Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.

Seventy-one fractures through the neck of the talus were clinically evaluated and classified on the basis of roentgenographic appearance. The follow-up interval averaged 12.7 years. Good or excellent results were achieved in 59 per cent of the fractures. Accurate anatomical reduction of displaced fractures, if necessary by open reduction and internal fixation, is recommended. Avascular necrosis of the talar body occurred in 52 per cent of the fractures (in two of thirteen non-displaced fractures, in half of the fractures with subluxation or dislocation of the subtalar joint, and in sixteen of nineteen fractures with complete dislocation of the body of the talus). Many patients with avascular necrosis treated conservatively had satisfactory results. The complications of avascular necrosis, malunion, subtalar arthritis, and infection required twenty-five secondary procedures. Triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.     

Prognosis of fracture of the talus in children: 21 (7-34)-year follow-up of 14 cases

14 children suffering from a fracture of the talar neck or body were examined after 21 (7-34) years. The talar neck was fractured in 10 children and the talar body in 4. 3 fractures were displaced and primarily treated with reduction and immobilization. Nondisplaced fractures were treated conservatively. All fractures healed. All patients with displaced fractures had exercise-induced pain at follow-up. Of 11 patients with nondisplaced fractures only 1 had minor complaints.

CT and conventional radiographs showed arthrosis in the talocrural joint and normal subtalar joints in those with displaced fractures. The radio- graphic findings were normal after nondisplaced fractures.     

An unusual fracture of the talus associated with a bimalleolar ankle fracture. A case report and review of the literature

A 53-year-old man sustained a fall from 1.25 m, injuring his hindfoot and ankle. Roentgenographic examination demonstrated a displaced vertical fracture through the neck of the talus with dislocation at the subtalar and tibiotalar joints (Hawkins Group III) and an ipsilateral bimalleolar fracture. Prompt anatomic reduction of the talus and bimalleolar fracture with rigid internal fixation was performed. Roentgenograms three years postinjury confirmed solid union of all fractures. Avascular necrosis of the talus had not occurred. Minimally disabling post-traumatic arthritis as both the ankle and subtalar joints was the only sequela. Only four similar injuries seem to have been reported previously in the literature. Despite the generally high incidence of avascular necrosis in Hawkins Group III talar neck fractures, none of these four cases developed this complication. A possible explanation is that with the presence of ipsilateral bimalleolar fracture, there is preservation of the extraosseous vascular supply that accompanies the deltoid and talofibular ligamentous complexes.     

Talar neck fracture associated with talonavicular dislocation and fracture of posteromedial process of talus

Canale and Kelly modified the Hawkins classification of talar neck fractures by adding a type IV fracture dislocation to the original 3 types described. Type IV injury occurs rarely and is the only type involving dislocation of the talonavicular joint. To our knowledge, only 2 unusual cases have been described in published studies in which a fracture of neck of the talus occurred in association with talonavicular dislocation but the ankle and subtalar joints remained intact. We describe a very unusual case of an adult male with a fracture of the neck of the talus with talonavicular dislocation, subtalar subluxation, an intact ankle joint, and a fracture of the posteromedial tubercle of talus. Open reduction and internal fixation of the talar neck and posteromedial tubercle was undertaken. The talar neck fracture united without any evidence of avascular necrosis, but the posteromedial tubercle remained un-united. Such an injury is unusual, and the injury pattern is unique and cannot be classified using existing systems.     

Treatment strategy for talus fractures

Fractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively. The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.     

Therapiestrategie bei Talusfrakturen

Fractures of the talus are uncommon, but they present difficult treatment challenges. The classifications of fractures are based on conventional X-rays, but the CT scan is necessary for treatment decisions. Open fractures, displaced fracture dislocations, or extrusion of the talus must be reduced and stabilized as an emergency procedure. In all cases of displaced fractures, ORIF is indicated. The use of standardized approaches depends on the type of fracture and the soft tissue lesion. Precise anatomic reduction of all facets and reconstruction of the shape of the talus and stabilization with interfragmentary lag screws is the method of choice in almost all fractures. This procedure allows early mobilization postoperatively. The outcome is related to the degree of fracture displacement and the soft tissue lesion but may be poor due to inadequate treatment. Talus malunion, nonunion, and secondary deformity should be corrected early with preservation of the joints whenever possible. Arthrodeses should be restricted to the affected joints.     

Open reduction and stable fixation of isolated, displaced talar neck and body fractures

BACKGROUND: The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. METHODS: The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). RESULTS: The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures. CONCLUSIONS: Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.     

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.     

An unusual fracture of the talus in a snowboarder

Fractures of the talus are uncommon. However, snow- boarding and skateboarding are 2 activities that are specifically associated with talus fractures. These patients sustain occult lateral talus process fractures that present as a severe ankle injury. The diagnosis is difficult because of subtle clinical and plain radiographic findings. Computed tomography is a very useful tool for the assessment of these injuries. Although the majority of these athletes have lateral sided talus fractures, there are variants. We present an unusual case of a displaced intra-articular fracture of the subtalar joint involving the middle articular facet of the talus with extension of the fracture into the talar head. This highlights the importance of carefully assessing snowboarders' "ankle injuries."     

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.     

Osteosynthese zentraler Talusfrakturen

Objective

Anatomic reduction of talar neck and body fractures with axial realignment and restoration of the articular surfaces of the talus.

Indications

Displaced talar neck and body fractures.

Contraindications

High perioperative risk, soft tissue infection, neurogenic osteoarthropathy.

Surgical technique

Reduction of the axial alignment of the talus and its joints via bilateral approaches according to the preoperative CT-based planning. A medial malleolar osteotomy may be necessary to approach the talar dome. The blood supply via the deltoid ligament and the sinus tarsi has to be respected. Manipulation of the main fragments with K-wires introduced temporarily; a mini-distractor is helpful in restoring the length. Internal fixation is tailored to the individual fracture pattern, including conventional and headless screws, bioresorbable pins, lost K-wires, and/or minifragment plates. Joint transfixation for 6 weeks to ensure ligamentous healing if instability persists after internal fixation. With severe soft tissue damage, temporary tibiometatarsal external fixation is applied until soft tissue consolidation.

Postoperative management

Range of motion exercises of the ankle and subtalar joints starting postoperative day 2 except for cases with joint transfixation. Partial weight bearing of 20 kg for 10–12 weeks. Use of a cast or walker for 6 weeks followed by intensive active and passive range of motion exercises of the ankle and subtalar joints.

Results

Over 8 years 79 fractures of the talar neck and body were treated. In all, 43 patients with 45 talar neck (n?=?30) and body (n?=?15) fractures were re-examined clinically and radiologically (mean follow-up 3 years). Definite treatment consisted of open reduction and screw fixation of the talus in 41 cases and small plate fixation in 2 cases supplemented by temporary external fixation for 1–3 weeks in 12 cases. At follow-up, the Maryland Foot Score averaged 86.1 and the AOFAS Ankle/Hindfoot Score averaged 78.9. The Hawkins classification was of prognostic value in talar neck fractures. The functional results and the rate of avascular necrosis (AVN) were unaffected by the time to definite internal fixation. AVN was observed in 11 cases (24?%); with only partial AVN involving less than one third of the talar body in 8 of these patients. Due to complete AVN with collapse of the talar dome, 3 patients (6.7?%) required fusion. Signs of posttraumatic arthritis of the tibiotalar or subtalar joint were seen in 21 cases (47?%). The rate of symptomatic posttraumatic arthritis correlated with the occurrence of total AVN, but not with partial AVN.     

Simultaneous bilateral fracture-dislocation of the talus: A case report

A bilateral talar body fracture-dislocation in a 29-year-old multitrauma patient is presented. There was a comminuted fracture associated with an ankle, subtalar and talonavicular subluxation on the right lower limb and an open fracture with complete dislocation of the body of talus on the left side. We performed a minimal invasive reduction and stabilization of the fractures with the use of K-wires, due to severe contamination of the wounds and the patient's poor general condition. After a 28-month follow-up there were signs of posttraumatic arthritis but no signs of avascular necrosis of the talus bilaterally. The range of motion in both ankle joints was limited but the patient had a satisfactory level of activity.     

Fracture of the posterior process of the talus: a case report

Fractures of the posterior process of the talus are very important because they involve the articular surfaces of the ankle and subtalar joints. Involvement of these weight bearing joints would lead to significant disability because of the risk of mal-union and degenerative arthritis. These fractures are rare but need to be aware of as they can be easily missed. Outcome of these are shown to be poor. We present a patient who sustained a displaced fracture of the posterior process of the talus and managed appropriately by internal fixation. Follow-up revealed that the fracture united successfully with good functional outcome and the patient resumed his former job.     

Long-term follow-up after surgical treatment of talar fractures

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.     

Results of surgically treated talar fractures

Objective：Talar fractures present a great challenge to surgeons due to poor treatment outcome and high incidence of sequelae.The purpose of this study was to report the surgical treatment outcome of displaced talar fractures treated by internal fixation.Methods：Atotal of 30 patients with a mean age of 38 years presenting with talar body or neck fractures were studied retrospectively to assess postoperative outcome based on American Orthopaedic Foot ＆ Ankle Society AnkleHindfoot scale.Results：Postoperatively,malunion was found in 18 cases,infection in 5 cases and avascular necrosis in 12 cases.There were 12 cases with subtalar arthritis and 18 cases with both subtalar and malleolar arthritis.The average score of questionnaire was 64± 12.Functional score was 53± 15 and pain score was 65±13.Range of motion failure was detected as 15±4.Conclusion：Talar injuries can compromise motion of the foot and ankle and result in poor prognosis on longterm evaluation.Late complications subsequent to surgically treated talar body fractures are inevitable,and patients are supposed to be counseled about the adverse outcome.     

Anteromedial Subtalar Dislocation

Subtalar dislocation is the simultaneous dislocation of the distal articulations of the talus at both the talocalcaneal and talonavicular joints. It can occur in any direction and can always produce significant deformity. The medial dislocation is most common. Less common presentations are lateral, anterior, and posterior dislocations. These dislocations are associated with osteochondral fractures. Closed reduction and immobilization remain the mainstays of treatment. Proper radiographs and computed tomography scan confirm the postreduction alignment stability of subtalar joints and intraarticular fracture fragments. We report a case of anteromedial subtalar dislocation with no osteochondral fracture fragments in a 25-year-old man.     

Low-Energy Hawkins Type III Talar Neck Fracture-Dislocation With Neurovascular and Tendon Entrapment in a Pediatric Patient

Several serious complications can occur after talar neck fractures. However, these fractures are extremely rare in children. We present a pediatric low-energy Hawkins type III fracture-dislocation that had excessive displacement accompanied by neurovascular and tendon entrapment. A 9-year-old male patient referred to our hospital 5 hours after jumping off a swing in a children's playground. An excessively displaced talar neck fracture-dislocation was observed at the initial evaluation. The patient underwent urgent surgery. The tibialis posterior flexor digitorum longus tendons, posterior tibial artery, and tibial nerve were entrapped at the fracture site. The talar neck fracture was reduced using open reduction. The neurovascular structures and tendons were removed from the fracture site. The fracture was fixed using two 4.5-mm cannulated screws. The patient was able to bear full weight at 10 weeks postoperatively. At 6 months, the patient was able to walk unassisted with full ankle range of motion. However, at 2 years, his American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score had decreased to 72 points, and we observed avascular necrosis in the talar head. In conclusion, talar fractures are rare but can lead to serious complications. In the pediatric population, even low-energy trauma, such as had occurred in our patient, can result in severe displaced fracture-dislocations. After severe displaced fracture-dislocations, important soft tissue structures can become entrapped between fracture fragments, and surgeons should be aware of this situation when considering using closed reduction.     

距骨骨折畸形愈合及不愈合的手术治疗

目的 探讨距骨骨折畸形愈合及不愈合的手术治疗方法.方法 2000年1月至2008年1月,手术治疗距骨骨折畸形愈合及不愈合22例,其中男性17例,女性5例,年龄15-52岁,平均34岁.根据Zwipp提出的距骨骨折畸形愈合及不愈合的分类标准,Ⅰ型(距骨骨折畸形愈合或伴有关节脱位)10例,Ⅱ型(距骨骨折不愈合伴关节脱位)8例,Ⅲ型(在Ⅰ或Ⅱ型的基础上出现部分距骨缺血性坏死)4例.采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝、后足评分标准,术前评分平均35.4分(28.0～41.0分),采用的手术方法为切开复位截骨矫形内固定术或关节融合术.结果 17例患者获得随访,随访时间12～24个月,平均14个月.伤口Ⅰ期愈合,无感染.所有患者均牢固愈合,未发生再次移位,也未发现距骨缺血性坏死的进一步发展.骨折愈合时间12～18周,平均14周.患者术后平均14周(12～18周)时可完全负重行走,无明显疼痛不适.术后AOFAS踝、后足评分标准评分平均86.6分(78.0～98.0分).结论 对于陈旧性距骨骨折患者应积极进行手术治疗,根据距骨骨折畸形愈合的具体情况采用不同的治疗方案,以达满意疗效.     

An unreported delayed complication of hind foot arthrodesis

Isolated low energy fractures of the talus are rare. This case report highlights an unique, insidious fracture of the neck of talus which occurred 8 months following sound arthrodesis of the ipsilateral ankle and subtalar joints. This case reports a hitherto unreported complication following arthrodesis of the ankle and subtalar joints.