The most common position of talar neck malunion is varus and this deformity can lock the subtalar and transverse tarsal joints leading to diminished motion and ultimately subtalar arthrosis. Medial opening wedge osteotomy of the talar neck has been described to restore the anatomy of the talus and preserve hindfoot motion.
Daniels et al performed a biomechanical study of hindfoot motion following medial osteotomy and varus malalignment of the talar neck. The authors found a direct correlation between the degree of varus malalignment and dimished forefoot and subtalar motion, and caution against compressive fixation of the medial talus in the presence of comminution.
Monroe and Manoli present a case report of talar neck malunion and describe their technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. They found a significant improvent in the AOFAS ankle-hindfoot score and no evidence of osteonecrosis with follow-up greater than 4 years.
Huang and Cheng retrospectively review their results with anatomic reconstruction of the talar neck in 9 patients who presented a minimun of four weeks after the initial injury with a malreduced or neglected talar neck fracture. They found favorable outcomes with delayed reconstruction as determined by the AOFAS ankle-hindfoot score at an average follow up of 53 months, however note that six patients subsequently developed radiographic hindfoot arthrosis.
Answer 1: Total ankle arthroplasty is reserved for patients with end-stage tibiotalar arthritis. This patient has an intact and functional tibiotalar joint
Answer 2: Lateral calcaneus closing wedge osteotomy would correct some hindfoot varus, however would not address the talar neck deformity leading to diminished motion.
Answer 3: Calcaneal neck opening wedge osteotomy would exacerbate the patient's deformity
Answer 5: Triple arthrodesis would be not be a viable option in a patient with a preserved tibiotalar and subtalar joint.
Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion. J Bone Joint Surg Am. 1996 Oct;78(10):1559-67.
PMID:8876585 (Link to Abstract)
Monroe MT, Manoli A 2nd. Osteotomy for malunion of a talar neck fracture: a case report. Foot Ankle Int. 1999 Mar;20(3):192-5. PubMed PMID: 10195299
PMID:10195299 (Link to Abstract)
Huang PJ, Cheng YM. Delayed surgical treatment for neglected or mal-reduced talar fractures. Int Orthop. 2005 Oct;29(5):326-9. Epub 2005 Aug 11
PMID:16094539 (Link to Abstract)