The Journal of Foot & Ankle Surgery 56 (2017) 817821

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Review Article

Complications of Talar Neck Fractures by Hawkins Classication:

A Systematic Review
Richard K. Jordan, MS 1, Kunaal R. Bafna, MS 1, Jiayong Liu, MD 2, Nabil A. Ebraheim, MD 3
1
Medical Student, College of Medicine and Life Sciences, University of Toledo, Toledo, OH
2
Orthopedist and Assistant Professor, Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH
3
Orthopedist and Professor, Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 1 The goal of the present study was to perform a systematic review of the published data on talar neck fractures
for a better understanding of the postoperative clinical outcomes using open reduction and internal xation
Keywords:
ankle stratied by Hawkins type. A PubMed search was performed using the keywords talar, neck, and fracture.
arthritis This search identied 209 potential studies, which were reviewed to yield 16 studies that met the criteria. The
necrosis surgical outcomes of talar neck fractures stratied by the Hawkins classication analyzed in the present study
surgery were as follows: American Orthopaedic Foot and Ankle Society scale score was 77.00 for type I, 86.10 for type
talus II, 68.30 for type III, 68.30 for type IV, and 76.50 for all talar neck fractures. Avascular necrosis presented in
0.00% of type I fractures, 15.91% of type II fractures, 38.89% of type III fractures, 55.00% of type IV fractures, and
26.47% of all fractures. Osteoarthritis presented in 25.00% of type I fractures, 41.33% of type II fractures, 54.23%
of type III fractures, 72.73% of type IV fractures, and 51.69% of all fractures. Subtalar arthritis presented in 0.00%
of type I fractures, 54.29% of type II fractures, 46.43% of type III fractures, 45.45% of type IV fractures, and
44.97% of all fractures. The malunion prevalence was 13.29% and the nonunion prevalence was 3.97% for all
fractures. Type II fractures were the most common (50.88%) fracture type reported in the reports reviewed in
the present study.
2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

Talar neck fractures are among some of the rarest and most chal-
lenging injuries for surgeons to repair (19). Although they account for
<1% of all bone fractures of the ankle and foot, many controversies
surround their treatment, including assessment measures, surgical ap-
proaches, xation methods, and frequency of postoperative complica-
tions (1012). During the past 2 decades, substantial improvements
have occurred in the surgical treatment of these fractures. The imple-
mentation of mini-fragment and small-fragment implants has demon-
strated effectiveness in maintaining fragment placement without
causing excessive damage to the adjacent blood supply (1315).
The talus is the most superiorly located bone of the foot and is vital
in maintaining ankle function and range of motion (16). For anatomic
purposes, the talus can be classied into a head, neck, body, posterior
process, and lateral process. Talar neck fractures account for nearly
48% of the fractures of the talus and most commonly occur as a result
of high-energy trauma, such as falling from a height or automobile
accidents (17,18). The high-energy nature of these injuries produces
Financial Disclosure: None reported.
Conict of Interest: None reported.
Address correspondence to: Jiayong Liu, MD, Department of Orthopaedic Surgery,
University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH 43614.
E-mail address: jiayong.liu@utoledo.edu (J. Liu).
fracture displacement, comminution, and acute soft tissue damage,
which commonly correlate with open lesions (11). Management of
these injuries is difcult owing to the unique osseous and vascular
anatomy of the talus, resulting in historically poor outcomes and a
high incidence of complications.
The most common mechanism of talar neck fractures is hyper-
dorsiexion of the ankle, which often occurs in high-energy trauma to
the ankle. In such cases, the posterior ligaments of the subtalar joint
initially rupture and the talar neck contacts the leading anterior edge
of the distal tibia, causing a fracture line. With continued force, the
calcaneus and the rest of the foot, including the head of the talus,
sublux anteriorly. At this point, concomitant eversion can cause lateral
dislocation, and inversion can cause medial dislocation (19).
Fractures of the talar neck and body are commonly categorized
using the Hawkins classication system, modied by Canale and Kelly
(20), which provides descriptive and prognostic information. Type I
fractures indicate a nondisplaced fracture. Type II fractures indicate a
fracture with subluxation (IIA) or dislocation (IIB) at the subtalar joint.
Type III fractures refer to a fracture with a dislocated tibiotalar joint,
and type IV fractures indicate a dislocated talonavicular joint (18,20,21).
A variety of complications, including avascular necrosis (AVN) and
osteoarthritis (OA), are understood to be related to the initial fracture
displacement. They result from the increased risk of trauma to the

1067-2516/$ - see front matter 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2017.04.013
818 R.K. Jordan et al. / The Journal of Foot & Ankle Surgery 56 (2017) 817821

vascular blood supply of the talar body. Talar neck fractures with
associated body fractures have had a greater prevalence of AVN than
talar neck fractures without body injury. Talar body fractures are
associated with weakening of the talar trochlea, which can subject the
body to full collapse and subsequent degenerative changes (19,22).
Urgent open reduction and internal xation (ORIF) of dislocated talar
neck fractures is recommended to minimize soft tissue complications
and increase the chances of revascularization (12). Nonoperative
treatment or percutaneous xation is most commonly used for non-
displaced talar neck fractures.
Currently, multiple systematic reviews are available on fractures of
the talar neck; however, minimal information has focused entirely on
the outcomes of ORIF-treated fractures stratied by the Hawkins
classication. The goal of the present study was to perform a sys-
tematic review of the available published data on talar neck fractures
repaired using ORIF for a better understanding of the postoperative
clinical outcomes and complications stratied by Hawkins classica-
tion type.

Materials and Methods

A PubMed search was performed using the keywords talar, neck, and fracture.
This search identied 209 studies, which were then reviewed. The exclusion criteria
were studies reported in a language other than English, studies that did not use ORIF as
the surgical method, and studies that did not use the Hawkins classication system
(Fig). The references of each of the 16 selected studies were examined to locate any
additional studies that had not been found in the initial PubMed search. However, no
additional studies that met our criteria were identied. Additionally, no unpublished
studies were included.
When the studies included both talar neck fractures and other talus fractures
(body), only the data referencing the talar neck fractures were extracted. This was the
case for 3 of the 16 studies (11,12,23). The data extracted from the 16 studies were
compiled and analyzed. Particular emphasis was placed on data pertaining to post-
operative AVN, OA (subtalar and tibiotalar arthritis), malunion, nonunion, and average
American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Unreported infor-
mation, based on our criteria, was noted. Furthermore, the data were divided and
analyzed by the Hawkins classication system.

Results

All the reviewed studies were retrospective. A total of 508 talar

fractures were initially reported among the 16 examined reports.
However, that was reduced to 340 fractures using our criteria and
because some patients were lost during the follow-up period of the
original retrospective studies. Of the 340 fractures,10 (2.94%) were type Fig. Flowchart showing the method of study selection.

I, 173 (50.88%) were type II, 116 (34.12%) were type III, and 41 (12.06%)
were type IV. The demographic data for the patient population are
listed in Table 1 (11,12,2436). The treatment type was ORIF for all
patients; however, the internal xation type was highly variable. In-
ternal xation included 3.5-mm cortical screws, 4.0-mm cancellous
screws, small Herbert screws, bioabsorbable screws, bioabsorbable
pins, cannulated screws, and Kirschner wires. Of the 447 fractures
specied as open or closed, 82 were open and 365 were closed (Table 1).
The average interval to surgery across 6 of the 16 reports
(11,24,26,27,33,36) that specically reported this information was
2.36 days (Table 1). AVN is a common complication after a talar neck
fracture. It results from disruption of the blood supply to the talar
body, which corresponds to the severity of the initial injury and the
number of joints dislocated during the trauma (8,16,18,20,37). All 16
studies (11,12,23,26,27,3036,38) reported the overall AVN rate;
however, not every study reported the AVN rates stratied by Haw-
kins classication type (Table 2). AVN occurred in 90 of the 340 pa-
tients, for an overall incidence rate of 26.47%. For 229 patients, the rate
of AVN was stratied by the specic Hawkins classication type.
Analysis revealed that AVN occurred in 0.00% (0 of 5) of type I frac-
tures, 15.91% (21 of 132) of type II fractures, 38.89% (28 of 72) of type
III fractures, and 55.0% (11 of 20) of type IV fractures (Table 2).
Post-traumatic OA has been recognized as the most prevalent
complication after talar neck fractures and has been listed as the
primary cause of secondary reconstructive procedures (12,31,39). In
the present review, 14 of the 16 studies reported information on OA
(11,12,23,26,3035,38). Of the 296 reported fractures, 153 (51.69%)
were associated with the postoperative development of OA (Table 2).
From the studies reporting OA stratied by Hawkins type, 25.00% (1 of 4)
of type I fractures, 41.33% (31 of 75) of type II fractures, 54.24% (32 of 59)
of type III fractures, and 72.73% (8 of 11) of type IV fractures resulted in
OA (Table 2).
The AOFAS scale scores of 74 patients (11,27,32) were reported and
delineated by Hawkins type (Table 2). The average functional AOFAS
scale score for type I fractures was 77.00 (n 16), 86.10 (n 35) for
type II fractures, 68.30 (n 11) for type III fractures, and 68.30 (n 4)
for type IV fractures. Despite the increase in functional score between
type I and type II fractures, the overall lesser score for types III and IV
fractures was likely associated with increased soft tissue injury and
the greater incidence of AVN.
Malunion and nonunion can result in incongruity and arthritis in
the subtalar and tibiotalar joints and have been reported in 30% of
cases (1,11,39). Of 143 patients, 19 (13.29%) developed postoperative
 R.K. Jordan et al. / The Journal of Foot & Ankle Surgery 56 (2017) 817821 819

Table 1
General overview of the 16 included studies

Study Study Type Total Talar Neck Fractures Open Classication Male Average Average Interval Follow-Up Period
(Total Fractures Reported) (Closed) Used (Female) Age (y) to Surgery (hr)
Annappa et al (11), 2015 Retrospective 20 7 (13) Hawkins 16 (4) 28.4 13.8 hr 34 mo
Lindvali et al (24), 2004 Retrospective 18 (26) 7 (19) Hawkins 10 (15) 37.6 10.5 hr 74 mo
Wu et al (25), 2016 Retrospective 14 2 (12) Hawkins 8 (6) 41.6 5.29 days 24 mo
case-control
Vallier et al (26), 2004 Retrospective 102 24 (78) Hawkins 60 (40) 32.6 3.7 days 67 mo
Chen et al (27), 2014 Retrospective 48 NR Hawkins 29 (15) 38.3 NR 12 mo
Isaacs et al (28), 2009 Retrospective 1 NR Hawkins 1 (0) 42 NR 12 mo
Yeganeh et al (23), 2013 Retrospective 28 (30) 3 (27) Hawkins 25 (3) 38 NR 36 mo
Haverkort et al (29), 2015 Retrospective 3 2 (1) Hawkins 3 (0) 40.3 NR Minimum 11 mo
Beltran et al (30), 2016 Retrospective 24 2 (20) Hawkins NR NR NR 44 mo
Sanders et al (31), 2004 Retrospective 104 10 (94) Hawkins 57 (47) 34 NR 5.2 y
Bastos et al (32), 2010 Retrospective 20 4 (16) Hawkins 16 (4) 30.5 NR 70.75 mo
Maceroli et al (33), 2016 Retrospective 26 8 (18) Hawkins 14 (12) 39.1 3.7 days 18.3 mo
Ohl et al (12), 2011 Retrospective 10 (20) 4 (6) Hawkins 5 (5) 37.6 NR 90 mo
Freund (34), 1988 Retrospective 7 1 (6) Hawkins 4 (6) 39.5 <1 day 78.75 mo
Grob et al (35), 1985 Retrospective 41 4 (37) Hawkins 31 (10) 28 <1 day 9.8 y
Low et al (36), 1998 Retrospective 22 4 (18) Hawkins 19 (3) 35 11.5 hr 4.4 y

Abbreviation: NR, not reported.

malunion (11,12,23,31), and of 151 patients, 6 (3.97%) developed
nonunion (11,12,24,26,33,34). The risk of malunion is primarily
inuenced by the quality of reduction, fracture type, and osteosyn-
thesis technique used (12).
Discussion
Talar neck fractures are associated with multiple complications,
including AVN, OA, subtalar arthritis, tibiotalar arthritis, malunion,
and nonunion. Although ORIF is predominantly used for Hawkins
types III and IV talar neck fractures, the method of treatment for types
I and II depends on the severity of the injury, the associated injuries,
and surgeon experience (18,40,41).
Although the talus possesses a large articulating surface, it has a
limited vascular supply (29,42,43). This anatomic anomaly explains
the high risk of AVN and OA associated with talar neck fractures. In the
past, the blood supply of the talus was considered to be poor; how-
ever, more recent ndings have shown multiple arteries form a rich
vascular network for the talus (18,44,45). The blood supply to the
talus is composed of 3 arteries: the posterior tibial artery, anterior
tibial artery, and perforating peroneal arteries. The posterior tibial
artery supplies the deltoid artery and the tarsal tunnel. The anterior
tibial artery supplies the lateral tarsal artery, and the perforating
peroneal arteries supply the tarsal sinus artery (38). These 3 arteries
anastomose multiple times to perfuse the talar neck from the tarsal
sinus (42). In talar trauma with accompanying dislocations, the blood
supply to the neck of the talus can be disrupted, resulting in the body
of the talus being vascularized by the deltoid artery (46). Most of these
arteries enter the talar head and retrogradely supply the body (47).
As such, an increased risk of AVN of the body and talar dome exists
with neck fractures and associated dislocations. This likely explains
the increasing AVN rates with increasing Hawkins classication type.
Previous studies have reported the incidence of AVN after a talar neck
fracture as follows: 14% for Hawkins type I, 20% to 50% for Hawkins
type II, 80% to 100% for Hawkins type III, and approximately 100% for
Hawkins type IV (16,18,48,49). The present study differs slightly from
the percentages historically seen. This difference could have resulted
from a smaller sample size but still reects the general trend of
increasing AVN rates from Hawkins type I to Hawkins type IV. These
ndings support previous research that found that as the number of
dislocated joints increases, an increase occurs in the loss of blood
supply to the talus, resulting in AVN (37).
Malunion is another common complication arising from this type
of fracture, with the most common type being varus malalignment
(20). Postoperative malunion from talar neck fractures commonly
results in secondary reconstructive procedures and usually involves
peritalar arthrodesis (2). Sanders et al (31) reported that 24% of pa-
tients after 1 year, 32% after 2 years, 38% after 5 years, and 48% after
10 years required secondary surgeries after these fractures. To mini-
mize the incidence of malunion, a study recommended restoration of
the talar neck length and to minimize compression screwing across a
comminuted area at the origin of a talar neck shortening (12). Attiah
et al (47) reviewed multiple screw congurations in comminuted talar
neck fractures and concluded that anteroposterior screws have
reduced yield point and stiffness of approximately 20% compared
with posteroanterior screws. However, Annappa et al (11) concluded
that cancellous screws inserted posteriorly to anteriorly were asso-
ciated with fewer complications. With the lack of consensus, further
research should be conducted in this area.
Studies have linked the development of post-traumatic OA to
malunion, nonunion, AVN, and cartilage damage resulting from the
injury (4,11,31). Many of these studies also depicted a correlation
between low AOFAS scale scores and the development of OA.
Anatomic reduction is challenging to obtain owing to the complex
anatomy of the talus and the comminuting nature of its fractures.
Modifying surgical techniques to better preserve the vascular supply

Table 2
Clinical complications and outcomes stratied by Hawkins classication

Hawkins Fracture Classication AVN OA Subtalar Arthritis ORIF Average AOFAS Scale Score

Total n % Total n % Total n %

Total reported 340 90 26.47 296 153 51.69 189 85 44.97 74 76.50
Type I 5 0 0.00 4 1 25.00 1 0 0.00 16 77.00
Type II 132 21 15.91 75 31 41.33 35 19 54.29 35 86.10
Type III 72 28 38.89 59 32 54.24 28 13 46.43 11 68.30
Type IV 20 11 55.00 11 8 72.73 11 5 45.45 4 68.30

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; AVN, avascular necrosis; OA, osteoarthritis; ORIF, open reduction and internal xation.
820 R.K. Jordan et al. / The Journal of Foot & Ankle Surgery 56 (2017) 817821
and cartilage within talar joints should play a signicant role in
limiting the development of post-traumatic arthritis in future cases.
The present study has shown that the incidence of OA develop-
ment is increased with more complicated joint fractures. Fournier
et al (9) observed a high rate of OA (74%) in their study of 114 cases of
neck fractures. Furthermore, they concluded that a correlation exists
between a higher Hawkins classication level and an increased
prevalence of OA. The results of the present study further validate this
conclusion.
Although the average interval to surgery was not analyzed with
respect to the development of postoperative complications, Vallier
et al (26) suggested that early operative intervention, at least in the
form of dislocation reduction, protects an already threatened blood
supply to the posterior talus after talar neck fracture. In addition,
waiting until minimal soft tissue swelling is present before xation
might provide stability to promote fracture healing and earlier
weightbearing (3).
The limitations of the present study included the relatively small
sample size and the retrospective design of the reviewed data. This
small sample size can be attributed to the rarity (<1% of foot fractures)
of talar neck fractures and the lack of sufcient published data that
met our specic criteria. Because the present review was aimed
specically at complications occurring after ORIF, many studies that
did not distinguish the outcomes by ORIF and other treatment
methods or that did not provide complete data according to our
criteria could not be included. This further limited our sample size. In
addition, any bias associated with these retrospective studies was
inherently associated with our review. The studies reviewed did not
use a standardized clinical follow-up protocol or assessment of
complications, which prevented us from uniformly analyzing and
manipulating the data more extensively. To eliminate this bias and
perform statistical comparisons according to our specic criteria, a
prospective study design with original patient data is needed. Alter-
natively, a cohort study could be performed.
In conclusion, we found the average AOFAS scale score was 77.00
for type I, 86.10 for type II, 68.30 for type III, 68.30 for type IV, and
76.5 for all talar neck fractures. AVN presented in 0.00% of type I
fractures, 15.91% of type II fractures, 38.89% of type III fractures,
55.00% of type IV fractures, and 26.47% of all fractures. OA presented
in 25.00% of type I fractures, 41.33% of type II fractures, 54.24% of
type III fractures, 72.73% of type IV fractures, and 51.69% of all
fractures. Subtalar arthritis presented in 0.00% of type I fractures,
54.29% of type II fractures, 46.43% of type III fractures, 45.46% of type
IV fractures, and 44.97% of all fractures. The malunion prevalence
was 13.29% and the nonunion prevalence was 3.97% for all fractures.
Type II fractures were the most common (50.88%) fracture type in
the reports analyzed in the present study. Talar neck fractures
represent only a small percentage of injuries that orthopedic sur-
geons treat; however, they present a large challenge owing to the
postoperative complications that accompany them. Patients with
talar neck fractures should be prepared for the greater likelihood of
long-term complications and should be offered a low threshold for
repeat contact with the surgeon. A deep understanding of the talar
bone anatomy and preservation of its vasculature will continue to
play critical roles in enhancing operative methods and post-
operative outcomes. The results of the present investigation could
be very useful in the development of prospective case-control
studies to further analyze and discuss the postoperative outcomes
of talar neck fractures.
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