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The Journal of Foot & Ankle Surgery 52 (2013) 56–61

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The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Talar Neck Fractures: A Systematic Review of the Literature

Jason J. Halvorson, MD, S. Bradley Winter, MD, Robert D. Teasdall, MD, Aaron T. Scott, MDWake Forest University Baptist Medical Center, Winston-Salem, NC

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:avascular necrosisboneinjurynonunionsurgerytalus

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Aaron T. Scott, MD,

Medical Center, Medical Center Boulevard, Winston-SE-mail address: aascott@wakehealth.edu (A.T. Sco

1067-2516/$ - see front matter � 2013 by the Americhttp://dx.doi.org/10.1053/j.jfas.2012.10.008

a b s t r a c t

Considerable controversy surrounds the management of talar neck fractures regarding the rate of post-traumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery onthese variables. A data search using PubMed was performed with the keywords “talus” and “fracture.” Thesearch found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Dataconcerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis,and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and func-tional outcomes were collected and analyzed. The variables examined were not uniformly reported in allstudies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between theinterval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, withnonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients,although secondary salvage procedures were only performed in 19% of patients. Functional outcomes weredifficult to assess, given the variability of reported outcomes and unvalidated measures. The optimalmanagement of talar neck fractures has yet to be determined. Although the present review has improvedunderstanding of these difficult fractures, additional studies that use validated outcomes measures are war-ranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods.

� 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.

Although fractures of the talar neck represent fewer than 1% of allfoot and ankle fractures (1,2), they have historically garnereda tremendous amount of attention owing to the talus’ unique osseousand vascular anatomy (3) and the unusually high level of morbidityassociated with fractures at this location. Despite more than 1200reports published in the English language, our knowledge regardingthe relative rates of complications, effect of fracture severity onpatient outcomes, results of treatment, and appropriate timing oftreatment remains limited. Much of the confusion and controversy isrelated to the relative infrequency of this injury, which has resulted ina plethora of small, retrospective case series. Adding to the confusionhas been that the available reports have not consistently used thesame classification systems, nor have they focused specifically onfractures through the neck of the talus, rendering head-to-headcomparisons difficult, if not impossible, in some situations. The goalof the present study was to perform a systematic review of theavailable data evaluating talar neck fractures in an attempt to gaina better appreciation of the overall complication rates, effects of

Wake Forest University Baptistalem, NC 27157.tt).

an College of Foot and Ankle Surgeon

fracture severity on prognosis, functional outcomes after treatment,role of timing with respect to operative intervention, and need forsecondary salvage procedures.

Materials and Methods

A PubMed search was performed using the keywords “talus” and “fracture.” Thissearch identified 1280 studies that were then reviewed for relevance to only frac-tures of the talar neck. Exclusion criteria included studies published in a languageother than English, studies focusing on talar body or talar process fractures,cadaveric studies, studies with fewer than 5 patients, and studies focusing on“primary salvage” of talus fractures (i.e., Blair fusion, primary subtalar arthrodesis).The remaining 21 studies (4–24) are listed in Table 1. The references from each of the21 selected studies were also reviewed in an attempt to locate additional relevantreports that were not identified during the initial PubMed search. However, no otherqualifying studies were found. One additional report, by Coltart (25), waspurposefully omitted. Although of historic interest, the lack of a classificationsystem, outcomes, and follow-up data within the study made inclusion with theremaining studies difficult.

When studies examining both talar neck fractures and other talus fractures (body,head or process fractures) were encountered, only the data relating to the talar neckfractures and fracture dislocations were extracted. This was the case for 8 of the 21selected studies (7,8,13–15,18,22,23). The data from these 21 studies were compiledand subsequently analyzed, with particular emphasis placed on the rate of avascularnecrosis, infection, and post-traumatic arthrosis, the functional outcomes aftersurgery, the effects of operative delay on the avascular necrosis (AVN) rate, and therates of secondary salvage procedures. Furthermore, an attempt was made to corre-late these findings with the fracture severity, as outlined by the numerous classifi-cation systems.

s. All rights reserved.

Table 1Overview of 21 included studies

Study Study Type Total Talar NeckFractures (totalfractures reported)

Open (infected) ClassificationUsed

MaleGender

AverageAge (y)

Outcome Average Intervalto Surgery

AVN Nonunion Malunion Follow-up (y)

Inokuchi et al (13),1996

Retrospective 52 (86) 17 Hawkins 70 26.4 Hawkins criteria NR 30 d d 14.9

Marsh et al (17), 1995 Retrospective 18 18 (7) Hawkins 10 31.4 NR 8 h NR d d 7.4Frawley et al (9), 1995 Retrospective 28 4 Szyszkowitz 18 45 Subjective Most within 12 h 4 d 3 6Freund (10), 1988 Retrospective 7 1 Hawkins 6 37 Hawkins criteria <24 h 4 2 mo d 6.5Szyszkowitz et al (23),

1985Retrospective 56 (69) 21 Szyszkowitz 64 NR Subjective NR NR d d 4.2

Comfort et al (6), 1985 Retrospective 36 NR Hawkins NR 25 Hawkins criteria <12 h for 18, 1–7 d for9, 17 d for 1

12 0 0 7

Grob et al (11), 1985 Retrospective 41 NR Hawkins 31 28 Hawkins criteria <8 h for 28, 10 d for 8,>10 d for 5

4 d d 9.8

Penny et al (11), 1980 Retrospective 40 NR Hawkins 30 30 Hawkins criteria NR 13 5 d 6.2Elgafy et al (8), 2000 Retrospective 27 (60) NR Hawkins 39 32 AOFAS, Maryland score,

HawkinsNR 7 d d 2.5

Schulze et al (22), 2002 Retrospective 46 (80) 10 (1) Hawkins,Marti-Weber

67 33 Hawkins, Mazur 18 within 6 h; median0 d if directadmission, 6d if treated

17 3 1 6

Canale et al (4), 1978 Retrospective 71 17 (4) Hawkins NR 30 Hawkins criteria NR 33 d 18 12.7Chateau et al (5), 2002 Retrospective 23 NR Hawkins 10 28 Subjective NR 4 d 2 1.8Hawkins (12), 1970 Retrospective 54 12 Hawkins 38 30.4 Hawkins criteria NR 30 d d 3.8Lindvall et al (15), 2004 Retrospective 18 (26) 7 (2) Hawkins 10 37.3 AOFAS Average 85 h, 12

patients <6 h (NS)13 d d 6.2

Sanders et al (21), 2004 Retrospective 70 10 Hawkins 57 34 SMFA, AOFAS, AOS NR 8 d 21 5.2Vallier et al (24), 2004 Retrospective 102 24 Hawkins 60 32.6 FFI, MFA 3.7 d (NS) 19 2 d 2.5Kenwright et al (14),

1970Retrospective 21 21 (1) Coltart 49 35 Subjective NR 8 4

Dunn et al (7), 1966 Retrospective 23 3 (1) Head, neck, body NR 46 Subjective NR 16 3 5 6.4Pennal (18), 1966 Retrospective 41 (98) NR Coltart NR 38 Subjective NR 28 d d NRPeterson et al (20),

1977Retrospective 46 NR Hawkins 34 NR Hawkins NR 6 0 13 6

Lorentzen et al (16),1977

Retrospective 123 13 Hawkins 107 39 Subjective NR 26 5 18 1.8

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; AOS, ankle osteoarthritis scale; AVN, avascular necrosis; FFI, Foot Function Index; MFA, Musculoskeletal Function Assessment; NR, not reported; NS, nostatistically significant difference; SMFA, Short Musculoskeletal Function Assessment.

J.J.Halvorson

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Surgery52

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Table 3Overall reported rate of avascular necrosis after talar neck fracture

Variable Total Patients (n) AVN (n) AVN Rate (%)

Total of studies reporting AVN 848 282 33.30%Total in studies using Hawkins

classification735 174 23.60%

Hawkins type I 159 9 5.70%Hawkins type II 314 58 18.40%Hawkins type III 228 102 44.70%Hawkins type IV 33 4 12.10%Other 1 1 100%

Abbreviation: AVN, avascular necrosis.

J.J. Halvorson et al. / The Journal of Foot & Ankle Surgery 52 (2013) 56–6158

Results

All selected studies were retrospective. A total of 943 talar neckfractures were reported among the 21 articles. Demographic datafrom the patient population is listed in Table 1. The treatment typewas highly variable and included nonoperative management (with orwithout closed reduction), open reduction, internal fixation usinga variety of methods, closed reduction with percutaneous pinning,external fixation, and primary salvage procedures (Table 2). Given thewide range of treatment modalities, methods, and approaches,comparisons were not possible among the different treatmentmodalities and outcome measures.

Of the 21 studies, 14 (208 total cases) reported their experiencewith open talar neck fractures (4,7,9,10,12–17,21–24) (Table 1). Ofthese 14 studies, 6 reported the rate of deep infection for open frac-tures (4,7,14,15,17,22). Also, 16 studies reported that deep infections inthe collective group of 76 fractures were observed, for an overallinfection rate of 21%. Treatment of these infections varied greatlyamong the studies and included: removal of hardware, salvageprocedures such as talectomy and/or fusion, and amputation.

A total of 19 studies (4–16,18–22,24) reported the overall rate ofAVN within their series (Table 1). AVN occurred in 282 of these 848fractures, for an overall incidence of 33.3% (Table 3). Sixteen studiesused the Hawkins classification systemwhen analyzing the AVN rates(Table 1). Of the 735 talar neck fractures classified according to theHawkins classification system, AVN was identified in 174 cases, for anoverall rate of 23.6% in those particular studies. Additional analysisrevealed that AVN occurred in 5.7% of Hawkins type I fractures, 18.4%of Hawkins type II fractures, 44.7% of Hawkins type III fractures, and12.1% of Hawkins type IV fractures (Table 3). An increased risk of AVNwas also identified by Vallier et al (24), who found a statisticallysignificant difference in the AVN rates in open fractures versus closedfractures (p ¼ .05). In contrast, Lindvall et al (15) demonstrateda similar trend, although they were unable to demonstrate statisticalsignificance (p ¼ .073; data not shown).

Eight studies reported the interval to operative interventionwithintheir series (6,9–11,15,17,22,24) (Table 1). The interval to surgeryvaried widely across these studies, and all studies retrospectivelyreviewed this factor. However, when examined, no statistically

Table 2Overview of fixation methods and management in 21 studies

Study NonoperativeManagement/Closed Reduction (n)

ORIF(n)

ExternalFixation (n)

OtherPrimaryProcedure (n)

Inokuchi et al (13), 1996 d 38 48 d

Marsh et al (17), 1995 6 11 d 1Frawley et al (9), 1995 12 16 d d

Freund (10), 1988 4 d d d

Szyszkowitz et al (23), 1985 0 56 d d

Comfort et al (6), 1985 d d d d

Grob et al (11), 1985 0 37 d 4Penny et al (11), 1980 d d d d

Elgafy et al (8), 2000 5 42 1 5Schulze et al (22), 2002 d 70 1 9Canale et al (4), 1978 3 26 d 5Chateau et al (5), 2002 d 23 d d

Hawkins (12), 1970 18 34 d 5Lindvall et al (15), 2004 d 26 d d

Sanders et al (21), 2004 d 70 d d

Vallier et al (24), 2004 d 102 d d

Kenwright et al (14), 1970 2 13 d d

Dunn et al (7), 1966 15 8 d d

Pennal (18), 1966 3 NR d 4Peterson et al (20), 1977 31 15 d d

Lorentzen et al (16), 1977 0 15 d 2

Abbreviations: NR, not reported; ORIF, open reduction internal fixation.

significant differences were reported for the association between theinterval to fracture fixation and the incidence of AVN (15,24).

The reporting of malunion and nonunion is listed in Table 4. A total8 studies (6,7,10,16,19,20,22,24) reported on the rate of nonunion in423 fractures. In total, 21 nonunions were identified, for a rate of 5%.Likewise, 9 studies (4–7,9,16,20–22) reported their incidence of mal-union for a total of 466 fractures. Of the 466 fractures, 81 were re-ported as malunions, for an incidence of 17%.

The overall rate of post-traumatic arthrosis was 67.8% in thestudies that specifically evaluated this parameter. In this group of 635patients, the involved joints included the tibiotalar joint, subtalarjoint, talonavicular joint, and combinations of these joints. Overall,the subtalar joint was the most commonly involved joint. These dataare presented in Table 5. Only Elgafy et al (8) examined the rates ofarthritis as they related to the severity of the injury using the Hawkinsclassification. Therefore, we were unable to determine the effects ofthe fracture severity on the incidence of post-traumatic arthrosisoutside of the study by Elgafy et al (8).

The incidence of secondary salvage procedures (any operationperformed after failure of the initial treatment or in response to thedevelopment of arthrosis) was reported in 18 studies (4,6–15,17–19,21–24) (Table 6). Only 2 studies (19,21) determined the rateof secondary salvage procedures using a given classification system orfracture type. Therefore, no attempt was made to compile data on therates of secondary salvage procedures for specific classificationsystems or grade, given these low numbers. The overall incidence ofsecondary procedures was 18.6%, with subtalar arthrodeses per-formed most commonly (34.6%), followed by ankle arthrodeses andtriple arthrodeses (20.3% and 16.5%, respectively).

The measurement of functional outcomes in patients variedgreatly among the studies, making comparisons difficult. Ten studiesused the Hawkins clinical evaluation for functional outcome(4,6,8,10–13,19–22). A total of 429 patients were evaluated using theHawkins criteria, with results reported in Table 7. The Hawkins clinicalevaluation is a 4-category system in which points are assigned forpain, limp, anklemotion, and subtalar motion and then summed, withhigher scores indicating better results. An excellent result is definedas a score of 13 to 15, a good result as a score of 10 to 12, a fair resultas a score of 7 to 9, and a poor result as a score of 0 to 6. Table 8 liststhe 5 studies (6,12,13,19,20) in which the Hawkins clinical criteria wasused in combination with the Hawkins classification system. Giventhe inconsistent use of the other outcome measures (patient report,investigators’ physical examination findings, American OrthopaedicFoot and Ankle Society [AOFAS] scoring system, ankle osteoarthritis

Table 4Overall reported rate of nonunion and malunion after talar neck fracture

Nonunion Malunion

Total fractures (n) 423 466Total nonunion or malunion (n) 20 81Percentage 5% 17.80%

Table 5Overall reported rate of post-traumatic arthrosis after talar neck fracture

Post-traumatic Arthrosis Patients (n)

Total 635Tibiotalar 115Subtalar 265Talonavicular 2Ankle plus subtalar 44Ankle, subtalar, talonavicular 1Unspecified location 4

Table 7Functional outcomes using Hawkins clinical criteria

Outcomes Using Hawkins Criteria Patients (n ¼ 429)

Excellent 87Good 152Fair 96Poor 94

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scale, Maryland Foot Score, and others), comparisons among somestudies were not possible.

Discussion

Talus fractures have confounded physicians for centuries. Reportsas early as 1820 (18) have demonstrated poor outcomes and a highmortality rate after this injury and its subsequent management,leading some early surgeons to recommend amputation as theprimary treatment (26). As anesthesia has evolved as a distinctspecialty and modern orthopedic techniques have been developed,numerous case series and reports of talus fractures have been pub-lished, with wide variations in treatment strategies and patientoutcomes (4–24). Despite modern advances, talar neck fracturescontinue to represent problematic injuries that are associated withnumerous complications and less than satisfactory results aftertreatment. The current published studies impart valuable informationbut lack the meta-analyses and systematic reviews necessary to guideclinical practice. Thus, the treatment of talar neck fractures has reliedon longstanding paradigms and traditions. The present systematicreview was undertaken in an attempt to further define the compli-cation rates, prognoses as they relate to injury severity, effects ofsurgical delay, functional outcomes after treatment, and incidence ofsecondary operative procedures. Fractures of the talar body, talarhead, and the various processes of the talus carry their own distinctset of complications, treatment considerations, and outcomes and,thus, were excluded from the present review.

Among themost notable of the complications associatedwith talarneck fractures is avascular necrosis of the talar body, which is thoughtto be related to the talus’ tenuous blood supply (3,27,28). Reports ofAVN rates have varied widely, with a range of 0% to 13% for Hawkinstype I fractures, 20% to 50% for Hawkins type II fractures, and 80% to100% for Hawkins type III and IV fractures (2). In the present analysis,the overall rate of AVN across all studies was 36.8%. When evaluatingthe studies that specifically used the Hawkins classification system,AVN was noted in 23.6% of patients. The type III fractures had thegreatest rate of AVN at 44%, with type IV fractures surprisingly havinga rate of only 12%. We acknowledge that this rate might have beenartifactually low and believe that it might be related to the relative

Table 6Overall reported incidence of secondary procedure after talar neck fracture

Secondary Procedures n

Total 715Ankle fusion 27Subtalar fusion 46Tibiocalcaneal fusion 15Talectomy 9Triple arthrodesis 22Amputation 4Talonavicular 1Total ankle 2Fusion 7

rarity of the Hawkins type IV injury, which accounted for only 4.5% ofall “Hawkins classified” talus fractures in our review. Furthermore, thedesignation of Hawkins type IV did not exist before 1977. Therefore,many of the Hawkins type IV fractures would have been classified astype III injuries and treated with older techniques. Overall, the rates ofAVN we obtained during our review were lower than many of thepreviously published rates and might represent a more accurateassessment of the true rates of AVN, because more patients wereincluded.

Historically, urgent or emergent open reduction and internalfixation of talar neck fractures has been recommended in an effort torestore or protect the blood supply of the talar body and thus reducethe incidence of AVN. However, few reports have specifically focusedon operative delays and their association with the development ofAVN. In our review, we were unable to identify any studies whoseresults would support urgent or emergent intervention. Recent dataseem to indicate that an operative delay is not associated with anincreased risk of AVN (15,24), but that this process is most likelya result of the severity of the initial injury and disruption of the bloodsupply and that anatomic reduction and internal fixation does notadequately restore the disrupted blood supply. This change inthinking has been highlighted in a recent survey of orthopedic trau-matologists conducted by Patel et al (29). In their survey, 60% oforthopedic traumatologists thought that care after 8 hours wasappropriate for a displaced talar neck fracture, with roughly one half(46%) indicating that they believed a delay of more than 24 hours wasacceptable.

The malunion and nonunion rates were difficult to quantify in theavailable studies. Not all studies reported on their incidence of mal-union and nonunion. In addition, defining the investigators’ criteriafor both nonunion and malunion were not equivalent among thestudies, and few went so far as to report their numbers on basis ofopen versus closed treatment or the rate in conjunction with openfracture, and so forth. However, from the available data, malunion canbe expected to occur in approximately 20% of cases and nonunion inapproximately 5% of cases. Although these raw percentages are ofvalue, correlation with type of operative procedure, rates of arthrosisand/or secondary procedures, and functional outcomes is scarce. Theadvent of newer advances in operative technique such as dual incisionand referral of these injuries to “foot and ankle” or “trauma-trained”specialists might decrease the percentage of “open internal fixation”in more recent years. Additional studies are required before definitiveconclusions regarding how the rates of malunion and nonunion affectthe history and clinical outcomes of talar neck fractures.

Table 8Relationship between Hawkins clinical criteria and Hawkins classification

Outcomes Using Hawkins Criteria Fracture Type by Hawkins Classification

Type I Type II Type III Type IV Total

Excellent 35 11 6 2 54Good 33 17 25 1 76Fair 6 13 30 0 49Poor 5 14 19 3 41Total 79 55 80 6 220

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The relative rates of post-traumatic arthrosis were difficult toaccurately quantify from the information provided in the 21 selectedstudies. Of the 635 patients for whom follow-up data were available,67.8% of patients were reported to have some level of arthrosis.However, some studies made nomention of the incidence of arthrosis(7,13,17–19), and others simply combined “arthritis” into 1 categorywithout specifically indicating the site involved. Furthermore, thediagnostic criteria for post-traumatic arthrosis varied among thestudies, with some choosing to define the condition clinically andothers using radiographic parameters. In those studies that reportedthe rates of arthrosis, subtalar arthrosis was most commonly diag-nosed, occurring in 38% of patients and accounting for 62% of thearthritis reported overall. Few studies considered the rates of specificarthritis as it related to the severity of the injury (19,21) or classifi-cation system. No meaningful numbers were able to be extrapolatedfrom the current data regarding the rates of post-traumatic arthrosisafter talar neck fracture. Therefore, no comment can be maderegarding the incidence of secondary arthritis as it relates to theseverity of the injury.

Secondary salvage procedures are common after talus fracturesand typically involve peritalar arthrodesis. Sanders et al (21) reportedin their analysis that the calculated percentage of patients requiringsecondary surgery at 1, 2, 5, and 10 years was 24%, 32%, 38%, and 48%,respectively. Our analysis has demonstrated a lower incidence ofsecondary procedures, with an overall rate of 18% at an averagefollow-up of 6 years. Of the 133 secondary procedures reported,subtalar fusion predominated, occurring 35% of the time, followed byankle fusion and triple arthrodesis at 20% and 17%, respectively.Sanders et al (21) demonstrated that secondary reconstructiveprocedures are most likely needed in comminuted fractures andHawkins type III or IV fractures. In their series, only 7 of 26 patientsrequiring secondary surgery were classified as having Hawkins type IIfractures (21). No Hawkins type I fracture required a secondaryreconstructive surgery. On the basis of our review, which found anoverall rate of arthrosis of 67.8% and a rate of secondary salvageprocedures of 18%, it appears that many of the patients who werediagnosed with arthrosis were either minimally symptomatic orasymptomatic. As stated, no study delineated between symptomaticand asymptomatic post-traumatic arthritis. Therefore, the clinicalsignificance of a 67.8% rate of post-traumatic arthrosis in the setting ofan 18% rate of secondary surgery is questionable. It would thus seemthat most patients will develop some form of arthritis after talar neckfracture, but that most of those patients will either be asymptomaticor will choose not to undergo secondary salvage procedures.

No functional outcomes measure was universally used across allstudies. The Hawkins clinical evaluation score was the most commonoutcomesmeasure used in our group of selected studies and was usedin 10 of the 21 studies examined. Of the 429 fractures for which theHawkins clinical evaluation score was used, only 20% of the outcomeswere rated as excellent, with 22% of patients having a poor outcomeand more than one half having either a fair or poor outcome. In thestudies that used both the Hawkins classification system and theHawkins clinical evaluation (220 total fractures), only 44% of patientswith a type I fracture had an excellent result compared with an 8%excellent result for patients sustaining a type III injury. However, only6 type IV fractures were reported in this group, with 3 (50%) havingexcellent or good results and 43 (50%) poor results. Thus, in ourreview, an increasing severity of injury, as established by the Hawkinsclassification system, correlated with a worse functional outcome, asindicated by the patient’s score on the Hawkins clinical evaluation.

The remaining outcomes assessments used throughout the studiesmade evaluation difficult, because few consistent outcome measuresexisted across all examinations. More recent studies (8,15,21) haveattempted to use validated outcomes questionnaires for functional

assessment. Sanders et al (21) reported that roughly one half of theirpatients without a salvage procedure during follow-up reporteda visual analog scale pain score of 4.2 of 10. In addition, the AOFAShindfoot score ranged from 52 for those patients with malalignmentor secondary arthritis to 92 for those patients with anatomic reduc-tion and no signs of secondary arthritis. Elgafy et al (8) reported theaverage AOFAS score in their cohort of patients was 79 (range 37 to99). Finally, Lindvall et al (15) reported an AOFAS score of 46.7 pointswhen a neck fracture resulted in AVN versus a score of 76 points forthose without AVN. The AOFAS score of those patients with radio-graphically documented subtalar arthritis and subtalar plus anklearthritis was 63.2 and 60.4, respectively. As with the Hawkins clinicalevaluation, comorbid conditions developing after talar neck fracture(i.e., AVN, arthritis) resulted in decreased validated outcomes scores.Therefore, increased severity of injury, arthritis, and AVN increasesthe likelihood of a worse outcome after talar neck fracture.

Inherent weaknesses were present with the present systemicreview. First, all studies reviewedwere retrospective. As such, the biasassociated with retrospective studies was also associated with ourreview. Future studies, although difficult in this population, shouldfocus on prospective examinations for variables such as the incidenceof AVN and timing of surgery as it relates to AVN. In addition, thenonstandardized clinical follow-up and assessment made compari-sons difficult among the studies across all the variables examined.This also dramatically decreased the numbers available for compar-ison in some instances, limiting the true power of the more than 900reported talar neck fractures. Not only were no standardizedoutcomes available, also no standardized treatment methods wereused among the studies. This was the primary reason the historicalstudy by Coltart (25) was not included in the present analysis. Thetreatment methods, classification system, outcomes, and technologyvaried so greatly from those currently in use that we believe thatincluding these patients in the present analysis would have confusedthe final data collection and results. The remaining included studiesreviewed spanned more than 4 decades, and an evolution in treat-ment philosophy and strategywas seen as the reports were published.Early, investigators advocated conservative treatment with eitherimmobilization or closed reduction followed by immobilization. Thisresulted in described techniques of casting in equinus for weeks ata time (14,18). When surgery was performed, a wide variety ofmethods was chosen for open reduction and internal fixation. Withmore recent advances in operative techniques and instrumentation,these options have increased to the use of biodegradable screws,plates, standard screws, Kirschner wires, or, even, external fixation(13,30,31). Open reduction and internal fixation has decreased theoverall reported incidence of AVN (2) in more recent examinationscompared with historical controls. Therefore, in including all reportsboth before and after themove to open reduction and internal fixationfor talus fractures, we might have biased the evidence becausecomparisons in treatment methods and philosophies will obviouslyinfluence the overall rates of AVN, functional outcomes, secondaryprocedures, and so forth.We also did not include any study examiningthe use of a primary salvage procedure for talar neck fractures.Therefore, another cohort of patients exists, who undergo primaryreconstructive/salvage surgery, that we could not comment on orcompare with our cohort. Functional outcomes are also difficult tocompare because the more recent studies focused on validatedoutcomes questionnaires and older studies did not have this methodavailable. However, few of the newer studies used the same validatedoutcomes questionnaires; therefore, despite the high-quality report-ing of outcomes, comparisons between series were difficult.

In conclusion, talar neck fractures continue to represent injuriesthat demand respect from orthopedic surgeons. One third of thesepatients will develop AVN and two thirds will develop arthritis,

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resulting in a 20% salvage procedure rate. Functionally, as defined bythe classic Hawkins clinical criteria, almost one fourth of patients willend up with a poor outcome, with almost one half of patients havinga fair or poor outcome. Although modern orthopedic techniques havecontinued to evolve and have dramatically decreased the overall ratesof AVN and, potentially, poor functional results, continued work isrequired to help improve patient care and outcomes.

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