Session I - Foot & Ankle
Fri., 10/8/04 Foot & Ankle, Paper #4, 9:40 am
The Extruded Talus: Results of Reimplantation
Purpose: Previous reports of hindfoot injuries with associated extrusions have been limited to small series and case reports, both demonstrating poor results due to infection and other complications. Therefore, treatment recommendations have included discarding the talus in open injuries. The purpose of this retrospective review was to assess the clinical results and functional outcome after reimplantation of extruded tali after high-energy trauma.
Methods: Records of 27 patients treated over an 8-year period were identified as having a documented complete extrusion of either the entire talus or the talar body (in patients with an associated talar-neck fracture). These patients were identified from a database of 119 open-talus injuries treated over the same period. Eighteen injuries resulted from motor vehicle collisions, with the remainder from falls (N = 3), plane crashes (N = 2), motorcycle accidents (N = 2) and crush injuries (N = 2). Data collected included injury pattern, wound location, number of operations, infections, subsequent operations, presence of avascular necrosis (AVN), associated injuries, age, injury side, and mechanism of injury. Preoperative and follow-up radiographs were reviewed. Patients were contacted by phone for assessment of functional outcome and to determine whether any subsequent complications or surgical procedures were required after their last documented clinical visit. The primary clinical determinants of outcome were infection and the need for a secondary surgical procedure. The Musculoskeletal Functional Assessment (MFA) score and ability to walk were used to assess functional outcome.
Results: Extrusion of the entire talus without fracture occurred in 8 patients, and 19 had associated fractures, including the talar neck (N = 13), body (N = 3), lateral process (N = 2) and talar head (N = 1). Other associated fractures occurred commonly and were documented in 78% of the patients. Infection occurred in two patients; in one, this was acute (within 6 weeks of injury). In the other patient, an infection occurred after corrective calcaneal osteotomy at 19 months. Clinical follow-up with a minimum period of 1 year was obtained on a subset of 17 patients (average follow-up, 41 months; range, 12 to 93). Radiographic findings were available for 12 of the 17 patients. Full MFA scores were obtained for 13 patients. The other 4 patients were contacted by phone to assess activity level and to determine whether they had undergone subsequent operations, but they declined to provide MFA data. Radiographs consistent with altered talar perfusion were noted for 10 patients. Four had sclerosis but no collapse and six had partial-to-complete collapse. Two patients had evidence of talar perfusion with maintenance of the normal anatomy of the talus. The average number of surgical procedures per patient was 2.1 during the initial hospitalization and 0.9 as delayed reconstructive operations. Secondary surgical procedures in these patients included total ankle arthroplasty (N = 2), removal of hardware (N = 3), cheilectomy (N = 1), calcaneal osteotomy (N = 1), tibiotalar fusion (N = 1), and split-thickness skin graft (N = 1). All patients interviewed were able to walk on the affected extremity. No patient required a delayed amputation secondary to complications associated with their injury. Of the 13 patients for whom MFA values were available, the average MFA score was 26.8. The average MFA score for patients 1 year after isolated foot injuries was 22.1 and for normal individuals is 8.9. The following variables were associated with a poorer functional outcome according to the MFA: talus fracture and number of procedures during the primary hospitalization.
Discussion and Conclusions: Replacement of a completely or partially extruded talus is controversial. Such injuries are associated with traumatic open wounds, ipsilateral lower extremity fractures, and other remote injuries. The most obvious early risk of reimplantation is infection, which can produce devastating results. The long-term consequences of discarding the talus are largely unknown but are certainly suboptimal. This review of the records of 27 patients with talar extrusions demonstrates a lower infection rate (7.4%) than previously reported. In the subset of 17 patients with a minimum clinical follow-up of 1 year, subsequent procedures were necessary for 7 (41%). Functional outcome according to the MFA demonstrated significant compromise. However, all patients were ambulatory and none had late amputations. Salvage of the extruded talus appears to be a reasonably safe operation that allows maximal flexibility in aftercare and preserves the most normal anatomy in the face of this potentially devastating injury.
Significance: We report on a series of patients with this complex injury in whom an acceptably low infection rate was attained subsequent to talar reimplantation. The goal of treating these injuries should be retention of the talus whenever possible, as this provides the maximum flexibility for subsequent treatment options.