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Atraumatic Osteonecrosis of the Talus*

RONALD E. DELANOIS, M.D., MICHAEL A. MONT, M.D., TAEK RIM YOON, M.D., MARK MIZELL, M.D. and DAVID S. HUNGERFORD, M.D., BALTIMORE, MARYLAND

Investigation performed at the Division of Arthritis Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, The Good Samaritan Hospital, Baltimore

	Abstract

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Thirty-seven ankles in twenty-four patients were treated at our institution between July 1, 1974, and December 31, 1996, for atraumatic osteonecrosis of the talus. This group represents 2 per cent of the 1056 patients who were managed for osteonecrosis during this period. There were twenty-one women and three men, and their mean age was forty years (range, twenty-six to sixty-two years) at the time of the diagnosis. Thirteen (54 per cent) of the twenty-four patients had bilateral involvement. Sixteen patients (67 per cent) had a disease that affects the immune system, including systemic lupus erythematosus (thirteen patients), scleroderma (one), insulin-dependent diabetes mellitus (one), and multiple sclerosis (one). Four patients had a history of regular alcohol use, and four patients had a history of moderate smoking. One patient had a protein-S deficiency, one patient had had a renal transplant, and one patient had a history of asthma. Two patients had no identifiable risk factors for osteoarthrosis. Fifteen patients (63 per cent) had involvement of other large joints. The mean duration of symptoms before the patients were seen was 5.4 months (range, two months to two 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. A radiographic review revealed that, according to the system of Ficat and Arlet, eight ankles had stage-III or IV disease of the talus at presentation. The remaining twenty-nine ankles had stage-II disease. The osteonecrosis was seen in the posterolateral aspect of the talar dome (zones III and IV on the sagittal images and zones II, III, and IV on the coronal images) in twenty-two of the twenty-three ankles for which magnetic resonance images were available. The osteonecrosis was seen in the anteromedial aspect of the talar dome (zones I and II on the sagittal images and zone I on the coronal images) in the remaining ankle. Bone scans, which were available for eleven ankles, revealed increased uptake in the talus. All patients were initially managed non-operatively with restricted weight-bearing, an ankle-foot orthosis, and use of analgesics; two ankles responded to this regimen. 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 a mean of seven years (range, two to fifteen years) postoperatively; the remaining three ankles had an arthrodesis after the core decompression failed. Three ankles were treated initially with an arthrodesis for postcollapse (stage-III or IV) disease. All six of the ankles that had an arthrodesis fused, at a mean of seven months (range, five to nine 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 non-operatively or with core decompression and thus reduce the need for arthrodesis. We also believe that when a patient has osteonecrosis of the talus, the hips should be screened with use of standard radiography or magnetic resonance imaging, or both.

	Introduction

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Osteonecrosis of the talus after severe injury of the ankle is well recognized¹⁵, and the radiographic identification, characterization, and treatment of the lesion have been well documented¹². However, to the best of our knowledge, there is no such information on atraumatic osteonecrosis in the literature. Because of the nature of the extraosseous and intraosseous blood supply of the talus, which has been well described^3,9, post-traumatic osteonecrosis involves the body of the talus more frequently than it does the neck or head of the talus. However, the pathogenesis of post-traumatic osteonecrosis still is not completely understood; for example, it is not clear why osteonecrosis sometimes does not develop in a completely severed talar body. The pathogenesis of atraumatic osteonecrosis is even more unclear; it has been reported in association with various conditions, such as hyperlipidemia⁵, hyperuricemia^10,16,18, occlusive vascular disease⁷, systemic lupus erythematosus^14,23,26, sickle-cell disease^4,19, alcoholism¹³, pancreatitis⁴, and use of corticosteroids^1,5,11,23,26.

The purpose of the present study was to define the clinical, demographic, and radiographic patterns of atraumatic osteonecrosis of the talus at presentation and to report the treatment and outcome of this condition.

	Materials and Methods

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Between July 1, 1974, and December 31, 1996, 1056 patients were managed at our facility for osteonecrosis of the hip, knee, shoulder, or ankle. Of these patients, thirty-seven (fifty ankles) were identified as having osteonecrosis of the talus. Thirteen patients (thirteen ankles) in whom the osteonecrosis had developed following acute trauma, such as a displaced fracture of the neck of the talus or dislocation of the talus, were excluded from the study. Thus, thirty-seven ankles in twenty-four patients were included in this study. The mean age of the twenty-one women and three men was forty years (range, twenty-six to sixty-two years).

A retrospective clinical and radiographic review was performed. Hospital outpatient records were analyzed with respect to demographic data, including age at presentation, gender, associated diseases, alcohol use, tobacco use, symptoms at presentation, family history, weight, involvement of other joints, and use of corticosteroids. All of the patients were examined clinically and radiographically by us, and the clinical data were obtained at the time of presentation and at the most recent follow-up examination.

Use of corticosteroids was assigned, according to dosage, to one of three categories²² to assess the association between the dosage and the severity of the symptoms or the extent of the disease at presentation. Category 1 meant that the patient had been taking less than thirty milligrams of prednisone a day for less than six months; category 2, that the patient at some time had been taking thirty to fifty-nine milligrams of prednisone a day or had been using corticosteroids for six months to two years; and category 3, that the patient had been taking at least sixty milligrams of prednisone a day or had been taking corticosteroids (regardless of dose) for more than two years.

The radiographic review included plain radiographs, computerized tomographic scans, and magnetic resonance images. Anteroposterior and lateral radiographs had been made of all ankles in order to stage and characterize the osteonecrosis at presentation and at the most recent follow-up examination. Magnetic resonance images, including coronal and sagittal images through the hindfoot, midfoot, and forefoot, were made at presentation for twenty-three of the thirty-seven ankles. These images allowed identification of other bones affected by osteonecrosis. The talar dome was divided into four sections on both the coronal and the sagittal images in order to better describe the extent of the osteonecrosis (Fig. 1). All of the ankles were classified with use of the system of Ficat and Arlet, as modified for the ankle^7,8,23 (Table I). Technetium-99m bone scans were made for eleven ankles, and we attempted to associate the findings of these studies with those on the plain radiographs and the magnetic resonance images.

View larger version (21K): [in this window] [in a new window]   Fig. 1 Illustrations showing anteroposterior and lateral views of the talus with the four zones used to define the area involved with osteonecrosis.

Treatment Methods
All ankles were initially treated non-operatively for a minimum of three months with use of an ankle-foot orthosis, analgesics, and partial weight-bearing. Two ankles responded to this regimen. Persistent severe pain on weight-bearing led to treatment of the remaining thirty-five ankles with core decompression²³ or arthrodesis²⁶ (Table III). These procedures and their rehabilitation protocols have been described elsewhere^23,26. Thirty-two ankles were treated with core decompression. All but five of these ankles had stage-II disease at presentation^7,8,23; the remaining five had stage-III disease. Two ankles with stage-III disease and one with stage-IV disease were treated initially with an arthrodesis. An arthrodesis was also performed after the core depression in three of the five ankles that had stage-III disease.

	Results

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Clinical Evaluation
Thirteen (54 per cent) of the twenty-four patients had bilateral talar involvement. Sixteen patients (67 per cent) had a disease that affected the immune system, including systemic lupus erythematosus (thirteen patients), scleroderma (one), insulin-dependent diabetes mellitus (one), and multiple sclerosis (one). Four patients had a history of regular alcohol use, but only two consumed more than 400 milliliters of alcohol (equivalent to twenty cans of beer) a week. The other two patients reported that they drank two beers or cocktails a day. Four patients had a history of smoking; only one smoked more than one pack a day. One patient had a protein-S deficiency, one patient had had a renal transplant, and one patient had a history of asthma. Two patients had no identifiable risk factors for osteonecrosis.

Twenty patients (83 per cent) had a history of corticosteroid use. Eleven of the patients had a history of category-1 use; four, category-2; and five, category-3. We could detect no relationship between the extent of osteonecrotic involvement of the talus and the amount or duration of corticosteroid use or the prevalence of bilateral talar involvement. Although the patients who had bilateral talar osteonecrosis did not substantially differ from those who had unilateral involvement with regard to age (mean for the bilateral group, forty-one years) or duration of symptoms (mean, 5.6 months), the two groups differed with regard to corticosteroid use. Of the thirteen patients who had bilateral involvement, twelve had a history of corticosteroid use: eight had a history of category-2 or 3 use and four, category-1. In comparison, eight of the eleven patients who had unilateral involvement had used corticosteroids: seven had a history of category-1 use and one, category-3.

The mean score at presentation, according to the system of Mazur et al., was 34 points (range, 2 to 75 points). The mean score for the patients who had bilateral involvement was 32 points compared with 36 points for the patients who had unilateral involvement. The mean pain score was 10 points (range, 0 to 40 points). There was no association between the extent of talar involvement with osteonecrosis and the score according to the system of Mazur et al.

The mean score at the most recent follow-up examination was 89 points (range, 60 to 96 points).

Fifteen patients (63 per cent) had osteonecrotic involvement of at least one other large joint, and nine of them had involvement of at least three other joints. Thirteen patients had involvement of one hip or both, ten had involvement of one knee or both, and seven had involvement of one shoulder or both. All nine of the patients who had a history of category-2 or 3 corticosteroid use had involvement of another large joint. Of the nine patients who had involvement of at least three joints, eight had used corticosteroids: seven had a history of category-3 use and one, category-1. The remaining patient had a protein-S deficiency and was the only one of the four patients who had not used corticosteroids to have involvement of another joint. Of the fifteen patients who had involvement of at least one other joint, only two were seen initially because of involvement of the talus. All of the other joints of these two patients were asymptomatic at presentation, but osteonecrosis was diagnosed in both hips of one patient and in both hips and knees of the other patient after symptoms developed three and six months later, respectively. Of the remaining thirteen patients, eight were seen because of osteonecrosis of the hip or knee, or both, a mean of five months (range, one to nine months) before they were seen because of osteonecrosis of the talus and five were seen because of osteonecrosis of the hip or knee, or both, at the same time that they were seen because of osteonecrosis of the talus.

The mean duration of the symptoms before the diagnosis was 5.4 months (range, two months to two years). At presentation, all of the patients had pain of the involved ankle or ankles. There was subjective swelling of eighteen ankles (49 per cent), but this was not quantified by the examining physician. There was a 5 to 10-degree loss of motion, primarily dorsiflexion, of fourteen ankles (38 per cent).

Radiographic Evaluation
The plain radiographs made at presentation revealed stage-II disease (sclerosis with cystic changes) in twenty-nine ankles (Fig. 2), stage-III disease (subchondral collapse) in seven (Fig. 3), and stage-IV disease (arthrotic changes on both sides of the joint) in one^7,8,23. No ankle had stage-I disease. Twenty-two of the twenty-three ankles for which magnetic resonance images were available had evidence of disease in the posterolateral aspect of the dome of the talus (zones III and IV on the sagittal images and zones II, III, and IV on the coronal images) (Figs. 4-A and 4-B). The remaining patient had evidence of disease in zones I and II on the sagittal images and in zone I on the coronal images. This patient had the highest functional score (75 points), according to the system of Mazur et al., and almost no symptoms at presentation.

View larger version (126K): [in this window] [in a new window]   Fig. 2 Anteroposterior radiograph of a forty-nine-year-old woman who had had pain for two months but no loss of motion. There is sclerosis in the talus (arrowhead), indicating stage-II osteonecrosis, according to the system of Ficat and Arlet7,8,23.

View larger version (138K): [in this window] [in a new window]   Fig. 3 Anteroposterior radiograph of a forty-one-year-old woman who had had a four-month history of pain in the talus and loss of motion. There is a crescent sign (arrowheads), indicating subchondral collapse (stage-III osteonecrosis, according to the system of Ficat and Arlet7,8,23).

View larger version (142K): [in this window] [in a new window]   Figs. 4-A and 4-B: Magnetic resonance images of a forty-four-year-old woman with systemic lupus erythematosus who was seen because of pain in the ankle. She had been managed with high-dose corticosteroid therapy for several years (category 3). Osteonecrosis of both hips and knees had been diagnosed eight months earlier. Fig. 4-A: The sagittal image reveals an area of osteonecrosis in the posterior aspect of the talus (arrowheads).

View larger version (84K): [in this window] [in a new window]   Fig. 4-B The coronal image reveals a large area of osteonecrosis (arrowheads). The most medial aspect of the talus is not involved.

View larger version (149K): [in this window] [in a new window]   Fig. 5 Magnetic resonance image of a forty-three-year-old woman who had multiple sclerosis. She had been managed with high-dose corticosteroid therapy (category 3) and had initially been seen by her primary-care physician because of pain in the hip. Radiographs of the hips revealed osteonecrosis. When she was seen by one of us (M. A. M.), three months later, she had pain in the ankle of new onset. Areas of the talus, the distal aspect of the tibia, and the calcaneus were involved by osteonecrosis (arrowheads).

Results of Treatment
All but five of the ankles that were treated with core decompression had had stage-II disease^7,8,23 at the time of presentation; the other five had had stage-III disease. Three of these five ankles remained symptomatic and were subsequently treated with an arthrodesis. No additional operation was performed in the other twenty-nine ankles, which had a fair-to-excellent result by the time of the most recent follow-up examination at a mean of seven years (range, two to fifteen years) postoperatively. Seven of the ankles with stage-II disease progressed to stage-III. All six ankles that had had an arthrodesis (two that had stage-III disease, one that had stage-IV disease, and three that had a failed core decompression) fused at a mean of seven months (range, five to nine months), and the patients were able to walk outside of the house at the time of the most recent follow-up examination. The two ankles that responded to non-operative treatment (both of which had stage-II disease) were functioning well, with scores of 80 and 92 points, after two and four years of follow-up.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
This report describes the clinical, radiographic, and demographic characteristics of atraumatic osteonecrosis of the talus. There have been previous case reports about the lesion, but none have provided an extensive description of more than two patients. Adleberg and Smith reported a case of atraumatic osteonecrosis of the talus, suggesting that it was associated with the use of corticosteroids. The patients in the present study were similar to the one reported on by Adleberg and Smith with regard to the clinical, radiographic, and demographic findings, which included pain, loss of motion, radiographic collapse of the dome of the talus, and use of corticosteroids.

Several observations were made in the present study. Although there was a high prevalence of corticosteroid use (twenty of twenty-four patients), we did not find a relationship between the dosage of corticosteroids and the severity of the symptoms or the radiographic extent of the osteonecrosis at presentation. However, there was a relationship between the dosage of corticosteroids and the prevalence of involvement of other large joints. All nine of the patients who had a history of category-2 or 3 use of corticosteroids had involvement of other joints. Fifteen of the twenty-four patients in the series had osteonecrotic involvement of other large joints. The hip was most often involved, followed by the knee and the shoulder, but the overall 54 per cent prevalence of osteonecrosis of the hip in the present study (thirteen of twenty-four patients) is much lower than the reported rates for patients who have osteonecrosis of the proximal aspect of the humerus (79 per cent; thirty-seven of forty-seven patients^20,24) or the distal aspect of the femur (98 per cent; seventy-nine of the eighty-one patients^20,21). Nevertheless, we recommend a thorough investigation of the hips of patients who are seen because of osteonecrosis of the talus, as two of our patients in whom osteonecrosis of the femoral head developed were initially seen because of a talar lesion. With regard to symptoms alone, the patients in the present report are similar to those who have involvement of another joint^8,19 in that pain and loss of motion were common at presentation. The mean duration from the onset of symptoms to the diagnosis was 5.4 months, but the range was wide (two months to two years). This wide range may be related to the index of suspicion, but it may also be due to the fact that patients who place lower demands on the ankle wait longer to be seen because of talar involvement than do patients who place higher demands on the ankle. As the activity levels were not assessed in this study, this issue warrants further study.

The posterolateral corner of the talus, which receives the least blood supply, was osteonecrotic in all but one of the patients for whom magnetic resonance images were available. There did not seem to be a relationship between the incidental findings of involvement of other bones within the foot and ankle and the severity of the presenting symptoms or the score according to the system of Mazur et al. Additional study is needed to determine the exact clinical relevance of involvement of the other bones of the foot and ankle.

The options for treatment of symptomatic osteonecrosis of the talus are limited. Non-operative treatment consists of use of analgesics, partial weight-bearing, and an ankle-foot orthosis. Core decompression²³ has been reported to relieve symptoms when patients remain symptomatic. Arthrodesis of the ankle is reserved for lesions involving collapse of the joint (Ficat and Arlet stage III or IV^7,8,23). Unfortunately, many authors have reported difficulty in obtaining a successful fusion in such ankles^1,6,25,26. In the present study, thirty-five (95 per cent) of the thirty-seven ankles eventually needed operative intervention because of progression. Thirty-two ankles had a core decompression, six (three of which had had a core decompression initially) had an arthrodesis, and two were treated only non-operatively with partial weight-bearing, an ankle-foot orthosis, and analgesics. Some of these patients have been reported on previously^23,26.

This study is limited in that it is a retrospective review of an uncommon entity. Large, multicenter studies are needed to clearly define the best diagnostic and treatment methods for these patients. Awareness and early detection of atraumatic osteonecrosis of the talus may improve the treatment and the prognosis as well as change the presenting demographics as described in this study.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopaedic Surgery, The Good Samaritan Hospital, Professional Office Building, Suite G-1, 5601 Loch Raven Boulevard, Baltimore, Maryland 21239. Please address requests for reprints to Dr. Mont. E-mail address for Dr. Mont: rhondamont@aol.com.

	References

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1. Adleberg, J. S., and Smith, G. H.: Corticosteroid-induced avascular necrosis of the talus. J. Foot Surg., 30: 66-69, 1991.[Medline]
2. Agnew, P. S.: Avascular necrosis of the talus in a toddler. J. Foot and Ankle Surg., 34: 132-134, 1995.
3. Aquino, M. D.; Aquino, L.; and Aquino, J. M.: Talar neck fractures: a review of vascular supply and classification. J. Foot Surg., 25: 188-193, 1986.[Medline]
4. Baron, M.; Paltiel, H.; and Lander, P.: Aseptic necrosis of the talus and calcaneal insufficiency fractures in a patient with pancreatitis, subcutaneous fat necrosis, and arthritis. Arthrit. and Rheumat., 27: 1309-1313, 1984.
5. Cruess, R. L.: Steroid-induced osteonecrosis: a review. Canadian J. Surg., 24: 567-571, 1981.[Medline]
6. Dall, D., and Macnab, I.: Spontaneous avascular necrosis of the talus: a report of two cases. South African Med. J., 44: 193-196, 1970.
7. Ficat, R. P.: Nécrose aseptique de la tête fémoral. Pathogénie: la théorie circulatoire. Acta Orthop. Belgica, 47: 198-199, 1981.[Medline]
8. Ficat, R. P.: Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J. Bone and Joint Surg., 67-B(1): 3-9, 1985.
9. Gelberman, R. H., and Mortensen, W. W.: The arterial anatomy of the talus. Foot and Ankle, 4: 64-72, 1983.
10. Harrington, K. D.; Murray, W. R.; Kountz, S. L.; and Belzer, F. O.: Avascular necrosis of bone after renal transplantation. J. Bone and Joint Surg., 53-A: 203-215, March 1971.[Abstract/Free Full Text]
11. Harris, R. D., and Silver, R. A.: Atraumatic aseptic necrosis of the talus. Radiology, 106: 81-83, 1973.[Medline]
12. Hawkins, L. G.: Fractures of the neck of the talus. J. Bone and Joint Surg., 52-A: 991-1002, July 1970.[Abstract/Free Full Text]
13. Hirota, V.; Hirohata, T.; Fukuda, K.; Mori, M.; Yanagawa, H.; Ohno, Y.; and Sugioka, Y.: Association of alcohol intake, cigarette smoking, and occupational status with the risk of idiopathic osteonecrosis of the femoral head. Am. J. Epidemiol., 137: 530-538, 1993.[Abstract/Free Full Text]
14. Hungerford, D. S., and Zizic, T. M.: II. The treatment of ischemic necrosis of bone in systemic lupus erythematosus. Medicine, 59: 143-148, 1980.[Medline]
15. Lancaster, S.; Horowitz, M.; and Alonso, J.: Subtalar dislocations: a prognosticating classification. Orthopedics, 8: 1234-1240, 1985.[Medline]
16. Langevitz, P.; Buskila, D.; Stewart, J.; Sherrard, D. J.; and Hercz, G.: Osteonecrosis in patients receiving dialysis: report of two cases and review of the literature. J. Rheumatol., 17: 402-406, 1990.[Medline]
17. Mazur, J. M.; Schwartz, E.; and Simon, S. R.: Ankle arthrodesis. Long-term follow-up with gait analysis. J. Bone and Joint Surg., 61-A: 964-975, Oct. 1979.[Abstract/Free Full Text]
18. Miskew, D. B. W., and Goldflies, M. L.: Atraumatic avascular necrosis of the talus associated with hyperuricemia. Clin. Orthop., 148: 156-159, 1980.
19. Mont, M. A., and Hungerford, D. S.: Current concepts review. Non-traumatic avascular necrosis of the femoral head. J. Bone and Joint Surg., 77-A: 459-474, March 1995.[Free Full Text]
20. Mont, M. A.; and Hungerford, D. S.: Osteonecrosis of the shoulder, knee, and ankle. In Osteonecrosis: Etiology, Diagnosis, and Treatment, pp. 429-436. Edited by J. R. Urbaniak and J. P. Jones. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1997.
21. Mont, M. A.; Tomek, I. M.; and Hungerford, D. S.: Core decompression for avascular necrosis of the distal femur. Long term followup. Clin. Orthop., 334: 124-130, 1997.
22. Mont, M. A.; Fairbank, A. C.; Petri, M.; and Hungerford, D. S.: Core decompression for osteonecrosis of the femoral head in systemic lupus erythematosus. Clin. Orthop., 334: 91-97, 1997.
23. Mont, M. A.; Schon, L. C.; Hungerford, M. W.; and Hungerford, D. S.: Avascular necrosis of the talus treated by core decompression. J. Bone and Joint Surg., 78-B(5): 827-830, 1996.
24. Mont, M. A.; Maar, D. C.; Urquhart, M. W.; Lennox, D.; and Hungerford, D. S.: Avascular necrosis of the humeral head treated by core decompression. A retrospective review. J. Bone and Joint Surg., 75-B(5): 785-788, 1993.
25. Schmidt, D. M., and Romash, M. M.: Atraumatic avascular necrosis of the head of the talus: a case report. Foot and Ankle, 8: 208-211, 1988.
26. Urquhart, M. W.; Mont, M. A.; Michelson, J. D.; Krackow, K. A.; and Hungerford, D. S.: Osteonecrosis of the talus: treatment by hindfoot fusion. Foot and Ankle Internat., 17: 275-282, 1996.

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