SLR - July 2018 - Louis Reper II
Reference: Joseph A. Buckwalter V, MD, PhD Robert Westermann, MD Brian Mooers, MD Matthew Karam, MD Brian Wolf, MD, MS. Timing of Surgical Reduction and Stabilization of Talus Fracture-Dislocations. Am J Orthop. 2017 November;46(6):E408–E413.Scientific Literature Review
Reviewed By: Louis Reper II, DPM
Residency Program: Larkin Community Hospital, South Miami, FL
Podiatric Relevance: Talar fractures although not common present with serious complications, such as avascular necrosis (AVN) and posttraumatic osteoarthritis (PTOA). The purpose of the study was to compare the recent outcomes of surgical treatment with the variables of the patient population, surgery and severity of injury. The main goal was to determine the effect timing of surgery had on the overall outcome of the injury.
Method: This study retrospectively assessed 106 talar fractures classified by the Hawkins and AO/OTA classifications that were all definitively treated with ORIF and compared their outcomes by analyzing postoperative radiographs. They compared outcomes for the development of AVN, PTOA or secondary surgery in open versus closed fractures and separately looked at Hawkins type 3 and 4 fracture-dislocations.
Results: Of the 106 talar fractures compared, 13 (12 percent) were Hawkins 1 fractures, 31 (29 percent) were Hawkins 2 fractures, 25 (24 percent) were Hawkins 3 fractures and seven (7 percent) were Hawkins 4 fractures. Overall, 41 percent (43) of the 106 patients developed AVN/PTOA, which is within the normal range. There was no significant difference in mean age, BMI, presence of polytrauma or surgical timing of the overall group. However, there was a significant difference when comparing all of the open fractures with the development of AVN/PTOA. Fifteen of the 43 patients with AVN/PTOA were open injuries versus 10 of the 63 who did not develop ANV/PTOA were open fractures (35 percent versus 16 percent). Although an open injury was significant for the development of AVN/PTOA for all of the fracture types overall, it was not true for the AO/OTA 81-B3 fracture-dislocation type. Analysis showed 50 percent (5/10) of the 81-B3 open fractures developed AVN/PTOA, half of which were open and half were not. There was no significant difference in mean age, BMI, presence of polytrauma or surgical timing of the 81-B3 group.
Conclusion: This study’s results suggested that there should not be as much an emphasis on surgical timing as should be on the severity of the injury for surgical reduction and stabilization of talus fracture dislocations. So in the absence of open fractures, skin necrosis or soft-tissue/neurovascular compromise, they suggest that talar fracture dislocations be surgically reduced and fixated when optimal resources are available.