Dody Pratama Masri * Dimas Radithya Boedijono Sp.OT **

1. DodyPratamaMasri* Dimas RadithyaBoedijonoSp.OT** *Resident of Orthopaedics & Traumatology, University of Indonesia, Fatmawati Hospital, Jakarta **Staff Department of Orthopaedics & Traumatology, University of Indonesia, Fatmawati Hospital, Jakarta GOOD OUTCOME WITH OPEN REDUCTION INTERNAL FIXATION AND CIRCULAR CAST APPLICATION IN TALUS FRACTURES : CASE SERIES

2. INTRODUCTION • Fracture of talus are very rare. • Less than 1% of all fractures. • Talus fracture involves in 2% of all lower extremity injuries and involves in 5-7% of all foot injuries • Isolated fracture more uncommon. • Hospital Accident Service of the Redcliffe Infirmary, Oxford : 1949 – 1968  58 cases. • Reputation: problematic fracture • Difficult reduction • Poor prognosis • Many complications

3. INTRODUCTION • Talus is an important bonebecause: • Major weight bearing structure  carries greatest load per unit area than any other bone. • Vulnerable blood supply  common site for post traumatic ischemic necrosis  lead to severe disability.

4. COMPLICATIONS • Malunions • Result of inadequate reduction • Distortion of joint surface • Limitation of movement + pain on weightbearing • Incidence 27% • Avascular Necrosis • 60% of the bone sufrace is carltilage • Type I: 10%, Type II: 30-40%, Type III: >90% • Sign: increase density of avascular segment (Hawkin Signs)  flattened  fragmented  pain & disability • Solution: Ankle arthrodesis

5. COMPLICATIONS • Skin Necrosis • Ankle and SubtalarArthrofibrosis • Secondary Osteoarthritis • > 50% incident with talar neck fracture • Causes: • Articular damage from initial trauma • Malunion/distortion of articular surface • Avascular necrosis • Solution  Ankle Arthrodesis

6. ANATOMY OF TALUS

8. VASCULAR SUPPLY OF TALUS

9. VASCULAR SUPPLY OF TALUS

10. VASCULAR SUPPLY OF TALUS

11. VASCULAR SUPPLY OF TALUS • Vascular supply: retrograde flow --> Higher incident in the talar body region

12. PATTERN OF INJURY • Involvement: • Neck, body, head, bony process, dislocation, osteochondral fracture, chip/avulsion fracture • Mechanism of injury: • “Aviators Astragalus” : flying accident (talar neck) • Traffic accident • Falls from height  body • Severe ankle hyperextension  talar neck • Ligament strains  avulsion fracture

13. Supporting Examination • X-Ray • Ankle series • Foot  asses adjacent bone integrity • CT Scan • For severe displacement • Pre operative planning • MRI • To evaluate avscular necrosis incident

14. Classification of Talus Fracture (Coltart) • Chip/Avulsion Fracture • Compression Fracture of the Head • Fracture of the Neck • Fracture of the Body

15. Classification of Talar Neck Fracture (Hawkins-Canale Kelly) • Group I – undisplaced • Group II – displaced (minimal) and associated with subtalarsubluxation/dislocation • Group III – displaced, with dislocation of the body of talus from ankle joint • Group IV – displaced vertical talar neck fracture with disruption of talonavicular joint

16. TREATMENT OPTIONS • Undisplaced fracture • Split below knee plaster  below knee cast (plantarflexed)  plantigrade (6-8 weeks) • Displaced fracture (body/neck) • Closed manipulation under anesthesia  anatomic  below knee cast (equinus)  gradually plantigrade (8-12 weeks) • Open reduction and fixation with screw • Prognosis is poor

17. TREATMENT OPTIONS • Fracture of talar process • Large fragment: ORIF with k-wire/mini screw • Small fragment: excision • Osteochondral fracture • Cast immobilization • Operative reduction and internal fixation • Excision  drilling of the exposed bone

18. CASE 1 • Identity • Name : Mr. J • Age : 34 years old • Address : Sukamanah, Cigalontang, Tasikmalaya, West Java • Education : High School • Occupation : Hotel Bellboy

19. CASE 1: Clinical Presentation • Mechanism of Injury • Motorcycle accident

20. CASE 1: Clinical Presentation • Diagnosis: Closed Fracture of Posterior Process of (L) Talus

21. CASE 1: Management

22. CASE 1: Management • Below knee cast for 6 weeks • Full weight bearing after 6 weeks

23. Case 1: 9-months follow up • Full Ankle ROM • Full activities • No painful ankle • Sometimes mild pain when walking upstairs

24. Case 1: 9-months follow up Functional Score: • AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot score: 97 (range 55-100) • FADI (Foot and Ankle Disability Index) score: 98,1 (range 0-100)

25. Case 1: 9-months follow up

26. CASE 2 • Identity • Name : Nn. A • Age : 24 years old • Address : KampungJambu, Nagara Padang, Petir, KabubatenSerang, Banten • Education : High Scholl • Occupation : Actress, Model

27. CASE 2: Clinical Presentation • Mechanism of Injury • Fell from height (15 meters)

28. CASE 2: Clinical Presentation • Diagnosis: Closed Fracture ofTalar Neck (L) Hawkins Group II • Assosiated Injury:Vertebral Fracture, Mandibula fracture

29. CASE 2: Management • Open Reduction and Internal Fixation • Double approach: • Anteromedial approach • Anterolateral approach • Two 4.0 mm cannulated screw • C-Arm Guided • Partial weight bearing after 6 weeks • Full weight bearing after 12 weeks

30. CASE 2: Management

31. CASE 2: Management

32. CASE 2: 9-months Follow Up • Full ankle ROM • No painful ankle • Full activities • Mild pain when standing for 2 hours

33. CASE 2: 9-months Follow Up Functional Score: • AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot score: 97 (range 55-100) • FADI (Foot and Ankle Disability Index) score: 96,2 (range 0-100)

34. CASE 2: 9-months Follow Up

35. DISCUSSION • Our both give satisfactory result • Treatment Options for posterior process talus fracture • Primary excision • ORIF with small screw • Below Knee Cast optional: Secondary excision (non union, symptomatic)

36. DISCUSSION • Treatment Options for talar neck fracture grade II • Closed reduction and below knee cast • ORIF Variability: • Number of screws (one or two?) • Approach (single/double? Anterolateral? Anteromedial? Posterolateral? Posteromedial? Need of malleolusosteotomy?) • Screw direction (Anterior to Posterior / Posterior to Anterior) • Using mini plate and screws • Magnetic-free screw

37. DISCUSSION • Avascular Necrosis complication should be tightly monitored. • Sign and symptoms: • Painful ankle • Limitation of ROM • Hawkins Sign  not conclusive • MRI  need of non-magnetic screw

38. How to manage AVN in the talus: still controversy • Post operative rotected weight bearing reduced the incidence of AVN? • Use of patellar tendon bearing brace? • decrease weight bearing to talus • Neutralize varus-valgus ankle stresses. • Tibiocalcaneal fusion +/- Interposition iliac crest bone graft • Blair tibiotalar fusion • Triple arthrodesis

39. CONCLUSION • Talus fracture is a rare case but not an easy one. • Open reduction of talus fracture need familiarity with its vascular supply. (Iatrogenic AVN may happen) • Surgeons must prepare for incidence of complications, esp. avascular necrosis • Adequate reduction and management will benefit for long term functions.

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