Temporary Transarticular Screw Fixation for Traumatic Peritalar Instability After Talar Fracture-Dislocation

Abstract

Background:

Traumatic peritalar instability following talar fracture-dislocation is a complex surgical challenge with no consensus on adjunctive stabilization. Current strategies can involve extensive soft tissue dissection or external fixation. We report a retrospective case series evaluating temporary transarticular screw fixation as an adjunct to open reduction and internal fixation (ORIF).

Methods:

We conducted a retrospective case series of 9 patients (10 extremities) treated at a single tertiary institution between 2015 and 2024 for traumatic peritalar instability persisting after ORIF. After primary ORIF of the talus, persistent subtalar instability was addressed with one or two 4.0-mm cortical screws placed across the subtalar joint. Screws were removed after radiographic evidence of fracture union. Primary outcomes were resolution of instability judged by intraoperative resolution of dislocation/subluxation with maintenance of joint congruity to injury resolution. Secondary outcomes were incidence of complications, including avascular necrosis (AVN) and posttraumatic arthritis (PTA).

Results:

The cohort included 9 patients (mean age 37 years) with a mean follow-up of 27 months. All 10 operative extremities achieved full resolution of peritalar instability. Three extremities required subsequent arthrodesis because of PTA and/or AVN. Two extremities developed AVN, with 2 of the 3 arthrodeses following AVN development. One patient did not have the transarticular screw removed because of articular surface damage at the time of index injury. Three extremities developed infections: 2 superficial infections resolved with oral antibiotics, and 1 deep infection necessitated tibiotalar and subtalar arthrodesis using an antibiotic-coated intramedullary nail due to osteomyelitis, with infection resolution and return to activity. Nine extremities exhibited some form of PTA in the peritalar articulations. Four of 10 patients underwent Achilles tendon lengthening for contracture. Eight of 9 patients returned to unprotected weightbearing and full activity at the most recent follow-up; 6 resumed work and could perform a double-leg heel rise, and 2 required bracing.

Conclusion:

Temporary transarticular screw fixation appears safe in this limited series and effective for resolving traumatic peritalar instability. The observed AVN rate (20%) is lower than many published series but should be interpreted cautiously given the small sample size. PTA rates remain high but are consistent with the expected results because of the severity of the initial injury. This technique may serve as a valuable, minimally invasive adjunct in the management of complex talar trauma.

Level of Evidence:

Level IV, retrospective case series.

Graphical Abstract.

Introduction

Fracture-dislocations of the talus are rare, accounting for less than 1% of adult fractures, but carry high morbidity due to the complex anatomy and fragile vascularity of the talus. ¹ They usually occur after high-energy trauma such as motor vehicle collisions or falls. ² The talus forms critical articulations with the tibia, fibula, calcaneus, and navicular, making its stability essential for gait. ¹ With nearly 70% of its surface covered by articular cartilage, the bone has surface area available for vascular entry points, rendering it highly susceptible to avascular necrosis (AVN) after displaced fractures. ²

Severe talar neck or body fractures are often associated with severe soft tissue injury and disruption of surrounding ligamentous and capsular tissue. As a result, fracture-dislocations of the talus are at severely increased susceptibility to instability in the form of persistent subluxation or dislocation.^{1,3 -5} Persistent dislocation or subluxation of the talus on any of its neighboring articulations following traumatic injury constitutes traumatic peritalar instability. Subtalar instability is the most commonly described form of traumatic peritalar instability, typically following subtalar dislocation. Subtalar dislocations occur in approximately 15% of all injuries of the talus. Subtalar joint dislocations occur in the horizontal plane, with medial dislocations occurring in approximately 80% of all cases followed by lateral and posterior dislocations with 15% to 35% and 0.8% to 2.5% of all cases, respectively.^4,5 Peritalar instability may persist even after anatomic open reduction and internal fixation (ORIF), predisposing patients to fixation failure, malunion, and chronic disability.^2,5 Standard fixation techniques with screws and plates require extensive dissection, which can theoretically compromise the remaining blood supply. ³

Temporary adjuncts to definitive fixation have been described for the treatment of peritalar instability including external fixation or transarticular Kirschner wires. Both methods have been used safely and effectively in the past with generally satisfactory results although these methods have their own detriments. External fixation has the benefit of being a strong construct that can maintain reduction but has been linked to variable rates of pin site infections and is cumbersome for patients to deal with as a long-term treatment. Kirschner-wire fixation, typically with smooth wires to allow for subsequent removal, is a lower profile option. However, it is a weaker construction that has a theoretical risk of pulling out prematurely because of the nature of the wire or breakage due to the wire’s smaller diameter. These methods are overall safe and effective; however, there is no consensus regarding optimal treatment for these injuries.^3,6,7 This study describes a cohort of patients with peritalar instability treated with temporary transarticular screw fixation across the subtalar joint as a minimally invasive adjunct to ORIF. It is hypothesized that this method will lead to similar rates of success in resolution of peritalar instability and similar rates of complications including AVN and infection compared with currently described methods. We report a description of the technique used alongside clinical and radiographic outcomes.

Methods

Study Design and Ethical Approval

We conducted a retrospective case series at a level 1 trauma center between January 2015 and December 2024. The study followed the Declaration of Helsinki and was exempt from institutional review board IRB approval because of its retrospective nature.

Patient Population

Inclusion criteria were skeletally mature patients with acute talar fracture-dislocations and intraoperatively confirmed persistent subtalar instability after ORIF. Patients with pathologic fractures, isolated dislocations, or primary arthrodesis were excluded. Nine patients (10 extremities) met criteria.

Surgical Technique

All cases were performed by fellowship-trained foot and ankle orthopaedic surgeons. After ORIF of talar and associated fractures, subtalar stability was assessed under fluoroscopy. Instability was assessed intraoperatively via manual subtalar stress radiographs, placing the foot in forced maximum dorsiflexion and supination. Instability was defined as visible alteration in talar tilt, significant increase in the distance from the posterior facet of the calcaneus to the posterior facet of the talus or appreciable anteroposterior subluxation/dislocation of the talus on the calcaneus.

If instability was noted following definitive fixation, then 1.6-mm Kirschner wires were placed, either in an antegrade fashion starting at the anterosuperior talar neck or in a retrograde fashion starting at the posterior aspect of the calcaneal tuberosity. The Kirschner wires were placed across the subtalar joint, with the trajectory assessed on the anteroposterior, lateral, and Harris radiographic views. The Kirschner wires were placed across 3 cortices, without penetrating the far cortex. A 2.7-mm cannulated drill was used to drill to the level of the far cortex under fluoroscopic guidance. The drill was removed completely and 4.0-mm solid screws were inserted percutaneously across the subtalar joint in either an antegrade or a retrograde fashion at the operating surgeon’s discretion with fluoroscopic guidance. Screws, rather than 2.0-mm Kirschner wires or a threaded Steinmann pin, were used for ease of removal, decrease risk of pin site infection, and decrease risk of hardware failure. Typically 1 screw was used, and if dynamic instability was still appreciated then a second screw would be inserted in the same fashion. In one instance, 3 screws were used. Following screw placement, they were assessed a final time on anteroposterior, lateral, and the Harris views to ensure that there were no violations of the tibiotalar joint or breaches of the medial/lateral calcaneal cortex. No joint preparation was used to minimize risk of arthrodesis (Figures 1 and 2).

Figure 1.

Stepwise intraoperative images detailing the described technique starting at (A) & (B) An Anteroposterior and Lateral views of the ankle following open reduction and internal fixation and assessment of peritalar instability. (C) & (D) Anteroposterior and Lateral views following placement of Kirschner wires in both an antegradeand retrograde fashion accross the subtalar joint without any drilling or other preparation of the joint for arthrodesis. Kirschner Wires are placed perpindicular to the subtalar joint from the talar neck to the calcaneal tuberosity. (E) Retrograde drilling with a cannulated drill to follow the trajectory of the Kirschner wire, drilling with the same diameter drill throughout to ensure no compression and (F) Placement of the 4.0mm solid screw accross the subtalar joint following the trajectory of the drill.

Figure 2.

Continuation of intraoperative flouroscopic images from Figure 1 of the described technique following initial retrograde screw placement with (A) & (B) Anteroposterior and Lateral views of the Ankle confirming appropriate screw placement without violation of the articular surface, interval removal of initial antegrade Kirschner Wire. (C) Placement of second retrograde solid screw, parallel to first screw. (D) & (E) Demonstration of antegrade screw placement from talar neck to calcaneal tuberosity. (F) Anteroposterior view of the ankle demonstrating intact articular surface and (G) Harris view of the Calcaneus demonstrating appropriate screw placement without violation of the medial or lateral calcaneal cortices.

Postoperative Management and Hardware Removal

Patients were kept nonweightbearing for 10-12 weeks until radiographic union, followed by outpatient screw removal to restore subtalar motion. Patients were placed into a short leg nonweightbearing cast at their first postoperative visit. At 4-6 weeks, they were allowed to wear a controlled ankle movement (CAM) / fracture boot and start on early gentle range of motion exercise pending evidence of radiographic healing.

Data Collection and Outcome Measures

Data collected included demographics, fracture type, and operative details. Primary outcome was resolution of peritalar instability. Secondary outcomes included AVN, posttraumatic arthritis (PTA), infection, and need for further surgery.

Statistical Analysis

Given the small sample size, descriptive statistics were used.

Results

Patient and Injury Characteristics

Nine patients (10 extremities) were included, with a mean age of 37 years (range 24-52). Mean follow-up was 27 months. All injuries were high-energy, most from motor vehicle collisions; 3 were open fractures. Seven patients sustained polytrauma. Three cases were Hawkins type III talar neck fractures. Detailed patient data are presented in Table 1.

Table 1.

Patient Demographics and Injury Characteristics.

Extremity No.	Age	Sex	Mechanism	Open/Closed	Talar Injury Type	Concurrent Injuries
1	52	F	MVC	Open	Talar neck (Hawkins III)	N/A
2	28	F	Unknown	Open	Talar neck (Hawkins III)	N/A
3	43	M	MVC	Closed	Talar body Fx	R pilon, L anterior process calcaneus Fx
4	24	M	Fall	Closed	L unspecified talus Fx	Bilateral pilon Fx, R 5th metatarsal base Fx
5	24	M	Fall	Closed	R unspecified talus Fx	Bilateral pilon Fx, R 5th metatarsal base Fx
6	45	M	MVC	Closed	Talar body Fx, subtalar dislocation	R trimalleolar ankle Fx
7	38	M	Fall	Closed	Talar head Fx, subtalar dislocation	N/A
8	24	F	MVC	Closed	Talar body Fx, subtalar dislocation	R calcaneus Fx
9	49	M	MVC	Closed	Talar body & navicular dislocation	L distal femur, patella, navicular, cuneiform, Lisfranc, bimalleolar Fx
10	30	M	MVC	Open	Talar neck (Hawkins III)	Ipsilateral bimalleolar ankle Fx, contralateral talar body Fx

Abbreviations: Fx, fracture; L, left; MVC, motor vehicle collision; R, right.

Operative and Clinical Outcomes

Peritalar instability was successfully resolved in all extremities (Figure 3). No recurrent dislocations or subluxations occurred after screw removal. Screws were typically removed at a mean of 23 weeks. One patient did not undergo removal because of severe articular damage with planned arthrodesis. At last follow-up, 8 of 9 patients (9 of 10 extremities) were ambulatory. Two of the 8 ambulatory patients required some form of bracing or medical equipment for ambulation. Six of the 8 patients returned to some resemblance of their preoperative functionality, judged objectively as return to work and/or ability to perform at minimum a double leg heel rise. The sole nonambulatory patient was nonambulatory at his last follow-up because of a cardiopulmonary condition, not limited by his extremity. Although all patients felt their extremity permitted them to accomplish their activities of daily living, all patients did report loss of strength and motion in their operative extremity secondary to their injury. Subtalar motion was assessed manually by the senior author in clinic during physical examination and found to be approximately 5 degrees of inversion/eversion in 6 of the extremities, 10 degrees inversion and 5 degrees of eversion in 2 extremities, and 15 degrees inversion with 10 degrees of eversion in 2 extremities.

Figure 3.

Examples of the demonstrated technique with only one 4.0-mm solid cortical screw placed in a retrograde fashion from the calcaneal tuberosity. (A) A talar body fracture with residual instability treated with a single screw. (B) A patient with concurrent medial and lateral malleolar fractures who was found to have peritalar instability following fixation of these injuries but with fractures of the talus thought to be too small for fixation at the time of index surgery, treated with a single retrograde screw. (C) A patient with a talar neck fracture extending into the talar body with an ipsilateral tibial plafond/pilon injury treated with a single retrograde screw.

Complications

The rates of major complications are detailed in Table 2. The most common complication seen in this patient population was PTA with 9 of 10 extremities demonstrating radiographic evidence of PTA at their final follow-up including arthritic changes within at least one of the subtalar, tibiotalar, or talonavicular joints. Tibiotalar arthritis was noted in 5 of 10 extremities, subtalar arthritis within 7 of 10 extremities, and talonavicular arthritis within 3 of 10 extremities. Other notable complications included AVN of the talus, infection, superficial deep vein thrombosis, and Achilles tendon contracture. AVN was documented in 20% of extremities; infection in 30% of extremities, with 2 of 10 extremities having superficial infections that resolved with oral antibiotics and 1 deep infection requiring antibiotic-coated cement intramedullary nail; and 40% of patients developed Achilles tendon contractures requiring tendo-Achilles lengthening. One patient developed a superficial deep vein thrombosis that was treated successfully with thrombectomy and anticoagulation. Thirty percent of extremities had such significant pain and residual dysfunction that they underwent a salvage procedure, including arthrodesis of the ankle or subtalar joint.

Table 2.

Operative Details, Complications, and Outcomes.

Extremity No.	Time to Screw Removal (wk)	Total No. of Surgeries	AVN	Arthritis (TT, ST, TN)	Other Complications	Final Outcome / Salvage Procedure
1	23	2	Y, complete	Y, Y, Y	Osteomyelitis	Tibiotalar and subtalar arthrodesis (IMN)
2	14	2	N	N, N, N	Achilles contracture	TAL, fracture resolution
3	0 a	5	N	Y, N/A, N	None	Subtalar arthrodesis
4	33	5	N	Y, Y, N	None	Fracture resolution
5	33	5	Y, complete	Y, Y, N	Tibiotalar non-union	Tibiotalar arthrodesis, ST autofusion
6	22	5	N	Y, Y, N	DVT, Achilles contracture	TAL, fracture resolution
7	17	3	N	N, N, Y	None	Fracture resolution
8	21	3	N	N, Y, N	Achilles contracture, claw toe	TAL, flexor tendon release, fracture resolution
9	20	2	N	N, Y, N/A	None	Talonavicular fusion, fracture resolution
10	25	3	N	N, N, Y	Superficial infection	Fracture resolution

Abbreviations: AVN, avascular necrosis; DVT, deep vein thrombosis; IMN, intramedullary nail; ST, subtalar; TAL, tendo-Achilles lengthening; TN, talonavicular; TT, tibiotalar.

^aScrew not removed.

Discussion

This study suggests that temporary transarticular screw fixation may be a simple and potentially effective adjunct to currently described treatment strategies including external fixation and ORIF for severe talar fracture-dislocations. Stability was restored in all cases, with no recurrent subluxation after screw removal. The AVN rate in this population was 20% (2/10 extremities), lower than historical rates for comparable high-risk fractures, particularly Hawkins type III injuries, where reported rates often exceed 40% to 90%.^8-12 The percutaneous and minimally invasive nature of this technique may theoretically help preserve vascular inflow to the talus by avoiding additional soft tissue stripping and approaching the talus at a location where there is no blood supply to disrupt. Further research is necessary to support the validity of this claim given the relatively low power of this study to detect any appreciable difference compared with more standard techniques.

In contrast, radiographic PTA was nearly universal (90%). This is consistent with the severity of initial chondral injury and is considered an inevitable sequela rather than a complication of the fixation method. ⁵ Although it is possible that this technique contributed to the development of arthritis via disruption of the articular surface, it is the experience of the senior author that this technique is effective at preventing more devastating outcomes such as malunion and chronic instability, which would have led to earlier, more disabling arthritis. An additional advantage of this technique is that it is theoretically motion-sparing, especially compared to a primary arthrodesis. Although some degree of subtalar stiffness is expected, both becase of the nature of the technique and the severity of the injury, by removing screws after fracture healing and without preparing the joint for fusion, subtalar motion is theoretically preserved. Further research is necessary to quantify the degree of subtalar motion present following this technique objectively in comparison to treatment with currently established practices. An additional benefit of this technique is that salvage procedures such as arthrodesis remain easily achievable if symptomatic arthritis develops.^10,11

Limitations include the retrospective design, small sample size, lack of a control group, and variable follow-up. Longer-term studies with validated functional outcomes are needed to determine whether this technique improves quality of life compared with other adjuncts such as external fixation or K-wires. The heterogeneity of the included injuries and patients, although representative of real-world clinical practice, also makes it difficult to isolate the effect of the technique for a single fracture pattern. Despite these limitations, our findings support temporary transarticular screw fixation as a safe and reliable option either as an alternative or a supplement to currently described treatment strategies.

Conclusion

Temporary transarticular screw fixation appears to be a safe, minimally invasive technique for managing persistent peritalar instability. In this small series, the method restored stability and showed a lower-than-expected rate of AVN. Although PTA remained common, this likely reflects the severity of the initial injuries rather than the fixation itself. Further research is necessary in larger cohorts of patients to better evaluate the utility of this technique compared with contemporary treatments.