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LATERAL INVERTED OSTEOCHONDRAL FRACTURE OF THE TALUS: CASE REPORTS AND REVIEW OF THE LITERATURE/OKRENUTI KOSTANOHRSKAVICNI FRAGMENT NA LATERALNOJ PLOHI TALUSA: PRIKAZI SLUCAJEVA I PREGLED LITERATURE.

Introduction

Osteochondral lesion of the talus (OLT) can occur in 6.5% of patients sustaining ankle sprain (1,2). According to the Berndt and Harty radiological classification, OLT can appear in the forms of subchondral compression (stage I) to displaced osteochondral fragment (stage IV) (3). In rare cases, stage IV OLT of the lateral side of the talar dome is inverted in situ by 180[degrees]. This is called lateral inverted osteochondral fracture of the talus (LIFT) (4). Early recognition of LIFT lesion is crucial, given that treatment options depend on the articular cartilage condition and sufficiency of the adjacent bone of the fragment (4). To date, there have been 9 single case reports and one case series of LIFT lesions described in the literature (3).

Our goal with these case reports is to emphasize the importance of recognizing the orientation of an osteochondral fragment after assessing anterolateral localization of OLT, in order to select optimal treatment modality and achieve good clinical outcome.

Case Reports

Here we present two cases, a 15-year-old boy (patient 1) and 13-year-old girl (patient 2), referred from other institutions after unsuccessful conservative treatment of OLT. They sustained an inversion injury of the right ankle during football training and skateboarding, respectively. Patient 1 had one-month and patient 2 five-month history of persistent pain in the lateral aspect of the right ankle. Physical examination of both patients revealed swelling and tenderness over the anterolateral aspect of the right ankle with limited range of motion (ROM). Anterior drawer test was also positive. Plain radiographs at the examination, as well as the magnetic resonance imaging (MRI) scans from the referring physicians showed displaced lateral osteochondral fragment (Figs. 1 and 2). On the MRI scans of patient 2, we noticed that the fragment was actually inverted in situ by 180[degrees], thereby showing the LIFT lesion (Fig. 2).

Parental permission was obtained for publication of data concerning these cases.

Surgical technique

In both patients, operation was performed by the senior author (I. B.) using the same protocol. The patients were under spinal anesthesia, placed supine, and a thigh tourniquet was applied to the affected limb throughout the operation. Standard anteromedial and anterolateral portals were used for arthroscopic access (5,6). No distraction device was used during the operative procedure. In both patients, OLT was situated on the anterolateral site of the talar dome. Closer examination revealed subchondral bone on the top of the fragment with the articular cartilage facing the defect, suggesting inversion of the fragment in situ by 180[degrees] (Fig. 3). The articular cartilage was significantly damaged in both patients, as a result of the non-anatomic orientation. In addition, there was insufficient amount of the adjacent bone, so the fragment was completely excised. Excision was followed by curettage of the defect surface to remove debris and devitalized tissue. Care was taken to preserve and create a circumferential, perpendicular rim of healthy cartilage. The subchondral base of the defect was then picked by a microfracture awl to a depth of 4 mm, starting at the periphery to improve edge integration. Care was taken to place the holes 3 to 4 mm apart to avoid becoming confluent and destabilizing the microfracture area.

Rehabilitation

The patients started with active and passive ROM exercises from the first postoperative day (7). A posterior night splint for the ankle in the neutral position was used for 3 weeks after surgery. During the first 6 weeks, both patients were kept on crutch-assisted touchdown weight-bearing (no more than 10 kg). In the next 4 weeks, the patients still used crutches and gradually increased the weight-bearing by 1/3 of their body weight in the first 2 weeks of this period and by 2/3 in the second 2 weeks. This was followed by full weight-bearing with gradual removal of crutches over a period of 2 weeks.

Clinical outcomes

At the final follow up visit, 2 years postoperatively in patient 1 and 1 year postoperatively in patient 2, neither patient complained of foot and ankle pain or swelling, nor reported giving way or instability with the operated foot. Both patients had normal ROM of the operated foot, with no side-to-side difference compared to the non-operated foot. Both patients continued to participate in sports activities at the desired activity level. Postoperative plain radiographs of patient 1 are shown in Figure 4.

Discussion

Lateral inverted osteochondral fracture of the talus represents an acute OLT of the lateral talar dome that is the result of an inversion injury in which the forces are strong enough, so that the 'flip of the coin' phenomenon occurs, causing the fragment to rotate in situ by 180[degrees]. Such a completely inverted fragment cannot heal by itself and remaining in the non-anatomical position it will undoubtedly lead to damage to the articular cartilage and adjacent bone. Therefore, clinicians should be aware that the most important thing when dealing with LIFT lesion is early recognition of this condition. Studies report that LIFT lesion usually occurs during sports activities, putting especially younger patients under a major risk (1,4,8). The main symptoms are nonspecific, mainly a combination of pain, swelling and tenderness over the lateral part of the ankle.

The LIFT lesions should be visible on plain radiograph as a displaced osteochondral fragment or stage IV OLT according to the Berndt and Harty radiological classification (3). However, recognizing LIFT is not simple because the orientation of the fragment is rarely obvious. In some LIFT lesions, osteochondral fragment may seem as non-displaced, while it is actually displaced, inverted and impacted into the defect (9,10). By using radiographs alone, the diagnosis of OLT can be missed in up to 43% of patients (11). Therefore, in the case of lateral OLT seen after acute trauma, MRI or computed tomography (CT) scans should always be performed. Signs suggestive of fragment inversion are inversion of the subchondral-bone plate crescent, reversal of the subchondral-cancellous bone layers, and the presence of a radiolucent gap beneath the fragment (1,10). On MRI scans, there will be a marked degree of edema within the talus surrounding the osteochondral fragment (8). However, this can be seen in other OLT lesions as well. Namely, in the case report by Wade and Bustillo, MRI scans showed edema beneath the fragment, but the fragment appeared non-displaced (8). On the operation, they found the fragment actually to be rotated in situ by 180[degrees], which made them change the preoperatively planned procedure of fragment fixation into arthroscopic excision and drilling (8). In the case of our patient 1, inversion of the fragment was not noticed preoperatively on MRI scans either.

Once the LIFT is diagnosed, decision on which technique to use for the treatment depends mostly on the condition of the inverted osteochondral fragment. Although this assessment is usually possible preoperatively by using MRI or CT scans, definitive decision will be made under direct visualization during the operative procedure. Starting the treatment arthroscopically allows clear evaluation of the osteochondral fragment, assessment of the talar defect and identification, as well as treatment of associated disorders (4). If arthroscopic examination of the ankle reveals damaged articular cartilage or insufficient subchondral bone of the osteochondral fragment, excision followed by microfracture has proven to be a good surgical choice (8,12). On the other hand, if viability of the articular cartilage and sufficiency of the adjacent subchondral bone is maintained, fixation of the fragment is the treatment of choice. Different fixation techniques have been described, but bioabsorbable pins are most frequently used (Table 1) (1,4,11,13,14). These implants provide the same support as metal fixation for protection against shear and rotational forces (14). They are not demanding for use, can be adopted for a variety of lesions, and removal is not required. A potential complication is a foreign body reaction, which, however, can be reduced with the use of poly-p-dioxanon compared to polyglycolide products (15). Kristensen et al. reported in 1990 a case of a 42-year-old active woman with LIFT lesion, treated arthroscopically by use of bioabsorbable pins. Fifteen months after the operation, she had no pain, had normal ROM, and CT scans showed the fragment to have healed in place (16). Other studies where bioabsorbable pins were used for LIFT lesion also revealed good to excellent clinical results after early- to mid-term follow-up (1,4,11,13,14). However, besides the case report by Kristensen et al. (16), where fixation was performed arthroscopically, in all other LIFT studies fixation was always done by using arthrotomy, or by switching arthroscopic procedure to an open approach (1,4,11,13,14). Unlike the satisfying clinical results obtained with fixation, it seems that at the same time radiological findings are not as good. In a recent and most comprehensive study on LIFT lesion published by Dunlap et al., radiographs revealed some evidence of osteoarthritis in all patients after the mean follow up of 9.3 years (4). In the same study, MRI scans also indicated limitations in the ability to completely repair the lesion with fixation technique, while showing moderate surface and subchondral plate irregularities with some residual cystic formation in most patients (4).

Seeing that LIFT is a consequence of an acute inversion injury of the ankle, a variable degree of the anterior talofibular ligament (ATFL) damage is usually present (3). If ankle instability is recorded, there is the possibility to combine fixation techniques of the osteochondral fragment with ligament repair, thereby avoiding two separate procedures. In the reported LIFT studies where ATFL was torn, repairing of the ligament was done in an open manner (1,4,11,13). However, advancements in ankle arthroscopy have enabled repairing of ligaments by arthroscopic approach (17-19). Thus, it is reasonable to expect that in the case of LIFT lesion associated with ankle instability, definitive treatment could be performed during the single arthroscopic procedure.

The management of the LIFT lesion is very challenging due to its rarity, nonspecific radiographic features, and time-dependent treatment possibilities. LIFT can be successfully managed only if recognized acutely. Care must be taken to carefully inspect the condition of the articular cartilage and the adjacent subchondral bone of the displaced fragment. If the articular cartilage appears intact with sufficient subchondral bone, fixation of the fragment is optimal management, otherwise excision and microfracture can be the treatment of choice.

References

(1.) Schepers T, De Rooij PP, Van Lieshout EM, Patka P. Reinsertion of an inverted osteochondral lesion of the talus: a case report. J Foot Ankle Surg. 2011;50:486-9. doi: 10.1053/j.jfas.2011.04.003

(2.) O'Loughlin PF, Heyworth BE, Kennedy JG. Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle. Am J Sports Med. 2010;38:392-404. doi: 10.1177/0363546509336336

(3.) Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41-A: 988-1020.

(4.) Dunlap BJ, Ferkel RD, Applegate GR. The "LIFT" lesion: lateral inverted osteochondral fracture of the talus. Arthroscopy. 2013;29:1826-33. doi: 10.1016/j.arthro.2013.08.012

(5.) van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy. 1997;13:90-6.

(6.) van Dijk CN, van Bergen CJ. Advancements in ankle arthroscopy. J Am Acad Orthop Surg. 2008;16:635-46.

(7.) Jurina A, Dimnjakovic D, Mustapic M, Smoljanovic T, Bojanic I. Clinical and MRI outcomes after surgical treatment of osteochondral lesions of the talus in skeletally immature children. J Pediatr Orthop. 2018;38:122-7. doi: 10.1097/bpo.0000000000000745

(8.) Wade AM, Bustillo J. Unusual orientation of talar osteochondral fragment: a case report. Foot Ankle Surg. 2010;16:e96-9. doi: 10.1016/j.fas.2010.02.002

(9.) Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am. 1980;62:97-102.

(10.) Kenny CH. Inverted osteochondral fracture of the talus diagnosed by tomography. A case report. J Bone Joint Surg Am. 1981;63:1020-2.

(11.) Verzin EJ, Henderson SA. Inverted osteochondral fracture of the talus with rupture of the lateral ankle ligaments. Foot Ankle Surg. 2004;10:207-11.

(12.) Looze CA, Capo J, Ryan MK, Begly JP, Chapman C, Swanson D, et al. Evaluation and management of osteochondral lesions of the talus. Cartilage. 2017;8:19-30. doi: 10.1177/1947603516670708

(13.) Zelent ME, Neese DJ. Talar dome fracture repaired using bioabsorbable fixation. J Am Podiatr Med Assoc. 2006;96:256-9. doi. 10.7547/0960256

(14.) Chandran P, Kamath RP, Nihal A. Osteochondral fracture of the talus treated with bio absorbable pins. Foot. 2008;18:56-8. doi: 10.1016/j.foot.2007.10.001

(15.) Lavery LA, Peterson JD, Pollack R, Higgins KR. Risk of complications of first metatarsal head osteotomies with biodegradable pin fixation: Biofix versus Orthosorb. J Foot Ankle Surg. 1994;33:334-40.

(16.) Kristensen G, Lind T, Lavard P, Olsen PA. Fracture stage 4 of the lateral talar dome treated arthroscopically using Biofix for fixation. Arthroscopy. 1990;6:242-4.

(17.) Acevedo JI, Mangone P. Arthroscopic brostrom technique. Foot Ankle Int. 2015;36:465-73. doi: 10.1177/1071100715576107

(18.) Vega J, Golano P, Pellegrino A, Rabat E, Pena F. All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int. 2013;34:1701-9. doi: 10.1177/1071100713502322

(19.) Matsui K, Takao M, Miyamoto W, Innami K, Matsushita T.. Arthroscopic Brostrom repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Trauma Surg. 2014;134:1461-7. doi: 10.1007/s00402-014-2049-x

Andrija Jurina (1), Valentina Delimar (2), Damjan Dimnjakovic (3) and Ivan Bojanic (3,4)

(1) Department of Surgery, Division of General and Sports Traumatology and Orthopedic Surgery, Merkur University Hospital, Zagreb, Croatia; (2) Krapinske Toplice Special Hospital for Medical Rehabilitation, Krapinske Toplice, Croatia; (3) Department of Orthopedic Surgery, Zagreb University Hospital Centre, Zagreb, Croatia; (4) University of Zagreb, School of Medicine, Zagreb, Croatia

Correspondence to: Andrija Jurina, MD, Department of Surgery, Division of General and Sports Traumatology and Orthopedic Surgery, Merkur University Hospital, Zajceva 19, HR-10000 Zagreb, Croatia

E-mail: andrija.jurina1@gmail.com

Received February 28, 2017, accepted September 6, 2017

doi: 10.20471/acc.2018.57.02.21
Table 1. Summary of literature reports on patients undergoing surgical
treatment due to LIFT lesion

Authors,            No.      Preoperative  LIFT lesion     Ankle
year                of LIFT  diagnostics   recognized      instability
                    cases                  preoperatively

Berndt and           1       Plain         Yes             Yes
Harty, 1959                  radiographs
Canale and           1       Plain         No              Unknown
Bending, 1980                radiographs
Kenny, 1981          1       Plain         Yes             No
                             radiographs
Kristensen et al.,   1       Plain         Yes             Yes
1990                         radiographs
Verzin and           1       Plain         Yes             Yes
Henderson,                   radiographs,
2004                         CT, MRI
Zelent and           1       Plain         No              Yes
Neese, 2006                  radiographs,
                             MRI
Chandran et al.,     1       Plain         No              Unknown
2007                         radiographs,
                             CT
Wade and             1       Plain         No              No
Bustillo, 2010               radiographs,
                             MRI
Schepers et al.,     1       Plain         Yes             Yes
2011                         radiographs,
                             CT
Dunlap et al.,      10       Plain         Yes             Yes
2013                         radiographs,
                             CT, MRI

Authors,            Time span     Operation technique
year                from injury
                    to operation

Berndt and           2 days       Arthrotomy:
Harty, 1959                       simple impaction
Canale and          Unknown       Arthrotomy:
Bending, 1980                     unknown technique
Kenny, 1981         Several days  Arthrotomy:
                                  excision and curettage
Kristensen et al.,   2 days       Arthroscopy: fixation
1990                              (bioabsorbable pins)
Verzin and           1 day        Arthrotomy:
Henderson,                        simple impaction,
2004                              ligament repair
Zelent and           1 day        Arthrotomy: fixation
Neese, 2006                       (bioabsorbable pins),
                                  ligament repair
Chandran et al.,     1 day        Arthrotomy: fixation
2007                              (bioabsorbable pins)
Wade and            84 days       Arthroscopy: excision
Bustillo, 2010                    and microfracture
Schepers et al.,     9 days       Arthrotomy: fixation
2011                              (bioabsorbable pins),
                                  ligament repair
Dunlap et al.,      Mean 15.4     Arthroscopy (2): excision
2013                (range 3-65)  and microfracture
                    days          arthrotomy (8): fixation
                                  (bioabsorbable pins),
                                  ligament repair (10)

LIFT = lateral inverted osteochondral fracture of the talus;
CT = computed tomography; MRI = magnetic resonance imaging
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Title Annotation:Case Report
Author:Jurina, Andrija; Delimar, Valentina; Dimnjakovic, Damjan; Bojanic, Ivan
Publication:Acta Clinica Croatica
Article Type:Author abstract
Date:Jun 1, 2018
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