Abstract
Purpose
This study aimed to evaluate and compare the efficiency, safety and accuracy of robot-assisted internal fixation and traditional freehand percutaneous screw in talar neck fracture treatment.
Methods
This study included 23 patients in the robot-assisted group and 23 patients in the traditional group. Age, injured side, average post-operative follow-up time, time from injury to surgery, operation time, intraoperative blood loss, intraoperative fluoroscopic dose, fracture healing time, American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score, Visual Analogue Scale (VAS) score and 12-item Short-Form Survey (SF-12) score were recorded and compared.
Results
This study revealed no statistical difference in baseline characteristics between the two groups, as well as the average post-operative follow-up time, injury to operation time, intraoperative blood loss, fracture healing time, VAS score, 12-item Short-Form Survey (SF-12) score and AOFAS score (P > 0.05). A significant difference was found between the robot-assisted group and the traditional group at the time of operation and intraoperative fluoroscopic dose (P < 0.05).
Conclusion
Robot-assisted screw placement for talar neck fractures achieved clinical outcomes comparable to those of traditional surgery, with the advantages of significantly shorter operation time and lower intraoperative fluoroscopic dose. Robot-assisted surgery appears to be a safe, effective, and low-radiation alternative for selected talar neck fractures (Hawkins type II).
Keywords: TiRobot, Talar neck fracture, Fluoroscopic dose, Internal fixation
Introduction
The talus is the key bone that transmits body weight from the leg to the foot, serving as a crucial link between the lower limb and the foot. Talar neck fractures are a rare orthopaedic disorder, accounting for < 1% of all fractures [1]. Talar avascular necrosis and fracture nonunion following a talar neck fracture have always been difficult problems in clinical treatment due to the special anatomical structure of the talus [2–4]. Internal fixation options for talar neck fractures include plates, screws, etc. The use of cannulated screw can accelerate fracture healing and most procedures are performed minimally invasively after satisfactory reduction. However, accurate screw placement is the key to the success of minimally invasive surgery, which significantly increases radiation exposure.
Robot-assisted technology developed in recent years enables accurate screw insertion and has been successfully applied to the spine [5, 6], pelvis [7], femoral neck [8], and scaphoid [9], among other anatomical sites, with satisfactory results. We consider whether it can also be applied to talar neck fractures and also have excellent performance based on the application of orthopaedic robots in the above-mentioned parts. However, few studies reported on the use of robots in talar neck fracture treatment, especially the comparative study of intraoperative fluoroscopic dose. Therefore, this study specifically focused on Hawkins type II talar neck fractures, which are the most common type amenable to closed reduction and percutaneous screw fixation, and compared robot-assisted and traditional surgery.This study retrospectively analysed the clinical data of patients with talar neck fractures and compared whether robot-assisted surgery is superior to traditional surgery in terms of fluoroscopic dose and surgical outcomes to clarify the safety and effectiveness of robot-assisted talar neck fracture surgery.
Materials and methods
This study was performed following the principles of the Declaration of Helsinki and approved by the Ethics Committee of the Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, China (Date 2020.9.30/No.424). All participants provided informed consent. A single experienced surgeon performed all surgeries.
Patient selection
This study included 46 patients with talar neck fractures admitted to our department from October 2017 to August 2021. Inclusion criteria: (1) Hawkins type Ⅱ fracture, (2) complete pre-operative plain radiographs and computed tomography examinations, (3) willing to accept internal fixation, (4) no pre-operative ankle osteoarthritis and (5) closed fractures. Exclusion criteria: (1) old fractures, (2) severe osteoporosis, (3) smokers, (4) follow-up time of < 24 months.
Surgical methods and procedures
The operation used the following instruments: the third generation of the ‘Tianji’ orthopaedic robot (Beijing TINAVI Medical Technology Co., Ltd.) with a supporting robot operation bed and 5.0-mm cannulated screws (Changzhou Dean Medical Technology Co., Ltd.); the C-arm uses the ARCADIS Orbic three-dimensional (3D) system (Siemens, Germany).
A dose of antibiotics is infused half an hour pre-operatively. The patient was placed in the supine position after satisfactory general anaesthesia and the dorsalis pedis artery was routinely palpated and marked, the drape was disinfected, blood was expelled and a tourniquet was applied (for spare).
Talar neck fracture reduction in the traditional group was performed as follows. The hip and knee of the affected limb were flexed to 90° to reduce Achilles tendon tension, and the assistant applied calcaneal traction. Push and reset in the opposite direction according to the fracture displacement direction and pay attention to controlling the reduction force to avoid fracture fragment displacement to the opposite side or other secondary injuries. Obtain the C-arm fluoroscopy for anteroposterior (AP) and lateral views of the ankle and Canale view images after fracture reduction. Insert 1–2 pieces of 1.2-mm Kirschner wires from front to back for fixation after satisfaction, then check the AP and lateral plain radiographs of the ankle joint and Canale view images again for fracture reduction and the Kirschner wire position. Place the cannulated screw when satisfied.
The reduction method in the robot-assisted group was performed similarly to the traditional group. After resetting, prepare the robot system, install the positioning ruler, scan the talus with the 3D C-arm and transmit the data to the robot workstation to plan the screw placement. Afterwards, the robotic arm automatically moves to the screw placement position, cuts a small incision and then bluntly separates it. Implant a guide pin to the bone surface, assisted by an electric drill and implant a cannulated screw after the C-arm fluoroscopy shows the correct position. Sutured each screw track with 1 stitch in the whole thickness and bandage with elastic bandage. Figure 1 shows the typical procedure using TiRobot.
Fig. 1.
The TiRobot-assisted procedure performed on a 27-year-old male patient with a left talar neck fracture: a fixation of the TiRobot tracker; b robot registration and three-dimensional planning film; c guide pin insertion; d intraoperative anteroposterior radiograph of the ankle; e intraoperative lateral ankle radiograph; f postoperative anteroposterior radiograph of the ankle; g postoperative lateral radiograph of the ankle
Post-operative management and follow-up indicators
Antibiotics were not routinely used post-operatively and routine analgesia was given, the dressing was changed 24 h post-operatively, the incision was observed and functional exercises were guided. Weight-bearing is avoided for 6 weeks post-operatively and gradually conducted thereafter. The patient decides whether to perform physical rehabilitation therapy as needed after full weight bearing.
Follow-up visits were done monthly until the fracture is healed and every 6 months thereafter. Fracture healing time, AOFAS ankle-hindfoot score, VAS score and 12-item Short-Form Survey (SF-12) score, including mental component score and physical component score, were observed and recorded to assess post-operative functional outcome [10]. Two people who were not involved in the surgical treatment conducted these assessments.
Statistical analysis
Statistical Package for the Social Sciences version 26.0 (IBM, Corporation, Armonk, NY) was used for statistical analysis. Continuous variables were expressed as mean ± standard deviation and an independent sample t-test or Mann-Whitney U test was used for comparison between the two groups. Differences between categorical variables were assessed via the chi-square test or Fisher’s exact test. P-values of < 0.05 were considered significant for all tests.
Sample size calculation was performed based on the primary outcome (operation time). Assuming a mean difference of 15 min between groups, a standard deviation of 10 min, α = 0.05, and β = 0.2 (80% power), the required sample size was calculated as 21 patients per group. Considering a potential dropout rate of 10%, 23 patients per group were finally enrolled.
Results
General and clinical characteristics
All 46 patients included in this study had Hawkins type II talar neck fractures. The traditional group consisted of 12 males and 11 females (mean age: 43.7 ± 12.4 years; range: 30–74 years), including 10 cases of left foot fractures and 13 cases of right foot fractures caused by falls from height (n = 17), traffic accidents (n = 4) and sports injuries (n = 2). The mean time from injury to surgery was 22.7 ± 9.1 (13–43) h. The robot-assisted group consisted of 13 males and 10 females (mean age: 48.0 ± 13.1 years; range: 20–70 years), including 12 cases of left foot fractures and 11 cases of right foot fractures caused by falls from height (n = 13), traffic accidents (n = 7) and sports injuries (n = 3). The mean time from injury to surgery was 21.7 ± 8.1 (12–36) h. Gender, age, injured side, body mass index, time from injury to operation and intraoperative blood loss demonstrated no significant differences among the groups (p > 0.05, Table 1).
Table 1.
Comparison of general data of two groups
| Robot-assisted group (n = 23) | Traditional group (n = 23) |
P-value | |
|---|---|---|---|
| Male/female, n | 13/10 | 12/11 | 0.767 |
| Age, year | 48.0 ± 13.1 | 43.7 ± 12.4 | 0.259 |
| Right/left, n | 11/12 | 13/10 | 0.555 |
| BMI, kg/m2 | 22.3 ± 1.4 | 22.7 ± 1.5 | 0.273 |
| Time from injury to surgery, hour | 21.7 ± 8.1 | 22.7 ± 9.1 | 0.683 |
| Operation time, min | 44.7 ± 3.2 | 60.0 ± 2.2 | < 0.001 |
| Blood loss, ml | 15.9 ± 2.2 | 16.6 ± 3.0 | 0.371 |
| Fluoroscopic dose, Gy·cm2 | 64.7 ± 0.9 | 77.4 ± 4.8 | < 0.001 |
BMI body mass index
Operation outcomes
The mean operation time in the traditional group was 60.0 ± 2.2 min, which was significantly longer than that in the robot-assisted group (44.7 ± 3.2 min, P < 0.001). The intraoperative fluoroscopic dose was also significantly lower in the robot-assisted group (64.7 ± 0.9 Gy·cm² vs. 77.4 ± 4.8 Gy·cm², P < 0.001). (Table 1). One patient in the robot-assisted group experienced walking fatigue and pain after full weight-bearing. The patient was considered to have a progressive collapsing foot deformity through gait and physical examination and the symptoms significantly improved after using custom-made insoles. The fractures of the two groups all healed, with no significant differences in the healing time, SF-12 score, AOFAS score and VAS score (P > 0.05, Table 2).
Table 2.
Comparisons of post-operative outcomes of two groups
| Robot-assisted group (n = 23) | Traditional group (n = 23) |
P-value | |
|---|---|---|---|
| Follow-up time, months | 28.7 ± 2.6 | 28.6 ± 2.8 | 0.871 |
| Fracture union time, weeks | 15.6 ± 1.9 | 15.4 ± 2.7 | 0.801 |
| VAS score, points | 1.2 ± 0.7 | 1.5 ± 0.6 | 0.065 |
| AOFAS score, points | 85.6 ± 2.6 | 86.4 ± 1.8 | 0.212 |
| SF-12 MCS, points | 51.2 ± 1.5 | 50.3 ± 1.5 | 0.055 |
| SF-12 PCS, points | 52.2 ± 1.2 | 51.9 ± 1.7 | 0.484 |
AOFAS American Foot and Ankle Surgery Association, VAS Visual Analogue Scale, SF-12 MCS 12-item Short-Form Survey-mental component score, SF-12 PCS 12-item Short-Form Survey-physical component score
Discussion
The principal finding of this study is that robot-assisted cannulated screw fixation for Hawkins type II talar neck fractures achieved comparable clinical outcomes to traditional freehand percutaneous surgery, with the advantages of significantly shorter operation time (44.7 ± 3.2 min vs. 60.0 ± 2.2 min, P < 0.001) and lower intraoperative fluoroscopic dose (64.7 ± 0.9 Gy·cm² vs. 77.4 ± 4.8 Gy·cm², P < 0.001). These results align with previous studies on robot-assisted fracture fixation in other anatomical sites [9, 11, 12].
Accuracy and planning advantages of robot-assisted screw placement
Achieving accurate screw placement is a critical determinant of successful minimally invasive surgery for talar neck fractures [13]. The talus has a complex three-dimensional anatomy, with 60% to 75% of its surface covered by articular cartilage and no muscle or tendon attachments [14]. This anatomical feature leaves the talar blood supply particularly vulnerable to iatrogenic injury during screw insertion [15]. The conventional freehand technique relies heavily on the surgeon‘s experience and requires repeated intraoperative fluoroscopy to confirm screw position, which may lead to suboptimal screw placement, extended operation time, and increased radiation exposure [7, 9].
Robot-assisted systems, such as the TiRobot used in this study, offer a potential solution to these challenges. By integrating preoperative CT data with intraoperative three-dimensional fluoroscopic imaging, the robotic platform enables precise trajectory planning prior to screw insertion [5, 7]. The system’s real-time navigation capability allows the surgeon to verify the planned screw path relative to critical anatomical structures, including the tarsal canal artery and the subtalar joint surfaces. In the present study, although we did not quantitatively measure screw placement deviation, the absence of malposition-related complications (e.g., screw penetration into the subtalar or talonavicular joint, iatrogenic vascular injury) suggests that robot-assisted planning may facilitate reproducible and appropriate screw placement.
Previous studies on robot-assisted screw fixation in other anatomical regions have demonstrated superior accuracy compared with freehand techniques. A meta-analysis by Chen et al. comparing robot-assisted versus conventional freehand percutaneous screw fixation for femoral neck fractures reported that robotic assistance significantly reduced the number of guide pin insertion attempts and improved the rate of optimal screw placement [11]. Similarly, Xiao et al. reported that robot-assisted screw fixation for scaphoid waist fractures achieved more accurate screw placement with fewer fluoroscopic exposures compared with traditional freehand technique [9]. These findings are consistent with our observation that robotic assistance facilitates precise screw placement, which is particularly important in talar neck fractures where limited bone stock and adjacent articular surfaces leave little room for error.
Reduction of intraoperative radiation exposure
The reduction in intraoperative fluoroscopic dose observed in this study (approximately 16.4% reduction in the robot-assisted group) has both patient safety and occupational health implications. Orthopaedic trauma surgeons are among the most heavily exposed to cumulative radiation doses across all surgical specialties due to the frequent use of intraoperative fluoroscopy in fracture fixation procedures [16]. A recent meta-analysis by Watanuki et al. encompassing 675 patients across 10 comparative studies demonstrated that robotic guidance significantly reduces radiation time compared with manual fluoroscopy, with a robust effect size. The authors further noted that even with full use of standard shielding, vulnerable anatomical areas such as the head, neck, and breasts may not be adequately protected, underscoring the importance of minimizing fluoroscopy time as a primary radiation reduction strategy [16, 17].
In our study, the robot-assisted group required a mean fluoroscopic dose of 64.7 Gy·cm², compared with 77.4 Gy·cm² in the traditional group. This reduction can be attributed to the robotic system‘s ability to generate a single intraoperative three-dimensional scan for trajectory planning, after which screw insertion is performed with minimal additional fluoroscopic confirmation. The traditional freehand technique, by contrast, necessitates intermittent fluoroscopic checks to verify guide pin position, adjust trajectory, and confirm final screw placement. Although the absolute difference (12.7 Gy·cm²) may seem modest, the cumulative reduction over multiple cases represents a meaningful decrease in occupational radiation exposure, particularly for high-volume trauma surgeons.
Clinical considerations regarding screw direction
Cannulated screw fixation remains the dominant internal fixation method for closed reduction of talar neck fractures, offering advantages such as stable fixation, fracture end compression, and preservation of the residual blood supply [18, 19]. Two primary screw placement directions have been described: anterior-to-posterior (via an anteromedial or anterolateral approach) and posterior-to-anterior [20, 21]. Biomechanical studies have suggested that posterior-to-anterior screw orientation may offer superior compression at the fracture site [22]; however, this approach requires a posterior incision that places the sural nerve at risk [23, 24] and may compromise the tarsal canal artery, a critical contributor to talar blood supply [25].
In the present study, we adopted an anterior-to-posterior screw placement approach under robotic guidance for all patients. The robotic navigation system‘s three-dimensional planning capability enabled us to optimize screw trajectory, length, and entry point preoperatively, thereby minimizing the risk of screw tip impingement on the talonavicular joint. Although Charlson et al. reported that anterior-to-posterior screw tips may cause symptomatic impingement requiring hardware removal [26], we did not encounter this complication in our series, which we attribute to the use of countersunk screws and careful preoperative planning. Given that bone ingrowth may preclude screw removal in some patients, we informed all participants of this possibility prior to surgery.
Limitations
This study has several limitations that should be acknowledged. First, the sample size was limited (23 patients per group), and the follow-up period (approximately two years) remains relatively short for detecting late complications such as talar avascular necrosis, which may present years after the index injury. A prospective, multicenter study with larger sample sizes and extended follow-up is warranted. Second, the study focused exclusively on Hawkins type II talar neck fractures; the findings cannot be generalized to more severe fracture patterns (Hawkins types III and IV) or to open fractures. Third, our sample size calculation was based on the primary outcome (operation time); the study was not powered to detect differences in secondary outcomes (e.g., AOFAS score, VAS score), and these results should be interpreted with caution. Fourth, the retrospective design may introduce selection bias, although consecutive cases were included. Finally, not all talar neck fractures are suitable for closed reduction; repeated or forceful attempts at closed reduction may damage the talar blood supply and should be avoided.
Conclusion
In summary, compared with traditional freehand percutaneous screw fixation, robot-assisted screw placement for Hawkins type II talar neck fractures significantly reduced operation time and intraoperative fluoroscopic dose, while achieving comparable functional outcomes and fracture healing. Robot-assisted surgery is a safe, effective, and low-radiation option for treating selected talar neck fractures.
Acknowledgements
Gonghao Zhang and Wei Xian contributed equally to this work. The authors thank all of the patients who participated in the study.
Ethics approval number
No.424
Registration details
Approved by the Research Ethics Committee of the Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital and the date of approval: September/30/2020.
Abbreviations
- AOFAS
American Foot and Ankle Surgery Association
- VAS
Visual Analogue Scale (VAS)
- SF-12
12-item Short-Form Survey
- AVN
avascular necrosis
- AP
anteroposterior
Authors’ contributions
Gonghao Zhang, Wei Xian made substantial contributions to the acquisition, analysis, and interpretation of the data. Gonghao Zhang was responsible for the conception and design of the study and drafting and writing of this manuscript. Xinwei Yuan made substantial contributions to writing ideas and manuscript revision. All the authors confirm the authenticity of the raw data. All authors have read and approved the final manuscript.
Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Data availability
The datasets generated and/or analysed during the current study are available in the Zenodo repository (https://zenodo.org/records/14175493).
Declarations
Ethics approval and consent to participate
This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the Research Ethics Committee of the Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, China (No.424 and date of approval: September/30/2020). Informed consent was obtained from all individual participants included in the study.
Consent for publication
Written informed consent to publish was obtained from all participants.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Gonghao Zhang, Wei Xian and Xinwei Yuan are co-first authors.
References
- 1.Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(2):114–27. 10.5435/JAAOS-D-20-00116. [DOI] [PubMed] [Google Scholar]
- 2.Parekh SG, Kadakia RJ. Avascular Necrosis of the Talus. J Am Acad Orthop Surg. 2021;29(6):e267–78. 10.5435/JAAOS-D-20-00418. [DOI] [PubMed] [Google Scholar]
- 3.Buza JA 3rd, Leucht P. Fractures of the talus: Current concepts and new developments. Foot Ankle Surg. 2018;24(4):282–90. 10.1016/j.fas.2017.04.008. [DOI] [PubMed] [Google Scholar]
- 4.Halvorson JJ, Winter SB, Teasdall RD, Scott AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg. 2013;52(1):56–61. 10.1053/j.jfas.2012.10.008. [DOI] [PubMed] [Google Scholar]
- 5.Lin S, Tang LY, Wang F, Yuan XW, Hu J, Liang WM. TiRobot-assisted percutaneous kyphoplasty in the management of multilevel (more than three levels) osteoporotic vertebral compression fracture. Int Orthop. 2023;47(2):319–27. 10.1007/s00264-022-05580-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Zhang R-J, et al. Rates and risk factors of intrapedicular accuracy and cranial facet joint violation among robot-assisted, fluoroscopy-guided percutaneous, and freehand techniques in pedicle screw fixation of thoracolumbar fractures: a comparative cohort study. BMC Surg. 2022;22(1):52. 10.1186/s12893-022-01502-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Li N, Zhu Z, Xiao C, et al. The efficacy of TiRobot orthopaedic robot-assisted VS conventional fluoroscopic percutaneous screw fixation of the sacroiliac joint. Int Orthop. 2023;47(2):351–8. 10.1007/s00264-022-05655-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Zhu ZD, Xiao CW, Tan B, et al. TiRobot-Assisted Percutaneous Cannulated Screw Fixation in the Treatment of Femoral Neck Fractures: A Minimum 2-Year Follow-up of 50 Patients. Orthop Surg. 2021;13(1):244–52. 10.1111/os.12915. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Xiao C, Wei D, Zhu Z, et al. Robot-assisted vs traditional percutaneous freehand for the scaphoid fracture treatment: a retrospective study. Int Orthop. 2023;47(3):839–45. 10.1007/s00264-022-05532-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Busija L, Pausenberger E, Haines TP, Haymes S, Buchbinder R, Osborne RH. Adult measures of general health and health-related quality of life: Medical Outcomes Study Short Form 36-Item (SF-36) and Short Form 12-Item (SF-12) Health Surveys, Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), Medical Outcomes Study Short Form 6D (SF-6D), Health Utilities Index Mark 3 (HUI3), Quality of Well-Being Scale (QWB), and Assessment of Quality of Life (AQoL). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S383–412. 10.1002/acr.20541. [DOI] [PubMed] [Google Scholar]
- 11.Al-Naseem AO, Gonnah AR, Al-Ali H, et al. Robot-assisted versus conventional freehand percutaneous screw fixation for femoral neck fractures: a systematic review and meta-analysis. Cureus. 2022;14(4):e24258. 10.7759/cureus.24258. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Vermue H, et al. How should we evaluate robotics in the operating theatre? Bone Joint J. 2020;102–B(4):407–13. 10.1302/0301-620X.102B4.BJJ-2019-1210.R1. [DOI] [PubMed] [Google Scholar]
- 13.Griffin JT, et al. The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy. J Bone Joint Surg Am. 2024;106(11):958–65. 10.2106/JBJS.23.00906. [DOI] [PubMed] [Google Scholar]
- 14.Miller AN, Prasarn ML, Dyke JP, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the talus with gadolinium-enhanced magnetic resonance imaging. J Bone Joint Surg Am. 2011;93(12):1116–21. 10.2106/JBJS.J.00693. [DOI] [PubMed] [Google Scholar]
- 15.Clare MP, Patrick JM. Prevention of Avascular Necrosis with Fractures of the Talar Neck. Foot Ankle Clin. 2019;24(1):47–56. 10.1016/j.fcl.2018.09.003. [DOI] [PubMed] [Google Scholar]
- 16.Hess S, et al. Applications and accuracy of 3D-printed surgical guides in traumatology and orthopaedic surgery: A systematic review and meta-analysis. J experimental Orthop. 2024;11(3):e12096. 10.1002/jeo2.12096. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014;96(3):192–7. 10.2106/JBJS.L.01680. [DOI] [PubMed] [Google Scholar]
- 18.Zhang X, Shao X, Yu Y, Zhang Y, Zhang G, Tian D. Comparison between percutaneous and open reduction for treating paediatric talar neck fractures [published correction appears in Int Orthop. 2017;41(12):2639 10.1007/s00264-017-3631-y. [DOI] [PubMed]
- 19.Abdelgaid SM, Ezzat FF. Percutaneous reduction and screw fixation of fracture neck talus. Foot Ankle Surg. 2012;18(4):219–28. 10.1016/j.fas.2012.01.003. [DOI] [PubMed] [Google Scholar]
- 20.Rammelt S, Zwipp H. Talar neck and body fractures. Injury. 2009;40(2):120–35. 10.1016/j.injury.2008.01.021. [DOI] [PubMed] [Google Scholar]
- 21.Attiah M, Sanders DW, Valdivia G, et al. Comminuted talar neck fractures: a mechanical comparison of fixation techniques. J Orthop Trauma. 2007;21(1):47–51. 10.1097/01.bot.0000247077.02301.d0. [DOI] [PubMed] [Google Scholar]
- 22.Fan Z, Ma J, Chen J, et al. Correction to: Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. J Orthop Surg Res. 2022;17(1):156. 10.1186/s13018-020-1560-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Roberts LE, Pinto M, Staggers JR, Godoy-Santos A, Shah A, de Cesar Netto C. Soft Tissue Structures at Risk With Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck. Foot Ankle Int. 2018;39(10):1237–41. 10.1177/1071100718777771. [DOI] [PubMed] [Google Scholar]
- 24.Aktan Ikiz ZA, Uçerler H, Bilge O. The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int. 2005;26(7):560–567. 10.1177/107110070502600712. [DOI] [PubMed] [Google Scholar]
- 25.Ebraheim NA, Mekhail AO, Salpietro BJ, Mermer MJ, Jackson WT. Talar neck fractures: anatomic considerations for posterior screw application. Foot Ankle Int. 1996;17(9):541–7. 10.1177/107110079601700906. [DOI] [PubMed] [Google Scholar]
- 26.Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int. 2006;27(5):340–3. 10.1177/107110070602700505. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are available in the Zenodo repository (https://zenodo.org/records/14175493).