Published online: 09.01.
2020
Original Article
Surgical Treatment of Talar Neck and Body Fractures:
Mid-Term Results of 24 Cases
Operative Versorgung von zentralen Talusfrakturen: Behandlungs-
ergebnisse von 24 Fällen im mittel- bis langfristigen Verlauf
Authors
Dominik von Winning 1, Daniela Adolf 2, Wiebke Schirrmeister 1, Stefan Piatek 1
Affiliations
1 Department for Trauma Surgery, Otto-von-Guericke
University, Magdeburg Medical Faculty
2 Company for Clinical and Healthcare Research mbH,
StatConsult, Magdeburg
Key words
talus, fracture, talar body, talar neck, internal fixation
Schlüsselwörter
Talus, Fraktur, Taluskörper, Talushals, Osteosynthese
Bibliography
DOI https://doi.org/10.1055/a-1023-4715
published online | Z Orthop Unfall © Georg Thieme Verlag KG
Stuttgart · New York | ISSN 1864‑6697
Correspondence
Dominik von Winning
Department for Trauma Surgery, Otto-von-Guericke
University, Magdeburg Medical Faculty
Leipziger Straße 44, 39120 Magdeburg
Phone: 03 91/67 21-4 87, Fax: 03 91/6 71 56 37
dominikvonwinning@web.de
AB STR AC T
Background Talar neck and body fractures are rare. Major
posttraumatic complications with a potential reduction in
the quality of life are arthrosis and necrosis due to the specific
vascular supply. The aim of the study was to evaluate mid-
term results of surgery for talar fractures of neck and body.
Parameters that potentially affected/influenced treatment
outcomes were analysed exploratively.
Methods 24 patients with 24 talar neck and body fractures
(Marti type II n = 9, type III n = 12, type IV n = 3) were retro-
spectively examined for radiological and clinical functional
outcomes. The independent parameters evaluated included
age (< 40, ≥ 40 years), sex (male, female), general overall ex-
tent of injury (polytrauma/multiple injuries/multiple fractures
of the extremities, additional injuries to the same foot, iso-
lated talus fracture), soft tissue damage (open, closed), surgi-
cal latency (< 6, ≥ 6 h), fracture classification/displacement
von Winning D et al. Surgical Treatment of … Z Orthop Unfall
(undisplaced [= Marti II], displaced [= Marti III, IV]) and frac-
ture type (talar body, neck fracture). The potential influencing
parameters were analysed by univariate analyses.
Results With an average follow-up of 8.7 years (1,25–16
years) the AOFAS score was 71.4 ± 22.9 points, the Foot Func-
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tion Index score 35.9 ± 28.3 points; the physical and mental
component summary scores of the Short Form 36, version 2,
was 43.8 ± 10.9 and 47.4 ± 13.6 points (mean ± standard de-
viation), respectively. Thus, the patient reported physical
health of the patients was slightly reduced compared to the
German population, while the mental health remained largely
unaffected. Two patients developed partial avascular necrosis
(8 %), 10 patients developed osteoarthritis (42 %). Of the inde-
pendent parameters, only the general overall extent of injury
showed a significant influence on osteoarthritis (p = 0.002). In
the evaluation of undisplaced (n = 9) and displaced (n = 15)
fractures, surgical treatment after more than 6 hours did not
result in a worse outcome.
Conclusion The clinical outcome of internal fixation of talar
neck and body fractures can be classified as good. In the study
group, there was no correlation between the occurrence of ar-
throsis and the Marti fracture classification.
ZU SAM ME N FA SS UN G
Einleitung Zentrale Talusfrakturen (Hals- und Körperfraktu-
ren) sind selten. Als wesentliche posttraumatische Komplika-
tionen mit potenzieller Minderung der Lebensqualität gelten
die Arthrose sowie die Nekrose aufgrund der besonderen Ge-
fäßversorgung. Studienziel war die Evaluation mittelfristiger
Ergebnisse nach osteosynthetischer Versorgung einschließ-
lich explorativer Analyse potenzieller Einflussparameter auf
die Behandlungsergebnisse.
Material und Methodik 24 Patienten mit 24 operierten
zentralen Talusfrakturen (Typ II nach Marti n = 9, Typ III n = 12,
Typ IV n = 3) wurden retrospektiv radiologisch und klinisch
nachuntersucht. Betrachtet wurden die Einflussgrößen Le-
bensalter (< 40, ≥ 40 Jahre), Geschlecht (männlich, weiblich),
allgemeines Gesamtverletzungsausmaß (Polytrauma/Mehr-
fachverletzung/multiple Extremitätenfrakturen, weitere Ver-
letzungen am gleichen Fuß, isolierte Talusfraktur), Weichteil-
schaden (offen, geschlossen), OP-Latenz (< 6, ≥ 6 h) sowie
Frakturklassifikation/Dislokation (undisloziert [= Marti II], dis-
 Original Article
loziert [= Marti III, IV]) und die Frakturlokalisation (Körper-,
Halsfraktur). Die potenziellen Einflussgrößen wurden mittels
univariater Analysen untersucht.
Ergebnisse Das mittlere Follow-up lag bei 8,7 Jahren (1,25–
16 Jahre). Im Studienkollektiv betrug der AOFAS 71,4 ± 22,9
Punkte, der Fuß-Funktions-Index 35,9 ± 28,3 Punkte; die kör-
perliche Summenskala und psychische Summenskala des
Short Form-36 Version 2 lag bei 43,8 ± 10,9 und 47,4 ± 13,6
Punkten (Mittelwert ± Standardabweichung). Somit bewerte-
ten die Patienten ihre körperliche Gesundheit etwas schlech-
ter als der deutsche Durchschnitt, die psychische Komponen-
te dagegen blieb weitestgehend unbeeinträchtigt. Zwei Pa-
Introduction
Fractures of the talus constitute 0.3 % of all fractures [1]. Even
some experienced surgeons have mastered only a few open re-
ductions and internal fixations of this fractures.
Blood supply after a fracture is a critical aspect, especially with
fractures of the talar neck. Sixty percent of the talus is covered by
cartilage [2, 3] The tarsal canal and sinus tarsi arteries enter be-
tween the joints at the talar neck and supply the talar body from
distal to proximal [3]. Aseptic bone necrosis, osteoarthritis of ad-
jacent joints, non-unions and malalignments are potential com-
plications and carry the subsequent risk of a poor functional out-
come and a reduction in the quality of life.
Undisplaced fractures of the talar neck and body (Hawkins I,
Marti II) can be treated non-operatively [2]. Given the advantages
of early functional treatment, however, they are considered a rel-
ative indication for surgery [4]. Displaced fractures of the neck or
body, on the other hand, represent absolute indications for sur-
gery [5].
The treatment results of 24 patients after open reduction and
internal fixation (ORIF) of talar fractures were evaluated retro-
spectively over the medium to long-term course. Focus was di-
rected towards the following questions: What are the osteoarthri-
tis and necrosis rates over the medium to long term? What are the
functional outcomes and how is health-related quality of life?
Which parameters influence the treatment result?
Materials and Methods
Opinion of the Ethics Committee
The study was approved by our university ethics committee
(No. 97/16) and by the Federal Office for Radiation Protection
(No. Z 5-22462/2-2016-123).
Patients
Forty-six patients with talar fractures who were operated from
01.01.2000 to 31.12.2015 in a national trauma centre were eval-
uated retrospectively. Forty-six patients were written to, of which
27 (59 %) attended the follow-up examination. Two patients with
multiple fractures (1× talar neck and head, 1× talar neck and later-
al talar process) and one patient who had undergone primary fu-
tienten entwickelten eine partielle Nekrose (8 %), 10 Patienten
eine Arthrose (42 %). Von den Einflussgrößen zeigte einzig das
allgemeine Gesamtverletzungsausmaß einen signifikanten
Einfluss auf die Arthrose (p = 0,002). In der Gesamtauswer-
tung undislozierter (n = 9) und dislozierter (n = 15) Frakturen
ergab die operative Versorgung nach über 6 h kein signifikant
schlechteres Outcome.
Schlussfolgerung Die klinischen Ergebnisse nach osteosyn-
thetischer Versorgung sind gut. In unserem Studienkollektiv
ergab sich keine signifikante Korrelation zwischen dem Auf-
treten einer Arthrose und der Frakturklassifikation nach Marti.
sion of the subtalar joint were excluded from any further investi-
gation. Of the remaining 19 patients, one had died, two were un-
able to participate due to other illnesses, seven were of unknown
address and nine were not interested in participating.
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Classification and surgery
The Marti classification was used for all the fractures and the Haw-
kins classification as modified by Canale for fractures of the talar
neck [6 – 8]. A fracture gap ≥ 2 mm was classified as displaced [9].
Closed soft-tissue injury was rated as described by Tscherne-Oes-
tern and open soft-tissue injury according to Gustilo-Anderson
[10, 11]. A distinction was made between three groups with re-
gard to total extent of injury:
1. Patients with polytrauma or multiple injuries and/or multiple
limb fractures,
2. patients with a talar fracture and additional concomitant inju-
ries to the same foot, including complex foot trauma, and
3. patients with an isolated talar fracture.
Complex foot trauma was rated using Zwippʼs criteria [12]. The
time of injury and of surgery were established from patient notes,
and the time window to fracture fixation was categorised into
< 6 hours and ≥ 6 hours, with the point in time selected being that
of ORIF.
Seven of the eight fractures of the talar neck underwent prima-
ry open reduction and internal fixation (▶ Fig. 1). Cancellous
(n = 6) and cortical screws (n = 1) of 3.5 to 4.0 mm diameter were
used for lag screw fracture fixation. One patient with a non-dis-
placed fracture of the talar neck and complex foot trauma (frac-
tures of the talar neck, the sustentaculum tali and cuboid bone,
fractures of the base of the third and fourth metatarsals, fractures
of the second to fifth metatarsal heads, second-degree closed
soft-tissue injury with imminent compartment syndrome) initially
underwent fasciotomy and plaster-cast immobilisation, followed
after seven days by ORIF with two cancellous screws (6.5 mm di-
ameter). An anteromedial approach was used in each case for ac-
cess (n = 8), supplemented in two cases by additional skin inci-
sions (anterolateral, posteromedial).
Fourteen talar body fractures received initial definitive treat-
ment. Cancellous (n = 12) and cortical screws (n = 1) and a com-
bination of cancellous and cortical screws (n = 1) (2.0 to 4.0 mm
diameter) were used (▶ Fig. 2). In one patient with a Marti III frac-
von Winning D et al. Surgical Treatment of … Z Orthop Unfall
 ▶ Fig. 1 23-year-old male with an isolated Hawkins II fracture of the talar neck secondary to a sprain injury sustained while playing recreational
sport: Preoperative plain radiograph (a), plain radiograph on the first day after surgery (b), plain radiograph at follow-up seven months after
ORIF (c).

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▶ Fig. 2 37-year-old male with an isolated Marti III fracture of the talar body secondary to jumping off a horse (approx. 1.7 m): Preoperative CT scan
(a), plain radiograph at the time of follow-up examination 137 months after ORIF (b).

ture, ORIF with cancellous screws was supplemented with tempo-
rary K-wire transfixation of the talonavicular joint for ten weeks.
Another patient with a Marti III fracture was treated with a joint-
bridging external fixator in addition to ORIF. After initial reduc-
tion, one patient with a Marti III fracture and one patient with a
Marti IV fracture underwent K-wire fixation of the talus and K-wire
transfixation of the talonavicular joint, followed by plaster-cast
immobilisation. This was followed in both cases by ORIF using can-
cellous screws (each with a diameter of 4.0 mm) after 11 and 56
days, respectively, as definitive treatment with deferred urgency.
In general, anteromedial (n = 8), anterolateral (n = 3), posterome-
dial (n = 3), posterolateral (n = 1) approaches were used, and in
one case access was determined by the open fracture (n = 1). In
three cases medial malleolus osteotomy and in one case fibular
osteotomy were necessary.
After screw fixation, in each case postoperative treatment in-
volved immobilisation with a lower leg plaster cast or a short
walker without weight-bearing for 6–12 weeks plus early func-
tional treatment.
Clinical and radiological follow-up
The postoperative course was evaluated using patient notes. Fol-
low-up examinations included functional outcome (Foot Function
Index (FFI) [13], Ankle-Hindfoot Scale of the American Orthopae-
dic Foot and Ankle Society (AOFAS) [14]), health-related quality of
life (SF36v2) [15] and radiological outcome (malunion, non-
union, osteoarthritis, aseptic necrosis). The results of the AOFAS
were classified according to the criteria “excellent” (90–100
points), “good” (80–89 points), “moderate” (70–79 points) and
“poor” (69 or less points) [16]. Calculation of the scores of the
SF36v2 was carried out using the Outcomes™ Scoring Software
5.0 (QualityMetric Inc., Lincoln, RI, USA). The licence to use
SF36v2 was granted by OPTUM™ (Eden Prairie, Minnesota, USA,
QM040308). The radiological examination included lateral and
antero-posterior (AP) views of the ankle in 20° internal rotation
(Mortise view). Osteoarthritis was classified as described by Bar-
gon [17]. Grades I–III were classified as posttraumatic osteoarthri-
tis because grade 0 can also be present independent of any trau-
ma and is not necessarily regarded as posttraumatic osteoarthritis
[9]. Non-union was defined as the absence of bony healing after
six months [9]. The criteria of Ficat und Arlet, modified for the ta-
lus by Mont, were used to assess radiological evidence of avascu-

von Winning D et al. Surgical Treatment of … Z Orthop Unfall

 Original Article

▶ Table 1 Demographic data of our study population.

Talar neck fractures Talar body fractures Total

Number of fractures (n)  8 16 24
Average age (range) (years) 42 [21–76] 35 [17–74] 37 [17–76]
Sex (n) male  6 11 17
female  2  5  7
Injured side (n) right  3  8 11
left  5  8 13
Causes of injury (n) car accident  2  6  8
motor bike accident  2  1  3
fall > 1 m height  3  6  9
isolated sprain  1  3  4
Medical insurance employersʼ liability insurance association  2  5  7
provider (n) health insurance fund  6 11 17
Extent of injury (n) isolated talar fracture  2  5  7
talar fracture + further foot injury  1  3  4

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talar fracture + multiple injuries/  3  4  7
patient with polytrauma*  2  4  6
Complex foot trauma as described by Zwipp (n)  1  1  2
Soft-tissue damage open**  0  2  2
(n) closed  8 14 22

* Injury Severity Score (19–34 points), ** Grade II and Grade IIIA

lar talar necrosis [18, 19]. Stages II to IV were classified as radio-

logically confirmed necrosis. A further distinction was made be-
tween partial (< 1⁄3) and complete necrosis.
Statistical analysis
Statistical analysis was conducted using SAS9.4 software (SAS
Institute Inc., Cary, NY, USA). Target parameters were radiologi-
cally recognisable parameters (malunion, non-union, osteoarthri-
tis and aseptic necrosis) as well as AOFAS, FFI and SF36v2 (physical
and mental health summary scale). Age (< 40, ≥ 40 years), sex
(male, female), general overall extent of injury (talar fracture and
polytrauma or patient with multiple injuries or multiple limb frac-
tures, talar fracture and other injuries to the same foot [incl. com-
plex foot trauma], isolated talar fracture), soft-tissue damage
(open, closed), surgical latency (< 6 hours, ≥ 6 hours), fracture
classification/displacement [undisplaced (= Marti II), displaced
(= Marti III, IV)] and fracture type (talar body, neck fracture) were
used as independent parameters. Unadjusted analysis was per-
formed to assess correlations between individual independent
variables and the target parameters. Fisherʼs exact test was used
for categorial target values. The robust t-test (Satterthwaite) or
an ANOVA (analysis of variance) was performed for continuous
target variables and independent factors with two or more cate-
gories. Correlation of the results was examined using Pearson cor-
relation coefficients. Since it was possible to perform unadjusted
analysis for four functional target variables, a Bonferroni correc-
tion (factor 4) in the form of multiple testing was implemented
directly. Thus, every p-value p ≤ 0.05 was a significant result.
Results
Predominantly males between the ages of 20 and 50 years (13 of
17) and females of young (19–22 years, n = 4) or advanced age
(51–76 years, n = 3) sustained talar fractures (▶ Table 1 and 2).
Altogether, nine fractures (37 %) were undisplaced and 15 frac-
tures (63 %) displaced. All nine patients with undisplaced fractures
(Marti II) did not undergo ORIF until only after six hours. Five of
the 15 patients (33 %) with displaced fractures (Marti III–IV) re-
ceived definitive treatment by ORIF within six hours. Ten patients
(67 %) were treated by definitive ORIF after more than six hours
(range: 10.5 hours – 56 days).
One third of patients were initially diagnosed elsewhere and
then transferred to us for surgical treatment. Closed reduction
and immobilisation in a plaster cast were performed in a total
of four patients to prevent soft-tissue pressure damage, with
two cases undergoing additional K-wire transfixation. The one
case which underwent ORIF after 56 days was a patient with
polytrauma (ISS = 34). After life-preserving measures, splenec-
tomy was performed during the initial phase, together with
placement of a pelvic C-clamp and packing of a haemodynami-
cally unstable pelvic fracture plus placement of an external fixator
for an open fracture of the tibia. Furthermore, closed reduction of
the Marti IV fracture of the talar body was performed, together
with K-wire retention and plaster-cast immobilisation. Given the
overall severity of the sustained injuries, treatment on the inten-
sive care unit was necessary for just under five weeks, during
which time definitive fracture treatment of pelvis and tibia was

von Winning D et al. Surgical Treatment of … Z Orthop Unfall

 ▶ Table 2 Prevalence of all talar fractures (n = 24) using the Marti classification and, additionally, of fractures of the talar neck (n = 8) using Hawkins
classification.

Type Marti n Hawkins n

I Fractures of the “distal” neck, including talar head and talar – Undisplaced talar neck fracture 3
process fractures
II Undisplaced “proximal” talar neck or talar body fractures  9 Talar neck fracture with dislocation of the subtalar joint 5
III Displaced proximal talar neck or body fractures 12 Talar neck fracture with dislocation of the subtalar and –
tibiotalar joints
IV Proximal talar neck or body fractures with dislocation of the  3 Talar neck fracture with dislocation of the subtalar, –
body out of the mortise, comminuted fractures tibiotalar and talonavicular joints
Total 24 8

▶ Table 3 Grade of osteoarthritis according to fracture classifica- ▶ Table 4 Results of the AOFAS Ankle-Hindfoot Scale as described by
tion and site. Schuh et al. [16] for the talar neck group (n = 8) and talar body group
(n = 16).

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Fracture Osteoarthritis grade (as described by Bargon)
classification I II III AOFAS categories Points Talar body Talar neck

Hawkins type I STJ TNJ Excellent 90 to 100 4 2

Hawkins type I STJ+TNJ Good 80 to 89 3 1

Hawkins type II TNJ Moderate 70 to 79 2 1

Hawkins type II STJ Poor 69 or less 7 4

Marti type II TNJ STJ

Marti type III AJ
Marti type III AJ+STJ+TNJ
Marti type III AJ+TNJ
Marti type IV STJ
Marti type IV TNJ
AJ = ankle joint; STJ = subtalar joint; TNJ = talonavicular joint
undertaken. After transfer back to the regular ward, definitive OR-
IF of the Marti IV fracture was completed.
Hardware removal was performed in seven talar body and
three neck fractures (a total of 42 %) for foreign-body sensation
or pain.
There were no cases of abnormal wound healing, post-opera-
tive wound infection or postoperative bleeding requiring revision
surgery. Two of the total 24 patients (8 %) developed partial talar
necrosis. Each of these patients had talar body fractures. Ten of
the 24 patients (42 %) went on to develop osteoarthritis (▶ Table
3). These comprised four patients with a previous talar neck frac-
ture and six with talar body fractures. Secondary fusion of the
subtalar joint was performed in one patient (4 %) after 3.5 years
for osteoarthritis, with fusion of the ankle joint after a further ten
years.
The median AOFAS Ankle-Hindfoot Score was 71.3 ± 24.0
points for patients with talar body fractures. The median AOFAS
Ankle-Hindfoot Score was 71.5 ± 22.1 points for patients with
talar neck fractures. Consequently, ten patients (42 %) achieved
an excellent or good result, three patients (12 %) a moderate and
11 patients (46 %) a poor result (▶ Table 4). As regards FFI, the
total score in the talar body group was 35.2 ± 29.5 points and
STJ
37.4 ± 27.7 points in the talar neck group. The median value for
AJ
the physical health summary scale was 43.9 ± 11.0 points in the
talar body group and 43.7 ± 11.6 points in the neck group. As re-
gards the mental health summary scale, patients with talar body
fractures achieved 50.1 ± 11.2 points and those with neck frac-
tures 42.1 ± 17.0 points (average value ± standard deviation in
each case).
No significant difference was found in any of the results of the
unadjusted analysis when comparing the target parameters of
AOFAS, FFI and SF36v2 (physical and mental health summary
scale) (▶ Fig. 3). Of the radiological target parameters, only osteo-
arthritis was subjected to statistical evaluation. Surprisingly, only
the general overall extent of injury for osteoarthritis produced a
statistically significant difference (p = 0.002). In the correlation
analysis between the SF-36v2 and the foot scores, strong correla-
tion was detected between the AOFAS (positive correlation) and
the FFI (negative correlation) for the physical health summary
scale (each p < 0.0001). The mental health summary scale also
correlated significantly in the same directions with the AOFAS
(p < 0.0001) and the FFI (p = 0.0008), to a lesser degree, however,
than with the physical health summary scale.
Discussion
According to the literature, avascular necrosis is reported as 0–
24 % for Hawkins I, 0–50 % for Hawkins II and 9–100 % for Hawkins
III and IV fractures [20, 21]. Necrosis rates of 5 to 44 % are re-
ported for undisplaced talar body fractures (Marti II) and of about

von Winning D et al. Surgical Treatment of … Z Orthop Unfall

 Original Article

MCS (SF36)

PCS (SF36)
Arthrose

AOFAS

FFI
Geschlecht 1.000 0.218 1.000 1.000 1.000

Alter 1.000 1.000 0.581 0.181 0.806 0.8

Verletzungsausmaß 0.002 0.433 0.249 1.000 0.154

0.6

p-Wert
Frakturklassifikation 1.000 1.000 0.845 0.384 1.000

0.4
Weichteilschaden 1.000 1.000 1.000 1.000 1.000

Frakturentität 1.000 1.000 1.000 1.000 1.000 0.2

definitive operative Versorgung 1.000 1.000 0.616 0.365 1.000

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▶ Abb. 3 Heatmap for the individual parameters (No further statistical analysis was performed for the target parameter aseptic necrosis due to the
small number of cases). AOFAS: Ankle-Hindfoot Scale of the American Orthopaedic Foot and Ankle Society; FFI: Foot Function Index; SF36-MCS:
mental health summary scale of the SF36v2; SF36-PCS: physical health summary scale of the SF36v2.

50 % for displaced talar body fractures (Marti III and IV) [20, 22].
No necrosis developed in fractures of the talar neck in our study
population. It should be taken into account that only patients with
Hawkins I and II fractures were followed-up. Partial necrosis devel-
oped in two cases with talar body fractures (2/16 patients). One
patient had a Marti II fracture and one patient a Marti IV fracture,
both of which had undergone ORIF after six hours. Altogether,
therefore, one of our six patients with a Marti II fracture suffered
partial necrosis, which is slightly increased in comparison with the
literature (Overview in [22]). At the time, this fracture went unrec-
ognized at the initial radiological examination, so that the patient
did not present for ORIF until after three months. The delayed sur-
gical treatment could well be a reason for the necrosis. One in
three patients with Marti IV fractures developed partial necrosis.
So we lie in the lower range of studies so far published for this
fracture classification (Overview in [22]). Post-traumatic osteoar-
thritis rates after talar fractures vary in the literature from 16 to
100 % (Overview in [22]). In our study, ten patients suffered post-
traumatic osteoarthritis (42 %). Our study population has a lower
rate in comparison with the study by Schulze et al. (osteoarthritis
rate 67 %, n = 80) who had a follow-up time of similar duration
[23]. There was only a significant correlation with the general
overall extent of injury (p = 0.002). There was no statistical corre-
lation between fracture classification (undisplaced [Marti II] vs.
displaced [Marti III and IV]) and osteoarthritis rate in our study
population (p = 1.000). There was also no significant correlation
between the point in time of the follow-up examination and the
osteoarthritis rate. Osteoarthritis was diagnosed in 45 % of pa-
tients with a follow-up > 10 years and 38 % of patients with a fol-
low-up < 10 years (5/11 vs. 5/13, p = 1.000).
Our patients with fractures of the talar neck ranked lower on the
AOFAS Score with regard to Hawkins type I fractures (67 points)
than in other publications (Overview in [22]). The underlying rea-
sons may be found in the inhomogeneity and severity of the total
extent of injury of our patient population (three patients had sus-
tained multiple injuries or polytrauma; 2/3 of the patients had ad-
ditional fractures of the ipsilateral foot). If the total AOFAS results
of our study population are compared with those of Rammelt et
al., then our results are slightly poorer (n = 45; 79 vs. 71 points).
However, we also had a more than double follow-up period [5].
In the total FFI score, patients with isolated talar fractures (n = 7)
had a result of 36.3 points, whereas patients with additional foot
injury/fracture (n = 4) had only 6.2 points. The total FFI score for
the severely injured patients (polytrauma, multiple injuries, multi-
ple limb fractures; n = 13) was 44.8 points. It should be noted that
the patient group with an isolated fracture had an average follow-
up interval of 10 years, the group with other foot injuries 7.3
years, and the group of severely injured patients of 8.5 years. For
the SF-36v2, the patients assessed their physical health as slightly
poorer than the general German population. When summarising
the SF-36v2 component mental health, however, the results of
the patients remained on a par with the national average [24].
Consequently, there are no signs that sequelae following surgery
for talar fractures result in any mental impairment during every-
day life.
A retrospective reappraisal of the patient population showed
that, at that time, only one approach was being used for predom-
inantly low grades of displacement. From todayʼs perspective, a
bilateral verification of reduction using two approaches is gener-
ally recommended to avoid axis deviations and rotational deformi-

von Winning D et al. Surgical Treatment of … Z Orthop Unfall

ties of displaced fractures of the talar neck. A bilateral approach
should also be used for talar body fractures for visual assessment
of the subtalar joint surface [5].
In individual cases, hardware removal was eventually per-
formed due to the development of symptoms. These individual
cases consistently confirmed subjective improvement of the
symptoms at follow-up after hardware removal. In general, how-
ever, removal of implants is not recommended for access-related
morbidity [25].
As with the femoral head-preserving management of femoral
neck fractures, earliest possible definitive treatment in the form
of an emergency operation was for a long time propagated for
displaced talar fractures in particular as being the key factor for
the low complication rate and good clinical results [26]. Mean-
while, it is no longer believed that there is an automatic connec-
tion between the time of ORIF and the clinical and radiological
outcome, in particular the rate of avascular necrosis [4, 5, 9, 22,
23, 27 – 30]. Early ORIF has long since ceased to correspond to ac-
tual treatment reality [30]. Dislocation fractures should always be
reduced as soon as possible to prevent severe soft-tissue damage
from fragment pressure from within. This should be accomplished
even before CT investigations [22]. Should closed reduction not
succeed, then open reduction and retention with an external fixa-
tor should be undertaken [22]. In the descriptive assessment of
our displaced fractures (Marti III–IV) with regard to the timing of
surgery, no trend was recognised that surgical treatment after six
hours results in a poorer outcome either. Of ten patients with de-
layed treatment, only one patient developed partial talar necrosis.
Eleven of the 24 patients who were followed-up had a preoper-
ative CT scan. At that time, cross-sectional diagnostic imaging did
not yet form part of standardised hospital procedure. It was dis-
pensed with in many cases of radiologically minimally displaced
fractures. Nowadays, a CT scan should be requested to assess
completely the extent of the injury and plan the approach. A post-
operative CT scan is sometimes also recommended for quality as-
surance [5, 20].
Conclusion
In our patient population of 24 patients with displaced (n = 15)
and undisplaced (n = 9) talar fractures followed-up after ORIF,
the clinical results (AOFAS, FFI, SF36v2) are good. The aseptic ne-
crosis rate was 8 %, the osteoarthritis rate 42 %. The overall extent
of injury of the patients had a significant effect on the develop-
ment of osteoarthritis. There was no significant correlation with
the Marti classification. There was no recognisable tendency to
suggest that delayed surgical treatment (≥ 6 hours) produces a
poorer outcome. Nevertheless, the low number of cases should
be borne in mind when interpreting these results since only very
strong effects and correlations can be demonstrated with any
significance with these case numbers. Prompt reduction should
be pursued for displaced fractures, especially when immediate
operative treatment of the talar fracture is not possible (e.g.
polytrauma).
von Winning D et al. Surgical Treatment of … Z Orthop Unfall
Interessenkonflikt
DvW, WS and ST have no conflict of interests with regard to this study.
DA (StatConsult) received remuneration for statistical work and analysis.
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von Winning D et al. Surgical Treatment of … Z Orthop Unfall