A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?

Posttraumatic Avascular Necrosis of the Talus: Prevention, Course, and Treatment Options

Avascular necrosis (AVN) of the talus in a posttraumatic setting describes a condition of temporary or permanent bone death of a different extent, initiated by a circulatory disturbance. It is estimated that about 75% of all talar AVNs are caused by a prior trauma. The incidence of posttraumatic AVN rises with higher energy of injury, severity of talar body or neck displacement, fracture comminution, and injury to the soft tissues and major vessels in the lower leg and ankle region. These conditions are often seen in open fractures, fracture dislocations, and pure dislocations.

Ballistic talus fractures: a retrospective analysis

INTRODUCTION

Ballistic talus fractures are difficult to treat and there is a paucity of literature regarding the subject. The goal of the current study is to outline our experience and epidemiological findings from a single center with a large case series of ballistic talus fractures.

MATERIALS AND METHODS

Institutional Review Board approval was obtained for a retrospective review of skeletally mature patients with ballistic talus fractures from August 2019 to June 2023. Fracture morphology of the talus, the presence of displacement, and the talar declination angle (TDA) were all characterized. Demographic variables were obtained. All complications were recorded.

RESULTS

21 tali were included in this cohort (average age = 26, SD = 9.5). 11 (52%) talus fractures were displaced at initial injury and 17 (81%) had additional fractures of the ipsilateral foot and ankle. 29% (6/21) of tali were treated operatively with fixation: 2 talar body, 2 talar neck, and 2 talar head. TDA improved in patients treated operatively (21.8° pre-operatively, 19.6° post-operatively) but not in those treated non-operatively (24.5° pre-operatively, 25.5° at final follow-up). The overall complication rate was 29% (6/21) including 2 minor complications (superficial wound dehiscence) and 4 major complications: 3 patients with early signs of avascular necrosis (AVN)/collapse and 1 infected non-union. Although we had 3 patients with signs of AVN, one of which was converted to an ankle fusion, all patients were sucessfully treated with limb salvage.

CONCLUSIONS

The current study offers a unique and previously unreported cohort of gunshot related talar fractures. Our deep infection rate of 4.8% was similar to other studies of closed talus fractures. We found an improvement in the average TDA for the operatively treated fractures, which may represent improvements in fracture reduction with operative fixation. Further studies with longer follow-up are necessary improve our limited understanding of these injuries and to enhance treatment.

Avascular Necrosis of the Talus: Diagnosis, Treatment, and Modern Reconstructive Options

Talar avascular necrosis (AVN) is a devastating condition that frequently follows type III and IV talar neck fractures. As 60% of the talus is covered by hyaline cartilage, its vascular supply is limited and prone to trauma, which may eventually lead to AVN development. Early detection of AVN (Hawkins sign, MRI) is crucial, as it may prevent the development of the irreversible stages III and IV of AVN. Alertness is advised regarding non-obvious conditions that may cause this complication (sub chondroplasty, systemic lupus erythematosus, diabetes mellitus). Although, in stages I-II, AVN may be treated with non-surgical procedures (ESWT therapy, non-weight bearing) or joint-sparing techniques (core drilling, bone marrow aspirate injections), stages III-IV require more advanced procedures, such as joint-sacrificing procedures (hindfoot arthrodesis/ankle arthrodesis), or replacement surgery, including total talar replacement (TTR) or combined total ankle replacement (TAR). The advancement of 3D-printing technology and increased access to implant manufacturing are contributing to a rise in the production rates of third-generation total talar prostheses. As a result, there is a growing frequency of alloplasty procedures and combined total ankle replacement (TAR) surgeries. By performing TTR as opposed to deses, the operator avoids (i) delayed union, (ii) a shortening of the limb, (iii) a lack of mobility, and (iv) the stiffening of adjacent joints, which are the main disadvantages of joint-sacrificing procedures. Simultaneously, TTR and combined TAR offer (i) a brief period of weight-bearing restriction, (ii) quick pain relief, and (iii) preservation of the length of the limb. Here, we summarize the most up-to-date knowledge regarding AVN diagnosis and treatment, with a special focus on the role of TTR.

A rare combination of talar neck fracture (Hawkins 3) and bimalleolar ankle fracture: A case report

INTRODUCTION

The combination of talar neck fractures with malleolar fractures is a rare. This rare association accounts for 0.3 % of all bone fractures. We describe a one-of-a-kind ankle dislocation with a talar neck fracture and a bimalleolar fracture.

CASE PRESENTATION

A 24-year-old male patient presented to the emergency department after a traffic accident. A physical examination revealed swelling and tenderness in the left ankle. The radiograph and the CT scan showed a Hawkins type III comminuted talar neck fracture, with an oblique fracture of the medial malleolus and an infra-syndesmotic fracture of the lateral malleolus. The patient underwent open reduction and internal fixation involving screw fixation for talar neck fracture and the medial malleolus and plating for the lateral malleolus. The treatment and post-operative follow-up showed successful healing and functional recovery, with a score of 85 on the American Orthopedic Foot and Ankle Society ankle-hindfoot at the last follow up.

DISCUSSION

The discussion includes insights on the rarity of this fracture combination, treatment challenges, and potential complications such as avascular necrosis. This article emphasizes the importance of achieving anatomical reduction and stable fixation for optimal outcomes in such complex fractures.

CONCLUSION

This case report highlights the successful treatment of a rare combination of talar neck and bimalleolar ankle fractures, emphasizing the importance of anatomical reduction and stable fixation for optimal outcomes in complex fractures.

Management of Talus Fractures

Fractures of the talus are life-changing events. The talus is of vital importance to normal gait. Given its importance, great care is needed in diagnosing and treating these injuries. The threshold for operative treatment and accurate anatomic reduction should be low. Surgical tenets include the avoidance of extensive subperiosteal dissection to minimize vascular disruption. The complications with injuries to the talus are extensive and include avascular necrosis (AVN). Although AVN can prove to be a devastating sequela from this injury, it occurs less frequently than posttraumatic arthritis.

The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

BACKGROUND

Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy.

METHODS

A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing.

RESULTS

In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked.

CONCLUSIONS

A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis

OBJECTIVES

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs).

METHODS

DESIGN

Retrospective cohort.

SETTING

Single level I trauma center.

PATIENT SELECTION CRITERIA

Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse.

RESULTS

There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)].

CONCLUSIONS

This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Midterm Outcomes after Operative Management of Hawkins Type III Talar Neck Fractures

Background

This study aims to report the midterm outcomes after surgical treatment of Hawkins Classification III Talar neck fractures.

Methods

From March 2010 to April 2022, among a total of 155 patients who visited our hospital with talus fractures, 31 patients underwent surgical treatment for Hawkins classification III talar neck fractures. The inclusion criteria comprised patients with a symptom duration of over 1 year who were available for outpatient follow-up and underwent magnetic resonance imaging (MRI) follow-up 2 months after surgery. Exclusion criteria included patients without preoperative ankle periarticular arthritis, and a total of 27 patients were enrolled. Traffic accidents and falls accounted for 86% of 23 cases, open fractures were 8 cases, and the mean follow-up period was 34.10 months (range, 12-80 months). Clinical outcomes were measured by American Orthopaedic Foot and Ankle Society (AOFAS) score and Foot function index (FFI), and radiological results were obtained using simple radiographs before and after surgery and MRI at 2 months postoperatively to confirm bone union and complications.

Results

Complete bone union was achieved in all cases, and the mean duration of union was 4.9 months (range, 4-6 months) and there were no nonunion and varus malunion. At the final follow-up, the mean AOFAS score was 80.18 points (range, 36-90 points) and the mean FFI score was 31.43 points (range, 10-68 points), showing relatively good clinical outcomes. There were 15 cases of avascular necrosis, 6 cases of traumatic arthritis of the ankle joint, 6 cases of irritation of the posterior tibial nerve, and 4 cases of wound problems.

Conclusions

Hawkins classification III talar neck fractures are mostly caused by high-energy injuries and have a relatively poor prognosis due to the high incidence of complications such as avascular necrosis or posttraumatic arthritis. However, if correct anatomical reduction and rigid internal fixation are performed within a short time after the injury, good results can be expected.

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.

Infection Rates and Surgical Procedures Associated With Isolated Open Talar Neck and Body Fractures

BACKGROUND

Open fractures of the talar body and neck are uncommon. Previous reports of associated deep infection rates and resulting surgical requirements vary widely. The primary objective of this study is to report the incidence of deep infections for isolated open talar body and neck fractures, and secondarily the incidence and number of total surgeries performed (TSP), secondary salvage procedures (SSPs), and nonsalvage procedures (NSPs).

METHODS

Retrospective case-control study of 32 consecutive isolated open talus fracture patients (22 neck, 10 body) were followed for an average of 39.2 months.

RESULTS

Five (15.6%) fractures developed deep infections. Fifty percent of open body fractures became infected compared with 0% of neck fractures (P < .001). There was no difference between infected group (IG) and uninfected fracture group (UG) with respect to age, sex, body mass index, tobacco, diabetes, vascular disease, open fracture type, wound location, hours to irrigation and debridement, or definitive treatment. The majority (92.6%) of UG fractures used a dual incision with open wound extension. There were more single extensile approaches in the IG group (P = .04). The IG required 5.8 TSP per patient compared with 2.1 in the UG (P = .004). All (100%) of the IG required an SSP compared with 29.6% of the UG (P = .006). All (100%) of the IG required an NSP compared to 40.7% of the UG (P = .043). In the IG, 2.8 NSPs per patient were required after definitive surgery compared with 1.18 in the UG (P = .003). Of those followed 1 year, the incidence of SSP remained higher in the IG (P = .016).

CONCLUSION

The incidence of deep infection following isolated open talar fractures is high and occurs disproportionally in body fractures. Infected fractures required nearly 6 surgeries, and all required SSP.

LEVEL OF EVIDENCE

Level IV, prognostic.

Primary total talus arthroplasty for Hawkins type IV talar neck fracture dislocation

A woman in her 40s was involved in a motor vehicle collision and sustained a closed Hawkins type IV talar neck fracture dislocation. The injury was treated with reduction, percutaneous pinning and spanning external fixation, followed by definitive treatment with total talus arthroplasty (TTA) 2 months following injury. This is a unique example of definitive management for a severe talar neck fracture dislocation with arthroplasty in the subacute setting. TTA is perhaps a primary option for these injuries at high risk for avascular necrosis, non-union, malunion and post-traumatic arthritis.

Identifying Risk Factors for Osteonecrosis After Talar Fracture

OBJECTIVE

To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors.

METHODS

DESIGN

Retrospective chart review.

SETTING

21 US trauma centers and 1 UK trauma center.

PATIENT SELECTION CRITERIA

Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes.

RESULTS

In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.

CONCLUSIONS

Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A rare case of floated talar head accompanying medial subtalar dislocation

INTRODUCTION AND IMPORTANCE

Concomitant medial subtalar dislocation and a rotated displaced talar neck fracture may result in poor outcomes. This study aimed to explain this extremely rare injury and assess the clinical outcomes following surgical treatment.

CASE PRESENTATION

A 22-year-old Iranian man referred to the emergency department with a gross deformity and pain in his right foot and ankle after a falling from 2 m. Plain radiographs showed a rotated free talar head accompanying medial subtalar dislocation. Closed reduction was performed in the emergency department under sedation. Prompt open reduction and internal fixation of talar fracture was done, after removal of free osseocartilaginous fragments in the subtalar and talonavicular joints. At 25 months postoperatively, the clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and visual analogue scale for pain which were 73 and 3, respectively. In exam, the patient had a stiffed subtalar joint without talar osteonecrosis or collapse.

CLINICAL DISCUSSION

Several osseous and soft tissue barriers could prevent a successful closed reduction of a subtalar dislocation. Associated cartilage injuries or fractures may result in poor clinical outcomes such as persistent pain, limping, osteoarthritis, and osteonecrosis. Immediate open reduction and rigid fixation of associated fractures and resection of small free osseocartilaginous fragments may prevent further soft tissue damages and preserve clinical functions.

CONCLUSIONS

Satisfactory clinical outcome could be expected following proper on-time approach to a subtalar dislocation associated with a rotated displaced talar neck fracture.

History of the management of talar fractures: from the fall of king Darius to Garibaldi's bullet and from the earliest to current operative strategies

PURPOSE

This historical review aims to highlight the important roles of the talus in antiquity and to summarise the multiple attempts of managing talar fractures throughout history.

METHOD

Archaeological, religious, artistic, literary, historical and scientific accounts were searched for the descriptions of talus fractures in different eras and their treatments to provide a thorough analysis of the evolution of trauma care up to the present.

RESULTS

This review shows how the talus has always had an important role in several societies: it was used as a die or considered to have a divinatory function in Mesopotamian civilisations, among Greeks and Romans, in Mongolia and in pre-Columbian Americas. Famous talus fractures are recorded in Herodotus' Histories and in the Acts of the Apostles. We report the earliest injuries described and the first operative managements between 1600 and 1800, including the one that saved Garibaldi's life in 1862, until the modern osteosynthesis by the first screws and nails and the current fixation by plating.

CONCLUSION

The blooming of orthopaedic surgery at the end of nineteenth century and the high volume of traumas managed in the World Wars brought a better understanding of fracture patterns and their operative treatment. By the work of Hawkins and his classification, the introduction of the CT scan, a better knowledge of injury modalities and bone vascularisation, these challenging injuries finally land in the contemporary era without mysteries. The subsequently developed surgical procedures, although not guaranteeing success, greatly reduce the risk of necrosis and complication rate, improving patient outcomes.

New Classification Based on CT and Its Value Evaluation for Fractures of the Lateral Process of the Talus

This study aimed to develop a comprehensive classification system for fractures of the lateral process of the talus (LPTF) based on CT, and to evaluate its prognostic value, reliability and reproducibility. We retrospectively reviewed 42 patients involving LPTF with an average follow-up of 35.9 months for clinical and radiographic evaluations. In order to develop a comprehensive classification, a panel of experienced orthopedic surgeons discussed the cases. All fractures were classified according to Hawkins, McCrory-Bladin and new proposed classifications by 6 observers. The analysis of interobserver and intraobserver agreements was measured using kappa statistics. The new classification included 2 types based on presence of concomitant injuries or not, with type I consisting of 3 subtypes and type II of 5 subtypes. Average AOFAS score was 91.5 in the type Ia of new classification, 86 in type Ib, 90.5 in type Ic, 89 in type IIa, 76.7 in type IIb, 76.6 in type IIc, 91.3 in type IId, and 83.5 in type IIe. Interobserver and intraobserver reliability of the new classification system were almost perfect (κ = 0.776 and 0.837, respectively), showing a higher interobserver and intraobserver reliability compared to the Hawkins classification (κ 0.572 and 0.649, respectively) as well as McCrory-Bladin classification (κ = 0.582 and 0.685, respectively). The new classification system is a comprehensive one that takes into account concomitant injuries and shows good prognostic value with clinical outcomes. It is more reliable and reproducible and could be a useful tool for decision-making on treatment options for LPTF.

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

BACKGROUND

The 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.

METHODS

We 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.

RESULTS

In 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.

CONCLUSION

We 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 EVIDENCE

Level IV, Case series.

Complications after talus fractures: A trauma centre experience

BACKGROUND

Talus 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.

METHODS

We 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.

RESULTS

The 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.

CONCLUSION

Our 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 body and posterior talar process fracture combined with peritalar luxation (clinical case)

The uniqueness of this clinical case is due to a rare combination of peritalar luxation of the talus with a fracture of its body and posterior process. No description of the same clinical case was found in the literature, however, it has been proven that such injuries have an unfavorable prognosis and are fraught with multiple complications. Also, the limited information associated with the low inci-dence of this type of severe injury puts practitioners in front of the difficulties of diagnosis and treatment. A 35-year-old man was injured while playing basketball. Upon admission, computed tomography (CT) revealed a fracture of the body of the talus with displacement of the distal fragment and its dislocation in the talonavicular, subtalar and talo-tibial joints, as well as a fracture of the posterior process of the talus. After an unsuccessful attempt at closed reduction, open removal of the dislocation and reposition of fragments were per-formed, followed by osteosynthesis of the fracture of the body of the talus. In the postoperative period, additional immobilization in the ANF was performed, followed by replacement with a functional orthosis. 6 months after the injury, the patient restored the level of his daily activities almost completely, the control CT showed no signs of post-traumatic arthrosis of the subtalar and ankle joints, how-ever, there were signs of the development of partial aseptic necrosis of the talus. This injury is unique, and despite its severity, the use of the correct treatment tactics can provide a satisfactory clinical and functional outcome.

Talar neck and body fracture outcomes: a multicentre retrospective review

PURPOSE

Talar neck and body fractures are uncommon injuries that are challenging to manage with high reported complication rates, including post-traumatic arthritis, avascular necrosis, and poor functional outcomes. The aim of this study was to assess the complication rates for patients with talus fractures across three major trauma centres (MTCs) in England.

METHODS

A retrospective analysis was performed of prospectively collected trauma databases. Data were collected from three English MTCs. Patients with talar neck and/or body fractures sustained between August 2015 and August 2019 were identified and their clinical course reviewed radiologically and clinically. Isolated process fractures, osteochondral defects and paediatric patients were excluded. Patients were analysed by fracture type and for definitive treatment method with separation into non-operative and operative management groups. Procedure type was identified in the operative group. Superficial infection, deep infection, non-union, avascular necrosis, post-traumatic arthritis and removal of metalwork rates were analysed.

RESULTS

Eighty-five patients with talar neck and/or body fractures were included. Seventy-five patients received operative management, 10 non-operative. The overall AVN rate was 5.9% (five patients), overall post-traumatic arthritis rate was 18.8% (16 patients), deep infection rate 1.2% (one patient), non-union rate 4.7% (four patients). Removal of metalwork rate was 9.4% (eight patients).

CONCLUSION

Our reported outcomes and complication rates are generally lower than those previously described. This may be a result of improved techniques, a higher frequency of open reduction with direct visualisation or by surgery occurring in centralised specialist centres.

3D-Printed Total Talus Replacement After Free Vascularized Medial Femoral Condyle Osteocutaneous Flap for Avascular Necrosis of the Talus Leads to Poor Clinical Outcomes: A Case Series

INTRODUCTION

Avascular necrosis (AVN) of the talus is 1 of the most difficult foot and ankle pathologies to diagnose and manage. The purpose of this study was to report on the functional outcomes of 3D-printed total talus replacement (TTR) in 2 patients with talar AVN who both underwent a failed revascularization.

METHODS

This is a case series of 2 patients with TTR after a failed revascularization and a comparison group of 25 patients with primary TTR. Clinical and functional outcomes are used to compare both groups.

RESULTS

Patient 1 had a postrevascularization Visual Analogue Scale (VAS) pain score of 9. Imaging showed failure of the medial femoral condyle to incorporate with talar fragmentation. Patient underwent TTR at 5 months postoperatively. At 2 years postoperatively, the patient underwent a cavovarus foot reconstruction; however, patient continued to suffer from ankle pain (VAS 6) and ultimately underwent below knee amputation at 3 years after the TTR. Patient 2 initially underwent a core decompression for a talar bone infarct followed by revascularization procedure at 6 months postoperatively due to persistent pain and bony infarcts. At 18 months postrevascularization, the patient had a VAS pain score of 9 and progression of the AVN. She underwent a TTR. At 1-year follow-up, the VAS pain score was 8. Both patients had an ankle plantarflexion of 30° at their last TTR follow-up. The comparison group consisted of 25 patients who underwent 3D-printed TTR with mean postoperative VAS score and ankle plantarflexion of 3.7° and 41.8°.

CONCLUSION

Patients 1 and 2 demonstrated reduced plantarflexion and ankle motion after TTR relative to the comparison group which improved in both physical assessments. The first patient needed a below knee amputation for persistent pain. Patient 2 showed less improvement in all the foot and ankle outcome scores as compared with the primary TTR group.

LEVEL OF EVIDENCE

Level V: Retrospective case series.

An Unusual Inverted Talar Neck Fracture–Dislocation

Talar neck fractures occur on a continuum of injury severity. Hawkins classification, later modified by Canale, is the gold standard method of describing talar neck fractures by the degree of dislocation. It has proven to be clinically relevant in predicting risk of osteonecrosis. Despite its merits, talar neck fractures present on a wide spectrum of involvement of the body and neck, dislocation, and concomitant injuries, making every situation a challenge in treatment. We present a unique case of a talar neck fracture in which the talar dome had dislocated and inverted 180°, which is not described in the widely used Hawkins classification. We recommend urgent open reduction, low threshold for use of a transcalcaneal traction pin and dual incisions, and guarded prognosis of osteonecrosis and posttraumatic arthritis.

Talus Fractures: An Update on Current Concepts in Surgical Management

Talus fractures can be challenging injuries to treat because of complex talar shape, an abundance of articular cartilage, a potentially unforgiving soft-tissue envelope, and an easily injured blood supply. In addition, the spectra of energy involved, soft-tissue injury, and the fracture pattern are wide. Temporizing treatment is sometimes required, including débridement of open fractures, reduction of dislocations, and occasionally spanning external fixation. Definitive treatment first requires an understanding of the fracture pattern, including location and fracture line orientation. Multiple options for surgical exposure exist and are selected based on the fracture pattern and condition of the soft tissues. Newer fixation techniques, including the use of fixed-angle and minifragment implants, are useful in achieving stable fixation.

Complications and Functional Outcome Following Operative Treatment of Talus Neck and Body Fractures: A Systematic Review

Background:

Central talar fractures are rare and often associated with impaired functional outcome. Despite recent advances in diagnosis and management of talus fractures, complications rates remain high and functional outcome is generally poor. This study aims to provide an overview of complication rates and functional outcome following operative treatment of talar neck and body fractures. This may help in clinical decision making by improving patients’ expectation management and tailored treatment strategies.

Methods:

A systematic review of the literature was conducted of studies published from January 2000 to July 2021 reporting functional outcome and/or complications following operative treatment of talar neck, body, or combined neck and body fractures. Keywords used were (Talar fracture) or (Talus fracture). Data on complication rates and functional outcome was extracted from selected articles.

Results:

A total of 28 articles were included in our analysis reporting 1086 operative treated talar fractures (755 neck [70%], 227 body fractures [21%], and 104 combined body and neck fractures [9%]). The mean follow-up was 48 (range 4-192) months. Complications occurred frequently with; 6% surgical site infection, 8% nonunion, 29% avascular necrosis, 64% osteoarthritis, and in 16% a secondary arthrodesis was necessary. A wide variety in functional outcome was reported; however, there seems to be a correlation between fracture classification and postoperative complications.

Conclusion:

Operative treatment of central talar fractures is associated with a high incidence of early and late complications and often leads to an impaired functional outcome. Standardization of talar fracture classification and scoring systems in combination with large sample-sized prospective studies are warranted to detect further predictive factors influencing tailormade treatment strategies and patient expectation management.

Level of Evidence:

Level III, Systematic review of case series and case-control studies.

Functional outcome and quality of life in surgically treated talar neck and body fractures; how is it affected by complications

BACKGROUND

Since talus fractures are rare, study populations are frequently small. The aim of this study is to describe how surgical treatment of talar neck and body fractures and postoperative complications affect functional outcome and quality of life measured by validated questionnaires.

METHODS

All patients following surgically treated talar neck and/or body fracture between January 2000 and December 2019 at a level 1 trauma center were included in this retrospective cohort study. Primary outcomes were functional outcomes measured by Lower Extremity Functional Score (LEFS), the Foot Function Index (FFI), and the Quality of Life (QOL) measured by the EuroQol 5-dimension questionnaire (EQ-5D). Linear regression was used to assess the relationship between continuous variables and the outcome, and multivariable linear regression was used to identify the predictors of the functional outcome.

RESULTS

Ninety patients were included, of which 73 responded to our questionnaires. The median follow-up time was 50.5 (interquartile range (IQR), 18.3-97.3) months. Our study showed the following results: a mean LEFS of 58.4 (range, 17-80), a median FFI of 15.7 (IQR, 3.5-35.2), a median EQ-5D index score of 0.83 (IQR, 0.81-1.00), a median patient satisfaction of 9.0 (IQR, 8.0-10.0), a patient reported health status of 76.8 (range, 20-100), and a mean AOFAS score of 75.7 (range, 28-100). Implant removal and secondary arthrodesis were associated with a reduced AOFAS outcome score (p=0.001, p<0.001), and implant removal was also a predictive factor for a less favorable LEFS outcome score (p=0.001).

CONCLUSION

Patients who underwent implant removal and/or secondary arthrodesis had poorer functional outcome compared to patients who did not undergo additional procedures. Careful consideration of re-intervention must be made in combination with patient expectation management. Future studies should focus on how to lower the rate of complications and the effect of secondary intervention with the use of validated questionnaires.

Union Rates of Talar Neck Fractures With Substantial Bone Defects Treated With Autograft

BACKGROUND

This study evaluated the union rate of talar neck fractures with substantial bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis.

METHODS

A case series at a level 1 trauma center was performed to identify consecutive patients who underwent operative fixation of talar neck fracture with autograft (Current Procedural Terminology codes 28445 and 20902) between 2015 and 2018. "Substantial bone defect" was defined as a gap greater than 5 mm in the sagittal plane and greater than one-third of width of the talar neck in the coronal plane. Postoperative foot computed tomographic (CT) scans were obtained for all patients. Primary outcome was union, and secondary outcomes were malunion, avascular necrosis (AVN), post-traumatic arthritis (PTA), and patient-reported outcomes (PROs).

RESULTS

Twelve patients with 12 fractures were included in the series, with an average length of follow-up of 26 months (range: 7-55) The average age was 34 years (17-59), and the most common mechanism of injury was motor vehicle crash. The Hawkins classification of the fractures was 4 type II (2 type IIA and 2 type IIB) (33%) and 8 type III (67%). Four fractures (33%) were open fractures. Union was achieved in 11 patients (92%). There was 1 malunion (8%). AVN was identified on postoperative CT scans in 11 patients (92%). Three of these 11 eventually showed collapse. Ten patients (83%) had radiographic evidence of some degree of ankle PTA, and 12 patients (100%) had radiographic evidence of some degree of subtalar PTA. Average Patient-Reported Outcomes Measurement Information System-Short Form score was 37 (32-45) and average Foot and Ankle Ability Measure activities of daily living and sports subscale scores were, respectively, 61 (31-87) and 31 (0-71), respectively. Average visual analog scale score was 5 (0-10), and average Foot Function Index was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients.

CONCLUSION

In this relatively small series, tibial autograft in primary osteosynthesis of comminuted talar neck fractures with substantial bone defects is associated with excellent union rates and low malunion rates. Despite high union rates, secondary outcomes of AVN with or without collapse, ankle and subtalar PTA, and relatively low PROs were common.

LEVEL OF EVIDENCE

Level IV, case series.

Medical Malpractice Trends in Foot and Ankle Surgery

Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Forty-nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Talus Fractures: All I need to know

Talus fractures result following high energy trauma and can lead to significant functional impairment. The complex morphology of the talus, it's multiple articulations and tenuous blood supply translate into significant challenges that must be overcome to achieve the best possible outcomes. Despite advances made in their management, they continue to have high complication rates. Nonetheless, restoration of normal alignment will optimise outcomes. In this article, we report on the epidemiology, anatomy, classification, patient evaluation and current evidence for the management of talus fractures.

Talar fracture: Epidemiology, treatment and results in a multicenter series

INTRODUCTION

Talar fracture is rare. Treatment is surgical for neck and/or body fractures with displacement. The aims of the present study were to collect epidemiological data on talar fractures, and to assess the impact of trauma via various functional scores and radiographic impact in the medium term.

HYPOTHESIS

Displaced talar fracture shows negative medium-term functional and radiological/clinical impact.

MATERIAL AND METHODS

A multicenter retrospective study was performed with a minimum follow-up of 12 months post-trauma. Inclusion criteria included radiographic assessment at a minimum 12 months post-trauma and data on 3 functional scores: SF12, AOFAS and FAAM. 225 patients were initially included, 81 of whom had follow-up with functional and radiological/clinical assessment.

RESULTS

Fracture reduction was anatomic in 61% of cases when CT was performed; reduction quality was independent of approach (p>0.05). 45% of patients showed subtalar osteoarthritis at a mean 2 years, significantly related to reduction defect (p<0.05). Mean AOFAS score was acceptable, at 74/100. Factors for functional prognosis comprised: reduction quality, hindfoot alignment, subtalar osteoarthritis, and talar osteonecrosis with dome collapse.

DISCUSSION

Talar fracture led to late complications with socioeconomic impact. Subtalar osteoarthritis affects almost half of patients within some months of trauma. Optimal reduction is the key to fair progression. Postoperative CT assessment now seems mandatory.

LEVEL OF EVIDENCE

IV; multicenter retrospective study.

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 and Sustentaculum Fracture Fixation

SUMMARY

Talar neck fractures are uncommon fractures that result from high-energy trauma causing bony and soft tissue injury. When combined with sustentaculum fractures, care must be taken to plan the approach and fracture fixation strategy. We present a 57-year-old woman who experienced a motor vehicle accident, sustaining a Hawkins II talar neck fracture with associated sustentaculum tali fracture. We demonstrate the dual-incision approach to the talar neck with medial screw and lateral plate fixation. The sustentaculum fixation was accomplished with cannulated screws through a direct medial approach.

Different patterns and characteristics of Talar injuries at two main orthopedic trauma centers in Shiraz, south of Iran

BACKGROUND

Categorizing different injury patterns of the talus, describing demographic data, mechanisms of injury and associated fractures are important issues in orthopedic trauma surgeries. Injuries of the talus require careful attention with appropriate treatment approaches in order to reduce possible complications.

METHODS

In a cross-sectional study, the demographic characteristics, mechanism of injury, fracture type, and associated fractures were compiled from all patients' files and operation notes with diagnosis of talar injuries from January 2014 to December 2019.

RESULTS

Among 367 patients, 317 (86.4%) males and 50 (13.6%) females with mean age of 31.8 ± 11.6 years were identified. There were three (0.8%) patients with bilateral talar fractures. The most common mechanism of injury was motor vehicle accident (MVA) (46.1%), followed by falls (43.3%), direct trauma (6.2%) and sport injuries (4.4%). About half of the patients injured in MVAs were motorcyclists. Isolated talar body fractures (21.9%) were more common than isolated talar neck (19.2%) or combined body & neck fractures (14.6%). Isolated lateral process fracture is the most frequent fractured process of the talus (14.3%). Hawkin type IIA (39.2%) was the most common type of talar neck, followed by Hawkin type III (22.3%), type I (21.5%), type IIB (14.6%) and type IV (2.3%). Medial malleolus, fibula and calcaneus were the most common associated fractures, respectively.

CONCLUSIONS

The population that is most affected by talar injury are active young men who are involved in motor vehicle accidents, especially motorcycle crashes, with fracture of body and/or neck of talus being the most common type.

Surgical management of displaced talus neck fractures: single vs double approach, screw fixation alone vs screw and plating fixation-systematic review and meta-analysis

PURPOSE

To provide a direct comparison between two important aspects related to talar neck fractures management - surgical approaches and fixation strategies.

DATA SOURCES

A systematic review and meta-analysis was performed using PubMed, SciELO, and gray literature databases. The keyword "talus fracture" and the combined terms "talus neck fracture AND surgical approach" and "talus neck fracture AND fixation strategy" were used.

STUDY SELECTION

Study selection, data extraction, and the risk of bias assessment were performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Searches were limited to human studies and the English and Portuguese. Inclusion criteria were articles in full text that reported on any aspect of surgical approach and fixation strategy for talus neck fractures. Exclusion criteria were skeletally immature patients, mean follow-up of less than 12 months, studies that did not use the Hawkins classification system, primary treatment of arthrodesis, studies published before year 2000, and studies published in languages other than English and Portuguese.

DATA EXTRACTION

Basic information was collected including journal, author(s), year published, level of evidence, number of fractures, and follow-up. Specific information was collected including fracture classification, surgical approach, fixation strategy, complication rate, type of complication(s), and outcome measurement(s).

DATA SYNTHESIS

Fixed-effects model was used for meta-analysis. The choice for surgical approach(es) and fixation strategy was stratified based on fracture classification. Complication rate, type of complication(s), and outcome measurement(s) were calculated for all studies and delineated by fracture classification.

CONCLUSION

There is a significant correlation between poor scores and poor fracture reduction, but not with the modified Hawkins classification, surgical approach, and fixation strategy. The presence of an open talus neck fracture-dislocation jeopardizes the functional outcome, increasing the risk of complications. The overall avascular necrosis and post-traumatic osteoarthritis event rate was 0.279 and 0.400, respectively. Both complications were highly correlated to higher energy fracture patterns and to the use of combined approaches, but not to fixation strategy.

LEVEL OF EVIDENCE

I (systematic review and meta-analysis).

Custom-Made Total Talonavicular Replacement in a Professional Rock Climber: Functional Evaluation With Gait Analysis and 3-Dimensional Medical Imaging in Weightbearing at 5 Years' Follow-Up

With the goal to restore ankle and foot function also in the long term, custom-made prostheses are becoming more frequently possible solutions for severe bone loss and avascular necrosis of the talus. A young professional rock climber was implanted with a custom-made talonavicular prosthesis, and short-term (30 months) assessment has been published. A thorough assessment at the intermediate term (60 months), with state-of-the-art gait and medical imaging analyses, is reported here. Level walking and more demanding motor tasks were analyzed with both a full-body and a multisegment foot protocol on the operated and contralateral limbs. Cone-beam computer-tomography was also used to obtain 3-dimensional (3D) position and orientation of bone models on the operated ankle. These models were also used for a 3D video fluoroscopy analysis, with the ankle in 3 joint positions at the extremes of motion. Distance map analysis was performed to check for possible changes over time of bone morphology and joint contact areas, in all 3 joint positions. Very satisfactory functional results were observed, with large and symmetric joint motion and physiological muscular recruitment even in demanding motor tasks. Distance map analyses revealed that very small morphologic and contact patterns changes occurred in the replaced ankle between 30 and 60 months. Concerns about possible wear of the cartilage in the tibial mortise are not yet supported by experimental evidence.

Avascular Necrosis of the Talus

Talar osteonecrosis results from trauma to the fragile blood supply to the talus. Many etiologies exist that can cause talar osteonecrosis, with the most common being talar neck fractures. Patients with talar osteonecrosis frequently present with progressive ankle pain and limited range of motion. Treatment strategy depends primarily on the stage of disease. Conservative care in the form of medications and bracing treatment can be beneficial for patients with low functional status and early disease stages. Surgical options also exist for early disease without talar collapse that can potentially preserve the tibiotalar joint. Once talar collapse develops, surgical treatment is move invasive and typically involves an arthrodesis or talus arthroplasty. Although some treatment guidelines exist based on the disease stage, talar osteonecrosis is a complex problem, and treatment strategy should always be determined on a case-by-case basis carefully examining all clinical aspects.

3D Printed Total Talus Replacement for Avascular Necrosis of the Talus

BACKGROUND

Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend on disease severity and functional goals. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study was to evaluate outcomes following TTR with a custom 3D printed metal implant.

METHODS

Patients who underwent TTR were retrospectively reviewed over a 3-year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog scale (VAS) scores, Foot and Ankle Outcome Scores (FAOSs), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre- and postoperatively. Twenty-seven patients underwent TTR for talar AVN with a mean follow-up of 22.2 months.

RESULTS

Ankle range of motion remained unchanged postoperatively. VAS pain scores improved postoperatively from 7.1 to 3.9 (P < .001). FAOSs improved postoperatively with regard to pain (P < .001), symptoms (P = .001), quality of life (P < .001), and activities of daily living (P < .001). There were 3 complications requiring reoperation in this cohort.

CONCLUSION

3D printed TTRs represent a unique surgical option for patients with severe talar AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and AVN.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Talar Neck Fractures: Single or Double Approach?

Correct approach selection in talar neck injuries is crucial to obtain adequate access to the entire fracture site avoiding malreduction and angular deformity. The major concern about a single incision technique is lack of visualization. Combined lateral and medial approaches are strongly recommended in complex talar neck fractures providing better control of dorsal and varus displacement of the talar head.

Pedobarography shows no differences in gait after talar fractures

BACKGROUND

Fractures of the talus often lead to permanent restrictions of the affected limb. Possible alterations after these fractures in gait have not been evaluated yet.

OBJECTIVE

To evaluate possible alterations of gait by pedybarography after talar fractures.

METHODS

We conducted a retrospective single-centre study at a level I trauma center. Twenty patients with operatively treated talar fractures were followed up. Objective and subjective function of the ankle was measured using range of motion, clinical scores and dynamic pedobarography (emed-M; Novel, Germany).

RESULTS

There were 11 talar neck and 9 talar body fractures. All patients received screw fixation. There was a significant reduction in range of motion. The outcome was moderate to satisfying and the severity of the injury correlated with the clinical outcome and the range of motion. The presence of posttraumatic arthritis and joint incongruity lead to a decreased function of ankle and subtalar joint and resulted in a worse clinical outcome. AVN rate was associated to initial displacement. Dynamic pedobarography showed no significant changes in gait pattern.

CONCLUSIONS

Fractures of the talus lead to dissatisfaction, pain and malfunction. However, a change in gait pattern could not be proved.

Talus Fractures: Evaluation and Treatment

The talus is unique in having a tenuous vascular supply and 57% of its surface covered by articular cartilage. Fractures of the head, neck, or body regions have the potential to compromise nearby joints and impair vascular inflow, necessitating surgical treatment with stable internal fixation in many cases. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Percutaneous screw fixation has also demonstrated success in certain patterns. Despite this modern technique, osteonecrosis and osteoarthritis remain common complications. A variety of new treatments for these complications have been proposed, including vascularized autograft, talar replacement, total ankle arthroplasty, and improved salvage techniques, permitting some patients to return to a higher level of function than was previously possible. Despite these advances, functional outcomes remain poor in a subset of severely injured patients, making further research imperative.

Tibial Nerve Dysfunction Associated With Operatively Treated Talar Neck Fractures

OBJECTIVE

To investigate the presence of tibial nerve dysfunction (TND) in operatively treated talar neck fractures.

DESIGN

Retrospective chart review.

SETTING

Urban Level-1 trauma center.

PATIENTS

Sixty-four patients for a total of 65 talar neck fractures treated with open reduction and internal fixation between January 1, 2014, and May 1, 2018.

MAIN OUTCOME MEASURES

Incidence of TND.

RESULTS

Evidence of TND was documented in 20 of 65 cases (30.8%) of talar neck fractures. There were no cases of TND associated with Hawkins I fractures, but TND was found in 7 of 32 Hawkins II fractures (21.9%), 10 of 24 Hawkins III fractures (41.7%), and 3 of 5 Hawkins IV fractures (60%). TND was reported in 11 of 19 open talar neck fractures (57.9%) (P = 0.002). TND was associated with tibiotalar dislocation (P = 0.017) but not subtalar dislocation (P = 0.17). TND did not occur in the absence of subtalar subluxation/dislocation. Of 18, a total of 6 (33.3%) reported partial recovery, and 6 (33.3%) reported full recovery within 6 months of the initial injury. By 12 months, of the 18, 8 (44.4%) reported partial recovery and 7 (38.9%) reported full recovery.

CONCLUSION

The tibial nerve and its distal branches are at risk of injury in the setting of displaced talar neck fracture, tibiotalar subluxation/dislocation, and open talar neck fracture with increasing risk among those with a higher Hawkins grade.

LEVEL OF EVIDENCE

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

Primary Triple Arthrodesis Equivalent for Complete Extruded Missing Talus with Associated Midfoot Instability: A Case Report

CASE

Complete extrusion of the talus is rare and associated with high rates of complications including infection, osteonecrosis, persistent pain and stiffness, and post-traumatic arthritis. Less well described is associated midfoot instability. We report a case of a complete extruded missing talus that resulted in significant midfoot instability treated with a modified triple arthrodesis of the tibiocalcaneal, tibionavicular, and calcaneocuboid joints.

CONCLUSIONS

This approach resulted in a radiographic fusion at 3 months without complication, acceptable subjective and Patient-Reported Outcome Measurement System (PROMIS) scores at the 18-month follow-up, and presents a viable treatment strategy in the case of a complete extruded missing talus.

Arthroscopically Assisted Reduction and Internal Fixation of Talar Neck Fracture: A Case Report

Introduction

Arthroscopic-assisted reduction and internal fixation (ARIF) is a recent concept and is increasingly used for articular fractures, due to the minimally invasive nature and high accuracy. However, there are few reports in literature about this procedure in talar fractures.

Case Report

The authors describe a clinical case of a 22-year-old woman with a closed right articular talar neck fracture, Hawkins type II, treated with arthroscopically ARIF.

Conclusion

This is a minimally invasive technique that can allow close accurate reduction and stable fixation of selected articular talar fractures. It avoids some complications of multiple and large incisions of the conventional open surgery, with good functional outcomes and patient satisfaction.

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.

Acute Fractures and Dislocations of the Ankle and Foot in Children

Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. These injuries represent approximately 13% of all pediatric osseous injuries. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. The authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. The different types of ankle and foot fractures are described, and the American College of Radiology guidelines used to determine appropriate imaging recommendations for patients who meet the Ottawa ankle and foot rules are discussed. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. This information is intended to supplement radiologists' understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Fractures of the Talus: Current Concepts

Talus fractures continue to represent a challenging and commonly encountered group of injuries. Its near-complete articular cartilage surface, and its role in force transmission between the leg and foot, makes successful treatment of such injuries a mandatory prerequisite to regained function. Familiarity with the complex bony, vascular, and neurologic anatomy is crucial for understanding diagnostic findings, treatment indications, and surgical techniques to maximize the likelihood of anatomic bony union. This review details the structure and function of the talus, a proper diagnostic workup, the treatment algorithm, and post-treatment course in the management of talus fractures.

Surgical Treatment of Talar Neck and Body Fractures: Mid-Term Results of 24 Cases

BACKGROUND

Talar neck and body fractures are rare. Major posttraumatic complications with a potential reduction in the quality of life are arthrosis and necrosis due to the specific vascular supply. The aim of the study was to evaluate mid-term results of surgery for talar fractures of neck and body. Parameters that potentially affected/influenced treatment outcomes were analysed exploratively.

METHODS

24 patients with 24 talar neck and body fractures (Marti type II n = 9, type III n = 12, type IV n = 3) were retrospectively examined for radiological and clinical functional outcomes. The independent parameters evaluated included age (< 40, ≥ 40 years), sex (male, female), general overall extent of injury (polytrauma/multiple injuries/multiple fractures of the extremities, additional injuries to the same foot, isolated talus fracture), soft tissue damage (open, closed), surgical latency (< 6, ≥ 6 h), fracture classification/displacement (undisplaced [= Marti II], displaced [= Marti III, IV]) and fracture type (talar body, neck fracture). The potential influencing parameters were analysed by univariate analyses.

RESULTS

With an average follow-up of 8.7 years (1,25 - 16 years) the AOFAS score was 71.4 ± 22.9 points, the Foot Function Index score 35.9 ± 28.3 points; the physical and mental component summary scores of the Short Form 36, version 2, was 43.8 ± 10.9 and 47.4 ± 13.6 points (mean ± standard deviation), respectively. Thus, the patient reported physical health of the patients was slightly reduced compared to the German population, while the mental health remained largely unaffected. Two patients developed partial avascular necrosis (8%), 10 patients developed osteoarthritis (42%). Of the independent parameters, only the general overall extent of injury showed a significant influence on osteoarthritis (p = 0.002). In the evaluation of undisplaced (n = 9) and displaced (n = 15) fractures, surgical treatment after more than 6 hours did not result in a worse outcome.

CONCLUSION

The clinical outcome of internal fixation of talar neck and body fractures can be classified as good. In the study group, there was no correlation between the occurrence of arthrosis and the Marti fracture classification.

Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures

Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BACKGROUND

The main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.

METHODS

From January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.

RESULTS

27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49-119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7-7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0-11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9-10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).

CONCLUSIONS

Despite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

[Arch-shaped approach : New modified medial approach for the treatment of talus fractures]

OBJECTIVE

Anatomical reduction and fixation of complex talar fractures (Hawkins type III and IV, Marti type III and IV) using a medial approach.

INDICATIONS

Displaced talar fractures (Hawkins type III and IV, Marti type III and IV) with the need for a medial malleolar osteotomy or the simultaneous treatment of a medial malleolus fracture.

CONTRAINDICATIONS

High perioperative risk, severe soft tissue injuries in the medial approach area, infected soft tissues.

SURGICAL TECHNIQUE

Medial arch-shaped approach about 12 cm in length over the medial malleolus using a simultaneous medial malleolus fracture or via an additional medial malleolar osteotomy. Dissection and retraction of the terminal branches of the saphenous vein and the saphenous nerve. Protection of the blood supply in the area of the medial talus and in the sinus tarsi. Reduction of the talar joint surfaces and reconstruction of the anatomical axes according to the preoperative planning by means of native radiological and computed tomographic imaging. Osteosynthesis adapted to the fracture type using Kirschner wires, conventional screws, cannulated screws, double-threaded screws, resorbable pins, magnesium screws, small fragment plates.

POSTOPERATIVE MANAGEMENT

Lower leg splint or orthesis for 6 weeks, partial weight-bearing with 20 kg for 10-12 weeks. Early range of motion exercise of the ankle, subtalar and mid-tarsal joints.

RESULTS

In the past 5 years, 11 patients with either Hawkins type III and IV or Marti type III and IV fractures were treated operatively using the arch-shaped approach. No soft tissue problems were seen related to the arch-shaped approach. Of the 7 patients who could be followed up after an average of 2 years, the mean American Orthopedic Foot and Ankle Score was 73. Avascular necrosis occurred in 3 cases (43%). These were partial necroses of less than one third of the talar body with asymptomatic course at the time of examination. In 4 patients (57%) radiographic signs of osteoarthritis occurred within 2 years, whereby in two of those cases (29%) an arthrodesis of the upper ankle was performed.