Tag Archive | talar fracture

JBJS 100: Talar Neck Fractures, Knee Cartilage Repair

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Fractures of the Neck of the Talus
L G Hawkins: JBJS, 1970 July; 52 (5): 991
This article, richly illustrated with radiographs, reports on >1-year results from 43 patients treated after sustaining a vertical fracture of the neck of the talus. Hawkins introduced a 3-group classification system based on the initial radiographic appearance of the fracture, and he provided an in-depth discussion of the complication of avascular necrosis.

Autologous Chondrocyte Implantation and Osteochondral Cylinder Transplantation in Cartilage Repair of the Knee Joint
U Horas, D Pelinkovic, G Herr, T Aigner, R Schnettler: JBJS, 2003 February; 85 (2): 185
In the 15 years since this paper appeared in JBJS, nearly 800 articles have been published that have “autologous chondrocyte implantation” (ACI) in their title. This study—replete with histologic, biopsy-specimen, and electron microscopy images—compared 2-year results among 40 patients who had received either ACI or autologous osteochondral transplants for knee cartilage defects. Both treatments decreased symptoms, but the authors concluded that “the improvement provided by the [ACI] lagged behind that provided by the osteochondral cylinder transplantation.” For more current information on these cartilage-repair techniques, see the JBJS Clinical Summary on Knee Cartilage Injuries.

JBJS Classics: Fractures of the Talar Neck

JBJS Classics LogoOrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

One of the most challenging diagnoses for general orthopedic surgeons as well as fracture specialists is a fracture of the talar neck. The infrequency of displaced talar fractures means that orthopaedic residents receive relatively little training in this area. A pivotal JBJS article in 1978 focused attention on these vexatious injuries. “Fractures of the Neck of the Talus” by Canale and Kelly provides clinically useful information and does two things that are very difficult to do today:

  • Follows patients for a long time (an average of nearly 13 years)
  • Obtains direct evidence of outcomes by physical exam, one-on-one measurement, and long-term imaging.

This remarkable duration of follow-up, so important in determining the impact of treatment in musculoskeletal injury, is very difficult today as a result of overly enthusiastic privacy protections and a costly regulatory infrastructure.

This classic JBJS article capitalizes on other classics, such as those by Blair (1943) on talar body salvage and studies by Halliburton (1958) and Mulfinger (1970) on the anatomy of talar blood supply. While Mulfinger showed the vascular supply of the talus,1 that study did not link that information to clinical care. The study by Canale and Kelly provides insight into how our care for patients with these uncommon fractures affects outcomes. In addition, the relatively primitive state of art at the time for the operative treatment of talar fractures led to fear of infection, and limited understanding of the basics of fracture healing and underdeveloped implants for fixation steered many surgeons away from rigid fixation in favor of closed reduction and cast immobilization.

The authors identified 107 fractures treated over a 33-year period; they examined and obtained radiographs on 71 of those fractures in 70 patients at an average follow-up of almost 13 years. (Fourteen of the patients were followed for more than 20 years, and 5 were followed for more than 30 years.) The preferred treatment protocol was closed reduction and casting. A reduction with less than 5 mm of displacement and 5° of misalignment was considered adequate. Open reduction with internal fixation was performed when these criteria were not met.

To assess outcomes, the authors directly measured ankle and subtalar motion, assessed whether a limp was present, and asked patients to rate their pain. Long before “patient-reported outcome measures” was a recognized term, these authors recorded them. Only 59% of patients in this series achieved good or excellent outcomes. The authors identified the high morbidity of these injuries, including avascular necrosis in more than half and 25 who needed later surgical intervention. The authors also recommended against talectomy as a salvage procedure.

While hampered by relatively low-resolution imaging and outcome measures that don’t meet current standards of reproducibility, Canale and Kelly provided a great deal of information that focused attention on the importance of quality of reduction. In addition, the paper created an enduring fracture classification that paralleled complication rates and potential outcomes.

Bruce Sangeorzan, MD
JBJS Deputy Editor

Reference

  1. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970 Feb;52(1):160-7