Session IX - Foot & Ankle
Isolated Displaced Fractures of the Talar Neck and Body: Results of Treatment with Open Reduction and Stable Fixation
Eric M. Lindvall, DO; George Haidukewych, MD; Thomas G. DiPasquale, DO; Dolfi Herscovici, Jr., DO; Roy Sanders, MD, Florida Orthopaedic Institute, Tampa, FL
Purpose: To assess the results of treatment of isolated, displaced fractures of the talar neck and body using stable internal fixation.
Materials and Methods: Between 1/935/98, 53 fractures of the talar neck and body in 52 patients were treated at our institution. Inclusion criteria required an isolated displaced talar neck and/or body fracture that was treated with stable internal fixation. Patients with additional ipsilateral peri-talar fractures and patients requiring subsequent amputations were excluded from this study. 33 fractures met inclusion criteria; seven patients were lost to follow-up. The resultant 26 fractures in 25 patients had a minimum follow-up of 22 months and an average follow-up of 49.6 months. Average age was 37.1 years. The study group consisted of 14 talar neck fractures, 8 body fractures, 2 combined neck + body fractures, and 2 combined neck + head fractures (OTA talus classification 72-A1.2, and displaced 72-B and 72-C). All neck fractures were Hawkins II or greater (18 cases). There were 19 closed and 7 open fractures ( type II/3, type IIIA /2, type IIIB/1, type IIIC/1). Closed fractures were operated on as soon as medical clearance was obtained, while all but one of the open fractures were operated on within 6 hours of injury. Post-operatively, all patients were kept non-weight bearing for 10-12 weeks. A/P, lateral and mortise radiographs were obtained at 2 weeks, 6 weeks, 10-12 weeks, and 6 months post-op. AOFAS hindfoot scores were gathered at the final follow-up visit.
Results: Only two fractures showed neither signs of post-traumatic arthritis nor avascular necrosis. Traumatic arthritis was the most common finding (92.3%) with more subtalar (23) than ankle joint involvment (17). Pain was the second most common finding (88.5%), while avascular necrosis was seen in half the cases. Avascular necrosis was seen in 4/11 Hawkins II fractures (36%) and in 4/7 Hawkins III fractures (57%). All cases with avascular necrosis presented with traumatic arthritis (100%).
All 19 closed fractures united after the index procedure (ave.=3.1 mos). Traumatic arthritis was seen in 17/19 (90%) closed fractures while avascular necrosis was seen in 7/19 (36.8%) cases. Of the 7 open fractures, 3 went on to non-union with two of these developing osteomyelitis. Of these 3 non-unions, two were successfully fused while one required a total talectomy.
A comparison between closed fractures treated < 6 hrs versus > 6 hrs after injury showed no statistical difference in the incidence of traumatic arthritis, avascular necrosis, or AOFAS hindfoot scores. When comparing fracture types (neck vs body), no statistical difference was noted in the incidence of traumatic arthritis, avascular necrosis, or AOFAS hindfoot scores.
Discussion: Post-traumatic arthritis was the most consistent complication seen following an isolated displaced talar neck and/or body fracture. It was a much more common finding than avascular necrosis, with the subtalar joint involved more commonly than the ankle. There was no difference in the incidence of traumatic arthritis, avascular necrosis, or AOFAS hindfoot scores in closed fractures when fracture type (neck or body), or timing of surgery were compared. This was in contradistinction to open fractures however, which fared dramatically worse in nearly all aspects of evaluation.
Conclusion: Patients should be made aware of the fact that based on the results of this study, post-traumatic arthritis and chronic pain are expected outcomes following isolated talar neck and/or body fractures. In addition, avascular necrosis can be expected to occur in half of these patients. Finally, an open fracture will worsen the prognosis significantly.