Consequently, injury to a por-tion of the talus may lead to degen-erative changes of the articular sur-faces and subsequent loss of range of motion ROM.1The talus has a lim-ited reparati
Trang 1Aaron K Schachter, MD, Andrew L Chen, MD, MS, Ponnavolu D Reddy, MD, and Nirmal C Tejwani, MD
Abstract
Early accurate diagnosis of
osteochon-dral lesions of the talus is important
because optimal ankle joint function
requires talar integrity.1 Boyd and
Knight2showed that the tibiotalar
ar-ticulation is subjected to more load per
unit area than any other joint in the
body Consequently, injury to a
por-tion of the talus may lead to
degen-erative changes of the articular
sur-faces and subsequent loss of range of
motion (ROM).1The talus has a
lim-ited reparative capacity because a large
portion of it is covered by articular
cartilage, which limits the vascular
supply.3-6
Osteochondral fractures refer to
le-sions affecting the articular cartilage
of the talar dome and the underlying
subchondral bone.7Originally
refer-red to as “osteochondritis dissecans,”
these lesions were thought to be
is-chemic.8 Subsequent studies have
shown that, in most cases, these
injuries are sequelae of previous
trauma.7,9-13Moreover, the results of
these studies showed that the
lo-cation of the lesion could be
pre-dicted, based on the mechanism of injury
Etiology and Epidemiology
Fractures of the talar body account for approximately 1% of all fractures in the human body.14A large proportion
of these are transchondral or com-pression fractures of the talar dome, which are often unrecognized be-cause frequently they are associated with other, more obvious injuries to the foot and ankle Alexander and Lichtman11observed that 28% of these injuries were associated with other fractures These coexisting fractures, approximately half of which involve the ankle malleoli, may overshadow
a significant osteochondral defect of the talus.1Similarly, Van Buecken et
al15 reported that these injuries (ie, transchondral talar fractures) were as-sociated with 6.5% of ankle sprains
Berndt and Harty7found that 57% of talar dome lesions were located me-dially and 43% laterally Others have
reported a fairly equivalent distribu-tion9(Fig 1)
In a series of 70 patients (71 frac-tures), all lateral talar dome injuries were associated with a traumatic event, whereas only 64% of medial ta-lar dome injuries were attributed to trauma.10Others have corroborated these results, reporting that all
later-al lesions were associated with
trau-ma (Fig 1, B and C) but only 82% of medial lesions were11(Fig 1, A) Al-though trauma usually is the cause
of injury, it may not be a single event but may consist of a series of
repeat-ed, less intense injuries.12In a com-prehensive review of published stud-ies of 500 patients, Flick and Gould13 reported that a history of trauma was present in 98% of lateral dome lesions
Dr Schachter is Resident, Department of Ortho-paedic Surgery, NYU–Hospital for Joint Dis-eases, New York, NY Dr Chen is in private practice, Littleton, NH Dr Reddy is Fellow, Department of Orthopaedic Surgery, NYU–Hos-pital for Joint Diseases Dr Tejwani is Associate Professor, Department of Orthopaedic Surgery, NYU–Hospital for Joint Diseases.
None of the following authors or the departments with which they are affiliated has received anything
of value from or owns stock in a commercial com-pany or institution related directly or indirectly
to the subject of this article: Dr Schachter, Dr Chen, Dr Reddy, and Dr Tejwani.
Reprint requests: Dr Tejwani, Bellevue Hospital–
NB, 21 W 37, 550 First Avenue, New York, NY 10016.
Copyright 2005 by the American Academy of Orthopaedic Surgeons.
Osteochondral lesions of the talus occur infrequently and usually represent late
se-quelae of ankle trauma Because of the functional significance of the talus and its
limited capacity for repair, correct early diagnosis is important Osteochondral
frac-tures should be suspected in patients with chronic ankle pain, especially those with
a prior ankle injury Historically, plain radiographs have been used to stage lesions;
more recently, magnetic resonance imaging and arthroscopy have been used
Non-surgical management remains the mainstay of treatment of acute, nondisplaced
os-teochondral lesions Surgical management is reserved for unstable fragments or
fail-ure of nonsurgical treatment Recent advances in osteochondral grafting have allowed
reconstruction of the talar dome, leading to more predictable relief of pain and
im-provement of function.
J Am Acad Orthop Surg 2005;13:152-158
Trang 2but in only 70% of medial dome
le-sions Persistent ankle pain in the
ab-sence of any recognized trauma should
heighten suspicion of a talar
osteo-chondral lesion
Mechanism of Injury
Berndt and Harty7originally described
two possible mechanisms for
osteo-chondral fractures of the talus
Com-pressive injury to an ankle positioned
in dorsiflexion and inversion (eg, a
di-rect tibiotalar impact) may crush the
subchondral bone of the lateral talar
dome, with or without overlying
car-tilage damage Alternatively,
subject-ing the plantarflexed ankle to impact
forces of inversion and external
rota-tion can produce osteochondral
inju-ries to the medial talar surface O’Farrell
and Costello16also suggested that the
medial talar osteochondral lesion is
caused by a combination of inversion
with plantar flexion Other mechanisms
thought to account for lesions in other
locations17include impaction of the
dome against the lateral malleolus,
re-sulting in lateral dome lesions, or
against the posterior tibial lip,
result-ing in medial defects.7,18
Classification
In 1959, Berndt and Harty7proposed
a staging system based on
radio-graphic findings: stage I, small area
of subchondral bone compression;
stage II, osteochondral fragment par-tially detached; stage III, osteochon-dral fragment completely detached but not displaced; stage IV, osteo-chondral fragment completely de-tached and displaced Other grading systems based on more recent radio-logic techniques also have been de-scribed For example, Anderson et
al19and Ferkel et al20used magnetic resonance imaging (MRI) to classify talar osteochondral injury
With interest in and use of ankle arthroscopy increasing, some have questioned the accuracy of classifica-tion based solely on plain tomogra-phy Pritsch et al21graded lesions ac-cording to articular injury visualized during ankle arthroscopy, ranging from grade I (intact appearance) to grade III (frayed appearance) The au-thors found that radiographic and ar-throscopic findings correlated
poor-ly Fifty percent of lesions classified
as stage IV according to the Berndt and Harty system were found to be intact viewed through the arthroscope
However, direct visualization of an in-tact articular surface does not permit the underlying bone to be examined;
thus, the extent of a bony lesion may
be underestimated Pritsch et al21 em-phasized that treatment protocols should be based on the integrity of the articular cartilage and that plain radiographs may not necessarily show
the critical elements of talar osteochon-dral injury This concept under-scores that MRI and ankle arthroscopy have the potential to play important roles in the evaluation of these injuries
Clinical Evaluation
The first step in assessing ankle pain should be a meticulous clinical eval-uation to differentiate among the many potential diagnoses, including liga-mentous injury, fractures of the fib-ula, and fractures of the tibial plafond
In patients with acute injury, the an-kle and foot may be swollen and pain-ful, limiting the specificity of the ex-amination Nonetheless, the ankle and foot should be palpated to identify any discrete locations of tenderness A careful neurovascular assessment is also essential ROM of the injured an-kle and hindfoot should be compared with ROM in the contralateral lower extremity Testing for instability should
be performed, including an anterior drawer test with the ankle in both plantar flexion and dorsiflexion The ankle also should be subjected to inversion and eversion stress testing Although ankle sprains are more common than osteochondral injuries
of the talus, talar osteochondral
inju-ry should be included in the differ-ential diagnosis of chronic ankle pain The index of suspicion for talar osteo-chondral injury should be high in the
Figure 1 Plain radiographs of posttraumatic osteochondral injuries (arrows) A, Mortise view of a medial injury B, Anteroposterior view
of a lateral lesion of the talus C, Oblique view of a lateral lesion of the talus.
Trang 3setting of ankle pain without any
rec-ognized trauma or with persistent
an-kle pain after an acute injury has
re-solved
Radiographic Evaluation
Plain Radiography
Standard radiographic views of the
ankle should be obtained, including
anteroposterior, lateral, and mortise,
with weight bearing if possible Canale
and Kelly10proposed that the talar
pro-file may be visualized better with an
ankle radiograph made with 15° of
foot pronation and with the tube
an-gled 75° cephalad Nonstandard
pro-jections that allow further elucidation
of the talar profile include the
mor-tise view of the ankle in plantar
flex-ion to visualize posteromedial lesflex-ions
and stress views to detect
ligamen-tous laxity DeLee22suggested that
ra-diography cannot identify
cartilagi-nous defects or grade I (nondisplaced)
lesions The inability of plain
radiog-raphy to visualize nonosseous
struc-tures limits its usefulness.10
Computed Tomography
Computed tomography (CT) allows
the integrity of the subchondral bone
to be assessed in multiple planes, and
CT is often invaluable in preoperative
planning10,23(Fig 2) However, CT is
limited in its ability to visualize
cer-tain osteochondral lesions, especially
cartilaginous or nondisplaced (grade
I) lesions In comparing the use of CT
and MRI to evaluate possible
osteo-chondral talar defects identified by
bone scintigraphy, Anderson et al19
re-ported that, although CT and MRI were
90% concordant in identifying lesions
visible by plain radiography, CT was
capable of identifying only 4 of 14
le-sions that were not evident on plain
radiographs (stage I), whereas MRI
demonstrated all 14
Bone Scintigraphy
Anderson et al19examined the role
of bone scintigraphy in the evaluation
of patients with posttraumatic ankle disability, reporting a 57% incidence
of osteochondral defects of the talar dome, despite normal appearance on radiography The authors found bone scintigraphy to be useful in evaluat-ing ankle injuries when radiographs appear to be normal but suggested that a positive bone scan be followed
up with MRI Urman et al24 found that when bone scans showed abnor-mal uptake in the talar dome on at least one view, the scan was 94% sen-sitive and 96% specific for osteochon-dral injury
Magnetic Resonance Imaging
MRI allows multiplanar evalua-tion and offers the advantage of
vi-sualizing the surface of articular car-tilage and subchondral bone as well
as edema and other features of the surrounding soft tissue (Fig 3) MRI also allows early subchondral dam-age (stdam-age I lesions) to be
detect-ed.25,26In one study,19MRI allowed grade I osteochondral lesions to be identified correctly in all 14 patients who had had abnormal results on bone scintigraphy MRI findings also have been found to correlate closely with visual findings during arthros-copy.20
Radiographic Protocol
Stone27proposed a radiographic protocol for evaluating osteochondral lesions of the talus Plain radiography
Figure 2 Computed tomography scans of a medial talar osteochondral lesion A, Coronal view demonstrating extent of the lesion B, Axial view showing the medial malleolar lesion
(arrow).
Figure 3 MRI scans of an ankle A, Sagittal T2-weighted scan demonstrating an anterior talar dome lesion B, Coronal T1-weighted scan demonstrating a medial talar dome defect.
Trang 4should be used for initial evaluation
of patients presenting with acute
an-kle injury with hemarthrosis or with
significant tenderness at the bony
landmarks of the ankle Any
osteo-chondral lesion identified should
then be evaluated with CT to
deter-mine the size, shape, location, and
de-gree of displacement Persistence of
pain despite normal appearance on
plain radiographs warrants further
investigation, such as MRI or bone
scintigraphy The MRI scans should
be scrutinized for associated injuries
(eg, ligamentous disruption) that may
be responsible for, or contribute to,
persistent ankle pain
Treatment
Nonsurgical
Generally, nonsurgical treatment
in-volves an initial period of no weight
bearing with cast immobilization,
fol-lowed by progressive weight bearing
and mobilization to full ambulation
by 12 to 16 weeks.1Berndt and Harty7
found that, after acute osteochondral
injury, nonsurgical treatment with
im-mobilization nearly always resulted
in healing Many authors have
sug-gested that the decision to operate
should depend on the grade of the
le-sion Berndt and Harty grade I and
II lesions should be managed
non-surgically for up to 1 year to allow
for resolution before resorting to
surgery.9,11,15,27-29Nevertheless, a
meta-analysis of 14 studies with a total of
201 patients showed only a 45%
suc-cess rate of nonsurgical treatment of
grade I, grade II, and medial grade
III talar osteochondral lesions (not all
injury types were specified).30
Non-surgical treatment of chronic lesions
had a success rate of 56%.30Shelton
and Pedowitz29reported just 25%
sat-isfactory results for nonsurgical
treat-ment of grade II and III lesions
Surgical
Failure of nonsurgical
manage-ment or the presence of advanced
grade III or IV lesions often necessi-tates surgical intervention
Excision, Drilling, and Curettage
Excision may be done with either open or arthroscopic techniques Ex-cision of the subchondral fragment and curettage of the lesion’s surface
is done to remove debris, fibrous tis-sue, or devitalized cartilage This pro-cedure has been recommended in the treatment of chronic lesions and le-sions with necrotic material.22 Vascu-lar access channels are then created
in the underlying subchondral bone using an awl, drill, or arthroscopic shaver This allows marrow elements
to migrate into the site of injury and produce fibrocartilage to cover the le-sion.1,27,30,31
Generally, arthroscopic excision and drilling can be done as outpatient pro-cedures They are associated with fa-cilitated rehabilitation, a quick return
to normal function, and minimal wound-healing complications.27 Trans-articular drilling may be indicated in the treatment of a symptomatic os-seous lesion underlying an intact car-tilaginous surface.27However, expo-sure can be limited by the topography
of the joint as well as by the diffi-culty in reaching posterior lesions through standard anterior portals
Transarticular drilling is also user de-pendent and requires specialized equipment and arthroscopic instru-ments
Results of excision and drilling have been encouraging compared with those of nonsurgical treatment In a review of 16 studies with a total of
165 patients, Tol et al30found excision, curettage, and drilling to have had good to excellent results in 88% of pa-tients with grade III and higher lesions
However, simple excision and curet-tage without drilling (9 studies, 111 patients) had a success rate of 78%, whereas excision alone (5 studies, 63 patients) had a success rate of 38%.30 The success rate of excision alone has been shown to be lower than that of nonsurgical treatment (45%).32
Internal Fixation
Internal fixation of osteochondral lesions may be done using a variety ofmethods,includingscrews,Kirsch-ner wires, and bioabsorbable
devic-es.33,34DeLee22proposed that internal fixation is indicated when the injury occurs acutely and the fracture is
larg-er than one third the size of the re-spective dome Stone27suggested that the lesion should be at least 7.5 mm
in diameter and that the patient be young for surgical fixation
The surgical approach is determined
by the location of the lesion Lesions
on the lateral aspect of the talar dome may be approached using either an anterolateral or posterolateral approach; anteromedial lesions may be accessed through an anteromedial approach Posteromedial lesions may require os-teotomy of the medial malleolus for adequate exposure Tochigi et al35 sug-gested using an anterolateral tibial os-teotomy to allow access to centrolat-eral talar lesions Excision of loose fragments with débridement and curet-tage of the lesions should be performed before internal fixation of the osteo-chondral fragment.22
Current Trends
Osteochondral Allograft
Fresh-frozen osteochondral al-lografts have been used to repair os-teochondral lesions of the talus Gross
et al36reported retrospectively on a series of nine patients in whom they had implanted talar osteochondral al-lografts to avoid the donor-site mor-bidity associated with autograft har-vest Only four of the patients had an identifiable previous trauma to the af-fected ankle One of the procedures was performed for a traumatic open fracture with talar osteochondral de-ficiency The authors’ indications for performing the procedure included a lesion with a diameter of at least 1 cm and a depth of at least 5 mm as well
as inability to perform primary repair
of the fragment
Trang 5Following open débridement of
the lesion to a bleeding host bed,
prefashioned fresh-frozen cadaveric
osteochondral allografts were
trans-planted using one or two
minifrag-ment cancellous screws for graft
fixation Postoperative management
included cast immobilization for 2
weeks, with subsequent ROM
exer-cises and a patellar tendon–bearing
brace for 1 year At a mean follow-up
of 11 years, six of the nine grafts
remained intact The three failures
resulted from fragmentation and
resorption of the allograft
Osteochondral Autograft
Osteochondral autografts use
car-tilage and subchondral bone
harvest-ed from host non–weight-bearing
ar-ticular surfaces Both the knee and the
talus itself have been used as donor
sites.37-42
Assenmacher et al43reported on
arthroscopically assisted autograft
transplantation in nine patients with
talar dome lesions The lesions were
graded using both MRI and
arthros-copy Unstable lesions were identified
by radiographic evidence of grade III
or IV injury or by the arthroscopic
vi-sualization of a loose fragment
Pa-tients considered to have unstable
le-sions underwent autograft of the talar
osteochondral defect with a plug
har-vested from the ipsilateral distal
fe-mur The lesions were débrided
be-fore the grafts were placed After
adequate débridement, grafting was
performed through an arthrotomy
The prefashioned graft was inserted
into a reamed recipient site and
packed into place Postoperatively,
patients remained non–weight
bear-ing for 7 weeks, with ROM exercises
begun 10 days postoperatively There
were no complications or revision
surgery, and results were good or
ex-cellent as assessed with the American
Orthopaedic Foot and Ankle
Soci-ety (AOFAS) ankle-hindfoot score
Follow-up MRI demonstrated that
the grafts were incorporated in all
subjects at 9 months postoperatively
Scranton and McDermott44reported
on osteochondral autograft replace-ment of stage IV talar lesions in 10 pa-tients The distal femur was used as
a donor site; average increase in the AOFAS ankle-hindfoot score was 27 points Mendicino et al38corroborated these results; they reported a high level
of patient satisfaction, excellent return
to function, and no donor site com-plaints with the use of distal femoral osteochondral autografts to treat stage III and IV lesions
The anterior talar dome also has been used as a donor site for osteo-chondral autograft of the talus Lee39 reported no postoperative complica-tions and cited advantages of the ta-lar dome donor site that include elim-ination of a second surgical site, decreased intraoperative time, and a close match in shape of the graft to the native recipient site
Mosaicplasty autograft also has been described, with reconstruction
of the osteochondral defect using multiple, small-diameter plug au-tografts as opposed to one large, pre-fashioned graft Hangody and col-leagues41,42reported on the outcomes
of talar mosaicplasty, with the
medi-al or latermedi-al femormedi-al condyle as the do-nor site In 36 patients, multiple grafts
of 4.5 × 3.5 mm were harvested to re-constitute the talar defects, which av-eraged 1 cm in diameter (Fig 4) Us-ing the Hanover scorUs-ing system, ankle function was judged to be good
or excellent in 34 of the 36 patients (94%) at follow-up of 2 to 7 years.42 All patients returned to full activity
Functional performance of osteo-chondral grafts has been evaluated
Histologic analysis by Giannini et
al40 showed that, unlike drilled le-sions, which heal with fibrocarti-lage,41,45 osteochondral autografts heal with type II collagen at the re-cipient site Type II collagen is char-acteristic of hyaline cartilage Gian-nini et al40reported an increase in the AOFAS ankle-hindfoot score from an average of 32 preoperatively to 91 postoperatively in eight patients
Summary
Because talar integrity is important for ankle function and because artic-ular repair is difficult, osteochondral lesions may result in functional im-pairment and, later, chronic ankle pain and functional debilitation Os-teochondral injury should be sus-pected in cases of recalcitrant ankle pain once more common causes, such as ligamentous injury, are ruled out Although occasionally the etiol-ogy of such lesions is unidentifiable, the majority arise as late sequelae of ankle trauma Lateral lesions are thought to be secondary to com-bined forceful dorsiflexion and ever-sion of the ankle, whereas medial in-juries may result from combined ankle inversion and plantar flexion
If an osteochondral talar defect is suspected but plain radiographs fail
to reveal the lesion, MRI may be use-ful for identifying early, nondis-placed lesions
Early (grade I or II) lesions may be amenable to nonsurgical treatment; more severe (grade III or IV) lesions
or those for which nonsurgical man-agement has failed may necessitate surgical intervention Subchondral drilling is done for stable lesions to encourage fibrocartilage growth, and osteochondral grafts may be used to restore the talar articular surface for unstable or larger defects To date, functional outcomes reported for
os-Figure 4 Mosaicplasty Intraoperative pho-tograph showing osteochondral autografts (arrows) at the site of a talar dome defect.
Trang 6teochondral grafting of the talus
gen-erally have been favorable Recent
re-search has suggested that healing of
such grafts may occur with a predom-inance of type II collagen, but further investigation is necessary to
deter-mine whether these weight-bearing surfaces are biomechanically similar
to hyaline cartilage
References
1 Saunders R: Fractures and fracture
dis-locations of the talus, in Mann RA,
Coughlin MJ (eds): Surgery of the Foot
and Ankle, ed 7 St Louis, MO: Mosby,
1991, vol 2, pp 1465-1518.
2 Boyd HS, Knight RA: Fractures of the
astralgus South Med J 1942;35:160-167.
3 Kleiger B: Injuries of the talus and its
joints Clin Orthop 1976;121:243-262.
4 Mulfinger GL, Trueta J: The blood
sup-ply of the talus J Bone Joint Surg Br 1970;
52:160-167.
5 Haliburton RA, Sullivan CR, Kelly PJ,
Peterson LFA: The extra-osseous and
intra-osseus blood supply of the talus.
J Bone Joint Surg Am 1958;40:1115-1120.
6 Kelly PJ, Sullivan CR: Blood supply of
the talus Clin Orthop 1963;30:37-44.
7 Berndt AL, Harty M: Transchondral
fractures (osteochondritis dissecans) of
the talus J Bone Joint Surg Am 1959;41:
988-1020.
8 Konig F: Veber freie korper in der
ge-henken Dtsch Z Chir 1888;27:90-109.
9 Canale ST, Belding RH: Osteochondral
lesions of the talus J Bone Joint Surg Am
1980;62:97-102.
10 Canale ST, Kelly FB Jr: Fractures of the
neck of the talus: Long-term evaluation
of seventy-one cases J Bone Joint Surg
Am 1978;60:143-156.
11 Alexander AH, Lichtman DM: Surgical
treatment of transchondral talar-dome
fractures (osteochondritis dissecans):
Long-term follow-up J Bone Joint Surg
Am 1980;62:646-652.
12 Ray RB, Coughlin EJ: Osteochondritis
dissecans of the talus J Bone Joint Surg
1947;29:697-706.
13 Flick AB, Gould N: Osteochondritis
dis-secans of the talus (transchondral
frac-tures of the talus): Review of the
liter-ature and a new surgical approach for
medial dome lesions Foot Ankle 1985;5:
165-185.
14 Sneppen O, Christensen SB, Krogsoe O,
Lorentzen J: Fracture of the body of
the talus Acta Orthop Scand 1977;48:
317-324.
15 Van Buecken K, Barrack RL, Alexander
AH, Ertl JP: Arthroscopic treatment of
transchondral talar dome fractures Am
J Sports Med 1989;17:350-356.
16 O’Farrell TA, Costello BG:
Osteochon-dritis dissecans of the talus: The late
re-sults of surgical treatment J Bone Joint
Surg Br 1982;64:494-497.
17 Davidson AM, Steele HD, MacKenzie
DA, Penny JA: A review of twenty-one cases of transchondral fractures of the
talus J Trauma 1967;7:378-415.
18 Resnick D, Goergen TG, Niwayama G:
Physical injury and diagnosis of bone disorders, in Resnick D, Niwayama G
(eds): Diagnosis of Bone and Joint
Disor-ders, ed 2 Philadelphia, PA: WB
Saun-ders, 1988, pp 2756-3009.
19 Anderson IF, Crichton KJ, Grattan-Smith
T, Cooper RA, Brazier D: Osteochondral
fractures of the dome of the talus J Bone
Joint Surg Am 1989;71:1143-1152.
20 Ferkel RD, Flannigan BD, Elkins BS:
Magnetic resonance imaging of the foot and ankle: Correlation of normal
anat-omy with pathologic conditions Foot
Ankle 1991;11:289-305.
21 Pritsch M, Horoshovski H, Farine I: Ar-throscopic treatment of osteochondral
lesions of the talus J Bone Joint Surg Am
1986;68:862-865.
22 DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds):
Surgery of the Foot and Ankle, ed 6 St.
Louis, MO: Mosby, 1991, pp 1465-1518.
23 Reis ND, Zinman C, Besser MIB, et al:
High-resolution computerised
tomog-raphy in clinical orthopaedics J Bone
Joint Surg Br 1982;64:20-24.
24 Urman M, Ammann W, Sisler J, et al:
The role of bone scintigraphy in the evaluation of talar dome fractures.
J Nucl Med 1991;32:2241-2244.
25 Deutsch AL: Osteochondral injury of the talar dome, in Deutsch AL, Mink
JH, Kerr R (eds): MRI of the Foot and
Ankle Philadelphia, PA:
Lippincott-Raven, 1996, pp 111-134.
26 Dipaolo JD, Nelson DW, Colville MR:
Characterizing osteochondral lesions
by magnetic resonance imaging
Ar-throscopy 1991;7:101-104.
27 Stone JW: Osteochondral lesions of the
talar dome J Am Acad Orthop Surg 1996;
4:63-73.
28 Pettine KA, Morrey BF: Osteochondral fractures of the talus: A long-term
follow-up J Bone Joint Surg Br 1987;69:89-92.
29 Shelton ML, Pedowitz WJ: Injuries to the talar dome, subtalar joint, and
mid-foot, in Jahss MH (ed): Disorders of the
Foot & Ankle: Medical and Surgical Man-agement, ed 2 Philadelphia, PA: WB
Saunders, 1991, vol 3, pp 2274-2292.
30 Tol JL, Struijs PAA, Bossuyt PMM, Ver-hagen RAW, van Dijk CN: Treatment strategies in osteochondral defects of the talar dome: A systematic review.
Foot Ankle Int 2000;21:119-126.
31 Kumai T, Takakura Y, Higashiyama I, Tamai S: Arthroscopic drilling for the treatment of osteochondral lesions of
the talus J Bone Joint Surg Am 1999;81:
1229-1235.
32 Parisien JS, Vangsness T: Operative ar-throscopy of the ankle: Three years’
ex-perience Clin Orthop 1985;199:46-54.
33 Shea MP, Manoli A II: Osteochondral
lesions of the talar dome Foot Ankle
1993;14:48-55.
34 Mallon WJ, Wombwell JH, Nunley JA: Intra-articular talar fractures: Repair
using the Herbert bone screw Foot
An-kle 1989;10:88-92.
35 Tochigi Y, Amendola A, Muir D, Saltz-man C: Surgical approach for centrolat-eral talar osteochondral lesions with an
anterolateral osteotomy Foot Ankle Int
2002;23:1038-1039.
36 Gross AE, Agnidis Z, Hutchison CR: Osteochondritis defects of the talus treated with fresh osteochondral
al-lograft transplantation Foot Ankle Int
2001;22:385-391.
37 Chang E, Lenczner E: Osteochondritis dissecans of the talar dome treated with
an osteochondral autograft Can J Surg
2000;43:217-221.
38 Mendicino RW, Hallivis RM, Cirlicione
AS, Catanzariti AR, Krause N: Osteo-chondral autogenous transplantation for osteochondritis dissecans of the ankle
joint J Foot Ankle Surg 2000;39:343-348.
39 Lee MS: Anterior talar dome as an al-ternative donor site for osteochondral transplantation for medial talar dome
lesions Clin Podiatr Med Surg 2001;18:
545-549.
40 Giannini S, Buda R, Grigolo B, Vannini F: Autologous chondrocyte transplanta-tion in osteochondral lesions of the
an-kle joint Foot Anan-kle Int 2001;22:513-517.
41 Hangody L, Kish G, Kárpáti Z, Szerb I, Eberhardt R: Treatment of osteochon-dritis dissecans of the talus: Use of the mosaicplasty technique–a preliminary
Trang 7report Foot Ankle Int 1997;18:628-634.
42 Hangody L, Kish G, Módis L, et al:
Mo-saicplasty for the treatment of
osteo-chondritis dissecans of the talus: Two to
seven year results in 36 patients Foot
Ankle Int 2001;22:552-558.
43 Assenmacher JA, Kelikian AS, Gottlob
C, Kodros S: Arthroscopically assisted autologous osteochondral transplantion for osteochondral lesions of the ta-lar dome: An MRI and clinical
follow-up study Foot Ankle Int 2001;22:544-587.
44 Scranton PE Jr, McDermott JE: Treat-ment of type V osteochondral lesions of
the talus with ipsilateral knee
osteo-chondral autografts Foot Ankle Int 2001;
22:380-384.
45 Buckwalter JA, Mow VC, Ratcliffe A: Restoration of injured or degenerated
articular cartilage J Am Acad Orthop
Surg 1994;2:192-201.