Session II - Foot and Ankle
Talus Fractures, a Fated Foot Injury, Operative or Conservative Treatment, Long-Term Results
Gholam S. Pajenda, MD; Thomas Heinz, MD, Prof.; Brian Reddy, MD; Vilmos Vécsei, MD, Prof.; University Clinic for Traumatology, Vienna University Hospital, Waehringer Gaertel, Vienna, Austria
Introduction: Talus fractures belong to the rarest and most challenging injuries that trauma surgeons have to deal with. They represent 0.3 % of all fractures and 3.4 % of all foot injuries. These fractures are often associated with other ankle, foot and skeletal injuries, which complicate their treatment and in some cases delay their diagnosis. While the non-displaced talus fractures have a good prognosis through conservative treatment, the displaced talus fractures must be treated by closed and, if necessary, open reduction with internal fixation. Anatomical reconstruction of the joint using stable osteosynthesis allows early passive and active motion. Surgical treatment is undertaken in dislocated talus fractures, especially in young adults.
In this follow-up study, we investigated the relation between the fracture type and degree of surgical reduction observed radiographically regarding complication rates and functional outcome. Our intent was to elicit some inherent principles in order to obtain a more quantitative understanding of long-term outcome based on early radiographic findings. This information could allow an earlier exploration of alternatives such as arthodesis in patients with unsatisfactory results.
Material and Methods: Between 1992 and 1996, 70 patients, 50 males and 20 females, with a mean age of 29 years (range 16 to 58 years), were treated for talus fractures. Of these patients 23 (32%) had been injured in automobile accidents, 28 patients (40%) fell from a great height and 19 (27%) after inversion trauma; 10 (15%) had multiple injuries. There were 50 (71%) severe fractures of the neck and body of the talus. Using Hawkin- Canale and Kelly's classification criteria, there were 16 of Type I, 14 of Type II, 9 of Type III and 11 of Type IV. Flake fractures were seen in 14 cases and fractures of the posterior or lateral process of the talus in 6 cases.
Forty three (61%) patients underwent an operative treatment; 27 (63%) patients by open reduction and internal fixation with screws, 4 (9%) patients by closed reduction using percutaneus K-wire, 5 (12%) patients with percutaneus screws, and 7 (16%) patients by external fixateur. External fixation was applied in cases of associated irreducible and unstable comminuted fractures of calcaneus, ankle joint, and dislocated or severe open fractures.
After admission, the extent of the injuries to each patient was evaluated with priority, and the appropriate treatment performed. Plain antero-posterior and sagittal radiographs of the ankle joint were obtained. In cases of complex fractures CT-scans had also been necessary. Every grossly dislocated fracture was reduced using fluoroscopy. Reduction of the ankle dislocation is a surgical emergency. A late unreduced dislocation is extremely difficult to deal with and may jeopardize the blood supply to the talus, causing avascular necrosis. Depending on their associated injuries, most patients were operated on, at the latest, within 10 hours following their injuries. Depending on the fracture type, the following approaches were made: posterior approach (n=8), antero-medial approach in 16 cases and the combined anterior and posterior approach in 4 cases. A traction pin was inserted in the calcaneus in 6 cases to reduce the fracture and expose the articular surface of the talus. Whenever greater exposure was necessary, in particular in patients with fracture of the body and neck of the talus (Hawkins type IV), osteotomy of the medial ankle was performed.
Postoperative management: Ambulation using crutches with Allgoewer-apparatus without weight bearing was allowed after the second postoperative day. After the 6th postoperative week, passive and active exercises in the ankle joint were begun in all patients. Partial weight bearing (10 - 15 kg) was allowed after 8 weeks followed by full weight bearing between the 12th and 16th postoperative week depending on the radiographic control. For evaluation of the vitality of the talus body we prefer to use intraosseous phlebography and in cases with titaneum implants MRI. Each patient was evaluated both clinically and radiographically. Radiographs were taken every 2 weeks in the first 3 months, then at 3-month intervals within the first year. The radiographs were examined for the union of the fracture, failure of fixation, and aseptic necrosis of the talus body.
For the functional evaluation of the ankle joint we used the Weber classification. This evaluation is based on six variables: pain, activity, gait, function of ankle and subtalar joint and radiographic outcome. Results were rated excellent (0 points), good (1-2 points), fair and poor (3-4 points). Recently, we have also been using the Phillips score, which is based on the variables of pain, function, gait and range of motion. No significant difference could be observed between the scores in the clinical evaluation of the ankle joint.
Results: Patients suffering non-dislocated fractures of the talus neck that did not include the articulating surface of the talus in the ankle joint had considerably better outcomes (95% excellent or good) than individuals suffering dislocated fractures with involvement of the articulating surface (70% good and excellent). The worst outcome was in patients whose fracture pattern included the ankle and subtalar joint with concommitant calcaneus comminuted fractures (10% good or excellent), showing the highest rates of complications (deep infection in 5 [7%] cases). These were treated by revision and local application of antibiotics (pmma gentamaicin chain). No episode of non-union was observed in any of the fracture patterns. Superficial wound infection was observed in 2 cases (3%), which healed after local revision and systemic antibiotic therapy.
Mild osteoarthritis was seen in 20 patients (28%), severe osteoarthritis (spur formation and subchondral sclerosis formation) in 9 (13%) patients, five of which led subsequently to arthrodesis of the ankle joint. Avascular talus necrosis was seen in 3 patients (4%) with satisfactory clinical result. Talus fractures associated with polytrauma have much poorer results due to the delay of the diagnosis and treatment.
Discussion: Appropriate therapeutic strategy of the talus neck and body fractures is a subject of constant turmoil. In 1844 Syme reported about 84% mortality caused by open talus fractures. In 1892 Ernest von Bergmann from Berlin used the first open reduction and internal fixation of the talus fracture. All operative methods described in the literature recommend immediate reduction and stable fixation. We attribute the good and excellent functional outcomes in displaced talus fractures to the exact management, i.e. immediately closed or open reduction and stable osteosynthesis, as well as to the postoperative functional treatment without weight bearing until positive Hawkins sign or positive intraosseous phlebography.
Conservative treatment is only justified in non-displaced fractures and in flake-type fractures where the relationship between the talus and the tibia and fibula is rarely disturbed. In older patients with reduced general condition and osteoporotic bone, internal fixation is difficult to achieve. Contra-indicated for surgery are patients with poor general physical condition due to preexisting internal diseases.
Conclusion: As is the case in all other articular fractures, closed or open reduction and internal fixation is required in displaced fractures of the talus. Surgical reduction of talus fractures, however, remains a difficult procedure and should be performed with patience by experienced surgeons under optimal conditions. Preoperative planning of the operation is vital.