The prognostic value of the hawkins sign and diagnostic value of MRI after talar neck fractures

The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

BACKGROUND

Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy.

METHODS

A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing.

RESULTS

In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked.

CONCLUSIONS

A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy.

LEVEL OF EVIDENCE

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

Anteromedial cannulated screw fixation for Hawkins II/III talus fractures in children: a retrospective study

OBJECTIVE

To investigate the clinical effect of the anteromedial cannulated screw approach in the treatment of Hawkins II/III talus fractures in children.

METHODS

A retrospective study was conducted on 20 children with talar fractures admitted to Renmin Hospital from September 2018 to February 2022. The fracture healing and functional recovery of the affected limb were strictly followed up after the operation. There were 14 males and 6 females. The average age was 9 years (range 6-12 years). According to the Hawkins classification, there were 12 cases of talar neck fracture type II and 8 cases of type III. All patients were fixed with cannulated compression screws via an anteromedial approach. According to the American Orthopedic Foot and Ankle Society ankle and hindfoot function scoring system, limb function was evaluated before and after the operation. A visual analog scale was used to evaluate the degree of postoperative pain.

RESULTS

All 20 children were followed up for 12 months to 30 months, with an average of 15 months. We found that there was no significant difference in the excellent and good rate (76.9%) and necrosis rate (30.8%) between male children and female children (71.4%) and necrosis rate (28.6%) (P > 0.05). The excellent and good rates (92.9%) of children younger than 9 years old at the time of injury were higher than those of children older than 9 years old (33.3%), and the incidence of avascular necrosis of the talus was lower. The differences between the two groups were statistically significant (P < 0.05). The average prognosis score of children who underwent surgery within 5 days after injury was 89.2 ± 6.4, which was significantly higher than that of children who underwent surgery after 5 days (72.9 ± 13.1), and the difference was statistically significant (P < 0.05). There was no significant difference between patients who underwent surgery within 5 days after injury (15.4%) and those who underwent surgery after 5 days (51.7%) (P > 0.05). The excellent and good rates of talar neck fracture type II and talar neck fracture type III were 90.1% and 55.6%, respectively.

CONCLUSION

The anteromedial approach combined with cannulated compression screws for the treatment of Hawkins II/III talus fractures in children not only has a clear surgical field, but the fracture can also be reduced and fixed under direct vision using this technique. It does not affect the stability of the ankle joint and is conducive to the recovery of ankle function. It can be used as a surgical scheme for the treatment of talar fractures in children.

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.

Avascular necrosis of the talus causing meniscoid lesions in the ankle joint: a case report

Background

Meniscoid lesions have been reported in patients with chronic ankle injuries, especially in soccer athletes, and such lesions cause soft-tissue impingement and pain. To our knowledge, we are the first to report a meniscoid lesion in the ankle joint presenting as a long-term sequela of avascular necrosis of the talus that developed in childhood.

Case presentation

In this paper, we describe a 55-year-old Caucasian male patient who presented with a 1-year history of intermittent locking, “giving way,” weight-bearing pain, and swelling over the anterior aspect of the ankle joint. Imaging showed a rare case of avascular necrosis of the talus associated with an unstable plica-like lesion that was removed arthroscopically after unsuccessful conservative treatment.

Conclusion

We demonstrate that unstable meniscoid lesions of the ankle joint can be treated successfully with arthroscopic debridement. We obtained satisfactory short-term clinical results at the 2-year follow-up, even though advanced osteoarthritis was present.

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.

Moon (or Eid) Crescent Sign of the Femoral Head

Avascular necrosis (AVN) of the femoral head following slipped capital femoral epiphysis (SCFE) is a serious complication that often leads to a permanent disability. Radiological findings of AVN may take up to two years to become apparent. This means painful waiting for children, parents, and treating teams. We would like to describe a new radiological sign that we noted in four patients. The sign has been named as the crescent moon sign or eid crescent sign. It may become visible as early as six weeks following surgery, and it carries a good prognosis that the femoral head is viable and will not develop AVN. Two out of the four patients were treated in our hospital by Ganz surgical dislocation. The other two patients had been featured in other publications, but the significance of the moon crescent signs, which were present, was not recognized or appreciated. All four patients did not develop AVN. A relatively similar radiological sign has been described in talus bone fractures (Hawkins' sign). Like SCFE, talus bone fractures have a high AVN rate. Both, the crescent moon sign and Hawkins' sign carry a good prognosis and indicate that the bone blood supply is restored.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Therapeutic Efficacy Analysis of Talar Fracture Internal Fixation with Lateral Malleolar Osteotomy

Background

There are many surgical treatment approaches for talar fractures. However, due to the unique anatomical and blood supply characteristics of the talus, the traditional approaches tend to lead to blood supply damage. In order to best preserve the blood supply of the talus, we proposed a surgical approach of internal fixation of the talar fracture with lateral malleolar osteotomy and analyzed its efficacy.

Material/Methods

Twenty-six patients with talar fractures underwent open reduction surgery between January 2010 and December 2016. Following the lateral malleolar osteotomy, the talus was fully exposed. After anatomical reduction, the talus was fixed with 2 screws, and the lateral malleolus was fixed with distending wires. The treatment effects were assessed in the follow-up.

Results

All patients were followed for 7 to 22 months, for an average of 14.34 months. According to the Maryland Foot Score, 19 cases were excellent (90–100 points), 4 cases were good (85–90 points), and 3 cases were moderate (50–74 points).

Conclusions

Internal fixation of talar fractures with lateral malleolar osteotomy is a viable surgical approach to reduce injury to blood supply and maximize surgical exposure.

Prevention of Avascular Necrosis with Fractures of the Talar Neck

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.

Tibiotalocalcaneal Arthrodesis for Severe Talar Avascular Necrosis

Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.

Natural History of Avascular Necrosis in the Talus: When to Operate

Avascular necrosis (AVN) of the talus bone is a progressive and debilitating consequence of trauma or exposure to a variety of risk factors. The Ficat classification describes current understanding of the natural history of AVN, including preclinical, preradiographic, precollapse, postcollapse, and arthritic stages. The size and location of the avascular region likely determines risk of progression; however, symptoms do not correlate with stage. Patients may be minimally symptomatic despite diffuse involvement for long periods. Joint-sparing strategies have shown promise but do not universally prevent progression of the disease. When bone structure fails, joint-sacrificing strategies may be required.

Current Concepts in Talar Neck Fracture Management

PURPOSE OF THE REVIEW

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

RECENT FINDINGS

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

Fractures of the talus: Current concepts and new developments

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

Management Options in Avascular Necrosis of Talus

Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

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

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

Osteotomies of the Talar Neck for Posttraumatic Malalignment

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

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.