Secondary correction of talar fractures: asking for trouble?

Secondary anatomical reconstruction of malunions or nonunions after talar fractures or fracture-dislocations with preservation of all three joints aims at maximal functional rehabilitation. A corrective osteotmy or revision of a pseudoarthrosis with axial realignment and internal fixation was carried out in 22 patients (aged 15 to 50) at a mean of 9 (range, 1.5 to 45) months after having sustained a fracture of the talar head, neck or body. 20 patients were followed for a mean of 4.8 (range, 1.5 to 14) years after reconstruction. No signs of development or progression of avascular necrosis (AVN) were observed in any case. Some amount of progression of peritalar arthritis was seen in 12 of 20 patients (60%). One patient required ankle fusion 7.5 years after reconstruction, another patient needed talo-navicular fusion after 5 years, and a third required a two-stage fusion of the ankle and the subtalar joint after 18 months. Two patients underwent arthrolysis of the ankle and screw removal after 7 and 14 years for dorsiflexion deficit at the ankle. The mean AOFAS ankle/hindfoot score increased from 36.9 preoperatively to 87.5 after correction (p < 0.001). Secondary correction after talar fractures appears promising in active and compliant patients without symptomatic arthritis, with good bone stock, no or partial AVN (less than one-third of the talar body), and no infection. Late fusion with a well-aligned talus remains a salvage option in cases of progressive arthritis.