Repair of a Comminuted Talar Neck Fracture using a Cellular Bone Allograft combined with a Textured Allograft Wedge

Category: Trauma; Ankle Introduction/Purpose: Talar neck fractures are uncommon and are characterized by displacement, comminution, and soft tissue injury. Treatment of talar neck fractures while avoiding complications, such as osteonecrosis and long-term morbidity, presents a unique challenge to surgeons. One option for treating talar neck fractures is cellular bone allograft containing viable lineage- committed bone cells (V-CBA), which provides the osteoconductive, osteoinductive, and osteogenic properties needed for bone formation. Additionally, a structural textured allograft (STA) wedge designed to resist migration and sustain compressive force can also be used in repairing talar neck fractures. This case study describes the successful repair of a comminuted talar neck fracture using V-CBA combined with an STA wedge. Methods: A 46-year-old male patient sustained a talar neck fracture following a fall from a 12-foot ladder. Radiographic and computed tomography (CT) imaging revealed significant comminution, consequent varus angulation, and a large bony void, as well as dislocation of the posterior subtalar joint. The patient was otherwise healthy with no comorbidities. Open reduction internal fixation was performed laterally to reduce the posterior subtalar dislocation. Medially, a 6.5mm STA wedge was used to correct the varus deformity and 1cc of V-CBA was used to fill the void. Results: At 6 months, the talar neck fracture had healed with solid osseous consolidation evident on radiographic images. Conclusion: These results demonstrate that an STA wedge, with a textured design that resists migration, used in combination with a V-CBA successfully repaired a comminuted talar neck fracture.

Peroneal tendon dislocation in Talus fracture and diagnostic value of fleck sign

Category: Trauma Introduction/Purpose: INTRODUCTION: Talus fractures are not uncommon and one of the serious fractures in foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. AIM: To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation. Methods: We retrospectively reviewed 100 consecutive talus fractures in the period between 1/1/2011 to 1/7/2017. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and 3 views ankle plain radiographs. 2 independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification if any. Any dispute was resolved by the senior author. Patient records were reviewed for laterality, age, sex, mode of injury, associated injuries and operative interventions. 43 ankles met inclusion criteria. 42 were males, mean age was 31 year and the predominant modes of injury were fall from height or unknown. Results: Peroneal tendon dislocation was found in 9 patients out of 43. (20%). All dislocations were found in talar neck fractures, and up to 67% of Hawkins type III and IV Talar neck fractures were associated with peroneal tendon dislocation. Risk of dislocation increased with severity of the fracture. 5 cases of peroneal tendon dislocation out of 9 were associated with lateral or bimalleolar fractures. Most of the dislocations were missed and no additional procedures were done to address such injury. Fleck sign sensitivity was 44.4% while specificity was 88%. The Negative Predictive Value (PPV) was 86%. Conclusion: Peroneal tendons dislocation is associated with 20% of talus fractures. The incidence of dislocation increases with neck fracture and severity of these fractures. Fleck sign is highly specific radiographic sign and hence we recommend intra-operative assessment of peroneal tendons in patients with fleck sign.

Arthroscopically assisted fixation of Hawkins type II talar neck fractures

Aims Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures. Patients and Methods A total of seven consecutive patients (four women and three men, mean age 39 years (19 to 61)) underwent attempted surgical treatment of a closed Hawkins type II talar neck fracture using arthroscopically assisted reduction and percutaneous screw fixation. Functional and radiological outcome were assessed using plain radiographs, as well as weight-bearing and non-weight-bearing CT scans as tolerated. Patient satisfaction and pain sensation were also recorded. Results Primary reduction was obtained arthroscopically in all but one patient, for whom an interposed fracture fragment had to be removed through a small arthrotomy to permit anatomical reduction. The quality of arthroscopic reduction and restoration of the talar geometry was excellent in the remaining six patients. There were no signs of talar avascular necrosis or subtalar degeneration in any of the patients. In the whole series, the functional outcome was excellent in five patients but restricted ankle movement was observed in two patients. All patients had a reduction in subtalar movement. At final follow-up, all patients were satisfied and all but one patient were pain free. Conclusion Arthroscopically assisted reduction and fixation of talar neck fractures was found to be a feasible treatment option and allowed early functional rehabilitation. Cite this article: Bone Joint J 2018;100-B:461–7.

Importance of Computed Tomography (CT) in Talar Neck Fractures. Case Studies

Computed tomography is a modern technique producing high quality image of scanned organs. It plays a significant role in diagnostic work-up on orthopedics wards. This paper presents an analysis of management of two cases of Hawkins type I talar neck fracture with ankle joint rotation. In both patients, the diagnosis was based on conventional radiographs of the ankle joint in two projections and was subsequently verified with CT scans. The findings of a CT scan of the talus had a significant impact on further treatment and physiotherapy. Non-surgical treatment consisting in immobilization with a short leg cast combined with medication and magnetic field therapy produced a positive therapeutic outcome. A follow-up CT scan of the talus revealed bone union with remodelling in both patients. The functional outcome according to the AOFAS scale should be regarded good. Computed tomography is the radiological modality for detecting talar neck fractures and determining the presence of displacement. Follow-up CT scans evaluate the natural process of bone healing, which is crucial for treatment decisions regarding weight-bearing status. A correct diagnosis based on CT helps to prevent the development of necrosis and posttraumatic (secondary) degenerative changes as well as advanced physical disability, especially among youn­ger patients, in whom the injury is most common, consequently helping to avoid a long and costly treatment.