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Arthroscopically assisted osteochondral autogenous transplantation for osteochondral lesion of the talus using a transmalleolar approach
Technical Note
Arthroscopically Assisted Osteochondral Autogenous Transplantation for Osteochondral Lesion of the Talus Using a Transmalleolar Approach Kazuhiro Sasaki, M.D., Yasuyuki Ishibashi, M.D., Hideki Sato, M.D., and Satoshi Toh, M.D.
Abstract: Osteochondral autogenous transplantation for osteochondral lesions of the talar dome is usually performed through a miniarthrotomy approach, and a medial malleolus osteotomy approach is selected if the lesion is located posteromedially. Recently, we used a transmalleolar approach without osteotomy of the medial malleolus to perform osteochondral autogenous transplantation for a lesion located in the posteromedial portion of the talar dome. We report on this technique and discuss its advantages, disadvantages, and indications. Key Words: Osteochondral autogenous transplantation—Transmalleolar approach—Osteochondral lesion of talus.
O
steochondral lesions (OCL) of the talar dome involve numerous pathologic conditions. Lesions vary from small cartilage defects to completely detached osteochondral fragments. In 1959, Berndt and Harty1 reported the most accepted classification of OCL of the talar dome: stage I, a small area of compression of subchondral bone; stage II, a partially detached osteochondral fragment; stage III, a completely detached fragment that remains within its bed; and stage IV, a displaced fragment. The treatment of OCL of the talar dome depends on these stages. Conservative treatment is preferred for stage I, stage II, and medial stage III lesions. Surgical treatment is recommended for lateral stage III and stage IV lesions.2 Osteochondral autogenous transplantation for OCL
is one of the surgical treatments used.3-8 Generally, this technique is used with a mini-arthrotomy approach. When the OCL is located posteromedially of the talar dome and a mini-arthrotomy approach cannot be used, a medial malleolus osteotomy approach is usually used.4,6,8 Recently, we use a transmalleolar approach without osteotomy of the medial malleolus to perform arthroscopically assisted osteochondral autogenous transplantation for OCL located in the posteromedial portion of the talar dome. We report on this technique and discuss its advantages, disadvantages, and indications. To our knowledge, no reports on arthroscopically assisted transmalleolar osteochondral autogenous transplantation for OCL of the talar dome have been reported. SURGICAL TECHNIQUE
From the Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan. Address correspondence and reprint requests to Kazuhiro Sasaki, M.D., Department of Orthopaedic Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 0368562, Japan. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1908-3516$30.00/0 doi:10.1053/S0749-8063(03)00746-1
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Under general or spinal anesthesia, the patient is placed in the supine position. Initially, a complete diagnostic arthroscopy is performed using anteromedial and anterolateral portals under a pneumatic tourniquet application. A 4-mm diameter arthroscope with 30° viewing angle is usually used, and no mechanical traction device is used. The OCL is probed and assessed for location, size, and stability (Fig 1).
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 8 (October), 2003: pp 922-927
TRANSMALLEOLAR APPROACH
FIGURE 1. The osteochondral lesion is probed and assessed for location, size, and instability arthroscopically.
If the lesion is located too posteriorly to treat with a miniarthrotomy approach with maximum plantar flexion of the ankle joint, the transmalleolar approach is selected without medial malleolus osteotomy. First, a marking hook drill guide (Arthrex, Naples, FL) and a 1.5-mm-diameter guide pin is inserted from the medial cortex of the tibia toward the medial corner of the talar dome through the medial malleolus (Fig 2).
923
Then, a coring reamer guide is exchanged for the guide pin, and a transmalleolar bone tunnel is made using an 8-mm coring reamer (Arthrex) (Fig 3). The core is taken from the reamer and kept within a saline-soaked gauze sponge (Fig 4). This bone tunnel is used as an accessory arthroscopic portal (transmalleolar portal). Using the transmalleolar portal view (tunnel view), we confirm that the bone tunnel is adequate. During passive ankle joint dorsiflexion and plantar flexion with the arthroscope inserted, the tunnel view shows the entire OCL of the talar dome. This confirms that the bone tunnel is adequate (Fig 5). After the transmalleolar portal is made, the osteochondral autograft is performed using the Osteochondral Autograft Transfer System (OATS; Arthrex). The size of the osteochondral lesion is inspected using a sizer-tamp. The appropriate recipient tube harvester is used to make a recipient socket for the donor graft (Fig 6). The depth and direction of the socket is measured by an alignment rod. The depth of the recipient socket is approximately 10 to 15 mm. The donor graft is then arthroscopically harvested from the ipsilateral femoral intercondylar notch using a donor tube harvester. The diameter is 1 mm bigger than the recipient tube harvester to create a donor graft that will press-fit into the recipient socket. The donor graft is placed into the recipient socket using the driver-extractor. The graft is left about 1 mm above the socket margin and tapped by the sizer-tamp
FIGURE 2. Application of a marking hook drill guide. (A) The marking hook is inserted into the ankle joint, and the drill guide sleeve is applied to the medial tibial cortex. (B) The marking hook is placed in the medial corner of the tibial plafond arthroscopically.
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FIGURE 3. Making the transmalleolar bone tunnel. (A) Using an 8-mm coring reamer, the transmalleolar bone tunnel is made. (B) The transmalleolar bone tunnel is made.
to make a smooth articular surface (Fig 7). Graft number depends on the area of the lesion. Using the transmalleolar portal view, we ascertain the graft number needed for transplantation and confirm that the graft is placed adequately (Fig 8). After osteochondral autogenous transplantation, the core, which has been kept in gauze, is returned to the medial malloelus bone tunnel (Fig 9). The core slides easily in the bone tunnel and we prevent motion by grafting a wedge-shaped bone (harvested from the recipient site) between the core and the medial malleolus bone tunnel wall.
DISCUSSION Many surgical treatments for OCL have been reported. They involve lesion excision,9-11 drilling,12-14 screw fixation,15 and osteochondral grafting.4,6-8 In the stage III lesions, osteosynthesis of the fragment is preferable to excision of the fragment, because hyaline cartilage will be preserved. However, in failed stage III lesions and stage IV lesions, fixing the os-
Postoperative Rehabilitation Postoperative immobilization is not usually necessary, and application of an elastic bandage is often sufficient. Range of motion exercise is started immediately, and partial weight bearing is permitted 2 weeks after surgery. Full weight bearing is permitted 4 to 6 weeks after surgery.
FIGURE 4. Coring reamer guide and bone core taken from the transmalleolar bone tunnel.
FIGURE 5. The transmalleolar portal view shows the entire osteochondral lesion of the talar dome during passive ankle joint dorsiflexion and plantar flexion.
TRANSMALLEOLAR APPROACH
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FIGURE 6. Recipient site harvest. (A) Using the appropriate recipient tube harvester, the recipient socket is made arthroscopically. (B) Scheme showing the recipient socket made through the transmalleolar bone tunnel.
teochondral fragment and excising the fragment can be difficult and curettage and subchondral drilling are needed. Recently, Hangody et al.4 described osteochondral autogenous transplantation for osteochondritis dissecans of the talus, and several reports on this technique have been presented.3-8 The benefit of this procedure is the ability to replace the lesion with a
cylindrical osteochondral graft covered with hyaline cartilage. The approach to OCL of the medial portion of the talar dome is performed using a miniarthrotomy approach in cases with anteriorly located lesions and using a medial malleolus osteotomy when the lesion is posteriorly located.9,16 Tsuchiya et al.15 reported the
FIGURE 7. The osteochondral graft is placed into the recipient socket. (A) Osteochondral graft taken from ipsilateral knee is placed into the recipient socket arthroscopically. (B) The graft is left about 1 mm above the socket margin and tapped by the sizer-tamp.
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FIGURE 8. Using the transmalleolar portal view, we confirm the number of grafts needed for transplantation and the adequate placement of the graft.
technique of osteosynthesis of the osteochondral fragment with a Herbert screw using a transmalleolar approach. They made a transmalleolar bone tunnel using a drill. Our method was similar to that approach, but we restored the bone tunnel with bone core. The
indications of the transmalleolar approach are (1) posteromedial lesion of the talar dome, (2) cases in which the mini-open approach cannot expose the lesions, (3) lesions that are not broad. One advantage of the transmalleolar approach is that it is less invasive than medial malleolus osteotomy. This approach does not require screws or pin fixation for the medial malleolus and subsequent removal of those fixation devices. Assenmacher et al.7 reported arthroscopically assisted osteochondral autograft transplantation for OCL using a “plafondplasty” approach. This approach permits grafting to the lesion perpendicularly. However, it requires partial resection of the anterior tibial plafond and therefore does not restore the tibial plafond. The transmalleolar approach permits early range of motion exercise and weight bearing. One of the disadvantages of the transmalleolar approach is the difficulty of adequately positioning the transmalleolar bone tunnel. The most ideal direction of grafting is perpendicular to the joint surface, but the transmalleolar bone tunnel is never perpendicular to the OCL. Therefore, we needed to carefully shape the donor site articular cartilage surface. We selected the donor site so that its surface conformed to the shape of the recipient site and then harvested the graft obliquely. We have not encountered medial malleolus fracture as a complication, but the risk of fracture will be
FIGURE 9. Restoration of the transmalleolar bone tunnel. (A) After osteochondral autogenous transplantation, the core is returned to the transmalleolar bone tunnel. (B) Scheme of the restoration of the transmalleolar bone tunnel.
TRANSMALLEOLAR APPROACH higher because the diameter of this bone tunnel increases. Although we have no data about the suitable size of this bone tunnel, we think the 8-mm-diameter tunnel is appropriate for osteochondral autograft for OCL of the talus. OCL of the talus is difficult to treat, and osteochondral autogenous transplantation is a reliable treatment. The transmalleolar approach is technically challenging, but we believe the transmalleolar approach is beneficial if adequately performed. REFERENCES 1. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am 1959;41:9881020. 2. Canale ST, Belding RH. Osteochondral lesion of the talus. J Bone Joint Surg Am 1980;62:97-102. 3. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption: case report. Arthroscopy 1993;9:318-321. 4. Hangody L, Kish G, Karpati Z. Treatment of osteochondritis dissecans of the talus: Use of the mosaicplasty technique. A preliminary report. Foot Ankle 1997;18:628-634. 5. Mendicino RW, Hallivis RM, Cirlincione AS. Osteochondral autogenous transplantation for osteochondritis dissecans of the ankle joint. J Foot Ankle Surg 2000;39:343-348.
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6. Scranton PE, McDermott JE. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Foot Ankle 2001;22:380-384. 7. Assenmacher JA, Kelikian AS, Gottlob C. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: An MRI and clinical follow-up study. Foot Ankle 2001;22:544-551. 8. Gautier E, Kolker D, Jakob RP. Treatment of cartilage defect of the talus by autologous osteochondral grafts. J Bone Joint Surg Br 2002;84:237-243. 9. McCullough CJ, Venugopal V. Osteochondritis dissecans of the talus: The natural history. Clin Orthop 1979;144:264-268. 10. Pettine KA, Morrey BF. Osteochondral fractures of the talus: A long-term follow-up. J Bone Joint Surg Br 1987;69:89-92. 11. Ogilvie-Harris DJ, Sarrosa EA. Arthroscopic treatment of osteochondritis dissecans of the talus. Arthroscopy 1999;15:805808. 12. Alexander AH, Lichtman DM. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). J Bone Joint Surg Am 1980;62:646-652. 13. O’Farrell TA, Costello BG. Osteochondritis dissecans of the talus: The late results of surgical treatment. J Bone Joint Surg Br 1982;64:494-597. 14. Bryant DD, Siegel MG. Osteochondritis dissecans of the talus: A new technique for arthroscopic drilling. Arthroscopy 1993; 9:238-241. 15. Tsuchiya A, Moriya H, Nishiyama H. Arthroscopic surgery for talar osteochondral lesion. Jpn J Orthop Sports Med 1990;9: 309-312. 16. Yvars MF. Osteochondral fractures of the dome of the talus. Clin Orthop 1976;114:185-191.
Arthroscopically Assisted Osteochondral Autogenous Transplantation for Osteochondral Lesion of the Talus Using a Transmalleolar Approach Kazuhiro Sasaki, M.D., Yasuyuki Ishibashi, M.D., Hideki Sato, M.D., and Satoshi Toh, M.D.
Abstract: Osteochondral autogenous transplantation for osteochondral lesions of the talar dome is usually performed through a miniarthrotomy approach, and a medial malleolus osteotomy approach is selected if the lesion is located posteromedially. Recently, we used a transmalleolar approach without osteotomy of the medial malleolus to perform osteochondral autogenous transplantation for a lesion located in the posteromedial portion of the talar dome. We report on this technique and discuss its advantages, disadvantages, and indications. Key Words: Osteochondral autogenous transplantation—Transmalleolar approach—Osteochondral lesion of talus.
O
steochondral lesions (OCL) of the talar dome involve numerous pathologic conditions. Lesions vary from small cartilage defects to completely detached osteochondral fragments. In 1959, Berndt and Harty1 reported the most accepted classification of OCL of the talar dome: stage I, a small area of compression of subchondral bone; stage II, a partially detached osteochondral fragment; stage III, a completely detached fragment that remains within its bed; and stage IV, a displaced fragment. The treatment of OCL of the talar dome depends on these stages. Conservative treatment is preferred for stage I, stage II, and medial stage III lesions. Surgical treatment is recommended for lateral stage III and stage IV lesions.2 Osteochondral autogenous transplantation for OCL
is one of the surgical treatments used.3-8 Generally, this technique is used with a mini-arthrotomy approach. When the OCL is located posteromedially of the talar dome and a mini-arthrotomy approach cannot be used, a medial malleolus osteotomy approach is usually used.4,6,8 Recently, we use a transmalleolar approach without osteotomy of the medial malleolus to perform arthroscopically assisted osteochondral autogenous transplantation for OCL located in the posteromedial portion of the talar dome. We report on this technique and discuss its advantages, disadvantages, and indications. To our knowledge, no reports on arthroscopically assisted transmalleolar osteochondral autogenous transplantation for OCL of the talar dome have been reported. SURGICAL TECHNIQUE
From the Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan. Address correspondence and reprint requests to Kazuhiro Sasaki, M.D., Department of Orthopaedic Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 0368562, Japan. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1908-3516$30.00/0 doi:10.1053/S0749-8063(03)00746-1
922
Under general or spinal anesthesia, the patient is placed in the supine position. Initially, a complete diagnostic arthroscopy is performed using anteromedial and anterolateral portals under a pneumatic tourniquet application. A 4-mm diameter arthroscope with 30° viewing angle is usually used, and no mechanical traction device is used. The OCL is probed and assessed for location, size, and stability (Fig 1).
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 8 (October), 2003: pp 922-927
TRANSMALLEOLAR APPROACH
FIGURE 1. The osteochondral lesion is probed and assessed for location, size, and instability arthroscopically.
If the lesion is located too posteriorly to treat with a miniarthrotomy approach with maximum plantar flexion of the ankle joint, the transmalleolar approach is selected without medial malleolus osteotomy. First, a marking hook drill guide (Arthrex, Naples, FL) and a 1.5-mm-diameter guide pin is inserted from the medial cortex of the tibia toward the medial corner of the talar dome through the medial malleolus (Fig 2).
923
Then, a coring reamer guide is exchanged for the guide pin, and a transmalleolar bone tunnel is made using an 8-mm coring reamer (Arthrex) (Fig 3). The core is taken from the reamer and kept within a saline-soaked gauze sponge (Fig 4). This bone tunnel is used as an accessory arthroscopic portal (transmalleolar portal). Using the transmalleolar portal view (tunnel view), we confirm that the bone tunnel is adequate. During passive ankle joint dorsiflexion and plantar flexion with the arthroscope inserted, the tunnel view shows the entire OCL of the talar dome. This confirms that the bone tunnel is adequate (Fig 5). After the transmalleolar portal is made, the osteochondral autograft is performed using the Osteochondral Autograft Transfer System (OATS; Arthrex). The size of the osteochondral lesion is inspected using a sizer-tamp. The appropriate recipient tube harvester is used to make a recipient socket for the donor graft (Fig 6). The depth and direction of the socket is measured by an alignment rod. The depth of the recipient socket is approximately 10 to 15 mm. The donor graft is then arthroscopically harvested from the ipsilateral femoral intercondylar notch using a donor tube harvester. The diameter is 1 mm bigger than the recipient tube harvester to create a donor graft that will press-fit into the recipient socket. The donor graft is placed into the recipient socket using the driver-extractor. The graft is left about 1 mm above the socket margin and tapped by the sizer-tamp
FIGURE 2. Application of a marking hook drill guide. (A) The marking hook is inserted into the ankle joint, and the drill guide sleeve is applied to the medial tibial cortex. (B) The marking hook is placed in the medial corner of the tibial plafond arthroscopically.
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FIGURE 3. Making the transmalleolar bone tunnel. (A) Using an 8-mm coring reamer, the transmalleolar bone tunnel is made. (B) The transmalleolar bone tunnel is made.
to make a smooth articular surface (Fig 7). Graft number depends on the area of the lesion. Using the transmalleolar portal view, we ascertain the graft number needed for transplantation and confirm that the graft is placed adequately (Fig 8). After osteochondral autogenous transplantation, the core, which has been kept in gauze, is returned to the medial malloelus bone tunnel (Fig 9). The core slides easily in the bone tunnel and we prevent motion by grafting a wedge-shaped bone (harvested from the recipient site) between the core and the medial malleolus bone tunnel wall.
DISCUSSION Many surgical treatments for OCL have been reported. They involve lesion excision,9-11 drilling,12-14 screw fixation,15 and osteochondral grafting.4,6-8 In the stage III lesions, osteosynthesis of the fragment is preferable to excision of the fragment, because hyaline cartilage will be preserved. However, in failed stage III lesions and stage IV lesions, fixing the os-
Postoperative Rehabilitation Postoperative immobilization is not usually necessary, and application of an elastic bandage is often sufficient. Range of motion exercise is started immediately, and partial weight bearing is permitted 2 weeks after surgery. Full weight bearing is permitted 4 to 6 weeks after surgery.
FIGURE 4. Coring reamer guide and bone core taken from the transmalleolar bone tunnel.
FIGURE 5. The transmalleolar portal view shows the entire osteochondral lesion of the talar dome during passive ankle joint dorsiflexion and plantar flexion.
TRANSMALLEOLAR APPROACH
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FIGURE 6. Recipient site harvest. (A) Using the appropriate recipient tube harvester, the recipient socket is made arthroscopically. (B) Scheme showing the recipient socket made through the transmalleolar bone tunnel.
teochondral fragment and excising the fragment can be difficult and curettage and subchondral drilling are needed. Recently, Hangody et al.4 described osteochondral autogenous transplantation for osteochondritis dissecans of the talus, and several reports on this technique have been presented.3-8 The benefit of this procedure is the ability to replace the lesion with a
cylindrical osteochondral graft covered with hyaline cartilage. The approach to OCL of the medial portion of the talar dome is performed using a miniarthrotomy approach in cases with anteriorly located lesions and using a medial malleolus osteotomy when the lesion is posteriorly located.9,16 Tsuchiya et al.15 reported the
FIGURE 7. The osteochondral graft is placed into the recipient socket. (A) Osteochondral graft taken from ipsilateral knee is placed into the recipient socket arthroscopically. (B) The graft is left about 1 mm above the socket margin and tapped by the sizer-tamp.
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FIGURE 8. Using the transmalleolar portal view, we confirm the number of grafts needed for transplantation and the adequate placement of the graft.
technique of osteosynthesis of the osteochondral fragment with a Herbert screw using a transmalleolar approach. They made a transmalleolar bone tunnel using a drill. Our method was similar to that approach, but we restored the bone tunnel with bone core. The
indications of the transmalleolar approach are (1) posteromedial lesion of the talar dome, (2) cases in which the mini-open approach cannot expose the lesions, (3) lesions that are not broad. One advantage of the transmalleolar approach is that it is less invasive than medial malleolus osteotomy. This approach does not require screws or pin fixation for the medial malleolus and subsequent removal of those fixation devices. Assenmacher et al.7 reported arthroscopically assisted osteochondral autograft transplantation for OCL using a “plafondplasty” approach. This approach permits grafting to the lesion perpendicularly. However, it requires partial resection of the anterior tibial plafond and therefore does not restore the tibial plafond. The transmalleolar approach permits early range of motion exercise and weight bearing. One of the disadvantages of the transmalleolar approach is the difficulty of adequately positioning the transmalleolar bone tunnel. The most ideal direction of grafting is perpendicular to the joint surface, but the transmalleolar bone tunnel is never perpendicular to the OCL. Therefore, we needed to carefully shape the donor site articular cartilage surface. We selected the donor site so that its surface conformed to the shape of the recipient site and then harvested the graft obliquely. We have not encountered medial malleolus fracture as a complication, but the risk of fracture will be
FIGURE 9. Restoration of the transmalleolar bone tunnel. (A) After osteochondral autogenous transplantation, the core is returned to the transmalleolar bone tunnel. (B) Scheme of the restoration of the transmalleolar bone tunnel.
TRANSMALLEOLAR APPROACH higher because the diameter of this bone tunnel increases. Although we have no data about the suitable size of this bone tunnel, we think the 8-mm-diameter tunnel is appropriate for osteochondral autograft for OCL of the talus. OCL of the talus is difficult to treat, and osteochondral autogenous transplantation is a reliable treatment. The transmalleolar approach is technically challenging, but we believe the transmalleolar approach is beneficial if adequately performed. REFERENCES 1. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am 1959;41:9881020. 2. Canale ST, Belding RH. Osteochondral lesion of the talus. J Bone Joint Surg Am 1980;62:97-102. 3. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption: case report. Arthroscopy 1993;9:318-321. 4. Hangody L, Kish G, Karpati Z. Treatment of osteochondritis dissecans of the talus: Use of the mosaicplasty technique. A preliminary report. Foot Ankle 1997;18:628-634. 5. Mendicino RW, Hallivis RM, Cirlincione AS. Osteochondral autogenous transplantation for osteochondritis dissecans of the ankle joint. J Foot Ankle Surg 2000;39:343-348.
927
6. Scranton PE, McDermott JE. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts. Foot Ankle 2001;22:380-384. 7. Assenmacher JA, Kelikian AS, Gottlob C. Arthroscopically assisted autologous osteochondral transplantation for osteochondral lesions of the talar dome: An MRI and clinical follow-up study. Foot Ankle 2001;22:544-551. 8. Gautier E, Kolker D, Jakob RP. Treatment of cartilage defect of the talus by autologous osteochondral grafts. J Bone Joint Surg Br 2002;84:237-243. 9. McCullough CJ, Venugopal V. Osteochondritis dissecans of the talus: The natural history. Clin Orthop 1979;144:264-268. 10. Pettine KA, Morrey BF. Osteochondral fractures of the talus: A long-term follow-up. J Bone Joint Surg Br 1987;69:89-92. 11. Ogilvie-Harris DJ, Sarrosa EA. Arthroscopic treatment of osteochondritis dissecans of the talus. Arthroscopy 1999;15:805808. 12. Alexander AH, Lichtman DM. Surgical treatment of transchondral talar-dome fractures (osteochondritis dissecans). J Bone Joint Surg Am 1980;62:646-652. 13. O’Farrell TA, Costello BG. Osteochondritis dissecans of the talus: The late results of surgical treatment. J Bone Joint Surg Br 1982;64:494-597. 14. Bryant DD, Siegel MG. Osteochondritis dissecans of the talus: A new technique for arthroscopic drilling. Arthroscopy 1993; 9:238-241. 15. Tsuchiya A, Moriya H, Nishiyama H. Arthroscopic surgery for talar osteochondral lesion. Jpn J Orthop Sports Med 1990;9: 309-312. 16. Yvars MF. Osteochondral fractures of the dome of the talus. Clin Orthop 1976;114:185-191.