Treatment of necrosis of the talus of the ankle joint in Moscow

Fracture of the talus is a rare and complex pathology. Accounts for less than 1% of skeletal bone fractures, less than 20% of foot bone fractures.

Fractures of the talus can be divided into fractures of the neck, body, head and processes.

Fractures of the neck of the talus are the most common (50%). They are a consequence of high-energy trauma (road accident, fall from height). The mechanism of injury is forced dorsiflexion of the foot and simultaneous axial load. Often accompanied by other fractures in both the lower leg and hip on the same side.

Fractures of the body of the talus account for 13-23%, most often the result of high-energy trauma, axial load in the position of pronation and supination of the foot.

Fractures of the head of the talus almost never occur in an isolated form.

Fractures of the external process of the talus account for 10-11% of fractures. Occur under the influence of axial load in the position of dorsiflexion of the foot, inversion and external rotation. Often found among snowboarders.

Fractures of the posterior process of the talus are the result of avulsion of a bone fragment by the posterior tibiotalar ligament, or the posterior portion of the deltoid ligament. The second mechanism of injury is often found in athletes, especially football players.

The talus has a complex anatomy and a small number of blood supply sources, which largely determines the difficulties in treating its injuries and often unsatisfactory functional results.

The Hawkins classification of talar neck fractures is based on the degree and direction of displacement, which in turn determines the degree of disruption of the blood supply and the risk of avascular necrosis.

Diagnosis of a fracture of the neck of the talus.

In addition to the clinical picture, radiographs are required for a complete diagnosis. In addition to the frontal and lateral projections, the Canale projection is used, which is optimal for visualizing the neck of the talus.

Canale projection in maximum equinus, pronation 15°, photograph taken at an angle of 75°.

In difficult cases, CT scanning is indicated.

In the case of an acute displaced fracture, closed removal of the displacement is indicated in all cases. If the position of the fragments is satisfactory (displacement less than 2 mm), conservative treatment is possible, plaster immobilization for 8-12 weeks, 6 weeks without putting weight on the leg.

In all cases of displaced fractures, open reduction and osteosynthesis are indicated.

For adequate visualization of the entire neck of the talus and quality control of reposition, it is recommended to use 2 approaches, anteromedial and anterolateral.

For the convenience of performing the operation, it is desirable to have a distractor, joysticks (Schanz screw + universal handle), and a headlamp for better lighting. If reduction is difficult, an extended approach through the medial malleolus is recommended.

After achieving reposition, preliminary fixation with knitting needles is performed. Often a zone of bone tissue compression is determined along the anterior-internal and anterior-outer surfaces. In this situation, the use of a bone graft or synthetic bone replacement material is indicated.

After X-ray control, final fixation of the fracture is performed with compression screws and/or plates and screws.

After open reduction and osteosynthesis, a 3-month period without load follows. It is necessary, if possible, to place the limbs in an elevated position and use local cooling. Development of active and passive movements from the first day after surgery.

Unfortunately, fractures of the neck of the talus are accompanied by a large number of complications. In 50% of cases, subtalar arthrosis develops, in 33% tibiotalar arthrosis. Depending on the degree of displacement, the risk of avascular necrosis increases. It can be identified by radiographs at 6-8 weeks after surgery, in the form of foci of sclerosis, against the background of a decrease in bone density in the area of ​​the dome of the talus.

They are more rare than fractures of the neck of the talus. The principles of treatment remain the same - conservative treatment if the displacement is less than 2 mm and surgical treatment if more than 2 mm. Adequate visualization of the body of the talus will require an ankle osteotomy (usually the internal one).

After adequate reposition, preliminary fixation with knitting needles is performed.

For final fixation of the fracture, compression screws with a diameter of 3.5 and 4 mm are used, and, if necessary, plates.

Fractures of the body of the talus are characterized by the same complications as fractures of the neck.

This fracture is often confused with a common ankle sprain. The mechanism of injury is forced eversion with axial load on the hindfoot. This fracture is also often called a snowboarder's fracture.

It is not always possible to detect a fracture on conventional direct radiographs. In this situation, CT comes to the rescue.

For fractures of the lateral process of the talus, the Hawkins classification is used.

Fractures of the lateral process are always intra-articular, since the lateral process participates in articulation with both the calcaneus and the fibula. For this reason, if the fracture is displaced, surgical treatment is recommended. If the fracture is type B, then it is possible to perform open reduction and osteosynthesis; for type C fractures, resection of the lateral process is performed. In cases of symptomatic nonunion in chronic lesions, resection is also performed.

For surgical treatment, direct external access is used, directly under the apex of the outer malleolus. In cases where it is possible to perform osteosynthesis, the external process of the talus is fixed with one or two screws, 2.4 or 3.5 mm, depending on the size of the fragment. When the fragment is too small or fragmented, its resection is performed.

A fracture of the posterior process of the talus is characterized by several different mechanisms of occurrence. Depending on the mechanism, the morphology of the fracture differs.

The first mechanism is sharp dorsiflexion at the ankle joint. More often it occurs in athletes, either as a result of a sudden transition to a squatting position, or due to an unsuccessful landing after a jump.

The second mechanism is sharp dorsiflexion with simultaneous pressure on the area of ​​the heel tubercle.

And the third mechanism is often found in football players and dancers, excessive dorsiflexion. To implement this mechanism, it is necessary to have an anatomically sufficiently large posterior process of the talus.

The diagnosis of a fracture of the posterior process of the talus is very often made untimely or not made at all. This is due to both a blurred clinical picture and visualization difficulties. During the clinical examination, a posterior impingement test is performed - the thumb and index finger of one hand are placed paraachillary and apply pressure towards the posterior process of the talus, while the other hand is plantarflexed. If the test causes pain, jamming, or crunching, all this indicates damage to the posterior process of the talus. Radiographs often reveal a triangular bone, which differs from a fracture of the posterior process by its smooth contours and rounded shape. It can also often cause pain along the back surface of the ankle joint, especially if its synchondrosis with the posterior process is damaged. In such cases, its removal is indicated.

For non-displaced fractures, conservative treatment is possible, consisting of plaster immobilization for a period of 6 weeks. If there is significant displacement or a large fragment, surgical treatment, open reduction and fixation with 1 or 2 screws are recommended. For comminuted or chronic fractures accompanied by severe pain, resection of the posterior process is recommended. In general, treatment is carried out according to the same principles as for the external process.

POLYTRAUMA / POLYTRAUMA

Bondarenko A.V., Batrak Y.Yu., Plotnikov I.A.

Federal State Budgetary Educational Institution of Higher Education "Altai State Medical University" of the Ministry of Health of the Russian Federation, Regional State Budgetary Institution of Health Care "Regional Clinical Hospital of Emergency Medical Care", Barnaul, Russia

TREATMENT OF DAMAGES TO THE ASTRAL BONE DURING POLYTRAUMA

Fractures and dislocations of the talus are a rare and complex pathology. Being a consequence of high-energy impacts, they often occur in polytrauma (PT) [1-3]. Due to its unique anatomy, blood supply, and numerous complex articulations, treatment of injuries to the talus presents significant challenges. Their course is often accompanied by the development of infectious complications, degenerative arthrosis, hindfoot deformities, avascular necrosis, unsatisfactory outcomes and a high level of disability [4-6]. Since almost all talar fractures are intra-articular, they require precision reduction, stable fixation and early function [4, 7]. The presence of several severe injuries in patients complicates the use of conventional surgical methods for treating injuries of the talus or postpones their implementation to a later date, which leads to the development of complications - edema, epidermal blisters, fibrous changes in soft tissues, and avascular necrosis [8-10]. In the late period, it is often not possible to satisfactorily compare fragments and hold them using traditional methods. Taking this into account, it is necessary to search for simple, minimally invasive methods of surgical treatment of injuries to the talus in patients with PT, both in the early and late periods. Purpose of the study

– to find out the frequency and nature of injuries to the talus during polytrauma, treatment features, including the use of modern minimally invasive methods of osteosynthesis.

MATERIAL AND METHODS

The study was carried out in accordance with the ethical principles of the Declaration of Helsinki (World Medical Assosiation Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013) and the “Rules of Clinical Practice in the Russian Federation” (Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266) with patient consent to participate and approved by the local ethics committee. Patients were included in the study in a continuous manner from a limited area over a limited period of time. From 2000 to 2021, 175 patients with 182 injuries of the talus, aged from 14 to 80 years (median - 32 years, interquartile range - from 27 to 42 years) were treated at the Regional Clinical Hospital of Emergency Medical Care in Barnaul. . Men - 145 (82.9%), women - 30 (17.1%), workers - 91 (52%), non-working people of working age - 69 (39.4%), students and pupils - 9 (5.1%) ), pensioners – 6 (3.4%). 145 (82.8%) patients were injured as a result of high-energy impacts: in road traffic accidents - 97 (55.4%), in falls from great heights - 48 (27.4%), as a result of low-energy impacts : in case of accidents at home - 21 (12%), in case of sports injuries - 9 (5.1%). In 117 (66.9%) patients, injuries to the talus were one of the components of PT. Its severity according to the ISS scale [11] in 75 (64.1%) patients ranged from 17 to 25 points, in 26 (22.2%) – from 25 to 40 points, in 16 (13.7%) – over 41 points. Traumatic brain injuries were detected in 24, of which 15 had cerebral concussions, 9 of them had brain contusions, 2 of them had intracranial hemorrhages, 1 of them had fractures of the base of the skull. Injuries to the internal organs of the chest and abdomen - 21 of them, of which pneumothorax - in 2, hemothorax - in 2, kidney bruises - in 9, liver ruptures - in 3, spleen - in 3, intestines - in 1, omentum - in 1. Injuries to the musculoskeletal system of other localizations - in 83 (shoulder fractures – in 8, forearms – in 5, hips – in 18, shins – in 49, calcaneus – in 21, spine – in 21, ribs – in 14, pelvis – in 13). In 58 (33.1%) patients, the injury to the talus was isolated. Closed injuries to the talus were observed in 160 (87.9%) cases, open - in 22 (12.1%). The work used Coltart's classification (1952) [9], which allows the damage to be most accurately detailed. The following were identified: 1. Fractures of the body of the talus without and with displacement (Fig. 1a). 2. Fractures of the neck of the talus of three types: type I – fractures of the neck of the talus without displacement of bone fragments (Fig. 1b); Type II – fractures of the neck of the talus with displacement of bone fragments and subluxation in the subtalar joint (Fig. 1c); Type III – fractures of the neck of the talus with dislocation of the body (Fig. 1d). 3. Subluxations and dislocations in the subtalar joint (Fig. 1e). 4. Complete dislocations of the talus (Fig. 1f).

Figure 1.
Types of injuries to the talus: a) fractures of the body of the talus are located posterior to the lateral process and involve both the ankle and subtalar joints; b) Type I – fractures of the neck of the talus without displacement; c) Type II – fractures of the neck of the talus with displacement and subluxation in the subtalar joint; d) Type III – fractures of the neck of the talus with dislocation of its body; e) subluxations and dislocations in the subtalar joint; f) complete dislocation of the talus

Fractures of the body of the talus were noted in 78 (42.9%) cases, without displacement - in 61 (33.5%), with displacement - in 17 (9.3%). Fractures of the neck of the talus of all three types – 54 (29.7%), I – 15 (8.2%), II – 26 (14.3%), III – 13 (7.1%). Dislocations and subluxations in the subtalar joint – 41 (22.5%). Complete dislocations of the talus – 9 (4.9%). Upon admission, patients with hindfoot injuries underwent radiographs of the ankle and foot in 2 standard views. To detail the damage, multislice computed tomography (MSCT) was performed. Indications for surgical treatment of injuries of the talus were: fractures of the body within the articular cartilage with a displacement of more than 2 mm, fractures of the neck of the talus with displacement, dislocations of the talus that could not be conservatively reduced and subtalar dislocations of the foot, open injuries. In case of isolated injuries, elimination of dislocations, reposition and fixation, including surgical fixation, were performed immediately until swelling and epidermal blisters appeared. Patients with PT were guided by the “Damage control” concept [12]. According to the recommendations of V.A. Sokolov, in the process of inpatient treatment of patients with PT, resuscitation and specialized clinical stages were distinguished [2]. In case of closed injuries and the absence of the possibility of surgical intervention, gross displacements were eliminated in full with immobilization with plaster, an external fixation device (AF) (Fig. 2) or temporary percutaneous fixation of the subtalar and ankle joints with K-wires (Fig. 3). Final osteosynthesis was carried out after stabilization of the condition and when the quality of the skin was satisfactory. In case of open injuries and extremely serious condition of patients after primary surgical treatment (PST), as a rule, temporary percutaneous fixation of the subtalar and ankle joints with K-wires was used, which provided the opportunity to perform further diagnostic and therapeutic procedures, and also reduced the severity of edema. Once the condition was stabilized, final osteosynthesis was also performed.

Figure 2.
Extrafocal osteosynthesis of an open fracture-dislocation of the talus with displacement of fragments

Figure 3.
Transarticular fixation with Kirschner wires of subtalar dislocation and dislocation in the Chopar joint

1. Fractures of the body of the talus.

There were 71 closed and 7 open fractures. Upon admission, all patients with closed fractures underwent plaster immobilization; in 57 patients it was the final method of treatment; 14 subsequently underwent osteosynthesis, of which 8 had open reduction and internal osteosynthesis with 3.5-mm cortical screws (Fig. 4). in 6 – closed reduction and transcutaneous minimally invasive osteosynthesis (MIO) with screws with a 4.0 mm channel (Fig. 5).

Figure 4. X-ray after open reduction of the talus body fracture and osteosynthesis with cortical screws with a diameter of 3.5 mm

Figure 5. Closed minimally invasive osteosynthesis of a fracture of the body of the talus using cannulated screws with a diameter of 4.0 mm with dorsal installation

All patients with open fractures underwent PSO with ANF osteosynthesis upon admission. In 3 patients this was the final method of treatment; in 4 patients, after the wound healed, open reduction was performed with osteosynthesis of the body of the talus with 3.5 mm cortical screws. 2. Fractures of the neck of the talus.

There were 47 closed and 7 open fractures.
All 15 type I talar neck fractures were closed. Upon admission, patients underwent plaster immobilization; in 9 patients it was the final method of treatment; in 6 patients, MIO of the talus was subsequently performed with 4.0-mm screws with a channel. There were 25 closed fractures of the neck of the talus type II, and 1 open. Upon admission, 15 patients with closed fractures underwent closed reduction with plaster immobilization, 6 underwent closed reduction with transarticular fixation with K-wires, and 4 underwent ANF osteosynthesis. Subsequently, at the profile-clinical stage, 15 patients with plaster immobilization underwent closed reduction and MIO with 4.0-mm screws with a channel. In 5 patients, after transarticular fixation, in 3 patients, after transosseous osteosynthesis, the ANF underwent open reduction with fixation with 3.5-mm cortical screws. In 2 patients, transarticular fixation and osteosynthesis of the ANF were the final treatment methods. On admission, a patient with an open fracture of the neck of the talus type II underwent PSO with ANF osteosynthesis. Based on wound healing, external fixation was changed to MIO with 4.0 mm channel screws. There were 9 closed type III fractures of the neck of the talus, 4 open ones. At the resuscitation stage, 3 patients with closed fractures underwent closed reduction of dislocations of the body of the talus with plaster immobilization, 4 patients underwent closed reduction with transarticular fixation with K-wires, and 2 patients underwent closed reduction. reduction with ANF osteosynthesis. At the profile clinical stage, 3 patients with plaster immobilization, 3 with transarticular fixation with K-wires, and 1 with ANF underwent open reduction and osteosynthesis with 3.5-mm cortical screws. In 2 patients, transarticular fixation with K-wires and ANF were the definitive treatment methods. Upon admission, all 4 patients with open fractures of the neck of the talus type III underwent PSO with reduction of the dislocated body of the talus and osteosynthesis of the ANF. Based on wound healing, external fixation of the ANF was changed to internal fixation with 3.5-mm cortical screws. 3. Subluxations or dislocations in the subtalar joint.
There were 36 closed injuries of this type, 5 open ones. For closed injuries, 5 patients underwent closed reduction of the dislocation with plaster immobilization, 27 patients underwent closed reduction with transarticular fixation with K-wires, and 4 patients underwent closed reduction with ANF osteosynthesis. Subsequently, at the profile-clinical stage, 4 patients with transarticular fixation and 2 patients with ANF underwent closed arthrodesis of the subtalar joint with 7.3-mm cannulated screws (Fig. 6). In 5 patients, plaster immobilization, in 23 – transarticular fixation with K-wires, in 2 – ANF were the final methods of treatment.

Figure 6. Radiographs of the foot after arthrodesis of the subtalar joint with osteosynthesis with cannulated screws with a diameter of 7.3 mm

For open injuries, transarticular fixation with K-wires was performed after PSO and reduction in 2 patients, and ANF osteosynthesis was performed in 3 patients. Subsequently, at the profile-clinical stage, in a patient with transarticular fixation, arthrodesis of the hindfoot joints was performed using a lockable Expert HAN nail (Switzerland) (Fig. 7), and in a patient with ANF, arthrodesis of the subtalar joint was performed with 7.3-mm screws with a channel. For 2 patients, ANF osteosynthesis was the final treatment method.

Figure 7. Radiographs of the foot after arthrodesis of the subtalar and ankle joints with a locking pin

4. Complete dislocation of the talus.

Closed complete dislocations of the talus were observed in 5 patients, open ones - in 4. In all patients with closed dislocations of the talus, upon admission, it was possible to close the prolapsed bone into place; after which, in 4 of them, transarticular fixation was performed with K-wires through the ankle and subtalar joints; in 1, ANF was used for fixation. These treatment methods were definitive. In case of open complete dislocations of the talus, 2 patients underwent PSO of open dislocation with reduction of the talus and transarticular fixation with K-wires; in 2 patients, PSO of open dislocation with reduction and osteosynthesis of the ANF was performed. At the profile-clinical stage, one patient with transarticular fixation underwent arthrodesis of the subtalar joints of the hindfoot using a lockable Expert HAN nail. For the rest, the osteosynthesis methods used upon admission became final. Thus, the final method of treatment was plaster immobilization in 71 cases, transarticular fixation with K-wires – in 30, osteosynthesis with 3.5 mm cortical screws after open reposition – in 31, MIO 4.0 mm screws with a channel – in 28, osteosynthesis of the ANF - in 12, arthrodesis of the subtalar joint with screws with a channel - in 8, arthrodesis of the hindfoot joints with locked Expert HAN nails - in 2. When studying the results, hospital mortality, the nature and number of complications, and the outcomes of the treatment were assessed. Long-term anatomical and functional results were monitored in 50 (38.6% of the primary cohort) patients with 51 injuries of the talus over a period of one to three years. To assess the results, the AO FAS [13] and Matthies-Luboschitz-Schwarzberg scales [14] were used. Data analysis began with the construction of a frequency polygon. When studying the statistical significance of differences, we used the calculation of the χ2 test with the Yates correction and the Bonferroni method for multiple comparisons. The critical level of significance of differences was taken to be less than 0.05 [15].

RESULTS AND DISCUSSION

Throughout the entire observation period, 117 (66.9%) patients with injuries to the talus, which were one of the components of PT, were delivered from Barnaul to the hospital, while during the same time period, isolated injuries to the talus were noted in 58 (33 ,1 %). Thus, injuries to the talus during PT occurred 2 times more often than isolated ones; the differences are statistically significant (p <

0.001). Table 1 shows the number of patients with isolated injuries of the talus and with PT, depending on the type of injury. All injuries to the talus under PT conditions occurred as a result of high-energy impacts - road accidents and catatraumas, while most of its isolated injuries were obtained as a result of low-energy impacts - household and sports injuries (Table 1).

Table 1.
Number of patients with isolated injuries of the talus and with PT depending on the type of injury

Table 2 shows the distribution of talar injuries according to Coltart's classification for isolated trauma and PT. Isolated injuries to the talus were represented in most cases by fractures of the body and neck of the talus without displacement, while the majority of injuries to the talus in PT were fractures of the body and neck with displacement, dislocations of the foot in the subtalar joint and complete dislocations of the foot (Table 2) .

Table 2.
Distribution of talus injuries according to Coltart's classification in isolated injuries and PT

Of 124 injuries to the talus during PT, open injuries were noted in 21 cases, while out of 58 cases of isolated injury - only in one, the differences are statistically significant (p <

0.01).
2 patients died, both with PT. The overall mortality rate for injuries to the talus was 1.1%, in patients with PT – 1.7%. In one deceased, the cause of death was edema and swelling of the brain due to an open craniocerebral injury, in another – acute massive blood loss, hemorrhagic shock due to blunt abdominal trauma with rupture of internal organs. Both deaths were not associated with damage to the talus. 51 somatic complications were noted in 34 (19.4%) patients. With isolated injuries of the talus, 5 complications were identified in 3 (1.7%) victims (deep vein thrombosis of the lower extremities in 3 cases, bronchopulmonary complications in 2 cases). In PT – 46 complications in 31 (17.7%) patients (in 19 cases – deep vein thrombosis of the lower extremities, in 15 – bronchopulmonary complications, in 9 – bedsores, in 2 – sepsis, in 1 – thromboembolism of the branches of the pulmonary artery ). In patients with PT, all somatic complications developed when the severity on the ISS scale was over 30 points, but their connection with the severity of injuries to the talus was not traced. The differences in the frequency of somatic complications in patients with isolated trauma of the talus and PT are statistically significant (p < 0.05). 22 local complications were noted in 20 (11.4%) patients: with closed injuries – 11 complications (6.9% of the total number of closed ones), with open ones – 11 (50% of the total number of open ones). Of the complications, 5 cases of instability in the ANF were noted, which led to secondary displacements, 5 suppuration of postoperative wounds, 5 ischemic necrosis of the wound skin edges, 6 soft tissue inflammations in the circumference of the transosseous elements of the ANF, 1 fracture of K-wires during transarticular fixation at the level of the joint space of the ankle joint The most common local complications were observed when using transosseous osteosynthesis of the ANF (10 cases), transarticular fixation of the ankle joint with K-wires (9 cases), open reduction and internal fixation with 3.5 mm cortical screws (2 cases), arthrodesis of the subtalar joint with screws with channel 7 .3 mm (1 case). There were no local complications with transcutaneous MIO using screws with a 4.0 mm channel. 1. Fractures of the body of the talus.
There were no complications with closed injuries; with open injuries, 4 local complications were noted: in 2 cases, inflammation in the wound area and in 2 cases, instability of transosseous elements.
All complications were observed during the treatment of ANF. The incidence of local complications in fractures of the body of the talus is 5.1%. 2. Fractures of the neck of the talus.
7 local complications were noted.
No complications were identified in type I neck fractures. In type II, 1 local complication was noted - instability of the transosseous elements of the ANF in a closed fracture. The frequency of local complications in type II is 3.8%. In type III - 6 local complications (for closed fractures - 5, for open fractures - 1). In closed fractures, local tissue inflammation in the area of ​​transosseous elements of the ANF - 1, inflammation in the wound after open reduction and osteosynthesis with 3.5 mm cortical screws - 2, ischemic necrosis of the wound edges during open reduction and transarticular fixation with K-wires - 2. In open in fractures, inflammation in the wound area after PSO and osteosynthesis with 3.5 mm cortical screws – 1. The frequency of local complications in type III is 46.1%. 3. Subluxations or dislocations in the subtalar joint.
8 local complications were noted (for closed injuries – 5, for open ones – 3).
In case of closed injuries, inflammation of the soft tissues around the transosseous elements of the ANF - 1, ischemic necrosis of the wound edges during transarticular fixation with K-wires - 1, instability of the transosseous elements of the ANF - 1, relaxation during transarticular fixation with K-wires - 1, fracture of the K-wires in conditions of transarticular fixation – 1. In case of open injuries, inflammation in the wound area under conditions of ANF osteosynthesis – 2, with arthrodesis of the subtalar joint with screws with a 7.3 mm channel – 1. The frequency of local complications with subluxations and dislocations in the subtalar joint – 19.5%. 4. Complete dislocations of the talus.
Three local complications were noted, all with open injuries. Inflammation in the area of ​​the postoperative wound during osteosynthesis of the ANF - 1, ischemic necrosis of the wound edges under conditions of transarticular fixation with K-wires - 1, inflammation in the area of ​​the transosseous elements of the ANF - 1. The frequency of local complications in complete dislocations of the talus is 33.3%. Thus, the highest frequency of local complications was observed in type III fractures of the neck of the talus (46.1%), complete dislocations of the talus (33.3%), and subtalar dislocations of the foot (19.5%). Long-term treatment results were studied in 50 (38.6% of the initial population) victims from 3 to 6 years after the injury. The assessment was carried out using the AO FAS [16] and Matthies-Luboschitz-Schwarzberg scales [17]. Table 3 shows clinical outcome data according to the AO FAS scale. There were no excellent results; good results were observed in victims with fractures of the body and neck of the talus of types I and II. For type III talar neck fractures, subluxations and dislocations in the subtalar joint, the treatment results are satisfactory. No unsatisfactory results were noted (Table 3).

Table 3.
Long-term results of treatment of injuries of the talus according to AO FAS

Table 4 shows clinical outcome data according to the Matthies-Luboschitz-Schwarzberg scale. Good results were observed in patients with fractures of the body and all types of fractures of the neck of the talus; satisfactory results prevailed in cases of subluxations and dislocations in the subtalar joint. No unsatisfactory results were noted (Table 4).

Table 4. Long-term results of treatment of injuries of the talus according to the Matthies-Luboschitz-Schwarzberg scale

Satisfactory results were due to the presence of pain syndrome in patients, partial disability, the presence of signs of the formation of avascular necrosis of the talus, degenerative arthrosis of the ankle and subtalar joints.

CONCLUSIONS:

1. Damage to the talus during PT occurs from high-energy impacts and occurs 2 times more often than isolated ones. The largest share among them is occupied by dislocations and displaced fractures, open injuries, characterized by a more severe nature of the course. 2. Somatic complications with injuries to the talus in patients with PT are an order of magnitude more common (17.7%) than with isolated injury (1.7%). 3. The most common local complications of injuries to the talus were observed with open fractures (up to 50%), fractures of the neck of the talus type III (46.1%), complete dislocations of the talus (33.3%), subtalar dislocations of the foot (19.5 %) obtained from high-energy impacts in patients with PT. 4. In cases of severe general condition of patients with PT, as a temporary measure, patients are shown transarticular fixation with K-wires of the ankle and subtalar joints, which, unlike a plaster cast, provides more rigid fixation, free access to the injured limb, is simpler and more quickly performed, than ANF fixation. 5. Despite the fact that the majority of local complications were noted when using ANF osteosynthesis, it is almost impossible to use any other method of definitive treatment due to the nature of soft tissue damage in patients with severe open injuries of the talus during PT. 6. The results of using transcutaneous minimally invasive osteosynthesis with 4.0-mm screws with a channel for fractures of the body and neck of the talus allow us to recommend the method for wider use in patients with PT.

Funding and conflict of interest information

The study had no sponsorship.

The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

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What is osteochondritis of the talus?

Osteochondral injuries of the talus, sometimes also called osteochondritis, osteochondritis dissecans, or osteochondral fractures, are injuries to the cartilage and underlying structures of the dome of the talus. Osteochondritis of the talus is one of the causes of pain in the ankle joint, with which the patient turns to an orthopedic traumatologist. Osteochondritis of the talus often goes unrecognized and can lead to serious consequences if left untreated. For example, osteochondral lesions of the talus occur in 40% of ankle fractures.

Symptomatic osteochondral lesions of the talus often require surgical intervention. These injuries usually result from one or more traumatic events, resulting in partial or complete avulsion of a section of cartilage from the underlying bone. Such defects cause deep pain in the ankle joint with axial load, limited range of motion, impaired walking function, stiffness, a feeling of jamming of the joint, and swelling. These symptoms can cause limitations in physical activity and disability.

Fractures of the foot bones

Fractures of the talus

The talus has features that distinguish it from the other bones of the foot.
Firstly, the pressure of the entire weight of the human body is transmitted to the foot through the talus. Secondly, the talus is the only bone of the foot to which no muscle is attached. Thirdly, the talus plays a significant role in the formation of the arches of the feet. Fractures of the talus are rare in traumatology (about 3% of the total number of fractures of the bones of the foot), belong to the group of severe injuries to the bones of the foot and are often combined with other injuries (fractures of the ankles, dislocations of the foot, fractures of other bones of the foot). There are fractures of the body, head, neck, lateral or posterior edge of the talus.

Fractures of the talus are most often the result of indirect trauma (twisting the foot, jumping, falling from a height). Less commonly, the cause of injury is compression of the foot or a direct blow from a heavy object.

Symptoms

The patient complains of sharp pain in the damaged area. The foot and ankle joint are swollen, hemorrhages are visible on the skin, mainly in the area of ​​the inner ankle. When fragments are displaced, deformation is revealed. Movement in the ankle joint is almost impossible due to pain.

Sharp pain is detected when palpated at the level of the joint space, and with neck fractures the pain is more pronounced in the front, and with fractures of the posterior process - along the posterior surface outward from the Achilles tendon.

To confirm a fracture of the talus, determine its location, and identify the nature and degree of displacement of the fragments, radiography is performed in 2 projections.

Treatment

In case of a displaced fracture, urgent reduction of the fragments is indicated. It should be taken into account that as the age of the injury increases, comparison of bone fragments becomes very difficult or even impossible. Failure of closed reduction is an indication for open reduction or skeletal traction.

For fractures of the posterior process, plaster is applied for 2-3 weeks, for other fractures of the talus - for 4-5 weeks. From 3-4 weeks, the patient is recommended to remove the injured leg from the splint and make active movements in the ankle joint.

Subsequently, exercise therapy, massage and physiotherapy are prescribed. Restoration of working capacity occurs after 2.5-3 months. For a year after the injury, patients are recommended to wear arch supports to prevent traumatic flat feet.

Scaphoid fractures

This type of foot fracture usually occurs as a result of direct trauma (a heavy object falling on the back of the foot). Less commonly, the cause of a scaphoid fracture is compression between the sphenoid bones and the head of the talus. Often, scaphoid fractures are combined with other fractures of the bones of the foot.

Symptoms

Support on the leg is limited due to pain. Swelling and hemorrhages are detected on the dorsum of the foot. Palpation of the navicular bone, rotation of the foot inward and outward, as well as abduction and adduction of the foot cause sharp pain in the area of ​​the fracture. To confirm a fracture of the scaphoid, an x-ray of the foot is performed in 2 projections.

Treatment

For fractures of the scaphoid without displacement of bone fragments, the traumatologist applies a circular plaster cast with carefully modeled arches of the foot. For displaced fractures, reduction is performed. If the fragments cannot be reduced or retained, open reduction is performed. Fixation with a plaster cast is carried out within 4-5 weeks.

Fractures of the cuboid and sphenoid bones

The injury is usually caused by a heavy object falling on the back of the foot. The soft tissues in the area of ​​injury are swollen. Pain is detected when palpating, pressing, or turning the foot inward and outward. To confirm this type of fracture of the foot bones, radiography is of great importance. Treatment is a circular plaster cast for a period of 4-5 weeks. For a year after such a fracture of the foot bones, the patient must wear an arch support.

History of the study of osteochondritis of the talus.

The term "osteochondritis dissecans" was first published by Konig in 1888, which described the formation of a loose body in the knee joint as a consequence of fracture of the articular cartilage and underlying bone.

In 1922 Kappis described this phenomenon in the ankle joint. In 1959, the code Berndt and Harty proposed a radiological classification of these lesions, and although it has changed significantly since then, it is still widely used. Currently, the community of orthopedic traumatologists uses the term osteochondral injury of the talus (abbreviated OPTK) as the most accurately reflecting the essence of the problem, which is rarely reduced to a single injury (fracture), avascular necrosis (osteochondritis dissecans) or permanent microtrauma, but includes a combination of all of the above factors.

Anatomical studies conducted using cadaver material showed that the main mechanism leading to osteochondral fractures of the outer part of the dome of the talus is its forced inversion. Indication of injury occurs in approximately 85% of cases of OTC (Osteochondral Injury of the Talus), but in 15% of cases patients cannot associate the onset of pain with a traumatic event. Most often this occurs in cases where the source of damage is located on the posterior - inner surface of the talus. There are also cases of bilateral damage and identical damage observed in families or in identical twins, which indicates a possible genetic predisposition to avascular necrosis in some patients.

Treatment strategies for OPTK have undergone significant changes over the past 10 years. Conservative treatment for minor injuries includes functional offloading or plaster immobilization. Surgical treatment is intended for more serious injuries and includes excision, excision and curettage, excision + curettage + microfracture or reaming, installation of an auto- or allograft, antegrade and retrograde reaming, fixation of the fragment using bioabsorbable screws, autologous implantation of chondrocytes and some others. Below we will compare their effectiveness.

The goal of treatment for osteochondral lesions in all cases is to reduce pain, swelling, increase range of motion, and restore function. In many cases, several of the above techniques may be used, depending on the surgeon's preference.

Osteochondral injuries of the talus are a rare disease, but they are much more common in patients with a history of ankle fractures or ankle instability.

Classification by stages

Signs of avascular necrosis of the ankle joint help determine the extent of the damage. More accurate information is provided by an x-ray, from which a specialist accurately determines the phase of the disease.

• I – initial subarachnoid compression affects 10% of the bone tissue. The disease does not limit movement; it periodically makes itself felt after exercise.
• II - partial fragmentation of a separate area, the appearance of severe pain, cracks.
• III - bone damage by 40-50%.
• IV - total destruction and necrosis of cells with cartilage separation, destructive changes in the tibia. Fragmentation leads to loss of functionality of the legs. A patient with necrosis of the talus cannot do without surgery.

Technology for the treatment of aseptic necrosis of the talus in Stoparthrosis If you have similar problems, contact the clinic. We employ traumatologists, orthopedists, and physiotherapists with 15-20 years of experience, specializing in the treatment of joint diseases. On the day of treatment, doctors relieve symptoms and provide first aid.

Pathophysiology of osteochondral injuries of the talus.

Anterior-external OPTCs are a consequence of inversion and dorsiflexion of the foot, they are characterized by a large area and are rarely deep. This is most likely due to the longitudinal direction of the injury force vector.

OPTK along the posterior-medial surface, on the contrary, are more often deep, cup-shaped, or accompanied by the formation of a cyst with a cap of cartilage on top. Apparently this is due to the vertical concentrated direction of the trauma force vector.

Thus, it becomes clear that osteochondral injuries of the talus are often combined with instability of the ankle joint, damage to the ligamentous apparatus of the ankle joint, and ankle fractures.

Anatomical studies have shown that the cartilage of the talus is 18-35% softer than the cartilage of the corresponding areas of the tibia. The thickness of the cartilage is inversely proportional to the load it experiences, which can also affect the location of the damage zone.

As studies have shown, the distribution of load in the ankle joint is disrupted when the defect size is more than 7.5\15 mm, which can be used to predict delayed results.

Causes and symptoms

The pathology is provoked by: lupus erythematosus, arthritis, Gaucher disease, anemia, diabetes mellitus. Also leading to aseptic necrosis:

• embolism;
• thrombosis;
• use of vasoactive drugs;
• problems with lipid metabolism;
• intraosseous pressure;
• load on the tibia, sharp flexion of the soles, affecting the great vessels.;

Symptoms of necrosis due to the similarity of pain symptoms, the disease is often mistaken for arthrosis. The difference lies in the rapid progression of subjective signs and the age of the patients. Damage to the ankle joints occurs more often in active people 20-45 years old. The main symptoms of post-traumatic aseptic necrosis of the left talus:

• increasing pain in the ankle;
• limitation of motor function;
• the appearance of swelling and lameness.

With progressive symptoms, medical attention is necessary, otherwise the disease will lead to disability.

Classification of osteochondral injuries of the talus.

Radiological classification of osteochondral lesions of the talus by Berndt and Harty

CT classification of osteochondral lesions of the talus Ferkel and Sgaglione

MRI classification of osteochondral lesions of the talus Hepple.

Surgical treatment of osteochondral injuries of the talus.

Surgical treatment of OPTC depends on many factors: patient characteristics such as age, activity level, comorbidities, characteristics of the lesion itself such as its location, size, depth of the lesion, lesion morphology, duration. Basically, surgical treatment is based on one of three principles: 1) removal of the loose body with or without bone marrow stimulation through microfracture, reaming 2) preservation of cartilage through retrograde reaming, fixation of the fragment or replacement of the defect with cancellous bone 3) stimulation of the formation of new hyaline cartilage by due to osteochondral block transplantation, mosaic chondroplasty, allograft.

Open surgery for osteochondral injuries of the talus.

When accessing the anterior-outer part of the ankle joint, it is necessary to remember the branches of the superficial peroneal nerve located in this area.

To access the posteromedial sections, it will be necessary to perform an osteotomy of the medial malleolus, while it is necessary to exclude damage to the tibial plateau, which bears the main axial load. Before performing an osteotomy, it is necessary to pre-drill for subsequent installation of screws fixing the osteotomized fragment.

Injury to the anterior and posterior tibial tendons, flexor pollicis longus tendon, great saphenous vein, posterior tibial artery and nerve should also be avoided. An alternative is to use two approaches at once - anteromedial and posteromedial, which allow visualization of up to 80% of the dome of the talus and avoid osteotomy of the medial malleolus.

Currently, ankle arthroscopy has become widespread. Arthroscopic approaches are much less traumatic, which avoids the formation of rough postoperative scars and greatly facilitates rehabilitation. 2.7 mm arthroscopes allow visualization of the entire dome of the talus.

Removal, curettage and bone marrow stimulation.

After debridement, several channels are produced that communicate the defect with the bone marrow. This procedure can be performed using reaming or microfracturing. The purpose of the manipulation is to destroy the barrier of sclerotic subchondral bone that prevents the migration of stem cells from the bone marrow. As a result, a clot is formed, saturated with growth factors and stem cells, which is subsequently rebuilt into hyaline-like cartilage tissue. Most often used for stages 3-4 of the disease. The size of the defect should not exceed 1.5 cm. In clinical studies, the effectiveness of the method was estimated from 46 to 100% (on average 85%).

Osteochondral transplantation.

For osteochondral transplantation, cartilage tissue from the ipsilateral knee joint is most often used. Indications for transplantation are large and deep defects, often with the formation of a cyst, as well as the lack of effect from the surgical treatment methods proposed above. The possibility of using the calcaneal bone site at the Achilles-calcaneal joint as a source of tissue for osteochondral transplantation is currently being studied, with good early results.

The objective of the method is to restore the structural and biomechanical characteristics of damaged hyaline cartilage. This method is characterized by a long and difficult rehabilitation period. Morbidity of the donor site (pain in the knee joint after removal of columns of osteochondral blocks) is observed in 12% of cases. The technique itself is technically complex and time-consuming.

In clinical studies, the effectiveness of the method was estimated from 74 to 100% (average 87%).

A set of exercises to develop muscles after a leg fracture

You should regularly perform exercises that will help your muscles quickly gain tone and restore normal balance when walking. It is recommended that you first seek the help of a doctor or exercise therapy instructor, who will monitor the correct execution and explain in detail how to develop an ankle after a fracture.

With a ball

The patient presses a special ball, a physioball, against the wall with his lower back. The feet and torso are pushed forward. You should squat smoothly so that the ball does not fall. The knees should bend until a right angle is formed (90°).

On the platform

Standing on an unstable surface, the healthy leg should be slightly bent at the knee. First you just need to learn how to balance and keep your balance. After mastering it, you can take the ball and, without losing a stable position, throw it at the wall and catch it. Exercise activates stabilizer muscles and restores balance.

Jumping

You need to jump on each leg alternately along the line marked on the floor. With each jump you need to land on different sides. The hip muscles are strengthened, balance and coordination of movements are trained. By how easily this can be done, one can assess the degree of development of the joint after an ankle fracture.

On a roller

Alternately stand with your foot on the bolster, and with the other foot you need to perform moderate swings back and to the side. For stability, the leg standing on the roller must be slightly bent, while keeping it straight. You can use a loop of elastic tape attached to the bottom of the wall. It is put on the leg that swings.

You can simply stand on your leg while maintaining your balance using the elastic loop on your other leg. Legs must be alternated.

If you follow the doctor’s advice and your own desire and perseverance, joint mobility is completely restored in a fairly short time.

Retrograde reaming.

This method will require the use of x-ray control and knowledge of the exact topography of the defect location. Retrograde reaming is the method of choice in the presence of a large subchondral cyst and with intact articular cartilage, as well as in cases of deep defect location, when it is difficult to reach it using the arthroscopic method. For medial defects, the entry point of the wire becomes the tarsal sinus. In clinical studies, the effectiveness of the method was estimated from 81 to 100% (average 88%).

Fixation.

Fixation of the fragment is performed only in cases of fresh extensive damage. The torn osteochondral fragment is lifted, the underlying bed is subjected to microfracture or reaming, and then the fragment is fixed using submersible absorbable screws or fibrin glue. The method is technically complex and its indications are quite narrow, but when it was used according to indications, a good result was observed in 89% of cases.

Thus, the most effective and technically simple method of treating the vast majority of osteochondral injuries of the talus at the moment is removal, curettage and bone marrow stimulation. Depending on the equipment of the operating room and the skills of the operating surgeon, this intervention can be performed either openly or arthroscopically.

Rehabilitation after surgery for osteochondral injuries of the talus.

Most authors adhere to the standard rehabilitation protocol, which recommends 6 weeks of immobilization after surgery using bone marrow stimulation. However, recently, work has appeared indicating that a 2-week period of immobilization is more than enough for small and medium-sized defects. Rehabilitation consists of training active and passive range of motion, muscle strength and muscle balance of the lower leg, reducing swelling and proprioceptive training.

Pain, a sensation of wedging, and swelling often persist for up to 1 year after surgery. After 6 months, it is advisable to perform an MRI control to assess the dynamics; in the presence of severe bone marrow edema, the prognosis is unfavorable. In such cases, progression of the lesion may further lead to the need for arthrodesis or ankle replacement.

How to develop an ankle after a fracture (physical therapy)

It is also impossible to do without therapeutic physical training - when an injured person lies for a long time and does not move, his muscles gradually atrophy, worse if the so-called pseudojoint. There is one “golden rule”, it is true for any physical injury: the patient must remain motionless for two weeks! Then you need to start moving slowly with the help of crutches or a walker.

At first, the patient will have to endure some pain while performing simple exercises - this is normal. The main thing is that a person does not try to immediately develop a joint, but strictly follows an individual schedule under the supervision of a medical professional, otherwise you may encounter complications!

If the injured person experiences acute pain while performing a specific exercise, then he is prescribed a long rest or the patient moves on to a less complex and painful exercise. Yes, everything needs to be done gradually and without sudden movements. Next, the doctor prescribes a set of exercises using special balls, expanders and simulators for the ankle joint.