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 ::  Abstract
 ::  Case History
 ::  Discussion
 ::  Conclusion
 ::  References
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CASE REPORT
Year : 2008  |  Volume : 54  |  Issue : 2  |  Page : 140-143

Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy: A dual case report


1 Department of Orthopedics, Meir University Hospital, Sapir Medical Center, Kfar Saba, Israel
2 Department of Orthopedics, Meir University Hospital, Sapir Medical Center, Kfar Saba; Ribstein Center for Research and Sports Medicine Sciences, Wingate Institute, Israel
3 Rambam Hyperbaric Unit, Elisha Hospital, Haifa, Israel

Correspondence Address:
O Mei-Dan
Department of Orthopedics, Meir University Hospital, Sapir Medical Center, Kfar Saba
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.40782

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 :: Abstract 

Talar neck fractures are a rare injury that account for less then 2% of all foot fractures. Displaced fractures are associated with an exceedingly high rate of avascular necrosis (AVN). The incidence of AVN following Hawkins Type 3 fractures of the talar neck may approach 100%, particularly if diagnosis and reduction are delayed. Severe cases may present as pain and disability of the ankle and the subtalar joints due to a talar dome collapse, resulting in degenerative changes that usually require hind foot arthrodesis. We present two cases of traumatic displaced talar neck fractures which were treated surgically more than 2 weeks following injury due to a delay in diagnosis. Both patients underwent hyperbaric oxygen therapy (HBOT) after the operation and neither resulted in AVN of the talus in a three-year follow-up. We suggest that this favorable result may be due to the beneficial effects of HBOT.


Keywords: Avascular necrosis, hyperbaric oxygen therapy, talar fracture


How to cite this article:
Mei-Dan O, Hetsroni I, Mann G, Melamed Y, Nyska M. Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy: A dual case report. J Postgrad Med 2008;54:140-3

How to cite this URL:
Mei-Dan O, Hetsroni I, Mann G, Melamed Y, Nyska M. Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy: A dual case report. J Postgrad Med [serial online] 2008 [cited 2019 May 20];54:140-3. Available from: http://www.jpgmonline.com/text.asp?2008/54/2/140/40782


Talar neck fractures are a rare injury, [1],[2],[3],[4] that account for less then 2% of all foot fractures. [5] Displaced fractures are associated with an exceedingly high rate of avascular necrosis (AVN). [6],[7] The major causes of talar neck fractures associated with AVN are devastating motor vehicle accidents and falls from height. [2],[8]

The incidence of AVN following Hawkins Type 3 fractures of the talar neck (talar neck fracture with dislocations involving the subtalar and ankle joints) may approach 100%, [9],[10] particularly if diagnosis and reduction are delayed. [1],[2],[3]

Severe cases may present as pain and disability of the ankle and the subtalar joints due to a talar dome collapse, resulting in degenerative changes that usually require hind foot arthrodesis. [11]

We present two cases of traumatic displaced talar neck fractures which were treated with open reduction and internal fixation more than 2 weeks following injury due to a delay in diagnosis. Both patients underwent hyperbaric oxygen therapy (HBOT) after the operation and neither resulted in AVN of the talus in a three-year follow-up. We suggest that this favorable result, despite displacement of the fracture and a delay in diagnosis and treatment, may be due to the beneficial effects of HBOT.


 :: Case History Top


Case 1

A 29-year-old professional endurance race athlete was injured when he struck a cliff during a parachute jump off Table Mountain in Cape Town, South Africa. The athlete was hanging from a cliff by his canopy strings, 50 m above the ground and was rescued a couple of hours later by a climbing team which took him to the local emergency room.

On examination, the right ankle was markedly inverted, swollen, tender and exhibited a lateral hematoma. He could not bear any weight on it because of the pain. On initial ankle radiography no fracture was seen and a diagnosis of ankle sprain was made for which he was treated with physical therapy.

Ultrasound did not show any major ligamentous injury. Ten days later, due to severe pain, swelling of the hind foot, difficulty in weight bearing and plantar hematoma, he was reevaluated in an orthopedic clinic.

Computerized tomography demonstrated Hawkins Type 3 fracture of the talar neck with the body of the talus dislocated posteriorly and engaged in the posterior facet. The tibial aspect of the tibio-talar joint was not damaged.

The patient went for open reduction and internal fixation 14 days after the injury, using dual medial and lateral approaches and two AO screws. Small bone fragments in the sinus tarsi were debrided. The athlete was treated by non-weight-bearing cast for 6 weeks. Hyperbaric oxygen therapy was initiated, 11 days post operation and 25 days post injury (protocol - five treatments a week, 35 sessions, 2 atmosphere absolute (ATA), 100% O2, 90min).

Six weeks post operation (8 weeks post injury) a plain radiograph showed a complete healing of the fracture with no signs of AVN. The cast was removed, physical therapy and swimming were initiated.

Nine weeks post operation the patient started full weight bearing and hydrotherapy was added (walking and running in the water with the "Aqua Jogger" floating belt). Fifteen weeks post operation he resumed full training, free of pain, performing up and downhill jogging, mountain biking, white water kayaking and parachuting. Only the last range of motion of plantar and dorsiflexion and subtalar joint were absent. A few weeks later he was back rock and ice climbing.

On three years follow-up there was full range of motion of the ankle and subtalar joints, free of pain even in strenuous activity. A series of plain radiograph films showed no sign of AVN.

Case 2

A 27-year-old female athlete fractured her talus after falling on her left ankle while rock climbing. The fracture was initially misdiagnosed at the local facility in Turkey and she did not present to our specialist outpatient clinic until Day 18 post injury. A Hawkins Type 2 displaced fracture of the neck of the talus was evident and she was operated on that same day with open reduction and internal fixation. The rehabilitation regimen was the same as the previous case, initiating HBOT 14 days post operation (32 days post injury) under the same protocol.

Six weeks post operation and 9 weeks post injury a plain X-ray showed the fracture to be healed with no sign of AVN.

On a three-year follow-up after the injury she is back to low-level sport activity due to minor degree of subtalar joint arthrosis but with no signs of AVN on a series of radiograph films.


 :: Discussion Top


During the administration of HBOT the patient is breathing 100% oxygen intermittently at a pressure greater than 1ATA, [Figure - 1]A, B.

Hyperbaric oxygenation of plasma and tissue fluids is the primary aim of HBOT, during which oxygen tension can be increased up to 10-fold (1000%). The oxygen physically carried in the plasma under HBO conditions of 3 ATA is sufficient to keep mammalian organisms alive without hemoglobin-carried oxygen! [12] With hemoglobin-carried oxygen plus the 10-fold increase in plasma-carried oxygen with HBOT, the blood oxygen content is increased by 125% and the distance oxygen diffuses through tissue fluids increased by a threefold (300%) factor. [13],[14] Optimal tissue oxygen tension enhances osteogenesis and neovascularization which fill the dead space with new boneand promotes soft tissues healing. [15],[16],[17] In addition, HBOT enhances osteoclastic activity assisting removal of necrotic bone [18] and has a major effect in reducing edema in traumatic crush injuries [19],[20] and compartment syndrome. [21] These HBOT roles suggest its treatment will lower edema which accompany traumatic injuries [22],[23] and lead to a better fracture recovery.

Hyperbaric oxygen has been shown to be effective in the treatment of early AVN of the femoral head. [18] Reis et al. claimed that the most rapid action of HBOT is the abolition of edema, thereby lowering the intra-osseous pressure, restoring venous drainage and rapidly improving the microcirculation. [18],[19] The elevated PO2 gradient arising between arterial blood and hypoxic tissue during HBOT, produces an osmotic fluid pump in the desired direction for resolving edema. [24]

To date, numerous professional athletic teams, including hockey (NHL), football (NFL), basketball (NBA) and soccer (MLS), utilize and rely on the use of hyperbaric oxygen as adjuvant therapy for numerous sports-related injuries acquired from playing competitive sports. [25]

There is no data in the literature concerning the prevention of post-traumatic AVN. It is possible that hyperbaric oxygen as a treatment modality which has been shown to restore function and eliminate radiographic evidence of an early AVN of the femur would play an equal role in the prevention of that same entity in displaced fractures of the talus. Many studies concluded that talar neck fractures can complicate to AVN in up to 100% of the cases, according to the degree of injury. [1],[10] The relatively favorable results in a few of these patients have been attributed to immediate operative therapy with open reduction and internal fixation. [1],[2],[3],[4],[26],[27]

Our cases suggest that with the application of HBOT it is possible that the process leading to AVN is reversible, even when reduction and fixation is delayed.

Both patients fractured their talus abroad and the fracture was misdiagnosed on a plain radiograph film, leading to a delay in the surgical intervention. Hyperbaric oxygen therapy in these two cases was delayed for 11 and 14 days postoperatively (about 1 month post-injury), but neither patient developed AVN [Figure - 2],[Figure - 3].

Further research is needed to confirm these results and verify the mechanisms involved in HBOT and the optimal protocols and timing for initiating such treatment.

In both cases presented the talar neck fracture was displaced for more than 2 weeks. Nevertheless AVN was not evident in a three-year follow-up, clinically and by radiographic examinations, contrary to what is generally expected from such cases, suggesting a beneficial effect of HBOT.

Our cases suggest that resolving bone and soft tissue edema can help in restoring oxygen supply to the bone after the injury, even when major blood vessels supplying the talus are damaged and may therefore decrease the risk of skin necrosis, wound dehiscence, infection and other complications seen in such cases. [1],[28]

The disadvantages of this mode of therapy are the long duration of treatment, its inconvenience (2h of daily treatment) and it's relatively high cost ($100 to $400 dollars per treatment [18],[29] ) although, if appropriate candidates are carefully identified, this mode of treatment has been shown to significantly reduce the length of the patient's hospital stay, amputation rate and wound care expenses, making it a cost-effective modality. [30]


 :: Conclusion Top


Hyperbaric oxygen therapy as adjunct management for displaced talar neck fractures may improve fracture healing and lower the probability for AVN. Hyperbaric oxygen therapy may prevent AVN even after a delay in the surgical treatment and late intervention. We conclude that for compliant and well-motivated people, the addition of HBOT to both operative and rehabilitative therapy may be associated with significantly improved outcomes.

 
 :: References Top

1.Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-24.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Frawley PA, Hart JA, Young DA. Treatment outcome of major fractures of the talus. Foot Ankle Int 1995;16:339-45.  Back to cited text no. 2  [PUBMED]  
3.Schulze W, Richter J, Russe O, Ingelfinger P, Muh RG. Surgical treatment of talus fractures: A retrospective study of 80 cases followed for 1-15 years. Acta Orthop Scand 2002;73:344-51.  Back to cited text no. 3    
4.Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-9.  Back to cited text no. 4  [PUBMED]  
5.Juliano PJ, Dabbah M, Harris TG. Talar neck fractures. Foot Ankle Clin 2004;9:723-36.  Back to cited text no. 5  [PUBMED]  
6.Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-34.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am 2003;85:1716-24.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Adelaar RS, Madrian JR. Avascular necrosis of the talus. Orthop Clin North Am 2004;35:383-95,xi.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970;52:991-1002.  Back to cited text no. 9  [PUBMED]  
10.Penny JN, Davis LA. Fractures and fracture-dislocations of the neck of the talus. J Trauma 1980;20:1029-37.  Back to cited text no. 10  [PUBMED]  
11.Fortin PT, Balazsy JE. Talus fractures: Evaluation and treatment. JAm Acad Orthop Surg 2001;9:114-27.  Back to cited text no. 11    
12.Boerema I, Meijne NG, Brummelkamp WK. Life without blood: Astudy of the influence of high atmospheric pressure and hypothermia on dilution of the blood. J Cardiovasc Surg 1960;1:133-46.  Back to cited text no. 12    
13.Krogh E. Oxygen diffusion model number of capillaries per unit and oxygen diffusion radient. J Physiol 1919;52: 409-15.  Back to cited text no. 13    
14.Peirce EC 2 nd . Pathophysiology, apparatus and methods, including the spcial techniques of hypothermia and heperbaric oxygen, in extracorporeal circulation for open-heart surgery. Charles C Thomas: Springfield, IL; 1969. p. 84-8.  Back to cited text no. 14    
15.Sawai T, Niimi A, Takahashi H, Ueda M. Histologic study of the effect of hyperbaric oxygen therapy on autogenous free bone grafts. J Oral Maxillofac Surg 1996;54:975-81.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Ueng SW, Lee SS, Lin SS, Wang CR, Liu SJ, Yang HF, et al . Bone healing of tibial lengthening is enhanced by hyperbaric oxygen therapy: A study of bone mineral density and torsional strength on rabbits. J Trauma 1998;44:676-81.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Sheikh AY, Gibson JJ, Rollins MD, Hopf HW, Hussain Z, Hunt TK. Effect of hyperoxia on vascular endothelial growth factor levels in a wound model. Arch Surg 2000;135:1293-7.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Reis ND, Schwartz O, Militianu D, Ramon Y, Levin D, Norman D, etal. Hyperbaric oxygen therapy as a treatment for stage-1 avascular necrosis of the femoral head. J Bone Joint Surg Br 2003;85:371-5.  Back to cited text no. 18    
19.Nylander G, Lewis D, Nordstrom H, Larsson J. Reduction of postischemic edema with hyperbaric oxygen. Plast Reconstr Surg 1985;76:596-603.  Back to cited text no. 19    
20.Nylander G, Nordstrom H, Lewis D, Larsson J. Metabolic effects of hyperbaric oxygen in postischemic muscle. Plast Reconstr Surg 1987;79:91-7.  Back to cited text no. 20    
21.Skyher MJ, Hargens AR, Strauss MB, Gershuni DH, Hart GB, Akeson WH. Hyperbaric oxygenation reduces edema and necrosis of skeletal muscles in compartment syndromes associated with hemorrhagic hypotension. J Bone Joint Surg Am 1986;68:1218-24.  Back to cited text no. 21    
22.Spuentrup E, Buecker A, Adam G, van Vaals JJ, Guenther RW. Diffusion-weighted MR imaging for differentiation of benign fracture edema and tumor infiltration of the vertebral body. AJR Am J Roentgenol 2001;176:351-8.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Pun WK, Chow SP, Fang D, Cheng CL, Leong JC, Ng C. Post-traumatic oedema of the foot after tibial fracture. Injury 1989;20:232-5.  Back to cited text no. 23  [PUBMED]  
24.Hills BA. A Role of O2 Induced Osmosis in HBOT. Medical Hypothesis: 1999;52:259-63. 1999 Harcourt Brace and Co. Ltd: Article No. mehy. 1997. p. 0640.  Back to cited text no. 24    
25.Babul S, Rhodes EC. The role of hyperbaric oxygen therapy in sports medicine. Sports Med 2000;30: 395-403.  Back to cited text no. 25  [PUBMED]  
26.Grob D, Simpson LA, Weber BG, Bray T. Operative treatment of displaced talus fractures. Clin Orthop Relat Res 1985;199:88-96.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]
27.Inokuchi S, Ogawa K, Usami N, Hashimoto T. Long-term follow up of talus fractures. Orthopedics 1996;19:477-81.  Back to cited text no. 27  [PUBMED]  
28.Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma 1999;13:369-72.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]
29.Best TM, Loitz-Ramage B, Corr DT, Vanderby R. Hyperbaric oxygen in the treatment of acute muscle stretch injuries: Results in an animal model. Am J Sports Med 1998;26:367-72.  Back to cited text no. 29  [PUBMED]  [FULLTEXT]
30.Wang J, Li F, Calhoun JH, Mader JT. The role and effectiveness of adjunctive hyperbaric oxygen therapy in the management of musculoskeletal disorders. J Postgrad Med 2002;48:226-31.  Back to cited text no. 30  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
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