[Fractures of the talus]. / Talusfrakturen.

Fractures of the neck of the talus are a relatively uncommon fracture of the foot but they have potentially serious complications. This article details the Hawkins classification, operative treatment and indications, and complications of fractures of the neck of the talus. It also discusses the treatment of fractures of the body of the talus and talar head. An English full text version of this article is available at SpringerLink as supplemental.

Talar body fractures.

Fractures to the body of the talus include a wide array of injuries, varying from relatively minor posterior tuberosity fractures to devastating comminuted body fractures. Fracture types include osteochondral fractures, sagittal transverse or coronal whole-body fractures, posterior tubercle fractures, lateral process fractures, and crush injuries. Treatment varies from excision of small fragments, such as arthroscopic treatment of osteochondral injuries, to open reduction and internal fixation of body fractures, usually by a medial malleolar osteotomy. Prognosis logically correlates with the magnitude of the injury with whole-body fractures, especially crush injuries, having the worst prognosis. Talar body fractures, similar to talar neck fractures, also can be complicated by subtalar arthritis, ankle arthritis, malunion, and avascular necrosis.

Pediatric calcaneal fractures.

Calcaneal fractures in pediatric patients are seen infrequently. We retrospectively reviewed 22 skeletally immature patients with 23 fractures of the calcaneus before their distal tibial physis had fused. Eighteen (78%) of these fractures were intraarticular and five (22%) were extraarticular. Nine patients were followed for an average of 4.4 years. Of these nine fractures, 8 were treated non-operatively and one was treated with open reduction and internal fixation. A modification of the American Orthopaedic Foot and Ankle Society scoring system, which focuses on residual complaints of pain, work or sports restrictions, ability to walk on different surfaces and gait abnormalities, was employed to assess their outcome. Seven of the nine patients were free of pain, had unrestricted foot function, and possessed no apparent gait abnormalities. Two patients had activity related and cold weather related pain. We believe that the excellent prognosis for both intraarticular and extraarticular fractures, seen in this study is multi-fold. First, the immature talus and calcaneus have a superior capacity to remodel. Second, pediatric calcaneal fractures are usually consequence of low energy trauma. Lastly, a favorable intraarticular fracture pattern, unique to the skeletally immature calcaneus may exist, rendering a good prognosis.

Congenital crossover fifth toe correction with soft tissue release and cutaneous Z-plasty.

Congenital overriding of the fifth toe causes symptoms in approximately half of all patients. The results of three patients treated with a simpler procedure involving metatarsal phalangeal capsular release dorsally and medially, oblique lengthening of the extensor tendon, and Z-plasty of the skin is reported. At an average of 33 month follow-up, no recurrence is noted with this simple procedure.

Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial.

Thirty-two patients who had pronation-lateral rotation (PLR) fractures occurring four centimeters or more proximal to the ankle joint or lower if the talus was displaced greater than one centimeter laterally were enrolled in this study. Seventeen patients were randomized to fibular plate fixation with a 4.5 ml polylactic acid (PLA) bioabsorbable syndesmotic screw, and fifteen patients randomized to fibular plate fixation with a 4.5 mm stainless steel syndesmotic screw. All thirty-two patients had uncomplicated healing of their fibular fracture without loss of reduction. There was neither evidence of osteolysis nor sterile effusion in the patients who were treated with the PLA screw. There were no wound complications in either group. No difference in range of motion or subjective complaints was noted in either group. Use of the PLA syndesmotic screw at short-term follow-up was well tolerated and avoided the need for subsequent screw removal.

The adductor hallucis revisited.

To evaluate anatomic variability in the insertion of the adductor hallucis into the lateral sesamoid and proximal phalanx of the great toe and to evaluate the extent of release of the adductor hallucis tendon performed through an incision in the dorsal first-web space, we recorded the angle of hallux valgus in 42 fresh-frozen specimens from human cadavers. An incision was made for a realignment of the soft tissues, dissecting down to the level of the intermetatarsal ligament. A loop of suture was placed around the identifiable adductor hallucis tendon through this incision along the lateral aspect of the lateral sesamoid. Then a plantar dissection removed all soft tissue to the level of the intermetatarsal ligament, adductor hallucis (transverse and oblique heads), lateral sesamoid, and lateral flexor hallucis brevis. The Insertion of these muscles into the proximal phalanx was evaluated. Specifically, we looked for separate slips of the adductor tendon inserting into the base of the proximal phalanx or separate insertions of the adductor tendon and the tendon of the flexor hallucis brevis muscle. In 33 of the 42 specimens, the entire adductor hallucis tendon had been isolated by the loop of suture through the incision in the dorsal first web. In eight of the remaining nine specimens, a small slip of the tendon (comprising less than 25% of its substance) had not been included. No specimen was found to have a separate slip of the adductor tendon inserting into the base of the proximal phalanx. Instead, all specimens were found to have only a conjoined insertion of fibers of the adductor hallucis and of the flexor hallucis brevis from the lateral sesamoid into the base of the proximal phalanx. We did not identify a separate tendon-insertion into the proximal phalanx in any specimen. Therefore, great caution should be exercised in releasing an isolated insertion of the adductor tendon from the base of the proximal phalanx of the great toe since it may actually represent the conjoined insertion of the lateral flexor hallucis brevis tendon and the adductor tendon. We found that by simply releasing the adductor tendon from its insertion along the lateral aspect of the sesamoid, accomplished through an incision in the dorsal first web, that an adequate release was achieved in most specimens.

Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity.

Seven adult males with rigid, severe equinovarus deformities underwent single-stage corrective surgery. The procedure included extensive soft tissue release, talectomy and tibiocalcaneal, calcaneocuboid, and tibionavicular fusion. All seven patients fused successfully at an average of 3.5 months with a plantigrade foot. All feet were stiff and had an average of 3.5 cm limb length discrepancy. All of the patients were satisfied with the surgery and would choose to have the procedure again. This small series represents one method of achieving a plantigrade foot in patients with severe, rigid equinovarus deformities.

The role of ankle arthroscopy on the surgical management of ankle fractures.

Nineteen patients were prospectively randomized for operative treatment of their ankle fracture to be supplemented with or without ankle arthroscopy. All patients had an SER or PER fracture with an intact medial malleolus requiring operative treatment without evidence of intra-articular debris preoperatively. All patients underwent plate fixation of their fibula fracture and had a similar postoperative protocol. Ten patients were randomized to the control group with plate fixation only and nine patients randomized to the plate fixation plus operative arthroscopy. The average follow-up was 21 months. The arthroscopic examination of the study group revealed eight of the nine patients to have articular damage to the dome of the talus. Minimal arthroscopic treatment of these joints was required. All patients healed their fractures. No difference was noted between SF-36 scores or lower extremity scores between the two groups. At short-term follow-up, it does not appear that the arthroscopic procedure will impact upon the patient's eventual outcome in this small group of patients.

Outcome study of hallux valgus surgery--an AOFAS multi-center study.

Three hundred and eleven patients have been enrolled in a multi-center prospective study evaluating the outcome of hallux valgus surgery by the members of the American Orthopaedic Foot and Ankle Society. One hundred seventy-nine of these patients have completed six-month follow-up questionnaires, and 195 have completed 12-month questionnaires. The AAOS Lower Limb Outcomes Data Collection Questionnaire and the Foot and Ankle Outcomes Data Collection Questionnaire were used to assess patients' perceptions of their results. Both of these instruments are validated lower extremity instruments. They contain the SF-36 instrument as well as questions relating to lower extremity function. At six- and 12-month follow-up, significant improvement has been noted in the patients' SF-36 physical function scores, role physical scores, and bodily pain scores. Role emotional scores were increased at six months but returned to baseline at 12 months. The scores for physical health and pain and satisfaction with symptoms for the lower extremity have significantly improved. The global foot and ankle score and shoe comfort score from the foot and ankle module have also significantly improved. This outcome study is the first to focus on the patient's perception of results of hallux valgus surgery and demonstrates a significant improvement in pain, function, and satisfaction after bunion surgery performed by members of the American Orthopaedic Foot and Ankle Society.

Management of foot pain associated with accessory bones of the foot: two clinical case reports.

STUDY DESIGN: Case study. OBJECTIVES: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. BACKGROUND: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. METHODS AND MEASURES: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. RESULTS: The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level. CONCLUSIONS: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain.

Complications after treatment of tibial pilon fractures: prevention and management strategies.

Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis.

Sepsis and osteomyelitis about the ankle joint.

Sepsis and osteomyelitis about the ankle joint present a challenging clinical problem. Osteomyelitis usually follows open fracture of the distal tibia, often with a pilon fracture component. This article outlines the prevention of osteomyelitis in these difficult fractures. Treatment of subsequent osteomyelitis and sepsis, including the authors' experiences, is discussed. Septic ankle arthritis can occur hematogenously. In some patients, the optimal treatment for concomitant osteomyelitis and sepsis is a below knee amputation.

Complications of foot and ankle surgery.

Surgery of the foot and ankle encompasses many pathologic entities, each with its own pitfalls. Some complications can be prevented through accurate diagnosis, careful patient selection, appropriate selection of surgical procedure, and thorough performance of surgical technique. Although they may arise from systemic events, immediate complications also can be diminished by training operating room personnel and nursing staff.

Ankle fusion in a high risk population: an assessment of nonunion risk factors.

Between July 1992 and April 1996, 88 ankle fusions were performed at our institution. Sixty-seven of these had adequate follow-up for evaluation for union of the fusion, including adequate records and/or radiographs. The average age of patients was 43 years. There were 37 men and 24 women. The charts were reviewed to determine what level of trauma had resulted in posttraumatic arthritis (low energy, high energy, or open fracture). Alcohol use, drug abuse, diabetes, peripheral vascular disease, psychiatric history, smoking, or technical problems were also assessed. A chi-square analysis was used to evaluate the statistical significance. Nineteen of sixty-seven ankle fusions progressed to nonunion (28%). Eighty-five percent of the patients had posttraumatic arthritis. Among 17 patients with a history of open trauma, nine patients developed a nonunion (P < 0.03). A trend toward significance was noted for patients who were smokers, drank alcohol, had diabetes, had a psychiatric disorder, or used illegal drugs. Even with current techniques, this study demonstrates that a high risk population in a trauma center is at risk for nonunion after an ankle fusion caused by multiple risk factors, including a history of open trauma, tobacco use, alcohol use, illegal drug use, a history of psychiatric disorders, or diabetes.

Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail.

Twelve patients underwent successful tibiotalocalcaneal arthrodesis using a locked intramedullary nail with posterior moldable bone grafting. Two of the patients developed a nondisplaced stress fracture around the proximal interlocking screws, which responded to immobilization at 8 and 15 months after surgery. In 7 of 12 patients, > or =2 mm of cortical hypertrophy was noted between the proximal interlocking screws along the medial and/or lateral aspect of the tibia. Although intramedullary nailing can achieve satisfactory tibiotalocalcaneal arthrodesis, the stress risers in the tibial diaphyses do result in a stress reaction in a significant number of patients.

Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report.

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.

Superior compressive strength of a calcaneal fracture construct augmented with remodelable cancellous bone cement.

Twenty-six paired, fresh-frozen cadaveric feet were disarticulated at the ankle joint, and the dome of the talus was potted. Stress-risers were placed along the medial, lateral, and posterior aspects of the calcaneus, and the specimen was loaded rapidly to failure in a testing machine to produce a type-IIB displaced intra-articular fracture according to the classification system of Sanders et al. One specimen of each pair was treated with standard internal fixation with bone-grafting (the control group), and the other was treated with similar fixation but with SRS (Skeletal Repair System) calcium phosphate bone cement placed in any osseous defect. All of the specimens were cured for twenty-four hours in a bath of saline solution at 37 degrees Celsius. The specimens were tested cyclically for ten cycles from zero to 100 newtons at one hertz and for 1010 cycles from zero to 350 newtons at one hertz. The deformation per cycle (millimeters per cycle), first-cycle deformation (millimeters), number of cycles to failure, and number of specimens withstanding the cyclical testing were calculated. The specimens were examined radiographically before and after fracture and after reconstruction and testing. A large difference in the results of the cyclical testing was noted. The specimens that had been augmented with the SRS bone cement had an average deformation of 0.00195 millimeter per cycle compared with 1.013 millimeters per cycle in the control group (p < 0.005). A similar magnitude of difference was noted when the results were stratified for good and poor-quality bone. Visual examination and radiographs demonstrated that a type-IIB displaced intra-articular fracture had been created reproducibly, and computed tomographic scans showed that nearly anatomical reconstruction had been achieved in all of the specimens. The computerized tomographic scans revealed good filling of the osseous voids and no evidence of failure of the cement after cyclical loading.