SLR - February 2020 - Stephen J. Kriger
Reference: Romeo NM, Hirschfeld AG, Githens M, Benirschke SK, Firoozabadi R. Significance of Lateral Process Fractures Associated with Talar Neck and Body Fractures. J Orthop Trauma. 2018 Dec; 32(12), 601-606.Scientific Literature Review
Reviewed By: Stephen J. Kriger, DPM
Residency Program: Scripps Mercy Hospital – San Diego, California
Podiatric Relevance: The lateral process of the talus has a large cartilaginous surface for its articulations with both the posterior facet of the calcaneus and the fibula, and it plays a critical role in hindfoot biomechanics. There is a lack of literature regarding lateral process fractures associated with talar neck or body fractures. Post-traumatic arthritis of the subtalar joint is the most common sequelae of displaced talar neck and body fractures, and the contribution of lateral process involvement to the development of this type of arthritis is unknown. The primary purpose of this study is to identify the incidence of radiographic subtalar arthritis in patients undergoing surgical treatment for talar neck or body fractures with a combined lateral process fracture compared with a cohort of patients undergoing surgical treatment of a talar neck or body fracture without a lateral process fracture. The secondary purpose is to evaluate whether patients who underwent reduction and fixation of the lateral process component of the fracture had a lower rate of subtalar arthritis as compared to those excised or left untreated.
Methods: This is a retrospective review performed at an academic Level 1 trauma center. Eighty-two patients (86 fractures) that were treated for talar neck (n=43) or body (n=43) fractures that had greater than one-year radiographic follow-up from March 2010 to April 2015 were included. Preoperative radiographic images were evaluated for involvement of the lateral process of the talus, involvement of the talus inferior articular surface, fracture pattern, and the frequency and direction of subtalar dislocation. Intraoperative and postoperative radiographs were evaluated to assess the quality of reduction. Follow-up radiographs were evaluated for the development of radiographic subtalar arthritis. Subtalar arthritis was graded according to the Kellgren and Lawrence scale. Two groups, those with and without lateral process involvement, were analyzed. Several subgroup analyses including evaluation of talar neck fractures with and without lateral process involvement and talar body fractures with and without lateral process involvement were performed.
Results: Seventy-six percent of talar neck fractures with involvement of the lateral process went on to develop radiographic evidence of subtalar arthritis compared with 36 percent of talar neck fractures without lateral process involvement which was statistically significant. There was no statistically significant difference when evaluating talar body fractures with or without lateral process involvement. Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures. An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis. Eighteen patients underwent reoperation where the most common procedure was implant removal (n=6).
Conclusions: Fracture of the talar neck with involvement of the lateral process is a marker for involvement of the inferior articular surface of the talus, which increases radiographic evidence of subtalar arthritis. Comminution of the inferior articular surface of the talus and a non-anatomic reduction are risk factors for development of radiographic subtalar arthritis. Further prospective randomized trials must be completed.