Open Reduction and Internal Fixation of a Pediatric Talar Body Fracture using a Medial Malleolar Osteotomy – A Case Report

Introduction:Talus fracture injuries are rare and most literature pertains to fractures in skeletally mature adults. It is unusual for pediatric talus fractures to be treated operatively and is normally treated with immobilization. The location of the talus fracture required a medial malleolar osteotomy to facilitate exposure and reduction, which was fixed with temporary smooth K-wires. The authors were unable to identify a previous description of this technique in the literature. Case Report:An 11-year-old female was referred to our hospital due to polytraumatic injuries sustained in a roll-over MVC. A displaced fracture of the talus body was present. Due to the fracture location, a medial malleolar osteotomy was required for exposure. An open reduction and internal fixation was performed using subchondral minifragment screws under general anesthesia. The patient healed uneventfully, regained a normal gait and full, pain-free range of motion. Conclusions:Medial malleolar osteotomy with smooth K-wire fixation appears to be a safe method for gaining access to the talus when required for reduction and/or fixation of pediatric talus fractures. Keywords:Adolescent, talus fracture, osteotomy.

Single-incision Non-weight-bearing Area Autologous Osteochondral Transplantation for the Treatment of Osteochondral Lesions of the Talus

Background: Autologous osteochondral transplantation (AOT) is one of the most effective treatments for osteochondral lesions of the talus (OLTs). Normally, medial malleolar osteotomy is used to expose posteromedial lesions. However, medial malleolar osteotomy causes additional ankle injuries and a risk of persistent pain in the ankle joint. The purpose of the current study was to evaluate a new medial malleolar triplane osteotomy method and the functional outcomes of AOT from a non-weight-bearing area of the talus for OLTs.Methods: Twenty-three patients (23 ankles), including 14 males and 9 females, received AOT with triplane osteotomy of the medial malleolus for symptomatic OLTs between September 2015 and December 2017. The mean age was 35.6 years. The mean size of the lesion area was 141.5 mm2. The visual analog scale (VAS) for pain during walking and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for the pre- and postoperative evaluations. In addition, the incorporation of the grafts was assessed by computed tomography (CT).Results: All patients had a minimum follow-up of 22 months, with an average of 37.1 months. The mean time from osteotomy to full weight-bearing activity was 8.1±2.3 weeks (range, 5-12 weeks). The VAS score improved from 4.34 preoperatively to 0.53 postoperatively (P <0.01). The AOFAS ankle-hindfoot score improved significantly in all domains (P<0 .01). Twenty-one patients returned to sport at their previous level, and 2 returned at a lower level compared with preinjury (mean return to play, 7.4 months). According to CT, the medial malleolus recovered in all patients, and the graft was incorporated well. One patient suffered from flexor hallucis longus tendon discomfort due to internal fixation screw irritation posteromedial to the ankle. The general complication rate was 4.3% (1/23).Conclusions: AOT combined with medial malleolus triplane osteotomy is a viable option for OLTs. Patients could perform weight-bearing exercise and return to sport as early as possible, with few complications at the osteotomy site and donor site.

Medial malleolar osteotomy for intralesional curettage and bone grafting of primary aneurysmal bone cyst of the talus

Access to the cystic lesion of the talar body without damage to the articular surface is difficult. This case report is about a 23-year-old man who had a symptomatic huge cystic lesion in the left-sided talus bone. Radiograph and CT scan showed an expansile lytic lesion within the talar body. The MRI revealed a well-defined lesion with fluid-fluid levels. The needle biopsy aspirate was haemorrhagic, and hence a diagnosis of the aneurysmal bone cyst was made. As the lesion was beneath the talar dome with an intact neck and head, a medial approach with medial malleolar osteotomy was performed. The lesion was curetted out, and the cavity was filled up with a morselised bone graft. The limb was splinted for 6 weeks, and complete weight bearing was started after 3 months. At 1-year follow-up, the lesion was found to be healed up, and the patient was pain-free with no recurrence.

A Novel Medial Malleolar Osteotomy Technique for the Treatment of Osteochondral Lesions of the Talus

Background: The current techniques for medial malleolar osteotomy may lead to posterior tibial tendon injury and have a high rate of malunion. Purpose: To describe a novel partial step-cut medial malleolar osteotomy technique and evaluate its technical feasibility and its advantages compared with traditional methods. Study Design: Case series; Level of evidence, 4. Methods: The novel technique consisted of osteotomy of the anterior one-third to two-thirds of the medial malleolus. A total of 19 ankles (18 patients) with osteochondral lesions of the talus underwent the novel osteotomy technique before osteochondral reconstruction. All patients were evaluated for more than 2 years. Radiographs were analyzed for postoperative displacement and malunion, and postoperative ankle function was evaluated according to the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the visual analog scale (VAS) for pain. Results: The partial step-cut osteotomy technique was able to provide adequate intra-articular exposure without disturbing the posterior tibial tendon. The 19 ankles healed at a mean of 7.3 ± 1.5 weeks (range, 6-12 weeks). There was slight incongruence in 4 ankles, with a displacement of 1.0 ± 0.1 mm proximally and 0.3 ± 0.1 mm medially. The mean postoperative AOFAS and VAS scores improved compared with preoperatively, from 54.2 ± 12.1 to 84.6 ± 6.6 and from 6.4 ± 1.0 to 1.8 ± 1.3, respectively ( P < .001 for both). No intraoperative tendon injuries were observed. Conclusion: Results indicated that partial step-cut osteotomy is a reliable and effective method for providing enough exposure, avoiding displacement after reduction, and not disturbing the anatomic structures behind the medial malleolus.

Quantification and Comparison of Talar Exposure Utilizing a Posteromedial Approach and Medial Malleolar Osteotomy

Background: Fractures of the talus are a rare but challenging injury. This study sought to quantify the area of osseous exposure afforded by a posteromedial approach to the talus and medial malleolar osteotomy. Methods: Five fresh-frozen cadaveric lower extremities were dissected using a posteromedial approach and medial malleolar osteotomy respectively. Following exposure, the talar surfaces directedly visualized were marked and captured using a calibrated digital image. The digital images were then analyzed using ImageJ software (National Institutes of Health) to calculate the surface area of the exposure. Results: The average square area of talus exposed using the posteromedial approach was 9.70 cm2 (SD = 2.20, range 7.20-12.46). The average quantity of talar exposure expressed as a percentage was 9% (SD = 1.58, range 7.03-10.40). The average square area of talus exposed using a medial malleolar osteotomy was 14.32 cm2 (SD = 2.00, range 11.26-16.66). The average quantity of talar exposure expressed as a percentage was 12.94% (SD = 1.79, range 9.97-14.73). The posteromedial approach provided superior visualization of the posterior talus, whereas the medial malleolar osteotomy offered greater access to the medial body. Conclusion: The posteromedial approach and medial malleolar osteotomy allow for significant exposure of the talus, yielding 9.70 and 14.32 cm2, respectively. Given the differing portions of the talus exposed, surgeons may prefer to use the posteromedial approach for operative fixation of posterior process fractures and elect to use a medial malleolar osteotomy in cases requiring more extensive medial and distal exposure for neck or neck/body fractures. Level of Evidence: Level IV.