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Arthroscopically Assisted Transfibular Talar Dome Fixation With a Headless Screw
Technical Note
Arthroscopically Assisted Transfibular Talar Dome Fixation With a Headless Screw Andrew Dodd, B.Sc., David Simon, M.D., and Ross Wilkinson, M.D.
Abstract: We describe an articular talar dome fracture treated with the use of an arthroscopically assisted placement of a transfibular Acutrak screw (Accumed, Hillsboro, OR). This minimally invasive technique can be used to avoid the large incision used in the traditional open reduction and internal fixation of these fractures. Accurate reduction and stable fixation of fractures of the articular surface of the talus is a must, and this technique allows this while avoiding the morbidity of the open approach. Key Words: Arthroscopy—Fracture—Minimally invasive—Talus—Transfibular.
A
fter the calcaneus, the talus is the second most commonly fractured tarsal bone. A direct axial load frequently causes these fractures after a fall from height. Studies have also shown a high incidence of chondral lesions of the talar dome in association with ankle fractures, with frequency rates between 27% and 38%.1 Anatomic reconstruction of the articular cartilage is an essential component of managing talar dome fractures. This aids in minimizing the common postoperative complication of post-traumatic arthritis.2 The usual method of fixation of talar dome fractures is open reduction and internal fixation using a single medial or lateral incision. A medial or lateral malleolar osteotomy is often performed to allow for adequate exposure of the articular surface.3 Other approaches include tibiofibular osteotomies, which some argue provide better visualization of the talar dome but sacrifice the distal tibiofibular joint.4 Open ap-
From the University of Calgary Medical School (A.D.), Calgary, Alberta, and the Division of Orthopaedics, University of Ottawa (D.S., R.W.), Ottawa, Ontario, Canada. The authors report no conflict of interest. Address correspondence and reprint requests to Andrew Dodd, B.Sc., Undergraduate Medical Education, University of Calgary, 813 1st Ave. NW, Calgary, AB T2N-OA4, Canada. E-mail: andrew. [email protected] © 2009 by the Arthroscopy Association of North America 0749-8063/09/2507-8694$36.00/0 doi:10.1016/j.arthro.2009.01.002
806
proaches often require incisions of up to 10 cm, which many surgeons would like to avoid.4 Arthroscopically assisted fixation of tibial plateau and ankle fractures involving the articular cartilage have been described in the literature, but a paucity of similar techniques in the fixation of talar dome fractures exists. Arthroscopy is increasingly being used to treat— or to assist in the treatment of—pathologies of the foot and ankle. The goal of using arthroscopy is to decrease postoperative pain and provide a more rapid recovery than traditional open methods.5 Currently, arthroscopy is being used in ankle arthrodesis, fixation of osteochondral lesions, and the treatment of post-traumatic arthrofibrosis and various retrocalcaneal pathologies.5 An area of particular interest in arthroscopy is the treatment of osteochondral lesions of the talus.6-8 These lesions are often a result of trauma and have poor nonsurgical treatment results.6 Previous surgical approaches for these lesions required a large incision and malleolar osteotomy, which was associated with great patient morbidity.7 New arthroscopic techniques of autologous chondrocyte implantation have been shown to be successful and avoid the traumatic open approach.7,8 Our goal is to describe a similar approach to treat a fracture of the talar dome with an associated chondral lesion (Table 1). We describe the arthroscopically assisted transfibular Acutrak screw fixation (Accumed, Hillsboro, OR) of a talar dome fracture.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 7 (July), 2009: pp 806-809
TALAR DOME FIXATION WITH A HEADLESS SCREW TABLE 1. Key Points Regarding Fracture of the Talar Dome With an Associated Chondral Lesion ● ● ● ● ● ●
Fractures of the articular surface of the talus are common Current methods of fixation are plagued by significant morbidity Arthroscopy is being increasingly used to assist procedures involving the ankle and foot Arthroscopy provides adequate visualization of the talar dome A transfibular approach is a novel way to access the talar dome A transfibular approach with the use of headless screws was successful in anatomic reduction of a talar dome fracture
TECHNIQUE A 19-year-old man suffered bilateral talar dome fractures after falling from a height of 7 meters (approximately 20 feet) and landing on both feet. The right ankle was treated with traditional open reduction and internal fixation. The initial radiographs of the left ankle revealed an osteochondral fracture of the talar dome. Subsequently, a computed tomography scan was performed. A vertically oriented sagittal-oblique comminuted fracture in the talar dome measuring 18 ⫻ 4 ⫻ 7 mm was found (Fig 1). Because the articular surface of the talar dome was involved, the fracture required anatomic reduction with stable fixation. This would normally require a large medial or lateral incision with additional medial or lateral malleolar osteotomy. To preserve the soft tissues and still meet the described goals, an arthroscopically assisted technique was employed to place a transfibular Acutrak screw for fixation. An anterior arthroscopic portal was made over the left ankle, through which the arthroscope was introduced. An anterolateral outflow port was also established. Irrigation and drainage of the fracture hematoma was performed to aid in visualizing the anatomy. The lateral talar dome fracture in the sagittal plane was displaced 2 to 3 mm with a step deformity at the joint surface (Fig 1B). The fracture was reduced with direct pressure from an arthroscopic probe (Fig 2A). A 1-mm guidewire from the Acutrak set was advanced through the distal fibula and advanced through the talar fracture site under fluoroscopic control. A 3.5-mm cannulated drill bit was then advanced over the guidewire, creating the track for the screw. A 20-mm Acutrak screw was then advanced over the guidewire with the Acutrak hand drill until it crossed the fracture site, providing compression and adequate stabilization. Anatomic reduction of the articular surface was con-
807
firmed using the arthroscope (Fig 2B). The tibiotalar joint was irrigated once more before closing the arthroscopic portals and a small fibular incision with absorbable No. 3-0 sutures. The limb was placed in a short leg cast and the patient was kept non–weight bearing for a period of 8 weeks. Range of motion exercises were initiated at 2 weeks postsurgery. There were no wound healing or other perioperative complications. No complications were associated with the distal fibular drill hole. Same-day postoperative radiographs confirmed excellent alignment at the fracture site, and serial follow-up examinations have shown a congruent articular surface with no evidence of loss of reduction, avascular necrosis, or post-traumatic degeneration. After 1 year of follow-up, the patient remains satisfied
FIGURE 1. (A) Anteromedial view of the 3-dimensional computed tomographic reconstruction of the talar dome fracture of the left ankle. The fracture is vertically oriented in the sagittal-oblique plane measuring 18 ⫻ 4 ⫻ 7 mm (red circle). (B) Initial view through the anterior arthroscopic portal of the left talar dome fracture (black arrow) before reduction and fixation. There is a step deformity in the articular cartilage with the lateral aspect being depressed. The patient is in the supine position.
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A. DODD ET AL.
with his level of function in the left ankle, and radiographic evidence of a congruent articular surface remains (Fig 3). DISCUSSION Arthroscopically assisted fixation of ankle fractures involving the articular surface has shown satisfactory results.9 Other studies have also shown successful treatment of osteochondral lesions of the talus using arthroscopic techniques.7,8 No such results have been described in the treatment of talus fractures with ar-
FIGURE 3. One-year postoperative mortise-view radiograph showing articular congruity and fracture healing of the previous left talar dome fracture. The headless screw remains in place in the talus (as shown).
ticular involvement. The need for anatomic reduction has frequently required a large skin incision to allow adequate visualization of the talus in the traditional approach to fixation. Along with the need for an adjuvant malleolar osteotomy, this makes a less invasive approach to talar dome fractures an appealing treatment option when the fracture pattern is relatively simple. An arthroscopically assisted approach may aid in the reduction of complications of infection and incision-site skin necrosis while still providing the anatomic reduction needed to reduce post-traumatic arthritis rates. Which talar dome fracture types and TABLE 2. Advantages and Disadvantages of the Arthroscopically Assisted Transfibular Approach to the Talar Dome
FIGURE 2. (A) View through the anterior arthroscopic portal of the fracture reduction maneuver using an arthroscopic probe (labeled) with the patient in the supine position. The step deformity has been reduced with direct pressure from the probe on the medial aspect of the left talar dome fracture (black arrow). (B) View through the anterior arthroscopic portal of the chondral surface of the left talar dome fracture (black arrow) after arthroscopic reduction and transfibular fixation. The articular congruity has been restored and the fragments fixated with a headless screw using a transfibular approach. The patient is in the supine position.
Advantages
Disadvantages
Minimal soft tissue trauma Novel, minimally invasive approach to a common fracture Avoids the need for an osteotomy Direct visualization of fracture possible Anatomic reduction of articular cartilage possible Theoretical reduction in perioperative complications compared to open techniques
Technically demanding Surgeons must be familiar with arthroscopy of the ankle joint Unlikely to be as useful in complicated fracture patterns
TALAR DOME FIXATION WITH A HEADLESS SCREW patterns may be amenable to transfibular or possibly transtibial fixation with headless screws requires further elucidation and study. Our first attempt at an arthroscopically assisted transfibular Acutrak screw fixation of a talar dome fracture was successful, and there are many potential advantages to this approach (Table 2). Original radiographs in this case show anatomic fixation of the joint surface; 1-year follow-up images are unchanged. The patient is satisfied with his functional result. This fixation technique may be an acceptable method of treating articular talar body fractures, and further investigation would help to validate the technique. REFERENCES 1. Aktas S, Kocaoglu B, Gereli A, Nalbantodlu U, Güven O. Incidence of chondral lesions of the talar dome in ankle fracture types. Foot Ankle Int 2008;29:287-292.
809
2. Fortin PT, Balazsy JE. Talus fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:114-127. 3. Vallier H, Nork S, Benirschke S, Sangeorzan B. Surgical treatment of talar body fractures. J Bone Joint Surg Am 2003;85: 1716-1724. 4. Bluman EM, Antosh IJ. Technique tip: Tibiofibular osteotomy for increased access to the lateral ankle joint. Foot Ankle Int 2008;29:735-738. 5. Southam JD, Juliano PJ. An update on arthroscopy and endoscopy of the foot and ankle. Curr Orthop Pract 2008;19:260263. 6. Sexton AT, Labib SA. Osteochondral lesions of the talus: Current opinions on diagnosis and management. Curr Opin Orthop 2007;18:166-171. 7. Giannini S, Buda R, Vannini F, Di Caprio F, Grigolo B. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus. Am J Sports Med 2008;36: 873-880. 8. Ferkel RD, Zanottie RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus. Am J Sports Med 2008;36:1750-1762. 9. Ono A, Nishikawa S, Nagoa A, Irie T, Sasaki M, Kouno T. Arthroscopically assisted treatment of ankle fractures: Arthroscopic findings and surgical outcomes. Arthroscopy 2004;20: 627-631.
Arthroscopically Assisted Transfibular Talar Dome Fixation With a Headless Screw Andrew Dodd, B.Sc., David Simon, M.D., and Ross Wilkinson, M.D.
Abstract: We describe an articular talar dome fracture treated with the use of an arthroscopically assisted placement of a transfibular Acutrak screw (Accumed, Hillsboro, OR). This minimally invasive technique can be used to avoid the large incision used in the traditional open reduction and internal fixation of these fractures. Accurate reduction and stable fixation of fractures of the articular surface of the talus is a must, and this technique allows this while avoiding the morbidity of the open approach. Key Words: Arthroscopy—Fracture—Minimally invasive—Talus—Transfibular.
A
fter the calcaneus, the talus is the second most commonly fractured tarsal bone. A direct axial load frequently causes these fractures after a fall from height. Studies have also shown a high incidence of chondral lesions of the talar dome in association with ankle fractures, with frequency rates between 27% and 38%.1 Anatomic reconstruction of the articular cartilage is an essential component of managing talar dome fractures. This aids in minimizing the common postoperative complication of post-traumatic arthritis.2 The usual method of fixation of talar dome fractures is open reduction and internal fixation using a single medial or lateral incision. A medial or lateral malleolar osteotomy is often performed to allow for adequate exposure of the articular surface.3 Other approaches include tibiofibular osteotomies, which some argue provide better visualization of the talar dome but sacrifice the distal tibiofibular joint.4 Open ap-
From the University of Calgary Medical School (A.D.), Calgary, Alberta, and the Division of Orthopaedics, University of Ottawa (D.S., R.W.), Ottawa, Ontario, Canada. The authors report no conflict of interest. Address correspondence and reprint requests to Andrew Dodd, B.Sc., Undergraduate Medical Education, University of Calgary, 813 1st Ave. NW, Calgary, AB T2N-OA4, Canada. E-mail: andrew. [email protected] © 2009 by the Arthroscopy Association of North America 0749-8063/09/2507-8694$36.00/0 doi:10.1016/j.arthro.2009.01.002
806
proaches often require incisions of up to 10 cm, which many surgeons would like to avoid.4 Arthroscopically assisted fixation of tibial plateau and ankle fractures involving the articular cartilage have been described in the literature, but a paucity of similar techniques in the fixation of talar dome fractures exists. Arthroscopy is increasingly being used to treat— or to assist in the treatment of—pathologies of the foot and ankle. The goal of using arthroscopy is to decrease postoperative pain and provide a more rapid recovery than traditional open methods.5 Currently, arthroscopy is being used in ankle arthrodesis, fixation of osteochondral lesions, and the treatment of post-traumatic arthrofibrosis and various retrocalcaneal pathologies.5 An area of particular interest in arthroscopy is the treatment of osteochondral lesions of the talus.6-8 These lesions are often a result of trauma and have poor nonsurgical treatment results.6 Previous surgical approaches for these lesions required a large incision and malleolar osteotomy, which was associated with great patient morbidity.7 New arthroscopic techniques of autologous chondrocyte implantation have been shown to be successful and avoid the traumatic open approach.7,8 Our goal is to describe a similar approach to treat a fracture of the talar dome with an associated chondral lesion (Table 1). We describe the arthroscopically assisted transfibular Acutrak screw fixation (Accumed, Hillsboro, OR) of a talar dome fracture.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 7 (July), 2009: pp 806-809
TALAR DOME FIXATION WITH A HEADLESS SCREW TABLE 1. Key Points Regarding Fracture of the Talar Dome With an Associated Chondral Lesion ● ● ● ● ● ●
Fractures of the articular surface of the talus are common Current methods of fixation are plagued by significant morbidity Arthroscopy is being increasingly used to assist procedures involving the ankle and foot Arthroscopy provides adequate visualization of the talar dome A transfibular approach is a novel way to access the talar dome A transfibular approach with the use of headless screws was successful in anatomic reduction of a talar dome fracture
TECHNIQUE A 19-year-old man suffered bilateral talar dome fractures after falling from a height of 7 meters (approximately 20 feet) and landing on both feet. The right ankle was treated with traditional open reduction and internal fixation. The initial radiographs of the left ankle revealed an osteochondral fracture of the talar dome. Subsequently, a computed tomography scan was performed. A vertically oriented sagittal-oblique comminuted fracture in the talar dome measuring 18 ⫻ 4 ⫻ 7 mm was found (Fig 1). Because the articular surface of the talar dome was involved, the fracture required anatomic reduction with stable fixation. This would normally require a large medial or lateral incision with additional medial or lateral malleolar osteotomy. To preserve the soft tissues and still meet the described goals, an arthroscopically assisted technique was employed to place a transfibular Acutrak screw for fixation. An anterior arthroscopic portal was made over the left ankle, through which the arthroscope was introduced. An anterolateral outflow port was also established. Irrigation and drainage of the fracture hematoma was performed to aid in visualizing the anatomy. The lateral talar dome fracture in the sagittal plane was displaced 2 to 3 mm with a step deformity at the joint surface (Fig 1B). The fracture was reduced with direct pressure from an arthroscopic probe (Fig 2A). A 1-mm guidewire from the Acutrak set was advanced through the distal fibula and advanced through the talar fracture site under fluoroscopic control. A 3.5-mm cannulated drill bit was then advanced over the guidewire, creating the track for the screw. A 20-mm Acutrak screw was then advanced over the guidewire with the Acutrak hand drill until it crossed the fracture site, providing compression and adequate stabilization. Anatomic reduction of the articular surface was con-
807
firmed using the arthroscope (Fig 2B). The tibiotalar joint was irrigated once more before closing the arthroscopic portals and a small fibular incision with absorbable No. 3-0 sutures. The limb was placed in a short leg cast and the patient was kept non–weight bearing for a period of 8 weeks. Range of motion exercises were initiated at 2 weeks postsurgery. There were no wound healing or other perioperative complications. No complications were associated with the distal fibular drill hole. Same-day postoperative radiographs confirmed excellent alignment at the fracture site, and serial follow-up examinations have shown a congruent articular surface with no evidence of loss of reduction, avascular necrosis, or post-traumatic degeneration. After 1 year of follow-up, the patient remains satisfied
FIGURE 1. (A) Anteromedial view of the 3-dimensional computed tomographic reconstruction of the talar dome fracture of the left ankle. The fracture is vertically oriented in the sagittal-oblique plane measuring 18 ⫻ 4 ⫻ 7 mm (red circle). (B) Initial view through the anterior arthroscopic portal of the left talar dome fracture (black arrow) before reduction and fixation. There is a step deformity in the articular cartilage with the lateral aspect being depressed. The patient is in the supine position.
808
A. DODD ET AL.
with his level of function in the left ankle, and radiographic evidence of a congruent articular surface remains (Fig 3). DISCUSSION Arthroscopically assisted fixation of ankle fractures involving the articular surface has shown satisfactory results.9 Other studies have also shown successful treatment of osteochondral lesions of the talus using arthroscopic techniques.7,8 No such results have been described in the treatment of talus fractures with ar-
FIGURE 3. One-year postoperative mortise-view radiograph showing articular congruity and fracture healing of the previous left talar dome fracture. The headless screw remains in place in the talus (as shown).
ticular involvement. The need for anatomic reduction has frequently required a large skin incision to allow adequate visualization of the talus in the traditional approach to fixation. Along with the need for an adjuvant malleolar osteotomy, this makes a less invasive approach to talar dome fractures an appealing treatment option when the fracture pattern is relatively simple. An arthroscopically assisted approach may aid in the reduction of complications of infection and incision-site skin necrosis while still providing the anatomic reduction needed to reduce post-traumatic arthritis rates. Which talar dome fracture types and TABLE 2. Advantages and Disadvantages of the Arthroscopically Assisted Transfibular Approach to the Talar Dome
FIGURE 2. (A) View through the anterior arthroscopic portal of the fracture reduction maneuver using an arthroscopic probe (labeled) with the patient in the supine position. The step deformity has been reduced with direct pressure from the probe on the medial aspect of the left talar dome fracture (black arrow). (B) View through the anterior arthroscopic portal of the chondral surface of the left talar dome fracture (black arrow) after arthroscopic reduction and transfibular fixation. The articular congruity has been restored and the fragments fixated with a headless screw using a transfibular approach. The patient is in the supine position.
Advantages
Disadvantages
Minimal soft tissue trauma Novel, minimally invasive approach to a common fracture Avoids the need for an osteotomy Direct visualization of fracture possible Anatomic reduction of articular cartilage possible Theoretical reduction in perioperative complications compared to open techniques
Technically demanding Surgeons must be familiar with arthroscopy of the ankle joint Unlikely to be as useful in complicated fracture patterns
TALAR DOME FIXATION WITH A HEADLESS SCREW patterns may be amenable to transfibular or possibly transtibial fixation with headless screws requires further elucidation and study. Our first attempt at an arthroscopically assisted transfibular Acutrak screw fixation of a talar dome fracture was successful, and there are many potential advantages to this approach (Table 2). Original radiographs in this case show anatomic fixation of the joint surface; 1-year follow-up images are unchanged. The patient is satisfied with his functional result. This fixation technique may be an acceptable method of treating articular talar body fractures, and further investigation would help to validate the technique. REFERENCES 1. Aktas S, Kocaoglu B, Gereli A, Nalbantodlu U, Güven O. Incidence of chondral lesions of the talar dome in ankle fracture types. Foot Ankle Int 2008;29:287-292.
809
2. Fortin PT, Balazsy JE. Talus fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:114-127. 3. Vallier H, Nork S, Benirschke S, Sangeorzan B. Surgical treatment of talar body fractures. J Bone Joint Surg Am 2003;85: 1716-1724. 4. Bluman EM, Antosh IJ. Technique tip: Tibiofibular osteotomy for increased access to the lateral ankle joint. Foot Ankle Int 2008;29:735-738. 5. Southam JD, Juliano PJ. An update on arthroscopy and endoscopy of the foot and ankle. Curr Orthop Pract 2008;19:260263. 6. Sexton AT, Labib SA. Osteochondral lesions of the talus: Current opinions on diagnosis and management. Curr Opin Orthop 2007;18:166-171. 7. Giannini S, Buda R, Vannini F, Di Caprio F, Grigolo B. Arthroscopic autologous chondrocyte implantation in osteochondral lesions of the talus. Am J Sports Med 2008;36: 873-880. 8. Ferkel RD, Zanottie RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus. Am J Sports Med 2008;36:1750-1762. 9. Ono A, Nishikawa S, Nagoa A, Irie T, Sasaki M, Kouno T. Arthroscopically assisted treatment of ankle fractures: Arthroscopic findings and surgical outcomes. Arthroscopy 2004;20: 627-631.