Surgical Management of Displaced Talus Neck Fractures: Single versus Double Approach, Screw Fixation Alone versus Screw and Plating Fixation - Systematic Review and Meta-Analysis

SLR - October 2021 - Justin Adame

Reference: Giordano V, Liberal BR, Rivas D, Souto DB, Yazeji H, Souza FS, Godoy-Santos A, Amaral NP. Surgical Management of Displaced Talus Neck Fractures: Single versus Double Approach, Screw Fixation Alone versus Screw and Plating Fixation - Systematic Review and Meta-Analysis. Injury. 2021 Jul;52 Suppl 3:S89-S96.

Level of Evidence: Level I

Scientific Literature Review

Reviewed By: Justin Adame, DPM
Residency Program: McLaren Oakland Hospital – Pontiac, MI

Podiatric Relevance: Talar neck fracture are rare but can have devastating consequences if not properly managed. The blood supply to the talus may become disrupted with dislocated fractures and fixation is vital to prevent avascular necrosis (AVN) and restore anatomic function. AVN risk increases with high energy injuries. The purpose of this study was to provide a direct comparison of common fixation strategies as well as surgical approaches in order to help guide the foot and ankle surgeon in planning reduction of talar neck fractures.

Methods: Data collection was performed using searches of PubMed, SciELO, and gray literature databases with exclusion of articles that were in languages other than English and Portuguese. Inclusion criteria was any method of surgical approach and fixation strategy found through the search terms: “talus fracture”, “talus neck fracture and surgical approach” and “talus neck fracture and fixation strategy”. Each of the articles were chosen by the principal investigator and then further vetted by his colleagues. The information gathered from each article included: fracture classification, surgical approach, fixation strategy, complication rate, type of complications, and outcome measurements.

Results: The dual incision approach was correlated with increased incidence of AVN and post-traumatic arthritis (PTOA) that was statistically significant (p=0.003). When comparing rates of AVN and PTOA, there was no statistically significant difference in screw versus plate fixation or the direction of drilling for lag screws. It was found that when using a combination of screw and plates, there was increased incidence of impingement with screw placement anterior-posterior if the screw heads were prominent and used with medially based mini-plates. Poor fracture reduction resulted in poor AOFAS scores (p=0.001). AVN and PTOA were more likely in Hawkins 3 and 4 fractures (p=0.001). There was little correlation between AOFAS scores and the modified Hawkins classification system, surgical approach and fixation strategy.

Conclusions: Surgeons should practice care with patient selection when choosing to utilize a dual incision approach for talar neck fractures especially in the case of Hawkins 3 and 4 fractures which often result in higher incidence of AVN and PTOA. Even though fixation type does not seem to play much of a significant role in outcomes, the fracture classification itself does. The limitation to this study is the relatively poor data quality that was derived from all level IV studies. Despite this, the authors provide a better understanding for the surgeon of the risks involved with different methods of surgical management of talar neck fractures and to guide preoperative patient conversations.