Contact characteristics of the subtalar joint: the effect of talar neck misalignment

Management of Talus Fractures

Fractures of the talus are life-changing events. The talus is of vital importance to normal gait. Given its importance, great care is needed in diagnosing and treating these injuries. The threshold for operative treatment and accurate anatomic reduction should be low. Surgical tenets include the avoidance of extensive subperiosteal dissection to minimize vascular disruption. The complications with injuries to the talus are extensive and include avascular necrosis (AVN). Although AVN can prove to be a devastating sequela from this injury, it occurs less frequently than posttraumatic arthritis.

Treatment of Complex Central Talar Fractures with Lateral Plate Combination with Medial Screw Fixation

OBJECTIVE

The treatment of talar neck and/or body fractures is known to be difficult and challenging, with significant impact on the long-term functional outcome for the patient. The optimal management, including the choice of surgical approaches and implants, are still under constant discussion. The purpose of the study was to investigate the clinical effects of lateral mini-plate combined with medial lag screws for the treatment of complicated central talar fractures.

METHODS

The data of eight patients with complex central talus fractures treated between June 2019 and January 2021 were retrospectively analyzed. There were six males and two females, ranging in age from 15 to 66 years, with an average age of 37.4 years. There were three cases on the left and five cases on the right. All fractures were comminuted, including talar neck with talar body fracture in seven cases and talar body comminuted with subluxation of subtalar joint in one case. All patients were treated with the anteromedial combined anterolateral approach, lateral talar mini-plate fixation and medial lag screw fixation. Fracture reduction quality, union time, and complications were recorded, and functional outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) scoring system.

RESULTS

The time from injury to surgery was 1-6 days, with an average of 3.38 days. The follow-up period was 34-53 months (mean 44.88 months). All fractures healed with a mean healing time of 16.75 weeks (13-23 weeks). Anatomical reduction was observed in six cases and near in two cases. After operation, there was no loosening or breakage of implant, loss of fracture reduction, and irritation of skin and soft tissue by internal fixation. The average AOFAS score was 87.38 (48-100), with excellent five cases, good two cases and poor one case, and the excellent and good rate was 87.5%. Superficial skin necrosis in one surgical incision healed after dressing exchange. No deep infection occurred. One case (1/8, 12.5%) developed avascular necrosis of the talus without collapse. Posttraumatic arthritis was found in four cases (4/8, 50%).

CONCLUSION

The utilization of lateral mini-plates in combination with medial screws for treating complex central talar fractures results in satisfactory reduction and stable fixation, mitigating complications associated with poor reduction. However, due to the absence of an anatomical mini-plate, pre-contouring is necessary when applying the lateral plate. This demands a surgeon's thorough familiarity with the anatomical morphology of the talus and proficiency in surgical techniques. Posttraumatic arthritis is the most common complication of complex central talar fractures.

Locking vs. non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens

BACKGROUND

Talar neck fractures are rare but potentially devastating injuries, with early reduction and rigid fixation essential to facilitate union and prevent avascular necrosis. Even small degrees of malunion will alter load transmission and subtalar joint kinematics. Changes in fixation techniques have led to dual plating strategies. While locked plating has perceived advantages in porotic bone and comminution, its biomechanical benefits in talar neck fractures have not been shown.

AIM

To compare the strength of locking vs. non-locking plate fixation in comminuted talar neck fractures.

METHOD

Seven pairs of cadaveric tali were randomised to locking or non-locking plate fixation. A standardised model of talar neck fracture with medial comminution was created, and fixation performed. The fixed specimens were mounted onto a motorised testing device, and an axial load applied.

RESULTS

Peak load to failure, deformation at failure, work done to achieve failure, and stiffness of the constructs were measured. No statistically significant difference was found between locking and non-locking constructs for all parameters.

CONCLUSIONS

Both constructs provide similar strength to failure in talar neck fracture fixations. Mean peak load to failure did not exceed the theoretical maximum forces generated of 1.1 kN when weight-bearing. We would advocate caution with early mobilisation in both fixations.

Effects of added trunk load on the in vivo kinematics of talocrural and subtalar joints during landing

BACKGROUND

Landing from heights is a common movement for active-duty military personnel during training. And the additional load they carry while performing these tasks can affect the kinetics and ankle kinematic of the landing. Traditional motion capture techniques are limited in accurately capturing the in vivo kinematics of the talus. This study aims to investigate the effect of additional trunk load on the kinematics of the talocrural and subtalar joints during landing, using a dual fluoroscopic imaging system (DFIS).

METHODS

Fourteen healthy male participants were recruited. Magnetic resonance imaging was performed on the right ankle of each participant to create three-dimensional (3D) models of the talus, tibia, and calcaneus. High-speed DFIS was used to capture the images of participants performing single-leg landing jumps from a height of 40 cm. A weighted vest was used to apply additional load, with a weight of 16 kg. Fluoroscopic images were acquired with or without additional loading condition. Kinematic data were obtained by importing the DFIS data and the 3D models in virtual environment software for 2D-3D registration. The kinematics and kinetics were compared between with or without additional loading conditions.

RESULTS

During added trunk loading condition, the medial-lateral translation range of motion (ROM) at the talocrural joint significantly increased (p < 0.05). The subtalar joint showed more extension at 44-56 ms (p < 0.05) after contact. The subtalar joint was more eversion at 40-48 ms (p < 0.05) after contact under the added trunk load condition. The peak vertical ground reaction force (vGRF) significantly increased (p < 0.05).

CONCLUSIONS

With the added trunk load, there is a significant increase in peak vGRF during landing. The medial-lateral translation ROM of the talocrural joint increases. And the kinematics of the subtalar joint are affected. The observed biomechanical changes may be associated with the high incidence of stress fractures in training with added load.

Influence of Surgical Approach and Fixation on Complications in Talus Fractures: A Multicenter Review

Fractures of the talus are infrequent injuries often associated with substantial morbidity and imperfect outcomes. We undertook a retrospective review of talus fractures at multiple level 1 trauma centers in order to identify common treatment patterns and potential predictors of complications. All cases of talar fractures meeting inclusion criteria at our institution were reviewed. 54 of 103 talus fractures met inclusion criteria. 33 (61.1%) involved the talar neck, 13 (24.1%) the talar body, and 6 (9.2%) involved the lateral process. The most common etiology was motor vehicle accidents, accounting for 27 (50.0%). Mean follow up was 13.6 months (range 8-52 months). 37 (68.5%) fractures were fixated with screws, and 17 (31.5%) were fixated with a plate construct. Single and dual incisions were used in 63.0% and 25.9% of cases, respectively. Complications were seen in 46.3% of cases, with post-traumatic osteoarthritis being the most common complication (35.1%). Avascular necrosis occurred in 4 (7.4%) patients. No independent variables met the statistical threshold to be associated with complications. The present data alludes to possibility of over-reporting complications due to historical literature and the need for further studies.

Parameters That Can Be Used to Quantify Reduction Accuracy in Talar Neck Fractures and Malunions: A PRISMA-Compliant Scoping Review and Meta-Analysis

Understanding the three-dimensional anatomy of the talar neck is essential in assessing the accuracy of reduction in talar neck fractures as well as for planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. We aimed to identify from the existing literature, geometrical parameters that describe the anatomy of the talar neck, determine how these are measured, and their normative values. A scoping literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. The primary searches were conducted on the PubMed, Embase, and Scopus databases. Any original research study looking at the human talus neck geometry was included. Parameters that described the anatomy of the talar neck were identified, and pooled estimates were determined by the random-effects meta-analysis model. Heterogeneity was assessed by the I2 test and leave-one-out meta-analysis. Subgroup analysis was done to compare the values of parameters between the Asian and Non-Asian populations. The risk of bias was assessed by the National Institutes of Health (NIH) Case Series Tool. The combined searches yielded 6326 results, of which 21 studies were included in the review and 15 in six different sets of metanalysis. The majority of the studies (n=19, 90.5%) evaluated adult tali, and only two (9.5%) evaluated pediatric tali. In most of the studies (n=13, 61.9%), talus neck geometry was evaluated on dry bones or anatomical specimens; evaluation by imaging techniques (radiographs, CT, MRI, and radiostereometric analysis) was used in eight studies, (39.1%). A total of eight different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Although the literature reports geometrical parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Most of the available literature describes measurement techniques on cadaveric tali, and there is no literature on how these parameters should be measured on conventional CT or MRI slices. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

Identifying Risk Factors for Osteonecrosis After Talar Fracture

OBJECTIVE

To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors.

METHODS

DESIGN

Retrospective chart review.

SETTING

21 US trauma centers and 1 UK trauma center.

PATIENT SELECTION CRITERIA

Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes.

RESULTS

In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.

CONCLUSIONS

Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of cadaveric simulation in talus fracture research: A scoping review

BACKGROUND

Talus fractures are rare (<1% of all fractures), and their rarity limits the number of studies available to guide management. In instances such as this, cadaveric studies can play an important role. The purpose of this scoping review was to identify and describe the current body of literature on cadaveric studies of fractures of the talus.

METHODS

Through multiple electronic database searches (Medline, Embase, Scopus) we identified a broad body of cadaveric research into talus fractures, and these were classified into 4 main themes. Study characteristics were summarised along with any descriptive results and conclusions.

RESULTS

The search yielded 484 articles of which 19 met the inclusion criteria. They provide valuable insights into benefits and drawbacks of surgical approaches to the talus, particularly with regard to direct visualisation of anatomic reduction, and risks of neurovascular or tendon compromise. For talar neck fractures it is clear that cannulated screws offer superior fixation over plates, however, are inferior when considering anatomic reduction of the fracture. Direct visualisation of fracture reduction is far superior to intraoperative radiographic assessment, and mal-reduction leads to reduced subtalar joint range of motion, midfoot deformity, and increased joint contact pressures.

CONCLUSIONS

This study provides a summary of the existing literature surrounding the use of cadaver studies in fractures of the talus. We have identified gaps in the literature, particularly surrounding strength of fixation of new locking plate fixation techniques.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

The hindfoot consists of the talus and calcaneus, spans the tibiotalar to transverse tarsal joints, and is critical for support of body weight and absorption and transfer of physiologic loads during bipedal movements. Hindfoot fractures account for approximately 17% of foot and ankle fractures, with calcaneal fractures being more common than talar fractures. Hindfoot fractures are usually caused by high-impact axial loads such as falls from heights and motor vehicle accidents, and understandably, they are often seen in patients with polytrauma. Long term, these fractures have implications in development of posttraumatic osteoarthrosis with associated pain and stiffness, affecting daily living activities. An overview of the talus and calcaneus is presented, with emphasis on fractures with articular involvement-namely, the tibiotalar and subtalar joints. Articular talar and calcaneal injuries can also alter hindfoot alignment, causing ankle and foot function abnormalities. Optimal treatment-that is, restoration of articular surfaces and hindfoot alignment followed by rigid fixation until fracture union-is dependent on an accurate understanding of the injury that is well depicted with imaging, radiography and CT in particular. The discussion of talar and calcaneal fractures includes a review of the normal anatomy, epidemiologic factors, classification systems, and imaging and pathologic-anatomic features of common injury patterns. This review is intended to aid surgical management and restoration of articular and hindfoot alignment for optimal ankle and foot function, thereby reducing patient morbidity in these often devastating injuries. ^©RSNA, 2022.

Union Rates of Talar Neck Fractures With Substantial Bone Defects Treated With Autograft

BACKGROUND

This study evaluated the union rate of talar neck fractures with substantial bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis.

METHODS

A case series at a level 1 trauma center was performed to identify consecutive patients who underwent operative fixation of talar neck fracture with autograft (Current Procedural Terminology codes 28445 and 20902) between 2015 and 2018. "Substantial bone defect" was defined as a gap greater than 5 mm in the sagittal plane and greater than one-third of width of the talar neck in the coronal plane. Postoperative foot computed tomographic (CT) scans were obtained for all patients. Primary outcome was union, and secondary outcomes were malunion, avascular necrosis (AVN), post-traumatic arthritis (PTA), and patient-reported outcomes (PROs).

RESULTS

Twelve patients with 12 fractures were included in the series, with an average length of follow-up of 26 months (range: 7-55) The average age was 34 years (17-59), and the most common mechanism of injury was motor vehicle crash. The Hawkins classification of the fractures was 4 type II (2 type IIA and 2 type IIB) (33%) and 8 type III (67%). Four fractures (33%) were open fractures. Union was achieved in 11 patients (92%). There was 1 malunion (8%). AVN was identified on postoperative CT scans in 11 patients (92%). Three of these 11 eventually showed collapse. Ten patients (83%) had radiographic evidence of some degree of ankle PTA, and 12 patients (100%) had radiographic evidence of some degree of subtalar PTA. Average Patient-Reported Outcomes Measurement Information System-Short Form score was 37 (32-45) and average Foot and Ankle Ability Measure activities of daily living and sports subscale scores were, respectively, 61 (31-87) and 31 (0-71), respectively. Average visual analog scale score was 5 (0-10), and average Foot Function Index was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients.

CONCLUSION

In this relatively small series, tibial autograft in primary osteosynthesis of comminuted talar neck fractures with substantial bone defects is associated with excellent union rates and low malunion rates. Despite high union rates, secondary outcomes of AVN with or without collapse, ankle and subtalar PTA, and relatively low PROs were common.

LEVEL OF EVIDENCE

Level IV, case series.

Talus Fractures: All I need to know

Talus fractures result following high energy trauma and can lead to significant functional impairment. The complex morphology of the talus, it's multiple articulations and tenuous blood supply translate into significant challenges that must be overcome to achieve the best possible outcomes. Despite advances made in their management, they continue to have high complication rates. Nonetheless, restoration of normal alignment will optimise outcomes. In this article, we report on the epidemiology, anatomy, classification, patient evaluation and current evidence for the management of talus fractures.

Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications

The integrity of the talus is crucial for the physiologic function of the feet. The present study sought to summarize the available evidence on clinical outcomes and complications following conservative and surgical treatment of talar fractures. We systematically searched Medline via OVID to find relevant studies with a follow-up of at least six months. Hereafter, the success and complication rates were extracted and analyzed in a random effects proportion meta-analysis. Complications were defined as avascular bone necrosis (AVN) and posttraumatic osteoarthritis (OA). Additionally, a subgroup analysis was performed for fracture localization (talar neck fractures (TN) and combined talar body/neck fractures (TN/TB)) and severity of the fracture. The quality of the included studies was assessed utilizing the Coleman Methodology Score (CMS). A total of 29 retrospective studies, including 987 fractures with a mean follow-up of 49.9 months, were examined. Success rates were 62%, 60%, and 50% for pooled fractures, TN, and TN/TB, respectively. The overall complication rate for AVN was 25%. The rate was higher for TN (43%) than TN/TB (25%). Talar fractures revealed a 43% posttraumatic osteoarthritis (OA) rate in our meta-analysis. Success rates showed an association with fracture severity, and were generally low in complex multi-fragmentary fractures. The mean CMS was 34.3 (range: 19-47), indicating a moderate methodological quality of the studies. The present systematic review on clinical outcomes of patients undergoing conservative or surgical treatment for talar fractures reveals a lack of reliable prospective evidence. Talar fractures are associated with relatively poor postoperative outcomes, high rates of AVN, and posttraumatic osteoarthritis. Poor outcomes revealed a positive association with fracture severity. Prospective studies investigating predictors for treatment success and/or failure are urgently needed to improve the overall quality of life and function of patients undergoing surgical treatment due to talar fractures.

Use of Calcaneal Osteotomies in the Correction of Inframalleolar Cavovarus Deformity

Cavovarus deformity is a complicated condition most commonly resulting from neurologic, posttraumatic, or iatrogenic pathologic conditions. Careful evaluation of the cavovarus patient is necessary in determining appropriate treatment course. Weight-bearing radiographs are necessary, and advances in computed tomographic technology can be beneficial in identifying level of involvement. In the case of operative treatment of inframalleolar deformity, assessment of the subtalar joint position and relation of calcaneocuboid joint can be of assistance. Multiple osteotomies have been described providing uniplanar, biplanar, and triplanar correction and in the appropriate setting can prove beneficial to the surgeon in treating hind-foot cavovarus deformity.

Footloose: Articular surface morphology and joint movement potential in the ankles of lorisids and cheirogaleids

OBJECTIVES

The competing functional demands of diarthrodial joints, permitting mobility while retaining enough stability to transmit forces across the joint, have been linked with the shape and size of the joint's articular surfaces. A clear understanding of the relationship between joint morphology and joint movement potential is important for reconstructing locomotor behaviors in fossil taxa.

METHODS

In a sample of matched tali and calcanei of lorisids (n = 28) and cheirogaleids (n = 38), we quantify the surface areas of the talar and calcaneal ectal (=posterior talocalcaneal) articular surfaces and model the principal curvatures of these surfaces with quadric formulas. These two taxonomic groups have similar body masses, but differ substantially in positional behavior, so that differences in joint surface morphology should reflect adaptive demands of their locomotor behavior.

RESULTS

Compared with cheirogaleids, lorisids exhibit: (a) a significantly greater area difference between their paired joint surfaces; and (b) a more pronounced saddle shape for the talar ectal facet.

CONCLUSION

The increased subtalar joint mobility observed in lorisids may be achieved by increasing the amount of sliding and rolling that can occur at the subtalar joint. The subtalar joint morphology observed in two fossil euarchontans, the plesiadapiforms Purgatorius sp. and Plesiadapis cookei, compares favorably with the morphology observed among lorisids, potentially suggesting antipronograde postures within these extinct taxa.

Talar Neck Fractures: Single or Double Approach?

Correct approach selection in talar neck injuries is crucial to obtain adequate access to the entire fracture site avoiding malreduction and angular deformity. The major concern about a single incision technique is lack of visualization. Combined lateral and medial approaches are strongly recommended in complex talar neck fractures providing better control of dorsal and varus displacement of the talar head.

Talus Fractures: Evaluation and Treatment

The talus is unique in having a tenuous vascular supply and 57% of its surface covered by articular cartilage. Fractures of the head, neck, or body regions have the potential to compromise nearby joints and impair vascular inflow, necessitating surgical treatment with stable internal fixation in many cases. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Percutaneous screw fixation has also demonstrated success in certain patterns. Despite this modern technique, osteonecrosis and osteoarthritis remain common complications. A variety of new treatments for these complications have been proposed, including vascularized autograft, talar replacement, total ankle arthroplasty, and improved salvage techniques, permitting some patients to return to a higher level of function than was previously possible. Despite these advances, functional outcomes remain poor in a subset of severely injured patients, making further research imperative.

A combination of bimalleolar fracture and fracture on talar body and neck: A rare case report

RATIONALE

Talar fracture accompanied with malleolar fracture is rare, and its management is complex. Ankle soft tissue is much thinner than other parts of the human body, and the shape of the ankle makes wounds difficult to close immediately after surgery, which may result in poor skin condition if the wound tension is too high. However, joint congruity and osteonecrosis are the main concerns of talar fracture.

PATIENT CONCERNS

A 57-year-old man presented at the emergency department following a motorcycle accident.

DIAGNOSES

Physical examination revealed swelling and tenderness of the left ankle and midfoot. The patient had comminuted talar fracture and was indicated for dual-screw fixation or even plate with screw fixation.

INTERVENTIONS

We performed single screw fixation after assessing the soft tissue condition and employed a technique of using continuous longitudinal force to bring together fracture fragments (ankle ligamentotaxis) during surgery. Open reduction with a mini-hook plate and tension band wire was used for bimalleolar fracture repair using the combined anteromedial and anterolateral approach with extension of the incision. Kirschner wire for temporary fixation was performed using ligamentotaxis, and a 2.4 headless screw was inserted from the posteromedial to the anterolateral direction.

OUTCOMES

The patient was discharged with a standard short leg splint and was instructed not to bear weight on the affected ankle for 2 months. The patient walked well without discomfort, and the Hawkins sign was clearly visible. Single screw fixation preserves the integrity of the talus bone as minimal space is used for this operative technique. Single screw fixation preserves more bony stock when most of the internal fixator is located within the bone. Additionally, surgery time is shorter than multiple implantations even when performing the same procedure; as a result, there was less ankle soft tissue swelling.

LESSONS

This case provides evidence of using the single screw fixation technique for addressing both malleolar and talar fractures, and that talar fracture management can be less aggressive with limited weight bearing and initial limited range of motion given the presence of malleolar fracture. The alignment and stability of bony fragments also benefit from ankle ligamentotaxis.

Post-Traumatic Hindfoot Arthritis

The hindfoot is functionally defined as the articulations between the talus, calcaneus, navicular, and cuboid. It is a biomechanically important peritalar unit for shock absorption and propulsion with the subtalar and talonavicular joint essential to its function. The primary cause of hindfoot arthritis is post-traumatic. Other causes include long-term misalignment such as adult-acquired flatfoot, cavus foot, and inflammatory arthritis. Prevention of post-traumatic hindfoot arthritis is the primary objective. Anatomical reduction and fixation of articular hindfoot fractures is the preferred pathway. This article discusses the principles of treatment of hindfoot arthritis. When post-traumatic changes cannot be managed by nonsurgical means, an anatomical well-aligned arthrodesis is indicated. This article addresses the principles of managing this condition, which have been championed by Professor Sigvard T. Hansen. New approaches and techniques are discussed that achieve the goals of a stable, functional plantigrade foot.

Technique for Open Reduction and Internal Fixation of Lateral Process Talus Fractures

Lateral process fractures of the talus may occur either in isolation or in combination with a talar neck or body fracture. Screw fixation has been well described as a means of stabilization; however, many patients have multifragmentary fragments, unable to be controlled by isolated screw fixation alone. Plate fixation of the lateral process has been yet to be described in detail with presence of a clinical series. Here, we describe our technique of plate fixation for both isolated lateral process fractures and those that occur in conjunction with talar neck or body fracture.

[Outcome of corrective osteotomy of shortened medial foot column after old talar neck fracture]

OBJECTIVE

To investigate the effectiveness of corrective osteotomy for shortened medial foot column after old talar neck fracture.

METHODS

The clinical data of 10 patients with shortened medial foot column after old talar neck fracture between June 2012 and May 2017 was retrospectively analyzed. There were 7 males and 3 females with an average age of 45.8 years (mean, 21-67 years). The time from fracture to corrective osteotomy was 9-60 months (mean, 20.9 months). The preoperative visual analogue scale (VAS) score was 7.1±1.2, the American Orthopaedic Foot and Ankle Society (AOFAS) score was 48.5±12.3, and the short-form 36 health survey scale (SF-36) score was 46.7±10.5. All 10 cases received open wedge osteotomy of medial talus. Among them, 2 received subtalar fusion and Achilles tendon lengthening, 2 lateralizing calcaneal osteotomy, and 2 Achilles tendon lengthening.

RESULTS

All incisions healed by first intention. All patients were followed up 13-72 months (mean, 38.0 months). The X-ray film showed that the angle between longitudinal axis of 1st metatarsal bone and talus increased from (-9.6±4.5) ° before operation to (1.3±2.7) ° at last follow-up ( t=16.717, P=0.000); the angle between longitudinal axis of calcaneus and tibia increased from (-12.0±7.4) ° before operation to (-1.5±4.8) ° at last follow-up ( t=5.711, P=0.000). At last follow-up, the VAS score, AOFAS score, and SF-36 score were 1.6±1.0, 88.3±5.4, and 85.4±9.2, respectively, which increased significantly when compared with the preoperative scores ( t=13.703, P=0.000; t=14.883, P=0.000; t=16.919, P=0.000). X-ray film and CT showed that the osteotomy and arthrodesis sites healed well at 2-4 months after operation.

CONCLUSION

It's a proper procedure of anatomic reduction and reconstruction for patients with shortened medial foot column and good articular cartilage morphology after old talar fracture. Opening wedge osteotomy of medial talus is recommended and can obtain satisfactory clinical and radiographic results.

Hindfoot Injuries: How to Avoid Posttraumatic Varus Deformity?

Posttraumatic hindfoot varus may result from nonoperative treatment or inadequate reduction and fixation of talar and calcaneal fractures. Adequate visualization of the talar neck via bilateral approaches is essential in avoiding malreduction. In cases of medial comminution of the talar neck, lag screws must be avoided and the use of single or double plates should be considered. A Schanz screw introduced into the calcaneal tuberosity is instrumental in realigning shortening, varus, or valgus deformity of the heel. Special attention should be paid to addressing impaction of the medial facet of both the talus and calcaneus to avoid hindfoot varus.

Management of Calcaneal Fracture Malunion with Bone Block Distraction Arthrodesis: A Systematic Review and Meta-Analysis

One of the most severe complications in calcaneal fractures is a malunion. When a malunion occurs, subtalar bone block distraction arthrodesis provides restoration of calcaneal height, length, correction of varus deformity, and elimination of subtalar joint arthritis. A systematic review showed the union rate for all procedures was 95.78%. The overall complication rate was 38% for all procedures. This is the first study to categorically break down complications with statistical analysis. The data presented indicate the level of difficulty of the subtalar distraction bone block arthrodesis for calcaneal malunions and may even suggest the need for newer techniques.

Distal fibular malrotation and lateral ankle contact characteristics

BACKGROUND

Any amount of malreduction of the syndesmotic joint compared with the uninjured syndesmosis has been associated with an adverse effect on functional outcome. The amount of malrotation that may lead to clinically relevant pressure change in this joint has not been reported. Our purpose was to determine whether small degrees of external and internal malrotation would be associated with statistically significant changes in contact pressure in the tibiofibular and talofibular articulations.

METHODS

Twelve cadaveric ankles were osteotomized above the syndesmosis and instrumented with a rotatable distal fibula plate. Sensors at the distal tibiofibular and talofibular articulations recorded contact pressure and area at neutral position and at 5 and 10° of external and internal malrotation through a full range of ankle motion.

RESULTS

Compared with neutral rotation, there was a significant decrease in contact pressure at the talofibular articulation with external rotation of 5° (103±113kPa versus 52±69kPa; P=0.01) and 10° (43±62kPa; P=0.01) in plantarflexion.Contact pressure at the tibiofibular articulation in plantarflexion increased with 10° of internal malrotation compared with neutral rotation (56±30kPa versus 74±38kPa; P=0.05) in plantarflexion. Contact area decreased significantly with plantarflexion and 10° of external rotation and increased significantly in plantarflexion and after cyclic loading with 10° of internal rotation (P≤0.05).

CONCLUSION

Any degree of distal fibular external rotation significantly reduced contact pressure in the talofibular articulation with plantarflexion. A minimal increase in contact pressure was found in the tibiofibular and talofibular joints with plantarflexion and mild internal rotation of 5°, but pressure increased significantly in both articulations with 10° of internal rotation. The findings support clinical findings that subtle degrees of fibular malrotation may be associated with alteration of lateral ankle mechanics.

LEVEL OF EVIDENCE

Controlled biomechanical study.

Significance of Lateral Process Fractures Associated With Talar Neck and Body Fractures

OBJECTIVES

To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures.

DESIGN

Retrospective review.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period.

INTERVENTION

Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis.

MAIN OUTCOME MEASUREMENTS

Radiographic evidence of subtalar arthritis.

RESULTS

Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001).

CONCLUSION

Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Current Concepts in Talar Neck Fracture Management

PURPOSE OF THE REVIEW

Talar neck fractures are a rare but potentially devastating injury, which require a comprehensive understanding of the unique osteology, vasculature, and surrounding anatomy to recognize pathology and treat correctly. The purpose of this article is to describe both classic and current literature to better understand the evolution of talar neck fracture management.

RECENT FINDINGS

Urgent reduction of displaced fractures and dislocations remains the standard of care to protect the soft tissue envelope and neurovascular structures. Delayed definitive fixation has proven to be safe. CT is the imaging modality of choice to fully identify the fracture pattern and associated injuries. Anatomic reduction and restoration of the peritalar articular surfaces are the pillars of talar neck fracture treatment. Dual incision approach with plate and screw fixation has become the modern surgical strategy of choice to accomplish these goals. Although complications such as osteonecrosis (ON) and posttraumatic arthritis (PTA) can still occur at high rates, treatment should be dictated by patient symptoms. Talar neck fractures pose treatment challenges with both initial injury and potential sequelae. Future research will determine whether modern treatment algorithms will decrease complication rate and improve patient outcome.

Subtalar Joint Biomechanics: From Normal to Pathologic

Subtalar joint biomechanics are primarily driven by the shape of the articulations with contributions from the surrounding soft tissues. The joint motion occurs about a single axis oriented medially and superiorly. Joint contact forces change during different stages of gait and are affected by hindfoot alignment and traumatic alterations to their normal anatomy. A valgus subtalar joint axis is likely a contributing, and perhaps primary, risk factor for progression to adult acquired flat foot. The subtalar joint axis also contributes to the clinical picture of a cavus foot and a special subset of patients with dynamic varus.

Fractures of the talus: Current concepts and new developments

Fractures of the talus are challenging to manage, with historically poor outcomes and a high rate of complications. The rare nature of this injury limits the number of studies available to guide treatment. Fortunately, a number of advancements have been made in the last decade. There is increased recognition regarding the importance of anatomic reconstruction of the osseous injury. Advanced imaging is used to assess the subtalar joint, where even slight displacement may predispose to arthritis. Increasing use of dual anteromedial and anterolateral approaches, along with plate fixation, has improved our ability to accurately restore the anatomy of the talus. Modification of the original Hawkins classification can both guide treatment and allow us to better predict which patients will develop avascular necrosis. Lastly, improved reconstructive techniques help address the most common complications after talus fracture, including arthritis, avascular necrosis, and malunion.

Management of Talar Fractures

Fractures of the talus are significant injuries with associated significant complications where the recovery zenith is less frequently good to excellent, and more commonly fair to satisfactory. These outcomes are a consequence of combinations of the inherent intrinsic and surrounding anatomy, technical and logistic difficulties in adequate fracture access, and the high-energy mechanisms typically associated with these injuries that further traumatize the surrounding tissues. This article reviews and provides current management recommendations for these devastating injuries.

Talar Body Reconstruction for Nonunions and Malunions

BACKGROUND

Talar body and neck nonunions and malunions may undergo a reconstructive surgery when joint cartilage is still viable, and no talar collapse or infection has occurred. This is a rare condition and the studies supporting the procedure have small number of cases. The objective of the present study is to report a case series of six patients who underwent talar reconstructions.

MATERIALS AND METHODS

Six patients with talar malunions or nonunions who underwent surgical treatment were reviewed in this retrospective study. There were three nonunions and two malunions of the talar body and one malunion of the talar neck. Clinical evaluation included all the parameters used in the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale. Arthritic degeneration of the ankle joint was assessed according to a modified Bargon scale.

RESULTS

The mean followup was 86 months (range 24-282 months). There were no cases of postoperative avascular necrosis of the talus. Four of the six patients in our series required a subtalar fusion as part of the reconstruction procedure. The average preoperative AOFAS hindfoot score was 34, and at the time of the last evaluation, it was 74. The mean preoperative score on the modified Bargon scale for the tibiotalar joint was 1.17. At the last followup, it rose to 1.33. Three different deformities of the talus were identified (a) flattening of the talus (b) extra-articular step and (c) intraarticular step.

CONCLUSION

Reconstruction of talar nonunions and malunions improved function in selected patients with a low risk of complications. Three different anatomical patterns of talar nonunions and malunions were identified.

Plate Fixation of Talus Fractures: Where, When, and How?

Talus fractures are rare orthopedic injuries. Surgical fixation is challenging for treating surgeons. The clear majority of fractures require operative treatment. The indication and use of plates in fixation of talus fractures are reviewed. Specific applications including fractures of the lateral process, posterior fractures, extreme comminution, bone grafting, and spring plating to hold key segments are reviewed in this article.

Displaced Intra-articular Calcaneal Fractures: Classification and Treatment

The calcaneus is the most commonly fractured tarsal bone. Displaced intraarticular calcaneal fractures are usually caused by a fall from height with one or both heels directly hitting the ground. Displaced intra-articular calcaneal fractures are complex and highly disabling injuries. There is ongoing debate regarding the optimal treatment for each type of displaced intra-articular calcaneal fracture. This review aims to summarize the classification of, various treatment options for, prevention of perioperative complications in, and management algorithms for displaced intra-articular calcaneal fractures. [Orthopedics. 2017; 40(6):e921-e929.].

Joint-Preserving Surgery for Talar Malunions or Nonuions

OBJECTIVE

To describe the technique and analyze the outcomes of joint-preserving surgical treatments which included anatomical reconstruction or alignment correction for talar malunions or nonunions, and avoid development of degenerative changes in the adjacent joints.

METHODS

Eight patients who had painful talar malunions or nonunions treated between 2009 and 2015 were included in this retrospective study. The mean age of the patients was 35.6 years, with patients aged from 18 to 58 years. Two patients had talar neck fractures and six had talar body fractures. According to a classification of post-traumatic talar deformities, five patients were classified as type I (malunion and/or residual joint displacement), two as type II (nonunion with displacement), and one as type III (malunion with partial avascular necrosis [AVN]). Of these patients, six cases were treated with an osteotomy through the malunited fracture or removal of the pseudarthrosis, and two cases were corrected by supramalleolar or calcaneal osteotomies owing to complete disappearance of the former fracture lines. The follow-up evaluation methods included the 36-Item Short Form Health Survey (SF-36) score, the American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion (ROM), and radiological analysis. The differences between postoperative scores and preoperative scores were evaluated statistically with the paired Student's t-test. Significance was assumed at P < 0.05.

RESULTS

The mean follow-up time was 25.6 months. No wound healing problems or infections were observed. Solid union was obtained without redislocation in all cases, and with no signs of development or progression of AVN. At a mean of 25.6 months (range, 16-36 months) after reconstruction, all patients were satisfied with the result. The mean AOFAS score increased from 30.0 ± 7.0 pre-operatively to 86.5 ± 7.8 post-operatively (P < 0.001), the mean SF-36 score increased from 38.8 ± 4.1 to 81.4 ± 7.7 (P < 0.001), and the average ROM (tibiotalar joint) increased from 40.5° ± 8.7° to 43.9° ± 7.2° (P < 0.05).

DISCUSSION

Joint-preserving procedures for talar malunions or nonunions can bring about satisfactory outcomes, and the appropriate procedure should be adopted according to different types of post-traumatic deformities.

Can operations achieve good outcomes in elderly patients with Sanders II-III calcaneal fractures?

The aim of this study was to compare the clinical effect of operative treatment and nonoperative treatment for elderly patients with Sanders II-III calcaneal fractures.The study consisted of 60 patients with Sanders II-III calcaneal fractures who were treated in our institution from January 2007 to April 2012. The clinical effect between the operative treatment group of 32 patients and the nonoperative treatment group of 28 patients was studied. Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height were measured before and after treatment, and these indexes were also measured on the uninjured foot. All patients were followed-up for at least 2 years, and at the last follow-up, we evaluated foot function that was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score system. A 10-cm visual analog scale (VAS) was used to measure the degree of pain.Böhler angle, Gissane angle, calcaneal width, and calcaneal height, which were preoperatively and postoperatively measured, had a significant difference in the operative group (P < .001), but there was no significant difference between pretreatment and post-treatment in the nonoperative group. Subtalar joint motion was measured pre-treatment and post-treatment and had a significant difference in the 2 groups. When we compared the values of Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height between post-treatment and the uninjured foot, there was no significant difference in the operative group, but there was a significant difference in the nonoperative group. The values measured after treatment in the 2 groups had a significant difference. Finally, the AOFAS score in the operative group and the nonoperative group were 83.4 ± 9.7 and 74.7 ± 10.3, respectively, and there was a significant difference (P < .001). Also, the 10-cm VAS had a significant difference between the 2 groups.Good clinical result could be obtained with operative treatment in elderly patients with Sanders II-III calcaneal fractures. Open reduction and internal fixation should be performed if there is no surgical contraindication.

Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation

PURPOSE

Early post-operative exercise and weight-bearing activities are found to improve the functional recovery of patients with displaced intra-articular calcaneal fractures (DIACFs). We hypothesized that early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. A prospective study was conducted to verify this hypothesis.

METHODS

From December 2012 to September 2013, patients with unilateral DIACFs were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weight bearing starting week three, and full weight bearing starting week 12. Patients in the control group followed a conventional post-operative protocol of partial weight bearing after week six and full weight bearing after the bone healed. Computed tomography (CT) scanning was performed at post-operative day one, week four, week eight, and week 12 to reconstruct coronal, sagittal, and axial images, on which the maximal residual displacements of the fractures were measured. Function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12th post-operative month.

RESULTS

Twenty-eight patients in the study group and 32 in the control group were followed up for more than 12 months; their data were collected and used for the final analysis. Repeated-measures analysis of variance (ANOVA) of the maximal residual displacements of the fracture measured on CT images revealed significant differences between the study and the control groups. There were interaction effects between group and time point. Except for the first time point, the differences between the groups at all studied time points were significant. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at post-operative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12.

CONCLUSIONS

Early functional exercise and weight bearing activity can smooth and shape the subtalar joint and reduce the residual displacement of the articular surface, improving functional recovery of the affected foot. Therefore, early rehabilitation functional exercise can be recommended in clinical practice.

Three-dimensional Computer-assisted Modeling of Talus Morphology in Chinese Patients

OBJECTIVE

To provide more accurate reference data for the assessment and treatment of talar injuries by constructing 3-D computer-assisted models of the talus and comparing them with reference data obtained from measurements on cadaver specimens.

METHODS

Three-dimensional talus models were constructed from CT data recorded for healthy Chinese volunteers using SuperImage Orthopedics software. Structural variables such as length, width, height and volume of talus were compared using the Fisher least significant difference test to determine the significance of bilateral or sex-specific differences in the study cohort.

RESULTS

Measurement data were normally distributed. No significant difference between the left and right talus in either men or women was identified for any measurement (P > 0.05). The bilateral mean volume of the talus in men (37.87 ± 6.69 mm) was significantly larger than that in women (26.95 ± 5.73 mm; P < 0.05). Although the dimensions of most of the structural features and articular surfaces of the talus were significantly larger in men than in women (P < 0.05), no significant differences in the angles of the talar neck and head were observed between men and women in our cohort (P > 0.05).

CONCLUSION

Our method of 3-D model construction provided precise measurements of the structural features of the talus. The talar dimensions in our Chinese study cohort differ from those previously reported for people of different ethnic groups. Our models should provide accurate reference data for constructing models based on CT images for the assessment and treatment of talar injuries in Chinese patients.

Treatment of Comminuted Talar Neck Fractures With Use of Minifragment Plating

OBJECTIVES

To assess the healing and radiographic outcomes of displaced and comminuted talar neck fractures treated with medial position screws augmented with lateral minifragment plate fixation.

DESIGN

Retrospective case series.

SETTING

Two level I trauma centers.

PATIENTS

The records of 26 patients with displaced and comminuted talar neck fractures who underwent open reduction and internal fixation with medial-sided position screws augmented with lateral minifragment plates.

INTERVENTION

Surgery consisted of medial and lateral approaches to the talus, fixation with a laterally placed minifragment plate, and screw construct augmenting sagittal-plane-oriented, medial-sided position screws.

MAIN OUTCOME MEASUREMENTS

The incidences of nonunion, malunion, avascular necrosis, post-traumatic arthritis, and symptomatic implants.

RESULTS

Nonunion occurred in 3/26 (11.5%) displaced and comminuted talar neck fractures. There were no instances of malunion. Avascular necrosis developed in 7/26 (27%) cases. Post-traumatic arthritis was the most common complication affecting 10/26 (38%) tali. The subtalar joint was most commonly affected. There were no instances of hardware removal due to symptomatic medial impingement.

CONCLUSIONS

Lateral minifragment plate fixation augmenting medially placed sagittal plane position screws provides a length stable construct that prevents talar neck shortening and malunion. Medial position screws can help avoid secondary surgeries for removal of symptomatic implants due to medial impingement as is common with medially based minifragment plates. This fixation strategy should be considered in the setting of displaced and comminuted talar neck fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pedobarographic and Radiological Analysis After Treating a Talus Neck Fracture

Misalignment of the talar neck after surgical repair can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, which can change the joint biomechanics, cause arthritis, and impair function. However, we found no studies analyzing the plantar pressures after treatment of talus neck fracture. We determined the dynamic plantar pedobarographic and radiographic characteristics and ankle range of motion, function, and pain among patients after surgical repair of talar neck fractures. A total of 19 patients completed the assessments. The median follow-up period was 29 (range 12 to 113) months. At the last visit, the mean pain score was 3.3 on a 10-cm visual analog scale. The mean American Orthopaedic Foot and Ankle Society function scale score was fair (73.5), and the mean range of motion was restricted in 4 planes. The mean maximum force was lower in the hindfoot (p = .002) and midfoot (p = .03) of the injured foot than in the noninjured foot. The mean peak pressure was lower in the hindfoot (p = .05) but higher in the forefoot (p = .03). Radiographic measurements revealed differences between the feet in the talo-first metatarsal angle (p = .002), Meary's angle (p = .001), and the medial cuneiform-fifth metatarsal angle (p = .002). Radiographic and pedobarographic analysis showed an elevated arch in the injured foot. Thus, talar injury and immobilization can affect the stance and the gait cycle in these patients. Pain, range of motion, function, and the weight transfer pattern should be evaluated carefully during the follow-up period to provide the best postoperative results.

Osteotomies of the Talar Neck for Posttraumatic Malalignment

A talar neck malunion is one of the major complications following operative or nonoperative treatment of talar neck fractures. The most common posttraumatic talar malunion results in varus malalignment of the talar neck and can lead to painful overload of the lateral foot and substantial impairment of hindfoot function. Secondary procedures in patients with painful malunited talar neck fracture include salvage procedures and anatomic reconstruction procedures. Anatomic reconstruction of the talar neck is a reliable surgical treatment to regain function, decrease pain, and restore hindfoot alignment and range of motion.

Secondary Reconstruction for Malunions and Nonunions of the Talar Body

Malunions and nonunions after central or peripheral fractures of the talar body frequently lead to pain and disability. In properly selected, compliant patients without symptomatic arthritis or total avascular necrosis leading to collapse of the talar dome, and sufficient bone stock, secondary anatomic reconstruction with osteotomy along the former fracture plane and preservation of the essential peritalar joints may lead to considerable functional improvement. Bone grafting is needed after resection of a fibrous pseudarthrosis, sclerotic, or necrotic bone. Malunions and nonunions of the lateral or posterior process are treated with excision of the malunited or loose fragments.

Fractures of the Talus: State of the Art

Talus fractures occur rarely but are often associated with complications and functional limitations. Urgent reduction of associated dislocations is recommended with open reduction and internal fixation of displaced fractures when adjacent soft tissue injury permits. Delayed definitive fixation may reduce the risks of wound complications and infections. Restoration of articular and axial alignment is necessary to optimize ankle and hindfoot function. Despite this, posttraumatic arthrosis occurs frequently after talar neck and body fractures, especially with comminution of the talar body. Osteonecrosis is reported in up to half of talar neck fractures, although many of these injuries will revascularize without collapse of the talar dome. Initial fracture displacement and presence of open fractures increase the risk of osteonecrosis. Talar process fractures may be subtle and easily missed on plain radiographs. Advanced imaging will provide detail to facilitate treatment planning.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Corrective Osteotomies Used in Cavus Reconstruction

The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes.

Distraction subtalar arthrodesis

There is a high potential for disability following calcaneal fracture. This potential exists whether a patient is treated with conservative or operative management. Subfibular impingement and irritation of the peroneal tendon and sural nerve may also be present. Posttraumatic arthritis of the subtalar joint can occur. In patients with symptomatic calcaneal malunion, systematic evaluation is required to determine the source of pain. Nonsurgical treatment may be effective. One surgical treatment option is subtalar distraction arthrodesis. High rates of successful arthrodesis and patient satisfaction have been reported with this surgical option in correctly selected patients.

Antegrade-retrograde opposing lag screws for internal fixation of simple displaced talar neck fractures

The talar neck is deviated medially with reference to the long axis of the body of the talus. In addition, it deviates plantarward. The talar neck fracture line is sometimes observed to be oriented obliquely (not perpendicular to the long axis of the talar neck). This occurs when the medially deviated talar neck strikes the horizontally oriented anterior lower tibial edge. Internal fixation of a simple displaced talar neck fracture usually requires 2 lag screws. Because the fracture line is obliquely oriented, a better method for positioning the screws perpendicular to the fracture line is to place them in a reversed direction to provide maximum interfragmentary compression at the fracture site, which could increase the likelihood of absolute stability with subsequent improvement in the incidence of fracture union and a reduction of complications, such as avascular necrosis of the body of the talus. Two lag screws are used, with the first inserted from posteriorly to anteriorly (perpendicular to the fracture line) using a medial approach after medial malleolar chevron osteotomy. The second screw is inserted from anteriorly to posteriorly (perpendicular to the fracture line) using an anterolateral approach. Both screw heads should be countersunk. A series of 8 patients underwent this form of internal fixation for talar neck fracture repair, with satisfactory functional outcomes. In conclusion, the use of antegrade-retrograde opposing lag screws is a reasonable method of internal fixation for simple displaced talar neck fractures.

Epidemiological study on talus fractures

OBJECTIVE

to analyze the characteristics of patients with talus fractures and the injuries that they present.

METHODS

retrospective analysis on patients hospitalized in the Institute of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine of the University of São Paulo, between 2006 and 2011, with talus fractures. Patient profile parameters, risk factors, fracture characteristics, treatment data and acute complications were analyzed.

RESULTS

analysis on 23 cases showed that men were more affected than women, with a ratio of 4.8:1. The most frequent trauma mechanism was traffic accidents, followed by falls from a height. The most frequent type of fracture was at the neck of the talus, with 17 cases. Among the 23 cases, seven had peritalar dislocation at the time of presentation, four had exposed fractures and 11 presented other associated fractures. The mean length of time between the trauma and the definitive treatment was six days, while the mean length of hospital stay was 11 days. Three patients presented acute postoperative complications.

CONCLUSION

talus fractures occurred most commonly in the region of the talar neck and most frequently in young males who suffered high-energy trauma. In almost half of the cases, there were other associated fractures. The length of hospital stay was 11 days.

The cavus foot

The cavus, or high-arched, foot can present in either childhood or adulthood as a function of muscle imbalance. Neurologic, traumatic, and idiopathic processes have been identified, along with residual clubfoot, as the primary causes of adult cavus foot deformity. A thorough history and physical examination is important and can help identify the underlying cause of deformity. Conservative treatment modalities are always used first, with surgical intervention reserved for refractory cases. The goal of surgery is to correct muscle imbalance, which can be achieved via tendon transfers, corrective osteotomies, and, in the most severe cases, fusion.

A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?

BACKGROUND

Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes.

METHODS

The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%).

RESULTS

One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).

CONCLUSIONS

Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.