Session VIII - Foot and Ankle

Immediate vs. Delayed Operative Management of Fractures of the Neck of the Talus

David E. Karges, DO, Kathryn E. Cramer, MD, James S. Kapotas, MD

Henry Ford Hospital, Detroit, Michigan, USA

Purpose: To compare the results of immediate versus delayed operative management of displaced fractures and fracture dislocations, of the neck of the talus.

Materials: A retrospective review of 21 talar neck fractures (Hawkins II, III, IV) using contemporary reduction techniques, internal fixation methods, and dual anteromedial and anterolateral surgical approaches were performed at our institution from October 1, 1992 to July 30, 1996. Nine patients (3 - Hawkins II{1 open} , 6 - Hawkins III{3 open} , 1 -Hawkins IV) were treated immediately. Due to delays in patient transfer, surgical clearance, and compromised soft tissue, eleven patients with closed injuries (7 - Hawkins II, 4 - Hawkins III) had a delay in surgical treatment. At the time of reconstruction, six fractures in both the immediate (Group I) and delayed (Group II) treatment groups were immobilized in foot and ankle external fixators for six weeks to put damaged soft tissues to rest, decrease stresses across talar neck fractures associated with bone loss, and control equinovarus deformity. All patients remained nonweight-bearing for ten weeks followed by progression to full weight-bearing. Data collection included time from injury to OR, associated injuries, fracture reduction, radiographic evidence of AVN, collapse, and signs of ankle and subtalar arthrosis. Clinical rating of the Ankle and Hindfoot (AOFAS), and Musculoskeletal Functional Assessment was performed on all patients.

Results: In Group I there were six females (1 bilateral) and three males, average age 37 years. In Group II there were three females and eight males, average age 39 years. Time to OR for all patients in Group I averaged 6.4 hours (range 2-12 hours) and 9.3 days (range 6-12 days) in Group II. In the delayed group closed reductions were achieved on all time of last clinical follow-up. All three open Hawkins III fracture-dislocation and the sole Hawkins IV in Group I developed localized AVN. Two patients developed mild ankle arthrosis and a third patient required a subtalar arthrodesis at 18 months due to subtalar arthrosis. Average follow-up in Group I was 2.2 years. Ankle and subtalar motion demonstrated restriction in 70% of hindfeet in Group I, yet 85% of these patients with previous jobs have returned to part-time or full-time employment. One Hawkins II in Group II developed localized AVN. There was no evidence of radiographic ankle or subtalar arthrosis in Group II Hawkins II patients. All four Hawkins III injuries in Group II had radiographic signs of AVN with one talus developing symptomatic and radiographic collapse of the talar dome at one year. Radiographic ankle and subtalar arthrosis were noted on x-ray in two Hawkins III injuries in Group II. No subsequent surgery has been required at the time of most recent follow-up for the Group II patients. Average follow-up for all Group II patients was 1.7 years. All patients in Group II demonstrated restricted ankle and subtalar range of motion, yet 90% of these patients previously holding jobs returned to part-time or full-duty jobs.

Discussion: All 21 fractures of the neck of the talus healed. There were no bone or soft tissue infections. Radiographic signs of AVN, and arthrosis and restriction of joint motion was similar between Group I and Group II Hawkins II fractures. It is concluded that closed Hawkins II fractures may be treated safely in a delayed fashion if other factors preclude their acute management. Localized AVN, arthrosis, and restriction of motion was comparable between Group I and Group II Hawkins III fracture-dislocation. The radiographic and symptomatic collapse of the talar dome in one Group II Hawkins III injury was not evident in any Group I Hawkins III or IV injury. It is strongly recommended that closed Hawkins III and IV injuries are managed immediately to reduce the dislocation, restore articular relationships, and prevent any potentially harmful soft tissue and neurovascular local pressure injury.