INTRODUCTION

Talar extrusion is an extremely rare injury, accounting for 0.06% of all dislocations and 2% of talar injuries [1]. It is typically caused by high-energy trauma, most often in motor vehicle accidents [2]. Open talar dislocation represents 73.7% to 97% of all talar dislocations [3]. The treatment of this highly uncommon condition remains a topic of debate. Open dislocations have historically been treated with talectomy and primary tibiocalcaneal arthrodesis [4]. More recently, reimplantation of the talus has been recommended for open dislocations, even if severe contamination is present [5]. The soft tissues are often heavily damaged, necessitating early wound closure and soft tissue coverage with pedicled or free flaps [6]. Some authors have reported good results with talar body prostheses after traumatic talar extrusion. This treatment option usually involves a temporary cement spacer followed by full talar implantation several months after the initial injury. However, this technique requires customized implants, which are not widely available [7]. Although satisfactory results have been described for each technique, patients remain at risk of complications including infection, avascular necrosis, and secondary arthritis. In this report, we describe a case of open talar dislocation treated with talar reimplantation and early soft tissue coverage with a reverse sural flap.

CASE REPORT

An 18-year-old male patient was admitted to the emergency department after a motorbike accident. On admission, his Glasgow Coma Scale score was 15, and polytrauma examination revealed no abdominal, thoracic, or brain injuries. No fractures of the pelvis or long bones were noted. The patient had a complete extrusion of the left talus. Computed tomography showed nondisplaced fractures of the cuboid, the second and third cuneiforms, and the fourth and fifth metatarsal bones on the same foot (Fig. 1). Clinical examination indicated a 15×10-cm wound on the anterolateral side of the ankle. The left talus had extruded through the wound, and all soft tissue attachments had been lost except a cuff of tissue on the medial side of the talar neck (Fig. 2). The patient’s medical history was unremarkable. Physical examination revealed no vascular lesions, while neurological assessment indicated a loss of sensation in the dorsolateral part of the foot.

The patient received a tetanus immunoglobulin injection upon arrival. Cefazolin and gentamicin were initiated as prophylactic antibiotics. Approximately 5 hours after admission, the patient was taken to the operating room for irrigation and debridement. All necrotic and nonviable tissue was removed. The talus was extensively irrigated with saline, and all debris was cleared. After irrigation and debridement, the talus was deemed viable, as it retained a residual cuff of tissue on the medial side of the neck that remained connected to the surrounding soft tissues. The talus was reduced in situ. An external fixator was implanted, and provisional tibiotalocalcaneal arthrodesis was performed with a K-wire (Fig. 3). The wound was closed using negative pressure wound therapy (NPWT).

On day 3, the patient was taken to the operating room for a second look and NPWT exchange. On day 10, the wound was covered with a reverse adipofascial sural flap (Fig. 4). The external fixator was retained. A double-layered skin substitute (Pelnac, Biomedica) was placed over the flap. On day 21, the flap was grafted with skin. The external fixator was removed 35 days after the initial surgical procedure, and the K-wire was removed 1 month later.

Movement of the ankle in flexion and extension was permitted 2 months after the trauma, as was toe-touch weight-bearing. A magnetic resonance imaging (MRI) scan performed 3 months postoperatively showed bone edema at the neck of the talus but no signs of avascular necrosis (AVN). By the third month after surgery, weight-bearing was allowed as tolerated. By 1 year after the trauma, the wound had completely healed, and radiographs indicated satisfactory joint congruency. The patient had lost about 10° of plantar flexion and dorsiflexion but reported no pain and walked without limping (Fig. 5). The loss of sensation in the dorsolateral and lateral parts of the foot did not improve, as the intermediate dorsal cutaneous nerve was damaged at the time of injury and the sural nerve was sacrificed during flap harvesting. After 1 year, MRI showed no signs of AVN, although mild varus malalignment of the ankle was noted (Fig. 6).

At the last available examination, 3 years after the injury, the patient was able to walk without aids and the ankle showed no signs of instability. Occasional pain in the lateral part of the ankle was reported. A mild residual varus deformity of the hindfoot was present, for which an orthosis was prescribed but declined by the patient.

Ethics statement

Written informed consent for the publication of this case report and the accompanying images was obtained from the patient.

DISCUSSION

While talar fractures have been well documented, total talar dislocations without concomitant talar fractures are extremely rare. The literature on this condition includes only one review, with a limited number of patients, as well as a few case reports [8]. Various treatments have been proposed. Earlier reports recommended primary talus removal with tibiocalcaneal arthrodesis, whereas more recent recommendations advocate reimplantation of the talus whenever possible [4,5]. The decision to reimplant or excise the extruded talus depends on the extent of contamination and the vascularization of the talus. Surgeons should understand that osteonecrosis and infection are the most common causes of treatment failure for talar extrusion.

Despite the high prevalence of complications necessitating follow-up surgery, many reports on talar extrusion recommend reimplantation of the talus to preserve joint space, leg length, and bone stock, thus maintaining normal hindfoot anatomy. This approach greatly facilitates future talar fusion or ankle arthroplasty [9].

Clinical and radiographical evidence (including bone scans and angiograms) has demonstrated that in open anterolateral talar dislocations, the vascular supply to the talus is maintained by anterior soft tissue attachments containing branches of the dorsalis pedis artery [10]. In their case report, Breccia et al. [11] noted that key factors for successful reimplantation of the talus include the absence of fractures and the presence of residual soft tissue attachments. In our patient, the only remaining soft tissue attachment was a cuff of tissue on the anteromedial aspect of the talar neck, which enabled efficient vascularization of the reimplanted talus.

In high-energy and contaminated open fractures, thorough debridement is essential to avoid infection, and in large defects, a free or pedicled flap may be required to close the wound. However, the aforementioned review by Weston et al. [8] did not consider the degree of soft tissue injury or the type of wound coverage. In contrast, Smith et al. [4] attributed their low infection rate to the use of multiple debridements and early soft tissue closure. Abdulazim et al. [6] reported favorable results in a high-grade open fracture-dislocation managed with NPWT and gracilis flap coverage; nevertheless, the talus of their patient was not considered viable and was eventually removed. In our patient, early coverage of the soft tissue defect with a pedicled flap prevented infections and maintained an adequate blood supply to the reimplanted talus, thereby avoiding major complications.

Different rates of AVN have been reported in the literature, with the largest review indicating 24% AVN after reimplantation [8]. The most recent review, conducted by Boden et al. [12], reported a much higher rate of AVN, with 14 of 18 talar dislocations affected; however, only two of these patients developed talar collapse. The rate of AVN has been postulated to correlate with the severity of the original dislocation. More importantly, only complete AVN with talar collapse appears to lead to worse clinical outcomes and additional surgery [13]. Interestingly, Vallier et al. [14] demonstrated that in fractures of the talar body and neck, osteonecrosis consistently occurs within 10 months of trauma, with subsequent collapse or revascularization developing within a further 36 weeks. Our patient showed no signs of AVN on MRI scans 3 and 12 months after the trauma, making such a complication unlikely.

In conclusion, total talar extrusions are extremely rare injuries. High complication rates are reported in the literature, with infections and AVN being the most common. Reimplantation of the talus has been demonstrated to be a reliable treatment, provided that thorough debridement and early soft tissue closure are performed. Reimplantation should always be attempted to preserve hindfoot anatomy and bone stock in the event of further surgical procedures.

ARTICLE INFORMATION

Author contributions

Conceptualization: AG, MGL, GA, NS; Investigation: AG, GT, ET, EP; Methodology: AG, MGL, ET, GA; Writing–original draft: AG; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Three-dimensional reconstruction of an ankle computed tomography scan demonstrating talar extrusion. (A) Anteroposterior view. (B) Lateral view.

Fig. 2.

Initial images. (A) Clinical presentation of the extruded talus upon arrival at the emergency department, prior to irrigation and debridement. (B) Close-up image showing limited soft tissue attachments.

Fig. 3.

(A) Intraoperative picture taken after irrigation and debridement shows a soft tissue defect measuring approximately 15×10 cm. (B) Postoperative anteroposterior view of the ankle with an external fixator in place and provisional tibiotalocalcaneal fixation using a K-wire. (C) Lateral view of the ankle with the same configuration.

Fig. 4.

Images of the flap. (A) Intraoperative image showing harvesting of the reverse adipofascial sural flap. (B) The flap is rotated distally and anteriorly to cover the anterolateral aspect of the ankle. (C) Clinical image taken 5 days postoperatively, demonstrating a viable flap. At this stage, the external fixator and K-wire remain in situ.

Fig. 5.

Range of motion of the ankle 1 year after the trauma. Only a few degrees of (A) plantar flexion and (B) dorsiflexion were lost.

Fig. 6.

Multimodal images of the ankle 1 year after the injury. (A) Anteroposterior and (B) lateral views of plain radiographs show no signs of posttraumatic arthritis. (C) Magnetic resonance imaging demonstrating acceptable joint congruency with mild varus tilt of the talus, but no signs of avascular necrosis.

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Figure & Data

References

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