SLR - July 2012 - Evie Plummer
Reference: Xavier Ohl, Alain Harisboure, Xavier Hemery, Emile Dehoux. Long-term Follow-up after Surgical Treatment of Talar Fractures. International Orthopaedics, 2011; 35:93-99
Scientific Literature Review
Reviewed by: Evie Plummer, DPM
Residency Program: North Colorado Podiatric Medicine and Surgical Residency
Podiatric Relevance:
Displaced talar fractures may be a therapeutic challenge for the podiatric surgeon with many potential early or late complications. This study evaluates the long-term outcomes of talar fractures following operative treatment. Talar fractures are often associated with a high complication rate, including malunion, osteonecrosis or osteoarthritis. It is important to assess the operative treatment of such fractures to minimize these complications.
Methods:
This retrospective study evaluated twenty patients with displaced talar fractures with an average follow-up of 7.5 years. The study consisted of 10 talar neck fractures and 10 talar body fractures. A single surgical approach was utilized with fixation comprised of either percutaneous fixation (40 percent of cases), cannulated screws (35 percent of cases), or a combination of K-wires and screws (25 percent of cases). The patients were then immobilized in a non-weightbearing cast in neutral alignment for a period of three months. Progressive weightbearing combined with physiotherapy was implemented after this period of immobilization. The authors chose to avoid a more aggressive operative treatment with a systematic dual surgical approach in hopes of maintaining a low rate of osteonecrosis. The final follow-up examination included determination of the AHS score (ankle-hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiographical analysis.
Results:
Using the AOFAS ankle-hindfoot scale, the average functional score was 67 points (range 45-88 points). Results were good in seven cases, fair in 11 cases and poor in two cases. There was no excellent result. The AOFAS score was not statistically different in relation to the fracture type (64.6 for the talar neck fractures and 69.2 for the talar body fractures). At final follow-up, the injured foot demonstrated a significant loss of range of motion compared to the healthy foot for both ankle and subtalar joint movement. Postoperative radiographic analysis confirmed the difficulty of obtaining an anatomical reduction for talar neck or body fractures. Reduction was anatomical in six cases (30 percent), nearly anatomical in nine cases (45 percent), and poor in five cases (25 percent). Four patients (20 percent) presented with osteonecrosis of the talus during the post-operative course. At final follow-up, 94 percent of the patients presented with post-traumatic osteoarthritis in one or more of the following joints: subtalar (84 percent), ankle (76 percent) and talonavicular (20 percent). Thirty-five percent of patients underwent a secondary surgery, consisting of subtalar arthrodesis, tibiotalar arthrodesis, tibiotalocalcaneal arthrodesis, total ankle arthroplasty, ankle arthrolysis or ankle arthroscopy.
Conclusions:
This study confirms a high complication rate associated with displaced talar fractures. Despite the authors' demonstrating a lower rate of osteonecrosis compared to other studies reported in the literature, there remains a low rate of anatomical reduction along with other complications described in this study. There were a number of limitations in this study, including a small sample size and single center trial. The operative treatment of displaced talar fractures should involve both precise anatomic reduction and essential respect of soft tissues to limit skin complications and osteonecrosis.