Session V - Foot and Ankle

Surgical Treatment of Fractures of the Talar Body

Heather A. Vallier, MD; Sean E. Nork, MD; Stephen K. Benirschke, MD; Bruce J. Sangeorzan, MD; Harborview Medical Center, University of Washington, Seattle, Washington, USA

Purpose: Fractures of the talar body are uncommon and poorly described. In displaced fractures, surgical treatment is necessary to restore articular congruity and to allow early range of motion of the ankle and subtalar joints. The purposes of this study were to characterize these fractures, to describe their treatment, and to evaluate the clinical, radiographic, and functional outcomes of operatively treated fractures of the body of the talus.

Methods: During a 67-month period, we identified 56 patients with 57 talar-body fractures who were operatively treated at a level-1 trauma center. These patients had an average age of 34.1 years (range, 15 to 74) and an average Injury Severity Score of 15.2 (range, 9 to 50). Twenty-three (40%) had concomitant talar-neck fractures. Eleven fractures (19%) were open. All fractures were articular and involved the talar body. Isolated process fractures and transchondral lesions were excluded. Fractures were classified according to OTA guidelines, with the primary fracture located laterally in the sagittal plane (72-B1) in 18 patients, medially in the sagittal plane (72-B2) in 9 patients, in the coronal plane (72-B3) in 20 patients, and comminuted (72-C2) in 10 patients. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Responses on the Foot Function Index (FFI) and the Musculoskeletal Functional Assessment (MFA) questionnaires were tabulated.

Results: Thirty-eight patients were evaluated after an average follow-up of 33 months (range, 12 to 76). Early complications occurred in 21%. Osteonecrosis of the talar body developed in 38% of patients. Half of these patients experienced talar dome collapse at a mean of 10.2 months after surgery. All patients with a combination of an open fracture and osteonecrosis developed collapse. Posttraumatic arthritis was present in the tibiotalar joint in 65% and in the subtalar joint in 35%. Patients with fractures of both the talar body and neck developed advanced arthritis more frequently than patients with talar body fractures only, 82% versus 36% (P = 0.042). All patients with open fractures had end-stage posttraumatic arthritis (P = 0.05). Overall, radiographic evidence of osteonecrosis or posttraumatic arthritis or both was identified in 88% of patients. Increased impairment, as measured by the FFI, was present among patients who had comminuted or open fractures. Osteonecrosis or posttraumatic arthritis adversely affected FFI and MFA scores. The mean standardized MFA values for patients with osteonecrosis and collapse or with posttraumatic arthritis were 65.6 and 35.6, respectively. Reference values for hindfoot or midfoot injuries and for uninjured people are 22.1 and 9.3, respectively (Engelberg et al. 1999).

Discussion and Conclusions: Fractures of the talar body are rare and generally have a poor prognosis. These injuries typically involve articular surfaces of both the ankle and subtalar joints. 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 develop radiographic evidence of osteonecrosis or posttraumatic arthritis or both. Associated talar-neck fractures or open fractures more commonly result in osteonecrosis or advanced arthritis. Decreased functional outcomes are seen in patients with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their prognosis and potential complications.