Avascular necrosis of Talus

( Causes and management)

 Definition
• Avascular necrosis (AVN) occurs due to the
temporary or permanent loss of the blood supply to
an area of bone.
• As a result, the bone tissue dies and the bone
collapses.
 • Surface 60% cartilage
Anatomy of Talus • covered by a large percentage of
articular cartilage which is not
penetrated by blood vessels
• No muscular or tendinous
insertions
• Supported solely by the joint
capsules ,ligaments , and
synovial tissues
Vascular Supply
Talus supplied by 3 main
arterial branches

•Dorsalis Pedis
•Arteries of tarsal sinus
and canal
•Deltoid artery
Avascular necrosis of Talus
AVN involves the bones of a joint (e.g.: the talus) it often
leads to destruction of cartilage, resulting in arthritis and
pain. In the case of the talus, three joints can be affected:

•Ankle joint
•Talonavicular joint (a joint in the middle of the foot)
•Subtalar joint (the joint below the ankle)
 Causes
AVN of the talus can be classified on the basis of the traumatic and atraumatic
processes that impair nutrient blood supply to the bone
Nontraumatic
Traumatic • include idiopathic (no cause is ever
• fracture and found),
dislocation disrupts • steroids (e.g.: anabolic and high
the blood supply to dose corticosteroids (prednisone)
given for such diseases as
the bone.
rheumatoid arthritis, lupus, and
• The talar neck, one cancer),
of the areas of the • excess alcohol consumption,
talus most at risk • sickle cell anemia,
for injury • radiation treatments and
chemotherapy
 Hawkins Classification
According to Hawkins classification, there are four types of fractures.
Type I: Undisplaced fracture of the talar neck; risk of avascular
necrosis (AVN) <10%
Type II: Displaced fracture with subtalar subluxation or dislocation of
subtalar joint ; risk of AVN >40%
Type III: Displaced fracture with subtalar and ankle dislocation risk of
AVN >90%
Type IV: Type III + variants (eg, dislocation of talonavicular joint); risk
of AVN 100%
Hawkins I
Hawkins II
Hawkins III
Hawkins IV
 Radiographs:
AVN may not be present for 3 or more months following
injury;
• dx of AVN is a radiographic one, w/ talar body initially
showing increase density compared to the surrounding bone
(which is vascular & is undergoing disuse atrophy);
•later as revascularization occurs, there is partial or complete
complete collapse of subchondral bone, narrowing of joint
space, and occasionally fragmentation of the talar body;
•the posterolateral corner of the talus will show osteonecrotic
changes most often, since it has the poorest blood supply;
• The Hawkins sign is visualized as a thin subchondral
radiolucent line along all or part of the talar dome best
seen on the AP view
• Becomes evident 6–8 weeks after injury
• Its presence indicates an adequate blood supply that can
lead to bone resorption and is an indicator used to
determine that AVN of the talus will probably not occur
MRI
Magnetic resonance imaging evaluation
can also be useful to assess the
percentage of avascular necrosis
involvement and help guide appropriate
treatment.
Magnetic resonance imaging is the most
sensitive test for determining the
presence of avascular necrosis and
estimating the amount of talar dome
involvement.
 Early Management
• Determine etiology of AVN
•  Quantify the extent of AVN: 
     - AVN can involve the entire talar body or only a small percentage; 
    - use of MRI to determine the percentage of AVN involvement helps with determining potential for
collapse; 
• Attempt to achieve fracture union: 
- first goal is always for anatomical union of fracture which should occur even in face of AVN; 
    - talus fractures are reduced and stabilized using screw fixation; 
    - if secure fixation is achieved, early motion is instituted. 
    - patient should be protected from wt bearing until union is secure
• Reconstitution of the talus: 
     - when union has occurred, body of the talus will still be avascular, since up to 36 months is
required for complete creeping substitution of body; 
    - the best results are obtained w/ non weight bearing until revascularization is obtained; 
Nondisplaced Hawkins I fractures can be treated conservatively with cautious monitoring for
reduction maintenance in a nonweight-bearing cast for 6 to 12 weeks.
 Late Management and Salvage
When nonsurgical management fails to prevent avascular necrosis and collapse of the talar dome,
surgical interventions should be considered.
•Secondary or salvage treatments
- include talectomy, bone grafting, tibiocalcaneal fusion, Blair fusion, and pantalar fusion.
- physical exam, radiographs, and differential injections are used to determine which joints are
painful; 
 - in most cases ankle and subtalar arthrodesis will be required; 
 - often an external fixator is helpful to stabilize the fusion (inaddition to internal fixation) and is
often
removed at 12 weeks; 
 - bone grafting is often necessary to achieve union; 
•Arthrodesis suggested for use during primary treatment of severe talar neck fractures, with the
aim of eliminating pain and the limitations of subtalar arthritis. 
•Arthrodesis options ankle arthrodesis,Blair fusion, sub talar fusion, triple arthrodesis 
Conclusion
• The tenuous blood supply to the talus and its multiple
articulations make it vulnerable to multiple significant
complications.
• Early recognition of displacement with anatomic reduction
and stabilization is necessary to offer the best chance of a
good outcome.
• Careful radiographic assessment and monitoring with plain
radiographs,CTs, and MRIs can guide treatment from injury
through recovery
Reference
Netter's Anatomy 3rd Edition , John. T. Hansen
Text book of Orthopedic and Trauma 4th Edition, GS Kulkarni
Essential Orthopaedic 5th edition, Maheswari & Mhaskar
Avascular Necrosis of Talus : A Pictorial Essay , Dawn . H. Pearce
http://pubs.rsna.org/doi/full/10.1148/rg.252045709
Avascular Necrosis of Talus: Learning Radiology
Avascular Necrosis of Talus , Joel W. Brook D.P.M
Talar neck Fracture , Janice Hsu. MD