title: Treatments for avascular necrosis of the talus: a systematic review.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level II.
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Gross
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Bryan
authors.initials: B
authors.lastname: Haughom
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Jaskarndip
authors.initials: J
authors.lastname: Chahal
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois flogik@aol.com.
authors.forename: George B
authors.initials: GB
authors.lastname: Holmes
mesh_terms: D006801:Humans; D019637:Orthopedic Procedures / Q000379:methods*; D010020:Osteonecrosis / Q000628:therapy*; D017410:Practice Guidelines as Topic; D013628:Talus
keywords: osteonecrosis; systematic review; talar avascular necrosis