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。     

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.     

Open Talar Neck Fracture With Medial Subtalar Joint Dislocation: A Case Report

We present a unique case of an open talar neck fracture with medial subtalar joint dislocation. This rare and traumatic injury was treated with immediate open reduction of the subtalar joint and open reduction internal fixation of the talar neck fracture. After a follow-up of 2.2 years, highlighted by numerous complications including posttraumatic arthritis, soft tissue abscess, and fibrotic adhesions, the patient recovered sufficiently to return full activity.     

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。     

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.     

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.     

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.     

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus

BACKGROUND: Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS: The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS: The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION: On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeon's ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.     

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.     

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.     

Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results.     

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.     

Talus fractures: evaluation and treatment

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

Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1-15 years

We retrospectively reviewed 79 patients (80 talar fractures) operated on between 1994 and 1997. The average follow-up was 6 (1-15) years. 15 patients had a Marti/Weber fracture type I, 14 patients a type II, 32 patients a type III, and 19 patients a type IV fracture. 46 patients suffered a fracture of the talar neck, Hawkins type I in 10 patients, type II in 18, type III in 17 and type IV in 1 patient. 18/23 patients directly placed in our department were operated on within 6 hours of admission. Primary arthrodesis of both the ankle and subtalar joint was performed twice. Secondary arthrodesis of the ankle joint was done in only 3 patients. Combined secondary arthrodesis of the ankle and subtalar joint was performed in 5 and arthrodesis of the talonavicular joint in 1 patient. According to the Hawkins score, 35/80 feet achieved good/very good function versus 43 with the Mazur score. Radiographs showed ankle or subtalar arthrosis in two thirds of the patients. A normal range of motion was achieved in 18 ankle and 19 subtalar joints. The overall rate of talar necrosis was 9/80 fractures.     

Treatment of talar neck fractures: Clinical results of 50 patients

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

Process breaks. A diagnostic problem in ankle injuries

Peripheral talar fractures are frequently overlooked and should be considered in the differential diagnosis of patients with acute and chronic ankle pain. Early diagnosis allows specific treatment options to prevent long-term complications and enables better overall results. Computertomography is obligatory for definite evaluation of the pathology and to determine the need for conservative or operative treatment. Conservatively treated displaced fractures lead to pain and decreased range of motion from ongoing arthrosis of the subtalar joint. Large or displaced fragments require, according to the scare literature, open reduction and internal fixation. Comminution or small fragments are best addressed by surgical excision, although alteration in the biomechanics of the subtalar joint may occur.     

Calcaneal fractures in adolescents. CT classification and results of operative treatment

The morphology of calcaneal fractures in 9 adolescents (mean age 13.4 years) with 10 fractures were classified using plain films and computed tomography scans. The patterns were found to be similar to those in adults.All except one of the fractures (which was not significantly displaced) were treated with open reduction and internal fixation. In all cases it was possible to achieve anatomic reduction and rigid internal fixation. Seven patients had 'excellent' long-term clinical results. One patient with pending litigation scored 'good', and one patient with an ipsilateral fracture of the talar neck scored 'fair'. This patient had mild limitation of ankle movement, all others had full ankle movement. Five had unrestricted subtalar movement, in two it was mildly limited and in three it was moderately limited (50-80%). There was no evidence of abnormality of the physes on follow up X-rays. We conclude that operative treatment of this fracture yields good results.     

Calcaneus fractures: facts, controversies and recent developments

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.     

Fracture of the talus as a complication of subtalar arthroereisis

Subtalar joint arthroereisis remains a popular procedure for a flexible flatfoot deformity. Potential complications of the procedure have been discussed in published reports and are often believed to have resulted from shortcomings related to the mechanical properties of the biomaterial, implant size, and/or implant placement. In the present report, we describe the case of a talar neck fracture with migration of the implant after subtalar joint arthroereisis performed 10 years earlier. The 19-year-old patient was treated with implant removal and open reduction internal fixation and bone void filler and recovered unremarkably thereafter.