Most fractures of the talus occur because of high-energy trauma, and they are relatively uncommon constituting less than 1% of all fractures.1 Since the talus contributes to 3 essential joints (ankle, subtalar, and midtarsal joints), malunions or nonunions after displaced talar head, neck, or body fractures may cause significant pain, deformity, and disability.2 In addition, since these fractures occur following high-velocity injuries, they are associated with considerable soft tissue damage. Closed injuries may have elements of internal degloving, which increases the risk for wound healing complications and infections. Open talar fractures occur frequently, accounting for 20% to 25% of injuries, with a greater incidence of fracture displacement, and in these cases, urgent surgical debridement is typically undertaken.3
In contrary, due to a growing population with prolonged life expectancy and increased activity levels, ankle fractures account for many of the foot and ankle injuries that occur throughout the United States each year. A large-scale epidemiological study by Scheer et al found that the most common mechanisms of injury were falls (54.83%) and sports (20.76%).4 With increased life expectancy, there has also been a corresponding increase in patients with significant medical comorbidities undergoing open reduction and internal fixation (ORIF) for unstable ankle fractures such as diabetes mellitus, peripheral vascular disease, and chronic obstructive pulmonary disease.5,6 Unfortunately, when surgical intervention is required, reported adverse outcomes for the fixation of ankle fractures have included infection, failure of fixation, amputation, and potentially death.7
Indications and Contraindications
Indications for revisional surgery of talar and ankle fractures include but are not limited to pain, deformity that is not braceable or impedes ability to ambulate in shoe gear, the presence of nonhealing wound(s), nonunion, malunion, painful hardware, hardware failure, and acute or chronic osteomyelitis recalcitrant to conservative treatment methods such as local wound care and antibiotic therapy.
Contraindications for revisional surgery may include the presence of medical comorbidities that preclude optimization for surgical intervention, uncorrectable peripheral arterial disease, poor bone stock that cannot accommodate reconstruction, severe patient noncompliance, and patient’s refusal of reoperation.
For all patients undergoing revisional surgery for the consequences of talar or ankle fractures, a thorough history and clinical examination is critical for planning in order to determine any medical comorbidities, which may need to be optimized preoperatively, and to investigate any prior surgical intervention(s), which may contribute to the revisional surgical approach. Bilateral standing radiographs and computed tomography scans with 3-dimensional planar reconstructions should be obtained. To assess the amount of avascular necrosis (AVN) of the talar body, magnetic resonance imaging should be performed. Advanced imaging with nuclear bone scans may be useful for determining extent of bone infection and especially helpful with concomitant Charcot neuroarthropathy of the hindfoot/ankle. Noninvasive vascular testing including ankle brachial indices, toe brachial indices, and Doppler ultrasound with segmental pressures for the lower extremities should be performed in patients with risk of vascular impairment such as those with diabetes mellitus, smoking history, and cardiovascular disease. Vascular surgical consultation may be warranted if evidence of arterial occlusive disease is found. In addition, the patient’s ability to maintain compliance for the postoperative period must be assessed thoroughly during preoperative planning, so that both the patient’s and surgeon’s expectations are clearly discussed and agreed upon.
Revisional fracture reduction of the ankle with or without osteotomy and/or bone grafting may be considered in cases where the ankle joint presents with minimal or no evidence of posttraumatic arthritis, without evidence of Charcot neuroarthropathy, and there is optimal viability of both the soft tissue and osseous structures. Otherwise, ankle, tibiocalcaneal, or tibiocalcaneal arthrodesis may be suitable in more complex cases (Figures 25.3 and 25.4).