|Beitragstitel||A trans-Achilles posterior approach to access a plurifragmentary fracture of the posterior talar body.|
Posterior talar body fractures are rare. The crucial point, aiming an anatomical reconstruction of the articular surface, is to access this region locked into the mortise. Due to its location, this might be very challenging. The literature advocates a posterior approach associated with an osteotomy of the medial malleolus in the majority of cases. This approach, however, does not allow a good access to the posterolateral part of the talus, which can best be addressed via a posterolateral approach in combination with an osteotomy of the distal fibula. Both approaches present, furthermore, the disadvantages associated with malleolar osteotomies.
In order to avoid the need for a double malleolar osteotomy we used a posterior approach through an inverted Z-tenotomy of the Achilles tendon in the frontal plane (longitudinal plane of the Z). After having opened the deep fascia, we sectioned the pulley of the flexor hallucis longus tendon which could be then retracted medially, offering both a protection of the neurovascular bundle and a complete view on the posterior portion of the talar body. We were then able to identify, reduce anatomically and fix from posterior to anterior the 4 distinct fragments of the posterior talar body to its anterior counterpart. After closure of the articular capsule we sutured the pulley of the flexor hallucis longus tendon, the deep fascia, and then realized a Krakow suture of the Achilles tendon. We then closed the skin with simple sutures.
The posterior approach combined with an inverted Z-tenotomy of the Achilles tendon in the frontal plane helped us gain access to the entire posterior part of the talar body and reduce and fix anatomically a complex posterior talar body fracture without the need of malleolar osteotomies.
The presented approach is a useful alternative to malleolar osteotomy to gain extensive access to the posterior portion of the talar body and, thanks to the Achilles tenotomy, also increases the maximal dorsiflexion of the ankle, thus enhancing the view on the articular surface. Performing an inverted Z-tenotomy in the frontal plane allows, in our opinion, for the preservation of a smooth posterior aspect of the tendon.