Effect of percutaneous and arthroscopically assisted osteosynthesis of talar body fractures

doi:10.21203/rs.3.rs-1631338/v1

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Effect of percutaneous and arthroscopically assisted osteosynthesis of talar body fractures

https://doi.org/10.21203/rs.3.rs-1631338/v1

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Background: Talar fractures are relatively rare. The complex anatomy of the talus makes it difficult to visualize, reduce and fix without performing an arthrotomy or osteotomy. Currently, few studies focused on complications of the percutaneous and arthroscopically assisted talar osteosynthesis technique. This clinical retrospective study aims to investigate the effectiveness of the percutaneous and arthroscopically assisted talar osteosynthesis based on the complications and functional outcomes.

Methods: The percutaneous and arthroscopically assisted talar osteosynthesis was performed in 15 patients with 16 fractures (one bilateral). The mean patients age was 31 years (range, 14 to 52 years). There were 10 males and 5 females. Sneppen classification for talar body fractures was type II in 14 cases and type III in 2 cases.

Results: Fifteen patients with 16 fractures were followed up, and the average follow-up period was 36 months (range, 24 to 65 months). No skin infections, osteomyelitis, skin necrosis in all patients were observed. During the follow-up, bony nonunion and/or delayed union were not found. At the final follow-up, two out of 15 patients (13.3%) occurred the peri-talar osteoarthritis. The ankle-hindfoot pain was absent in 11 patients (12 ankles), mild in 4 patients. Based on the AOFAS ankle–hindfoot scale, functional results were excellent in 7 ankles, good in 9 ankles. The mean AOFAS Ankle-Hindfoot Score of all patients was 85.7 points (range, 79 to 93 points).

Conclusions: The percutaneous and arthroscopically assisted talar osteosynthesis technique is a reliable and feasible, and gives good clinical outcomes.

Level of Evidence: IV

talar body fractures

ankle arthroscopy

percutaneous osteosynthesis

Talar fractures are usually caused by high energy traumas such as motor vehicle accidents and high fall injuries. Talar fractures are relatively rare with an estimated incidence ranging from 0.1–0.85% of all fractures [1], accounting for 3–5% of foot and ankle fractures [2]. The talus has a unique anatomical structure that over one half of the surface of the talus is covered by articular cartilage and there are no muscular attachments [3]. Furthermore, the complicated anatomy of the talus makes it difficult to visualize, reduce and fix [4]. Thus, the treatment of talar fractures poses a serious challenge to orthopedic surgeons.

Based on the anatomic region, talar fractures are divided into the fractures of the head, neck, and body[2], of which talar body fractures account for 7–38% of all talar fractures [5]. Talar body fractures are one of the most difficult fractures to treat operatively in the foot and ankle surgery [6]. According to the pattern and location, Sneppen et al. classified talar body fractures into 5 types: I: compression or osteochondral dome fracture, II: coronal, sagittal or horizontal shear fracture, III: posterior tubercle fracture, IV: lateral tubercle fracture, V: crush comminuted fracture [7]. Currently, conventional open reduction-internal fixation (ORIF) is often recommended to treat displaced talar body fractures [5, 8], and various surgical approaches have been used to operatively reduce and firm talar body fractures [8]. If necessary, a medial or lateral malleolar osteotomy is used as an alternative or auxiliary method to the anteromedial or anterolateral approach to the talus[6, 8]. Unfortunately, these surgical techniques can cause high rates of postoperative complications and a poor prognosis. Vallier et al. reported that the talar body fractures treated with ORIF had a 38.5% rate of osteonecrosis, a 65.4% rate of arthritis in the ankle joint, and a 34.6% rate of arthritis in the subtalar joint [5]. Biz et al. concluded that the complications of the talar body fractures treated with ORIF included malunions (21.4%), wound problems (25%), avascular necrosis (25%), and post-traumatic arthritis (78.6%) [9].

Abdelgaid et al. in 2012 reported the percutaneous reduction and screw fixation for the treatment of the talus neck fracture [10]. Jorgensen et al. in 2014 reported the surgical techniques for arthroscopic treatment of talar body fractures [11]. Currently, few studies focused on complications of the percutaneous and arthroscopically assisted osteosynthesis of talar body fractures. Importantly, the effectiveness of the percutaneous and arthroscopically assisted osteosynthesis of the displaced talar body fractures has yet to be determined. Thus, this clinical retrospective study aims to investigate the effectiveness of the percutaneous and arthroscopically assisted osteosynthesis of the displaced talar body fractures based on the complications and functional outcomes.

This study was approved by the research ethics committee of the Second Hospital of Shandong University. All methods were carried out in accordance with WMA declaration of Helsinki ethical principles for medical research involving human subjects. In our series, the patients who suffered from displaced talar body fractures of Sneppen type I-V [7] and articular displacement > 1mm were selected (Fig. 1). Furthermore, the patients with multiple (ankle or subtalar or talonavicular) joint dislocation capable of closed reduction, or bilateral fractures were also included in this study. The patients with the displaced talar body fractures of the articular displacement ≤ 1mm were excluded. Accordingly, we reviewed medical records of inpatients and found that 17 patients with talar body fractures from June 2016 to October 2019 underwent the percutaneous and arthroscopically assisted osteosynthesis. In our series, two patients were excluded because they refused to participate in this study during the follow-up period. Finally, fifteen patients took part in this study.

Surgical technique

All patients underwent operative treatment under general anesthesia. The tourniquet was used on the affected side thigh. Before surgery, the X-rays and computed tomography (CT) scans (Fig. 1) were used to assess the anatomical location and severity of talus body fracture and the condition of joint dislocation for the choice of surgical approach. When the talar body fracture was combined with the ankle joint and/or subtalar joint and/or talonavicular joint dislocation, the reduction of the joint dislocation was performed immediately after trauma.

According to the anatomical site of the fracture, when the fracture occurred in the front two-thirds of the talar body, the patient was initially placed in the supine position. The anteromedial and anterolateral ankle arthroscopy portals are used. The anteromedial portal is located at medial to the junction of the anterior line of the ankle joint and the tibialis anterior tendon. The anterolateral portal is situated at lateral to the junction of the anterior line of the ankle joint and the peroneus tertius tendon. A 4.0-mm-diameter arthroscope with a 30^° oblique viewing angle was used to visualize the condition of the fracture and articular surface displacement. Under the arthroscopic visualization, the hematoma, tiny bony fragments and inflammatory tissue were removed using a 4.0-mm-diameter cutter, with the aid of the straight microprobe and linvatec straight grasping forceps. The fracture fragments were raised and reduced using the straight microprobe and osteotome under arthroscopic visualization. The 2.0-mm-diameter Kirschner wire was imbedded under arthroscopic visualization to temporarily stabilize the fracture. If there was a non-constant bony fragment, it can be fixed with a 2.5-mm-diameter hollow screw. After that, the patient was positioned in a prone position. The posterolateral and posteromedial ankle arthroscopy portals, adjacent to the Achilles tendon, were used. The posteromedial portal was placed lateral to the flexor hallucis longus tendon to protect the neurovascular bundle from injury. Under arthroscopic visualization, the hematoma, tiny bony fragments, and inflammatory tissue behind the ankle joint were resected using a 4.0-mm-diameter cutter. The flexor hallucis longus tendon was exposed and retracted medially. The extent of damage to the ankle and subtalar joints was evaluated through the arthroscopic posterior approach. Simultaneously, the fracture blocks were raised and reduced and temporarily fixed with the K-wires. The reduction state of talar body fractures at the ankle and subtalar joints was again assessed via the arthroscopic posterior approach. Intraoperative x-ray examination ensure that the guide pin was located at the middle of the talar head. 4.0 mm-diameter hollow screws were inserted and all the Kirschner wires were removed (Fig. 2 and Fig. 3).

Postoperative management

The compression dressing of the affected side limb was performed within one week after operation. The skin sutures were removed in the postoperative for 2 weeks. The short-leg non-walking cast was worn for 8 weeks after the operation. Functional exercises of the ankle joint and subtalar joint were performed. Partial weight-bearing walking on the affected side limb was allowed at postoperative 9–10 weeks, and full weight-bearing walking was performed from 11 weeks after surgery.

Function evaluation

The quality of reduction of the talar body fracture was evaluated by the intraoperative fluoroscopy and post-operative CT scan. At the final follow-up, the radiographic examination including the anteroposterior and lateral view of the ankle was performed to assess the malunion, nonunion, peri-talar osteoarthritis and osteonecrosis. Malunion was referred to as non-anatomic healing of the talus, and nonunion as lack of bony healing within one year [12]. Peri-talar osteoarthritis was defined as the formation of the periarticular tiny osteophyte, the narrowing of the joint space, or development of subchondral sclerosis or cysts, but was not graded according to its severity [13]. Compared with the adjacent structures, any area where the density of the talar dome has augmented on the x-rays was considered as the osteonecrosis (Hawkins sign) [13]. The pain level at the affected-side limb was evaluated with the visual analog scale (VAS) score between 0 and 10 points (0: no pain, 1–3: mild pain; 4–6: moderate pain, and 7–10:severe pain) [14]. Wound scar was measured with the modified vancouver scar scale (mVSS) score ranging from 0 to 15 points (pigmentation: 0–3, vascularity: 0–3, pliability: 0–5, height: 0–4), with the higher the scores, the severer the scar [15]. Clinical outcomes were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score [16], and the Manchester-Oxford foot questionnaire (MOxFQ) [17, 18]. According to the AOFAS ankle-hindfoot scale [16], ROM of the ankle joint was evaluated with the ankle in the neutral position: normal or mild restriction (30^o or more) was assessed as three points, moderate restriction (15^o-29^o) was assessed as two points, and severe restriction (less than 15^o) was assessed as one point; ROM of the subtalar joint was also assessed with the ankle in the neutral position: normal or mild restriction (75–100% normal) was evaluated as three points, moderate restriction (25–74% normal) was evaluated as two points and severe restriction (less than 25% normal) was evaluated as one point. Finally, the AOFAS ankle-hindfoot scale score was grouped into excellent (90–100 points), good (75–89 points), fair (50 − 47 points), failure (< 50 points) [16, 19]. MOxFQ is a specific patient-reported outcome measure of the foot and ankle, including three parts: foot pain, walking/standing problems, and issues related to social interaction including feelings of self-consciousness about foot/footwear appearance. This scale score ranges from 0 to 100 points with 0 points representing an optimal result [17, 18].

Baseline information

Fifteen patients were followed up, and the average follow-up period was 36 months (range, 24 to 65 months). The patients’ mean age at the time of surgery was 31 years (range, 14 to 52 years). Fifteen patients did not suffer from diabetes mellitus, hypertensive disease, and soft tissue swelling with fracture blisters. Of the15 patients, there were 10 males and 5 females, and one patient occurred the bilateral talar body fractures while the remaining patients occurred the unilateral talar fractures; of which, talar body fractures occurred in 5 cases on the left and 11 cases on the right. Sneppen classification for talar body fractures was type II in 14 cases and type III in 2 cases. Also, three out of 15 patients occurred the talar body fracture with joint dislocation (ankle and subtalar joint = 1, subtalar and talonavicular joint = 2). The most common injury mechanism was high fall injury (n = 9). Basic information of 15 patients were shown in Table 1.

Table 1

The basic information of 15 patients with 16 talar body fractures.
Case	Gender	Laterality	Injury Mechanism	Sneppen Type	Joint Dislocation	Initial Reduction	Complications^#
1	F	Right	Vehicle accident	II	No	Anatomical	NO
2	M	Right	High fall injury	III	Subtalar joint and talonavicular joint	Anatomical	NO
3	M	Right	High fall injury	II	No	Anatomical	NO
4	M	Left	Crushing	II	No	Anatomical	NO
5	M	Right	High fall injury	II	No	Anatomical	NO
6	F	Left	High fall injury	II	No	Anatomical	NO
		Right	High fall injury	III	No	Anatomical	NO
7	F	Right	High fall injury	II	No	Anatomical	NO
8	M	Left	High fall injury	II	No	Nearly anatomical	Osteoarthritis
9	M	Right	High fall injury	II	No	Anatomical	NO
10	M	Left	Twisting injury	II	Ankle joint and subtalar joint	Anatomical	NO
11	F	Right	Twisting injury	II	No	Anatomical	NO
12	F	Right	Twisting injury	II	No	Anatomical	NO
13	M	Right	High fall injury	II	No	Anatomical	NO
14	M	Right	High fall injury	II	Subtalar joint and talonavicular joint	Anatomical	Osteoarthritis
15	M	Left	Vehicle accident	II	No	Anatomical	NO
F: Female, M: male, #: There were no complications of skin infection, skin necrosis, osteomyelitis, osteonecrosis, or non-union.

Complications and clinical outcomes

No skin infections, osteomyelitis, skin necrosis in all patients were observed. During the follow-up, osteonecrosis, bony nonunion and/or delayed union were not found.

At the final follow-up, two out of 15 patients (13.3%) occurred the peri-talar osteoarthritis. The ankle-hindfoot pain was absent in 11 patients (12 ankles), mild in 4 patients. The wound scar score ranged from 0 to 3 points (mean, 0.63 points). The ROM of the ankle joint was normal or mild restriction in 10 ankles, moderate restriction in 6 ankles. The subtalar joint mobility was moderate restriction in 9 ankles, severe restriction in 7 ankles. Those indicated that the injured foot demonstrated a loss of ROM in comparison to the healthy foot for the ankle and subtalar joint.

At the final follow-up, based on the AOFAS ankle–hindfoot scale, functional results were excellent in 7 ankles, good in 9 ankles. The mean AOFAS Ankle-Hindfoot Score of all patients was 85.7 points (range, 79 to 93 points). The mean MOxFQ score was 6.48 (range, 0 to 12.5 points). The patients obtained a satisfactory result (Fig. 4).

In this study, our outcomes demonstrated that the percutaneous and arthroscopically assisted talar osteosynthesis technique is a reliable and feasible, and gives good clinical outcomes and a low risk of complications, although to a level still less than that on the healthy foot.

Compared with the conventional ORIF [6, 8], the percutaneous and arthroscopically assisted talar osteosynthesis technique can avoid the requirement of medial or lateral malleolar osteotomy for exposure. The percutaneous and arthroscopically assisted talar osteosynthesis technique can effectively protect the fragile soft tissue envelope surrounding the injury and lower the risk of damage to the anatomical structures and vasculature surrounding the talus. Moreover, the wounds are often scar-free. In contrast to the ORIF [6, 8] and the technique of Abdelgaid et al. [10], arthroscopy can identify and evaluate the intra-articular loose bodies, cartilage injuries, and trans-chondral defects that are not significant on the radiographic image. Furthermore, it can aid the surgeons to visualize and manipulate joint structures and control the reduction and position of the osteosynthesis devices and perform the stable fixation without performing an arthrotomy, avoiding the protrusions and dislocations of the implant. However, both our technique and Abdelgaid’s [10] technique have the advantage of early minimally invasive fracture reduction and fixation, rapid rehabilitation.

However, previous literature reported that talar body fractures with the treatment of ORIF usually possess much higher incidence of postoperative complications such as infection, skin necrosis, peri-talar osteoarthritis, and avascular necrosis (Table 2) [5, 9, 13, 19–21]. Also, previous studies concluded that the severity and incidence of these complications are associated with the level of soft tissue envelope injury surrounding the ankle, the extent of intrinsic vascular injury following the talar fractures, the extent of fracture displacement, the absence or presence of joint dislocation, and the adequacy of fracture reduction, but not related to the surgical timing [9, 22, 23]. According to Table 2, we found that peri-talar osteoarthritis and avascular osteonecrosis were the most common complications after the surgery of the talar body fractures. However, in our series, no bony nonunion, delayed union were found in all patients during the follow-up period. There may be some reasons for the low incidence of postoperative complications in our study: (1) the percutaneous and arthroscopically assisted talar osteosynthesis technique has little damage to the tissues surrounding talus and effectively protect the fragile soft tissue envelope surrounding the injury and lower the risk of damage to vasculature surrounding the talus; (2) the anatomical reduction rate following the talar body fracture was very high; (3) the condition of fracture union, osteonecrosis, and osteoarthritis may be underestimated in the radiographic examination.

Table 2

The AOFAS score and complications rate of conventional open reduction-internal fixation for treatment of talar body fractures.
Authors	Year	Age (Year) (mean, range)	Number of patients (talus)	Number of talar body fracture	Infection	Skin necrosis	Peri-talar osteoarthritis	Avascular necrosis	AOFAS Ankle-Hindfoot Score (mean, range)
Elgafy[18]	2000	32 (14–74)	58 (60)	11	18.2%	N/A	Subtalar arthritis: 90.9%, Ankle arthritis: 90.9%	27.3%	58 (10–90)
Vallier[5]	2003	34 (15–74)	56 (57)	57	7.1%	1.8%	Subtalar arthritis: 34.6%, Ankle arthritis: 65.4%	38.5%	N/A
Ebraheim[19]	2008	31 (21–68)	19 (19)	19	15.8%	5.3%	Subtalar arthritis: 31.6%, Ankle arthritis: 57.9%	36.8%	68.6 (44–94)
Gomes de Sousa [20]	2009	38.5 (14–63)	19 (19)	5	N/A	N/A	Subtalar arthritis: 50.0%, Ankle arthritis: 40%	45.5%	72 (19–100)
Ohl [12]	2011	38.8 (17–76)	20 (20)	10	10%	0%	Subtalar arthritis: 87%, Ankle arthritis: 76%	20.0%	67 (45–88)
Biz [8]	2019	38.3 (18–81)	31(33)	18 (19)	0%	5.3%	Subtalar arthritis: 36.8%, Ankle arthritis: 31.6%	15.8%	81 (55–97)

Talar body fractures can influence the normal joint motion of the ankle and lead to a poor prognosis on long-term evaluation [24]. As previously reported in the literature [5, 9, 13, 19–21], the patients with talar body fractures using the treatment of ORIF often have a low AOFAS score (Table 2). Table 2 was shown that the mean AOFAS Ankle-Hindfoot Score ranged from 58 to 81 points. Whereas, in our study, the mean AOFAS Ankle-Hindfoot Score of all patients was 85.7 points (range, 79 to 93 points). However, compared with the percutaneous and arthroscopically assisted talar osteosynthesis technique, we found that the most difficult of ORIF is to minimize the damage to the normal tissue surrounding talus, for maintaining the talus blood supply and providing a large enough field for fracture reduction and internal fixation. Also, conventional surgical approaches usually fail to afford full exposure of the talus body, and medial or lateral malleolar osteotomy would be inevitable. Therefore, the protection of the remaining blood supply would become difficult to achieve, not to mention the possibility of talus nonunion and malunion.

Currently, ankle arthroscopy is becoming increasingly prevailing in diagnosis and treatment for the ankle diseases and fractures [25, 26]. The intra-articular displacement of more than 2 mm can change the biomechanics of the ankle joint [27]. In our study, 15 of the 16 talus fractures achieved the anatomical reduction while a talus fracture nearly anatomical reduction. According to our experience, the severer the talar body fractures, the more difficult it is to achieve anatomical reduction under arthroscopy. The indications of the percutaneous and arthroscopically assisted talar osteosynthesis technique were described as follow: (a) talar body fractures of the Sneppen I-IV, (b) articular displacement > 1 mm, (c) soft tissue swelling with the fracture blisters, (d) multiple (ankle or subtalar or talonavicular) joint dislocation capable of closed reduction.

This was a retrospective study that has some limitations. Firstly, if the joint dislocation was combined, there might be a high possibility of vascular injury around the talus. This might affect the incidence of osteoarthritis or avascular necrosis of the talus after fracture reduction. Unfortunately, we cannot determine the level of vascular injury around the talus after joint reduction. Secondly, the condition of fracture union, osteonecrosis, and osteoarthritis may be underestimated in the radiographic examination, and the absence of a later CT or better MRI is also a major flaw in this study. Finally, the follow-up time was relatively short and the sample size was small. The effectiveness of the outcomes in our series requires confirmation in a multicenter study.

The percutaneous and arthroscopically assisted talar osteosynthesis technique is a reliable and feasible, and gives good clinical outcomes and a low risk of complications, although to a level still less than that on the healthy foot.

AOFAS

American Orthopaedic Foot and Ankle Society

ORIF

open reduction-internal fixation

computed tomography

mVSS

modified vancouver scar scale

MOxFQ

Manchester-Oxford foot questionnaire.

Ethical approval and Consent to Participate

Consent to Publish

All the data of this study were approved from each participant. Written informed consent was obtained from each patient.

Authors Contributions

Conception and design: XL, YH; data analysis and interpretation: XL, ZL; data collection: ZL, YW, NZ, WX; writing the article: XL; approving final version: YH, ZL, XL. This manuscript has not been published elsewhere in whole or in part. All authors have read and approved the final version of this manuscript.

Funding

This study was supported by Key Research and Development Project of Shandong Province (NO.2019GSF108092), and Jinan Science and Technology Development Project (NO.20180512).

Competing Interest

None

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Acknowledgement

Not Applicable

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You are reading this latest preprint version

Effect of percutaneous and arthroscopically assisted osteosynthesis of talar body fractures

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Version 1

Abstract

Figures

Background

Methods

Surgical technique

Postoperative management

Function evaluation

Results

Baseline information

Complications and clinical outcomes

Discussion

Conclusions

Abbreviations

Declarations

Ethical approval and Consent to Participate

Consent to Publish

Authors Contributions

Funding

Availability of data and materials

Acknowledgement

References

Status:

Version 1