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Three cases of transchondral fracture of the dome of the talus are reported. Two were treated surgically, one conservatively. A review of the literature is presented and the relative values of surgical intervention and conservative therapy are discussed.
A retrospective review of nine patients with fractures of the lateral process of the talus indicates that a substantial portion of patients will have persistent symptoms if the fracture is not diagnosed and appropriately treated soon after the injury. When a patient is evaluated for the symptoms of a "sprained ankle," these fractures are often overlooked on the initial roentgenograms. If untreated, these fractures often fail to heal, and persistent pain over the lateral aspect of the ankle following an inversion injury should be investigated for the possibility of this diagnosis. Prompt treatment of acute fractures appears to lead to the best result. Nondisplaced fractures heal well in a short-leg cast, with six weeks of immobilization. Large displaced fracture fragments require surgical treatment: single large fragments should be reduced and internally fixed, and large comminuted fragments should be excised.
Four types of talus fractures can be distinguished and the prognosis predicted on the basis of vascular patterns before and after injury. Early decompression of the soft tissues or anatomic reduction by closed or (if not possible) open methods is indicated. Stable fixation by lag screws and functional aftertreatment help to improve the prognosis. The late results with reference to necrosis, posttraumatic arthrosis, secondary arthrodesis, and functional outcome show that open reduction and internal fixation, applied early, can produce better functions than was heretofore thought possible. Special emphasis is placed on careful indications, operative techniques, and postoperative treatment--particularly the time of partial weight-bearing with a caliper brace.
Fractures of the neck of the talus are rare in children. A grade I injury in a 5-year-old girl, with apparent bony union at 6 weeks after the accident, confirmed after 4 months, is reported.
The clinical and radiological findings in 7 cases of osteochondritis dissecans of the talus indicate that this is a potentially progressive condition. Surgical treatment was carried out in 4 cases while the remaining 3 were treated conservatively. Surgery produced good clinical and radiological results. The conservative treatment consisted of immobilisation and abstention from weight-bearing. This was unsuccessful in 2 adult patients but in a 9 year old girl it led to a virtually complete recovery in 3 months.
Since 1962, the authors have used a technique of sub-talar arthrodesis combined with talar-calcaneal reposition ("horseman" operation) in cases of valgus flat foot, accompanied by symptoms, in moderate forms with exaggerated talar-calcaneal divergence and verticalisation of the talus. This operation involves only the sub-talar joint. The mid-tarsal joint is untouched. Technique must be precise in order to avoid hyper or hypo-correction. The results are constantly good. The mid-tarsal joint remains free, which offers a definite advantage in comparison with classical double tarsectomy.
Lesions of the talar cartilage are extremely difficult to diagnose clinically or roentgenologically. Often they are masked by accompanying lesions of the bone or the capsular ligaments, so that arthrotomy will be necessary to obtain information on the condition of the cartilage. Reconstruction of the articular surface is a most important prerequisite für restoring the ability of the cartilage to cope with physiological load. Hence, the aim of the treatment is the replantation of abraded cartilaginous fragments. The use of concentrated fibrinogen as a biological tissue adhesive has been gaining in importance as an alternative to the methods of refixation practised so far. The actual process of gluing is technically simple. 7 patients in whom gluing of the cartilage at the talus had been performed, remained free from complaints for a follow-up period of three years.
In this paper the authors discuss the classification, management, and complications of different types of fracture of the neck of the talus. They recommend immediate reduction of displaced fractures to lessen the probability of avascular necrosis and traumatic arthritis.
The authors report 7 cases of sub-taloid dislocation, to which they prefer Allieu's term of talo-navicular-calcaneal dislocation, either internal (the most frequent) or external (rare) depending on the direction of displacement of the foot. After studying their mechanism, they analyse the results, which, contrary to dislocation-fractures of the talus, are usually good, in spite of the frequency of subtalal arthritis.
Although malignant cartilage tumors of the foot and especially of the talus are uncommon, the treating physician must become suspicious when a "simple ankle sprain" is resistant to standard treatment. In such a case, the comparison of serial radiographs may reveal subtle changes and the use of a radioactive bone scan may be of diagnostic value.
It is essential to distinguish congenital vertical talus from calcaneovalgus deformity in infants as the proper treatment must begin at an early age. The key clinical finding in the differential diagnosis of flexible and rigid flatfoot conditions is the range of motion at the subtalar joint. In rigid flatfoot conditions, subtalar joint motion is impossible because of the rigidity of the deformity. Also, in the rigid type of deformity, the calcaneus will be in an equinus position.
Although the presence of hyperuricemia and avascular necrosis of the hip is well documented, a similar association in the talus seems not to have been previously reported. The clinical and radiographic findings were confirmed by the histologic alterations in bone structure. Successful arthrodesis of the destroyed left ankle joint was accomplished by iliac bone graft.
This is a case report of a 12-year-old boy with reflex sympathetic dystrophy who had surgery for two benign tumors of the right talus. The reflex sympathetic dystrophy began before the first tumor was diagnosed and at a time when the boy was under emotional stress because of conflicts relating to his parents' divorce. The case is typical of reflex sympathetic dystrophy in children, which is only rarely reported. Associated with the syndrome are anxiety, depressive symptoms, emotional instability and acute stressful life events, which makes an interdisciplinary approach imperative.
A classification of Vertical Talus deformities into three types is proposed. The three types, Teratogenic, Neurogenic and Acquired have different etiologies, clinical features and behavior characteristics. It is anticipated that this classification will permit easier recognition of these entities and development of more individualized treatments.
A case of 35 years old patient with open, total, fixed dislocation of the talus reduced with heel traction is presented. The Sudeck syndrome subsided after one year. Weight bearing was not allowed for 7 months. An examination after 2.5 years revealed minor osteoarthritis, full range of movement in the foot but limited walking capability.
Clinical and radiological results of surgical treatment of congenital vertical talus with the method introduced by the author have been presented. Along with Ingram's peritalar release and Grice's extra articular arthrodesis the author introduced elongation of the lateral column of the foot by interposing a bony graft into the calcaneocuboid joint. Five feet in children aged 5 on an average have been operated. An average follow-up was of 5 years. Clinically, three results were rated excellent and two good, radiologically two were excellent, two good and one fair. The results were assessed with a point scale, parameters worsening the outcome are presented in the tables.
From 1982 to 1992 we treated 66 talar injuries at our institution, 44 of which were central fractures (25 talar neck fractures, 17 corpus fractures, 1 comminuted fracture and 1 complete dislocation of the intact talus). In 77% of patients additional injuries were present; 34% were polytraumatized. In 41 patients (93%) clinical and radiological follow-up was possible after an average of 6.3 years. All displaced fractures were treated by open reduction (84%) and, usually, screw fixation, 41% of these within 6 h after the accident. Only 1 required an osteotomy of the medial malleolus, and in 4 a cancellous bone graft was performed. Non-displaced fractures were treated by plastering and partial weight-bearing for an average of 3.1 months. This regime made it possible to contain the rate of aseptic necrosis of the talar body at 12%. The infection rate was 5%. Degenerative changes of the tibiotalar and subtalar joints were seen in 34%. Although there were no cases of non-union and only 2 of malunion, we observed only 6 patients (15%) with complete functional recovery (painfree, normal gait, full professional and recreational activities). A good result (start-up pain, slight limp) was seen in 15 (37%), and a fair result (pain on walking, but normal gait) was achieved in 7 (17%). We observed 13 patients (32%) who had pain on walking and/or at rest and a definite limp at follow-up examination. The average time off work was 8.7 (2.3-26) months. A poor result was associated with additional injuries and subtalar osteoarthritis.(ABSTRACT TRUNCATED AT 250 WORDS)
The authors present a retrospective study of 67 transchondral fractures of the talus in 64 patients that were treated surgically. A thorough literature review, physiology of articular cartilage and subchondral bone repair, and a comprehensive treatment of transchondral lesions are presented. Consideration is given to surgical approaches that require fibular and medial malleolar osteotomy, and to open reduction with internal fixation of the transchondral fractures. A new, practical, radiographic classification with appropriate terminology is proposed which acknowledges recent fractures from subsequent avascular necrosis of the lesions.