Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus

Eleven patients with medial impingement syndrome of the anterior tibio-talar fascicle (ATTF) of the deltoid ligament on the talus were identified. Six sustained inversion injuries, one talus and four ankle fractures. The mean preoperative Ankle-Hindfoot Scale (AHS) was 56 and the postoperative was 87. Surgical debridement of the ATTF was performed. A thickened ATTF and localized synovitis were seen. Talar osteophytes were removed in 8 patients. Mean follow up 4 years. Nine patients had good to excellent results and all patients returned to work.     

Assessment of the lateral ligaments of the ankle after healed fractures

BACKGROUND: Lateral ligament complex injuries are difficult to diagnose immediately after ankle fracture, and treatment is focused on the fracture. This study examines the prevalence of ligamentous injuries after severe ankle fractures. METHODS: Lateral ligament instability can be revealed by inversion and anterior stress views after fracture healing. The results of 54 inversion and anterior stress examinations of the ankle after fracture healing, using a Telos stress device at 15 kPa force, were compared with uninjured ankles. RESULTS: No patient had 5 degrees or more of talar tilt or 6 mm or more of anterior displacement of the talus in uninjured ankles; however, in ankles with fractures, we found abnormal talar tilt angle in 12 and excessive anterior displacement in five. An abnormal inversion stress test was found to be considerably more common in the fractured ankles. CONCLUSION: Our study revealed that lateral ligament injuries may occur simultaneously with ankle fractures, with the most frequently injured being the calcaneofibular ligament.     

Open Talus Fractures: Early Infection and Its Epidemiological Characteristics

Open talus fractures are relatively rare and severe open injuries with a high risk of severe infection. To better understand the epidemiological characteristics of this kind of injury, a monocentric case review was conducted among open talus fracture patients admitted in West China Hospital of Sichuan University between January 2010 and December 2014. Fifty-one (N?=?51) patients were recruited to the study, including 44 (86.3%) males and 7 (13.7%) females. Fifty-two cases of open talus fractures were diagnosed among the patients (1 patient had bilateral fractures). The primary cause of open talus fracture was a fall from a height. The rate of concurrent injuries associated with open talus fracture was 84.3%. The overall infection rate was 41.2%, rising with the increase of injury severity classified by Gustilo-Anderson classification and the existence of peritalar dislocation. Therefore, it can be concluded that open talus fractures are at high risk of concurrent complications and early infection. It is necessary to perform a complete physical examination to search for possible concurrent injuries. When evaluating the risk of infection, in addition to the severity of open talus fracture, the existence and severity of peritalar dislocation should also be taken into consideration.     

Fractures of the talus

Peripheral fractures of the talus, such as fractures of the posterior and lateral process, need no special therapy. Larger fragments with dislocation require open reduction and screw fixation. Small flake fractures with stability of the joint can be removed arthroscopically, but larger fractures should be repositioned with K-wires, small screws. Ethipin or fibrin sealant. Dislocated fractures of the head of the talus should be reduced and fixed by screws or K-wires. Fractures of the neck of the talus with anteromedial or lateral dislocation can be treated by closed reduction and external fixation, irreducible fractures by open reduction and screw fixation. Fractures of the neck and body of the talus with dorsal dislocation or subluxation in the talonavicular joint require osteotomy of the internal malleolus, open reduction and screw fixation. Comminuted and open fractures of the body of the talus are treated by minimal osteosynthesis with K-wires or external fixation. In necrosis of the talus, revascularization using iliac crest bone with vascular pedicle seems to be successful. In arthrosis cases, triple arthrodesis is the best solution.     

Incidence and pattern types of fractures of the lateral process of the talus

Fractures of the lateral process of the talus have historically been considered unusual. This study sought to more precisely define the typical lateral talar process fracture pattern and its incidence in general trauma patients. Such information may have implications for the clinical treatment of these seemingly increasingly recognized injuries. A retrospective review was performed at our level I trauma center of the x-rays and available computed tomography scans of all talus fractures treated between 2000 and 2005 to identify the respective incidence and variation in fracture configuration of all isolated lateral process injuries. The incidence was 10.4%. The fractures were most commonly single large fragments closely followed in frequency by nonarticular chip patterns.     

Process and tubercle fractures of the hindfoot

Process and tubercle fractures of the talus and calcaneus can be a source of significant pain and dysfunction. Successful management requires extensive knowledge of the complex osseoligamentous anatomy of the hindfoot. The large posterior process of the talus is composed of a medial and a lateral tubercle; an os trigonum may exist posterior to the lateral tubercle. The talus has a lateral process that articulates with the fibula and subtalar joint; the calcaneus possesses a frequently injured anterior process that articulates with the cuboid. Injury to these hindfoot structures is caused by inversion and eversion of the ankle, which can occur during athletic activity. These injuries often are misdiagnosed as ankle sprains. A high degree of clinical suspicion is warranted, and specialized radiographs or other imaging modalities may be required for accurate diagnosis. Nonsurgical management with cast immobilization is frequently successful when the fracture is correctly diagnosed acutely. Large fragments may be amenable to open reduction and internal fixation. Untreated, chronic injuries can cause significant pain and functional impairment that may be improved substantially with late surgical intervention.     

Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature.

Fractures of the head, neck, and body of the talus present difficult treatment challenges. The vulnerable blood supply and abundant articular surfaces may lead to long-term problems with osteonecrosis and osteoarthrosis. Previous studies of these relatively rare injuries have been mostly small, inconsistent, or anecdotal, leading to confusion and controversy regarding the optimum treatment of various types of talus fractures. The surgeon who treats these injuries must be prepared to address meticulous reduction and fixation, maintain attentive follow-up, and manage the complications that may result despite appropriate treatment. This review summarizes the findings of the literature on each type of talus fracture to provide a clearer picture of their recommended management.     

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."     

Diagnostic imaging of trauma to the ankle and foot: I. Fractures about the ankle

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle. The review is divided into six parts. The initial presentation deals with ankle fractures. Subsequent dialogues will consist of ligamentous injuries, trauma to the talus, calcaneal fractures, midfoot, and forefoot injuries. Plain x-ray film, as well as sophisticated studies, will assist in recognizing these conditions.     

Zur Behandlung der Talusfraktur

It is useful to subdivide talus fractures in central and peripheric ones, as serious complications have to be expected only in the first group. Under 207 central talus fractures the feared talus necrosis has been found after operative treatment as well of collum as of corpus-trochlea fractures in about 21 % of the cases, after conservative treatment in 11 respectively 19%, while posttraumatic arthrosis appears in over 50% (talus fractures with side injuries). The isolated central talus fracture has a better prognosis. The earlier the exact anatomical reposition is realized, the better are the results. Open talus fractures are threatened by infection. The so called central talus fractures — open or closed — are surgical emergency cases and so they have to be treated.     

Talus fractures: a current concepts review of diagnoses, treatments, and outcomes

The talus is the key articular segment linking the leg and foot, and as such, is subject to complex loads and may occasionally fracture. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Appropriate, expedient treatment provides the patient the best chance of obtaining a good functional outcome. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. This current concepts review discusses the pathomechanics, presentation, workup, treatment, and prognosis of fractures of the talar head, neck, body, lateral process, posterior process, and talar extrusions. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review.     

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

BackgroundEpidemiological data on talus fractures from large nationwide and multicenter studies are rare. This study aims to describe the epidemiology, fracture classification and treatment regimens of talus fractures in a large adult Swedish population.MethodsThis observational study is based on data from the Swedish Fracture Register (SFR) including talar fractures in patients ≥18 with a sustained fracture between 2012 and 2021. Epidemiological data on sex, age, injury date, injury mechanism and type (high or low energy trauma), fracture classification (side, type), initial treatment and mortality were analysed.ResultsWe included 1794 talus fractures (1757 patients, 60 % men). Mean age was 40.3 years (range 18–96), and a biphasic age distribution was seen in women. High-energy trauma caused 33 % of all talus fractures. Of all talus fractures, 817 (45.5 %) were classified as AO/OTA type A fractures (avulsion), 370 (20.6 %) as type B (neck) and 435 (24.2 %) as type C (body). The remaining 172 (9.6 %) talus fractures were not classified/unclassifiable. Men were in the majority in all fracture groups except A1. For type A1–3, B1 and C1–2 fractures, most patients were treated non-operatively; in B2–3 and C3 fractures most patients received operative management. Fracture fixation with screws was the dominating surgical treatment. The overall 30-day mortality was 0.2 %.ConclusionTalus fractures are most commonly encountered in young and middle-aged men. In contrast to men, a biphasic age distribution was observed in women. Approximately half of the talus fractures are avulsions. Operative treatment, mostly screw fixation, is performed in more complex fracture configurations (B2, B3 and C3 fractures).Level of evidenceIV, retrospective observational cohort study     

Centrally located osteochondral fracture of the talus.

Osteochondral lesions of the talus are common sequelae of ankle inversion injuries. Many often remain undiagnosed, which may lead to chronic pain and disability. Although attributed to other causes, most authors agree that trauma is the most common etiology. Because of this, transchondral or osteochondral fracture is a more appropriate term. Numerous cases have been documented in the literature with a preponderance for the anterolateral and posteromedial portions of the talar dome. Centrally located lesions are rare and should be treated with early surgical intervention due to the high level of compression transmitted through this area. The authors review osteochondral lesions of the talus and present a case report of a rare centrally located lesion.     

The key role of the lateral malleolus in displaced fractures of the ankle.

The reason why late degenerative arthritis developed in some patients who had sustained displaced bimalleolar fractures of the ankle was investigated. The roentgenograms indicated that incomplete reduction of the lateral malleolus and a residual talar tilt were present. When bimalleolar fractures were created in cadavera the talus could be anatomically repositioned only when the lateral malleolus was accurately reduced. Fifty-three patients with bimalleolar fractures were treated by anatomically fixing the lateral malleolus with a four-hole plate. There was an anatomical reduction of the talus and medial malleolus in each instance and there were no late cases of degenerative arthritis when these patients were followed for from six months to nine years. We concluded that the lateral malleolus is the key to the anatomical reduction of bimalleolar fractures, because the displacement of the talus faithfully followed that of the lateral malleolus.     

A retrospective analysis of the definitive management of open talus fractures at a major trauma centre,comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines

Purpose

Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion.

Methods

A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient’s age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM.

Results

Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group.

Conclusion

FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

     

Ankle fractures in children

In the present work we address the issue of rare childhood bone fractures of the talus. In the study, we retrospectively analyzed a group of pediatric patients with fractures of the talus treated in the space of 10 years at two workplaces of trauma surgery. Patients were evaluated clinically and radiographically with at least one year follow-up. Fourteen patients with a mean age of 12 years met the methodological criteria. All suffered low-energy trauma. According to Marti-Weber classification six of them suffered central fracture of the talus. Of these, two were treated by closed reduction and internal fixation. The other patients were treated conservatively. In one patient we observed the presence of Hawkins' sign. We observed only minor complications in patients with peripheral fractures of the talus. Hawkins' overall average score of our patients was 15 points. The discussion is a comparison of some aspects of fractures of the talus in children and adults. We also note the discrepancies in the conclusions of several authors dealing with the issue of pediatric talar fractures. We specialize in central talus fractures, mechanisms of their origin, their optimal treatment and the issue of factors affecting the emergence of avascular necrosis of the talus. The absence of serious complications in our series of patients may be due to their low numbers, early definitive treatment, or the nature of their fractures. Good therapeutic results may be also due to the lower tendency for developing complications after talar fractures in pediatric patients. In the absence of relevant data in the literature we can accept with certainty only that fracture of the talus in a child should not be overlooked and should be treated according to principles that adhere to the treatment of fractures of the talus in adults, followed by long-term dispensary.     

Fractures of the lateral process of the talus

A retrospective review of nine patients with fractures of the lateral process of the talus indicates that a substantial portion of patients will have persistent symptoms if the fracture is not diagnosed and appropriately treated soon after the injury. When a patient is evaluated for the symptoms of a "sprained ankle," these fractures are often overlooked on the initial roentgenograms. If untreated, these fractures often fail to heal, and persistent pain over the lateral aspect of the ankle following an inversion injury should be investigated for the possibility of this diagnosis. Prompt treatment of acute fractures appears to lead to the best result. Nondisplaced fractures heal well in a short-leg cast, with six weeks of immobilization. Large displaced fracture fragments require surgical treatment: single large fragments should be reduced and internally fixed, and large comminuted fragments should be excised.     

Fractures and dislocations of the talus

Some of the peculiarities of the anatomy of the talus are of special interest: the lack of muscle insertions, the vulnerability of the blood supply, and the fact that about 60% of the surface is covered by hyaline cartilage. This implies that most of the fractures are intra-articular. In 1983, the results of 262 talus fractures were published. Kuner and Lindenmaier found post-traumatic arthritis in about 50% of the cases. A subdivision of peripheral and central fractures is useful; complications like avascular necrosis are found in about 18% of fracture cases of the central talus. Magnetic resonance imaging may be helpful in the early diagnosis of talus necrosis. Hawkins' sign in an anteroposterior roentgenogram after 6 or 8 weeks of fracture dislocation and non-weight-bearing shows that subchondral atrophy is present in the dome of the talus. This excludes the diagnosis of avascular necrosis. Absence of subchondral atrophy in the early months and then later density of the dead bone and atrophy of the surrounding bones imply avascular necrosis. Dislocations around the talus without fractures are classified into three types: talocrural dislocation (i.e., luxatio pedis cum talo), subtalar dislocation (i.e., luxatio pedis sub talo), and the extremely unusual total dislocation of the talar body. The dislocations should be reduced promptly to avoid breakdown of the skin and distal circulatory compromise.     

Diagnostic imaging of trauma to the ankle and foot: IV. Fractures of the calcaneus

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle and foot. This review is divided into six parts. The previous presentations involved ankle fractures, ligamentous injuries, and trauma to the talus. Subsequent dialogues will consist of midfoot and forefoot injuries. Plain x-ray films, as well as sophisticated studies, will assist in recognizing these conditions.