New modification to the Hawkins classification scheme is more predictive of osteonecrosis: commentary on an article by Heather A. Vallier, MD, et al.: "A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?".

Talar neck fractures are rare injuries that are typically the result of high-velocity traumas. Because of the high rate of osteonecrosis and posttraumatic arthritis associated with talar neck fractures, application of current classification systems for prognostication of the development of talar osteonecrosis and posttraumatic arthritis has been challenging. In a large retrospective review of talar fractures, Halvorson et al.1 reported the overall rate of posttraumatic talar osteonecrosis in a series of 848 patients to be 33.3% (282 patients). Additional analysis revealed that osteonecrosis occurred in 5.7% (nine) of 159 Hawkins type-I fractures, 18.4% (fifty-eight) of 314 Hawkins type-II fractures, 44.7% (102) of 228 Hawkins type-III fractures, and 12.1% (four) of thirty-three Hawkins type-IV fractures1. In another study, Vallier et al.2 revealed that osteonecrosis occurred in approximately 39% of Hawkins type-II fractures and 64% of Hawkins type-III fractures. Several areas of controversy exist, specifically the wide range of osteonecrosis for Hawkins type-II fractures and potentially the timing of operative fixation. First, one key observation …