Management of Bone Cyst of Talar Body by Endoscopic Curettage, Nanofracture, and Bone Graft Substitute

Abstract

Large bone cyst of the talar body is frequently associated with an osteochondral lesion. The talar bone cyst can be an incidental radiologic finding. However, when the talus is extensively destroyed, there is a risk of pathologic fracture and damage to the articular cartilage, leading to persistent swelling and pain of the subtalar joint and ankle joint. Open debridement and bone grafting frequently requires extensive soft-tissue dissection or even different types of malleolar osteotomy for proper access to the lesion. The purpose of this Technical Note is to describes the technique of endoscopic curettage, nanofracture, and filling the cyst with injectable bone graft substitute. This minimally invasive approach has minimal disruption of the normal cartilage surface.

Fig 1

Management of bone cyst (BC) of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. Preoperative radiographs of the illustrated case showed BC at medial part of the talar body. (A) Anteroposterior view; (B) lateral view.

Fig 2

Management of bone cyst (BC) of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. Preoperative computed tomography of the illustrated case showed BC at medial part of the talar body. Arrowheads show the sites where the cyst is closest to the cortex or subchondral bone, corresponding to the anteromedial bone portal and the trans-OCL portal. (A) Coronal view; (B) transverse view; (C) sagittal view.

Fig 3

Management of bone cyst (BC) of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. Preoperative magnetic resonance imaging of the illustrated case shows BC at medial part of the talar body communicating with the osteochondral lesion (OCL). (A) Sagittal view; (B) coronal view.

Fig 4

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. The anterolateral portal is the viewing portal and the anteromedial portal is the working portal. The osteochondral lesion is debrided with an arthroscopic probe. (AP, arthroscopic probe; OCL, osteochondral lesion; T, distal tibia; TD, talar dome.)

Fig 5

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. (A) The anterolateral portal is the viewing portal and the proximal anteromedial portal is the working portal. A guidewire with a drill sleeve is inserted into the ankle joint. (B) The anterolateral portal is the viewing portal and the proximal anteromedial portal is the working portal. The guidewire is drilled through the osteochondral lesion to the bone cyst. (ALP, anterolateral portal; AMP, anteromedial portal; DS, drill sleeve; GW, guidewire; OCL, osteochondral lesion; PAMP, proximal anteromedial portal.)

Fig 6

Management of bone cyst (BC) of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. After insertion of the guidewire (GW) into the BC, correct positioning of the wire is confirmed under fluoroscopy. (A) Lateral view; (B) anteroposterior view.

Fig 7

Management of bone cyst (BC) of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. Insertion of the guidewire (GW) through the medial talar facet (anterior to the medial malleolus) to the BC under fluoroscopy. (A) Anteroposterior view; (B) lateral view.

Fig 8

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. The anteromedial bone portal is the viewing portal and the trans-OCL portal is the working portal. The membranous lining (M) of the cyst is debrided with the arthroscopic shaver (AS).

Fig 9

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in supine position with the legs spread. The ankle is plantarflexed. (A) The arthroscope is inserted through the proximal anteromedial portal to the trans-OCL portal. The arthroscopic shaver is inserted into the anteromedial bone portal. (B) The trans-OCL portal is the viewing portal and the anteromedial bone portal is the working portal. The membranous lining of the cyst is debrided with a small curette. (AMBP, anteromedial bone portal; C, curette; M, membranous lining; PAMP, proximal anteromedial portal.)

Fig 10

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in supine position with the legs spread. The ankle is plantarflexed. (A) Both the arthroscope and arthroscopic shaver are inserted into the proximal anteromedial portal. The arthroscopic shaver is inserted deeper through the trans-OCL portal into the bone cyst. (B) The proximal anteromedial portal is the viewing portal. The arthroscopic shaver is inserted via the trans-OCL portals into the bone cyst and the fibrous tissue and membranous lining of the cyst is debrided. (AMBP, anteromedial bone portal; AMP, anteromedial portal; AS, arthroscopic shaver; PAMP, proximal anteromedial portal.)

Fig 11

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in supine position with the legs spread. The ankle is plantarflexed. The anteromedial bone portal is the viewing portal and the trans-OCL portal is the working portal. Nanofracture of the cyst wall is performed with PleuriStik Guide Wire via the Hand Instrument. (HI, hand instrument; NFPH, nanofracture penetration hole; PSGW, PleuriStik Guide Wire.)

Fig 12

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. It is converted into dry arthroscopy and endoscopy. (A) The anteromedial bone portal is the viewing portal. The fluid inflow is switched off and the blood of the cyst is sucked out. The PRO-DENSE injectable regenerative graft (Wright, Memphis, TN) is injected into the cyst via the proximal anteromedial and trans-OCL portals. (B) Ankle arthroscopy is repeated with the anterolateral portal as the viewing portal. The injectable regenerative graft is packed into the cyst by a periosteal elevator via the anteromedial portal. (IRG, injectable regenerative graft; PE, periosteal elevator; TD, talar dome.)

Fig 13

Management of bone cyst of talar body of the right ankle by endoscopic curettage, nanofracture, and bone graft substitute. The patient is in the supine position with the legs spread. The ankle is plantarflexed. Intraoperative fluoroscopy (A: anteroposterior view; B: lateral view) and post-operative radiographs (C: anteroposterior view; D: lateral view) shows the talar bone cyst is filled up with injectable regenerative graft (IRG).