Foot Ankle Clin N Am 9 (2004) 757 773

Avascular necrosis of the talus: current treatment options

Frank Horst, MDa,*, Brett J. Gilbert, MDb, James A. Nunley, MDb
Department of Orthopaedic Surgery, St. Josef-Stift Sendenhorst, Westtor 7, 48324 Sendenhorst, Germany b Department of Orthopaedic Surgery, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA
a

When considering osteonecrosis of the talus, it is convenient to classify the amount of bone that is involved by distinguishing small (osteochondral lesions), partial, and total involvement of the talus. The osteochondral lesion of the talus can be considered to be a partial osteonecrosis; its treatment options have been covered in other issues. A fracture of the talar neck can heal in the presence of avascular necrosis (AVN) of the talus [1,2]. This leads to a treatment algorithm (Fig. 1) that seems to be reasonable and practical and is based on what we know about the natural history of AVN of the talus. It makes sense to distinguish between early- and late-stage AVNlate is more than 9 to 12 months after injury. In the late stages only a few options remain; one is arthrodesis and the other is talectomy. In the early stages it is important to notice whether the AVN developed secondary to a fracture. The Hawkins sign is the most helpful radiographic sign [1,35]; the MRI also is useful, but may be too sensitive to offer any prognostic value or assist in algorithms that are used for treatment. If subchondral atrophy in the talar dome is not present at 6 or more weeks after fracture (absent Hawkins sign) and the fracture has healed radiographically, the concern shifts to avoiding late segmental collapse of the talus. Creeping substitution of the talar body can take up to 36 months to complete [6]. Controversy exists concerning the best way

* Corresponding author. E-mail address: famhorst172@yahoo.com (F. Horst). 1083-7515/04/$ see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.fcl.2004.08.001

foot.theclinics.com

758

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

AVN early Without fx Progressive wb bonegraft Nonvascularized Allo or Auto Resolution Arthrodesis
Fig. 1. Treatment algorithm for AVN of the Talus. fx, fracture; PTB, patellar tendonbearing brace; wb, weight bearing; P/Nwb, partial or no weight bearing.

late

Arthrodesis Talectomy

With fx

P/Nwb until union PTB brace

Core decompression Progression Vascularized

to treat patients who have a healed fracture and an absent Hawkins sign that indicates AVN of the talar body. Penny and Davis [2] concluded that weight bearing on a sclerotic and avascular talus poses no real danger for dome collapse, especially when the subsequent revascularization occurs slowly. If, however, revascularization occurs rapidly, it will proceed to a profound structural weakness within the trabecular bone and result in gross collapse of the talar dome. There is

Fig. 2. (A ,B ) PTB brace.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

759

no way to determine the period and speed with which the talus will revascularize; it has not been proven that nonweight bearing prevents talar collapse. Therefore, some investigators suggest nonweight bearing until fracture healing and until revascularization is complete [79], whereas others propose protected weight bearing in a patellar tendonbearing brace (PTB) (Fig. 2A and B) until revascularization has occurred [1012]. A third group believes that it is impossible to keep the patients non- or partially weight bearing sufficiently; they concentrate instead on treating the sequelae symptomatically [1,2,13]. Poor results with AVN of the talus could not be correlated with the methods of treatment or time off from weight bearing [2]. Therefore, the only symptom that helps us to move on in the algorithm is pain. If the fracture is healed and there is no pain, progressive weight bearing is accepted and is recommended (also for bone remodeling) [14]. The two best courses of the disease are spontaneous resolution or the wearing of a PTB (see Fig. 2A and B) and continuing to a complete resolution. If that does not occur, the orthopedic surgeon has two optionscore decompression and bone grafting.

Fig. 3. Preoperative and postoperative radiographs of a patient who was treated with core decompression for AVN of the talus. (A ,B ) preop. (C ) postop.

760

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

Technique of core decompression The theory behind core decompressionto decrease intraosseous pressure and to enhance revascularizationis well-known and will not be discussed in this article. It is only recommended in stages I and II AVN of the talus. The surgeon will either use a small, 1.5- to 2-mm drill or a 4.0-mm drill to perforate the area of AVN. With the small drill we prefer several holes (810), whereas with the 4.0-mm drill we use 2 to 4 holes (Fig 3). It is easy to use the posterolateral approach between the peroneal tendons and the Achilles tendon. Rarely, other approaches are used (eg, a lateral or medial one, through small incisions with a little dissection). Typically, 70% of patients have reduced pain and increased motion and would be considered to have a good result. Core decompression techniques are used with pressure sensors in the humerus (C. Basamania, MD, personal communication, July 2003). This could be transferred to the talus easily and a pressure-guided and more focused decompression could be possible. Postoperatively, the patients are put in a short leg cast for 2 weeks and start range of motion (ROM) exercises after wound healing. Most patients are treated with a PTB brace. After 6 weeks, partial weight bearing is allowed and is increased individually to full weight bearing.

Results of core decompression Mont et al [15] reviewed 11 patients (17 ankles) who had had core decompression for symptomatic AVN of the talus before collapse. The Mazur grading system was used to assess function preoperatively and at final follow-up; radiographs were graded according to the Ficat and Arlet classification that was modified for the ankle. At a mean follow-up of 7 years (range, 2 to 14 years) 14 ankles (82%) had an excellent or good outcome (Mazur scores N80 points; pain scores N40 points [range, 41 to 50]). The other three ankles required tibiotalar fusion at a mean of 13 months (range, 5 to 20) after core decompression. The investigators concluded that core decompression is a viable method of treatment for symptomatic AVN of the talus before collapse. In 1998, Delanois et al [16] reviewed 37 ankles in 24 patients that were treated at their institution between July 1, 1974, and December 31, 1996 for atraumatic osteonecrosis of the talus. The mean duration of symptoms before the patients were seen was 5.4 months (range, 2 months to 2 years). The mean ankle score at the time of presentation was 34 points (range, 2 to 75 points), according to the system of Mazur et al [17]. A radiographic review revealedaccording to the system of Ficat and Arlet that 8 ankles had stages III or IV disease of the talus at presentation. The remaining 29 ankles had stage II disease. Thirty-two ankles that remained severely symptomatic were treated with core decompression, which was useful in the treatment of precollapse (stage II) disease. Twenty-nine of these ankles had a fair to excellent clinical outcome at a

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

761

Fig. 4. Sagittal (A ) and axial (B ) MRI 1 year after core decompression for AVN of the talus.

mean of 7 years (range, 2 to 15 years) postoperatively; the remaining 3 ankles had an arthrodesis after the core decompression failed. Three ankles were treated initially with an arthrodesis for postcollapse (stages III or IV) disease. All 6 of the ankles that had an arthrodesis fused at a mean of 7 months (range, 5 to 9 months) postoperatively. When patients who have a history of osteonecrosis are seen because of pain in the ankle, the diagnosis of osteonecrosis of the talus should be considered. Early detection may allow the ankle to be treated nonoperatively or with core decompression, and thus, reduce the need for arthrodesis. If the pain resolves after core decompression and the patient is full weight bearing, they are scheduled for reassessment every 3 months (Fig. 4). If there is no segmental collapse and no pain, it is considered to be resolved. In cases of increasing pain when weight bearing is progressed, bone grafting is the next reasonable option. Four types of bone graft generally are available for these casesnonvascularized auto- or allograft and vascularized pedicle or free autograft. There are no long-term results with large bone substitutes and no personal experience.

Nonvascularized autograft The nonvascularized autograft from the iliac crest probably is the most widely used bone graft, followed by the allograft (eg, talus, femoral head). Fig. 5 is taken from a 48-year-old male smoker who had no significant past medical history and presented with left ankle pain. His radiologic studies revealed subtotal AVN of the talus. He had been treated nonoperatively for 6 months. Because of his increasing symptoms we decided to treat him surgically. We used a tricortical iliac crest bone graft as a scaffold and cancellous bone graft after excising the necrosis (Fig. 6AC). The approach was a lateral one with a fibula osteotomy (Fig. 7). Postoperatively, the rest was filled with cancellous bone graft. Postoperatively, the patient was nonweight bearing for 6 weeks and then started

762

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

763

Fig. 5 (continued ).

protected partial weight bearing in a Controlled Ankle Motion (CAM) walker with ROM exercises. Two years later we performed an MRI (Fig. 8). The patient mostly was painfree, although he had intermittent painful episodes, especially after exercising. At first glance, the MRI is disappointing because it seems that large areas of osteonecrosis remain and revascularization is incomplete; however, creeping substitution may take up to 36 months. So far there had been a reduction in pain, slight improvement of ROM, and no segmental collapse.

Nonvascularized allograft If smaller parts of the talus are necrotic and mainly involve the articular surface, a talar allograft may be the only option. This requires the availability of a fresh tissue lab or the surgeon is forced to buy an allograft, that is very expensive. The following case is a 34-year-old basketball player who presented with a large Osteochondral Defect (OCD) of the talus that was considered to be partial necrosis. Initial treatment consisted of arthroscopic debridement and refixation with a small screw. After 4 months, the screw was removed. The patient presented with persistent severe pain to his left ankle 1 year later. It was decided to proceed with a talar allograft from the Duke University Medical Center Fresh Tissue Laboratory; it was placed exactly into the defect after fibula osteotomy and open debridement. The allograft was fixed with two screws that were placed subchondrally (Fig. 9). Two years later the patient returned to the office with a reduced pain level and no segmental collapse. The option of taking an allograft is not available to every surgeon or patient, based on availability and cost. In addition, there are no long-term results for talar
Fig. 5. Anteroposterior radiograph (A ) and coronal MRI (B ) of subtotal AVN of the talus. Sagittal radiograph (C ) and MRI (D ) of subtotal AVN of the talus.

764

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

Fig. 6. (A,B,C ) Insertion of tricortical bone graft into necrotic defect in the talus through a lateral window.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

765

Fig. 7. Final intraoperative situs after closing the window (A ) and postoperative radiograph (B ).

allograft survival rates in larger numbers of patients. There are no data on revascularization, which is considered to be the most important factor for remodeling of the talus.

Vascularized bone graft Mulfinger and Trueta [18] published a complete analysis of the talar circulation in 1970. Gelberman and Mortensen [19] studied the extraosseous and intraosseous blood supply of the talus in 1983, with a new chemical debridement technique. To improve operative incisions for talar fracture treatment, Giebel et al [20] looked at the extraosseous blood supply to the tibia, fibula, and talus. Further

766

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

Fig. 8. Coronal (A ) and sagittal (B ) MRI 2 years after scaffolding.

studies looked at the blood vessels in the sinus tarsi [21], the blood supply to the calcaneus [22,23]. In 1989, Hussl et al [24] reported a vascularized bone graft from the iliac crest that was used for revascularization of the talus in posttraumatic AVN in a 16 year-old patient. In 2001, Gilbert et al [25] studied 14 fresh-frozen cadaver lower extremities with injection of Batsons compound and bone clearing with a modified Spalteholz technique. A second group of specimens was injected with Wards red latex to dissect potential new rotational vascularized pedicle bone grafts. Through this study, they were able to identify a

Fig. 9. (A,B ) Postoperative radiographs after talar allograft.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

767

consistent blood supply to the distal fibula, cuboid, and cuneiform I and III with reliable nutrient arteries. The transverse pedicle branch of the proximal lateral tarsal artery reached and supplied the cuboid in every specimen. The proximal lateral tarsal artery with the cuboid pedicle is approximately 4.1 cm long and can be rotated even to the medial malleolus (Fig. 10). The first cuneiform was found to be supplied by the middle pedicle branch of the distal medial tarsal artery. This is a short pedicle that can be used for navicular pseudarthrosis but is too short for the talus. Basically, the same is true for the next pedicle of the transverse branch to the third cuneiform off the distal lateral tarsal artery (Fig. 11). The fourth potential vascular pedicle was a transverse segment of the anterior lateral malleolar artery to the lateral malleolus. The pedicle also is approximately 4 cm long but usually is an extremely small vessel. The identification of these new rotational vascular pedicle bone grafts could help the foot and ankle surgeon to treat some patients who have AVN of the talus. A few patients who had AVN of the talus were treated with a vascularized bone

Fig. 10. (A,B ) Proximal lateral tarsal artery with the cuboid pedicle and its range.

768

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

Fig. 11. Vascularized pedicles of the distal lateral and medial tarsal artery to the first and third cuneiforms.

graft by James A. Nunley, MD, at the Duke University Medical Center. There are no long-term results yet, but the surgeries were promising.

Salvage procedures/arthrodeses What are the options if the aforementioned methods do not work? There are several salvage possibilities (eg, ankle arthrodesis, subtalar arthrodesis, tibiotalocalcaneal arthrodesis). All of these arthrodeses are disabling to the patient. Although they may revascularize the body of the talus to some extent, the patient is left with a pronounced gait abnormality and the expectation for arthritis in the surrounding joints over time. It is recommended to place the ankle in neutral dorsiflexion/plantarflexion, 08 to 58 of hindfoot valgus, and 58 to 108 of external rotation with the talus translated posteriorly [2629]. If possible, the talus should be positioned exactly under the tibia. The surgeon always should examine the contralateral side for individual modifications in position; generally, the hindfoot is realigned with the leg and the foot is positioned plantigrade. Many techniques can be used that combine a preferred approach with a preferred method of arthrodesis and fixation. Special circumstances, however, might necessitate alteration of a preferred approach or require the use of different fixation techniques. In general, there are surgical principles to be followed (eg, creating broad, congruent cancellous bone surfaces and stabilizing with rigid internal fixation). If there is no or little malalignment of the ankle joint, it is possible to perform an arthroscopic ankle arthrodesis [30]. Using the anterolateral, medial, and posterolateral portals, the surgeon performs an anterior synovectomy and debridement of the ankle with a full radius shaver. Then the articular surfaces are denuded of cartilage with the periosteal elevator followed by a power burr. The medial and lateral gutter also are denuded to expose bleeding subchondral

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

769

bone, while maintaining the contour of the bony surfaces. Internal or external fixation in situ is accomplished by two or three percutaneous, cannulated, or noncannulated, cancellous screws that are parallel or converging. The advantages of this method are less blood loss, a shorter time to union, and an increased union rate because of the minimal interruption of the surrounding soft tissue with subsequent better blood supply. Furthermore, there are fewer complications in patients who have compromised healing potential (eg, vascular disease, diabetes, rheumatoid arthritis, history of corticosteroid use, previous skin or soft tissue flaps). The main disadvantages are that deformities cannot be corrected if they are more than a few degrees and severe bone deficiencies cannot be addressed well [31]. The mini-open technique is similar to the arthroscopic technique but the portals are extended to an anterolateral and anteromedial 1.5- to 2-cm incision. The advantages and disadvantages correspond with the ones of the arthroscopic technique. It is important to close the anterior capsule meticulously. With this technique it is possible to perform additional iliac crest grafting. Several investigators have offered modifications of the open technique. Simin et al [32] described a technique with a distal tibial inlay graft without fixation that may be used as a primary or secondary salvage procedure. Lionberger et al [33] reported a 28% pseudarthrosis rate and fibrous ankylosis secondary to prolonged immobilization. They developed a modified Blair fusion and suggested using a pediatric hip compression screw and a modified Stone staple for fixation. Morris [34] modified Blairs technique by placing a screw in the tibial inlay and using a longitudinal Steinmann pin. Patterson et al [35] described a technique with an anterior sliding graft to provide fixation and fusion. They used an anterolateral approach and limited the periosteal elevation to the anterior aspect of tibia in the region of the graft site. The joint is debrided of cartilage and fibrous tissue while maintaining its shape. The anterior tibial graft (1.2 cm wide, 1.5 cm depth, 5 cm long) is cut out with a saw and removed. After positioning the ankle in the desired position, the quadrilateral area in the talar dome is marked through the tibial defect with the talus positioned posterior in the tibia plafond. The bone is removed from the talus in a plantarflexed position. One 6.5-mm screw is inserted from the posterior medial malleolus directed anteriorly and one 6.5-mm screw is inserted from the anterior lateral tibia into the posterior talus. The tibial graft is implanted and fixed with two 4.5-mm screws. The postoperative treatment includes 6 weeks of nonweight bearing and 6 weeks in a short leg cast with weight bearing as tolerated. There is a moderate risk of an anterior stress fracture of the tibia. The technique that was proposed by Mann and Rongstad [36] in 1998 includes a transfibular approach with resection of the distal fibula; this allows good joint visualization. They did not propose to maintain joint shape but preferred two matched parallel cuts on the distal tibia and the talar dome. This is especially necessary to correct massive malalignment or angular deformities. Two parallel interfragmentary compression screws are inserted from the sinus tarsi into the tibia with the screw tip engaging the medial tibial cortex. The screw heads are

770

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

buried in the sinus tarsi. A partial or total resection of the medial malleolus may be necessary. In cases of total resection, an additional screw or another fixation device should be considered. Rarely does the surgeon need to augment with medial staples. This technique results in slight limb shortening of approximately 4 mm to 9 mm but rarely are there any problems with the peroneal tendons. The deltoid arterial blood supply to the medial talus is preserved. The arthrodesis usually does not require bone grafting. The disadvantages include disruption of the sinus tarsi and difficult placement of the screws; two parallel screws provide less stability than crossed screws [37]. With flat surfaces it can be difficult to align the joint properly. Resection of the fibula allegedly interferes with proper blood supply and subluxation of the peroneal tendons. This technique usually results in greater shortening and the lack of the medial and lateral malleolus provides less stability than with other techniques; however, it allows for the greatest correction of angular deformities [31]. Our preferred open method includes a lateral approach with subperiosteal dissection of the tibia and talus from the lateral side. The cartilage is removed from all surfaces of the tibia and talus. After drilling all surfaces to enhance osteoblast/cyte ingrowth, the ankle is positioned correctly and fixed with three 6.5-mm screws, starting with the posterolateral one. At the end we insert the autologous bone graft from the excised medial one half of fibula to front and back and fix the lateral part of the fibula onto the fusion site with one or two 4.0-mm cancellous screws. It is important to check the peroneal tendons so that they do not sublux. Another described technique is the Insitu dowel grafting method, which consists of using a rotated bone plug in patients who have rheumatoid arthritis or painful, nondeformed ankles. This technique includes using a hollow trocar to create a plug of bone that is approximately 8 mm in diameter and is cut across the ankle parallel to the joint surface. The plug is then rotated 908. Besides fixing the arthrodesis site with screws, the surgeon can use different external fixators (eg, monoplanar, multi-planar) or plate fixation. If using a lateral plate, a large or small fragment T-plate is applied to the lateral side (compression type) or a pediatric 908 osteotomy compression plate can be used [38]. The other possibility is to use a double T-plate fixationthat is stronger than the fibular strut fixation (lateral fibular strut fixed is with two 4.5-mm screws in tibia)with the crossed screw fixation (6.5 mm) [39]. In certain cases of severe osteoarthritis or joint destruction or in salvage procedures it may be necessary to use an anterior plate that is bent accordingly to hold the joint in the desired position. Screw purchase is obtained in the tibia and the dorsal foot (talus, navicular, cuboid, cuneiforms, or metatarsals). This fixation method often includes bone grafting, either with allograft or the iliac crest. The posterior plate requires a posterior approach; the arthrodesis is fixed with a 908 osteotomy plate and the blade is in the talus. Kirschner wires or vertical Steinmann pins do not provide compression. Staples only should be used as a supplement [31].

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

771

The patient is usually kept nonweight bearing for 12 weeks and then is allowed to increase weight bearing with a removable upright walking boot [36]. Some investigators advocate 4 to 6 weeks of nonweight bearing and then weight bearing is progressed. In any case, an individual postoperative treatment is necessary according to the patients habits, occupation, social integration, and compliance. Unprotected weight bearing is allowed only after bone trabeculation is seen across the arthrodesis site. After ankle arthrodesis, the foot is allowed dorsiflexion/plantarflexion of 108 to 268 [40,41]. It is important to address postoperatively a possible leg length discrepancy and the tendency to rotate the hip externally, even with proper positioning of the fusion. Patients compensate and try to facilitate the stance phase of their gait with external rotation of their ipsilateral hip. In cases of fusion with bone graft after failed Total Ankle Replacement (TAR), the patient will be kept nonweight bearing for 4 to 6 months until there is evidence of bone union through the massive bone graft. For a limited time after surgery, some patients may benefit from an orthotic or even a double-upright brace with a locked ankle and solid ankle cushion heel to compensate for heelground contact. A rocker-bottom sole helps to translate the tibia over the foot [31].

Complications in ankle arthrodesis Complications are not rare. Besides wound problems that are due to hematoma, dehiscence, and soft tissue irritation during surgery, the complication that is noted most often is the literature is nonunion, which may occur in up to 40% of cases. Other complications include overresection of subchondral joint surfaces with excessive shortening of the leg and delayed union that may require the use of an internal or external bone stimulator. If an arthrodesis malunion occurs, several sequelae can follow, including increased stress on other structures in the foot, knee, hip, and spine. Increased stress in adjacent joints could lead to the need for extension of the arthrodesis in the long-term. As with every surgical procedure there can be an infection (eg, wound, pin tract, osteomyelitis, sepsis) or a talar or tibial fracture (eg, distal anterior tibial stress fracture after anterior sliding graft technique). The need for a Below the Knee Amputation (BKA) is rare [26]. In the case of large bony defects in failed arthroplasty, large slabs of iliac crest graft usually are needed for reconstruction. The plastic surgeon may need to be involved to cover larger skin defects with musculocutaneous flaps (local or free). Nonunions might cause subtalar involvement so that in revision surgery that joint has to be addressed additionally and also be fused with screws, an intramedullary nail, an external fixator, or even a plate. The ideal position for pantalar arthrodesis is approximately 58 of valgus. A double plate fixation or anterior plate, in cases with bone loss with fibular bone graft or iliac crest, are possible. Revision arthrodesis for tibiotalar pseudarthrosis is a worthwhile procedure [42,43].

772

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

Summary AVN of the talus is a challenging disease process with respect to pathophysiology and treatment. We believe that our algorithm is a legitimate approach to aid the orthopedic surgeon in initiating a promising treatment. It is divided into different levels and allows to change between some. This is not the only way to proceed but it seems promising, especially if the long-term results with the vascularized bone grafts show revascularization of the talus. As always in medicine, the treatment needs to be individualized. Arthrodesis always should be the last option and is a challenging procedure.

References
[1] Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970;52:991 1002. [2] Henderson RC. Posttraumatic necrosis of the talus: the Hawkins sign versus magnetic resonance imaging. J Orthop Trauma 1991;5(1):96 9. [3] Canale ST, Kelly Jr FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143 56. [4] Wright DG, Adelaar RS. Avascular necrosis of the talus. Foot Ankle Int 1995;16:743 4. [5] McKeever FM. Treatment of complications of fractures and dislocations of the talus. Clin Orthop 1963;30:45 52. [6] Penny JN, Davis LA. Fractures and fracture-dislocations of the neck of the talus. J Trauma 1980; 20:1029 37. [7] Adelaar RS. The treatment of complex fractures of the talus. Orthop Clin North Am 1989;20: 691 707. [8] Canale ST. Fractures of the neck of the talus. Orthopedics 1990;10:1105 15. [9] Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br 1970;52:36 48. [10] Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop 1985;199:81 7. [11] Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88 96. [12] Szyszkowitz R, Reschauer R, Seggl W. Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop 1985;199:97 107. [13] Rammelt S, Zwipp H, Gavlik JM. Avascular necrosis after minimally displaced talus fracture in a child. Foot Ankle Int 2000;21:1030 6. [14] Trauth J, Blasius K. Talusnekrose und ihre Behandlung. [Talus necrosis and its treatment]. Aktuelle Traumatol 1988;18:152 6 [in German]. [15] Mont MA, Schon LC, Hungerford MW, Hungerford DS. Avascular necrosis of the talus treated by core decompression. J Bone Joint Surg Br 1996;78:827 30. [16] Delanois RE, Mont MA, Yoon TR, Mizell M, Hungerford DS. Atraumatic osteonecrosis of the talus. J Bone Joint Surg Am 1998;80:529 36, Rec #: 140. [17] Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am 1979;61(7):964 75. [18] Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br 1970;52:160 7. [19] Gelberman RH, Mortensen WW. The arterial anatomy of the talus. Foot Ankle 1983;4:64 72. [20] Giebel GD, Meyer C, Koebke J, Giebel G. The arterial supply of the ankle joint and its importance for the operative fracture treatment. Surg Radiol Anat 1997;19:231 5. [21] Schwarzenbach B, Dora C, Lang A, Kissling RO. Blood vessels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat 1997;10:173 82.

F. Horst et al / Foot Ankle Clin N Am 9 (2004) 757773

773

[22] Andermahr J, Helling HJ, Rehm KE, Koebke Z. The vascularization of the os calcaneum and the clinical consequences. Clin Orthop 1999;363:212 8. [23] Andermahr J, Helling HJ, Landwehr P, Fischbach R, Koebke J, Rehm KE. The lateral calcaneal artery. Surg Radiol Anat 1998;20:419 23. [24] Hussl H, Sailer R, Daniaux H, Pechlaner S. Revascularization of a partially necrotic talus with a vascularized bone graft from the iliac crest. Arch Orthop Trauma Surg 1989;108:27 9. [25] Gilbert B, Horst F, Nunley J. Potential donor rotational bone grafts using vascular territories in the foot and ankle. J Bone Joint Surg Am 2004;86(9):185773. [26] Scranton Jr PE. Results of arthrodesis of the tarsus: talocalcaneal, midtarsal, and subtalar joints. Foot Ankle 1991;12:156 64. [27] Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am 1987;69:1052 62. [28] Morrey BF, Wiedeman Jr GP. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 1980;62:777 84. [29] Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg Am 1985;67:546 50. [30] Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop 1991;268:84 95. [31] Horst F, Nunley JA. Ankle arthrodesis. J Surg Orthop Adv 2004;13(2):8190. [32] Simin RM, ONeil Jr CJ, Karlin JM, Silvani SH, Scurran BL. Fractures of the neck of the talus and the Blair fusion: a review of the literature and case report. Clin Podiatr Med Surg 1988;5: 393 420. [33] Lionberger DR, Bishop JO, Tullos HS. The modified Blair fusion. Foot Ankle 1982;3:60 2. [34] Morris HD, Hand WL, Dunn AW. The modified Blair fusion for fractures of the talus. J Bone Joint Surg Am 1971;53(7):1289 97. [35] Patterson BM, Inglis AE, Moeckel BH. Anterior sliding graft for tibiotalar arthrodesis. Foot Ankle Int 1997;18:330 4. [36] Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int 1998; 19:3 9. [37] Friedman RL, Glisson RR, Nunley II JA. A biomechanical comparative analysis of two techniques for tibiotalar arthrodesis. Foot Ankle Int 1994;15:301 5. [38] Braly WG, Baker JK, Tullos HS. Arthrodesis of the ankle with lateral plating. Foot Ankle Int 1994;15:649 53. [39] Dohm MP, Benjamin JB, Harrison J, Szivek JA. A biomechanical evaluation of three forms of internal fixation used in ankle arthrodesis. Foot Ankle Int 1994;15:297 300. [40] Hintermann B, Nigg BM. Influence of arthrodeses on kinematics of the axially loaded ankle complex during dorsiflexion/plantarflexion. Foot Ankle Int 1995;16:633 6. [41] Abdo RV, Wasilewski SA. Ankle arthrodesis: a long-term study. Foot Ankle 1992;13:307 12. [42] Levine SE, Myerson MS, Lucas P, Schon LC. Salvage of pseudoarthrosis after tibiotalar arthrodesis. Foot Ankle Int 1997;18:580 5. [43] Anderson JG, Coetzee JC, Hansen ST. Revision ankle fusion using internal compression arthrodesis with screw fixation. Foot Ankle Int 1997;18:300 9.