Magnetic resonance imaging to detect avascular necrosis after open reduction and internal fixation of talar neck fractures

[Fractures of the talar neck and body : An overview]

Fractures to the talar neck and talar body (central talar fractures) are rare injuries but often result in devastating outcomes. It is therefore important to diagnose these injuries early and provide the best possible treatment. The analysis, classification, and surgical planning of central talar fractures should be based on computed tomography (CT) imaging. In the case of dislocated fractures, surgeons must strive for an anatomic reduction and fixation. The approach routes are based on the fracture morphology and must enable adequate reduction of the fracture. This can often only be achieved by two or more approach routes. The outcome correlates with fracture complexity and the quality of the reduction. Complications such as avascular necrosis and posttraumatic osteoarthritis are common and have a negative effect on the results of the treatment.

Low-Flow Ankle Arthroscopy for Gunshot Wounds With Retained Intra-Articular Ballistic

Gunshot injuries to the foot and ankle can cause unique and challenging situations for orthopaedic surgeons. The foot and ankle have limited soft-tissue coverage and highly congruent joint spaces, leading to injuries that are often intra-articular with substantial tissue loss. These injuries are often confounded by feet shod in footwear that is pulled into the path of the missile and corresponding tissue. Thus, we report our experience of using low-flow arthroscopy for extraction of retained ballistics, while irrigating and debriding the path of the missile.

Epidemiology, Cause, and Anatomy of Osteonecrosis of the Foot and Ankle

Osteonecrosis arises throughout the foot and ankle in various forms and due to numerous causes, with a thousand US cases per year estimated for the ankle alone. Although research continues to elucidate specific mechanisms at work, the pathophysiology remains poorly understood. Nevertheless, the various osteonecrosis pathways converge on osteocyte death, and bony lesions follow a pattern of progression. Understanding the specific anatomy and biomechanics associated with common forms of foot and ankle osteonecrosis should help guide diagnosis and interventions, particularly at earlier stages of disease where etiology-specific approaches might become optimal.

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.

Management of Talar Fractures

Fractures of the talus are significant injuries with associated significant complications where the recovery zenith is less frequently good to excellent, and more commonly fair to satisfactory. These outcomes are a consequence of combinations of the inherent intrinsic and surrounding anatomy, technical and logistic difficulties in adequate fracture access, and the high-energy mechanisms typically associated with these injuries that further traumatize the surrounding tissues. This article reviews and provides current management recommendations for these devastating injuries.

Hawkins' type-II talar fracture with subtalar dislocation: A very unusual combination

We report the unusual case of a 16-year-old young man who sustained a rare association of a Hawkins' type-II talar neck fracture with a complete medial subtalar dislocation (Hawkins type-IIB) that occurred as an isolated injury after indirect trauma during a soccer game. Following closed reduction of the subtalar dislocation, standard radiographs and computed tomography (CT) demonstrated a comminuted fracture of the talus involving the base of the talar neck. Open reduction was performed and the fracture was stabilized by ORIF. At 1-year follow-up, functional and radiographic outcomes were graded as excellent, with no radiographic evidence of talar osteonecrosis.

Secondary Reconstruction for Malunions and Nonunions of the Talar Body

Malunions and nonunions after central or peripheral fractures of the talar body frequently lead to pain and disability. In properly selected, compliant patients without symptomatic arthritis or total avascular necrosis leading to collapse of the talar dome, and sufficient bone stock, secondary anatomic reconstruction with osteotomy along the former fracture plane and preservation of the essential peritalar joints may lead to considerable functional improvement. Bone grafting is needed after resection of a fibrous pseudarthrosis, sclerotic, or necrotic bone. Malunions and nonunions of the lateral or posterior process are treated with excision of the malunited or loose fragments.

Diagnosis and treatment of talar dislocation fractures illustrated by 3 case reports and review of literature

INTRODUCTION

Talar fractures are a rare type of fractures (less than 1%). They are difficult to treat and outcome is often complicated by arthritis and avascular necrosis. In this article three cases are presented with different types of dislocated talar neck fractures. Anatomy of the talus, treatment, outcome and follow up of these fractures are discussed. Further, review of literature and guidelines for treatment and follow up for dislocated talar neck fractures are discussed.

DISCUSSION

The risk of developing arthritis or avascular necrosis of the talus after dislocated talar neck fractures depends on the initial trauma with vascular compromise due to dislocation of the talus. The modified Hawkins classification gives an insight in the risk of developing avascular necrosis. During follow up the Hawkins sign can be an indication of a vital talus. To diagnose avascular necrosis MRI is the only suitable diagnostic tool.

CONCLUSION

Reduction of a dislocated talar fracture is a medical emergency in an effort to reduce the vascular compromise of the talus. Definitive fixation can be delayed but should be performed by an experienced surgeon to achieve an optimal reconstruction of the talar surface. Long-term follow up is important to evaluate signs of arthritis and avascular necrosis.

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

BACKGROUND

The early diagnosis of avascular necrosis of the talus (AVN) and prediction of ankle function for talar fractures are important. The Hawkins sign, as a radiographic predictor, could exclude the possibility of developing ischemic bone necrosis after talar neck fractures, but its relationship with ankle function remains unclear. The purpose of this study was to illustrate the prognostic effect of the Hawkins sign on ankle function after talar neck fractures and to study the value of early MRI in detecting the AVN changes after talus fractures.

METHODS

Cases of talar neck fractures between November 2008 and November 2013 were evaluated. The occurrences of the Hawkins sign and AVN were studied. X-ray imaging was performed at multiple time points from the 4th to the 12th week after the fractures, and MRI examinations were used in the Hawkins sign negative group, with the time span ranging from 1.5 to 12 months. AOFAS scores of the Hawkins sign positive and negative groups were compared during the follow-up. Forty-four cases (48 feet) were evaluated.

RESULTS

The occurrence of positive Hawkins sign was 50%, 30%, and 33.3%, the incidence of AVN was 0%, 10%, and 50%, respectively, in type I, type II, and type III and IV talus fractures, respectively. The AOFAS scores showed no statistically significant difference between Hawkins sign positive group and negative group in type I and II fractures. The Hawkins sign positive group had better AOFAS scores than the negative group in type III and IV fractures. However, there was no statistically significant difference between Hawkins sign positive and negative groups when AVN cases were excluded in type III and IV fractures.

CONCLUSION

The Hawkins sign was a reliable predictor excluding the possibility of AVN. It did not have predictive value on the ankle function in low-energy fractures and may predict better ankle function in high-energy fractures. MRI can diagnose AVN during an earlier period, and we believe Hawkins sign negative patients should undergo MRI examinations 12 weeks after the fractures, especially in high-energy traumatic cases.

LEVEL OF EVIDENCE

Level III, comparative case series.

The use of arthroscopy in acute foot and ankle trauma: a review

The use of arthroscopy in the management of acute traumatic conditions of the foot and ankle has increased in recent years, primarily because of an appreciation of fracture morphology and the utility of reducing the surgical footprint. This article presents an overview of the use of this modality in foot and ankle trauma and presents an anatomical survey of the various fractures where arthroscopic assistance can be of benefit. In addition, a discussion of the seminal articles on this subject is included.

LEVEL OF EVIDENCE

Therapeutic Level IV: Review.

Antegrade-retrograde opposing lag screws for internal fixation of simple displaced talar neck fractures

The talar neck is deviated medially with reference to the long axis of the body of the talus. In addition, it deviates plantarward. The talar neck fracture line is sometimes observed to be oriented obliquely (not perpendicular to the long axis of the talar neck). This occurs when the medially deviated talar neck strikes the horizontally oriented anterior lower tibial edge. Internal fixation of a simple displaced talar neck fracture usually requires 2 lag screws. Because the fracture line is obliquely oriented, a better method for positioning the screws perpendicular to the fracture line is to place them in a reversed direction to provide maximum interfragmentary compression at the fracture site, which could increase the likelihood of absolute stability with subsequent improvement in the incidence of fracture union and a reduction of complications, such as avascular necrosis of the body of the talus. Two lag screws are used, with the first inserted from posteriorly to anteriorly (perpendicular to the fracture line) using a medial approach after medial malleolar chevron osteotomy. The second screw is inserted from anteriorly to posteriorly (perpendicular to the fracture line) using an anterolateral approach. Both screw heads should be countersunk. A series of 8 patients underwent this form of internal fixation for talar neck fracture repair, with satisfactory functional outcomes. In conclusion, the use of antegrade-retrograde opposing lag screws is a reasonable method of internal fixation for simple displaced talar neck fractures.

Fractures of the talus

The talus is the most proximal bone of the hindfoot that couples the foot to the leg. It is the second most common fracture of the tarsal bones, second in frequency to the calcaneous. However, overall injuries to the talus are relatively rare, and most surgeons have little experience in managing them. This article discusses fractures of the talus, including injuries to the talar neck, body, head, and processes. Although subtalar dislocations and osteochondral injuries are important topics, they are not addressed in this article.

Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases

INTRODUCTION

Displaced talar neck and body fractures are rare and challenging for the surgeon. Results are often disappointing due to inadequate reduction or internal fixation and high rates of osteoarthritis and osteonecrosis. Very few published series describe the long-term results after internal fixation of talar factures. One of the goals of the 2011 SOO meeting symposium was to specifically evaluate the long-term results after internal fixation of talar fractures. This study included only central fractures.

MATERIAL AND METHODS

We reviewed the results of 114 central talar fractures that had been treated by internal fixation between 1982 and 2006 in nine hospitals in the Western part of France. The clinical and radiological follow-up was 111 months on average. All the patients with a radiological assessment had at least 5 years of follow-up.

RESULTS

Poor reduction was apparent in 33% of cases. The average Kitaoka score was 70/100, which corresponds to an average functional level. At the last follow-up evaluation, 34% of cases had osteonecrosis and 74% had peritalar osteoarthritis. Secondary fusion was required in 25% of cases with an average follow-up of 24 months.

DISCUSSION

The complication rate for talar fractures was high, mostly due to osteonecrosis and osteoarthritis; these conditions had an impact on the final outcome. The outcome could be improved by better evaluating these fractures with a CT scan, developing dual surgical approaches to best preserve the bone vascular supply and achieve better reduction, and improving the internal fixation hardware, especially the use of plates for comminuted fractures.

Secondary correction of talar fractures: asking for trouble?

Secondary anatomical reconstruction of malunions or nonunions after talar fractures or fracture-dislocations with preservation of all three joints aims at maximal functional rehabilitation. A corrective osteotmy or revision of a pseudoarthrosis with axial realignment and internal fixation was carried out in 22 patients (aged 15 to 50) at a mean of 9 (range, 1.5 to 45) months after having sustained a fracture of the talar head, neck or body. 20 patients were followed for a mean of 4.8 (range, 1.5 to 14) years after reconstruction. No signs of development or progression of avascular necrosis (AVN) were observed in any case. Some amount of progression of peritalar arthritis was seen in 12 of 20 patients (60%). One patient required ankle fusion 7.5 years after reconstruction, another patient needed talo-navicular fusion after 5 years, and a third required a two-stage fusion of the ankle and the subtalar joint after 18 months. Two patients underwent arthrolysis of the ankle and screw removal after 7 and 14 years for dorsiflexion deficit at the ankle. The mean AOFAS ankle/hindfoot score increased from 36.9 preoperatively to 87.5 after correction (p < 0.001). Secondary correction after talar fractures appears promising in active and compliant patients without symptomatic arthritis, with good bone stock, no or partial AVN (less than one-third of the talar body), and no infection. Late fusion with a well-aligned talus remains a salvage option in cases of progressive arthritis.

Osteosynthesis of talar body shear fractures assisted by hindfoot and subtalar arthroscopy: technique tip

Level of Evidence: V, Expert Opinion

[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.

Management of talar neck fractures

Talar neck fractures are usually the result of high-energy trauma. It remains controversial whether talar neck fractures require emergent treatment. Most surgeons recommend the use of dual surgical approaches, anteromedial and anterolateral, to allow accurate visualization and anatomic reduction. It is important to carefully preserve any remaining talar blood supply. Obtaining satisfactory clinical results, while avoiding complications, presents a unique challenge in the treatment of talar neck fractures. Common complications include posttraumatic arthritis, avascular necrosis, malunion, and nonunion.

Partial avascular necrosis after talar neck fracture

BACKGROUND

Recently, it has been shown that avascular necrosis of the talus can occur in only a portion of the talar body. There is little information regarding the geographic location of the avascular segment and the clinical significance of an incomplete avascular process.

METHODS

Seven patients with partial avascular necrosis after Hawkins type II or III fracture dislocations were evaluated with magnetic resonance scans. The precise anatomic location of the avascular segment was determined and assigned to a specific quadrant of the talar body. The operative exposure, incidence of collapse, and time to operative intervention was recorded.

RESULTS

The avascular segment of the talar body was located predominantly in the anterior lateral and superior portion in six of the seven patients. Collapse occurred in three of the patients in the area of avascular process. There were no observable trends with regard to operative exposure, Hawkins classification, incidence of collapse, or time to operative intervention to the location of the avascular segment.

CONCLUSION

Partial avascular necrosis can occur after fracture dislocation of the talus. The predominant location of the avascular segment was the anterior lateral and superior portion of the talar body. This observation corresponds to regional damage to the blood supply of the talus and may help clarify the pathogenesis of partial avascular process.

Talar neck and body fractures

Fractures of the talar neck and body are rare and serious injuries. The vast majority are either intra-articular or lead indirectly to an intra-articular incongruity through a dislocation at the talar neck. Because of the high energy needed to produce talar fractures, they are frequently seen in multiply injured and polytraumatised patients. Open fractures and fracture-dislocations are treated as emergencies. Preoperative planning of definite internal fixation requires CT scanning. To obtain a complete intra-operative overview allowing for anatomical reconstruction of the articular surfaces and the axial deviation bilateral approaches are usually necessary. Internal fixation is achieved with screws or mini-plates supplemented by temporary K-wire transfixation in cases of marked additional ligamentous instability. The clinical outcome after talar neck and body fractures is determined by the severity of the injury and the quality of reduction and internal fixation. The timing of definite internal fixation does not appear to affect the final result. The rates of avascular necrosis (AVN) correlate with the degree of initial dislocation. Only total AVN with collapse of the talar body leads to inferior results with the need for further surgery whilst prolonged immobilisation or offloading of the affected foot is not indicated for partial AVN. Talar malunions and non-unions after inadequate treatment of displaced fractures are debiliating conditions that should be treated by surgical correction. Treatment options include corrective osteotomy by recreating the former fracture with secondary fixation, free or vascularised bone grafting and salvage by realignment and fusion of the affected joint(s).

Talus fractures: surgical principles

Surgical treatment of talus fractures can challenge even the most skilled foot and ankle surgeon. Complicated fracture patterns combined with joint dislocation of variable degrees require accurate assessment, sound understanding of principles of fracture care, and broad command of internal fixation techniques needed for successful surgical care. Elimination of unnecessary soft tissue dissection, a low threshold for surgical reduction, liberal use of malleolar osteotomy to expose body fracture, and detailed attention to fracture reduction and joint alignment are critical to the success of treatment. Even with the best surgical care complications are common and seem to correlate with injury severity and open injuries.

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.

Bone stress injury of the ankle in professional ballet dancers seen on MRI

Background

Ballet Dancers have been shown to have a relatively high incidence of stress fractures of the foot and ankle. It was our objective to examine MR imaging patterns of bone marrow edema (BME) in the ankles of high performance professional ballet dancers, to evaluate clinical relevance.

Methods

MR Imaging was performed on 12 ankles of 11 active professional ballet dancers (6 female, 5 male; mean age 24 years, range 19 to 32). Individuals were imaged on a 0.2 T or 1.5 T MRI units. Images were evaluated by two musculoskeletal radiologists and one orthopaedic surgeon in consensus for location and pattern of bone marrow edema. In order to control for recognized sources of bone marrow edema, images were also reviewed for presence of osseous, ligamentous, tendinous and cartilage injuries. Statistical analysis was performed to assess the strength of the correlation between bone marrow edema and ankle pain.

Results

Bone marrow edema was seen only in the talus, and was a common finding, observed in nine of the twelve ankles imaged (75%) and was associated with pain in all cases. On fluid-sensitive sequences, bone marrow edema was ill-defined and centered in the talar neck or body, although in three cases it extended to the talar dome. No apparent gender predilection was noted. No occult stress fracture could be diagnosed. A moderately strong correlation (phi = 0.77, p= 0.0054) was found between edema and pain in the study population.

Conclusion

Bone marrow edema seems to be a specific MRI finding in the talus of professional ballet dancers, likely related to biomechanical stress reactions, due to their frequently performed unique maneuvers. Clinically, this condition may indicate a sign of a bone stress injury of the ankle.

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.

A specific bone marrow edema around the foot and ankle following trauma and immobilization therapy: pattern description and potential clinical relevance

BACKGROUND

We describe a characteristic pattern of bone marrow edema about the foot and ankle seen by MRI in patients who have undergone recent immobilization therapy and investigate potential etiologies as well as possible clinical significance.

METHODS

Three reviewers retrospectively evaluated 52 ankle MRI examinations in 18 patients with abnormal signals compatible with bone marrow edema who had been treated with various types and durations of immobilization of the lower limb after traumatic injury. Bone marrow edema patterns were characterized by distribution, extent, location, and interval evolution or resolution on subsequent followup MRI examination. These MRI findings were then correlated with clinical history, symptomatology and treatment regimens.

RESULTS

All patients had a characteristic pattern of bone marrow edema about the foot and ankle predominating in subchondral, subcortical, and subenthesial locations. The occurrence of this edema pattern was most often noted on MRI within the first 12 weeks after completion of immobilization therapy or resumption of partial or full weightbearing and did not correlate well with new symptomatology or pain. In patients with protracted imaging followup, the bone marrow edema ultimately resolved and was not associated with reported setbacks in recovery course or unexpected delays in restoration of function. All MRI examinations performed more than 18 weeks after the immobilization period showed resolution or stabilization of bone marrow signal, with no continued evolution. No patient had a clinical picture suspicious for reflex sympathetic dystrophy.

CONCLUSIONS

A distinctive pattern of bone marrow edema on MRI of the foot and ankle can be seen on MRI after a variety of weightbearing and nonweightbearing immobilization therapies. This pattern has a consistent appearance on MRI and does not seem to be related to clinical symptomatology. At present, no substantial conclusions can be made regarding the etiology of this phenomenon. However, these bone marrow signal alterations should not mandate further imaging or a change in therapy on the basis of MRI findings alone.

Imaging of the talus

There are numerous options for imaging talar pathology. Of these, radiography, CT, scintigraphy, and MRI are used most commonly. Advantages and limitations of these techniques should be considered when formulating an imaging algorithm for evaluation of the patient's clinical problem.

Osteonecrosis of the talus

Talar osteonecrosis remains partially understood and a clinical challenge. Further research is necessary to elucidate the etiology, pathophysiology, and true incidence of this complex disorder fully. Optimal imaging strategies and staging systems also require further investigation. As our understanding of talar osteonecrosis evolves, so will our ability to treat this disorder promptly and properly.

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.

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.

Surgical treatment of talar body fractures

BACKGROUND

Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment.

METHODS

Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed.

RESULTS

Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores.

CONCLUSIONS

Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

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.

MRI assessment of the proximal pole of the scaphoid after internal fixation with a titanium alloy Herbert screw

We report a series of scaphoid fractures fixed with titanium alloy Herbert screws in which postoperative Magnetic Resonance Imaging (MRI) was used to assess the marrow signal in the proximal pole of the scaphoid and thus detect the presence of avascular necrosis. The artefact produced by the titanium alloy Herbert screw did not preclude this assessment.

Subtendinous bone marrow edema patterns on MR images of the ankle: association with symptoms and tendinopathy

OBJECTIVE

We sought to describe a pattern of subtendinous bone marrow edema on MR images of the ankle and to determine if there is an association with location of symptoms and overlying tendinopathy.

MATERIALS AND METHODS

At 1.5 T, 141 MR examinations of the ankle (116 clinical examinations of patients with chronic pain, 25 of asymptomatic control patients) were performed using T1-weighted, proton density-weighted fast spin-echo, and T2-weighted fat-suppressed fast spin-echo sequences. Images were retrospectively reviewed by two musculoskeletal radiologists for presence of bone marrow edema occurring in a subcortical location associated with the course of the medial or lateral tendon groups, as well as focal thickening or increased T2 signal within the tendons. These findings were correlated with clinical information regarding symptom location. The association of subtendinous marrow edema with tendinopathy and symptom location was statistically analyzed.

RESULTS

Subtendinous bone marrow edema was present at 26 sites on 24 ankle MR examinations (17%) (at the medial malleolus [n = 17] associated with the posterior tibialis tendon, at the lateral malleolus [n = 6] and the calcaneus [n = 2] associated with the peroneus longus and brevis tendons, and at the cuboid [n = 1] associated with the peroneus longus tendon). These subtendinous bone marrow edema patterns were significantly associated with overlying tendon abnormality medially (p = 0.001) and laterally (p = 0.001), and with symptoms medially (p = 0.0016) but not laterally (p = 0.078).

CONCLUSION

On MR images of the ankle, bone marrow edema localized in a subtendinous location is associated with overlying tendinopathy medially and laterally and with ankle pain medially.

Talus fractures: evaluation and treatment

Fractures of the talus are uncommon. The relative infrequency of these injuries in part accounts for the lack of useful and objective data to guide treatment. The integrity of the talus is critical to normal function of the ankle, subtalar, and transverse tarsal joints. Injuries to the head, neck, or body of the talus can interfere with normal coupled motion of these joints and result in permanent pain, loss of motion, and deformity. Outcomes vary widely and are related to the degree of initial fracture displacement. Nondisplaced fractures have a favorable outcome in most cases. Failure to recognize fracture displacement (even when minimal) can lead to undertreatment and poor outcomes. The accuracy of closed reduction of displaced talar neck fractures can be very difficult to assess. Operative treatment should, therefore, be considered for all displaced fractures. Osteonecrosis and malunion are common complications, and prompt and accurate reduction minimizes their incidence and severity. The use of titanium screws for fixation permits magnetic resonance imaging, which may allow earlier assessment of osteonecrosis; however, further investigation is necessary to determine the clinical utility of this information. Unrecognized medial talar neck comminution can lead to varus malunion and a supination deformity with decreased range of motion of the subtalar joint. Combined anteromedial and anterolateral exposure of talar neck fractures can help ensure anatomic reduction. Posttraumatic hindfoot arthrosis has been reported to occur in more than 90% of patients with displaced talus fractures. Salvage can be difficult and often necessitates extended arthrodesis procedures.

Talar body fractures

Fractures to the body of the talus include a wide array of injuries, varying from relatively minor posterior tuberosity fractures to devastating comminuted body fractures. Fracture types include osteochondral fractures, sagittal transverse or coronal whole-body fractures, posterior tubercle fractures, lateral process fractures, and crush injuries. Treatment varies from excision of small fragments, such as arthroscopic treatment of osteochondral injuries, to open reduction and internal fixation of body fractures, usually by a medial malleolar osteotomy. Prognosis logically correlates with the magnitude of the injury with whole-body fractures, especially crush injuries, having the worst prognosis. Talar body fractures, similar to talar neck fractures, also can be complicated by subtalar arthritis, ankle arthritis, malunion, and avascular necrosis.

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.

Treatment of talar neck fractures: clinical results of 50 patients

Fractures of the neck and body of the talus present as one of the most challenging and rare injuries. These fractures are often associated with other ankle, foot, and skeletal injuries, which complicate their treatment. The clinical course of 50 patients with a mean age of 29 years with a severe talus fracture between 1992 and 1997 is presented. According to the Hawkins classification there were 16 (32%) of type I, 14 (28%) of type II, 9 (18%) of type III, and 11 (22%) of type IV. Forty-three patients (86%) underwent operative treatment: 27 (63%) by open reduction and internal fixation with screws, seven (16%) by external fixation, five (12%) with percutaneous screws, and four (9%) by closed reduction with K-wire fixation. Mild osteoarthritis of the talocrural joint was seen in 14 patients (28%) and severe osteoarthritis in 10 patients (20%), five of whom required subsequent arthrodesis of the ankle joint. Arthrodesis of the subtalar joint was observed in 4 cases. Avascular necrosis with collapse of the talar body was seen in four patients (8%). The function of the ankle joint was evaluated according to the Weber score. Patients with talus fractures of Hawkins' type I and II had considerably better outcomes (with 95% being excellent or good) than individuals suffering dislocated fractures with involvement of the articulating surface with 70% good results in Hawkins' type III and 10% good results in Hawkins' type IV fractures. For the evaluation of the vitality of the talus body in cases with titanium implants, the authors used magnetic resonance imaging and intraosseous phlebography in cases with stainless steel implants. The displaced talus fractures must be treated by closed and, if necessary, open reduction with internal fixation. The initial postoperative management should consist of ambulation without weightbearing until radiographic appearance of trabecular bone in the fracture zone, indicating revascularization, can be manifested.