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Fluoroscopy with cone beam CT may help for talar fractures, but no significant differences found
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In the operative treatment of talar fractures, conventional fluoroscopy with additional intraoperative cone beam CT may be beneficial but its impact was not statistically significant, according to published results.
In a retrospective cohort analysis, 24 patients with isolated, displaced talus fractures were examined intraoperatively either with conventional fluoroscopy alone or with the addition of cone beam CT. The Siremobile Iso-C3-D (Siemens Healthcare, Forchheim, Germany) was used during the cone beam CT scan. From March 2005 onward, investigators used the ARCADIS Orbic 3-D (Siemens). Patients underwent fracture reduction and screw fixation between August 2001 and December 2013. Mean follow-up was 6.66 years. The foot function index, American Foot and Ankle Society Ankle-hindfoot scale and the SF-12 survey were used to assess clinical outcomes. Investigators determined the Kellgren-Lawrence score using X-rays.
Results showed no significant differences were seen between groups with regard to the foot function index, AOFAS, the SF-12 physical and mental component scores. Osteoarthritis assessed with the Kellgren-Lawrence score in the talonavicular, subtalar and ankle joints was minor in patients examined with cone beam CT; however, differences were not significant. – by Monica Jaramillo
Disclosures: Vetter reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Roy W. Sanders, MD
A recent paper by Vetter and colleagues looked at cone beam fluoroscopy as a means to better assess talar neck and body fractures after initial reduction. The authors used this technique after conventional fluoroscopy in a series of non-randomized cases. They then compared those that had this extra step vs. those that did not. They found that the patients with the cone beam had better long-term clinical scores but that this was not statistically significant.
Cone beam technology offers a 3-D image based on more than 100 fluoroscopic images taken through a motorized fluoroscopic unit. This offers the operator an unparalleled view of surface anatomy and offers the promise of improved articular reductions and hopefully better functional outcomes as a result.
Unfortunately, the publication omits information that would help the reader understand the benefits of this technology. This was not a randomized prospective study. It was not clinically blinded. It is unclear whether one or two approaches were used to reduce the neck fracture. This is important as one cannot determine an accurate reduction or fracture rotation without medial and lateral incisions. When one uses conventional fluoroscopy, coupled cone beam fluoroscopy, the radiation exposure by definition is greater. Once the cone beam identifies a nonanatomic reduction, which is then corrected, does the operator repeat the study in the OR? This would not only increase radiation exposure but add time to the procedure. Finally, the study showed figures which in neither case was the reduction truly anatomic.
Regardless of this particular study, cone beam fluoroscopy offers the promise of better reduction verification intraoperatively. This has been shown to be most effective in pelvic and acetabular surgery where direct visualization is difficult. In talus fractures, with direct visualization possible using two approaches and malleolar osteotomies when needed, the role of cone beam fluoroscopy may be minimal.
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