Alley Maxwell C, Vallier Heather A, Tornetta Paul
Boston Medical Center, Boston, MA; and.
Case Western Reserve University, Cleveland, OH.
J Orthop Trauma. 2024 Jan 1;38(1):25-30. doi: 10.1097/BOT.0000000000002706.
To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors.
Retrospective chart review.
21 US trauma centers and 1 UK trauma center.
Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation.
The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes.
In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.
Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
确定距骨骨折后与缺血性坏死（AVN）发生相关的患者、损伤及治疗因素，尤其关注可改变因素。
回顾性图表审查。
21家美国创伤中心和1家英国创伤中心。
回顾性分析2008年至2018年的距骨颈和/或体部骨折患者。纳入标准为年龄至少18岁、有距骨颈或体部骨折且随访至少12个月或更早诊断为AVN的患者。进一步排除标准包括非手术治疗的骨折、病理性骨折、全距骨脱位以及接受一期关节融合术或一期截肢治疗的骨折。
主要结果测量指标为AVN的发生。感染、骨不连和关节炎为次要结果。
共纳入798例患者（409例男性；389例女性；年龄18 - 81岁，平均38.6岁），798处骨折（532例右侧；264例左侧），分为Hawkins I型（51例）、IIA型（71例）、IIB型（113例）、III型（158例）、IV型（40例）、颈加体部骨折（177例）和体部骨折（188例）。798例患者中共有336例发生AVN（42%），距骨颈骨折后发生AVN更为常见（47.0%），而单纯体部骨折为（26.1%，P < 0.001）。更严重的Hawkins分级、颈和体部联合骨折、体重指数、吸烟、右侧骨折、开放性骨折、双前内侧和前外侧手术入路以及合并内踝骨折与AVN相关（P < 0.05）。多因素回归分析后，骨折类型、吸烟、开放性骨折、双入路、年龄和体重指数仍具有显著性（P < 0.05）。排除晚期病例（>7天）后，Hawkins IIB - IV型距骨颈损伤患者关节复位时间在发生AVN和未发生AVN的患者中无差异。受伤后6小时内复位脱位的AVN发生率与>6小时复位的分别为48.8%和57.5%。并发症包括60例（7.5%）感染和70例（8.8%）骨不连。
所有距骨骨折患者中有42%发生AVN，距骨颈骨折、移位更明显的骨折和开放性损伤发生率更高。与损伤相关的因素对AVN风险的预后影响最大。强调解剖复位且不对剩余血供造成医源性损伤的手术技术似乎是谨慎的。
预后性III级。有关证据级别的完整描述见作者指南。
