Original Article
Talus fractures. Functional results for polytraumatized patients
Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados
F.J. Hierro-Cañas
, P. Andrés-Cano, G. Rabadán-Márquez, M.A. Giráldez-Sánchez, P. Cano-Luis
Corresponding author
Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Functional results for polytraumatized patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "336" "paginaFinal" => "341" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F.J. Hierro-Cañas, P. Andrés-Cano, G. Rabadán-Márquez, M.A. Giráldez-Sánchez, P. Cano-Luis" "autores" => array:5 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Hierro-Cañas" "email" => array:1 [ 0 => "javi.hierro89@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Andrés-Cano" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Rabadán-Márquez" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Giráldez-Sánchez" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Cano-Luis" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 965 "Ancho" => 1583 "Tamanyo" => 40720 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Surgical delay according to group.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction and objectives</span><p id="par0005" class="elsevierStylePara elsevierViewall">Talus fractures are one of the most severe ankle fractures due to the difficulty of treatment and the major sequelae they may cause. Fractures of this type are not very common, at around 0.1–0.85% of fractures of the human body and approximately 3% of those affecting the foot. This is because the talus is very well protected by the bone and ligament covering that keeps it in its anatomical position. Although there are not many such fractures, they are highly important in prognostic and social terms due to their associated high rate of complications and functional sequelae.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The high rate of complications<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> has been associated historically with the poor vascularisation and peculiar anatomy of this tarsal bone, with more than 60% of its surface covered in joint cartilage. However, in recent years studies have shown that it does not have such poor vascularisation.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3–5</span></a> The most important complications include arthrosis of one of the neighbouring joints, which often have to be treated by arthrodesis, and avascular necrosis (AVN).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> Talus neck fractures may be classified according to Hawkins’ classification, which we describe below, and we will be able to know the probabilities of one of these complications arising according to the type of fracture in question.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Fractures of this type are usually secondary to high energy trauma,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> generally traffic accidents and falls from a great height, so that they may occur within the context of multiple trauma that, for many reasons, may compromise the functional prognosis even more. This is because of the need for surgery to control injuries and bring about initial stabilisation, and this usually delays the definitive osteosynthesis of the talus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to analyse the functional results and clinical evolution of patients operated on in our hospital for talus fractures, regardless of whether or not they occurred within the context of polytraumatism.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">After approval by the hospital ethics committee an observational study was performed of a retrospective cohort of 24 patients operated on for talus fracture in our hospital from March 2008 to June 2016. All of the patients were evaluated during a visit or telephonically at the end of follow-up, and they were informed that their data would be used in the study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">All of the patients operated on in the hospital for talus fracture were included, regardless of whether an open reduction with internal fixation or closed reduction and internal fixation had been performed, independently of the osteosynthesis executed<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9–12</span></a> (Kirschner needles or cannulated screws). The time lapse from the moment of the fracture to the surgical operation was also recorded. Cases of pure luxation of the talus or posttraumatic osteochondral lesions of the same were excluded.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The sociodemographic variables reviewed were age at the moment of injury, sex, patient comorbidities and whether or not they were smokers at the time of the fracture.</p><p id="par0040" class="elsevierStylePara elsevierViewall">All of the fractures were classified radiographically by simple X-ray and CT<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13,14</span></a> according to Hawkins’ classification.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> Type I, fractures without displacement; type <span class="elsevierStyleSmallCaps">ii,</span> fractures with associated luxation or subluxation of the subtalar joint; type <span class="elsevierStyleSmallCaps">iii,</span> with luxation of the subtalus and tibiotalar joint; and type <span class="elsevierStyleSmallCaps">iv,</span> which adds luxation of the talar-scaphoid joint to the others. All types of fracture were included in the study. Records were also kept of whether lesions were open or closed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The Injury Severity Score (ISS)<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> scale was used to define the 2 main groups in the study: ISS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16 for polytraumatised patients and ISS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>16 points for those who were not polytraumatised. Other data recorded were the other types of injuries in polytraumatised patients<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> (CET, facial injuries, abdominal injuries, pelvic or spinal trauma, thoracic trauma and associated fractures).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Evaluation of functional results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The Analogue Visual Scale (AVS) was used to make it possible to analyse the results of these interventions. This enables measurement of the pain felt by patients subjectively on a scale from 0 to 10, where 0 is the absence of pain and 10 is the maximum possible pain. Postoperative functionality was evaluated using the Foot and Ankle Disability Index (FADI).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> This questionnaire was designed to evaluate the functional limitations arising due to foot and ankle pathologies, taking into account pain and the difficulty in performing certain everyday activities. FADI scores run from 0 to 100, where 100 is no discomfort or difficulty for any of the activities asked about, and 0 is complete disability and unbearable pain for the activities recorded.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally the appearance of the most frequent complications following talus fracture were recorded during follow-up; development into clinically significant arthrosis, the need for arthrodesis in any of the neighbouring joints or the development of AVN in the same. The absence of Hawkins’ sign<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> was used to diagnose necrosis, and a MR scan was taken in all cases.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> The Ficat and Arlet AVN scale was used, modified for the ankle and based on radiology (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The data from both scales and the record of complications were compiled in surgeries after the consent of the patient at the time of undertaking this study, so the time of evolution coincides with the follow-up time, which amounted to an average of 4.2 years (.5–9 years).</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Demographic data</span><p id="par0065" class="elsevierStylePara elsevierViewall">24 patient cases were reviewed, with 25 talus fractures (one case of bilateral fracture is included) in the period from March 2008 to June 2016, operated on in our hospital and with an average age of 38 years old (19–75 years old). The average follow-up time was 4.2 years (.5–9 years).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Talus fractures are considered to be an emergency according to current evidence.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> In this study 64% (16/25) of talus fractures were operated on in less than 24<span class="elsevierStyleHsp" style=""></span>h, 12% were operated on from 24<span class="elsevierStyleHsp" style=""></span>h to 48<span class="elsevierStyleHsp" style=""></span>h, and 24% (6/25) were operated on after more than 48<span class="elsevierStyleHsp" style=""></span>h. The last group includes 4 cases that have a delay of more than 2 days in their diagnosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">According to Hawkins’ classification, 12% (3) of the fractures were type <span class="elsevierStyleSmallCaps">i</span>, 32% (8) were type <span class="elsevierStyleSmallCaps">ii</span>, 32% (8) were type <span class="elsevierStyleSmallCaps">ii</span> and 16% (4) were type <span class="elsevierStyleSmallCaps">iv</span>. There was only one case (4%) of an open lesion.</p><p id="par0080" class="elsevierStylePara elsevierViewall">According to the ISS<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> and classifying the patients as polytraumatised (ISS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16) or not polytraumatised (ISS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>16) 56% of patients were found to be polytraumatised (14) while 44% of patients (11) had suffered an isolated talus fracture. The average ISS score was 18 (13–48).</p><p id="par0085" class="elsevierStylePara elsevierViewall">The most common associated lesion in the group of polytraumatised patients was pelvic or spinal trauma; in 63% of cases (7/11) in our series talus fracture was associated with fracture of the pelvic ring or spinal column. In 45% of patients (5/11) with an ISS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16 the diagnosis was accompanied by thoracic trauma involving rib or sternum fracture, and in 27% there was associated CET.</p><p id="par0090" class="elsevierStylePara elsevierViewall">No complications were recorded in 48% of patients during follow-up, while 36% (9) developed arthrosis, of which 12.5% (5) were operated for arthrodesis and 12% developed AVN.</p><p id="par0095" class="elsevierStylePara elsevierViewall">At the time of the examination the average score recorded on the AVS was 4.96, within a range of from 0 to 9. The average score on the FADI<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> was 70 points (29–100).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Data analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">Once the 24 patients had been divided into the 2 groups described above of polytraumatised and non-polytraumatised patients, they were examined and the distribution of the variables recorded was analysed.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Descriptive statistical analysis was performed using SPSS<span class="elsevierStyleSup">®</span> v.20 (IBM Chicago, IL, U.S.A.) software, with core tendency and dispersion measurements for quantitative variables and frequency distribution for qualitative variables. Bivariate analysis of the distribution between groups was applied, where the grouping variable was whether or not patients were polytraumatised. The chi-squared test was applied to qualitative variables and the Mann–Whitney <span class="elsevierStyleItalic">U</span> test was used for quantitative variables. The limit of significance was set at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p><p id="par0110" class="elsevierStylePara elsevierViewall">A similar distribution between both groups was found for the Hawkins’ classification (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>): type <span class="elsevierStyleSmallCaps">i</span> 18.2% in polytraumatised patients vs 7.1% in non-polytraumatised patients; type <span class="elsevierStyleSmallCaps">ii</span> 36.4% in polytraumatised patients vs 28.6% in non-polytraumatised patients; type <span class="elsevierStyleSmallCaps">iii</span> 27.3% in polytraumatised patients vs 35.7% in non-polytraumatised patients, and type <span class="elsevierStyleSmallCaps">iv</span> 9.1% in polytraumatised patients vs 21.4% in non-polytraumatised patients. These differences were not statistically significant.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Respecting surgical delay (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), in non-polytraumatised patients 85.7% were operated on in less than 24<span class="elsevierStyleHsp" style=""></span>h vs 36.4% of polytraumatised patients. No non-polytraumatised patient was operated on after a delay of from 24<span class="elsevierStyleHsp" style=""></span>h to 48<span class="elsevierStyleHsp" style=""></span>h, while 3/11 (36.4%) of the polytraumatised patients were operated on in this period. As was pointed out above, 6 patients were operated on more than 48<span class="elsevierStyleHsp" style=""></span>h after the fracture occurred, in the majority of cases due to delayed diagnosis. 2 of these patients were non-polytraumatised (14.3%) and 4 were polytraumatised (36.4%). No statistically significant differences were found in terms of surgical delay between both groups.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Respecting the evaluation of the functional results for the groups on the FADI<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> scale (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a) the score was 62/100 in the polytraumatised patients and 76.95/100 in the non-polytraumatised patients (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.232). The score on the AVS (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>b) was 5.8 in the group of polytraumatised patients and 4.3 in the non-polytraumatised patients (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.257).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">When the frequency of complications was analysed (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) according to the group in which patients were assigned, it was found that 57% of the patients with an isolated talus fracture developed no adverse events, while only 36% of the patients who suffered such a fracture in the context of polytraumatism did not develop any associated complications. 35% of the group of non-polytraumatised patients% (5/14) had clinical and radiological signs of arthrosis in one of the neighbouring joints, of which 28% (4) required arthrodesis in one of them. These figures are similar to those for polytraumatised patients, of which 36% (4/11) had arthrosis and 27% (3) required arthrodesis. <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> shows the accumulated percentage to be higher than 100% because the “arthrosis” heading included the patients subjected to arthrodesis due to arthrosis.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">None of the patients included in the group of non-polytraumatised patients has been diagnosed AVN at the time of this study, while 27% of the polytraumatised patients (3/11) have satisfied criteria for the diagnosis of tarsal AVN.</p><p id="par0135" class="elsevierStylePara elsevierViewall">No statistically significant differences were found between both groups in terms of the appearance of complications.</p><p id="par0140" class="elsevierStylePara elsevierViewall">No statistically significant differences were found between the other sociodemographic variables (age, sex, smoker/non-smoker or the side of the fracture) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">An observational study was performed on a retrospective cohort of 25 talus fractures operated on in our hospital. A series of demographic variables were recorded and the patients were divided into 2 groups, of polytraumatised patients and non-polytraumatised patients, according to the ISS classification. After this division the functional results were studied, together with the incidence of complications in both groups.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Treating talus fractures is still a challenge for surgeons, and they continue to arouse a high level of interest due to the impact which the results of treatment may have on patients’ quality of life.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In this study the average AVS and FADI scores showed better results in the group with isolated talus fracture. The polytraumatised patients had an average AVS of 5.8 vs 4.3 in the other group, showing that there is a certain tendency in our sample for the polytraumatised patients to feel greater subjective residual pain. The statistical analysis of these data gave a value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.257, so that we can conclude that the differences are not statistically significant.</p><p id="par0160" class="elsevierStylePara elsevierViewall">As was the case for pain, the functional results recorded in this work by the FADI scale also show worse results in the group of polytraumatised patients. More specifically, the average FADI score in the polytraumatised patients was 76.95/100 vs 62/100 in the group of non-polytraumatised patients. Following statistical analysis of these data the conclusion was reached that the differences were not statistically significant, as <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.05 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.232), probably due to the small size of the sample. In any case a tendency was detected for polytraumatised patients with talus fractures to have greater functional sequelae in the extremity.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The other aspect analysed was comparison of the incidence of complications associated with talus fracture between both groups. In our series 43% of the patients with isolated talus fracture developed some type of adverse event prior to the date of the study, vs 64% of the polytraumatised patients. The incidence of AVN was also analysed, and none of the patients with isolated talus fracture developed this complication while 3 of the 11 fractures in the group of polytraumatised patients fulfilled the diagnostic criteria for AVN of the talus. This last complication, talar AVN, is the result of fracture of the neck or head of the talus in 75% of cases.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> It gives rise to a major challenge for the surgeon because of the same factors that were described above, the precarious vascularisation and anatomical arrangement of this bone. Up to 31% of talus fractures eventually develop this complication of AVN.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Talar AVN is a cause of ankle fracture that is hard to diagnose, and it is often the consequence of fracture of the talus. Talar osteonecrosis arises when there is a reduction in the vascular supply to the talus and the bone is deprived of its source of oxygen. This may occur alone or in association with bone loss, collapse, sepsis, deformity and severe arthritis of the neighbouring joints.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Based on these data it can be said that there is a certain tendency for the prognosis in talus fractures to be worse in the context of multiple trauma, and it would be necessary to study the possible causes of this. One of the proposed causes is the increased delay prior to surgery, as polytraumatised patients have to be stabilised beforehand, together with other emergency procedures. Although some papers<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,22,23</span></a> find no differences in terms of functional results or the rate of complications depending on the time lapse between a fracture and its definitive fixation, in our series there is a tendency for the delay to be longer in polytraumatised patients, so that this hypothesis may explain our results. However, the said studies<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,22,23</span></a> consider any type of open fracture to be a surgical emergency, together with reduction in the case of luxation.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The purpose of this study was to determine the differences in the functional results of talus fractures operated on in polytraumatised patients and others with an isolated talus fracture. Other factors were also studied, as they may influence the functional results and possible complications. Follow-up was achieved with only one loss, and a sufficiently large sample size was achieved for analysis of both groups. It should also be pointed out that the type of sample stratification used of polytraumatised and non-polytraumatised patients, would require a study with a larger sample to make it possible to draw significant conclusions in the resulting analyses.</p><p id="par0185" class="elsevierStylePara elsevierViewall">No differences were found in the results obtained according to fracture type according to Hawkins’ classification or the sociodemographic variables studied (age at the time of trauma, sex, patient comorbidities and whether or not they smoked or when the fracture occurred).</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study found less a favourable clinical evolution and functional results in patients with talus fracture in the context of multiple traumas, in comparison with the patients with an isolated fracture that was operated on. The former scored 1.5 points worse on the AVS and 14.95 points less on the FADI.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Thanks to the introduction of the damage control concept in the treatment of polytraumatised patients, their morbidity and mortality have declined in recent decades. The lesions that traditionally have a poor prognosis and which may lead to severe functional restriction over the long term, such as talus fractures, requires therapeutic optimisation in polytraumatised patients to improve their clinical results over the long term.</p><p id="par0200" class="elsevierStylePara elsevierViewall">With all of these arguments we may conclude that it is necessary to optimise the management of talus fractures in the emergency department in polytraumatised patients, to improve the results of surgical treatment.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Level of evidence</span><p id="par0205" class="elsevierStylePara elsevierViewall">Level of evidence II.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1239356" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1150222" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1239355" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1150223" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction and objectives" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and method" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Evaluation of functional results" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Demographic data" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Data analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Level of evidence" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-09-04" "fechaAceptado" => "2019-04-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1150222" "palabras" => array:5 [ 0 => "Talus" 1 => "Fracture" 2 => "Trauma" 3 => "Polytraumatized" 4 => "Functional results" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1150223" "palabras" => array:5 [ 0 => "Astrágalo" 1 => "Fractura" 2 => "Trauma" 3 => "Politraumatismo" 4 => "Resultados funcionales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Talar fractures are uncommon lesions (0.1–0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to analyse the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Observational study on a retrospective cohort of 24 patients operated in our centre (2008–2016). They were grouped according to whether they were polytraumatized (ISS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16) or not (ISS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI –Foot and Ankle Disability Index) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Review of 25 talar fractures in 24 patients with a mean age of 38 years (19–75) and a mean follow-up of 4.2 years (0.5–9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las fracturas de astrágalo son lesiones poco frecuentes (0,1-0,9%) y con un alto índice de complicaciones. Una de las situaciones en las que puede darse una fractura de astrágalo es en el contexto de un politraumatismo, lo que puede comprometer aún más el pronóstico funcional.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente trabajo ha sido analizar los resultados funcionales en los pacientes con fracturas de astrágalo según se produjeran en el contexto de un politraumatismo o no.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional sobre una cohorte retrospectiva de 24 pacientes intervenidos por fractura de astrágalo en nuestro centro (2008-2016). Se agruparon según fuesen politraumatizados (ISS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16) o no (ISS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>16). Revisión de variables sociodemográficas, radiográficas, funcionales (escala EVA de dolor y FADI –Foot and Ankle Disability Index–) y la aparición de complicaciones como artrosis o necrosis avascular.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Revisión de 25 fracturas de astrágalo en 24 pacientes con una edad media de 38 años (19-75) y un seguimiento medio de 4,2 años (0,5-9). Según el ISS un 44% de pacientes (11) fueron politraumatizados y un 56% (14) no.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Respecto a los resultados funcionales entre politraumatizados y no politraumatizados, la puntuación media según la escala FADI fue de 62 puntos y de 76,9 respectivamente y según la escala EVA fue de 5,8 y 4,3 puntos respectivamente.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Respecto a las complicaciones, en el grupo de politraumatizados se presentaron en un 64% de los pacientes y en los no politraumatizados en un 43%. Un 36% de los pacientes politraumatizados tuvieron signos clínicos y radiológicos de artrosis subastragalina y un 27% fueron intervenidos mediante una artrodesis frente al 35% y al 27% del grupo de no politraumatizados, Respecto a la necrosis avascular del astrágalo, se registro un 27% frente a un 0% de los no politraumatizados.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hierro-Cañas FJ, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez MA, Cano-Luis P. Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados. Rev Esp Cir Ortop Traumatol. 2019;63:336–341.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1172 "Ancho" => 1583 "Tamanyo" => 74539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Percentages of fracture type according to group.</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" => 965 "Ancho" => 1583 "Tamanyo" => 40720 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Surgical delay according to group.</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" => 877 "Ancho" => 2158 "Tamanyo" => 44089 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">(a) Average FADI according to group. (b) Average AVS according to group.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 895 "Ancho" => 1583 "Tamanyo" => 47340 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Complications according to group.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Radiology \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cysts or osteosclerotic lesions, with no subchondral fractures or loss of talus outline \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subchondral collapse \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IV \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Narrowing of the joint space, changes in the distal tibia (cysts, osteophytes and chondral destruction) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117771.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Ficat and Arlet AVN staging.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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"><th 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" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Polytraumatism (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No polytraumatism (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.7 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M: 4 (36.4%)H: 7 (63.6%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M: 5 (35.7%)H: 9 (64.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Side \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I: 4 (36.4%)D: 7 (63.6%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I: 7 (50%)D: 7 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smokers \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes: 6 (54.5%)No: 5 (45.5%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes: 4 (28.6%)No: 10 (71.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRIF: 7 (63.6%)ORIF: 4 (36.4%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRIF: 9 (64.3%)ORIF: 5 (35.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117770.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Variables studied in both groups.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional outcomes following displaced talar neck fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.W. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 1 | 7 |
| 2024 October | 26 | 1 | 27 |
| 2024 September | 48 | 3 | 51 |
| 2024 August | 38 | 5 | 43 |
| 2024 July | 34 | 3 | 37 |
| 2024 June | 27 | 2 | 29 |
| 2024 May | 23 | 3 | 26 |
| 2024 April | 60 | 6 | 66 |
| 2024 March | 66 | 2 | 68 |
| 2024 February | 49 | 8 | 57 |
| 2024 January | 40 | 6 | 46 |
| 2023 December | 46 | 11 | 57 |
| 2023 November | 24 | 3 | 27 |
| 2023 October | 34 | 11 | 45 |
| 2023 September | 11 | 1 | 12 |
| 2023 August | 18 | 5 | 23 |
| 2023 July | 14 | 3 | 17 |
| 2023 June | 24 | 2 | 26 |
| 2023 May | 59 | 4 | 63 |
| 2023 April | 63 | 7 | 70 |
| 2023 March | 41 | 1 | 42 |
| 2023 February | 35 | 2 | 37 |
| 2023 January | 44 | 6 | 50 |
| 2022 December | 16 | 6 | 22 |
| 2022 November | 32 | 3 | 35 |
| 2022 October | 34 | 6 | 40 |
| 2022 September | 22 | 5 | 27 |
| 2022 August | 24 | 4 | 28 |
| 2022 July | 23 | 10 | 33 |
| 2022 June | 22 | 7 | 29 |
| 2022 May | 29 | 9 | 38 |
| 2022 April | 34 | 8 | 42 |
| 2022 March | 29 | 6 | 35 |
| 2022 February | 23 | 6 | 29 |
| 2022 January | 17 | 11 | 28 |
| 2021 December | 34 | 10 | 44 |
| 2021 November | 37 | 9 | 46 |
| 2021 October | 80 | 9 | 89 |
| 2021 September | 52 | 7 | 59 |
| 2021 August | 56 | 3 | 59 |
| 2021 July | 21 | 5 | 26 |
| 2021 June | 18 | 10 | 28 |
| 2021 May | 19 | 2 | 21 |
| 2021 April | 40 | 16 | 56 |
| 2021 March | 27 | 9 | 36 |
| 2021 February | 10 | 8 | 18 |
| 2021 January | 13 | 4 | 17 |
| 2020 December | 2 | 0 | 2 |
| 2019 September | 1 | 0 | 1 |
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