Talus Fractures: Evaluation and Treatment

Evaluation of the horizontal approach to the medial malleolar facet in sagittal talar fractures through dorsiflexion and plantarflexion positions

BACKGROUND

Talar fractures often require osteotomy during surgery to achieve reduction and screw fixation of the fractured fragments due to limited visualization and operating space of the talar articular surface. The objective of this study was to evaluate the horizontal approach to the medial malleolus facet by maximizing exposure through dorsiflexion and plantarflexion positions.

METHODS

In dorsiflexion, plantarflexion, and functional foot positions, we respectively obtained the anterior and posterior edge lines of the projection of the medial malleolus on the medial malleolar facet. The talar model from Mimics was imported into Geomagic software for image refinement. Then Solidworks software was used to segment the medial surface of the talus and extend the edge lines from the three positions to project them onto the "semicircular" base for 2D projection. The exposed area in different positions, the percentage of total area it represents, and the anatomic location of the insertion point at the groove between the anteroposternal protrusions of the medial malleolus were calculated.

RESULTS

The mean total area of the "semicircular" region on the medial malleolus surface of the talus was 542.10 ± 80.05 mm2. In the functional position, the exposed mean area of the medial malleolar facet around the medial malleolus both anteriorly and posteriorly was 141.22 ± 24.34 mm2, 167.58 ± 22.36mm2, respectively. In dorsiflexion, the mean area of the posterior aspect of the medial malleolar facet was 366.28 ± 48.12 mm2. In plantarflexion, the mean of the anterior aspect of the medial malleolar facet was 222.70 ± 35.32 mm2. The mean overlap area of unexposed area in both dorsiflexion and plantarflexion was 23.32 ± 5.94 mm2. The mean percentage of the increased exposure area in dorsiflexion and plantarflexion were 36.71 ± 3.25% and 15.13 ± 2.83%. The mean distance from the insertion point to the top of the talar dome was 10.69 ± 1.24 mm, to the medial malleolus facet border of the talar trochlea was 5.61 ± 0.96 mm, and to the tuberosity of the posterior tibiotalar portion of the deltoid ligament complex was 4.53 ± 0.64 mm.

CONCLUSIONS

Within the 3D model, we measured the exposed area of the medial malleolus facet in different positions and the anatomic location of the insertion point at the medial malleolus groove. When the foot is in plantarflexion or dorsiflexion, a sufficiently large area and operating space can be exposed during surgery. The data regarding the exposed visualization area and virtual screws need to be combined with clinical experience for safer reduction and fixation of fracture fragments. Further validation of its intraoperative feasibility will require additional clinical research.

Three-dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures

OBJECTIVE

The talus is an important component in the ankle, and its treatment after injury is crucial. However, complications and adverse events due to incomplete traditional classifications may still occur, and these classifications fail to analyze the patterns and distribution of fractures from a three-dimensional perspective. Therefore, in this study, we aimed to analyze the location and distribution of fracture lines in different types of talus fractures using three-dimensional (3D) and heat mapping techniques. Additionally, we aimed to determine the surface area of the talus that can be utilized for different approaches of internal fixation, aiding in the planning of surgical procedures.

METHODS

We retrospectively analyzed data from CT scans from 126 patients diagnosed with talus fractures at our two hospitals. We extracted the CT data of a healthy adult and created a standard talus model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization. Additionally, we measured 20 specimens to determine the boundary for various ligaments attached to the talus. We determined the surface area of the talus available for different surgical approaches by integrating the boundary data with previously reported data on area of exposure.

RESULTS

Without considering the displacement distance of the fracture, fracture types were classified as follows, by combining Hawkins and Sneppen classifications: talar neck, 41.3%; posterior talar tubercle, 22.2%; body for the talus and comminuted, 17.5%; lateral talar tubercle, 11.9%; and talar head, 7.1%. We established fracture line and heat maps using this classification. Additionally, we demonstrated the available area for anteromedial, anterolateral, posteromedial, posterolateral, and medial malleolus osteotomy and Chaput osteotomy approaches.

CONCLUSION

Fracture line and heat map analyses can aid surgeons in planning a single or combined surgical approach for the reduction and internal fixation of talus fractures. Demonstrating the different surgical approaches can help surgeons choose the most effective technique for individual cases.

Infection Rates and Surgical Procedures Associated With Isolated Open Talar Neck and Body Fractures

BACKGROUND

Open fractures of the talar body and neck are uncommon. Previous reports of associated deep infection rates and resulting surgical requirements vary widely. The primary objective of this study is to report the incidence of deep infections for isolated open talar body and neck fractures, and secondarily the incidence and number of total surgeries performed (TSP), secondary salvage procedures (SSPs), and nonsalvage procedures (NSPs).

METHODS

Retrospective case-control study of 32 consecutive isolated open talus fracture patients (22 neck, 10 body) were followed for an average of 39.2 months.

RESULTS

Five (15.6%) fractures developed deep infections. Fifty percent of open body fractures became infected compared with 0% of neck fractures (P < .001). There was no difference between infected group (IG) and uninfected fracture group (UG) with respect to age, sex, body mass index, tobacco, diabetes, vascular disease, open fracture type, wound location, hours to irrigation and debridement, or definitive treatment. The majority (92.6%) of UG fractures used a dual incision with open wound extension. There were more single extensile approaches in the IG group (P = .04). The IG required 5.8 TSP per patient compared with 2.1 in the UG (P = .004). All (100%) of the IG required an SSP compared with 29.6% of the UG (P = .006). All (100%) of the IG required an NSP compared to 40.7% of the UG (P = .043). In the IG, 2.8 NSPs per patient were required after definitive surgery compared with 1.18 in the UG (P = .003). Of those followed 1 year, the incidence of SSP remained higher in the IG (P = .016).

CONCLUSION

The incidence of deep infection following isolated open talar fractures is high and occurs disproportionally in body fractures. Infected fractures required nearly 6 surgeries, and all required SSP.

LEVEL OF EVIDENCE

Level IV, prognostic.

Parameters That Can Be Used to Quantify Reduction Accuracy in Talar Neck Fractures and Malunions: A PRISMA-Compliant Scoping Review and Meta-Analysis

Understanding the three-dimensional anatomy of the talar neck is essential in assessing the accuracy of reduction in talar neck fractures as well as for planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. We aimed to identify from the existing literature, geometrical parameters that describe the anatomy of the talar neck, determine how these are measured, and their normative values. A scoping literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. The primary searches were conducted on the PubMed, Embase, and Scopus databases. Any original research study looking at the human talus neck geometry was included. Parameters that described the anatomy of the talar neck were identified, and pooled estimates were determined by the random-effects meta-analysis model. Heterogeneity was assessed by the I2 test and leave-one-out meta-analysis. Subgroup analysis was done to compare the values of parameters between the Asian and Non-Asian populations. The risk of bias was assessed by the National Institutes of Health (NIH) Case Series Tool. The combined searches yielded 6326 results, of which 21 studies were included in the review and 15 in six different sets of metanalysis. The majority of the studies (n=19, 90.5%) evaluated adult tali, and only two (9.5%) evaluated pediatric tali. In most of the studies (n=13, 61.9%), talus neck geometry was evaluated on dry bones or anatomical specimens; evaluation by imaging techniques (radiographs, CT, MRI, and radiostereometric analysis) was used in eight studies, (39.1%). A total of eight different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Although the literature reports geometrical parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Most of the available literature describes measurement techniques on cadaveric tali, and there is no literature on how these parameters should be measured on conventional CT or MRI slices. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

Pathological progress and remission strategies of osteoarthritic lesions caused by long-term joint immobilization

OBJECTIVE

While joint immobilization is a useful repair method for intra-articular ligament injury and periarticular fracture, prolonged joint immobilization can cause multiple complications. A better understanding how joint immobilization and remobilization impact joint function and homeostasis will help clinicians develop novel strategies to reduce complications.

DESIGN

We first determined the effects of long-term immobilization on joint pain and osteophyte formation in patients after an extraarticular fracture or ligament injury. We then developed a mouse model of joint immobilization and harvested the knee joint samples at 2, 4, and 8 weeks. We further determined the effects of remobilization on recovery of the osteoarthritis (OA) lesions induced by immobilization in mice.

RESULTS

We found that the long-term (6 weeks) joint immobilization caused significant joint pain and osteophytes in patients. In mice, 2-week immobilization already induced moderate sensory innervation and increased pain sensitivity and infiltration in synovium without inducing marked osteophyte formation and cartilage loss. Long-term immobilization (4 and 8 weeks) induced more severe sensory innervation and inflammatory infiltration in synovium, massive osteophyte formation on both sides of the femoral condyle, and the edge of the tibial plateau and significant loss of the articular cartilage in mice. Remobilization, which ameliorates normal joint load and activity, restored to certain extent some of the OA lesions and joint function in mice.

CONCLUSIONS

Joint immobilization caused multiple OA-like lesions in both mice and humans. Joint immobilization induced progressive sensory innervation, synovitis, osteophyte formation, and cartilage loss in mice, which can be partially ameliorated by remobilization.

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.

Clinical Potential of Cellular Material Sources in the Generation of iPSC-Based Products for the Regeneration of Articular Cartilage

Inflammatory joint diseases, among which osteoarthritis and rheumatoid arthritis are the most common, are characterized by progressive degeneration of the cartilage tissue, resulting in the threat of limited or lost joint functionality in the absence of treatment. Currently, treating these diseases is difficult, and a number of existing treatment and prevention measures are not entirely effective and are complicated by the patients' conditions, the multifactorial nature of the pathology, and an incomplete understanding of the etiology. Cellular technologies based on induced pluripotent stem cells (iPSCs) can provide a vast cellular resource for the production of artificial cartilage tissue for replacement therapy and allow the possibility of a personalized approach. However, the question remains whether a number of etiological abnormalities associated with joint disease are transmitted from the source cell to iPSCs and their chondrocyte derivatives. Some data state that there is no difference between the iPSCs and their derivatives from healthy and sick donors; however, there are other data indicating a dissimilarity. Therefore, this topic requires a thorough study of the differentiation potential of iPSCs and the factors influencing it, the risk factors associated with joint diseases, and a comparative analysis of the characteristics of cells obtained from patients. Together with cultivation optimization methods, these measures can increase the efficiency of obtaining cell technology products and make their wide practical application possible.

History of the management of talar fractures: from the fall of king Darius to Garibaldi's bullet and from the earliest to current operative strategies

PURPOSE

This historical review aims to highlight the important roles of the talus in antiquity and to summarise the multiple attempts of managing talar fractures throughout history.

METHOD

Archaeological, religious, artistic, literary, historical and scientific accounts were searched for the descriptions of talus fractures in different eras and their treatments to provide a thorough analysis of the evolution of trauma care up to the present.

RESULTS

This review shows how the talus has always had an important role in several societies: it was used as a die or considered to have a divinatory function in Mesopotamian civilisations, among Greeks and Romans, in Mongolia and in pre-Columbian Americas. Famous talus fractures are recorded in Herodotus' Histories and in the Acts of the Apostles. We report the earliest injuries described and the first operative managements between 1600 and 1800, including the one that saved Garibaldi's life in 1862, until the modern osteosynthesis by the first screws and nails and the current fixation by plating.

CONCLUSION

The blooming of orthopaedic surgery at the end of nineteenth century and the high volume of traumas managed in the World Wars brought a better understanding of fracture patterns and their operative treatment. By the work of Hawkins and his classification, the introduction of the CT scan, a better knowledge of injury modalities and bone vascularisation, these challenging injuries finally land in the contemporary era without mysteries. The subsequently developed surgical procedures, although not guaranteeing success, greatly reduce the risk of necrosis and complication rate, improving patient outcomes.

Epidemiology, classification, treatment and mortality of Talus fractures: An observational study of 1794 talus fractures from the Swedish Fracture Register

BACKGROUND

Epidemiological data on talus fractures from large nationwide and multicenter studies are rare. This study aims to describe the epidemiology, fracture classification and treatment regimens of talus fractures in a large adult Swedish population.

METHODS

This observational study is based on data from the Swedish Fracture Register (SFR) including talar fractures in patients ≥18 with a sustained fracture between 2012 and 2021. Epidemiological data on sex, age, injury date, injury mechanism and type (high or low energy trauma), fracture classification (side, type), initial treatment and mortality were analysed.

RESULTS

We included 1794 talus fractures (1757 patients, 60 % men). Mean age was 40.3 years (range 18-96), and a biphasic age distribution was seen in women. High-energy trauma caused 33 % of all talus fractures. Of all talus fractures, 817 (45.5 %) were classified as AO/OTA type A fractures (avulsion), 370 (20.6 %) as type B (neck) and 435 (24.2 %) as type C (body). The remaining 172 (9.6 %) talus fractures were not classified/unclassifiable. Men were in the majority in all fracture groups except A1. For type A1-3, B1 and C1-2 fractures, most patients were treated non-operatively; in B2-3 and C3 fractures most patients received operative management. Fracture fixation with screws was the dominating surgical treatment. The overall 30-day mortality was 0.2 %.

CONCLUSION

Talus fractures are most commonly encountered in young and middle-aged men. In contrast to men, a biphasic age distribution was observed in women. Approximately half of the talus fractures are avulsions. Operative treatment, mostly screw fixation, is performed in more complex fracture configurations (B2, B3 and C3 fractures).

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

[Short-term effectiveness of TiRobot combined with O-arm navigation system in minimally invasive treatment of hindfoot fracture]

OBJECTIVE

To investigate the short-term effectiveness of TiRobot combined with O-arm navigation system in the minimally invasive treatment of hindfoot fracture.

METHODS

Between March 2019 and March 2021, 25 patients with hindfoot fractures were admitted. There were 14 males and 11 females, with an average age of 51.7 years (range, 19-76 years). The causes of injuries included falling from height in 17 cases and traffic accident in 8 cases. The interval between injury and operation was 1-3 days (mean, 2.1 days). There were 16 cases of calcaneus fracture, 7 cases of talus fracture, and 2 cases of calcaneus and talus fractures. According to Sanders classification criteria, the calcaneus fractures were classified as type Ⅱ in 10 cases and type Ⅲ in 8 cases; according to the Hawkins classification criteria, the talus fractures were classified as type Ⅱ in 4 cases and type Ⅲ in 5 cases. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 48.1±9.1. During operation, the fractures were fixed with the percutaneous cannulated screws with the assistance of the TiRobot combined with the O-arm navigation system. The operation time, hospital stay, and the occurrence of related complications were recorded. X-ray films were reviewed to evaluate the fracture healing and the occurrence of talus osteonecrosis, and the width, length, height, Böhler's angle, and Gissane's angle of the calcaneus were measured; AOFAS ankle-hindfoot score was used to evaluated the foot function.

RESULTS

The operation time ranged from 47 to 71 minutes (mean, 60.5 minutes). The length of hospital stay ranged from 2 to 5 days (mean, 3.4 days). All incisions healed by first intention. All patients were followed up 12-24 months (mean, 17.3 months). One patient demonstrated hypoesthesia on the lateral side of foot after operation and recovered after symptomatic treatment. All fractures healed confirmed by X-ray films and the healing time ranged from 10 to 16 weeks (mean, 11.8 weeks). No talus osteonecrosis occurred during follow-up. There were significant differences in the width, length, height, Böhler's angle, and Gissane's angle of the calcaneus between pre-operation and at last follow -up ( P<0.05). At last follow-up, AOFAS ankle-hindfoot score was 91.2±5.0, the difference was significant when compared with preoperative score ( t=22.169, P<0.001). The results were excellent in 16 cases and good in 9 cases, with an excellent and good rate of 100%.

CONCLUSION

TiRobot combined with O-arm navigation system for minimally invasive treatment of hindfoot fractures can obtain the satisfactory short-term effectiveness, with the advantages of less surgical trauma, precise fixation, and fewer complications.

Posteromedial Talar Body Fracture: Case Discussion and Surgical Technique

Posteromedial talar body fractures are a rare form of talus fracture that involves the tibiotalar and subtalar joints. In cases of displaced injuries, open reduction and internal fixation is typically recommended to minimize the risk of instability and post-traumatic osteoarthritis. This video presents a case of a posteromedial talar body fracture and highlights the technique for operative fixation through a posteromedial approach. Multiple methods to obtain reduction are discussed, and considerations with implant placement are described. The indications for surgical intervention are reviewed, and published outcomes following operative and nonoperative management of these injuries are presented.

Total Talar Replacement With Custom-Made Vitallium Prosthesis for Talar Avascular Necrosis

Background: The current study investigated the application of three-dimensional (3D) printing technology in the treatment of talar avascular necrosis (TAN). Custom-made Vitallium talar prostheses were designed and generated via 3D printing. We hypothesized that these talar prostheses would facilitate more stable positioning, better ergonomically fit the ankle joint surfaces, and promote favorable long-term prognoses. Material and Methods: Computed tomography scans of both ankle joints were acquired from three patients diagnosed with TAN. The talar on the unaffected side was used as the design blueprint. Hence, with the aid of 3D printing technology a customized talar prosthesis made from a novel Vitallium alloy could be manufactured for each individual patient. Results: In all three cases there were no signs of prosthesis loosening or substantial degenerative change in the surrounding area of the joint, but small osteophytes were observed on the tibial side and navicular side. No chronic infection or other prosthesis-related complications were observed in any of the patients. All three were able to walk without pain at the most recent follow-up. Conclusion: With the aid of 3D printing and a novel Vitallium alloy, total talar replacement achieved encouraging results in 3/3 patients. All patients were satisfied with their joint function, and were able to return to their daily activities without limitations. Although more cases and longer-term follow-up periods are required, the success rate reported herein is encouraging.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

The hindfoot consists of the talus and calcaneus, spans the tibiotalar to transverse tarsal joints, and is critical for support of body weight and absorption and transfer of physiologic loads during bipedal movements. Hindfoot fractures account for approximately 17% of foot and ankle fractures, with calcaneal fractures being more common than talar fractures. Hindfoot fractures are usually caused by high-impact axial loads such as falls from heights and motor vehicle accidents, and understandably, they are often seen in patients with polytrauma. Long term, these fractures have implications in development of posttraumatic osteoarthrosis with associated pain and stiffness, affecting daily living activities. An overview of the talus and calcaneus is presented, with emphasis on fractures with articular involvement-namely, the tibiotalar and subtalar joints. Articular talar and calcaneal injuries can also alter hindfoot alignment, causing ankle and foot function abnormalities. Optimal treatment-that is, restoration of articular surfaces and hindfoot alignment followed by rigid fixation until fracture union-is dependent on an accurate understanding of the injury that is well depicted with imaging, radiography and CT in particular. The discussion of talar and calcaneal fractures includes a review of the normal anatomy, epidemiologic factors, classification systems, and imaging and pathologic-anatomic features of common injury patterns. This review is intended to aid surgical management and restoration of articular and hindfoot alignment for optimal ankle and foot function, thereby reducing patient morbidity in these often devastating injuries. ^©RSNA, 2022.

Talar Dome Access Through Posteromedial Surgical Intervals for Fracture Care

BACKGROUND

Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction.

METHODS

Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro-computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals.

RESULTS

The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02).

CONCLUSION

The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially.

LEVEL OF EVIDENCE

Level V, Cadaveric Study.

Osteopenia in Scaphoid Fracture: An Indicator of Good Prognosis or Is it Cause for Concern?: A Case Report

CASE

A 32-year-old man sustained a scaphoid waist fracture and was managed nonoperatively in a short-arm cast. Radiographic follow-up at 6 weeks showed marked loss of radiodensity of the whole scaphoid, although the fracture was clinically united. Patchy ossification at 3 months was followed by the complete restoration of radiodensity and trabecular pattern by 20 weeks. The patient had an uneventful and full functional recovery.

CONCLUSION

This, perhaps unreported, finding seems to be an indicator of preserved vascularity in scaphoid fractures. Further research/reporting of this radiological pattern in these fractures will help improve their understanding and management.

Mapping of Posterior Talar Dome Access Through Posteromedial Versus Posterolateral Approaches

OBJECTIVE

To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction.

METHODS

A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals.

RESULTS

The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach.

CONCLUSION

The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.

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.