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TREATMENT OF TALUS INJURIES IN POLYTRAUMA
Bondarenko A.V., Batrak Ya.Yu., Plotnikov I.A.
Altai State Medical University, Regional Clinical Hospital of Emergency Medical Care, Barnaul, Russia
Fractures and
dislocations of the talus is a rare and complex pathology. Being the consequence
of high energy impactions, they are common in polytrauma (PT) [1-3]. Owing to
unique anatomy, features of blood perfusion and multiple complex junctions, the
treatment of talus injuries is associated with significant difficulties. Their
course is often associated with development of infectious complications,
degenerative arthrosis, posterior foot deformations, avascular necrosis, poor
outcomes and high rate of disability [4-6].
Since almost
all fractures of the talus are intraarticular, they require for precise
reposition, stable fixation and early function [4, 7]. The presence of several
severe injuries hinders the use of the common surgical techniques for talus
injuries or delays their carrying out, resulting in development of
complications – edema, epidermal bullas, soft tissue fibrous alteration, and
avascular necrosis [8-10]. In the late period, it is impossible to perform
adequate reposition of fragments and to fix it with the common techniques.
Considering this fact, it is necessary to search some low-invasive surgical
techniques for treatment of talus injuries in patients with PT in early and
late periods.Objective – to find out the incidence, the features of the talus injuries in
polytrauma, the peculiarities of the treatment, and the use of modern methods
of minimally invasive osteosynthesis.
MATERIALS AND METHODS
The study was carried out in compliance with World Medical Association Declaration of Helsinki – Ethical
Principles for Medical Research Involving Human Subjects, 2013, and to the
Rules for Clinical Practice in the Russian Federation (the Order of Russian
Health Ministry, 19 June 2003, No.266), with the written consent and the
approval by the ethical committee. The continuous technique was used for
inclusion to the study over the limited territory and over the limited time.
175 patients with 182 talus injuries, at the age of
14-80 (the median – 32 years, interquartile range – 27-42) were treated in
Barnaul Regional Clinical Hospital in 2000-2018. There were 145 men (82.9 %),
30 women (17.1 %), 91 employed (52 %), 69 unemployed persons of working age, 9
students (5.1 %), 6 retired persons (3.4 %). The injuries after high energy
impaction were in 145 (82.8 %) patients: road traffic accidents (RTA) – 97
(55.4 %), falling from high altitude – 48 (27.4 %). The low energy mechanisms
were in the following cases: home accidents – 21 (12 %), sports injuries – 9
(5.1 %).
117 (66.9 %) patients had the talus injuries as one of
the components of PT. 75 (64.1 %) patients had ISS [11] of 17-25, 26 patients
(22.2 %) – 25-40, 16 (13.7 %) – more than 41. Traumatic brain injuries were in
24 patients, brain concussion – in 15, brain contusion – in 9, intracranial
hemorrhage – in 2, skull base fracture – in 1. Internal abdominal and thoracic
injuries were in 21 patients, including 2 cases of pneumothorax, hemothorax –
2, kidney contusion – 9, liver laceration – 3, spleen laceration – 3,
intestinal perforation – 1, omentum laceration – 1. Locomotor system injuries
in other locations were in 83 patients (fractures of the humerus – 8, of the
forearm – 5, of the hip – 18, of the leg – 49, of calcaneal bone – 21, of the
spine – 21, of ribs – 14, of the pelvis – 13). 58 (33.1 %) patients had the single
injuries to the talus. Closed injuries to the talus were identified in 160
(87.9 %) cases, opened ones – in 22 (12.1 %).
Coltart’s classification was used in the study (1952)
[9]. It allowed more detailed characterization of the injuries. There were the
following injuries:
1) Fractures of the talus body with displacement and
without it (Fig. 1a).
2) Fractures of talus body were of three types: type I
– fractures the talus neck without displacement of bone fragments (Fig. 1b);
type 2 – fractures of the talus neck with displacement of bone fragments and
subluxation in the subtalar joint (Fig. 1c); type 3 – fractures of talus neck
with dislocation of the body (Fig. 1d).
3. Subluxation and dislocations in the subtalar joint
(Fig. 1e).
4. Complete dislocations of the talus (Fig. 1f).
Figure 1. Types of talus
injuries: a) fractures of talus body are located posteriorly from the
lateral process, and they involve both ankle and subtalar joints; b) type
1 – fractures of talus neck without displacement; c) type 2 – fractures of
talus neck with displacement and subluxation in the subtalar joint; d) type
3 – fractures of talus neck with dislocation of the body; e) subluxations
and dislocations in the subtalar joint; f) full dislocation of talus
Fractures of the talus body were identified in 78(42.9 %) cases, without displacement – in 61 (33.5 %), with displacement – in
17 (9.3 %).There were 54 (29.7 %) talus fractures of all 3 types, type 1 – 15
(8.2 %), type 2 – 26 (14.3 %), type 3 – 13 (7.1 %). There were 41 dislocations
and subluxations in the subtalar joint. There were 9 complete dislocations of the talus (4.9 %).
At the moment of admission, the patients with
posterior foot injuries were examined with X-ray imaging of the ankle joint and
the foot in two standard plains. Multi-spiral computer tomography (MSCT) was
used for detailed study of the injuries.
The indications for surgical treatment of talus
injuries were fractures of the bone body within the limits of the articular
cartilage with displacement not more than 2 mm, displaced fractures of the
talus neck, subtalar dislocations of the foot, and opened injuries.
Correction of dislocations, reposition and fixation
(also surgical one) were carried out for single injuries immediately before
development of edema and epidermal bullas.
Damage Control concept was used for patients with PT
[12]. According to the recommendations by Sokolov V.A., the resuscitation and
profile clinical stages were separated during inhospital treatment for patients
with PT [2].
For closed injuries and impossible surgical
intervention, we corrected the rough displacements by means of plaster
immobilization, the external fixing device (Fig. 2) or temporary transcutaneous
fixation with K-wires for subtalar or ankle joints (Fig. 3). The final
osteosynthesis was realized after condition stabilization and in satisfactory
state of skin surfaces. Temporary transcutaneous fixation with K-wire for
subtalar and ankle joints was usually used for opened injuries and for
extremely severe condition of patients. It provided the possibility for
realization of subsequent diagnostic and curative procedures, and decreased the
intensity of edema. After condition stabilization, the final osteosynthesis was
carried out.
Figure 2. Exrafocal fixation of
opened fracture-dislocation of talus with dislocation of fragments
Figure 3. Transarticular
fixation with K-wire for subtalar dislocation and dislocation in chopar joint
1. Fractures of talus body. There were 71 closed fractures and 1 opened fracture. After admission, all patients with closed injuries received the plaster immobilization; for 57 patients it was the final technique of treatment. 14 patients were treated with osteosynthesis, including 8 cases of opened reposition and internal fixation with 3.5 mm cortical screws (Fig. 4), 6 – closed reposition and transcutaneous low-invasive with 4 mm screws (Fig. 5).
Figure 4. X-ray image after
opened reposition of talus body and after fixation with cortical screws (3.5 mm
diameter)
Figure 5. Closed low invasive
fixation of talus body with cannulated screws (4 mm) with dorsal placement
All patients with opened fractures received the
primary surgical preparation with external fixation. It was the final treatment
technique for 3 patients; 4 patients received the opened reposition with
fixation of the talus body with 3.5 mm cortical screws after wound healing.
2. Fractures
of talus neck. There were 47 closed and 7 opened fractures. All 15
fractures of the talus neck of type 1 were closed. At admission, all patients
received the plaster immobilization, which was the final treatment for 9
patients; 6 patients later received the low-invasive fixation of the talus with
4 mm channel screws.
There were 25 closed fractures of the talus neck of
type 2 and 1 opened fracture. 15 patients with closed fractures received the
closed reposition with plaster immobilization, 6 – closed reposition with
transarticular fixation with K-wire, 4 – external fixation. Subsequently, at
the profile-clinical stage, 15 patients with plaster splint received the closed
reposition and low-invasive fixation with 4 mm channel screws. Opened
reposition with 3.5 cortical screws was used for 5 patients after
transarticular fixation and for 3 patients after transosseous fixation.
Transarticular fixation and external osteosynthesis were the final treatment
techniques for 2 patients.
The patient with an opened fracture of the talus neck
of type 2 received the primary surgical preparation and external fixation at
admission. After the wound healing, the external fixation was changed to
low-invasive fixation with 4 mm channel screws.
There were 9 closed fractures of the talus neck of
type 3, and 4 opened ones. At the intensive care stage, 3 patients with closed
fractures received the closed reduction of dislocations of the talus body with
use of plaster immobilization, 4 – closed reduction with transarticular
fixation with K-wire, 2 – closed reduction with external fixation. At the profile-clinical
stage, the opened reposition and fixation with 3.5 cortical screws was carried
out for 3 patients with plaster splint, for 3 patients with transarticular
fixation with K-wire and for 1 patient with external fixation. For 2 patients,
transarticular fixation with K-wire, and the external fixation were the final
treatment techniques.
At admission, all 4 patients with opened fractures of
the talus neck of type 3 received the primary surgical preparation with
reduction of dislocation of the talus body and external fixation.
3. Subluxations
and dislocations in the subtalar joint. There were 36 closed and 5
opened injuries of such type. 5 patients with closed injuries received the
closed reposition of dislocation with plaster immobilization, 27 – closed
reduction with K-wire transarticular fixation, 4 – closed reduction with
external fixation. Subsequently, at the profile-clinical stage, the closed
arthrodesis with 7.3 mm cannulated screws was performed for 4 patients with
transarticular fixation and for 2 patients with external fixation (Fig. 6). The
final treatment techniques were plaster immobilization in 5 patients, K-wire
transarticular fixation in 23, external fixation – in 2.
Figure 6. X-ray images of the
foot after subtalar joint arthrodesis with fixation with cannulated screws (7.3 mm)
2 patients with opened injuries received K-wire
transarticular fixation after primary surgical preparation and reduction, 3
patients received the external fixation. Subsequently, at the profile-clinical
stage, a patient with transarticular fixation received the arthrodesis of the
posterior part of the foot with Expert HAN (Switzerland) (Fig. 7). A patient
with external fixation received the arthrodesis of the subtalar joint with 7.3
mm channel screws. For 2 patients, the external fixation was the final
treatment method.
Figure 7. X-ray images of the
foot after arthrodesis of subtalar and ankle joint with the locking nail
4. Complete
dislocations of the talus. Closed complete dislocations of the talus
were identified in 5 patients, opened ones – in 4. After admission, it was
possible to perform the closed reduction of the bone in all patients with
closed dislocations of the talus. After that, 4 patients received the K-wire
transarticular fixation through ankle and subtalar joints. 1 patient received
the external fixation. These treatment techniques were final.
2 patients with opened complete dislocations of the
talus received the primary surgical preparation of opened dislocation with
talus reduction and transarticular fixation with K-wire, 2 patients – primary
surgical preparation with reduction and external fixation. At the
profile-clinical stage, 1 patient with transarticular fixation received the
arthrodesis of the subtalar joint of the posterior foot with use of the Expert
HAN locked nail. For others, the osteosynthesis techniques used at admission
were final.
Therefore, the plaster immobilization was the final
technique in 71 cases, transarticular fixation with K-wire – in 30,
osteosynthesis with 3.5 cortical screws after opened reposition – in 31,
low-invasive osteosynthesis with 4 mm channel screws – in 28, external fixation
– in 8, arthrodesis for the posterior foot with use of Expert HAN – in 2.
During examination of the results, the hospital
mortality, features and number of complications, and the treatment outcomes
were estimated. The long term anatomic and functional results were estimated in
50 (38.6 % of the primary sample) patients with talus injuries for the period of
1-3 years. AO FAS [13] and Mattis-Luboschitz-Schwarzberg scale [14] were used
for estimation of the results.
The data analysis was initiated from making the frequency
diagram. χ2-test
with Yates' correction, and Bonferroni’s method for multiple comparisons were
used for examination of statistical significance. The critical level of significance
was less than 0.05 [15].
RESULTS AND DISCUSSION
Over the
whole period of the follow-up, 117 (66.9 %) patients with talus injuries (as
one of the components of PT) were admitted to the hospital from the territory
of Barnaul city. For the same time interval, the single injuries to the talus
were identified in 58 (33.1 %). Therefore, the talus injuries in PT were
identified two times more often than single injuries. The differences were statistically significant (p < 0.001).
The table 1
shows the amount of patients with single injuries to the talus and injuries as
a part of PT in dependence on types of injuries. All talus injuries in PT
appeared after high-energy impact (RTA and catatrauma), whereas most single
injuries were caused by low-energy factors (home or sports injuries) (the table
1).
Table 1. Number of patients with single talus injuries and with polytrauma, depending on injury types
|
Injury features |
Injury type |
Total |
|||
|
Road traffic accident |
Catatrauma |
Home injury |
Sports injury |
||
|
Single injury to talus |
22 |
6 |
21 |
9 |
58 |
|
Talus injury in polytrauma |
75 |
42 |
- |
- |
117 |
|
Total |
97 |
48 |
21 |
9 |
175 |
The table 2 shows the distribution of talus injuries according to Coltart’s classification in single injury and in PT. In most cases, the single injuries were presented by fractures of the body and the neck of the talus without displacement, whereas most talus injuries in PT were fractures of the body and the neck of the talus with displacement, foot dislocation in the subtalar joint, and complete dislocations (the table 2).
Table 2. Distribution of talus injuries according to Coltart’s classification in single injuries and polytrauma
|
Injury features |
Injury type |
Total |
||||||
|
Talus body fracture |
Talus neck fracture |
Subtalar dislocations |
Full dislocation of talus |
|||||
|
without displacement |
with displacement |
type 1 |
type 2 |
type 3 |
||||
|
Single injury to talus |
28 |
4 |
14 |
3 |
- |
9 |
- |
58 |
|
Talus injury in polytrauma |
33 |
13 |
1 |
23 |
13 |
32 |
9 |
124 |
|
Total |
61 |
17 |
15 |
26 |
13 |
41 |
9 |
182 |
Among 124
talus injuries in PT, the opened injuries were identified in 21 cases, and only
in 1 case among 58 cases with single injuries. The differences were statistically
significant (p < 0.01).
Two patients with
PT died. The general mortality after talus injuries was 1.1 %, in patients with
PT – 1.7 %. The cause of the lethal outcome was brain edema and swelling in
opened traumatic brain injury in the first patient, and acute massive blood
loss, with hemorrhagic shock in blunt abdominal injury with laceration of
internal organs in the second patient. Both lethal outcomes were not associated
with the talus injury.
There were 51
somatic injuries in 34 (19.4 %) patients. 5 complications were found in single
injuries in 3 (1.7 %) patients (deep venous thrombosis of lower extremities in
3 cases, bronchopulmonary complications in 2 cases). 31 patients with PT had 46
complications (17.7 %) (19 cases – deep venous thrombosis of lower extremities,
15 – bronchopulmonary complications, 9 – bedsores, 2 – sepsis, 1 – thromboembolism
of pulmonary artery branches). In patients with PT, all somatic complications
developed with ISS > 30, but the relationship with severity of talus
injuries was not found. The differences in incidence of somatic complications
in patients with single injuries to the talus and PT were statistically
significant (p < 0.05).
There were 22
local complications in 20 (11.4 %) patients: 11 complications in closed
injuries (6.9 % of total amount of closed injuries), 11 complications in opened
injuries (50 % of total amount of opened injuries). There were 5 complications
with instability of the external fixator, resulting in secondary dislocations,
5 cases of postsurgical wound purulence, 5 cases of ischemic necrosis of
boundaries of wounds, 6 cases with inflammation of soft tissue near
transosseous elements of the external fixator, 1 fracture of K-wire after
transarticular fixation at the level of articular cavity of the ankle joint.
More often,
the local complications were found in use of transosseous fixation with the
external fixator (10 cases), transarticular fixation of the ankle joint with
K-wire (9 cases), opened reposition and internal fixation with 3.5 mm cortical
screws (2 cases), subtalar joint arthrodesis with 7.3 mm screws (1 case). There
were not any complications after low-invasive osteosynthesis with 4 mm screws.
1. Talus body fractures. There were
not any complications in closed injuries. 4 local complications were found in
opened injuries: 2 cases with inflammation in the wound site, 2 cases with
instability of transosseous elements. All complications were found after external
fixation. The incidence of local complications after talus body fractures were
5.1 %.
2. Fracture of talus neck. There
were 7 local complications. No complications were found after talus neck
fractures of type 1. There was 1 local complication of type 2 – instability of
transosseous elements of the external fixator after a closed fracture. The type
2 was associated with 3.8 % of local complications. The type 3 was associated
with 6 local complications (5 – after closed fractures, 1 – after opened
fracture). The closed fractures were associated with local inflammation in the
region of transosseous elements of the external fixator. 2 cases were related
to wound inflammation after opened reposition and osteosynthesis with 3.5 mm
cortical screws. Ischemic necrosis of wound borders after opened reduction and
transarticular fixation with K-wire was found in 2 cases. After opened
fractures, the inflammation in the wound site after primary surgical
preparation and fixation with 3.5 mm cortical screws was found in 1 case. The
incidence of local complications for the type 3 was 46.1 %.
3. Subluxation and dislocation in the
subtalar joint. There were 8 local complications (5 – after closed
injuries, 3 – after opened ones). After closed injuries, the soft tissue
inflammation in the site of transosseous elements of the external fixator was
found in 1 case, ischemic necrosis of the wound borders after transarticular
fixation with K-wire – in 1 case, instability of transosseous elements of the
external fixator – in 1, reluxation in conditions of transarticular fixation
with K-wire – in 1, fractures of K-wire after transarticular fixation – in 1.
After opened injuries, the inflammation in the wound site after external
fixation was found in 2 cases, after subtalar joint arthrodesis with 7.3 mm
screws – in 1. The incidence of local complications in subluxation and
dislocation of the subtalar joint was 19.5 %.
4. Complete dislocations of the talus.
There were 3 local complications. All of them were after opened injuries. The
inflammation in the postsurgical wound site after external fixation was in 1
case, ischemic necrosis of the wound borders in conditions of transarticular
fixation with K-wire – 1, inflammation in the region of transosseous elements
of the external fixator – 1. The incidence of local complications after complete
dislocation of the talus was 33.3 %.
Therefore,
the highest incidence of local complications was found for fractures of the
talus neck of type 3 (46.1 %), complete dislocation of the talus (33.3 %) and
subtalar dislocations of the foot (19.5 %).
The long term
results of treatment were examined in 50 (38.6 % of the primary group) patients
within 3-6 years after injuries. The estimation was conducted with use of AO
FAS [16] and Mattis-Luboschitz-Swarzberg score [17]. The table 3 shows the data
of clinical outcomes according to AO FAS. There were not any excellent results.
The good results were found in patients with fractures of the talus body and
neck of types 1-2. The results of treatment were satisfactory for subluxation
and dislocation in the subtalar joint after fractures of the talus neck of type
3. There were no poor outcomes (the table 3).
Table 3. Long term results of treatment of talus injuries according to AO FAS
|
Injury features |
Number
of cases |
Average
sum of points of AOFAS |
Result |
|
Talus body fracture |
28 |
82 ± 3.7 |
Good |
|
Talus neck fracture |
9 |
79 ± 3.9 |
Good |
|
Type 1 |
5 |
81 ± 2.9 |
Good |
|
Type 2 |
3 |
78 ± 2.6 |
Good |
|
Type 3 |
1 |
72 ± 0 |
Satisfactory |
|
Subdislocations in subtalar joint |
12 |
59 ± 6.9 |
Satisfactory |
|
Dislocations |
2 |
61 ± 9.9 |
Satisfactory |
The table 4 shows the clinical findings of the outcomes according to Mattis-Luboschitz-Swarzberg score. The good results were found in patients with talus body fractures and in all types of the talus neck fractures. The satisfactory results prevailed in subluxation and dislocation in the subtalar joint. There were no poor results (the table 4).
Table 4. Long term results of treatment of talus injuries according to Mattis-Luboshitz-Schwarzberg score
|
Injury features |
Number
of cases |
Average
sum of points of AOFAS |
Result |
|
Talus body fracture |
28 |
3.6 ± 0.4 |
Good |
|
Talus neck fracture |
9 |
3.77 ± 0.2 |
Good |
|
Type 1 |
5 |
3.8 ± 0.2 |
Good |
|
Type 2 |
3 |
3.8 ± 0.16 |
Good |
|
Type 3 |
1 |
3.6 ± 0 |
Good |
|
Subdislocations in subtalar joint |
12 |
3.4 ± 0.3 |
Satisfactory |
|
Dislocations |
2 |
3.4 ± 0.3 |
Satisfactory |
The satisfactory results were determined by pain syndrome, partial loss of working capability, signs of avascular necrosis of the talus, and degenerative arthrosis of ankle and subtalar joints.
CONCLUSION
1. Talus injuries
in PT appear after high energy impact. Their incidence is two times higher than
in single injuries. The highest proportion is presented by dislocations and
displaced fractures, and by opened injuries with higher severity.
2. Somatic
complications after talus injuries in patients with PT are identified more
often (17.7 %) than in single injuries.
3. More often,
the local complications of the talus were identified after opened fractures (up
to 50 %), after fracture of the talus neck of type 3 (46.1 %), complete
dislocations of the talus (33.3 %), and subtalar impact in patients with PT.
4.
Transarticular fixation with K-wire for ankle and subtalar joints is indicated
for severe condition of patients with PT. In contrast to plaster splint, it
provides more rigid fixation and free approach to the injured extremity. It is
simpler and easier to perform than external fixation.
5. Despite of
the fact that most local complications are identified after external fixation,
it is almost impossible to use any other technique of final treatment due to
characteristics of soft tissue injuries in patients with severe opened injuries
to the talus in PT.
6. The
results of transcutaneous low-invasive fixation with 4 mm screws for fractures
of talus body and neck allow recommending this technique for wider use for
patients with PT.
Information on financing and conflict of interest
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interest relating to this article.
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