Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases

The combined talus and sustentaculum fracture: A case series

BACKGROUND

The sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture.

METHODS

Retrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate.

RESULTS

Sustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively).

CONCLUSION

Talar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries.

LEVEL OF EVIDENCE

IV.

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.

Infection Rates and Surgical Procedures Associated With Isolated Open Talar Neck and Body Fractures

BACKGROUND

Open fractures of the talar body and neck are uncommon. Previous reports of associated deep infection rates and resulting surgical requirements vary widely. The primary objective of this study is to report the incidence of deep infections for isolated open talar body and neck fractures, and secondarily the incidence and number of total surgeries performed (TSP), secondary salvage procedures (SSPs), and nonsalvage procedures (NSPs).

METHODS

Retrospective case-control study of 32 consecutive isolated open talus fracture patients (22 neck, 10 body) were followed for an average of 39.2 months.

RESULTS

Five (15.6%) fractures developed deep infections. Fifty percent of open body fractures became infected compared with 0% of neck fractures (P < .001). There was no difference between infected group (IG) and uninfected fracture group (UG) with respect to age, sex, body mass index, tobacco, diabetes, vascular disease, open fracture type, wound location, hours to irrigation and debridement, or definitive treatment. The majority (92.6%) of UG fractures used a dual incision with open wound extension. There were more single extensile approaches in the IG group (P = .04). The IG required 5.8 TSP per patient compared with 2.1 in the UG (P = .004). All (100%) of the IG required an SSP compared with 29.6% of the UG (P = .006). All (100%) of the IG required an NSP compared to 40.7% of the UG (P = .043). In the IG, 2.8 NSPs per patient were required after definitive surgery compared with 1.18 in the UG (P = .003). Of those followed 1 year, the incidence of SSP remained higher in the IG (P = .016).

CONCLUSION

The incidence of deep infection following isolated open talar fractures is high and occurs disproportionally in body fractures. Infected fractures required nearly 6 surgeries, and all required SSP.

LEVEL OF EVIDENCE

Level IV, prognostic.

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.

[Fractures of the talar neck and body : An overview]

Fractures to the talar neck and talar body (central talar fractures) are rare injuries but often result in devastating outcomes. It is therefore important to diagnose these injuries early and provide the best possible treatment. The analysis, classification, and surgical planning of central talar fractures should be based on computed tomography (CT) imaging. In the case of dislocated fractures, surgeons must strive for an anatomic reduction and fixation. The approach routes are based on the fracture morphology and must enable adequate reduction of the fracture. This can often only be achieved by two or more approach routes. The outcome correlates with fracture complexity and the quality of the reduction. Complications such as avascular necrosis and posttraumatic osteoarthritis are common and have a negative effect on the results of the treatment.

Bosworth Fractures of the Ankle: A Systematic Literature Review

Bosworth lesions are fracture-dislocations of the ankle and are characterized by entrapment of the proximal segment of the fibula behind the posterior tubercle of the distal tibia. Treatment is challenging, mainly due to failure of a closed reduction. The aim of this study was to review the literature concerning this type of injury. A total of 103 patients with Bosworth fractures were included in the study. The analyzed studies yielded a total of 103 cases, of which 68% (n = 70) were male and 32% (n = 33) were female. Bosworth fractures are mainly due to accidental trauma (58.2%), sports-related injuries (18.4%), and traffic accidents (18.4%). More than 76% of the patients presented a Danis-Weber B fracture, 8.7% a type C fracture, and only 0.97% presented a type A fracture. In 92.2% of the patients, the attempted closed reduction was unsuccessful. A definitive treatment with open reduction and internal fixation (ORIF) was used in 96 patients (93.2%). The most frequent complication was post-traumatic arthritis (10.7%). Bosworth fractures are challenging. The available literature lacks adequate information about this fracture, and an approved standardized algorithm for treating such fractures is not available.

Operative outcomes of a high-grade talar neck fracture - Lessons from 20 years' clinical experience in a single, tertiary hospital

BACKGROUND

The operative treatment of high-grade talar neck fractures remains challenging, despite numerous previous reports. Our goal was to determine long-term outcomes and to establish a plan for management of postoperative complications (especially, avascular necrosis [AVN] of talar body) after high-grade talar neck fractures. We hypothesized that not every case with AVN of talar body require secondary surgical interventions.

METHODS

We retrospectively reviewed the radiographic and clinical findings of 14 patients who underwent operative treatment for high-grade talar neck fractures (modified Hawkins type III and IV) between January 2000 and December 2017. The minimum follow-up duration for inclusion was 3 years. Using radiographs during follow-up, we assessed the development of AVN of the talar body, malunion, nonunion, and posttraumatic osteoarthritis. Information about the secondary operations and their outcomes were also investigated using visual analogue scale (VAS) and American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot scale at the final follow-up.

RESULTS

In 10 of 14 patients (71.4 %), talar body AVN developed during follow-up. However, secondary operation was required in only 30.0 % (3 of 10 patients). In the remaining 7 patients who did not undergo secondary operation, the symptoms were tolerable with a maximum of 89 months follow-up; although the talar body presented sclerotic changes, but without talar dome collapse. The rates of malunion and post-traumatic subtalar osteoarthritis were 21.4 % and 14.3 %, respectively. No patients presented with fracture site nonunion. After a mean of 55.86 ± 14.45 months (range, 37-89) follow-up, the final mean VAS and AOFAS scores were 3.07 ± 0.73 (range, 2-4) and 80.43 ± 3.11 (range, 75-85), respectively.

CONCLUSION

We recommend leaving talar body AVN untouched, unless the patient's symptoms become intolerable. In our clinical practice, postoperative AVN could be stably maintained without talar dome collapse for more than 7 years, although the sclerotic change persisted. Despite the small number of patients, our clinical experience may benefit patients with high-grade talar neck fractures and surgeons who treat such rare, serious, and challenging foot injuries.

LEVEL OF EVIDENCE

Level IV, Case series.

Clinical and radiological outcomes of internal fixation of complex talar neck and body fractures with locking plates through a dual approach

INTRODUCTION

Talar fractures are rare and surgical treatment has not been standardized. The literature is rather poor on preserving talar vascularization in single or dual approaches. A dual approach allows better exposure and should limit devascularization. Locking plates are one of the modern solutions for challenging comminuted fractures. The aim of this study was to determine clinical and radiological outcomes in complex talar fracture (CTF) of the neck and body, fixed by locking plates through a dual approach with at least one locking plate.

HYPOTHESIS

Locking-plate fixation of CTF through a dual approach leads to good clinical outcome.

MATERIAL AND METHODS

A single-center retrospective study included 12 cases of CTF treated between January 2007 and May 2019. 3D CT was systematically performed to plan surgery. A dual approach and at least one locking plate were used for fixation. Clinical outcome was evaluated on AOFAS score. Reduction quality and correlation to clinical results were evaluated, reduction with<2mm joint step being considered satisfactory. Consolidation rate and occurrence of avascular necrosis of the talus (ANT), post-traumatic arthritis (PTA) and postoperative complications were analyzed.

RESULTS

Mean follow-up was 27 months (range, 15-47). Mean AOFAS score was 70±18 (range, 30-97). Inframillimetric reduction was achieved in 67% of cases, without significant correlation with clinical results. The consolidation rate was 91.6%, ANT rate 18.2% and PTA rate 45.5%. One patient presented septic osteoarthritis secondary to scar necrosis.

CONCLUSION

Locking plate fixation of CTF through a dual approach provided acceptable clinical outcomes.

LEVEL OF EVIDENCE

IV; retrospective study.

Complications and Functional Outcome Following Operative Treatment of Talus Neck and Body Fractures: A Systematic Review

Background:

Central talar fractures are rare and often associated with impaired functional outcome. Despite recent advances in diagnosis and management of talus fractures, complications rates remain high and functional outcome is generally poor. This study aims to provide an overview of complication rates and functional outcome following operative treatment of talar neck and body fractures. This may help in clinical decision making by improving patients’ expectation management and tailored treatment strategies.

Methods:

A systematic review of the literature was conducted of studies published from January 2000 to July 2021 reporting functional outcome and/or complications following operative treatment of talar neck, body, or combined neck and body fractures. Keywords used were (Talar fracture) or (Talus fracture). Data on complication rates and functional outcome was extracted from selected articles.

Results:

A total of 28 articles were included in our analysis reporting 1086 operative treated talar fractures (755 neck [70%], 227 body fractures [21%], and 104 combined body and neck fractures [9%]). The mean follow-up was 48 (range 4-192) months. Complications occurred frequently with; 6% surgical site infection, 8% nonunion, 29% avascular necrosis, 64% osteoarthritis, and in 16% a secondary arthrodesis was necessary. A wide variety in functional outcome was reported; however, there seems to be a correlation between fracture classification and postoperative complications.

Conclusion:

Operative treatment of central talar fractures is associated with a high incidence of early and late complications and often leads to an impaired functional outcome. Standardization of talar fracture classification and scoring systems in combination with large sample-sized prospective studies are warranted to detect further predictive factors influencing tailormade treatment strategies and patient expectation management.

Level of Evidence:

Level III, Systematic review of case series and case-control studies.

Functional outcome and quality of life in surgically treated talar neck and body fractures; how is it affected by complications

BACKGROUND

Since talus fractures are rare, study populations are frequently small. The aim of this study is to describe how surgical treatment of talar neck and body fractures and postoperative complications affect functional outcome and quality of life measured by validated questionnaires.

METHODS

All patients following surgically treated talar neck and/or body fracture between January 2000 and December 2019 at a level 1 trauma center were included in this retrospective cohort study. Primary outcomes were functional outcomes measured by Lower Extremity Functional Score (LEFS), the Foot Function Index (FFI), and the Quality of Life (QOL) measured by the EuroQol 5-dimension questionnaire (EQ-5D). Linear regression was used to assess the relationship between continuous variables and the outcome, and multivariable linear regression was used to identify the predictors of the functional outcome.

RESULTS

Ninety patients were included, of which 73 responded to our questionnaires. The median follow-up time was 50.5 (interquartile range (IQR), 18.3-97.3) months. Our study showed the following results: a mean LEFS of 58.4 (range, 17-80), a median FFI of 15.7 (IQR, 3.5-35.2), a median EQ-5D index score of 0.83 (IQR, 0.81-1.00), a median patient satisfaction of 9.0 (IQR, 8.0-10.0), a patient reported health status of 76.8 (range, 20-100), and a mean AOFAS score of 75.7 (range, 28-100). Implant removal and secondary arthrodesis were associated with a reduced AOFAS outcome score (p=0.001, p<0.001), and implant removal was also a predictive factor for a less favorable LEFS outcome score (p=0.001).

CONCLUSION

Patients who underwent implant removal and/or secondary arthrodesis had poorer functional outcome compared to patients who did not undergo additional procedures. Careful consideration of re-intervention must be made in combination with patient expectation management. Future studies should focus on how to lower the rate of complications and the effect of secondary intervention with the use of validated questionnaires.

Talar Body Fracture Treated by Hindfoot Endoscopic Reduction and Internal Fixation

Background

A talar body fracture is relatively rare. Surgical treatment for the fracture is generally indicated for the displaced fracture types and traditionally performed via open approaches. However, open approaches may not be able to achieve adequate exposure of the talus body owing to the difficulty in achieving reduction and fixation of the fracture. In this case report, we describe a case of talar body fracture treated by hindfoot endoscopic reduction and internal fixation. Case report. A 39-year-old man who was a carpenter complained of right hindfoot pain after he fell from a stepladder during work. Although plain radiographs of the right ankle showed no abnormal findings, noncontrast computed tomography demonstrated a fracture line from the lateral side of the posterior lateral process to the medial side of the talus body. In addition, the fracture line extended to the posterior ankle and subtalar joints, and the bone fragment was slightly displaced. We diagnosed him with the talar body fracture and performed operative treatments using hindfoot endoscopic reduction and internal fixation. At 14 weeks after the operation, he was able to return to work at the preinjury activity level without dysfunction of the ankle nor complications.

Conclusion

We reported a case of talar body fracture treated by hindfoot endoscopic reduction and internal fixation. In this case, the hindfoot endoscopic technique provided visualization of the fracture site with less invasiveness and increased safety, which enabled proper reduction and internal fixation of the fracture site. Therefore, the patient was able to return to work at the preinjury activity level at 14 weeks after surgery without dysfunction of the ankle nor complications. This surgical technique may be a useful option for the talar body fracture.

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.

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.

Talar fracture: Epidemiology, treatment and results in a multicenter series

INTRODUCTION

Talar fracture is rare. Treatment is surgical for neck and/or body fractures with displacement. The aims of the present study were to collect epidemiological data on talar fractures, and to assess the impact of trauma via various functional scores and radiographic impact in the medium term.

HYPOTHESIS

Displaced talar fracture shows negative medium-term functional and radiological/clinical impact.

MATERIAL AND METHODS

A multicenter retrospective study was performed with a minimum follow-up of 12 months post-trauma. Inclusion criteria included radiographic assessment at a minimum 12 months post-trauma and data on 3 functional scores: SF12, AOFAS and FAAM. 225 patients were initially included, 81 of whom had follow-up with functional and radiological/clinical assessment.

RESULTS

Fracture reduction was anatomic in 61% of cases when CT was performed; reduction quality was independent of approach (p>0.05). 45% of patients showed subtalar osteoarthritis at a mean 2 years, significantly related to reduction defect (p<0.05). Mean AOFAS score was acceptable, at 74/100. Factors for functional prognosis comprised: reduction quality, hindfoot alignment, subtalar osteoarthritis, and talar osteonecrosis with dome collapse.

DISCUSSION

Talar fracture led to late complications with socioeconomic impact. Subtalar osteoarthritis affects almost half of patients within some months of trauma. Optimal reduction is the key to fair progression. Postoperative CT assessment now seems mandatory.

LEVEL OF EVIDENCE

IV; multicenter retrospective study.

Different patterns and characteristics of Talar injuries at two main orthopedic trauma centers in Shiraz, south of Iran

Background

Categorizing different injury patterns of the talus, describing demographic data, mechanisms of injury and associated fractures are important issues in orthopedic trauma surgeries. Injuries of the talus require careful attention with appropriate treatment approaches in order to reduce possible complications.

Methods

In a cross-sectional study, the demographic characteristics, mechanism of injury, fracture type, and associated fractures were compiled from all patients’ files and operation notes with diagnosis of talar injuries from January 2014 to December 2019.

Results

Among 367 patients, 317 (86.4%) males and 50 (13.6%) females with mean age of 31.8 ± 11.6 years were identified. There were three (0.8%) patients with bilateral talar fractures. The most common mechanism of injury was motor vehicle accident (MVA) (46.1%), followed by falls (43.3%), direct trauma (6.2%) and sport injuries (4.4%). About half of the patients injured in MVAs were motorcyclists. Isolated talar body fractures (21.9%) were more common than isolated talar neck (19.2%) or combined body & neck fractures (14.6%). Isolated lateral process fracture is the most frequent fractured process of the talus (14.3%). Hawkin type IIA (39.2%) was the most common type of talar neck, followed by Hawkin type III (22.3%), type I (21.5%), type IIB (14.6%) and type IV (2.3%). Medial malleolus, fibula and calcaneus were the most common associated fractures, respectively.

Conclusions

The population that is most affected by talar injury are active young men who are involved in motor vehicle accidents, especially motorcycle crashes, with fracture of body and/or neck of talus being the most common type.

Surgical management of displaced talus neck fractures: single vs double approach, screw fixation alone vs screw and plating fixation-systematic review and meta-analysis

PURPOSE

To provide a direct comparison between two important aspects related to talar neck fractures management - surgical approaches and fixation strategies.

DATA SOURCES

A systematic review and meta-analysis was performed using PubMed, SciELO, and gray literature databases. The keyword "talus fracture" and the combined terms "talus neck fracture AND surgical approach" and "talus neck fracture AND fixation strategy" were used.

STUDY SELECTION

Study selection, data extraction, and the risk of bias assessment were performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Searches were limited to human studies and the English and Portuguese. Inclusion criteria were articles in full text that reported on any aspect of surgical approach and fixation strategy for talus neck fractures. Exclusion criteria were skeletally immature patients, mean follow-up of less than 12 months, studies that did not use the Hawkins classification system, primary treatment of arthrodesis, studies published before year 2000, and studies published in languages other than English and Portuguese.

DATA EXTRACTION

Basic information was collected including journal, author(s), year published, level of evidence, number of fractures, and follow-up. Specific information was collected including fracture classification, surgical approach, fixation strategy, complication rate, type of complication(s), and outcome measurement(s).

DATA SYNTHESIS

Fixed-effects model was used for meta-analysis. The choice for surgical approach(es) and fixation strategy was stratified based on fracture classification. Complication rate, type of complication(s), and outcome measurement(s) were calculated for all studies and delineated by fracture classification.

CONCLUSION

There is a significant correlation between poor scores and poor fracture reduction, but not with the modified Hawkins classification, surgical approach, and fixation strategy. The presence of an open talus neck fracture-dislocation jeopardizes the functional outcome, increasing the risk of complications. The overall avascular necrosis and post-traumatic osteoarthritis event rate was 0.279 and 0.400, respectively. Both complications were highly correlated to higher energy fracture patterns and to the use of combined approaches, but not to fixation strategy.

LEVEL OF EVIDENCE

I (systematic review and meta-analysis).

Quantification and Comparison of Talar Exposure Utilizing a Posteromedial Approach and Medial Malleolar Osteotomy

Background:

Fractures of the talus are a rare but challenging injury. This study sought to quantify the area of osseous exposure afforded by a posteromedial approach to the talus and medial malleolar osteotomy.

Methods:

Five fresh-frozen cadaveric lower extremities were dissected using a posteromedial approach and medial malleolar osteotomy respectively. Following exposure, the talar surfaces directedly visualized were marked and captured using a calibrated digital image. The digital images were then analyzed using ImageJ software (National Institutes of Health) to calculate the surface area of the exposure.

Results:

The average square area of talus exposed using the posteromedial approach was 9.70 cm² (SD = 2.20, range 7.20-12.46). The average quantity of talar exposure expressed as a percentage was 9% (SD = 1.58, range 7.03-10.40). The average square area of talus exposed using a medial malleolar osteotomy was 14.32 cm² (SD = 2.00, range 11.26-16.66). The average quantity of talar exposure expressed as a percentage was 12.94% (SD = 1.79, range 9.97-14.73). The posteromedial approach provided superior visualization of the posterior talus, whereas the medial malleolar osteotomy offered greater access to the medial body.

Conclusion:

The posteromedial approach and medial malleolar osteotomy allow for significant exposure of the talus, yielding 9.70 and 14.32 cm², respectively. Given the differing portions of the talus exposed, surgeons may prefer to use the posteromedial approach for operative fixation of posterior process fractures and elect to use a medial malleolar osteotomy in cases requiring more extensive medial and distal exposure for neck or neck/body fractures.

Level of Evidence:

Level IV.

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.

Fractures of the Talus: Current Concepts

Talus fractures continue to represent a challenging and commonly encountered group of injuries. Its near-complete articular cartilage surface, and its role in force transmission between the leg and foot, makes successful treatment of such injuries a mandatory prerequisite to regained function. Familiarity with the complex bony, vascular, and neurologic anatomy is crucial for understanding diagnostic findings, treatment indications, and surgical techniques to maximize the likelihood of anatomic bony union. This review details the structure and function of the talus, a proper diagnostic workup, the treatment algorithm, and post-treatment course in the management of talus fractures.

Bilateral Symmetry, Sex Differences, and Primary Shape Factors in Ankle and Hindfoot Bone Morphology

Background:

Ankle injuries and joint degeneration may be related to ankle bone morphology. Little data exist to characterize healthy hindfoot bone morphology. The purpose of this study was to characterize side-to-side symmetry and sex differences in ankle and hindfoot bone morphology, and to identify the primary shape factors that differentiate ankle and hindfoot bone morphology among individuals.

Methods:

Computed tomography was used to create 3D surface models of the distal tibia, talus, and calcaneus for 40 ankle and hindfoot bones from 20 healthy individuals. Morphologic differences between left and right bones of the same individual and between males and females were determined. Statistical shape modeling was performed to identify primary shape variations among individuals.

Results:

Side-to-side differences in bone morphology averaged 0.79 mm or less. The average distal tibia in males was larger overall than in females. No significant sex difference was noted in the tali. The average female calcaneus was longer and thinner than the average male calcaneus. Variability in ankle and hindfoot bone morphology is primarily associated with articulating surface shape, overall length and width, and tendon/ligament attachment points.

Conclusion:

In general, the contralateral ankle can serve as an accurate guide for operative restoration of native ankle morphology; however, specific regions demonstrate higher asymmetry.

Clinical Relevance:

Knowledge of regions of high and low bilateral symmetry can improve hindfoot and ankle reconstruction. Design of ankle prostheses can be improved by accounting for differences in bone morphology associated with sex and shape differences among individuals.

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BACKGROUND

The main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.

METHODS

From January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.

RESULTS

27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49-119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7-7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0-11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9-10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).

CONCLUSIONS

Despite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

Association of Bosworth, Pilon, and Open Talus Fractures: A Very Unusual Ankle Trauma

Introduction

A Bosworth fracture-dislocation is a rare lesion resulting in a fixed dislocation of the distal fibula behind the posterior tibial tubercle. Only few cases have been reported showing an associated consequent fracture, namely, a pilon or a medial malleolus fracture.

Case Report

We present a case report of a patient with an unusual combination of a Bosworth injury with a pilon fracture and an open multifragmentary talus fracture and our approach for open reduction and internal fixation. At one year postoperative, the patient developed an invalidating tibiotalar and subtalar arthrosis that eventually required an ankle-hindfoot arthrodesis. A Bosworth injury is an infrequent entity and is even rarer when associated with other fractures. Careful preoperative planning is necessary, as the combination of these fractures is a surgical challenge. Special care must be taken to preserve the neurovascular bundle.

Discussion

The present case highlights a Bosworth injury involving a severity that has never been described before and suggests adding an eighth stage to the classification presented by Perry et al.

Long-Term Outcome After Operative Management of Talus Fractures

BACKGROUND:

Controversies remain regarding the preferred treatment strategy for talus fractures. The primary goal of this study was to evaluate the long-term outcome after operative management of talus fractures. Secondarily, we identified those factors that affected the outcome and defined strategies to improve the outcome.

METHODS:

This is a retrospective outcome study of 84 patients with an average follow-up time of 9.1 years. We assessed the functional results, return to daily activities, and general health status using the Foot Function Index-5pt, a numeric rating scale for pain, and the Short Form-36 Health Survey. Furthermore, we conducted a correlation analysis between the outcomes and 14 demographic, clinical, and radiologic variables.

RESULTS:

We found moderate mean Foot Function Index pain and disability scores of 30.2 and 28.7, respectively. The mean numeric rating scale score was 3.2. Of all responders, 41% (27/66) did not return to their daily activities. We reported low physical, but good mental, Short Form-36 component summary scores of 42.7 and 48.3, respectively. We recorded a complication rate of 56%. Osteoarthritis, articular incongruence and talus body fractures correlated significantly with a poorer functional outcome. Delayed surgery after trauma was associated with better outcome measures.

CONCLUSIONS:

Talus fractures have a major long-term impact on ankle and hindfoot function and on physical health. Success of operative treatment depends on the occurrence of osteoarthritis postoperatively, type of fracture, and quality of fracture reduction. Because only the latter is modifiable, efforts should be made to restore articular congruence in order to improve the outcome. Therefore, we recommend reviewing the quality of the reduction postoperatively on CT. Furthermore, talus fractures should not be considered operative emergencies, but rather treated after recovery of the soft-tissues.

LEVEL OF EVIDENCE:

Level III, comparative study.

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.

Traumatic Injury to the Subtalar Joint

Traumatic injury to the subtalar joint occurs during subtalar dislocations, talar and calcaneal fractures, and fracture-dislocations. After closed reduction of subtalar dislocations, peripheral talar or calcaneal fractures need to be ruled out by computed tomography scanning. In fractures and fracture-dislocations of the talus and calcaneus involving the subtalar joint, anatomic reconstruction of joint congruity is essential for functional rehabilitation. Failure to anatomically reduce the subtalar joint potentially leads to chronic instability, subtalar arthritis and posttraumatic hindfoot deformity. Despite adequate management, subtalar arthritis may develop as a result of primary cartilage damage at the time of injury.

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 fractures: radiological and CT evaluation and classification systems

INTRODUCTION

The talus is the second largest bone of the foot. It is fundamental to ensure normal ankle-foot movements as it connects the leg and the foot. Talar fractures are usually due to high energy traumas (road accidents, high level falls). They are not common as they account for 3-5% of ankle and foot fractures and 0.85% of all body fractures. However, talar fractures not correctly diagnosed and treated can lead to avascular necrosis of the astragalus, pseudoarthrosis, early osteoarthrisis and ankle instability, declining the quality of life of patients.

METHODS

A PubMed search was performed using the terms "talus" "talus AND radiology", "talar fractures", and "talar fractures classification", selecting articles published in the last 98 years. We selected articles about pre-treatment and post-surgery talar fractures diagnostic imaging. We also selected articles about talar fractures complications and traumatic talar dislocations. Case reports have not been included.

AIM OF THE WORK

to describe radiological evaluations, classification systems, and biomechanical patterns involved in talar fractures. Also we will briefly describe talar fractures complications and treatment option and strategies.

CONCLUSIONS

This work suggests a radiological approach aimed to classify talar fractures and guide treatment strategies, improving patient outcomes.

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.

Outcomes of Talus Fractures Associated With High-Energy Combat Trauma

BACKGROUND

Talus fractures are infrequent injuries that are often associated with poor clinical outcomes. Literature reviewing talus fractures is limited to a civilian population, with few studies characterizing these injuries sustained in active duty personnel. The aim of this study was to characterize talus fractures sustained in combat trauma by reporting their surgical outcomes.

METHODS

The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained talus fractures in battle conditions between 2001 and 2014. These patients underwent a retrospective chart review. Injury and fracture patterns were characterized. We examined the incidence of secondary surgical procedures and reviewed patients undergoing early and late transtibial amputations. Forty-eight talus fractures were identified.

RESULTS

All injuries were related to high-energy trauma: 43 (90%) resulting from improvised explosive devices (IED), 3 (6%) from gunshot wounds (GSW), and 2 (4%) from propelled explosive devices. Ten (20.8%) patients underwent early transtibial amputation. Early amputations were associated with calcaneus fractures (10/10 vs 16/38, P = .0009) but not with open fractures (8/10 vs 20/38, P = .163). Twenty-six fractures were available with longer term follow-up. Twenty-three fractures had associated injuries to the ipsilateral lower extremity. Sixteen (61.54%) injuries underwent a total of 26 additional surgical procedures. Eight fractures required secondary fusions (30.8%). Subtalar fusions were associated with ipsilateral calcaneus fractures (5/6 vs 2/10, P = .03). One patient underwent a delayed transtibial amputation 17 months after injury.

CONCLUSIONS

Talus fractures sustained within the combat environment were associated with high rates of early amputations and secondary surgical intervention. When the limb was salvaged, patients could expect the need for additional procedures to address ongoing issues.

LEVEL OF EVIDENCE

Level IV, case series.

The Diagnosis, Management and Complications Associated with Fractures of the Talus

Fractures of the talus are uncommon injuries that can have devastating consequences. The blood supply to the talus is tenuous and injuries are associated with a higher incidence of avascular necrosis and malunion. Talar neck fractures are the most common fractures. This review looks at the different types of fractures of the talus, particularly focusing on talar neck fractures. The diagnosis and management are discussed as well as the complications.

Complications of Talar Neck Fractures by Hawkins Classification: A Systematic Review

The goal of the present study was to perform a systematic review of the published data on talar neck fractures for a better understanding of the postoperative clinical outcomes using open reduction and internal fixation stratified by Hawkins type. A PubMed search was performed using the keywords "talar," "neck," and "fracture." This search identified 209 potential studies, which were reviewed to yield 16 studies that met the criteria. The surgical outcomes of talar neck fractures stratified by the Hawkins classification analyzed in the present study were as follows: American Orthopaedic Foot and Ankle Society scale score was 77.00 for type I, 86.10 for type II, 68.30 for type III, 68.30 for type IV, and 76.50 for all talar neck fractures. Avascular necrosis presented in 0.00% of type I fractures, 15.91% of type II fractures, 38.89% of type III fractures, 55.00% of type IV fractures, and 26.47% of all fractures. Osteoarthritis presented in 25.00% of type I fractures, 41.33% of type II fractures, 54.23% of type III fractures, 72.73% of type IV fractures, and 51.69% of all fractures. Subtalar arthritis presented in 0.00% of type I fractures, 54.29% of type II fractures, 46.43% of type III fractures, 45.45% of type IV fractures, and 44.97% of all fractures. The malunion prevalence was 13.29% and the nonunion prevalence was 3.97% for all fractures. Type II fractures were the most common (50.88%) fracture type reported in the reports reviewed in the present study.

Arthroscopic Capsular Release of the Talocalcaneonavicular Joint

Arthrofibrosis of the talocalcaneonavicular joint can follow talar neck fracture especially if anterior approaches have been used for fracture fixation. Capsular release of the talocalcaneonavicular joint is indicated if the painful hindfoot stiffness cannot be controlled with conservative treatment. Open capsular release of the talocalcaneonavicular joint demands extensive soft tissue dissection and hinders early postoperative mobilization exercise of the joint. The purpose of this technical note is to describe a minimally invasive approach of arthroscopic capsular release of the talocalcaneonavicular joint that is composed of arthroscopic release of the talonavicular joint and the anterior subtalar joint. This allows immediate postoperative mobilization of the joint.

Talar Neck Fractures Treated Using a Highly Selective Incision: A Case-Control Study and Review of the Literature

We describe a highly selective incision combined with percutaneous manipulation for reduction and internal fixation of talar neck fractures. We retrospectively investigated the clinical data from 29 cases of talar neck fractures treated from January 2009 to June 2013. Fifteen patients (study group) were treated using a 1- to 2-cm limited incision placed on the anteromedial or anterolateral side of the talus, followed by percutaneous reduction and fixation. Another 14 patients (control group) underwent open reduction and internal fixation through a conventional anteromedial or anterolateral approach. All cases were fixed with Herbert screws or cannulated titanium screws. All the patients were followed up for a minimum of 18 (median 24) months. All the fractures displayed bony union at or before the final follow-up visit. The mean American Orthopaedic Foot and Ankle Society ankle scale score in the study group was 75.3 ± 17.7, 9 patients (60%) had good or excellent results, and 3 (20%) developed talar avascular necrosis. The mean ankle scale score in the control group was 78.9 ± 15.2, 9 patients (64.3%) had good to excellent results, and 6 (42.9%) developed avascular necrosis. No statistically significant differences were found in the American Orthopaedic Foot and Ankle Society score, the number of good to excellent outcomes, or the incidence of complications between the incision groups. A highly selective incision combined with percutaneous reduction and internal fixation can be used to treat fractures of the neck of the talus satisfactorily.

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.

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.

Mechanical Comparison of Headless Screw Fixation and Locking Plate Fixation for Talar Neck Fractures

For talar neck fractures, open reduction and internal fixation have been thought to facilitate revascularization and prevent osteonecrosis. Newer screw systems allow for placement of cannulated headless screws, which provide compression by virtue of a variable pitch thread. The present study compared the biomechanical fixation strength of cannulated headless variable-pitch screw fixation and locking plate fixation. A reproducible talar neck fracture was created in 14 fresh cadaver talar necks. Talar head fixation was then performed using 2 cannulated headless variable-pitch 4-mm/5-mm diameter (4/5) screws (Acutrak; Acumed, Hillsboro, OR) and locking plate fixation. Headless variable-pitch screw fixation had lower failure displacement than did locking plate fixation. No statistically significant differences were found in failure stiffness, yield stiffness (p = .655), yield load (p = .142), or ultimate load between the 2 fixation techniques. Cannulated headless variable-pitch screw fixation resulted in better failure displacement than locking plate fixation in a cadaveric talus model and could be considered a viable option for talus fracture fixation. Headless, fully threaded, variable-pitch screw fixation has inherent advantages compared with locking plate fixation, because it might cause less damage to the articular surface and can compress the fracture for improved reduction. Additionally, plate fixation can increase the risk of avascular necrosis owing to the wider incision and dissection of soft tissues.

Treatment of displaced talar neck fractures using delayed procedures of plate fixation through dual approaches

PURPOSE

Treatment of talar neck fractures is challenging. Various surgical approaches and fixation methods have been documented. Clinical outcomes are often dissatisfying due to inadequate reduction and fixation with high rates of complications. Obtaining satisfactory clinical outcomes with minimum complications remains a hard task for orthopaedic surgeons.

METHODS

In the period from May 2007 to September 2010, a total of 31 cases with closed displaced talar neck fractures were treated surgically in our department. Injuries were classified according to the Hawkins classification modified by Canale and Kelly. Under general anaesthesia with sufficient muscle relaxation, urgent closed reduction was initiated once the patients were admitted; if the procedure failed, open reduction and provisional stabilisation with Kirschner wires through an anteromedial approach with tibiometatarsal external fixation were performed. When the soft tissue had recovered, definitive fixation was performed with plate and screws through dual approaches. The final follow-up examination included radiological analysis, clinical evaluation and functional outcomes which were carried out according to the Ankle-Hindfoot Scale of the American Orthopaedic Foot and Ankle Society (AOFAS), patient satisfaction and SF-36.

RESULTS

Twenty-eight patients were followed up for an average of 25 months (range 18-50 months) after the injury. Only two patients had soft tissue complications, and recovery was satisfactory with conservative treatment. All of the fractures healed anatomically without malunion and nonunion, and the average union time was 14 weeks (range 12-24 weeks). Post-traumatic arthritis developed in ten cases, while six patients suffered from avascular necrosis of the talus. Secondary procedures included three cases of subtalar arthrodesis, one case of ankle arthrodesis and one case of total ankle replacement. The mean AOFAS hindfoot score was 78 (range 65-91). According to the SF-36, the average score of the physical component summary was 68 (range 59-81), and the average score of the mental component summary was 74 (range 63-85).

CONCLUSIONS

Talar neck fractures are associated with a high incidence of long-term disability and complications. Urgent reduction of the fracture-dislocation and delayed plate fixation through a dual approach when the soft tissue has recovered may minimise the complications and provide good clinical outcomes.

Surgical treatment of talus fractures

Talus fractures result from high-energy mechanisms and usually occur at the neck. Functional outcome after talar neck fracture worsens with increasing Hawkins grade. The mainstay of treatment for talar neck fractures is anatomic reduction and internal fixation. Prompt reduction of dislocations should be performed. Patients should be taken to the operating room as soon as stabilized. Dual incisions and a combination of minifragment plates and screws should be used. Talar body fractures have a high rate of ankle and subtalar arthritis. Lateral process fractures are frequently missed on radiographs. Complications after talus fractures include osteonecrosis, malunion, post-traumatic arthritis, and infection.