The patient was twenty-six years old at the time of the accident, which
occurred in December 1998. She was injured when she was struck by an
automobile while riding her motorbike. Her only injuries involved the
musculoskeletal system. The patient had been wearing boots at the time of the
accident. The right boot was in place on the right lower extremity, but the
left boot was not attached to her foot and had been brought in separately. The
left foot was noted to be in a position of external rotation with respect to
the leg and was flaccid. Radiographs of the lower extremity were performed in
the Emergency Department prior to removing the patient's pants. Then a
scissors was used to cut open the pants on the left lower extremity, beginning
at the distal cuff. Immediately upon splitting the fabric, the talus was noted
to be lying on the anterior aspect of the distal part of the tibia. There was
a 10-cm burst-type open wound over the ankle joint with no apparent loss of
soft tissue. The extensor tendons were visible in the wound, and there was an
obvious communication with the ankle joint. The neurological status of the
lower extremity was completely intact. Inspection of the talus revealed that
it had not sustained any fracture. It was placed in a basin of sterile saline
solution to which antibiotics (second generation cephalosporin and Garamycin
[gentamicin]) had been added.
Radiographs of the left ankle and leg (Figs.
1-A and 1-B) revealed the
extruded talus lying anteriorly over the distal one-third of the tibia.
The patient was taken directly to the operating room. While the talus was
held in the surgeon's hand (Fig.
2), it was thoroughly cleaned with pulsatile lavage. The cavity
from which it came was copiously irrigated, and the talus was replaced. It
found its proper position with respect to the tibia and subtalar joints
without difficulty. No internal fixation was performed, and the wound was
closed over a drain. An external fixator was applied with two pins placed into
the proximal aspect of the tibia, and one each in the calcaneus, the fifth
metatarsal, and the first metatarsal. The ankle was maintained in a neutral
position with regard to flexion-extension, valgus, and varus.
The other injuries included a 4-cm disruption of the pubic symphysis, which
was treated with open reduction and plate fixation, and an open posterior
dislocation of the left knee with partial loss of the lateral femoral condyle.
The knee wound was débrided and irrigated, left open, and covered with
a dressing. A spanning external fixator was applied to bridge the knee joint
until the wound was healed at three weeks postoperatively, at which time
continuous passive motion was begun. The patient was then given a knee
orthosis, and the knee injury was subsequently followed by a different
orthopaedic surgeon.
Intravenous Zinacef (cefuroxime; GlaxoSmithKline, Münchenbuchsee,
Switzerland) was started preoperatively and was continued at a dosage of 1.5 g
three times daily for seventy-two hours. The external fixator for the ankle
and foot was left in place for six weeks. All wounds healed well and there was
no infection. Walking with partial weight-bearing was begun at the eighth
postoperative week. Four weeks later, the patient progressed to full
weight-bearing, and by the end of the fifth month she was walking without the
use of external support.
The patient was followed on a yearly basis. At the most recent follow-up
evaluation, five years after the injury, the patient stated that she was able
to wear all types of footwear, regardless of whether the shoes were flat or
high-heeled. She noted no pain about the left ankle and foot with walking for
up to two hours, but beyond that time she noted mild pain over the medial part
of the midfoot region, occasionally requiring her to take over-the-counter
medication. She did not describe any giving-way or instability about the
ankle. She was active in bicycling and skiing, and she tolerated these
activities very well with only occasional pain. She was working full-time as
an accountant. Physical examination of the left ankle and foot revealed no
swelling, and all wounds were well healed. The hindfoot, midfoot, and forefoot
were in good alignment, and there was no clawing of the toes. Deep palpation
over the talonavicular joint was slightly painful. The neurovascular status
was normal. The ankle range of motion was pain-free, with plantar flexion of
35° and extension to 0°. Subtalar motion was 10° of inversion and
5° of eversion with slight pain at the talonavicular joint. On the
contralateral, uninjured side, the ankle range of motion was plantar flexion
of 35° and extension of 20°; subtalar motion was 25° of inversion
and 15° of eversion. No instability of the ankle or subtalar joints was
noted. The patient walked with a normal gait without pain and had no limp. She
was able to walk on her toes and heels without difficulty.
The talus maintained a normal density on the annual radiographic
examination. At no time were we able to state with certainty that there was
sclerosis consistent with avascular changes. Radiographic evidence of
arthritis with associated subchondral sclerosis and anterior ankle impingement
was first noted at the three-year examination. No major progression of these
changes was noted at the five-year follow-up visit (Figs.
3-A,
3-B, and
3-C). On the anteroposterior
radiograph (Fig. 3-A), the
tibiotalar joint space was normal. On the lateral radiograph
(Fig. 3-B), however, there was
moderate narrowing of the anterior aspect of the ankle joint with localized
subchondral sclerosis. A moderate-sized osteophyte arising from the anterior
aspect of the neck of the talus was noted. There was narrowing of the
talocalcaneal joint, particularly in the posterior facet. The medial oblique
radiograph of the foot (Fig.
3-C) revealed marked narrowing of the talonavicular joint with
some subchondral sclerosis and anterior osteophyte formation.
It would seem logical that a patient with a totally extruded talus, without
any remaining soft-tissue connection, would be prone to infection,
osteonecrosis of the talus, and long-term functional disability. Yet the
results of reimplantation of the talus are not consistent with such a
hypothesis. Table I lists the
reported cases of patients who had open talar extrusion in which no soft
tissue remained attached to the talus, or there was only the smallest amount
of soft-tissue connection. In one case
report3, the talus
was never found and the foot was so severely damaged that a primary
below-the-knee amputation was performed. In the cases of two patients
described by Hiraizumi et
al.2, the missing
talar bones were found after the patients arrived at the hospital. The talus
from one of them, a twenty-year-old man, was found intact three hours after
the accident. After thorough débridement, the talus was replaced.
Increased density in the talus was noted within the first five to six months
following the injury, but at one year the architecture of the bone was normal.
No infection developed. At two and one-half years, the patient was mildly
symptomatic with some restricted motion and a narrowed tibiotalar joint on
radiographs. He had returned to his usual work as a truck driver. The missing
talus from the other patient was found three days after the injury, was
heavily contaminated, and was not replaced. Brewster and Maffulli described an
additional two patients with total extrusion of the talus leaving no
soft-tissue attachment who were both treated with reimplantation of the
talus1. In one
forty-one-year-old man, the talus was found in his sock. The talus was
cleaned, the wound was débrided, and the talus was reimplanted and
fixed with Kirschner wires. Radiographs made at six weeks revealed increased
density in the talus, but by nine months the radiodensity approached that of
the normal surrounding bones. At two years, there was some limitation of
ankle, subtalar, and midtarsal movements with radiographic evidence of
osteoarthritis of the ankle and talonavicular joints. In the other patient, a
thirty-six-year-old man, the talus was reimplanted and the foot and ankle were
immobilized in a cast. No infection developed and there was no definite
evidence of osteonecrosis. At the twenty-six-month evaluation, the patient was
noted to have made a good functional recovery although with moderate
restriction of ankle motion and only a jog of subtalar motion. Radiographs
revealed normal talar density with no evidence of arthritic changes in the
ankle or subtalar joints. In another
report6, a
seventeen-year-old boy sustained an open total dislocation of the talus, but
no mention was made about where the talus was lying—that is, whether it
was truly completely extruded from the ankle, leaving no soft-tissue
attachment. The talus was replaced, and radiographs made at nine months after
the injury revealed normal talar density, nonunion of an associated navicular
fracture, and incongruity of the talonavicular joint. Eighteen months after
the injury, the patient was minimally symptomatic without substantial
limitation of function.
In another early report on this
injury4, the talus
was found lying beneath the patient's sock attached to the structures of the
foot by a "shred of ligament" that was 3 mm in diameter. The wound
was thoroughly cleaned, and the talus was replaced. A minor superficial wound
slough developed, but there was no infection. After a follow-up period of only
eight months, at which time the patient did not complain of any pain, the
motion of the ankle joint was slightly limited with no motion at the subtalar
joint, and the radiographs revealed a normal ankle joint but evidence of
"ankylosis" at the talocalcaneal joint. Similar results were
reported for two patients who presented with an open talar dislocation with a
thin soft-tissue
connection5. There
was no infection nor was there evidence of osteonecrosis. Both patients had
moderate restriction of ankle and subtalar motion at a follow-up of more than
two years, with radiographic evidence of ankle and subtalar joint-space
narrowing in one patient. In an additional patient who presented with a
totally extruded talus that was "hanging by a thread of soft
tissue," the talus was cleaned and replaced and no infection
developed8.
Radiographs made at three months revealed a dense talar body, with changes of
creeping substitution noted on follow-up radiographs at six, ten, and thirteen
months after the injury. At the final review at six years, the patient had few
symptoms and participated in sports, had mild restriction of ankle movement
but marked loss of subtalar motion, and had radiographic findings showing
normal density of the talus with some pantalar arthritic changes.
In the report by Palomo-Traver et
al.7, a
twenty-nine-year-old man sustained an open total extrusion of the talus with a
low level of contamination. The only soft tissue that remained attached to the
talus was a thin 3-mm pedicle running from the navicular to the neck of the
talus. Following irrigation and débridement, the talus was reduced and
the limb was immobilized in a cast. No infection developed. At sixteen weeks
after the injury, a bone scan revealed talar vascularity. At a follow-up
examination four years after the injury, the patient was asymptomatic and had
a full range of painless ankle and subtalar motion except for a small loss of
supination, and radiographs revealed normal osseous architecture and no
joint-space narrowing. In an extensive review of the
literature7, those
authors noted that infection and osteonecrosis were not frequent and
recommended preservation of the talus. However, they did favor excision of the
bone if it is extruded out of the wound.
Numerous cases of patients with an open or a closed total talar dislocation
with a remaining soft-tissue connection have been reported in the
literature10-14.
Ritsema14 described
five patients with a closed dislocation, one of whom had an early
(two-month-postinjury) arthrodesis. Of the remaining four patients, one had
osteonecrosis develop with the eventual replacement of the necrotic bone
without collapse. He recommended against primary excision of the talus,
especially in cases with a pure dislocation. Conversely, Marsh et
al.10 recommended
that consideration be given to primary excision of the talar body in patients
in whom the talus has extruded through the wound; however, the majority
(thirteen) of their seventeen patients sustained a Hawkins Type-III
injury—that is, they had a total talar dislocation with a fracture. One
of the four patients with a total dislocation without a fracture had an
infection develop and required a late arthrodesis. In a much earlier report on
nine patients who had a total
dislocation9—only
three of whom did not have a fracture—the extent of the specific injury
or the treatment modalities, such as antibiotics or type of stabilization,
were not clearly described. Of the three patients who had a dislocation
without a fracture, two of them (one of whom also had osteonecrosis) had an
infection develop and the third had osteonecrosis. The authors advised against
replacing the talus.
With the limited number of cases reported, and our experience with a single
patient, it is difficult to give definitive advice as to the best method of
skeletal stabilization. Clearly, cast immobilization is a poor choice because
of the open nature of these injuries, and external fixation should be an
integral part of the treatment strategy. The question as to whether the talus
needs to be further immobilized with Kirschner wires is difficult to determine
as no consistent treatment has been reported in the literature. Thorough
débridement and pulsatile lavage of the extruded talus and the open
wound are mandatory.
Patients with a totally extruded talus, with or without a thin soft-tissue
connection, represent the most severe risk in terms of the loss of
vascularity. However, neither our patient nor any of the patients in the cases
reviewed had an infection or changes of osteonecrosis at the time of the final
evaluation. Our opinion is that total extrusion of the talus, even with the
bone lying outside the patient's body, should be managed with thorough
cleaning and débridement of the wound and reimplantation of the talus.
Certainly, modifying circumstances, such as delayed retrieval of a heavily
contaminated talus that had been missing for three days from a patient with
circulatory dysfunction to the
limb2, may change
the treatment protocol.