Background: Talar neck fractures occur infrequently and have been
associated with high complication rates. The purposes of the present study
were to evaluate the rates of early and late complications after operative
treatment of talar neck fractures, to ascertain the effect of surgical delay
on the development of osteonecrosis, and to determine the functional outcomes
after operative treatment of such fractures.
Methods: We retrospectively reviewed the records of 100 patients
with 102 fractures of the talar neck who had been managed at a level-1 trauma
center. All fractures had been treated with open reduction and internal
fixation. Sixty fractures were evaluated at an average of thirty-six months
(range, twelve to seventy-four months) after surgery. Complications and
secondary procedures were reviewed, and radiographic evidence of osteonecrosis
and posttraumatic arthritis was evaluated. The Foot Function Index and
Musculoskeletal Function Assessment questionnaires were administered.
Results: Radiographic evidence of osteonecrosis was seen in nineteen
(49%) of the thirty-nine patients with complete radiographic data. However,
seven (37%) of these nineteen patients demonstrated revascularization of the
talar dome without collapse. Overall, osteonecrosis with collapse of the dome
occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in
association with nine (39%) of twenty-three Hawkins group-II fractures and
nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation
was 3.4 days for patients who had development of osteonecrosis, compared with
5.0 days for patients who did not have development of osteonecrosis. With the
numbers available, no correlation could be identified between surgical delay
and the development of osteonecrosis. Osteonecrosis was associated with
comminution of the talar neck (p < 0.03) and open fracture (p < 0.05).
Twenty-one (54%) of thirty-nine patients had development of posttraumatic
arthritis, which was more common after comminuted fractures (p < 0.07) and
open fractures (p = 0.09). Patients with comminuted fractures also had worse
functional outcome scores.
Conclusions: Fractures of the talar neck are associated with high
rates of morbidity and complications. Although the numbers in the present
series were small, no correlation was found between the timing of fixation and
the development of osteonecrosis. Osteonecrosis was associated with talar neck
comminution and open fractures, confirming that higher-energy injuries are
associated with more complications and a worse prognosis. This finding was
strengthened by the poor Foot Function Index and Musculoskeletal Function
Assessment scores in these patients. We recommend urgent reduction of
dislocations and treatment of open injuries. Proceeding with definitive rigid
internal fixation of talar neck fractures after soft-tissue swelling has
subsided may minimize soft-tissue complications.
Level of Evidence: Prognostic study, Level II-1
(retrospective study). See Instructions to Authors for a complete description
of levels of evidence.