medial malleolar osteotomy w/osteochondral allograft


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PREOPERATIVE DIAGNOSIS: Painful osteochondral lesion, medial talar dome, left ankle.

POSTOPERATIVE DIAGNOSIS: Painful osteochondral lesion, medial talar dome, left ankle.

PROCEDURE PERFORMED: Arthroscopy followed by open osteochondral transplant using an allograft and a medial malleolar osteotomy.

ASSISTANT: XXX This operation could not have been safely performed (without compromising the technical results or length of the procedure) without the assistance of a skilled surgical assistant. A surgical assistant was medically necessary for positioning, retraction and instrumentation throughout this surgical encounter.




SEDATION: 1 g of Ancef.

TOURNIQUET TIME: 1 hour and 20 minutes, supplemental peroneal block.

This is a 48-year-old with progressive pain in the ankle treated conservatively. MRI shows a collapsed osteochondral lesion of medial talar dome.

After placing the patient in the supine position under adequate anesthesia, the tourniquet was elevated to 250 mmHg. Using a medial portal for ingress, we distended the joint and used the lateral portal for visualization. We could see the osteochondral lesion but basically it was too far posterior to get to. The rest of the joint looked very good. We decided to go ahead and do an open incision immediately saving the saphenous vein.

We did a medial malleolar osteotomy by starting the cut with a saw and then finishing with an osteotome. We were able to see the articular surface that was damaged. It was just off the shelf of the talar dome. For this reason what we decided to do was drill the defect using an 8-mm plug and we then took an 8-mm plug from an allographic talar dome. Unfortunately, this was done on an angle and because of that it was difficult to get the measurements properly done on the first one. We had it redo the talar dome allograft a second time using it on a slant so that we could get it to fit properly. Once we did that we put the talar plug in and basically it was little high laterally so that we impacted it so that it was flushed. It was less than 0.5 mm proud laterally. We were very happy with the anterior, medial, posterior aspects. The lateral aspect was extremely minutely elevated. I did not want to impact any more from fear of damaging the articular surface but it was less than 0.5 mm. At this point, we irrigated copiously. We used two malleolar screws to reduce the medial malleolus, which had been previously drilled prior to the osteotomy. We then closed the wound. It should be noted when we did the osteotomy we made sure we identified the posterior tibial tendon and the flexor digitorum. This was protected with Penrose and we were able to make sure that we did not get under neurovascular structures. At this point, the wound was closed with 0-Vicryl, 3-0 Vicryl and skin staples. The patient was put in a posterior splint and started on a CPAP machine at home. He will be nonweightbearing. We will see him in 10 days.