Talar Dome Resurfacing
with the HemiCap Prosthesis
Take-Home Points
A new metallic implantation technique
for secondary osteochondral defects of
the medial talar dome appears to be a
promising treatment option.
The surface of the prosthetic device
should be placed slightly recessed rela-
tive to the surrounding surface of the
talar cartilage.
Clinical and radiological short-term fol-
low-up are encouraging; however, more
patients and longer follow-up are clearly
needed to draw any firm conclusions.
17.1 Introduction
In 62 % of osteochondral defects of the talus
(OCDs), the defect is located on the medial talar
dome [6]. These medial defects are generally
17
deep and cup-shaped [4]. An OCD may some-
times heal and stabilize but often progresses to a
cystic lesion causing deep ankle pain on weight
bearing, prolonged swelling, diminished range of
motion, and synovitis [15, 25].
Arthroscopic debridement and bone marrow
stimulation is considered the primary treatment
and yields 85 % success [29]. In case of failure of
the primary treatment, current secondary treat-
ment options include osteochondral autograft
transfer, autogenous bone graft, and autologous
chondrocyte implantation [3, 8, 9, 20]. However,
these techniques are sometimes associated with
donor site morbidity, involve two-stage surgery,
or poor graft integration [2, 1214].
For treatment of large lesions of the medial
talar dome or after failed primary treatment, a
contoured articular inlay implant (HemiCAP,
Arthrosurface Inc., Franklin, MA, USA) with a
fixed diameter of 15 mm has been developed
[24]. Its goals are to offer relief of pain, return to
activity, and prevent degeneration/further cyst
formation. There are two components: a Cobalt-
Chromium articular component and a Titanium
screw. Fifteen articular component offset sizes
are available, based on the surface geometry of
the medial talar dome. The offset sizes have been
found appropriate for a variety of talar specimens
in a cadaveric study [24]. Since October 2007,
this implant has been used in our institution in
patients with persistent complaints more than 1
year after primary surgical treatment of a large
osteochondral defect of the medial talar dome
145
146
(anterior-posterior or medial-lateral diameter
>12 mm on CT) [21]. Contraindications of this
procedure are age <18 years, OCD size >20 mm,
ankle osteoarthritis grade II or III [26], concomi-
tant ankle pathology (tibial OCD, instability,
fracture <6 months old, tendonitis), diabetes mel-
litus, advanced osteoporosis, infection, and a
known allergy to the implant material. However,
these indications/contraindications are not strict
because the HemiCap is still in the experimental
stage.
17.2 Surgical Technique
The procedure is carried out under general or spi-
nal anesthesia. The patient is placed in the supine
position with a tourniquet applied around the
upper leg and a rolled-up apron underneath the
lateral malleolus to facilitate eversion of the foot
and improve exposure of the talus. A curved skin
incision of approximately 7 cm is made over the
medial malleolus. The anterior skin is mobilized
using a scalpel and forceps, and a skin retractor
is placed to retract the skin. A Hohmann retrac-
tor is placed over the distal tibia. A small ante-
rior arthrotomy exposes the anteromedial talar
dome. The level of this anterior superior border
of the talar dome will later in the procedure act
as a guide to identify the level of the posterior
ankle joint. Next, the sheath of the posterior
tibial tendon is incised and another Hohmann
retractor is placed posterior to the medial mal-
leolus and anterior to the posterior tibial tendon.
The posterior capsule of the ankle joint can be
visualized now and incised. The posterior inter-
section between the medial malleolus and tibial
plafond is identified using an arthroscopic probe.
The surgeon carefully inserts the 5-mm tip of the
probe in the posteromedial joint space by slid-
ing along the posterior aspect of the distal tibia
at the intersection with the medial malleolus and
gently pulls in an oblique craniomedial direction
[22]. This maneuver identifies the posterior part
of the intersection between the tibial plafond and
medial malleolus. The periosteum at the level of
the intended osteotomy is marked with a surgical
knife, sterile marker pen, or osteotome. Next, the
probe is placed in the anteromedial tibial notch
M.L. Reilingh and C.N. van Dijk
and pulled in an oblique craniomedial direction,
identifying the anterior part of the intersection.
The anterior intersection is marked, and this is
connected to the posterior intersection as a ref-
erence guide to the osteotomy. Before creating
the osteotomy, two screw holes are predrilled
and tapped in the medial malleolus, using a can-
nulated drill. An oscillating saw is placed on the
incised periosteum and directed at the marked
intersection of the tibial plafond and medial mal-
leolus. The osteotomy is created up to approxi-
mately 2 mm above the articular cartilage, while
two Hohmann retractors protect the adjacent soft
tissue. The optimal angle for the osteotomy has
determined to be at a mean angle of 30 relative
to the long tibial axis [23]. The osteotomy is com-
pleted with the use of an osteotome. This way, the
surgeon controls the osteotomy of the articular
surface and minimizes the risk of damaging the
talar cartilage. After the osteotomy has been com-
pleted, the surgeon manually retracts and everts
the medial malleolus using gauze. Optionally, the
distal part is temporarily transfixed by drilling a
large diameter K-wire into the talus through one
of the predrilled holes (Fig. 17.1). Exposure of
the talar dome is improved by forced eversion of
the heel. The fibula is hereby used as a fulcrum
(take care not to use too much force) and the talus
is tilted.
The necrotic fragment of the defect can now
be identified and debrided. Utilizing a drill guide,
a guide pin is placed into the center of the defect,
perpendicular to the curvature of the medial talar
dome. The guide pin ensures that a perpendicu-
lar direction is maintained throughout the pro-
cedure. The titanium screw of the metal implant
is inserted after drilling a pilot hole. A contact
probe is used to determine the radius of curva-
ture in the sagittal and coronal planes to allow
for a precise fit of the articular component to the
existing articular surface. A matching reamer
prepares the site for placement of the articular
component. The reamer is a cannulated instru-
ment used over the guide pin with a diameter of
15 mm. A sizing trial with corresponding offsets
allows for final verification of proper fit. The
selected articular component is oriented into the
correct planes and is placed on the screw. It is
impacted with a gentle hammer-stroke on an
17 Talar Dome Resurfacing with the HemiCap Prosthesis 147

Fig. 17.1 The osteochondral

defect (arrow) is exposed
through an oblique medial
malleolar osteotomy.
A K-wire can be inserted into
the talus through one of the
predrilled holes to hold the
medial malleolus in place

Fig. 17.2 Final view after the

articular component (arrow)
is oriented into the correct
planes and is placed on the
screw. Note that the edges of
the implant are slightly
recessed (approximately
0.5 mm) compared to the
adjacent cartilage level

instrument with a plastic tip, thereby engaging
the taper interlock (Fig. 17.2). After the confir-
mation of slightly recessed implant edges, the
osteotomy is reduced. Initially, large diameter
K-wires are placed through the predrilled screw
holes to confirm correct alignment. A Weber
bone clamp can be placed for initial compres-
sion. Placement of the proximal leg of the Weber
clamp is facilitated by creating a small hole in
the distal tibial cortex proximal to the osteotomy
using a 2.5-mm drill. We routinely use two 3.5-
mm cancellous lag screws with a length of 40
or 45 mm. The posterior tibial tendon sheath
is not repaired and the wound is closed with
Ethilon 3.0 sutures using a vertical mattress
(Donati) technique.
17.3 Rehabilitation
The postoperative management consists of a
plaster cast for 1 week. A functional non-weight-
bearing brace (Walker) or a detachable plaster
cast can be applied for another 5 weeks. During
148
this period, non-weight-bearing sagittal range of
motion exercises are allowed, i.e., 15 min twice
daily. After these 6 weeks, radiographs of the
operated ankle are obtained to confirm consolida-
tion of the malleolar osteotomy. Subsequently,
physical therapy is prescribed to assist in func-
tional recovery and facilitate the return to full
weight bearing over approximately 1 month.
Return to normal weight bearing and walking
should thus be accomplished 10 weeks after sur-
gery. Impact activities, such as running, are
allowed when no signs of prosthetic loosening
and migration are seen after 6 months of follow-
up. Non-contact sports are allowed after 9 months
of follow-up and contact sports 1 year after sur-
gery. However, the risk of periprosthetic fracture
during contact sports should be discussed with
the patient. We reported the first clinical case
report of the talus implant in which the patient
was able to play korfball (contact sports) at the
preinjury level after 1 year and continued to play
at this level at 2 years follow-up [21].
17.4 Discussion
Treatment of osteochondral lesions or osteone-
crosis by means of metal resurfacing implants
is relatively new, and the literature is scarce.
Promising clinical results have been reported for
the treatment of the femoral [27] and humeral
head [18], as well as the first metatarsal [10] and
patellar surface [5]. Two biomechanical cadav-
eric studies provided foundations for use of the
talus implant in the ankle joint [1, 24]. We per-
formed a prospective case series of 15 patients
with a clinical follow-up of 1 year [16]. All
patients had failed prior surgical treatment of
a large defect of the medial talar dome. Failed
prior surgical treatments were debridement and
bone marrow stimulation, cancellous bone graft-
ing of the defect, and screw fixation. Various
outcome measures were recorded prospectively,
including numeric rating scales (NRS) of pain
at rest, climbing stairs, and running, American
Orthopaedic Foot & Ankle Society (AOFAS)
Ankle and Hindfoot clinical rating System,
Foot and Ankle Outcome Score (FAOS), and
M.L. Reilingh and C.N. van Dijk
Short Form 36 (SF-36). After 1 year follow-up,
there was significant improvement in the NRS,
AOFAS, four of five subscales of the FAOS, and
the SF-36 physical component scale. There were
four minor complications that resolved within
the study period. Three patients reported an
area of numbness about the scar, which resolved
within the postoperative year. Another patient
had a superficial wound infection, which was
effectively treated by oral antibiotics. On radio-
graphs there were no signs of prosthetic loosen-
ing, cyst formation, or degenerative changes at 1
year follow-up (Fig. 17.3). The medial malleolar
osteotomy healed in all cases.
Alternative current treatment methods for
large or secondary lesions are osteochondral
autograft transfer system (OATS), cancellous
bone grafting, an osteochondral allograft, ankle
arthrodesis, or ankle arthroplasty. Although
excellent results of OATS have been published
[17], the risk of donor site morbidity in the knee
is worrisome [19]. An additional disadvantage of
osteochondral autografts is difficulty in matching
the talar surface geometry and poor graft integra-
tion [12]. Limited availability and donor site pain
are also disadvantages of cancellous bone graft-
ing [2]. Osteochondral allografts can be used for
massive defects but are not recommended for
localized OCDs, based upon the gradual dete-
rioration of the hyaline part of such grafts in the
knee and resorption and fragmentation of the
graft [20]. Ankle arthrodesis and prosthesis are
definite solutions for a recurrent OCD but are not
preferable in young patients. Should the metal
implant fail in the long term, it can be removed
and the ankle joint fused.
The surgical approach is an important part of
the implantation technique because the accuracy
of implantation of this device strongly depends
on the approach and quality of exposure. If
the osteotomy is created too medially, i.e., in
the articular facet of the malleolus, exposure of
the talar dome may be insufficient for adequate
treatment. Furthermore, a small distal fragment
may be prone to fracture when fixed at the end
of the procedure. Conversely, if the osteotomy
is created too laterally, it will exit in the tibial
plafond. This is undesirable because the medial
17 Talar Dome Resurfacing with the HemiCap Prosthesis
a b
Fig. 17.3 Mortise (a) view and lateral (b) weight-bearing radiographs of a left ankle 1 year postoperatively showing
correct positioning of the implant
tibial plafond directly articulates with the medial
talar dome [11, 24], and damage to this weight-
bearing area might lead to secondary osteoar-
thritis [7]. We therefore routinely use a probe to
determine the intersection of the tibial plafond
and the articular facet of the medial malleolus
when performing the osteotomy [22].
The surface of the prosthetic device should
be placed slightly recessed relative to the sur-
rounding surface of the talar cartilage because
talar cartilage deforms during weight bearing
while the implant does not. Wan et al. measured
a peak cartilage deformation of 34.5 % 7.3 %
under full body weight in persons with a medial
talar dome cartilage thickness of 1.42 0.31 mm
[28]. We therefore aim at an implantation level
of 0.5 mm below the adjacent cartilage. This
implantation level was found appropriate in
a previous cadaveric study [24]. When the
149
prosthetic device is correctly implanted, exces-
sive contact pressures of the implant on the tibial
plafond are avoided [24].
Conclusion
In summary, the metallic implantation tech-
nique appears to be a new promising treat-
ment option for osteochondral defects of the
medial talar dome after failed primary treat-
ment. Although the clinical and radiological
results with 1 year follow-up are encourag-
ing, more patients and longer follow-up are
clearly needed to draw any firm conclusions
and determine if the results continue with
time.
Conflict of Interest The author has no current conflict of
interests with the products presented