Long term surgical treatment outcome of talar body fracture

Objective: Talar body fractures are rare and have poor treatment outcome. The purpose of this study is to report the long term surgical treatment outcome of closed talar dome fractures.Methods: Eight closed talar body fractures, treated by open reduction and internal fixation with small fragment cancellous screws and/or Herbert screws in our level Ⅰ trauma centre were retrospectively analyzed. Preoperative and postoperative radiographs of the foot (antero-posterior, lateral and oblique views) and ankle (antero-posterior, lateral and mortise views) were obtained. The patients were followed up both radiologically and functionally (foot function index, FFI) after 3 weeks, 6 weeks, 3 months, 6 months and then annually.Results: There were five crush fractures and three shear fractures (two sagittal shear and one coronal shear),with average follow-up of 5 years. No early complications were noticed in these patients. Late complications included osteoarthrosis of subtalar/ankle joints in six patients and osteonecrosis oftalar body in four patients. On functional assessment, mean FFI after 5 years was 104.63 points and worse outcome was noticed in crush injury and coronal shear fractures. Sagittal shear fractures had a good functional and radiological outcome.Conclusions: Late complications subsequent to surgically treated talar body fractures are inevitable, even though exact reduction and rigid fixation are achieved, thus patients are supposed to be counseled about the adverse outcome. Although crush and coronal shear fractures have poor outcome, sagittal injuries have good prognosis on long term evaluation.     

Combined ipsilateral fractures of talus and calcaneus

INTRODUCTION: The purpose of this study was to evaluate the frequency of combined ipsilateral talar and calcaneal fractures, the fracture pattern in combination and the clinical outcome of the combined operative treatment. MATERIALS AND METHODS: Out of 950 patients with calcaneal fractures and 190 patients with talar fractures treated operatively between 1984 and 2003, 11 patients (1% of calcaneal and 6% of talar fractures) were identified with combined ipsilateral talar and calcaneal fractures. Closed reduction and external fixation was performed in one patient with a crush foot injury, and ORIF in all other patients and fractures. All patients underwent clinical and radiological evaluation after a minimum followup period of one year using the AOFAS-Hindfoot Score. RESULTS: Seven patients had central talar body and 4 patients talar neck fractures. Nine calcaneal fractures were extraarticular sustentaculum, as well as processus anterior fractures, and two were intraarticular fractures. Average followup was 6 (range, 1 to 12.5; median, 4.5) years. There were no perioperative complications related to ORIF. AOFAS-Hindfoot-Score averaged 78.6 (range, 50 to 100). The followup x-rays showed post-traumatic arthritis in the ankle joint in 3 patients and in the subtalar joint in five. AVN with peudarthorsis was present in one patient with an intraarticular calcaneal fracture. Patients with intraarticular calcaneal fractures presented with the worst functional results (AOFAS-Score, 50 and 64), none of these patients required a secondary ankle or subtalar fusion. All other patients had good and excellent functional outcome. CONCLUSION: Combined ipsilateral talar and calcaneal fractures are rare injuries. Extraarticular calcaneal fractures are more common in this injury pattern, while there was no preference for either talar neck or talar body fractures. Operative treatment with anatomic open reduction and internal fixation may result in favorable clinical outcome. Combined surgical approaches to the hindfoot did not result in increased morbidity.     

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.     

Operative Management of a Pediatric Talar Body and Neck Fracture: A Case Report

Pediatric talus fractures are rare injuries that generally result from high-energy trauma. The relative elasticity of pediatric bone is thought to contribute to the lower rate of fracture in children. Although these injuries are rare, complications of talar body fractures, including avascular necrosis, collapse of the talar dome, and tibiotalar arthrosis, are well described. In the pediatric patient, these complications can result in poor outcomes and a disabling position for the patient. There is a relative paucity of data given the low incidence of these injuries and lack of consensus on operative versus nonoperative management. The authors present the case of an 11-year-old female with a combined talar neck and body fracture. The patient underwent open reduction internal fixation of her fractures with combined cannulated screw and Kirshner wire fixation. She was followed to 7 years postoperatively with excellent functional outcome and no evidence of avascular necrosis or collapse of the talar body.     

距骨颈骨折治疗的近期疗效分析

目的探讨距骨颈骨折的治疗方法及近期疗效。方法对22例距骨颈骨折患者根据Hawkins分型,Ⅰ型(4例)骨折者行膝下短腿石膏管形固定,Ⅱ型(11例)和Ⅲ型(7例)骨折者除1例Ⅲ型骨折行距下关节一期融合外,其余采用切开复位螺钉内固定。观察术后伤口愈合、骨折愈合及内固定情况。疗效采用Hawkins标准进行评定。结果 19例获随访,时间12个月～2年10个月。术后1例患者外侧切口皮缘局部坏死,1例伤口感染,经换药及抗感染等对症处理后分别于术后3周及1周治愈;距骨缺血坏死2例,足踝及距下关节创伤性关节炎3例;至末次随访时X线未发现螺钉松动、断裂。Hawkins评分:优11例(Ⅰ型3例,Ⅱ型8例),良5例(Ⅱ型2例,Ⅲ型3例),可2例(Ⅲ型),差1例(Ⅲ型)。结论术前正确的骨折分型、选择合理的治疗方式及恰当的手术时机是治疗距骨颈骨折的有效方法;能减少并发症、提高近期疗效。     

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.     

Complications after talus fractures: A trauma centre experience

BackgroundTalus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series.MethodsWe retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded.ResultsThe mean age was 35 years (range: 18–76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis.ConclusionOur study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.     

Talar neck fractures: results and outcomes

BACKGROUND: Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. METHODS: We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. RESULTS: Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. CONCLUSIONS: Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.     

Fractures of the talus: experience of two level 1 trauma centers

Fifty-eight patients with 60 talar fractures were retrospectively reviewed. There were 39 men and 19 women. The age average was 32 (range, 14-74). Eighty six percent of the patients had multiple injuries. The most common mechanism of injury was a motor vehicle accident. Twenty-seven (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body. Forty-eight fractures had operative treatment and 12 had non-operative management. The average follow-up period was 30 months (range, 24-65). Thirty-two fractures (53.3%) developed subtalar arthritis. Two patients had subsequent subtalar fusion. Fifteen fractures (25%) developed ankle arthritis. None of these patients required ankle fusion. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints. Ten fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse. Avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck. Three rating scores were used in this series to assess the outcome: the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Maryland Foot Score, and Hawkins Evaluation Criteria. The outcome was different with every rating system. However, the outcome with AOFAS Ankle-Hindfoot Score and Hawkins Evaluation Criteria were almost equivalent. Assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then the body fractures.     

距骨颈骨折治疗方法及疗效分析

[目的]探讨距骨颈骨折的治疗方法及疗效.[方法]对2005年6月～2009年10月收治的48例距骨颈骨折患者中获得随访的45例患者进行回顾性分析.根据Hawkins分型,Ⅰ型7例,Ⅱ型20例,Ⅲ型15例,Ⅳ型3例.Ⅰ型骨折采用石膏外固定或闭合经皮克氏针固定及石膏固定方法;Ⅱ型骨折行闭合复位克氏针固定或切开复位螺钉固定;Ⅲ型、Ⅳ型骨折行切开复位螺钉内固定术.应用x2检验对手术时机、骨折类型、开放与否、骨折复位情况及是否合并距骨周围骨折因素进行分析,观察这些因素与手术疗效的相关性.[结果]平均随访时间3.6年(2～5年),依据Hawkins评分进行评估,其中优26例,良12例,中5例,差2例,优良率为84％;距骨体缺血坏死9例,Ⅱ型骨折3例,Ⅲ型骨折4例,Ⅳ型骨折2例.距骨坏死率与骨折的开放性、复位不良及是否合并周围骨折呈正相关性(P＜0.05);创伤性关节炎14例(31％),畸形愈合7例(16％),无骨折不愈合病例.[结论]移位的距骨颈骨折应积极行手术治疗,正确的治疗方法可以降低并发症的发生率;骨折后继发距骨缺血性坏死并不影响最终的功能结果.     

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.     

Fractures of the neck of the talus and the Blair fusion: a review of the literature and case report

Historically, fractures of the neck of the talus have been serious injuries with sometimes devastating results. Several mechanisms have been reviewed to explain the types of injuries most commonly seen. Hawkin's classification of the types of talar neck fractures has been explained and used as a guideline in a review of treatment and results of talar neck fractures. Hawkin's group I fractures generally require only immobilization and are frequently without serious sequelae. Hawkin's group II fractures are more serious injuries, which may frequently be treated with closed reduction. Open reduction is occasionally necessary. Hawkin's group III fractures have the most potentially devastating results. These generally require open reduction with internal fixation or occasionally primary salvage procedures. Secondary salvage procedures are also sometimes necessary. Avascular necrosis of the talar body is reviewed in detail, including correlation with the type of fracture as well as diagnostic techniques and treatment. Other complications, including soft-tissue damage, osteomyelitis, malunion, and posttraumatic arthrosis, are discussed. The Blair tibiotalar arthrodiesis is reviewed in detail, with the consideration that it may be used as a primary or secondary salvage procedure with good results. Finally, a case in which the Blair fusion was used successfully is reported with 1-year follow-up.     

Talar neck fractures and rates of avascular necrosis.

Talar neck fractures are unique and potentially debilitating injuries. Their successful treatment requires an understanding of talar anatomy and arterial blood supply, as well as knowledge of the sequelae of these injuries, particularly avascular necrosis of the talar body. Presented is an extensive literature review on talar neck fractures and Hawkins' classification, with special emphasis on the rates of avascular necrosis as determined by selected researchers on the topic.     

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.     

距骨颈骨折的治疗策略

目的 探讨距骨颈骨折的治疗方法及疗效.方法 2003年1月至2008年1月共收治32例距骨颈骨折患者,男22例,女10例;年龄18～55岁,平均38.5岁.骨折根据改良的Hawkins方法分型:Ⅰ型6例,Ⅱ型19例,Ⅲ型7例.Ⅰ型骨折:2例采用保守治疗,非负重石膏固定6～8周;4例采用经皮螺钉固定.Ⅱ型和Ⅲ型骨折:21例采用切开复位螺钉内固定,5例粉碎性骨折采用钢板内固定. 结果 24例患者术后获平均20个月(12～48个月)随访,8例失访.伤口均Ⅰ期愈合,无感染发生.采用美国足踝外科协会踝与后足评分评定:术后评分平均为80.5分(60～96分).术后评分70分以下者5例,其中距骨颈骨折不愈合1例,为Ⅱ型骨折,再次行切开复位植骨重建内固定术后愈合;距骨体缺血性坏死4例,为Ⅲ型骨折,其中2例采用保守治疗2个月后症状减轻,2例行距下关节融合术. 结论 距骨颈骨折应根据骨折的具体情况采用不同的治疗方案:Ⅰ型骨折建议采用保守治疗或经皮螺钉固定;Ⅱ型、Ⅲ型骨折建议采用切开复位螺钉内固定,若为粉碎性骨折,则采用钢板固定.     

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.     

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.     

可吸收螺钉固定治疗移位的距骨颈骨折

目的 研究距骨颈骨折新的手术治疗方法。方法 1996年4月～2001年3月，采用足内侧途径加内踝截骨显露距骨颈骨折，利用可吸收螺钉对骨折行内固定治疗9例移位的距骨颈骨折。术后膝下石膏管型固定6～12周，骨折有明显愈合迹象后，患者每日定时在短石膏靴外进行一定范围内活动。结果 9例均获随访15～60个月，平均28个月，骨愈合时间20～42周。按AOFAS足部评分标准，功能优良率77．8％(7／9)。术后1例伤口表浅皮肤感染并皮缘部分坏死，为HawkinsⅢ型。术后随访2例并发距骨体缺血性坏死，1例为HawkinsⅡ型，系5周即扶拐负重，评分为中；1例HawkinsⅢ型，经保守治疗无效后行踝关节融合术，评分为差。结论 以足内侧途径为入路，应用可吸收拉力螺钉固定治疗；矩骨颈骨折是一种新手术方法，辅以严格的术后处理可获得良好的临床治疗效果，值得推广使用。     

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).     

Operative outcomes of a high-grade talar neck fracture – Lessons from 20 years’ clinical experience in a single,tertiary hospital

BackgroundThe operative treatment of high-grade talar neck fractures remains challenging, despite numerous previous reports. Our goal was to determine long-term outcomes and to establish a plan for management of postoperative complications (especially, avascular necrosis [AVN] of talar body) after high-grade talar neck fractures. We hypothesized that not every case with AVN of talar body require secondary surgical interventions.MethodsWe retrospectively reviewed the radiographic and clinical findings of 14 patients who underwent operative treatment for high-grade talar neck fractures (modified Hawkins type III and IV) between January 2000 and December 2017. The minimum follow-up duration for inclusion was 3 years. Using radiographs during follow-up, we assessed the development of AVN of the talar body, malunion, nonunion, and posttraumatic osteoarthritis. Information about the secondary operations and their outcomes were also investigated using visual analogue scale (VAS) and American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot scale at the final follow-up.ResultsIn 10 of 14 patients (71.4 %), talar body AVN developed during follow-up. However, secondary operation was required in only 30.0 % (3 of 10 patients). In the remaining 7 patients who did not undergo secondary operation, the symptoms were tolerable with a maximum of 89 months follow-up; although the talar body presented sclerotic changes, but without talar dome collapse. The rates of malunion and post-traumatic subtalar osteoarthritis were 21.4 % and 14.3 %, respectively. No patients presented with fracture site nonunion. After a mean of 55.86 ± 14.45 months (range, 37–89) follow-up, the final mean VAS and AOFAS scores were 3.07 ± 0.73 (range, 2–4) and 80.43 ± 3.11 (range, 75–85), respectively.ConclusionWe recommend leaving talar body AVN untouched, unless the patient’s symptoms become intolerable. In our clinical practice, postoperative AVN could be stably maintained without talar dome collapse for more than 7 years, although the sclerotic change persisted. Despite the small number of patients, our clinical experience may benefit patients with high-grade talar neck fractures and surgeons who treat such rare, serious, and challenging foot injuries.Level of evidenceLevel IV, Case series