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Médecine et chirurgie du pied

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The Place of Talus Drilling in Avascular Necrosis: a Case Study and a Literature Review Volume 31, issue 4, Décembre 2015

Authors

Introduction

The talus is the second largest tarsal bones, with very precarious vascular network, the type II Hawkins classification, exposed to a risk of 20–50% of avascular necrosis.

Medical observation

In January 2013, L.K., a 30-year-old patient, presented a polytraumatism, with a type II fracture of the neck of the left talus confirmed by computed tomography (CT) and classified by Hawkins, amended by Canale and Kelly. The fracture has been fixed by screwing in open reduction with internal fixation. After 10 months, the patient reported pain. Magnetic resonance imaging (MRI) was requested to confirm the diagnosis of talar osteonecrosis, and the surgical decision was to place a drill bit with a cannulated 3.2 mm making two holes associated with the end of a splint for 2 weeks with a non-weight-bearing instruction for 3 months. The patient then reported pain relief.

Discussion

The osteonecrosis of the talus is not only the consequence of vascular disruption induced by lesions of the talar capsule, but also by surgery. Plain radiography still plays a crucial role in the diagnosis. Tezval et al. confirmed the value of the sign of Hawkins as an excellent predictor of vascularization of the talus after a fracture. Thordarson et al. have evaluated the interest of MRI in monitoring osteosynthesis. Horst et al. described the drilling technique. It is indicated in stages I and II of talar osteonecrosis, or they use a bit of small pins from 1.5 to 2.0 or 4.0 mm. They realize with the first several holes, while with the 4.0 mm drill, they use 2–4 holes posterolateral route between the fibular tendons and the calcanues tendon, rarely by lateral or medial direction.

Conclusion

Avascular osteonecrosis is one of the major complications of fractures of the talus. Plain radiography, followed by MRI remains a modality of choice to help early care where drilling retains a prominent place in order to obtain a good clinical and radiological result for stages I and II, but need mastery of technique and close monitoring of patients.