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Fracture stage 4 of the lateral talar dome treated arthroscopically using biofix for fixation
Arthroscopy: The Journal of Arthroscopic and Related Surgery 6(3):242-244 Published by Raven Press, Ltd. 0 WI0 Arthroscopy Association of North America
Case Report
Fracture Stage 4 of the Lateral Talar Dome Treated Arthroscopically Using Biofix for Fixation Gert Kristensen, M.D., Thomas Lind, M.D., Peter Lavard, M.D., and Peter Albrecht Olsen, M.D.
Summary: A
stage-4 osteochondral fracture of the anterolateral part of the talar dome in a 42-year-old sports-active woman was treated arthroscopically using biodegradable fixation [polyglycolic acid/(Biofix)l. She returned to the previous sport after 3 months without any complaints and, 15 months later, she is still without any symptoms from the ankle joint. A computed tomography scan after 15 months showed normal conditions. The technique is described, and arthroscopic surgery is proposed in the treatment of osteochondral lesions of the anterior part of the talar dome. Key Words: Ankle-Osteochondral fracture-Osteochondritis dissecans-Biodegradable fixation.
Editor’s Comment: This article is being publishedfor two reasons. Arthroscopicfixation offracture stage 4 of the ankle is technically difficult, and in the instance reported here the end result after 15 months has been satisfactory. The author is to be commended for being able to accomplish this successfully, especially as a ftxation through a small open incision would have been far easier and less time consuming. The other reason for the publication of this article is to acknowledge the apparent discrepancy between the appearance of the radiograph and that of the scan. A completely detached fragment should present as an area of increased bone density, not as an area of bone loss. If this fragment became displaced, as was suggested by the reviewers of this article, its location in the joint was not revealed by the scan, but its presence was suggested on the six-week radiograph.
(stages 1 and 2) is conservative and for displaced lesions (stages 3 and 4) is operative (2). The operative treatment consists of excising the fragment and curetting the bed in small lesions by arthrotomy (3,4) or arthroscopically (5,6) and in large lesions by open fixation of the displaced fragment (7). In all cases, early operation is recommended. We have treated one patient with a stage-4 lateral lesion by arthroscopic reduction of the displaced fragment followed by arthroscopic fixation of the fragment using a Biofix 2-mm rod. Biofix is a biodegradable material developed for fracture fixation, and is mostly used for malleolar fractures (8). The use of Biotix for treatment of osteochondritis in open operations has been described in a few cases (9). CASE REPORT
“Osteochondritis dissecans” or, more precisely, osteochondral fractures of the talar dome, are classified into four stages by Berndt and Harty (1). The recommended treatment of undisplaced lesions
A 42-year-old woman had a sprain in her left ankle. X-ray film showed an anterolateral osteochondral stage-4 fracture of the talus, with the fragment turned upside-down in the fracture bed (Fig. 1). Lateral instability of the ankle was found. Two days after the injury, arthroscopy was performed. From an anteromedial arthroscopic approach the fracture site was well exposed with a 5-mm 30” wide-angle Storz arthroscope. A small blood clot was removed
From the Department of Surgery T, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark. Address correspondence and reprint requests to Dr. Gert Kristensen, Department of Surgery T, Gentofte Hospital, University of Copenhagen, DK-2900 Hellerup, Denmark.
242
STAGE 4 FRACTURE
ARTHROSCOPY
FIG. 1. Fracture stage 4 of the lateral talar dome with displacement of osteochondral fragment.
from the crater with a probe from a median approach and the fragment, -7 x 10 x 12 mm, was turned 180”using the probe and a spinal needle (18 gauge). It could be reduced exactly and was held by two thinner needles, inserted percutaneously just anterior to the lateral malleolus. Between these needles, a 2-mm drill with soft-tissue protector was introduced to the joint via a 5-mm skin incision. A 2-mm drill hole was made under arthroscopic control through the fragment and into the talus at a depth of 30 mm. Using a special introducer the 2mm BioIix rod was hammered in place, still under arthroscopic control, with the tip of the rod placed at cartilage level (Fig. 2). It was not possible to move the fragment with the probe after fixation. Aftertreatment consisted of 6 weeks immobilization without weight bearing, 3 weeks with partial weight bearing and range-of-motion exercises, and then full weight-bearing and muscle-strengthening exercises. An x-ray film postoperatively showed the fragment in anatomical position. After 6 weeks,
FIG. 2. Osteochondral Biofix rod.
243
WITH BIOFIX
FIG. 3. Fracture stage 4 of the lateral talar dome 6 weeks after treatment. Note the radiolucency of the lateral talar comer.
the position was still anatomical but in contrast to what would be expected with signs of osteoporosis of the fragment (Fig. 3). The patient was without pain and with normal motion of the ankle joint after 9 weeks and no lateral instability could be demonstrated. The patient started sports activities after 3 months, and an x-ray film 6 months after injury showed normal conditions (Fig. 4). Fifteen months after injury, the patient is still without any symptoms and with normal motion of the ankle joint. A computed tomography scan at this time showed the fragment healed in place, and it was just possible to see the hole from the Biofix rod (Fig. 5). DISCUSSION This case illustrates that arthroscopic surgery may be an alternative to open surgery in the treatment of displaced osteochondral lesions of the anterior part of the talar dome with restoration of the
fragment reduced and fixed with a 2-mm FIG. 4. X-ray film 6 months after treatment with Biofix.
Arthroscopy.
Vol. 6. No. 3, 1990
G. KRISTENSEN
244
ET AL.
cially if more than one fragment is found, arthroscopic removal of fragment(s) and curettage should be performed. The use of Biofix has the advantage of other internal fixation devices: Removal is not required. The biodegradable implant is gradually absorbed during 3-4 months (9). The osteoporosis of the small, totally avascular fragment, seen after 6 weeks immobilization should be taken into account for an early revascularization. This step in the remodeling of the bone is most likely caused by vascular ingrowth from the talus. It might however have been nourished from the synovial fluid alone due to the thin bony attachment on the avulsed fragment. That is how the cartilage is nourished (IO)-but nourishment of bone this way has not yet been described. REFERENCES 1. Bemdt AL, Harty M. Transchondral
FIG. 5. Computed tomography scan of the talar dome 15 months after treatment.
normal anatomy of the talus instead of removal of the fragment and curettage of the crater. The method described in this case can be performed by any experienced arthroscopic surgeon-not only in the ankle joint but in all major joints with osteochondritis/osteochondral fractures, at least if arthroscopy is performed early after injury. We find that arthroscopic surgery should be tried before open operations in cases with osteochondral lesions of the anterior part of the talar dome, and that fixation should be tried in cases with a single fragment large enough to allow insertion of a Biofix rod without breaking the fragment. In other cases, espe-
Arthroscopy.
Vol. 6, No. 3, 1990
fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg [Am] 1959;41:988-1020. 2. Canale ST. Ankle injuries. In: Crenshaw AH. Campbells operative orthopaedics, 7th ed. St. Louis, Washington DC, Toronto: CV Mosby, 1987:2265-81. 3. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Sura IAml 1980:62:97-102. 4. Pettine KA, Moiey BP. Ostkochondral fractures of the talus. J Bone Joint Surg [Br] 1987;69:89-92. 5. Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. JBone Joint Surg [Am] 1986;68:862-5.
6. Baker CL, Andrews JR, Ryan JB. Arthroscopic treatment of transchondral talar dome fractures. Arthroscopy 1986;2: 82-7.
7. Murkherjee SK, Young AB. Dome fractures of the talus: a report of ten cases. J Bone Joint Surg [Br] 1973;55:319-26. 8. Rokkanen P, Borstman 0, Vainionpti S, et al. Biodegradable implants in fracture fixation: early results of treatment of fractures of the ankle. Lancer 1985:2: 14224. 9. VainionpU S. Biodegradation and fuaiion properties of biodegradable implants in bone tissue. Helsinki: Multiprint, 1987. 10. Ham AW. Histology, 6th ed. Philadelphia and Toronto: JB Lippincott, 1%9.
Case Report
Fracture Stage 4 of the Lateral Talar Dome Treated Arthroscopically Using Biofix for Fixation Gert Kristensen, M.D., Thomas Lind, M.D., Peter Lavard, M.D., and Peter Albrecht Olsen, M.D.
Summary: A
stage-4 osteochondral fracture of the anterolateral part of the talar dome in a 42-year-old sports-active woman was treated arthroscopically using biodegradable fixation [polyglycolic acid/(Biofix)l. She returned to the previous sport after 3 months without any complaints and, 15 months later, she is still without any symptoms from the ankle joint. A computed tomography scan after 15 months showed normal conditions. The technique is described, and arthroscopic surgery is proposed in the treatment of osteochondral lesions of the anterior part of the talar dome. Key Words: Ankle-Osteochondral fracture-Osteochondritis dissecans-Biodegradable fixation.
Editor’s Comment: This article is being publishedfor two reasons. Arthroscopicfixation offracture stage 4 of the ankle is technically difficult, and in the instance reported here the end result after 15 months has been satisfactory. The author is to be commended for being able to accomplish this successfully, especially as a ftxation through a small open incision would have been far easier and less time consuming. The other reason for the publication of this article is to acknowledge the apparent discrepancy between the appearance of the radiograph and that of the scan. A completely detached fragment should present as an area of increased bone density, not as an area of bone loss. If this fragment became displaced, as was suggested by the reviewers of this article, its location in the joint was not revealed by the scan, but its presence was suggested on the six-week radiograph.
(stages 1 and 2) is conservative and for displaced lesions (stages 3 and 4) is operative (2). The operative treatment consists of excising the fragment and curetting the bed in small lesions by arthrotomy (3,4) or arthroscopically (5,6) and in large lesions by open fixation of the displaced fragment (7). In all cases, early operation is recommended. We have treated one patient with a stage-4 lateral lesion by arthroscopic reduction of the displaced fragment followed by arthroscopic fixation of the fragment using a Biofix 2-mm rod. Biofix is a biodegradable material developed for fracture fixation, and is mostly used for malleolar fractures (8). The use of Biotix for treatment of osteochondritis in open operations has been described in a few cases (9). CASE REPORT
“Osteochondritis dissecans” or, more precisely, osteochondral fractures of the talar dome, are classified into four stages by Berndt and Harty (1). The recommended treatment of undisplaced lesions
A 42-year-old woman had a sprain in her left ankle. X-ray film showed an anterolateral osteochondral stage-4 fracture of the talus, with the fragment turned upside-down in the fracture bed (Fig. 1). Lateral instability of the ankle was found. Two days after the injury, arthroscopy was performed. From an anteromedial arthroscopic approach the fracture site was well exposed with a 5-mm 30” wide-angle Storz arthroscope. A small blood clot was removed
From the Department of Surgery T, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark. Address correspondence and reprint requests to Dr. Gert Kristensen, Department of Surgery T, Gentofte Hospital, University of Copenhagen, DK-2900 Hellerup, Denmark.
242
STAGE 4 FRACTURE
ARTHROSCOPY
FIG. 1. Fracture stage 4 of the lateral talar dome with displacement of osteochondral fragment.
from the crater with a probe from a median approach and the fragment, -7 x 10 x 12 mm, was turned 180”using the probe and a spinal needle (18 gauge). It could be reduced exactly and was held by two thinner needles, inserted percutaneously just anterior to the lateral malleolus. Between these needles, a 2-mm drill with soft-tissue protector was introduced to the joint via a 5-mm skin incision. A 2-mm drill hole was made under arthroscopic control through the fragment and into the talus at a depth of 30 mm. Using a special introducer the 2mm BioIix rod was hammered in place, still under arthroscopic control, with the tip of the rod placed at cartilage level (Fig. 2). It was not possible to move the fragment with the probe after fixation. Aftertreatment consisted of 6 weeks immobilization without weight bearing, 3 weeks with partial weight bearing and range-of-motion exercises, and then full weight-bearing and muscle-strengthening exercises. An x-ray film postoperatively showed the fragment in anatomical position. After 6 weeks,
FIG. 2. Osteochondral Biofix rod.
243
WITH BIOFIX
FIG. 3. Fracture stage 4 of the lateral talar dome 6 weeks after treatment. Note the radiolucency of the lateral talar comer.
the position was still anatomical but in contrast to what would be expected with signs of osteoporosis of the fragment (Fig. 3). The patient was without pain and with normal motion of the ankle joint after 9 weeks and no lateral instability could be demonstrated. The patient started sports activities after 3 months, and an x-ray film 6 months after injury showed normal conditions (Fig. 4). Fifteen months after injury, the patient is still without any symptoms and with normal motion of the ankle joint. A computed tomography scan at this time showed the fragment healed in place, and it was just possible to see the hole from the Biofix rod (Fig. 5). DISCUSSION This case illustrates that arthroscopic surgery may be an alternative to open surgery in the treatment of displaced osteochondral lesions of the anterior part of the talar dome with restoration of the
fragment reduced and fixed with a 2-mm FIG. 4. X-ray film 6 months after treatment with Biofix.
Arthroscopy.
Vol. 6. No. 3, 1990
G. KRISTENSEN
244
ET AL.
cially if more than one fragment is found, arthroscopic removal of fragment(s) and curettage should be performed. The use of Biofix has the advantage of other internal fixation devices: Removal is not required. The biodegradable implant is gradually absorbed during 3-4 months (9). The osteoporosis of the small, totally avascular fragment, seen after 6 weeks immobilization should be taken into account for an early revascularization. This step in the remodeling of the bone is most likely caused by vascular ingrowth from the talus. It might however have been nourished from the synovial fluid alone due to the thin bony attachment on the avulsed fragment. That is how the cartilage is nourished (IO)-but nourishment of bone this way has not yet been described. REFERENCES 1. Bemdt AL, Harty M. Transchondral
FIG. 5. Computed tomography scan of the talar dome 15 months after treatment.
normal anatomy of the talus instead of removal of the fragment and curettage of the crater. The method described in this case can be performed by any experienced arthroscopic surgeon-not only in the ankle joint but in all major joints with osteochondritis/osteochondral fractures, at least if arthroscopy is performed early after injury. We find that arthroscopic surgery should be tried before open operations in cases with osteochondral lesions of the anterior part of the talar dome, and that fixation should be tried in cases with a single fragment large enough to allow insertion of a Biofix rod without breaking the fragment. In other cases, espe-
Arthroscopy.
Vol. 6, No. 3, 1990
fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg [Am] 1959;41:988-1020. 2. Canale ST. Ankle injuries. In: Crenshaw AH. Campbells operative orthopaedics, 7th ed. St. Louis, Washington DC, Toronto: CV Mosby, 1987:2265-81. 3. Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Sura IAml 1980:62:97-102. 4. Pettine KA, Moiey BP. Ostkochondral fractures of the talus. J Bone Joint Surg [Br] 1987;69:89-92. 5. Pritsch M, Horoshovski H, Farine I. Arthroscopic treatment of osteochondral lesions of the talus. JBone Joint Surg [Am] 1986;68:862-5.
6. Baker CL, Andrews JR, Ryan JB. Arthroscopic treatment of transchondral talar dome fractures. Arthroscopy 1986;2: 82-7.
7. Murkherjee SK, Young AB. Dome fractures of the talus: a report of ten cases. J Bone Joint Surg [Br] 1973;55:319-26. 8. Rokkanen P, Borstman 0, Vainionpti S, et al. Biodegradable implants in fracture fixation: early results of treatment of fractures of the ankle. Lancer 1985:2: 14224. 9. VainionpU S. Biodegradation and fuaiion properties of biodegradable implants in bone tissue. Helsinki: Multiprint, 1987. 10. Ham AW. Histology, 6th ed. Philadelphia and Toronto: JB Lippincott, 1%9.