TREATMENT OF TALUS INJURIES IN POLYTRAUMA Bonadarenko 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).
Figure 1a
Types of talus injuries: a) fractures of talus body are located posteriorly from the lateral process, and they involve both ankle and subtalar joints
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).
Figure 1b
Types of talus injuries: type 1 – fractures of talus neck without displacement
Figure 1c
Types of talus injuries: type 2 – fractures of talus neck with displacement and subluxation in the subtalar joint
Figure 1d
Types of talus injuries: type 3 – fractures of talus neck with dislocation of the body
3. Subluxation and dislocations in the subtalar joint (Fig. 1e).
Figure 1e
Types of talus injuries: subluxations and dislocations in the subtalar joint
4. Complete dislocations of the talus (Fig. 1f).
Figure 1f
Types of talus injuries: 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
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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)
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Figure 5
Closed low invasive fixation of talus body with cannulated screws (4 mm) with dorsal placement
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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)
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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
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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 (n) |
Average sum of points of AOFAS (M ± δ) |
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 (n) |
Average sum of points of AOFAS (M ± δ) |
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.