Original Article
Is the Hawkins sign able to predict necrosis in fractures of the neck of the astragalus?
¿Es el signo de Hawkins capaz de predecir la necrosis en las fracturas del cuello astragalino?
S. Rodríguez-Paz
, J.M. Muñoz-Vives, M.Á. Froufe-Siota
Corresponding author
Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Girona Josep Trueta, Girona, Spain
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"tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "403" "paginaFinal" => "408" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Is the Hawkins sign able to predict necrosis in fractures of the neck of the astragalus?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 993 "Ancho" => 1500 "Tamanyo" => 93664 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Varón de 38 años con fractura del cuello astragalino Hawkins tipo <span class="elsevierStyleSmallCaps">II</span> tras sufrir una precipitación (<a class="elsevierStyleCrossRef" href="#fig0010">fig. 2</a>a). 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "403" "paginaFinal" => "408" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Rodríguez-Paz, J.M. Muñoz-Vives, M.Á. Froufe-Siota" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Rodríguez-Paz" "email" => array:1 [ 0 => "susanarpaz@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Muñoz-Vives" ] 2 => array:2 [ "nombre" => "M.Á." "apellidos" => "Froufe-Siota" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Girona Josep Trueta, Girona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Es el signo de Hawkins capaz de predecir la necrosis en las fracturas del cuello astragalino?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1114 "Ancho" => 900 "Tamanyo" => 126119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image from a 31-year-old female suffering Hawkins type II talar neck fracture caused by a traffic accident (A and B). Radiographic control at 8 weeks after the trauma with no Hawkins sign (C). Magnetic resonance imaging scan showing avascular necrosis of the astragalus (D).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fractures of the astragalus (or talus) bone are highly uncommon lesions (0.1–0.85%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The peculiar anatomy of the talus, along with its distinctive vascular supply,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> make it a feared lesion due to the complications or sequelae that may result, especially avascular necrosis (AVN).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Hawkins<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> developed a classification scale for talar neck fractures based on the existence or absence of talar body dislocation and the type of dislocation: type I for vertical fractures of the neck without displacement, type II for fractures with subluxation or dislocation of the subtalar joint and type III for fractures with subluxation or dislocation of both the subtalar and tibiotalar joints. Subsequently, Canale and Kelly<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> described a fourth type for talar neck fractures associated not only to subtalar and tibiotalar dislocation, but also to talonavicular dislocation. This type of fracture also includes the only case described so far in the literature with neck fracture and dislocation, whilst maintaining the body of the astragalus in its anatomical position.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The relevance of the classification system offered by Hawkins lies in proving that the greater the dislocation of the body of the astragalus, the greater the lesion of its vascularization and, therefore, the greater the vascular damage. Thus, in Hawkins type I fractures, the damaged vessels are only those originating from the anterolateral portion of the neck. Type II lesions also affect vessels entering through the tarsal canal and sinus. In type III, 3 blood supply sources are damaged, as in type IV, with the difference that AVN which will take place will not only affect the talar body, but also the head.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Identifying the existence of bone necrosis is not always a simple task. Hawkins determined that between 6 and 8 weeks after the trauma it is detectable through the familiar Hawkins sign<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>: subchondral bone resorption in the talar dome, especially in ankle mortise and anteroposterior (AP) projections. The sign is said to be negative when it cannot be observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and positive when it can (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This sign indicates that the vascularization of the talus is preserved because it allows bone resorption caused by immobilization and disuse of the limb and, therefore, AVN is unlikely. However, its absence does not always imply necrosis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In order to reduce vascular damage, some authors advocate early reduction in talar neck fractures. However, no relationship has been found between the appearance of AVN and the time elapsed until fracture fixation. On the other hand, a relationship has been found with the level of comminution of the fracture, and with the fact of it being open or closed. This confirms that high-energy trauma lesions entail more complications and, therefore, a worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">During the elaboration of this work we retrospectively reviewed the medical records and complementary tests of patients with talar fractures treated at Dr. Josep Trueta University Hospital in Girona (tertiary center) over a period of 13 years, from January 1st, 1997 to December 31st, 2010. We found a total of 63 talar fractures. Of the total 31 talar neck fractures gathered, 23 were monitored (74%), representing a total of 21 patients (2 bilateral cases): 7 type I cases, 11 type II cases, 4 type III cases and the only type IV case. Follow-up had a mean duration of 23 months (range: 1 month to 11 years).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The variables collected in the study were age, gender, mechanism of injury (high- or low-energy trauma), fracture pattern (classified according to the anatomical region affected: head, neck and body of the astragalus, whilst the Hawkins<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> classification was used for neck fractures, including the fourth type added by Canale and Kelly<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>), soft tissue involvement (closed or open fractures according to the classification by Gustilo and Anderson<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>), type of reduction, type of treatment, complications, observation of Hawkins sign during monitoring of talar neck fractures and functional clinical outcomes according to the Hawkins scoring system.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We used the software packages Stata<span class="elsevierStyleSup">®</span> and SPSS<span class="elsevierStyleSup">®</span>. The statistical tests used were the Fischer test for 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2 contingency tables and the Kruskal–Wallis test to compare continuous and ordinal variables. We considered as statistically significant results of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>.05.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We evaluated the sensitivity and specificity of the Hawkins sign as a diagnostic test for the detection of AVN at 6–8 weeks of trauma.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">We collected 63 talar fractures, of which 31 affected the neck of the talus in 29 patients (2 bilateral cases).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Of these 29 patients, 90% were males (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>26). The mean age was 30 years, with a range varying from 5 to 56 years.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Except in 1 case, the mechanism of fracture was high-energy trauma: 23 traffic accidents and 6 falls.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We identified 12 Hawkins type I fractures, 13 type II, 5 type III and only 1 type IV fracture.</p><p id="par0070" class="elsevierStylePara elsevierViewall">After analyzing 31 talar neck fractures we found 4 open fractures (12%): 2 Gustilo type II (on a non-displaced fracture of the neck and on another with subtalar dislocation) and 2 Gustilo type III fractures of the talar neck with subtalar and tibiotalar dislocation (1 IIIA case and 1 IIIB case).</p><p id="par0075" class="elsevierStylePara elsevierViewall">After removing all type I fractures with no displacement and, therefore, not requiring reduction and 1 patient with type II talar neck fracture whose records did not indicate whether a reduction was performed or not, we obtained a total of 18 fractures which did undergo reduction. Of these, 14 were reduced in the first 48<span class="elsevierStyleHsp" style=""></span>h after arrival at the emergency room, with a mean value of 2 days and a range between 0 and 17 days. In 6 cases (33.3%) reduction was closed: 4 with Hawkins type II, 1 with type III and 1 with the only type IV fracture in the series. In 12 cases (66.6%) the reduction was open, of which 2 cases underwent an unsuccessful initial attempt at closed reduction: 8 cases of Hawkins type II fracture and 4 of type III.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In reference to the treatment performed, 17 of the 31 talar neck fractures (55%) were treated surgically and the rest were treated conservatively.</p><p id="par0085" class="elsevierStylePara elsevierViewall">When analyzing the type of treatment received, whether surgical or conservative, depending on the degree of displacement of the fracture according to the Hawkins classification, we found that 9 fractures (75%) without displacement received conservative treatment, 9 Hawkins type II fractures (69%) received surgical treatment, the 5 Hawkins type III talar neck fractures in the series all received surgical treatment, and the only case of Hawkins type IV fracture was treated conservatively.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Out of the fractures treated surgically, 11 (64%) underwent osteosynthesis with retrograde screws; in 4 (23%) cases with antegrade screws, in 1 case with Kirschner wires and in 1 case with external fixation.</p><p id="par0095" class="elsevierStylePara elsevierViewall">All intervened Hawkins type I talar neck fractures were treated with screws (2 retrograde and 1 antegrade), as was also the case in type II (7 retrograde and 2 antegrade). In type III there was more treatment variability: osteosynthesis with retrograde screws in 2 fractures, antegrade in 1, with needles in 1 and osteotaxis in 1.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The anteromedial approach was the most commonly employed (47%), followed by the posterolateral and anterolateral (23%, respectively). Only in 1 Hawkins type II fracture did we use a combination of 2 surgical approaches, anterior and posterior.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In 3 cases, in addition to surgery we also associated malleolar osteotomy in order to achieve a correct reduction and fixation of the fracture: in 2 Hawkins type III talar neck fractures we performed osteotomy of the tibial malleolus and in 1 Hawkins type II fracture of the fibular malleolus. A further 3 cases already presented a fracture of the tibial malleolus and this facilitated the approach: 1 in a Hawkins type I fracture, 1 in a type II and 1 in a type III.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The definitive surgical intervention took place after a mean period of 3 days (range: 0–17 days).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Complications appeared in 78% of fractures. In order of highest to lowest frequency, these were: posttraumatic arthritis (11), intolerance to osteosynthesis material (7), AVN (4), problems of skin necrosis or alteration of the healing process (4), infection (2), algodystrophy (or reflex sympathetic dystrophy) (1), irritation in the fibular region (1) and neurovascular lesion (1).</p><p id="par0120" class="elsevierStylePara elsevierViewall">Up to 48% of monitored talar neck fractures developed posttraumatic osteoarthritis: 5 cases of subtalar osteoarthritis (3 Hawkins type I fractures and 2 type II), 3 tibiotalar (1 case in a Hawkins type I fracture, 1 in a type II and 1 in a type III) and 3 with involvement of both joints (1 in a Hawkins type II fracture, 1 in a type III and 1 in the only case with type IV).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Only 1 case of subtalar osteoarthritis underwent arthrodesis. This corresponded to a type I talar neck fracture associated to a fracture of the lateral tuberosity.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Degenerative signs were not related to the displacement of the fracture (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.667) or to the fractures being open or closed (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.59).</p><p id="par0135" class="elsevierStylePara elsevierViewall">We detected 4 cases (17%) of AVN: 2 in Hawkins type II fractures and 2 in type III fractures (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Only 1 of the 4 cases of AVN appeared in a type II open fracture.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">AVN was not related to the displacement of the talar neck (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.273) or to the fracture being open or closed (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.562).</p><p id="par0145" class="elsevierStylePara elsevierViewall">After eliminating the fractures without displacement, we recorded the type of reduction performed, when it was performed and whether or not AVN appeared. Out of these 16 patients, only 11 (69%) underwent open reduction, 3 of whom presented AVN, and 5 cases of closed reduction, with only 1 case of AVN. In 1 case of AVN, the reduction was performed within the first 24<span class="elsevierStyleHsp" style=""></span>h after the lesion, in 2 cases within the first 48<span class="elsevierStyleHsp" style=""></span>h and in 1 case the reduction was delayed for 7 days. We found no relationship between the occurrence of AVN and a delay in reduction (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.569).</p><p id="par0150" class="elsevierStylePara elsevierViewall">We opted for conservative treatment in 7 of the 23 cases, in which only 1 case of AVN appeared, whilst in 16 cases we applied surgical treatment, 3 of which suffered AVN. The delay in surgery was less than 24<span class="elsevierStyleHsp" style=""></span>h in 1 case and less than 48<span class="elsevierStyleHsp" style=""></span>h in the other 2 cases. Delay in surgery was also unrelated to the occurrence of AVN (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.35).</p><p id="par0155" class="elsevierStylePara elsevierViewall">We assessed the presence or absence of Hawkins sign in the 23 patients with talar neck fracture. None of the 12 patients with positive Hawkins sign developed AVN (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.037). The following 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2 contingency table shows the corresponding data (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">If we assess the sensitivity and specificity of Hawkins sign as a diagnostic test for the detection of AVN following talar neck fracture, we obtain a sensitivity of 100%, a specificity of 37%, a positive predictive value of 100% and a negative predictive value of 63%.</p><p id="par0165" class="elsevierStylePara elsevierViewall">We observed Hawkins sign in talar body fractures, but there were no cases of AVN. All cases of AVN were due to talar neck fractures.</p><p id="par0170" class="elsevierStylePara elsevierViewall">In 1 case of type II talar neck fracture it is unknown whether the patient was maintained without load or for how long, whilst in another case the affected limb was kept without load for 8 months because the fracture was treated conservatively. In the other 2 cases of AVN in type III talar neck fractures, which were both treated surgically, the limb was maintained without load for 2 months after surgery. Full load was authorized after 3 months, once the consolidation of the fracture had been verified.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Patients were evaluated using the Hawkins Scoring System in order to assess their functional outcome. We found 9 patients with an excellent result (40%), 4 with a good result (17%), 7 with a moderate result (30%) and 3 with a poor outcome (13%).</p><p id="par0180" class="elsevierStylePara elsevierViewall">We evaluated whether there was a relationship between the degree of displacement of the fracture and the score on the Hawkins functional scale, that is, with the functional outcome obtained by the patient at the end of the follow-up period. No statistically significant differences were found (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.29).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">In our review we included 63 fractured taluses (31 fractures of the neck) which occurred within a period of 13 years. After eliminating patients who were lost during nearly 2 years of follow-up, we were left with 39 taluses (23 fractures of the neck) to perform our analysis and discuss the results.</p><p id="par0190" class="elsevierStylePara elsevierViewall">It is worth highlighting the predominance in the literature of males with a mean age in the fourth decade of life<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–16</span></a> and high-energy trauma as mechanism of lesion,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,9,10,12,14–16</span></a> as was also the case in our study.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The classification system proposed by Hawkins for talar neck fractures not only allows description of fracture patterns, but also helps to guide their treatment and predict the results.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,17</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Specifically analyzing the talar neck fractures included in our study, we found 12 Hawkins type I fractures, 13 type II, 5 type III and 1 type IV, which accounted for 39%, 42%, 16% and 3%, respectively.</p><p id="par0205" class="elsevierStylePara elsevierViewall">A total of 12% presented open fractures and the 2 cases of type III Gustilo fractures occurred in Hawkins type III fractures, that is, with considerable displacement.</p><p id="par0210" class="elsevierStylePara elsevierViewall">In 78% of cases, reduction of displaced fractures was performed within the first 48<span class="elsevierStyleHsp" style=""></span>h from the initial emergency care, as recommended by various authors to alleviate soft tissue involvement and minimize the risk of further injury to talar vascularization.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,11,18,19</span></a> Two-thirds of cases required an open reduction.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Up to 55% of talar neck fractures were treated surgically, with this rate increasing alongside the degree of fracture displacement: 25% in non-displaced fractures, 69% in Hawkins type II and 100% in type III.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The anteromedial approach was also the most commonly used in our series (47%).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12,14,16</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Despite the recommendations of Trillat et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Swanson et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and Ebraheim et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> who maintain that osteosynthesis with antegrade screws through a posterolateral approach distributes the load better, the technical difficulty entailed by this type of treatment limits its use. Surgeons require a longer learning curve and, due to the limited number of cases available, this is not always feasible. The mean delay in surgery was approximately of 3 days (range: 0–17 days).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,23</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">When assessing the complications in the group of talar neck fractures, posttraumatic arthrosis was the most common complication (48%), 3 times more so than AVN, albeit with a somewhat lower incidence than that reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10,19</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">When reviewing the literature, the reported incidence of AVN varies widely (0–67%).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6,7,11,16,19</span></a> This is partly due to the reduced number of cases examined by numerous studies, as well as to differences in the treatment protocols of the various researchers, which have changed over the years. What is common to all studies is that the rate of AVN is related to the Hawkins classification: the greater the displacement, the greater the number of affected vessels, the more blood supply to the talus is reduced and the greater the possibility of osteonecrosis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">We found 4 cases of AVN in 23 talar neck fractures (17%), a similar rate to that reported by other authors.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Our results can be explained by considering the anastomotic network of vessels that make up the blood supply to the talus. There were no cases of AVN in type I talar neck fractures because only 1 point of the blood supply corresponding to the anterolateral side of the talus was injured. The incidence of AVN was higher (18%) in Hawkins type II fractures because 2 blood supply paths to the talus were interrupted. It is natural to find that the incidence of AVN in Hawkins type III fractures was 50%, since the 3 blood supply paths were affected. We found no cases of AVN in Hawkins type IV fractures, although we only examined 1 patient.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> We found no significant differences regarding the onset of AVN and the degree of displacement of the talar neck and being open fractures.</p><p id="par0250" class="elsevierStylePara elsevierViewall">Although the recommendation for displaced talar neck fractures is to urgently reduce them in order to minimize the risk of necrosis, there are no studies demonstrating that urgent surgery reduces this possibility.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9–11,17,18</span></a> We found no relationship between the delay in reduction or fixation of the fracture and the onset of osteonecrosis.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Regarding the ability of Hawkins sign to predict the onset of AVN, we did find significant differences (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03), with a sensitivity of 100% (0 of 4) and a specificity of 37% (7 of 19).</p><p id="par0260" class="elsevierStylePara elsevierViewall">When comparing our results with those reported in the literature we found that we obtained a sensitivity equal to Tezval et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> but lower specificity than any other author.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,23,24</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The observation of Hawkins sign during patient follow-up will allow us to predict that the astragalus will not suffer necrosis. Conversely, if Hawkins sign is not observed we cannot assure that necrosis will appear, so other complementary tests, such as MRI, should be performed to confirm it.</p><p id="par0270" class="elsevierStylePara elsevierViewall">The functional results obtained by our patients were satisfactory, since 59% of them presented a good or excellent functional outcome. These figures were similar to those reported by other studies which also used the Hawkins Scoring System for assessment.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12,15</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Schulze et al. observed that the greater the severity of the injury, the lower the score obtained, although in our study we have not observed differences between the degree of displacement and the score obtained in the functional assessment scale.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Based on the knowledge of the precarious blood supply of the astragalus, early reduction, either by closed or open methods, should continue to be applied for displaced talar neck fractures.</p><p id="par0285" class="elsevierStylePara elsevierViewall">Surgical treatment becomes more relevant with increasing displacement of the fracture according to the Hawkins classification, with osteosynthesis using retrograde screws by an anteromedial approach being the most common.</p><p id="par0290" class="elsevierStylePara elsevierViewall">Positive Hawkins sign enables us to predict that a fractured talus will not develop AVN. The absence of Hawkins sign is not predictive of the onset of necrosis.</p><p id="par0295" class="elsevierStylePara elsevierViewall">The development of AVN (prevalence of 17%) is not related to the initial displacement of the fracture, being an open or closed fracture, or to a delay in reduction or surgery.</p><p id="par0300" class="elsevierStylePara elsevierViewall">The functional result is not related to the displacement of the fracture.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0305" class="elsevierStylePara elsevierViewall">Level of evidence IV.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0320" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0325" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres298326" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec281563" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres298325" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec281564" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack70205" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-16" "fechaAceptado" => "2013-09-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec281563" "palabras" => array:4 [ 0 => "Talus" 1 => "Avascular necrosis" 2 => "Fracture" 3 => "Hawkins sign" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec281564" "palabras" => array:4 [ 0 => "Astrágalo" 1 => "Necrosis avascular" 2 => "Fractura" 3 => "Signo de Hawkins" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess if the Hawkins sign can predict whether or not astragalus fractures of the neck will develop avascular necrosis. It is also assessed whether the occurrence of this complication is related to the displacement of the fracture, soft tissue injury, or delay in the reduction or surgery. The results were compared with those found in the literature.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 23 talar neck fractures recorded over a period of thirteen years. The following variables were analyzed: displacement of the fracture, soft tissue injury, delay and type of treatment, complications, observation of the Hawkins sign, and functional outcome.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were 7 type <span class="elsevierStyleSmallCaps">I</span> Hawkins fractures, 11 type <span class="elsevierStyleSmallCaps">II</span>, and 4 type <span class="elsevierStyleSmallCaps">III</span> and 1 type <span class="elsevierStyleSmallCaps">IV</span>. Four cases developed avascular necrosis (2 Hawkins type <span class="elsevierStyleSmallCaps">II</span> and 2 type <span class="elsevierStyleSmallCaps">III</span>). Hawkins sign was observed in 12 cases, of which none developed necrosis. Four cases with negative Hawkins sign developed necrosis. No statistically significant differences were found when comparing the development of avascular necrosis with the displacement of the fracture, soft tissue injury, or delay in treatment. Differences were found when comparing the development of avascular necrosis with the Hawkins sign (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03).</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A positive Hawkins sign rules out that the fractured talus has developed avascular necrosis, but its absence does not confirm it.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar si el signo de Hawkins predice que el astrágalo fracturado a nivel del cuello desarrollará o no una necrosis avascular (NAV), y determinar la relación con el desplazamiento de la fractura, la lesión de partes blandas, o la demora en la reducción o en la cirugía.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 23 fracturas de cuello de astrágalo recogidas durante 13 años. Se recogen las siguientes variables: desplazamiento de la fractura, lesión de partes blandas, demora y tipo de tratamiento, complicaciones, observación del signo de Hawkins y resultado funcional.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se registraron 7 fracturas Hawkins tipo <span class="elsevierStyleSmallCaps">I</span>, 11 tipo <span class="elsevierStyleSmallCaps">II</span>, 4 tipo <span class="elsevierStyleSmallCaps">III</span> y una tipo <span class="elsevierStyleSmallCaps">IV</span>. Cuatro casos desarrollaron una NAV (2 Hawkins tipo <span class="elsevierStyleSmallCaps">II</span> y 2 tipo <span class="elsevierStyleSmallCaps">III</span>). Se observó el signo de Hawkins en 12 casos, de los cuales ninguno desarrolló necrosis. Cuatro casos con signo de Hawkins negativo desarrollaron necrosis. No se hallaron diferencias al comparar el desarrollo de NAV con el desplazamiento de la fractura, la lesión de partes blandas o la demora en el tratamiento. Sí se hallaron diferencias al comparar el desarrollo de NAV con la observación del signo de Hawkins (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,03).</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El signo de Hawkins positivo descarta que el astrágalo fracturado desarrolle una NAV, pero su ausencia no lo confirma.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez-Paz S, Muñoz-Vives JM, Froufe-Siota MA. ¿Es el signo de Hawkins capaz de predecir la necrosis en las fracturas del cuello astragalino? Rev Esp Cir Ortop Traumatol. 2013;57:403–408.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1114 "Ancho" => 900 "Tamanyo" => 126119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image from a 31-year-old female suffering Hawkins type II talar neck fracture caused by a traffic accident (A and B). Radiographic control at 8 weeks after the trauma with no Hawkins sign (C). Magnetic resonance imaging scan showing avascular necrosis of the astragalus (D).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 596 "Ancho" => 900 "Tamanyo" => 61081 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Image from a 38-year-old male suffering Hawkins type II talar neck fracture caused by a fall (A). Radiographic control at 6 weeks after the trauma showing positive Hawkins sign (B). The patient did not suffer necrosis of the astragalus.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 775 "Ancho" => 1668 "Tamanyo" => 61994 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Number of cases of avascular necrosis according to the type of talar neck fracture.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AVN: avascular necrosis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AVN</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">Hawkins sign</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab436093.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2 contingency table showing the number of cases with positive and negative Hawkins sign, as well as the number of patients who developed avascular necrosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fracturas del astrágalo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. 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Ingelfinger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2003" "editorial" => "BG-Klinik Bergmannsheil, der Ruhr-Universität-Bochum" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack70205" "titulo" => "Acknowledgements" "texto" => "<p id="par0330" class="elsevierStylePara elsevierViewall">I wish to express my gratitude to the coauthors of this work for guiding me during these months of hard work and granting me some of their precious time.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/19888856/0000005700000006/v1_201312121036/S1988885613000941/v1_201312121036/en/main.assets" "Apartado" => array:4 [ "identificador" => "7577" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/19888856/0000005700000006/v1_201312121036/S1988885613000941/v1_201312121036/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885613000941?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 0 | 16 |
| 2024 October | 45 | 4 | 49 |
| 2024 September | 79 | 7 | 86 |
| 2024 August | 53 | 7 | 60 |
| 2024 July | 49 | 5 | 54 |
| 2024 June | 52 | 2 | 54 |
| 2024 May | 34 | 4 | 38 |
| 2024 April | 33 | 3 | 36 |
| 2024 March | 54 | 6 | 60 |
| 2024 February | 68 | 12 | 80 |
| 2024 January | 55 | 12 | 67 |
| 2023 December | 69 | 15 | 84 |
| 2023 November | 67 | 9 | 76 |
| 2023 October | 101 | 14 | 115 |
| 2023 September | 44 | 4 | 48 |
| 2023 August | 42 | 6 | 48 |
| 2023 July | 71 | 6 | 77 |
| 2023 June | 58 | 7 | 65 |
| 2023 May | 56 | 8 | 64 |
| 2023 April | 34 | 1 | 35 |
| 2023 March | 60 | 3 | 63 |
| 2023 February | 63 | 4 | 67 |
| 2023 January | 63 | 4 | 67 |
| 2022 December | 50 | 6 | 56 |
| 2022 November | 59 | 14 | 73 |
| 2022 October | 44 | 9 | 53 |
| 2022 September | 52 | 6 | 58 |
| 2022 August | 57 | 8 | 65 |
| 2022 July | 45 | 6 | 51 |
| 2022 June | 45 | 15 | 60 |
| 2022 May | 46 | 10 | 56 |
| 2022 April | 38 | 11 | 49 |
| 2022 March | 65 | 9 | 74 |
| 2022 February | 58 | 6 | 64 |
| 2022 January | 58 | 5 | 63 |
| 2021 December | 51 | 15 | 66 |
| 2021 November | 55 | 8 | 63 |
| 2021 October | 45 | 12 | 57 |
| 2021 September | 14 | 12 | 26 |
| 2021 August | 35 | 8 | 43 |
| 2021 July | 30 | 9 | 39 |
| 2021 June | 17 | 7 | 24 |
| 2021 May | 22 | 9 | 31 |
| 2021 April | 25 | 23 | 48 |
| 2021 March | 18 | 14 | 32 |
| 2021 February | 11 | 12 | 23 |
| 2021 January | 8 | 8 | 16 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 10 | 0 | 10 |
| 2018 January | 10 | 1 | 11 |
| 2017 December | 13 | 0 | 13 |
| 2017 November | 10 | 1 | 11 |
| 2017 October | 14 | 3 | 17 |
| 2017 September | 14 | 3 | 17 |
| 2017 August | 19 | 1 | 20 |
| 2017 July | 10 | 1 | 11 |
| 2017 June | 27 | 10 | 37 |
| 2017 May | 33 | 0 | 33 |
| 2017 April | 26 | 2 | 28 |
| 2017 March | 19 | 1 | 20 |
| 2017 February | 42 | 4 | 46 |
| 2017 January | 34 | 0 | 34 |
| 2016 December | 16 | 3 | 19 |
| 2016 November | 12 | 2 | 14 |
| 2016 October | 40 | 4 | 44 |
| 2016 September | 31 | 9 | 40 |
| 2016 August | 16 | 0 | 16 |
| 2016 July | 12 | 1 | 13 |
| 2016 June | 15 | 27 | 42 |
| 2016 May | 10 | 15 | 25 |
| 2016 April | 16 | 7 | 23 |
| 2016 March | 17 | 9 | 26 |
| 2016 February | 9 | 20 | 29 |
| 2016 January | 7 | 10 | 17 |
| 2015 December | 5 | 15 | 20 |
| 2015 November | 7 | 11 | 18 |
| 2015 October | 0 | 3 | 3 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
| 2015 April | 0 | 1 | 1 |
| 2015 February | 1 | 0 | 1 |
| 2014 March | 1 | 0 | 1 |
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