Bulk Allograft Transplantation for Osteochondral Lesions of the Talus

What are osteochondral lesions of the talus? 

Osteochondral lesions of the talus (OLTs) are ankle joint injuries involving damage to the joint surface (cartilage) and/or underlying talus bone. Cartilage and bone can be damaged by injuries such as ankle sprains or broken bones. In some cases, the blood supply to the talus may be compromised and lead to weakness and collapse of the cartilage and bone.

What is bulk allograft transplantation for an OLT?

Bulk allograft transplantation takes bone and cartilage from a cadaver and places it into the damaged talus. This surgery is reserved for severe cases of OLT that have either failed previous surgical management or involve a very large part of the talus. These types of OLTs may not respond to lesser surgeries.

What signs indicate bulk allograft transplantation may be needed?

Treatment for OLTs depends on several factors. The size and location of an OLT is important, as are the patient’s activity level and any previous treatments. Nonsurgical treatment options include medications, changes in activity, and braces or casts. Surgery may remove damaged cartilage and bone so that the underlying bone is stimulated to heal. If none of these are successful, bulk allograft transplantation is an option.

General Details of the Procedure

The surgery is usually done under a general anesthetic. A nerve block (injection of medication to numb the foot and ankle) may be used to help with pain after surgery. At least one incision is made, usually over the front or inside of the ankle. Commonly the tibial bone needs to be cut with a saw in order to allow access to the talus.
The OLT is then identified and removed. This is akin to a golf course green where a “plug” is removed to make the hole. A similar “plug” is then taken from a cadaver talus. That cadaver “plug” is then placed into the hole in the patient’s talus. If the tibia was cut, it is typically fixed with metal screws and/or a plate. The incision is closed. A splint or cast is commonly placed. The patient may go home the same day as the surgery or may stay overnight in the hospital.

What happens after the procedure?

Bulk allograft transplantation requires a substantial recovery period. In general, no pressure or weight is allowed on the operative side for six weeks or more. The patient is typically given a walker or crutches. A kneeling walker/scooter may also be an option. A transition is then made to partial weightbearing in a cast or boot. Daily activities are allowed between three to four months with complete recovery taking up to a year or more. 

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Specific risks of this procedure include nonunion (incomplete healing of the bones) of the graft and/or the site of the bone cuts, pain around the surgical site or hardware, and advancement of arthritic changes in the ankle joint. The graft may “fail” and collapse even several years after surgery.

Frequently Asked Questions

What is the outcome for most people?
Most patients have less pain and are able to do more activities after bulk allograft transplantation. These improvements have been shown to last several years and may last many more.
What happens if this surgery does not work?
Patients may still experience pain with activities after this procedure. If medications, bracing and activity modifications fail to improve symptoms, revision surgery may be considered. Ankle fusion and possibly ankle replacement may be treatment options.
Can my body reject the bone graft?
Rejection of the allograft does not appear to occur. An allograft may fail to heal and/or break but this does not seem to be from the body rejecting the graft itself. 
Is there a risk of getting HIV or other diseases from a bone graft?
It is estimated that the risk of HIV transmission from allograft transplantation is less than one in a million. There is a risk of transmitting other viruses such as hepatitis, but the risk is one in several hundred thousand.
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