Management Options in Avascular Necrosis of Talus

Abstract

Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

Keywords: Avascular necrosis; Necrosis; autograft; avascular of bone; decompression; management; surgical; talar joint; talus fracture; treatment options.

Figure 1

Flowchart showing the methodology

Figure 2

A clinical photograph showing indigenously designed brace used for conservative management of early AVN Talus (a) Front view of leg (b) Back view of leg

Figure 3

X-ray ankle joint lateral view of 20 year long term followup showing that Blair's Fusion done by excision of talar body and anterior tibial sliding Graft after which the patient recovered and currently is working as a Restaurant manager in Australia

Figure 4

Suggested treatment algorithm