Cartilage allograft transplantation for challenging medial talar dome osteochondral defects: A retrospective case series utilizing medial malleolar osteotomy

BACKGROUND Osteochondral defects (OCDs) of the medial talar dome represent a complex surgical challenge due to limited arthroscopic accessibility. Medial malleolar osteotomy allows optimal access for cartilage restoration in challenging medial talar dome lesions. This case series examines the clinical and radiographic outcomes of treating medial talar OCDs with the cartilage allograft following arthroscopic evaluation and medial malleolar osteotomy. AIM To evaluate the clinical and radiographic outcomes of treating large, symptomatic medial talar dome OCDs using a single-stage technique combining medial malleolar osteotomy, bone marrow aspirate augmentation, and cartilage allograft transplantation. We assessed functional improvement using validated outcome measures and graft integration using magnetic resonance imaging (MRI)-based Magnetic Resonance Observation of Cartilage Repair Tissue scoring at midterm follow-up. METHODS A retrospective analysis was conducted on 23 consecutive patients (mean age 35.4 years; 15 males, 8 females) presenting with symptomatic, isolated OCDs of the medial talar dome (Raikin zone 4) after failed conservative management. Each patient underwent arthroscopic evaluation followed by medial malleolar osteotomy, systematic defect preparation with drilling, bone marrow aspirate application, and the cartilage allograft implantation secured with fibrin glue. Clinical assessment utilized the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Short Form-36, and Visual Analogue Scale for pain at mean 24-month follow-up. Pre and post operative radiographic and MRI was used to evaluate graft integration and fill. RESULTS The mean American Orthopaedic Foot and Ankle Society score demonstrated improvement from 54.2 ± 12.1 preoperatively to 88.7 ± 7.5 postoperatively (P < 0.001). Mean Visual Analogue Scale pain scores decreased from 6.4 ± 1.0 to 1.5 ± 1.2 (P < 0.001). Short Form-36 scores exhibited significant enhancement across all domains. Eighteen of 23 patients (80%) achieved good to excellent outcomes. Five patients experienced residual mild pain, though substantially improved from preoperative status. Postoperative MRI revealed complete or substantial graft fill and integration in 20 of 23 patients (87%). Complications included one delayed union of the osteotomy and two superficial wound complications which resolved with conservative management. CONCLUSION Treatment of symptomatic OCDs of the medial talar dome with cartilage allograft following medial malleolar osteotomy represents a safe and effective procedure, yielding significant clinical and radiographic improvements at midterm follow-up. This single-stage procedure offers a promising therapeutic option for these challenging lesions. Long-term follow-up remains necessary to assess repair durability and outcomes.