Outcomes of medial talar dome lesions treated with a medial malleolar osteotomy

Background: Osteochondritis dissecans (OCD) lesions of talus are common injuries in adolescent athletes. Some lesions are located at the medial talar dome. Arthroscopy and/or arthrotomy is the optimal surgical approach for most osteochondritis dissecans (OCD) lesions of the talus; however, posteromedial lesions are often difficult to access with arthroscopy alone and may require a medial malleolar osteotomy. This study aims to report the outcomes and complications of symptomatic posteromedial OCD lesions of the talus treated via a medial malleolar osteotomy. Methods: The study was approved by the college of medicine institutional review board. Four adolescent athletes treated surgically for symptomatic posteromedial talar OCD were retrospectively reviewed. All patients had failed greater than 6 months of conservative treatment. An oblique medial malleolar osteotomy was performed to access the OCD lesion. Postoperatively, patients were immobilized in a cast or Controlled Ankle Motion (CAM) boot for 4 weeks with toe-touch weight-bearing, followed by progressive weight-bearing and gradual return to sports. Clinical outcomes were measured using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score and Alexander/Lichtman score. Radiographic outcomes were measured using the Higuerua score and Berndt and Harty score. Results: Four adolescent female patients were studied. All had closed growth plates. The average age was 14.2 years. The average size of the lesion was 7.6 mm × 5.8 mm x 2.7 mm. Preoperative Berndt and Harty classification was Stage 3 (2) and Stage 4 (2). At surgery, debridement and marrow stimulation followed by fragment fixation was performed via the medial malleolar osteotomy. Tourniquet time averaged 65.7 minutes. Patients returned to sports at an average of 7.2 months. The osteotomy demonstrated osseous union at an average of 6.2 weeks. 3 of 4 patients (75 %) had the osteotomy fixation screws removed due to hardware irritation. Average duration follow-up was 22.7 months. At final follow-up, the AOFAS ankle hindfoot score averaged 96.5. Alexander/Lichman scores and the Higuera scores were all excellent. Berndt and Harty scores were all good, and no complications occurred. Conclusion: The duration of conservative management, optimal surgical modality and postoperative rehabilitation protocol have not been well established. Osteotomy of the medial malleolus provides excellent visualization of the medial talar dome to treat medial OCD lesions with marrow stimulation and fragment fixation. Performing the osteotomy at 30° to the axis of the tibia and pre-drilling the screw holes for fixation resulted in excellent outcomes and full return to sports.