SLR - February 2013 - Seymour
Reference: Suter T, Barg A, Knupp M, Henninger H and Hintermann B. Surgical Technique: Talar Neck Osteotomy to Lengthen the Medial Column After a Malunited Talar Neck Fracture. Clinical Orthopaedics and Related Research. 2012; 1-9.
Scientific Literature Review
Reviewed by: Pauline Seymour, DPM
Residency Program: St. John Hospital and Medical Center, Detroit, MI
Podiatric Relevance:
The rate of a talar fracture malunion ranges from 9 percent to 47 percent. Additionally, shortening of the medial column may contribute to a poor outcome. Varus malalignment of the talar neck is common and even as little as two millimeters can change the degree of subtalar motion, therefore impeding normal daily activity. Currently there are limited studies that address anatomic reconstruction to restore normal foot function as an alternative to arthrodesis of talar fracture malunions. A new method has been reviewed through a retrospective observational study in patients with malunited talar neck fractures by way of a correcting osteotomy with interposition of allograft or autograft and internal fixation using buttress plates and/or screws.
Methods:
Seven patients with malunited talar neck fractures were treated with a corrective osteotomy between January 2002 and May 2009. All patients had initially sustained a closed talar neck fracture, and open reduction and internal fixation with K-wires or screw fixation were the initial treatments in four patients. The remaining three patients were immobilized in a cast for six to eight weeks. Range of motion of the ankle, tibiotalar and subtalar joint were assessed preoperative and postoperatively. All patients used the visual analog scale (VAS) to rate their pain and a questionnaire was completed to evaluate their quality of life. Radiographs were independently analyzed by two experienced orthopaedic residents. Integrity and contour of bone was assessed utilizing computed tomography to plan the correcting osteotomy. Bony union, position of implants and presence of avascular necrosis were assessed at the first clinical and radiographic follow-up. Clinical and radiographic follow-ups were then conducted at four months, one year and annually thereafter. Two reviewers, who did not operate on any of the patients, saw all the patients postoperatively. All data were retrieved from the medical records and radiographs. Minimum follow-up was 2.5 years, with no patients lost to follow-up.
Results:
There were three major complications observed. Nonunion of the talar neck osteotomy was noted in one patient and a talonavicular and subtalar arthrodesis was performed seven months later, resulting in no additional adverse events. In another patient, postoperative scar formation was noted at the time of implant removal, and an arthroscopic arthrolysis of the ankle was performed. A buttress plate, which was required for stability after the correcting osteotomy and graft insertion, was removed after bone healing at the osteotomy site of a third patient secondary to anterior ankle impingement during dorsiflexion. All patients showed substantial improvement postoperatively with range of motion, pain relief and quality of life, and were overall satisfied with the results. Radiographic evidence of union of the talar osteotomy site was shown in all but one patient within two to three months postoperatively. There was no avascular necrosis, arthritic changes or loss of correction seen in any of the patients.
Conclusions:
Anatomic restoration is essential for optimal functional outcomes in patients with malunited talar neck fractures. In this study, a new surgical technique was demonstrated to restore anatomical position, and as a result, provide pain relief, improve foot and ankle range of motion and therefore enhance quality of life with a correcting osteotomy and interposition of an allograft or autograft with internal fixation using buttress plate and/or screws as described above. Although arthrodesis is an alternative approach for treating malunited talar fractures, the authors of this article demonstrated lengthening osteotomies are a reasonable option.