Abstract
Research Type:
Level 4 – Case series
Introduction/Purpose:
Traumatic talar instability is a complex condition often resulting from high-energy injuries. The management of these injuries typically involves surgical intervention to achieve stable fixation and restore joint congruity. There is no consensus on the treatment of these injuries. Current treatment options include talar stabilization using External Fixation, temporary Kirschner wire fixation or internal plate fixation. These treatment strategies have strengths and weaknesses with variable degrees of soft tissue trauma, success in holding the reduction and require removal of temporary implants. We present a Case Series of an alternate treatment strategy, a novel surgical technique for treatment of traumatic talar instability via temporary trans-articular screw fixation with minimal soft tissue trauma and lessened difficulty in regards to hardware removal.
Methods:
This retrospective case series reviewed 9 patients (10 extremities) who underwent temporary temporary trans-articular screw fixation for traumatic talar instability at a single tertiary care institution from 2015 to 2024.
Patients were selected based on the presence of traumatic talar instability confirmed by clinical and radiographic evaluation following talar fracture-dislocation. The surgical technique involved temporary trans-articular fixation utilizing either one or two 4.0mm cortical screws across the subtalar joint and or talonavicular joint after intra-operative confirmation of persistent talar instability following open reduction and internal fixation of the talus and any associated injuries. After evidence of radiographic union of the fracture of the talus was confirmed the patient underwent a secondary procedure for removal of the implanted subtalar screw. Injury characteristics, patient outcomes and complications including post-traumatic osteoarthritis and avascular necrosis were monitored. Data were analyzed to evaluate the efficacy and safety of the novel surgical technique.
Results:
All 10 operative extremities achieved full resolution of talar instability. Three extremities required subsequent arthrodesis due to post-traumatic arthritis and/or avascular necrosis (AVN). Two extremities developed AVN, with two of the three arthrodesis’ following AVN development. One patient did not the trans-articular screw removed due articular surface damage at the time of index injury. Two extremities developed infections: one superficial infection resolved with oral antibiotics, and one deep infection necessitated tibiotalar and subtalar arthrodesis using an antibiotic-coated intramedullary nail due to osteomyelitis, with infection resolution and return to activity. Nine extremities exhibited some form of post-traumatic arthritis in the peri-talar articulations. Four of ten patients underwent tendon lengthening for contracture. Eight of nine patients returned to unprotected weight-bearing and full activity at most recent follow-up.
Conclusion:
Temporary trans-articular screw fixation for treatment of traumatic talar instability is a novel and safe surgical technique. Temporary trans-articular fixation has been used for decades to treat Lisfranc Fracture-Dislocations effectively and safely. The rate of AVN found in this case series is significantly lower than the established rates for similar injuries, indicating that the decreased dissection and soft tissue trauma in this technique may lead to lower rates of AVN. However due to the limited population this claim is very limited. Rates of complications, in particular peri-talar arthritis were high but consist with previously reported literature for similar injuries.
Table 1
Patient Demographics, injury details, complications and outcomes