Fractures of the talar body can have devastating results despite treatment. While talar body fractures are uncommon, they have worse outcomes than do other fractures of the talus, including more osteonecrosis and posttraumatic arthritis1,2. Crush injuries are the most difficult to treat as a result of a very constrained anatomy, the comminution of the fracture fragments, and articular cartilage damage. These fractures are challenging to reconstruct and stabilize and often have poor outcomes3.
Conservative treatment does not appear to be better than operative treatment for talar body fractures4. For crush injuries, very aggressive techniques such as primary fusion of the talocrural joint, primary tibiotalar arthrodesis and subtalar arthrodesis, and salvage ankle fusion techniques with structural bone blocks are usually used3,5,6.
There have been isolated reports of surgical treatment for crush injuries of the talar body with open reduction and internal fixation; however, these procedures either have had unsatisfactory outcomes2 or were used when there was comminution of only part of the talar dome7. It is generally accepted that severe crush fractures cannot be treated satisfactorily with open reduction and fixation5,8.
We describe a case of a severely comminuted talar body and neck fracture treated effectively with surgical reconstruction with a satisfactory result. The patient gave permission for this information to be submitted for publication.
A twenty-three-year-old man injured the right ankle in a high-speed motorcycle accident. At the time of admission, the patient had local swelling and varus deformity of the ankle, severe pain, and an inability to actively and passively move the ankle and subtalar joints. He had no neurovascular deficit, tension of the surrounding soft tissue was noted, and there was no open skin lesion.
Anteroposterior and lateral radiographs (Figs. 1-A and 1-B) showed a comminuted, displaced talar body fracture with tibiotalar and subtalar joint incongruity, corresponding to stage IV according to the Marti-Weber classification9.
Computed tomography (CT) images showed that the fracture involved almost the entire talar body with severe comminution, which extended to the talar neck, with marked incongruity of the subtalar and ankle joints (Figs. 2-A, 2-B, and 2-C). No other lesion was demonstrated by the clinical and radiographic investigations. Prior to surgery, the patient was managed with plaster cast immobilization, elevation, and application of ice.
Closed fracture reduction was not attempted. Open reduction and internal fixation of the fracture was performed twelve days after injury, once the swelling had decreased. A medial surgical approach with a reverse-V medial malleolar osteotomy was used. Reduction of the articular fragments of the talar body was obtained despite difficulties caused by fracture comminution, and fixation was accomplished with one 1.2-mm and three 1.5-mm smooth Kirschner wires, two 2.7-mm poly-L-lactide (PLLA) screws, and six 1.5-mm PLLA pins (SmartScrew and SmartPin; ConMed Linvatec, Largo, Florida) (Fig. 3). With use of fluoroscopic guidance, the reconstructed talar body was connected with the remaining portion of the talar neck and head with a 5-mm partially threaded titanium cannulated screw (Asnis; Stryker Orthopaedics, Mahwah, New Jersey).
Postoperatively, the ankle was immobilized for six weeks in a cast, and then the patient began both active and passive range-of-motion exercises. He started partial weight-bearing with an ankle brace at twelve weeks after surgery and began unrestricted full weight-bearing four weeks later.
At the time of the latest follow-up, three years after the surgery, the patient had returned to his original activities as a skilled worker and was walking without a limp or pain. He could walk on tiptoe; ankle motion consisted of 0° of dorsiflexion (compared with 10° on the contralateral side) and 40° of plantar flexion (compared with 50° on the contralateral side) (Figs. 4-A and 4-B). There was limited motion of the subtalar joint, which was only 50% of the subtalar motion in the contralateral foot.
Radiographs demonstrated a healed fracture, a well-aligned foot, mild arthritic changes at the tibiotalar and subtalar articulations, and sclerosis of the talar body without flattening or collapse of the talar dome due to osteonecrosis (Figs. 5-A and 5-B).
To our knowledge, this is the first case of severe crush injury of the talar body treated with operative reconstruction that had a good outcome. There have been only occasional reports of surgical treatment of similar lesions. In one case, a thirty-eight-year-old man with an open comminuted fracture of the talar body underwent open reduction and internal fixation through anteromedial and anterolateral approaches, but thirteen months later he had talar osteonecrosis with collapse of the talar dome2. In another case, a good result was reported after open reduction and internal fixation with bioresorbable screws was used to treat a comminuted talar body fracture in a thirty-year-old man7. However, in that case, comminution was only partial—i.e., it affected only the posterior portion of the talus. In our case, the comminution destroyed most of the talar body and neck, with only an intact lateral fragment, and the fracture involved more than half of the diameter of the articular surface of the dome.
Talar body fractures are defined radiographically by their extension into or posterior to the lateral process of the talus10. These lesions are uncommon, accounting for only 7% to 38% of all fractures of the talus2. Within this group, a crush injury of the talar body is an extremely rare event, representing <8% of talar fractures4, and typically carries a poor prognosis with a high probability of posttraumatic arthritis and osteonecrosis of the talus1,2,8,11,12.
Considering the relatively young age of our patient, we opted for a reconstructive treatment that would allow for a later fusion of the talocrural joint after the healing of the fracture, avoiding an immediate tibiocalcaneal fusion. Despite the poor prognosis for this surgical treatment, including the fact that a talar neck fracture was associated with the fracture of the talar body2, the final result three years after injury was excellent.
Positive prognostic factors included a closed fracture1,2,13,14; accurate reduction of the displaced fracture fragments15; and, possibly, the use of a single medial surgical approach instead of a combined medial and lateral incision (usually described in the literature2,13), which could have reduced the risk of iatrogenic injury to the tarsal sinus artery and other lateral anastomotic vessels.
We used biodegradable implants for a portion of the fracture fixation. Although biodegradable implants can be complicated by osteolysis16,17, they reduce artifacts during magnetic resonance imaging (MRI) evaluation and lead to fewer articular problems in case of joint mobilization7. Moreover, biodegradable implants provide sufficient stability in the fixation of fractures of weight-bearing cancellous bones18. Since PLLA implants are associated with a low incidence of osteolysis19, they were a good choice for the osteosynthesis of the talar dome.
Had the patient developed an infection, an open access would have been necessary to remove the Kirschner wires. The presence of Kirschner wires in the talar body makes follow-up MRI more difficult; in other reported cases, MRIs were not used even when there was evidence of vascular compromise on radiographs2. In our case, the talus did not show any collapse or other signs of osteonecrosis or failure of fracture fixation on follow-up radiographs.
This case demonstrates the possibility of obtaining a good result when treating a severely comminuted fracture of the talar body with anatomic open reduction and internal fixation, even when the fracture involves most of the body of the talus with incongruity of both the tibiotalar and the subtalar joint surfaces.