No Time for Fatalism—Encouraging Long-Term Results After Talar Fracture Fixation

It is often said that nothing compromises clinical outcomes more than long-term follow-up. The article by Roddy and colleagues in this issue ¹ on 10-year results following talar fracture fixation seems to somewhat mitigate this sarcastic notion. The authors are to be congratulated for collecting long-term results on a sizeable number of patients with these rare and serious injuries. The minimum follow-up was 5 years and validated patient-reported outcome measures were used to evaluate the clinical and functional results. In addition, a short-term radiographic follow-up (median of 11 months) was obtained.

The patient demographics are typical for cohorts with talus fractures: the average age was relatively low and more than half of the patients had additional injuries. Likewise, there was a wide range of central (neck and body) and peripheral (head and lateral process) fractures with varying degrees of soft tissue damage. The management represented the state of the art with respect to timing of reduction and fixation, choice of approaches, type of fixation, and postoperative regimen.^1-5

Compared with the classic works on that topic from the 1970s and 1980s and even more recent studies from the early 2000s, the results are very encouraging. The median FAAM score at a mean of 10 years was 83, both for the whole cohort and patients with talar neck and body fractures. Not surprisingly, patients who underwent a salvage procedure like fusion, arthroplasty, or amputation had significantly lower scores. However, the total number of these cases was low, with less than 10% of patients actually requiring a salvage procedure. ¹

At a median follow-up of 11 months, half of the patients already showed radiographic signs of posttraumatic arthritis. It is conceivable that this number could approach 100% in the long term.^4,6,7 However, as in comparable studies, it can be inferred that only a small proportion become symptomatic, as reflected by the high overall scores and low revision rate. The same can be assumed for the 13% of patients with signs of avascular necrosis (AVN) in the short term. A partial AVN—at least transitory—should be suspected in any patient with a displaced talar neck and body fracture. ⁸ However, it has been shown that remodeling of the talar body may last up to 2 years after the injury, and only total AVN of the talar body will eventually lead to collapse of the talar dome necessitating further intervention.^6,8 Consequently, in multivariate analysis, only increasing injury severity and AVN with collapse remained significant predictors of conversion to salvage procedures in the present study. ¹

The authors do not specifically report on the quality of reduction, but it can be assumed that, with contemporary dual-approach techniques and rigid fixation, they aimed at anatomic reduction that would be maintained over time. This is particularly important in both central and peripheral talus fractures as only exact reconstruction of the articular surfaces of the ankle, subtalar, and talonavicular joints and axial realignment of the talar neck will be compatible with normal or near-normal global foot function. Failure to achieve anatomic reduction reportedly leads to the rapid development of posttraumatic arthritis requiring salvage procedures like ankle arthroplasty or fusion.^4,7,9,10 Given the young age of the patients with talar fractures, neither of these procedures is likely to be the last because loosening, nonunion, and adjacent joint arthritis remain a matter of concern with these procedures.

In a similar study in the same journal, Vints et al ¹⁰ found that osteoarthritis, talar body fractures, and articular incongruence correlated significantly with a poorer functional outcome, whereas delayed surgery after trauma was even associated with better outcome measures. Given the relative rarity of talar fractures, the individual experience of any single surgeon with these injuries is limited. Anatomic reduction of talar fractures while maintaining meticulous soft tissue handling via bilateral approaches requires a significant learning curve. In the study by Vints et al, ¹⁰ the one surgeon who operated on 55% of all talus fractures achieved superior patient-reported outcomes on every scale compared to other surgeons, which was statistically significant for Foot Function Index pain scores. It therefore seems reasonable to refer patients to a center with particular expertise in this area after early, gross reduction of fracture-dislocations. The results of the present study from a renowned center for trauma and foot and ankle surgery seem to support these assumptions.

In the discussion, the authors highlight the importance of detecting and bridging anteromedial talar-neck comminution to avoid varus malalignment, which is likely the most common malunion after talar fractures. ³ They also rightly point to the utility of a dual approach to avoid malrotation at the talar neck and restore all affected joint surfaces, as these are essential for global foot function.^2,4 Adequate assessment of talar neck realignment, ankle, and subtalar joint congruity in complex fractures is not possible with single approaches.

The authors duly acknowledge the inherent limitations of this study, such as a high rate of loss to follow-up and the variability of fracture patterns, including talar head and process fractures, which have a pathomechanism different from that of talar neck and body fractures. Furthermore, there was a high number of associated injuries, varying degrees of soft tissue damage, and only short-term follow-up regarding the radiologic findings. Therefore, a long-term study with a high patient number from a single center with a consistent treatment concept and outcome assessment may be more valuable than systematic reviews on this topic that are invariably fraught with different cohorts, fixation strategies, and outcome measures.

In summary, the results from Roddy and colleagues refute fatalistic historical expectations about talar fractures, showing that good to excellent outcomes can be achieved by experienced surgeons employing contemporary techniques. As with other rare and challenging injuries, definitive treatment should preferably be performed in centers with appropriate experience.

Stefan Rammelt, MD, PhD University Center of Orthopaedics, Trauma and Plastic Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany