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Internal fixation of a complex fracture of the Talus using a dual-incision extensile approach – A case report with a review of classifications

Open AccessPublished:November 17, 2021DOI:https://doi.org/10.1016/j.fastrc.2021.100099

      Highlights

      • A complex Talus fracture pattern.
      • Talus fracture does not fit into existing classification systems.
      • Dual-incision extensile approach used to fix the fracture.
      • No AVN, excellent return of function.

      Abstract

      Case

      A 29-year old male patient sustained an isolated fracture of the left talus in a fall down a staircase. This was a displaced, complex comminuted fracture that affected the talar neck and body. The fracture fragment was subluxed at the tibiotalar joint, but not at the subtalar or talonavicular joints. The patient underwent open reduction internal fixation (ORIF) of the talus via a dual-incision extensile approach, with excellent functional outcome at the end of 18 months.

      Conclusion

      Internal fixation of a complex talar neck-and-body fracture could be safely performed via a dual-incision extensile approach with good results.

      Keywords

      Abbreviations:

      ORIF (Open Reduction Internal Fixation), AVN (Avascular Necrosis)

      Introduction

      The talus is the second-largest tarsal bone in the human foot, and is vital to the function of the foot and ankle. It has no muscle or tendon attachments, relying on its nutrient arteries in the talar neck and surrounding vessels interwoven through the capsule and ligaments for its blood supply. Injuries to the talar neck and body which are not promptly and properly treated can often result in avascular necrosis and early osteoarthritis.
      • Ohl X.
      • Harisboure A.
      • Hemery X.
      • Dehoux E.
      Long-term follow-up after surgical treatment of talar fractures: twenty cases with an average follow-up of 7.5 years.
      • Vallier H.A.
      Fractures of the Talus: state of the Art.
      • Cronier P.
      • Talha A.
      • Massin P.
      Central talar fractures–therapeutic considerations.
      • Ebraheim N.A.
      • Patil V.
      • Owens C.
      • Kandimalla Y.
      Clinical outcome of fractures of the talar body.
      • Lindvall E.
      • Haidukewych G.
      • DiPasquale T.
      • Herscovici Jr, D.
      • Sanders R.
      Open reduction and stable fixation of isolated, displaced talar neck and body fractures.
      Some authors concluded that the severity of the initial injury, rather than a delay in fracture fixation, could determine the probability of osteonecrosis.
      • Lindvall E.
      • Haidukewych G.
      • DiPasquale T.
      • Herscovici Jr, D.
      • Sanders R.
      Open reduction and stable fixation of isolated, displaced talar neck and body fractures.
      Talar fractures are uncommon, usually occurring as a result of high energy trauma, with a reported incidence of less than 1% of all fractures in the body.
      • Hawkins L.G.
      Fractures of the neck of the talus.
      Despite this low incidence, the talus is the second most commonly fractured tarsal bone, after the calcaneus.
      • Dale J.D.
      • Ha A.S.
      • Chew F.S.
      Update on talar fracture patterns: a large level I trauma center study.
      ,
      • Santavirta S.
      • Seitsalo S.
      • Kiviluoto O.
      • Myllynen P.
      Fractures of the talus.
      Talar fractures were classified and described by various authors, including Hawkins
      • Hawkins L.G.
      Fractures of the neck of the talus.
      Coltart,
      • Caracchini G.
      • Pietragalla M.
      • De Renzis A.
      • et al.
      Talar fractures: radiological and CT evaluation and classification systems.
      Butel,
      • Coltart W.D
      Aviator's astragalus.
      Canale and Kelly
      • Butel J.
      • Witvoët J.
      Les fractures et les luxations de l'astragale [Fractures and dislocations of the astragalus].
      (Table 1), Sneppen
      • Canale S.T.
      • Kelly Jr., F.B.
      Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.
      (Table 2), Inokuchi,
      • Sneppen O.
      • Christensen S.B.
      • Krogsoe O.
      • Lorentzen J.
      Fracture of the body of the talus.
      the AO/OTA classification
      • Inokuchi S.
      • Ogawa K.
      • Usami N.
      Classification of fractures of the talus: clear differentiation between neck and body fractures.
      and the 2011 SOO ‘Total Talar Fracture’ classification
      • Marsh J.L.
      • Slongo T.F.
      • Agel J.
      • et al.
      Fracture and dislocation classification compendium - 2007: orthopaedic Trauma Association classification, database and outcomes committee.
      (Table 3).
      Table 1Hawkins-Canale classification
      • Butel J.
      • Witvoët J.
      Les fractures et les luxations de l'astragale [Fractures and dislocations of the astragalus].
      of Talar neck fractures.
      Fracture TypeDescriptionRisk of Osteonecrosis (%)
      INondisplaced Talar neck fracture0–15
      IITalar neck fracture and talo-calcaneal dislocation20–50
      IIITalar neck fracture with talocalcaneal and tibiotalar dislocation100
      IVTalar neck fracture with disruption of all talar articulations100
      Table 2Sneppen
      • Canale S.T.
      • Kelly Jr., F.B.
      Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.
      classification of Talus body fractures.
      Type ACompression or osteochondral dome fracture
      Type BCoronal shear fractures
      Type CSagittal shear fractures
      Type DPosterior tubercle fractures
      Type ELateral tubercle fractures
      Type FCrush Comminuted fractures
      Table 32011 SOO classification of Talar fractures.
      • Marsh J.L.
      • Slongo T.F.
      • Agel J.
      • et al.
      Fracture and dislocation classification compendium - 2007: orthopaedic Trauma Association classification, database and outcomes committee.
      PartialHead, lateral process, posterior process, dome
      CentralNeck and frontal talar body fractures:

      Type 0: displacement < 2 mm

      Type I: displacement of 2 mm or more

      Type II: with posterior ST subluxation or dislocation

      Type III: with posterior ST and TT dislocation (enucleation)

      Type IV: with ST or TT dislocation and TN subluxation or dislocation

      • “True” body fractures: sagittal, horizontal, comminuted

      Add C (complex) if nearby structure also fractured (tibial plafond, malleoli, calcaneus, cuboid, navicular, etc.)

      Add A (simple fracture) or B (comminuted)
      This case report describes a fracture of the talus that does not fit neatly into the most popular classification systems.
      • Butel J.
      • Witvoët J.
      Les fractures et les luxations de l'astragale [Fractures and dislocations of the astragalus].
      ,
      • Canale S.T.
      • Kelly Jr., F.B.
      Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.
      ,
      • Inokuchi S.
      • Ogawa K.
      • Usami N.
      Classification of fractures of the talus: clear differentiation between neck and body fractures.
      The fracture involves comminution of the neck of the talus, and extends into and subluxes the anterior part of the body superiorly, while exiting anterior to the intact posterior facet of the subtalar joint on the inferior aspect.

      Case report

      A 29 y/o male with no significant past medical history presented to our emergency department after he slipped and fell down a flight of stairs. The patient was unable to ambulate on his left foot due to pain, and subsequently was taken to the hospital by Emergency Medical Services. Upon evaluation by the Orthopedic/Podiatric team the patient had intact neurovascular function of the right lower extremitywith muscle power to the flexors andextensors of the toeslimited by pain. A significant amount of edema and ecchymosis were noted over the foot and ankle, with range of motion limited by pain. X-rays (Fig. 1) showed a displaced biplanar intra-articular fracture of the body of the talus with extension into the neck, and a CT with 3D reconstruction demonstrated a form of multi-planar fracture through the talar neck and anterior body, extending into the ankle joint (Fig. 2, Fig. 3), with the distal fragment displaced dorsolaterally, subluxed from the tibiotalar joint. The neck of the talus showed comminution. The subtalar and talonavicular joints were intact. The patient was splinted in the Emergency Department and monitored as an outpatient in clinic until soft tissue edema and fracture blisters resolved to allow for internal fixation.
      Fig 1
      Fig. 1Lateral X-Ray of the foot demonstrating the displaced talus fracture.
      Fig 2
      Fig. 2Sagittal view CT, demonstrating the talar body fracture, with the anterior fragment superiorly displaced.
      Fig 3
      Fig. 3CT demonstrating the body fracture extending into the neck.
      The patient underwent internal fixation of the talus via a 2-incision technique. The first incision was medial, midway between the tibialis anterior and tibialis posterior tendons, over the medial malleolus and extending towards the navicular bone on the medial border of the foot. The second was a lateral incision made just anterior to the distal fibula and extending towards the fourth toe. Through the medial incision, The medial malleolus was exposed through the medial incision and after pre-drilling screw holes for its later fixation, an oblique osteotomy was made through it, hinging it open on the deltoid ligament.. The two incisions were used in tandem to visualize, disimpact and reduce the talar body and neck fracture. Temporary fixation with K-wires was used to hold the reduction (Fig. 4). Medial-to-lateral buried 3.5-mm diameter cannulated headless compression screws were then inserted to fix the talar body and neck. A butterfly-shaped 4-hole plate was used to fixate the talar neck via the lateral incision, and a 6-holed mini-fragment locking plate was contoured to fit the medial border of the talus extending toward the anterior edge of the talar neck. The medial fracture site had a gap after disimpaction and reduction, and was filled with bone chips soaked in Vancomycin powder in normal saline. Following satisfactory reduction and fixation of the talar fracture, the medial malleolus was reduced, clamped and fixed using two 3.5-mm diameter cortical screws placed through the pre-drilled holes. Fluoroscopy was used intra-operatively to confirm reduction and fixation. Following closure, patient was placed in a posterior splint and kept non-weight bearing and a post-operative CT was obtained.
      Fig 4
      Fig. 4Intra-operative Fluoroscopy-provisional fixation.
      The patient was followed post-operatively in clinic following the surgery. The patient was placed in a short-leg cast with non-weight-bearing for a period of 3 months following the surgery. The cast was changed every 3–4 weeks, with foot hygiene performed at each instance. Post-operative course was uncomplicated. Patient began physical therapy and transitioned to range-of-motion exercises and a progressive increase in weight-bearing as tolerated in a lace-up ankle brace at the 3-month post-operative visit. At the patient's most recent 18-month post-operative follow-up, the patient was able to ambulate bearing full weight on the left lower extremity with no pain. Patient currently ambulates in non-prescription footwear and does not use orthoses. There was no radiologic evidence of avascular necrosis of the talus (Fig. 5). Full and pain-free range of motion at the ankle and sub-talar joint were noted during this last visit. The patient's AOFAS Ankle Hindfoot Score was calculated at the last visit to be 99/100, an improvement from 85/100 at the 6-month visit.
      Fig 5
      Fig. 5X-ray image from the 10-month post-operative visit, showing healing of the fracture of the talus and medial malleolus osteotomy without Avascular Necrosis.

      Discussion

      The unusual fracture pattern reported in this case provided a challenge to the surgeon and the radiologist in classifying it. In one of the largest studies- on 132 talar fractures- Dale et al.
      • Dale J.D.
      • Ha A.S.
      • Chew F.S.
      Update on talar fracture patterns: a large level I trauma center study.
      indicate that 113 of their fractures were talar body fractures while 44 of them were talar neck fractures, concluding that the talar body is the most common site for a fracture on the talus. While the study defines talar body fractures as “a fracture posterior to the line drawn anterior to the talar dome and the lateral process,” it does not allow for classifying fractures that cross the line, as seen in this case report. Another commonly referenced article by Inokuchi et al.
      • Sneppen O.
      • Christensen S.B.
      • Krogsoe O.
      • Lorentzen J.
      Fracture of the body of the talus.
      distinguishes talar neck and body fractures by the location of the inferior fracture line. They define talar neck fractures as “a fracture crossing the lateral entrance of the tarsal sinus on the inferior surface of the talus, regardless of whether or not it crossed over the anteromedial aspect of the trochlea of the talus”, while talar body fractures are “a fracture crossing the lateral border of the posterior subtalar joint.”
      According to an inter-and intra-observer comparison by Williams et al.
      • Williams T.
      • Barba N.
      • Noailles T.
      • et al.
      Total talar fracture - inter- and intra-observer reproducibility of two classification systems (Hawkins and AO) for central talar fractures.
      of the Hawkins-Canale-Kelly
      • Hawkins L.G.
      Fractures of the neck of the talus.
      ,
      • Butel J.
      • Witvoët J.
      Les fractures et les luxations de l'astragale [Fractures and dislocations of the astragalus].
      and AO/OTA
      • Inokuchi S.
      • Ogawa K.
      • Usami N.
      Classification of fractures of the talus: clear differentiation between neck and body fractures.
      classifications, a CT scan was critical to assess talus fractures. They found moderate inter- and intra-observer correlations for the fracture classifications and analysis of fracture lines. Based on their analysis, they proposed a composite system (Table 3), the 2011 SOO Classification for talar fractures.
      In this case report, the talar fracture at the superior surface extended into the talar dome (consistent with a talar body fracture) with an inferior extension to the sinus tarsi anterior to the intact subtalar joint (consistent with a talar neck fracture), with subluxation of the fractured body fragment at the tibiotalar joint. The medial part of the neck was comminuted and there was no involvement of the talonavicular joint. This pattern was not classifiable by any one system. The importance of distinguishing talar body and talar neck fractures lies in differences in surgical plans and prognoses of these fracture patterns. The incidence of talar AVN (avascular necrosis) in non-displaced talar neck fractures can be as high as 15% with no associated joint dislocations around the talus.
      • Hawkins L.G.
      Fractures of the neck of the talus.
      The risk of AVN increases to 50% or more in displaced fractures of the talar neck in conjunction with dislocation of the talo-calcaneal and the tibio-talar joints.
      • Ohl X.
      • Harisboure A.
      • Hemery X.
      • Dehoux E.
      Long-term follow-up after surgical treatment of talar fractures: twenty cases with an average follow-up of 7.5 years.
      • Vallier H.A.
      Fractures of the Talus: state of the Art.
      • Cronier P.
      • Talha A.
      • Massin P.
      Central talar fractures–therapeutic considerations.
      • Ebraheim N.A.
      • Patil V.
      • Owens C.
      • Kandimalla Y.
      Clinical outcome of fractures of the talar body.
      • Lindvall E.
      • Haidukewych G.
      • DiPasquale T.
      • Herscovici Jr, D.
      • Sanders R.
      Open reduction and stable fixation of isolated, displaced talar neck and body fractures.
      • Hawkins L.G.
      Fractures of the neck of the talus.

      Conclusion

      The surgical strategy in our patient with this complex talar fracture was guided by current exposure and fixation strategies of both talar body and neck fractures (including osteochondral injuries), showing the utility and safety of medial and lateral dual-incision extensile exposure. The outcome at 18 months was satisfactory, with no avascular necrosis and a safe return to activities of daily living and profession (as a home care attendant) without restriction.

      Informed patient consent

      The authors declare that informed patient consent was taken from all the patients.

      Declaration of interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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