Talar body fractures occur uncommonly, accounting for 7% to 38% of all fractures of the talus [1, 2]. The treatment of talar body fractures remains poorly defined in the literature [1]-[6]. Sneppen et al. reported the early results for patients with fractures of the talar body, most of them had been treated non-operatively [7]. High rates of malunion, osteonecrosis, and arthritis were noted. There have been isolated reports of operative treatment [2]-[4, 8]-[14]. The clinical outcome after talar body fractures is determined by the severity of the injury and the quality of reduction and internal fixation. However, the outcome after operative treatment remains poorly understood. The timing of definite internal fixation does not appear to affect the final result [15, 16]. The incidence of avascular necrosis is almost certainly dictated by the fracture pattern and its disruption of the intrinsic blood supply to the talus [17]. The revascularisation process can be achieved by stable surgical reduction and internal fixation [5, 11, 14]. Thus, the importance of surgical reconstruction in displaced fractures is not only to anatomically reduce the articular surfaces and restore the dimensions of the talar body, but also to ensure that the remaining precarious blood supply to the talus is not iatrogenically reduced further [1, 11, 17, 18].

Preoperative planning of definite internal fixation requires CT scanning. To obtain a complete intraoperative overview allowing for anatomical reconstruction of the articular surfaces and the axial deviation bilateral approaches are usually necessary. Internal fixation is achieved with screws or mini-plates supplemented by temporary K-wire transfixation in cases of marked additional ligamentous instability [18, 19].

This combined injury pattern seems to be very rare; a few reports of a talar body fracture combined with ankle malleolar fractures found in the literature.

The aim of the present study was to characterize these fractures, to describe to our limited experiences about surgical treatment approach, and to evaluate the clinical, radiographic, and functional outcomes.

Talar body fractures are extremely rarer still. The body of the talus articulates with tibia, fibula and the calcaneus. Complexity in the blood supply to the talus itself makes it one of the bones in the body vulnerable to avascular necrosis [17]. Arthritis in the ankle and subtalar joints can occur in the absence of avascular necrosis of the talus and joint incongruity [6, 16].

The reported incidence of avascular necrosis for severely comminuted talar body fracture is around 50%-75% [5, 10, 12, 20]-[22]. Vallier et al. reporting on radiographic findings of 26 talar body fractures with a minimum follow-up of 1 year, noted a 38% incidence of AVN, 65% incidence of post-traumatic tibiotalar arthritis and 34% incidence of posttraumatic subtalar arthritis. Worse outcomes were noted in association with comminuted fractures, associated talar neck fractures and open fractures [4]. Lindvall et al., in 2004, reported on 26 isolated cases of talar neck and body fractures with a minimum follow-up of 48 months and found a 50% incidence of AVN and 100% incidence of post-traumatic arthritis. Timing of fixation did not seem to affect the outcome, union or prevalence of AVN in the later study [10].

The appearance of a radiolucent zone 4-8 weeks after the injury at the subcortical bone of the talar dome indicating bone remodelling "Hawkins' sign" is highly predictive of a revitalisation of the talar body after a fracture. We had not seen AVN in our patients. All cases with a positive Hawkins sign. Thirteen months (mean follow-up period) after the initial injury, our patient made full recovery with no evidence of avascular necrosis or collapse radiologically and clinically. The reason for not seeing avascular necrosis, however, could be our short follow-up period. The mild osteo-arthritic changes seen at the 3 years follow-up are expected in our patient, since the incidence of degenerative changes after talar body fractures is high, affecting more often the tibiotalar than the subtalar joint.

Talar body fractures are produced by an axial compression of the talus between the tibial plafond and calcaneus [6, 12]. In cases with a combined medial malleolar fracture, an additional inversion torque seems to distribute this force to the medial structures, producing a vertical split of the talar body and the medial malleolar fracture [8]. A lateral side talar body fracture could be produced by pronation-external rotation [7]. Recently, Frawley et al. showed in their series of 26 talar fracture patients, 15 talar fractures in the right feet, which push brake pedals, in 16 car drivers [23]. Fractures in the neck and the lateral process of the talus were believed to occur when both the foot and ankle are hyperdorsiflexed [9]. The fracture pattern in our cases suggests an inversion, axial loading, and external rotation mechanism.

In our patients, open reduction and internal fixation was performed with the use of 4.5 mm AO cannulated or headless cannulated (acutrak^®, Acumed) screws. We performed surgery through three different (single) approach individually (case1, anteromedial; case 2, anterolateral; case 3, anterior approach). The screws are introduced into the posterior part of the talar body in order to achieve maximum purchase. On the other hand, additional screw was inserted percutaneously. Because posteroanterior screw position gave more stability in a biomechanical trial [19].

Open reduction and internal fixation may restore the joint congruity allowing early range of movement in the tibio-talar and subtalar joints. Plaster cast application was not used and range of motion exercise was encouraged at the early post-operative period but full weight bearing was allowed at 12 weeks [8].

Fractures of the talar body are often severe injuries. Conservative treatment with closed reduction and casting leads to a very high rate of complications. Hence, open reduction and internal fixation in the appropriately selected patient can be performed safely with the prospect of reducing complications. An accurate reduction and stable fixation are also mandatory in order to provide the best biomechanical environment for revascularization of the lateral part of the talar body. Early treatment with open reduction and stable internal fixation, using minimal invasive technique, may improve the final outcome.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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