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Percutaneous Screw Fixation of a Talar Fracture under Computed Tomography and Fluoroscopy Guidance
LETTER TO THE EDITOR
Percutaneous Screw Fixation of a Talar Fracture under Computed Tomography and Fluoroscopy Guidance From: Nicolas Amoretti, MD Laurent Huwart, MD, PhD Department of Radiology Centre Hospitalo-Universitaire de Nice Hˆopital Archet 2 151, route Saint-Antoine de Ginestiere 06200 Nice, France
Editor: Computed tomography (CT) imaging is routinely used to evaluate talar fractures and plan surgical treatment. We present a case that shows the usefulness of a combined technique of CT-guided and fluoroscopy-guided percutaneous screw fixation in a case of nonunion of a talar fracture after unsuccessful surgical fixation. A 28-year-old man presented to the emergency department 1 hour after a fall from approximately 3 m that resulted in left ankle trauma. Radiographs and CT scan of the ankle revealed a minimally displaced fracture with a vertical line extending through the talar neck. Neither comminution nor major displacement was present, excluding the need for reduction (type I Hawkins fracture). Surgery was performed the following day and consisted of fracture fixation with two screws through an anteromedial incision using fluoroscopy guidance. However, a follow-up CT scan performed 1.5 months after surgery showed nonhealing because of incorrect positioning of the two fixation screws, which were surgically retrieved 9 days later. It was decided 2 months after the initial surgery that an orthopedic surgeon and interventional radiologist would attempt fixation jointly in an interventional CT suite using CT (GE Lightview 8-row MDCT scanner; GE Healthcare, Waukesha, Wisconsin) and lateral fluoroscopy (GE Stenescope C-arm; GE Healthcare) guidance. The patient was placed supine on the CT table, and images of the foot were obtained to plan the operative approach. Millimeter multiplanar reconstructions were analyzed on a GE Advantage 4.2 workstation (GE Healthcare) to determine the best possible angle for the trajectory of the Kirschner guide wire and the positioning of the screws, which should ideally be perpendicular to the fracture line. The reconstructions were also used to find an anterior path avoiding the anterior tibial artery, tendons, and nerves. Radiopaque markers were placed on the skin before and after administering a local anesthetic (lidocaine 1%; Neither of the authors has identified a conflict of interest. DOI: http://dx.doi.org/10.1016/j.jvir.2012.09.006
AstraZeneca, S¨odart¨alje, Sweden), and a 20-gauge 20-cm Chiba needle (Cook, Inc, Bloomington, Indiana) was inserted using a fluoroscopically guided anterior approach until the bone was contacted. CT imaging confirmed the correct positioning of the needle tip. Using the Chiba needle, additional local anesthesia was administered to the periosteum. The Chiba needle was then used as a guide for a 13gauge 10-cm Trocar t’am (Thiebaud, Thonon-les-Bains, France), which was placed under fluoroscopy after the hub had been cut and manually removed. CT and fluoroscopy were employed to guide the trocar to transfix the talar fracture line perpendicularly. Axial CT scan images (SmartStep system; GE Healthcare) confirmed progression of the trocar, which was advanced to just before perforating the distal cortex. Additional local anesthetic (1 mL) was administered via a Chiba needle temporarily placed through the trocar. A 2.0-mm Kirschner guide wire (Synthes, Inc, West Chester, Pennsylvania) was placed through the cannula of the trocar. After withdrawal of the trocar, a 45-mm-long and 4.0-mm-diameter cannulated self-drilling/tapping screw (Asnis III; Stryker, Mahwah, New Jersey) was placed over the Kirschner guide wire under CT and fluoroscopy guidance and fixed in place using a hollow screwdriver (Fig a–d). When acceptable positioning of the screw was confirmed by CT, the guide wire was withdrawn. To stabilize the fracture better, the same steps were repeated to place a second 40-mm-long screw parallel to the first one. A CT scan of the foot was performed at the end of the procedure to confirm the fixation of the fracture. The procedural time from patient positioning on the CT table to discharge from the suite was 60 minutes. The intervention was well tolerated by the patient. No acute hemorrhage was observed on the final procedural CT scan. The patient was hospitalized for 48 hours under the care of the orthopedic surgeon. Pain after the intervention was mild and temporary and was controlled by nonsteroidal antiinflammatory drugs. The patient was discharged home, and physiotherapy was begun on the second postoperative day. The wound healed without any skin complication in a below-kneenon–weight-bearing cast. Full weight bearing was allowed after 12 weeks when radiologic union was evident on follow-up CT images. At the 3-month follow-up examination, the patient’s American Orthopaedic Foot and Ankle Society hindfoot score was 100 points out of 100 (1). He was asymptomatic with no tenderness over the ankle and foot and had achieved full range of talocrural joint and subtalar joint motion. Follow-up CT scans showed no evidence of talar avascular necrosis. This case shows that osteosynthesis of a talar fracture can be successfully performed using percutaneous screw fixation under dual fluoroscopy and CT guidance. Percutaneous screw fixation potentially offers several advantages over an open surgical procedure. The precision of dual imaging guidance may give more freedom in the choice of
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Letters to the Editor
Amoretti and Huwart
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JVIR
Figure. Placement of the two screws. (a) A 4.0-mm cannulated self-drilling/tapping screw (Asnis III) (white arrow), which was placed over the Kirschner guide wire, was fixed in place using a hollow screwdriver (black arrow). (b) Axial CT scan acquisition (SmartStep system) shows the screw (arrow) just before transfixing the talar fracture line (arrowheads). (c) Lateral fluoroscopy shows the screw (white arrow) was fixed in place using a hollow screwdriver (black arrow). (d) Axial CT scan confirms that the two screws (arrows) transfixed the fracture line (arrowhead). (Available in color online at www.jvir.org.)
the approach augmenting optimal screw fixation of the fracture line and potentially reducing neurovascular and tendinous injuries. Minimal incisions likely avoid skin complications in this high-risk anatomic region. Virtually no dissection was needed with this percutaneous method, which is probably associated with decreased postoperative edema and may yield other benefits, such as decreased postoperative narcotic use and earlier mobilization. Finally, the whole procedure was performed with only local anesthesia.
REFERENCE 1. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994; 15:349–353.
Percutaneous Screw Fixation of a Talar Fracture under Computed Tomography and Fluoroscopy Guidance From: Nicolas Amoretti, MD Laurent Huwart, MD, PhD Department of Radiology Centre Hospitalo-Universitaire de Nice Hˆopital Archet 2 151, route Saint-Antoine de Ginestiere 06200 Nice, France
Editor: Computed tomography (CT) imaging is routinely used to evaluate talar fractures and plan surgical treatment. We present a case that shows the usefulness of a combined technique of CT-guided and fluoroscopy-guided percutaneous screw fixation in a case of nonunion of a talar fracture after unsuccessful surgical fixation. A 28-year-old man presented to the emergency department 1 hour after a fall from approximately 3 m that resulted in left ankle trauma. Radiographs and CT scan of the ankle revealed a minimally displaced fracture with a vertical line extending through the talar neck. Neither comminution nor major displacement was present, excluding the need for reduction (type I Hawkins fracture). Surgery was performed the following day and consisted of fracture fixation with two screws through an anteromedial incision using fluoroscopy guidance. However, a follow-up CT scan performed 1.5 months after surgery showed nonhealing because of incorrect positioning of the two fixation screws, which were surgically retrieved 9 days later. It was decided 2 months after the initial surgery that an orthopedic surgeon and interventional radiologist would attempt fixation jointly in an interventional CT suite using CT (GE Lightview 8-row MDCT scanner; GE Healthcare, Waukesha, Wisconsin) and lateral fluoroscopy (GE Stenescope C-arm; GE Healthcare) guidance. The patient was placed supine on the CT table, and images of the foot were obtained to plan the operative approach. Millimeter multiplanar reconstructions were analyzed on a GE Advantage 4.2 workstation (GE Healthcare) to determine the best possible angle for the trajectory of the Kirschner guide wire and the positioning of the screws, which should ideally be perpendicular to the fracture line. The reconstructions were also used to find an anterior path avoiding the anterior tibial artery, tendons, and nerves. Radiopaque markers were placed on the skin before and after administering a local anesthetic (lidocaine 1%; Neither of the authors has identified a conflict of interest. DOI: http://dx.doi.org/10.1016/j.jvir.2012.09.006
AstraZeneca, S¨odart¨alje, Sweden), and a 20-gauge 20-cm Chiba needle (Cook, Inc, Bloomington, Indiana) was inserted using a fluoroscopically guided anterior approach until the bone was contacted. CT imaging confirmed the correct positioning of the needle tip. Using the Chiba needle, additional local anesthesia was administered to the periosteum. The Chiba needle was then used as a guide for a 13gauge 10-cm Trocar t’am (Thiebaud, Thonon-les-Bains, France), which was placed under fluoroscopy after the hub had been cut and manually removed. CT and fluoroscopy were employed to guide the trocar to transfix the talar fracture line perpendicularly. Axial CT scan images (SmartStep system; GE Healthcare) confirmed progression of the trocar, which was advanced to just before perforating the distal cortex. Additional local anesthetic (1 mL) was administered via a Chiba needle temporarily placed through the trocar. A 2.0-mm Kirschner guide wire (Synthes, Inc, West Chester, Pennsylvania) was placed through the cannula of the trocar. After withdrawal of the trocar, a 45-mm-long and 4.0-mm-diameter cannulated self-drilling/tapping screw (Asnis III; Stryker, Mahwah, New Jersey) was placed over the Kirschner guide wire under CT and fluoroscopy guidance and fixed in place using a hollow screwdriver (Fig a–d). When acceptable positioning of the screw was confirmed by CT, the guide wire was withdrawn. To stabilize the fracture better, the same steps were repeated to place a second 40-mm-long screw parallel to the first one. A CT scan of the foot was performed at the end of the procedure to confirm the fixation of the fracture. The procedural time from patient positioning on the CT table to discharge from the suite was 60 minutes. The intervention was well tolerated by the patient. No acute hemorrhage was observed on the final procedural CT scan. The patient was hospitalized for 48 hours under the care of the orthopedic surgeon. Pain after the intervention was mild and temporary and was controlled by nonsteroidal antiinflammatory drugs. The patient was discharged home, and physiotherapy was begun on the second postoperative day. The wound healed without any skin complication in a below-kneenon–weight-bearing cast. Full weight bearing was allowed after 12 weeks when radiologic union was evident on follow-up CT images. At the 3-month follow-up examination, the patient’s American Orthopaedic Foot and Ankle Society hindfoot score was 100 points out of 100 (1). He was asymptomatic with no tenderness over the ankle and foot and had achieved full range of talocrural joint and subtalar joint motion. Follow-up CT scans showed no evidence of talar avascular necrosis. This case shows that osteosynthesis of a talar fracture can be successfully performed using percutaneous screw fixation under dual fluoroscopy and CT guidance. Percutaneous screw fixation potentially offers several advantages over an open surgical procedure. The precision of dual imaging guidance may give more freedom in the choice of
1712
’
Letters to the Editor
Amoretti and Huwart
’
JVIR
Figure. Placement of the two screws. (a) A 4.0-mm cannulated self-drilling/tapping screw (Asnis III) (white arrow), which was placed over the Kirschner guide wire, was fixed in place using a hollow screwdriver (black arrow). (b) Axial CT scan acquisition (SmartStep system) shows the screw (arrow) just before transfixing the talar fracture line (arrowheads). (c) Lateral fluoroscopy shows the screw (white arrow) was fixed in place using a hollow screwdriver (black arrow). (d) Axial CT scan confirms that the two screws (arrows) transfixed the fracture line (arrowhead). (Available in color online at www.jvir.org.)
the approach augmenting optimal screw fixation of the fracture line and potentially reducing neurovascular and tendinous injuries. Minimal incisions likely avoid skin complications in this high-risk anatomic region. Virtually no dissection was needed with this percutaneous method, which is probably associated with decreased postoperative edema and may yield other benefits, such as decreased postoperative narcotic use and earlier mobilization. Finally, the whole procedure was performed with only local anesthesia.
REFERENCE 1. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994; 15:349–353.