Historically, fractures of the talar neck and/or body have not only been difficult to treat but have been associated with rates of osteonecrosis ranging from 12% to 53%1-12. Posttraumatic arthritis, although discussed less frequently in the literature, may be an even more common sequela3,7,10,11. Previously published series of talar fractures have typically combined all types, including nondisplaced fractures as well as those associated with an ipsilateral malleolar, calcaneal, navicular, or distal tibial fracture. Unfortunately, these associated injuries can obscure the true effect of the talar injury on the final clinical outcome. In addition, isolated talar neck fractures are unusual and are frequently associated with comminution that extends into the body. Similarly, crush injuries of the talar body are associated with talar neck fractures. We decided to combine our evaluations of these two fracture types on the basis of our experience that they had many treatment and outcome parameters in common, including multiple joint involvement, similar operative incisions, similar fixation techniques, and similar complications such as osteonecrosis, nonunion, and/or arthritis. Furthermore, the analysis of neck and/or body fractures allowed us to evaluate any differences between the two types of fracture. The purpose of this paper was to specifically evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. We were also interested in determining whether arthritis was a more common long-term complication than osteonecrosis after surgical reduction and internal stabilization of these fractures.
Materials and Methods
Inclusion criteria limited this study to isolated, displaced talar neck and/or talar body fractures. Isolated peripheral fractures of the talus such as lateral process, talar head, colliculi, and osteochondral fractures were excluded. A total of fifty-three isolated talar neck and/or talar body fractures in fifty-two patients were treated at our institution between January 1993 and May 1998. We excluded eight fractures because they were associated with an ipsilateral tibial, pilon, ankle, navicular, or calcaneal fracture; three fractures because the patient died prior to hospital discharge; six nondisplaced fractures because they were treated nonoperatively; two fractures because an immediate amputation had been done as a result of severe open injury; and one fracture because an immediate fusion had been performed as a result of substantial bone loss. A minimum follow-up period of forty-eight months was required to accurately evaluate the presence of osteonecrosis and/or arthritis.
Seven patients (seven fractures) were lost to follow-up, leaving twenty-six fractures in twenty-five patients that met the inclusion criteria (see Appendix). These consisted of eighteen talar neck fractures, classified according to the method of Hawkins as modified by Canale1 (eleven type 2, six type 3, and one type 4), and eight talar body fractures. Of the eighteen talar neck fractures, sixteen were isolated and two were combined with a body fracture. According to the Gustilo-Anderson classification13, there were seven open fractures (three type 2, two type 3A, one type 3B, and one type 3C) and nineteen closed fractures. There were ten male patients and fifteen female patients with an average age of 37.3 years (range, twenty-four to eighty-three years; median, thirty-eight years). Of the twenty-five patients, nine (nine fractures) smoked a minimum of one pack of cigarettes per day.
Eighteen fractures (eighteen patients) were initially seen in the emergency department at our institution. Four patients (four fractures) were transferred from outlying facilities, whereas three patients (four fractures) were referred to our office practice for elective treatment.
Closed fractures were treated surgically as soon as medical clearance was obtained, and open fractures were operated on within six hours after the injury (except for one fracture in a patient who was transferred to our institution late). The patient was positioned supine on a radiolucent table, and a tourniquet was applied; however, the tourniquet was inflated only if necessary to control bleeding. An anteromedial, anterolateral, combined anteromedial-anterolateral, or posteromedial (one fracture) surgical approach was used for exposure as needed. All open wounds (including those with vascular injuries) were débrided and irrigated according to a standard protocol14,15. Stable fixation was achieved through compression if the fracture pattern allowed it without shortening, translation, or angulation of the fracture fragments. If the talar neck was excessively comminuted or if there was substantial bone loss, position (non-lag) screws16 were placed to maintain length. No bone-grafting was employed in this series. A variety of fixation devices were used to maintain reduction, depending on the fracture pattern; the devices included 3.5-mm cortical screws, 4.0-mm cancellous screws, small Herbert screws (Zimmer, Warsaw, Indiana), and bioabsorbable screws and bio-absorbable pins (Bionx Implants, Blue Bell, Pennsylvania). Mini-plates were not used17.
Fracture reduction was rated on postoperative radiographs, including anteroposterior, lateral, mortise, and Canale views3. An anatomic reduction meant that there was no step-off at the neck or body and no angulation. A nearly anatomic reduction was defined as a 1 to 3-mm step-off of any fracture fragment or slight varus angulation (≤5°). A poor reduction was an articular or neck mismatch, a step-off or gap of >3 mm, or neck angulation of >5°.
Patients were kept non-weight-bearing by wearing an off-the-shelf fracture boot with early foot and ankle motion for ten to twelve weeks, until radiographs and clinical examination revealed evidence of union. Anteroposterior, lateral, and mortise radiographs were routinely made at two weeks, six weeks, ten to twelve weeks, and six months postoperatively. Additional radiography, computed tomography scans, and magnetic resonance imaging were performed as often as needed but were carried out at least annually, specifically to evaluate for the development of osteonecrosis and posttraumatic arthritis. The final follow-up for this study included anteroposterior, lateral, and mortise radiographs; a clinical evaluation; and determination of AOFAS (American Orthopaedic Foot and Ankle Society)18 hindfoot scores (see Appendix) at a minimum of forty-eight months after the injury. Posttraumatic arthritis was defined as a decreased joint space, juxta-articular osteophytes, subchondral sclerosis, and/or subchondral cysts seen either on plain radiographs or on computed tomography scans. Osteonecrosis was documented as present or absent as seen on standard radiographs. Partial or total collapse of the talar body was also noted.
Fractures were given a minimum of six months to unite. If there was no progression of healing, and no additional evidence of healing on standard radiographs for three consecutive months thereafter, the fracture was considered to be a nonunion. All data were obtained from the patient's private-office medical records chart or radiology jacket. These files contained not only a complete record of follow-up office visits and radiographs, but also a complete duplicate of all hospital admission data, both radiographic and with respect to records documentation. On accepting care by the physicians at our private facility, our patients are requested to sign the Authorization to Use Patient Medical Information for Medical Research Form, which allows use of their data for research purposes. All patients in this study signed this form. Charts were reviewed retrospectively at the time of follow-up. Because of the nature of chart review and the sequential evaluation of radiographs at that visit, the reviewers were not blinded to the clinical history or the radiographs of the individual patients.
Variables that were analyzed to determine their significance included wound type (open or closed), fracture type (neck or body), Hawkins/Canale type (1 through 4), comminution, timing of the surgical intervention (within six hours after the injury or not), surgical approach, quality of reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). The Fisher exact test, Wilcoxon two-sample test, and Kruskal-Wallis test were performed to compare these variables and to assess for significance. A p value of ≤0.05 was considered significant.
Closed Compared with Open Fracture
The average duration of follow-up was 73.6 months (range, forty-eight to 113 months). Twenty-three of the twenty-six fractures healed after the index procedure, for an overall union rate of 88%. All nineteen closed fractures united without an additional operation. The average time to union for these fractures was 3.1 months. Osteonecrosis developed after seven of the nineteen closed fractures, whereas posttraumatic arthritis developed after all nineteen. Osteonecrosis developed after six of the seven open fractures, and posttraumatic arthritis developed after all seven. Only four of the seven open fractures went on to uneventful union. Three fractures failed to heal, two of which were associated with osteomyelitis prior to the final procedure. Of these three fractures, two were treated with late arthrodesis and one required a subsequent talectomy to treat a septic nonunion. The patient with the septic non-union ultimately requested and received a below-the-knee amputation because of instability and pain. Of the four open fractures that went on to union, one required additional surgery (bone-grafting). The average time to union of these four open fractures was 3.9 months. The prevalence of osteonecrosis was much higher following the open fractures than it was following the closed fractures (86% compared with 37%); this difference approached significance (p = 0.073).
Neck Fracture Compared with Body Fracture
With the numbers available, there were no significant differences between the sixteen isolated neck fractures and the eight isolated body fractures with regard to union rate, AOFAS hind-foot scores, osteonecrosis rate, or prevalence of posttraumatic arthritis. The overall union rate for the neck fractures was the same as that for the body fractures (88%). Isolated neck fractures complicated by osteonecrosis were associated with a much lower average AOFAS hindfoot score (46.7 points) than were isolated neck fractures without osteonecrosis (76 points). The two groups differed significantly with regard to the total score (p = 0.009) and the subscores for function (p = 0.004) and alignment (p = 0.04). The average AOFAS score did not differ significantly between isolated body fractures with osteonecrosis (51.4 points) and those without osteonecrosis (60.3 points) (p = 0.2).
Timing of Surgery
Twelve of the twenty-six fractures received surgical treatment within six hours after the injury. Overall, the time to surgery averaged eighty-five hours with a range of two to 504 hours (median, 10.5 hours). With the numbers available, no significant difference was seen between the six closed fractures fixed within six hours after the injury and the thirteen closed fractures fixed more than six hours after the injury with respect to the AOFAS hindfoot score, nonunion rate, osteonecrosis rate, or prevalence of posttraumatic arthritis. Open fractures were operated on within six hours more frequently (six of seven) than were closed fractures (six of nineteen). This difference was significant (p = 0.03). When open and closed fractures were considered together, again no significant difference was seen between early and late fixation with regard to the average AOFAS hindfoot score, nonunion rate, osteonecrosis rate, or prevalence of posttraumatic arthritis.
Comparisons were also made between the surgical approaches used for internal fixation. Both anteromedial and anterolateral incisions were used to treat thirteen fractures, and osteonecrosis developed after the treatment of eight of them. Five of these fractures were open, and osteonecrosis developed after the treatment of all five. Only an anteromedial incision was used to treat seven fractures, and osteonecrosis developed after the treatment of four of them. One of these four fractures was open, and osteonecrosis developed after the treatment of that fracture. Five fractures were fixed through only an anterolateral incision; osteonecrosis developed after the treatment of one closed fracture. The numbers were too small to identify any significant differences between surgical approaches with regard to osteonecrosis rates or AOFAS hindfoot scores.
Surgical intervention resulted in anatomic reduction of sixteen fractures, nearly anatomic reduction of five, and poor reduction of five. All eight noncomminuted fractures were anatomically reduced. The ability to obtain an anatomic reduction was significantly associated with the amount of comminution (p = 0.003). With the numbers available, no association was seen between the quality of the reduction and the fracture type. The quality of the reduction did significantly affect the total AOFAS score (p = 0.05) as well as the function (p = 0.05) and alignment (p = 0.006) subscores.
Overall, the union rate was 88% (twenty-three of twenty-six). Closed fractures were more likely to unite than were open fractures (p = 0.01), and fractures with a better reduction had a somewhat greater likelihood of uniting (p = 0.05). Furthermore, there was a trend for the time until union to be associated with the quality of the reduction in the twenty-three fractures that went on to union (p = 0.07).
The union rate for the isolated talar neck fractures was 88% (fourteen of sixteen). Importantly, all thirteen closed displaced talar neck fractures healed after treatment with standard techniques, regardless of the time delay until surgical intervention, which was twenty-one days in one case. Closed fractures united earlier than did open fractures (p = 0.02). The better the reduction of the neck fracture, the higher the probability of union (p = 0.05). The AOFAS scores were not associated with union or the time to union.
Posttraumatic arthritis of the subtalar joint was the most common radiographic finding and was seen in all patients at the time of final follow-up. Isolated arthritis of the ankle did not develop in any patient. Posttraumatic arthritis of the subtalar joint alone developed in ten limbs, traumatic arthritis within both the subtalar and the ankle joint developed in fifteen, and subtalar, ankle, and talonavicular joint arthritis developed in one. With the numbers available, there was no association between osteonecrosis and joint arthritis (p = 0.23). The average AOFAS hindfoot score was 63.2 points for the patients with involvement of the subtalar joint alone and 60.4 points for those with combined subtalar and ankle arthritis.
Osteonecrosis was the second most common radiographic finding, seen after thirteen of the twenty-six fractures (eight neck and five body fractures). There was also a trend for the rate of osteonecrosis to be higher after open fractures than after closed fractures (p = 0.073). Importantly, with the numbers available, osteonecrosis was not related to the quality of the reduction (p = 0.31), comminution (p = 0.2), operative approach (p = 0.34), type of fracture (neck or body) (p = 0.7), or time to surgery (p = 0.7). Arthritis of more than one joint developed in ten of the thirteen limbs with osteonecrosis. The average AOFAS hindfoot score was 49.5 points in the group in which osteonecrosis developed and 72.9 points in the group in which it did not. As expected, the average total AOFAS score was significantly better when osteonecrosis was absent (p = 0.009). Both the function and the alignment AOFAS subscores were also significantly worse when osteonecrosis was present (p = 0.0013 and p = 0.0151, respectively).
Of the sixteen limbs with a fracture involving the talar neck alone, seven had osteonecrosis postoperatively; four of the ten type-2 talar neck fractures, two of the five type-3 fractures, and the one type-4 fracture were associated with osteonecrosis. Importantly, with the numbers available, neither the time to surgery (p = 0.6) nor the operative approach (p = 0.53) was associated with the presence of osteonecrosis. With regard to the accuracy of the Hawkins sign for predicting the development of osteonecrosis after the treatment of the sixteen isolated talar neck fractures, the sensitivity was 67% (six of nine), the specificity was 86% (six of seven), and the accuracy was 75% (twelve of sixteen). Thus, the sign was a good predictor of the development of osteonecrosis (p = 0.06).
Pain was the most common subjective finding and was reported by all patients. According to the AOFAS scoring system, five patients (five fractures) had severe pain, ten patients (eleven fractures) had moderate pain, and ten patients (ten fractures) had mild pain. The AOFAS subscore for pain was not associated with any variable in this study.
With the numbers available, no significant difference in the union or osteonecrosis rate was seen between smokers and nonsmokers.
This study, which included only isolated displaced talar neck and talar body fractures, confirms previous reports of osteonecrosis and posttraumatic arthritis as common long-term sequelae. Importantly, in our series, arthritis surpassed osteonecrosis as the principal long-term finding associated with these fractures. Posttraumatic arthritis of the subtalar joint developed in every patient; arthritis of both the subtalar and the ankle joint, in fifteen; and arthritis of the subtalar, ankle, and talonavicular joints, in one.
In early reports, displaced and nondisplaced talar neck fractures were often treated nonoperatively or without internal fixation. Osteonecrosis was found to be the major complication, and it was seen more commonly than posttraumatic arthritis. Hawkins, in his initial study of fifty-seven talar neck fractures in 1970, reported an overall prevalence of osteonecrosis of 53% while only briefly noting posttraumatic arthritis in the form of “routinely marked decrease in motion.”8 When only the displaced fractures in Hawkins' series were considered, however, the osteonecrosis rate increased to 59%. Hawkins also noted that arthritis may be a result of osteonecrosis. In a 1978 study of the long-term results of seventy-one talar neck fractures, Canale and Kelly reported a 52% prevalence of osteonecrosis and stated that posttraumatic arthritis developed in fewer than one-half of the limbs1. However, the osteonecrosis rate associated with only the displaced fractures was 63%. More than one-half of the fractures in the above two studies were treated nonoperatively, including thirty of fifty-four Hawkins type-2 fractures and seven of fifty Hawkins type-3 fractures. (An additional four Hawkins type-3 fractures underwent an open reduction without any internal fixation.) It is difficult, if not impossible, to compare these results of closed treatment of displaced talar fractures with the results in current studies because the current treatment of Hawkins type-2, 3, and 4 fractures is open reduction and internal fixation.
In 1980, Penny and Davis reported an osteonecrosis rate of 48% in twenty-seven patients with a talar neck fracture but did specify subtalar joint symptoms as a reason for their poor rate of success10. Similar to the findings of Hawkins8 and Canale and Kelly1, the osteonecrosis rate in the study by Penny and Davis increased to 59% when only displaced fractures were considered. In 1985, Comfort et al. noted an overall 43% prevalence of osteonecrosis following treatment of displaced talar neck fractures with open reduction and internal fixation17. They also noted that subtalar motion decreased by an average of 50%, although only approximately one-third of patients demonstrated osteophytic changes on radiographs. The authors of the above two studies were, to our knowledge, the first to advocate anatomic reduction through open reduction and internal fixation in order to achieve the best results.
Investigators who have noted much lower osteonecrosis rates than typically reported in the literature have attributed them to early fixation. Grob et al. reported an osteonecrosis rate of 16% in a series in which twenty-eight of forty-one talar fractures were fixed surgically within eight hours after the injury4. When only displaced fractures of the neck and body were considered, the prevalence of osteonecrosis increased to 33%. Frawley et al. also reported an osteonecrosis rate of 16%, after operating on fourteen of twenty patients within twelve hours after the injury3. Seven of the twenty-eight fractures in that study were not displaced. Elgafy et al. presumed that the low prevalence of osteonecrosis (16.6%) in their study was due to early anatomical fixation, although the rate increased to 32% when only displaced neck and body fractures were considered7. As mentioned, Comfort et al. found an osteonecrosis rate of 43% and, although they noted that the degree of osteonecrosis was not related to a delay in fracture fixation, they still recommended early fixation17.
In our study of isolated displaced talar neck and body fractures, the prevalence of osteonecrosis was 50%. The rate of osteonecrosis was associated with the Hawkins classification, as was noted in other published reports1,3,7-9,19. The rate of osteonecrosis was not related to the timing of fixation but rather to the initial degree of fracture displacement and the presence of an open injury. It is probable that modern techniques of fixation offer enough stability and compression to allow revascularization to occur even after a delay in treatment. It appears that the severity of the injury itself, and not a delay in fracture fixation, may ultimately be responsible for higher rates of osteonecrosis. In addition, although our series confirms an overall high association between the Hawkins sign and the presence of osteonecrosis, the Hawkins sign appears not to be a foolproof evaluation tool as our series included both false-positive and false-negative findings.
More recent studies have demonstrated a higher prevalence of posttraumatic arthritis than had been previously reported after the treatment of talar fractures. In addition, posttraumatic arthritis has now been shown to be a more common finding than osteonecrosis. Szyszkowitz et al., in 1985, reported an increased prevalence of posttraumatic arthritis after the treatment of displaced talar fractures, with the arthritis involving the subtalar joint in 74% of their cases and the ankle joint in 52%20. Although Grob et al. reported a low prevalence of posttraumatic arthritis (37%), they found it to be much more common than osteonecrosis (16%) when they analyzed both displaced and nondisplaced fractures4. In 1995, Frawley et al. stated that “DJD is the most common and disabling complication and osteonecrosis is not as common a problem as the literature suggests.”3 Elgafy et al., in 2000, found a 53% prevalence of subtalar arthritis in patients with a talar fracture7.
The observations in these recent studies more closely parallel the findings in our study, in which posttraumatic arthritis was twice as common as osteonecrosis. However, many of the previous studies1,3,7-9,21,22 included minor talar fractures, nondisplaced fractures, and associated ipsilateral peritalar fractures (i.e., ankle, pilon, calcaneal, and navicular fractures), which may predispose to the development of posttraumatic arthritis in those joints, even in the absence of a talar fracture. The authors of these previous studies failed to make a distinction between minor and major fractures. In addition, minor talar fractures and nondisplaced talar fractures would likely be associated with lower rates of posttraumatic arthritis than would displaced neck and body fractures. Because only isolated, displaced neck and body fractures were included in our study, the prevalence of posttraumatic arthritis that we reported more accurately reflects the true occurrence of this sequela following a displaced talar neck or body fracture.
The frequency of posttraumatic arthritis has been purported to be higher after talar body fractures than after neck fractures6,7,23. Inokuchi et al. provided definitions of talar neck and body fractures based on the inferior, not the superior, fracture line6. Neck fractures, according to their definition, are extra-articular and between the posterior and middle facets of the subtalar joint, whereas body fractures are intra-articular and involve the posterior facet. With the numbers available in our study, we found no significant difference in the prevalence of posttraumatic arthritis between displaced neck and body fractures.
Recently, Vallier et al. reported on fifty-six surgically treated talar body fractures, including thirty-three involving only the talar body (with twenty-six associated foot and ankle injuries) and twenty-three involving the neck and body (with sixteen associated foot and ankle injuries)24. The authors concluded that the functional outcomes were worse when the talar body fracture was followed by the development of arthritis or osteonecrosis with collapse. Although the majority of patients in that study were lost to follow-up, it is clear that talar body fractures can be devastating injuries despite excellent fixation techniques and management; however, our data indicate that the outcomes of these fractures are no better or worse than those of isolated talar neck fractures.
Overall, the open fractures in our series fared much worse than did the closed fractures, with a much lower union rate, a higher osteonecrosis rate, and substantially higher reoperation and infection rates. Other series of talar fractures have also shown the results associated with open fractures to be inferior to those associated with closed fractures1,7,24-26.
We applied the widely used AOFAS scoring system as the standard method for reporting clinical status in our patients18. Authors of recent studies, however, have questioned the value of this system27. In a study of ninety-one patients with foot and ankle problems, SooHoo et al. found that, overall, the AOFAS clinical rating system correlated poorly with the Short Form-36 (SF-36) score27. They noted that the validity of the AOFAS system was limited by an overemphasis on a single question evaluating pain, while the physical examination parameters exhibited poor interobserver and intraobserver reliability. They concluded that the AOFAS instruments were invalid for evaluating health status, and they suggested that new foot and ankle outcomes instruments be developed. Because we used this system exclusively in our study, extrapolations made from our AOFAS scores must be limited. We believe that, in the future, the SF-36 should be used to obtain clinical outcome data for patients with foot and ankle problems, at least until a new scoring system can be developed and validated.
As with all clinical studies, ours had limitations. These include the retrospective nature of the review, the fact that the reviewers were not blinded to the patients' clinical or radiographic data, that the radiographic studies were not performed on a regularly prescribed basis and were not graded in a blinded fashion, and that a potentially flawed functional instrument (the AOFAS score) was used to analyze part of the outcome.
In conclusion, on the basis of an overall union rate of 88% and the fact that all nineteen closed fractures united without additional operations in our study, we believe that displaced talar neck and/or body fractures should be treated with open reduction and internal fixation. Although the time to surgical fixation should be minimized, a delay does not appear to adversely affect the outcome, specifically with regard to the development of osteonecrosis. In addition, posttraumatic arthritis, particularly affecting the subtalar joint, appears to be much more common than osteonecrosis. Osteonecrosis developed after 50% of the isolated, displaced talar neck and/or body fractures and probably is a result of the degree of displacement and/or the associated open injury. The Hawkins sign may not always be a reliable predictor of the development of osteonecrosis. Open fractures fared dramatically worse than did closed fractures with regard to nearly all aspects evaluated. On the basis of the results of this study, we believe that patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and with no evidence of osteonecrosis.
Tables showing patient demographics, fracture patterns, and AOFAS outcome scores are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Florida Orthopaedic Institute, Tampa, Florida
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