Original Research

Timing of Surgical Reduction and Stabilization of Talus Fracture-Dislocations

Am J Orthop. 2017 November;46(6):E408-E413

Talus fractures with associated dislocations are rare but have high rates of complications, including avascular necrosis (AVN). Management of these injuries involves urgent surgical reduction and fixation, although there are no definitive data defining an operative time frame for preserving the blood supply and preventing complications.

To determine the effect of time to surgical reduction of talus fractures and talus fracture-dislocations on rates of AVN and posttraumatic osteoarthritis (PTOA), we retrospectively reviewed talus fractures surgically managed at a level I trauma center during the 10-year period 2003 to 2013. Operative reports were obtained and reviewed, and 3 independent reviewers, using the Hawkins and AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) systems, classified the injuries on plain radiographs. Analysis of AO/OTA 81 fractures with associated tibiotalar, subtalar, or talonavicular dislocations was performed. Primary outcomes were presence of AVN/PTOA and subsequent arthrodesis of tibiotalar
or subtalar joints.

We identified 106 surgically managed talus fractures. Rates of AVN/PTOA were 41% for all talus fractures and 50% for talus fracture-dislocations. Mean time to surgical reduction was not significant for development of AVN/PTOA for all talus fractures (P = .45) or talus fracture-dislocations (P = .29). There was no difference in age (P = .20), body mass index (P = .45), or polytrauma (P = .79) between patients who developed AVN and those who did not. Open fractures were significantly correlated with the development of AVN/PTOA (P = .009).

Talar fracture-dislocations are devastating injuries with high rates of complications. Our data suggest there is no effect of time from injury to surgical reduction of talus fractures or talus fracture-dislocations on rates of AVN and PTOA.

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References

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Take-Home Points

There is a 41% rate of AVN or PTOA after operatively managed talus fracture.
Surgical timing does not affect development of AVN or PTOA.
Open fractures are associated with development of AVN and PTOA.
Quality of reduction is likely more important than timing of reduction.
Urgent surgical treatment is necessary for threatened soft tissue or neurovascular compromise.

Talus fractures are rare injuries that present a significant treatment dilemma.^1-12These fractures represent <1% of all fractures⁴ and are second only to calcaneus fractures in fractures of the hindfoot. Talus fractures with associated dislocations are even rarer and may provide treating surgeons with a significant surgical quandary.^6,13-16

Talus fractures historically have been characterized by their anatomical location: head, neck, or body. Two systems are commonly used to classify talus fractures: Hawkins and AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association). The first, developed by Hawkins⁷ and modified by Canale and Kelly² and Vallier and colleagues,¹identifies 4 basic fracture types with associated dislocations. The other system, published in 1996¹⁷ and republished in 2007,¹⁸ uses the combined methods of AO and OTA to systematically describe talus fractures. Although these classification systems accurately describe talus fractures with associated dislocation, both have difficulty predicting clinical outcomes.^1,19,20

Talus fractures commonly result in avascular necrosis (AVN) of the talus and posttraumatic osteoarthritis (PTOA) of the tibiotalar and subtalar joints.^{3,8,9,12,14-16} Hawkins⁷ initially described subchondral lucency as indicating revascularization of the talus after injury. AVN and PTOA rates traditionally have been thought to be related to a blood supply disruption, given the prognostic value of the Hawkins sign.^1,7,12,21 New methods, including a dual-incision approach and expedited transfer to foot and ankle surgeons or orthopedic traumatologists, have improved reduction quality^21-24 but not patient outcomes.^{3,5,8,9,12,14}

Recently, time from injury to surgical intervention has been a topic of much discussion, and there have been studies on the specific effects of timing with respect to outcome.^1,15,16 Vallier and colleagues,¹ who wanted to identify injury characteristics predictive of osteonecrosis, found that delaying reduction and surgical fixation did not increase the risk of AVN. Another study found that urgent reduction of fracture-dislocation with delayed open reduction and internal fixation (ORIF) using a dual approach may improve clinical outcomes.²¹

In this vein, we conducted a study to evaluate the effect of time to surgical reduction of talus fractures and talus fracture-dislocations on the development of AVN and PTOA. We hypothesized that time to surgical reduction of talus fracture-dislocation as classified with the AO/OTA system would have no effect of the development of AVN/PTOA.

Methods

After this study received Institutional Review Board approval, we retrospectively reviewed the records on talus fractures surgically managed at a level I trauma center during the 10-year period 2003 to 2013. Of the 119 potential cases identified using Current Procedural Terminology code 28445 (ORIF of talus), 13 were excluded (12 for inaccurate coding or missing documentation, 1 for being a pediatric case), leaving 106 for analysis. Using the Hawkins and AO/OTA systems, 3 independent reviewers classified the injuries on plain radiographs.

Injury dates and times were obtained from the medical records. Operating room start times were also obtained. Surgical timing was defined as time from injury to operating room start. For cases without an injury time, time of presentation to emergency department was used.

Open fracture-dislocations were managed with intravenous antibiotics, urgent surgical irrigation, débridement, and immediate fixation or temporizing external fixation after reduction. All fractures were definitively managed with standard ORIF with an anteromedial, anterolateral, or dual approach and mini-fragment implants. After fixation, weight-bearing typically was restricted for 6 to 12 weeks.

Follow-up radiographs were evaluated. Presence or absence of Hawkins sign⁷ was noted on radiographs at 6 or 8 weeks, and all follow-up radiographs were evaluated for AVN as defined by increased radiographic density within the talar dome or collapse of the articular surface. All radiographs were evaluated for PTOA as defined by loss of joint space within the tibiotalar, subtalar, or talonavicular joint on follow-up radiographs.

Clinical outcomes were analyzed for development of AVN, PTOA, or secondary corrective surgery or arthrodesis. Continuous variables were evaluated with the t test, and the χ² test was used to compare distributions of categorical variables. The Wilcoxon rank sum test was used to compare non-normally distributed variables. Significance was set at P < .05.