Session VII - Foot and Ankle
Timing of Surgical Fixation of Talar Neck Fractures
Eric G. Meinberg, MD1; James F. Kellam, MD1; Michael J. Bosse, MD1; William T. Obremskey, MD2;
Purpose: Adequate treatment of fractures of the neck of the talus remains a significant challenge for the orthopaedic surgeon. Early studies have reported poor clinical results, with arthrosis and avascular necrosis rates ranging from 25% to 100%. As an appreciation of the importance of expedient anatomic reduction of all articular fractures has grown, management techniques have improved significantly in the past 30 years. More recent studies have associated a reduced rate of avascular necrosis and late arthrosis with emergent anatomic fixation. Critical review of these studies fails to demonstrate that early fixation affords a significantly better result. The purpose of this study was to retrospectively review the clinical and radiographic records of all patients who received operative treatment at this institution for talar neck fractures and determine whether early surgical intervention resulted in an outcome superior to that of those who were treated at a later time.
Methods: After obtaining Institutional Review Board approval, the trauma registries of three regional trauma centers were used to identify all patients treated for talar neck fractures (OTA classification 72-A-1). Patient charts and pre- and postoperative radiographs were reviewed to verify diagnosis, fracture type, surgical management, time elapsed from injury to surgery, complications, and clinical and radiographic outcome. Patients were separated into early (<12 hours) and late (>12 hours) treatment groups, and classified according to the modified Hawkins' classification. To date a total of 111 patients have been identified.
Results: Complete records and follow-up of 84 patients with an average age of 28.6 years (range, 15 to 73) were identified. Follow-up averaged 62 months (range, 12 to 128). Thirteen Hawkins' type I, 28 type II, 26 type III, and 17 type IV fractures were identified. Both groups were similar with regard to distribution of fracture type. All patients underwent open reduction and rigid stabilization with use of K-wires and mini- or small-fragment instrumentation. Forty-two patients were treated within 12 hours of injury and 42 later than 12 hours. In the early treatment group, 14 (33%) complications occurred and 19 (45%) revision procedures were required, compared with 9 (21%) complications (P = 0.33) and 17 (40%) revisions for the late group (P = 0.83). Radiographically apparent ankle or subtalar joint arthrosis occurred in five (12%) patients in each group (P = 1.26) and avascular necrosis occurred in four (10%) of the early and one (2%) of the late group (P = 0.36). Six (14%) early and five (12%) late-treated patients required later ankle, subtalar joint, or triple arthrodesis (P = 1.0).
Conclusion/ Significance: Significant differences in avascular necrosis, ankle or subtalar joint arthrosis, major or minor surgical complications, or need for salvage arthrodesis were not noted between early and late treatment groups. These findings suggest that other factors such as severity of injury, quality of reduction, and surgical complications affect outcome more than the timing of reduction and fixation of talar neck fractures.