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A New Look at the Hawkins Classification for Talar Neck Fractures: Which Features of Injury and Treatment Are Predictive of Osteonecrosis?
Abstract
Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes.
The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%).
One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
... Vallier, et al., observed 81 talar neck and body fractures to determine whether or not a delay in open reduction internal fixation increased the rate of talar AVN. Similarly to Watson, et al., the authors found an overall rate of osteonecrosis for all injury types to be 25% with type IV injuries at 33% [9]. The authors determined that time of reduction of up to eighteen hours after the injury did not result in a significant change in the rate of AVN [9]. ...
... Similarly to Watson, et al., the authors found an overall rate of osteonecrosis for all injury types to be 25% with type IV injuries at 33% [9]. The authors determined that time of reduction of up to eighteen hours after the injury did not result in a significant change in the rate of AVN [9]. ...
... Jordan, et al., found an overall rate of post-traumatic arthritis to be 51.69% with rates of 25% in Hawkins type I, 41.33% in type II, 54.24% in type III and 72.73% in type IV. Vallier, et al., had similar findings in rates of post-traumatic arthritis following talar neck fractures [9]. ...
Total talar dislocations are rare, significant surgical challenges for foot and ankle surgeons. These dislocations can be very difficult to manually close-reduce, requiring immediate surgical intervention secondary to arterial impingement, pain and risk of skin necrosis attributable to skin tenting. In this case series, we report on three patients who presented to the emergency room following a traumatic ankle injury. Ankle radiographs and computed tomography (CT) scans were obtained, revealing pantalar dislocations. Closed reduction utilizing Charnley’s principles was attempted in the emergency room through manual accentuation of the deformity, traction and reduction. Closed reduction was unsuccessful in all three patients which led to immediate surgical intervention consisting of open reduction of the dislocated talus with internal fixation of concomitant fracture patterns. Postoperatively, all patients were carefully monitored for avascular necrosis of the talus with serial radiographs. One year following surgical intervention, no evidence of talar avascular necrosis (AVN) was observed and two of the three cases developed subtalar joint arthritis. This case report serves to display the treatment and outcomes of a rare dislocation with follow up to complete return to normal activity.
... Another article published by Vallier et al. [11]. looked at factors that contribute to osteonecrosis after talar neck fractures. ...
... Type-III fractures as well as those with associated talar body extension also had increased risk of osteonecrosis and development of post-traumatic arthritis. Their conclusion is that possibly separating Hawkins Type II into IIa and IIb types, where IIa is a subtalar subluxation and IIb is a subtalar dislocation, can possibly help predict rates of osteonecrosis of the talus [11]. We had a much smaller patient population, so statistical analysis would have a Type I error. ...
Background: Displaced talar neck fractures are subject to avascular necrosis and degenerative joint disease. A single-lateral-incision approach may avoid damage to the remaining blood supply to the talar body provided by the deltoid artery. The purpose of this paper is to describe the surgical technique for a single approach to talar neck fractures, to evaluate the outcomes in a cohort of patients, and to review the literature on the topic. Method: A retrospective review. Patients were identified at a single medical center and met the following inclusion criteria: closed fracture, type-II talar neck fracture with displacement of the subtalar joint, single lateral operative approach, and radiographic follow-up of at least 6 months. Results: Five patients were identified meeting the inclusion criteria. The mean follow-up was 18 months (12–25). The mean VAS (Visual Analog Score) score at the final follow-up was 1.2 (0–3). Four of five patients returned to running at the final follow-up. The one patient who did not return to running was able to bike and hike. There were no cases of avascular necrosis and no cases of degenerative joint disease. Conclusions: Although a two-incision approach could be considered for all displaced talar neck fractures, there are certain fractures that can be anatomically reduced and stabilized through a single lateral incision which may limit the risk of avascular necrosis.
... They insisted that this decrease was due to an improvement in the treatment methods such as broader indications for surgical interventions and technical advances in fixation materials (plates and screws). Furthermore, Vallier et al. [13] suggested that AVN did not occur unless the subtalar joint was completely dislocated. In their study, delaying reduction and definite internal fixation did not increase the risk of developing AVN. ...
... With regard to clinical outcomes, it should be emphasized that posttraumatic talar body AVN should be treated according to symptom aggravation, which might be related to the collapse of the talar dome. Some previous studies [13,18] reported that the talus could revascularize spontaneously if sufficient time was given. However, we did not observe an improvement in talar body sclerosis along with revascularization during follow-up. ...
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
... Hawkins classification, later modified by Canale, is the gold standard method of describing talar neck fractures by the degree of dislocation [5,6]. It has proven to be clinically relevant in predicting risk of osteonecrosis [7,8]. 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. ...
... At 4 months, adequate union of the fracture was achieved, but the sclerosis had progressed significantly. This complication aligns with previous literature that the degree of initial displacement and Case Reports in Orthopedics fracture comminution are significant predictors of osteonecrosis [7,8]. ...
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.
... The major concern is the potential threat to talus body vascularity: the additional damage involved in two close surgical approaches could increase the chance of developing osteonecrosis. Due to the low incidence of these injuries, the published evidence with this strategy remains scarce and limited to some case series, preventing the ability to draw definitive conclusions (1,(5)(6)(7)(8)(9) . ...
Objective: The aim of this study was to evaluate the outcomes of Hawkins type II fractures treated with a simultaneous dual approach. Methods: A retrospective multicenter study was conducted at four major trauma centers. Patients with Hawkins type II closed talar neck fractures managed by a simultaneous dual approach with complete preoperative medical records and a minimum follow-up of six months were included. Results: Eighteen patients were identified. The anatomical reduction was achieved in 17 cases, with a mean follow-up of 53.57 ± 31.77 months (range 8 to 116 months), and the American Orthopaedic Foot & Ankle Society (AOFAS) score was 91.42 ± 7.66 points (range 75 to 100). There were two cases of subtalar arthritis (11%) and two cases of partial avascular necrosis of the talar body (11%), all of them asymptomatic and not requiring secondary surgical procedures up to the latest clinical follow-up. Conclusion: The simultaneous dual approach is a safe and reliable strategy for managing Hawkins type II talar neck fractures without significantly compromising the talar circulation. We recommend that future prospective studies with a larger sample be conducted to validate these findings further. Level of evidence IV; Therapeutic studies; Case series.
... Elle a été modifiée en 1978 par Canale et Kelly [13] qui y ajoutent un stade. Elle ne concerne toutefois que les fractures-séparations totales transversales et elle apprécie le risque de nécrose, majoré avec le déplacement du corps du talus [54,55] . ...
Les fractures et luxations du talus sont complexes et ne peuvent être réduites à une seule entité. Du fait de son anatomie singulière, on distingue les fractures totales (corps et col) et les fractures parcel-laires (processus postérieur, processus latéral, tête). Parmi ces dernières, on doit encore isoler les lésions ostéochondrales du dôme du talus (anciennement lésions ostéochondrales du dôme de l'astragale), qui font l'objet d'une question à part. Toutes ces lésions ont leurs spécificités, par leur présentation clinique, leur physiopathologie ou leur prise en charge thérapeutique. Leur prise en charge chirurgicale relève du défi technique et le taux de complications reste encore élevé et pourvoyeur de résultats fonctionnels pou-vant rester décevants. L'étude de la vascularisation, des mécanismes vulnérants, la plus grande précision des indications thérapeutiques et les innovations techniques (ostéosynthèse percutanée, outil arthrosco-pique et arthroplastie de cheville) permettent de tempérer le pessimisme des chirurgiens pionniers et font reculer le recours à des chirurgies délabrantes comme la talectomie ou les arthrodèses pantaliennes antérieurement préconisées. © 2025 Elsevier Masson SAS. Tous droits réservés, y compris ceux relatifs à la fouille de textes et de données, à l'entraînement de l'intelligence artificielle et aux technologies similaires. Note de l'éditeur : Elsevier adopte une position neutre en ce qui concerne les conflits territoriaux ou les revendications juridictionnelles dans les contenus qu'il publie, y compris dans les cartes et les affiliations institutionnelles.
... In their classification, progressive per-talar dislocation is associated with increased risk of osteonecrosis and post-traumatic arthritis. [13] Talar body fractures have their own classification, developed by Sneppen et al., which further describes anatomic location and injury mechanism. [14] Neither of these classification systems included, nor are mechanistically applicable, to ballistic injuries. ...
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.
... Over the past two decades, medical literature has consistently advised the use of both lateral and medial techniques for surgical treatment of talar neck fractures [12][13][14][15][16][17][18]. ...
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.
... It is well known that complications such as avascular necrosis and posttraumatic arthritis are common in talar neck fractures, and their frequency tends to increase with higher Hawkins types. 14,15) Avascular necrosis, in particular, is known to occur at a higher rate in Hawkins type III talar neck fractures. Previous studies have reported a 44.7% occurrence rate by Halvorson et al. 16) and a 55.0% occurrence rate by Jordan et al. 5) In our study, all patients underwent postoperative MRI scans at 2 months after surgery to monitor the occurrence of avascular necrosis. ...
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.
... Rather, it focuses on factors such as the degree of fracture displacement and the occurrence of subtalar joint dislocation. 17 Vallier et al. 18 modified the Hawkins classification and clearly identified Hawkins's views, indicating that initial talar neck fracture displacement and complete joint dislocation are risk factors for osteonecrosis. Therefore, preventing malreduction during surgical fixation is crucial. ...
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.
... The complications after subtalar dislocation are skin necrosis, neurovascular injury, tendon laceration, recurrent subtalar instability, posttraumatic degenerative arthritis, osteonecrosis of the talus, and peritalar joint stiffness (5). Following talar neck fractures, the maximum time for appearing of osteonecrosis, defined as increased radiographic density of the talar dome, is eight months and collapse of the talus occurs within 11 months of the injury (15). Our case did not develop talar osteonecrosis because we did not see any increased density or collapse on plain radiographs during 25 months following the surgery. ...
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.
... The analysis of the problem found that there is no alertness among clinicians in diagnosing the disease in the early stages. There is a need for clear guidelines for the diagnosis and treatment of patients with AOTB [20][21][22]. The clinical picture in the early stages of the AOTB disease resembles an arthritic syndrome without pathological changes in radiographs of the ankle joint, while the formation of talus cysts, varus/valgus deformity of the foot, "disfiguring" osteoarthritis of the ankle, subtalar and Chopart joint, collapse and fragmentation of the talus are radiologically noted at advanced stages of the disease [23][24][25]. ...
Introduction The paper discusses the main issues of treating patients with avascular osteonecrosis of the talus. The importance of the problem of treating
patients with avascular osteonecrosis of the talus is explained by its high incidence, the difficulty of diagnosis in the early stages of the disease and poor
treatment results with the use of traditional methods. Рurpose Based on the analysis of foreign and domestic literature, to determine the current state
of the problem of surgical treatment of avascular osteonecrosis of the talus and to identify the range of possible surgical interventions in patients with the
pathology under the study, to analyze in historical retrospect the arthroplasty of the talus bone due to its total involvement in the pathological process.
Materials and methods The review analyzes the literature on this topic, in which 79 foreign studies, published in the period from 1911 to 2021, were
selected along with 9 domestic publications for the period from 2011 to 2021. PubMed, MedLine and eLibrary Internet resources were used to search
for publications. Results Based on the literature data, the issues of the history, etiology, pathogenesis, systematization and diagnosis of this disease are
highlighted. The existing methods of treatment have been analyzed along with their advantages and shortcomings. Conclusion The analysis of current
professional literature has demonstrated the preference of the method of talus bone arthroplasty in its total avascular osteonecrosis, in comparison
with arthrodesis of the joints of the hind foot of various extent. Nowadays, the technology of arthroplasty of the talus bone is scientifically sound,
biomechanically confirmed and effective for the treatment of patients with avascular osteonecrosis of the talus bone and its consequences, while
the demand for this technology has been growing all over the world. There is a constant improvement of tools, technologies, methods and materials.
... He proved that the risk profile of talar fractures remained severe even in the face of diagnostic and technical advancement. Hawkins' classification was further expanded by Canale, Kelly [46], Williams [47] and Vallier [48] with the addition of other subtypes of fracture patterns. To date, Hawkins' classification remains widely employed and taught, together with the AO/ASIF/OTA classification system, that although complete, is of difficulty to use in everyday practice because of its complexity [47]. ...
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.
... Кроме того, в настоящее время нет доказательств, связывающих сроки фиксации и развитие посттравматического остеонекроза [6,21,23]. Скорее, смещение перелома и сопутствующее повреждение мягких тканей являются предикторами некроза таранной кости [25]. Имеются некоторые ограниченные доказательства того, что отсроченная фиксация может обеспечить лучшие результаты, что, как предполагается, связано с лучшим восстановлением мягких тканей и передачей пациента более опытным хирургам, а также возможностью более тщательного планирования операции [22]. ...
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.
... In the past, early surgical treatment was advocated to prevent osteonecrosis. However, Vallier et al. demonstrated no relationship between the timing of surgery and the rate of osteonecrosis, which was in line with the ndings of our study (21). Some authors advocate immediate close reduction for severely displaced fractures to preserve the remaining blood supply and prevent further soft tissue damage (19,22). ...
Talus fracture is often associated with debilitating complications, including osteonecrosis, non-union, malunion, and osteoarthritis. This study aimed to evaluate the clinical and radiographic outcomes of different types of surgically treated talus fractures and factors affecting outcomes. A total of 38 patients with talus fractures from April 2014 to April 2019 were included. Radiological evaluations, including standard ankle radiographs and ankle CT scans, were performed pre-and post-operatively to assess union, malunion, osteonecrosis, and osteoarthritis of adjacent joints. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS), visual analogue scale (VAS), and Manchester Oxford Foot Questionnaire (MOXFQ) questionnaires. Talar fractures included talar neck (52.6%), talar body (28.9%), body fractures extend to neck (15.7%), lateral and posterior process fracture (2.6%). Osteoarthritis was the most common complication (52.6%), followed by osteonecrosis (47.3%). The mean AOFAS, MOXFQ, and VAS scores were 60.3 (SD=+/-18.6), 67.6 (SD=+/-20.7), and 4.9 (SD=+/-2.1), respectively. There was no significant difference in VAS, MOXFQ, and AOFAS scores between different types of talar fractures (p > 0.05). There was no correlation between the time of surgery and the rate of osteonecrosis (p > 0.05). In conclusion, talus fracture was associated with many complications that adversely affected the clinical outcome of the patients. Delay in surgical fixation did not appear to affect the outcome or prevalence of osteonecrosis.
Level of Clinical Evidence (LOCE):4
... Type II fractures are displaced with associated subluxation or dislocation of the subtalar joint, whereas the tibiotalar and talonavicular joints remain in proper alignment. Vallier et al42 shed new light on the Hawkins type II fractures, separating Hawkins type II fractures into those without (type IIA) and those with (type IIB) subtalar dislocation. This could help to predict the development of avascular necrosis (AVN). ...
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.
Introduction
Talus fractures are troublesome injuries. It is very difficult to achieve good functional and radiological outcome in Hawkins type 3 comminuted fracture neck of talus.
Case Report
In our study, 7 cases of Hawkins type 3 comminuted fracture neck of talus were operated in R.D. Gardi Medical College, Ujjain between August 2020 to August 2023 with the sequence of early closed reduction of dislocation and application of external fixator (SPAN) on the day of admission, followed by 3 dimensional computed tomography – scanning (SCAN) and then, definitive surgery through open reduction of fracture (through dual incision approach) and internal fixation with cannulated cancellous screws (FIX) along with Primary bone grafting.
Results
With the surgical management protocol followed by us, the union was achieved in all 7 cases. Hawkins sign was seen in all 7 cases by 10 weeks post-operatively. There was no incidence of complications, such as wound dehiscence and infections post-operatively. The present study had a minimum follow-up of 6 months.
Conclusion
Our Surgical management protocol led to excellent functional and radiological outcomes in all cases. Patients were able to return to their pre-injury functional activities along with full-weight-bearing walking without support within 6 months of surgery.
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.
Talus fractures and fracture-dislocations are rare conditions that are associated with high risk of complications and long-term disability. Its meticulous anatomy and intricate vascularization need to be considered when planning a proper treatment in order to prevent or deal with possible complications. Talus fractures represent 0.1–2.5% of all fractures in general and 3% in the foot. The most commonly used classification system was originally described by Hawkins consisting of three types, based on the blood supply damage and the radiographic pattern.
Standard imaging protocol for talus fractures includes a routine foot series (AP, lateral, and oblique) and ankle series (including AP and mortise) in addition to a CT scan of the foot.
Non-operative treatment is reserved for confirmed nondisplaced Hawkins type I fractures. Biomechanical studies have demonstrated that a minimum displacement of 2 mm significantly alters subtalar congruency, which may predispose to osteoarthritis.
Current standard of care for displaced talar neck and body fractures is open reduction and internal fixation.
Subtalar joint arthritis is the most common complication after a talar neck or body fracture, and the one that leads to reconstructive surgeries such as arthrodesis and osteotomies. The incidence of avascular necrosis after talar neck fracture is proportional to the initial fracture displacement. A non-anatomic fracture reduction or fixation may lead to a hindfoot malalignment. Slight displacement of talar neck fractures may produce symptomatic varus malunion in almost 50% of these fractures secondary to comminution of the medial aspect of the neck.
Among all the fractures Talus fracture
constitutes less than 1% and talar neck fractures are
the commonest among them [1] comprising
between 3% and 6%.Because of the large weight
bearing surface and the complex vascularisation the
accurate treatment of fractures becomes crucial.
Talar fractures are notorious for morbidity, as they
are prone for avascular necrosis, arthritis and non�union. This series includes the treatment and
outcome of four patients with neglected talar
fractures. Further, guidelines for treatment and
follow up on this rare type of fractures are
discussed
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.
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 to 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 six months 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 (54.7%) patients were female with mean age of 39 years (range, 17-85), and 111 (96.5%) fractures 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 (46%) patients developed AVN in the TNIFAF group compared to 19 (30%) patients 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 to the ITN group [Odds Ratio, 2.43 (95% CI, 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.
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.
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.
Background
Talus fractures are often result of high energy mechanisms and can lead to devastating complications. Treatment is often operative; however, the appropriate timing of this has been debated. The purpose of this study is to determine the efficacy and safety of the early treatment of talus fractures.
Methods
Patients aged 18 years or older who underwent definitive operative stabilization of their talus fracture at a single urban level 1 trauma center were retrospectively reviewed. Patients were split into 2 groups based on their time to definitive fixation: ≤ or >24 hours. Pertinent demographic, surgical, and follow-up data were collected and analyzed.
Results
A total of 108 fractures were treated with 65 in the ≤24 hours fixation group and 43 in the >24 hours fixation group. Fractures involving the talar neck were the most commonly treated fracture pattern followed by the body and the head. There was no difference between the 2 groups in length to full weight bearing, union, or time to union. Open fracture was found to be the only significant risk factor for nonunion in both groups. There was no significant difference in infection or arthrodesis rates between the 2 groups.
Conclusion
Definitive treatment of talus fractures within 24 hours from presentation is both safe and effective with equal outcomes and without increased complications when compared with those injuries that undergo delayed or staged definitive fixation.
Level of Evidence
Level III
Objective:
To identify patient, injury, and treatment factors associated with development of avascular necrosis (AVN)following talar fractures, with particular interest in modifiable factors.
Design:
Retrospective chart review.
Setting:
21 US trauma centers and 1 UK trauma center.
Patients:
2,220 patients with talar neck and/or body fractures.
Intervention:
Open reduction internal fixation of talar neck and body fractures.
Main outcome measurements:
Development of AVN. Infection, nonunion, and arthritis were secondary outcomes.
Results:
796 patients (408 M; 388 F; age 18-81, avg 38.6) with 796 (532R; 264L) fractures were included and were classified as Hawkins 1(51), IIA(71), IIB(113), III(158), IV(40), neck plus body (177), body (188). 336/798 developed AVN (42%), more commonly following any neck fracture (47.0%) vs isolated body fracture (26.1%, p<0.001). More severe Hawkins' classification, combined neck and body fractures, body mass index (BMI), tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN. After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and BMI remained significant.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 vs >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.
Conclusion:
42% of all 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 anatomical reduction, without iatrogenic damage to remaining blood supply is essential.
Level of evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Fractures of the talus are rare injuries and generally result from high energy mechanisms. Historically, talus neck and body fractures have portended poor prognoses due to high rates of associated osteonecrosis and post-traumatic arthrosis. Expeditious initial management of dislocations, timely surgical care, and accurate reduction with rigid fixation will provide the best chances for a functional outcome [1].
Talus fractures are relatively rare, accounting for approximately 0.55% of total body fractures. However, as the second most common foot fracture, they account for 3–5.54% of total foot fractures. More than 80% of talus fractures occur in male patients. Talar neck fractures are most common among talus fractures (Zhang 2016).
Background:
The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures.
Methods:
A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs.
Results:
There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99).
Conclusion:
We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures.
Level of evidence:
Level III, retrospective cohort study.
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.
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.
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
Purpose
Unique anatomy, precise articulations, fragile vascularity, and the demand for anatomic reduction make talar neck fractures challenging to treat, whether with screws and/or plates. Multifocal percutaneous pin fixation (MPPF) offers an alternative to ORIF, particularly in the polytraumatized patient.
Methods
Unless an open lateral wound or medial malleolus fracture was present, a standard anteromedial approach was performed. K-wires placed within the talar head were used as joysticks to facilitate and finalize reduction. At least 3 wires were placed medially and 2 laterally across the talar neck. Incisions were closed in 2 layers, and either a well-padded short leg splint or adjunctive ankle-spanning external fixation was utilized. Patients remained non-weightbearing until K-wire removal in the office at approximately 6 – 8 weeks postoperatively.
Results
MPPF was performed in 7 patients, the majority of whom were female (6 of 7). The average patient age at the time of injury was 30.3 years (range 17 to 51 years). The median time of final follow up was 27 months. Comminution was present in all patients. Avascular necrosis (AVN) developed in 3 patients and non-union occurred in 2 patients. All patients developed subtalar posttraumatic arthritis, and 6 additionally developed tibiotalar arthritis. No patients underwent talectomy or osteotomy, and there were no superficial pin site infections or loosening of pins prior to scheduled removal.
Conclusions
Obtaining and maintaining an adequate reduction is possible with minimal soft tissue compromise through MPPF. Despite the complexity of the series, outcomes utilizing MPPF are comparable to those reported in the literature.
Talus fractures are infrequent and challenging injuries with potentially devastating clinical consequences and high complication rates. They are generally associated with a high-energy mechanism because significant forces are needed to compromise their structure. Although managment criteria depends on the location and the fracture subtype, most of them require active behavior in the emergency through closed manipulation and transitory stabilization to protect soft tissues and preserve body’s vascularization and careful definitive surgical handling by means of open reduction and stable internal fixation. The most frequently reported complication is subtalar arthritis, whose incidence varies widely.
Purpose:
Open reduction and internal fixation (ORIF) is the most commonly used surgical technique for talar neck fracture, but there are high risks for complications and poor functional outcomes. In this study, we reported the closed reduction and percutaneous internal fixation (CRPIF) technique of the bilateral approach of the Achilles tendon for simple displaced talar neck fracture, in comparison with ORIF.
Methods:
Data of 15 patients in the CRPIF group and 22 in the ORIF group were included. The American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analog Scale (VAS) score, 12-item Short-Form Survey (SF-12) score, range of motion (ROM), complications, and radiographic results were recorded and compared.
Results:
The mean follow-up in the CRPIF group was 33.9 months. Complications included two cases of avascular necrosis (AVN) and two cases of osteoarthritis. All patients achieved bony union and recovered their pre-operative mobility. The mean follow-up in the ORIF group was 39 months. Complications included two cases of bony nonunion, nine AVN, and seven cases of osteoarthritis. Moreover, the mobility of the ORIF group was significantly lower than the CRPIF group post-operatively. The AOFAS score, VAS score, and SF-12 physical component score (PCS) for the CRPIF group were better improved than those for the ORIF group (ALL, P < 0.05).
Conclusions:
The CRPIF technique of the bilateral approach of the Achilles tendon was an effective method for the treatment of simple displaced talar neck fractures. Compared with the ORIF, the limited blood supply of the talus was protected, provide better functional outcomes and biomechanical fixation, and lower incidence of resurgery and complication in the CRPIF.
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.
The talus transfers the weight of the whole body onto the foot and is therefore an important factor of stability and posture. The prerequisite for successful treatment of talus neck fractures is knowledge of anatomy, understanding of the mechanisms that lead to fractures of the talus neck, knowledge of the potential complications of all treatment methods, as well as knowledge of indications for surgical treatment. About 55% of the talus surface is covered with articular cartilage, and displaced fractures lead to the destabilization of several joints. Since fractures are caused by high energy trauma, the result can easily be comminution and/or dislocation (displacement). Fractures of the talus neck can occur as an isolated injury, as well as part of polytrauma (falls from height, traffic accidents). The X-ray is the basic diagnostic tool for making an accurate diagnosis, in case of suspect talus fracture. Multi-slice computerized tomography is the most useful method for studying fracture patterns and is indispensable in planning surgical treatment. The Hawkins classification of talus neck fractures, from 1970, has remained in use to this day, while recommended treatment methods vary depending on the type of fracture. The main goal of treatment is anatomical reduction. The anatomical characteristics of the talus, the particular blood supply, as well as the "high energy" mechanism of fracture, pose a challenge for clinical evaluation and optimal treatment of talus fractures. This paper highlights the necessity of the knowledge of surgical techniques for the selection of an adequate method of treatment, in order to prevent unwanted consequences for the patient, which in the case of suboptimal treatment can be severe.
Introducción: Las fracturas del cuello del astrágalo son infrecuentes, pero la tasa de complicaciones y reintervenciones es alta. El objetivo de este estudio fue analizar y describir las complicaciones a mediano y largo plazo en 20 pacientes con fractura del cuello del astrágalo. Nuestra hipótesis fue que, en las lesiones graves, la reducción abierta y fijación interna genera una tasa alta de complicaciones que requerirán de nuevas intervenciones quirúrgicas. Materiales y Métodos: Se evaluó a 20 pacientes con fractura del cuello del astrágalo: 6 Hawkins II (29%), 11 Hawkins III (52%) y 3 Hawkins IV (19%). El seguimiento promedio fue de 11 años. Se analizaron el tipo de fractura (simple o conminuta), las lesiones asociadas, las complicaciones y la necesidad o no de un nuevo procedimiento quirúrgico. Resultados: Once pacientes (55%) tenían lesiones asociadas y 14 (70%), conminución en el trazo de fractura. Quince (75%) sufrieron complicaciones. Nueve (45%) requirieron una segunda intervención para tratar la complicación. Conclusiones: Los factores más relacionados con el desarrollo de complicaciones y la necesidad de una nueva intervención son: conminución en el trazo de fractura, lesiones asociadas en el miembro inferior homolateral, fracturas tipos III y IV de Hawkins, y fracturas expuestas. Creemos que, en las lesiones graves del cuello del astrágalo (tipos III y IV de Hawkins) con uno o más de estos factores, la artrodesis primaria podría disminuir el riesgo de complicaciones y de nuevas cirugías, y acortar el tiempo de recuperación de los pacientes.
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 shows 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
We report a case of a crush fracture of the body of the talus associated with an anterior tibial plafond fracture. This injury is a rare variant of talar body fracture which merits special attention. The bony injury in this type of fracture is associated with multiple loose fragments involving both weightbearing surfaces of the ankle joint. After appropriate imaging to allow preoperative planning, we utilized a two-incision approach which was necessary to achieve adequate exposure and fixation. We used basic fracture management principles to deal with a previously undocumented fracture pattern.
Displaced talar neck and body fractures are rare and serious injuries with important outcomes. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment in our centre between 1993 and 2005. Displaced talar fractures have a high rate of long-term complications. This was a retrospective study concerning 20 patients with an average follow-up of 7.5 years. The final follow-up examination included determination of the AHS score (ankle-hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiological analysis. Mean age at the time of trauma was 38.8 years. This study comprised ten talar neck fractures and ten talar body fractures. We always used a single surgical approach and obtained anatomical reduction in 30% of the whole series of both groups. Four early complications were noted in four patients (20%). We noted no skin complications and the rate of consolidation was 100%. Four patients (20%) developed avascular necrosis of the talus, and at final follow-up seven patients (35%) had undergone secondary surgery. Radiographic analysis showed an osteoarthritis rate of 94% and a malunion rate of 59%. The mean AOFAS score was 66.9/100 and range of motion was systematically decreased. Contrary to undisplaced talar fractures, displaced talar fractures are a therapeutic challenge with many early or late complications. The outcome often revealed stiffness and osteoarthritis.
Eighty-six patients who had experienced a fracture of the talus more than 10 years previously were assessed. The fracture had occurred in the neck of the talus in 52 feet and in the body of the talus in 27 feet. The fracture was complicated by dislocation in 47 feet, and aseptic necrosis had developed in 33 feet. The outcome was rated as excellent in 20 feet, good in 43, fair in 18, and poor in 7. The cause of poor outcome in the late stage was posttraumatic osteoarthritis secondary to avascular necrosis and incongruity of the joint surface. Early active exercise without weight bearing is recommended to prevent contracture and bone atrophy due to disuse, which may promote osteoarthrosis. Arthrodesis is recommended in patients with pain because the outcome is greatly improved by arthrodesis, even when performed more than 10 years after the injury.
We retrospectively reviewed 79 patients (80 talar fractures) operated on between 1994 and 1997. The average follow-up was 6 (1-15) years. 15 patients had a Marti/Weber fracture type I, 14 patients a type II, 32 patients a type III, and 19 patients a type IV fracture. 46 patients suffered a fracture of the talar neck, Hawkins type I in 10 patients, type II in 18, type III in 17 and type IV in 1 patient. 18/23 patients directly placed in our department were operated on within 6 hours of admission. Primary arthrodesis of both the ankle and subtalar joint was performed twice. Secondary arthrodesis of the ankle joint was done in only 3 patients. Combined secondary arthrodesis of the ankle and subtalar joint was performed in 5 and arthrodesis of the talonavicular joint in 1 patient. According to the Hawkins score, 35/80 feet achieved good/very good function versus 43 with the Mazur score. Radiographs showed ankle or subtalar arthrosis in two thirds of the patients. A normal range of motion was achieved in 18 ankle and 19 subtalar joints. The overall rate of talar necrosis was 9/80 fractures.
Displaced talar neck fractures are relatively rare injuries with potentially serious long-term morbidity. Expedient treatment has long been held as a treatment principle. The purpose of this study was to assess the current state of practice of treating displaced talar neck fractures by recognized orthopaedic trauma experts working at level 1 trauma centers.
A group of expert orthopaedic trauma surgeons were surveyed to determine what they considered "the maximal acceptable time delay from injury to the operating room representing the minimal standard of care at a level 1 trauma center for a displaced talar neck fracture?" Each survey recipient had been selected as a moderator at a national orthopaedic trauma meeting during the past 5 years. Eighty-nine of 109 (82%) responded to the survey.
For a displaced talar neck fracture, 60% of respondents stated that treatment after 8 hours is acceptable, with 46% percent of respondents stating that treatment at or after 24 hours is acceptable.
These results indicate that most expert orthopedic trauma surgeons do not believe that an immediate operation is necessary to adequately treat a displaced talar neck fracture.
Fractures of the talar body present a great challenge to surgeons due to their rarity and high incidence of sequelae. This study reports the medium-term results of displaced fractures of the talar body treated by internal fixation. Nineteen patients (13 M, 6 F, mean age 31) with talar body fractures were studied retrospectively to assess outcome after operative treatment. The fractures were classified as coronal (11), sagittal (6) and crush fractures (2). Six patients sustained open fractures and two had associated talar neck fractures. Average follow-up was 26 months (range: 18-43). Clinical outcome based on American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scoring was excellent function in four patients, good in six, fair in four and poor in five. Early complications included two superficial wound infections, one partial wound dehiscence, one instance of skin necrosis and one deep infection. Other complications included delayed union in one, avascular necrosis in seven and malunion in one patient. Talar injuries are serious because they can compromise motion of the foot and ankle and result in severe disability. Crush fractures of the talar body and those associated with open injuries and talar neck fractures are associated with a less favourable outcome.
1. This is a follow-up study of fifty-seven vertical fractures of the neck of the talus in fifty-five patients. I examined and evaluated forty-three of the patients more than one year after injury.
2. A classifications based on the initial roentgenographic appearance of the fracture or fracture-dislocation is suggested.
3. Initial treatment is discussed with open reduction through a medial incision suggested.
4. Following anatomical reduction of a vertical fracture-dislocation of the talus, not complicated by avascular necrosis, a good or excellent result is the expected outcome.
5. The early-recognition of, the incidence of, and a plan for the treatment of avascular necrosis is discussed. The results of various methods of treatment of avascular necrosis of the talus are evaluated.
6. Following anatomical reduction of a vertical fracture-dislocation of the talus associated with avascular necrosis only a fair or poor result can be anticipated.
Talus fractures represent a major therapeutic challenge. Improved results with displaced variants can be obtained with early open reduction and internal fixation followed by mobilization. Optimum management is predicted on precise diagnosis of the fracture pattern, prudent surgical approach, and rigid stabilization.
(C) Williams & Wilkins 1987. All Rights Reserved.
Recently, it has been shown that avascular necrosis of the talus can occur in only a portion of the talar body. There is little information regarding the geographic location of the avascular segment and the clinical significance of an incomplete avascular process.
Seven patients with partial avascular necrosis after Hawkins type II or III fracture dislocations were evaluated with magnetic resonance scans. The precise anatomic location of the avascular segment was determined and assigned to a specific quadrant of the talar body. The operative exposure, incidence of collapse, and time to operative intervention was recorded.
The avascular segment of the talar body was located predominantly in the anterior lateral and superior portion in six of the seven patients. Collapse occurred in three of the patients in the area of avascular process. There were no observable trends with regard to operative exposure, Hawkins classification, incidence of collapse, or time to operative intervention to the location of the avascular segment.
Partial avascular necrosis can occur after fracture dislocation of the talus. The predominant location of the avascular segment was the anterior lateral and superior portion of the talar body. This observation corresponds to regional damage to the blood supply of the talus and may help clarify the pathogenesis of partial avascular process.
Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series.
To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures.
Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review.
Post-operative complications, the need for secondary surgery, and the visual analogus pain score.
Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0.
The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation.
Seventy-one fractures through the neck of the talus were clinically evaluated and classified on the basis of roentgenographic appearance. The follow-up interval averaged 12.7 years. Good or excellent results were achieved in 59 per cent of the fractures. Accurate anatomical reduction of displaced fractures, if necessary by open reduction and internal fixation, is recommended. Avascular necrosis of the talar body occurred in 52 per cent of the fractures (in two of thirteen non-displaced fractures, in half of the fractures with subluxation or dislocation of the subtalar joint, and in sixteen of nineteen fractures with complete dislocation of the body of the talus). Many patients with avascular necrosis treated conservatively had satisfactory results. The complications of avascular necrosis, malunion, subtalar arthritis, and infection required twenty-five secondary procedures. Triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.
Fifty-one patients with fracture of the body of the talus were seen at follow-up examination an average of 23 months after treatment. Osteonecrosis had developed in 8 out of 17 patients with displaced shearing or crush fractures of the trochlea. Malunion as well as subluxation predisposed to osteoarthrosis in the subtalar and talocrural joints. Thus, osteoarthrosis was present in 9 out of 21 patients without malunion, in 8 out of 16 patients with malunion, and in 11 out of 14 with malunion as well as subluxation. Judging from the nature of the complaints, the difficulties in rehabilitation, and the disability assessment, the prognosis was fairly grave, also after the small, usually non-displaced fractures of the posterior and lateral tubercles. Out of 20 patients with fractures of this type only 6 obtained almost complete relief from their symptoms, only 8 could go back to their previous work on a full-time basis, and 11 were assessed to be 10 per cent or more disabled. Fractures in the posterior and lateral tubercles must therefore be interpreted as links in more extensive injuries involving the subtalar joint and possibly the talocrural joint with associated injuries to articular cartilage, joint capsules, and ligaments.
In this study we determined the effects of misalignment of the talar neck on the contact characteristics of the subtalar joint. Each of seven fresh cadaver lower extremities was mounted in a loading jig and a vertical load was applied, 90% of which was directed through the tibia and 10% through the fibula. The foot was allowed to displace freely in the horizontal plane so that relative rotations, known to occur in the subtalar joint, would not be prevented. Pressure-sensitive film, inserted into the posterior and anterior/middle articulations, was used to quantify changes in contact characteristics. After testing in the normal condition, the talar neck was osteotomized and stabilized with internal and external skeletal fixation. Contact characteristics were then determined in each of the following stages: anatomic realignment, or with 2-mm displacement of the talar neck either dorsally, medially, laterally, or complex (dorsal and varus) with respect to the body of the talus. Measurements showed no significant changes in overall contact area or high pressure area in the posterior facet, although four of the seven specimens demonstrated increased localization of the contact area into two discrete regions. The combined anterior/middle facet, on the other hand, was significantly unloaded by all but medial displacement of the talar neck. An extraarticular load path and/or increased loading directly on the talonavicular joint was presumed to account for the loss of load transfer in the talocalcaneal joint.
Four types of talus fractures can be distinguished and the prognosis predicted on the basis of vascular patterns before and after injury. Early decompression of the soft tissues or anatomic reduction by closed or (if not possible) open methods is indicated. Stable fixation by lag screws and functional aftertreatment help to improve the prognosis. The late results with reference to necrosis, posttraumatic arthrosis, secondary arthrodesis, and functional outcome show that open reduction and internal fixation, applied early, can produce better functions than was heretofore thought possible. Special emphasis is placed on careful indications, operative techniques, and postoperative treatment--particularly the time of partial weight-bearing with a caliper brace.
The talus is a bone with unique biomechanical features and vascular supply. Displaced fractures of the talus, therefore, frequently create problems of proper management. Forty-one severe talar fractures were treated operatively. The incidence of avascular necrosis was relatively low in this series (16%), and all of these were of Type III and IV fractures of the Marti-Weber classification. Type IV fractures were successfully treated by arthrodesis per primam, and suggested that fusion may be the indicated method of treatment in these severe injuries. Fusion of the tibiotalar joint has been used to encourage revascularization and to preserve the important function of the subtalar joint. In all other fracture types with dislocation, anatomic reduction is performed to restore joint congruity and encourage maintenance of talar dome viability. Painstaking postoperative management is important for the complete restoration of function.
Twenty-seven patients were examined on an average of 5 years after sustaining a vertical fracture of the talus. One patient had bilateral fractures. In spite of degenerative osteoarthrosis being visible on the radiographs, the functional results were good. Necrosis of the talus with deformity was consistent with surprisingly good function of the foot, subjectively and objectively. Operative reduction of the fracture had a high frequency of complications. The indications for primary talectomy in a fracture of this bone, as advocated by some other authors, is discussed. Closed reduction should be tried before open reduction is performed. If operation is necessary, the soft tissues must be treated with the utmost care in order to avoid necrosis and infection.
1. Fifty-eight major injuries in the region of the talus were reviewed regarding treatment, incidence of complications and long-term results.
2. The prognosis for simple fractures of the head, neck or body was good, as was that for dislocations of the midtarsal and peritalar joints.
3. The prognosis for fracture-dislocations of the neck and body was better than has been frequently reported. It was related to the degree of initial trauma. A good result occurs only if accurate reduction is effected and maintained. Fixation with a Kirschner wire is a useful method of maintaining the reduction after unstable fracture-dislocations.
4. Avascular necrosis occurred only in the more severe injuries and its incidence was related to the degree of initial displacement. The late results were better than have been previously described. The condition is best treated conservatively by protection from weight-bearing until revascularisation is well advanced.
5. A case with an unusual pattern of fracture of the neck of the talus is described following a plantar-flexion inversion injury.
1. The intraosseous and extraosseous circulation of the talus was examined in thirty necropsy specimens.
2. The blood supply to the talus is quite diffuse and arises from the three major arteries of the lower leg.
3. The common patterns of circulation, as well as the variations, have been documented.
A total of 35 patients treated in the years 1970 to 1977 for fractures of the talus were investigated for an analysis of the long-term clinical end results. Falling from height was the most common cause of injury (15 patients), the next most common being road traffic accidents (13 patients). The mean followup time was 8 years. At followup, 19 patients were free of any discomfort and none had pain at rest. The incidence of pain was correlated significantly (p less than 0.01) with the grade of dislocation both before and after reduction. In severely dislocated fractures open reduction and osteosynthesis with a compression screw are recommended.
The extraosseous and intraosseous vascularity of the talus was studied in 26 fresh cadaver limbs. The specimens were injected with latex or Batson's compound, debrided by a nondissection technique, and cleared by a modified Spalteholz method. The extraosseous vascularity was through the branches of the three major regional arteries which entered the five nonarticulating surfaces of the bone. The major blood supply to the body was provided by the artery of the tarsal canal. The deltoid and sinus tarsi vessels provided significant minor sources of vascularity. The superior neck and posterior tubercle vessels supplied small areas of the body, but did have anastomoses with the other arteries in some specimens. These vascular patterns correlated well with the reported incidence of avascular necrosis of the body of the talus following injury.
Twenty-six patients with major fractures of the talus were studied to assess the long-term outcome. The patients were admitted to a university teaching hospital and major trauma center from 1983 to 1991. The study excluded isolated fractures of the talar dome and posterior tubercle.
Fifteen patients were treated using internal fixation and 11 patients were treated using nonsurgical methods. Avascular necrosis was detected in only four of the 26 patients. Subtalar osteoarthritis was a significant problem in 61%. Seven of these patients have come to secondary fusion procedures, with another three contem-plating fusion procedures at the time of review. Only one patient developed significant avascular necrosis requiring a fusion procedure. Only three of 26 patients had not returned to work at a mean 6 years after their injury. Eleven of the 26 (42%) had not returned to their premorbid activity level.
The majority of these patients (25/26) had sustained multiple injuries, which compromised the functional recovery from the talar injury.
Early accurate diagnosis and anatomical reduction gave the best results. The low incidence of avascular necrosis in this study has been attributed to early anatomical stabilization of the fracture. We believe an early CT scan can more accurately assess the severity of the talar fracture and offers the best information for an appropriate treatment plan.
We performed an in vitro study on twelve specimens of the foot and ankle from cadavera to determine whether varus malalignment of the talar neck alters the position of the foot and subtalar motion. An osteotomy of the talar neck was performed, and the specimens were studied with and without removal of a medially based wedge of bone. Removal of the wedge produced an average varus malalignment of the talar neck of 17.1 +/- 2.4 degrees (range, 12.5 to 21.0 degrees). In the coronal plane, the average arc of motion of the subtalar joint decreased from 17.2 +/- 3.3 degrees before the osteotomy to 11.7 +/- 2.9 degrees after the osteotomy and removal of the wedge. In the transverse plane, it decreased from 17.5 +/- 2.9 degrees to 11.9 +/- 2.4 degrees. In the sagittal plane, it decreased from 8.9 +/- 2.4 degrees to 6.8 +/- 2.3 degrees. The decrease in subtalar motion was characterized by an inability to evert the foot; inversion was not limited, however. The malalignment produced an average of 4.8 +/- 1.2 degrees of varus deformity and 8.7 +/- 2.3 degrees of internal rotation of the hindfoot and an average of 5.5 +/- 2.0 degrees of varus deformity and 11.5 +/- 2.4 degrees of adduction of the forefoot. A linear correlation analysis was used to compare the change in subtalar motion and the position of the foot with the degree of varus malalignment at the talar neck. The correlation coefficient was 0.90 (p < 0.01) for subtalar motion, 0.76 (p < 0.01) for internal rotation of the calcaneus, and 0.81 (p < 0.01) for adduction of the forefoot. This indicated a direct correlation between the degree of varus malalignment at the talar neck and the change in the position of the foot and in subtalar motion.
Nine ipsilateral fractures of the talus and calcaneus were treated at Tampa General Hospital between 1991 and 1994 and entered into the trauma registry of this level 1 trauma center. During this same period, a total of 78 talar fractures and 334 calcaneal fractures were entered into the registry. The patients who sustained this rare combined injury were studied retrospectively to characterize the fractures that occurred, examine the treatments instituted, and determine outcomes. Four patients had severe intra-articular damage of the subtalar joint surfaces and underwent either primary or delayed arthrodesis. This subgroup of patients was followed for an average of 39 months (range, 25-45 months), and all had excellent or good outcome as assessed by the Maryland Foot Score. Three patients had nondisplaced or avulsion-type fractures of both bones, which were treated with immobilization. These all healed well. One patient had a Hawkins type 2 talus fracture with an extra-articular avulsion fracture of the Achilles tendon. This patient did well with open reduction and internal fixation of both fractures. The final patient had a crushed lower extremity in association with her hindfoot injury, which resulted in primary below-knee amputation. In general, we believe each individual fracture in this combined injury can be addressed with standard treatment regimens.
Fractures of the neck and body of the talus present as one of the most challenging and rare injuries. These fractures are often associated with other ankle, foot, and skeletal injuries, which complicate their treatment. The clinical course of 50 patients with a mean age of 29 years with a severe talus fracture between 1992 and 1997 is presented. According to the Hawkins classification there were 16 (32%) of type I, 14 (28%) of type II, 9 (18%) of type III, and 11 (22%) of type IV. Forty-three patients (86%) underwent operative treatment: 27 (63%) by open reduction and internal fixation with screws, seven (16%) by external fixation, five (12%) with percutaneous screws, and four (9%) by closed reduction with K-wire fixation. Mild osteoarthritis of the talocrural joint was seen in 14 patients (28%) and severe osteoarthritis in 10 patients (20%), five of whom required subsequent arthrodesis of the ankle joint. Arthrodesis of the subtalar joint was observed in 4 cases. Avascular necrosis with collapse of the talar body was seen in four patients (8%). The function of the ankle joint was evaluated according to the Weber score. Patients with talus fractures of Hawkins' type I and II had considerably better outcomes (with 95% being excellent or good) than individuals suffering dislocated fractures with involvement of the articulating surface with 70% good results in Hawkins' type III and 10% good results in Hawkins' type IV fractures. For the evaluation of the vitality of the talus body in cases with titanium implants, the authors used magnetic resonance imaging and intraosseous phlebography in cases with stainless steel implants. The displaced talus fractures must be treated by closed and, if necessary, open reduction with internal fixation. The initial postoperative management should consist of ambulation without weightbearing until radiographic appearance of trabecular bone in the fracture zone, indicating revascularization, can be manifested.
Fifty-eight patients with 60 talar fractures were retrospectively reviewed. There were 39 men and 19 women. The age average was 32 (range, 14-74). Eighty six percent of the patients had multiple injuries. The most common mechanism of injury was a motor vehicle accident. Twenty-seven (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body. Forty-eight fractures had operative treatment and 12 had non-operative management. The average follow-up period was 30 months (range, 24-65). Thirty-two fractures (53.3%) developed subtalar arthritis. Two patients had subsequent subtalar fusion. Fifteen fractures (25%) developed ankle arthritis. None of these patients required ankle fusion. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints. Ten fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse. Avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck. Three rating scores were used in this series to assess the outcome: the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Maryland Foot Score, and Hawkins Evaluation Criteria. The outcome was different with every rating system. However, the outcome with AOFAS Ankle-Hindfoot Score and Hawkins Evaluation Criteria were almost equivalent. Assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then the body fractures.
To describe an unreported technique of fixation for talar neck fractures.
Retrospective review and telephone interview of patients with fractures of the talar neck (OTA 72-A1.2, 72-A1.3, 72-C2).
Level-one trauma center with six trauma surgeons.
Twenty-three patients treated with minifragment plates over a four-year period. Follow-up intervals were an average of twenty months.
Talar neck fractures were stabilized with one or two 2.0 or 2.4 plates, with additional 2.0, 2.7, or 3.5 lag screws when necessary. Most fractures were approached through medial and lateral incisions.
Union rates, pain, and incidence of complications. Functional outcome will be best determined by a further review with longer follow-up.
Mini fragment plates were placed on the side with the most comminution, and all wounds and fractures healed uneventfully. Four patients underwent hardware removal. Two patients developed a mild extension malunion, but there was no evidence of varus malunion, as measured on Canale views.
Initial review suggests that plate fixation of comminuted talar neck fractures is a successful technique, with low rates of complications compared with those discussed in the literature. A further review in a few years will allow functional assessment studies.
1. Although fractures and dislocations of the talus have been described since 1608 the rarity of the more severe and complicated injuries has meant a dearth of accurate descriptions or classification in the literature.
2. A series of 228 injuries of the talus occurring in members of the Royal Air Force between 1940 and 1943 has been reviewed.
3. A simple but comprehensive classification of injuries of the talus is presented, together with a review of the pathological anatomy, clinical features, and methods of treatment. The importance of distinguishing between fractures and fracture-dislocations, and of watching carefully for displacements of the subtalar joint, is emphasised.
4. The important complicationsâinfection, avascular necrosis and traumatic arthritis of the ankle or subtalar jointâare discussed. Infection may be the result of a compound injury, or may follow sloughing of the skin stretched over a displaced talus. Early reduction is, therefore, of great urgency in closed injuries. Avascular necrosis of the talus occurs in gross injuries when all or most of the soft-tissue attachments to the bone are severed. Revascularisation and regeneration will take place with patient conservative treatment.
5. The mechanism of injury is discussed.
6. The results of excision of the talus are poor. Every effort should be made to preserve the body of the talus, but if its loss is inevitable a useful foot can be regained by deliberate fusion of the tibia to the calcaneum.
The talus is supplied with blood by the three main arteries of the leg through a periosteal vascular network and also by two discrete vessels, the artery of the tarsal sinus arising from the dorsolateral arteries and the artery of the tarsal canal arising from the posterior tibial artery.
At dissection an artery of the tarsal sinus was found in five specimens, and an artery of the tarsal canal was found in thirteen specimens. The intra-osseous vascular pattern was visible in all specimens after decalcification, sectioning, and clearing by the Spalteholz technique. The head is supplied by vessels entering from the superior surface of the neck and the inferolateral aspect of the neck which faces the tarsal sinus. The body is mainly supplied by vessels which enter antero-inferiorly through the neck of the talus and by vessels which enter through the medial surface below the articular facet. Smaller vessels enter the body from the superior surface of the neck, the anterolateral surface of the body, and the posterior tubercle.
To determine the outcome of displaced talar neck fractures at long-term follow-up in terms of functional outcome and secondary reconstructive surgery.
Retrospective cohort study.
Academic level 1 trauma center.
Seventy patients with displaced talar neck fractures.
All patients were treated with open reduction and screw fixation.
Functional outcome of patients who did not require secondary surgery was assessed using the Short Musculoskeletal Function Assessment, Ankle Osteoarthritis Scale score, and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. The incidence of secondary reconstructive hindfoot surgery, including arthrodesis or talectomy, was measured using life table analysis.
Mean Short Musculoskeletal Function Assessment score was 20 +/- 18 out of 100, with a lower score indicative of better outcome; mean Ankle Osteoarthritis Scale score was 3.8 +/- 2.4 out of 10 (lower score better); and mean Ankle Society Ankle-Hindfoot Score was 71 +/- 19 out of 100 points (higher score better). The incidence of secondary reconstructive surgery increased from 24 +/- 5% at 1 year to 48 +/- 10% at 10 years postinjury.
Functional outcome varied and was most dependent upon the development of complications. The incidence of secondary reconstructive surgery following talar neck fractures increased over time and was most commonly performed to treat subtalar arthritis or misalignment.
Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures.
We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered.
Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores.
Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.
Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment.
Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed.
Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores.
Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.
The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation.
The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment).
The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures.
Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.
The purpose of this new classification compendium is to republish the Orthopaedic Trauma Association's (OTA) classification. The OTA classification was originally published in a compendium of the Journal of Orthopaedic Trauma in 1996. It adopted The Comprehensive Classification of the Long Bones developed by Müller and colleagues and classified the remaining bones. In this compendium, the introductory chapter reviews new scientific information about classifying fractures that has been published in the last 11 years. The classification is presented in a revised format that is easier to follow. The OTA and AO classification will now have a unified alpha-numeric code eliminating the differences that have existed between the 2 codes. The code was significantly revised for the clavicle and scapula, foot and hand, and patella. Dislocations have been expanded on an anatomic basis and for most joints will be coded separately. This publication should stimulate new developments and interest in a unified language to code and classify fractures. Further improvements in classification will result in better patient care and clinical research.
The purpose of this study was to evaluate the frequency of combined ipsilateral talar and calcaneal fractures, the fracture pattern in combination and the clinical outcome of the combined operative treatment.
Out of 950 patients with calcaneal fractures and 190 patients with talar fractures treated operatively between 1984 and 2003, 11 patients (1% of calcaneal and 6% of talar fractures) were identified with combined ipsilateral talar and calcaneal fractures. Closed reduction and external fixation was performed in one patient with a crush foot injury, and ORIF in all other patients and fractures. All patients underwent clinical and radiological evaluation after a minimum followup period of one year using the AOFAS-Hindfoot Score.
Seven patients had central talar body and 4 patients talar neck fractures. Nine calcaneal fractures were extraarticular sustentaculum, as well as processus anterior fractures, and two were intraarticular fractures. Average followup was 6 (range, 1 to 12.5; median, 4.5) years. There were no perioperative complications related to ORIF. AOFAS-Hindfoot-Score averaged 78.6 (range, 50 to 100). The followup x-rays showed post-traumatic arthritis in the ankle joint in 3 patients and in the subtalar joint in five. AVN with peudarthorsis was present in one patient with an intraarticular calcaneal fracture. Patients with intraarticular calcaneal fractures presented with the worst functional results (AOFAS-Score, 50 and 64), none of these patients required a secondary ankle or subtalar fusion. All other patients had good and excellent functional outcome.
Combined ipsilateral talar and calcaneal fractures are rare injuries. Extraarticular calcaneal fractures are more common in this injury pattern, while there was no preference for either talar neck or talar body fractures. Operative treatment with anatomic open reduction and internal fixation may result in favorable clinical outcome. Combined surgical approaches to the hindfoot did not result in increased morbidity.
Late results of injuries to the talus. Analysis of forty cases
Mindell ER, Cizek EE, Kartalian G, Dziob JM. Late results of injuries to the talus. Analysis of forty cases. J Bone Joint Surg Am. 1963;45:221-45.