Antiresorptive treatment and talar collapse after displaced fractures of the talar neck: a long-term follow-up of 19 patients

Background and purpose — Displaced fractures of the talar neck are associated with a high risk of structural collapse. In this observational analysis we hypothesized that pharmacological inhibition of osteoclast function might reduce the risk of structural collapse through a reduction in bone resorption during revascularization of the injured bone.Patients and methods — Between 2002 and 2014 we treated 19 patients with displaced fractures of the talar neck with open reduction and internal fixation. Of these, 16 patients were available for final follow-up between January and November 2017 (median 12 years, IQR 7–13). Among these, 6 patients with Hawkins type 3 fractures and 2 patients with Hawkins type 2b fractures received postoperative antiresorptive treatment (7 alendronate, 1 denosumab) for 6 to 12 months. The remaining 8 patients received no antiresorptive treatment. The self-reported foot and ankle score (SEFAS) was available in all patients and 15 patients had undergone computed tomography (CT) at final follow-up, which allowed evaluation of structural collapse of the talar dome and signs of post-traumatic osteoarthritis.Results — The risk for partial collapse of the talar dome was equal in the 2 groups (3 in each group) and post-traumatic arthritis was observed in all patients. The SEFAS in patients with antiresorptive treatment was lower, at 21 points (95% CI 15–26), compared with those without treatment, 29 points (CI 22–35).Interpretation — Following a displaced fracture of the talar neck, we found no effect of antiresorptive therapy on the rate of talar collapse, post-traumatic osteoarthritis, and patient-reported outcomes.

Talar neck fractures are often the result of a high-energy trauma and are associated with a high risk of complications (Dodd and Lefaivre 2015). Given the intraarticular location of the talus and its extensive cartilage coverage, its blood supply is vulnerable. Traumatic disruption of the blood supply during fracture of the talar neck leaves the talar dome at a high risk of avascular necrosis (AVN). The risk of AVN seems to be dependent on the presence of subtalar joint dislocation. If the joint is dislocated (type 2b and more severe types) the risk of AVN is 25–50%. No AVN is seen in cases of minor joint displacement (type 2a) (Vallier et al. 2014).Interruption of the blood supply to the talar dome impairs the fracture healing capacity and bone remodeling. Subsequently, with revascularization of avascular areas, damaged osteocytes trigger the formation of osteoclasts (Glimcher and Kenzora 1979). These osteoclasts resorb the dead bone, and osteoblasts deposit new bone material (Hofstaetter et al. 2006). If the rate of bone resorption exceeds the rate of new bone formation the mechanical properties of the talar dome will deteriorate and may not be sufficient to withstand the forces transmitted during weight-bearing. The resulting collapse of the talus is associated with severe loss of function, limited range of motion and pain (Annappa et al. 2015).Bisphosphonates reduce osteoclast function and thereby inhibit bone resorption. These agents have been proven to be successful in the treatment of several bone metabolic disorders, such as osteoporosis, osteogenesis imperfecta, Paget’s disease of bone, and metastatic bone disease. In addition, in the treatment of AVN of the femoral head, bisphosphonate treatment is associated with a reduction in the rate of structural collapse (Luo et al. 2014).Considering the detrimental effects of post-traumatic AVN of the talus, and the low-risk profile of short-term antiresorptive treatment after a fracture (Abrahamsen 2010, Li et al. 2015), our department has encouraged postoperative treatment with antiresorptives after displaced fractures of the talar neck. In this retrospective analysis we evaluated the effects of this recommended treatment on the risk of talar collapse, the development of post-traumatic osteoarthritis (OA), and patient-reported outcome.     

Delayed surgical treatment for neglected or mal-reduced talar fractures

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

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Résumé De 1993 à 2002, nous avons traité neuf malades pour fracture du talus négligée ou mal réduite. Lâge moyen des malades était de 39 ans (20–64) et la moyenne de suivi était 53 mois. Lintervalle de temps entre le traumatisme et lopération étudiée était de 4 semaines à 4 années. Les techniques chirurgicales ont inclus la réduction ouverte, avec ou sans greffe dos dans six cas; la réduction ouverte combiné avec larthrodèse de la cheville dans un cas; lostéotomie du col de talus dans un cas, et lostéotomie du col du talus combiné avec larthrodèse sous-talienne dans un cas. Tous les cas avaient une union osseuse solide. Un malade a développé une nécrose avasculaire du talus et a pour cela été arthrodésé. Chez six malades une arthrose de larrière-pied sest développée. Le score de cheville AOFAS était en moyenne de 77.4. Nous concluons que dans les fractures astragaliennes négligées et mal réduites, le traitement chirurgical peut mener à un résultat favorable si les articulations de larrière pied sont sans arthrose.

     

Long-term follow-up of osteoarthritis after conservative treatment of ankle fractures

In a period between 1982 and 1998 a total of 171 patients with ankle fracture were treated conservatively and rehabilitated in the same rehabilitation institution. All patients were seen at follow up in 1998 exactly at the date of the fracture in five groups with one, two, three, eleven and sixteen years from the fracture respectively. There were not significant differences in sex and age among groups. According to Danis-Weber's system, in the total material there were 53.8% type A, 40.9% type B and 5.3% type C fractures, and according to Lauge-Hansen's system there were 54.4% type SA, 34.5% type SE, 7.6% type PA and 3.5% type PE fractures. According to the Olerud's and Molander's scoring system there were the highest percentages of good results in all series (in average 52%) and there were not found significant differences between the results of the groups (P = 0.154). According to linear analogue scale of function there were the highest percentages of good results in all groups (in average 55.6%) and with significant differences between the results of the groups (P = 0.012). There were found significant differences between the results of late reductions of malleolar fragments of the groups (P = 0.028) with changing for the worse in groups with longer time interval from fracture. Posttraumatic osteoarthritis was found in first year after fracture already (41.5%). There were found significant differences between the results of the groups (P = 0.001) with severe degrees of osteoarthritis in groups with longer time from fracture.     

Reconstruction after talar fractures

Malunited and nonunited talar fractures cause significant disability. Distinction between partial and total avascular necrosis (AVN) determines the choice of treatment. Patients who have minimal or no AVN and well-preserved joint cartilage may be amenable to corrective osteotomy through the malunited fracture or removal of the pseudoarthrosis. Secondary reconstruction with joint preservation leads to considerable functional improvement in painful talar malunions and nonunions in reliable patients. If symptomatic arthritis is present, arthrodeses and correction of deformity through the fusion or with additional osteotomies provide predictable results, although they do not restore normal foot function. Fusions should be limited to the affected joint. If the subtalar joint shows severe arthritic changes, every attempt should be made to salvage the ankle and talonavicular joints.     

Long-term results of displaced talar neck fractures

Of 36 fractures of the talar neck without comminution of the body, eight were undisplaced, treated closed, and 28 were displaced and treated by open reduction. Twenty of the operations were less than 12 hours after injury. Nineteen of 20 were performed through a medial approach, six with a medial malleolar osteotomy. The long-term results were evaluated by a standard rating system based on classification by the fracture. A protective brace was developed for non-weight-bearing in two patients with complete avascular necrosis, and ankle protection with weight-bearing in ten with partial necrosis. Prompt open reduction and internal fixation, malleolar osteotomy, and protected weight-bearing are recommended in selected cases.     

Arthroscopic treatment of transchondral talar dome fractures: a long-term follow-up study.

Arthroscopic treatment of transchondral talar dome fractures allows accurate visualization and debridement of the lesion with less postoperative morbidity and earlier mobilization than arthrotomy. Although many studies document the results of open treatment, no reports of long-term results of arthroscopic treatment of these fractures have been published. We reviewed the results in 12 patients who had arthroscopic excision and curettage of a transchondral talar dome fracture and had an average of 10.1 years of follow up (range, 8.1 to 13.9 years). There were 5 medial and 7 lateral lesions. According to the four-stage classification of Berndt and Harty, 2 were stage II; 8 were stage III; and 2 were stage IV. All patients were evaluated with a subjective questionnaire, ankle radiographs, and a physical examination. The long-term subjective and objective results were good or excellent in 10, fair in 1, and poor in 1 patient. All patients' radiographs showed residual subchondral changes at the site of the original lesion, but minimal to no degenerative changes. Patients who are treated with arthroscopic debridement and curettage for transchondral talar dome fractures achieve a predictably high percentage of successful results with low morbidity.     

Long-term follow-up of meningiomas of the cavernous sinus after surgical treatment alone

OBJECT: The authors report on the long-term outcome in 100 consecutive patients with meningiomas arising from the cavernous sinus (CS) with compressive extension outside the CS. The treatment in all cases was surgery alone without adjuvant radiosurgery or radiotherapy. The aim of this study was to evaluate the percentage of patients in whom surgery alone was able to produce long-term tumor control. METHODS: All 100 patients harbored meningiomas with supra- and/or laterocavernous extension, and 27 had petroclival extension. Surgery was performed via frontopterionotemporal craniotomy associated with orbital and/or zygomatic osteotomy in 97 patients. Proximal control of the internal carotid artery at the foramen lacerum was undertaken in 65 patients; the paraclinoid carotid segment was exposed extradurally at the space made by the anterior clinoidectomy in 81 patients. For the petroclival tumor extension, a second-stage surgery was performed via a presigmoid-retrolabyrinthine or retrosigmoid approach in 13 and 14 patients, respectively. RESULTS: The mortality rate was 5% and two patients had severe hemiplegic or aphasic sequelae. The creation or aggravation of disorders in vision, ocular motility, or trigeminal function occurred in 19, 29, and 24% of patients respectively, with a significantly higher rate of complications when resection was performed inside the CS (p < 0.05). Gross-total removal of both the extra- and intracavernous portions was achieved in 12 patients (Group 1), removal of the extracavernous portions with only a partial resection of the intracavernous portion in 28 patients (Group 2), and removal only of the extracavernous portions was performed in 60 patients (Group 3). The follow-up period ranged from 3 to 20 years (mean 8.3 years). There was no tumor recurrence in Group 1. In the 83 surviving patients in Groups 2 and 3 combined, the tumor remnant did not regrow in 72 patients (86.7%); regrowth was noted in 11 (13.3%). CONCLUSIONS: The results suggest that there is no significant oncological benefit in performing surgery within the CS. Because entering the CS entails a significantly higher risk of complications, radiosurgical treatment should be reserved for remnants with secondary growth and clinical manifestations.     

距骨颈骨折的手术治疗

目的：探讨手术复位螺钉内固定治疗距骨颈骨折的临床效果。方法：28例距骨颈骨折患者,男20例,女8例;年龄22～72岁,平均38岁。所有骨折按Hawkins法分型,Ⅰ型6例,Ⅱ型18例,Ⅲ型4例。均行切开复位螺钉内固定,其中6例行急诊手术。结果：28例均获随访,时间1～7年,平均2.8年。按Hawkins疗效标准：优14例,良9例,可3例,差2例,优良率为83.2%。术后出现距骨体坏死5例,Ⅱ型骨折3例,Ⅲ型骨折2例,其中2例因距骨体坏死、塌陷或疼痛性关节炎而行踝关节融合术;术后出现单纯踝关节炎3例;距骨下关节炎6例,其中2例合并踝关节炎;无伤口感染和踝关节内侧皮肤坏死。结论：手术复位螺钉内固定治疗距骨颈骨折可取得满意的临床疗效,保护残存血运,解剖复位,稳定内固定可提高治疗效果。     

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.     

距骨体骨折的手术治疗

目的 探讨距骨体骨折的手术治疗效果及注意事项.方法 2002年4月至2008年7月,手术治疗距骨体骨折患者44例,男41例,女3例;年龄15～61岁,平均31.7岁;左侧26例,右侧18例.根据Sneppen分型,Ⅱ型24例,V型20例.开放性骨折11例,根据Gustilo和Anderson分型,Ⅰ型3例,Ⅱ型7例,ⅢA型1例.致伤原因:高处坠落伤18例,交通事故伤13例,重物砸伤8例,扭伤4例,刀砍伤1例.开放性骨折平均在伤后5.3 h手术,闭合性骨折平均在伤后8.9 d手术.闭合性骨折采用前内侧切口15例,前外侧切口3例,内外侧联合切口15例.44例患者中,3例单纯应用克氏针固定;5例采用螺钉辅以克氏针短期固定;2例采用可吸收螺钉固定;34例采用空心拉力螺钉固定,其中4例辅以全螺纹松质骨螺钉固定.结果 35例患者获得随访,随访时间21～89个月,平均44.5个月.4例出现切口皮缘坏死,1例出现伤口感染,均经治疗后愈合.骨折均愈合,愈合时间为17～41周,平均22周.美国足与踝关节协会(AOFAS)功能评分为43～100分,平均77.3分;优11例,良13例,可10例,差1例,优良率为68.6%.5例患者发生距骨缺血性坏死;19例患者发生创伤性关节炎,其中4例行关节融合术.结论 治疗距骨体骨折时应根据骨折和软组织损伤的具体情况选择手术时机和入路,保护血供、解剖复位及早期功能锻炼是取得良好疗效的关键.

Abstract：

Objective To investigate the results and related key points in operative treatment of talar body fractures. Methods From April 2002 to July 2008, 44 patients with talar body fractures underwent the operation. There were 3 females and 41 males. The mean age of the patients was 31.7 years. The fractures occurred on the left side in 26 patients and on the right side in 18 patients. According to Sneppen classification, 24 type Ⅱ, 20 type V. Eleave cases were open fractures, according to the Gustilo-Anderson classification, there were 3 cases in type Ⅰ , 7 in type Ⅱ, 1 type in Ⅲ A. The mean interval between injury and surgical treatment for open fractures and close fractures was 5.3 hours and 8.9 days. The mechanism of injury was a fall from the height in 18 patients, a traffic accident in 13 patients, a crush injury in 8 patients, a sprain injury in 4 patients and a cut injury in 1 patient. Anteromedial approach was used for 15 close fractures, anterolateral approach for 3 and combined anteromedial-anterolateral approach for 15. K-wires fixation were utilized for 3 fractures, screws and temporary K-wires fixation for 5 cases, bioabsorbable screws for 2fractures, cannulated screws for 30 fractures and cannulated screws and threaded cancellous screws for 4cases. Results Thirty-five patients were followed up 21 to 89 months (average, 44.5 months). Necrosis of incision was found in 4 cases, wound infection occurred in 1 case. All fractures had achieved bone union;the average healing time was 22 weeks. Functional results were assessed according to AOFAS score, the average score was 77.3, There were 11 patients in excellent results, 13 in good, 10 in fair and 1 in poor. The overall excellent and good rate was 68.6%. Avascular necrosis occurred in 5 cases. Traumatic arthritis occurred in 19 cases. Arthrodesis was needed in 5 cases. Conclusion The timing and approach of surgery is determined by the condition of the talar fractures and soft tissue. Anatomical reduction, preservation of the blood supply and early active pain-free mobilization are key points in the treatment of the talar body fractures.     

Long-term follow-up of surgical treatment for thumb duplication

There are few long-term follow-up reports concerning the treatment of thumb duplication. We reviewed the treatment of 19 of 74 patients treated at our institution between 1956 and 2002. The average follow-up was 22 (range, 7 years to 35 years) years. Satisfactory function was achieved in 18 thumbs and cosmesis in 12 thumbs. Six thumbs were cold-intolerant at this late follow-up. Pinch strength was similar to the contralateral normal thumbs. Collateral ligament repair did not significantly contribute to joint stability. An objective method of postoperative evaluation showed good results in five, fair results in 12 and poor results in two thumbs.     

Long-term follow-up of the surgical treatment of intracranial coenurosis

Intracranial infestation by the coenurus of the tapeworm Taenia multiceps is a rare occurrence in humans, with about 55 cases having been reported so far. Although most of these cases were observed in African or South American countries, the illness was occassionally found also in sheep-raising areas of Western Europe and the United States. Out of 4 personal cases, who were operated upon over an 18-year-period, 2 were neurologically intact respectively 20 and 3 years following surgical treatment. CT scans confirmed the absence of a progression of the disease. One patient was able to work 6 years after surgery, when he was killed in a road accident. A further, severely impaired patient remained unchanged and died with intercurrent infection 10 years following the operation.     

胸椎结核外科治疗的长期临床随访

目的回顾性分析胸椎结核的外科治疗及疗效,探讨手术入路、内固定的选择、术后及远期并发症的原因及对策。方法 1997年4月～2010年4月收治胸椎结核患者107例。病灶位于上段胸椎10例,中段胸椎46例,下段胸椎51例。结核病灶累及单节段64例,2个节段21例,≥3个节段22例。开胸入路65例,胸腹膜外入路22例,单纯后路9例,前后联合入路11例。使用内固定61例,单纯病灶清除植骨融合46例。从治愈率、内固定并发症及神经功能恢复等方面进行长期随访。结果 89例获得1.0～13.8年随访,平均7.6年,87例达到了临床治愈,复发2例。内固定断裂2例,螺钉松动3例。结论前路一期病灶清除、植骨融合结合内固定是胸椎结核外科治疗的主要手段,手术入路、内固定应用应当根据病灶节段、患者年龄、病灶特点及稳定性等因素个性化选择,可有效减少术后并发症发生,提高疗效。     

Long-term follow-up after fractures of the tibial and fibular shafts

Thirty-seven patients who sustained a closed or a Grade-I open tibial and fibular fracture were evaluated an average of twenty-nine years after injury. All of the patients had had uncomplicated treatment with a plaster cast. Clinically, 78 per cent of the ankles were rated good or excellent, and 92 per cent of the knees were rated excellent. Radiographic assessment for osteoarthritic changes revealed a good or excellent result for 76 per cent of the ankles and an excellent result for 92 per cent of the knees. The clinical and radiographic outcomes were unaffected by the amounts of anterior or posterior and of varus or valgus angulation, as well as by the level of the fracture. The length of immobilization, which did not exceed one year, also did not affect the outcomes.     

Peripheral talar fractures

Peripheral fractures of the talus are uncommon and often overlooked. CT scanning has become the imaging modality of choice and is necessary for decision making on treatment. Displaced peripheral fractures have to be managed with open reduction and internal fixation. Precise anatomical reduction is necessary to achieve a good result. A rigid internal fixation with interfragmentary lag screws is the method of choice in almost all fractures, which allows early postoperative mobilization. The outcome is related to the degree of the chondral lesion and the degree of instability of the subtalar joint, but it may be poor due to the treatment. Early diagnosis and proper treatment achieve the best possible results and prevent long-term complications. Typical complications of the fracture are nonunion and malalignment with slight subtalar instability or osseous overgrowth with secondary impingement and posttraumatic subtalar arthritis.     

Long-term follow-up study of the surgical treatment of pulmonary adenocarcinoma

The surgical treatment of pulmonary adenocarcinoma was studied on the basis of the postoperative long-term results in 211 cases. The overall five-year survival rate was 42% for adenocarcinoma and 48% for squamous cell carcinoma, and there was no significant difference. In stage I, as the degree of differentiation became lower, the prognosis became poorer. In stage III, the five-year survival rate was 50% for the alveolar cell type and 32% for the well differentiated type. The prognosis was better than in the moderately or poorly differentiated types. The prognosis of T1N0 cases was 79% in T1, but it was significantly lower 39% for T2 cases. Among T3 or T4 cases other than N2, the two-year survival rate was 15%, and the longest survival recorded was 32 months. The results were also poor in 9 cases undergoing extensive surgery, with the two-year survival rate being only 10%. Of the N2 cases undergoing extensive surgery all died within a year, except for one case surviving two years following panpleuro-pneumonectomy. In N2, the prognosis was significantly worse if there were two or more foci of mediastinal lymph node metastasis or if subcarinal lymph node metastasis was present. In the long surviving cases, cancer-bearing survivors were about twice as common as with squamous cell carcinoma. Recurrence was usually by distant metastasis (mainly to the brain), being twice as common as local recurrence. Therefore, in adenocarcinoma the significance of postoperative adjuvant therapy was considered to be greater than in squamous cell carcinoma.     

Long-term outcome after surgical treatment of thoracolumbar fractures versus a control group of healthy volunteers

The authors conducted a retrospective study on the long term outcome (+/- 9 years) after instrumentation for thoracolumbar fractures. This study is probably unique in that it compares the surgical group with a control group of healthy volunteers, rather than with a group of conservatively treated patients. All classical outcome measures were used: ODI, RMDQ, VASSS, VAS, Denis Pain scale, SF-36 Bodily Pain, SF-12 Bodily Pain, the remaining SF-36 and SF-12 scores, and the Denis Work Scale. As expected, the large majority of the scores was better in the healthy group. The difference was significant, except as far as the SF-tests were concerned.