Prospective Study Investigating the Prevalence and Evolution of Malnourishment in the Acute Orthopaedic Trauma Patient.

Background: Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this study was to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients and determine when and what labs should be ordered. The secondary aim was to determine if malnourished patients had increased complications. Methods: Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritional status over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritional laboratory markers on admission, day 3, day 7, and 6 weeks post-op. Results: 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourished based on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR) as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted based on the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilized at 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12% of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markers throughout the hospital stay. Conclusion: The prevalence of malnourishment, based on serum nutritional markers, in the presence of acute orthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbumin or albumin levels on hospital day 3 to assess nutritional status.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction.

INTRODUCTION: The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach. METHODS: Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome. RESULTS: The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed. CONCLUSIONS: ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Significance of Lateral Process Fractures Associated With Talar Neck and Body Fractures.

OBJECTIVES: To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures. DESIGN: Retrospective review. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period. INTERVENTION: Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis. MAIN OUTCOME MEASUREMENTS: Radiographic evidence of subtalar arthritis. RESULTS: Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001). CONCLUSION: Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Posteromedial Talus Fractures: Technique Description and Results of 10 Cases.

BACKGROUND: The aim of this study is to describe a surgical technique for successful treatment of posteromedial talar body fractures and establish treatment recommendations for fractures of the posterior aspect of the talus. MATERIALS AND METHODS: Ten patients treated operatively for a posteromedial talar body fractures entering both the subtalar and ankle articulations with a minimum of 1-year followup were identified from a trauma database. Age, mechanism of injury, associated injuries, time to surgery, complications, the range of motion, secondary procedures, and need for arthrodesis were evaluated. RESULTS: Followup averaged 4.8 years (1-10). Eight of ten patients had high-energy mechanisms of injury. Six patients had associated medial subtalar dislocations with two open. Associated injuries were common. No surgical complications occurred. The range of motion was present but decreased. No arthrodesis procedures were performed. CONCLUSIONS: Operative fixation of posteromedial talus fractures with the described surgical technique resulted in acceptable outcomes in this series of patients with improved outcomes when compared to prior reports in the literature.

Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series.

The derangement in calcaneal morphology after a fracture can be significant and is often associated with severe soft tissue envelop problems. Medial calcaneal external fixation is useful for early restoration of calcaneal morphology and the corresponding soft tissue envelop. When performed in a stepwise fashion, external fixation can successfully restore normal calcaneal height, length, width, and coronal plane alignment. For severely displaced joint depression and broken tongue-type calcaneus fractures where open treatment is the preferred strategy, early external fixation restores the normal soft tissue tension, allows a stable environment for soft tissue recovery, and facilitates the definitive operation by restoring and maintaining overall calcaneal architecture. We describe the stepwise approach to calcaneal reduction and external fixation and report a case series demonstrating this method is safe and effective for staged management of severely displaced calcaneus fractures.

Obtaining Correct Ankle Alignment Using Intraoperative External Fixation for Ankle Arthrodesis.

Ankle arthrodesis remains an important treatment option for patients with ankle arthritis. Many methods have been described; however, no consensus has been reached regarding the best technique to achieve both successful fusion and a good position for optimal foot mechanics. Furthermore, as arthroplasty has become more popular, preservation of the fibula to allow for future arthroplasty has become critical. The present report describes an innovative technique in which temporary external fixation at operative fixation is used, along with internal fixation, to achieve both an optimal foot position and high fusion rates, while maintaining the integrity of the fibula. Seventeen patients were identified who met the criteria for inclusion. Their medical records, including pre- and postoperative radiographs, were reviewed retrospectively. Preoperative and postoperative coronal and sagittal alignment was determined. All patients achieved successful fusion, although 1 (5.9%) patient experienced delayed union. The average tibial/talar ratio preoperatively was 21% (range 8% to 33%), demonstrating anterior subluxation. Postoperatively, this ratio improved to 33% (range 26% to 40%), approximating the normal anatomic ratio. Of the 17 patients, 5 (29.4%) had preoperative varus or valgus alignment of the talas >5°. All 5 cases were successfully corrected to within 2° of normal anatomic alignment. This technique allows the surgeon to achieve good visualization of the joint for preparation and to obtain the optimal position of the foot at arthrodesis without compromising the lateral column significance of the fibula. All patients obtained fusion, and minimal complications were associated with the use of this technique.

Incidence of Preoperative Deep Vein Thrombosis in Calcaneal Fractures.

OBJECTIVES: This study examined the incidence and risk factors of preoperative deep vein thrombosis (DVT) in patients presenting to an outpatient setting with an isolated calcaneal fracture. DESIGN: Retrospective chart review. SETTING: All patients included in the study presented to the treating surgeon at a Level I trauma center with isolated calcaneal fractures as an outpatient between 2005 and 2013. METHODS: These patients were either referred from outside hospitals, had been evaluated in the emergency department initially and presented for definitive care, or presented initially to the outpatient clinic. Patients included were over the age of 18, had a preoperative duplex ultrasonography of bilateral lower extremities per the treating surgeon's protocol, and had at minimum 6 weeks follow-up. Patients were excluded if they were a polytrauma, had a documented hypercoagulable state, or were on baseline pharmacologic anticoagulation for another condition. All patients had a preoperative duplex ultrasound of both lower extremities to evaluate for DVT at least 7 days after injury. MAIN OUTCOME MEASURE: Patients found to have a preoperative DVT were compared with those who did not have preoperative DVT for possible risk factors. RESULTS: One hundred fifty-nine patients qualified for our study and of these, 19 (12%) were found to have a DVT preoperatively, almost all of which were in distal veins. All risk factors, including age, sex, and body mass index were analyzed as continuous variables. Older age was found to be a risk factor for DVT (P = 0.009, Odds Ratio = 1.06, 95% CI, 1.01-1.11). All other predictor variables, including body mass index (P = 0.05) and sex (P = 0.08), were not statistically significant predictors in our sample. CONCLUSIONS: The incidence of preoperative DVT found here is almost 2 times as high as any previously published examination of lower extremity injuries. Physicians should be aware of this increase so they may counsel patients about the risks of DVTs and the likelihood of any sequelae from developing a DVT that may affect a patient's recovery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Joint-Preserving Osteotomies for Malaligned Intraarticular Calcaneal Fractures.

Intraarticular calcaneal fracture treatments that result in malalignment often require reconstructive surgery. Seven cases are used to demonstrate the intricacies of reconstructive case management. Reestablishment of calcaneal height, length, orientation, and position relative to the other tarsals is necessary to reestablish appropriate foot function. Inherent or acquired gastrocnemius equinus should be treated with recession to reduce destructive forces on the reconstruction.

Open surgical management of high energy ipsilateral fractures of the fibula and calcaneus.

BACKGROUND: Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity. METHODS: A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks. RESULTS: Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united. CONCLUSIONS: Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.

Entrapped posteromedial structures in pilon fractures.

OBJECTIVES: To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 Trauma Center. PATIENTS/PARTICIPANTS: About 394 patients with 420 pilon fractures treated between January 2005 and November 2011. INTERVENTION: Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture. MAIN OUTCOME MEASUREMENTS: Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure. RESULTS: 40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%). CONCLUSIONS: In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries.

The midfoot is a complex association of five bones and many articulations between the forefoot metatarsals and the talus and calcaneus, which make up the hindfoot. These anatomic relationships are connected and restrained by an even more complex network of ligaments, capsules, and fascia, which must function as a unit to provide normal and painless locomotion. The common eponyms of Lisfranc and Chopart refer to the distal and proximal joint relationships of the midfoot, respectively. Midfoot injuries range from single ligament strains to complicated fracture-dislocations involving multiple bones and joints. To provide best outcomes for patients, it is important to understand the anatomy and the mechanical function of the midfoot; to review the epidemiology, mechanism, and classification of injuries encountered in an orthopaedic clinical practice; and to review the principles, indications, and surgical techniques for managing midfoot fractures and dislocations.

Ipsilateral talar and calcaneal fractures: a retrospective review of complications and sequelae.

BACKGROUND: Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series. OBJECTIVE: To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures. METHODS: Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review. MAIN OUTCOME MEASUREMENTS: Post-operative complications, the need for secondary surgery, and the visual analogus pain score. RESULTS: Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0. CONCLUSION: The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation.

A prospective study evaluating incision placement and wound healing for tibial plafond fractures.

OBJECTIVES: To report the soft tissue complications after fixation of tibial plafond fractures to test the validity of the recommendation that a 7-cm skin bridge represents the minimum safe distance between surgical incisions. DESIGN: Prospective observational cohort. SETTING: Level 1 Trauma Center. PATIENTS: A total 42 patients with 46 tibial plafond fractures. INTERVENTION: All injuries had a minimum of 2 surgical approaches for operative management of the tibial plafond and associated fibula fracture (if applicable). Two low-energy injuries had single-stage open reduction internal fixation of the tibia and fibula, and the remaining high- energy fractures had a 2-staged approach to management. MAIN OUTCOME MEASUREMENTS: The surgical approaches used, length of the incisions, distance between the incisions, and overlap between the incisions were recorded. Wound healing was assessed in the outpatient clinic over a 3-month period. RESULTS: Two surgical approaches were used in 32 fractures, and 3 approaches were used in 14 fractures. The mean width of the skin bridge was 5.9 cm. The majority of the skin bridges were 5.0 to 5.9 cm (n = 25) or 6.0 to 6.9 cm (n = 16). Only 17% of the skin bridges were greater than 7.0 cm. Soft tissue complications occurred in 4 (9%) of 46 fractures. Healing of 2 anterolateral incisions was complicated by eschars that ultimately resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection. CONCLUSIONS: Despite a measured skin bridge of less than 7 cm in 83% of instances, the soft tissue complication rate was low in this group of tibial plafond fractures. With careful attention to soft tissue management and surgical timing, incisions for tibial plafond fractures may be placed less than 7 cm apart, allowing the surgeon to optimize exposures on the basis of injury pattern.

Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.

BACKGROUND: Plate fixation of comminuted bicondylar tibial plateau fractures remains controversial. This retrospective study was performed to evaluate the perioperative results and functional outcomes of medial and lateral plate stabilization, through anterolateral and posteromedial surgical approaches, of comminuted bicondylar tibial plateau fractures. METHODS: Over a seventy-seven-month period, eighty-three AO/OTA type-41-C3 bicondylar tibial plateau fractures were treated with medial and lateral plate fixation through two exposures. Injury radiographs were rank-ordered according to fracture severity. Immediate biplanar postoperative radiographs were evaluated to assess the quality of the reduction. The Musculoskeletal Function Assessment (MFA) questionnaire was used to evaluate functional outcome. RESULTS: Twenty-three male and eighteen female patients (average age, forty-six years) who completed the MFA questionnaire were included in the study group. The mean duration of follow-up was fifty-nine months. Two patients had a deep wound infection. Complete radiographic information was available for thirty-one patients. Seventeen (55%) of those patients had a satisfactory articular reduction (< or =2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87 degrees +/- 5 degrees ), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9 degrees +/- 5 degrees ), and all thirty-one patients demonstrated satisfactory tibial plateau width (0 to 5 mm). Patient age and polytrauma were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When these variables were accounted for, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a better MFA score (p = 0.029). Rank-order fracture severity was also predictive of MFA outcome (p < 0.001). No association was identified between rank-order severity and a satisfactory articular reduction (p = 0.21). The patients in this series demonstrated significant residual dysfunction (p < 0.0001), compared with normative data, with the leisure, employment, and movement MFA domains displaying the worst scores. CONCLUSIONS: Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fractures through medial and lateral surgical approaches is a useful treatment method; however, residual dysfunction is common. Accurate articular reduction was possible in about half of our patients and was associated with better outcomes within the confines of the injury severity.

The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures.

BACKGROUND: Isolated coronal plane fractures of the distal femoral condyles (Hoffa fractures) occur uncommonly, are difficult to diagnose, and may be challenging to treat. The combination of supracondylar distal femoral fractures and these coronal plane fractures is thought to occur rarely. The purposes of the present study were to identify the frequency of the association between supracondylar-intercondylar distal femoral fractures and coronal fractures of the femoral condyle and to describe the radiographic evaluation of these injuries. METHODS: One hundred and eighty-nine patients with 202 supracondylar-intercondylar distal femoral fractures were retrospectively evaluated clinically and radiographically. RESULTS: Coronal plane fractures were diagnosed in association with seventy-seven (38.1%) of the 202 supracondylar-intercondylar distal femoral fractures. Fifty-nine (76.6%) of these coronal fractures involved a single condyle, and eighteen involved both the medial and lateral femoral condyles. Eighty-five percent of the coronal fractures involving a single condyle were located laterally. Patients with an open distal femoral fracture were 2.8 times more likely to have a coronal plane fracture than patients with a closed fracture were (95% confidence interval, 1.54 to 5.25). Coronal plane fractures were diagnosed in 47% of the 102 knees that were evaluated with computerized tomography, compared with 29% of the 100 knees that were not (p = 0.008). Ten coronal plane fractures that had been unrecognized preoperatively were identified only at the time of operative fixation of the distal femoral fracture; none of these fractures occurred in patients who had been evaluated with computerized tomographic scanning preoperatively. CONCLUSIONS: Coronal plane fractures frequently occurred in association with high-energy supracondylar-intercondylar distal femoral fractures; in the present study, the prevalence of associated coronal plane fractures was 38%. The lateral condyle was involved more frequently than the medial condyle was. Coronal plane fractures of both condyles were observed commonly, and the majority of coronal plane fractures were associated with open wounds. Since the surgical tactic for the treatment of a supracondylar-intercondylar distal femoral fracture may be altered by the additional diagnosis of a coronal plane fracture component, preoperative computerized tomographic scanning of the injured distal part of the femur, particularly when there is an associated open wound, is strongly recommended.

Surgical treatment of talar body fractures.

BACKGROUND: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

Talar neck fractures: results and outcomes.

BACKGROUND: Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. METHODS: We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. RESULTS: Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. CONCLUSIONS: Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.

Surgical treatment of talar body fractures.

BACKGROUND: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.