Session VII - Foot and Ankle

Technique and Results of Mini Fragment Plate Fixation of Talar Neck Fractures

Clifford B. Jones, MD; Patrick M. Zietz, MD; James R. Ringler, MD; Terrence J. Endres, MD; John J. Anderson, MD; and Donald R. Bohay, MD; Michigan State University, Spectrum Health Medical Center, Grand Rapids, Michigan, USA

Purpose: We evaluated the results and compared them with historical controls of urgent mini fragment plate fixation of talar neck fractures.

Methods: A retrospective analysis of prospectively gathered data was performed over a 3-year period at a level I trauma center. All displaced talar neck fractures requiring operative reduction and stabilization were included. Patients lost to follow-up or those who did not have mini fragment plate fixation (2.0 mm or 2.7 mm) were excluded, leaving a total of 47 patients with 49 fractures. Two patients had bilateral injuries. Two patients were lost to follow-up; thus, 45 patients with 47 displaced talar neck fractures were studied. The average age was 31 years (range, 17 to 48); 30 of the 45 patients were male. The mechanism of injury was a motor vehicle accident (22), a fall (19), or a motorcycle accident (6). The average follow-up was 1.5 years (range, 1.0 to 4.5). Thirty-nine of the 45 patients had other associated injuries, and 33 of the 45 patients had other associated foot and ankle injuries. The Hawkins classification was determined for the fractures: I (0), II (32), III (13), and IV (2). Dual anteromedial and anterolateral approaches were used for all patients, and medial malleolar osteotomies were used for five patients to enhance the exposure.

Results: Forty-one fractures had dual 2.0-mm condylar buttress plates (Synthes, Paoli, Pennsylvania). Three fractures had 2.7-mm quarter tubular and 2.0-mm condylar buttress plates. Three fractures had 3.5-mm cortical screws with a medial 2.0-mm buttress plate. Twenty-six fractures had comminuted talar neck fractures, with 10 requiring bone grafting. No malunions, nonunions or fixation or hardware failures were noted. Four patients developed osteonecrosis/Hawkins sign. No dome collapse was noted. The average range of motion was 10°, 39°, and 27% for ankle dorsiflexion, ankle plantarflexion, and the percentage of contralateral subtalar motion, respectively. Twenty patients reported pain with activities. Ten patients have developed subtalar arthrosis; the diagnosis was obtained with CT and subtalar injections. A majority of these 10 patients will require subtalar fusions. Five patients had prominent hardware (mainly laterally) that necessitated removal. One patient developed wound dehiscence and infection and subsequently required amputation.

Conclusion: Talar neck fractures can be successfully reduced and stabilized with mini fragment plate fixation that requires dual incisions. Dual incisions enhance the accuracy of reduction. Appropriate dissection to minimize talar vascular supply is paramount. When compared with historical controls, mini fragment plate fixation reduces the risk of nonunion, malunion, and osteonecrosis. If placed over the lateral process, the plate may become prominent and irritating. Posttraumatic subtalar arthrosis is still a problem, manifesting itself with pain and stiffness.

Significance: A dual-incision approach for displaced talar neck fractures allows for accurate reduction. Mini fragment dual-plate fixation reduces the historical risk of talar neck nonunion and malunion, with markedly reduced rates of talar dome osteonecrosis.