SLR - September 2013 - Rebecca Sundling
Reference: Suter T, Barg A, Knupp M, Henninger H, Hintermann B. Talar Neck Osteotomy to Lengthen the Medial Column After a Malunited Talar Neck Fracture. Clinical Orthopaedics and Related Research. 471(4); 2013: 1356-64.
Scientific Literature Review
Reviewed by: Rebecca Sundling, DPM
Residency Program: Grant Medical Center, Columbus, Ohio
Podiatric Relevance: Malunited talar neck fractures are noted in nine to 47 percent of all talar neck fractures, and can result in chronic pain, overload of the lateral foot, and degeneration of adjacent joints. With varus malunion being most common, a shortened medial column and hindfoot varus often result. Commonly, arthrodesis of adjacent joints, including triple arthrodesis, is used as a method of treatment. This study aimed to present an operative treatment that allows to restoration of function and preservation of joints.
Methods: This was level IV retrospective study of seven patients who underwent correction of a malunited talar neck fracture. Indications included patients with shortening of the medial column with hindfoot varus, forefoot varus and adducted position. Patients were excluded in the presence of skin lesions, ulcerations or avascular necrosis of talus. A dorsomedial incision was used to access the deformity and previous implants were removed when applicable. Distraction was used to allow for rotational correction and implantation of bone graft: allograft in five patients, whereas two patients requested use of autograft. Two screws were used for stability of the graft and a buttress plate was applied in cases noted to be lacking distraction stability. Additional fusions and tendon lengthening or releases were performed as necessary. Patients were partial weight bearing for eight weeks. Each patient was assessed pre- and postoperatively with the VAS pain score, SF-36 questionnaire, AOFAS Hindfoot scale, radiographs and tibiotalar and subtalar range of motion. Follow-up was noted at six weeks, four months, 12 months and annually thereafter.
Results: No patients were lost to follow-up, with average follow-up of 2.5 years. Three patients had complications, including nonunion, need for additional arthrolysis of the ankle due to scar formation and removal of buttress plate secondary to anterior ankle impingement. VAS score decreased from 7.4 ± 1.0 to 1.7 ± 0.8. The AOFAS hindfoot score and physical portion of the SF-36 showed improvement. Tibiotalar joint ROM increased from 41.3 ± 9.1, preoperatively, to 44.3 ± 7.7, postoperatively. Subtalar joint ROM decreased from 22 ± 6.0 preoperatively, to 17 ± 17 postoperatively. All but one patient showed union of osteotomy site. All patients reported being satisfied and stated they would have surgery again.
Conclusions: Malunion of talar neck fractures is a common issue often treated with arthrodesis of adjacent joints. Based on the above methods of evaluation, use of a talar neck osteotomy with implantation of bone graft is a reasonable option for treatment of malunited talar neck fractures; however, larger studies with longer follow-up would be warranted. This method allows for preservation of joints and restoration of function while relieving pain and improving daily activity for patients.