Approach to Osteochondral Lesions of the Posteromedial Talar Dome: A Review of Arthroscopic Videos.

Background: Osteochondral lesions of the talus (OLTs) most commonly occur in the posteromedial talar dome; however, there are no consensus guidelines on the appropriate approach to performing microfracture; that is, whether adequate visualization can be achieved solely through anterior ankle arthroscopy as well as the circumstances under which posterior ankle arthroscopy is required. Purpose: To ascertain whether (1) arthroscopic microfracture of posteromedial OLT can be accomplished solely through anterior ankle arthroscopy and (2) if there are specific conditions that may require posterior ankle arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively reviewed videos of patients who underwent primary arthroscopic microfractures for OLT on the posteromedial talar dome between January 2010 and June 2021. The enrolled patients were divided into 2 groups according to the direction of arthroscopy (anterior or posterior). Then, we focused on whether visualization of the posteromedial OLT was adequate through the anteromedial or anterolateral portal in the anterior ankle arthroscopy group (posteromedial or posterolateral portal in the posterior ankle arthroscopy group). Similarly, we assessed whether a sufficient microfracture technique was feasible during surgery. Results: A total of 79 patients were included in this study, among which 62 and 17 were assigned to the anterior and posterior ankle arthroscopy groups, respectively. Posteromedial OLTs were fully observed through the anteromedial portal in 79.0% of cases and better observed through the anterolateral portal (93.5%). Among the patients who underwent anterior ankle arthroscopy, only 4 (6.5%) experienced limited visualization, leading to an insufficient microfracture procedure. In 2 of these 4 patients, we observed challenges in advancing the arthroscopy and other devices owing to the narrow joint space, even with sufficient distraction, whereas the remaining 2 showed infeasibilities derived from the location extending posteriorly beyond the tibial plafond on preoperative magnetic resonance imaging. In contrast, microfracture of posteromedial OLT via posterior ankle arthroscopy was successfully performed in all patients. Conclusion: When surgically treating patients with posteromedial OLT, anterior ankle arthroscopy allowed for the successful performance of the microfracture procedure in most cases, unless there was a combined pathology necessitating surgical intervention on the posterior ankle. Posterior ankle arthroscopy can be selectively utilized only for far posteromedial OLT or in patients with narrow joint space, even with sufficient distraction.