Bevoni, R.

Buda, R.

Giannini, S.

Grigolo, B.

Vannini, F.

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16.1 Total joint reconstruction of the arthritic ankle joint using bipolar shell allograft 

Abstracts of ICRS 2007, Warsaw, Poland B34
16.1
Total joint reconstruction of the arthritic ankle joint using bipolar 
shell allograft 
S. Giannini, R. Buda, F. Vannini, R. Bevoni, B. Grigolo, Italy 
Post-traumatic arthritis of the ankle in the young and active patient 
represents a reconstructive challenge. Ankle arthrodesis provides 
satisfactory pain relief but functional and psychological limitations 
are reported. Furthermore, inevitable loosening of joint arthroplasty 
in a young and active population has lead in the search for a biologic 
method of repair. The use of frozen allografts as limb salvage surgery 
for malignant bone tumors, alone or in association with prosthesis 
as a modular versatile and durable solution to the resected bone 
segment with limited immunogenic risk, is well documented. More 
recently, the institution of large institutional bone banks allowed for 
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their applicability. Fresh osteochondral allografts would provide 
viable cartilage that can survive transplantation and bone that 
would provide an intact structure until host bone replaces it. This 
approach is intriguing and increasingly popular since it can provide a 
reconstructive solution for younger and higher demanding patients 
where implants are not desirable and arthrodesis is not acceptable. 
The purpose of this study is to describe the preliminary results of 
a series of 25 bipolar shell ankle allografts performed by using a 
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25 patients, 18 males and 7 females (mean age 32±11 years) affected 
by post traumatic arthritis of the unilateral ankle joint grade III, 
received bipolar shell allograft of the ankle. The ideal patient to 
allograft match was permitted through CT scan and x-rays. Patient 
evaluation was carried out clinically by AOFAS and radiographically 
by x-rays, CT scans, and MRI. The preoperative evaluation included 
acquiring a complete history of the patient and a physical and 
radiographic examination. The history and nature of the ankle 
trauma and previous treatments attempted were recorded. The ankle 
was checked for instability, malaligment, and ROM. A panoramic 
radiographic examination of the lower limbs, including antero-
posterior and lateral weight-bearing views of both ankles and a CT 
scan of the affected joint were taken. Candidates were then placed 
in a waiting list until an appropriate size donor became available. 
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donation. Prior to surgery, the size of the donor tibia and talus was 
matched to the host using radiographs and CT scans. No tissue or 
blood type matching was performed. Harvesting of the ankle from the 
donor involved excision of the entire joint with an intact capsule and 
synovial membrane. The ankle was then placed in a sterile container 
with L-glutamine, NaHCO3 and antibiotics solution. This was then 
stored at 4°C until transplantation (within 14 days). A CT scan of 
the harvested ankle was performed in order to obtain standard 
measurements. On the basis of the measurements obtained, the 
compatible patients were individualized from a computerized 
database. Surgical procedure: Surgical treatment was performed in 
two steps, one for the graft preparation and the other for surgery in 
the recipient. First step surgery: On a separate table, the harvested 
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jigs, the allograft was prepared. Second step surgery: The patient 
was placed in supine position with tourniquet at the thigh. The 
internal surface of the medial malleolus was prepared by using a 
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lateral aspect of the ankle. Using the same sized probe utilized for 
preparing the graft, the curved jig for the tibial cut was positioned at 
the proper level and the cut of the distal tibia was then performed, 
followed by the talar surface cut. The damaged joint surfaces were 
then removed and the allograft surfaces were positioned in the host 
ankle, ensuring that the ankle permits a natural and free of overload 
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twist-off screws. Rehabilitation protocol: plaster cast was applied 
for 15 days. Continuous passive motion (CPM) was advised the day 
after cast removal. Walking with crutches and no weight bearing 
on the affected ankle was also advised. Partial weight bearing was 
permitted 4 months after surgery if radiological signs of healing are 
visible, and 6-8 months after surgery complete weight bearing was 
advised. 
The mean follow-up was 20 months (range 32-8). A medial malleolar 
fracture occurred as an intraoperative complication. All the patients 
demonstrated good consolidation rates of the allograft at x-rays, CT 
scan, and MRI controls performed at 4, 6, 8, and 12 months, at an 
average of 5 months. At 6 months follow-up, all the patients were 
allowed complete weight bearing. Normal ROM of the ankle and 
regular gait with no pain and no need of support was resumed in 
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one case, cause of the fracture was patient non-compliance to the 
weight-bearing restriction. In the other case, the fracture occurred 
distally to the osteotomy site, possibly due to trauma. Both cases 
required revision of the graft that appeared damaged in the lateral 
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was lost at follow-up. A bioptic harvest of the transplanted cartilage 
in 16 patients at 1 year follow up demonstrated chondrocytes vitality 
> 90%. 
The rationale for fresh osteochondral allograft is clinical and 
experimental evidence of maintenance of viability and function 
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Furthermore, the bony parts of allograft are progressively replaced by 
host bone in 2-3 years. The fresh osteochondral allograft is becoming 
increasingly popular for the treatment of ankle arthritis in the young 
and active patient, even if it is a very technically demanding technique 
and a high percentage of complications and failure have been 
reported. The technique described has the advantage of dramatically 
reducing the possibility of incongruence between the graft and the 
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of a complete osteoarticualar surface. Furthermore, the curved cut 
of the tibia, obtained through the lateral access, provides extensive 
contact surface and good stability of the graft, with consequent 
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to obtain a congruent allograft of proper thickness and appropriate 
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correction of joint malaligment, and stable but minimal internal 
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the height of the graft be used to correct malaligment of the limb 
and maximum graft thickness should be 1 cm. In conclusion, fresh 
total shell osteochondral allograft of the ankle, although technically 
demanding, is a viable alternative to arthrodesis or arthroplasty in 
individuals with advanced ankle arthritis. The technique presented, 
with the use of the newly developed jigs, represents an improvement 
in allowing a precise and reproducible procedure with the possibility 
of modular cuts. Although preliminary results are encouraging, 
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viability and the validity of the technique. 


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16.1 Total joint reconstruction of the arthritic ankle joint using bipolar shell allograft

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