Novel technique of intraosseous arteriogram to evaluate talar viability after high-energy trauma

This study describes an innovative, minimally-invasive technique to evaluate perfusion to the talar dome and body as a predictor of avascular necrosis and structural collapse after an open, talar neck fracture/dislocation. The patient was a 31-year-old female status-post polytraumatic motor vehicle accident, with an open talar neck fracture/dislocation. The patient was managed surgically and the 6-week AP radiograph showed positive “Hawkins sign” to central and medial dome, with questionable sclerosis laterally. Due to concerns of developing avascular necrosis, a novel technique utilizing an intraosseous arteriogram (IOA) of the right talus was performed. IOA revealed brisk perfusion to the central and medial dome, with anterolateral ischemia. The anterolateral talus was decompressed and backfilled with calcaneal autograft. This technique allowed for evaluation of talar dome perfusion along with decompression of the talus via bone biopsy. Radiographic findings, pathology and Magnetic Resonance Imaging were combined to confirm diagnosis. The patient returned to ambulation with significant improvement in function in 8-weeks. Serial radiographic surveillance revealed union across the fracture site without collapse of the talar dome, which was confirmed on the 18-month postoperative CT scan. This case demonstrates evaluation and treatment of talar neck AVN utilizing various imaging modalities, including intra-osseous arteriogram with a unique surgical technique. This innovative practice offers advancement of current treatment methods which could lead to improved time to diagnosis and treatment.