RESUMO
OBJECTIVE: Anatomical reduction and fixation of complex talar fractures (Hawkins type III and IV, Marti type III and IV) using a medial approach. INDICATIONS: Displaced talar fractures (Hawkins type III and IV, Marti type III and IV) with the need for a medial malleolar osteotomy or the simultaneous treatment of a medial malleolus fracture. CONTRAINDICATIONS: High perioperative risk, severe soft tissue injuries in the medial approach area, infected soft tissues. SURGICAL TECHNIQUE: Medial arch-shaped approach about 12â¯cm in length over the medial malleolus using a simultaneous medial malleolus fracture or via an additional medial malleolar osteotomy. Dissection and retraction of the terminal branches of the saphenous vein and the saphenous nerve. Protection of the blood supply in the area of the medial talus and in the sinus tarsi. Reduction of the talar joint surfaces and reconstruction of the anatomical axes according to the preoperative planning by means of native radiological and computed tomographic imaging. Osteosynthesis adapted to the fracture type using Kirschner wires, conventional screws, cannulated screws, double-threaded screws, resorbable pins, magnesium screws, small fragment plates. POSTOPERATIVE MANAGEMENT: Lower leg splint or orthesis for 6 weeks, partial weight-bearing with 20â¯kg for 10-12 weeks. Early range of motion exercise of the ankle, subtalar and mid-tarsal joints. RESULTS: In the past 5 years, 11 patients with either Hawkins type III and IV or Marti type III and IV fractures were treated operatively using the arch-shaped approach. No soft tissue problems were seen related to the arch-shaped approach. Of the 7 patients who could be followed up after an average of 2 years, the mean American Orthopedic Foot and Ankle Score was 73. Avascular necrosis occurred in 3 cases (43%). These were partial necroses of less than one third of the talar body with asymptomatic course at the time of examination. In 4 patients (57%) radiographic signs of osteoarthritis occurred within 2 years, whereby in two of those cases (29%) an arthrodesis of the upper ankle was performed.
