Foot Ankle Clin N Am 9 (2004) 757 – 773

Avascular necrosis of the talus: current treatment options
Frank Horst, MDa,*, Brett J. Gilbert, MDb, James A. Nunley, MDb
Department of Orthopaedic Surgery, St. Josef-Stift Sendenhorst, Westtor 7, 48324 Sendenhorst, Germany b Department of Orthopaedic Surgery, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA

When considering osteonecrosis of the talus, it is convenient to classify the amount of bone that is involved by distinguishing small (osteochondral lesions), partial, and total involvement of the talus. The osteochondral lesion of the talus can be considered to be a partial osteonecrosis; its treatment options have been covered in other issues. A fracture of the talar neck can heal in the presence of avascular necrosis (AVN) of the talus [1,2]. This leads to a treatment algorithm (Fig. 1) that seems to be reasonable and practical and is based on what we know about the natural history of AVN of the talus. It makes sense to distinguish between early- and late-stage AVN—‘‘late’’ is more than 9 to 12 months after injury. In the late stages only a few options remain; one is arthrodesis and the other is talectomy. In the early stages it is important to notice whether the AVN developed secondary to a fracture. The Hawkins’ sign is the most helpful radiographic sign [1,3–5]; the MRI also is useful, but may be too sensitive to offer any prognostic value or assist in algorithms that are used for treatment. If subchondral atrophy in the talar dome is not present at 6 or more weeks after fracture (absent Hawkins’ sign) and the fracture has healed radiographically, the concern shifts to avoiding late segmental collapse of the talus. Creeping substitution of the talar body can take up to 36 months to complete [6]. Controversy exists concerning the best way

* Corresponding author. E-mail address: (F. Horst). 1083-7515/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.fcl.2004.08.001

Penny and Davis [2] concluded that weight bearing on a sclerotic and avascular talus poses no real danger for dome collapse. however. Treatment algorithm for AVN of the Talus. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 AVN early Without fx Progressive wb bonegraft Nonvascularized Allo or Auto Resolution Arthrodesis Fig. There is Fig. P/Nwb. late Arthrodesis Talectomy With fx P/Nwb until union PTB brace Core decompression Progression Vascularized to treat patients who have a healed fracture and an absent Hawkins’ sign that indicates AVN of the talar body. partial or no weight bearing. (A . revascularization occurs rapidly. it will proceed to a profound structural weakness within the trabecular bone and result in gross collapse of the talar dome. weight bearing. fx. fracture. patellar tendon–bearing brace. especially when the subsequent revascularization occurs slowly. . 2.758 F. PTB. If. wb.B ) PTB brace. 1.

whereas others propose protected weight bearing in a patellar tendon–bearing brace (PTB) (Fig.or partially weight bearing sufficiently. some investigators suggest nonweight bearing until fracture healing and until revascularization is complete [7–9].B ) preop. (A .2. 2A and B) and continuing to a complete resolution.F. the only symptom that helps us to move on in the algorithm is pain. Therefore. (C ) postop. 2A and B) until revascularization has occurred [10–12]. If the fracture is healed and there is no pain. The two best courses of the disease are spontaneous resolution or the wearing of a PTB (see Fig. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 759 no way to determine the period and speed with which the talus will revascularize. it has not been proven that nonweight bearing prevents talar collapse. the orthopedic surgeon has two options—core decompression and bone grafting. Poor results with AVN of the talus could not be correlated with the methods of treatment or time off from weight bearing [2]. they concentrate instead on treating the sequelae symptomatically [1.13]. 3. progressive weight bearing is accepted and is recommended (also for bone remodeling) [14]. A third group believes that it is impossible to keep the patients non. Fig. Therefore. Preoperative and postoperative radiographs of a patient who was treated with core decompression for AVN of the talus. If that does not occur. .

41 to 50]).0-mm drill we use 2 to 4 holes (Fig 3). July 2003). Typically. Most patients are treated with a PTB brace.0-mm drill to perforate the area of AVN.760 F. the patients are put in a short leg cast for 2 weeks and start range of motion (ROM) exercises after wound healing. The mean ankle score at the time of presentation was 34 points (range. partial weight bearing is allowed and is increased individually to full weight bearing. 2 to 75 points). The mean duration of symptoms before the patients were seen was 5.5. Core decompression techniques are used with pressure sensors in the humerus (C. other approaches are used (eg. radiographs were graded according to the Ficat and Arlet classification that was modified for the ankle. Rarely. which was useful in the treatment of precollapse (stage II) disease. MD. At a mean follow-up of 7 years (range. through small incisions with a little dissection). The remaining 29 ankles had stage II disease. personal communication. Basamania. a lateral or medial one. according to the system of Mazur et al [17]. Delanois et al [16] reviewed 37 ankles in 24 patients that were treated at their institution between July 1. In 1998. The Mazur grading system was used to assess function preoperatively and at final follow-up. whereas with the 4. 5 to 20) after core 2-mm drill or a 4. 1. and December 31. A radiographic review revealed—according to the system of Ficat and Arlet— that 8 ankles had stages III or IV disease of the talus at presentation. The surgeon will either use a small. The other three ankles required tibiotalar fusion at a mean of 13 months (range. Thirty-two ankles that remained severely symptomatic were treated with core decompression. It is easy to use the posterolateral approach between the peroneal tendons and the Achilles tendon. Results of core decompression Mont et al [15] reviewed 11 patients (17 ankles) who had had core decompression for symptomatic AVN of the talus before collapse. 2 to 14 years) 14 ankles (82%) had an excellent or good outcome (Mazur scores N80 points. 1996 for atraumatic osteonecrosis of the talus. 70% of patients have reduced pain and increased motion and would be considered to have a good result. pain scores N40 points [range. It is only recommended in stages I and II AVN of the talus. The investigators concluded that core decompression is a viable method of treatment for symptomatic AVN of the talus before collapse.4 months (range. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 Technique of core decompression The theory behind core decompression—to decrease intraosseous pressure and to enhance revascularization—is well-known and will not be discussed in this article. 1974. 2 months to 2 years). After 6 weeks. Postoperatively. With the small drill we prefer several holes (8–10). This could be transferred to the talus easily and a pressure-guided and more focused decompression could be possible. Twenty-nine of these ankles had a fair to excellent clinical outcome at a .

Early detection may allow the ankle to be treated nonoperatively or with core decompression. Postoperatively. 7). 5 is taken from a 48-year-old male smoker who had no significant past medical history and presented with left ankle pain. There are no long-term results with large bone substitutes and no personal experience.or allograft and vascularized pedicle or free autograft. Sagittal (A ) and axial (B ) MRI 1 year after core decompression for AVN of the talus. 6A–C). In cases of increasing pain when weight bearing is progressed. followed by the allograft (eg. Postoperatively. Three ankles were treated initially with an arthrodesis for postcollapse (stages III or IV) disease. His radiologic studies revealed subtotal AVN of the talus. We used a tricortical iliac crest bone graft as a scaffold and cancellous bone graft after excising the necrosis (Fig.F. mean of 7 years (range. Because of his increasing symptoms we decided to treat him surgically. it is considered to be resolved. 5 to 9 months) postoperatively. they are scheduled for reassessment every 3 months (Fig. the patient was nonweight bearing for 6 weeks and then started . the rest was filled with cancellous bone graft. When patients who have a history of osteonecrosis are seen because of pain in the ankle. 4). Fig. If there is no segmental collapse and no pain. If the pain resolves after core decompression and the patient is full weight bearing. Nonvascularized autograft The nonvascularized autograft from the iliac crest probably is the most widely used bone graft. the diagnosis of osteonecrosis of the talus should be considered. 4. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 761 Fig. The approach was a lateral one with a fibula osteotomy (Fig. Four types of bone graft generally are available for these cases—nonvascularized auto. 2 to 15 years) postoperatively. the remaining 3 ankles had an arthrodesis after the core decompression failed. He had been treated nonoperatively for 6 months. reduce the need for arthrodesis. bone grafting is the next reasonable option. femoral head). and thus. All 6 of the ankles that had an arthrodesis fused at a mean of 7 months (range. talus.

Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 .762 F.

that is very expensive. The patient mostly was painfree. Two years later the patient returned to the office with a reduced pain level and no segmental collapse. This requires the availability of a fresh tissue lab or the surgeon is forced to buy an allograft. the MRI is disappointing because it seems that large areas of osteonecrosis remain and revascularization is incomplete. although he had intermittent painful episodes. The following case is a 34-year-old basketball player who presented with a large Osteochondral Defect (OCD) of the talus that was considered to be partial necrosis. based on availability and cost. The allograft was fixed with two screws that were placed subchondrally (Fig. The patient presented with persistent severe pain to his left ankle 1 year later. Anteroposterior radiograph (A ) and coronal MRI (B ) of subtotal AVN of the talus. it was placed exactly into the defect after fibula osteotomy and open debridement. Two years later we performed an MRI (Fig. and no segmental collapse. So far there had been a reduction in pain. the screw was removed. 8). slight improvement of ROM. Sagittal radiograph (C ) and MRI (D ) of subtotal AVN of the talus. 5. 9). Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 763 Fig. After 4 months. especially after exercising. 5 (continued ). however. In addition. Initial treatment consisted of arthroscopic debridement and refixation with a small screw. The option of taking an allograft is not available to every surgeon or patient. . At first glance. there are no long-term results for talar Fig.F. a talar allograft may be the only option. creeping substitution may take up to 36 months. protected partial weight bearing in a Controlled Ankle Motion (CAM) walker with ROM exercises. It was decided to proceed with a talar allograft from the Duke University Medical Center Fresh Tissue Laboratory. Nonvascularized allograft If smaller parts of the talus are necrotic and mainly involve the articular surface.

. 6. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 Fig.B.764 F.C ) Insertion of tricortical bone graft into necrotic defect in the talus through a lateral window. (A.

Giebel et al [20] looked at the extraosseous blood supply to the tibia. Gelberman and Mortensen [19] studied the extraosseous and intraosseous blood supply of the talus in 1983. allograft survival rates in larger numbers of patients.F. To improve operative incisions for talar fracture treatment. fibula. Further . Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 765 Fig. with a new chemical debridement technique. which is considered to be the most important factor for remodeling of the talus. and talus. 7. Vascularized bone graft Mulfinger and Trueta [18] published a complete analysis of the talar circulation in 1970. Final intraoperative situs after closing the window (A ) and postoperative radiograph (B ). There are no data on revascularization.

studies looked at the blood vessels in the sinus tarsi [21]. they were able to identify a Fig.B ) Postoperative radiographs after talar allograft. 8. (A. . In 1989. Through this study. Gilbert et al [25] studied 14 fresh-frozen cadaver lower extremities with injection of Batson’s compound and bone clearing with a modified Spalteholz technique. Coronal (A ) and sagittal (B ) MRI 2 years after scaffolding.766 F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 Fig. Hussl et al [24] reported a vascularized bone graft from the iliac crest that was used for revascularization of the talus in posttraumatic AVN in a 16 year-old patient. In 2001. 9.23]. the blood supply to the calcaneus [22. A second group of specimens was injected with Ward’s red latex to dissect potential new rotational vascularized pedicle bone grafts.

1 cm long and can be rotated even to the medial malleolus (Fig. The identification of these new rotational vascular pedicle bone grafts could help the foot and ankle surgeon to treat some patients who have AVN of the talus. The fourth potential vascular pedicle was a transverse segment of the anterior lateral malleolar artery to the lateral malleolus. 10. 10). . cuboid.B ) Proximal lateral tarsal artery with the cuboid pedicle and its range. This is a short pedicle that can be used for navicular pseudarthrosis but is too short for the talus. the same is true for the next pedicle of the transverse branch to the third cuneiform off the distal lateral tarsal artery (Fig. The first cuneiform was found to be supplied by the middle pedicle branch of the distal medial tarsal artery. The transverse pedicle branch of the proximal lateral tarsal artery reached and supplied the cuboid in every specimen. The proximal lateral tarsal artery with the cuboid pedicle is approximately 4. The pedicle also is approximately 4 cm long but usually is an extremely small vessel.F. A few patients who had AVN of the talus were treated with a vascularized bone Fig. 11). Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 767 consistent blood supply to the distal fibula. (A. Basically. and cuneiform I and III with reliable nutrient arteries.

ankle arthrodesis. Special circumstances. 11. the surgeon performs an anterior synovectomy and debridement of the ankle with a full radius shaver. and posterolateral portals. The medial and lateral gutter also are denuded to expose bleeding subchondral . 08 to 58 of hindfoot valgus. there are surgical principles to be followed (eg. medial. at the Duke University Medical Center. tibiotalocalcaneal arthrodesis). There are no long-term results yet. In general. If there is no or little malalignment of the ankle joint. Salvage procedures/arthrodeses What are the options if the aforementioned methods do not work? There are several salvage possibilities (eg. All of these arthrodeses are disabling to the patient. Vascularized pedicles of the distal lateral and medial tarsal artery to the first and third cuneiforms. generally. Then the articular surfaces are denuded of cartilage with the periosteal elevator followed by a power burr. and 58 to 108 of external rotation with the talus translated posteriorly [26–29]. it is possible to perform an arthroscopic ankle arthrodesis [30]. Nunley. the patient is left with a pronounced gait abnormality and the expectation for arthritis in the surrounding joints over time. Although they may revascularize the body of the talus to some extent. the talus should be positioned exactly under the tibia. creating broad. If possible. It is recommended to place the ankle in neutral dorsiflexion/plantarflexion. MD. congruent cancellous bone surfaces and stabilizing with rigid internal fixation). Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 Fig. Using the anterolateral. Many techniques can be used that combine a preferred approach with a preferred method of arthrodesis and fixation. might necessitate alteration of a preferred approach or require the use of different fixation techniques. The surgeon always should examine the contralateral side for individual modifications in position.768 F. subtalar arthrodesis. however. graft by James A. but the surgeries were promising. the hindfoot is realigned with the leg and the foot is positioned plantigrade.

There is a moderate risk of an anterior stress fracture of the tibia. while maintaining the contour of the bony surfaces. Two parallel interfragmentary compression screws are inserted from the sinus tarsi into the tibia with the screw tip engaging the medial tibial cortex. rheumatoid arthritis.F.5-mm screws. Morris [34] modified Blair’s technique by placing a screw in the tibial inlay and using a longitudinal Steinmann pin. Lionberger et al [33] reported a 28% pseudarthrosis rate and fibrous ankylosis secondary to prolonged immobilization. Patterson et al [35] described a technique with an anterior sliding graft to provide fixation and fusion. With this technique it is possible to perform additional iliac crest grafting. and an increased union rate because of the minimal interruption of the surrounding soft tissue with subsequent better blood supply. After positioning the ankle in the desired position. The advantages and disadvantages correspond with the ones of the arthroscopic technique. They used an anterolateral approach and limited the periosteal elevation to the anterior aspect of tibia in the region of the graft site. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 769 bone. cannulated. Internal or external fixation in situ is accomplished by two or three percutaneous. vascular disease. Several investigators have offered modifications of the open technique. The screw heads are . The advantages of this method are less blood loss. They did not propose to maintain joint shape but preferred two matched parallel cuts on the distal tibia and the talar dome. 5 cm long) is cut out with a saw and removed. The main disadvantages are that deformities cannot be corrected if they are more than a few degrees and severe bone deficiencies cannot be addressed well [31].to 2-cm incision. The mini-open technique is similar to the arthroscopic technique but the portals are extended to an anterolateral and anteromedial 1.5. or noncannulated. the quadrilateral area in the talar dome is marked through the tibial defect with the talus positioned posterior in the tibia plafond. this allows good joint visualization. The technique that was proposed by Mann and Rongstad [36] in 1998 includes a transfibular approach with resection of the distal fibula.5-mm screw is inserted from the posterior medial malleolus directed anteriorly and one 6. This is especially necessary to correct massive malalignment or angular deformities. there are fewer complications in patients who have compromised healing potential (eg. Simin et al [32] described a technique with a distal tibial inlay graft without fixation that may be used as a primary or secondary salvage procedure. It is important to close the anterior capsule meticulously. a shorter time to union.5-mm screw is inserted from the anterior lateral tibia into the posterior talus. The postoperative treatment includes 6 weeks of nonweight bearing and 6 weeks in a short leg cast with weight bearing as tolerated.5 cm depth. 1. They developed a modified Blair fusion and suggested using a pediatric hip compression screw and a modified Stone staple for fixation.2 cm wide. diabetes. The anterior tibial graft (1. The bone is removed from the talus in a plantarflexed position. One 6. cancellous screws that are parallel or converging. history of corticosteroid use. Furthermore. The joint is debrided of cartilage and fibrous tissue while maintaining its shape. previous skin or soft tissue flaps). The tibial graft is implanted and fixed with two 4.

Another described technique is the ‘‘Insitu dowel grafting’’ method. A partial or total resection of the medial malleolus may be necessary. Kirschner wires or vertical Steinmann pins do not provide compression. Rarely does the surgeon need to augment with medial staples.5-mm screws. After drilling all surfaces to enhance osteoblast/cyte ingrowth. the surgeon can use different external fixators (eg. At the end we insert the autologous bone graft from the excised medial one half of fibula to front and back and fix the lateral part of the fibula onto the fusion site with one or two 4. however. It is important to check the peroneal tendons so that they do not sublux. either with allograft or the iliac crest. two parallel screws provide less stability than crossed screws [37]. In cases of total resection. Staples only should be used as a supplement [31]. the ankle is positioned correctly and fixed with three 6. Resection of the fibula allegedly interferes with proper blood supply and subluxation of the peroneal tendons. In certain cases of severe osteoarthritis or joint destruction or in salvage procedures it may be necessary to use an anterior plate that is bent accordingly to hold the joint in the desired position. The arthrodesis usually does not require bone grafting. This technique usually results in greater shortening and the lack of the medial and lateral malleolus provides less stability than with other techniques. monoplanar. an additional screw or another fixation device should be considered.5-mm screws in tibia)—with the crossed screw fixation (6. a large or small fragment T-plate is applied to the lateral side (compression type) or a pediatric 908 osteotomy compression plate can be used [38]. it allows for the greatest correction of angular deformities [31]. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 buried in the sinus tarsi. which consists of using a rotated bone plug in patients who have rheumatoid arthritis or painful. multi-planar) or plate fixation.5 mm) [39].770 F. the arthrodesis is fixed with a 908 osteotomy plate and the blade is in the talus. cuneiforms.0-mm cancellous screws. Screw purchase is obtained in the tibia and the dorsal foot (talus. The disadvantages include disruption of the sinus tarsi and difficult placement of the screws. With flat surfaces it can be difficult to align the joint properly. Our preferred open method includes a lateral approach with subperiosteal dissection of the tibia and talus from the lateral side. This technique results in slight limb shortening of approximately 4 mm to 9 mm but rarely are there any problems with the peroneal tendons. The other possibility is to use a double T-plate fixation—that is stronger than the fibular strut fixation (lateral fibular strut fixed is with two 4. cuboid. The deltoid arterial blood supply to the medial talus is preserved. or metatarsals). starting with the posterolateral one. The cartilage is removed from all surfaces of the tibia and talus. navicular. The posterior plate requires a posterior approach. This technique includes using a hollow trocar to create a plug of bone that is approximately 8 mm in diameter and is cut across the ankle parallel to the joint surface. . The plug is then rotated 908. Besides fixing the arthrodesis site with screws. If using a lateral plate. This fixation method often includes bone grafting. nondeformed ankles.

the foot is allowed dorsiflexion/plantarflexion of 108 to 268 [40. As with every surgical procedure there can be an infection (eg.43]. the complication that is noted most often is the literature is nonunion. or even a plate. Horst et al / Foot Ankle Clin N Am 9 (2004) 757–773 771 The patient is usually kept nonweight bearing for 12 weeks and then is allowed to increase weight bearing with a removable upright walking boot [36].41]. Some investigators advocate 4 to 6 weeks of nonweight bearing and then weight bearing is progressed. some patients may benefit from an orthotic or even a double-upright brace with a locked ankle and solid ankle cushion heel to compensate for heel–ground contact. In cases of fusion with bone graft after failed Total Ankle Replacement (TAR). in cases with bone loss with fibular bone graft or iliac crest. The plastic surgeon may need to be involved to cover larger skin defects with musculocutaneous flaps (local or free). social integration. are possible. which may occur in up to 40% of cases. Increased stress in adjacent joints could lead to the need for extension of the arthrodesis in the long-term. Complications in ankle arthrodesis Complications are not rare. For a limited time after surgery. Revision arthrodesis for tibiotalar pseudarthrosis is a worthwhile procedure [42. pin tract. A rocker-bottom sole helps to translate the tibia over the foot [31]. wound. Unprotected weight bearing is allowed only after bone trabeculation is seen across the arthrodesis site. hip. dehiscence. occupation. and spine. knee. an intramedullary nail. It is important to address postoperatively a possible leg length discrepancy and the tendency to rotate the hip externally. large slabs of iliac crest graft usually are needed for reconstruction. . osteomyelitis. even with proper positioning of the fusion.F. A double plate fixation or anterior plate. and soft tissue irritation during surgery. In the case of large bony defects in failed arthroplasty. In any case. Nonunions might cause subtalar involvement so that in revision surgery that joint has to be addressed additionally and also be fused with screws. sepsis) or a talar or tibial fracture (eg. Besides wound problems that are due to hematoma. The ideal position for pantalar arthrodesis is approximately 58 of valgus. If an arthrodesis malunion occurs. the patient will be kept nonweight bearing for 4 to 6 months until there is evidence of bone union through the massive bone graft. several sequelae can follow. The need for a Below the Knee Amputation (BKA) is rare [26]. After ankle arthrodesis. an external fixator. Other complications include overresection of subchondral joint surfaces with excessive shortening of the leg and delayed union that may require the use of an internal or external bone stimulator. Patients compensate and try to facilitate the stance phase of their gait with external rotation of their ipsilateral hip. and compliance. distal anterior tibial stress fracture after anterior sliding graft technique). an individual postoperative treatment is necessary according to the patient’s habits. including increased stress on other structures in the foot.

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