- Email: [email protected]
Pedobarographic and Radiological Analysis After Treating a Talus Neck Fracture
The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Pedobarographic and Radiological Analysis After Treating a Talus Neck Fracture _ ba Kuru C¸olak, PT, PhD 1, Ilker € ven Bulut, MD 4, Tug C¸olak, MD 2, Eren Timurtas¸, PT, MSc 3, Gu € lden Polat, PT, PhD 5 M. Gu 1
Asstistant Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey € tfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey Department of Orthopaedics and Traumatology, Dr Lu Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey 4 € tfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey Associate Professor, Department of Orthopaedics and Traumatology, Dr Lu 5 Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Misalignment of the talar neck after surgical repair can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, which can change the joint biomechanics, cause arthritis, and impair function. However, we found no studies analyzing the plantar pressures after treatment of talus neck fracture. We determined the dynamic plantar pedobarographic and radiographic characteristics and ankle range of motion, function, and pain among patients after surgical repair of talar neck fractures. A total of 19 patients completed the assessments. The median follow-up period was 29 (range 12 to 113) months. At the last visit, the mean pain score was 3.3 on a 10-cm visual analog scale. The mean American Orthopaedic Foot and Ankle Society function scale score was fair (73.5), and the mean range of motion was restricted in 4 planes. The mean maximum force was lower in the hindfoot (p ¼ .002) and midfoot (p ¼ .03) of the injured foot than in the noninjured foot. The mean peak pressure was lower in the hindfoot (p ¼ .05) but higher in the forefoot (p ¼ .03). Radiographic measurements revealed differences between the feet in the talo–first metatarsal angle (p ¼ .002), Meary’s angle (p ¼ .001), and the medial cuneiform–fifth metatarsal angle (p ¼ .002). Radiographic and pedobarographic analysis showed an elevated arch in the injured foot. Thus, talar injury and immobilization can affect the stance and the gait cycle in these patients. Pain, range of motion, function, and the weight transfer pattern should be evaluated carefully during the follow-up period to provide the best postoperative results. Ó 2016 Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons.
Keywords: foot fracture injury pedobarography talus
Most fractures of the talus occur in the neck. Talar neck fractures comprise <1% of ankle–foot fractures (1–3) and are generally seen in young males as the result of high-energy trauma, such as a fall, motor vehicle accident, or direct trauma (3–5). The talus is the most superiorly located bone in the foot and is important in maintaining the normal ankle range of motion (ROM) and function (6). With serious injuries, all foot and ankle movements will be affected. Osteonecrosis, malunion, nonunion, post-traumatic arthrosis, skin necrosis, and infection are possible complications after treatment (5–8). Deformity as a consequence of post-traumatic misalignment of the talus leads to painful functional impairment
Financial Disclosure: None reported. Conflict of Interest: None reported. ba Kuru C¸olak, PT, PhD, Fizyoterapi ve RehabilAddress correspondence to: Tug € € lu € mu € , Marmara Universitesi, Sag lık Bilimleri Faku € ltesi, E-5 Yanyol Uzeri, itasyon Bo _ Cevizli, Kartal, Istanbul, Turkey. E-mail address: [email protected] (T.K. C¸olak).
(6,9,10). The most common deformity after malunion (47%) of a talar fracture is varus misalignment of the hindfoot, which markedly decreases subtalar and midtarsal motion. This misalignment is particularly common after closed reduction of Hawkins type 2 talar neck fractures (7,11–13). Varus misalignment of the talar neck can shorten the medial column considerably, which locks the hindfoot in varus and internal rotation (13). The degree of varus misalignment is also associated with changes in foot position and the degree of subtalar motion (13). Even 2 mm of misalignment at the talar neck can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, changing the joint biomechanics and resulting in arthritis (13,14). This possible varus and internal rotation of the talus neck also disrupts the normal relationship between the midfoot and hindfoot and reduces the mobility of the midtarsal joint (13). The decreased ROM in the subtalar and midtarsal joints often causes a painful, rigid, and cavovarus foot. An increase in the lateral load transfer in the foot results in callus formation (15).
1067-2516/$ - see front matter Ó 2016 Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons. http://dx.doi.org/10.1053/j.jfas.2016.07.017
2
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Table 1 Characteristics and long-term outcomes of 19 patients with surgically treated fractures of the talus neck or talus neck and body Characteristic
Value
Male gender (n) Age (yr) Mean SD Median Range Injured foot (n) Right Left Injury type (n) Fall from a height Crushing Motor vehicle accident Hawkins classification (n) 1 2 3 4 Interval from injury to surgery (n) Within 24 hr 24 to 48 hr 5 days, after leaving ICU 10 days, after leaving ICU Cast immobilization Immobilization period (days) Mean SD Median Range Pain score Mean SD Median Range AOFAS scale score Mean SD Median Range Excellent (n) Good (n) Fair (n) Poor (n) Subtalar arthritis (n) Tibiotalar arthritis (n)
15 33.3 11.1 34 15 to 55 13 6 13 (68.4) 1 (5.2) 5 (26.3) 4 10 4 1
(21.1) (52.6) (21.1) (5.2)
13 1 2 1 2
(68.4) (5.2) (10.5) (5.2) (10.5)
64.2 35.2 60 30 to 160 3.3 2.1 3 0 to 7 73.5 1.1 76 50 to 100 3 (15.8) 6 (31.6) 6 (31.6) 4 (21.1) 16 (84.2) 14 (73.7)
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; ICU, intensive care unit; SD, standard deviation. Data in parentheses are percentages.
Table 2 Ankle range of motion and structural angles at a mean follow-up point of 45 months Outcome
Ankle dorsiflexion ROM ( ) Mean SD Median Range Ankle plantarflexion ROM ( ) Mean SD Median Range Ankle inversion ROM ( ) Mean SD Median Range Ankle eversion ROM ( ) Mean SD Median Range Kite’s angle ( ) Mean SD Median Range Talo–first metatarsal angle ( ) Mean SD Median Range Meary’s angle ( ) Mean SD Median Range Hibbs’ angle ( ) Mean SD Median Range Calcaneal pitch angle ( ) Mean SD Median Range Medial cuneiform–fifth metatarsal angle ( ) Mean SD Median Range Talonavicular coverage angle ( ) Mean SD Median Range
Injured Foot (n ¼ 19)
Noninjured Foot (n ¼ 19)
12.4 5.8 10 5.0 to 25.0
19.4 2.1 18 18.0 to 25.0
25.0 10.9 30 5.0 to 45.0
41.8 2.8 42 37.0 to 50.0
9.4 7.1 8 0 to 25.0
24.5 2.6 25 20.0 to 30.0
7.1 5.6 5 0 to 20.0
14.7 1.7 15 12.0 to 20.0
25.2 6.7 24 13 to 38
26.1 5.6 25 20 to 39
6.7 9.9 5 11 to 34
0.25 6.7 1 13 to 15
7.8 7.9 7.5 4 to 26
1.1 7.0 3 14 to 12
134.0 7.1 135 120 to 147
136.3 7.3 135 124 to 149
21.0 5.7 20 14 to 36
18.6 4.7 20 11 to 25
17.2 8.2 20 1 to 28
10.2 7.1 10 0 to 25
5.7 6.5 5 5 to 22
8.0 7.9 7 10 to 26
p Value
<.001
<.001
<.001
.001
.29
.002
<.001
.06
.05
.002
.116
Abbreviations: ROM, range of motion; SD, standard deviation.
All these changes have negative effects on plantar pressures. However, we found no studies of the plantar pressure after talus neck fracture. Pedobarographic pressure analysis shows biomechanical alterations and can objectively evaluate the foot after different orthopedic foot and ankle problems, injuries, and surgeries (16–18). Therefore, we sought to determine the dynamic plantar pressure and radiographic characteristics of patients who had undergone surgery or cast immobilization for a talar neck fracture.
Patients and Methods The ethics committees of our institutions approved the present study. All the patients provided written informed consent. We enrolled patients presenting with a fracture of the talar neck (International Classification of Diseases code S92.11) or of the talar body (International Classification of Diseases code S92.12) and talar neck € tfi Kırdar Kartal Education and Research who presented to the Dr Lu Hospital from December 2005 to January 2014. The exclusion criteria were the presence of a concomitant injury in the ipsilateral or contralateral lower extremity, the use of arthrodesis
or amputation of a lower extremity, a congenital deformity or neurologic problem, previous surgery of the spine or lower extremity, poor balance, the use of medications that could affect balance, an open wound on the foot, and any mental problems or any situation that might interfere with the patient walking barefoot. Patients with a fracture of the talar neck or of the talar body and talar neck treated at our institution during the study period were identified from the computerized hospital records. Patients who met the inclusion criteria were interviewed by telephone and invited to participate in the present study. All patients underwent a comprehensive physical examination of the injured foot and radiographic and pedobarographic evaluations. The ankle ROM, function, and pain were measured in all patients at the follow-up visits. Data on age, sex, the mechanism of trauma, the interval from injury to surgery, and the duration of the immobilization period were also recorded. Pain was assessed using a 10-cm visual analog scale (VAS), with 0 representing no pain and 10, the worst pain imaginable (19). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scale consists of 9 questions related to pain, activity and functional limitations, walking distance, difficulty with different terrains, gait
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
3
Fig. 1. A 36-year-old male with a Hawkins type III fracture, with the peak pressure significantly decreased in the hindfoot and increased in the forefoot of the injured foot.
abnormality, sagittal ROM at the ankle, and ROM, stability, and alignment (plantigrade or not) of the subtalar joint. The best functional score is 100 points. From the data in the patient medical records and from the radiographic examinations, a physician completed these 9 sections related to alignment and ROM. The other sections were completed by the patients. A score of 90 to 100 was considered excellent, 80 to 89, good, 70 to 79, fair, and <70 poor (20,21). The active ROM of both feet was measured using a universal goniometer according to the procedures described by the American Academy of Orthopaedic Surgeons. Dorsiflexion, plantar flexion, inversion, and eversion were measured with the patient seated. All measurements were repeated 3 times, and the average value was recorded (22). Radiographs were taken of the dorsoplantar and lateral views of both feet with the patient standing. The fracture type was classified according to the Hawkins system as modified by Canale and Kelly (12),
with the fractures divided into 4 groups. Digital measurements were taken of Kite’s angle (the talocalcaneal angle), the talo–first metatarsal angle, and the talonavicular coverage angle on the dorsoplantar view and Meary’s angle (the talo–first metatarsal angle), Hibbs’ angle (the calcaneal–first metatarsal angle), the calcaneal pitch angle, and the medial cuneiform–fifth metatarsal distance in the lateral view (23,24). A talonavicular coverage angle >78 was accepted as joint subluxation (25). The presence of post-traumatic osteoarthritis in the subtalar and tibiotalar joints was also evaluated. Pedobarographic measurements were obtained using an EmedÒa50/D system (Novel GmbH, Munich, Germany), which consists of a 380-mm 240-mm pressure platform with 2 sensors/cm2, a pressure range of 10 to 950 kPa, and sampling frequency of 50/60 Hz. To achieve a normal gait pattern, all patients were asked to walk with bare feet before the evaluation. Next, 5 trials of both the injured and noninjured foot were recorded in dynamic mode.
4
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Fig. 2. A 23-year-old male with a Hawkins type II fracture, with the peak pressure significantly decreased in the hindfoot and increased in the forefoot of the injured foot.
We measured the peak pressure (kPa), maximum force (N), and contact area cm2; (Automask; Novel GmbH) in the forefoot, midfoot, hindfoot, and toes. The arch index was calculated by dividing the pressure area of the midfoot by the total pressure areas of the forefoot, midfoot, and midfoot (26). Date are presented as the mean standard deviation or percentages. Measurements of the injured foot were compared with those of the noninjured foot using Wilcoxon signed rank tests. Correlations between the angular and pressure measurements were assessed using Spearman’s rho. Statistical analyses were performed using the SPSS, version 18.0, for Windows software (IBM, Armonk, NY). Alpha was set at 0.05, and all tests were 2-tailed. Results Of 32 enrolled patients, 19 (59%) completed the assessments (Table 1). The follow-up period ranged from 12 to 113 (median 29) months. Two patients with Hawkins type I fractures were treated conservatively with a short leg cast; all other patients were treated
surgically. The fracture was a closed fracture in 16 patients (84.2%), a type I open fracture in 1 patient (5.2%), and a type II open fracture in 2 patients (10.5%). Five patients (26.3%) had accompanying fractures (3 medial malleol and 2 distal radius fractures). Of the 19 patients, 13 (68.4%) underwent surgery within the first 24 hours, and 7 patients (36.8%) received physiotherapy postoperatively. Post-traumatic arthritis was detected in the tibiotalar joint of 16 patients (84.2%) patients and in the subtalar joint of 14 (73.7%). Avascular necrosis was diagnosed in 8 patients (42.1%) and hammer toe deformity in 2 (10.5%). The mean AOFAS scale score was fair (73.5). The score was poor in 3 patients (15.8%), fair in 6 (31.6%), good in 6 (31.6%), and excellent in 4 (21.1%; Table 1). The ROM in the injured ankle differed significantly from that of the noninjured ankle (Table 2). Radiographic measurements of the talo– first metatarsal angle, Meary’s angle, and the medial cuneiform–fifth metatarsal angle of the injured ankle also differed significantly from those from the radiographs of the noninjured ankle. Dynamic pedobarographic analysis revealed no significant differences between the injured and noninjured feet in the total contact
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
area and other regions of the foot. However, the maximum forces of the hindfoot and midfoot and the peak pressures of the hindfoot and forefoot differed significantly between the injured and noninjured feet (Figs. 1 and 2 and Table 3). The arch index evaluation showed a statistically significant increase in the arch of the injured foot (p ¼ .03). Age, immobilization period, receipt of postoperative physiotherapy, and postoperative follow-up did not correlate with any differences in ROM or pedobarographic variables. Statistically significant positive correlations were found between the talo–first metatarsal angle difference and flexion (p ¼ .020, r ¼ 0.530), inversion (p ¼ .009, r ¼ 0.579), and eversion (p ¼ .007, r ¼ 0.593). A significant positive correlation was found between the fracture type (Hawkins classification) and Meary’s angle (p ¼ .036, r ¼ 0.484). The statistically significant correlations between some of the differences in the radiographic and pedobarographic parameters are listed in Table 4.
Discussion The aim of the present study was to determine the dynamic plantar pressure and radiographic characteristics of the feet surgically or conservatively treated for fractures of the talar neck or talar neck and body. The average AOFAS scale score was fair, the ROM was restricted in all 4 planes of the injured ankle, and the injured feet all showed an increase in the arch. The pedobarographic analysis indicated that body weight was transferred to the noninjured foot during walking. In the injured foot, the mean maximum force in the hindfoot and midfoot and the peak pressure in the hindfoot were significantly decreased; however, the mean peak pressure in the forefoot was significantly increased (Figs. 1 and 2). Pain is the most common subjective finding during follow-up for patients treated for talar neck fractures (27–29). The proportion of patients reporting mild to severe pain at follow-up visits has been reported to range from 22% to 100% (27–29). In the present study, the highest pain intensity in 1 day was assessed using a VAS, and 17 patients (89.5%) reported pain after a mean of 45 (range 12 to 113) months. The mean AOFAS scale score of our patients was 73.5, similar to that reported in other studies with long-term follow-up (5,26). Ohl et al (5) reported a mean AOFAS scale score of 66.9, with a good AOFAS scale score in 7 patients, fair in 11, and poor in 2 after a follow-up period of 7.5 years. No patient had excellent scores, however. In our study, 3 patients had excellent AOFAS scale scores. Of these, 2 were the youngest patients and had a Hawkins type I fracture (aged 15 and 23 years), and the third patient was 40 years old with a Hawkins type II fracture and a minimum immobilization period (30 days). However, patient age and immobilization period did not correlate with the AOFAS scale scores, but the power to detect a correlation between these variables was low. No statistically significant correlation was found between the pedobarographic and radiographic results of the patients with excellent AOFAS scale scores. The talocrural and subtalar movements were significantly impaired compared with those of the noninjured foot. Yeganeh et al (10) reported a ROM limitation in the range of 10 to 20 . Ohl et al (5) reported that ankle dorsiflexion, plantar flexion, and subtalar movements of the injured foot had significantly less ROM than that of the healthy foot. However, another study reported similar ROM values for both injured and noninjured feet in 14 of 16 patients after an average follow-up period of 48 months (30). In addition to the type of injury, the use of postoperative physiotherapy can influence clinical results. Published data have reported that if stable fixation has been achieved, early ROM exercises can be
5
Table 3 Pedobarographic assessments at a mean follow-up point of 45 months Characteristic and Location Contact surface area (cm2) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Maximum force (N) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Peak pressure (kPa) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Arch index (%) Mean SD Median Range
Injured Foot (n ¼ 19)
Noninjured Foot (n ¼ 19)
152.5 21.7 157 98 to 190
157.3 23.3 153.5 127 to 192
37.5 6.4 39.7 21 to 47
38.5 5.3 40 30 to 48
33.9 8.1 34 17 to 47
34.4 7.0 34 23 to 48
57.6 7.4 58.9 41 to 67
59.3 8.2 55.9 47 to 72
22.7 6.5 22.4 7 to 31
24.5 7.7 23.4 12 to 36
1722.9 293.8 1712.6 1175 to 2176
1792.6 291.8 1864 1297 to 2313
413.3 171.5 371.5 51 to 694
584.1 135.3 567.2 369 to 794
265.3 122.3 249.5 105 to 499
219.4 72.6 223 95 to 328
875.5 199 896 522 to 1176
814.9 154.1 816 574 to 1073
167.6 78.5 180.6 14 to 289
173.4 79.8 168 43 to 316
679.6 280.2 655 235 to 1075
550.0 228.6 450 270 to 1070
191.1 86.8 185 35 to 370
285.0 60.9 275 205 to 360
180.3 72.6 155 125 to 390
165.7 52.5 160 105 to 280
629.6 299.3 610 155 to 1075
481.5 256.8 380 255 to 1075
320.3 183.7 395 125 to 715
357.3 225.3 270 40 to 865
22 0.05 20 18 to 30
26 0.02 26 22 to 31
p Value
.35
.51
.70
.11
.65
.08
.002
.03
.10
.92
.09
.005
.46
.03
.75
.03
Abbreviation: SD, standard deviation.
begun once the wounds have healed (7). We found no studies of physiotherapy programs or exercise protocols for this surgery, suggesting this topic should be studied.
6
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Table 4 Correlations between radiologic and pedobarographic assessments at a mean follow-up point of 45 months (N = 19 patients) Angle
Differences Between Injured and Noninjured Foot Peak Pressure Midfoot
Kite’s p Value r Value Talo–first metatarsal p Value r Value Meary’s p Value r Value Calcaneal p Value r Value Medial peritalar p Value r Value
Maximum Force Hindfoot
Maximum Force Forefoot
Contact Area Hindfoot
Contact Area Total Foot
NA
NA
NA
NA
NA
NA
.026 668 NA
.016 650 NA
.013 668 NA
NA
NA
NA
NA
NA
NA
NA .008 701 NA
NA
<.0001 835 NA
.034 589
Abbreviation: NA, not applicable.
In the present study, the increase in the talo–first metatarsal angle of the injured foot indicated that forefoot adduction was obtained. Meary’s angle and the medial cuneiform–fifth metatarsal angle were also increased, a circumstance associated with cavus foot, which was also detected. In addition, we found a statistically significant positive correlation between the Hawkins classification and Meary’s angle. Cavovarus foot and forefoot adduction after talar fracture have been reported (15). In our study, the arch index and adduction of the forefoot were increased, just as they have been in other studies (14,16). However, the hindfoot varus often seen after talus fractures (6,15) was not significantly apparent statistically, although 9 patients (47%) did have hindfoot varus (Kite’s angle). The small number of patients might explain why this finding was not statistically significant. Pedobarographic analysis clearly showed that patients transfer more weight to the noninjured foot and that maximum force and peak pressure were significantly decreased in the hindfoot of the injured foot. In the long-term follow-up of patients treated for Lisfranc fracture and dislocation, Schepers et al (16) reported that the contact surface of the forefoot was reduced and that the contact surface and maximum pressure were increased in the midfoot in the injured foot. Genc et al (17) reported that the maximum pressure in the metatarsals and medial hindfoot was significantly reduced in patients with intra-articular displaced calcaneal fractures. These results suggest that patients avoid weightbearing on the injured foot region when walking. Greater weightbearing on the noninjured foot displaces the body’s center of gravity and increases the mechanical loading on some muscles and other tissues, which can lead to overuse syndromes. The finding that the arch of the injured foot increased was consistent with the increase in Meary’s angles and the medial cuneiform angle associated with cavus foot. The correlation analysis of differences between the injured and noninjured feet showed significant positive and negative correlations between some pedobarographic and radiographic parameters. Schepers et al (16) found no such correlations in Lisfranc fracture dislocations; however, we found no similar analyses in studies of talus fractures. Our patient population did not use insoles, and special insoles were not recommended to them after surgical treatment. The use of a custom-made insole might prevent the development of foot ulcers and callus formation caused by repetitive high pressure and could help to improve biomechanical abnormalities in the foot and lower extremity, € der et al (31) relieve symptoms, and cure any foot conditions. Oc¸gu reported that the use of a custom-made insole improved advancement of the limb and weightbearing in patients with a displaced intraarticular calcaneal fracture. To the best of our knowledge, no previous
study has assessed the use of an insole in patients with talus fractures. Further studies are required to clarify the effects of the use of a custommade insole for patients with talus fractures. Varus misalignment of the hindfoot, forefoot adduction, and ROM limitation of the subtalar joint can affect the plantar pressure distribution. Pedobarography can be beneficial as an additional assessment to the clinical and radiologic evaluations in patients with talar neck fractures after surgical treatment. Some clinical changes cannot be detected visually by physical and radiological examinations. Pedobarography provides a functional assessment of the foot and data on the mechanical properties of the human foot tissue. It can be used to detect zones under high pressure that will result in overloading and could therefore be helpful in identifying complications and allow precautions to be taken. It can also be used as a guide to reconsider surgical treatment and post-treatment care methods. Our study was limited in that we could not rule out the effects of any preinjury characteristics of the injured foot, the lack of periodic examinations during the follow-up period, and that we did not assess the presentation of clinical changes over time. Some patients did not wish to participate in the study and some had moved out of the city or changed their contact number; thus, the loss of patients (41%) could be considered a limitation of our study. In conclusion, talar injury and immobilization can affect the stance and gait cycle in these patients. Pain, ROM, function, and the weight transfer pattern should be evaluated carefully during follow-up examinations to provide the best postoperative results. We would recommend a specific physiotherapy program for a longer period to normalize the plantar pressure and gait alterations occurring after talar trauma. References 1. Ahmad J, Raikin SM. Current concepts review: talar fractures. Foot Ankle Int 27:475–482, 2006. 2. Inokuchi S. Talus fractures: open reduction and internal fixation. In: An Atlas of € lker, MM Stephens, Foot and Ankle Surgery, pp. 251–261, edited by N Wu A Cracchilo, Taylor & Francis, Oxon, UK, 2005. 3. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 21:1023–1029, 2000. 4. Sneppen O, Christensen SB, Krogse O, Lorentzen J. Fracture of the body of the talus. Acta Orthop 48:317–324, 1977. 5. Ohl X, Harisboure A, Hemery X, Dehoux E. Long-term followup after surgical treatment of talar fractures: twenty cases with an average follow-up of 7.5 years. Int Orthop 35:93–99, 2011. 6. Rammelt S, Zwipp H. Talar neck and body fractures. Injury 40:120–135, 2009. 7. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 9:114–127, 2001. 8. Halvorson JJ, Winter SB, Teasdall RD, Scott AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg 52:56–61, 2013.
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
9. Rammelt S, Zwipp H. Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results. Int Orthop 37:1707– 1717, 2013. 10. Yeganeh A, Alaee A, Boddouhi B, Behkam-Rad A, Shahoseini G. Results of surgically treated talar fractures. Chin J Traumatol 16:361–364, 2013. 11. Baumhauer JF, Alvarez RG. Controversies in treating talus fractures. Orthop Clin North Am 26:335–351, 1995. 12. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. J Bone Joint Surg Am 60:143–156, 1978. 13. Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck: its effect on the position of the foot and on subtalar motion. J Bone Joint Surg Am 78:1559– 1567, 1996. 14. Sangeorzan BJ, Wagner UA, Harrington RM, Tencer AF. Contact characteristics of the subtalar joint: the effect of talar neck misalignment. J Orthop Res 10:544–551, 1992. 15. Sproule JA, Glazebrook MA, Younger AS. Varus hindfoot deformity after talar fracture. Foot Ankle Clin North Am 17:117–125, 2012. 16. Schepers T, Kieboom B, Van Diggele P, Patka P, Van Lieshout EM. Pedobarographic analysis and quality of life after Lisfranc fracture dislocation. Foot Ankle Int 31:857–864, 2010. 17. Genc Y, Gultekin A, Duymus TM, Mutlu S, Mutlu H, Komur B. Pedobarography in the assessment of postoperative calcaneal fracture pressure with gait. J Foot Ankle Surg 55:99–105, 2016. 18. Tuna H. Pedobarographic evaluation in foot disorders. Turk J Phys Med Rehab 51(suppl B):B51–B54, 2005. 19. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 8:1153–1157, 2001. 20. 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 15:349–353, 1994.
7
21. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg 46:65–74, 2007. erlendirme Prensipleri, ed 3, pp. 62–87, edited 22. Tedavi Hareketleretlerinde Temel Deg by S Otman, H Demirel, A Sade, Prizma Ofset, Ankara, 2003. 23. Foot and Ankle Core Knowledge in Orthopaedics, edited by CW DiGiovanni, J Greisberg, Elsevier Mosby, China, 2007. 24. Michelson JD. Triple Arthrodesis of the Hindfoot. In: Master Techniques in Orthopaedic Surgery: The Foot and Ankle, pp. 343–360, edited by H Kitaoka, Lippincott Williams & Wilkins Wolters Kluwer, China, 2013. 25. Sangeorzan B, Mosca V, Hansen S. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle 14:136–141, 1993. 26. Cavanagh PR, Rodgers MM. The arch index: a useful measure from footprints. J Biomech 20:547–551, 1987. 27. Fleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients. J Orthop Trauma 16:213–219, 2002. 28. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 86:2229–2234, 2004. 29. Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma 18:265–270, 2004. 30. Abdelgaid SM, Ezzat FF. Percutaneous reduction and screw fixation of fracture neck talus. Foot Ankle Surg 18:219–228, 2012. € der A, Go € k H, Heycan C, Tecimel O, To € nu € k E, Bozkurt M. Effects of custom31. Oc¸gu made insole on gait pattern of patients with unilateral displaced intra-articular calcaneal fracture: evaluation with computerized gait analysis. Acta Orthop Traumatol Turc 46:1–7, 2012.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Pedobarographic and Radiological Analysis After Treating a Talus Neck Fracture _ ba Kuru C¸olak, PT, PhD 1, Ilker € ven Bulut, MD 4, Tug C¸olak, MD 2, Eren Timurtas¸, PT, MSc 3, Gu € lden Polat, PT, PhD 5 M. Gu 1
Asstistant Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey € tfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey Department of Orthopaedics and Traumatology, Dr Lu Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey 4 € tfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey Associate Professor, Department of Orthopaedics and Traumatology, Dr Lu 5 Professor, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Misalignment of the talar neck after surgical repair can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, which can change the joint biomechanics, cause arthritis, and impair function. However, we found no studies analyzing the plantar pressures after treatment of talus neck fracture. We determined the dynamic plantar pedobarographic and radiographic characteristics and ankle range of motion, function, and pain among patients after surgical repair of talar neck fractures. A total of 19 patients completed the assessments. The median follow-up period was 29 (range 12 to 113) months. At the last visit, the mean pain score was 3.3 on a 10-cm visual analog scale. The mean American Orthopaedic Foot and Ankle Society function scale score was fair (73.5), and the mean range of motion was restricted in 4 planes. The mean maximum force was lower in the hindfoot (p ¼ .002) and midfoot (p ¼ .03) of the injured foot than in the noninjured foot. The mean peak pressure was lower in the hindfoot (p ¼ .05) but higher in the forefoot (p ¼ .03). Radiographic measurements revealed differences between the feet in the talo–first metatarsal angle (p ¼ .002), Meary’s angle (p ¼ .001), and the medial cuneiform–fifth metatarsal angle (p ¼ .002). Radiographic and pedobarographic analysis showed an elevated arch in the injured foot. Thus, talar injury and immobilization can affect the stance and the gait cycle in these patients. Pain, range of motion, function, and the weight transfer pattern should be evaluated carefully during the follow-up period to provide the best postoperative results. Ó 2016 Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons.
Keywords: foot fracture injury pedobarography talus
Most fractures of the talus occur in the neck. Talar neck fractures comprise <1% of ankle–foot fractures (1–3) and are generally seen in young males as the result of high-energy trauma, such as a fall, motor vehicle accident, or direct trauma (3–5). The talus is the most superiorly located bone in the foot and is important in maintaining the normal ankle range of motion (ROM) and function (6). With serious injuries, all foot and ankle movements will be affected. Osteonecrosis, malunion, nonunion, post-traumatic arthrosis, skin necrosis, and infection are possible complications after treatment (5–8). Deformity as a consequence of post-traumatic misalignment of the talus leads to painful functional impairment
Financial Disclosure: None reported. Conflict of Interest: None reported. ba Kuru C¸olak, PT, PhD, Fizyoterapi ve RehabilAddress correspondence to: Tug € € lu € mu € , Marmara Universitesi, Sag lık Bilimleri Faku € ltesi, E-5 Yanyol Uzeri, itasyon Bo _ Cevizli, Kartal, Istanbul, Turkey. E-mail address: [email protected] (T.K. C¸olak).
(6,9,10). The most common deformity after malunion (47%) of a talar fracture is varus misalignment of the hindfoot, which markedly decreases subtalar and midtarsal motion. This misalignment is particularly common after closed reduction of Hawkins type 2 talar neck fractures (7,11–13). Varus misalignment of the talar neck can shorten the medial column considerably, which locks the hindfoot in varus and internal rotation (13). The degree of varus misalignment is also associated with changes in foot position and the degree of subtalar motion (13). Even 2 mm of misalignment at the talar neck can redistribute the load among the posterior, middle, and anterior facets of the subtalar joints, changing the joint biomechanics and resulting in arthritis (13,14). This possible varus and internal rotation of the talus neck also disrupts the normal relationship between the midfoot and hindfoot and reduces the mobility of the midtarsal joint (13). The decreased ROM in the subtalar and midtarsal joints often causes a painful, rigid, and cavovarus foot. An increase in the lateral load transfer in the foot results in callus formation (15).
1067-2516/$ - see front matter Ó 2016 Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons. http://dx.doi.org/10.1053/j.jfas.2016.07.017
2
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Table 1 Characteristics and long-term outcomes of 19 patients with surgically treated fractures of the talus neck or talus neck and body Characteristic
Value
Male gender (n) Age (yr) Mean SD Median Range Injured foot (n) Right Left Injury type (n) Fall from a height Crushing Motor vehicle accident Hawkins classification (n) 1 2 3 4 Interval from injury to surgery (n) Within 24 hr 24 to 48 hr 5 days, after leaving ICU 10 days, after leaving ICU Cast immobilization Immobilization period (days) Mean SD Median Range Pain score Mean SD Median Range AOFAS scale score Mean SD Median Range Excellent (n) Good (n) Fair (n) Poor (n) Subtalar arthritis (n) Tibiotalar arthritis (n)
15 33.3 11.1 34 15 to 55 13 6 13 (68.4) 1 (5.2) 5 (26.3) 4 10 4 1
(21.1) (52.6) (21.1) (5.2)
13 1 2 1 2
(68.4) (5.2) (10.5) (5.2) (10.5)
64.2 35.2 60 30 to 160 3.3 2.1 3 0 to 7 73.5 1.1 76 50 to 100 3 (15.8) 6 (31.6) 6 (31.6) 4 (21.1) 16 (84.2) 14 (73.7)
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; ICU, intensive care unit; SD, standard deviation. Data in parentheses are percentages.
Table 2 Ankle range of motion and structural angles at a mean follow-up point of 45 months Outcome
Ankle dorsiflexion ROM ( ) Mean SD Median Range Ankle plantarflexion ROM ( ) Mean SD Median Range Ankle inversion ROM ( ) Mean SD Median Range Ankle eversion ROM ( ) Mean SD Median Range Kite’s angle ( ) Mean SD Median Range Talo–first metatarsal angle ( ) Mean SD Median Range Meary’s angle ( ) Mean SD Median Range Hibbs’ angle ( ) Mean SD Median Range Calcaneal pitch angle ( ) Mean SD Median Range Medial cuneiform–fifth metatarsal angle ( ) Mean SD Median Range Talonavicular coverage angle ( ) Mean SD Median Range
Injured Foot (n ¼ 19)
Noninjured Foot (n ¼ 19)
12.4 5.8 10 5.0 to 25.0
19.4 2.1 18 18.0 to 25.0
25.0 10.9 30 5.0 to 45.0
41.8 2.8 42 37.0 to 50.0
9.4 7.1 8 0 to 25.0
24.5 2.6 25 20.0 to 30.0
7.1 5.6 5 0 to 20.0
14.7 1.7 15 12.0 to 20.0
25.2 6.7 24 13 to 38
26.1 5.6 25 20 to 39
6.7 9.9 5 11 to 34
0.25 6.7 1 13 to 15
7.8 7.9 7.5 4 to 26
1.1 7.0 3 14 to 12
134.0 7.1 135 120 to 147
136.3 7.3 135 124 to 149
21.0 5.7 20 14 to 36
18.6 4.7 20 11 to 25
17.2 8.2 20 1 to 28
10.2 7.1 10 0 to 25
5.7 6.5 5 5 to 22
8.0 7.9 7 10 to 26
p Value
<.001
<.001
<.001
.001
.29
.002
<.001
.06
.05
.002
.116
Abbreviations: ROM, range of motion; SD, standard deviation.
All these changes have negative effects on plantar pressures. However, we found no studies of the plantar pressure after talus neck fracture. Pedobarographic pressure analysis shows biomechanical alterations and can objectively evaluate the foot after different orthopedic foot and ankle problems, injuries, and surgeries (16–18). Therefore, we sought to determine the dynamic plantar pressure and radiographic characteristics of patients who had undergone surgery or cast immobilization for a talar neck fracture.
Patients and Methods The ethics committees of our institutions approved the present study. All the patients provided written informed consent. We enrolled patients presenting with a fracture of the talar neck (International Classification of Diseases code S92.11) or of the talar body (International Classification of Diseases code S92.12) and talar neck € tfi Kırdar Kartal Education and Research who presented to the Dr Lu Hospital from December 2005 to January 2014. The exclusion criteria were the presence of a concomitant injury in the ipsilateral or contralateral lower extremity, the use of arthrodesis
or amputation of a lower extremity, a congenital deformity or neurologic problem, previous surgery of the spine or lower extremity, poor balance, the use of medications that could affect balance, an open wound on the foot, and any mental problems or any situation that might interfere with the patient walking barefoot. Patients with a fracture of the talar neck or of the talar body and talar neck treated at our institution during the study period were identified from the computerized hospital records. Patients who met the inclusion criteria were interviewed by telephone and invited to participate in the present study. All patients underwent a comprehensive physical examination of the injured foot and radiographic and pedobarographic evaluations. The ankle ROM, function, and pain were measured in all patients at the follow-up visits. Data on age, sex, the mechanism of trauma, the interval from injury to surgery, and the duration of the immobilization period were also recorded. Pain was assessed using a 10-cm visual analog scale (VAS), with 0 representing no pain and 10, the worst pain imaginable (19). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scale consists of 9 questions related to pain, activity and functional limitations, walking distance, difficulty with different terrains, gait
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
3
Fig. 1. A 36-year-old male with a Hawkins type III fracture, with the peak pressure significantly decreased in the hindfoot and increased in the forefoot of the injured foot.
abnormality, sagittal ROM at the ankle, and ROM, stability, and alignment (plantigrade or not) of the subtalar joint. The best functional score is 100 points. From the data in the patient medical records and from the radiographic examinations, a physician completed these 9 sections related to alignment and ROM. The other sections were completed by the patients. A score of 90 to 100 was considered excellent, 80 to 89, good, 70 to 79, fair, and <70 poor (20,21). The active ROM of both feet was measured using a universal goniometer according to the procedures described by the American Academy of Orthopaedic Surgeons. Dorsiflexion, plantar flexion, inversion, and eversion were measured with the patient seated. All measurements were repeated 3 times, and the average value was recorded (22). Radiographs were taken of the dorsoplantar and lateral views of both feet with the patient standing. The fracture type was classified according to the Hawkins system as modified by Canale and Kelly (12),
with the fractures divided into 4 groups. Digital measurements were taken of Kite’s angle (the talocalcaneal angle), the talo–first metatarsal angle, and the talonavicular coverage angle on the dorsoplantar view and Meary’s angle (the talo–first metatarsal angle), Hibbs’ angle (the calcaneal–first metatarsal angle), the calcaneal pitch angle, and the medial cuneiform–fifth metatarsal distance in the lateral view (23,24). A talonavicular coverage angle >78 was accepted as joint subluxation (25). The presence of post-traumatic osteoarthritis in the subtalar and tibiotalar joints was also evaluated. Pedobarographic measurements were obtained using an EmedÒa50/D system (Novel GmbH, Munich, Germany), which consists of a 380-mm 240-mm pressure platform with 2 sensors/cm2, a pressure range of 10 to 950 kPa, and sampling frequency of 50/60 Hz. To achieve a normal gait pattern, all patients were asked to walk with bare feet before the evaluation. Next, 5 trials of both the injured and noninjured foot were recorded in dynamic mode.
4
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Fig. 2. A 23-year-old male with a Hawkins type II fracture, with the peak pressure significantly decreased in the hindfoot and increased in the forefoot of the injured foot.
We measured the peak pressure (kPa), maximum force (N), and contact area cm2; (Automask; Novel GmbH) in the forefoot, midfoot, hindfoot, and toes. The arch index was calculated by dividing the pressure area of the midfoot by the total pressure areas of the forefoot, midfoot, and midfoot (26). Date are presented as the mean standard deviation or percentages. Measurements of the injured foot were compared with those of the noninjured foot using Wilcoxon signed rank tests. Correlations between the angular and pressure measurements were assessed using Spearman’s rho. Statistical analyses were performed using the SPSS, version 18.0, for Windows software (IBM, Armonk, NY). Alpha was set at 0.05, and all tests were 2-tailed. Results Of 32 enrolled patients, 19 (59%) completed the assessments (Table 1). The follow-up period ranged from 12 to 113 (median 29) months. Two patients with Hawkins type I fractures were treated conservatively with a short leg cast; all other patients were treated
surgically. The fracture was a closed fracture in 16 patients (84.2%), a type I open fracture in 1 patient (5.2%), and a type II open fracture in 2 patients (10.5%). Five patients (26.3%) had accompanying fractures (3 medial malleol and 2 distal radius fractures). Of the 19 patients, 13 (68.4%) underwent surgery within the first 24 hours, and 7 patients (36.8%) received physiotherapy postoperatively. Post-traumatic arthritis was detected in the tibiotalar joint of 16 patients (84.2%) patients and in the subtalar joint of 14 (73.7%). Avascular necrosis was diagnosed in 8 patients (42.1%) and hammer toe deformity in 2 (10.5%). The mean AOFAS scale score was fair (73.5). The score was poor in 3 patients (15.8%), fair in 6 (31.6%), good in 6 (31.6%), and excellent in 4 (21.1%; Table 1). The ROM in the injured ankle differed significantly from that of the noninjured ankle (Table 2). Radiographic measurements of the talo– first metatarsal angle, Meary’s angle, and the medial cuneiform–fifth metatarsal angle of the injured ankle also differed significantly from those from the radiographs of the noninjured ankle. Dynamic pedobarographic analysis revealed no significant differences between the injured and noninjured feet in the total contact
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
area and other regions of the foot. However, the maximum forces of the hindfoot and midfoot and the peak pressures of the hindfoot and forefoot differed significantly between the injured and noninjured feet (Figs. 1 and 2 and Table 3). The arch index evaluation showed a statistically significant increase in the arch of the injured foot (p ¼ .03). Age, immobilization period, receipt of postoperative physiotherapy, and postoperative follow-up did not correlate with any differences in ROM or pedobarographic variables. Statistically significant positive correlations were found between the talo–first metatarsal angle difference and flexion (p ¼ .020, r ¼ 0.530), inversion (p ¼ .009, r ¼ 0.579), and eversion (p ¼ .007, r ¼ 0.593). A significant positive correlation was found between the fracture type (Hawkins classification) and Meary’s angle (p ¼ .036, r ¼ 0.484). The statistically significant correlations between some of the differences in the radiographic and pedobarographic parameters are listed in Table 4.
Discussion The aim of the present study was to determine the dynamic plantar pressure and radiographic characteristics of the feet surgically or conservatively treated for fractures of the talar neck or talar neck and body. The average AOFAS scale score was fair, the ROM was restricted in all 4 planes of the injured ankle, and the injured feet all showed an increase in the arch. The pedobarographic analysis indicated that body weight was transferred to the noninjured foot during walking. In the injured foot, the mean maximum force in the hindfoot and midfoot and the peak pressure in the hindfoot were significantly decreased; however, the mean peak pressure in the forefoot was significantly increased (Figs. 1 and 2). Pain is the most common subjective finding during follow-up for patients treated for talar neck fractures (27–29). The proportion of patients reporting mild to severe pain at follow-up visits has been reported to range from 22% to 100% (27–29). In the present study, the highest pain intensity in 1 day was assessed using a VAS, and 17 patients (89.5%) reported pain after a mean of 45 (range 12 to 113) months. The mean AOFAS scale score of our patients was 73.5, similar to that reported in other studies with long-term follow-up (5,26). Ohl et al (5) reported a mean AOFAS scale score of 66.9, with a good AOFAS scale score in 7 patients, fair in 11, and poor in 2 after a follow-up period of 7.5 years. No patient had excellent scores, however. In our study, 3 patients had excellent AOFAS scale scores. Of these, 2 were the youngest patients and had a Hawkins type I fracture (aged 15 and 23 years), and the third patient was 40 years old with a Hawkins type II fracture and a minimum immobilization period (30 days). However, patient age and immobilization period did not correlate with the AOFAS scale scores, but the power to detect a correlation between these variables was low. No statistically significant correlation was found between the pedobarographic and radiographic results of the patients with excellent AOFAS scale scores. The talocrural and subtalar movements were significantly impaired compared with those of the noninjured foot. Yeganeh et al (10) reported a ROM limitation in the range of 10 to 20 . Ohl et al (5) reported that ankle dorsiflexion, plantar flexion, and subtalar movements of the injured foot had significantly less ROM than that of the healthy foot. However, another study reported similar ROM values for both injured and noninjured feet in 14 of 16 patients after an average follow-up period of 48 months (30). In addition to the type of injury, the use of postoperative physiotherapy can influence clinical results. Published data have reported that if stable fixation has been achieved, early ROM exercises can be
5
Table 3 Pedobarographic assessments at a mean follow-up point of 45 months Characteristic and Location Contact surface area (cm2) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Maximum force (N) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Peak pressure (kPa) Total Mean SD Median Range Hindfoot Mean SD Median Range Midfoot Mean SD Median Range Forefoot Mean SD Median Range Toes Mean SD Median Range Arch index (%) Mean SD Median Range
Injured Foot (n ¼ 19)
Noninjured Foot (n ¼ 19)
152.5 21.7 157 98 to 190
157.3 23.3 153.5 127 to 192
37.5 6.4 39.7 21 to 47
38.5 5.3 40 30 to 48
33.9 8.1 34 17 to 47
34.4 7.0 34 23 to 48
57.6 7.4 58.9 41 to 67
59.3 8.2 55.9 47 to 72
22.7 6.5 22.4 7 to 31
24.5 7.7 23.4 12 to 36
1722.9 293.8 1712.6 1175 to 2176
1792.6 291.8 1864 1297 to 2313
413.3 171.5 371.5 51 to 694
584.1 135.3 567.2 369 to 794
265.3 122.3 249.5 105 to 499
219.4 72.6 223 95 to 328
875.5 199 896 522 to 1176
814.9 154.1 816 574 to 1073
167.6 78.5 180.6 14 to 289
173.4 79.8 168 43 to 316
679.6 280.2 655 235 to 1075
550.0 228.6 450 270 to 1070
191.1 86.8 185 35 to 370
285.0 60.9 275 205 to 360
180.3 72.6 155 125 to 390
165.7 52.5 160 105 to 280
629.6 299.3 610 155 to 1075
481.5 256.8 380 255 to 1075
320.3 183.7 395 125 to 715
357.3 225.3 270 40 to 865
22 0.05 20 18 to 30
26 0.02 26 22 to 31
p Value
.35
.51
.70
.11
.65
.08
.002
.03
.10
.92
.09
.005
.46
.03
.75
.03
Abbreviation: SD, standard deviation.
begun once the wounds have healed (7). We found no studies of physiotherapy programs or exercise protocols for this surgery, suggesting this topic should be studied.
6
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
Table 4 Correlations between radiologic and pedobarographic assessments at a mean follow-up point of 45 months (N = 19 patients) Angle
Differences Between Injured and Noninjured Foot Peak Pressure Midfoot
Kite’s p Value r Value Talo–first metatarsal p Value r Value Meary’s p Value r Value Calcaneal p Value r Value Medial peritalar p Value r Value
Maximum Force Hindfoot
Maximum Force Forefoot
Contact Area Hindfoot
Contact Area Total Foot
NA
NA
NA
NA
NA
NA
.026 668 NA
.016 650 NA
.013 668 NA
NA
NA
NA
NA
NA
NA
NA .008 701 NA
NA
<.0001 835 NA
.034 589
Abbreviation: NA, not applicable.
In the present study, the increase in the talo–first metatarsal angle of the injured foot indicated that forefoot adduction was obtained. Meary’s angle and the medial cuneiform–fifth metatarsal angle were also increased, a circumstance associated with cavus foot, which was also detected. In addition, we found a statistically significant positive correlation between the Hawkins classification and Meary’s angle. Cavovarus foot and forefoot adduction after talar fracture have been reported (15). In our study, the arch index and adduction of the forefoot were increased, just as they have been in other studies (14,16). However, the hindfoot varus often seen after talus fractures (6,15) was not significantly apparent statistically, although 9 patients (47%) did have hindfoot varus (Kite’s angle). The small number of patients might explain why this finding was not statistically significant. Pedobarographic analysis clearly showed that patients transfer more weight to the noninjured foot and that maximum force and peak pressure were significantly decreased in the hindfoot of the injured foot. In the long-term follow-up of patients treated for Lisfranc fracture and dislocation, Schepers et al (16) reported that the contact surface of the forefoot was reduced and that the contact surface and maximum pressure were increased in the midfoot in the injured foot. Genc et al (17) reported that the maximum pressure in the metatarsals and medial hindfoot was significantly reduced in patients with intra-articular displaced calcaneal fractures. These results suggest that patients avoid weightbearing on the injured foot region when walking. Greater weightbearing on the noninjured foot displaces the body’s center of gravity and increases the mechanical loading on some muscles and other tissues, which can lead to overuse syndromes. The finding that the arch of the injured foot increased was consistent with the increase in Meary’s angles and the medial cuneiform angle associated with cavus foot. The correlation analysis of differences between the injured and noninjured feet showed significant positive and negative correlations between some pedobarographic and radiographic parameters. Schepers et al (16) found no such correlations in Lisfranc fracture dislocations; however, we found no similar analyses in studies of talus fractures. Our patient population did not use insoles, and special insoles were not recommended to them after surgical treatment. The use of a custom-made insole might prevent the development of foot ulcers and callus formation caused by repetitive high pressure and could help to improve biomechanical abnormalities in the foot and lower extremity, € der et al (31) relieve symptoms, and cure any foot conditions. Oc¸gu reported that the use of a custom-made insole improved advancement of the limb and weightbearing in patients with a displaced intraarticular calcaneal fracture. To the best of our knowledge, no previous
study has assessed the use of an insole in patients with talus fractures. Further studies are required to clarify the effects of the use of a custommade insole for patients with talus fractures. Varus misalignment of the hindfoot, forefoot adduction, and ROM limitation of the subtalar joint can affect the plantar pressure distribution. Pedobarography can be beneficial as an additional assessment to the clinical and radiologic evaluations in patients with talar neck fractures after surgical treatment. Some clinical changes cannot be detected visually by physical and radiological examinations. Pedobarography provides a functional assessment of the foot and data on the mechanical properties of the human foot tissue. It can be used to detect zones under high pressure that will result in overloading and could therefore be helpful in identifying complications and allow precautions to be taken. It can also be used as a guide to reconsider surgical treatment and post-treatment care methods. Our study was limited in that we could not rule out the effects of any preinjury characteristics of the injured foot, the lack of periodic examinations during the follow-up period, and that we did not assess the presentation of clinical changes over time. Some patients did not wish to participate in the study and some had moved out of the city or changed their contact number; thus, the loss of patients (41%) could be considered a limitation of our study. In conclusion, talar injury and immobilization can affect the stance and gait cycle in these patients. Pain, ROM, function, and the weight transfer pattern should be evaluated carefully during follow-up examinations to provide the best postoperative results. We would recommend a specific physiotherapy program for a longer period to normalize the plantar pressure and gait alterations occurring after talar trauma. References 1. Ahmad J, Raikin SM. Current concepts review: talar fractures. Foot Ankle Int 27:475–482, 2006. 2. Inokuchi S. Talus fractures: open reduction and internal fixation. In: An Atlas of € lker, MM Stephens, Foot and Ankle Surgery, pp. 251–261, edited by N Wu A Cracchilo, Taylor & Francis, Oxon, UK, 2005. 3. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 21:1023–1029, 2000. 4. Sneppen O, Christensen SB, Krogse O, Lorentzen J. Fracture of the body of the talus. Acta Orthop 48:317–324, 1977. 5. Ohl X, Harisboure A, Hemery X, Dehoux E. Long-term followup after surgical treatment of talar fractures: twenty cases with an average follow-up of 7.5 years. Int Orthop 35:93–99, 2011. 6. Rammelt S, Zwipp H. Talar neck and body fractures. Injury 40:120–135, 2009. 7. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 9:114–127, 2001. 8. Halvorson JJ, Winter SB, Teasdall RD, Scott AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg 52:56–61, 2013.
T.K. C¸ olak et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–7
9. Rammelt S, Zwipp H. Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results. Int Orthop 37:1707– 1717, 2013. 10. Yeganeh A, Alaee A, Boddouhi B, Behkam-Rad A, Shahoseini G. Results of surgically treated talar fractures. Chin J Traumatol 16:361–364, 2013. 11. Baumhauer JF, Alvarez RG. Controversies in treating talus fractures. Orthop Clin North Am 26:335–351, 1995. 12. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. J Bone Joint Surg Am 60:143–156, 1978. 13. Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck: its effect on the position of the foot and on subtalar motion. J Bone Joint Surg Am 78:1559– 1567, 1996. 14. Sangeorzan BJ, Wagner UA, Harrington RM, Tencer AF. Contact characteristics of the subtalar joint: the effect of talar neck misalignment. J Orthop Res 10:544–551, 1992. 15. Sproule JA, Glazebrook MA, Younger AS. Varus hindfoot deformity after talar fracture. Foot Ankle Clin North Am 17:117–125, 2012. 16. Schepers T, Kieboom B, Van Diggele P, Patka P, Van Lieshout EM. Pedobarographic analysis and quality of life after Lisfranc fracture dislocation. Foot Ankle Int 31:857–864, 2010. 17. Genc Y, Gultekin A, Duymus TM, Mutlu S, Mutlu H, Komur B. Pedobarography in the assessment of postoperative calcaneal fracture pressure with gait. J Foot Ankle Surg 55:99–105, 2016. 18. Tuna H. Pedobarographic evaluation in foot disorders. Turk J Phys Med Rehab 51(suppl B):B51–B54, 2005. 19. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 8:1153–1157, 2001. 20. 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 15:349–353, 1994.
7
21. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg 46:65–74, 2007. erlendirme Prensipleri, ed 3, pp. 62–87, edited 22. Tedavi Hareketleretlerinde Temel Deg by S Otman, H Demirel, A Sade, Prizma Ofset, Ankara, 2003. 23. Foot and Ankle Core Knowledge in Orthopaedics, edited by CW DiGiovanni, J Greisberg, Elsevier Mosby, China, 2007. 24. Michelson JD. Triple Arthrodesis of the Hindfoot. In: Master Techniques in Orthopaedic Surgery: The Foot and Ankle, pp. 343–360, edited by H Kitaoka, Lippincott Williams & Wilkins Wolters Kluwer, China, 2013. 25. Sangeorzan B, Mosca V, Hansen S. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle 14:136–141, 1993. 26. Cavanagh PR, Rodgers MM. The arch index: a useful measure from footprints. J Biomech 20:547–551, 1987. 27. Fleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients. J Orthop Trauma 16:213–219, 2002. 28. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 86:2229–2234, 2004. 29. Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma 18:265–270, 2004. 30. Abdelgaid SM, Ezzat FF. Percutaneous reduction and screw fixation of fracture neck talus. Foot Ankle Surg 18:219–228, 2012. € der A, Go € k H, Heycan C, Tecimel O, To € nu € k E, Bozkurt M. Effects of custom31. Oc¸gu made insole on gait pattern of patients with unilateral displaced intra-articular calcaneal fracture: evaluation with computerized gait analysis. Acta Orthop Traumatol Turc 46:1–7, 2012.