Original Research

Timing of Surgical Reduction and Stabilization of Talus Fracture-Dislocations

Am J Orthop. 2017 November;46(6):E408-E413

References

1. Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014;96(3):192-197.

2. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978;60(2):143-156.

3. Ebraheim NA, Patil V, Owens C, Kandimalla Y. Clinical outcome of fractures of the talar body. Int Orthop. 2008;32(6):773-777.

4. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(2):114-127.

5. Fournier A, Barba N, Steiger V, et al. Total talar fracture—long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res. 2012;98(4 suppl):S48-S55.

6. Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Clin Orthop Relat Res. 1985;(199):88-96.

7. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52(5):991-1002.

8. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am. 2004;86(10):2229-2234.

9. Ohl X, Harisboure A, Hemery X, Dehoux E. Long-term follow-up after surgical treatment of talar fractures: twenty cases with an average follow-up of 7.5 years. Int Orthop. 2011;35(1):93-99.

10. Rammelt S, Zwipp H. Talar neck and body fractures. Injury. 2009;40(2):120-135.

11. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G. Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1-15 years. Acta Orthop Scand. 2002;73(3):344-351.

12. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004;86(8):1616-1624.

13. Patel R, Van Bergeyk A, Pinney S. Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts. Foot Ankle Int. 2005;26(5):378-381.

14. Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma. 2004;18(5):265-270.

15. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int. 2000;21(12):1023-1029.

16 Frawley PA, Hart JA, Young DA. Treatment outcome of major fractures of the talus. Foot Ankle Int. 1995;16(6):339-345.

17. Fracture and dislocation compendium. Orthopaedic Trauma Association committee for coding and classification. J Orthop Trauma. 1996;10(suppl 1):v-ix, 1-154.

18. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1-S133.

19. Williams T, Barba N, Noailles T, et al. Total talar fracture—inter- and intra-observer reproducibility of two classification systems (Hawkins and AO) for central talar fractures. Orthop Traumatol Surg Res. 2012;98(4 suppl):S56-S65.

20. Zwipp H, Baumgart F, Cronier P, et al. Integral classification of injuries (ICI) to the bones, joints, and ligaments—application to injuries of the foot. Injury. 2004;35(suppl 2):SB3-SB9.

21. Xue Y, Zhang H, Pei F, et al. Treatment of displaced talar neck fractures using delayed procedures of plate fixation through dual approaches. Int Orthop. 2014;38(1):149-154.

22. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2003;85(9):1716-1724.

23. Fleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients. J Orthop Trauma. 2002;16(4):213-219.

24. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2004;86(suppl 1, pt 2):180-192.

Results

Classification Analysis (Table 1)

Table 1.

We identified 106 surgically managed talus fractures. Five (4.7%) were lateral process and talar head fractures (AO/OTA 81-A). Seventy-six (71.7%) were talar neck fractures (81-B), which included 13 (12%) 81-B1 fractures, 31 (29%) 81-B2 fractures, and 32 (30%) 81-B3 fractures. Twenty-five (23.6%) were talar body fractures (81-C). AO/OTA 81-B3 fractures were identified and separately analyzed and compared with talus fractures of all other classes. AO/OTA 81-B talar neck fractures were classified with the Hawkins system7 as well: 13 (12%) were Hawkins 1 fractures, 31 (29%) Hawkins 2 fractures, 25 (24%) Hawkins 3 fractures, and 7 (7%) Hawkins 4 fractures.

Subject Analysis (Table 2)

Table 2.

Of the 106 patients, 69 were female and 37 male. Mean age was 37.7 years (range, 18-78 years). Mean body mass index (BMI) was 29.45 kg/m². Of the 106 cases, 52 were managed by board- certified orthopedic trauma surgeons, 32 by board- certified foot and ankle surgeons, and 22 by orthopedic surgeons with other specialty training.

The mechanisms of injury were motor vehicle accident (70/106; 66%), fall from height (25; 24%), misstep (4), sports related (2), object falling on ankle (2), and not reported (3).

Of the 106 patients, 45 (42%) had isolated talus injuries, 35 had concomitant ipsilateral lower extremity injuries, 25 had concomitant contralateral lower extremity injuries, and 1 had a concomitant upper extremity injury.

Smoking status was everyday (14 patients), past (10), never (34), and unreported (48). Five patients reported a history of alcohol abuse, and 4 patients reported illicit drug use. Two had a history of atrial fibrillation, 9 had hypertension, 3 had hyperlipidemia, 3 had renal disease, 3 had heart disease, 4 had diabetes, 3 had lung disease, and 1 had a history of lung cancer.

Overall Analysis of AVN/PTOA (Table 3)

Table 3.

Of the 106 patients, 43 (41%) developed AVN/PTOA, and 63 (59%) did not, while fifty-four (51%) of the 106 patients who developed AVN/PTOA had polytrauma, and 52 (49%) of those who did not develop AVN/PTOA had polytrauma (P = .79). There was no significant difference in mean age (38.74 years for AVN/PTOA, 36.21 years for no AVN/PTOA; P = .20) or BMI (28.99 kg/m²for AVN/PTOA, 29.15 kg/m2 for no AVN/PTOA; P = .45). Direct comparison of proportions of polytrauma to development of AVN/PTOA revealed no significant difference. Direct comparison of the proportions of open injuries to development of AVN/PTOA revealed a significant difference. Fifteen (35%) of the 43 patients who developed AVN/PTOA had open injuries, and 10 (16%) of the 63 who did not develop AVN/PTOA had open injuries (P = .03). There was no significant difference in follow-up between patients who developed AVN/PTOA and those who did not (P = .26).

Analysis of AVN/PTOA in 81-B3 Fracture-Dislocations (Table 4)

Table 4.

Of the 32 patients with AO/OTA 81-B3 (Hawkins 3 or 4) fractures, 16 (50%) developed AVN/PTOA, and 16 did not. There was no significant difference in mean age (41.05 years for AVN/PTOA, 37.40 years for no AVN/PTOA; P = .29), BMI (28.86 kg/m²for AVN/PTOA, 27.94 kg/m2 for no AVN/PTOA; P = .38), or surgical timing (19.09 hours for AVN/PTOA, 16.65 hours for no AVN/PTOA; P = .29) for development of AVN/PTOA. Direct comparison of the proportions of polytrauma and open injuries to development of AVN/PTOA in patients with 81-B3 fracture- dislocations revealed no significant difference. Nine of the 16 patients (56%) who developed AVN/PTOA had polytrauma, and 11 of the 16 (69%) who did not develop AVN/PTOA had polytrauma (P = .465). Although open injury was found to predict AVN/PTOA overall, this was not true for talus fracture-dislocations alone. Five of the 10 patients who developed AVN/PTOA had open injuries, and 5 of the 10 who did not develop AVN/PTOA had open injuries (P = 1.0). There was a significant difference in follow-up time between these groups. Patients who had 81-B3 fracture-dislocations and developed AVN/PTOA were followed for a mean of 120.4 weeks, and those who did not develop AVN/PTOA were followed for a mean of 40.33 weeks (P = .001).