Talar neck fractures

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSION

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

LEVEL OF EVIDENCE

I (systematic review and meta-analysis).

Talar Neck Fractures: Single or Double Approach?

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.

Primary Arthrodesis in Severely Comminuted Fractures

At present there is controversy regarding the appropriate treatment of severely comminuted fractures of the lower extremity. Even with near-perfect anatomic reduction of severely comminuted fractures, development of posttraumatic arthritis is still present at an increased rate. Primary fusion of comminuted fractures of the foot and ankle creates successful and predictable outcomes, which dismisses the chance of developing posttraumatic arthritis and decreases complications and the need for revisional procedures.

Talar fractures: radiological and CT evaluation and classification systems

INTRODUCTION

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

METHODS

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

AIM OF THE WORK

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

CONCLUSIONS

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

Plate Fixation of Talus Fractures: Where, When, and How?

Talus fractures are rare orthopedic injuries. Surgical fixation is challenging for treating surgeons. The clear majority of fractures require operative treatment. The indication and use of plates in fixation of talus fractures are reviewed. Specific applications including fractures of the lateral process, posterior fractures, extreme comminution, bone grafting, and spring plating to hold key segments are reviewed in this article.

Joint-Preserving Surgery for Talar Malunions or Nonuions

OBJECTIVE

To describe the technique and analyze the outcomes of joint-preserving surgical treatments which included anatomical reconstruction or alignment correction for talar malunions or nonunions, and avoid development of degenerative changes in the adjacent joints.

METHODS

Eight patients who had painful talar malunions or nonunions treated between 2009 and 2015 were included in this retrospective study. The mean age of the patients was 35.6 years, with patients aged from 18 to 58 years. Two patients had talar neck fractures and six had talar body fractures. According to a classification of post-traumatic talar deformities, five patients were classified as type I (malunion and/or residual joint displacement), two as type II (nonunion with displacement), and one as type III (malunion with partial avascular necrosis [AVN]). Of these patients, six cases were treated with an osteotomy through the malunited fracture or removal of the pseudarthrosis, and two cases were corrected by supramalleolar or calcaneal osteotomies owing to complete disappearance of the former fracture lines. The follow-up evaluation methods included the 36-Item Short Form Health Survey (SF-36) score, the American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion (ROM), and radiological analysis. The differences between postoperative scores and preoperative scores were evaluated statistically with the paired Student's t-test. Significance was assumed at P < 0.05.

RESULTS

The mean follow-up time was 25.6 months. No wound healing problems or infections were observed. Solid union was obtained without redislocation in all cases, and with no signs of development or progression of AVN. At a mean of 25.6 months (range, 16-36 months) after reconstruction, all patients were satisfied with the result. The mean AOFAS score increased from 30.0 ± 7.0 pre-operatively to 86.5 ± 7.8 post-operatively (P < 0.001), the mean SF-36 score increased from 38.8 ± 4.1 to 81.4 ± 7.7 (P < 0.001), and the average ROM (tibiotalar joint) increased from 40.5° ± 8.7° to 43.9° ± 7.2° (P < 0.05).

DISCUSSION

Joint-preserving procedures for talar malunions or nonunions can bring about satisfactory outcomes, and the appropriate procedure should be adopted according to different types of post-traumatic deformities.

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.

Treatment of Comminuted Talar Neck Fractures With Use of Minifragment Plating

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.

Simultaneous Bilateral FractureUnilateral Dislocation of the Talus

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.

The influence of foot and ankle injury patterns and treatment delays on outcomes in a tertiary hospital; a one-year prospective observation

BACKGROUND

Ankle and foot fractures are amongst the most common injuries, and patterns may vary from primary care set up to tertiary hospitals. Severe foot injuries are projected to have significantly worse outcomes and surgical delays are thought to alter prognosis.

METHODS

All patients with foot and ankle trauma were prospectively evaluated at a Tertiary trauma centre over one year. The incidence, fracture patterns, risk factors, and outcomes were evaluated, and cases were divided into simple foot injuries (FASS ≤ 3) and severe foot injuries (FASS>3). Injury mechanisms, associated injuries, and delays in treatment were evaluated, and outcomes were analyzed using Visual-Analogue Scale Foot and Ankle (VASFA), Maryland Foot Score (MFS) and Foot and ankle disability index (FADI).

RESULTS

294 Foot and Ankle injuries (51 females, 243 males) were encountered in 2919 trauma cases (incidence of 10%). 80 patients (27.2%) had simple foot injuries and 214 (72.8%) had severe foot injuries. 29 patients (9.9%) were below 18 years; most (65.3%) patients were between 18 and 45 years age. Road traffic accident was most commonest mode of injury, with ankle fractures (30.6%) the most common. Metatarsal fractures (27.9%) and calcaneal fractures (21.4%) were 2nd and 3rd most common injuries in the foot. Surgical delay averaged 1 day in both severe and simple injuries. Injury led to 32 (10.9%) below knee amputations. Outcome evaluation in 127 (91 severe, 36 simple injuries) patients showed mean Maryland foot score of 89.30 in simple injury group and 84.87 in severe injury group. Mean VASFA score was 82.87 (simple) and 81.87 in severe injury, and mean FADI score was 93.13 (simple) and 91.05 (severe injury). More detailed analysis revealed that more good scores (64.4%) were documented in severe injuries group, and more excellent scores (52.8%) in simple injuries group.

CONCLUSION

Foot injuries constitute 10% of all orthopaedic trauma at tertiary hospitals; Majority of them are severe foot injuries, with 68.7% being open injuries. Surgical delay was similar in simple and severe foot and ankle injuries. Outcomes of severe injuries were similar to simple foot and ankle injuries, reflecting on the quality of care that could be administered to them when they present to tertiary hospitals.

Talar Fractures and Dislocations: A Radiologist's Guide to Timely Diagnosis and Classification

The talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns. The predominantly extraosseous vascular supply of the talus predisposes it to significant injury in the setting of trauma. In addition, the lack of muscular attachments and absence of a secondary blood supply can lead to subsequent osteonecrosis. Although talar fractures account for less than 1% of all fractures, they commonly result from high-energy trauma and may lead to complications and long-term morbidity if not recognized and managed appropriately. While initial evaluation is with foot and ankle radiographs, computed tomography (CT) is often performed to evaluate the extent of the fracture, displacement, comminution, intra-articular extension, and associated injuries. Talar fractures are divided by anatomic region: head, neck, and body. Talar head fractures can be treated conservatively if nondisplaced, warranting careful radiographic and CT evaluation to assess rotation, displacement, and extension into the neck. The modified Hawkins-Canale classification of talar neck fractures is most commonly used due to its simplicity, usefulness in guiding treatment, and prognostic value, as it correlates associated malalignment with risk of subsequent osteonecrosis. Isolated talar body fractures may be more common than previously thought. The Sneppen classification further divides talar body fractures into osteochondral talar dome, lateral and posterior process, and shear and crush comminuted central body fractures. Crush comminuted central body fractures carry a poor prognosis due to nonanatomic reduction, bone loss, and subsequent osteonecrosis. Lateral process fractures can be radiographically occult and require a higher index of suspicion for successful diagnosis. Subtalar dislocations are often accompanied by fractures, necessitating postreduction CT. Familiarity with the unique talar anatomy and injury patterns is essential for radiologists to facilitate appropriate and timely management.

Talar Neck Fracture after United Tibiotalar Fusion

Tibiotalar arthrodesis is a well-established treatment for tibiotalar arthritis, for example, in younger high demand patients. Talar neck fractures are less common though well-recognised sequelae of foot ankle trauma. Here we present the clinical case of a 69-year-old male who presented to our institution with a nonunion of a talar neck fracture, having undergone a left tibiotalar fusion 24 years previously. To the authors' knowledge, this injury has only been described once previously in the literature. However, the original case described a fracture sustained in the very early postoperative period following tibiotalar fusion, postulated to be secondary to postimmobilisation osteopaenia or stress risers from metalwork. The aetiology in this case is likely due to axial compression transmitted to the talar neck via the calcaneus. The predisposing factors for nonunion are discussed, highlighting the importance of vigilance for this injury in any patient with concomitant tibiotalar fusion and foot trauma. The management of this patient is discussed.

Hawkins Group I fracture of neck of talus and Salter Harris Type III tibial epiphyseal injury of medial malleolus

We are reporting an unusual combination of Hawkins Group I fracture of the neck of left talus in association with Salter Harris Type III distal tibial epiphyseal injury of medial malleolus in a child with cerebral palsy and hemiplegia of contralateral limbs and discussed the possible mechanism as well as management. Fractures of medial malleolus usually occur in Hawkins Group III fracture-dislocations in adults. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism, despite limited experimental and clinical evidence incriminating axial compression. Fracture of medial malleolus implicates supination. We managed this unusual pattern of injury conservatively. At 15 months, the child was asymptomatic with no radiological evidence of avascular necrosis of body of talus or growth disturbance of distal tibial epiphysis.

Delayed presentation of a loose body in undisplaced paediatric talar neck fracture

Fractures of the talus are rare in children. A high index of suspicion is needed to avoid missing such an injury, which is not an uncommon occurrence especially with undisplaced fractures. We present an unusual case of an undisplaced talar neck fracture in a five-year-old child leading to a delayed presentation of a symptomatic osteochondral loose body in the ankle joint. To our knowledge there are no reports in the literature of osteochondral loose bodies occurring in conjunction with an associated undisplaced talar neck fracture in either children or adults. The loose body was removed using anterior ankle arthroscopy. The child had an uneventful post operative recovery and regained full range of movement and function of his ankle joint and was discharged at one year follow-up. We aim to highlight the need to have a low threshold to further evaluate symptomatic children after fracture healing of an undisplaced talar neck fracture for a possible associated loose body in the ankle joint.

Three-dimensional geometric analysis of the talus for designing talar prosthetics

Proper understanding of the complex geometric shape of the talus bone is important for the design of generic talar body prosthetics and restoration of the proper ankle joint function after surgery. To date, all talus implants have been patient-specific with the limitation that complex computer modeling is required to produce a mirrored image from the unaffected opposite side followed by machining a patient-specific prosthesis. To develop an “off-the-shelf” non-custom talar prosthesis, it is important to perform a thorough investigation of the geometric shape of the talus bone. This article addresses the applicability of a scaling approach for investigating the geometric shape and similarity of talus bones. This study used computed tomography scan images of the ankle joints of 27 different subjects to perform the analysis. Results of the deviation analyses showed that the deviation in the articulating surfaces of the talus bones was not excessive in terms of talus size. These results suggest that a proposed range of five implant sizes is possible. Finally, it is concluded that the talus bones of the ankle joints are geometrically similar, and a proposed range of five implant sizes will fit a wide range of subjects. This information may help to develop generic talus implants that might be applicable to patients with a severe talus injury.

Ankle arthritis: review of diagnosis and operative management

The diagnostic and therapeutic options for ankle arthritis are reviewed. The current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities lack high-quality research studies to delineate their appropriateness and effectiveness. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable more informed decisions and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of surgical treatment for talar malunions and nonunions

OBJECTIVE:

To present our experiences of treating talar malunions and nonunions.

METHOD:

Between January 2000 and September 2009, 26 patients with malunions or nonunions after talar fractures underwent surgical treatment according to different types of talar deformities. The treatment outcomes were evaluated using AOFAS ankle-hindfoot scale as well as plain radiographs.

RESULTS:

20 patients were available for follow-up for 30 (range, 24 to 60) months. No wound healing problems or infections occurred and solid unions were achieved in all patients. Radiological unions were achieved at a mean time of 14 (range, 12 to 18) weeks. The mean time to complete weight-bearing was 16 (range, 14 to 20) weeks. The mean AOFAS score increased significantly from 36.2 (range, 27 to 43) to 85.8 (range, 74 to 98).

CONCLUSION:

Surgical interventions for malunions and nonunions after talar fractures can bring about satisfactory outcomes, and the appropriate procedure should be adopted according to different types of posttraumatic deformities. Level of Evidence: IV, Retrospective Study.

Fractures of the talus: a comprehensive review

The talus, a highly specialized bone with a unique anatomic design, is crucial for normal ambulation. Although uncommon, talar fractures can be potentially devastating to the patient. Although all talar fractures require appropriate diagnosis and treatment, some require surgical skill for appropriate correction. This article reviews the literature on talar fractures and their treatments.

Varus hindfoot deformity after talar fracture

Posttraumatic malalignment after talar neck fractures invariably leads to painful functional impairment. Anatomic reduction and definitive, stable osteosynthesis at the primary surgical intervention is preventative. Secondary anatomic reconstruction with joint preservation should be considered in the absence of arthrosis in the peritalar articulations. Reorientating arthrodeses should be entertained where deformity has resulted in joint incongruity and, ultimately, posttraumatic arthritis. TAA may have a role as a motion-conserving procedure in combination with adjacent subtalar and midtarsal fusions.

Talar neck fracture after tibiotalar arthrodesis: case report

Level of Evidence: V, Expert Opinion

Long-term follow-up after surgical treatment of talar fractures: Twenty cases with an average follow-up of 7.5 years

Displaced talar neck and body fractures are rare and serious injuries with important outcomes. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment in our centre between 1993 and 2005. Displaced talar fractures have a high rate of long-term complications. This was a retrospective study concerning 20 patients with an average follow-up of 7.5 years. The final follow-up examination included determination of the AHS score (ankle-hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiological analysis. Mean age at the time of trauma was 38.8 years. This study comprised ten talar neck fractures and ten talar body fractures. We always used a single surgical approach and obtained anatomical reduction in 30% of the whole series of both groups. Four early complications were noted in four patients (20%). We noted no skin complications and the rate of consolidation was 100%. Four patients (20%) developed avascular necrosis of the talus, and at final follow-up seven patients (35%) had undergone secondary surgery. Radiographic analysis showed an osteoarthritis rate of 94% and a malunion rate of 59%. The mean AOFAS score was 66.9/100 and range of motion was systematically decreased. Contrary to undisplaced talar fractures, displaced talar fractures are a therapeutic challenge with many early or late complications. The outcome often revealed stiffness and osteoarthritis.

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.

Etiology and biomechanics of ankle arthritis

Of all joints in the body, the ankle joint is subjected to the highest forces per square centimeter and is injured more commonly. Yet, the incidence of symptomatic ankle arthritis is much lower than that of the knee and hip. Various mechanical, biochemical and anatomic peculiarities of the ankle account for its apparent resilience to the process of aging and trauma. The goal of this article is to help the reader better understand the functional paradoxes that make the ankle joint a unique and fascinating articulation.

Clinical accuracy of imaging techniques for talar neck malunion

OBJECTIVES

To compare the ability of plain radiographs, computed tomography (CT), and radiostereometric analysis (RSA) to detect changes in talus fracture fragment position and alignment using an in vitro model.

METHODS

Eight cadaveric tali were osteotomized at the talar neck. RSA beads were inserted into each talar fragment. The talus was anatomically reduced and stabilized with a pair of 3.5-mm cortical screws. Plain radiographs and RSA films were obtained. The fragments were then displaced and rotated to create a varus and supination deformity, and screw fixation was repeated in nonanatomic alignment. Displacement and rotation were directly measured. Plain radiographs and RSA were repeated, and CT scans were obtained. The RSA measurements were interpreted in a blinded fashion by an experienced researcher. Two independent blinded orthopedic trauma surgeons measured the displacement and rotation using plain films and CT. The results from each radiographic measurement were compared to the measured displacement and rotation using ANOVA.

RESULTS

Plain radiographs, RSA, and CT all underestimated the measured talar neck displacement and rotation. Radiographs underestimated displacement by 5.0 +/- 2.9 mm, RSA by 5.9 +/- 2.0 mm, and CT scans by 2.4 +/- 4.8 mm (P < 0.05). Rotation was also underestimated by all 3 techniques, but the differences among techniques were not statistically significant.

CONCLUSIONS

The most accurate imaging technique to measure displacement in talar neck malunion is CT scan. RSA was less useful as an imaging technique in this study.

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.

Comminuted talar neck fractures: a mechanical comparison of fixation techniques

OBJECTIVE

To compare the mechanical performance of 3 fixation techniques for comminuted talar neck fractures.

DESIGN

In vitro biomechanical study.

SETTING

Bioengineering research laboratory.

PARTICIPANTS

Thirty previously frozen human cadaveric tali were osteotomized across the talar neck. A wedge of bone 2 cm long and extending 50% of the medial to lateral and superior to inferior dimension of the talus was removed to create an unstable, comminuted fracture.

INTERVENTION

The specimens were randomized to one of 3 fixation groups. The first group was fixed with 3 anterior-to-posterior screws. The second group was fixed with 2 cannulated screws inserted from posterior to anterior. The third group was fixed with 1 screw from anterior to posterior and a medially applied blade plate. Specimens were embedded in acrylic cement and mounted on an Instron mechanical testing machine. Loading was applied in the dorsal-medial direction to failure.

MAIN OUTCOME MEASURES

For each specimen, the load-displacement curve, yield point, and 3 mm displacement point were recorded in response to controlled dorsal-medial loading to failure. Stiffness was calculated as the linear portion of the slope of the load (kN) versus displacement (mm) curve. Statistical analysis of the data was conducted using analysis of variance.

RESULTS

The mean yield point of each of the fixation techniques tested exceeded 1.4 kN. No statistically significant difference was found between the fixation methods, even when variations in age and sex were considered.

CONCLUSIONS

The mean yield point of the fixation techniques tested exceeds the theoretical stress across the talar neck during active motion. Anterior plate fixation provided equivalent stability to posterior screw fixation.

Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model

BACKGROUND

Talar neck fracture fixation has been studied in noncomminuted fracture models, but no large clinical series of comminuted fracture patterns have been published and no biomechanical studies have compared plate fixation with screw fixation in comminuted talar neck fractures.

METHODS

Nine matched pairs of fresh frozen talar specimens were stripped of soft tissue and mounted in a cylindrical jig. The talar neck was fractured using a dorsally directed shear force at a rate of 200 mm/min, and dorsal comminution was simulated by removing a 2-mm section of bone from the distal fracture fragment. One specimen from each pair was fixed with either two solid 4.0-mm partially threaded cancellous screws posterior-to-anterior just lateral to the posterior process of the talus or with a four-hole 2.0-mm minifragment plate contoured to the lateral surface of the talar neck and secured with 2.7-mm screws. A 2.7-mm fully threaded cortical screw was placed medially using a lag technique. The specimens were then loaded to failure with a dorsally directed force at a rate of 200 mm/min. Failure was defined as the load producing 2 mm of displacement. A Student's t-test analysis was used with significance set at p < or = 0.05.

RESULTS

Posterior-to-anterior screw fixation had a statistically significant higher load to failure than plate fixation (p < 0.05). Mean load to failure for the screw group was 120.7 +/- 68.5 N and 89.7 +/- 46.6 N for the plating group.

CONCLUSIONS

Plate fixation may offer substantial advantages in the ability to control the anatomic alignment of comminuted talar neck fractures, but it does not provide any biomechanical advantage compared with axial screw fixation. Further, the fixation strength of both methods was an order of magnitude lower than those found in previous studies of noncomminuted fractures.

Delayed surgical treatment for neglected or mal-reduced talar fractures

From 1993 to 2002, we treated nine patients for neglected or mal-reduced talar fractures. Average patient age was 39 (20-64) years and average follow-up 53 months. The time interval between injury and index operation ranged from 4 weeks to 4 years. Surgical procedures included open reduction with or without bone grafting in six cases, open reduction combined with ankle fusion in one case, talar neck osteotomy in one case, and talar neck osteotomy combined with subtalar fusion in one case. All cases had solid bone union. One patient developed avascular necrosis of the talus needing subsequent ankle arthrodesis. In six patients, adjacent hindfoot arthrosis occurred. The overall AOFAS ankle-hindfoot score was in average 77.4. We conclude that in neglected and mal-reduced talar fractures, surgical treatment can lead to a favourable outcome if the hindfoot joints are not arthritic.

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.

Functional outcomes following displaced talar neck fractures

OBJECTIVES

To determine the outcome of displaced talar neck fractures at long-term follow-up in terms of functional outcome and secondary reconstructive surgery.

DESIGN

Retrospective cohort study.

SETTING

Academic level 1 trauma center.

PATIENTS

Seventy patients with displaced talar neck fractures.

INTERVENTION

All patients were treated with open reduction and screw fixation.

MAIN OUTCOME MEASUREMENTS

Functional outcome of patients who did not require secondary surgery was assessed using the Short Musculoskeletal Function Assessment, Ankle Osteoarthritis Scale score, and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. The incidence of secondary reconstructive hindfoot surgery, including arthrodesis or talectomy, was measured using life table analysis.

RESULTS

Mean Short Musculoskeletal Function Assessment score was 20 +/- 18 out of 100, with a lower score indicative of better outcome; mean Ankle Osteoarthritis Scale score was 3.8 +/- 2.4 out of 10 (lower score better); and mean Ankle Society Ankle-Hindfoot Score was 71 +/- 19 out of 100 points (higher score better). The incidence of secondary reconstructive surgery increased from 24 +/- 5% at 1 year to 48 +/- 10% at 10 years postinjury.

CONCLUSIONS

Functional outcome varied and was most dependent upon the development of complications. The incidence of secondary reconstructive surgery following talar neck fractures increased over time and was most commonly performed to treat subtalar arthritis or misalignment.

Primary fusion as salvage following talar neck fracture: a case report

For a 29-year-old man with a three-week-old Hawkins Type IV talar neck fracture, intra-operative reduction and fixation were not possible due to soft tissue contractures and severe comminution. A primary talonavicular and subtalar arthrodesis with the use of iliac crest bone graft was performed. Postoperative follow-up at 16 months demonstrated solid fusions, no avascular necrosis of the talus and a functional range of motion at the ankle. He was not capable of returning to his job of roof maintenance.

Foot and ankle fractures in the industrial setting

Fractures of the ankle and foot are common in the worker. Proper initial assessment and treatment can result in a functional recovery that is prompt and complete in many cases. Many fractures, however, have a poor long-term prognosis and prolonged recovery. Frank initial discussions with the patient and case manager can help the system better manage the patient's future.

Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients

OBJECTIVE

To describe an unreported technique of fixation for talar neck fractures.

DESIGN

Retrospective review and telephone interview of patients with fractures of the talar neck (OTA 72-A1.2, 72-A1.3, 72-C2).

SETTING

Level-one trauma center with six trauma surgeons.

PATIENTS/PARTICIPANTS

Twenty-three patients treated with minifragment plates over a four-year period. Follow-up intervals were an average of twenty months.

INTERVENTION

Talar neck fractures were stabilized with one or two 2.0 or 2.4 plates, with additional 2.0, 2.7, or 3.5 lag screws when necessary. Most fractures were approached through medial and lateral incisions.

MAIN OUTCOME MEASURES

Union rates, pain, and incidence of complications. Functional outcome will be best determined by a further review with longer follow-up.

RESULTS

Mini fragment plates were placed on the side with the most comminution, and all wounds and fractures healed uneventfully. Four patients underwent hardware removal. Two patients developed a mild extension malunion, but there was no evidence of varus malunion, as measured on Canale views.

CONCLUSIONS

Initial review suggests that plate fixation of comminuted talar neck fractures is a successful technique, with low rates of complications compared with those discussed in the literature. A further review in a few years will allow functional assessment studies.

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.

Outcome of foot injuries in multiply injured patients

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In one prospective study from the authors' institutions, however, multiple-trauma patients with foot injuries were shown to have a poorer functional outcome compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in polytrauma patients. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, focusing on functional outcomes of multiple-trauma patients with foot injuries.

Emergency department evaluation and treatment of ankle and foot injuries

Ankle and foot injuries are among the most common sports injuries and extremity complaints presenting to the emergency department. Although generally benign, some of these injuries have prolonged morbidity. This article reviews the anatomy of the foot and ankle and examines the approach and therapy for common types of injuries.

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.

High-energy bilateral talar neck fractures secondary to motocross injury

The authors present a case of bilateral Hawkins type II talar neck fractures sustained during a motocross race in a 23 year old man. Due to the complexity of the injuries, open reduction with internal fixation and primary subtalar joint arthrodesis was performed bilaterally. This is one of the few cases of bilateral talar neck fractures reported in the literature in the past 15 years and one of the first utilizing open reduction and internal fixation with concomitant subtalar joint arthrodesis as a primary treatment.

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.

Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion

We performed an in vitro study on twelve specimens of the foot and ankle from cadavera to determine whether varus malalignment of the talar neck alters the position of the foot and subtalar motion. An osteotomy of the talar neck was performed, and the specimens were studied with and without removal of a medially based wedge of bone. Removal of the wedge produced an average varus malalignment of the talar neck of 17.1 +/- 2.4 degrees (range, 12.5 to 21.0 degrees). In the coronal plane, the average arc of motion of the subtalar joint decreased from 17.2 +/- 3.3 degrees before the osteotomy to 11.7 +/- 2.9 degrees after the osteotomy and removal of the wedge. In the transverse plane, it decreased from 17.5 +/- 2.9 degrees to 11.9 +/- 2.4 degrees. In the sagittal plane, it decreased from 8.9 +/- 2.4 degrees to 6.8 +/- 2.3 degrees. The decrease in subtalar motion was characterized by an inability to evert the foot; inversion was not limited, however. The malalignment produced an average of 4.8 +/- 1.2 degrees of varus deformity and 8.7 +/- 2.3 degrees of internal rotation of the hindfoot and an average of 5.5 +/- 2.0 degrees of varus deformity and 11.5 +/- 2.4 degrees of adduction of the forefoot. A linear correlation analysis was used to compare the change in subtalar motion and the position of the foot with the degree of varus malalignment at the talar neck. The correlation coefficient was 0.90 (p < 0.01) for subtalar motion, 0.76 (p < 0.01) for internal rotation of the calcaneus, and 0.81 (p < 0.01) for adduction of the forefoot. This indicated a direct correlation between the degree of varus malalignment at the talar neck and the change in the position of the foot and in subtalar motion.

Ankle and subtalar fusion utilizing a tricortical bone graft, bone stimulator, and external fixator after avascular necrosis of the talus

A unique ankle and subtalar fusion was performed on a patient with avascular necrosis of the talus. The body of the talus was removed and replaced with an autogenous tricortical bone graft. Healing was aided by the use of a bone stimulator and external fixator. The authors believe this fusion to be a more stable fusion than others used to treat avascular necrosis of the talus.

Talar neck fracture with talar head dislocation and intact ankle and subtalar joints: a case report

The authors describe a rare case of fracture of the neck of the talus associated with talonavicular dislocation but no disruption of the ankle and subtalar joints. The fracture united after open reduction and internal fixation. The head of the talus revealed avascular necrosis but the body did not. A literature review retrieved one previous report of a similar injury, but it was open and became infected. The unique features of this injury pattern and its specific complication, isolated avascular necrosis of the talar head, are discussed.