Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for lateral osteochondral lesions of the talus: operative technique

OBJECTIVE: To provide a natural scaffold, good quality cells, and growth factors to facilitate replacement of the complete osteochondral unit with matching talar curvature for large osteochondral lesions of the lateral talar dome. INDICATIONS: Symptomatic primary and non-primary lateral osteochondral lesions of the talus not responding to conservative treatment. The anterior–posterior or medial–lateral diameter should exceed 10 mm on computed tomography (CT) for primary lesions; for secondary lesions, there are no size limitations. CONTRAINDICATIONS: Tibiotalar osteoarthritis grade III, malignancy, active infectious ankle joint pathology, and hemophilic or other diffuse arthropathy. SURGICAL TECHNIQUE: Anterolateral arthrotomy is performed after which the Anterior TaloFibular Ligament (ATFL) is disinserted from the fibula. Additional exposure is achieved by placing a Hintermann distractor subluxating the talus ventrally. Thereafter, the osteochondral lesion is excised in toto from the talar dome. The recipient site is micro-drilled in order to disrupt subchondral bone vessels. Thereafter, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exactly fitting shape to match the extracted lateral osteochondral defect and the talar morphology as well as curvature. The graft is implanted with a press-fit technique after which the ATFL is re-inserted followed by potential augmentation with an InternalBrace™ (Arthrex, Naples, FL, USA). POSTOPERATIVE MANAGEMENT: Non-weightbearing cast for 6 weeks, followed by another 6 weeks with a walking boot. After 12 weeks, a computed tomography (CT) scan is performed to assess consolidation of the inserted autograft. The patient is referred to a physiotherapist.