Treatments for avascular necrosis of the talus: a systematic review

Introduction: Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature.

Methods: We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations.

Results: 19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is "very low". Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN.

Discussion: Given the "very low" GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

Level of evidence: Level II.