Fractures of the talar body are uncommon injuries, which frequently have a
poor prognosis. Accurate articular reduction will restore congruity of the
tibiotalar and subtalar joints. Rigid internal fixation may provide stability
to promote early mobility of these joints. Surgical treatment, with these
goals in mind, may optimize foot and ankle function.
The initial management consists of urgent treatment of open injuries and
dislocations. Open wounds are irrigated, and sterile dressings are applied.
Intravenous antibiotics and tetanus prophylaxis are administered. Reduction
maneuvers are performed to improve fracture alignment whenever possible, and
provisional splints are applied.
Preoperative plain radiographs, including anteroposterior, oblique, and
lateral views of the foot and anteroposterior, mortise, and lateral views of
the ankle, are made. Computerized tomography scans are done for severely
comminuted fractures, to assist in preoperative planning. Axial images through
the tibiotalar and subtalar joints are obtained, and computer reconstructions
in the sagittal and coronal planes are generated (Figs.
1-A, 1-B, and
1-C).
Irrigation and débridement of open fractures and open reduction of
irreducible dislocations are undertaken on an urgent basis. Definitive
reduction and fixation of these injuries may be performed during the same
anesthesia session. Occasionally, the safe completion of surgical care is
precluded by associated life-threatening injuries, severe soft-tissue
swelling, or the need for additional radiographic information. In such
situations temporary Kirschner wire fixation, spanning external fixation,
and/or splinting may be performed. In these cases, and in the treatment of
high-energy closed fractures, surgical delay is recommended to allow
soft-tissue swelling to decrease. Delays of several days to as long as three
weeks may be necessary before definitive surgical treatment is attempted.
INDICATIONS:
All talar body fractures with >1 mm of articular displacement.
All talar body fractures with >1 mm of articular displacement.
CONTRAINDICATIONS:
Severe soft-tissue swelling or fracture blisters.Extensive open fracture wounds that limit access to the fracture
(Fig. 10).Severely contaminated open fracture wounds.
Severe soft-tissue swelling or fracture blisters.
Extensive open fracture wounds that limit access to the fracture
(Fig. 10).
Severely contaminated open fracture wounds.
PITFALLS:
Dissection should strictly follow the described anatomic landmarks. The
dorsalis pedis artery supplies the soft tissue between the two anterior
surgical incisions. We have not observed any compromise of the integrity of
this soft-tissue bridge or the overlying skin; however, we recommend sharp
dissection with maintenance of full-thickness flaps.Care must be taken to avoid any unnecessary surgical dissection that may
compromise the remaining talar blood supply.The integrity of the deltoid ligament should be respected, and inferior
dissection anterior to the deltoid ligament should be avoided.While an adjunctive medial malleolar osteotomy may improve visualization of
the articular surface of the talar body, nonunion of the medial malleolus is
possible. Use of a thin saw, predrilling, and accurate reduction in
compression should help to prevent this complication. An osteotome should be
used to complete the osteotomy, ensuring that the morphology of the medial
articular shoulder of the distal part of the tibia is maintained.Prominent screw heads on the articular surface can cause irritation of the
joint. Care should be taken to countersink these screws.
Dissection should strictly follow the described anatomic landmarks. The
dorsalis pedis artery supplies the soft tissue between the two anterior
surgical incisions. We have not observed any compromise of the integrity of
this soft-tissue bridge or the overlying skin; however, we recommend sharp
dissection with maintenance of full-thickness flaps.
Care must be taken to avoid any unnecessary surgical dissection that may
compromise the remaining talar blood supply.
The integrity of the deltoid ligament should be respected, and inferior
dissection anterior to the deltoid ligament should be avoided.
While an adjunctive medial malleolar osteotomy may improve visualization of
the articular surface of the talar body, nonunion of the medial malleolus is
possible. Use of a thin saw, predrilling, and accurate reduction in
compression should help to prevent this complication. An osteotome should be
used to complete the osteotomy, ensuring that the morphology of the medial
articular shoulder of the distal part of the tibia is maintained.
Prominent screw heads on the articular surface can cause irritation of the
joint. Care should be taken to countersink these screws.
AUTHOR UPDATE:
The surgical techniques have not been altered since the original article
was published.
Isolated, simple, sagittal fractures of the talar body may be approached
through a single medial or lateral incision, depending on the fracture
location. A large portion of the talar dome can be exposed with plantar
flexion of the foot. Talar body fractures with coronal displacement,
comminution, or an associated talar neck fracture are most accurately
addressed through dual anteromedial and anterolateral surgical approaches
(Figs. 2-A, 2-B,
2-C, 2-D, 2-E,
2-F, and
2-G)1-3.
Adjuvant osteotomies of the medial
malleolus3,4
or of the distal part of the fibula may be necessary to enhance the
exposure.
The patient is positioned supine on a radiolucent operating table. The
incision for the anteromedial surgical approach extends from the anterior
aspect of the medial malleolus to the navicular and is centered approximately
between the tibialis anterior and tibialis posterior tendons
(Figs. 2-B and 2-C). The intact
fibers of the deltoid ligament are protected, and plantar dissection is
avoided to protect any remaining talar blood supply from the branches of the
posterior tibial artery. The talonavicular joint capsule is sharply incised,
and the dorsomedial aspect of the talar neck is exposed. The medial aspect of
the anterior surface of the talar body can now be viewed. Frequently, a medial
malleolar osteotomy is required to gain access to the middle and posterior
portions of the medial part of the talar body for accurate reduction and
fixation. This osteotomy is inclined obliquely and is performed after
predrilling two parallel holes with a 2.5-mm drill bit. The osteotomy is
initiated with a microsagittal saw and is completed with a thin osteotome, to
fracture the subchondral bone and cartilage. The cut surfaces are irrigated
while the saw is used, in order to prevent thermal necrosis of the bone. The
adjacent posterior neurovascular structures and the tibialis posterior tendon
are protected. The medial malleolus is then retracted distally, allowing
visualization of the medial portion of the talar body
(Figs. 3-A through 3-D).
The incision for the anterolateral approach is centered at the ankle joint,
is parallel to the fourth metatarsal distally, and is parallel to and between
the tibia and fibula proximally (Fig.
2-A). Because of the need to retract the anterior compartment
tendons, the incision is extended proximal to the ankle joint. The incision
terminates slightly distal to the predicted location of the talonavicular
joint. Dissection through the skin and the subcutaneous tissues should proceed
sharply, and full-thickness skin flaps should be maintained. The superficial
peroneal nerve may cross the surgical field proximally. It should be
identified, mobilized, and protected throughout the procedure. The fascia over
the anterior compartment of the distal part of the tibia is incised sharply,
and the extensor retinaculum is incised. The entire anterior compartment,
including the peroneus tertius, can then be mobilized and retracted medially.
The fat in the sinus tarsi is excised, and the extensor digitorum brevis is
elevated and retracted inferiorly. The lateral aspect of the talar neck and
the lateral process of the talus are exposed, and the lateral aspects of the
talar body and dome can now be visualized
(Figs. 4-A and 4-B). The talar
head is exposed after the lateral talonavicular joint capsule is incised.
Occasionally, an osteotomy of the distal part of the fibula is required to
gain access to the lateral and posterior portions of the lateral aspect of the
talar body for accurate reduction and fixation.
Isolated fractures of the posteromedial aspect of the talar body are best
approached through a posteromedial incision
(Figs. 5-A and 5-B). The
patient is positioned either prone or supine. When the patient is in the
supine position, a bump is placed beneath the contralateral hip, promoting
external rotation of the affected lower extremity. The incision is curvilinear
and is centered halfway between the posterior aspect of the medial malleolus
and the medial edge of the Achilles tendon, approximately 3 cm proximal to the
distal aspect of the medial malleolus. It can be extended distally and
anteriorly, along the course of the toe flexors. The deep fascia and
retinaculum are incised. The deep dissection can be through the interval
between the flexor digitorum longus and the tibial neurovascular bundle, or
posterior to the flexor hallucis longus. The location for the deep dissection
is dictated by the pattern of the articular fracture. The tibiotalar joint
capsule is incised longitudinally, and the fracture is exposed.
Intraoperative exposure and indirect fracture reduction may be facilitated
by the use of a small femoral distractor, which is employed to tension the
soft tissues and open the ankle joint
(Figs. 6-A and 6-B). Schanz
pins are placed at sites remote from the injury, frequently in the distal part
of the tibial shaft, the calcaneus, and/or the navicular. Headlamp
illumination is helpful for visualization. The fractures are reduced, and
provisional Kirschner wires are placed. The alignment is assessed with
intraoperative fluoroscopy. The tibiotalar joint is best seen with the lateral
and mortise ankle views, and the subtalar joint is best seen with the lateral
and 45° mortise views. The axial alignment of the talar neck can be
further assessed with the talar neck view described by Canale and
Kelly5 (Figs.
7-A and
7-B).
Definitive internal fixation is performed with small-fragment and
mini-fragment implants. Small articular fracture fragments are best stabilized
with 2.4, 2.0, and 1.5-mm screws (Figs.
8-A and 8-B). These cruciform screw heads are flat, allowing
placement beneath the cartilage surface after counter-sinking. In fractures
isolated to the talar body, the lateral process of the talus is usually intact
and in continuity with the distal fragment, which includes the head and neck
of the talus. This permits placement of screws in an extra-articular location
from the firm cortical bone of the lateral aspect of the talar neck into the
posterior part of the talar body (Figs.
9-A, 9-B, 9-C, and
9-D). Sagittal plane articular fractures of the talar body
typically require fixation from medial to lateral with lag screws. After a
medial malleolar osteotomy is performed, these implants are inserted through
the medial aspect of the talar body. Small osteochondral fragments are best
fixed with individual screws (2.0 or 1.5 mm), which anchor into stable
portions of the talus. It has been our preference to use metal implants.
Biodegradable implants may be a reasonable option for the fixation of small
osteochondral fragments, but we do not have experience with them.
Small-fragment screws and/or mini-fragment plates and screws are used to
rigidly stabilize an associated talar neck
fracture1.
Bone-grafting is recommended for closed fractures with defects in the talar
neck. Morselized cancellous allograft chips and cancellous bone from the
ipsilateral calcaneal tuberosity are both effective.
The wounds are closed over small suction drains. A modified Donati-Allgower
suture technique is employed to dissipate tension on the skin
edges6. The ankle
and foot are splinted in neutral alignment until the wounds are sealed and the
soft-tissue swelling has decreased. Range-of-motion exercises of the ankle and
foot are then initiated. Spanning external fixation is used as an adjunct to
internal fixation in cases of severe fracture comminution or bone loss. The
external fixators are removed in the outpatient clinic after approximately six
weeks. No weight-bearing is permitted for twelve weeks postoperatively or
until fracture union.