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Purpose of the Study: Fractures of the lateral process of the talus are often not diagnosed. The cohorts of the literature are small. The aim of the study was to analyse these fractures with a large group of patients., Material and Method: Forty-four fractures in 43 patients were reviewed with an average follow-up of 17 months. The diagnosis had been made immediately in 14 cases and secondarily in 30 cases with a delay of 46 months. Patients had been evaluated with Kitaoka's score and radiographies using Hawkins classification. Fractures occurred during sport practise in 19 cases. The most frequent mechanism was association of dorsal flexion and pronation. There were associated lesions in 44% of cases., Results: In the group of delayed diagnosis, we found 14 cases of associated pseudarthrodesis and sub-talar osteoarthritis, two cases of isolated pseudarthrodesis, two cases of isolated sub-talar osteoarthritis. After treatment in this group, the result at the last follow up was very good in 15 cases (50%), good in seven cases (23%), average in seven cases (23%) and bad in one case (4%). In the group of immediate diagnosis five of 14 patients had at least one complication: 29% of pseudarthrodesis and 29% of sub-talar osteoarthritis. After treatment in this group, the result at the last follow-up was very good in eight cases (58%), good in four cases (28%) and average in two cases (14%). Immediate diagnosis was correlated with better results at the last follow-up. In the sub-group of immediate diagnosis, among patients who had an orthopaedic treatment, the rate of secondarily surgery was 42%., Conclusion: The fracture of lateral process of the talus is quite frequent and occurs among young people. Spontaneous evolution is severe with two major complications: pseudarthrodesis and sub-talar osteo-arthritis. Treatment is always required in case of displaced fracture.

Emergency departments frequently encounter pathology resulting from injury to the foot and ankle, with approximately 6000 case per day in France. In an ankle sprain, 85% of the lesions involve the lateral collateral ligament. Many other, much rarer, types of lesion with different therapeutic consequences can present, however. Interpretation of the initial conventional radiographs is vital to establishing the type lesion and to proposing adapted and rapid treatment. The objective of this article is to review the various osteoarticular and ligament injuries encountered in the foot and the ankle.

Unlabelled: We report outcome in eight cases of ankle arthrodesis after failure of a total ankle prosthesis., Material and Methods: This series included eight patients, mean age 57 years (range 36-76) who had initially: post-traumatic talocrural joint degeneration (n=4), rheumatoid polyarthritis (n=3), idiopathic talocrural degeneration (n=1). Three patients had a New Jersey (DePuy) cemented prosthesis, four had a Star (Link) uncemented prosthesis and one, whose implantation was performed in another institution, had a spherical cemented prosthesis. The preoperative Kitaoka score was 19.1 (0-32). Seven patients had subtalar joint degeneration; one patient had a subtalar arthrodesis. The tibial component was cemented alone in two patients, the talar piece in three (two with talar fracture). Failure resulted from loosening, talus fracture or deep infection. Bipolar loosening was observed in two patients. Time to revision was 36 months (range 4-108). Arthrodesis was associated with an iliac graft for seven patients: several tricortical grafts (vertical alignment of the corticals) and cancelous grafts for filling. The height of the graft was adjusted to the substance loss. A bone graft could not be used in one patient who had a deep infection. The arthrodesis was fixed with an anterior plate bridging the talocrural space in six patients, with an external fixator in infected patient, with a conventional centromedullary tibial nail transfixing the talocrural joint and planted in the talus and the calcaneus in one. Outcome was assessed with the Kitaoka score. Mean follow-up was 56 Months (range 10-114)., Results: The overall Kitaoka score improved to 54/100 (range 42-70) at last follow-up. The arthrodesis provided improvement in all patients although the final outcome was still considered poor in three patients. Radiographic healing was obtained in seven patients at a mean 3.1 months (range 2.5-6). Wound healing was slow in two patients. One patient developed a deep infection early., Discussion: The rate of fusion was 87%. This is in the general range reported in the literature; use of an iliac graft allows preserving joint height but because of the poor bone quality often encountered, residual bone stock may be insufficient to achieve complete fixation with screwing. Plate fixation appears to be a better way of achieving fixation. This provides a rate of fusion comparable with earlier series where external fixation was generally employed. For us, external fixation should be reserved for infected cases. Use of a conventional anterograde nail can be another solution in the event of poor bone quality. The overall result remains relatively modest although all the patients achieved a functional gain with arthrodesis. The results obtained are less satisfactory than after first-intention ankle arthrodesis.

Purpose of the Study: Complication rate is high after talar neck fractures. Avascular osteonecrosis and post-traumatic joint degeneration could be avoided by proper management. We analyzed long-term outcome in a series of 40 talar neck fractures treated in our unit from 1979 to 1995., Material and Methods: Mean follow-up was 9 years. Orthopedic and surgical management by Hawkins classification group was, respectively, type I=10 (7 and 3), type II=17 (3 and 14), type III=11 (1 and 10) and type IV=2 (both surgery). Two patients had bilateral fractures and 7 fractures were open. Among the 29 fractures treated surgically, the anteromedial approach was used for open reduction and fixation for 18. A dual approach was needed for 1 patient with a type III fracture. Fixation was achieved with cancelous screws for 17/29 fractures including 3 fluted screw fixations, cortical screws for 9, K-wires for 2 and staples for 1., Results: According to the AOFAS classification, mean function score at last follow-up was 94.4/100 for type I, 78.5 for type II, 69.5 for type III, and 57.5 for type IV. Signs of osteoarthritis were observed in 68% of the cases with clinical expression in 9 out of 10 cases., Discussion: The results show that conservative treatment is indicated for type I fractures while open reduction and fixation should be used for types II, III, and IV. Subsequent joint degeneration was correlated with the type of fracture and clearly influenced functional outcome. In our long-term follow-up, we only had two cases of osteonecrosis which finally necessitated arthrodesis. This low rate would be related to the fact that most of the patients were able to avoid weight bearing for several months.

The authors report a series of 32 complete transverse fractures of the neck or body of the talus. The fractures occurred mostly in young males, as a result of motor vehicle accidents. The fracture line was transverse in the neck or body of the talus in 20 cases, sagittal in four and comminuted in eight cases. Using Hawkins' classification, there were 10 type I, 16 type II, and 6 type III fractures. The treatment was conservative in 8 cases and surgical in 24. The patients were evaluated clinically and radiologically with an average follow-up of 7 years. All patients underwent radiological study at follow-up and 17 underwent NMR evaluation. Eleven underwent NMR evaluation at final follow-up, and the other 6 early in their postoperative evolution. The postoperative results were evaluated based upon clinical and radiological criteria. The clinical result was good or very good in 37.5% of cases. Segmental necrosis of the talar body was noted in 6 cases and complete necrosis in 5, which required arthrodesis in 8 cases. Avascular necrosis is a common complication. Its frequency depends on the type and displacement of the fracture. If it becomes symptomatic, the only treatment is tibiotalar or tibiotalocalcaneal arthrodesis. The contribution of NMR is very important, as it gives the positive diagnosis as well as information regarding evolution. Complete transverse fractures of the talar neck or body are rare; their treatment only gives a little over one third good and very good results in the long term. NMR gives the diagnosis early and shows the extent of necrosis. It can have predictive value for the collapse risk and guide reeducation with or without weight bearing.

Purpose of the Study: Neck fractures of the talus are rare. Necrosis is the complication most often observed. Mal union or non union are rarely reported: 11 cases of such complications have been treated and are presented with results of surgical treatment., Material: Seven non unions and 4 mal unions after separation fracture of the talus, presenting with pain and deformity of the hindfoot were treated. The treatment included removal of the fibrous tissue, heel reaxation, bone grafting, peritalar joints arthrodesis., Results: Bone healing was observed in 5 of 7 non unions, and the correction of the hindfoot deformity in 9 of the 11 cases., Discussion: Non union or mal union after separation fracture of the neck of the talus are poorly tolerated, the patients walking with the foot in internal rotation, bearing most of the weight on the lateral border of the foot. Such poor course results from: the less mechanical stiffness of the medial part of the talus, the severity and the comminution of the fracture, insufficienct reduction and fixation, too early weight bearing, and is associated with degenerative changes of peritalar joints. Functional and antomical good results can be obtained with bone healing, hindfoot reaxation and peritalar arthrodesis. We emphasize the interest of X Rays in the examination and the adequacy of a good initial treatment.

Purpose of the Study: Fracture of lateral process of the talus is an uncommon injury, fracture of the posteromedial tubercle of the talus is quite rare, and association of the two lesions is not reported previously. We report a case of an associated fracture of posteromedial tubercle an lateral process of the talus., Patient and Methods: The mechanism of injury was forced ankle dorsiflexion and pronation, this mechanism was responsible of an avulsion of the posteromedial tubercle by the postero talotibial ligament and a fracture of lateral process by compression between the lateral malleolus and the calcaneus., Results: Conventional radiographs permitted the diagnosis of the lateral process fracture but the fracture of the posteromedial tubercle was showed only on CT scans., Discussion: The fracture of the posteromedial tubercle was treated by internal fixation, through a posteromedial approach. At 12 months follow-up the patient was able to walk without pain and radiographic result was excellent (no avascular necrosis of the tubercle and no Arthrosis of subtalar joint).

Tibiotalar dislocations without fracture are extremely rare lesions. This series included 16 patients, 12 of whom have been examined clinically and radiographically. The purpose of this study was to specify the injury mechanism of the various anatomical types and to assess the long term outcome. The group included eight posteromedial dislocations (50%), four posterior dislocations (25%), one anterior dislocation, one high variety, one of the Huguier type, and one complex dislocation. The sex ratio was 14 males/2 females with an average age of 37 years. In half of the cases, dislocations were open. The average follow-up period was 11 years (range, 1 to 26 years). The eight closed dislocations and the open case type I according to the Cauchoix classification received non-operative treatment by reduction in the emergency room and immobilization in a plaster cast for 6 weeks. The seven patients who presented open dislocations Cauchoix type 2 and type 3 were treated by surgical debridement and ligament repair, followed in all cases by a plaster cast boot, and in two cases by temporary transplantar pinning. Twelve patients were reexamined clinically according to the Gay and Evrard modified score, and were radiographically evaluated with lateral and anteroposterior views focused on the tibiotalar joint, on both sides, static and dynamic. Anatomical factors resulting in predisposition such as medial malleolus shortness or lack of coverage of the talus have been evaluated. No patient presented tibiotalar joint instability. A 5 degrees to 10 degrees loss in the range of dorsiflexion was frequently observed. Two patients presented joint stiffness. In four cases, patients complained about paresthesias in the areas of the anterior tibial nerve or intermediary dorsal cutaneous nerve. Four cases of degenerative arthritis were radiographically observed, two of which presented an overall narrowing of the joint over 50%. Degenerative arthritis had occurred within the first four years in these 4 cases. The talus coverage index was similar to the standard population. Shortness of the medial malleolus was present in only two cases. The long-term prognosis after tibiotalar dislocation without fracture proves to be good. One should favor orthopedic treatment. The absence of tibiotalar instability argues against carrying out emergency ligamentous repair. Evolution towards degenerative arthritis is to be anticipated in 25% of cases, especially following open dislocations, or if transplantar pinning was required due to instability of the initial reduction.

Unlabelled: Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked., Cases: These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2, Cases: These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4, Cases: The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

A 62 year old male developed transient osteoporosis algodystrophy successively in several sites of the lower limbs (8 episodes of involvement of one or two sites over an 8-year period) three years after surgery for a chromophobic pituitary adenoma. Two stress fractures developed, during the sixth and seventh years, respectively, in bones previously affected by osteoporosis. A biopsy specimen from the distal tibia showed thin bone trabeculae and reduced cellular activity. The only etiologic factor was the patient's psychological profile characterized by anxiety and introversion.

The talo-navicular joint takes a part in both talocalcaneal and midtarsal joints's motion. Its arthrodesis produces all but suppression of subtalar joint motion. If there is surgical indication for deformed but flexible foot, better than a standard resectional subtalar arthrodesis, talo-navicular arthrodesis, with easy technique, is successful to maintain correction in right position, specially for valgus flat foot.

Twenty-eight arthrodeses of the ankle have been reviewed with a mean follow-up of nine-and-a-half years. The arthrodeses were all carried out using the same technique of osteotomy of the lateral malleolus and fixation with a Charnley compression device. The main indication for fusion was post-traumatic arthritis. The number of complications, most of them benign, was not negligible and amounted to 42 per cent, including superficial infections, skin necroses and lesions of the posterior tibial nerve. Revision operations were needed in 17.5 per cent of cases during the year after operation, most of them for malposition. The clinical results were satisfactory in three-quarters of the cases and poor in one-quarter. Radiological changes in the joints distal to the fusion were relatively marked in the subtaloid joint and slightly less in the midtarsal joint. Theses changes are a source of concern for the future because of their pre-arthritic appearance and their progressive nature. Adaptive hypermobility of the midtarsal joint was seen in only one-third of the cases. The changes were greater when the hindfoot was in equinus, a position which was often aimed for in this series. The author advises internal fixation with screws and discusses the future potential for arthroplasty.

The authors report 7 cases of sub-taloid dislocation, to which they prefer Allieu's term of talo-navicular-calcaneal dislocation, either internal (the most frequent) or external (rare) depending on the direction of displacement of the foot. After studying their mechanism, they analyse the results, which, contrary to dislocation-fractures of the talus, are usually good, in spite of the frequency of subtalal arthritis.

The authors have observed 20 cases of subtalar dislocation, 16 with medial displacement and 4 with lateral displacement. The treatment given and the results are described. An experimental study has also been made which confirms that in medial dislocations the talo-navicular joint dislocates first whilst in lateral dislocations the talo-navicular joint dislocates last. The severity of assoicated lesions is emphasised. It is concluded that in severe displacement with complete extrusion of the talus, tibio-calcaneal arthrodesis gave better results than excision of the talus.

The authors have reviewed 23 fractures of the talus in children. They propose a classification based on the radiological maturity of the bone and the specific type of fracture. Group I: Children younger than 6 years (6 cases). The fracture line separates the bone into two parts. The diagnosis was difficult, with displacement being underestimated in some cases. Associated lesions in the same limb were present in 5 cases. Five fractures of the neck of the talus were treated conservatively with excellent or fair results. One comminuted fracture was treated surgically with a poor result. In all cases treatment should aim to maintain a good tibio-tarsal joint. Group II: Children older than 6 years (17 cases). Eight cases were osteochondral fractures, two were partial fractures and seven were complete fractures. Two of these developed subsequent avascular necrosis. The relationship between osteochondral fractures and osteochondritis is discussed.

Eight cases of talus enucleations are reported. The patients ranged in age from 18 to 62 years. The follow-up period in this study extended from one year to 12 years. The talus was reduced in six cases and usually fixed with a trans-plantar pin. The main problem in the conservative treatment was represented by early infection which required a calcaneo-tibial arthrodesis. On the other hand, necrosis of the talus, although unavoidable, is usually well tolerated. That may be explained by the fact that the necrosis is dense and congruous and does not lead to severe arthritic changes. Among 5 cases of necrosis of the talus, fusion of the ankle and of the sub-talar joint was indicated in only one patient. The authors conclude that the conservative treatment should be systematically tempted and that arthrodesis should be indicated only for the infections, that usually appear early or the osteoarthritic changes which appear later.