Session IV - Foot & Ankle

Survivorship of Displaced Talar Neck Fractures at Two-to-Ten-Year Follow-up

David W. Sanders, MD; Matthew A. Busam, MD; Emily Hattwick, MD; Kenneth D. Johnson, MD; Mark P. McAndrew, MD, Vanderbilt University Medical Center, Nashville, TN

Purpose: Fractures of the talar neck are debilitating injuries. In this study, a cohort of patients with displaced talar neck fractures treated surgically were re-evaluated 2 to 10 years after the injury to examine the prevalence and causes of residual morbidity and late failure.

Methods: We identified 108 eligible patients with displaced talar neck fractures treated at a level-1 trauma center between 1988 and 1998. Sixty-six patients underwent review, including clinical examination and fluoroscopic joint-space assessment. Joint-specific outcome measures for the ankle and hindfoot and general outcome scores (the Short Musculoskeletal Function Assessment) were studied. The primary outcome measure was defined as need for salvage surgery, such as talectomy or arthrodesis. Survivorship was compared using Kaplan-Meier survivorship analysis. Injury, demographic, and surgical variables were compared using Student's t test to determine factors associated with failure. Statistical significance was defined as P<0.05.

Results: Survivorship decreased from 76 ± 5 % at 1 year to 52 ± 10 % at 10 years. The most common salvage procedure was a subtalar or triple arthrodesis (66%), followed by ankle arthrodesis (28%). Posttraumatic arthritis was the most common cause of failure (79%), whereas osteonecrosis (16%) and nonunion (5%) were rare. Salvage surgery was likely in fractures with comminution (P <0.001), high Hawkins' classification (P = 0.004), and ipsilateral extremity fractures (P = 0.01). Time to surgery, patient age, ISS, and number of surgical approaches were not associated with failure (P >0.05). Subtalar arthrosis was the most common cause of failure at long-term follow-up and was pervasive within the group of patients who had not undergone late surgery. Overall, the presence of malalignment or arthrosis at long-term follow-up were associated with poorer outcome scores (P <0.05)

Discussion: In this study, disability increased over time, as evidenced by a progressive decrease in survivorship. Outcome was dependent upon comminution, high Hawkins' classification, and associated ipsilateral lower extremity injuries. In contrast, variables such as time to surgery, patient age, and number of surgical approaches were not correlated with an increased rate of salvage surgery. Subtalar arthrosis was the single most common cause of late failure and was also associated with poorer outcome scores of patients who had not required salvage surgery.

Conclusions: The need for salvage surgery was common, particularly with comminuted fractures. Subtalar arthrosis was the most common cause of late morbidity. Further study is necessary to lessen the incidence of subtalar arthrosis following talar neck fractures.