Total talar extrusion: a case report

Pantalar Intact Dislocation: A Systematic Review

BACKGROUND

This scoping review analyzes the available literature on pure total talar dislocation, focusing on its epidemiology, clinical presentation, imaging techniques, surgical options, rehabilitation protocols, and complications.

METHODS

Following the PRISMA-ScR guidelines, a comprehensive search was conducted across the PubMed, Web of Science, and Scopus databases. The search yielded 185 articles, of which 30 satisfied the inclusion criteria and focused on pure total talar dislocation without fractures. Data from each study were extracted, including patient demographics, injury characteristics, treatment methods, and outcomes.

RESULTS

The studies included case reports, case series, and reviews. Despite the heterogeneity of the studies, the key findings suggest that early reduction, careful wound management, and soft tissue preservation are crucial in minimizing complications such as avascular necrosis (AVN), post-traumatic arthritis, and infection. The long-term outcomes varied, and the risk of AVN remained high, particularly in cases with compromised blood supply to the talus.

CONCLUSIONS

Pure total talar dislocation is a rare and challenging condition with no established management protocol. While talar reimplantation and joint fixation offer promising outcomes in preserving function, the risk of complications, particularly AVN, remains significant. Additional research is necessary to standardize treatment protocols and improve clinical outcomes for this rare but severe injury.

Total Talar and Navicular Extrusions: A Case Report

CASE

A 15-year-old adolescent boy sustained both talar and navicular extrusions after a dirt-bike accident. The talus and navicular were discarded during initial debridement because of contamination. Given extensive soft-tissue injury and bone loss, the patient's family opted for transtibial amputation, as described by Ertl, over limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation were performed.

CONCLUSION

Transtibial amputation is a viable treatment option for total talar and navicular extrusions, particularly if an optimal functional outcome is unachievable with limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation can potentially decrease neuroma formation and phantom limb pain.

The Masquelet technique in an extruded talus injury after open peri-talar dislocation-A case report

Extruded talus is a rare injury pattern that occurs following a high velocity injury loading on a supinated and plantar flexed foot. Treatment for such rare presentation varies from talectomy to arthrodesis. Reimplantation than excision has been favoured in literature, but it carries its own subset of issues to tackle from avascular necrosis to infection. Masquelet technique has been a saviour for open injuries most of the time in tackling both bone defects and infections. We present a case of open ankle injury with talar extrusion and assosciated talar bone loss along with calcaneum fracture, treated by masquelet technique.

Talar Dislocation: Is Reimplantation a Safe Procedure?

Total or complete dislocation of the talus is a triple dislocation of the tibiotalar, talocalcaneal, and talonavicular joints. It is a rare injury and is considered to be 1 of the most disabling ankle injuries. In light of the literature, there is a lack of consensus on their surgical treatment. The primary objective of this retrospective case series was to assess the long-term clinical and radiological outcomes of 5 patients who underwent talar reimplantation for total talar dislocation. From 2005 to 2011, 5 patients were admitted in emergency care unit with a total talar dislocation. The talar dislocation was surgically reduced and stabilized by a temporary internal fixation. Patients were reviewed with a mean follow-up of 60 months (48-70 months). Clinical and radiological evaluations were performed at the last follow-up. Despite 3 opened-dislocation (60%), none had infection. Three patients obtained subnormal biomechanical function with an American Orthopedic Foot and Ankle Score of 60 to 70/100. Two others patients (40%) underwent a secondary ankle arthrodesis because of avascular necrosis of the talus. Signs of necrosis appeared at 15 months and 24 months. Talar reimplantation should be attempted despite the risk of avascular necrosis: restoration of the talus in the ankle maintains normal hindfoot anatomy and preserves bone stock for future function or a subsequent surgical procedure. Patients should be informed of the risk of secondary surgery. Opened-dislocation seems to be a major risk factor of avascular necrosis, and surgeon must take care to keep soft tissues attached.

Outcomes of a Reimplanted Talus After a Total Open Extrusion

Total traumatic extrusion of the talus is a severe and disabling ankle injury that requires a high energy trauma. Many treatment options exist and none of them guarantee a successful result. Here, we present the case of a 67-year-old woman who experienced an open total traumatic extrusion of the talus. Based on the principles of open fracture management, we have realized an early administration of antibiotics and tetanus toxoid booster followed by an urgent debridement of the wound. Next, the talus was reimplanted and fixed with a K-wire. This allowed us to avoid the common complication and achieving good clinical outcomes. In our opinion, this is an encouraging and reasonable treatment option unless the talus is grossly contaminated or missing.

A Case Report of an Open Pan-Talar Dislocation

Total talar extrusion is a rare injury that most commonly occurs secondary to high-energy trauma. There are few reported cases of open dislocations in literature and still, there is no consensus regarding the appropriate treatment of the extruded talus. In this case report, we present a 12-month follow-up of a patient with an open talar dislocation with extrusion treated with immediate surgical debridement, reduction and temporary fixation with one Steinmann pin. No infection was reported, although the patient developed avascular necrosis.

Primary Triple Arthrodesis Equivalent for Complete Extruded Missing Talus with Associated Midfoot Instability: A Case Report

CASE

Complete extrusion of the talus is rare and associated with high rates of complications including infection, osteonecrosis, persistent pain and stiffness, and post-traumatic arthritis. Less well described is associated midfoot instability. We report a case of a complete extruded missing talus that resulted in significant midfoot instability treated with a modified triple arthrodesis of the tibiocalcaneal, tibionavicular, and calcaneocuboid joints.

CONCLUSIONS

This approach resulted in a radiographic fusion at 3 months without complication, acceptable subjective and Patient-Reported Outcome Measurement System (PROMIS) scores at the 18-month follow-up, and presents a viable treatment strategy in the case of a complete extruded missing talus.

Complete Revascularization of Reimplanted Talus After Isolated Total Talar Extrusion: A Case Report

Total traumatic extrusion of the talus is a rare and disabling ankle injury. Treatment may include talar reimplantation or talar body removal, but an optimal treatment protocol has not yet been established. Several case reports showed that disruption of the vascular supply and contamination could lead to major complications, such as infection and avascular necrosis, with the high risk of these complications being associated with both the traumatic ankle injury itself and subsequent talar reimplantation. No report to date has described the revascularization of a completely extruded talus, as shown by serial MRI, a less invasive surgical strategy consisting of immediate reimplantation, early administration of antibiotics, and a short period of cast immobilization followed by early motion exercises. The present study describes complete revascularization and good clinical outcomes in a 30-year-old man who underwent talus reimplantation after isolated total talar extrusion.

Use of Three-Dimensional Printing Techniques in the Management of a Patient Suffering From Traumatic Loss of the Talus

Traumatic loss of the whole talus is extremely rare, and its possible treatment options are limited. Our experience of treatment of a 30-year-old male suffering from traumatic loss of the whole talus with the insertion of an anatomical antibiotic-loaded talus cement spacer using 3-dimensional printing techniques as an interim measure was reviewed and reported. A young motorcyclist was brought to the emergency department after a road traffic accident. He sustained multiple injuries including traumatic loss of his left talus. Despite repeated surgeries of debridement and insertion of external fixator to his injured ankle, the patient had residual problem of ankle instability, ankle infection, and absence of his involved talus. With the help of computerized 3-dimensional printing techniques, an anatomical talus cement spacer was produced in the operating room and inserted into the patient's ankle 7 weeks after the initial trauma. The external fixator was kept for another 3 weeks before removal. At 14 months after the insertion of cement spacer, the patient could walk independently without any pain for 15 minutes with the help of a crutch occasionally. However, the range of motion of his left ankle was limited to 15° in the flexion-extension arc and minimal subtalar motion. The infection of the left ankle was under control.

Six-year survival of reimplanted talus after isolated total talar extrusion: a case report

Background

Open total extrusion of the talus without concomitant fracture is an extremely rare injury. We present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation.

Case presentation

A 55-year-old Asian man who had a totally extruded talus without fracture underwent immediate reimplantation surgery. A spanning external fixator with single antegrade K-wire fixation was applied to maintain the reimplanted talus. During 6 years of follow-up, he could walk without aids and could squat, corresponding to an American Orthopaedic Foot and Ankle Society score of 85. We found that the suspect lesion that was evident at 6 months after surgery had disappeared at 12 months postoperatively on the basis of sequential follow-up magnetic resonance imaging. There was no evidence of osteonecrosis of the dislocated talus at the final follow-up.

Conclusions

In patients with a totally extruded talus, a surgical strategy including immediate reimplantation of the talus and a temporary spanning fixator with single K-wire fixation might be useful to allow early mobilization around the ankle joint and to prevent additional damage of the foot without significant complications.

Critical-Sized Bone Defects: Sequence and Planning

Bone defects associated with open fractures require a careful approach and planning. At initial presentation, an emergent irrigation and debridement is required. Immediate definitive fixation is frequently safe, with the exception of those injuries that normally require staged management or very severe type IIIB and IIIC injuries. Traumatic wounds that can be approximated primarily should be closed at the time of initial presentation. Wounds that cannot be closed should have a negative pressure wound therapy dressing applied. The need for subsequent debridements remains a clinical judgment, but all nonviable tissue should be removed before definitive coverage. Cefazolin remains the standard of care for all open fractures, and type III injuries also require gram-negative coverage. Both induced membrane technique with staged bone grafting and distraction osteogenesis are excellent options for bony reconstruction. Soft tissue coverage within 1 week of injury seems critical.

Complications and Functional Outcomes After Pantalar Dislocation

BACKGROUND

Pantalar dislocations without associated talar fracture are rare and have high risks of complications, including infection, osteonecrosis, and posttraumatic osteoarthrosis. Limited information on later function exists. This study evaluated complications and outcomes following pantalar dislocation without talar fracture.

METHODS

Nineteen patients were identified with open (n = 14) or closed (n = 5) pantalar dislocations without talar fracture. Ten male and 9 female patients with a mean age of 39.6 years (range, 19 to 68 years) were included. Open injuries underwent surgical debridement. Sixteen patients had open reduction, and 2 had closed reduction. Fixation was achieved with Kirschner wires (n = 4), external fixation (n = 9), or both (n = 3). Two patients did not have fixation. Another patient had primary transtibial amputation due to nonreconstructible foot trauma. Charts and radiographs were reviewed to identify infection, osteonecrosis, and posttraumatic arthrosis. Data on pain, medications, range of motion, and secondary procedures were collected. After a minimum of 1 year, Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) surveys were administered.

RESULTS

The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems with prolonged drainage, which healed with dressing changes and oral antibiotics, and 1 patient developed cellulitis 4 months after injury, which resolved with intravenous antibiotics. No deep wound infections occurred. Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, 2 with collapse of the talar dome, and 7 (44%) developed arthrosis of ≥1 peritalar articulation. Outcome surveys were obtained for 11 (58%) of the 19 patients, at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 88% (14 of 16) of the patients with radiographic and clinical follow-up reported at least mild pain and 75% (12 of 16) were taking analgesics.

CONCLUSIONS

Urgent surgical debridement of open injuries and reimplantation of the talus after pantalar dislocation was not associated with deep infection. Osteonecrosis occurred in the majority of patients, but collapse was uncommon. Persistent pain and functional limitations are frequent after pantalar dislocation, as reflected in extremity-specific and generalized functional outcome scores.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Extruded talus treated with reimplantation and primary tibiotalocalcaneal arthrodesis

Extruded talus is a rare serious result from a high-energy injury to a supinated and plantar flexed foot. Treatment remains controversial with a lack of congruent evidence for talar reimplantation. A 34-year-old woman was involved in a road traffic accident at 40 mph. Imaging revealed a left talus extruded anterolaterally with a talar neck fracture. Additional injuries included right acetabular fracture, transverse process fractures and rib fractures, which were treated conservatively. The talus was reimplanted and the talar neck fixed with a cortical screw. A hindfoot nail was used to fuse the calcaneus, talus and tibia. Follow-up at two years showed solid tibiotalocalcaneal fusion, with no evidence of avascular development, and the patient was fully weight bearing without pain. We believe this is the first published case of successful primary tibiotalocalcaneal fusion for extruded talus injuries.

A systematic review of total dislocation of the talus

This review summarizes the treatment and resulting outcomes for total talar dislocation. The PubMed database was searched for articles about humans with total talar dislocation published in the English language in the last twenty years. The following data were entered into a Microsoft Excel spreadsheet: type of dislocation, nature of associated fractures (if any), type of reduction/fixation utilized, immobilization, weight-bearing status, outcome, complications and average follow-up time. Thirty-nine articles reporting a total of 86 cases of total talar dislocation are included in this review. Seventy-three of these were open injuries and 13 closed. Forty-three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. The talus was preserved in the initial management of 74 cases, whereas the remaining 12 cases were managed by primary talectomy. The mean duration of follow-up was 32 months. Twenty-two cases required a secondary arthrodesis or another additional procedure. A good outcome was achieved in 35% of cases, a fair outcome in 37% and a poor outcome in 27%. The complication of avascular necrosis (AVN) occurred in 22 cases and 14 subjects developed clinically significant osteoarthritis. Generally, the outcome of current treatments associated with total talar dislocation is not ideal, only 1/3 of cases achieving good outcomes. So far, preservation of the talus is the best treatment option. AVN is still a relatively common complication even in the absence of fracture or postoperative infection.

Early reimplantation for open total talar extrusion

PURPOSE

To review outcome of early reimplantation for open total talar extrusion in 7 patients.

METHODS

Medical records of 5 men and 2 women aged 19 to 53 years who underwent reimplantation for open total talar extrusion within 6 hours after road traffic accident (n= 6) or industrial injury (n=1) were reviewed. The talus was first irrigated with 9 to 10 litres of saline solution, followed by 10% povidone iodine. It was then reduced after thorough debridement and fixed with tension band wiring or external fixation. Ankle mobilisation exercises were started at week 6 and full weight bearing at week 14. Outcome was assessed using the American Foot And Ankle Society score.

RESULTS

After a mean follow-up of 31.9 (range, 24-46) months, the mean American Foot and Ankle Society score was 81, and the mean dorsiflexion-plantar flexion arc was 36.9º (range, 25º-45º). All patients were able to walk with a balanced, unaided gait with mild-to-moderate pain (n=3) or pain-free (n=4). No patient developed deep infection or instability. Three patients developed avascular necrosis of the talus; restriction of motion was moderate at the ankle joint and severe at the subtalar joint. None of these 3 patients opted for revision surgery, as the pain was tolerable and did not limit their daily activities, but their condition was expected to deteriorate with time.

CONCLUSION

Early reimplantation is recommended for open total talar extrusion, as it restores (to some extent) hind foot mechanics, heel height, and bone stock for activities of daily living and future reconstructive options.

An uncommon treatment of totally extruded and lost talus: a case report

Introduction

Total extrusion and loss of the talus is a rare injury with a wide choice of appropriate treatment, but rarely resulting in a fully functional recovery. We report on an uncommon case, both for the severity of the injury and for the uncommon treatment due to the patient’s rejection of secondary surgery.

Case presentation

We treated a 16-year-old Caucasian man with the most extreme variant of a totally extruded and lost talus, accompanied with complex injury of the soft tissues of the ankle and foot. The treatment included urgent microvascular foot reimplantation, microvascular muscle free flap transfer, and temporary fixation. This kind of injury should typically be treated by tibiocalcaneal arthrodesis. However, this was not performed, as after the successful early stages of the treatment he strongly objected to another surgery due to his fully functional status and the successful therapeutic results of our early treatment.

Conclusions

The injury described in this case study would ordinarily be treated by amputation, but due to the well-executed treatment in the early stages after the injury, the outcome was satisfying. Surprisingly and against our expectations, the late results of the treatment were successful even without arthrodesis. He is now 37 years old and has a functional foot 21 years after the injury.

Delayed debridement of an open total talar dislocation reimplanted in the emergency room

Open total talar dislocation is a rare but well known injury. Its management is controversial and fraught with complications such as infection, avascular necrosis, and post-traumatic osteoarthritis. We report the case of a woman sustaining a pure open talar dislocation reduced in the emergency room. Debridement was done three days after the injury in the operating room. There was no infection. One year after surgery she complained of occasional pain. Ambulation was normal. She wore regular shoes. The overall alignment of the ankle, hindfoot, and midfoot was normal. Movements of the tibiotalar and subtalar joints were not impaired. She has resumed her regular activities. Radiographs showed no signs of avascular necrosis. All components of the treatment strategy of open total dislocation should be carried out in emergency. This results in environment close to the original biological state. Good results can be achieved if infection is avoided.

Treatment of an open medial tibiotalar dislocation with no associated fracture

Tibiotalar dislocations without associated fractures are very uncommon in adults, and only a few studies have been published regarding this injury. More than 50% of these dislocations will be posteromedial, with a high incidence of open injuries, and 25% are pure posterior dislocations. In the present report, we discuss our experience and management of a medial tibiotalar dislocation with no associated fracture. In the present case, the patient was brought to the operating room on presentation to our facility and underwent irrigation and debridement with primary closure of his wound. He was immobilized postoperatively. The patient tolerated the operation well and did not sustain any postoperative complications. He was able to regain function of the injured extremity until he was lost to follow-up. Regarding treatment, the surgery should be speedy, gentle to the soft tissue, and with as little implanted material as possible. Although we do not advocate that our management and treatment of this injury become the standard, the present case provides a good example of some of the challenges often encountered when treating these injuries.

Treatment and outcome of open dislocation of the ankle with complete talar extrusion: a case report

BACKGROUND

Open total talar extrusion is a severe, disabling ankle injuries. The most appropriate treatment (reimplantation versus talar body removal and tibiocalcaneal arthrodesis) is still a controversial challenge; outcomes and fearful potential complications are not predictable.

OBJECTIVE

To report the case of an open ankle dislocation with talar extrusion, focusing on treatment modality and outcomes.

METHOD

Immediate reduction, surgical debridement and external fixation were performed under antibiotic coverage. Wound closure was achieved with accurate debridement, postoperative strict clinical surveillance and meticulous handling of medications. The patient maintained external fixator for three weeks, then kept non-weight bearing with a cast for an additional four weeks.

RESULTS

The patient's wound healed with no complications. Full weight-bearing was gained at 12 weeks postoperation. At 18 months postoperatively, the patient did not develop any infection or a vascular necrosis, which are the major complications associated to talar extrusion.

CONCLUSIONS

Good treatment procedure for a such severe open trauma, based on accurate debridement, wound care and stable temporary immobilization with external fixation allow reduction of infection risk and made preservation of extruded talus a successful option to preserve function and normal hindfoot anatomy at first instance. Talectomy should be considered as a salvage procedure.