Subtalar Fusion Preparation: What Are We Really Doing? A Cadaver Study

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study.

Bilateral Talus and Navicular Fractures accompanied with Unilateral Calcaneal Fracture: A Case Report

An 18-year old male patient, with a history of paragliding accident, sustaining a coronal shear fracture of the body of the talus, an anterior process fracture of the calcaneus extending to the calcaneocuboid joint and a nondisplaced navicular body fracture at the right foot and a displaced fracture of the navicular body accompanied with posteromedial process fracture of the talus at the left side was referred to our emergency clinic. For the right foot, the coronal plane fracture of the talar body was anatomically reduced and fixed with screws. For the left foot, screw fixation was performed through the lateral aspect to fix the large posteromedial fragment. Small bone fragments were removed from the left navicular fracture, and the main fragments were also fixed with screw. The talo-navicular joint was stabilised with a Kirschner wire. At 36 months follow-up, bilateral foot and ankle functions were satisfactory, Maryland scores of the right and left foot were 85 (good) and 90 (excellent), respectively, and the patient regained his full activity level by the 5th month postoperatively. With reference to the number and types of fractures in this one patient, we present a standard protocol for treatment of isolated talus, navicular and calcaneal fractures presenting together in a single foot injury.

Extra-articular Medial Impression Fracture of the Talus: A Previously Undescribed Injury

BACKGROUND

Peripheral fractures of the talus are uncommon. Almost all the literature regarding talar fractures consists of central intra-articular fractures, whereas studies about peripheral talar fractures are lacking. The aim of this study is to increase awareness in diagnosing an unusual peripheral extra-articular medial impression fracture of the talus.

METHODS

This study includes a retrospective case series of patients with an extra-articular medial impression fracture of the talus. Patient characteristics, trauma mechanism, diagnostics, fracture characteristics, and treatment were reported.

RESULTS

Eight consecutive patients with an extra-articular medial impression fracture of the talus were identified. In 80%, the trauma mechanism was a supination or inversion injury of the ankle and foot. An X-ray was obtained in all patients; in 7 (88%) patients, a computed tomography scan was done, and an additional magnetic resonance imaging was done in 3 (38%) patients. In 4 patients (50%), the correct diagnosis was missed at first presentation. The delay between injury and diagnosis was 0 to 180 days (of 36 days on average).

CONCLUSION

This is the first case series to describe patients with a peripheral extra-articular medial impression fracture of the talus. Good clinical examination and judicious use of diagnostic imaging are a necessity to find the talar impression fractures in a timely manner, and treatment can be started immediately.

LEVELS OF EVIDENCE

Level V.

Arthroscopic Reduction and Internal Fixation (ARIF) of a Comminuted Posterior Talar Body Fracture: Surgical Technique and Case Report

The talus is the second most common fractured tarsal bone. While their incidence may be low, talus fractures are severe injuries that can lead to long-term disability and pain. Displaced talar body fractures are typically treated through an open approach with the aim of obtaining anatomic reduction and stable fixation. There are several case reports in the literature demonstrating successful management of talus fractures arthroscopically. An arthroscopic approach minimizes soft tissue trauma, which can help decrease postoperative wound complications and infections. In this article, the authors describe a surgical technique of an arthroscopic reduction and internal fixation of a comminuted posterior talar body fracture. Compared with an open posterior approach with or without osteotomies, an arthroscopic technique improved visualization and allowed precise reduction and fixation.

LEVELS OF EVIDENCE

Level V: Case report.

Management of Nonunited Talar Fractures With Avascular Necrosis by Resection of Necrotic Bone, Bone Grafting, and Fusion With an Intramedullary Nail

BACKGROUND

The presence of nonunion of a talar fracture with displacement, together with complete avascular necrosis, is a challenging entity to treat.

METHODS

Twelve patients, 8 men (66.7%) and 4 women (33.3%), with nonunited talar fractures and extensive avascular necrosis of the talus were included. The average age was 27.7 years (range, 19-38 years). After exclusion of infection, the patients underwent resection of necrotic bone, bulk autograft, and fusion using an intramedullary nail. The posterior approach was used in 11 patients and the anterior approach in 1 patient. The primary outcome was solid osseous union at the ankle and subtalar level and between the talar head anteriorly and the posterior construct, as evidenced by computed tomographic examination. Functional assessment was performed with the American Orthopaedic Foot & Ankle Society score and subjective patient satisfaction Results: After a mean follow-up duration of 23 months (range, 12-60 months), solid osseous union was achieved in 8 patients (66.7%). Stable fibrous union was seen in 1 patient (8.3%). Three patients (25%) required reoperation, and osseous fusion was finally achieved. American Orthopaedic Foot & Ankle Society score improved from a mean of 39.3 (range, 12-56) preoperatively to 76.6 (range, 62-86) at last follow-up. Subjective patient satisfaction was graded good or excellent in all cases.

CONCLUSION

Resection of necrotic talar body and bulk autograft with tibiotalocalcaneal fusion by an intramedullary nail through a posterior approach was a reasonable option for the management of type IV posttraumatic talar deformity.

LEVEL OF EVIDENCE

Level IV, case series.

Total dislocation of the talus: a case report

Total talar dislocation is a rare injury that is usually open. We report a case of closed anterolateral dislocation in a 19 year old, following a fall from a bicycle. He was treated with prompt closed reduction. A magnetic resonance imaging scan 6 months later showed no signs of avascular necrosis. At 2 years follow-up, the patient had a full, pain free, range of motion at the ankle and subtalar joints.