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Daryoush JR, Sato EH, Rothberg DL, Higgins TF, Haller JM, Marchand LS. The combined talus and sustentaculum fracture: A case series. Injury 2024; 55:111766. [PMID: 39106534 DOI: 10.1016/j.injury.2024.111766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 08/09/2024]
Abstract
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.
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Affiliation(s)
- Joshua R Daryoush
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Eleanor H Sato
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - David L Rothberg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA.
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Maxwell L, Nava T, Norrish A, Kobezda T, Pizzimenti M, Brassett C, Pasapula C. Locking vs. non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens. Foot (Edinb) 2024; 59:102084. [PMID: 38513373 DOI: 10.1016/j.foot.2024.102084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
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.
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Affiliation(s)
- Luke Maxwell
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3DY, UK.
| | - Tobia Nava
- Department of Engineering, Trumpington Street, University of Cambridge, CB2 1PZ, UK
| | - Alan Norrish
- Orthopaedic and Trauma Department, The Queen Elizabeth Hospital King's Lynn NHS Trust, Norfolk PE30 4ET, UK
| | - Tamas Kobezda
- Orthopaedic and Trauma Department, The Queen Elizabeth Hospital King's Lynn NHS Trust, Norfolk PE30 4ET, UK
| | - Marc Pizzimenti
- Department of Anatomy and Cell Biology, Carver College of Medicine, The University of Iowa, Iowa City, IA 52242, USA
| | - Cecilia Brassett
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, CB2 3DY, UK
| | - Chandra Pasapula
- Orthopaedic and Trauma Department, The Queen Elizabeth Hospital King's Lynn NHS Trust, Norfolk PE30 4ET, UK
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Jaeblon T, Demyanovich H, Talwar S, Bonyun M, Benzel C, Harris B. Infection Rates and Surgical Procedures Associated With Isolated Open Talar Neck and Body Fractures. Foot Ankle Int 2024; 45:467-473. [PMID: 38400716 DOI: 10.1177/10711007241231235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
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.
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Affiliation(s)
- Todd Jaeblon
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Haley Demyanovich
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Sneh Talwar
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Marissa Bonyun
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD, USA
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Caroline Benzel
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
- Department of Orthopaedics, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Brett Harris
- Department of Orthopaedic Traumatology, University of Maryland Capital Region Medical Center, Largo, MD, USA
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Alley MC, Vallier HA, Tornetta P. Identifying Risk Factors for Osteonecrosis After Talar Fracture. J Orthop Trauma 2024; 38:25-30. [PMID: 37735752 DOI: 10.1097/bot.0000000000002706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors. METHODS DESIGN Retrospective chart review. SETTING 21 US trauma centers and 1 UK trauma center. PATIENT SELECTION CRITERIA Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation. OUTCOME MEASUREMENTS AND COMPARISONS The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes. RESULTS In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions. CONCLUSIONS Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Galanopoulos IP, Sellina D, Drakopoulos P, Psarakis SA. Posttraumatic Cavovarus Deformity Due to a Varus Malunited Talar Neck Fracture, Treated With Corrective Talar Osteotomy: A Case Report. Cureus 2024; 16:e52206. [PMID: 38347993 PMCID: PMC10860692 DOI: 10.7759/cureus.52206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/15/2024] Open
Abstract
Although talar fractures are frequent bone injuries, fracture displacements of the talar neck are rare, and they can lead to under-treatment and poor prognosis. Furthermore, maltreatment of the talar fractures leads to complications such as malunion (which is the most common), nonunion, osteonecrosis and hindfoot arthritis, which can cause significant disability. The most common position of the talar neck malunion is the varus malunion. Alternative treatments include open reduction with or without bone grafting, open reduction combined with ankle fusion, talar neck osteotomy and talar neck osteotomy combined with subtalar fusion. However, the outcomes of foot function after corrective arthrodesis are poor. In this paper, we present a patient who underwent an open wedge corrective osteotomy of the talus for a cavovarus deformity developed after a malunion of a comminuted talar neck fracture. The patient walked normally three months postoperatively.
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Affiliation(s)
| | - Dimitra Sellina
- Orthopaedics, Thriasio General Hospital of Elefsina, Athens, GRC
| | - Panagiotis Drakopoulos
- Laboratory for the Research of the Musculoskeletal System, KAT Hospital, University of Athens, Athens, GRC
- Orthopaedics, Thriasio General Hospital of Elefsina, Athens, GRC
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Park YU, Lee JW, Chung JY, Choi WS, Kim T, Seo YW. Intraoperative assessment of hindfoot alignment using C-arm fluoroscopy. J Orthop Sci 2023:S0949-2658(23)00253-1. [PMID: 37839978 DOI: 10.1016/j.jos.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/24/2023] [Accepted: 08/11/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Hindfoot malalignment can cause various foot and ankle problems. For better surgical performance and correction of hindfoot malalignments, reliable intraoperative determination of hindfoot alignment is essential. However, there is no standard method for the intraoperative assessment of hindfoot alignment. We devised an intraoperative modified Méary posteroanterior (IOPPA) view to assess intraoperative hindfoot alignment. This study aimed to compare this intraoperative method with other radiographic hindfoot alignment measurements. METHODS Thirty-seven patients (47 feet) with various foot and ankle conditions scheduled to undergo surgery were prospectively recruited. Before surgery, the Saltzman, long axial, and modified Méary views were taken in a controlled and standardized fashion. IOPPA views were obtained under simulated weight bearing conditions using C-arm fluoroscopy in the operating room before surgery. The relationship between the IOPPA view and the three radiographic hindfoot alignments was evaluated using Pearson's correlation. RESULTS The mean hindfoot alignment angle was varus 3.50° (CI, varus 1.91 to 5.08) on the Saltzman view, varus 2.00° (CI, varus 0.60 to 3.39) on the long axial view, varus 0.13° (CI, valgus 1.41 to varus 1.67) on the modified Méary view, and varus 1.32° (CI, valgus 0.02 to varus 2.65) on IOPPA view. The IOPPA view and the three other hindfoot alignment views were found to be significantly correlated (r = 0.60 for the Saltzman view, r = 0.50 for the long axial view, r = 0.71 for the modified Méary view, P < .05). The intraobserver ICC (Intraclass Correlation Coefficient) value was 0.974 and interobserver ICC (Intraclass Correlation Coefficient) value was 0.988 for the IOPPA view (P < .001). CONCLUSION There was a statistically significant correlation between the IOPPA view and the other three hindfoot alignment views. We also found that interobserver and intraobserver ICC values were excellent. This study proposes that the IOPPA view can be used as a reliable intraoperative assessment tool for hindfoot alignment. LEVEL OF EVIDENCE Prospective study.
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Affiliation(s)
- Young Uk Park
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Jong Wha Lee
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Jun Young Chung
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Wan-Sun Choi
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Taehun Kim
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Young Wook Seo
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea.
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Choi JY, Kim HS, Ngissah R, Suh JS. Operative outcomes of a high-grade talar neck fracture - Lessons from 20 years' clinical experience in a single, tertiary hospital. Foot Ankle Surg 2023; 29:118-127. [PMID: 36526523 DOI: 10.1016/j.fas.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/28/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Hyeong Suh Kim
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Reuben Ngissah
- Department of Orthopedic Surgery, Greater Accra Regional Hospital, Castle Rd, Accra, Ghana.
| | - Jin Soo Suh
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Parmeshwar SS, Sharma SL, Sharma A, Shetty A, B M K, Patil S. A comparative study of three different approaches in treatment of talar neck fractures. J Clin Orthop Trauma 2023; 37:102092. [PMID: 36711112 PMCID: PMC9875720 DOI: 10.1016/j.jcot.2022.102092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 06/30/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose The primary objective of this study was to observe and compare the radiographic and clinical outcomes among three different approaches which are anteromedial, anterolateral and combined approach in patients of talar neck fractures. The secondary objective was to observe various complications. Material and method A total of 30 patients underwent open reduction and internal fixation (ORIF) from September 2018 to march 2020 were selected retrospectively. 10 patients were there in each group. Talar neck fractures were classified according to Hawkins classification. All patients underwent ORIF with 4 mm Herbert screws. The follow-up examination included radiological evaluation, clinical and functional outcomes according to American Orthopaedic Foot and Ankle Society hind-foot score (AOFAS). Results 30 patients were followed up for an average of 20.85 months (range 16-24). The mean time to bony union was 17.25 weeks, 17.35 weeks and 15.92 weeks in groups operated with anteromedial approach, anterolateral approach and combined approach respectively. The mean AOFAS hind-foot score was 76.34, 77.16 and 78.34 at 18th month follow-up in all three groups respectively. In each group, 1 patient had deep wound infection and 2 patients had superficial wound infection. Subtalar arthritis was the most common complication. Conclusion There is no significant difference between the three groups in terms of AOFAS hind-foot score, further combined approach provides better visualization of talus fractures and early bony union but it takes longer duration of surgery with increased post-operative complications in comparison with other two groups.
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Affiliation(s)
| | - Shyoji Lal Sharma
- Department of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India
| | - Arun Sharma
- Department of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India
| | - Abhijit Shetty
- Department of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India
| | - Kiran B M
- Department of Orthopaedics, Grant Medical College, Mumbai, India
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Talar neck and body fracture outcomes: a multicentre retrospective review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:99-105. [PMID: 34807327 DOI: 10.1007/s00590-021-03161-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/01/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Talar neck and body fractures are uncommon injuries that are challenging to manage with high reported complication rates, including post-traumatic arthritis, avascular necrosis, and poor functional outcomes. The aim of this study was to assess the complication rates for patients with talus fractures across three major trauma centres (MTCs) in England. METHODS A retrospective analysis was performed of prospectively collected trauma databases. Data were collected from three English MTCs. Patients with talar neck and/or body fractures sustained between August 2015 and August 2019 were identified and their clinical course reviewed radiologically and clinically. Isolated process fractures, osteochondral defects and paediatric patients were excluded. Patients were analysed by fracture type and for definitive treatment method with separation into non-operative and operative management groups. Procedure type was identified in the operative group. Superficial infection, deep infection, non-union, avascular necrosis, post-traumatic arthritis and removal of metalwork rates were analysed. RESULTS Eighty-five patients with talar neck and/or body fractures were included. Seventy-five patients received operative management, 10 non-operative. The overall AVN rate was 5.9% (five patients), overall post-traumatic arthritis rate was 18.8% (16 patients), deep infection rate 1.2% (one patient), non-union rate 4.7% (four patients). Removal of metalwork rate was 9.4% (eight patients). CONCLUSION Our reported outcomes and complication rates are generally lower than those previously described. This may be a result of improved techniques, a higher frequency of open reduction with direct visualisation or by surgery occurring in centralised specialist centres.
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An Unusual Inverted Talar Neck Fracture–Dislocation. Case Rep Orthop 2022; 2022:8014529. [DOI: 10.1155/2022/8014529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 08/17/2022] [Accepted: 09/24/2022] [Indexed: 12/12/2022] Open
Abstract
Talar neck fractures occur on a continuum of injury severity. Hawkins classification, later modified by Canale, is the gold standard method of describing talar neck fractures by the degree of dislocation. It has proven to be clinically relevant in predicting risk of osteonecrosis. Despite its merits, talar neck fractures present on a wide spectrum of involvement of the body and neck, dislocation, and concomitant injuries, making every situation a challenge in treatment. We present a unique case of a talar neck fracture in which the talar dome had dislocated and inverted 180°, which is not described in the widely used Hawkins classification. We recommend urgent open reduction, low threshold for use of a transcalcaneal traction pin and dual incisions, and guarded prognosis of osteonecrosis and posttraumatic arthritis.
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11
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Linder A, Steiger V, Hubert L, Rony L. Clinical and radiological outcomes of internal fixation of complex talar neck and body fractures with locking plates through a dual approach. Orthop Traumatol Surg Res 2022; 108:103368. [PMID: 35850424 DOI: 10.1016/j.otsr.2022.103368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 08/15/2021] [Accepted: 11/08/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Adrien Linder
- Département de Chirurgie Osseuse, Centre Hospitalier Universitaire (CHU) d'Angers, 4, rue Larrey, 49000 Angers, France
| | - Vincent Steiger
- Département de Chirurgie Osseuse, Centre Hospitalier Universitaire (CHU) d'Angers, 4, rue Larrey, 49000 Angers, France
| | - Laurent Hubert
- Département de Chirurgie Osseuse, Centre Hospitalier Universitaire (CHU) d'Angers, 4, rue Larrey, 49000 Angers, France
| | - Louis Rony
- Département de Chirurgie Osseuse, Centre Hospitalier Universitaire (CHU) d'Angers, 4, rue Larrey, 49000 Angers, France.
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Guo S, Zhao G, Chen XM, Xue Y, OuYang XL, Liu JY, Huang YP, Liu YJ, Yao Q, Han L, Zhang CH, Li B, Wang Q, Zhao B. Effect of transcutaneous electrical acupoint stimulation on bone metabolism in patients with immobilisation after foot and ankle fracture surgery: a randomised controlled trial study protocol. BMJ Open 2022; 12:e056691. [PMID: 36691208 PMCID: PMC9462119 DOI: 10.1136/bmjopen-2021-056691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/08/2022] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Fracture is a disease with a high incidence worldwide. Foot and ankle fractures are common among fractures of the lower extremities. Foot and ankle fractures usually require surgical fixation and a period of fixed treatment, which can lead to decreased bone density. Although transcutaneous electrical acupoint stimulation (TEAS) is widely used for movement system diseases, there is minimal evidence to show the effectiveness of TEAS on patients after surgical fixation of ankle and foot fractures. This trial aims to evaluate whether TEAS can reduce bone loss in patients with immobilisation after ankle and foot fractures. METHODS AND ANALYSIS A randomised controlled trial will be conducted in which 60 patients will be randomly divided into two groups: (a) the control group will be treated according to the routine procedures of basic orthopaedics treatment; (b) in the treatment group, bilateral SP36, BL23 and ST36 will be performed on the basis of the control group, and the test will be performed for 30 min every other day for a total of 8 weeks. Bone turnover markers will be used as primary outcome. Secondary outcomes are composed of blood phosphorus, blood calcium and bone mineral density. Treatment safety will be monitored and recorded. ETHICS AND DISSEMINATION This trial is approved by the Ethics Committee of Beijing University of Chinese Medicine (2020BZYLL0611) and the Ethics Committee of Beijing Luhe Hospital (2020-LHKY-055-02), and inpatients who meet the following diagnostic and inclusion criteria are eligible to participate in this study. TRIAL REGISTRATION NUMBER ChiCTR 2000039944.
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Affiliation(s)
- Shiqi Guo
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Guozhen Zhao
- Capital Medical University, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Xue-Ming Chen
- Capital Medical University, Beijing Luhe Hospital, Beijing, China
| | - Ying Xue
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Xia-Li OuYang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jin-Yi Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Yue-Ping Huang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Ya-Jie Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Qin Yao
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Li Han
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Chun-Hui Zhang
- Capital Medical University, Beijing Luhe Hospital, Beijing, China
| | - Bo Li
- Capital Medical University, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Qi Wang
- Capital Medical University, Beijing Luhe Hospital, Beijing, China
| | - Baixiao Zhao
- Affiliated Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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13
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Wijers O, Posthuma JJ, Engelmann EWM, Schepers T. Complications and Functional Outcome Following Operative Treatment of Talus Neck and Body Fractures: A Systematic Review. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221127201. [PMID: 36199382 PMCID: PMC9528034 DOI: 10.1177/24730114221127201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Olivier Wijers
- Department of Traumasurgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Jelle J. Posthuma
- Department of Traumasurgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Esmee W. M. Engelmann
- Department of Traumasurgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Tim Schepers
- Department of Traumasurgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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14
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McMurtrie JT, Patch DA, Frazier MB, Wills BW, Prather JC, Viner GC, Hill MJ, Johnson MD. Union Rates of Talar Neck Fractures With Substantial Bone Defects Treated With Autograft. Foot Ankle Int 2022; 43:343-352. [PMID: 34689579 DOI: 10.1177/10711007211050032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | - David A Patch
- UAB Orthopaedics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Mason B Frazier
- Radiology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Bradley W Wills
- UAB Orthopaedics, University of Alabama Birmingham, Birmingham, AL, USA
| | - John C Prather
- UAB Orthopaedics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Gean C Viner
- UAB Orthopaedics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Margie J Hill
- Radiology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Michael D Johnson
- UAB Orthopaedics, University of Alabama Birmingham, Birmingham, AL, USA
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15
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Abstract
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.
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Affiliation(s)
- Talal Al-Jabri
- Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ.
| | | | - Ken Wong
- Royal National Orthopaedic Hospital, Stanmore, HA7 4LP
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16
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Talar fracture: Epidemiology, treatment and results in a multicenter series. Orthop Traumatol Surg Res 2021; 107:102835. [PMID: 33524630 DOI: 10.1016/j.otsr.2021.102835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/28/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
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.
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17
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Teh SW, Koh AEH, Tong JB, Wu X, Samrot AV, Rampal S, Mok PL, Subbiah SK. Hypoxia in Bone and Oxygen Releasing Biomaterials in Fracture Treatments Using Mesenchymal Stem Cell Therapy: A Review. Front Cell Dev Biol 2021; 9:634131. [PMID: 34490233 PMCID: PMC8417697 DOI: 10.3389/fcell.2021.634131] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 07/22/2021] [Indexed: 12/14/2022] Open
Abstract
Bone fractures have a high degree of severity. This is usually a result of the physical trauma of diseases that affect bone tissues, such as osteoporosis. Due to its highly vascular nature, the bone is in a constant state of remodeling. Although those of younger ages possess bones with high regenerative potential, the impact of a disrupted vasculature can severely affect the recovery process and cause osteonecrosis. This is commonly seen in the neck of femur, scaphoid, and talus bone. In recent years, mesenchymal stem cell (MSC) therapy has been used to aid in the regeneration of afflicted bone. However, the cut-off in blood supply due to bone fractures can lead to hypoxia-induced changes in engrafted MSCs. Researchers have designed several oxygen-generating biomaterials and yielded varying degrees of success in enhancing tissue salvage and preserving cellular metabolism under ischemia. These can be utilized to further improve stem cell therapy for bone repair. In this review, we touch on the pathophysiology of these bone fractures and review the application of oxygen-generating biomaterials to further enhance MSC-mediated repair of fractures in the three aforementioned parts of the bone.
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Affiliation(s)
- Seoh Wei Teh
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Avin Ee-Hwan Koh
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Jia Bei Tong
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Xiaoyun Wu
- Department of Technology, Research Center for Hua-Da Precision Medicine of Inner Mongolia Autonomous Region, Hohhot, China
| | - Antony V Samrot
- School of Bioscience, Faculty of Medicine, Bioscience and Nursing, MAHSA University, Jenjarom, Malaysia
| | - Sanjiv Rampal
- Department of Orthopedics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Pooi Ling Mok
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Suresh Kumar Subbiah
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Center for Materials Engineering and Regenerative Medicine, Bharath Institute of Higher Education and Research, Bharath University, Chennai, India
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18
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Pflüger P, Zyskowski M, Weber A, Gleisenberg K, Kirchhoff C, Biberthaler P, Crönlein M. Patient reported outcome of 33 operatively treated talar fractures. BMC Musculoskelet Disord 2021; 22:698. [PMID: 34399725 PMCID: PMC8369802 DOI: 10.1186/s12891-021-04572-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Michael Zyskowski
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Anne Weber
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Katharina Gleisenberg
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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19
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Saravi B, Lang G, Ruff R, Schmal H, Südkamp N, Ülkümen S, Zwingmann J. Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168274. [PMID: 34444022 PMCID: PMC8393919 DOI: 10.3390/ijerph18168274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
- Department of Spine Surgery, Loretto-Krankenhaus Freiburg, 79100 Freiburg, Germany
- Correspondence:
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
- Department of Spine Surgery, Loretto-Krankenhaus Freiburg, 79100 Freiburg, Germany
| | - Robert Ruff
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
| | - Hagen Schmal
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
| | - Norbert Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
| | - Sara Ülkümen
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
- Department of Spine Surgery, Loretto-Krankenhaus Freiburg, 79100 Freiburg, Germany
| | - Jörn Zwingmann
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany; (G.L.); (R.R.); (H.S.); (N.S.); (S.Ü.); (J.Z.)
- Department of Orthopedics and Trauma Surgery, St. Elisabeth Hospital Ravensburg, 88212 Ravensburg, Germany
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20
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Giordano V, Liberal BR, Rivas D, Souto DB, Yazeji H, Souza FS, Godoy-Santos A, Amaral NP. Surgical management of displaced talus neck fractures: single vs double approach, screw fixation alone vs screw and plating fixation-systematic review and meta-analysis. Injury 2021; 52 Suppl 3:S89-S96. [PMID: 34088463 DOI: 10.1016/j.injury.2021.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/31/2021] [Indexed: 02/02/2023]
Abstract
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).
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil; Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, Brazil.
| | - Bauer Ramos Liberal
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Daniela Rivas
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Danilo Baía Souto
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Henrique Yazeji
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Felipe Serrão Souza
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Alexandre Godoy-Santos
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Ney Pecegueiro Amaral
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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21
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Sanders D. Acute Arthrodesis of Ipsilateral Pilon and Talus Fracture: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00026. [PMID: 33979809 DOI: 10.2106/jbjs.cc.20.00175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a unique case of an ipsilateral distal tibia pilon fracture and talar body after motor vehicle collision. Our patient was successfully treated with acute arthrodesis of the tibiotalar joint, with return to good function 1-year after surgery. CONCLUSION Pilon and talus fractures are complex injuries. They require specialized surgical care, are complicated by loss of function, continued pain, and lead to subsequent reconstructive procedures such as arthrodesis or arthroplasty. In the presence of concomitant pilon and talus fractures, acute arthrodesis can yield good results and return to function.
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Affiliation(s)
- Drew Sanders
- University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
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22
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Khanfar A, Rimawi A, Al Qaroot B. Talar neck non-union in an athlete successfully treated with a synthetic bone graft: A case report. Trauma Case Rep 2021; 33:100405. [PMID: 33912646 PMCID: PMC8063905 DOI: 10.1016/j.tcr.2021.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Aws Khanfar
- School of Medicine, Special Surgery Department, University of Jordan, Jordan
| | - Ahmad Rimawi
- School of Medicine, University of Jordan, Jordan
| | - Bashar Al Qaroot
- School of Rehabilitation Sciences, Prosthetics and Orthotics Department, University of Jordan, Jordan
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Abstract
Correct approach selection in talar neck injuries is crucial to obtain adequate access to the entire fracture site avoiding malreduction and angular deformity. The major concern about a single incision technique is lack of visualization. Combined lateral and medial approaches are strongly recommended in complex talar neck fractures providing better control of dorsal and varus displacement of the talar head.
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Affiliation(s)
- Florencio Pablo Segura
- Department of Orthopaedics, Faculty of Medicine, Universidad Nacional de Córdoba, Nuevo Hospital San Roque, Bajada Pucará 1900, Piso 6, Ciudad de Córdoba, CP 5000, Argentina; Centro Privado de Ortopedia y Traumatología, Urquiza 358, Piso 8, Ciudad de Córdoba, CP 5000, Argentina.
| | - Santiago Eslava
- Foot and Ankle Division, Instituto Dupuytren, Av. Belgrano 3402, Ciudad Autónoma de Buenos Aires, CP 1078, Argentina
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Fenwick A, Kröger N, Jovic S, Hölscher-Doht S, Meffert R, Jansen H. Pedobarography shows no differences in gait after talar fractures. Technol Health Care 2020; 28:85-92. [PMID: 31104035 DOI: 10.3233/thc-191667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Abstract
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.
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Schwartz AM, Runge WO, Hsu AR, Bariteau JT. Fractures of the Talus: Current Concepts. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011419900766. [PMID: 35097362 PMCID: PMC8697161 DOI: 10.1177/2473011419900766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew M Schwartz
- Department of Orthopedics, Emory University School of Medicine, Atlanta, GA, USA
| | - William O Runge
- Department of Orthopedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew R Hsu
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA, USA
| | - Jason T Bariteau
- Department of Orthopedics, Emory University School of Medicine, Atlanta, GA, USA
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Gabrielli AS, Gale T, Hogan M, Anderst W. Bilateral Symmetry, Sex Differences, and Primary Shape Factors in Ankle and Hindfoot Bone Morphology. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420908796. [PMID: 35097367 PMCID: PMC8697112 DOI: 10.1177/2473011420908796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Alexandra S. Gabrielli
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tom Gale
- Biodynamics Lab, University of Pittsburgh, Pittsburgh, PA, USA
| | - MaCalus Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- The Foot and Ankle Injury Group, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Anderst
- Biodynamics Lab, University of Pittsburgh, Pittsburgh, PA, USA
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28
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Wang B, Xu X. [Outcome of corrective osteotomy of shortened medial foot column after old talar neck fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1345-1350. [PMID: 31650746 PMCID: PMC8337462 DOI: 10.7507/1002-1892.201903091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/29/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effectiveness of corrective osteotomy for shortened medial foot column after old talar neck fracture. METHODS The clinical data of 10 patients with shortened medial foot column after old talar neck fracture between June 2012 and May 2017 was retrospectively analyzed. There were 7 males and 3 females with an average age of 45.8 years (mean, 21-67 years). The time from fracture to corrective osteotomy was 9-60 months (mean, 20.9 months). The preoperative visual analogue scale (VAS) score was 7.1±1.2, the American Orthopaedic Foot and Ankle Society (AOFAS) score was 48.5±12.3, and the short-form 36 health survey scale (SF-36) score was 46.7±10.5. All 10 cases received open wedge osteotomy of medial talus. Among them, 2 received subtalar fusion and Achilles tendon lengthening, 2 lateralizing calcaneal osteotomy, and 2 Achilles tendon lengthening. RESULTS All incisions healed by first intention. All patients were followed up 13-72 months (mean, 38.0 months). The X-ray film showed that the angle between longitudinal axis of 1st metatarsal bone and talus increased from (-9.6±4.5) ° before operation to (1.3±2.7) ° at last follow-up ( t=16.717, P=0.000); the angle between longitudinal axis of calcaneus and tibia increased from (-12.0±7.4) ° before operation to (-1.5±4.8) ° at last follow-up ( t=5.711, P=0.000). At last follow-up, the VAS score, AOFAS score, and SF-36 score were 1.6±1.0, 88.3±5.4, and 85.4±9.2, respectively, which increased significantly when compared with the preoperative scores ( t=13.703, P=0.000; t=14.883, P=0.000; t=16.919, P=0.000). X-ray film and CT showed that the osteotomy and arthrodesis sites healed well at 2-4 months after operation. CONCLUSION It's a proper procedure of anatomic reduction and reconstruction for patients with shortened medial foot column and good articular cartilage morphology after old talar fracture. Opening wedge osteotomy of medial talus is recommended and can obtain satisfactory clinical and radiographic results.
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Affiliation(s)
- Bibo Wang
- Department of Orthopedics, Shanghai Ruijin Hospital, Medicine School of Shanghai Jiaotong University, Shanghai, 200025, P.R.China
| | - Xiangyang Xu
- Department of Orthopedics, Shanghai Ruijin Hospital, Medicine School of Shanghai Jiaotong University, Shanghai, 200025,
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Hierro-Cañas F, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez M, Cano-Luis P. Talus fractures. Functional results for polytraumatized patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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30
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Biz C, Golin N, De Cicco M, Maschio N, Fantoni I, Frizziero A, Belluzzi E, Ruggieri P. Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management. BMC Musculoskelet Disord 2019; 20:363. [PMID: 31391024 PMCID: PMC6686493 DOI: 10.1186/s12891-019-2738-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 07/24/2019] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Carlo Biz
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy.
| | - Nicolò Golin
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Michele De Cicco
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Nicola Maschio
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Ilaria Fantoni
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padova, Padova, Italy
| | - Elisa Belluzzi
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy.,Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Pietro Ruggieri
- Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, via Giustiniani 2, 35128, Padova, Italy
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31
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Hierro-Cañas FJ, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez MA, Cano-Luis P. Talus fractures. Functional results for polytraumatized patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:336-341. [PMID: 31078442 DOI: 10.1016/j.recot.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/31/2019] [Accepted: 04/01/2019] [Indexed: 11/17/2022] Open
Abstract
Talar fractures are uncommon lesions (0.1-0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis. The aim of this study was to analyze the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma. Observational study on a retrospective cohort of 24 patients operated in our centre (2008-2016). They were grouped according to whether they were polytraumatized (ISS>16) or not (ISS≤16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI -Foot and Ankle Disability Index-) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis. Review of 25 talar fractures in 24 patients with a mean age of 38 years (19-75) and a mean follow-up of 4.2 years (0.5-9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not. The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group. Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients.
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Affiliation(s)
- F J Hierro-Cañas
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - P Andrés-Cano
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - G Rabadán-Márquez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - M A Giráldez-Sánchez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - P Cano-Luis
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
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Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2019; 49:310-319. [PMID: 30759357 DOI: 10.2519/jospt.2019.8864] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients. OBJECTIVES To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. METHODS In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling. RESULTS There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%. CONCLUSION A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation. LEVEL OF EVIDENCE Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.
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33
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Abstract
Displaced talar neck fractures no longer constitute a surgical emergency; timing of definitive surgery has no bearing on the risk of osteonecrosis. Amount of initial fracture displacement is best predictor of osteonecrosis. Grossly displaced fractures or fracture-dislocations should be provisionally reduced, with or without temporary external fixation. Periosteal stripping should be limited to only that necessary to obtain anatomic reduction. Dissection within the sinus tarsi or tarsal canal should be avoided. Rigid internal fixation with solid cortical screws countersunk within the talar head and placed below the "equator" of the talar head is imperative for optimum stability.
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Affiliation(s)
- Michael P Clare
- Foot & Ankle Fellowship, Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637, USA.
| | - Patrick J Maloney
- The Institute for Foot and Ankle Reconstruction at Mercy, 301 St Paul Place, Baltimore, MD 21202, USA
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34
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Vetter SY, Steffen K, Swartman B, Schnetzke M, Keil H, Franke J, Grützner PA, Beisemann N. Influence of intraoperative conventional fluoroscopy versus cone beam CT on long-term clinical outcome in isolated displaced talar fractures. J Orthop Surg Res 2019; 14:8. [PMID: 30621768 PMCID: PMC6323861 DOI: 10.1186/s13018-018-1043-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The objective of the study was to compare the radiologic and clinical outcome of patients with an isolated displaced talus fracture treated intra-operatively with either conventional fluoroscopy or additional cone beam computed tomography (CT). METHODS Conventional intraoperative fluoroscopy was performed in group 1 and cone beam CT was added in group 2. Clinical outcome was assessed using the Foot Function Index (FFI), American Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, and the Short-Form 12 (SF-12) survey. In addition, the Kellgren-Lawrence score using X-rays was determined. RESULTS Overall, 24 cases were examined (group 1: 8 cases; group 2: 16 cases), with a mean follow up of 6.66 years. The FFI (group 1: 28.85 ± 22.78; group 2: 14.96 ± 15.11 points; p = 0.768), the AOFAS (group 1: 69.00 ± 24.71; group 2: 78.79 ± 17.07 points; p = 0.438), and the physical and mental component of the SF-12 (group 1: 44.79 ± 12.55; group 2: 47.63 ± 10.69 points; p = 0.136) (group 1: 46.19 ± 9.72; group 2: 53.57 ± 8.51; p = 0.242) did not differ significantly. Osteoarthritis of the talonavicular, subtalar, and ankle joints assessed using the Kellgren-Lawrence score appeared to be minor in the cone beam CT group but did not show significant differences (p = 0.309; p = 0.663; p = 0.082 respectively). DISCUSSION Intraoperative cone beam CT in addition to conventional fluoroscopy might be beneficial in the operative treatment of talar fractures but a statistical significance could not be demonstrated.
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Affiliation(s)
- Sven Y Vetter
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Kira Steffen
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Benedict Swartman
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Marc Schnetzke
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Holger Keil
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Paul Alfred Grützner
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany
| | - Nils Beisemann
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen, Heidelberg University Hospital, Ludwig-Guttmannstr. 13, 67071, Ludwigshafen, Germany.
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Abstract
OBJECTIVES To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures. DESIGN Retrospective review. SETTING Level 1 academic trauma center. PATIENTS/PARTICIPANTS Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period. INTERVENTION Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis. MAIN OUTCOME MEASUREMENTS Radiographic evidence of subtalar arthritis. RESULTS Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001). CONCLUSION Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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36
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Abstract
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.
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Affiliation(s)
- Colin Whitaker
- Department of Orthopedic Surgery, Einstein Healthcare Network, 5501 Old York Road, WCB4, Philadelphia, PA, 19141, USA
| | - Blake Turvey
- Department of Orthopedic Surgery, Einstein Healthcare Network, 5501 Old York Road, WCB4, Philadelphia, PA, 19141, USA
| | - Emmanuel M Illical
- Department of Orthopedic Surgery, Einstein Healthcare Network, 5501 Old York Road, WCB4, Philadelphia, PA, 19141, USA.
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37
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Abstract
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.
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Affiliation(s)
- Stefan Rammelt
- Foot & Ankle Section, University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Central Military Hospital Prague, U Vojenské nemocnice 1200, Prague 6 169 02, Czech Republic
| | - Kyeong-Hyeon Park
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
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Buza JA, Leucht P. Fractures of the talus: Current concepts and new developments. Foot Ankle Surg 2018; 24:282-290. [PMID: 29409210 DOI: 10.1016/j.fas.2017.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/09/2017] [Accepted: 04/14/2017] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- John A Buza
- NYU Langone Medical Center, Hospital for Joint Diseases, 301 E. 17th St., New York, NY 10003, United States
| | - Philipp Leucht
- NYU Langone Medical Center, Hospital for Joint Diseases, 301 E. 17th St., New York, NY 10003, United States.
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Abstract
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.
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Affiliation(s)
- Kwasi Y Kwaadu
- Department of Surgery, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
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40
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Albin SR, Koppenhaver SL, Van Boerum DH, McPoil TG, Morgan J, Fritz JM. Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial. J Man Manip Ther 2018; 26:147-156. [PMID: 30042629 DOI: 10.1080/10669817.2018.1432542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Study design Randomized clinical trial. Background Patients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there's little research on the optimal time to initiate a formal physical therapy program. Objectives To assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes. Methods Fifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery. Results The EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI -.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study. Conclusion Initiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures. Level of Evidence Therapy, level 2b.
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Affiliation(s)
- Stephanie R Albin
- School of Physical Therapy, Regis University, Denver, CO, USA.,Intermountain Healthcare, Salt Lake City, UT, USA
| | | | - Drew H Van Boerum
- Department of Orthopedics, The Orthopedic Specialty Hospital, Salt Lake City, UT, USA
| | - Thomas G McPoil
- School of Physical Therapy, Regis University, Denver, CO, USA
| | - James Morgan
- Department of Orthopedics, The Orthopedic Specialty Hospital, Salt Lake City, UT, USA
| | - Julie M Fritz
- Department of Physical Therapy, College of Health, University of Utah, Salt Lake City, UT, USA
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41
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Stem cell therapy in early post-traumatic talus osteonecrosis. INTERNATIONAL ORTHOPAEDICS 2018; 42:2949-2956. [PMID: 29305640 DOI: 10.1007/s00264-017-3716-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/03/2017] [Indexed: 12/11/2022]
Abstract
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.
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Braun BJ, Pelz P, Veith NT, Rollmann M, Klein M, Herath SC, Holstein JH, Pohlemann T. Long-term pathological gait pattern changes after talus fractures — dynamic measurements with a new insole. INTERNATIONAL ORTHOPAEDICS 2018; 42:1075-1082. [DOI: 10.1007/s00264-017-3720-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 12/10/2017] [Indexed: 12/23/2022]
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Abstract
Fractures of talar body are uncommon injuries often associated with fractures of other long bones and in polytraumatized patients. The integrity of the talus is essential for the normal function of the ankle, subtalar, and midtarsal joints. The relative infrequency of this injury limits the number of studies available to guide treatment. They occur as a result of high-velocity trauma and are therefore associated with considerable soft tissue damage. Axial compression with supination or pronation is the common mechanism of injury. Great care is necessary for diagnosing and treating these injuries. Clinically, talar body fractures present with soft tissue swelling, hematoma, deformity, and restriction of motion. Associated neurovascular injury of the foot should be carefully examined. The initial evaluation should be done with foot, and ankle radiographs and computed tomography is often done to analyze the extent of the fracture, displacement, intraarticular extension, comminution, and associated fractures. Differentiating talar neck from body fractures is important. Optimal treatment relies on an accurate understanding of the injury and the goals of treatment are the restoration of articular surface and axial alignment. Indications for nonoperative management are seldom indicated and are few as in nonambulatory patients, or in with multiple comorbidities who are not able to tolerate surgery. Splinting, followed by short leg casting for 6 weeks until fracture union should be undertaken. Surgery is indicated in most of the cases, and different approaches have been described. Sometimes, a dual approach with a malleolar osteotomy is necessary for articular restoration. Clinical outcomes depend on the severity of the initial injury and the quality of reduction and internal fixation. The various complications are avascular necrosis, malunion, infections, late osteoarthritis, and ankylosis of subtalar joint.
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Affiliation(s)
- S R Sundararajan
- Department of Foot and Ankle Surgery, Arthroscopy, Ganga Hospital, Coimbatore, Tamil Nadu, India,Address for correspondence: Dr. S R Sundararajan, Ganga Medical Centre and Hospitals Pvt Ltd, Department of Foot and Ankle Surgery, Arthroscopy, 313, Mettupalayam Road, Coimbatore - 641 043, Tamil Nadu, India. E-mail:
| | - Abdul Azeem Badurudeen
- Department of Foot and Ankle Surgery, Arthroscopy, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - R Ramakanth
- Department of Foot and Ankle Surgery, Arthroscopy, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Junge T, Bellamy J, Dowd T, Osborn P. Outcomes of Talus Fractures Associated With High-Energy Combat Trauma. Foot Ankle Int 2017; 38:1357-1361. [PMID: 28931325 DOI: 10.1177/1071100717729124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | | | - Thomas Dowd
- 3 San Antonio Military Medical Center, Ft Sam Houston, TX, USA
| | - Patrick Osborn
- 3 San Antonio Military Medical Center, Ft Sam Houston, TX, USA
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45
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Maher MH, Chauhan A, Altman GT, Westrick ER. The Acute Management and Associated Complications of Major Injuries of the Talus. JBJS Rev 2017; 5:e2. [DOI: 10.2106/jbjs.rvw.16.00075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jordan RK, Bafna KR, Liu J, Ebraheim NA. Complications of Talar Neck Fractures by Hawkins Classification: A Systematic Review. J Foot Ankle Surg 2017. [PMID: 28633784 DOI: 10.1053/j.jfas.2017.04.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Richard K Jordan
- Medical Student, College of Medicine and Life Sciences, University of Toledo, Toledo, OH
| | - Kunaal R Bafna
- Medical Student, College of Medicine and Life Sciences, University of Toledo, Toledo, OH
| | - Jiayong Liu
- Orthopedist and Assistant Professor, Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH.
| | - Nabil A Ebraheim
- Orthopedist and Professor, Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH
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Beltran MJ, Mitchell PM, Collinge CA. Posterior to Anteriorly Directed Screws for Management of Talar Neck Fractures. Foot Ankle Int 2016; 37:1130-1136. [PMID: 27340258 DOI: 10.1177/1071100716655434] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking. METHODS After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months. RESULTS According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients. CONCLUSION Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Michael J Beltran
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Phillip M Mitchell
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA
| | - Cory A Collinge
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA
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Abstract
OBJECTIVES To assess the healing and radiographic outcomes of displaced and comminuted talar neck fractures treated with medial position screws augmented with lateral minifragment plate fixation. DESIGN Retrospective case series. SETTING Two level I trauma centers. PATIENTS The records of 26 patients with displaced and comminuted talar neck fractures who underwent open reduction and internal fixation with medial-sided position screws augmented with lateral minifragment plates. INTERVENTION Surgery consisted of medial and lateral approaches to the talus, fixation with a laterally placed minifragment plate, and screw construct augmenting sagittal-plane-oriented, medial-sided position screws. MAIN OUTCOME MEASUREMENTS The incidences of nonunion, malunion, avascular necrosis, post-traumatic arthritis, and symptomatic implants. RESULTS Nonunion occurred in 3/26 (11.5%) displaced and comminuted talar neck fractures. There were no instances of malunion. Avascular necrosis developed in 7/26 (27%) cases. Post-traumatic arthritis was the most common complication affecting 10/26 (38%) tali. The subtalar joint was most commonly affected. There were no instances of hardware removal due to symptomatic medial impingement. CONCLUSIONS Lateral minifragment plate fixation augmenting medially placed sagittal plane position screws provides a length stable construct that prevents talar neck shortening and malunion. Medial position screws can help avoid secondary surgeries for removal of symptomatic implants due to medial impingement as is common with medially based minifragment plates. This fixation strategy should be considered in the setting of displaced and comminuted talar neck fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Çolak TK, Çolak İ, Timurtaş E, Bulut G, Polat MG. Pedobarographic and Radiological Analysis After Treating a Talus Neck Fracture. J Foot Ankle Surg 2016; 55:1216-1222. [PMID: 27600487 DOI: 10.1053/j.jfas.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Indexed: 02/03/2023]
Abstract
Misalignment of the talar neck after surgical repair can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, which can change the joint biomechanics, cause arthritis, and impair function. However, we found no studies analyzing the plantar pressures after treatment of talus neck fracture. We determined the dynamic plantar pedobarographic and radiographic characteristics and ankle range of motion, function, and pain among patients after surgical repair of talar neck fractures. A total of 19 patients completed the assessments. The median follow-up period was 29 (range 12 to 113) months. At the last visit, the mean pain score was 3.3 on a 10-cm visual analog scale. The mean American Orthopaedic Foot and Ankle Society function scale score was fair (73.5), and the mean range of motion was restricted in 4 planes. The mean maximum force was lower in the hindfoot (p = .002) and midfoot (p = .03) of the injured foot than in the noninjured foot. The mean peak pressure was lower in the hindfoot (p = .05) but higher in the forefoot (p = .03). Radiographic measurements revealed differences between the feet in the talo-first metatarsal angle (p = .002), Meary's angle (p = .001), and the medial cuneiform-fifth metatarsal angle (p = .002). Radiographic and pedobarographic analysis showed an elevated arch in the injured foot. Thus, talar injury and immobilization can affect the stance and the gait cycle in these patients. Pain, range of motion, function, and the weight transfer pattern should be evaluated carefully during the follow-up period to provide the best postoperative results.
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Affiliation(s)
- Tuğba Kuru Çolak
- Asstistant Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey.
| | - İlker Çolak
- Department of Orthopaedics and Traumatology, Dr Lütfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey
| | - Eren Timurtaş
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Güven Bulut
- Associate Professor, Department of Orthopaedics and Traumatology, Dr Lütfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey
| | - M Gülden Polat
- Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
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Aygün Ü, Çalçk Y, Alkan B, Işçk C. Simultaneous Bilateral Fracture Unilateral Dislocation of the Talus. J Am Podiatr Med Assoc 2016; 106:370-374. [PMID: 27762619 DOI: 10.7547/15-102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this study, we present the case of a 42-year-old man with a fracture and dislocation of the left talus neck, and a fracture of the right talus neck due to a fall. This kind of fracture can be considered rare, and thus few cases have been reported. Fracture fixation was provided through cannulated screws on either side. Splints were removed after 6 weeks, and passive/active joint movement exercises were started. The patient was able to walk with partial weightbearing at 2 months and with full weightbearing at 3 months. The magnetic resonance imaging scan at 1 year postoperatively revealed the presence of avascular necrosis on the left, whereas it did not exist on the right. Range of motion in both of the ankles was satisfactory. The patient expressed that he was able to perform daily activities without any difficulty and run for 30 minutes without pain. In this case report, in addition to providing a review of the relevant literature on the subject, we set out to show the importance of rigid fixation and early mobilization in these rare injuries.
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Affiliation(s)
- Ümit Aygün
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
| | - Yalkçn Çalçk
- Abant İzzet Baysal University, İzzet Baysal Physical Therapy and Rehabilitation Training and Research Hospital, Bolu, Turkey
| | - Barçş Alkan
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
| | - Cengiz Işçk
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
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