Any help is greatly appreciated.. THANKS

..........This allowed access to the medial aspect of the distal tibia and I carefully elevated in extra periosteal fashion. I also incised the posterior tibial tendon sheath posteriorly so I could identify the posteromedial tendons and protect them throughout the case. I also performed an anteromedial arthrotomy such that I could visualize the medial shoulder of the ankle joint. When I peformed the arthrotomy a volume of fluid was expressed. This was sent for analysis.

With the anatomy identified I turned my osteotomy using the Synthes locking small fragment system and a cannulated portion of the system, I placed to 1.25mm K wires in near parallel in a retrograde fashion across the medial malleolus. I then drilled the near cortex to cannulate the medial malleolus and then tapped across what would later be the osteotomy site. Using fluoroscopy as a guide, I outlined a chevron osteotomy of the medial malleolus. I was careful to make the osteotomy relatively laterally such that I would be able to visualize the more lateral portion of the talar dome I then used an oscillating saw to create the osteotomy down to subchondral bone. The osteotomy was then completed using an osteotome to minimize risk of damage to the cartilaginous surface. The talus was well protected. I then released soft tissues posteriorly and was able to rotate the medial malleolus inferiorly and medially to reveal the medial aspect of the talar dome. It was quickly evident that there was an unhealed osteocondral lesion of the superior/medial talar dome. It was well contained. It was ovoid in shape measuring approximately 1 cm in lenth and 6 mm in width. It did go down through subchondral bone, and consistent with her preoperative imaging, there was evidence of insufficiency of the talus and this tended to migrate laterally and distally.

I removed the poorly organized fibrinous tissue from the OCL bed. I then used curettage to remove non viable bone from the cyst, and degenerative bone within the talus. When I was pleased with the debridement, and with a stable cartilaginous border, I copiously irrigated the wound to remove any non viable material.

From the osteotomy site, I was actually able to harvest a small volume of tibial cancellous bone. This was packed into the defect into the talus down to a stable base.

I turned my attention to the allograft cartilage implantation. The product was aspirated to remove the medium from the cartilage samples. I then carefully placed a layer of cartilage within the defect. I used a bioglue to a thin layer of film through and over the cartilage to adhere it to the defect. This was then allowed to cure appropriately. There was a controur to the talus. I ran the ankle through a range of motion, the implant was stable and there was no evidence of crepitus. I debrided poorly organized tissue from the anteromedial apsect of the tibial side of the joint to ensure that there were no loose bodies within the joint. I irrigated away from the implant site. I was pleased with the construct.

I then turned to fixation of the osteotomy. The medial malleolus was rotated into position, and then held again temporarily with K-wires. I then placed two 40 mm partially threaded canulated screws over the guide pins, being careful not to compress the osteotomy site. Visualization and fluoroscopy shows anatomic alignment of medial malleolus......................