Clinical study of arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp

Clinical study of arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical study of arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp Wenpeng Xu, Lichao Jia, Weiye Zhang, Zhengxun Li, Ning Zhang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7245109/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2026 Read the published version in BMC Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Objective To investigate the surgical method of arthroscopic reduction and internal fixation (ARIF) for malunion and nonunion of type II talus fracture as per Zwipp classification, and to evaluate its therapeutic effect. Methods A retrospective analysis was performed on eight patients (five males and three females) with unilateral limbs treated with ARIF for malunion and nonunion of a talus fracture at our hospital between July 2014 and July 2022. The age ranged from 17 to 55 years, with an average of 34.9 ± 12.3 years. In all, five cases of talar body fracture and three cases of talar neck fracture were observed. The time interval between fracture and the present surgery was 8–16 months (average, 11.1 ± 2.5 months). According to the classification of malunion and nonunion of talus fracture by Zwipp, all the eight cases were classified as type II. Intraoperative autologous iliac bone grafting was performed for all patients. At the last follow-up, the ankle joint was assessed for range of motion and an X-ray examination was performed. Ankle joint function was evaluated as per the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Results All eight patients were followed up for 10 to 52 months (average, 30.2 ± 14.2 months). All patients achieved primary wound healing, and 2 of them experienced Achilles tendon contracture, with no case of avascular necrosis of the talus, fracture nonunion, infection, or other complications. Ankle joint function was assessed according to the AOFAS score, with four cases assessed as “Excellent” and four as “Good” on the scale. Conclusion ARIF is a safe and effective surgical method for malunion and nonunion of type II talus fracture as per Zwipp classification with lesser secondary damage to the blood supply of the talus, fewer postoperative complications, and faster recovery. Level of Evidence Level II. Arthroscopy talus fracture malunion and nonunion internal fixation Figures Figure 1 Introduction Talus fractures are often caused by high-energy injuries such as traffic accident injuries and falls from heights. Talus fractures account for approximately 3–5% of foot and ankle fractures. 2 According to the anatomical location of the talus, talus fractures are further divided into talar head, talar neck, and talar body fractures, among which talar neck fractures account for 50–80% of all talus fractures. 2 , 4 , 16 The talus is small and irregularly shaped, with no tendon attached, and 60% of the surface is covered by articular cartilage. Therefore, the blood supply to this area is very fragile. Malunion or nonunion is likely to occur if talus fracture is not treated properly. According to the literature, the incidence rate of malunion or nonunion after talus fracture ranges from 9–47%. The classifications of malunion and nonunion of talus fractures proposed by Zwipp and Rammelt are as follows: type I: malunion of talus fracture with joint dislocation; type II: nonunion of talus fracture with joint dislocation; type III: partial avascular necrosis of the talus on the basis of type I or type II; type IV: avascular necrosis of the entire talus on the basis of type I or type II; and type V: septic avascular necrosis of the talus on the basis of type I or II. It is difficult to cure malunion and nonunion of a talus fracture, which easily causes limb disability and affects the patients’ working ability and quality of life. With the development of arthroscopic techniques, arthroscopic reduction and internal fixation (ARIF) and arthroscopically assisted open reduction and internal fixation (ORIF) have become increasingly popular for the treatment of foot and ankle fractures and old fractures. 5 , 11 The application of arthroscopic technique avoids secondary trauma caused by open surgery or complications after osteotomy. 6 , 12 , 15 From July 2014 to July 2022, our department applied ARIF to treat eight cases of malunion and nonunion of type II talus fracture as per Zwipp classification, achieving satisfactory results. We report our experience in this study. Materials and methods 1.1 Inclusion and exclusion criteria Inclusion criteria: Malunion and nonunion of type II talus fracture as per Zwipp classification. Exclusion criteria: (1) Malunion and nonunion of talus fractures of types I, III, IV, and V as per Zwipp classification; (2) Malunion and nonunion of talus fractures with abnormal mechanical axis. 1.2 General data There were five males and three females in this study. Patient age ranged from 17 to 55 years, with an average age of 34.9 ± 12.3 years. All patients had secondary malunion or nonunion following closed fractures of the talar body or neck, with varying degrees of joint pain and dislocation. There were five cases of talar body fracture and three cases of talar neck fracture. The time interval from fracture to the present surgery ranged from 8 to 16 months, with an average of 11.1 ± 2.5 months. According to the classification of malunion and nonunion of talus fractures proposed by Zwipp and Rammelt, all eight cases were type II. Before the surgery, all patients underwent weight-bearing anteroposterior and lateral radiographs of ankle joints, long-axial radiographs of calcaneal bone, and CT to determine the location, mechanical axis, and classification of fractures. MRI was performed on all the patients suspected with osteonecrosis. Preoperative blood routine and C-reactive protein detection were performed for all patients to exclude the possibility of infection. Preoperative scoring was performed for all patients using the AOFAS Ankle-Hindfoot Scale, with an average score of 38.4 ± 6.1 (range, 30.0–45.0). All eight patients were followed up for 10 to 52 months, with an average of 30.2 ± 14.2 months (Table 1 ). The ethics committee of the Second Qilu Hospital of Shandong University approved this study and an internal review board, and informed consent was obtained from all patients. Table 1 Basic information of the patients ID Gender Age (year) Lateral side Classification by Zwipp Fracture site Time interval from fracture to the present surgery (months) Surgery time (min) Follow-up time (months) Complications American Orthopaedic Foot and Ankle Society (AOFAS) result assessment 1 Female 17 Right Ⅱ Talar body 8 190 46 — Excellent 2 Male 43 Right Ⅱ Talar neck 10 210 20 Contracture of Achilles tendon Good 3 Female 26 Right Ⅱ Talar body 11 220 18 — Good 4 Male 55 Left Ⅱ Talar body 12 240 29 Contracture of Achilles tendon Good 5 Male 34 Left Ⅱ Talar neck 9 200 32 — Excellent 6 Female 28 Right Ⅱ Talar body 13 160 10 — Excellent 7 Male 46 Left Ⅱ Talar body 16 240 52 — Good 8 Male 30 Right Ⅱ Talar neck 10 180 35 — Excellent 1.3 Surgical methods The patients underwent surgery under combined spinal-epidural anesthesia or general anesthesia, and the ipsilateral or contralateral iliac crests were disinfected for iliac bone grafting. First, the supine position was selected, and a pneumatic tourniquet (pressure of 50 Kpa) was applied to the root of the thigh. The arthroscopic lens and planer tool were inserted through the anteromedial and anterolateral portals of the ankle joint to clean up the synovium of the joint and to find the non-healing parts of the fracture. The bone callus and pseudarthrosis were thoroughly removed using the planer tool and grinding head until fresh and normal bone was exposed. First, the large bulks of talus and tibia were fixed with a 1.5 mm or 2.0 mm Kirschner wire; subsequently, the unstable bone mass was drilled using 1.5 mm or 2.0 mm Kirschner wire, and the bone mass was pried with a micro bone lever. If there was joint dislocation, the bone mass would be reset first. Following this, under direct arthroscopic visualization, the fracture fragments were pried and reset to correct angulation, rotation, and varus deformity, and the iliac bone graft was selected according to the size of the bone defect. The Kirschner wire was temporarily fixed, and C-arm fluoroscopy was performed to confirm that the fracture and joint were in good alignment and the force line was good. The patient position was changed to inclined position hereafter. Arthroscopic lenses and planer tools were placed on both sides of the Achilles tendon through the posterior medial and posterolateral approaches of the ankle joint to continue the cleaning of the posterior synovium of the ankle joint. The great flexor tendon of the foot was exposed and retracted to the medial side to protect blood vessels and nerves, and investigate and determine the reduction of the ankle joint or subtalar joint. After confirming that the joint reduction was good, the insertion points of guide wires were used in the posteromedial, posteromedial and posteromedial parts of the talar body, and the insertion point of the guide needle was in a "triangle" distribution. C-arm fluoroscopy ensured that the distal end of the guide wire was located in the middle of the talus bone. Hole drilling and hole sounding were conducted, hollow screws with a diameter of 3.5 mm or 4.5 mm were inserted according to the size of the fracture fragments, and balanced pressure was applied. After satisfactory observation was achieved by C-arm fluoroscopy and arthroscopy, the temporarily fixed Kirschner wires were removed. The arthroscope was withdrawn, the incision was sutured, and pressure was applied with sterile dressing. ARIF was performed on eight patients, and the surgery duration was 160–240 min. All patients underwent reduction and internal fixation and iliac bone grafting by posteromedial-posterolateral and anterolateral approaches under ankle arthroscopy. 1.4 Postoperative management Routine anti-inflammatory, detumescence, analgesia, and other symptomatic support treatments were performed after surgery. The aseptic dressing was changed every 3 days, and the incision sutures were removed 2 weeks after the surgery. The affected limbs were fixed using a brace for 6 weeks; the ankle joint function exercise was performed after the brace was removed and weight-bearing walking began 12 weeks after the surgery. 1.5 Observation indicators Physical examination and X-ray examination of the ankles were performed at the last follow-up. X-ray examination was used to evaluate the healing of talus fractures. The range of motion (ROM) of ankle joints was measured using a protractor. Ankle joint function was assessed using the AOFAS Ankle-Hindfoot Scale. In the scale, assessment items were divided into three categories: Pain (40 points), Function (45 points), and Mechanical axis (15 points), with the highest score of 100 points. A score of 90–100 ranked as “Excellent,” 75–89 as “Good,” 50–74 as “Average,”; and < 50 as “Poor” . 13 , 7 1.6 Statistical analyses SPSS 21.0 software was used for statistical analysis. Categorical variables are represented by frequency and continuous variables are represented as mean ± standard deviation. Shapiro-Wilk test was performed to evaluate whether all data distributions followed a normal distribution. Furthermore, t test was used for the analysis of normal distribution data. P < 0.05 was considered to indicate statistical significance. Results 2.1 ROM of ankle joints The angle of active dorsiflexion of the affected ankle joint from a neutral position was significantly smaller than the angle of active dorsiflexion of the contralateral ankle joint (P = 0.000), and the angle of active plantar flexion of the affected ankle joint from a neutral position was significantly smaller than the angle of active plantar flexion of the contralateral ankle joint (P = 0.000). The ROM of the affected ankle joint was smaller than that of the contralateral ankle (Table 2 ). Table 2 Comparison of active flexion and extension motion of the affected and healthy ankle joints ( , °) Side of the affected ankle joint Side of the healthy ankle joint t P Dorsiflexion 10.1 ± 1.5 12.9 ± 2.1 -7.514 0.000 Plantar flexion 43.0 ± 3.9 46.3 ± 3.3 -6.619 0.000 2.2 AOFAS score According to the AOFAS Ankle-Hindfoot Scale, the function of ankle joints was evaluated as follows: Excellent (4 cases) and Good (4 cases) (Table 1 ). 2.3 Complications All patients had one-stage healing of incisions, and there was no incision infection or skin necrosis. During follow-up, two of eight patients suffered Achilles tendon contracture and difficulty in squatting, but they refused to undergo secondary surgery. The occurrence of these complications may be associated with the patients not undergoing systematic functional rehabilitation exercises after surgery. No complications such as talus necrosis, nonunion, or infection were observed (Table 1 ). 2.4 Typical cases A 46-year-old male patient was diagnosed with malunion or nonunion of a type II talus fracture by as per Zwipp classification 16 months after talar body fracture surgery. ARIF and iliac bone grafting were performed, and the incisions healed in the manner of primary healing after the surgery. The patient was followed up for 52 months, and suffered no ankle pain, had good ROM, and showed good scores on the AOFAS ankle-hindfoot scale (Fig. 1–3). Discussion 3.1 Anatomy of the talus and treatment of malunion and nonunion of talus fractures The talus is a connecting structure between the lower leg and the foot through the tibiotalar joint, and plays a crucial role in maintaining normal biomechanics of the foot and ankle. 8 , 21 The talus has a unique structure with an irregular shape. Two-thirds of its surface is covered by articular cartilage, with no attached muscle, but only a small part is covered by the periosteum. In addition, the talus lacks special nourishing blood vessels and primarily relies on the branches of the posterior tibial artery, peroneal artery, and dorsalis pedis artery to anastomose and form a vascular network around it for maintaining blood supply. 1 This special structure of the talus is the main reason for the high incidence of traumatic arthritis, joint stiffness, osteonecrosis, malunion, and nonunion after talus fractures. 16 , 1 Malunion and nonunion of talus fractures are very common complications. It is challenging to treat malunion and nonunion of talus fractures, and once malunion and nonunion of talus fractures occur, surgery should be performed as soon as possible to avoid traumatic arthritis. Yu et al. believed that according to the classification by Zwipp, secondary osteotomy and anatomical reconstruction are feasible for young patients with type I, II, and III talus fractures who actively receive treatments and have good bone and cartilage conditions. 22 Orthopedic reconstruction and arthrodesis should be performed for patients with types I, II, and III talus fractures who suffer from severe post-traumatic arthritis or systemic diseases. Patients with type IV talus fractures can be treated via osteotomy for necrotic bone, autologous bone grafting, and tibiotalocalcaneal arthrodesis. For patients with type V talus fractures, complete debridement of the infected tissue and subtotal talectomy should be performed, and the function of the talonavicular head and talonavicular joint should be preserved. Gang et al. believed that although arthrodesis can effectively relieve pain and improve function, its long-term effect is moderate because of the degeneration of adjacent joints after arthrodesis. 9 For patients with types I, II, and III talus fractures with nonunion and athletic ability and compliance, anatomic reconstruction and internal fixation can be performed to preserve the three joints. For fractures of talar neck and talar head, anteromedial incision is recommended. For talar body fractures, medial malleolus osteotomy should be performed. For fractures of the talar neck and lateral or lateral process of the talar head, an anterolateral incision is recommended. There were five cases of talar body fractures and three cases of talar neck fractures in this group, all of which included malunion and nonunion of type II talus fractures as classified by Zwipp. All patients underwent ARIF and iliac bone grafting. The average follow-up duration was 30.2 months, and there were no serious complications after surgery. Postoperative AOFAS evaluations were all ranked as “Good” or “Excellent”. 3.2 Surgical techniques and indications for performing ARIF for the treatment of malunion or nonunion of type II talus fractures as per Zwipp classification Zwipp and Rammelt classified the malunion and nonunion of talus fractures into five types: type I, malunion of talus fracture with joint dislocation; type II, nonunion of talus fracture with joint dislocation; type III, partial avascular necrosis of the talus on the basis of type I or type II; type IV, avascular necrosis of the entire talus on the basis of type I or type II; and type V: septic avascular necrosis of the talus on the basis of type I or II. Before treatment, malunion and nonunion of talus fractures should be classified according to the CT results to facilitate the formulation of treatment plans and the prediction of surgery duration. Patients with type II talus fractures as per Zwipp classification can be treated by arthroscopy. First, in supine position, the fractured callus and pseudarthrosis were cleaned under arthroscopy. The large bone fragments that had been reduced was fixed with Kirschner wire, and then other bone fragments were reduced using a micro-bone lever or probe hook and fixed temporarily with Kirschner wire. In case there is a bone fragment in the front, it can directly be fixed with cannulated screws. Subsequently, in the prone position, a posterior-forward cannulated screw was inserted via the posterior malleolus approach for fixation. Arthroscopy can be used to investigate whether the fractures have been reduced and whether the reduction of the ankle joint and the subtalar joint can be anatomically viewed. When cannulated screws are used to fix fractures, the size and number of cannulated screws are determined by the size of the fracture fragments and the position of the fracture lines. The head of the anterior-posterior cannulated screws should be directed to the middle of the talar head and should be fixed with uniform pressure perpendicular to the fracture line. If the malunion and nonunion of talus fractures are classified as type II by Zwipp and the mechanical axis is good, ARIF is indicated. The contraindications are malunion or nonunion of talus fractures classified as type I, III, IV, or V by Zwipp; abnormal mechanical axis; poor skin condition; and severe traumatic arthritis. 3.3 Advantages and disadvantages of ARIF and traditional ORIF It is difficult for traditional surgical methods to completely preserve the remaining blood supply to the talus, and if an osteotomy is needed, there is a possibility of nonunion or malunion after the osteotomy. 3 , 14 , 17 , 19 For malunion and nonunion of type II talus fractures as per Zwipp classification, visualized anatomical reduction becomes rather difficult. Medial malleolus osteotomy is required for reduction and internal fixation when necessary. Considering the poor blood supply of the region and the severity of injury after talus fractures, the surgical approach must be based on minimizing damage to the surrounding tissues and blood supply, thereby reducing the risk of ischemic necrosis and post-traumatic arthritis. 18 Compared with traditional ORIF, ARIF has many advantages in the treatment of malunion or nonunion of talus fractures classified as type II by Zwipp: Arthroscopy can help surgeons reduce the dislocated joints and fractures without performing an incision and without osteotomy, thus reducing damage to normal tissues and maintaining the blood supply of the talus. It can obtain a large enough surgical field of view for debridement, reduction, and internal fixation of talus fracture ends in cases of nonunion of talus fractures. ARIF can cause less trauma to the ankle joint, reports fewer postoperative complications, and can achieve faster recovery. However, arthroscopic surgery also has some disadvantages: ARIF requires a long learning curve, changes of body position are required during the procedure, and the surgical duration may be longer than that for traditional ORIF. In conclusion, ARIF is a feasible, safe, and effective surgical approach for malunion and nonunion of talus fractures classified as type II by Zwipp, with less secondary trauma to the ankle joint, fewer postoperative complications, and faster recovery and maintains a more complete ankle joint anatomy. Abbreviations ARIF arthroscopic reduction and internal fixation ORIF open reduction and internal fixation AOFAS American Orthopaedic Foot and Ankle Society ROM range of motion Declarations Ethics approval and consent to participate: The experimental protocol was established according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of the Second Qilu Hospital of Shandong University. Written informed consent was obtained from individual or guardian participants. Consent for publication: Written informed consent for publication was obtained from all individual participants included in the study (or their parent or legal guardian in the case of children under 18). Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests. Funding: Not applicable. Authors' contributions: WY. Z and LC. J collected the patient data. N. Z and XC. L analyzed and interpreted the patient data. ZX. L and Y. H performed the operation. WP. X was a major contributor in writing the manuscript. HP. S and Y. W gave many advises in writing the manuscript.All authors read and approved the final manuscript. Conflict of Interest : Not applicable. Clinical trial number: Not applicable. Acknowledgements: The authors will thank all the colleagues of Department of foot and ankle surgery of the Second Qilu Hospital of Shandong University for their great help. References Buza JA, Leucht P. Fractures of the talus: current concepts and new developments. Foot Ankle Surg,2018,24(4):282-290. Caracchini G, Pietragalla M, De Renzis A, et al. Talar fractures: radiological and CT evaluation and classification systems. Acta Biomed,2018,89(1-S):151-165. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7245109","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501498416,"identity":"8d13dd1f-2537-42ea-958b-14d964dd5d8d","order_by":0,"name":"Wenpeng Xu","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Wenpeng","middleName":"","lastName":"Xu","suffix":""},{"id":501498417,"identity":"5425becb-8b2d-487e-84ac-f425bd054cdb","order_by":1,"name":"Lichao Jia","email":"","orcid":"","institution":"The People’s Hospital of Feicheng","correspondingAuthor":false,"prefix":"","firstName":"Lichao","middleName":"","lastName":"Jia","suffix":""},{"id":501498418,"identity":"2250d11a-bacc-4bb6-ab1f-348a55a46019","order_by":2,"name":"Weiye Zhang","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Weiye","middleName":"","lastName":"Zhang","suffix":""},{"id":501498419,"identity":"456da6db-1015-4a1c-954b-e85c0076c36f","order_by":3,"name":"Zhengxun Li","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Zhengxun","middleName":"","lastName":"Li","suffix":""},{"id":501498420,"identity":"52b7c8ba-eb4a-465e-9ca7-09a54365f216","order_by":4,"name":"Ning Zhang","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Zhang","suffix":""},{"id":501498421,"identity":"555d463c-1540-44af-90f5-625bca899fcc","order_by":5,"name":"Xiucun Li","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Xiucun","middleName":"","lastName":"Li","suffix":""},{"id":501498422,"identity":"9e02ce1f-003b-4414-9606-23ecda4794f4","order_by":6,"name":"Yang Wang","email":"","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Wang","suffix":""},{"id":501498423,"identity":"748a4e62-e800-4972-88c3-9893a27449e2","order_by":7,"name":"Haipeng Si","email":"","orcid":"","institution":"Qilu Hospital of Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Haipeng","middleName":"","lastName":"Si","suffix":""},{"id":501498424,"identity":"653b32f7-f900-4ee6-a30c-9f2806fbd225","order_by":8,"name":"Yong Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACAyCWgLIZHyRU1JCmhdngwZljpGlhk3zYwkxYizn72YM3f7bds+tn7z1WkdjAxsDf3p2AV4tlT16yNW9bcfLMnnNpNxJ3yDBInDm7Ab/DDuSYSTO2JSQb3Mgxu5F4ho3BQCKXgJbzb8wkfwK12AO1FCS2MROhBahSgrctwc5AIseMgUgtb4ytec4lJEicOWMskXDmGA9hv5zPMbz5oyzBnr+9x/Djj4oaOf72XvxaYCCxAcrgIUo5CNgTrXIUjIJRMApGHgAAKotImhRPkgsAAAAASUVORK5CYII=","orcid":"","institution":"The Second Qilu Hospital of Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2025-07-29 15:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7245109/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7245109/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03474-8","type":"published","date":"2026-01-07T15:59:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89672827,"identity":"ce887257-c5e4-4c85-8820-27cea35949ae","added_by":"auto","created_at":"2025-08-22 13:11:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":752949,"visible":true,"origin":"","legend":"\u003cp\u003eMale, 46 years, malunion or nonunion of a type II talus fracture by as per Zwipp classification A. Lateral view of the ankle joint; B. Anteroposterior view of the ankle joint; C. Coronal CT; D. Sagittal CT; E. Ankle arthroscopy using anterolateral-anteromedial approach for fracture reduction and bone grafting; F. Ankle arthroscopy using posterolateral and posteromedial approach for hollow screw internal fixation; G \u0026amp; H. immediate postoperative X-ray films; I \u0026amp; J. anteroposterior and lateral X-rays at 21 months after surgery; K \u0026amp; L. The ROM of the ankle joint at the follow-up 52 months after the surgery.\u003c/p\u003e","description":"","filename":"Figure1A.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7245109/v1/b6540b237f094fdc22685f84.jpg"},{"id":100070158,"identity":"1ac2f2d7-2391-4783-aae9-4594bc546507","added_by":"auto","created_at":"2026-01-12 16:16:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1568533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7245109/v1/fcc0aa02-042e-4447-ad8f-cb5ace6e0a8b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical study of arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTalus fractures are often caused by high-energy injuries such as traffic accident injuries and falls from heights. Talus fractures account for approximately 3\u0026ndash;5% of foot and ankle fractures.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e According to the anatomical location of the talus, talus fractures are further divided into talar head, talar neck, and talar body fractures, among which talar neck fractures account for 50\u0026ndash;80% of all talus fractures.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The talus is small and irregularly shaped, with no tendon attached, and 60% of the surface is covered by articular cartilage. Therefore, the blood supply to this area is very fragile. Malunion or nonunion is likely to occur if talus fracture is not treated properly. According to the literature, the incidence rate of malunion or nonunion after talus fracture ranges from 9\u0026ndash;47%. The classifications of malunion and nonunion of talus fractures proposed by Zwipp and Rammelt are as follows: type I: malunion of talus fracture with joint dislocation; type II: nonunion of talus fracture with joint dislocation; type III: partial avascular necrosis of the talus on the basis of type I or type II; type IV: avascular necrosis of the entire talus on the basis of type I or type II; and type V: septic avascular necrosis of the talus on the basis of type I or II. It is difficult to cure malunion and nonunion of a talus fracture, which easily causes limb disability and affects the patients\u0026rsquo; working ability and quality of life. With the development of arthroscopic techniques, arthroscopic reduction and internal fixation (ARIF) and arthroscopically assisted open reduction and internal fixation (ORIF) have become increasingly popular for the treatment of foot and ankle fractures and old fractures. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003eThe application of arthroscopic technique avoids secondary trauma caused by open surgery or complications after osteotomy.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e From July 2014 to July 2022, our department applied ARIF to treat eight cases of malunion and nonunion of type II talus fracture as per Zwipp classification, achieving satisfactory results. We report our experience in this study.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Inclusion and exclusion criteria\u003c/h2\u003e\u003cp\u003eInclusion criteria: Malunion and nonunion of type II talus fracture as per Zwipp classification. Exclusion criteria: (1) Malunion and nonunion of talus fractures of types I, III, IV, and V as per Zwipp classification; (2) Malunion and nonunion of talus fractures with abnormal mechanical axis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.2 General data\u003c/h2\u003e\u003cp\u003eThere were five males and three females in this study. Patient age ranged from 17 to 55 years, with an average age of 34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 years. All patients had secondary malunion or nonunion following closed fractures of the talar body or neck, with varying degrees of joint pain and dislocation. There were five cases of talar body fracture and three cases of talar neck fracture. The time interval from fracture to the present surgery ranged from 8 to 16 months, with an average of 11.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 months. According to the classification of malunion and nonunion of talus fractures proposed by Zwipp and Rammelt, all eight cases were type II. Before the surgery, all patients underwent weight-bearing anteroposterior and lateral radiographs of ankle joints, long-axial radiographs of calcaneal bone, and CT to determine the location, mechanical axis, and classification of fractures. MRI was performed on all the patients suspected with osteonecrosis. Preoperative blood routine and C-reactive protein detection were performed for all patients to exclude the possibility of infection. Preoperative scoring was performed for all patients using the AOFAS Ankle-Hindfoot Scale, with an average score of 38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1 (range, 30.0\u0026ndash;45.0). All eight patients were followed up for 10 to 52 months, with an average of 30.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2 months (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The ethics committee of the Second Qilu Hospital of Shandong University approved this study and an internal review board, and informed consent was obtained from all patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBasic information of the patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLateral side\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eClassification by Zwipp\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFracture site\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTime interval from fracture to the present surgery (months)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSurgery time (min)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eFollow-up time (months)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eAmerican Orthopaedic Foot and Ankle Society (AOFAS) result assessment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar neck\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eContracture of Achilles tendon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eContracture of Achilles tendon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar neck\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTalar neck\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Surgical methods\u003c/h2\u003e\u003cp\u003eThe patients underwent surgery under combined spinal-epidural anesthesia or general anesthesia, and the ipsilateral or contralateral iliac crests were disinfected for iliac bone grafting. First, the supine position was selected, and a pneumatic tourniquet (pressure of 50 Kpa) was applied to the root of the thigh. The arthroscopic lens and planer tool were inserted through the anteromedial and anterolateral portals of the ankle joint to clean up the synovium of the joint and to find the non-healing parts of the fracture. The bone callus and pseudarthrosis were thoroughly removed using the planer tool and grinding head until fresh and normal bone was exposed. First, the large bulks of talus and tibia were fixed with a 1.5 mm or 2.0 mm Kirschner wire; subsequently, the unstable bone mass was drilled using 1.5 mm or 2.0 mm Kirschner wire, and the bone mass was pried with a micro bone lever. If there was joint dislocation, the bone mass would be reset first. Following this, under direct arthroscopic visualization, the fracture fragments were pried and reset to correct angulation, rotation, and varus deformity, and the iliac bone graft was selected according to the size of the bone defect. The Kirschner wire was temporarily fixed, and C-arm fluoroscopy was performed to confirm that the fracture and joint were in good alignment and the force line was good. The patient position was changed to inclined position hereafter. Arthroscopic lenses and planer tools were placed on both sides of the Achilles tendon through the posterior medial and posterolateral approaches of the ankle joint to continue the cleaning of the posterior synovium of the ankle joint. The great flexor tendon of the foot was exposed and retracted to the medial side to protect blood vessels and nerves, and investigate and determine the reduction of the ankle joint or subtalar joint. After confirming that the joint reduction was good, the insertion points of guide wires were used in the posteromedial, posteromedial and posteromedial parts of the talar body, and the insertion point of the guide needle was in a \"triangle\" distribution. C-arm fluoroscopy ensured that the distal end of the guide wire was located in the middle of the talus bone. Hole drilling and hole sounding were conducted, hollow screws with a diameter of 3.5 mm or 4.5 mm were inserted according to the size of the fracture fragments, and balanced pressure was applied. After satisfactory observation was achieved by C-arm fluoroscopy and arthroscopy, the temporarily fixed Kirschner wires were removed. The arthroscope was withdrawn, the incision was sutured, and pressure was applied with sterile dressing.\u003c/p\u003e\u003cp\u003eARIF was performed on eight patients, and the surgery duration was 160\u0026ndash;240 min. All patients underwent reduction and internal fixation and iliac bone grafting by posteromedial-posterolateral and anterolateral approaches under ankle arthroscopy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e1.4 Postoperative management\u003c/h2\u003e\u003cp\u003eRoutine anti-inflammatory, detumescence, analgesia, and other symptomatic support treatments were performed after surgery. The aseptic dressing was changed every 3 days, and the incision sutures were removed 2 weeks after the surgery. The affected limbs were fixed using a brace for 6 weeks; the ankle joint function exercise was performed after the brace was removed and weight-bearing walking began 12 weeks after the surgery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e1.5 Observation indicators\u003c/h2\u003e\u003cp\u003ePhysical examination and X-ray examination of the ankles were performed at the last follow-up. X-ray examination was used to evaluate the healing of talus fractures. The range of motion (ROM) of ankle joints was measured using a protractor. Ankle joint function was assessed using the AOFAS Ankle-Hindfoot Scale. In the scale, assessment items were divided into three categories: Pain (40 points), Function (45 points), and Mechanical axis (15 points), with the highest score of 100 points. A score of 90\u0026ndash;100 ranked as \u0026ldquo;Excellent,\u0026rdquo; 75\u0026ndash;89 as \u0026ldquo;Good,\u0026rdquo; 50\u0026ndash;74 as \u0026ldquo;Average,\u0026rdquo;; and \u0026lt;\u0026thinsp;50 as \u0026ldquo;Poor\u0026rdquo; .\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e1.6 Statistical analyses\u003c/h2\u003e\u003cp\u003eSPSS 21.0 software was used for statistical analysis. Categorical variables are represented by frequency and continuous variables are represented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Shapiro-Wilk test was performed to evaluate whether all data distributions followed a normal distribution. Furthermore, \u003cem\u003et\u003c/em\u003e test was used for the analysis of normal distribution data. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.1 ROM of ankle joints\u003c/h2\u003e\u003cp\u003eThe angle of active dorsiflexion of the affected ankle joint from a neutral position was significantly smaller than the angle of active dorsiflexion of the contralateral ankle joint (P\u0026thinsp;=\u0026thinsp;0.000), and the angle of active plantar flexion of the affected ankle joint from a neutral position was significantly smaller than the angle of active plantar flexion of the contralateral ankle joint (P\u0026thinsp;=\u0026thinsp;0.000). The ROM of the affected ankle joint was smaller than that of the contralateral ankle (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of active flexion and extension motion of the affected and healthy ankle joints (\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e, \u0026deg;)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSide of the affected ankle joint\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSide of the healthy ankle joint\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDorsiflexion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-7.514\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlantar flexion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e46.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-6.619\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.2 AOFAS score\u003c/h2\u003e\u003cp\u003eAccording to the AOFAS Ankle-Hindfoot Scale, the function of ankle joints was evaluated as follows: Excellent (4 cases) and Good (4 cases) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Complications\u003c/h2\u003e\u003cp\u003eAll patients had one-stage healing of incisions, and there was no incision infection or skin necrosis. During follow-up, two of eight patients suffered Achilles tendon contracture and difficulty in squatting, but they refused to undergo secondary surgery. The occurrence of these complications may be associated with the patients not undergoing systematic functional rehabilitation exercises after surgery. No complications such as talus necrosis, nonunion, or infection were observed (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Typical cases\u003c/h2\u003e\u003cp\u003eA 46-year-old male patient was diagnosed with malunion or nonunion of a type II talus fracture by as per Zwipp classification 16 months after talar body fracture surgery. ARIF and iliac bone grafting were performed, and the incisions healed in the manner of primary healing after the surgery. The patient was followed up for 52 months, and suffered no ankle pain, had good ROM, and showed good scores on the AOFAS ankle-hindfoot scale (Fig.\u0026nbsp;1\u0026ndash;3).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Anatomy of the talus and treatment of malunion and nonunion of talus fractures\u003c/h2\u003e\u003cp\u003eThe talus is a connecting structure between the lower leg and the foot through the tibiotalar joint, and plays a crucial role in maintaining normal biomechanics of the foot and ankle. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003eThe talus has a unique structure with an irregular shape. Two-thirds of its surface is covered by articular cartilage, with no attached muscle, but only a small part is covered by the periosteum. In addition, the talus lacks special nourishing blood vessels and primarily relies on the branches of the posterior tibial artery, peroneal artery, and dorsalis pedis artery to anastomose and form a vascular network around it for maintaining blood supply.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eThis special structure of the talus is the main reason for the high incidence of traumatic arthritis, joint stiffness, osteonecrosis, malunion, and nonunion after talus fractures.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Malunion and nonunion of talus fractures are very common complications. It is challenging to treat malunion and nonunion of talus fractures, and once malunion and nonunion of talus fractures occur, surgery should be performed as soon as possible to avoid traumatic arthritis. Yu et al. believed that according to the classification by Zwipp, secondary osteotomy and anatomical reconstruction are feasible for young patients with type I, II, and III talus fractures who actively receive treatments and have good bone and cartilage conditions.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Orthopedic reconstruction and arthrodesis should be performed for patients with types I, II, and III talus fractures who suffer from severe post-traumatic arthritis or systemic diseases. Patients with type IV talus fractures can be treated via osteotomy for necrotic bone, autologous bone grafting, and tibiotalocalcaneal arthrodesis. For patients with type V talus fractures, complete debridement of the infected tissue and subtotal talectomy should be performed, and the function of the talonavicular head and talonavicular joint should be preserved. Gang et al. believed that although arthrodesis can effectively relieve pain and improve function, its long-term effect is moderate because of the degeneration of adjacent joints after arthrodesis.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003eFor patients with types I, II, and III talus fractures with nonunion and athletic ability and compliance, anatomic reconstruction and internal fixation can be performed to preserve the three joints. For fractures of talar neck and talar head, anteromedial incision is recommended. For talar body fractures, medial malleolus osteotomy should be performed. For fractures of the talar neck and lateral or lateral process of the talar head, an anterolateral incision is recommended.\u003c/p\u003e\u003cp\u003eThere were five cases of talar body fractures and three cases of talar neck fractures in this group, all of which included malunion and nonunion of type II talus fractures as classified by Zwipp. All patients underwent ARIF and iliac bone grafting. The average follow-up duration was 30.2 months, and there were no serious complications after surgery. Postoperative AOFAS evaluations were all ranked as \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Excellent\u0026rdquo;.\u003c/p\u003e\u003cp\u003e3.2 Surgical techniques and indications for performing ARIF for the treatment of malunion or nonunion of type II talus fractures as per Zwipp classification\u003c/p\u003e\u003cp\u003eZwipp and Rammelt classified the malunion and nonunion of talus fractures into five types: type I, malunion of talus fracture with joint dislocation; type II, nonunion of talus fracture with joint dislocation; type III, partial avascular necrosis of the talus on the basis of type I or type II; type IV, avascular necrosis of the entire talus on the basis of type I or type II; and type V: septic avascular necrosis of the talus on the basis of type I or II. Before treatment, malunion and nonunion of talus fractures should be classified according to the CT results to facilitate the formulation of treatment plans and the prediction of surgery duration. Patients with type II talus fractures as per Zwipp classification can be treated by arthroscopy. First, in supine position, the fractured callus and pseudarthrosis were cleaned under arthroscopy. The large bone fragments that had been reduced was fixed with Kirschner wire, and then other bone fragments were reduced using a micro-bone lever or probe hook and fixed temporarily with Kirschner wire. In case there is a bone fragment in the front, it can directly be fixed with cannulated screws. Subsequently, in the prone position, a posterior-forward cannulated screw was inserted via the posterior malleolus approach for fixation. Arthroscopy can be used to investigate whether the fractures have been reduced and whether the reduction of the ankle joint and the subtalar joint can be anatomically viewed. When cannulated screws are used to fix fractures, the size and number of cannulated screws are determined by the size of the fracture fragments and the position of the fracture lines. The head of the anterior-posterior cannulated screws should be directed to the middle of the talar head and should be fixed with uniform pressure perpendicular to the fracture line. If the malunion and nonunion of talus fractures are classified as type II by Zwipp and the mechanical axis is good, ARIF is indicated. The contraindications are malunion or nonunion of talus fractures classified as type I, III, IV, or V by Zwipp; abnormal mechanical axis; poor skin condition; and severe traumatic arthritis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Advantages and disadvantages of ARIF and traditional ORIF\u003c/h2\u003e\u003cp\u003eIt is difficult for traditional surgical methods to completely preserve the remaining blood supply to the talus, and if an osteotomy is needed, there is a possibility of nonunion or malunion after the osteotomy.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003eFor malunion and nonunion of type II talus fractures as per Zwipp classification, visualized anatomical reduction becomes rather difficult. Medial malleolus osteotomy is required for reduction and internal fixation when necessary. Considering the poor blood supply of the region and the severity of injury after talus fractures, the surgical approach must be based on minimizing damage to the surrounding tissues and blood supply, thereby reducing the risk of ischemic necrosis and post-traumatic arthritis.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCompared with traditional ORIF, ARIF has many advantages in the treatment of malunion or nonunion of talus fractures classified as type II by Zwipp: Arthroscopy can help surgeons reduce the dislocated joints and fractures without performing an incision and without osteotomy, thus reducing damage to normal tissues and maintaining the blood supply of the talus. It can obtain a large enough surgical field of view for debridement, reduction, and internal fixation of talus fracture ends in cases of nonunion of talus fractures. ARIF can cause less trauma to the ankle joint, reports fewer postoperative complications, and can achieve faster recovery. However, arthroscopic surgery also has some disadvantages: ARIF requires a long learning curve, changes of body position are required during the procedure, and the surgical duration may be longer than that for traditional ORIF.\u003c/p\u003e\u003cp\u003eIn conclusion, ARIF is a feasible, safe, and effective surgical approach for malunion and nonunion of talus fractures classified as type II by Zwipp, with less secondary trauma to the ankle joint, fewer postoperative complications, and faster recovery and maintains a more complete ankle joint anatomy.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eARIF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003earthroscopic reduction and internal fixation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eORIF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eopen reduction and internal fixation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAOFAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Orthopaedic Foot and Ankle Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003erange of motion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The experimental protocol was established according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of the Second Qilu Hospital of Shandong University. Written informed consent was obtained from individual or guardian participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Written informed consent for publication was obtained from all individual participants included in the study (or their parent or legal guardian in the case of children under 18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e WY. Z and LC. J collected the patient data. N. Z and XC. L analyzed and interpreted the patient data. ZX. L and Y. H performed the operation. WP. X was a major contributor in writing the manuscript. HP. S and Y. W gave many advises in writing the manuscript.All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors will thank all the colleagues of Department of foot and ankle surgery of the Second Qilu Hospital of Shandong University for their great help.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBuza JA, Leucht P. Fractures of the talus: current concepts and new developments. Foot Ankle Surg,2018,24(4):282-290.\u003c/li\u003e\n\u003cli\u003eCaracchini G, Pietragalla M, De Renzis A, et al. Talar fractures: radiological and CT evaluation and classification systems. Acta Biomed,2018,89(1-S):151-165.\u003c/li\u003e\n\u003cli\u003eCanale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg [Am] 1978;60-A:143\u0026ndash;156.\u003c/li\u003e\n\u003cli\u003eCanale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg [Am] 1978;60-A:143\u0026ndash;156.\u003c/li\u003e\n\u003cli\u003eChan KB, Lui TH. Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy,2016,32(11):2373-2380.\u003c/li\u003e\n\u003cli\u003eDei Giudici L, Di Muzio F, Bottegoni C, et al. The role of arthroscopy in articular fracture management: the lower limb. Eur J Orthop Surg Traumatol, 2015,25(5):807-813.\u003c/li\u003e\n\u003cli\u003eElgafy H, Ebraheim NA, Tile M, et al. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int, 2000,21(12):1023-1029.\u003c/li\u003e\n\u003cli\u003eFrigg A, Frigg R, Hintermann B, et al. The biomechanical influence of tibio-talar containment on stability of the ankle joint. Knee Surg Sports Traumatol Arthrosc, 2007,15(11):1355-1362.\u003c/li\u003e\n\u003cli\u003eGang Chen, Mu Hu, Yang Xu, et.al. Joint-Preserving Surgery for Talar Malunions or Nonuions. Orthopaedic Surgery 2017;9:34\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eHawkins LG. Fractures of the neck of the talus. J Bone Joint Surg [Am] 1970;52-A:991\u0026ndash;1002.\u003c/li\u003e\n\u003cli\u003eHamilton GA, Doyle MD, Castellucci-Garza FM. Arthroscopic-assisted open reduction internal fixation. Clin Podiatr Med Surg,2018,35(2):199-221.\u003c/li\u003e\n\u003cli\u003eKadakia R, Konopka J, Rodik T, et al. Arthroscopic reduction and internal fixation (ARIF) of a comminuted posterior talar body fracture: surgical technique and case report. Foot Ankle Spec, 2017,10(5):465-469.\u003c/li\u003e\n\u003cli\u003eKitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 1994,15(7):349-353.\u003c/li\u003e\n\u003cli\u003eLindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg [Am] 2004;86-A:2229\u0026ndash;2234.\u003c/li\u003e\n\u003cli\u003eLui TH, Pan XH, Pan Y. Arthroscopic and endoscopic management of common complications after displaced intra-articular calcaneal fractures. Clin Podiatr Med Surg, 2019,36(2):279-293.\u003c/li\u003e\n\u003cli\u003eRammelt S, Zwipp H. Talar neck and body fractures. Injury 2009;40:120\u0026ndash;135.\u003c/li\u003e\n\u003cli\u003eRomeo NM, Hirschfeld AG, Githens M, et al. Significance of lateral process fractures associated with talar neck and body fractures. J Orthop Trauma, 2018,32(12):601-606.\u003c/li\u003e\n\u003cli\u003eSuter T, Barg A, Knupp M, Henninger H, Hintermann B. Surgical technique: talar neck osteotomy to lengthen the medial column after a malunited talar neck fracture.Clin Orthop Relat Res 2013;471:1356\u0026ndash;1364.\u003c/li\u003e\n\u003cli\u003eVon Winning D, Adolf D, Schirrmeister W, et al. Surgical treatment of talar neck and body fractures: mid-term results of 24 cases. Z Orthop Unfall, 2020 Jan 9. doi: 10.1055/a-1023-4715. Online ahead of print.\u003c/li\u003e\n\u003cli\u003eWajsfisz A, Makridis KG, Guillou R, et al. Arthroscopic treatment of a talar neck fracture: a case report. Knee Surg Sports Traumatol Arthrosc 2012;20:1850\u0026ndash;1853.\u003c/li\u003e\n\u003cli\u003eYin Bing, Wang Jiangchao, Li Sheng. et al, The micro-hardness distribution in human metatarsal bones. Chinese Journal of Anatomy and Clinics, 2018,23(6):461-464.\u003c/li\u003e\n\u003cli\u003eYu Guangrong, Li Bing, Yang Yunfeng, et al. Surgical treatment of malunited or nonunited talus fractures. Chinese Journal of Surgery, 2010,5,48(9):658-661.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Arthroscopy, talus fracture, malunion and nonunion, internal fixation","lastPublishedDoi":"10.21203/rs.3.rs-7245109/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7245109/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo investigate the surgical method of arthroscopic reduction and internal fixation (ARIF) for malunion and nonunion of type II talus fracture as per Zwipp classification, and to evaluate its therapeutic effect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective analysis was performed on eight patients (five males and three females) with unilateral limbs treated with ARIF for malunion and nonunion of a talus fracture at our hospital between July 2014 and July 2022. The age ranged from 17 to 55 years, with an average of 34.9 ± 12.3 years. In all, five cases of talar body fracture and three cases of talar neck fracture were observed. The time interval between fracture and the present surgery was 8–16 months (average, 11.1 ± 2.5 months). According to the classification of malunion and nonunion of talus fracture by Zwipp, all the eight cases were classified as type II. Intraoperative autologous iliac bone grafting was performed for all patients. At the last follow-up, the ankle joint was assessed for range of motion and an X-ray examination was performed. Ankle joint function was evaluated as per the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll eight patients were followed up for 10 to 52 months (average, 30.2 ± 14.2 months). All patients achieved primary wound healing, and 2 of them experienced Achilles tendon contracture, with no case of avascular necrosis of the talus, fracture nonunion, infection, or other complications. Ankle joint function was assessed according to the AOFAS score, with four cases assessed as “Excellent” and four as “Good” on the scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eARIF is a safe and effective surgical method for malunion and nonunion of type II talus fracture as per Zwipp classification with lesser secondary damage to the blood supply of the talus, fewer postoperative complications, and faster recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLevel II.\u003c/p\u003e","manuscriptTitle":"Clinical study of arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 13:11:33","doi":"10.21203/rs.3.rs-7245109/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T09:33:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T06:17:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T12:05:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T14:19:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183710912517676305959159499911466665016","date":"2025-08-17T14:11:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46951415119592734626904429928017060283","date":"2025-08-17T07:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12159060590385546636065809535962619694","date":"2025-08-15T08:50:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315452354631327860671440506953990505271","date":"2025-08-14T18:28:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111344819571550883855135983390978349747","date":"2025-08-14T18:24:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T16:50:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T16:29:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-13T14:18:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-08-13T14:15:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38045b58-a95b-411d-bb97-3aceb0a41d7b","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:10:25+00:00","versionOfRecord":{"articleIdentity":"rs-7245109","link":"https://doi.org/10.1186/s12893-025-03474-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-01-07 15:59:08","publishedOnDateReadable":"January 7th, 2026"},"versionCreatedAt":"2025-08-22 13:11:33","video":"","vorDoi":"10.1186/s12893-025-03474-8","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03474-8","workflowStages":[]},"version":"v1","identity":"rs-7245109","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7245109","identity":"rs-7245109","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}