Arthroscopic Treatment of Talar Body Fractures

Abstract

Talar fractures can be severe injuries with complications leading to functional disability. Open reduction–internal fixation remains the treatment of choice for displaced talar fractures. Arthroscopic evaluation of the fracture and articular surfaces can play an important role in the treatment of these fractures. Arthroscopic reduction–internal fixation (ARIF) is increasingly used for certain intra-articular fracture types through the body. The minimally invasive nature of ARIF and high accuracy are enviable attributes of an evolving technique. This technical note describes arthroscopic evaluation of 2 intra-articular talar head fractures, using posterior portals, with ARIF performed in 1 case and excision of the fracture fragments in the other case.

Talar fractures represents 3% to 6% of fractures about the foot and ankle.^1,2 They can be anatomically grouped into fractures of the neck, dome, talar processes, and talar body. Sneppen et al.³ first classified talar body fractures into 5 groups based on pattern and location.

Arthroscopy has successfully been used for diagnostic evaluation and treatment of osteochondral lesions, ankle arthrodesis, anterior and posterior impingement, tendinopathy, and retrocalcaneal pathology.^1,4 Arthroscopic reduction–internal fixation (ARIF) is a recent concept and is increasingly used for certain intra-articular fracture types through the body.⁵ The minimally invasive nature of ARIF and high accuracy are enviable attributes of an evolving technique.

Two cases amenable to ARIF are presented: a 37 year-old man with a 9-mm lateral talar body fracture involving the articular surface (Sneppen type II) with displacement and multiple loose bodies (Fig 1) and a 22-year-old man with a comminuted, fragmented fracture of the posterolateral talar body (Sneppen type II) and concurrent intra-articular distal tibial fracture extending obliquely through the anterior aspect of the tibiotalar articular (Fig 2). ARIF was performed in the first patient, and the surgical technique is described; in the second case, given the chronicity of injury and arthroscopic appearance, excision of the talar fracture fragment was performed (Video 1) using the same positioning, portals, and exposure.

Fig 1.

Axial computed tomography slice showing an intra-articular lateral talar head fracture in a 37-year-old man who was treated with ARIF and a single headless compression screw (case 1). (ARIF, arthroscopic reduction–internal fixation.)

Fig 2.

Axial computed tomography slice showing an intra-articular posterolateral talar head fracture in a 22-year-old man who was treated with excision of the fracture fragment and microfracture (case 2).

Arthroscopic-assisted reduction allows direct vision of the therapeutic process, anatomic reduction of the articular surfaces, and preservation of the osseous blood supply by minimizing trauma to the soft-tissue envelope. We believe that ARIF has significant potential benefits for the evaluation and treatment of selected talar fractures in the future.

Surgical Technique

Operative treatment is performed with the patient under general anesthesia and placed in the prone position. A thigh tourniquet is inflated. Image intensification is required when ARIF is performed. Posteromedial and posterolateral ankle arthroscopy portals, adjacent to the calcaneal tendon, are used. The posteromedial portal is established by infusion of 10 mL of normal saline solution through a 22-gauge needle distending the ankle joint, before a small incision and passing of the arthroscopic cannula take place. Establishment of the posterolateral portal takes place under direct vision with the placement confirmed with a 22-gauge needle. Accessory portals may be established, as required.

A 2.7-mm-diameter camera with a 30° oblique viewing angle (Smith & Nephew, Andover, MA) allows for vision of the fracture and articular surface. The operative technique for each case is described in detail separately.

At the conclusion of each case, a below-the-knee plaster of Paris back slab was placed while the patient was still anesthetized. Two weeks postoperatively, review of the arthroscopic portal wounds was performed and a fiberglass below-the-knee immobilizing cast (Nemoa; Smith & Nephew) was applied. Six weeks postoperatively, the patient was provided with a removable Nextep immobilizing fracture boot (DJO Global, Vista, CA) and instructed to progress to full weight bearing within the boot. Passive and active ankle range-of-motion exercises were also commenced. Physiotherapy-assisted rehabilitation (strength and ankle proprioceptive control) occurred in the sixth to 10th postoperative weeks.

Case 1: ARIF

A 37-year-old man sustained a fall of 0.5 m from a ladder. Radiographic evaluation showed a 9-mm lateral talar body fracture involving the articular surface (Sneppen type II) with displacement and multiple loose bodies. The posteromedial portal provided direct vision of the fracture and articular surface (Fig 3A). A Dyonics Powermini Small Joint Shaver chondrotome, microprobe, and straight punch (Smith & Nephew) were used through the posterolateral portal to resect inflammatory tissue to allow for visualization. A 4-mm straight osteotome was used to elevate and reduce the fracture (Fig 3B).

Fig 3.

Arthroscopic views of the right ankle from the posteromedial portal in the case of a 37-year-old man with an intra-articular lateral talar head fracture (case 1). (A) The tibial surface (A), depressed posterolateral talar body fracture (B), and resultant inflammatory tissue are visualized. Clearance of the synovial and inflammatory tissue took place to access the fracture site. (B) The tibial surface (A), reduced talar articular surface (B), and 4-mm osteotome (C) are visualized. Percutaneously derived calcaneal bone graft was inserted into the subchondral fracture impaction void. (C) Talar fixation was achieved with a single 3.5-mm headless cannulated screw from posterior to anterior, with calcaneal bone graft inserted into the subchondral fracture impaction void.

A Kirschner wire, provisionally stabilizing the fracture, was inserted under arthroscopic vision, and its position was confirmed with image intensification. Calcaneal bone graft was percutaneously harvested from the lateral aspect of the calcaneal body and inserted into the subchondral fracture impaction void. A 3.5-mm headless compression cannulated screw (Smith & Nephew) was placed over the provisionally placed Kirschner wire to achieve compression and stabilization of the fracture (Fig 3C). A thigh tourniquet was inflated for 1 hour 51 minutes. The fluoroscopy time was 8 seconds.

Six months after surgery, range of motion had returned to being equal to the uninjured ankle and the patient had returned to all of his preinjury daily social and occupational activities. Radiologic examination at this time showed that the fracture had healed but a loose body persisted in the lateral gutter (Fig 4). At 6 and 12 months, the American Orthopaedic Foot & Ankle Society score was 100.

Fig 4.

Lateral radiograph obtained 6 months postoperatively showing a united fracture in the case of a 37-year-old man with an intra-articular lateral talar head fracture (case 1). (R, right; EM, equivalent man; WT, weight.)

Case 2: Arthroscopic Evaluation and Debridement

A 22-year-old man sustained a fall of 2 m from a rooftop. His presentation to a tertiary-level hospital was delayed. Radiographic evaluation showed a right-sided comminuted, fragmented fracture of the posterolateral talar body with small intra-articular loose bodies and a concomitant intra-articular anterior tibial fracture. The posterolateral portal provided direct vision of the fracture and articular surface (Video 1). The posteromedial portal was used to pass a Dyonics Powermini Small Joint Shaver chondrotome, osteotome, microprobe, straight punch and Pitbull Jr grasper (Smith & Nephew) to debride the talar fracture before excision took place. A 65° microfracture pick (Smith & Nephew) was used on the resultant fracture surface of the talus. The arthroscopy time was 53 minutes.

After removal of the talar body fracture fragments, internal fixation of the tibial fracture was performed by an anterolateral ankle approach.

Six months after surgery, range of motion was 10° of dorsiflexion to 20° of plantar flexion. Radiologic examination showed union at the tibial fracture site. Six months after, the American Orthopaedic Foot & Ankle Society score was 87.

Discussion

Use of ankle arthroscopy is increasing; a 210% increase has been seen over the past decade within Australia.⁶ Arthroscopy enables the identification of intra-articular loose bodies, cartilage injuries, and transchondral defects that are radiologically insignificant.^1,4 Cadaveric studies have shown that intra-articular displacement greater than 2 mm alters the biomechanics of the ankle joint.² Posterior ankle arthroscopy has allowed the evaluation of 2 talar body fractures, with successful ARIF and excision performed.

The extent of soft-tissue and bony dissection is one possible factor that we suggest may also contribute to post-traumatic ankle arthritis. Medial and lateral malleolar or tibiofibular osteotomies are often used to allow for adequate exposure without compromising the soft-tissue attachments to the talus. Regardless, with the use of osteotomies, soft-tissue trauma is inevitable during open reduction of articular talar fractures, and this may contribute to skin necrosis, infection, malunion, post-traumatic arthritis, and avascular necrosis (AVN).⁵

The rates of AVN are dependent on the type of fracture, degree of displacement, and type of surgical approach.⁷ ARIF is a surgical option that may reduce the risk of iatrogenic AVN. There are limited cases described in the literature of talar fracture fixation using arthroscopic techniques.^1,4,5,8 Boack and Manegold¹ in 2004 produced recommendations on the role of arthroscopy in the treatment of peripheral talar fractures with a fragment greater than 1 cm in length, involving the articular surface with displacement. These recommendations have not been extended to include talar body fractures.

Although there were no complications, we would be concerned by the prolonged operative time in the case of ARIF as a potential source of complications. We believe that our ARIF operative time was artificially extended by the fact that it was a novel procedure in our hands; thus extra time was taken to document and photograph the intraoperative findings. We believe that any future ARIF would have a shorter operative time. Another recognized potential negative effect of ARIF or attempted ARIF is that if conversion to an open procedure is required, fluid extravasation may impair exposure. This was not evident with the open approach to the distal tibia in our second case. Potential ARIF is limited by the comminution and chronicity of the fracture, which may result in excision or conversion to an open procedure (Table 1).

Table 1.

Technical Tips for Talar Arthroscopy Using Posterior Portals

Pearls

Radiographic and computed tomography scans can guide suitability for ARIF.

The need for medial or lateral osteotomies for exposure and access is avoided.

The posteromedial and posterolateral portals are placed adjacent to the calcaneal tendon.

The patient should be in the prone position with the feet over the end of the bed, with the surgeon connected to a traction delivery device; axial traction and dorsiflexion may be delivered to aid exposure.

Percutaneously harvested bone graft from the lateral calcaneus can be used to aid fracture fixation.

Deep vein thrombosis prophylaxis is recommended postoperatively.

Pitfalls

ARIF may not be suitable once arthroscopic evaluation has taken place.

The procedure is novel procedure, with potentially increased operative and tourniquet times.

Conversion to an open procedure may be difficult because of fluid extravasation.

Patient positioning and pressure area care need to be carefully managed.

Further studies comparing open reduction–internal fixation and ARIF of talar fractures would be worthwhile, but the relative infrequency of these injuries means that we are likely to rely on further case reports and technique development to guide operative techniques. We recommend that other authors contribute their experiences on this rare clinical scenario so that the collective experiences can increase the value of advice that readers can obtain from the literature.

We advocate that ankle arthroscopy is a reliable technique for the fixation of selected talar body fractures in the hands of experienced ankle arthroscopists. We suggest that it has the advantages of allowing anatomic reduction and stable fixation, direct vision of the therapeutic process, preservation of the soft-tissue envelope, and assessment of concomitant intra-articular lesions.

Supplementary Data

Video 1

Arthroscopic view of a right ankle from the posterolateral portal in the case of an intra-articular posterolateral talar head fracture in a 22-year-old man (case 2). The patient was positioned prone, and a thigh tourniquet was inflated. The surgical technique for the evaluation (and potential ARIF) of a talar body fracture is shown. Arthroscopic evaluation resulted in excision of the fracture fragment, removal of loose bodies, and microfracture of the talus.