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ARTHROSCOPIC TREATMENT FOR OSTEOCHONDRITIS
DISSECANS OF THE TALUS IN ADOLESCENTS. A REVIEW
OF 18 CASES.
I. VILALTA, R. ULLOT, E. PLANES, S. CEPERO
CHIEF RAMON HUGUET
HOSPITAL SANT JOAN DE DÉU
BARCELONA - SPAIN
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INTRODUCTION

• Its uncommon that the pathology of the ankle
  can be managed arthroscopycally in children and
  adolescents.
• This technique has been used in our service
  since 1996, being osteochondritis dissecans of
  the talus the most frequent pathology treated
  with 18 cases.

• Osteochondritis dissecans of the talus consists
  of an osteochondral defect located at level of
  the talar dome.
• The first description of this condition was made
  by Konig in 1888 in relation to lesions involving
  the knee, but it was not until 1922 that Kappis
  described the first case of osteochondritis
  dissecans of the talus, considered at the present
  time as the third more frequent anatomical
  location of this condition.

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INTRODUCTION

• The ethiology of the lesion still remains
  unknown. Different hypothesis exist on its causal
  agent endocrine factors, cartilage development
  disturbances, genetic alterations, etc.
• Posteromedial lesions of the talar dome are
  usually asymptomatic deep dome-shaped lesions,
  and the patient may not have a past trauma
  history. On the other hand, injuries involving
  the anterolateral aspect of the talar dome are
  more symptomatic and usually are secondary to a
  traumatic mechanism of inversion and dorsiflexion
  of the ankle.

• Osteochondritis dissecans of the talus is
  relatively frequent in the adult, but there are
  only a few cases described affecting children and
  adolescent patients showing a higher prevalence
  in boys.

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INTRODUCTION

• The first arthroscopic treatment of these
  lesions was carried out in 1982. Since then, the
  advances in arthroscopy techniques as well as in
  the diagnostic imaging techniques (CT-SCAN and
  MRI) allow better results in the surgical
  treatment of the osteochondritis of the talus.
• The aim of this study is to confirm that
  osteochondritis dissecans of the talus should be
  treated by arthroscopic drilling rendering
  excellent results and avoiding the potential
  complication of open surgery techniques.

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MATERIAL AND METHODS

• 18 patients (age range 10-17) were treated for
  an osteochondral defect of the talus by
  arthroscopic drilling in our service during the
  period from 1996 to 2006.
• There were 9 boys and 9 girls. The right talus
  was involved in 13 patients while the left talus
  was affected in 5 cases. 70 of the cases were
  associated to a previous trauma. 5 patients were
  affected in contralateral talus but with
  asymptomatic lesions. That is to say 25
  osteochondritis.

• All patients the clinical outcome was painful on
  the anteromedial side of the ankle.
• The 18 cases were diagnosed by means of plain
  films.

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MATERIAL AND METHODS

• CT-SCAN confirmed the diagnosis, and at the same
  time helped to localize and determinated the
  extension of the lesion.
• According to the Berndt and Harty
  classification 4 patients had a grade lesion I,
  7 patients had a lesion grade II and 7 patients
  had III, no patient presented grade lesion IV.
• We indicated arthroscopic treatment in cases of
  painful ankle, with a positive X-ray and CT-Scan
  showing persistent symptoms after 6 months of
  non-sporting physical activity.

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MATERIAL AND METHODS

• For the arthroscopic technique we used 2
  portals anteromedial and anterolateral. Drilling
  was carried out with a Kirschner wire, and if it
  was necessary for regularization purposes with a
  drill. In any case ankle arthrotomy was required.
• Postoperatively a bandage was used during 8
  15 days (mean 10,11 days).
• Non-weight bearing was maintained for 2-3
  months full weight-bearing was reengaged 3 4
  months postop.
• Return to sporting activities took place at the
  6 months postoperatively, except in the case of
  sports with pivotage, in which was delayed until
  9 months.

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RESULTS

• The follow-up period ranged from 1 to 10 years.
• Clinical and radiological aspects were
  evaluated. CT-Scan was performed on a yearly
  basis. Our 18 patients obtained a final excellent
  result according to the scale of Ogilvie-Harris
  absence pain, swelling, rigidities and limp, and
  all had a full ankle range of motion at the final
  follow-up.
• All patients returned to their habitual activity
  at 9 months of the surgery.
• A one year postoperative CT-Scan was performed
  showing healing of the osteochondritic are in all
  patients.
• Regarding complications, we had a case of
  osteoporosis that was resolved after weight
  bearing was initiated. We did not find any case
  of infection, hypoesthesia, hemartrhosis,
  hardware breakage or vascular injury.

30-4-97
21-11-97
15-6-99
10-10-00
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DISCUSSION

• Osteochondritis dissecans of the talus is an
  infrequent condition among children.
• Just a few reports in the medical literature
  describe its apparition in children.
• Although plain films are useful for the initial
  diagnosis, CT-Scan offers a better topography of
  the injury and its really useful to determine
  the extension of the affected area and the depth
  of the lesion.
• We would like to highlight the role of
  arthroscopy as a surgical technique allowing an
  appropriate visualization of the joint and
  avoiding the potential complications of the open
  surgical techniques, being also a technique that
  could be carried out in an ambulatory way .

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CONCLUSIONS

• Osteochondritis of the talus is rare in
  adolescents, its important to keep this
  condition in mind in front of a patient
  complaining of chronic pain in the ankle.
• We consider that osteochondritis of talus must
  be treated surgically in those adolescents who
  still complain of persistent symptoms after a
  reasonable period of avoidance of physical
  activity.
• Ankle arthroscopy is a valid technique for the
  treatment of the adolescents osteochondritis
  dissecans of the talus. In our series, the
  results have been excellent.

BIBLIOGRAPHY

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