Does a Medial Malleolar Osteotomy or Posteromedial Approach Provide Greater Surgical Visualization for the Treatment of Talar Body Fractures?

Abstract

Background: Surgical management of talar body fractures is influenced by soft-tissue condition and fracture pattern.Two common surgical approaches for the treatment of talar body fractures are the medial malleolar osteotomy (MMO) and the posteromedial approach (PMA). The purpose of this study was to compare the observable talar body surface area with the MMO and the PMA. We hypothesized that visualization following a PMA improves with distraction and distraction with a gastrocnemius recession.Methods: Five pairs of cadaver limbs were used. Each pair of specimens underwent both approaches to act as an internal control. The laterality of the PMA was determined by randomization, and the MMO was performed on the contralateral ankle. The PMA was performed to visualize the talus, and the talar surface area was recorded using a handheld 3D surface scanner. A distractor was then placed across the joint, and the surface area was remeasured. Finally, a gastrocnemius recession was performed, and the measured surface area under the distraction was recorded. The MMO was performed in standard fashion using fluoroscopy, and the observable talar surface area was recorded. Scans were performed twice for each approach, and the surface areas were averaged. The talus was excised and scanned after each approach in order to compare the visualized surface area with the total surface area of the native talus. Results:The MMO and the PMA exposed a mean of 11.2 and 6.7 cm 2 , respectively, of the talar surface. Visualization with the PMA was improved with distraction, revealing 8.3 cm 2 of the talus (p = 0.01 when compared with an isolated PMA). A PMA with distraction and gastrocnemius recession exposed 9.9 cm 2 of the talar dome and body. There was no significant difference in exposure between the MMO and the PMA with distraction and gastrocnemius recession (p = 0.32). Conclusions:The MMO and the PMA both afford excellent visualization for reduction and fixation of talar body fractures.Visualization using the PMA is improved with distraction and distraction with a gastrocnemius recession. The results of this study may assist surgeons in selecting the optimal approach for surgical repair of talar body fractures.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G742).

Dual Approach to Talar Dome Increases Access for Fracture Care Without Osteotomy

“…17,23,33 However, osteotomies have traditionally provided excellent access to the joint, with medial malleolar osteotomy reported to provide visualization to “nearly all” the talar dome surface in one study, and fibular-based osteotomy options reported to give perpendicular access to up to 95% of talar DSA. 4,9,18,21 Given this, a soft tissue option that provides comparable access is a desirable alternative. It should be noted that this amount of exposure would likely be limited in utility to extensive, complex fractures that require nearly full access to the talar dome articular surface given the need to reposition to achieve full visualization.…”

“…Most existing literature is in the setting of osteochondral lesions and promotes the use of osteotomies for access, which have well-documented complications and may increase overall morbidity in the setting of trauma. 1,2,4,[11][12][13]15,16,18,20,30,34 Previously described soft tissue-only exposures have been generally characterized as providing limited visualization, and few studies have focused on functional access in the orthopaedic trauma setting. 28 DeKeyser et al 6,7 described a modified posteromedial approach (mPM) to access the posterior talus for fracture care using the interval between the flexor hallucis longus and the medial border of the Achilles tendon.…”

“…Most existing literature is in the setting of osteochondral lesions and promotes the use of osteotomies for access, which have well-documented complications and may increase overall morbidity in the setting of trauma. 1,2,4,11-13,15,16,18,20,30,34…”

Three‐dimensional Mapping Analysis of Talus Fractures and Demonstration of Different Surgical Approaches for Talus Fractures

“…Subsequently, we collected data from previous literature to ascertain the size of the surface area regions (Table 1 ). 13 , 14 , 15 , 16 Finally, we utilized 3‐matic software (13.0, Materialise, Leuven, Belgium) on the standardized model to demonstrate the different surgical approaches by combining the determined boundary positions and sizes. In short, we utilized 3‐matic to mark the surgical approach's exposure boundary on a standard talus model base on ligament boundary data.…”

“…For the boundary of the ligament attached to the talus (Table 3), the results were as follows: A: 10.12 AE 1.37 mm; B: 1). [13][14][15][16] The virtual areas for the different surgical approaches, created for clinical reference, are depicted in Figure 6. These illustrations can help surgeons quickly identify the generally available surface area when using different surgical approaches and provide a reference for developing surgical plans.…”