A recent paper by Vetter and colleagues looked at cone beam fluoroscopy as a means to better assess talar neck and body fractures after initial reduction. The authors used this technique after conventional fluoroscopy in a series of non-randomized cases. They then compared those that had this extra step vs. those that did not. They found that the patients with the cone beam had better long-term clinical scores but that this was not statistically significant.
Cone beam technology offers a 3-D image based on more than 100 fluoroscopic images taken through a motorized fluoroscopic unit. This offers the operator an unparalleled view of surface anatomy and offers the promise of improved articular reductions and hopefully better functional outcomes as a result.
Unfortunately, the publication omits information that would help the reader understand the benefits of this technology. This was not a randomized prospective study. It was not clinically blinded. It is unclear whether one or two approaches were used to reduce the neck fracture. This is important as one cannot determine an accurate reduction or fracture rotation without medial and lateral incisions. When one uses conventional fluoroscopy, coupled cone beam fluoroscopy, the radiation exposure by definition is greater. Once the cone beam identifies a nonanatomic reduction, which is then corrected, does the operator repeat the study in the OR? This would not only increase radiation exposure but add time to the procedure. Finally, the study showed figures which in neither case was the reduction truly anatomic.
Regardless of this particular study, cone beam fluoroscopy offers the promise of better reduction verification intraoperatively. This has been shown to be most effective in pelvic and acetabular surgery where direct visualization is difficult. In talus fractures, with direct visualization possible using two approaches and malleolar osteotomies when needed, the role of cone beam fluoroscopy may be minimal.
Roy W. Sanders, MD
Orthopedics Today Editorial Section Board Editor, Trauma
Disclosures: Sanders reports no relevant financial disclosures.