Abstract
Background
This study sought to characterize a cohort of talar neck and body fractures, focusing on fracture characteristics, associated injuries, treatment and outcome.
Methods
We reviewed adult patients registered in the Swedish Fracture Register 2011–2021 with talar neck and body fractures. A minimum 2-year follow-up was conducted for treatment outcomes.
Results
We included 313 patients (318 fractures, median age 34 years, 67 % men) of which 106 involved the neck, 134 the body and 78 combined body and neck. 36 % had associated injuries. Operative treatment was implemented for 55 neck (52 %), 81 body (60 %), and 70 combined fractures (90 %). Reoperation rates were, 35 % for neck, 32 % for body and 44 % for combined fractures.
Conclusion
Talar fractures primarily occur in men and are associated with other fractures. A majority of the fractures are treated operatively and one in three patients undergoes reoperation, with higher reoperation rates in combined body and neck fractures.
1
Introduction
Talar fractures, while infrequent, exhibit a broad spectrum of severity, ranging from uncomplicated avulsions to complex comminuted fracture-dislocations . Approximately two thirds of the talus comprises five distinct articular surfaces, devoid of muscular attachments , . Talar injuries, even with minor malalignment, may compromise the vulnerable extra- and intraosseous vascular anastomoses, thereby impairing functional recovery , .
Concomitant injuries to the malleoli, calcaneus, navicular, cuboid and metatarsals increase the complexity of these injuries , . High rates of complications following different types of talar fractures have been reported in the literature, with persistent pain, post-traumatic arthritis and avascular necrosis (AVN) correlating with injury severity ,,,,,,,,,, . Published studies on adult talar body fractures and combined body and neck fractures, as well as their clinical outcomes, are limited ,,, .
Therefore, this study aimed to describe the demographics, fracture characteristics, associated foot and ankle injuries, treatment, treatment failures and revision surgeries associated with talar neck, body and combined fractures.
2
Patients and methods
2.1
Study design and setting
A retrospective cohort study was conducted using prospectively collected data from seven Swedish regions within the Swedish Fracture Register (SFR), representing all levels of trauma care . The SFR, established in 2011, is a national quality register for managing fractures. The register contains data on injury mechanisms, classification and treatment (operative or nonoperative) of Swedish residents with fractures sustained in Sweden. Detailed data on patient and fracture characteristics are recorded in each affiliated department through a pre-specified digital form by the physician or orthopedic surgeon. Patients with a unique 12-digit personal identification number (PIN), given to all Swedish permanent residents, are eligible for registration in the SFR . The proportion of departments affiliated with the SFR has increased gradually, from 40 % of orthopedic departments in January 2014 to full national coverage (54 of 54 departments) in January 2021. Compared to the Swedish National Patient Register, the completeness of foot fractures, including toe fractures, was 55 % in 2021 . In the SFR, talar fractures are classified according to the AO Foundation/Orthopedic Trauma Association (AO/OTA) classification system (2007 version) . The talar fracture classification system employed in the SFR lacks published validation. The registration of talus fractures in the SFR includes head and avulsion (81-A1, A2, A3), neck (81-B1, B2, B3) and body fractures (81-C1, C2, C3). Currently, no published studies have validated the AO/OTA classification system for talar fractures. Open fractures are classified according to the Gustilo-Anderson classification .
2.2
Patients
We used the PIN to collect data, including the review of medical records of all contributing departments in the seven selected regions, to verify and ensure the completeness of the data. The study cohort comprised patients aged ≥ 18 years with talar neck or body fractures, as documented by the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes S92.10/11, and registered in the SFR between 2011 and 2021 at participating orthopedic departments ( Fig. 1 ). The SFR patient data included age, sex, type of trauma mechanism, injury cause, initial treatment, fracture classification and associated foot fractures (classified), date of death and (from medical records) associated foot and ankle injuries, treatment failures, reoperations or late surgery.
Flowchart of study patients.
2.3
Radiographic assessment
Existing radiographic examinations, including plain lateral and anteroposterior radiographs and/or computed tomography (CT), were used to reclassify all fractures according to the AO/OTA 2018 version , . Talar neck fractures are classified according to the Hawkins classification, a component of the AO/OTA 2018 classification system ( Fig. 2 ). Talar body fractures are classified into four groups: partial articular simple fracture (81.1B2), partial articular fragmentary fracture (81.1B3), complete articular simple fracture (81.1C1) and complete multifragmentary articular fracture (81.1C3) ( Fig. 3 ). We chose to add a description of the main fracture direction for talar body fractures (sagittal, coronal or oblique). We distinguished between neck and body fractures in accordance with the criteria established by Inokuchi et al. . Lateral or posterior process fractures (81.1A2/81.1A3) and talar head fractures (81.3) were excluded from the analysis, though their presence as concomitant injuries is noted in Supplemental Table 1 . The degree of displacement was categorized as undisplaced (<2 mm), displaced (>2 mm), and complete fracture dislocation. Talar body fractures exhibiting extension into the talar neck or vice versa constituted a third group, designated the combined talar body-neck group ( Fig. 4 ). AVN was defined radiographically as talar volume loss, encompassing reductions in talar dome height or irregular contours on anterior-posterior or lateral ankle views.
The Hawkins classification of talar neck fractures.
The AO/OTA Classification of talar body fractures.
Illustration of a combined talar body and neck fracture.
2.4
Ankle related complications and reoperations
Ankle related complications were defined as readmission to an orthopedic department for a deep infection, pain and/or radiographic examination showing posttraumatic arthritis, avascular osteonecrosis, nonunion/malunion or implant failure.
Reoperations were defined as implant removal, arthrodesis, re-arthrodesis, arthroplasty, arthroscopy, removal of fragments, osteotomy, re-osteosynthesis due to mechanical failure, surgical debridement due to postoperative deep infection and amputation.
2.5
Statistics
Variables are presented as proportions of all fractures. Nominal variables are expressed as proportions of all fractures, while scale variables are reported as median and interquartile range (IQR) or means and ranges. Multivariate Cox regression modeling was performed to analyze the risk of reoperation (implant removal excluded) by fracture type (neck, body, combined body-neck), controlling for sex and age, only one side were included in the cox regression analysis. Proportional hazards were assessed using Kaplan-Meier estimates and time-dependent covariates. We used SPSS (IBM SPSS Statistics for Mac, Version 29.020, Armonk, NY: IBM Corp. USA) for all statistical analyses.
2.6
Ethics
The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the Swedish Ethical Review Authority (2022–04531–01; amendments 2023–00249–02, 2023–06071–02). The Swedish Etical Review Authority waived the need for individual consent for the present study. We are favorable to sharing data but are legally restricted from doing so according to the law on Public Access and Secrecy (Chapter 21, paragraph 7, and Chapter 25, paragraph 1). An application for data extraction can be sent to the Centre of Registers, Västra Götaland, after an approved ethical application has been submitted.
3
Results
3.1
Patients and descriptive data
1.138 talar fractures were extracted from the SFR ( Fig. 1 ). After exclusion, the final analytical cohort included 318 fractures: 134 body fractures, 106 neck fractures and 78 with combined body and neck fractures. Of all fractures, 209 of 318 (67 %) were sustained by men, and the median age was 34 (range 18–88, IQR 25) years (34 for men and 33 for women) ( Table 1 ). Median observation time was 69 (range 29–151) months. High-energy trauma was present in 64 % of ankles, and a fall from height was the most common mechanism of injury (42 %). The 2-year mortality for the cohort was 2.9 %.
Table 1
Patient characteristics.
| Body fracture | Neck fracture | Combined body-neck | Total | |
|---|---|---|---|---|
| Variable | N = 134 Fractures | N = 106 Fractures | N = 78 Fractures | N = 318 Fractures |
| Age | 34 (18−86) | 34 (18−88) | 33 (19−87) | 34 (18−88) |
| Sex | ||||
| Male | 94 (71.8 %) | 66 (63.5 %) | 49 (62.8 %) | 209 (66.8 %) |
| Side right | 65 (48.5 %) | 56 (52.8 %) | 38 (48.7 %) | 159 (50 %) |
| Type of trauma High energy | 77 (57.5 %) | 70 (66 %) | 58 (74.4 %) | 205 (64.5 %) |
| By fracture class |
B2
5 (31.3 %) |
Hawkins 1
36 (56.3 %) |
||
|
B3
18 (66.7 %) |
Hawkins 2
26 (78.8 %) |
|||
|
C1
19 (51.4 %) |
Hawkins 3
4 (80 %) |
|||
|
C3
35 (64.8 %) |
Hawkins 4
4 (100 %) |
|||
| Open fracture | 3 (2.2 %) | 11 (10.4 %) | 12 (15.4 %) | 26 (8.2 %) |
| By fracture class | B2 |
Hawkins 1
3 (4.7 %) |
||
|
B3
1 (3.7 %) |
Hawkins 2
4 (12.1 %) |
|||
|
C1
1 (2.7 %) |
Hawkins 3
1 (20 %) |
|||
|
C3
1 (1.9 %) |
Hawkins 4
3 (75 %) |
|||
| Diagnostic | ||||
| Computed tomography | 125 (93.3 %) | 99 (93.4 %) | 76 (97.4 %) | 300 (94.3 %) |
| MRI | 9 (6.7 %) | 4 (3.8 %) | 4 (5.1 %) | 17 (5.3 %) |
| Injury cause | ||||
| Motor vehicle accident | 23 (17.2 %) | 28 (26.4 %) | 23 (29.5 %) | 74 (23.3 %) |
| Fall from height | 56 (41.8 %) | 40 (37.7 %) | 36 (46.2 %) | 132 (41.5 %) |
| Simple fall | 29 (21.6 %) | 15 (14.2 %) | 6 (7.7 %) | 50 (15.7 %) |
| Bicycle | 7 (5.2 %) | 2 (1.9 %) | 1 (1.3 %) | 10 (3.1 %) |
| Horse | 9 (6.7 %) | 11 (10.4 %) | 7 (9 %) | 27 (8.5 %) |
| Other | 9 (6.7 %) | 9 (8.5 %) | 4 (5.1 %) | 22 (6.9 %) |
| Missing | 1 (0.7 %) | 1 (0.9 %) | 1 (1.3 %) | 3 (0.9 %) |
5 patients had bilateral talar fractures that were included: 2 patients with body/body, 1 with neck/neck, 1 with body/neck and 1 with combined/neck.
3.2
Talar neck fractures
There were 106 neck fractures in 105 patients, of these 106 fractures 64 (60 %) were classified as Hawkins 1, 33 (31 %) Hawkins 2, 5 (5 %) Hawkins 3 and 4 (4 %) Hawkins 4 ( Table 2 ). The operative treatment rate increased with increasing fracture severity, i.e., Hawkins 1, 15 (23 %); Hawkins 2, 31 (94 %); Hawkins 3, 5 (100 %); and Hawkins 4, 4 (100 %). Open reduction and internal fixation (ORIF) with screws was the most used operative method, employed in 48 ankles (87 %). The median time from injury to definitive surgical intervention was 5 (range 2–11) days.
Table 2
Classification and treatment of 318 talar fractures.
| Body fracture | Neck fracture | Combined body-neck | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
B2
(N = 16) |
B3
(N = 27) |
C1
(N = 37) |
C3
(N = 54) |
Body fractures
(N = 134) |
Hawkins 1
(N = 64) |
Hawkins 2
(N = 33) |
Hawkins 3
(N = 5) |
Hawkins 4
(N = 4) |
Neck fractures
(N = 106) |
Combined body-neck
(N = 78) |
|
| Displaced 2 mm | |||||||||||
| Yes | 1 (6.3 %) | 13 (48.1 %) | 13 (35.1 %) | 38 (70.4 %) | 65 (48.5 %) | 5 (7.8 %) | 25 (75.8 %) | 4 (80 %) | 3 (75 %) | 37 (34.9 %) | 46 (59 %) |
| No | 15 (93.8 %) | 13 (48.1 %) | 22 (59.5 %) | 7 (13 %) | 57 (42.5 %) | 59 (92.2 %) | 3 (9.1 %) | 62 (58.5 %) | 12 (15.4 %) | ||
| Fracture-dislocation | 1 (3.7 %) | 2 (5.4 %) | 9 (16.7 %) | 12 (9 %) | 5 (15.2 %) | 1 (20 %) | 1 (25 %) | 7 (6.6 %) | 20 (25.6 %) | ||
| Primary treatment | |||||||||||
| Nonoperative | 14 (87.5 %) | 13 (48.1 %) | 20 (54.1%) | 6 (11.1 %) | 53 (39.6 %) | 49 (76.6 %) | 2 (6.1 %) | 51 (48.1 %) | 8 (10.3 %) | ||
| Operative | |||||||||||
| Screw | 8 (29.6 %) | 17 (45.9 %) | 37 (68.5 %) | 62 (46.3 %) | 14 (21.9 %) | 27 (81.8 %) | 4 (80 %) | 3 (75 %) | 48 (45.3 %) | 57 (73.1 %) | |
| Plate | 4 (12.1 %) | 1 (20 %) | 1 (25 %) | 6 (5.7 %) | 7 (9 %) | ||||||
| Arthrodesis | 1 (6.3 %) | 1 (3.7 %) | 1 (1.9 %) | 3 (2.2 %) | |||||||
| Pin fixation | 2 (7.4 %) | 2 (3.7 %) | 4 (3 %) | ||||||||
| Other | 1 (6.3 %) | 3 (11.1 %) | 8 (14.8 %) | 12 (9 %) | 1 (1.6 %) | 1 (0.9 %) | 6 (7.7 %) | ||||
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