Therapeutic management of complicated talar extrusion: literature review and case report

Abstract

Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.

Complete Extrusion of Talar Body Associated With Ipsilateral Floating Knee

“…The total extrusion was treated initially with cement spacer and distally based sural fasciocutaneous flap, followed by delayed reimplantation and arthrodesis after confirming the negative cultures of the original talus. They suggested that the flap might have promoted revascularization, which ultimately avoided the avascular necrosis of the reimplanted talus [4].…”

“…Regardless of the treatment choice, when facing an open pantalar dislocation, commonly accompanied by an anterolateral wound of the ankle, early surgical debridement is the most important initial step [2][3][4][5][6][7][8][9]. The use of an external fixator to stabilize the joint while waiting for definitive treatment could also decrease wound complications and allow proper wound care [3,4].…”

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“…Open reduction has resulted in frequent complications like avascular necrosis and osteomyelitis affecting 38-85.7% of cases [4,18,19]. Delayed intervention leads to skin necrosis requiring sural fasciocutaneous island flap [20]. There is no evidence-based strategy in the management of TTD.…”

A Systematic Review of Total Dislocation of the Talus

“…In addition, the functional outcomes of patients managed by primary talectomy were worse than those of the group as a whole, none of the former cases achieving a good outcome. Many of the reviewed articles recommended attempting to preserve the talus, even in cases of total extrusion with significant contamination, preservation having a better chance for a good outcome and a similar risk of complications 3,[31][32][33][34][35][36][37][38] .…”