Talus Fractures
Khusdeep S. Vig
Curtis T. Adams
Andrew J. Rosenbaum
Sterile Instruments/Equipment
Radiolucent table
Periosteal elevators (dental probe, Cobb elevator, freer elevator, etc)
Small and medium bone reduction forceps
Mini-/small lamina spreaders
Small distractors
Ex-fix equipment
Small interfragmentary (3.5 mm) cortical screw fixation
Mini-fragment (2.7 or 2.0 mm) screw/plate instrumentation
Extra-long mini-screw (2.7 or 2.0 mm) with screw lengths up to 60 mm in length
Titanium constructs to allow for postoperative magnetic resonance imaging (MRI) to assess for osteonecrosis
Bioabsorbable pegs
Headless articular screws
Headlamp, if desired
Positioning
Radiolucent table without attachments at the foot (Figure 26.1)
Supine positioning with a bump under the ipsilateral hip until ankle malleoli on operative side are horizontal
Prone position for posteromedial or posterolateral approaches
Lateral recumbent effective for posterior-to-anterior fixation
Position patient with foot at end of table.
Drape with U-drape (one or two), and extremity drape.
Place C-armor, if desired.
Position C-arm machine perpendicular to foot/ankle from contralateral side.
Anteroposterior (AP), mortise, and lateral of the ankle
AP and oblique of the foot
Canale view of the heel with maximum dorsiflexion and x-ray 15° caudad
 Figure 26-1. A, Supine position for medial and anterolateral approaches. B, Supine position for direct lateral approach. C, Prone position for posterior approach. |
Surgical Approaches
Medial and anterolateral approach via dual incision technique (Figure 26-2)
Medial incision
Landmarks: dorsomedial tip of the medial malleolus extending in line with the axis of the foot to the tarsal navicular
5 mm dorsal to axis of posterior tibial tendon
Extension distal to navicular tuberosity
Anterolateral incision
Landmarks: parallel and 5 to 6 cm lateral to medial incision
Medial or in line with syndesmosis for lateral neck of talus
Shift more lateral to syndesmosis for comminution of the lateral process.
Deep dissection
Dangers: lateral branch of the superficial peroneal nerve
Incise the lateral retinaculum.
Retract extensor digitorum tendons medially, exposing extensor digitorum brevis.
Figure 26-2. A, Medial approach. B, Anterolateral approach.
Reflect brevis distally hinging on its proximal origin, allowing access to lateral capsule of the talus.
Lateral capsulotomy in line with the axis of the talar neck
Transmalleolar Approach
Indications: displaced body or complex talar neck fractures
Skin incision
Landmarks: dorsomedial tip of the medial malleolus extending in line with the axis of the foot to the tarsal navicular
5 mm dorsal to axis of posterior tibial tendon
Extension distal to navicular tuberosity
Extend longitudinally in line with axis of medial malleolus just proximal to the supramalleolar region.
Medial malleolar osteotomy (Figure 26-3)
Expose the medial malleolus; keep the periosteum intact.
Retrograde drill and tap distal tip of malleolus.
Use very thin oscillating saw blade to make an oblique osteotomy directed toward shoulder of medial ankle mortise.
Advance only to the level of the medial subchondral bone.
Complete the osteotomy by gentle levering of a thin-wide osteotome on the inner cortical bone.
Perform an anterior and partial posterior capsulotomy of the medial malleolus (allows mobilization of the medial malleolar fragment).
Gently retract to protect deltoid vessels perfusing medial body of talus.
Reduce and internally fix malleolus with two parallel 3.5- or 4.0-mm partially threaded cancellous screws.
Posterior approach (Figure 26-4)Related posts:
Management of Metatarsalgia and Equinus Contracture: Gastrocnemius Recession, Percutaneous Tendoachilles Lengthening, and Diaphyseal Metatarsal Shortening Osteotomy
Management of Lesser Toe Deformity: PIP Arthroplasty and Extensor Lengthening
Medial Malleolar Stress Fractures
Peroneal Tendinopathy
Fifth Metatarsal Stress Fractures
Arthroscopic Management of Osteochondral Lesions of the Talus
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