1. Talus Fractures Pat Yoon, MD Hennepin County Medical Center
Assistant Professor, University of Minnesota
2016

2. Disclosures Reviewer Board of directors Committees Consultant
Foot and Ankle International
Journal of the American Academy of Orthopaedic Surgeons
Board of directors
Surgical Implant Generation Network (SIGN)
Committees
OTA Humanitarian Committee
AAOS Program Committee for Trauma
AOFAS Health Policy Committee
Consultant
Orthofix
Arthrex Inc.
Paragon 28

3. Anatomy 60% covered by articular cartilage No tendon attachments
Tibiotalar (ankle) joint
Subtalar joint
Talonavicular joint
No tendon attachments
Limited area for vascular supply
Inferior aspect
Lateral aspect

4. Artery of the Tarsal Canal

5. Deltoid Branch

6. Artery of the Tarsal Sinus

7. Dorsalis pedis branches

8. Posterior Tubercle Branches

9. Subtalar joint mechanics
Heel strike
Subtalar joint goes from varus to valgus
Calcaneus in eversion
Unlocks transverse tarsal joint, foot flexible
Toe off
Subtalar joint goes into varus
Midfoot becomes rigid for pushoff
Varus malunion
Subtalar joint locked in inversion

10. Talar neck fractures Hyperdorsiflexion injury
The “aviator’s astragalus”
Relatively uncommon overall, but the most common (~50%) talus fracture type
Typically a high energy injury with frequent complications

11. Hawkins I Nondisplaced
Subtalar, tibiotalar, and talonavicular joints all reduced
Osteonecrosis 9.8%
Dodd JOT 29(5): , 2015

12. Hawkins II Subtalar joint Tibiotalar and talonavicular joints reduced
IIA: Subluxated
IIB: Dislocated
Tibiotalar and talonavicular joints reduced
Osteonecrosis 27.4%
IIA
IIA
Vallier HA JBJS 96-A(3):192-7, 2014
IIB
Dodd JOT 29(5): , 2015

13. Hawkins III
Subtalar and tibiotalar joints dislocated (i.e., body dislocated)
Head still in place (talonavicular joint reduced)
Osteonecrosis 53.4%
Dodd JOT 29(5): , 2015

14. Hawkins IV
Subtalar, tibiotalar, and talonavicular joints all dislocated
Osteonecrosis 48%
Dodd JOT 29(5): , 2015

15. Radiographic Evaluation

16. Radiographic Evaluation

17. Radiographic Evaluation

18. Radiographic Evaluation

19. Radiographic Evaluation

20. Radiographic Evaluation

21. Radiographic Evaluation

22. Nonsurgical Treatment
Not recommended in most cases
Problems:
Usually more displacement than apparent
Usually have to immobilize in plantarflexion to prevent displacement  leads to equinus
Might consider for nondisplaced Hawkins I
Rarely for displaced fractures
Severe soft tissue trauma
Unstable patient

23. Splinted x 2 weeks
Short leg cast x 4 weeks
Boot, ROM x 6 weeks
Start WB at 12 weeks
11 months post injury

24. Operative treatment Consider for most fractures, even Hawkins I
Allows earlier ROM
You otherwise have to splint them in equinus to prevent displacement  contracture
Radiographs and CT underestimate displacement seen at ORIF
Small amount of malunion significantly reduces subtalar ROM

25. Timing of Surgery Somewhat controversial
Frank dislocations and open fractures should be treated urgently
Once joint is reduced, ORIF can happen in a staged fashion
If irreducible closed, then immediate ORIF

26. Timing of Surgery
Experience suggests a wait of several days for ORIF probably does not increase osteonecrosis risk – provided joints reduced
Allows for
ORIF during daytime hours with the right team
Soft tissue condition to improve
Patient to be adequately resuscitated

27. Open fractures Urgent debridement & irrigation, reduction
Can involve posteromedial extrusion of talar body
Restore the body to the mortise
Recommend you keep the extruded body, not throw it away

28. Urgent reduction of dislocations

29. Urgent reduction of dislocations
Immediate closed reduction

30. Urgent reduction of dislocations

31. Urgent reduction of dislocations

32. Setup and positioning Thigh tourniquet Prep up past knee
Bump hip, foot pointing up
C-arm from opposite side

33. Radiographic Views Make sure you can get these views Lateral Mortise
Canale

34. True Lateral

35. True Lateral

36. C-arm tilted 15° towards the foot
Canale View
C-arm tilted 15° towards the foot

37. Canale View
“Rainbow” over the top !
C-arm tilted 15°

38. Canale View
Gets the calcaneus out of the way
Assess neck alignment

39. Canale View
Gets the calcaneus out of the way
Assess neck alignment

40. Approaches Dual incisions Medial malleolar osteotomy
Lateral
Medial
Medial malleolar osteotomy
Distal fibular osteotomy
Posterior approaches

41. Dual Incision Facilitates reduction
Helps minimize soft tissue stripping from trying to access both sides of bone from one incision
Medial
Lateral

42. Lateral incision Lateral border of EDL Superficial peroneal nerve
Exposes the largest area of nonarticular cortical bone on the lateral neck and anterior to the lateral process  plate

43. Medial incision Between tibialis anterior and posterior
Extensile proximally for possible medial malleolar osteotomy
Mostly articular cartilage on this side – countersink screws

44. Medial Malleolar Osteotomy
Occasionally needed for adequate exposure of fracture site or to access extruded body fragment
Hawkins III
Talar body fractures
Talus
PTT
Medial mall

45. Medial Malleolar Osteotomy
Extend anteromedial incision proximally
Protect PTT in back
Start with saw blade
Complete with osteotome to fracture subchondral bone
Pre-drill screw holes
PTT
Talus
Medial mall

46. Distal fibular osteotomy
Bevel below syndesmosis
7 mos postop

47. Posterior approaches Posterolateral Posteromedial
Use for posterior to anterior screws
Lateral position
Interval between FHL and peroneal tendons
Posteromedial
Usually for posteromedial body fractures
Prone
Interval between neurovascular bundle and FHL

48. Posterolateral approach
Lateral position
Small posterolateral incision
Protect sural nerve
Peroneals & FHL interval

49. Posteromedial approach
Occasionally required for posteromedial body fractures
Might potentially also come in useful for posteromedial  anterolateral screws for neck fractures
Do not do this percutaneously

50. Percutaneous technique
Not for displaced fractures
Reasonable option for nondisplaced fractures to prevent displacement and allow early ROM
1 year postop

51. Percutaneous technique
Screw trajectory depends on fracture obliquity
Posteromedial to anterolateral
Posterolateral to anteromedial

52. ORIF Open reduction usually recommended for displaced fractures
Combined medial and lateral approaches for most neck fractures

53. Reduction
Body pushed posteromedially  tension on FHL

54. Reduction
Pull body back into the mortise from the opposite side with a Schanz pin

55. Reduction
Dislodge from PT or FDL tendons

56. Reduction
Disimpact incarcerated fragments of bone and soft tissue from fracture site

57. Reduction
Pin through talar head to control varus/valgus

58. Reduction Must restore appropriate head-body alignment
This may entail some gapping due to medial comminution

59. Reduction Use both incisions simultaneously to effect a reduction
Check with:
Cortical read if possible
C-arm to assess congruency of subtalar joint

60. Reduction
Posterior facet
Middle facet
Cortical read when able

61. Reduction
Posterior facet
Middle facet
Cortical read when able

62. Reduction
Posterior facet
Middle facet
Cortical read when able

63. Reduction
Posterior facet
Middle facet
Cortical read when able

64. Reduction
Posterior facet
Middle facet
Cortical read when able

65. Reduction
Posterior facet
Middle facet
Cortical read when able

66. Lateral fixation
Lateral cortex usually the only part you can put a plate on
Can curve onto anterolateral body in front of the lateral process
Minifragment plate and screws, or just screws
Articular cartilage
Talar head
Soft tissue

67. Lateral fixation
Lateral cortex usually the only part you can put a plate on
Can curve onto anterolateral body in front of the lateral process
Minifragment plate and screws, or just screws
Articular cartilage
Contour plate
Talar head
Soft tissue

68. Lateral fixation
Anterior portion of talar body is a good anchor point for screws and / or plate

69. Medial fixation Medial screw or screws
Through medial incision or separate perc wound
Screw enters through talar head
May need to notch a small part of navicular for optimal trajectory

70. Medial fixation

71. Medial fixation
Countersink deep to articular surface

72. Common constructs Parallel postero-anterior screws
Medial screw(s), lateral plate
Crossed antero-posterior screws

73. Wound closure Close capsule with absorbable suture
Skin with interrupted nonabsorbable sutures
Postoperative splint
Thromboprophylaxis

74. Rehab Initial immobilization until wounds heal
Start ROM after wounds heal with a removable boot
Check for Hawkins sign at 6-8 weeks
NWB x 12 weeks
Consider MRI scan at that time
Consider long term use of PTB brace
Require long-term follow-up

75. Hawkins Sign Check mortise view at 6-8 weeks
Subchondral lucency along talar dome
Implies revascularization of dome

76. Outcomes Outcomes correlate with presence of complications
No complications  good outcome
>1 complication  poor outcome
Osteonecrosis has the worst outcome
Dodd et al JOT 29(5): , 2015

77. Complications
High complication rate – early patient education important
Delayed & nonunion
Malunion (varus)
Osteonecrosis
Post-traumatic arthritis

78. Nonunion
8 months postop
6 months postop

79. Malunion Typical deformity = varus Etiologies Orthoses
Medial comminution ?
Pull of PTT ?
Orthoses
Calcaneal osteotomy
Subtalar arthrodesis
Medial opening wedge osteotomy ?

80. Calcaneal osteotomy

81. Osteonecrosis Overall rate 31.2% Risk Factors
Open vs. closed
Hawkins type
Degree of displacement
Degree of comminution
Timing to ORIF not shown to be correlated
Mean time to onset ~ 7 months
Dodd et al, JOT 29(5) 2015
Vallier HA JBJS 96-A(3):192-7, 2014
Xue Y Int Orthop 2014
Vallier HA JBJS 96-A(3):192-7, 2014

82. Osteonecrosis Diagnosis Increased density on plain radiographs
MRI scan
Osteonecrosis
No osteonecrosis

83. Osteonecrosis – what to look for
No osteonecrosis
1 year postop
7 months postop

84. Osteonecrosis – what to look for
Partial ON
No collapse 7 years postop
9 months postop

85. Osteonecrosis – what to look for
Complete ON
Starts to collapse 3 months later
10 months postop

86. Post-traumatic arthritis
Rate of post-traumatic subtalar arthritis:
49% overall
81% with > 2 years follow-up
Rate of post-traumatic arthritis in either joint
54% overall
Subtalar > tibiotalar> talonavicular
Dodd et al, JOT 29(5) 2015
Vallier HA JBJS 96-A(3):192-7, 2014

87. Post-traumatic arthritis
Ankle joint

88. Post-traumatic arthritis
Subtalar joint

89. Post-traumatic arthritis
Both ankle and subtalar joints

90. Post-traumatic arthritis
All 3 (TT, ST, & TN)

91. Post-traumatic arthritis
All 3 (TT, ST, & TN)

92. Reconstructive Options
Bone grafting for any ununited fx lines
Soft tissue management – release of contractures (e.g., TAL)
Osteotomy (e.g., lateral calcaneal slide)
Arthrodesis
Tibiotalar (ankle fusion)
Subtalar fusion
Both (tibiotalocalcaneal fusion)

93. Ankle arthrodesis

94. Subtalar arthrodesis
Screw 1

95. Subtalar arthrodesis
Screw 2

96. Tibiotalocalcaneal arthrodesis

97. Reconstructive Options
Void management
Tibiocalcaneal fusion with or without transport
Morcellized graft
Structural graft (e.g., femoral head)
Fusion cage

98. Osteonecrosis with collapse
Immediate postop
2 years postop

99. 2 ½ years post reconstruction
Talar body nonviable
2 years post ORIF
2 ½ years post reconstruction

100. Other fracture types Talar Body Talar Dome Talar Head
Posterior Process
Lateral Process

101. Talar Body Fractures Posterior to the lateral process
Intra-articular into the tibiotalar joint

102. Talar Dome Fractures
Small dome fractures may sometimes occur with other fracture types
Depending on size, fix with small countersunk screws
May need to extend one of your 2 incisions to access this
1 month postop

103. Talar Dome Fractures
Stable minimally displaced fractures – nonsurgical treatment
Observe closely for any displacement
1 year post-injury
Stable, no pain

104. Talar Dome Fractures
Some isolated dome fractures may be amenable to arthroscopic-assisted reduction

105. Talar Head Fractures
Often minimally displaced and stable

106. Talar Head Fractures
Can occur with sustentacular fractures as part of a medial subtalar dislocation

107. Posterior Process Fractures
Can occur
Posteromedially
Posterolaterally
Both

108. Posteromedial Process
Can occur with medial subtalar dislocations

109. Posterior Process Fractures
Posterior talus wider medially than laterally
Usually more room for fixation medially
Must often mobilize FHL tendon

110. Posterior Process Fractures
Small, poorly vascularized
Access difficult
Posteromedial
Medial neurovascular bundle
Often need to mobilize FHL
Posterolateral
Interval between FHL and peroneals
Fixation difficult
Minifragment screws

111. Posterior Process Fractures
Post-traumatic arthritis, nonunion common
Consider excision instead for smaller fragments?
3 years postop
Painful, stiff, no further surgery

112. Lateral Process Fractures
Snowboarder’s fx
Involves varying amounts subtalar joint
Approach via sinus tarsi incision
Larger fragments: fix with interfrag screws
Smaller fragments: consider excision

113. Key points Fraught with complications – educate patient early
Frank dislocations should be reduced urgently
Actual fixation can occur in a staged fashion
Most talus fractures should be treated operatively and open with dual incisions

115. Elevate posterior tibial tendon
Thank You !