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Talar Neck Fractures: A Systematic Review of the Literature
The Journal of Foot & Ankle Surgery xxx (2013) 1–6
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The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Talar Neck Fractures: A Systematic Review of the Literature Jason J. Halvorson, MD, S. Bradley Winter, MD, Robert D. Teasdall, MD, Aaron T. Scott, MD Wake Forest University Baptist Medical Center, Winston-Salem, NC
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: avascular necrosis bone injury nonunion surgery talus
Considerable controversy surrounds the management of talar neck fractures regarding the rate of posttraumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery on these variables. A data search using PubMed was performed with the keywords “talus” and “fracture.” The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.
Although fractures of the talar neck represent fewer than 1% of all foot and ankle fractures (1,2), they have historically garnered a tremendous amount of attention owing to the talus’ unique osseous and vascular anatomy (3) and the unusually high level of morbidity associated with fractures at this location. Despite more than 1200 reports published in the English language, our knowledge regarding the relative rates of complications, effect of fracture severity on patient outcomes, results of treatment, and appropriate timing of treatment remains limited. Much of the confusion and controversy is related to the relative infrequency of this injury, which has resulted in a plethora of small, retrospective case series. Adding to the confusion has been that the available reports have not consistently used the same classification systems, nor have they focused specifically on fractures through the neck of the talus, rendering head-to-head comparisons difficult, if not impossible, in some situations. The goal of the present study was to perform a systematic review of the available data evaluating talar neck fractures in an attempt to gain a better appreciation of the overall complication rates, effects of
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Aaron T. Scott, MD, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address: [email protected] (A.T. Scott).
fracture severity on prognosis, functional outcomes after treatment, role of timing with respect to operative intervention, and need for secondary salvage procedures. Materials and Methods A PubMed search was performed using the keywords “talus” and “fracture.” This search identified 1280 studies that were then reviewed for relevance to only fractures of the talar neck. Exclusion criteria included studies published in a language other than English, studies focusing on talar body or talar process fractures, cadaveric studies, studies with fewer than 5 patients, and studies focusing on “primary salvage” of talus fractures (i.e., Blair fusion, primary subtalar arthrodesis). The remaining 21 studies (4–24) are listed in Table 1. The references from each of the 21 selected studies were also reviewed in an attempt to locate additional relevant reports that were not identified during the initial PubMed search. However, no other qualifying studies were found. One additional report, by Coltart (25), was purposefully omitted. Although of historic interest, the lack of a classification system, outcomes, and follow-up data within the study made inclusion with the remaining studies difficult. When studies examining both talar neck fractures and other talus fractures (body, head or process fractures) were encountered, only the data relating to the talar neck fractures and fracture dislocations were extracted. This was the case for 8 of the 21 selected studies (7,8,13–15,18,22,23). The data from these 21 studies were compiled and subsequently analyzed, with particular emphasis placed on the rate of avascular necrosis, infection, and post-traumatic arthrosis, the functional outcomes after surgery, the effects of operative delay on the avascular necrosis (AVN) rate, and the rates of secondary salvage procedures. Furthermore, an attempt was made to correlate these findings with the fracture severity, as outlined by the numerous classification systems.
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Table 1 Overview of 21 included studies Study Type
Total Talar Neck Fractures (total fractures reported)
Open (infected)
Classification Used
Inokuchi et al (13), 1996 Marsh et al (17), 1995 Frawley et al (9), 1995 Freund (10), 1988 Szyszkowitz et al (23), 1985 Comfort et al (6), 1985
Retrospective
52 (86)
17
Hawkins
Retrospective Retrospective Retrospective Retrospective
18 28 7 56 (69)
18 (7) 4 1 21
Hawkins Szyszkowitz Hawkins Szyszkowitz
Retrospective
36
NR
Hawkins
Grob et al (11), 1985
Retrospective
41
NR
Hawkins
Penny et al (11), 1980 Elgafy et al (8), 2000
Retrospective Retrospective
40 27 (60)
NR NR
Schulze et al (22), 2002
Retrospective
46 (80)
Canale et al (4), 1978 Chateau et al (5), 2002 Hawkins (12), 1970 Lindvall et al (15), 2004
Retrospective Retrospective Retrospective Retrospective
Sanders et al (21), 2004 Vallier et al (24), 2004 Kenwright et al (14), 1970 Dunn et al (7), 1966 Pennal (18), 1966 Peterson et al (20), 1977 Lorentzen et al (16), 1977
Male Gender
Average Age (y)
Outcome
Average Interval to Surgery
AVN
Nonunion
Malunion
Follow-up (y)
70
26.4
Hawkins criteria
NR
30
d
d
14.9
10 18 6 64
31.4 45 37 NR
NR Subjective Hawkins criteria Subjective
8h Most within 12 h <24 h NR
NR 4 4 NR
d d 2 mo d
d 3 d d
7.4 6 6.5 4.2
25
Hawkins criteria
12
0
31
28
Hawkins criteria
4
d
d
9.8
Hawkins Hawkins
30 39
30 32
13 7
5 d
d d
6.2 2.5
10 (1)
Hawkins, Marti-Weber
67
33
Hawkins criteria AOFAS, Maryland score, Hawkins Hawkins, Mazur
<12 h for 18, 1–7 d for 9, 17 d for 1 <8 h for 28, 10 d for 8, >10 d for 5 NR NR
17
3
1
6
71 23 54 18 (26)
17 (4) NR 12 7 (2)
Hawkins Hawkins Hawkins Hawkins
NR 10 38 10
30 28 30.4 37.3
Hawkins criteria Subjective Hawkins criteria AOFAS
Retrospective Retrospective Retrospective
70 102 21
10 24 21 (1)
Hawkins Hawkins Coltart
57 60 49
34 32.6 35
Retrospective Retrospective Retrospective
23 41 (98) 46
3 (1) NR NR
Head, neck, body Coltart Hawkins
NR NR 34
Retrospective
123
13
Hawkins
107
NR
0
7
33 4 30 13
d d d d
18 2 d d
12.7 1.8 3.8 6.2
SMFA, AOFAS, AOS FFI, MFA Subjective
18 within 6 h; median 0 d if direct admission, 6 d if treated NR NR NR Average 85 h, 12 patients <6 h (NS) NR 3.7 d (NS) NR
8 19 8
d 2
21 d
5.2 2.5 4
46 38 NR
Subjective Subjective Hawkins
NR NR NR
16 28 6
3 d 0
5 d 13
6.4 NR 6
39
Subjective
NR
26
5
18
1.8
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; AOS, ankle osteoarthritis scale; AVN, avascular necrosis; FFI, Foot Function Index; MFA, Musculoskeletal Function Assessment; NR, not reported; NS, no statistically significant difference; SMFA, Short Musculoskeletal Function Assessment.
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Study
J.J. Halvorson et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–6
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Results
Table 3 Overall reported rate of avascular necrosis after talar neck fracture
All selected studies were retrospective. A total of 943 talar neck fractures were reported among the 21 articles. Demographic data from the patient population is listed in Table 1. The treatment type was highly variable and included nonoperative management (with or without closed reduction), open reduction, internal fixation using a variety of methods, closed reduction with percutaneous pinning, external fixation, and primary salvage procedures (Table 2). Given the wide range of treatment modalities, methods, and approaches, comparisons were not possible among the different treatment modalities and outcome measures. Of the 21 studies, 14 (208 total cases) reported their experience with open talar neck fractures (4,7,9,10,12–17,21–24) (Table 1). Of these 14 studies, 6 reported the rate of deep infection for open fractures (4,7,14,15,17,22). Also, 16 studies reported that deep infections in the collective group of 76 fractures were observed, for an overall infection rate of 21%. Treatment of these infections varied greatly among the studies and included: removal of hardware, salvage procedures such as talectomy and/or fusion, and amputation. A total of 19 studies (4–16,18–22,24) reported the overall rate of AVN within their series (Table 1). AVN occurred in 282 of these 848 fractures, for an overall incidence of 33.3% (Table 3). Sixteen studies used the Hawkins classification system when analyzing the AVN rates (Table 1). Of the 735 talar neck fractures classified according to the Hawkins classification system, AVN was identified in 174 cases, for an overall rate of 23.6% in those particular studies. Additional analysis revealed that AVN occurred in 5.7% of Hawkins type I fractures, 18.4% of Hawkins type II fractures, 44.7% of Hawkins type III fractures, and 12.1% of Hawkins type IV fractures (Table 3). An increased risk of AVN was also identified by Vallier et al (24), who found a statistically significant difference in the AVN rates in open fractures versus closed fractures (p ¼ .05). In contrast, Lindvall et al (15) demonstrated a similar trend, although they were unable to demonstrate statistical significance (p ¼ .073; data not shown). Eight studies reported the interval to operative intervention within their series (6,9–11,15,17,22,24) (Table 1). The interval to surgery varied widely across these studies, and all studies retrospectively reviewed this factor. However, when examined, no statistically
Variable
Total Patients (n)
AVN (n)
AVN Rate (%)
Total of studies reporting AVN Total in studies using Hawkins classification Hawkins type I Hawkins type II Hawkins type III Hawkins type IV Other
848 735
282 174
33.30% 23.60%
159 314 228 33 1
9 58 102 4 1
5.70% 18.40% 44.70% 12.10% 100%
Table 2 Overview of fixation methods and management in 21 studies Study
ORIF External Other Nonoperative (n) Fixation (n) Primary Management/ Procedure (n) Closed Reduction (n)
Inokuchi et al (13), 1996 Marsh et al (17), 1995 Frawley et al (9), 1995 Freund (10), 1988 Szyszkowitz et al (23), 1985 Comfort et al (6), 1985 Grob et al (11), 1985 Penny et al (11), 1980 Elgafy et al (8), 2000 Schulze et al (22), 2002 Canale et al (4), 1978 Chateau et al (5), 2002 Hawkins (12), 1970 Lindvall et al (15), 2004 Sanders et al (21), 2004 Vallier et al (24), 2004 Kenwright et al (14), 1970 Dunn et al (7), 1966 Pennal (18), 1966 Peterson et al (20), 1977 Lorentzen et al (16), 1977
d 6 12 4 0 d 0 d 5 d 3 d 18 d d d 2 15 3 31 0
38 11 16 d 56 d 37 d 42 70 26 23 34 26 70 102 13 8 NR 15 15
48 d d d d d d d 1 1 d d d d d d d d d d d
Abbreviations: NR, not reported; ORIF, open reduction internal fixation.
d 1 d d d d 4 d 5 9 5 d 5 d d d d d 4 d 2
Abbreviation: AVN, avascular necrosis.
significant differences were reported for the association between the interval to fracture fixation and the incidence of AVN (15,24). The reporting of malunion and nonunion is listed in Table 4. A total 8 studies (6,7,10,16,19,20,22,24) reported on the rate of nonunion in 423 fractures. In total, 21 nonunions were identified, for a rate of 5%. Likewise, 9 studies (4–7,9,16,20–22) reported their incidence of malunion for a total of 466 fractures. Of the 466 fractures, 81 were reported as malunions, for an incidence of 17%. The overall rate of post-traumatic arthrosis was 67.8% in the studies that specifically evaluated this parameter. In this group of 635 patients, the involved joints included the tibiotalar joint, subtalar joint, talonavicular joint, and combinations of these joints. Overall, the subtalar joint was the most commonly involved joint. These data are presented in Table 5. Only Elgafy et al (8) examined the rates of arthritis as they related to the severity of the injury using the Hawkins classification. Therefore, we were unable to determine the effects of the fracture severity on the incidence of post-traumatic arthrosis outside of the study by Elgafy et al (8). The incidence of secondary salvage procedures (any operation performed after failure of the initial treatment or in response to the development of arthrosis) was reported in 18 studies (4,6–15, 17–19,21–24) (Table 6). Only 2 studies (19,21) determined the rate of secondary salvage procedures using a given classification system or fracture type. Therefore, no attempt was made to compile data on the rates of secondary salvage procedures for specific classification systems or grade, given these low numbers. The overall incidence of secondary procedures was 18.6%, with subtalar arthrodeses performed most commonly (34.6%), followed by ankle arthrodeses and triple arthrodeses (20.3% and 16.5%, respectively). The measurement of functional outcomes in patients varied greatly among the studies, making comparisons difficult. Ten studies used the Hawkins clinical evaluation for functional outcome (4,6,8,10–13,19–22). A total of 429 patients were evaluated using the Hawkins criteria, with results reported in Table 7. The Hawkins clinical evaluation is a 4-category system in which points are assigned for pain, limp, ankle motion, and subtalar motion and then summed, with higher scores indicating better results. An excellent result is defined as a score of 13 to 15, a good result as a score of 10 to 12, a fair result as a score of 7 to 9, and a poor result as a score of 0 to 6. Table 8 lists the 5 studies (6,12,13,19,20) in which the Hawkins clinical criteria was used in combination with the Hawkins classification system. Given the inconsistent use of the other outcome measures (patient report, investigators’ physical examination findings, American Orthopaedic Foot and Ankle Society [AOFAS] scoring system, ankle osteoarthritis Table 4 Overall reported rate of nonunion and malunion after talar neck fracture
Total fractures (n) Total nonunion or malunion (n) Percentage
Nonunion
Malunion
423 20 5%
466 81 17.80%
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Table 5 Overall reported rate of post-traumatic arthrosis after talar neck fracture
Table 7 Functional outcomes using Hawkins clinical criteria
Post-traumatic Arthrosis
Patients (n)
Outcomes Using Hawkins Criteria
Patients (n ¼ 429)
Total Tibiotalar Subtalar Talonavicular Ankle plus subtalar Ankle, subtalar, talonavicular Unspecified location
635 115 265 2 44 1 4
Excellent Good Fair Poor
87 152 96 94
scale, Maryland Foot Score, and others), comparisons among some studies were not possible. Discussion Talus fractures have confounded physicians for centuries. Reports as early as 1820 (18) have demonstrated poor outcomes and a high mortality rate after this injury and its subsequent management, leading some early surgeons to recommend amputation as the primary treatment (26). As anesthesia has evolved as a distinct specialty and modern orthopedic techniques have been developed, numerous case series and reports of talus fractures have been published, with wide variations in treatment strategies and patient outcomes (4–24). Despite modern advances, talar neck fractures continue to represent problematic injuries that are associated with numerous complications and less than satisfactory results after treatment. The current published studies impart valuable information but lack the meta-analyses and systematic reviews necessary to guide clinical practice. Thus, the treatment of talar neck fractures has relied on longstanding paradigms and traditions. The present systematic review was undertaken in an attempt to further define the complication rates, prognoses as they relate to injury severity, effects of surgical delay, functional outcomes after treatment, and incidence of secondary operative procedures. Fractures of the talar body, talar head, and the various processes of the talus carry their own distinct set of complications, treatment considerations, and outcomes and, thus, were excluded from the present review. Among the most notable of the complications associated with talar neck fractures is avascular necrosis of the talar body, which is thought to be related to the talus’ tenuous blood supply (3,27,28). Reports of AVN rates have varied widely, with a range of 0% to 13% for Hawkins type I fractures, 20% to 50% for Hawkins type II fractures, and 80% to 100% for Hawkins type III and IV fractures (2). In the present analysis, the overall rate of AVN across all studies was 36.8%. When evaluating the studies that specifically used the Hawkins classification system, AVN was noted in 23.6% of patients. The type III fractures had the greatest rate of AVN at 44%, with type IV fractures surprisingly having a rate of only 12%. We acknowledge that this rate might have been artifactually low and believe that it might be related to the relative
Table 6 Overall reported incidence of secondary procedure after talar neck fracture Secondary Procedures
n
Total Ankle fusion Subtalar fusion Tibiocalcaneal fusion Talectomy Triple arthrodesis Amputation Talonavicular Total ankle Fusion
715 27 46 15 9 22 4 1 2 7
rarity of the Hawkins type IV injury, which accounted for only 4.5% of all “Hawkins classified” talus fractures in our review. Furthermore, the designation of Hawkins type IV did not exist before 1977. Therefore, many of the Hawkins type IV fractures would have been classified as type III injuries and treated with older techniques. Overall, the rates of AVN we obtained during our review were lower than many of the previously published rates and might represent a more accurate assessment of the true rates of AVN, because more patients were included. Historically, urgent or emergent open reduction and internal fixation of talar neck fractures has been recommended in an effort to restore or protect the blood supply of the talar body and thus reduce the incidence of AVN. However, few reports have specifically focused on operative delays and their association with the development of AVN. In our review, we were unable to identify any studies whose results would support urgent or emergent intervention. Recent data seem to indicate that an operative delay is not associated with an increased risk of AVN (15,24), but that this process is most likely a result of the severity of the initial injury and disruption of the blood supply and that anatomic reduction and internal fixation does not adequately restore the disrupted blood supply. This change in thinking has been highlighted in a recent survey of orthopedic traumatologists conducted by Patel et al (29). In their survey, 60% of orthopedic traumatologists thought that care after 8 hours was appropriate for a displaced talar neck fracture, with roughly one half (46%) indicating that they believed a delay of more than 24 hours was acceptable. The malunion and nonunion rates were difficult to quantify in the available studies. Not all studies reported on their incidence of malunion and nonunion. In addition, defining the investigators’ criteria for both nonunion and malunion were not equivalent among the studies, and few went so far as to report their numbers on basis of open versus closed treatment or the rate in conjunction with open fracture, and so forth. However, from the available data, malunion can be expected to occur in approximately 20% of cases and nonunion in approximately 5% of cases. Although these raw percentages are of value, correlation with type of operative procedure, rates of arthrosis and/or secondary procedures, and functional outcomes is scarce. The advent of newer advances in operative technique such as dual incision and referral of these injuries to “foot and ankle” or “trauma-trained” specialists might decrease the percentage of “open internal fixation” in more recent years. Additional studies are required before definitive conclusions regarding how the rates of malunion and nonunion affect the history and clinical outcomes of talar neck fractures.
Table 8 Relationship between Hawkins clinical criteria and Hawkins classification Outcomes Using Hawkins Criteria
Fracture Type by Hawkins Classification Type I
Type II
Type III
Type IV
Total
Excellent Good Fair Poor Total
35 33 6 5 79
11 17 13 14 55
6 25 30 19 80
2 1 0 3 6
54 76 49 41 220
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The relative rates of post-traumatic arthrosis were difficult to accurately quantify from the information provided in the 21 selected studies. Of the 635 patients for whom follow-up data were available, 67.8% of patients were reported to have some level of arthrosis. However, some studies made no mention of the incidence of arthrosis (7,13,17–19), and others simply combined “arthritis” into 1 category without specifically indicating the site involved. Furthermore, the diagnostic criteria for post-traumatic arthrosis varied among the studies, with some choosing to define the condition clinically and others using radiographic parameters. In those studies that reported the rates of arthrosis, subtalar arthrosis was most commonly diagnosed, occurring in 38% of patients and accounting for 62% of the arthritis reported overall. Few studies considered the rates of specific arthritis as it related to the severity of the injury (19,21) or classification system. No meaningful numbers were able to be extrapolated from the current data regarding the rates of post-traumatic arthrosis after talar neck fracture. Therefore, no comment can be made regarding the incidence of secondary arthritis as it relates to the severity of the injury. Secondary salvage procedures are common after talus fractures and typically involve peritalar arthrodesis. Sanders et al (21) reported in their analysis that the calculated percentage of patients requiring secondary surgery at 1, 2, 5, and 10 years was 24%, 32%, 38%, and 48%, respectively. Our analysis has demonstrated a lower incidence of secondary procedures, with an overall rate of 18% at an average follow-up of 6 years. Of the 133 secondary procedures reported, subtalar fusion predominated, occurring 35% of the time, followed by ankle fusion and triple arthrodesis at 20% and 17%, respectively. Sanders et al (21) demonstrated that secondary reconstructive procedures are most likely needed in comminuted fractures and Hawkins type III or IV fractures. In their series, only 7 of 26 patients requiring secondary surgery were classified as having Hawkins type II fractures (21). No Hawkins type I fracture required a secondary reconstructive surgery. On the basis of our review, which found an overall rate of arthrosis of 67.8% and a rate of secondary salvage procedures of 18%, it appears that many of the patients who were diagnosed with arthrosis were either minimally symptomatic or asymptomatic. As stated, no study delineated between symptomatic and asymptomatic post-traumatic arthritis. Therefore, the clinical significance of a 67.8% rate of post-traumatic arthrosis in the setting of an 18% rate of secondary surgery is questionable. It would thus seem that most patients will develop some form of arthritis after talar neck fracture, but that most of those patients will either be asymptomatic or will choose not to undergo secondary salvage procedures. No functional outcomes measure was universally used across all studies. The Hawkins clinical evaluation score was the most common outcomes measure used in our group of selected studies and was used in 10 of the 21 studies examined. Of the 429 fractures for which the Hawkins clinical evaluation score was used, only 20% of the outcomes were rated as excellent, with 22% of patients having a poor outcome and more than one half having either a fair or poor outcome. In the studies that used both the Hawkins classification system and the Hawkins clinical evaluation (220 total fractures), only 44% of patients with a type I fracture had an excellent result compared with an 8% excellent result for patients sustaining a type III injury. However, only 6 type IV fractures were reported in this group, with 3 (50%) having excellent or good results and 43 (50%) poor results. Thus, in our review, an increasing severity of injury, as established by the Hawkins classification system, correlated with a worse functional outcome, as indicated by the patient’s score on the Hawkins clinical evaluation. The remaining outcomes assessments used throughout the studies made evaluation difficult, because few consistent outcome measures existed across all examinations. More recent studies (8,15,21) have attempted to use validated outcomes questionnaires for functional
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assessment. Sanders et al (21) reported that roughly one half of their patients without a salvage procedure during follow-up reported a visual analog scale pain score of 4.2 of 10. In addition, the AOFAS hindfoot score ranged from 52 for those patients with malalignment or secondary arthritis to 92 for those patients with anatomic reduction and no signs of secondary arthritis. Elgafy et al (8) reported the average AOFAS score in their cohort of patients was 79 (range 37 to 99). Finally, Lindvall et al (15) reported an AOFAS score of 46.7 points when a neck fracture resulted in AVN versus a score of 76 points for those without AVN. The AOFAS score of those patients with radiographically documented subtalar arthritis and subtalar plus ankle arthritis was 63.2 and 60.4, respectively. As with the Hawkins clinical evaluation, comorbid conditions developing after talar neck fracture (i.e., AVN, arthritis) resulted in decreased validated outcomes scores. Therefore, increased severity of injury, arthritis, and AVN increases the likelihood of a worse outcome after talar neck fracture. Inherent weaknesses were present with the present systemic review. First, all studies reviewed were retrospective. As such, the bias associated with retrospective studies was also associated with our review. Future studies, although difficult in this population, should focus on prospective examinations for variables such as the incidence of AVN and timing of surgery as it relates to AVN. In addition, the nonstandardized clinical follow-up and assessment made comparisons difficult among the studies across all the variables examined. This also dramatically decreased the numbers available for comparison in some instances, limiting the true power of the more than 900 reported talar neck fractures. Not only were no standardized outcomes available, also no standardized treatment methods were used among the studies. This was the primary reason the historical study by Coltart (25) was not included in the present analysis. The treatment methods, classification system, outcomes, and technology varied so greatly from those currently in use that we believe that including these patients in the present analysis would have confused the final data collection and results. The remaining included studies reviewed spanned more than 4 decades, and an evolution in treatment philosophy and strategy was seen as the reports were published. Early, investigators advocated conservative treatment with either immobilization or closed reduction followed by immobilization. This resulted in described techniques of casting in equinus for weeks at a time (14,18). When surgery was performed, a wide variety of methods was chosen for open reduction and internal fixation. With more recent advances in operative techniques and instrumentation, these options have increased to the use of biodegradable screws, plates, standard screws, Kirschner wires, or, even, external fixation (13,30,31). Open reduction and internal fixation has decreased the overall reported incidence of AVN (2) in more recent examinations compared with historical controls. Therefore, in including all reports both before and after the move to open reduction and internal fixation for talus fractures, we might have biased the evidence because comparisons in treatment methods and philosophies will obviously influence the overall rates of AVN, functional outcomes, secondary procedures, and so forth. We also did not include any study examining the use of a primary salvage procedure for talar neck fractures. Therefore, another cohort of patients exists, who undergo primary reconstructive/salvage surgery, that we could not comment on or compare with our cohort. Functional outcomes are also difficult to compare because the more recent studies focused on validated outcomes questionnaires and older studies did not have this method available. However, few of the newer studies used the same validated outcomes questionnaires; therefore, despite the high-quality reporting of outcomes, comparisons between series were difficult. In conclusion, talar neck fractures continue to represent injuries that demand respect from orthopedic surgeons. One third of these patients will develop AVN and two thirds will develop arthritis,
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resulting in a 20% salvage procedure rate. Functionally, as defined by the classic Hawkins clinical criteria, almost one fourth of patients will end up with a poor outcome, with almost one half of patients having a fair or poor outcome. Although modern orthopedic techniques have continued to evolve and have dramatically decreased the overall rates of AVN and, potentially, poor functional results, continued work is required to help improve patient care and outcomes.
References 1. Ahmad J, Raikin SM. Current concepts review: talar fractures. Foot Ankle Int 27:475–482, 2006. 2. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 9:114–127, 2001. 3. Haliburton RA, Sullivan CR, Kelly PJ, Peterson LFA. The extra-osseous and intraosseous blood supply of the talus. J Bone Joint Surg Am 40-A:1115–1120, 1958. 4. Canale ST, Kelly FB. Fractures of the neck of the talus: long-term evaluation of seventy-one cases. J Bone Joint Surg Am 60:143–156, 1978. 5. 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. 6. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop Relat Res 199:81–87, 1985. 7. Dunn AR, Jacobs B, Campbell RD. Fractures of the talus. J Trauma 6:443–468, 1966. 8. 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. 9. Frawley PA, Hart JA, Young DA. Treatment outcome of major fractures of the talus. Foot Ankle Int 16:339–345, 1995. 10. Freund KG. Complicated fractures of the neck of the talus. Foot Ankle 8:203–207,1988. 11. Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Clin Orthop Relat Res 199:88–96, 1985. 12. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 52:991–1002,1970. 13. Inokuchi S, Ogawa K, Usami N, Hashimoto T. Long-term follow up of talus fractures. Orthopedics 19:477–481, 1996. 14. Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br 52:36–48, 1970.
15. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 86-A:2229–2234, 2004. 16. Lorentzen JE, Christensen SB, Krogsoe O, Sneppen O. Fractures of the neck of the talus. Acta Orthop Scand 48:115–120, 1977. 17. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the talus. J Orthop Trauma 9:371–376, 1995. 18. Pennal GF. Fractures of the talus. Clin Orthop Relat Res 30:53–63, 1963. 19. Penny JN, Davis LA. Fractures and fracture-dislocations of the neck of the talus. J Trauma 20:1029–1037, 1980. 20. Peterson L, Goldie IF, Irstam L. Fracture of the neck of the talus: a clinical study. Acta Orthop Scand 48:696–706, 1977. 21. 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. 22. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G. Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1–15 years. Acta Orthop Scand 73:344–351, 2002. 23. Szyszkowitz R, Reschauer R, Seggl W. Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop Relat Res 199:97–107, 1985. 24. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am 86-A:1616–1624, 2004. 25. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 34-B:545–566, 1952. 26. Syme J. Contributions to the Pathology and Practice of Surgery, ed 1, Sutherland and Knox, Edinburgh, 1848. p 126. 27. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br 52: 160–167, 1970. 28. Wildenauer E. [Proceedings: discussion on the blood supply of the talus]. Z Orthop Ihre Grenzgeb 113:730, 1975. 29. Patel R, Van Bergeyk A, Pinney S. Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts. Foot Ankle Int 26:378–381, 2005. 30. Attiah M, Sanders DW, Valdivia G, Cooper I, Ferreira L, MacLeod MD, Johnson JA. Comminuted talar neck fractures: a mechanical comparison of fixation techniques. J Orthop Trauma 21:47–51, 2007. 31. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int 27:340–343, 2006.
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Original Research
Talar Neck Fractures: A Systematic Review of the Literature Jason J. Halvorson, MD, S. Bradley Winter, MD, Robert D. Teasdall, MD, Aaron T. Scott, MD Wake Forest University Baptist Medical Center, Winston-Salem, NC
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: avascular necrosis bone injury nonunion surgery talus
Considerable controversy surrounds the management of talar neck fractures regarding the rate of posttraumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery on these variables. A data search using PubMed was performed with the keywords “talus” and “fracture.” The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.
Although fractures of the talar neck represent fewer than 1% of all foot and ankle fractures (1,2), they have historically garnered a tremendous amount of attention owing to the talus’ unique osseous and vascular anatomy (3) and the unusually high level of morbidity associated with fractures at this location. Despite more than 1200 reports published in the English language, our knowledge regarding the relative rates of complications, effect of fracture severity on patient outcomes, results of treatment, and appropriate timing of treatment remains limited. Much of the confusion and controversy is related to the relative infrequency of this injury, which has resulted in a plethora of small, retrospective case series. Adding to the confusion has been that the available reports have not consistently used the same classification systems, nor have they focused specifically on fractures through the neck of the talus, rendering head-to-head comparisons difficult, if not impossible, in some situations. The goal of the present study was to perform a systematic review of the available data evaluating talar neck fractures in an attempt to gain a better appreciation of the overall complication rates, effects of
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Aaron T. Scott, MD, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address: [email protected] (A.T. Scott).
fracture severity on prognosis, functional outcomes after treatment, role of timing with respect to operative intervention, and need for secondary salvage procedures. Materials and Methods A PubMed search was performed using the keywords “talus” and “fracture.” This search identified 1280 studies that were then reviewed for relevance to only fractures of the talar neck. Exclusion criteria included studies published in a language other than English, studies focusing on talar body or talar process fractures, cadaveric studies, studies with fewer than 5 patients, and studies focusing on “primary salvage” of talus fractures (i.e., Blair fusion, primary subtalar arthrodesis). The remaining 21 studies (4–24) are listed in Table 1. The references from each of the 21 selected studies were also reviewed in an attempt to locate additional relevant reports that were not identified during the initial PubMed search. However, no other qualifying studies were found. One additional report, by Coltart (25), was purposefully omitted. Although of historic interest, the lack of a classification system, outcomes, and follow-up data within the study made inclusion with the remaining studies difficult. When studies examining both talar neck fractures and other talus fractures (body, head or process fractures) were encountered, only the data relating to the talar neck fractures and fracture dislocations were extracted. This was the case for 8 of the 21 selected studies (7,8,13–15,18,22,23). The data from these 21 studies were compiled and subsequently analyzed, with particular emphasis placed on the rate of avascular necrosis, infection, and post-traumatic arthrosis, the functional outcomes after surgery, the effects of operative delay on the avascular necrosis (AVN) rate, and the rates of secondary salvage procedures. Furthermore, an attempt was made to correlate these findings with the fracture severity, as outlined by the numerous classification systems.
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Table 1 Overview of 21 included studies Study Type
Total Talar Neck Fractures (total fractures reported)
Open (infected)
Classification Used
Inokuchi et al (13), 1996 Marsh et al (17), 1995 Frawley et al (9), 1995 Freund (10), 1988 Szyszkowitz et al (23), 1985 Comfort et al (6), 1985
Retrospective
52 (86)
17
Hawkins
Retrospective Retrospective Retrospective Retrospective
18 28 7 56 (69)
18 (7) 4 1 21
Hawkins Szyszkowitz Hawkins Szyszkowitz
Retrospective
36
NR
Hawkins
Grob et al (11), 1985
Retrospective
41
NR
Hawkins
Penny et al (11), 1980 Elgafy et al (8), 2000
Retrospective Retrospective
40 27 (60)
NR NR
Schulze et al (22), 2002
Retrospective
46 (80)
Canale et al (4), 1978 Chateau et al (5), 2002 Hawkins (12), 1970 Lindvall et al (15), 2004
Retrospective Retrospective Retrospective Retrospective
Sanders et al (21), 2004 Vallier et al (24), 2004 Kenwright et al (14), 1970 Dunn et al (7), 1966 Pennal (18), 1966 Peterson et al (20), 1977 Lorentzen et al (16), 1977
Male Gender
Average Age (y)
Outcome
Average Interval to Surgery
AVN
Nonunion
Malunion
Follow-up (y)
70
26.4
Hawkins criteria
NR
30
d
d
14.9
10 18 6 64
31.4 45 37 NR
NR Subjective Hawkins criteria Subjective
8h Most within 12 h <24 h NR
NR 4 4 NR
d d 2 mo d
d 3 d d
7.4 6 6.5 4.2
25
Hawkins criteria
12
0
31
28
Hawkins criteria
4
d
d
9.8
Hawkins Hawkins
30 39
30 32
13 7
5 d
d d
6.2 2.5
10 (1)
Hawkins, Marti-Weber
67
33
Hawkins criteria AOFAS, Maryland score, Hawkins Hawkins, Mazur
<12 h for 18, 1–7 d for 9, 17 d for 1 <8 h for 28, 10 d for 8, >10 d for 5 NR NR
17
3
1
6
71 23 54 18 (26)
17 (4) NR 12 7 (2)
Hawkins Hawkins Hawkins Hawkins
NR 10 38 10
30 28 30.4 37.3
Hawkins criteria Subjective Hawkins criteria AOFAS
Retrospective Retrospective Retrospective
70 102 21
10 24 21 (1)
Hawkins Hawkins Coltart
57 60 49
34 32.6 35
Retrospective Retrospective Retrospective
23 41 (98) 46
3 (1) NR NR
Head, neck, body Coltart Hawkins
NR NR 34
Retrospective
123
13
Hawkins
107
NR
0
7
33 4 30 13
d d d d
18 2 d d
12.7 1.8 3.8 6.2
SMFA, AOFAS, AOS FFI, MFA Subjective
18 within 6 h; median 0 d if direct admission, 6 d if treated NR NR NR Average 85 h, 12 patients <6 h (NS) NR 3.7 d (NS) NR
8 19 8
d 2
21 d
5.2 2.5 4
46 38 NR
Subjective Subjective Hawkins
NR NR NR
16 28 6
3 d 0
5 d 13
6.4 NR 6
39
Subjective
NR
26
5
18
1.8
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; AOS, ankle osteoarthritis scale; AVN, avascular necrosis; FFI, Foot Function Index; MFA, Musculoskeletal Function Assessment; NR, not reported; NS, no statistically significant difference; SMFA, Short Musculoskeletal Function Assessment.
J.J. Halvorson et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–6
Study
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Results
Table 3 Overall reported rate of avascular necrosis after talar neck fracture
All selected studies were retrospective. A total of 943 talar neck fractures were reported among the 21 articles. Demographic data from the patient population is listed in Table 1. The treatment type was highly variable and included nonoperative management (with or without closed reduction), open reduction, internal fixation using a variety of methods, closed reduction with percutaneous pinning, external fixation, and primary salvage procedures (Table 2). Given the wide range of treatment modalities, methods, and approaches, comparisons were not possible among the different treatment modalities and outcome measures. Of the 21 studies, 14 (208 total cases) reported their experience with open talar neck fractures (4,7,9,10,12–17,21–24) (Table 1). Of these 14 studies, 6 reported the rate of deep infection for open fractures (4,7,14,15,17,22). Also, 16 studies reported that deep infections in the collective group of 76 fractures were observed, for an overall infection rate of 21%. Treatment of these infections varied greatly among the studies and included: removal of hardware, salvage procedures such as talectomy and/or fusion, and amputation. A total of 19 studies (4–16,18–22,24) reported the overall rate of AVN within their series (Table 1). AVN occurred in 282 of these 848 fractures, for an overall incidence of 33.3% (Table 3). Sixteen studies used the Hawkins classification system when analyzing the AVN rates (Table 1). Of the 735 talar neck fractures classified according to the Hawkins classification system, AVN was identified in 174 cases, for an overall rate of 23.6% in those particular studies. Additional analysis revealed that AVN occurred in 5.7% of Hawkins type I fractures, 18.4% of Hawkins type II fractures, 44.7% of Hawkins type III fractures, and 12.1% of Hawkins type IV fractures (Table 3). An increased risk of AVN was also identified by Vallier et al (24), who found a statistically significant difference in the AVN rates in open fractures versus closed fractures (p ¼ .05). In contrast, Lindvall et al (15) demonstrated a similar trend, although they were unable to demonstrate statistical significance (p ¼ .073; data not shown). Eight studies reported the interval to operative intervention within their series (6,9–11,15,17,22,24) (Table 1). The interval to surgery varied widely across these studies, and all studies retrospectively reviewed this factor. However, when examined, no statistically
Variable
Total Patients (n)
AVN (n)
AVN Rate (%)
Total of studies reporting AVN Total in studies using Hawkins classification Hawkins type I Hawkins type II Hawkins type III Hawkins type IV Other
848 735
282 174
33.30% 23.60%
159 314 228 33 1
9 58 102 4 1
5.70% 18.40% 44.70% 12.10% 100%
Table 2 Overview of fixation methods and management in 21 studies Study
ORIF External Other Nonoperative (n) Fixation (n) Primary Management/ Procedure (n) Closed Reduction (n)
Inokuchi et al (13), 1996 Marsh et al (17), 1995 Frawley et al (9), 1995 Freund (10), 1988 Szyszkowitz et al (23), 1985 Comfort et al (6), 1985 Grob et al (11), 1985 Penny et al (11), 1980 Elgafy et al (8), 2000 Schulze et al (22), 2002 Canale et al (4), 1978 Chateau et al (5), 2002 Hawkins (12), 1970 Lindvall et al (15), 2004 Sanders et al (21), 2004 Vallier et al (24), 2004 Kenwright et al (14), 1970 Dunn et al (7), 1966 Pennal (18), 1966 Peterson et al (20), 1977 Lorentzen et al (16), 1977
d 6 12 4 0 d 0 d 5 d 3 d 18 d d d 2 15 3 31 0
38 11 16 d 56 d 37 d 42 70 26 23 34 26 70 102 13 8 NR 15 15
48 d d d d d d d 1 1 d d d d d d d d d d d
Abbreviations: NR, not reported; ORIF, open reduction internal fixation.
d 1 d d d d 4 d 5 9 5 d 5 d d d d d 4 d 2
Abbreviation: AVN, avascular necrosis.
significant differences were reported for the association between the interval to fracture fixation and the incidence of AVN (15,24). The reporting of malunion and nonunion is listed in Table 4. A total 8 studies (6,7,10,16,19,20,22,24) reported on the rate of nonunion in 423 fractures. In total, 21 nonunions were identified, for a rate of 5%. Likewise, 9 studies (4–7,9,16,20–22) reported their incidence of malunion for a total of 466 fractures. Of the 466 fractures, 81 were reported as malunions, for an incidence of 17%. The overall rate of post-traumatic arthrosis was 67.8% in the studies that specifically evaluated this parameter. In this group of 635 patients, the involved joints included the tibiotalar joint, subtalar joint, talonavicular joint, and combinations of these joints. Overall, the subtalar joint was the most commonly involved joint. These data are presented in Table 5. Only Elgafy et al (8) examined the rates of arthritis as they related to the severity of the injury using the Hawkins classification. Therefore, we were unable to determine the effects of the fracture severity on the incidence of post-traumatic arthrosis outside of the study by Elgafy et al (8). The incidence of secondary salvage procedures (any operation performed after failure of the initial treatment or in response to the development of arthrosis) was reported in 18 studies (4,6–15, 17–19,21–24) (Table 6). Only 2 studies (19,21) determined the rate of secondary salvage procedures using a given classification system or fracture type. Therefore, no attempt was made to compile data on the rates of secondary salvage procedures for specific classification systems or grade, given these low numbers. The overall incidence of secondary procedures was 18.6%, with subtalar arthrodeses performed most commonly (34.6%), followed by ankle arthrodeses and triple arthrodeses (20.3% and 16.5%, respectively). The measurement of functional outcomes in patients varied greatly among the studies, making comparisons difficult. Ten studies used the Hawkins clinical evaluation for functional outcome (4,6,8,10–13,19–22). A total of 429 patients were evaluated using the Hawkins criteria, with results reported in Table 7. The Hawkins clinical evaluation is a 4-category system in which points are assigned for pain, limp, ankle motion, and subtalar motion and then summed, with higher scores indicating better results. An excellent result is defined as a score of 13 to 15, a good result as a score of 10 to 12, a fair result as a score of 7 to 9, and a poor result as a score of 0 to 6. Table 8 lists the 5 studies (6,12,13,19,20) in which the Hawkins clinical criteria was used in combination with the Hawkins classification system. Given the inconsistent use of the other outcome measures (patient report, investigators’ physical examination findings, American Orthopaedic Foot and Ankle Society [AOFAS] scoring system, ankle osteoarthritis Table 4 Overall reported rate of nonunion and malunion after talar neck fracture
Total fractures (n) Total nonunion or malunion (n) Percentage
Nonunion
Malunion
423 20 5%
466 81 17.80%
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Table 5 Overall reported rate of post-traumatic arthrosis after talar neck fracture
Table 7 Functional outcomes using Hawkins clinical criteria
Post-traumatic Arthrosis
Patients (n)
Outcomes Using Hawkins Criteria
Patients (n ¼ 429)
Total Tibiotalar Subtalar Talonavicular Ankle plus subtalar Ankle, subtalar, talonavicular Unspecified location
635 115 265 2 44 1 4
Excellent Good Fair Poor
87 152 96 94
scale, Maryland Foot Score, and others), comparisons among some studies were not possible. Discussion Talus fractures have confounded physicians for centuries. Reports as early as 1820 (18) have demonstrated poor outcomes and a high mortality rate after this injury and its subsequent management, leading some early surgeons to recommend amputation as the primary treatment (26). As anesthesia has evolved as a distinct specialty and modern orthopedic techniques have been developed, numerous case series and reports of talus fractures have been published, with wide variations in treatment strategies and patient outcomes (4–24). Despite modern advances, talar neck fractures continue to represent problematic injuries that are associated with numerous complications and less than satisfactory results after treatment. The current published studies impart valuable information but lack the meta-analyses and systematic reviews necessary to guide clinical practice. Thus, the treatment of talar neck fractures has relied on longstanding paradigms and traditions. The present systematic review was undertaken in an attempt to further define the complication rates, prognoses as they relate to injury severity, effects of surgical delay, functional outcomes after treatment, and incidence of secondary operative procedures. Fractures of the talar body, talar head, and the various processes of the talus carry their own distinct set of complications, treatment considerations, and outcomes and, thus, were excluded from the present review. Among the most notable of the complications associated with talar neck fractures is avascular necrosis of the talar body, which is thought to be related to the talus’ tenuous blood supply (3,27,28). Reports of AVN rates have varied widely, with a range of 0% to 13% for Hawkins type I fractures, 20% to 50% for Hawkins type II fractures, and 80% to 100% for Hawkins type III and IV fractures (2). In the present analysis, the overall rate of AVN across all studies was 36.8%. When evaluating the studies that specifically used the Hawkins classification system, AVN was noted in 23.6% of patients. The type III fractures had the greatest rate of AVN at 44%, with type IV fractures surprisingly having a rate of only 12%. We acknowledge that this rate might have been artifactually low and believe that it might be related to the relative
Table 6 Overall reported incidence of secondary procedure after talar neck fracture Secondary Procedures
n
Total Ankle fusion Subtalar fusion Tibiocalcaneal fusion Talectomy Triple arthrodesis Amputation Talonavicular Total ankle Fusion
715 27 46 15 9 22 4 1 2 7
rarity of the Hawkins type IV injury, which accounted for only 4.5% of all “Hawkins classified” talus fractures in our review. Furthermore, the designation of Hawkins type IV did not exist before 1977. Therefore, many of the Hawkins type IV fractures would have been classified as type III injuries and treated with older techniques. Overall, the rates of AVN we obtained during our review were lower than many of the previously published rates and might represent a more accurate assessment of the true rates of AVN, because more patients were included. Historically, urgent or emergent open reduction and internal fixation of talar neck fractures has been recommended in an effort to restore or protect the blood supply of the talar body and thus reduce the incidence of AVN. However, few reports have specifically focused on operative delays and their association with the development of AVN. In our review, we were unable to identify any studies whose results would support urgent or emergent intervention. Recent data seem to indicate that an operative delay is not associated with an increased risk of AVN (15,24), but that this process is most likely a result of the severity of the initial injury and disruption of the blood supply and that anatomic reduction and internal fixation does not adequately restore the disrupted blood supply. This change in thinking has been highlighted in a recent survey of orthopedic traumatologists conducted by Patel et al (29). In their survey, 60% of orthopedic traumatologists thought that care after 8 hours was appropriate for a displaced talar neck fracture, with roughly one half (46%) indicating that they believed a delay of more than 24 hours was acceptable. The malunion and nonunion rates were difficult to quantify in the available studies. Not all studies reported on their incidence of malunion and nonunion. In addition, defining the investigators’ criteria for both nonunion and malunion were not equivalent among the studies, and few went so far as to report their numbers on basis of open versus closed treatment or the rate in conjunction with open fracture, and so forth. However, from the available data, malunion can be expected to occur in approximately 20% of cases and nonunion in approximately 5% of cases. Although these raw percentages are of value, correlation with type of operative procedure, rates of arthrosis and/or secondary procedures, and functional outcomes is scarce. The advent of newer advances in operative technique such as dual incision and referral of these injuries to “foot and ankle” or “trauma-trained” specialists might decrease the percentage of “open internal fixation” in more recent years. Additional studies are required before definitive conclusions regarding how the rates of malunion and nonunion affect the history and clinical outcomes of talar neck fractures.
Table 8 Relationship between Hawkins clinical criteria and Hawkins classification Outcomes Using Hawkins Criteria
Fracture Type by Hawkins Classification Type I
Type II
Type III
Type IV
Total
Excellent Good Fair Poor Total
35 33 6 5 79
11 17 13 14 55
6 25 30 19 80
2 1 0 3 6
54 76 49 41 220
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The relative rates of post-traumatic arthrosis were difficult to accurately quantify from the information provided in the 21 selected studies. Of the 635 patients for whom follow-up data were available, 67.8% of patients were reported to have some level of arthrosis. However, some studies made no mention of the incidence of arthrosis (7,13,17–19), and others simply combined “arthritis” into 1 category without specifically indicating the site involved. Furthermore, the diagnostic criteria for post-traumatic arthrosis varied among the studies, with some choosing to define the condition clinically and others using radiographic parameters. In those studies that reported the rates of arthrosis, subtalar arthrosis was most commonly diagnosed, occurring in 38% of patients and accounting for 62% of the arthritis reported overall. Few studies considered the rates of specific arthritis as it related to the severity of the injury (19,21) or classification system. No meaningful numbers were able to be extrapolated from the current data regarding the rates of post-traumatic arthrosis after talar neck fracture. Therefore, no comment can be made regarding the incidence of secondary arthritis as it relates to the severity of the injury. Secondary salvage procedures are common after talus fractures and typically involve peritalar arthrodesis. Sanders et al (21) reported in their analysis that the calculated percentage of patients requiring secondary surgery at 1, 2, 5, and 10 years was 24%, 32%, 38%, and 48%, respectively. Our analysis has demonstrated a lower incidence of secondary procedures, with an overall rate of 18% at an average follow-up of 6 years. Of the 133 secondary procedures reported, subtalar fusion predominated, occurring 35% of the time, followed by ankle fusion and triple arthrodesis at 20% and 17%, respectively. Sanders et al (21) demonstrated that secondary reconstructive procedures are most likely needed in comminuted fractures and Hawkins type III or IV fractures. In their series, only 7 of 26 patients requiring secondary surgery were classified as having Hawkins type II fractures (21). No Hawkins type I fracture required a secondary reconstructive surgery. On the basis of our review, which found an overall rate of arthrosis of 67.8% and a rate of secondary salvage procedures of 18%, it appears that many of the patients who were diagnosed with arthrosis were either minimally symptomatic or asymptomatic. As stated, no study delineated between symptomatic and asymptomatic post-traumatic arthritis. Therefore, the clinical significance of a 67.8% rate of post-traumatic arthrosis in the setting of an 18% rate of secondary surgery is questionable. It would thus seem that most patients will develop some form of arthritis after talar neck fracture, but that most of those patients will either be asymptomatic or will choose not to undergo secondary salvage procedures. No functional outcomes measure was universally used across all studies. The Hawkins clinical evaluation score was the most common outcomes measure used in our group of selected studies and was used in 10 of the 21 studies examined. Of the 429 fractures for which the Hawkins clinical evaluation score was used, only 20% of the outcomes were rated as excellent, with 22% of patients having a poor outcome and more than one half having either a fair or poor outcome. In the studies that used both the Hawkins classification system and the Hawkins clinical evaluation (220 total fractures), only 44% of patients with a type I fracture had an excellent result compared with an 8% excellent result for patients sustaining a type III injury. However, only 6 type IV fractures were reported in this group, with 3 (50%) having excellent or good results and 43 (50%) poor results. Thus, in our review, an increasing severity of injury, as established by the Hawkins classification system, correlated with a worse functional outcome, as indicated by the patient’s score on the Hawkins clinical evaluation. The remaining outcomes assessments used throughout the studies made evaluation difficult, because few consistent outcome measures existed across all examinations. More recent studies (8,15,21) have attempted to use validated outcomes questionnaires for functional
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assessment. Sanders et al (21) reported that roughly one half of their patients without a salvage procedure during follow-up reported a visual analog scale pain score of 4.2 of 10. In addition, the AOFAS hindfoot score ranged from 52 for those patients with malalignment or secondary arthritis to 92 for those patients with anatomic reduction and no signs of secondary arthritis. Elgafy et al (8) reported the average AOFAS score in their cohort of patients was 79 (range 37 to 99). Finally, Lindvall et al (15) reported an AOFAS score of 46.7 points when a neck fracture resulted in AVN versus a score of 76 points for those without AVN. The AOFAS score of those patients with radiographically documented subtalar arthritis and subtalar plus ankle arthritis was 63.2 and 60.4, respectively. As with the Hawkins clinical evaluation, comorbid conditions developing after talar neck fracture (i.e., AVN, arthritis) resulted in decreased validated outcomes scores. Therefore, increased severity of injury, arthritis, and AVN increases the likelihood of a worse outcome after talar neck fracture. Inherent weaknesses were present with the present systemic review. First, all studies reviewed were retrospective. As such, the bias associated with retrospective studies was also associated with our review. Future studies, although difficult in this population, should focus on prospective examinations for variables such as the incidence of AVN and timing of surgery as it relates to AVN. In addition, the nonstandardized clinical follow-up and assessment made comparisons difficult among the studies across all the variables examined. This also dramatically decreased the numbers available for comparison in some instances, limiting the true power of the more than 900 reported talar neck fractures. Not only were no standardized outcomes available, also no standardized treatment methods were used among the studies. This was the primary reason the historical study by Coltart (25) was not included in the present analysis. The treatment methods, classification system, outcomes, and technology varied so greatly from those currently in use that we believe that including these patients in the present analysis would have confused the final data collection and results. The remaining included studies reviewed spanned more than 4 decades, and an evolution in treatment philosophy and strategy was seen as the reports were published. Early, investigators advocated conservative treatment with either immobilization or closed reduction followed by immobilization. This resulted in described techniques of casting in equinus for weeks at a time (14,18). When surgery was performed, a wide variety of methods was chosen for open reduction and internal fixation. With more recent advances in operative techniques and instrumentation, these options have increased to the use of biodegradable screws, plates, standard screws, Kirschner wires, or, even, external fixation (13,30,31). Open reduction and internal fixation has decreased the overall reported incidence of AVN (2) in more recent examinations compared with historical controls. Therefore, in including all reports both before and after the move to open reduction and internal fixation for talus fractures, we might have biased the evidence because comparisons in treatment methods and philosophies will obviously influence the overall rates of AVN, functional outcomes, secondary procedures, and so forth. We also did not include any study examining the use of a primary salvage procedure for talar neck fractures. Therefore, another cohort of patients exists, who undergo primary reconstructive/salvage surgery, that we could not comment on or compare with our cohort. Functional outcomes are also difficult to compare because the more recent studies focused on validated outcomes questionnaires and older studies did not have this method available. However, few of the newer studies used the same validated outcomes questionnaires; therefore, despite the high-quality reporting of outcomes, comparisons between series were difficult. In conclusion, talar neck fractures continue to represent injuries that demand respect from orthopedic surgeons. One third of these patients will develop AVN and two thirds will develop arthritis,
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resulting in a 20% salvage procedure rate. Functionally, as defined by the classic Hawkins clinical criteria, almost one fourth of patients will end up with a poor outcome, with almost one half of patients having a fair or poor outcome. Although modern orthopedic techniques have continued to evolve and have dramatically decreased the overall rates of AVN and, potentially, poor functional results, continued work is required to help improve patient care and outcomes.
References 1. Ahmad J, Raikin SM. Current concepts review: talar fractures. Foot Ankle Int 27:475–482, 2006. 2. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 9:114–127, 2001. 3. Haliburton RA, Sullivan CR, Kelly PJ, Peterson LFA. The extra-osseous and intraosseous blood supply of the talus. J Bone Joint Surg Am 40-A:1115–1120, 1958. 4. Canale ST, Kelly FB. Fractures of the neck of the talus: long-term evaluation of seventy-one cases. J Bone Joint Surg Am 60:143–156, 1978. 5. 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. 6. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop Relat Res 199:81–87, 1985. 7. Dunn AR, Jacobs B, Campbell RD. Fractures of the talus. J Trauma 6:443–468, 1966. 8. 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. 9. Frawley PA, Hart JA, Young DA. Treatment outcome of major fractures of the talus. Foot Ankle Int 16:339–345, 1995. 10. Freund KG. Complicated fractures of the neck of the talus. Foot Ankle 8:203–207,1988. 11. Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Clin Orthop Relat Res 199:88–96, 1985. 12. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 52:991–1002,1970. 13. Inokuchi S, Ogawa K, Usami N, Hashimoto T. Long-term follow up of talus fractures. Orthopedics 19:477–481, 1996. 14. Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br 52:36–48, 1970.
15. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 86-A:2229–2234, 2004. 16. Lorentzen JE, Christensen SB, Krogsoe O, Sneppen O. Fractures of the neck of the talus. Acta Orthop Scand 48:115–120, 1977. 17. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the talus. J Orthop Trauma 9:371–376, 1995. 18. Pennal GF. Fractures of the talus. Clin Orthop Relat Res 30:53–63, 1963. 19. Penny JN, Davis LA. Fractures and fracture-dislocations of the neck of the talus. J Trauma 20:1029–1037, 1980. 20. Peterson L, Goldie IF, Irstam L. Fracture of the neck of the talus: a clinical study. Acta Orthop Scand 48:696–706, 1977. 21. 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. 22. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G. Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1–15 years. Acta Orthop Scand 73:344–351, 2002. 23. Szyszkowitz R, Reschauer R, Seggl W. Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop Relat Res 199:97–107, 1985. 24. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am 86-A:1616–1624, 2004. 25. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 34-B:545–566, 1952. 26. Syme J. Contributions to the Pathology and Practice of Surgery, ed 1, Sutherland and Knox, Edinburgh, 1848. p 126. 27. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br 52: 160–167, 1970. 28. Wildenauer E. [Proceedings: discussion on the blood supply of the talus]. Z Orthop Ihre Grenzgeb 113:730, 1975. 29. Patel R, Van Bergeyk A, Pinney S. Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts. Foot Ankle Int 26:378–381, 2005. 30. Attiah M, Sanders DW, Valdivia G, Cooper I, Ferreira L, MacLeod MD, Johnson JA. Comminuted talar neck fractures: a mechanical comparison of fixation techniques. J Orthop Trauma 21:47–51, 2007. 31. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int 27:340–343, 2006.