SLR - January 2017 - Alex Button

Diagnosis and Treatment of Talar Dislocation Fractures Illustrated by Three Case Reports and Review of Literature

Reference:
Haverkort JJ, Leenen LP, Wessem KJ. Diagnosis and Treatment of Talar Dislocation Fractures Illustrated by 3 Case Reports and Review of Literature. Int J Surg Case Rep. 2015; 16:106–111.

Scientific Literature Review

Reviewed By: Alex Button, DPM
Residency Program: Heritage Valley Health System, Beaver, PA

Podiatric Relevance:
Talar fractures are relatively uncommon when compared to other foot and ankle fractures. Talar fractures that involve any type of dislocation are very difficult to treat and unfortunately have poor outcomes associated with any treatment, surgical or nonsurgical. A treatment algorithm with a high level of evidence has not been described in literature, leaving surgical treatment of these fractures widely variable. The purpose of this article is to describe three dislocated talar fracture cases and a literature review to better direct treatment for these fractures. The cases involve dislocated talar fractures of increasing complexity to allow for treatment suggestions depending on the severity.

Methods:
Three cases were presented along with a literature review and recommendations. The first case involved a healthy 19-year-old who sustained a Hawkins II from a motorcycle accident. The second case involved an otherwise healthy 51-year-old who sustained a Hawkins III from falling off a ladder. The third case was the most difficult and complex. A 51-year-old otherwise healthy smoker was involved in a severe motor vehicle accident. He sustained a Hawkins IV talar fracture along with comminution of the body of the talus. For the literature review, they wrote in a PubMed search for keywords "talus" and "fracture." They excluded articles written in languages other than English, German and Dutch, cadaveric studies, case reports and studies focusing on primary arthrodesis. Ten papers for a total of 600 talar neck fractures were reviewed. All the papers reviewed were retrospective.

Results: In Case 1, closed reduction was obtained, and the patient was immobilized for six weeks. The patient did well with this treatment and was walking without pain 19 months post op. Case 2 could not obtain closed anatomic reduction of the Hawkins III, so ORIF with two screws and two wires were used. An external fixator was also placed to ensure stability for the first six weeks. Two years post op, the patient needed a small portion of the talar dome removed as it was causing pain. The patient reported no pain at the three-year follow-up post accident. In Case 3, the Hawkins IV dislocation fracture was treated with open reduction of the fracture along with application of external fixation. Internal fixation of the fracture was performed at 16 days post op. After 10 months, an STJ arthrodesis with a cannulated screw and iliac crest bone graft was performed because of pain caused by arthritis. This was due to an incongruent articulating surface. Avascular necrosis occurred shortly after, and a tibiotalocalcaneal arthrodesis was performed using an intramedullary nail. The patient healed uneventfully. In the literature review, they determined AVN rates for Hawkins I at 2.4 percent, Hawkins II at 28.3 percent, Hawkins III at 64.9 and Hawkins IV at 70.8. They also found that the rate of AVN was not influenced by delayed definitive fixation or time to internal fixation. Also, 54 percent of patients in all studies reviewed developed posttraumatic arthritis.

Conclusions:
The authors concluded that reduction of dislocated talar neck fractures should be done as soon as possible to minimize vascular compromise. However, they surmised that definitive fixation of the fracture could be delayed without any increased risk of AVN to obtain more optimal reconstruction of the articulating surfaces. The three cases they presented helped complement the literature review they performed to highlight real treatments for the different severities of talar fractures. The cases can help guide a loose or personal treatment algorithm into a more streamlined approach since none exist. Interestingly, the time to internal fixation was not nearly as important as reduction of the fracture. If I were to encounter a Hawkins IV, I would keep this in mind and reduce the fracture with as little vascular compromise as possible as soon as possible. I would then wait and fix the fracture once the circulation to the talus was more stable. Seeing that the surgical variability is so great and that a certain procedure will not determine the outcome, I would try multiple techniques and eventually use the technique with which I am most comfortable. A prospective study of specific techniques and time to definitive fixation would significantly help with the validation for fixation of these complex fractures.

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