A Simple Technique for Reduction of Nearly Extruded Talar Body in Hawkin’s Type III Fracture Neck Talus
Amr Farouk Abdel Rahman*, Mohamed Mokhtar Abd-Ella and Mohammed Zayan Ibrahim
Department of Orthopedic Surgery, Ain Shams University, Egypt
Submission: August 31, 2016; Published: September 16, 2016
*Corresponding author: Amr Farouk Abdel Rahman, Lecturer of Orthopedic surgery, Ain Shams University, Demerdash Hospital, 56 Ramsis street, Abbaseyya square, Egypt, Tel:+20 1007090067; + 202 26844195; Email:firstname.lastname@example.org
How to cite this article: Amr F A R, Mohamed M A-E, Mohammed Z I. A Simple Technique for Reduction of Nearly Extruded Talar Body in Hawkin’s Type III Fracture Neck Talus. Ortho & Rheum Open Access J. 2016; 2(4): 5555904. DOI: 10.19080/OROAJ.2016.02.555594
Background: Avascular necrosis of talar body and osteoarthristis of ankle and subtalar joints are very common complications in fracture neck talus. Early and prompt reduction of the extruded talar body and its adequate fixation is mandatory to save the delicate blood supply and the articular cartilage. Obstacles against reduction include tight mortis, entrapped tendons requiring vigorous manipulation that leads to soft tissue insult, articular cartilage scuffing, and propagation of undisplaced cracks adding more comminuted fragments.
Aim: To propose a distraction technique using a simple ring fixator to achieve anatomical easy reduction of extruded talar body without vigorous manipulation.
Methods: The distraction technique was conducted for 6 patients (four males and two females), mean age 28 years. All of them had fracture neck talus Hawkin’s type 3 with nearly extruded talar body. Simple two level ring fixator was applied for all patients, reduction was achieved and assessed by image intensifier then fixation was done by 2 cannulated 4 mm screws. Post operative x rays and CT scan were done for all patients. Partial weight bearing started at 4 weeks. Fixator was removed at 12 weeks, follow up period lasted for 12 months, functional scoring using AOFAS scoring was done to assess the patients at last follow up.
Results: Good reduction was achieved in all cases, two cases had superficial wound dehiscence treated by intravenous antibiotics and frequent dressing, two cases were complicated by Avascular necrosis that required no further intervension, one case required bone grafting for delayed union, mean AOFAS scoring system was 79.5 out of 100 at last follow up.
Conclusion: Distraction assisted reduction of extruded talar body is a good proposed technique for treatment of Hawkin’s type 3 fractures of neck talus without need for vigorous manipulation.
Although cases of talar fractures are not common, comprising only 3% of foot fractures, it is considered a very challenging type of fractures. Anatomically, talar fractures can be divided into body fractures, neck fractures, head fractures, lateral process fractures and posterior process fractures, of which neck fractures make up 50% . Hawkin’s classification which is mostly used to classify talar neck fractures consists of four types. Type I is non-displaced fracture. Type II is assosciated with subtalar subluxation or dislocation. Type III is assosciated with subtalar and ankle dislocation. Type IV is a type III with associated talonavicular subluxation or dislocation . Avascular necrosis of the talar body is a common complication after talar neck fracture. Its incidence is directly proportional to the Hawkin’s grade, with incidence from zero to 15% in type I and incidence reaching 100% in type IV.
The incidence in type II and III ranges from 15 to 75% [2,3] (Tables 1 & 2). Early and prompt reduction with adequate fixation of talar neck fracture dislocation is necessary in trying to save the delicate blood supply of the talus . Operative reduction of the dislocated talar body is sometimes so difficult due to contracted soft tissues in delayed cases or entrapped tendons as tibialis posterior and flexor hallucis longus so, the aim of this study is to evaluate the role of distraction using Ilizarov frame in facilitating open reduction of dislocated talar body in cases of talar neck fracture dislocation.
The new technique was conducted between 2014 to 2016
in Ain Shams University Hospitals on six patients, four males
and two females. All of them were between 3rd and 5th decade
(mean age 28 years). All of them had Hawkin’s type III talar
neck fracture with nearly extruded talar body (Figures 1 & 2).
The mechanism of injury was road traffic accident in four cases
and fall from height in two cases. Two cases were open fractures
Gustillo grade 2, and four patients had closed injury. One case
had associated upper limb fracture, another case had associated
rib fracture and one patient was a polytrauma patient with associated fracture lumbar spine and ipsilateral femur (Table
3), three cases had associated medial malleolar fracture .
One of the patients had vascular compromise with the posterior
tibial artery could not be palpated or heard by Doppler. Average
time elapsed between trauma and surgical intervention ranged
between 4 hours and 24 hours me elapsed between trauma.
Patient put in supine position, above knee tourniquet was
applied. Approach used is double anteromedial and anterolateral
approach. Anteromedial approach is made between tibialis
posterior and tibialis anterior tendons  (in both patients
with open fractures wounds were on medial aspect of the ankle
and were extended slightly proximally and distally following
the line of anteromedial approach), in patients with associated
medial malleolar fracture , it was not fixed except after fixing the
talar fracture to make use of the good exposure created by the
malleolar fracture while in patients with intact medial malleolus
osteotomy was not needed.
Anterolateral approach is made anterior to the lateral
malleolus extending towards the fourth metatarsal avoiding
branches of the superficial peroneal nerve , this incision is
used to double check the reduction of the talus and in introducing
one of both cannulated screws. Applying a ring fixator frame
formed of one ring put at fifteen cm proximal and parallel to the
ankle joint line and fixed to the tibia with two wires and two (five
mm) shanz pins , the distal foot piece is a 5/8 ring that is fixed to
the calcaneus by two wires and one (five mm) shanz pin (Figure
3). Both rings should be parallel to the joint line , wires are
tensioned and four connecting rods are put across both rings.
Distraction is now done equally across the four connecting
rods, distraction can be increased up to five cm and its extent is checked using the image intensifier (Figure 4), excessive
distraction should be avoided even if possible specially in cases
with vascular compromise, the sign for adequate distraction is
the clear vision of the articular cartilage of the distal tibia and
the posterior calcaneal facet through the anteromedial incision,
while the talar body is still extruded from the mortis. Entrapped
tendons of the tibialis posterior and flexor hallucis should be
cleared from the mortis through the medial incision to pave a
safe way for reducing the talar body back to the mortis , this
reduction can be now done very gently using one finger without
need for any vigorous manipulation .
In order to maintain the reduced talar body inside the mortis
the distraction has to be reversed across the four rods partially
till the distal tibia touches the talar dome.
Reduction is assessed by:
Image intensifier in Anteroposterior view, lateral view,
and Mortis view (Figure 5).
Both rings should be parallel to each other’s and to the
ankle joint line.
Hindfoot alignment should be neutral or seven degrees
Second and third methods of assessment are only applicable if
there is no preoperative hindfoot malalignment. Fixation of talar neck is done using two cannulated 4 mm cancellous screws in
anteroposterior direction , one screw through the anteromedial
incision and a second screw through the anterolateral incision,
both screws should not damage the articular cartilage of the talus.
Position of screws is checked using image intensifier (Figure 6).
In cases with fractured medial malleolus, it is reduced and fixed
using two cannulated 4 mm screws or K wires and tension band
technique. Closure of wounds done after release of tourniquet
and proper haemostasis using 2 zero vicryl sutures (Figure 7).
Plain X ray ankle (anteroposterior, lateral and Mortis view)
(Figure 8), CT scan (axial, coronal and sagittal cuts) (Figure
9) were done for all patients to assess accuracy of reduction.
Extar care was directed to wounds in order to avoid the
possible wound problems especially with the use of double
approach (frequent dressing till removal of sutures). Partial
weight bearing was allowed at four weeks postoperative, using
crutches. Average time for removal of fixator was at 12 weeks
.Average follow up time was 12 months. At last follow up visit
clinical assessment was done using ankle-hind foot scale of the
American Orthopaedic Foot and Ankle Society (AOFAS) to assess
functional outcome. The maximum score was 100 (this score
was used before by Elgafy et al.  to assess patients of talar
neck fractures), radiological assessment included plain x rays.
Our series included six patients, four males and two females.
Mean age 28 years, Right ankle was affected in four patients and
left side in two patients, two cases had open injuries with wound
at anteromedial side of ankle, three patients had associated
medial malleolar fractures, one patient had posterior tibial
artery compromise and its pulse was not felt but immediately
after reduction its pulse was palpated well. Average operative
time was 85 minutes. All of our patients had achieved good
reduction in the postoperative X rays.
Wound care was satisfactory except for both patients
with open wounds at medial side of ankle who had superficial
infection and dehiscence that responded well to frequent
dressing and parenteral antibiotics.
Fixator was removed at time of clinical union (no tenderness
at fracture site and comfortable weight bearing with the fixator),average time for removal of fixator was twelve weeks , in one
case fixator removal was delayed due to continuing tenderness
at facture site, frame was removed later on (at 16 weeks
postoperatively) because of increased pin tract infection , the
same case had delayed union and required bone grafting from
iliac crest to the medial aspect of the talar neck at six months
from operation. Two cases had radiological signs of AVN of talar
body (talar body sclerosis) without significant pain and they
required no intervention (Table 3). No cases required hard ware
All cases at last follow up had decreased range of motion of
ankle joint (mean dorsiflexion of five degrees and mean plantar
flexion of twenty degrees) this may be attributed not only to the
ankle osteoarthritis but also stiffness related to the frame. At
last follow up all patients had radiological signs of good union,
average functional score was 79.5 out of 100, three patients had
a score of 90 or more with minimal pain, walking unassisted, no
effort restrictions, three patients used one crutch occasionally
with some discomfort on walking on uneven ground (Table 4)
shows details of functional scoring.
Although many of the complications associated fracture
neck talus Hawkin’s type III are related to the main insult
but some of the postoperative complications start inside the
operating theater through the surgical technique and the
vigorous manipulation exerted during the procedure so recent
authors have stressed the importance of anatomic reduction and
the likehood of arthrosis with less than perfect reduction .
Vigorous manipulation during reduction leads to harming the
delicate blood supply predisposing to AVN of the talus, scuffing
of the articular cartilage may lead to early ankle or subtalar osteoarthritis  while pushing the extruded talar body back to
the tight mortis may cause propagation of the undisplaced cracks
adding more comminuted fragments, all of these disadvantages
can be avoided by using our technique.
The mean operative time of our technique (85 minutes)
is relatively longer than the usual time for doing the open
reduction and fixation of talar neck fractures; this may be related
to the time consumed in applying the frame. Although medial
malleolar osteotomy is recommended in Hawkin’s type III
talar neck fractures  but it is not necessary in our technique
because of the role of distraction in making better exposure
without needing the osteotomy which adds a new morbidity
for the patient. Unlike the other techniques, in our series the
reduction could be checked and readjusted freely depending on
the frame before fixation with screws, in one case after doing
the reduction there was a gap between the talar body and the
head in the lateral view, compression could be achieved through
translating the foot piece posteriorly in relation to the proximal
ring and then fixation was done.
Another tip is to start the fixation with the lateral screw
through the anterolateral incison before the medial screw to
avoid the overcompression at the medial side leading to varus
malalignment of the foot which is common in Hawkin’s type
III talar neck fractures  but it did not happen in any of our
cases. Partial weight bearing was allowed for our cases at four
weeks after operation which is much earlier than recommended
in Hawkin’s type III fracture talar neck (recommended 12 to
16 weeks of immobilization and non weight bearing after the
operation) , this is related to the presence of the frame which
acts as a protecting tool against the axial overloading force on
the articular cartilage, maintaining the reduction of talar neck
and keeping the hind foot alignment, although it may have a
role in decreasing the ankle range of motion later on thus we
suggest using a hinged fixator in the future to start earlier range
of motion even before removal of the frame.
Ankle osteoarthritis did not appear radiologically in any of
our patients compared to 25% of cases in Elgafy  series , our
technique may has no direct role on decreasing post-traumatic
ankle or subtalar arthritis , but we claim that good reduction,
respecting the articular cartilage during reducing the extruded
talar head back to the mortis in addition to some distraction that
happened intraoperatively may have some role in decreasing
incidence of osteoarthritis, this needs further follow up of larger
number of patients. Radiological signs of AVN of the talar body
occurred in two of our patients but they required no further
intervention till last follow up, incidence of AVN in Hawkin’s
type III reported in literature is 75% , this does not mean
that AVN is less in our series due to few number of patients, but we believe that achieving perfect reduction with less vigorous
manipulation in addition to the protective effect of the frame
on the talar dome may have a role in keeping the delicate blood
supply of the talus, this needs further vascular studies on large
number of patients to prove it. Limitations of the study is the
few number of patients , but our main aim is to highlight a new
proposed technique to facilitate the reduction and fixation of
Hawkin’s type III talar neck fractures with nearly extruded talar
Distraction assisted reduction of extruded talar body is
a good proposed technique for treatment of Hawkin’s type III
fractures of neck talus without need for vigorous manipulation.
The technique carries a lot of intraoperative and postoperative