Fractures of the talus

Talar neck and body fracture outcomes: a multicentre retrospective review

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.

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

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

Outcomes of Talar Neck Fractures: A Systematic Review and Meta-analysis

OBJECTIVES

To report the rates of osteonecrosis and subtalar arthritis after talar neck fractures and to examine if rates have changed over time.

DATA SOURCES

A systematic review and meta-analysis of the English literature was performed using EMBASE, MEDLINE, CENTRAL, and Cochrane in November 2011 and updated in November 2014.

STUDY SELECTION

Inclusion criteria were studies examining talar neck fractures that reported talar body osteonecrosis rates as a primary or secondary outcome. Exclusion criteria included case series with <10 patients or >50% pediatric patients, inability to isolate results of talar neck fractures, primary treatment of talar excision or arthrodesis, mean follow-up of <3 months, and non-English literature.

DATA EXTRACTION

Basic information was collected including journal, author, year published, level of evidence, number of fractures, and follow-up length. Specific information collected included fracture classifications, timing of interventions, method of treatment, osteonecrosis rates, subtalar arthrosis rates, and method of diagnosis of osteonecrosis.

DATA SYNTHESIS

Fixed-effects models were used for meta-analysis. The overall event rate of osteonecrosis was calculated and stratified based on Hawkins classification of the talar neck fractures. Mean rates of subtalar arthritis were calculated for all studies and for studies including >2 years of follow-up.

CONCLUSIONS

The overall rate of osteonecrosis was 0.312. Rates for Hawkins' types I-IV were 0.098, 0.274, 0.534, and 0.480, respectively. The mean rate of subtalar arthritis was 0.49 but increased to 0.81 in studies with >2 years of follow-up. Complication rates are high in talar neck fractures, and patients should be counseled accordingly.

Talar neck fractures: a systematic review of the literature

Considerable controversy surrounds the management of talar neck fractures regarding the rate of post-traumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery on these variables. A data search using PubMed was performed with the keywords "talus" and "fracture." The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods.

[Fractures of the talus]

Fractures of the neck of the talus are a relatively uncommon fracture of the foot but they have potentially serious complications. This article details the Hawkins classification, operative treatment and indications, and complications of fractures of the neck of the talus. It also discusses the treatment of fractures of the body of the talus and talar head. An English full text version of this article is available at SpringerLink as supplemental.

Complications of talus fractures in children

BACKGROUND

Pediatric talus fractures are rare with variable rates of posttraumatic complications reported in the literature. The purpose of this retrospective study was to evaluate posttraumatic complications in children after talus fracture and report injury characteristics.

METHODS

This study included 29 children with talus fractures sustained between 1999 and 2008 at an average age of 13.5 years (range, 1.2-17.8). Patient records and radiographs were reviewed to determine the mechanism of injury, fracture type, associated injuries, and treatment. Posttraumatic complications assessed were avascular necrosis, arthrosis, nonunion or delayed union, neurapraxia, infection or wound-healing problems, and the need for further unanticipated surgery. Clinical follow-up averaged 24 months (range, 6 mo-5 y).

RESULTS

Twenty-nine children sustained a major fracture of the talar body, neck, or head. Avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neurapraxia in 2 (7%), infection in 0, and the need for further surgery in 3 (10%). Both high-energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. The number and severity of talus fractures increased in older children.

CONCLUSIONS

In this case series, posttraumatic complications after pediatric talus fractures occurred more frequently after a high-energy mechanism of injury or a displaced fracture. Talus fractures occurred more commonly and with more severity in older children.

LEVEL OF EVIDENCE

Level IV. Retrospective case series.

Posttraumatic avascular necrosis of the talus

Avascular necrosis of the talus is one the most challenging problems encountered in posttraumatic reconstruction of the hindfoot. Since the first description of the talus injury in 1608 by Fabricius of Hilden, our knowledge of the talar anatomy, injuries, sequelae, and management has increased significantly. Adequate knowledge of the etiology, the extent of the disease, and the degree of patient symptoms are required to determine optimal treatment.

Post talus neck fracture reconstruction

Talar neck fractures are interesting fractures that require careful ORIF if the patient factors allow. The long-term sequelae of these fractures can be severe regardless of the quality of the reconstruction. Posttraumatic arthritis and avascular necrosis are devastating complications that are unfortunately common. Malunion and nonunion of talar neck fractures need to be evaluated carefully with attention to adjacent joints. A full workup is needed to fully evaluate the patient and fracture factors. If the patient has failed nonoperative treatment then reconstruction or salvage is considered. Reconstruction of ununited and malunited talar neck fractures can be successful if the patient is well selected. Corrective fusion is a viable alternative for those patients who have posttraumatic arthritis. Combined ankle replacement and subtalar fusion remains another motion-conserving procedure.

Avascular necrosis of the talus

Avascular necrosis (AVN) of the talus has always been a surgical challenge because the talus is hidden by its anatomic location and has a precarious blood supply. Most cases (75%) of talar AVN are traumatically induced in association with talar body and talar neck fractures.AVN of the talus can be a significant problem because collapse of the talar dome leads to degenerative changes and pain and disability of the ankle and subtalar joints. Although there are many published treatments for posttraumatic AVN of the talus, critical outcome studies are still lacking.

Partial Hawkins Sign in Fractures of the Talus: A Report of Three Cases

OBJECTIVE

We introduce the concept of the partial Hawkins sign in three cases of talar neck fracture that are associated with incomplete avascular necrosis. Our objective is to call attention to the intraosseous blood supply of the talar body, which can be interrupted by fractures to produce patterns of incomplete avascular necrosis.

CONCLUSION

We conclude that the Hawkins sign does not always have to be complete. Fractures of the talus occasionally can lead to partial avascular necrosis because of the disruption of end arteries within the body of the talus, even without subluxation or dislocation. Early recognition of the partial Hawkins sign should lead to MRI evaluation that can more readily define the involvement of the talar body and assist the treating physician in recommending when the patient can bear weight.

Functional outcome after modified Blair tibiotalar arthrodesis for talar osteonecrosis

BACKGROUND

Osteonecrosis of the talar body is a challenging problem for both patient and surgeon. One reconstruction option is an arthrodesis of the tibia to the talar neck, as described by Blair, which has the theoretical advantages of salvaging some hindfoot height and motion of the subtalar joint. A few case series have been published describing outcome after modified Blair fusions, none with validated functional outcomes. The purpose of this article is to describe a modification of Blair's original technique, and report the functional outcomes in a series of patients undergoing this procedure.

METHOD

A retrospective review of seven patients with talar osteonecrosis undergoing modified Blair tibiotalar arthrodesis was performed. The median patient age was 51 (range, 39-78). Median follow-up was 20 months (range, 12-112). Two patients required a repeat procedure for delayed/nonunion, with subsequent uneventful union. In all patients the procedure included compression screw fixation of the talar head to the anterior distal tibia, with the two repeat procedures and the most recent patient having an additional anterior compression plate and bone graft. Functional outcome measures using both the AOFAS ankle-hindfoot score and the SF-36 global health outcome measure were obtained at latest follow-up. In addition, radiographic assessment of bone union and time to union was determined.

RESULTS

Median SF-36 physical and mental component scores were 46 and 61, respectively. The median AOFAS ankle-hindfoot score was 67 out of 100. Median visual analog scales for postoperative pain and function were 7.1 and 6.0 respectively, out of a best possible score of 10.

CONCLUSION

Functional outcome scores after modified Blair arthrodesis are lower than similar scores after conventional tibiotalar fusion, and much lower than "normal" values; however, the procedure has similar, if not lower, complication rates to alternative complex hindfoot reconstructions, and this procedure is a valuable alternative in the management of talar osteonecrosis with arthrosis.

Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1-15 years

We retrospectively reviewed 79 patients (80 talar fractures) operated on between 1994 and 1997. The average follow-up was 6 (1-15) years. 15 patients had a Marti/Weber fracture type I, 14 patients a type II, 32 patients a type III, and 19 patients a type IV fracture. 46 patients suffered a fracture of the talar neck, Hawkins type I in 10 patients, type II in 18, type III in 17 and type IV in 1 patient. 18/23 patients directly placed in our department were operated on within 6 hours of admission. Primary arthrodesis of both the ankle and subtalar joint was performed twice. Secondary arthrodesis of the ankle joint was done in only 3 patients. Combined secondary arthrodesis of the ankle and subtalar joint was performed in 5 and arthrodesis of the talonavicular joint in 1 patient. According to the Hawkins score, 35/80 feet achieved good/very good function versus 43 with the Mazur score. Radiographs showed ankle or subtalar arthrosis in two thirds of the patients. A normal range of motion was achieved in 18 ankle and 19 subtalar joints. The overall rate of talar necrosis was 9/80 fractures.

Talar neck fractures

Clinical management of talar neck fractures is complex and fraught with complications. As Gaius Julius Caesar stated: "The die is cast"; often the outcome of a talar neck fracture is determined at the time of injury. The authors believe, however, that better results can be achieved by following some simple guidelines. The authors advocate prompt and precise anatomic surgical reduction, preferring the medial approach with secondary anterolateral approach. Preservation of blood supply can be achieved by a thorough understanding of vascular pathways and efforts to stay within appropriate surgical intervals. The authors advocate bone grafting of medial neck comminution (if present) to prevent varus malalignment and rigid internal fixation to allow for joint mobilization postoperatively. These guidelines may seem simple, but when dealing with the complexity of talar neck fractures, the foot and ankle surgeon needs to focus and rely on easily grasped concepts to reduce poor outcomes.

Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature

Fractures of the head, neck, and body of the talus present difficult treatment challenges. The vulnerable blood supply and abundant articular surfaces may lead to long-term problems with osteonecrosis and osteoarthrosis. Previous studies of these relatively rare injuries have been mostly small, inconsistent, or anecdotal, leading to confusion and controversy regarding the optimum treatment of various types of talus fractures. The surgeon who treats these injuries must be prepared to address meticulous reduction and fixation, maintain attentive follow-up, and manage the complications that may result despite appropriate treatment. This review summarizes the findings of the literature on each type of talus fracture to provide a clearer picture of their recommended management.

Talar neck fractures and rates of avascular necrosis

Talar neck fractures are unique and potentially debilitating injuries. Their successful treatment requires an understanding of talar anatomy and arterial blood supply, as well as knowledge of the sequelae of these injuries, particularly avascular necrosis of the talar body. Presented is an extensive literature review on talar neck fractures and Hawkins' classification, with special emphasis on the rates of avascular necrosis as determined by selected researchers on the topic.

Nonunion of a Hawkin's group II talar neck fracture without avascular necrosis

The authors present an unusual case of talar neck nonunion without avascular necrosis following a Hawkin's group II fracture. A review of the literature and treatment of this rare complication are discussed. The nonunion was treated by debridement and iliac crest bone grafting to the defect and external electrical bone stimulation. The deformity of the rearfoot caused by the fracture nonunion was addressed by using a triple arthrodesis utilizing the Synthes 7.3-mm cannulated screw system.

Isolated talus fractures: description of a new clinical sign

Isolated talus fractures are very uncommon and are usually associated with severe trauma. Five cases of isolated talus fracture associated with relatively minor trauma are reported. These five patients had one clinical sign in common, pain out of proportion to the severity of their injury. The treatment of talus fractures is reviewed.

Repair of talar neck nonunion with indirect corticocancellous graft technique: a case report and review of the literature

In this article, a case of talar neck fracture nonunion is presented. Union was accomplished with an indirect placement of a corticocancellous fibular graft through a posterolateral approach. The advantages and indications for this method of the treatment of talar neck nonunion are discussed, together with a review of the literature.

Osteonecrosis of the talus: treatment by hindfoot fusion

The results were reviewed for 11 ankles (10 patients) that had been treated with various hindfoot arthrodeses because of symptomatic osteonecrosis of the talus. Follow-up averaged 6.5 years (range, 2-15 years). A functional assessment using a modified Mazur grading system was performed both before surgery and at final follow-up. Data were also collected on the duration of the procedure, intraoperative findings, and the patient's assessment of postoperative cosmesis (excellent, good, fair, or poor). Radiographs were analyzed to determine the interval from the procedure until bony union. Nine of the 11 arthrodeses (82%) fused with the primary procedure and achieved excellent Mazur ratings (mean, 86 points; range, 81-90 points). The average interval until radiographic fusion was 7 months (range, 4-13 months). All eight patients (nine fusions) with successful fusions graded their cosmetic outcomes as excellent or good. The average length of the procedure was 148 minutes (range, 130-300 minutes), compared with an average of 92 minutes (range, 62-151 minutes) for ankle arthrodeses performed by the same surgeons in rheumatoid or osteoarthritic ankles (P < 0.001) and 102 minutes (range, 75-164 minutes) from a report in the literature. Two of the procedures were complicated by nonunions secondary to infections. In one patient, after treatment by debridement and intravenous antibiotics, reinfection and chronic osteomyelitis developed with a subsequent below-knee amputation. The other patient was treated successfully with debridement, antibiotics, and subsequent revision arthrodesis, which fused solidly at 9 months with an excellent result. We conclude that hindfoot arthrodeses for osteonecrosis can be technically demanding, but, despite having a long time to bony union, they can have an excellent clinical outcome.

Treatment outcome of major fractures of the talus

Twenty-six patients with major fractures of the talus were studied to assess the long-term outcome. The patients were admitted to a university teaching hospital and major trauma center from 1983 to 1991. The study excluded isolated fractures of the talar dome and posterior tubercle. Fifteen patients were treated using internal fixation and 11 patients were treated using nonsurgical methods. Avascular necrosis was detected in only four of the 26 patients. Subtalar osteoarthritis was a significant problem in 61%. Seven of these patients have come to secondary fusion procedures, with another three contemplating fusion procedures at the time of review. Only one patient developed significant avascular necrosis requiring a fusion procedure. Only three of 26 patients had not returned to work at a mean 6 years after their injury. Eleven of the 26 (42%) had not returned to their premorbid activity level. The majority of these patients (25/26) had sustained multiple injuries, which compromised the functional recovery from the talar injury. Early accurate diagnosis and anatomical reduction gave the best results. The low incidence of avascular necrosis in this study has been attributed to early anatomical stabilization of the fracture. We believe an early CT scan can more accurately assess the severity of the talar fracture and offers the best information for an appropriate treatment plan.

Subcapital talar osteotomy to correct transverse plane structural flatfoot deformities

Subcapital talar neck adductory wedge osteotomies have significant benefits in the correction of angular deformities of the talar head in the pediatric flatfoot. Reconstruction of a severe flatfoot may include an Evans opening calcaneal osteotomy, a modified Young's tenosuspension with a posterior tibial and spring ligament advancement and a tendo Achillies lengthening. Talar neck osteotomies should also be considered in the presurgical evaluation of the pediatric and adolescent flatfoot with severe transverse plane deformity.

Talar neck fractures

Talar neck fractures represent a serious injury, and a review of the literature reveals the controversies surrounding the treatment options. In spite of the differences, there are many aspects of management where little disagreement exists. Anatomic reduction is the goal in situations where a primary salvage procedure is not performed. If closed treatment is chosen, careful follow-up is necessary to prevent unrecognized displacement as swelling subsides in the cast. Weight-bearing should be delayed until radiographic signs of fracture healing are obvious. There is a growing tendency toward open reduction and internal stabilization of talar neck fractures. Results suggest improved maintenance of reduction, decreased time to union, and a better end result. Prior to attempting any type of salvage procedure, careful assessment of both the tibiotalar and subtalar complex is necessary. The incidence of poor results following a talar neck fracture is disappointingly high. Additional studies of the pathoanatomy and biomechanics may improve our understanding. Controlled prospective clinical series will help clarify the advantages of specific treatment approaches and lead to better clinical results.

[Primary and secondary arthrodeses following talus fractures]

In 18 cases out of 55 patients, who had been operated on talus fractures in our clinic, a primary or secondary arthrodesis of one or both adjacent joints had been necessary. We carried out a follow-up examination on those 18 patients. In 4 cases a primary or early secondary arthrodesis had been performed; the attempt to reconstruct the joint surfaces after the trauma would have been not promising. The indication of the secondary arthrodesis in the 14 patients is discussed. In all the patients there had been a bony healing of the arthrodesis in an adequate time, the gait pattern of the patients had been improved and they complained less pain. We conclude that in case of a not solvable complication after talus fracture like destroyed joint surfaces, secondary severe arthritis or bone necrosis early secondary arthrodesis should be considered as a measurement to avoid long periods of insufficient conservative treatment.

The modified Blair fusion

The Blair fusion is the accepted method to achieve an ankle arthrodesis in the presence of avascular necrosis or absence of the body of the talus. This procedure has not however, been reliable. A pseudarthrosis rate of 28% and fibrous ankylosis of the foot secondary to prolonged immobilization compromise the end result. A tibiotalar compression arthrodesis has been developed using an intermediate hip compression screw and a modified Stone staple. Five patients with avascular necrosis of the talus underwent a modified Blair fusion. Protected weightbearing was started at 6 weeks and healing occurred within 3 months. Although the number of cases is small, this study indicates that the addition of compression fixation to the Blair arthrodesis will significantly decrease the pseudarthrosis rate and perhaps the healing time.