Talar fractures constitute
The use of autologous bone-tissue allografts (from the iliac crest or femoral head) to treat talar neck and body fractures has been reported. However, these allograft procedures have been accompanied by primary fusion of one or more of the seven articular surfaces of the talus, most commonly the talocalcaneal, talonavicular, and talotibial joints, leading to considerable loss of function2-4. The use of whole-bone fresh-frozen allografts in the foot has only been reported for the treatment of bone tumors. Muscolo et al. reported on the use of whole fresh-frozen calcaneal allografts for the treatment of chondrosarcoma and giant-cell tumor of the calcaneus5. We are unaware of any previous reports on the use of bulk allografts as an alternative to subtalar arthrodesis for the treatment of severely comminuted fractures of the talus. In an attempt to minimize loss of function, we reconstructed a severely comminuted talar fracture with use of a portion of a fresh-frozen osteochondral talar allograft. We report our results after twenty- nine months of follow-up. The patient was informed that data concerning this case would be submitted for publication.
Fig. 1
Preoperative lateral radiograph of the ankle, showing a comminuted fracture of the posterior part of the body of the talus extending into the subtalar joint.
Case Report
A fifty-year-old man fell from a height of 16 ft (4.9 m). He complained of pain in the back and in the right ankle. Radiographs demonstrated a comminuted fracture of the posteroinferior aspect of the right talus. The fracture involved the posterior aspect of the talar dome and extended anteroinferiorly, with severe comminution of the articular surface of the subtalar joint (Figs. 1 and 2), consistent with an Orthopaedic Trauma Association type 72-C2 fracture. Associated injuries included T12 and L1 spinal compression fractures. Because of the small size of the fragments and the extensive articular cartilage damage, the decision was made to reconstruct the talus by replacing the comminuted area of its posterior half and the subtalar articular surface with a fresh- frozen osteoarticular allograft.
Fig. 2
Axial computerized tomographic scan showing a severely comminuted posteroinferior fracture of the body of the talus. Note the small size of many of the fragments.
Fig. 3
Photograph of the anteromedial incision, showing the void created after excision of the comminuted fragments of the posterior half of the talar dome, including the totality of the subtalar articular surface.
A height, side, and gender-matched fresh-frozen talar allograft was ordered from the American Red Cross following tissue-bank guidelines. The surgery took place six days after the initial trauma, once the swelling had subsided and the allograft had become available. A 5-cm vertical posteromedial skin incision was performed between the medial malleolus and the Achilles tendon, with the incision curving around the medial malleolus toward the talonavicular joint. Next, a transverse osteotomy of the medial malleolus was performed to allow distal reflection of the medial malleolus and the deltoid ligament. A femoral distractor was placed across the ankle joint to facilitate exploration of the comminuted talus. The talus was exposed, and many severely comminuted fragments constituting the posterior half of the talar dome as well as the totality of the subtalar articular surface were excised, leaving a large posteroinferior void (Fig. 3). The posterior portion of the osteoarticular allograft was then fashioned to match the remaining intact anterior portion of the talus, and an anatomic reduction was obtained between the graft and the host bone (Figs. 4-A and 4-B). The allograft was secured to the remaining portion of the talus with two 4-0 partially threaded cancellous titanium screws that were placed, one from anterior to posterior and one from posterior to anterior, under fluoroscopic guidance. The osteotomized medial malleolus was then fixed with two lag screws.
Fig. 4-A
Photographs showing the contouring of the talar allograft (Fig. 4- A) and its insertion into the ankle joint (Fig. 4-B).
Fig. 4-B
The patient wore a posterior splint for ten days after surgery. Upon removal of the sutures, he was managed with a brace and was kept from bearing weight for ten weeks. The brace was removed three times a day for active and passive range-of-motion exercises. The patient started partial weight-bearing up to 40 lb (18.1 kg) at ten weeks and was advanced toward full weight-bearing at twelve weeks.
Fig. 5-A
Fig. 5-B
Anteroposterior (Fig. 5-A) and lateral (Fig. 5-B) radiographs of the ankle, made after twenty-nine months of follow-up, showing healing of the allograft to the retained portion of the native talus.
The patient was evaluated at two, four, six, twelve, twenty- four, and twenty-nine months. No complications were noted. At twenty- nine months, the range of motion of the ankle was slightly decreased, with 10 of dorsiflexion and 30 of plantar flexion (a 5 and 10 decrease, respectively, as compared with the contralateral ankle). The range of motion of the subtalar joint was measured with the patient lying prone. The hip was flexed 90, and the ankle was kept in neutral alignment at 90. Inversion and eversion stresses were applied to the foot, and the measurements were made with a goniometer. The subtalar range of motion was 5 of eversion and 10 of inversion. No limb-length discrepancy was observed, and no pain or loss of sensation was reported. The Musculoskeletal Function Assessment score6 was 19.32 points (possible range, 0 to 100 points, with lower scores indicating better function). Radiographs revealed intact hardware and no signs of osteonecrosis or nonunion (Figs. 5- A and 5-B). A magnetic resonance image of the foot, acquired after twenty-nine months of follow-up, revealed revascularization of the allograft (Fig. 6). At the time of the latest follow-up, the patient was able to use regular shoes and had returned to part-time work as a construction worker.
Fig. 6
T1-weighted sagittal magnetic resonance image of the talus, acquired after twenty-nine months of follow-up. Despite some artifact from the titanium screws, the grafted portion of the talus has a homogeneous vital signal.
Discussion
Talar fractures, although uncommon, often are associated with a poor prognosis and severe complications such as osteonecrosis, loss of range of motion, posttraumatic arthritis, and rapid joint deterioration1,7-10. Displaced fractures of the talar neck and body are best treated with open reduction and internal fixation2,3,8,10. As severely comminuted talar fractures have a very poor prognosis, arthrodesis may be necessary. Notably, Blair fusion7,8,11 and bone block distraction arthrodesis4 are intended to minimize the heel- height discrepancy that results from ankle fusion1.
Various authors have reported different morbidity rates following joint arthrodesis, perhaps because of differences in the initial severity or treatment of the fracture as well as in the method of arthrodesis2-4,8-11. Arthrodesis can result in nonunion or malunion of the joint, varus or valgus deformity, pain at the site of hardware, arthritis of adjacent joints, and reflex sympathetic dystrophy8,10,12.
The subtalar joint is a critical structure that affects the ability to absorb axial compression forces and to accommodate to uneven surfaces when walking. Proper function of the subtalar joint directly correlates with quality of life, and therefore the preservation of this function should be a priority. In the case of our patient, we reconstructed the posteroinferior aspect of the talus with a fresh-frozen osteoarticular allograft in an effort to restore maximum functional integrity after a severely comminuted fracture of the talus. At twenty-nine months of follow-up, the need for a tibiocalcaneal arthrodesis had been avoided and the patient had an excellent intermediate-term result. We recognize that our patient was extremely cooperative and motivated and that, without his help, the final outcome could have been different. Although the outcome after twenty-nine months of follow-up was very encouraging, longer follow-up is necessary in order to fully assess the advantages of this procedure compared with more standard treatments.
NOTE: The authors thank Donna Cece, PA, for her contributions to this work.
References
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BY IVAN F. RUBEL, MD, AND ALEXANDRA CARRER, MS
Investigation performed at SUNY Downstate-Kings County Medical Center, Brooklyn, New York
Ivan F. Rubel, MD
Alexandra Carrer, MS
Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
doi:10.2106/JBJS.C.01671
Copyright Journal of Bone and Joint Surgery, Inc. Mar 2005
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