7] in which the anterior margin of the tibia is removed without damaging the native tibial cartilage. While the authors described treating lateral OLTs with this technique via an anterolateral arthrotomy without malleolar osteotomy, they did not include detail about the sagittal plane location of the lateral OLT and if posterolateral OLT could be accessed via this technique.

Recent reports suggest that juvenile allograft cartilage implantation may be an attractive alternative to osteochondral transfer and ACI [3, 13, 42, 48]. Juvenile allograft cartilage implantation does not require perpendicular access and may be implanted via relatively limited open approaches to treat OLTs failing to respond to primary arthroscopic management.

Giannini and coworkers reported that results for ACI or MACI performed arthroscopically may match those reported via the open technique [8, 28, 31]. The technique involves harvesting cartilage from the ankle during a first-stage arthroscopic inspection/debridement of the OLT, culturing these chondrocytes, embedding the chondrocytes in a scaffold, and then implanting the chondrocyte-seeded scaffold in the OLT during a second arthroscopy. The authors offer no detail regarding posterolateral OLTs being treated with this technique.

More recently, Giannini and coworkers presented a 4-year follow-up on patients treated with a one-step bone marrow-derived cell transplantation for OLTs [30]. The authors describe positioning the patient prone for bone marrow, aspirating bone marrow from the iliac crest, mixing the bone marrow concentrate with hyaluronic acid or collagen powder, and implanting the bone marrow “paste” in the prepared OLT arthroscopically. The authors note that nine lateral OLTs were treated by this method but do not offer detail about the location of the lateral OLTs in the sagittal plane.

Giannini and coworkers suggest that the arthroscopic ACI and MACI procedures carry less morbidity than their open technique [30, 31]. Magnan and coworkers also describe favorable outcome with a two-stage arthroscopic MACI technique for OLTs, using traditional arthroscopic techniques with the patient in the supine position [52]. These investigators treated seven centrolateral OLTs; their series did not include posterolateral OLTs. Early experience suggests that the juvenile allograft cartilage implantation may be performed arthroscopically [48]. Scholten and coworkers suggest that dedicated posterior ankle arthroscopy may allow better access to the posterior ankle than open techniques and affords a more rapid recovery [66]. Given that experience that has been gained in dedicated posterior arthroscopy, it seems that arthroscopic ACI, MACI, bone marrow-derived cell transplantation, and juvenile allograft cartilage implantation would lend themselves well to addressing posterolateral OLTs via posterior portals. This may be particularly applicable to the bone marrow-derived cell transplantation where Giannini and coworkers describe turning the patient supine to perform arthroscopic cell transplantation through traditional anterior portals after the patient is initially positioned prone for bone marrow aspiration [31].