Good morning. My name is Nick Strosser. I currently work at Vanderbilt Orthopaedics, and I was tasked with discussing talus fractures, a 360 degree approach. I do not have any financial disclosures as it pertains to this talk. So when I was looking at how to best present this, I came up with four different topics that I wanted to touch on when it came to managing talus fractures. First is discussing urgency and timing of surgery. Second was discussing approaches, approach preferences, tips for performing malleolar osteotomies in the form of a talus body fracture, and scenarios in which fusion may be considered a good option. I don't need to explain to this audience the etiology. Usually it's going to be high energy, but occasionally low energy. Complications are not uncommon, and it really is what we're trying to minimize when we discuss management of these injuries. The anatomy is going to be familiar to most, but I will take a second to highlight the importance of the blood supply to the talus, and being respective of it and understanding the anatomy when it comes to your approaches for fixing these. The classification is largely anatomic, with the exception of the neck, which has the classic Hawkins classification, and a recent subclassification in 2014, which we'll explore a little later. When it comes to managing these injuries, it always bears repeating that you want to obtain high quality x-rays as the findings can be relatively subtle, as in this case here, which has a very subtle appearing tailor neck fracture, and really scrutinizing these very highly and making sure that you're getting good quality imaging. I do, and I think most people agree, getting CT scans is quite helpful. It helps in terms of exploring the extent of the fracture, but also looking at things such as articular impaction, looking for loose fragments within the joint, and then associated injuries that may occur with these as well. This gentleman comes into your ER, and this has a lot of good discussion points. He sustained this injury off of a trampoline, and it's closed. Clearly, you can see he has a displaced tailor neck fracture with some comminution, but you also want to call out the fact that his sub-tailor joint is dislocated as well. It brings up the discussion of what are you going to do first, and why and how you want to approach that, because after all, we all talk about things such as osteonecrosis or AVN, and how the timing of that can matter. I think dogma has traditionally been that we need to fix these acutely, but recently, I think that thought process has continued to evolve and change over time. Everybody's familiar with the Hawkins classification, where a type 2 has a displaced tailor neck fracture with either a subloxed sub-tailor joint or a dislocated sub-tailor joint. I think we'd all agree that the image on the left and the image here on the right are actually quite different injuries in terms of severity. In 2014, this article looked at these two types where you have a subloxed sub-tailor joint and a dislocated sub-tailor joint and found and separated these two into a 2A or a 2B. When they subclassified those based off of the status of the sub-tailor joint, they found that the risk for avascular necrosis was largely contingent on the sub-tailor joint being dislocated and not necessarily the time to definitive internal fixation of the tailored neck, as we all used to think. So really, what came down to it is that those who had a dislocated sub-tailor joint had a 25% risk of AVN, while those who had either just a subloxed or an intact sub-tailor joint had a 0% risk of AVN. Other studies have supported this notion that not necessarily the time to definitive internal fixation, but more important to manage the reductions of any surrounding joints that are dislocated. And I think this article sums that up quite well in which they stated the more modern approach is an urgent reduction of the dislocation, and then the definitive fixation can be done in a delayed fashion. So when does timing matter? It's really when it comes down to managing the dislocated joint, the treatment of the open injuries, and the time to anatomic reduction in rigid fixation is probably less important when it comes down to managing and minimizing the risk of avascular necrosis. For those junior residents, this can be managed in a closed fashion in the emergency room, but a couple tips. One is you want to make sure the patients relax. You want to flex the knee and the ankle in order to take off the deforming forces, and you can provide traction across the foot. And in this case, you can see that the patient underwent a successful reduction in the emergency department. It was able to be managed in a delayed fashion a couple of days later once the soft tissue swelling has subsided. The Hawkins 3, if you'll recall, has the tibial tailor joint that's dislocated. Oftentimes, that tailor body is going to want to go posterior medial, and when it does that, it can put some tension on your FHL. You'll see that clinical photo, which shows a flexed FHL, and that's just a tip that you can pick up on sometimes in the emergency room that you have a pretty good idea of what's going on even before you see the x-ray. And this, you can try an attempted reduction in the ER, but most of the time, it's going to require an open reduction. These can be challenging, but you want to have a plan in how you want to manage it, and you don't want to get trapped into the thought, oh, I'll just open it and reduce it because there's a lot of, it can be very challenging. And some of the tips that can be helpful are to go opposite the side of the dislocation, having plenty of equipment available, whether it's a distractor or chance pins, and then having a freer or a joker as a skid ramp to help reduce that tibial tailor dislocation. This article talked about delivering the tailored body and using an anterolateral approach to approach from the opposite side, and then you're able to use a chance pin into the tailored body and almost clear the fibula, almost like clearing the shoulder when you're delivering a child. So kind of a nice technique article that can be used to help manage these dislocations. When it comes to approaches, my preference is to use both anterolateral and anteromedial approaches. Usually that foot's going to go into varus, and that's going to result in a tension-sided failure on the lateral side. So the lateral side gives you a good look at that tension failure. It allows access to clean out any fragments in the subtalar joint, and you can manage associated lateral process fractures if needed. On the medial side, you want to be careful because oftentimes that medial side has some dorsal medial comminution, and if you don't recognize that, you can overshorten the medial side and end up putting the talus into varus. Just some representative clinical photos. You can see that there's being very respective of the surrounding blood supply and the soft tissue dissection. You can see some of the comminution that can occur, and you want to make sure that you're managing that appropriately. Once you get the exposure through your anterolateral and your medial incision, then you can proceed with providing some provisional fixation. This can be done with using point-to-point reduction clamps. Sometimes you use a Steinmann pin in the more distal segment to help reduce and fine-tune the reduction of the talar neck. You can preload K-wires into the proximal segment and then advance once you get the reduction, and then just be aware of, in this case, there is a fracture that extended into the head segment, so being aware of that reduction as well. Really, I think you want to use that lateral approach for your direct reduction as opposed to the medial side because the medial side is going to want to shorten on you and put you into varus. In terms of fixation, there's several acceptable methods. My preference is a lateral plate, almost like a tension band plate, so using a mini-frag plate on the lateral side fits quite well. On the medial side, we will use position screws, just being aware that you don't want to over-shorten the medial side. There's also certainly acceptable methods such as anterior-to-posterior or posterior-to-anterior screws. Then again, on the medial side, making sure you use position screws, sometimes even needing bone graft if there's a lot of bone loss. Some representative images of what things might look like during your first post-op, and then this is the same patient coming back at 18 months after surgery, so you can see he's gone on to heal his tailor neck fracture. I think this is an accurate representation where there was no dislocation of the subtalar joint and he does not have any signs of avascular necrosis, but if you're looking at it critically, you can certainly see he has some subtalar arthritis in his long-term follow-up. I think being realistic with your patients on what that might look like is important. On the medial side, because there can be some bone loss, it can be tempting to want to use a plate and it's okay to do. You just have to be aware that it's a little more difficult to fashion and fit and there's a higher incidence of soft tissue impingement, but it can be done with a small plate on the medial side. When it comes to managing tailor body fractures, essentially this is just extension of the plantar fracture into the lateral process, but it can be more extensive as in this case you might that you see here. It's more likely to require extending your incision, particularly on the medial side in the form of a medial malleolar osteotomy. This gentleman is 18. He's a hiker and he sustained bilateral lower extremity injuries, but on this side you can see he has a ankle fracture with a tailored body fracture, and there's a coronal split that divided this into a medial and lateral half, and then on the medial side there's a sagittal component as well. You can also see that there is a fairly significant amount of comminution and articular impaction as well, making this actually quite challenging to treat. So he underwent application of an external fixator to provide him some soft tissue protection, and once his swelling went down, we returned with an extending and you're using dual incision and on the medial side extending the medial side to perform a malleolar osteotomy. Here you can see we've marked out our osteotomy based off our preoperative plan. When it comes to the technique, you want to extend your medial incision. You do want to be careful to expose and look at the posterior tibial tendon as this can be cut if you're not careful. You can mark out your preoperative based off your pre-op plan using k-wires as we showed here. I'll usually start it with a with a saw and then complete with an osteotome, and then pre-drilling and tapping leg screws even before the osteotomy can be helpful in terms of the reduction, but even if you do that, you want to have a low threshold to consider utilizing a buttress plate as there can be a malproduction rate with these. So this would be an image of what you can see. We have a femoral distractor in the background on the lateral side. On the medial side, we've exposed the osteotomy. We can see that split on the medial portion of that talus, and then you piece it together with a bunch of k-wires and then converting those to mini phrag screws and a combination of blood, sweat, and tears, and then you go to fix the malleolar osteotomy, and after a very challenging talus fracture, you can see that even in the case of it being pre-drilled and tapped, that our screws actually cause this to displace a little bit, and that certainly can be the case even in the form of a chevron malleolar osteotomy. You can see about a 30% malreduction rate, so actually having a low threshold to utilize the buttress plate as in this image here to help minimize the chance of developing or having a malreduction of your malleolar osteotomy. Lateral process fractures, we won't talk a lot about them, but you certainly will see them. It's a little different, smaller fracture obviously. It's about 20% of talus fractures. There's usually some form of dorsiflexion injury, and it's important to scrutinize your films as the findings can be relatively subtle, and we'll have a low threshold to obtain a CT scan if we suspect it's there, as oftentimes the size can be underappreciated on the plain films, and this would be a motocross athlete that came in who sustained this injury after coming down off the jump, and you can see where the arrow is. There's a disruption of the cortex on the lateral side of the talus, and if you look at the CT scan, it's a fairly sizable piece with a little bit of comminution. Certainly displaced enough and involved a fairly large enough piece of articular cartilage that we felt proceeding with fixing it would be warranted. So this was done through a sinus approach and a couple of mini phrag screws, and these are the six-month post-op x-rays, and you can see that it's gone on to heal. She's back to competing, and that actually I think was a good option for her as opposed to treating that non-operatively. If it's small and really comminuted, certainly can consider excision as well, depending on the extent of articular involvement. Moving around as we kind of keep working our way around the talus into the posterior body fractures, this would be a lower energy but carries some challenges just based off the patient's comorbidities. You can see he sustained a ground level fall with a fairly sizable posterior talar body fracture, and if you look at the CT scan, you can see there's also some pre-existing subtalar arthritis and some comminution within the fracture itself. The fracture is predominantly medial, posterior medial, and when we talked about options for him, I felt it needed to be fixed because it was too big to leave, and then may have considered an option for fusing primarily. I elected not to just based off of giving him another spot of concern for non-union in the setting of a current smoker, but certainly could have made a strong argument to consider fusing it acutely. I utilized a posterior medial incision, which was actually, I use it because it keeps me out of the neurovascular bundle, but it also gives you actually, and according to this article, a little bit better exposure to that posterior medial piece as well, and if you combine that approach between the Achilles and the FHL, it keeps you out of the neurovascular bundle, and if you use a femoral distractor as we used here, you can actually see that piece quite well. So, proceeded with fixing this with mini frag screws and plates, some of them independent. I did not do a fusion, but as you see, he comes back at three months, and he says he's fine, and he's doing pretty well, but calls you about a month later saying he's had a sharp increase of pain, and now he can't walk, and bring him back to the clinic, and you can see now he's had failure of the hardware. The piece has shifted, and his subtalar joint is continuing to progress with significant arthritic changes, so took him back to the OR because he was quite limited and did a hardware removal, bone grafting, and subtalar fusion, and in this case, went on to heal admittedly a little bit more dorsiflex than might have liked, but in this case, we just wanted to get this gentleman healed, and he's actually doing quite well. This would be at six months and is doing well. One other case for considering discussion of fusion, this would be a higher energy case in which this is a 45-year-old blogger. He's healthy, and he was taken care of by one of my partners. These are the only injury films that we had of his ankle, and you can see clearly he has a comminuted fracture of his talus. The tibial talar joint looks okay, but the subtalar joint is clearly dislocated, and then he has the usual quadra of other injuries that underwent treatment as well, and so he undergoes treatment of these multiple fractures. The talar neck fracture was dislocation was open laterally as you might expect based off of the position of the foot. They underwent a debridement of that. It was aggressive, and here are his images that you get text the next day saying, hey, can you manage this guy's fracture? Looking at it, hard to see too much with the plaster, but you go ahead and repeat the CT scan, and now you can see that really there's no talar head or neck left in this particular case as it was comminuted and contaminated, and so when considering options for him, I elected to take him back to the OR and repeat a debridement and try to get some form of stability and just get a sense of what we had left to work with, and in this case was able to fashion him a temporary spacer using cement, antibiotic cement. It was actually able to hold him relatively stable. I think now you could have considered also using immediately based external fixator, but this seemed to work pretty well, and then brought him back about six weeks later once the soft tissues had settled down and some of his other injuries continued to quiet down. Now he could bear weight on the other side a little bit better and was able to proceed with trying to fix this, and elected to use an allograft femoral head, which we fashioned to fit that space, and then did both a TN and a subtalar fusion, mostly because of how much bone loss was there to help maintain stability, and because he's worked comp, you see him quite frequently, and here he comes back in three years, and he's actually doing pretty well. You can see he's gone on to heal his talonevicular joint and his subtalar joint, and is actually reasonably functional, and I think a couple key points with this is one is when you have so much bone loss, using the contralateral foot as a template to try to gauge how much neck you need to recreate, using the axial alignment or hair spuse to get a sense for your hindfoot alignment as you can kind of put this anywhere, so trying to really recreate that. If you have some head remaining, you may want to pin that in the talonevicular joint and then gauge your length, because you don't want that piece moving around as well. So some different things to think about in this particular case for treatment. So in summary, we talked a little bit about treatment timing and making sure we look at the surrounding joints for reduction, using two approaches and why that's helpful to prevent malunion, some key tips to keeping out of trouble with the malleolar osteotomy, and then cases in which you may want to consider a fusion. Thank you.

talus fractures

surgery timing

malleolar osteotomies

fusion option

x-rays

classification