Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years

Management and classification of the fracture of lateral process of talus: An overview and literature update

Fracture of the lateral process of the talus (FLPT) is uncommon in clinical practice and can be easily missed or misdiagnosed. In recent years, as researchers from all over the world have further deepened their research on FLPT, there has been a breakthrough in the classification, and the methods and principles of clinical management have changed accordingly; however, there is still no standardized guideline for the diagnosis and management of FLPT, and there have been few relevant literature review articles related to this kind of fracture in the past at least 5 years. In this article, we review the clinical classification, classification-based therapeutic recommendations, and prognosis of FLPT, with the aim of providing a reference for the clinical diagnosis and management of this infrequent fracture.

Three-dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures

OBJECTIVE

The talus is an important component in the ankle, and its treatment after injury is crucial. However, complications and adverse events due to incomplete traditional classifications may still occur, and these classifications fail to analyze the patterns and distribution of fractures from a three-dimensional perspective. Therefore, in this study, we aimed to analyze the location and distribution of fracture lines in different types of talus fractures using three-dimensional (3D) and heat mapping techniques. Additionally, we aimed to determine the surface area of the talus that can be utilized for different approaches of internal fixation, aiding in the planning of surgical procedures.

METHODS

We retrospectively analyzed data from CT scans from 126 patients diagnosed with talus fractures at our two hospitals. We extracted the CT data of a healthy adult and created a standard talus model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization. Additionally, we measured 20 specimens to determine the boundary for various ligaments attached to the talus. We determined the surface area of the talus available for different surgical approaches by integrating the boundary data with previously reported data on area of exposure.

RESULTS

Without considering the displacement distance of the fracture, fracture types were classified as follows, by combining Hawkins and Sneppen classifications: talar neck, 41.3%; posterior talar tubercle, 22.2%; body for the talus and comminuted, 17.5%; lateral talar tubercle, 11.9%; and talar head, 7.1%. We established fracture line and heat maps using this classification. Additionally, we demonstrated the available area for anteromedial, anterolateral, posteromedial, posterolateral, and medial malleolus osteotomy and Chaput osteotomy approaches.

CONCLUSION

Fracture line and heat map analyses can aid surgeons in planning a single or combined surgical approach for the reduction and internal fixation of talus fractures. Demonstrating the different surgical approaches can help surgeons choose the most effective technique for individual cases.

Fifth Distal Phalanx Avulsion Fracture in a High-Level Marathon Runner

Fifth metatarsal fractures are common foot injuries that involve the long bone on the outer side of the foot, and avulsion fractures involving the short bone and the fifth distal phalanx of the foot have never been reported. A 25-year-old female marathon runner sustained an avulsion fracture of the distal lateral phalanges of the fifth metatarsal. The patient's high functional demands necessitated a conservative approach to minimize complications and facilitate efficient fracture healing. The patient underwent a comprehensive chiropractic rehabilitation program that focused on progressive weight-bearing exercises, range-of-motion activities, strengthening exercises, instrument-assisted soft tissue mobilization (IASTM), therapeutic ultrasound, and laser therapy to stimulate the speed of healing. The patient's progression was closely monitored throughout the rehabilitation process. Because of the nonoperative management and chiropractic rehabilitation, the patient successfully returned to her running activities within a six-week duration. This case demonstrates the effectiveness of nonoperative management and chiropractic rehabilitation in promoting the healing of avulsion fractures of the fifth metatarsal in high-level athletes. This conservative approach can facilitate a safe and efficient return to running activities while minimizing complications and reinjury risks.

Anatomical observation, classification, fracture and finite element analysis of the posterior process of the Asian adult talus

BACKGROUND

Fractures of the posterior process of the talus are rarely seen and frequently overlooked. In our study, anatomical observation and classification of the posterior process of the talus were carried out, and related imaging and finite element methods were combined. The study aimed to observe and provide anatomical data related to posterior process of talus in Asian adults and explore the potential relationships between the different types with fracture of posterior process of talus.

METHODS

Combined with the anatomical morphology and imaging data, the posterior process of talus was divided into four types, and the incidence and fracture situation were statistically analyzed. The finite element models of four different types of talus processes were established and verified, and the stress and strain were simulated and analyzed.

RESULTS

The total incidence of the posterior process of the talus was 97.47%. The proportions of the four types were neck-like 10.13%, flat 36.29%, pointy 12.66% and round blunt 38.39%. The overall incidence of bone cracks of the posterior process of the talus was 4.98%; the most common type was neck-like type. Compared with the value on the other types, the maximum von Mises stress increased by 67.66%, 83.90% and 111.18% on the neck-like posterior process of talus respectively.

CONCLUSIONS

It is speculated that different types of the posterior process of the talus may be related to the probability of fracture, and it may be better to consider different treatment strategies for different types of fractures.

Talar Dome Access Through Posteromedial Surgical Intervals for Fracture Care

BACKGROUND

Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction.

METHODS

Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro-computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals.

RESULTS

The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02).

CONCLUSION

The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially.

LEVEL OF EVIDENCE

Level V, Cadaveric Study.

Mapping of Posterior Talar Dome Access Through Posteromedial Versus Posterolateral Approaches

OBJECTIVE

To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction.

METHODS

A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals.

RESULTS

The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach.

CONCLUSION

The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.

Patient-Reported Outcomes After Lateral Process Talus Fracture

OBJECTIVES

To evaluate functional outcome after lateral process talus fracture using patient-reported instruments and identify injury characteristics that portend a worse prognosis.

DESIGN

Retrospective case series.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Fifty-three patients with isolated lateral process talus fracture and 12 months of minimum follow-up.

MAIN OUTCOME MEASUREMENTS

Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and Foot and Ankle Ability Measure (FAAM).

RESULTS

Mean patient age was 33 years (range, 17-62 years), and mean follow-up was 6.5 years (range, 1-12 years). Twenty-one patients were initially treated nonoperatively and 14 of these patients (67%) failed nonoperative management. Patients who failed nonoperative treatment more commonly had a displaced fracture (12 patients) (P = 0.009). Thirty-two patients had displaced fracture and were treated with early operative fixation. For the entire cohort, final PROMIS PF was 55 (SD -8.3), FAAM Activities of Daily Living (ADL) was 89 (SD -14), and FAAM sport was 77 (SD -20). The patients treated with operative fixation had significantly larger fracture fragments (2050 vs. 1066 mm3, P = 0.017). There was no difference in final outcome between operative and nonoperative patients for PROMIS PF (P = 0.84), FAAM ADL (P = 0.95), or FAAM sport (P = 0.94). There were significantly more subtalar fusions in the nonoperative group (4 patients) as compared to the operative group (one patient) (P = 0.05).

CONCLUSIONS

Most patients with lateral process talus fracture achieve excellent outcome as measured by the PROMIS PF and FAAM at medium-term follow-up. Displaced fractures are likely best managed with early surgical treatment. Patients treated with early surgery have significantly fewer subtalar fusions as compared to patients with nonoperative treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation

The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using open reduction and internal fixation (ORIF) through posteromedial approach and percutaneous screw fixation. From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. The clinical and radiological results were assessed after 4 and 12 months of operation with Visual Analog Scale (VAS) pain and American Orthopedic Foot and Ankle Society (AOFAS) scores. ORIF was performed in four of the cases and percutaneous screw fixation was performed in eight of the cases. The average follow-up period was 13 months. Complications such as wound infection, nerve injury, screw loosening, malunion or nonunion of fracture were absent. For clinical assessment, considerable mprovements were observed for the AOFAS and VAS scores at 4 and 12 months postoperatively for both techniques. There was no significant difference for AOFAS scores and VAS scores between the two techniques (p > 0.05). Both techniques showed good functional outcome and were performed for posterior talar process fracture following the fracture displacement guidelines. Percutaneous screw fixation treatment with computer-assisted three-dimensional evaluation shortened the operation time and reduced incidences of surgical complications.