Talar neck fractures: a systematic review of the literature

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis

OBJECTIVES

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs).

METHODS

DESIGN

Retrospective cohort.

SETTING

Single level I trauma center.

PATIENT SELECTION CRITERIA

Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse.

RESULTS

There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)].

CONCLUSIONS

This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders.

LEVEL OF EVIDENCE

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

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.

Midterm Outcomes after Operative Management of Hawkins Type III Talar Neck Fractures

Background

This study aims to report the midterm outcomes after surgical treatment of Hawkins Classification III Talar neck fractures.

Methods

From March 2010 to April 2022, among a total of 155 patients who visited our hospital with talus fractures, 31 patients underwent surgical treatment for Hawkins classification III talar neck fractures. The inclusion criteria comprised patients with a symptom duration of over 1 year who were available for outpatient follow-up and underwent magnetic resonance imaging (MRI) follow-up 2 months after surgery. Exclusion criteria included patients without preoperative ankle periarticular arthritis, and a total of 27 patients were enrolled. Traffic accidents and falls accounted for 86% of 23 cases, open fractures were 8 cases, and the mean follow-up period was 34.10 months (range, 12-80 months). Clinical outcomes were measured by American Orthopaedic Foot and Ankle Society (AOFAS) score and Foot function index (FFI), and radiological results were obtained using simple radiographs before and after surgery and MRI at 2 months postoperatively to confirm bone union and complications.

Results

Complete bone union was achieved in all cases, and the mean duration of union was 4.9 months (range, 4-6 months) and there were no nonunion and varus malunion. At the final follow-up, the mean AOFAS score was 80.18 points (range, 36-90 points) and the mean FFI score was 31.43 points (range, 10-68 points), showing relatively good clinical outcomes. There were 15 cases of avascular necrosis, 6 cases of traumatic arthritis of the ankle joint, 6 cases of irritation of the posterior tibial nerve, and 4 cases of wound problems.

Conclusions

Hawkins classification III talar neck fractures are mostly caused by high-energy injuries and have a relatively poor prognosis due to the high incidence of complications such as avascular necrosis or posttraumatic arthritis. However, if correct anatomical reduction and rigid internal fixation are performed within a short time after the injury, good results can be expected.

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.

Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study

PURPOSE

The aim of the present study was to investigate the effectiveness of a novel approach involving permissive weight bearing (PWB) in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities.

METHODS

Prospective comparative multicenter cohort study in one level 1 trauma center and five level 2 trauma centers. Surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities were included. Permissive weight bearing (PWB) in comparison to restricted weight bearing (RWB) was assessed over a 26-week post-surgery follow-up period. Patients' self-perceived outcome levels regarding activities of daily living (ADL), quality of life (QoL), pain and weight bearing compliance were used.

RESULTS

This study included 106 trauma patients (N = 53 in both the PWB and RWB groups). Significantly better ADL and QoL were found in the PWB group compared to the RWB group at 2-, 6-, 12- and 26-weeks post-surgery. There were no significant differences in postoperative complication rates between the PWB and RWB groups.

CONCLUSION

PWB is effective and is associated with a significantly reduced time to full weight bearing, and a significantly better outcome regarding ADL and QoL compared to patients who followed RWB regimen. Moreover, no significant differences in complication rates were found between the PWB and RWB groups.

LEVEL OF EVIDENCE

Level II.

REGISTRATION

This study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

[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.

Complications after talus fractures: A trauma centre experience

BACKGROUND

Talus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series.

METHODS

We retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded.

RESULTS

The mean age was 35 years (range: 18-76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis.

CONCLUSION

Our study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.

A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines

PURPOSE

Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion.

METHODS

A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM.

RESULTS

Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group.

CONCLUSION

FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

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.

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.

The economic burden of the postoperative management in surgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities: A prospective multicenter cohort study

OBJECTIVES

To estimate the economic burden expressed in costs and quality of life of the post-surgical treatment of peri‑ and/or intra-articular fractures in the lower extremity from a societal perspective.

DESIGN

This is a quantitative study as it aims to find averages and generalize results to wider populations. The design is a cost-of-illness and quality of life study focusing on costs (in euros), Activities of Daily Living (ADL) and Quality of Life (Qol) in patients with peri‑ and/or intra-articular fractures of the lower extremities.

SETTING

Surgically treated trauma patients with peri‑ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up. Patients were included from 4 hospitals in the Netherlands.

MAIN OUTCOME MEASURES

Costs, ADL and Quality Adjusted Life Years (QALY).

METHODS

Cost of illness was estimated through a bottom-up method. The Dutch Eq-5D-5 L questionnaire was used to calculate utilities while Lower Extremity Functional Scale (LEFS) scores were used as a measure of ADL. Non-parametric bootstrapping was used to test for statistical differences in costs. Subgroup analyses were performed to determine the influence of work status and further sensitivity analyses were performed to test the robustness of the results.

RESULTS

Total average societal costs were € 9836.96 over six months. Unexpectedly, total societal and healthcare costs were lower for patients with a paid job relative to patients without. Sensitivity analyses showed that our choice of a societal perspective and the EuroQol as our primary utility measurement tool had a significant effect on the outcomes. The ADL at baseline was respectively; 10.4 and at 26 weeks post-surgery treatment 49.5. The QoL was at baseline respectively; 0.3 and at 26 weeks post-surgery treatment 0.7. These findings are indicative of a significantly improved ADL and QoL (p ≤ 0.05) over time.

CONCLUSIONS

This study reveal a substantial economic burden in monetary terms and effect on QoL of patients with peri‑ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up.

REGISTRATION

This study was registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

Patient reported outcome of 33 operatively treated talar fractures

BACKGROUND

Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures.

METHODS

A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed.

RESULTS

In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145).

CONCLUSIONS

Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

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.

Antiresorptive treatment and talar collapse after displaced fractures of the talar neck: a long-term follow-up of 19 patients

Background and purpose - Displaced fractures of the talar neck are associated with a high risk of structural collapse. In this observational analysis we hypothesized that pharmacological inhibition of osteoclast function might reduce the risk of structural collapse through a reduction in bone resorption during revascularization of the injured bone.Patients and methods - Between 2002 and 2014 we treated 19 patients with displaced fractures of the talar neck with open reduction and internal fixation. Of these, 16 patients were available for final follow-up between January and November 2017 (median 12 years, IQR 7-13). Among these, 6 patients with Hawkins type 3 fractures and 2 patients with Hawkins type 2b fractures received postoperative antiresorptive treatment (7 alendronate, 1 denosumab) for 6 to 12 months. The remaining 8 patients received no antiresorptive treatment. The self-reported foot and ankle score (SEFAS) was available in all patients and 15 patients had undergone computed tomography (CT) at final follow-up, which allowed evaluation of structural collapse of the talar dome and signs of post-traumatic osteoarthritis.Results - The risk for partial collapse of the talar dome was equal in the 2 groups (3 in each group) and post-traumatic arthritis was observed in all patients. The SEFAS in patients with antiresorptive treatment was lower, at 21 points (95% CI 15-26), compared with those without treatment, 29 points (CI 22-35).Interpretation - Following a displaced fracture of the talar neck, we found no effect of antiresorptive therapy on the rate of talar collapse, post-traumatic osteoarthritis, and patient-reported outcomes.

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).

Graphic Representation of Intraosseous and Extraosseous Talus Blood Supply. Illustrated Anatomy

BACKGROUND

The vascular anatomy of the talus attracts intense research being not always easy to understand. The high intraosseous variability together with the anatomical characteristics makes some areas of the talus more prone to vascular compromise. The aim of this study is to describe the vascularization of the talus, both intraosseous and extraosseous.

MATERIAL AND METHODS

From the literature reviewed, we have developed a graphic scheme that allows easy observation of the irrigation distribution. To this end, nineteen anatomical dissections of human cadaveric feet have been carried out. Fifteen fresh-frozen slices have been cut in different planes and prepared using the modified Spalteholz technique and latex injection with blue and black ink to visualize the vascular network. In addition, the study has been complemented with a comprehensive literature review on this subject.

RESULTS

The findings allowed us to conclude that the posterior tibial artery provides the most important blood supply to the neck and body of the talus through the tarsal canal artery and the deltoid branch. The anterior tibial artery splits in the dorsal pedis artery, for the head and neck, and the lateral tarsal artery which throughout anastomoses breeds the tarsal sinus artery. The perforating peroneal artery branches out from the peroneal artery, creating an intraosseous anastomosis for the body and the posterior process.

CONCLUSION

The results obtained have contributed to develop a graphical representation that we present in this study, which allows a simple understanding of the intraosseus and extraosseus vascularization of the talus.

Talar neck non-union in an athlete successfully treated with a synthetic bone graft: A case report

Talar neck non-union is a rare complication of talar neck fractures. No guidelines are currently available for the proper management of this complication; thus, it can be hard for orthopaedic surgeons to successfully treat. Here we are reporting a case of talar neck non-union occurring in a 22-year-old male patient after a road traffic accident and presented to our institution 10 months after the initial injury. The non-union was managed surgically with an open reduction and internal fixation with the use of a synthetic bone graft to fill the defects. The patient regained full function and remained without complications after 7 years of follow up.

3D Printed Total Talus Replacement for Avascular Necrosis of the Talus

BACKGROUND

Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend on disease severity and functional goals. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study was to evaluate outcomes following TTR with a custom 3D printed metal implant.

METHODS

Patients who underwent TTR were retrospectively reviewed over a 3-year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog scale (VAS) scores, Foot and Ankle Outcome Scores (FAOSs), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre- and postoperatively. Twenty-seven patients underwent TTR for talar AVN with a mean follow-up of 22.2 months.

RESULTS

Ankle range of motion remained unchanged postoperatively. VAS pain scores improved postoperatively from 7.1 to 3.9 (P < .001). FAOSs improved postoperatively with regard to pain (P < .001), symptoms (P = .001), quality of life (P < .001), and activities of daily living (P < .001). There were 3 complications requiring reoperation in this cohort.

CONCLUSION

3D printed TTRs represent a unique surgical option for patients with severe talar AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and AVN.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Pedobarography shows no differences in gait after talar fractures

BACKGROUND

Fractures of the talus often lead to permanent restrictions of the affected limb. Possible alterations after these fractures in gait have not been evaluated yet.

OBJECTIVE

To evaluate possible alterations of gait by pedybarography after talar fractures.

METHODS

We conducted a retrospective single-centre study at a level I trauma center. Twenty patients with operatively treated talar fractures were followed up. Objective and subjective function of the ankle was measured using range of motion, clinical scores and dynamic pedobarography (emed-M; Novel, Germany).

RESULTS

There were 11 talar neck and 9 talar body fractures. All patients received screw fixation. There was a significant reduction in range of motion. The outcome was moderate to satisfying and the severity of the injury correlated with the clinical outcome and the range of motion. The presence of posttraumatic arthritis and joint incongruity lead to a decreased function of ankle and subtalar joint and resulted in a worse clinical outcome. AVN rate was associated to initial displacement. Dynamic pedobarography showed no significant changes in gait pattern.

CONCLUSIONS

Fractures of the talus lead to dissatisfaction, pain and malfunction. However, a change in gait pattern could not be proved.

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.

Tibial Nerve Dysfunction Associated With Operatively Treated Talar Neck Fractures

OBJECTIVE

To investigate the presence of tibial nerve dysfunction (TND) in operatively treated talar neck fractures.

DESIGN

Retrospective chart review.

SETTING

Urban Level-1 trauma center.

PATIENTS

Sixty-four patients for a total of 65 talar neck fractures treated with open reduction and internal fixation between January 1, 2014, and May 1, 2018.

MAIN OUTCOME MEASURES

Incidence of TND.

RESULTS

Evidence of TND was documented in 20 of 65 cases (30.8%) of talar neck fractures. There were no cases of TND associated with Hawkins I fractures, but TND was found in 7 of 32 Hawkins II fractures (21.9%), 10 of 24 Hawkins III fractures (41.7%), and 3 of 5 Hawkins IV fractures (60%). TND was reported in 11 of 19 open talar neck fractures (57.9%) (P = 0.002). TND was associated with tibiotalar dislocation (P = 0.017) but not subtalar dislocation (P = 0.17). TND did not occur in the absence of subtalar subluxation/dislocation. Of 18, a total of 6 (33.3%) reported partial recovery, and 6 (33.3%) reported full recovery within 6 months of the initial injury. By 12 months, of the 18, 8 (44.4%) reported partial recovery and 7 (38.9%) reported full recovery.

CONCLUSION

The tibial nerve and its distal branches are at risk of injury in the setting of displaced talar neck fracture, tibiotalar subluxation/dislocation, and open talar neck fracture with increasing risk among those with a higher Hawkins grade.

LEVEL OF EVIDENCE

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

Arthroscopically Assisted Reduction and Internal Fixation of Talar Neck Fracture: A Case Report

Introduction

Arthroscopic-assisted reduction and internal fixation (ARIF) is a recent concept and is increasingly used for articular fractures, due to the minimally invasive nature and high accuracy. However, there are few reports in literature about this procedure in talar fractures.

Case Report

The authors describe a clinical case of a 22-year-old woman with a closed right articular talar neck fracture, Hawkins type II, treated with arthroscopically ARIF.

Conclusion

This is a minimally invasive technique that can allow close accurate reduction and stable fixation of selected articular talar fractures. It avoids some complications of multiple and large incisions of the conventional open surgery, with good functional outcomes and patient satisfaction.

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.

Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures

Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.

Effect of Surgeon and Hospital Volume on Complications After Operative Tarsal Fracture Repair

OBJECTIVE

To determine whether increased surgeon and hospital volume is associated with lower rates of complications after tarsal fractures.

DESIGN

Retrospective cohort study of the State Inpatient Databases.

SETTING

Two hundred ninety-nine hospitals in Florida (2005-2012) and New York (2006-2008).

PATIENTS/PARTICIPANTS

Four thousand one hundred thirty-two tarsal fractures that underwent fixation by 1223 surgeons.

INTERVENTION

Surgical repair of tarsal fractures.

MAIN OUTCOME MEASUREMENTS

Composite of readmission for infection requiring operative treatment, wound dehiscence, nonunion, avascular necrosis, or amputation within 2 years of the index procedure.

RESULTS

The mean age was 44 (±15) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (±0.58). Multivariable logistic regression demonstrated a reduction in the likelihood of complications by 9% for each 5 additional surgeries performed by the operating surgeon [odds ratio (OR), 0.91 per 5 surgeries; 95% confidence interval (CI), 0.82-0.99]. Other factors associated with complications included increased age (OR, 1.23 per 10 years; 95% CI, 1.10-1.36), male sex (OR, 1.56; 95% CI, 1.12-2.17), open fractures (OR, 2.84; 95% CI, 1.92-4.19), number of Charlson comorbidities (OR, 1.23; 95% CI, 1.02-1.48), income quartile (OR, 1.48; 95% CI, 1.00-2.17), uninsured (OR, 2.47; 95% CI, 1.39-4.39), and other government program insurance (OR, 1.52; 95% CI, 1.06-2.18).

CONCLUSIONS

We observed a significant inverse relationship between surgeon volume and complication rates when controlling for patient and injury characteristics. In contrast to previous research, a volume-outcome relationship was not observed at the hospital level. These results suggest that such complex injuries should be triaged to the most experienced providers.

LEVEL OF EVIDENCE

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

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.

[Arch-shaped approach : New modified medial approach for the treatment of talus fractures]

OBJECTIVE

Anatomical reduction and fixation of complex talar fractures (Hawkins type III and IV, Marti type III and IV) using a medial approach.

INDICATIONS

Displaced talar fractures (Hawkins type III and IV, Marti type III and IV) with the need for a medial malleolar osteotomy or the simultaneous treatment of a medial malleolus fracture.

CONTRAINDICATIONS

High perioperative risk, severe soft tissue injuries in the medial approach area, infected soft tissues.

SURGICAL TECHNIQUE

Medial arch-shaped approach about 12 cm in length over the medial malleolus using a simultaneous medial malleolus fracture or via an additional medial malleolar osteotomy. Dissection and retraction of the terminal branches of the saphenous vein and the saphenous nerve. Protection of the blood supply in the area of the medial talus and in the sinus tarsi. Reduction of the talar joint surfaces and reconstruction of the anatomical axes according to the preoperative planning by means of native radiological and computed tomographic imaging. Osteosynthesis adapted to the fracture type using Kirschner wires, conventional screws, cannulated screws, double-threaded screws, resorbable pins, magnesium screws, small fragment plates.

POSTOPERATIVE MANAGEMENT

Lower leg splint or orthesis for 6 weeks, partial weight-bearing with 20 kg for 10-12 weeks. Early range of motion exercise of the ankle, subtalar and mid-tarsal joints.

RESULTS

In the past 5 years, 11 patients with either Hawkins type III and IV or Marti type III and IV fractures were treated operatively using the arch-shaped approach. No soft tissue problems were seen related to the arch-shaped approach. Of the 7 patients who could be followed up after an average of 2 years, the mean American Orthopedic Foot and Ankle Score was 73. Avascular necrosis occurred in 3 cases (43%). These were partial necroses of less than one third of the talar body with asymptomatic course at the time of examination. In 4 patients (57%) radiographic signs of osteoarthritis occurred within 2 years, whereby in two of those cases (29%) an arthrodesis of the upper ankle was performed.

Patient-reported functional outcomes and health-related quality of life following fractures of the talus

INTRODUCTION

The primary aim of this study was to investigate patient-reported outcomes following talar fractures. Secondary aims were to investigate health-related quality of life and to determine whether it is influenced by functional outcome.

MATERIALS AND METHODS

This retrospective study identified 56 talar fractures over eight years. Patients were contacted by post and the Olerud and Molander score (OMS), Manchester-Oxford Foot and Ankle scores (MOXFQ) and Euroqol-5D-3L collected.

RESULTS

The mean age was 35.2 years (range 13-78 years). There were four cases (7.1%) of avascular necrosis and one (1.8%) non-union occurred. Data from patient-reported outcome measures were available for 42 patients (75.0%) with a median follow-up of 67.1 months (range 23.2-111.8 months). Mean OMS was 60.0 (standard deviation ± 29.51) and median MOXFQ was 30.33 (interquartile range 47.13). Median Euroqol-5D-3L index was 0.74 (interquartile range 0.213) and median Euroqol-5D-3L visual analogue score was 80 (interquartile range 21). Older age, open fractures, multiple injuries and subsequent avascular necrosis were associated with worse patient-reported outcomes (P < 0.05), with older age, avascular necrosis and open fractures found to be independent predictors of poor OMS, and avascular necrosis and open fractures independently predicting MOXFQ score on regression analysis (P < 0.05). Poor self-reported function, measured by OMS and MOXFQ, correlated with worse health-related quality of life as measured by the Euroqol-5D-3L index (OMS: r = 0.764, P < 0.001; MOXFQ: r = 0.824, P < 0.001) and visual analogue score (OMS: r = 0.450, P = 0.003; MOXFQ: r=0.559, P < 0.001).

CONCLUSIONS

Older age, avascular necrosis and open fractures predict poorer functional outcomes following talar fractures. Patients with worse limb-specific functional outcomes are more likely to have a worse perception of health-related quality of life.

Open Talus Fractures: Early Infection and Its Epidemiological Characteristics

Open talus fractures are relatively rare and severe open injuries with a high risk of severe infection. To better understand the epidemiological characteristics of this kind of injury, a monocentric case review was conducted among open talus fracture patients admitted in West China Hospital of Sichuan University between January 2010 and December 2014. Fifty-one (N = 51) patients were recruited to the study, including 44 (86.3%) males and 7 (13.7%) females. Fifty-two cases of open talus fractures were diagnosed among the patients (1 patient had bilateral fractures). The primary cause of open talus fracture was a fall from a height. The rate of concurrent injuries associated with open talus fracture was 84.3%. The overall infection rate was 41.2%, rising with the increase of injury severity classified by Gustilo-Anderson classification and the existence of peritalar dislocation. Therefore, it can be concluded that open talus fractures are at high risk of concurrent complications and early infection. It is necessary to perform a complete physical examination to search for possible concurrent injuries. When evaluating the risk of infection, in addition to the severity of open talus fracture, the existence and severity of peritalar dislocation should also be taken into consideration.

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.

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.

Extra-articular Medial Impression Fracture of the Talus: A Previously Undescribed Injury

BACKGROUND

Peripheral fractures of the talus are uncommon. Almost all the literature regarding talar fractures consists of central intra-articular fractures, whereas studies about peripheral talar fractures are lacking. The aim of this study is to increase awareness in diagnosing an unusual peripheral extra-articular medial impression fracture of the talus.

METHODS

This study includes a retrospective case series of patients with an extra-articular medial impression fracture of the talus. Patient characteristics, trauma mechanism, diagnostics, fracture characteristics, and treatment were reported.

RESULTS

Eight consecutive patients with an extra-articular medial impression fracture of the talus were identified. In 80%, the trauma mechanism was a supination or inversion injury of the ankle and foot. An X-ray was obtained in all patients; in 7 (88%) patients, a computed tomography scan was done, and an additional magnetic resonance imaging was done in 3 (38%) patients. In 4 patients (50%), the correct diagnosis was missed at first presentation. The delay between injury and diagnosis was 0 to 180 days (of 36 days on average).

CONCLUSION

This is the first case series to describe patients with a peripheral extra-articular medial impression fracture of the talus. Good clinical examination and judicious use of diagnostic imaging are a necessity to find the talar impression fractures in a timely manner, and treatment can be started immediately.

LEVELS OF EVIDENCE

Level V.

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.

Arthroscopically assisted fixation of Hawkins type II talar neck fractures: a case series

Aims

Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures.

Patients and Methods

A total of seven consecutive patients (four women and three men, mean age 39 years (19 to 61)) underwent attempted surgical treatment of a closed Hawkins type II talar neck fracture using arthroscopically assisted reduction and percutaneous screw fixation. Functional and radiological outcome were assessed using plain radiographs, as well as weight-bearing and non-weight-bearing CT scans as tolerated. Patient satisfaction and pain sensation were also recorded.

Results

Primary reduction was obtained arthroscopically in all but one patient, for whom an interposed fracture fragment had to be removed through a small arthrotomy to permit anatomical reduction. The quality of arthroscopic reduction and restoration of the talar geometry was excellent in the remaining six patients. There were no signs of talar avascular necrosis or subtalar degeneration in any of the patients. In the whole series, the functional outcome was excellent in five patients but restricted ankle movement was observed in two patients. All patients had a reduction in subtalar movement. At final follow-up, all patients were satisfied and all but one patient were pain free.

Conclusion

Arthroscopically assisted reduction and fixation of talar neck fractures was found to be a feasible treatment option and allowed early functional rehabilitation. Cite this article: Bone Joint J 2018;100-B:461-7.

Permissive weight bearing in trauma patients with fracture of the lower extremities: prospective multicenter comparative cohort study

Background

The standard aftercare treatment in surgically treated trauma patients with fractures around or in a joint, known as (peri)- or intra-articular fractures of the lower extremities, is either non-weight bearing or partial weight bearing. We have developed an early permissive weight bearing post-surgery rehabilitation protocol in surgically treated patients with fractures of the lower extremities. In this proposal we want to compare our early permissive weight bearing protocol to the existing current non-weight bearing guidelines in a prospective comparative cohort study.

Methods/design

The study is a prospective multicenter comparative cohort study in which two rehabilitation aftercare treatments will be contrasted, i.e. permissive weight bearing and non-weight bearing according to the AO-guideline. The study population consists of patients with a surgically treated fracture of the pelvis/acetabulum or a surgically treated (peri)- or intra-articular fracture of the lower extremities. The inclusion period is 12 months. The duration of follow up is 6 months, with measurements taken at baseline, 2,6,12 and 26 weeks post-surgery.

Primary outcome measure: ADL with Lower Extremity Functional Scale. Outcome variables for compliance, as measured with an insole pressure measurement system, encompass peak load and step duration.

Discussion

This study will investigate the (cost-) effectiveness of a permissive weight bearing aftercare protocol. The results will provide evidence whether a permissive weight bearing protocol is more effective than the current non-weight bearing protocol.

Trial registration

The study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01–09-2016.

Stem cell therapy in early post-traumatic talus osteonecrosis

PURPOSE

Avascular necrosis of the talus is one of the most notable complications associated with talar neck fractures with frequent evolution of the osteonecrosis into a difficult arthrodesis. We tested whether the injection of bone marrow mesenchymal stem cells (MSCs) could improve the repair process of the osteonecrosis.

MATERIAL AND METHODS

Forty-five early (without collapse) post-traumatic talus osteonecroses (group 1; study group) were treated between 1995 and 2012 with percutaneous injection of progenitor cells (autologous bone marrow concentrate from the iliac crest). The number of MSCs transplanted in each ankle of group 1 was 124 × 103 cells (range 101 × 10³ to 164 × 10³ cells). The evolution of these osteonecroses treated with autologous bone marrow implantation was compared with the evolution of a control group of 34 talar osteonecroses without collapse and treated with only core decompression (group 2; control group) between 1985 and 1995. The outcome was determined by progression in radiographic stages to collapse, by the need of arthrodesis, and by the time to successfully achieve fusion for patients who needed arthrodesis.

RESULTS

For the 45 ankles with autologous concentrate bone marrow grafting, collapse frequency was lower (27%, 12 among 45 versus 71%, 24 among 34; odds ratio 0.1515, 95% CI 0.0563-0.4079; P = 0.0002) and follow-up showed longer duration of survival before collapse or arthrodesis, compared to 34 ankles of the control patients with core decompression alone. Furthermore, the time to successfully achieve fusion after arthrodesis was significantly shorter in patients treated with bone marrow progenitors as compared with the other ankles, which had core decompression alone.

CONCLUSION

In our study the early conservative surgical treatment with autologous bone marrow grafting improved the natural course of the disease as compared with core decompression alone.

Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series)

Ankle and foot injuries are the most common musculoskeletal injuries presenting to Australian EDs and are associated with a large societal and economic impact. The quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common ankle and foot injuries in the ED. Databases including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English language articles published in the last 12 years that addressed the acute assessment, management or prognosis in the ED were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1242 articles, of which 71 were included in the review (n = 22 primary articles, n = 35 systematic reviews and n = 14 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the ankle and foot in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. Following a thorough history and physical examination, including the application of the Ottawa ankle rules, ED clinicians should not only provide a diagnosis, but rate the severity of soft tissue injuries, or stability of fractures and dislocations, which are the pivotal decision points in guiding ED treatment, specialist referral and the follow-up plan.

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.

Safe Zone of Posterior Screw Insertion for Talar Neck Fractures on 3-Dimensional Reconstruction Model

OBJECTIVE

To investigate the optimal posterior screw placement and the geometry of safe zones for screw insertion in the talar neck.

METHODS

Computed tomography data for 15 normal feet were imported into Mimics 10.01 software for 3-dimensional reconstruction; 4.0-mm-diameter screws were simulated from the lateral tubercle of the posterior process of the talus to the talar head. The range of screw paths trajectories and screw lengths at nine locations that did not breach the cortex of the talus were evaluated. In addition, the farthest (point a) and nearest point (point b) of the safe zone to the subtalar joint at each location, the anteversion angle (angle A), which is parallel to the sagittal plane, and the horizontal angle (angle B), which is perpendicular to the sagittal plane, were measured.

RESULTS

The safe zone was mainly between the 30% location and the 60% location; the width of each safe zone was 13.6° ± 1.4°; the maximum height of each safe zone was 7.8° ± 1.2°. The height of the safe zone was lowest at the 30% location (4.5°) and highest at the 50% location (7.3°). The mixed safe zone of all tali was between the 50% location and the 60% location. When a screw was inserted at point a, the safe entry distance (screw length) ranged from 48.8 to 49.5 mm, and when inserted to point b, the distance ranged from 48.2 to 48.9 mm. And inserting a 48.7 mm screw, 5.6° laterally and 7.4° superiorly, from the lateral tubercle of the posterior process of the talus towards the talar head is safest.

CONCLUSION

The safe zone of posterior screw fixation have been defined applying to most talus, assuming the fractures are well reduced, this may strengthen the stability, shorten the operation time and reduce the incidence of surgical complications.

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.