Curvature-matched preoperative planning for osteoperiosteal grafting in Hepple V talar lesions: a propensity-score matched retrospective cohort study

The talar dome has a complex, asymmetric surface curvature, whereas the iliac crest is relatively flat. This anatomical mismatch may compromise graft congruence and contribute to edge loading after autologous osteoperiosteal transplantation (AOPT) for Hepple V lesions. We evaluated whether a digital preoperative planning protocol incorporating surface-deviation analysis is associated with improved early structural and functional outcomes. We retrospectively reviewed 82 consecutive AOPT patients (2020–2024). To mitigate selection bias, 1:1 propensity score matching (PSM) was performed for age, sex, body mass index, lesion volume, and preoperative PR-AOFAS scores. All lesions were medial, and a medial malleolar osteotomy was performed in all patients to ensure adequate exposure of the talar dome. The digital group used computer-assisted curvature analysis to quantify local defect sphericity and to screen the iliac crest for curvature-matched harvest zones. Total surgeon workload (planning plus operative time) was calculated. After PSM, 28 matched pairs (56 patients) were identified. The digital group had a shorter operative time (118.5 ± 23.1 vs. 152.6 ± 28.5 min; mean difference −34.1; 95% CI −42.8 to −25.4; P < 0.001). At 12 months, PR-AOFAS scores were higher (88.6 ± 6.4 vs. 81.5 ± 7.1; difference 7.1; 95% CI 3.9 to 10.3; P < 0.001), and mean articular step-off was lower (0.6 ± 0.2 vs. 1.2 ± 0.4 mm; P < 0.001). Total surgeon workload was comparable between groups ( P = 0.51). In an exploratory analysis, residual cysts were observed in 1/28 (3.6%) versus 5/28 (17.9%) (unadjusted P = 0.17). Given the retrospective design and limited event counts, these findings are hypothesis-generating and warrant confirmation in larger cohorts. In this PSM-adjusted retrospective cohort study, digital preoperative curvature matching was associated with a shorter operative time and a lower mean articular step-off at 12 months. However, given the retrospective design and modest sample size, these findings are consistent with a potentially clinically meaningful benefit and warrant confirmation in a prospective trial to determine whether this approach may provide durable joint-preserving benefits.