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Osteochondral Talar Fracture Treated with Arthroscopic Reduction and Internal Fixation: A Case Report

Thomas A Pagonis, Panagiotis D Symeonidis, Panagiotis K Givissis, Anastasios C Christodoulou

Thomas A Pagonis, Panagiotis K Givissis, Anastasios C Christodoulou, Trauma & Orthopaedic Department, Spinal Unit, The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk, IP4 5PD, the United Kingdom
Thomas A Pagonis, 1st Orthopaedic Department of Aristotle’s University of Thessaloniki, G.U.H.G.Papanikolaou, Thessaloniki, Hellenic Republic, Greece

Correspondence to: Thomas A Pagonis, 1st Orthopaedic Department of Aristotle’s University of Thessaloniki, G.U.H.G.Papanikolaou, Thessaloniki, Hellenic Republic, Greece
Email: iatros1@yahoo.com
Telephone: +44 (0)7896360517
Received: May 6, 2014
Revised: June 17, 2014
Accepted: June 23, 2014
Published online: August 23, 2014

ABSTRACT

INTRODUCTION: Arthroscopic reduction and internal fixation (ARIF) is becoming a popular technique for the management of articular fractures.

CASE REPORT: A 41 year old is admitted following an RTA with a transverse fracture of the left fibula and an avulsed TCF of the lateral cortex of the talus.

MANAGEMENT: Arthroscopic intervention from the anterior portals and ORIF with LC-DCP was selected. There was a Transchondral fracture (TCF) and 4 fragments measuring from 2-5 mm. All were removed. A larger TCF fragment was found to be positioned posteriorly to the portals and inaccessible so a posterior portal was opened so that the fragment could be dislodged, grasped and removed from the anterior portal. The size of this fragment was 9×11 mm. An uneventful ORIF of the fibular fracture was performed with a 7 hole LC-DCP with combined locking and normal holes.

DISCUSSION: Arthroscopic reduction and internal fixation may cost more initially but in the long-term it may result in reduced costs mainly associated with chronic conditions.

© 2014 The Authors. Published by ACT Publishing Group Ltd.

Key Words: Osteochondral fracture, Talar fracture, Ankle arthroscopisis, Talus

Pagonis TA, Symeonidis PD, Givissis PK, Christodoulou AC. Osteochondral Talar Fracture Treated with Arthroscopic Reduction and Internal Fixation: A Case Report. International Journal of Orthopaedics 2014; 1(2): 61-63 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/831

Introduction

The use of less invasive image-guided techniques for fracture management of small and medium size joints preserves the soft-tissue envelope and improves reduction. Arthroscopic reduction and internal fixation (ARIF) is becoming a popular technique for the management of articular fractures. In selected cases the use of ankle arthroscopy in a trauma setting is beginning to gain ground. Management of fractures about the ankle requires direct visualization of intra-articular injury during the reduction. A high incidence of intraarticular lesions and chronic ankle pain has been reported after anatomic reduction[1-4]. Arthroscopy has been proposed as a means to reduce the incidence of chronic complaints related to intra-articular fracture. However, indications for ARIF remain limited, and the effectiveness of ARIF compared with ORIF has not been determined[5].

A Transchondral fracture (TCF) is an intra-articular fracture produced by a force transmitted from a contiguous bone through the articular cartilage to the subchondral trabeculae. A high incidence of TCF is associated with ankle instability (23% to 95%)[6,7] and malleolar fracture (63% to 79%)[1,8]. The talar dome, particularly the posteromedial aspect, is the most frequently involved site. A four-stage radiographic classification of TCF by Berndt and Harty[9] is widely accepted: stage I, small compression fracture; stage II, incomplete avulsion of a fragment; stage III, complete avulsion of a fragment without displacement; and stage IV, displaced fragment.

CASE REPORT

A patient 41 years old is admitted in the emergency trauma unit due to a RTA (motorbike driver), having suffered a rotatory force type injury of the left ankle mortise. On radiological examination with plain X-rays, a transverse fracture (AO 43 A3.3) of the suprasyndesmotic area of the left fibula (Figure 1) was evident as well as an avulsed flake in the syndesmotic area with the suspicion of being an avulsed TCF fragment of the lateral cortex of the talus. The lower talofibular syndesmosis was suspected to be ruptured. A CT confirmed the diagnosis (Figure 2).



Management

The patient was scheduled for surgery the following day. Arthroscopic intervention was selected for the investigation of the talar avulsion TCF and ORIF with LC-DCP for the fibular fracture. Under general anaesthesia and on the arthroscopic supine position, the arthroscopic anterior portals were selected. There was an evidently fresh TCF of the lateral cortex of the left talus with 4 fragments measuring from 2-5 mm present. All were removed. The syndesmosis was found to be ruptured. A larger TCF fragment (the one evident on plain radiographs) was found to be positioned posteriorly to the portals and inaccessible so a posterior portal was opened so that the fragment could be dislodged, grasped and removed from the anterior portal. The size of this fragment was 9×11 mm (Figure 3).

An uneventful ORIF of the fibular fracture was performed with a 7 hole LC-DCP with combined locking and normal holes. 6 normal cortical screws were used and after that with the foot on dorsiflexion and under radiological control (mini C-arm) a syndesmosis screw was positioned (Figure 4, 5). The lower limb was supported with a posterior (backslab) splint for comfort.

Healing of the fibular fracture was uneventful and the ankle joint was checked 10 weeks post op by use of MRI. Physiotherapy was started immediately after the operation. At the post op review 8 weeks later, the patient had full range of motion on weight bearing. On the final follow up 6 months later, the healing process had completed uneventfully.





Discussion

Definite recommendation for the use of ARIF for management of ankle fractures is difficult[10]. However a general agreement regarding the high incidence of intra-articular pathology associated with an ankle fracture is present. In ankle fractures managed with ORIF, some of these fractures may be missed, resulting in chronic problems. A CT would be required to verify and detect possible fragments not visible in plain X-rays.

The main advantages of ARIF include limited exposure, blood supply preservation and improved visualization[11]. It is a minimally invasive technique of treatment in a very delicate weight bearing joint that is notorious for post operative osteoarthritis. ARIF delivers results similar to ORIF[11] while exhibiting less long term complications associated with postoperative morbidity. Moreover, the recuperation period is shortened and the postoperative mobilization is attenuated.

However, ARIF requires increased surgical time, is technically more challenging and may attenuate soft tissue swelling[12]. Nonetheless ARIF may cost more initially but in the long-term it may result in reduced costs mainly associated with circumvention of possible emergence chronic conditions like osteoarthritis.

CONFLICT OF INTEREST

There are no conflicts of interest with regard to the present study.

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Peer reviewer: Umile Giuseppe Longo, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200 – 00128 Rome, Italy; Rubén Daniel Arellano, Avenida Morelos 900 Oriente, Torreón Coahuila México.

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