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Arthroscopic Talus Fracture Fixation


Indications

  • Talar neck fractures that can be reduced without making an incision using traction or manipulation only

  • Lateral talar process fractures

  • Medial talar fractures

  • Posterior body fractures

  • Minimally comminuted talar body fractures

Indications Pitfalls

  • Talar neck fractures with lateral comminution

  • Talar body fractures not reducible closed

  • Talar neck fractures with talar body dislocations that cannot be reduced via traction

Indications Controversies

  • No outcome data to date

  • Likely allows better preservation of blood supply to the talar fragments

Examination/Imaging

  • Examine the skin for compound wounds

  • Fig. 41.1 depicts examination to determine hindfoot and forefoot varus

    FIG. 41.1

  • Determine the degree of displacement of the fracture

  • Fig. 41.2 shows a radiograph of a talar neck fracture

    FIG. 41.2

  • Perform a distal neurologic assessment, including a computed tomography scan ( Fig. 41.3 )

    FIG. 41.3

  • Ensure there are no other fractures in the foot or elsewhere as these are high-energy injuries

Treatment Options

  • Closed reduction and casting for minimally displaced fractures

  • Closed reduction and external fixation

  • Open reduction and internal fixation

Surgical Anatomy

  • The talus has no tendon attachments ( Fig. 41.4 ).

    FIG. 41.4

  • The body of the talus is mainly surfaced by cartilage on the dorsal, medial, lateral, and posterior sides with the majority of the blood supply coming from the anterior region from the neck.

  • Structures at risk are the tibial nerve and artery posterior medial to the talar body, and the dorsalis pedis artery and deep branch of the peroneal nerve in the midline anteriorly.

  • The blood supply of the talus comes from the artery of the tarsal canal, the dorsalis pedis artery, and from the limited soft-tissue attachments. This includes the deltoid ligament and the posterior capsule.

  • The flexor hallucis longus tendon passes close to the talar body in a tendon tunnel behind and medial to the posterior process and is held in a fibro-osseous tunnel.

Positioning

  • The patient is positioned on the table with the hip elevated and the foot at the bottom of the table ( Fig. 41.5 ).

    FIG. 41.5

  • Depending on the site of the foot needed to be reached, the foot may need to be more or less internally rotated.

  • Occasionally (for posterior body fractures), the patient can be positioned prone.

  • The patient can also be positioned in the lateral position if all the work required in the talus is anterior or lateral.

Positioning Pearls

  • The figure 4 position with the leg crossed over the nonoperative leg and the surgeon working seated from the other side of the table works for some medial fixation.

  • Make sure that the arthroscopy camera is positioned on the opposite side of the table.

  • Use a thigh tourniquet to prevent tightening of the leg muscles.

Positioning Pitfalls

  • Failing to position so that the fracture can be adequately approached during the case

Positioning Equipment

  • A beanbag is useful as it will allow the patient’s position to be changed during the procedure.

Positioning Controversies

  • Some surgeons advocate prone followed by supine positioning if both the anterior and posterior aspects of the talus require approach.

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