Tag Archives: Talus

Talectomy (astragalectomy) and tibiocalcaneal arthrodesis following traumatic talus fracture-dislocation

The Foot and Ankle Online Journal 12 (2): 4

by Dr Alison Zander, MBBCh, BSc (hons), MSc (PHNutr)1, Mr Anirudh Gadgil, MBBS, M.S. (Orth), FRCS (Ed), FRCS (Trauma & Ortho)2, Derek Protheroe, BSc(Hons), MSc, PgDip3*

Talus fractures occur rarely but are often associated with complications and functional limitations. Urgent reduction of associated dislocations is recommended with open-reduction and internal fixation of displaced fractures when adjacent soft tissue injury permits [1]. However, it is important to remember that there is a high incidence of long term complications, along with a significant impact on activities of daily living and quality of life.  This case report describes the successful treatment of a severely comminuted talar fracture dislocation with primary talectomy and tibio-calcaneal arthrodesis. A reminder that in selected cases that the talectomy (astragalectomy) may be a viable alternative.

Keywords: talus, comminuted, tibiocalcaneal arthrodesis, fusion, talectomy, astragalectomy, trauma, avascular-necrosis, AVN

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0004

1 – DLSHTM Foundation Year 1 Doctor, Cardiff and Vale University Health Board, University Hospital of Wales, Heath Park, Cardiff
2 – Consultant Orthopaedic Surgeon, Cardiff and Vale University Health Board, University Hospital of Wales, Heath Park, Cardiff
3 – Advanced Podiatry Practitioner, Prince Philip Hospital, Bryngwyn Mawr, Llanelli, Wales, SA14 8QF
* – Corresponding author: Derek.Protheroe@wales.nhs.uk


Talus fractures account for less than 1% of all fractures, they may be caused by high-energy trauma, and any other form of forced dorsiflexion injury to the ankle and foot [1]. Talar fractures may be classified anatomically as head, neck, body, lateral or posterior processes, displaced or non-displaced. A range of classifications have been established such as the original Hawkins, then modified by Canale & Kelly and then the Sneppe classification [2]. These sub-classifications help to guide treatment options[3]. Non-displaced fractures may be treated conservatively with a non-weight-bearing short-leg cast, whereas displaced fractures require open-reduction and internal fixation. Reconstruction after a talus fracture poses the greater surgical challenge if restoration of the articular surfaces is precluded secondary to comminution [4]. The talus is the second largest of the tarsal bones, with more than half of its surface being covered with articular cartilage, with no muscular attachments[1]. Therefore, the vascular supply of the talus is well-known to be tenuous, therefore predisposing the talus to significant ischemic injury after fractures [5]. Risk of post-traumatic avascular necrosis (AVN) increases with the magnitude of injury [6]. Extensive intraosseous anastomoses are present throughout the talus and are responsible for its survival during severe injuries. At least one of the three main anastomoses preserved may potentially allow adequate circulation via anastomotic channels [1].

Using the Hawkins’s classification system; 0-13% for grade I, 20-50% for grade II, 83-100% for grade III, and 100% for grade IV fracture dislocations result in AVN [1,6]. 

Clinical experience of talar fracture assessment and management is limited by their infrequent incidence, which is further exacerbated by the numerous sub-classifications of fracture, as previously alluded to. Case reports, although regarded as level V evidence can aid and develop an understanding of the risks and benefits of treatment options to achieve optimal patient outcomes [7].  Clinicians should maintain a high index of suspicion for AVN, which can only be diagnosed radiographically six to eight weeks following injury [8].  Furthermore, the potential for long term issues, such as hind-foot arthrosis and further revisionary surgery must be considered, alongside risks of repeated anesthetics for multiple procedures after complications. Approximately 25% of talus dislocations treated with internal reduction require additional surgery, including secondary arthrodesis [9].

Operative treatment measures for this area may be broadly split into two categories; joint sparing procedures – such as protected weight bearing, patella loading splints and bone graft or joint sacrifice procedures – such as talectomy and arthrodesis. Total talectomy and tibiocalcaneal arthrodesis may be viewed as a salvage procedure in this case report due to the case of severe comminuted fracture, where it may be impossible to anatomically reduce the talus and allow for adequate stable fixation. 

A literature search was performed using the keywords ‘talectomy’, ‘astragalectomy’, ‘fracture’, ‘tibiocalcaneal arthrodesis’ and Boolean search terms. Ovid SP databases (including embase & medline) was used with no exclusion dates to allow for a search of all historical literature. It appears that there was only one other reference in 1955 to such a procedure following a traumatic fracture to the talus body [10]. Historically, this case involved a Royal Navy soldier, where following a dislocated fracture a primary talectomy and tibiocalcaneal arthrodesis was performed.

Figure 1 Preoperative radiographs lateral and AP views.

Case Report

A sixty eight-year-old lady with no significant past medical history presented to Accident and Emergency.  She had been a seat-belted, front-seat passenger of a car that suffered a high-speed head-on road traffic collision.  She sustained a grade I (Gustilo-Anderson) open, comminuted fracture dislocation of the talus (Figure 1) with puncture wounds on the lateral aspect of the talus.  The foot was neurovascularly intact initially. The ankle was manipulated and back-slab applied. Apart from body ache and multiple minor abrasions and bruises there were no other injuries.  Whilst she was waiting on the ward to have a CT scan performed she developed increasing pain in foot, numbness of toes and sluggish capillary refill in the toes, which were not relieved even after removing the plaster slab.  She was counselled that she would need to be rushed to the operating room to attempt to reestablish circulation to her foot with a plan to open reduce the fracture and stabilize it. She was also made aware of the possibility of having to excise the fragments if it was not possible to operatively stabilize the fracture.

Procedure

Under spinal anaesthesia, antibiotic cover and usual sterile draping, the lateral puncture wounds were thoroughly debrided and lavaged with saline.  The fracture was exposed using an anterior approach between tibialis anterior and extensor hallucis longus, carefully protecting the neuro-vascular bundle throughout the procedure.  The displaced fracture fragments of the talus, the medial malleolus and the medial hematoma all appeared to have caused pressure on the posterior tibial neurovascular bundle. 

Figure 2 One year follow-up radiographs.

This was relieved after opening the fracture and the toes regained their color.  Intra-operatively, it became apparent that the fracture could not be anatomically reduced and fixated adequately due to the severe degree of comminution, and lack of any soft tissue attachments to the majority of the fragments. Hence, the original plan of anatomical reduction and internal fixation of the fracture was abandoned.  All loose fragments were excised, which involved removing all of the posterior process and body of the talus. Using the cancellous bone from the excised fragments as autogenous graft, the calcaneal and tibial articular surfaces were fused using three 7.5 mm cannulated AO screws (Figure 2). A small lateral malleolar avulsion fragment was excised.  The medial malleolus fragment was reduced and fixed with a cancellous 4mm AO screw (Figure 2). Post-operatively, the foot was observed to be well-vascularised. The lateral wounds were allowed to heal with regular dressings and a plaster of Paris splint was applied.  

Postoperative care protocol

Postoperatively, the patient received intravenous antibiotics for 24 hours, limb elevation for 48 hours and prophylactic anticoagulation for six weeks. Mobilization started with physiotherapy, consisting of non-weight bearing for six weeks, partial-weight bearing in air cast boot for two weeks and then allowed to fully-weight bear with an air cast boot.  The patient was advised to stop using the air cast boot at three months. The wounds healed well and there were no other complications.  

Outcomes

Due to the urgency of care required and history of trauma it was not deemed appropriate to use any form of patient reported outcome measure at the time of incident. However, the patient was reviewed frequently for eight weeks until the wounds healed. Then, accordingly, when she was allowed to weight bear, again at six months, one year and two years post-injury.  At six months, the patient had no pain or tenderness, with some dorsiflexion and plantar flexion possible at the mid-tarsal level. One-year follow-up showed that the tibio-calcaneal fusion was solid via plain x-ray (Figure 2). Final follow up at two years, she had a 2 cm shortening of her right leg measured in a weight bearing manner (measured blocks) and appropriate footwear adaptations were incorporated on the right side.  She is very happy with the outcome, has no pain and is fully mobile and weight bearing without support. 

Discussion

Talus fractures occur rarely and are commonly associated with complications and functional limitations [11].  The main complication being osteonecrosis, Vallier et al reviewed 100 talus fractures and reported osteonecrosis with collapse (31%), ankle arthritis (18%), subtalar arthritis (15%). Operative intervention was complicated by superficial (3.3%) and deep infection (5%), wound dehiscence (3.3%), delayed union (1.7%) and non-union (3.3%) [11]. Restoration of the axial alignment has been recommended to ensure optimisation of ankle and hindfoot function. It has been reported that tibiotalar and subtalar ranges of motion are reduced by up to 50% and arthrosis occurs in roughly 50% of fractures classified as Hawkins type III and IV [4]. The original paper proposing Hawkins classification even stated that comminuted fractures or those involving the body of the talus, were believed to be more problematic injuries and outside the scope of his original article [12].

A range of classifications for talus fractures exist, the most famous being the original Hawkins classification [2]. 

Historically, cases of talus injuries date as far back to as 1608. Interestingly, a term was coined known as ‘aviator’s astragalus’ due to its high frequency of injury in aircraft accidents [12]. The first case of talectomy for compound fracture was reported in 1609 by Hildanus  [13]. The patient had jumped over a ditch and turned his ankle on landing, causing the talus to dislocate completely out of the skin.  The talus was removed completely, following which the man was seen walking without apparent discomfort. In 1931, Whitman reported use of astragalectomy in correction of a calcaneus deformity of the foot [14]. Although these accounts are reported anecdotally, they demonstrate that the procedures used then are used in a similar fashion to case descriptions today. Talectomy has been used as a salvage procedure in correction of pathological deformity in conditions like  Charcot-Marie-Tooth, neglected idiopathic clubfoot, neurogenic clubfoot, cerebral palsy, gunshot wound, hemiplegia secondary to head trauma, Volkmann ischaemic contracture, poliomyelitis, arthrogryposis, myelomeningocele, and Charcot arthropathy  [15-18]. Talectomy has been used for patients with osteomyelitis or osteonecrosis of the talus [19,20]. We found only one study which reported 4 cases of total talectomy for Hawkins Type III fractures dislocations of talus in 1993 [21].  However, tibiocalcaneal arthrodesis was formally not carried out in the patients in this series.

Detenbeck and Kelley (1969) reported dire results following total dislocation of the talus in nine cases, of which seven were open [22]. Eight of the nine developed sepsis; seven required secondary talectomy, five with tibio-calcaneal fusion. This report highlights the serious consequences of this kind of injury. Their recommendations were to apply a more aggressive approach to initial treatment using talectomy and some form of tibio-calcaneal arthrodesis as the primary treatment for fracture-dislocation of the talus.  

Predominantly, cases of tibio-calcaneal (TC) arthrodesis are described for treatment of post-traumatic AVN of the talus or for treatment of rheumatoid arthritis [23-25]. Authors have reported TC arthrodesis of nine ankles in eight patients; seven were for post-traumatic talar AVN and one for rheumatoid arthritis [25]. Fixation was achieved using 6.5 or 7mm cannulated screws or multiple staples, with autologous cancellous bone graft.  Fusion was achieved in all patients between 12 and 40 weeks with a 2cm leg length discrepancy. Complications included local infection, malunion, wound dehiscence, prominent fibula and two patients required supplemental external fixation.  

In 1972, Reckling reported early TC fusion after displaced talus fractures in eight feet; Steinmann pins were used to achieve fixation without the use of bone grafting [26].  No wound complications were reported and bone union was achieved within 17 weeks. 

The main draw-back of TC fusion is the shortening of 2 to 3 cm that is produced in the limb.  It is also possible that secondary arthrosis of other joints of the foot may occur over time after TC fusion.

Using the technique of tibio-calcaneal fusion there is a potential to increase the calcaneal pitch angle. Intra-operatively, the surgeon must be careful to keep this in mind and achieve a well-aligned position of the foot. 7.5 mm cannulated AO screws were utilised providing stable compression across the fusion surfaces and encouraged rapid fusion of the inferior tibial surface to calcaneal articular surface.  There are other modes of fixation discussed within the literature such as intramedullary nail, pre-contoured plates or an external fixator. This would depend not only the surgeon’s experience and preference but in this case the setting (trauma) and clinical scenario due to the compromised blood supply.

Dennison et al treated six patients who had previous failed surgery and suffered post-traumatic AVN of the talus [27]. The necrotic body of the talus was excised and TC fusion achieved using an Ilizarov frame, combined with corticotomy and a lengthening procedure.   Patients were aged between 27 and 67 years. Shortening was corrected in four patients, and bony fusion achieved in all. Four out of six patients reported good or excellent results. 

Thomas and Daniels in 2003 reported using talonavicular and subtalar arthrodesis as a primary fusion to treat a three week old Hawkins type IV traumatic comminuted neck of talus fracture in a 29-year-old man [28]. Their case had similarities to ours, in that open reduction internal fixation had been planned, however, this was not possible anatomically due to the degree of comminution.  The patient underwent 16 months of follow-up and despite successful fusion without avascular necrosis, he was unable to return to his job as a roofer. 

Hantira et al reported treating a comminuted open fracture of the body of the talus on the same day of injury by tibio-talar fusion using the Blair technique [29].  Küntscher nails and cancellous screws remained in situ while the graft healed and they were removed at four and eight weeks post-surgery, respectively.  The patient started active and assisted foot exercises 14 weeks following surgery, with partial-weight bearing on crutches 20 weeks after the injury.  Fusion was complete at 10 months after injury and the patient was reportedly almost pain free.

Conclusion

The severity of talus fractures has increased over the last 3 decades due to modern safety equipment resulting in higher survival rates from serious accidents [2]. Due to recent advances in surgical and fixation techniques, the tendency is to reduce the talar fractures as anatomically as possible and stabilize them with screws.  

It is worthwhile considering the option of a talectomy in conjunction with a primary tibiocalcaneal arthrodesis. although cases of talus fractures with comminuted dislocations are rare. In this particular case study, to attempt to perform an open reduction and internal fixation procedure may have increased the potential risk and complications associated with these procedures, mainly AVN, traumatic hind foot arthrosis both potentially requiring further surgery. Ultimately, increasing the potential for a high rate of long-term complications and a significant impact on activities of daily living and quality of life after such treatment [30].

In summary, surgeons should be flexible in their approach in regards to consideration of treatment options in order to maximise patient outcomes.  This case highlights that the procedure choice of a primary talectomy and tibio-calcaneal arthrodesis is a viable treatment option for traumatic dislocated comminuted talar fractures, which intra-operatively was unable to be anatomically reduced and fixated.

Funding declaration: None  

Conflict of interest declaration: None

References

  1. Fortin PT and Balazsy JE.  Talus Fractures: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2001; 9(2):114-127. 
  2. Dale JD, Ha AS, Chew FS (2013). Update on Talar Fracture Patterns. A Large Level 1 Trauma Center Study. American Journal of Roentgenology. 201:1087-1092.
  3. Lamothe JM and Buckley RE. Talus fractures: a current concepts review of diagnoses, treatments, and outcomes. Acta Chir Orthop Traumatol Cech. 2012; 79(2):97-106.
  4. Ptaszek, A (1999) Immediate Tibiocalcaneal Arthrodesis with Interposition Fibular Autograph for Salvage After Talus Fracture: A Case Report. Journal of Orthopaedic Trauma. 13(8): 589-592.
  5. Pearce DH, Mongiardi CN, Fornasier VL, Daniels TR. Avascular necrosis of the Talus: A pictorial essay. RadioGraphics. 2005; 25(2):399-410. 
  6. Balaji GG and Arockiaraj J. Bilateral talus fracture dislocation: is avascular necrosis inevitable? BMJ Case Rep. Aug 25;2014. pii: bcr2014205367. doi: 10.1136/bcr-2014-205367
  7. Cutler L and Boot DA. Complex fractures, do we operate on enough to gain and maintain experience? Injury. 2003; 34(12):888-91.
  8. Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB. Talar Fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification. Radiographics. 2015; 35(3):765-79.
  9. Weston JT, Liu X, Wandtke ME, Liu J, Ebraheim NE.  A Systematic Review of Total Dislocation of the Talus. Orthop Surg. 2015; 7(2):97-101. 
  10. Marsden CM (1955). Ankle fusion after complete talectomy in fracture dislocation of the talus. Journal of the Royal Army Medical Corps. 101(1):60-2.
  11. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. Journal of Bone & Joint Surgery. 86: 1616-1624.
  12. Alton T, Patton DJ, O.Gee A (2015) Classification in Brief: The Hawkins Classification for Talus Fractures. Clinical Orthopaedics and Related Research. 473(9): 3046-49.
  13. Hilandus F (1608): Report quoted in Opera, quae extant omnia (1946), Obs. 67, p. 140. Francofurti ad Moenum : Beyer.
  14. Whitman A , Astragalectomy – Ultimate Result.  Americal Journal of Surgery. 1931; 11(2):357–358.
  15. Gursu S, Bahar H, Camurcu Y, Yildirim T, Buyuk F, Ozcan C, et al.  Talectomy and Tibiocalcaneal Arthrodesis with Intramedullary Nail Fixation for Treatment of Equinus Deformity in Adults. Foot Ankle Int. 2015 Jan; 36(1):46-50. doi: 10.1177/1071100714550649
  16. Ruet A, Desroches A, Pansard E, Schnitzler A, Denormandie P.  Role of talectomy in management of severe equinovarus deformity in adults. Annals of Physical and Rehabilitation Medicine. 2014 May; 57:e197. doi: 10.1016/j.rehab.2014.03.719
  17. Joseph TN and Myerson MS. Use of talectomy in modern foot and ankle surgery  Foot Ankle. Clin N Am. 2004; 9:775–785.
  18. Daghino W, Di Gregorio G, Cerlon R. Surgical reconstruction of a crush injury of the talar body: a case report. J Bone Joint Surg Am. 2011 Jul; 93(14):e80.
  19. Stapleton JJ, Zgonis T. Concomitant Osteomyelitis and Avascular Necrosis of the Talus Treated with Talectomy and Tibiocalcaneal Arthrodesis. Clin Podiatr Med Surg. 2013 Apr; 30(2):251-6. doi: 10.1016/j.cpm.2013.01.001
  20. Kharwadkar N, Nand S, Walker AP. Primary talectomy for severe fracture-dislocation of the talus with a 15-year follow up: case report. Foot Ankle Int. 2007; 28(2):272-275.
  21. Gunal I, Atilla S, Araç S, Gürsoy Y, Karagözlu H. A new technique of talectomy for severe fracture-dislocation of the talus. J Bone Joint Surg Br. 1993 Jan; 75(1):69-71.
  22. Detenbeck LC and Kelly PJ. Total Dislocation of the Talus. J Bone Joint Surg Am. 1969 Mar; 51(2):283-288.
  23. Cinar M, Derincek A, Akpinar S. Tibiocalcaneal arthrodesis with posterior blade plate in diabetic neuroarthropathy. Foot Ankle Int. 2010; 31(6):511-516
  24. Clements JR. Use of allograft cellular bone matrix in multi-stage talectomy with tibiocalcaneal arthrodesis: a case report. J Foot Ankle Surg. 2012; 51(1):83-86.
  25. Mann RA, Chou LB. Tibiocalcaneal arthrodesis. Foot Ankle Int. 1995; 16(7):401–405.
  26. Reckling FW. Early tibiocalcaneal fusion in the treatment of severe injuries of the talus. J Trauma. 1972; 12(5):390–396.
  27. Dennison MG, Pool RD, Simonis RB, Singh BS. Tibiocalcaneal fusion for avascular necrosis of the talus. J Bone Joint Surg Br. 2001; 83(2):199–203.
  28. Thomas RH, Daniels TR. Primary fusion as salvage following talar neck fracture: a case report. Foot Ankle Int. 2003 Apr; 24(4):368-71. 
  29. Hantira H, Al Sayed H, Barghash I. Primary ankle fusion using Blair technique for severely comminuted fracture of the talus. Med Princ Pract. 2003 Jan-Mar; 12(1):47-50E
  30. Stake IK, Madesan JE, Hvaal K, Johnsen E. Surgically treated talar fractures. A retrospective study of 50 patients. Foot and Ankle Surg. 2016; 22:85-9.

Coronal plane talar body fracture associated with subtalar and talonavicular dislocations: A case report

by Barıs YILMAZ, MD1, Baver ACAR, MD2, Baran KOMUR, MD3, Omer Faruk EGERCI, MD2, Ozkan KOSE MD, FEBOT, Assoc. Prof.2pdflrg

The Foot and Ankle Online Journal 9 (4): 3

Talar body fractures usually occur as a result of high-energy trauma and variety of different type of talar fractures may occur. Most of the talar fractures are included in classification systems.  Even though it is possible to observe talar fractures with concomitant dislocations, together by reason of their functional relationship with the tibiotalar, subtalar and talonavicular joints, such observations are only addressed in literature in the form of case studies.  The present case, exhibiting talar body fracture in the coronal plane observed together with subtalar and talonavicular dislocations, is of importance due to the rarity of the diagnosis, treatment, and 2-year follow-up results.

Keywords: Talar body fracture, subtalar dislocation, talonavicular dislocation, talus

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0003

1 – Fatih Sultan Mehmet Training and Research Hospital, Orthopedics and Traumatology Department, Istanbul, Turkey
2 – Antalya Training and Research Hospital, Orthopedics and Traumatology Department, Antalya, Turkey
3 – Kanuni Sultan Suleyman Training and Research Hospital, Orthopedics and Traumatology Department, Istanbul, Turkey
* – Corresponding author: drozkankose@hotmail.com


Talar fractures and fracture-dislocations are uncommon compared to other injuries to the ankle because of the location of the talus in the ankle joint and its anatomical structure. Talar fractures represent 0.32% of all fractures, 2% of lower-extremity fractures, and 5-7% of ankle fractures. However, the talus is the second most frequently fractured bone of all the tarsal bones[1, 2]. In the literature, the incidence of talar body fractures has been reported to be in the range of 7-38% of all talus fractures, and as 0.062% of all body fractures [3, 4].

The majority of these injuries occur as a result of high-energy trauma [5, 6]. The lack of muscle attached to the talus and that a large part of the surface is covered with articular cartilage create a predisposition to talus fractures and concurrently observed dislocations. The treatment of talar body fractures is rather problematic due to the complex anatomy and the diversity of fracture patterns [7, 8]. Treatment becomes even more difficult when these fractures are accompanied by dislocations of adjacent joints. The case presented in this paper emphasizes the importance of emergent open or closed reduction and stable fixation with lag screws and Kirschner wires.

The concurrency of talar body fractures specifically with dislocations of adjacent joints has been addressed with only a few case studies in literature. This case study presents a subtalar and talonavicular joint dislocation of a talar body fracture in the coronal plane and is of paramount significance in that it was treated with open reduction and internal fixation and the clinical follow-up results of 2 years are available.  

Case report

A 32-year-old male was brought to our Emergency Department after sustaining a motorcycle accident with complaints of intense pain and deformity of the right ankle. On physical examination, the ankle was seen to be in an inverted position and there was distinctive deformity accompanied by local paleness arising from skin tightness on the lateral side (Figure 1). The neurovascular examination results were normal. The patient had no accompanying additional injuries. Direct radiographs of the ankle revealed a talar body fracture accompanied by subtalar and talonavicular dislocations (Figure 2). Under conscious sedation, closed reduction was attempted twice in the Emergency Room with no success.  Computed Tomography (CT) was performed and demonstrated a coronal plane talar body fracture associated with subtalar and talonavicular dislocations. A distal fragment of the talus was dislocated, twisted and locked (Figure 3). Thereafter, open reduction and internal fixation of the fracture was planned.

fig1

Figure 1 Clinical image of the case in ED.

fig2

Figure 2 Pre-operative radiographic evaluation of the case.

fig3

Figure 3 Pre-operative CT scan.

Once the surgical preparations had been completed, the patient was taken to the operating room approximately 3 hours after the trauma. Under spinal anesthesia and tourniquet application, an anterolateral incision was used to expose the fracture. The talar head was observed to be locked in the form of a button and a hole in the anterior capsule.  The capsule was retrieved from the talar head and reduction was secured. The talus was fixed with two cannulated screws. The subtalar and talonavicular joints were seen to be unstable, and could be dislocated with a weak inversion strain. Therefore, both the subtalar and talonavicular joints were fixed with K-wires (Figure 4). The achievement of anatomic reduction of both the fracture and the subtalar and talonavicular reduction was monitored postoperatively through a CT scan.  The patient was discharged from the hospital with a short leg brace on the 2nd postoperative day.  The sutures were removed on the 20th day and the K-wires were removed and active ankle exercises were started in the 6th week of follow-up. Full weight bearing was started in the 8th week following the observation of complete healing of the fracture.

fig4

Figure 4 Post-operative radiographs.

The final clinical and radiological follow-up was performed in the second postoperative year (Figure 5). The patient had already returned to work and social life and his AOFAS score was 87 with no significant finding of arthrosis or any other complaint.

fig5

Figure 5 Post-operative CT examination of the case.

fig6

Figure 6 Radiographic evaluation of the case 2 years postoperatively.

Discussion

Fractures of the Talus typically involve the tibiotalar joint. In their simplest clinical forms, they can be classified as fractures of the talar head, talar neck, talar body, and talar process.  In the AO/OTA classification, however, talus fractures are defined as extra-articular fractures covering neck fractures and avulsion fractures, partial intra-articular fractures covering split or compression fractures, and intra-articular fractures divided into non-displaced, displaced and segmental fractures. The distinction between talar body and neck fractures is of great importance.  A relevant evaluation defined body fracture as a case with the fracture line lying proximal to the lateral process of the talus and neck fracture as a case with the fracture line lying distal to the lateral process of the talus [9, 10].

Talar body fractures have various classifications.  The generally utilized Sneppen classification divided these fractures into five main headings: Type I, osteochondral or transchondral; Type II, coronal, sagittal horizontal, non-segmental; Type III posterior tubercle; Type IV lateral process; and Type V, crush fractures [11]. The Fortin classification defines talar body fractures under three headings: Type 1, talar body fracture on any plane; Type 2, talar process or tubercle fracture; or Type 3 compression or impaction fracture of the talar body [12]. Apart from these headings, these fractures involving the talar dome can also be classified as sagittal, coronal, transverse or segmental fractures depending on the main fracture line. Certain types of fractures and fracture-dislocations not included in the aforementioned fracture classifications can at times be provided in the literature as case reports [13-18]. Identification and classification efforts are still ongoing for these fractures and accompanying dislocations [19]. However, there are some authors who argue that these means of classification do not contribute to the selection of suitable treatment or treatment results [2, 8, 12, 20]. The current case was defined as a talar body fracture on the coronal plane accompanied by subtalar and talonavicular dislocations outside the scope of these classifications. Therefore, these types of fracture-dislocations can be indicated as a rare injury where the fracture type has been classified in literature without any dislocation type specified.  

The mechanism of injury in talar body fractures is generally defined as the exposure of the talar region to axial load or shear forces between the tibia and calcaneus  [21]. This frequently occurs in motorcycle accidents, as in the current case, or incidents of individuals falling from height.  Moreover, these fractures may be accompanied by calcaneus, tibia and talar neck fractures since most of them are induced by high-energy injuries. The observation of dislocations and ligament injuries in various adjacent joints is not surprising with such a mechanism of injury. As an example, a case of medial total subtalar dislocation was reported without a fracture in the ankle [22]. Similarly, another case was defined as a talar body fracture accompanied by anterior talofibular ligament and peroneal longus tendon injuries [23]. Although the literature does not include a high number of series pertaining to dislocations observed together with talar body fractures, a series of 23 talus fractures provided the finding of 7 peritalar dislocations [24]. Adjacent joint fractures accompanying talar body fractures are addressed in the literature with only a few cases [13-18].

Talus fractures can be diagnosed through standard radiographies in general.  However, adjacent joint dislocations clearly add difficulty to the diagnosis of such fractures.  Hence, a good radiological evaluation from the beginning is of great value for prospective surgical planning.  At this stage, CT is of extreme importance to undertake a complete evaluation of the structure of the fracture and to guide the course of treatment.  At times, MRI might be required for the additional evaluation of soft tissue injuries in surrounding ligaments and tendons.

Early emergency reduction should be performed for all fracture-dislocations of the talus with a view to preventing soft tissue damage and not to disrupt the circulation in the talus.  Specifically displaced talar neck and body fractures should be treated with open reduction and stable internal fixation in the early stage.  Closed or percutaneous reduction may be attempted immediately after sufficient analgesia and relaxation.  However, repeated unsuccessful attempts at reduction may increase the damage in fracture-dislocations with already severe damage in soft tissues. However, open reduction is mandatory for locked dislocations, as in the present case or for dislocations with soft tissue in between which cannot be managed with close reduction. If a patient cannot be taken into open reduction for patient-related or other reasons such as in the case of polytrauma patients, the fracture should undergo initial reduction through minimally invasive methods to the extent possible and then be fixed with Kirschner wires [25]. As is the case in other open fractures, open talus fractures require surgical intervention [26]. Furthermore, if the foot is diagnosed with compartment syndrome, dorsomedial dermatofasciotomy should also be performed through upper and lower extensor retinacula.  This approach will also allow for open reduction and fixation.  Some cases may require medial malleolar osteotomy for anatomic reduction depending on the medial location and extension of the fracture. Patients with severe soft tissue damage and fracture-dislocations may have tibia-metatarsal external fixators applied and the necessary follow-up [25]. In the present case, it was decided to perform immediate open surgical reduction due to failure in the initial closed reduction and reduction was obtained by retrieving the talar head from the point where it was interlocked like a button and a buttonhole in the capsule by employing an anterolateral incision which could facilitate reduction. Open reduction approaches which have been suggested for anatomic reduction includes posteromedial, medial and anteromedial approaches.  Some authors have also reported the use of an anteromedial and anterolateral double incision [21]. These approaches provide various advantages. As an example, a posterolateral incision is known to disrupt the blood flow to a lesser extent, but makes it difficult to position the patient and offers a limited approach. Whereas a medial incision provides a more convenient approach specifically together with medial malleolar osteotomy, as there are known problems associated with osteotomy, in addition to the risks to the regional anatomic structures. Similarly, an anterolateral incision also has its own specific advantages and disadvantages. In general, the type of fracture and the experience level of the surgeon are considered to be more important for the approach to be selected [21]. Another important preference is the method of arthroscopic assisted internal fixation method, which has been defined in literature as a less invasive option specifically for the talar transchondral dome [21, 27].

Fixation with headless or bioabsorbable screws is recommended due to the anatomical structure of the talar bone and the articular nature of the major part of the surface.  In the current case, fracture fixation was secured with cannulated screws.  In cases where the fracture is accompanied by unstable joints and loss of reduction even after a small-scale strain, additional support may be provided to improve stability through the fixation of both subtalar and talonavicular joints with K-wires as in the current case. Consequently, talar body fractures involving distinct displacement pose a difficulty in treatment especially if they are accompanied by dislocation in an adjacent joint and long-term results are generally poor unless a good course of surgical treatment is followed.  Talectomy is not always practical because of problems such as pain on weight-bearing and instability, and should only be considered for adults. In this case, better results could be obtained when calcaneotibial fusion and talectomy are implemented concurrently [34].  Nevertheless, this should be included in the treatment as a final step.

Surgical complications pertaining to talus fractures notably include avascular necrosis [AVN], post-traumatic osteoarthritis, non-union, malunion, and infection. In a study of 26 cases of talar body fractures, poorest results were reported based on 1-year follow-up radiographs with AVN in 38%, with post-traumatic tibiotalar osteoarthritis in 65%, with post-traumatic subtalar osteoarthritis in 34%, and with segmental and severely displaced fractures [28]. Particularly after talar neck and body fractures, the AVN risk remains almost the same, while the risk of post-traumatic subtalar arthrosis is higher. Moreover, one study in literature reported the incidence of AVN for talar body fractures without dislocations to be 25% and the risk of AVN accompanying dislocation to be 50% [29]. Another meta-analysis indicated these rates as 10% without dislocation and 25% with dislocation [30]. The previously higher incidence of AVN has been reduced due to improved surgical approach methods that have been implemented in more recent literature [31, 32]. It has also been demonstrated that the waiting period for internal fixation does not create a significant effect in terms of the development of AVN in studies undertaken at various centres [32, 33]. Another study reported post-traumatic osteoarthritis at 50% in the ankle after compression fractures, at 41% after shear fractures and at 24% in the subtalar joint [11]. The incidence of osteoarthritis in talar body fractures is closely associated with the type of fracture and injury.  

Consequently, it is as difficult to diagnose talar body fractures as it is to apply treatment and to follow up the results of treatment. Even though extremely poor results have been reported for the treatment of such fractures in the past, much better results can be observed through accurate and meticulous surgical interventions in place today.  A study in literature reporting the results of talus fractures after a period of 30 months stated poorer AOFAS results for body fractures with an average score of 58 when compared to neck fractures with an average score of 79 and process fractures with an average score of 85.  The same study also noted the worse Maryland foot scores and Hawkins evaluation criteria for body fractures [ 2].  Another reference defined the average score in AOFAS as 68.4. [35]. The high value and successful AOFAS result obtained in the current case after a 2 year follow-up period can be considered to be due to the accurate interpretation of the fracture-dislocation,  anatomic reduction with early surgery, and good fixation.  However, there is still a need in literature for long-term results pertaining to such uncommon cases.

References

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  2. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.http://www.ncbi.nlm.nih.gov/pubmed/11139032
  3. Daniels TR, Smith JW. Talar neck fractures. Foot Ankle 1993;14:225-234. http://www.ncbi.nlm.nih.gov/pubmed/8359770
  4. Early JS. Management of fractures of the talus: body and head regions. Foot Ankle Clin N Am 2004;9:709– 722. http://www.ncbi.nlm.nih.gov/pubmed/15498702
  5. Coltart WD. Aviator’s astragalus. J Bone Joint Surg [Br] 1952; 34:545-66. http://www.ncbi.nlm.nih.gov/pubmed/12999945
  6. Fournier ABarba NSteiger VLourdais AFrin JMWilliams TFalaise VPineau VSalle de Chou ENoailles TCarvalhana GRuhlmann FHuten D. Total talus fracture – long-term results of internal fixation of talus fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res. 2012;6;98 (4 Suppl):S48-55. http://www.ncbi.nlm.nih.gov/pubmed/22621831
  7. Szyszkowitz R, Reschauer R, Seggl W. Eighty-five talus fractures treated by OR‹F with five to eight years of follow-up study of 69 patients. Clin Orthop Relat Res. 1985;(199):97-107. http://www.ncbi.nlm.nih.gov/pubmed/4042502
  8. Inokuchi S, Ogawa K, Usami N, Hashimoto T. Long-term follow up of talus fractures. Orthopedics 1996;19:477-481. http://www.ncbi.nlm.nih.gov/pubmed/8727342
  9. Inokuchi S, Ogawa K, Usami N. Classification of Fractures of the Talus: Clear Differentiation Between Neck and Body Fractures Foot Ankle Int .1996;12;17 :748-750. http://www.ncbi.nlm.nih.gov/pubmed/8973897
  10. Sneppen O, Buhl O. Fracture of the talus. A study of its genesis and morphology based upon cases with associated ankle fracture. Acta Orthop Scand 1974;45:307-320. http://www.ncbi.nlm.nih.gov/pubmed/4209770
  11. Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of the body of the talus. Acta Orthop Scand. 1977;48(3):317-24. http://www.ncbi.nlm.nih.gov/pubmed/920125
  12. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 2001;9:114–127. http://www.ncbi.nlm.nih.gov/pubmed/11281635
  13. Hafez MA, Bawarish MA, Guvvala R. Closed talar body fracture with talonavicular dislocation; a case report. Foot Ankle Int. 2000;7;21:599-601. http://www.ncbi.nlm.nih.gov/pubmed/10919629
  14. Clement ND, Phillips SA, Biant LC. The Edinburgh variant of a talar body fracture: a case report. J Orthop Surg Res. 2010;12;9;5:92. http://www.ncbi.nlm.nih.gov/pubmed/21143899
  15. Galanopoulos IFogg QAshwood N. Posterior talus fracture with dislocation of both talo-navicular and subtalar joints: a variant type II of the Sneppens classification. BMJ Case Rep. 2012 Jul 27;2012. pii: bcr2012006457. http://www.ncbi.nlm.nih.gov/pubmed/22847568
  16. Haverkort JJLeenen LPWessem KJ. Diagnosis and treatment of talar dislocation fractures illustrated by 3 case reports and review of literature. Int J Surg Case Rep. 2015;16:106-111. http://www.ncbi.nlm.nih.gov/pubmed/26451643
  17. Guler FOzyurek STuran AKose O. A large bone fragment posterior to talus following medial subtalar dislocation. BMJ Case Rep. 2013 Apr 9;2013. pii: bcr2013009262. http://www.ncbi.nlm.nih.gov/pubmed/23576666
  18. Mechchat A, Bensaad S, Shimi M, Elibrahimi A, Elmrini A. Unusual ankle fracture: A case report and literature review. J Clin Orthop Trauma. 2014 Jun;5 (2):103-106. http://www.ncbi.nlm.nih.gov/pubmed/25983480
  19. Melenevsky YMackey RAAbrahams RBThomson NB 3rd. Talus fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification. Radiographics. 2015 May-Jun;35 (3):765-779. http://www.ncbi.nlm.nih.gov/pubmed/25969933
  20. Vallier H, Nork S, Benirschke S, Sangeorzan B. Surgical treatment of talar body fractures. J Bone Joint Surg Am 2003;85-A (9):1716– 1724. http://www.ncbi.nlm.nih.gov/pubmed/12954830
  21. Smith NP, Ziran B. Fractures of talus. Operative Techniques in Orthopaedics, Vol 9, No 3 , 1999;7 : 229-238. http://dx.doi.org/10.1016/S1048-6666(99)80021-4
  22. Azarkane M, Boussakri H, Alayyoubi A, Bachiri M, Elibrahimi A, Elmrini A. Closed medial total subtalar joint dislocation without ankle fracture: a case report. J Med Case Rep. 2014 Sep 20;8:313.7 http://www.ncbi.nlm.nih.gov/pubmed/25240955
  23. Wang KCTu YKFang CMLiu HTUeng SW. Talar body fracture combined with traumatic rupture of anterior talofibular ligament and peroneal longus tendon.                                                Chang Gung Med J. 2004;1;27 :56-60. http://www.ncbi.nlm.nih.gov/pubmed/15074891
  24. Sakaki MH, Saito GH, de Oliveira RG, et al. Epidemiological study on talus fractures. Rev Bras Ortop. 2014;8 5;49 (4):334-339. http://www.ncbi.nlm.nih.gov/pubmed/26229823
  25. Rammelt S, Zwipp H. Talar neck and body fractures. Injury 2009;40:120-135. http://www.ncbi.nlm.nih.gov/pubmed/18439608
  26. Nyska M, Howard CB, Matan Y, et al. Fracture of the posterior body of the talus- the hidden fracture. Arch Orthop Trauma Surg 1998;117:114-117. http://www.ncbi.nlm.nih.gov/pubmed/9457355
  27. Subairy ASubramanian KGeary NP.Arthroscopically assisted internal fixation of a talus body fracture. Injury. 2004;1;35 :86-89. http://www.ncbi.nlm.nih.gov/pubmed/14728962
  28. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg [Am] 2003;85:1716-1724. http://www.ncbi.nlm.nih.gov/pubmed/12954830
  29. Adelaar RS. The treatment of complex fractures of the talus. Orthop. Clin. North Am 1989;4; 20 :691-707. http://www.ncbi.nlm.nih.gov/pubmed/2797758
  30. Kuner, E.H., Lindenmaier, H.L., and Munst, P.: Talus fractures. In Tscherne, H., and Schatzker, J. (eds.), Major Fractures of the Pilon, the Talus, and the Calcaneus: Current Concepts of Treatment. Berlin, Springer-Verlag, 1993: 71-85.
  31. Frawley PA, Hart JA, Young DA. Treatment outcome of major fractures of the talus. Foot Ankle Int 1995;16:339-345. http://www.ncbi.nlm.nih.gov/pubmed/7550941
  32. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G. Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1-15 years. Acta Orthop Scand 2002;73:344-351. http://www.ncbi.nlm.nih.gov/pubmed/12143985
  33. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg [Am] 2004;86: 2229-2234. http://www.ncbi.nlm.nih.gov/pubmed/15466732
  34. Adelaar RS. Complex fractures of the talus. Instr Course Lect 1997;46:323-338. http://www.ncbi.nlm.nih.gov/pubmed/9143977
  35. Ebraheim NAPatil VOwens CKandimalla Y. Clinical outcome of fractures of the talar body. Int Orthop. 2008 ;12;32 :773-777. http://www.ncbi.nlm.nih.gov/pubmed/17583811

Lateral Subtalar Dislocation of the Foot: A case report

by Dr. M.R.Jayaprakash 1, Dr.Vijaykumar Kulumbi 2, Dr.Ashok Sampagar 3, Dr.Chetan Umarani 4

The Foot and Ankle Online Journal 4 (11): 1

Subtalar dislocation, also known as peritalar dislocation, refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. Subtalar dislocation can occur medially or laterally with resulting deformity. Medial dislocations comprise up to 85% of subtalar dislocations whilst lateral subtalar dislocations are less frequent and in 15% to 20% of dislocations. Closed reduction and immobilization remains the treatment of choice. The tibialis posterior, talar head impaction, and entrapment of the joint capsule may cause difficulty in closed reduction of lateral dislocations; hence open reduction may be necessary. This case report presents an unsuccessful closed reduction of a lateral subtalar dislocation which required an open reduction technique using wire stabilization.

Key words: Subtalar dislocation, talus, trauma, closed reduction, open reduction.

Accepted: October, 2011
Published: November, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0411.0001


Subtalar dislocation is a rare rearfoot injury, it disturbs the normal anatomy and function between the talus, calcaneus and navicular bone. [1,2,3,7,10] The talocal-caneal and talonavicular joints can be dislocated simultane¬ously, without a fracture of the neck of the talus .This has also been referred to as a peritalar or subastragalar dislocation. [4]

Although some dislocations may completely reduce or even partially reduce on its own, there are basically two types of subtalar dislocation reported in the literature. In lateral subtalar dislocation, the head of talus is found medially and the rest of the foot is dislocated laterally. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially. [4,6]

However, in a lateral subtalar dislocation, the talus can remain fixed while the remaining structures of the foot are dislocated laterally along the talus. It is important to check the stability and congruity of the talus in the ankle mortise with any subtalar dislocation.

Subtalar dislocations present with an impressive amount of deformity. Medial dislocation has been referred to as an “acquired clubfoot”, while the lateral injury is described as an “acquired flatfoot”. [6,7] Lateral dislocations are particularly prone to poor results, due to the frequency of open injuries and associated fractures4. We report a case of lateral subtalar dislocation in 35 year-old man in whom closed reduction was unsuccessful hence open reduction was performed.

Case Report

A 35 year-old man, who sustained a high energy trauma while travelling on a two-wheeler. He was then hit by an oncoming tractor. He presented to Bapuji Hospital. The foot was diffusely swollen with a laceration over the medial border of the foot. The skin was distorted and markedly tented over the prominent head of the talus which was felt medially. The posterior tibial artery was not palpable due to severe swelling and the dorsalis pedis artery was palpable. Radiographs showed that the foot along with calcaneum had moved laterally off the talus. (Figs. 1A, 1B and 1C)

  

Figures 1A, 1B and 1C Radiographs showing talonavicular dislocation. (A and B).  Initial radiograph showing lateral subtalar dislocation without signs of fracture.  The talus is displaced along the ankle mortise. (C)

Initially a closed reduction was attempted and this was unsuccessful. The patient was then prepared for surgery for open reduction and stabilization. A medial incision was performed extending the lacerated wound. The posterior tibial tendon was identified. The displaced talus was relocated into the joint after further dissection and reduction. The posterior tibial tendon was retracted and the talus was levered into the position and reduction was achieved. Reduction was confirmed using a computer assisted radio monitor (c- arm). (Fig. 2A and 2B) A thick Kirschner wire was inserted from the calcaneum into the talus to hold the reduction. A below knee splint was applied after placing sterile dressing on the operative site. The splint was then replaced with a windowed cast to inspect the incision daily.The operative reduction was successful. (Fig. 3A and 3B)

 

Figures 2A and 2B  Intraoperative radiographic scans showing insertion of Kirschner wire through the calcaneum.

 

Figures 3A and 3B Intraoperative photographs showing correction of deformity after the reduction of dislocation.

Discussion

Dislocation of the talus can occur in conjunction with major talus fractures. [5] However, dislocations can also occur with no associated bony injury or with relatively minimal appearing fractures. [3,4] Subtalar dislocation, also known as peritalar dislocation refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. [4,6]

First described by Judcy and Dufaurets [7] in 1811, clinical reviews of subtalar dislocations are relatively infrequent and generally limited to small numbers of patients. Subtalar dislocation can occur in any direction. Significant deformity is always present. Up to 85% of dislocations are medial. [5,7] The calcaneus, with the rest of the foot is displaced medially while the talar head is prominent in the dorsolateral aspect of the foot. The navicular is medial and sometimes dorsal to the talar head and neck. Lateral dislocation occurs less often about 10-15%. [6,7,10]

In a lateral peritalar dislocation, the calcaneus and navicular is displaced lateral to the talus and the talar head is prominent medially. [4,10] Rarely, a subtalar dislocation is reported to occur in a direct anterior or posterior direction, [2,7] but these are usually associated with medial or lateral displacement as well.

Between 10% and 40% of subtalar dislocations are open. [13] Open injuries tend to occur more commonly with the lateral subtalar dislocation pattern and probably as the result of a more violent injury. Long term follow-up demonstrated very poor results with open subtalar dislocations. [13]

The majority of subtalar dislocations can be reduced in a closed manner in the emergency department with the use of local anesthesia and procedural sedation. Early reduction is essential to prevent loss of skin due to pressure necrosis from the underlying dislocation. [4]
In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved. [11,12] Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. [11] With medial dislocations, the talar head can become trapped by the capsule of the talonavicular joint, the extensor retinaculum or the extensor tendons, or the extensor digitorum brevis muscle. [11,12] With a lateral dislocation, the posterior tibial tendon may become when firmly entrapped and present as a barrier to closed and even open reduction. [7,12]

In 1954, Leitner [12] initially proposed a mechanism by which the flexor retinaculum is disrupted, allowing the tendon to drape over the talar head and preventing reduction. In 1982 DeLee, et al., [4] in their case series three of the four lateral disloca¬tions required open reduction. Of these three, the posterior tibial tendon was the obstructing agent in two and a fracture of the head of the talus prevented closed reduction in one.

In our case presentation, the patient had sustained high energy trauma. Initially a closed reduction was attempted, but was unsuccessful. In the open reduction, we identified the tibialis posterior tendon as obstructing the reduction. Open reduction with Kirschner wire or Steinman pin reduction is shown to successfully reduce a lateral subtalar dislocation in this case report.

References

1.Brunet P, Dubrana F, Burgand A, Nen De Le, Lefebre C. Subtalar dislocation: review of ten cases at mean ten-year follow-up. JBJS 2004 86B (Supp 1):57.
2. Lyrtzis CH, Papadopoulos A, Fotiadis E, Ntovas TH, Petridis P, Koimtzis M. Isolated medial subtalar dislocations -conservative treatment. EEXOT 2009: 195-198
3 Capelli RM, Galamnini V, Crespi L. Subtalar anterolateral dislocations: case report and literature review. J Orthop Traumatol 2002 3:181-183.
4. DeLee JC, Curtis R .Subtalar dislocations of the foot. JBJS 1982 64A: 433-437.
5. Monson ST, Ryan JR. Subtalar dislocation. JBJS 1981 63A: 1156-1158,
6. J. Terrence Jose Jerome, Mathew Varghese, Balu Sankaran, K. Thirumagal. Lateral subtalar dislocation of the foot: A case report. The Foot & Ankle Journal, 2008 1 (12): 2.
7. Sanders DW. Fractures of the talus. In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood and Green’s Fractures in Adults. Vol 1. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2249-2292, 2006.
8. Plewes LW, McKelvey KG. Subtalar dislocation. JBJS 1944 26A: 585-588.
9. Smith H. Subastragalar dislocation: a report of seven cases. JBJS 1937 19A: 373-380
10. Joel Horning,John DiPreta .Subtalar Dislocation. Orthopedics 2009; 32:904
11. Mulroy, R. D.: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. JBJS 1955 37A: 859-863.
12. Leitner, L., Baldo: Obstacles to reduction in subtalar dislocations. JBJS 1954 36A: 299-306.
13. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations: long-term results. JBJS 1995 77A: 1075 -1079


Address correspondence to: Dr.M.R.Jayaprakash Ramakrishna, 43, PJ extension, 2nd main, 7th cross, Davanagere, Karnataka India 577002 . Phone (Mobile) – +919448667305, (Clinic) – 08192-253609, Email- umaranicm@gmail.com, ashok.samp@gmail.com

1  Professor and Unit Head,Department of Orthopaedics, JJM Medical College,Davangere, India 577004.
2  Professor of Department of Orthopaedics. JJM Medical College, Davangere, India 577004.
3  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.
4  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.

© The Foot and Ankle Online Journal, 2011

Giant Cell Tumor of Talus: A case report of late presentation with extensive involvement

by Mohan Kumar J.1 , Narayan Gowda2

The Foot and Ankle Online Journal 4 (1): 1

Giant cell tumor (GCT) of bone, or osteoclastoma, is classically described as a locally invasive tumor that occurs close to the joint of a mature bone. It is generally considered to be a benign tumor. In our rural setup, a substantial proportion of patients seek traditional means of treatment before medical consultation. A case of GCT in a 20 year-old boy which had led to extensive destruction of the talus is reported. In view of the extensive involvement, total talectomy along with tibio – calcaneal arthrodesis was performed. At 6 months of follow-up, the patient had a painless and well arthrodesed ankle. There was no evidence of recurrence at 18 months of follow-up.

Key words: GCT, osteoclastoma of the talus ,tibiocalcaneal ,arthrodesis.

Accepted: December, 2010
Published: January, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0401.0001


In the talus, giant cell tumor (GCT) of bone is an infrequent primary bone tumor that can present late with extensive involvement of soft tissue and articular surface changes often making the joint preservation difficult or impossible. [1] GCT account for approximately 5-8% of all primary bone tumors. [2,3,4] The authors report a GCT which had led to destruction of the entire talus in a 20 year-old boy. In view of the extensive involvement, total talectomy along with tibiocalcaneal arthrodesis was performed with the aim of achieving a stiff but painless joint.

Case presentation

A 20 year-old boy presented with chief complaints of insidious onset pain in the left ankle since the last two years, swelling in the left ankle since the last six months and inability to bear weight on right side since the last six months. The patient was treated elsewhere with intralesional steroid. There was no history of fever, loss of appetite, loss of weight, similar complaints in other joints or history of similar complaints in the past. The family, occupational, recreational and drug histories were not significant. The general physical and systemic examinations were within normal limits. On local examination, the attitude of the limb was neutral. There was a 5 × 4 cm swelling over medial and anterior aspect of left ankle joint. (Fig. 1)

Figure 1 Clinical photo of the left ankle.

There were no visible veins, sinus or discharge from the swelling. There was hypopigmentation and the swelling was tender. All movements at the ankle joint were painfully restricted. Serum biochemistry studies were within normal limits. Anterior posterior (AP) and lateral radiographs of the ankle showed a radiolucent lesion occupying the whole talus. (Fig. 2) The magnetic resonance scan (MRI) revealed an expansible soft tissue mass in the talus causing cortical destruction and extension into soft tissues. (Fig. 3) A fine needle aspiration of the mass was performed and a provisional diagnosis of GCT was rendered.

Figure2 Radiograph showing the lesion (left ankle).

Figure 3 Preoperative MRI showing GCT extensive involvement of the left ankle.

The condition, its prognosis and various treatment modalities were discussed with the patient and his family. Because of extensive involvement of talus, total talectomy with tibiocalcaneal arthrodesis was planned. The patient was a manual labourer and therefore opted for a stiff but painless joint. Total talectomy was performed through an anterolateral approach. (Fig. 4) Fusion was achieved by autologous iliac crest graft and stabilization with a Steinmann pin and Chamley’s clamp. (Fig. 5) The patient was advised non weight bearing on the affected limb for 8 weeks and mobilized in a short leg walking cast thereafter.

Figure 4 Intraoperative image showing the lesion.

Figure 5 Immediate post-operative radiograph showing complete talectomy and pan talar fusion using external fixator.

At 6 months of follow-up (Fig. 6), the patient had a smooth healed scar with a painless and well arthrodesed ankle and no evidence of recurrence. He had shortening of 2 cms which he managed with a shoe rise. There was no evidence of recurrence at 18 months of follow-up.

Figure 6 Clinical photo 6 months after surgery.

Discussion

GCT, also known as osteoclastoma, is a fairly common bone tumor accounting for 5% of all the primary bone tumors. It is a benign tumor with a tendency for local aggressiveness and high chances of recurrence. GCT is most commonly seen in the distal femur proximal tibia, distal radius and the proximal humerus in descending order of frequency. [5]

The foot is an unusual site of presentation and GCTs involving hand and foot bones appear to occur in a younger age group and tend to be multicentric. [6] The clinical picture is that of insidious onset pain, which in many cases may be mismanaged as ankle sprain. A history of preceding trivial trauma may be present. Other features are non specific. Radiologically; the tumor appears as an eccentric lytic lesion with cortical thinning and expansion. There is absence of reactive new bone formation. The tumor may erode the cortex and invade the joint. Pathological fracture may also be seen. [7] MRI scanning permits accurate delineation of the tumor extent and helps in deciding the line of management i.e. (curettage versus talectomy).

Many authors have reported satisfactory results with intralesional curettage and bone grafting. [8] However, curettage alone has a high rate of recurrence and adjuvants like Methylmethacrylate (bone cement), cryotherapy and phenol have been suggested.

Partial or total talectomy may be contemplated in cases where there is extensive involvement of the talus. Arthrodesis may or may not be done, but it is said that arthrodesis is essential after resection of all tarsal bones except calcaneum. [9]

Fresh frozen osteochondral allograft reconstruction has also been described for an aggressive GCT of talus but there is paucity of literature on this particular modality of treatment. [10] The trend is towards limb salvage and amputation is reserved for recurrences and only rarely done. In conclusion, in a case of GCT of talus presenting late with extensive involvement and in a manual labourer, total excision and tibiocalcaneal arthrodesis is an valuable treatment option.

References

1. Ng ES, Saw A, Sengupta S. Giant cell tumour of bone with late presentation: review of treatment and outcome Journal of Orthopaedic Surgery 2002: 10(2): 120–128.
2. Huvos AG Bone Tumours: Diagnosis, Treatment and Prognosis. 1979, 1st Edition, Saunders, Philadelphia p265.
3. Schajowicz F. Tumors and Tumor Like Lesions of Bone and Joints. New York, NY: Springer; 1981.p 205.
4. Dahlin DC. Bone Tumours: General Aspects and Data on 6221 cases. 1981, 3rd Edition. Charles C Thomas Publisher, Springfield p99.
5. Stoker DJ. Bone tumors (1): general characteristics benign lesions. In: Grainger RG, Allison DJ (Editors). Diagnostic radiology a textbook of medical imaging. 3rd Edition. New York: Churchill Livingston; 1997. p. 629–1660,
6. Wold LE, Swee RG. Giant cell tumor of the small bones of the hand and feet. Semin Diagn Pathol 1984, 1:173-184.
7. Carrasco CH, Murray JA. Giant cell tumours. Orthop Clin North Am 1989, 20: 395- 405.
8. Bapat MR, Narlawar RS, Pimple MK, Bhosale PB. Giant cell tumour of talar body. J Postgrad Med 2000, 46:110.
9. Dhillon MS, Singh B, Gill SS, Walker R, Nagi ON. Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature. Foot Ankle 1993, 14(5):265-272.
10. Schoenfeld AJ, Leeson MC, Grossman JP. Fresh-frozen osteochondral allograft reconstruction of a giant cell tumor of the talus. J Foot Ankle Surg 2007, 46(3):144-148.


Address correspondence to: Department of Orthopaedics PESIMSR. Kuppam AP India 517425

1 Assistant professor, Dept of Orthopaedics PESIMSR.
2 Assistant professor, Dept of Orthopaedics PESIMSR.

© The Foot and Ankle Online Journal, 2011

Primary Modified Blair Arthrodesis for Group-III Hawkins Fracture-Dislocation: A Series of Five Cases

by Arunangsu Bhattacharyya, MS(Ortho)1 , Dibyendu Biswas, MS(Ortho)2 , Rajat Ghosh,M.B.B.S. 3

The Foot and Ankle Online Journal 3 (10): 1

Background: Fracture of the neck of the talus with dislocation of talo-tibial joint and subtalar joint might be one of the worst injuries that can happen around the ankle joint. Almost all cases are complicated with avascular necrosis of the body of the talus and takes years to be revascularized even after prolonged non weight bearing. Different types of arthrodesis has been advocated by several authors. In the reported series, Blair fusion is the opted procedure because of several merits.
Methods and Material: Five patients with Hawkins Group III were selected in this series. (4 male, 1 female) One patient had compound fracture-dislocation. They were treated with Blair arthrodesis and followed up for more than two years with serial radiographs and assessment of tibiopedal movement.
Results: Three patients (60%) recovered with excellent result with range of Tibiopedal movement was 15 to 20 degrees and it was painless and one had good result (20%) with occasional pain and range of movement was 10 to 15 degrees. One patient had pain on walking and the outcome was graded as poor (20%) and range of movement was less than 10 degrees. Heel shape and heel height were maintained after surgery.
Conclusions: Blair fusion may be recommended as it is a relatively easy way out of a complex problem around the ankle. Remained tibiopedal movement helps the patient to walk more physiologically

Key words: Fracture talar neck, Hawkins fracture-dislocation, Dislocation of body, Primary Modified Blair fusion, arthrodesis.

Accepted: September, 2010
Published: October, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0310.0001


Fracture of the neck and the body of the talus is one of the most devastating injuries around the ankle. Fractures are very often complicated with dislocation of talo-navicular or subtalar or talo-tibial joint.

Fractures that create difficulty in management are fractures of the talar neck with or without dislocation; dislocations of the body of the talus; and fractures with loss of a segment of the body of the talus because those are commonly complicated with avascular necrosis of the talus. There are different opinions on suitable treatment of this type of injury. Talar neck fracture and talar body dislocation can occur due to forced dorsiflexion of the talus against the anterior edge of the tibia. Non-displaced fracture of the body of the talus, subtalar or talonavicular subluxation or dislocation can be treated with closed manipulation and plastering.

In 1939, Miller and Baker recommended subtalar or pantalar fusion for the fractures with poor reductions. [1] Triple or subtalar arthrodesis as treatment of improperly reduced fracture dislocation of talus was suggested by Schrock, et al.,. [2]

In 1943, Blair described a type of tibiotalar fusion in which the body of the talus was excised and a sliding cortical bone graft was positioned between the anterior aspects of the tibia and the head of the talus. [3]

In 1969, Detenbeck and Kelley recommended talectomy and tibiocalcaneal compression arthrodesis as the primary treatment for fracture-dislocation of the talus. They reported no significant functional disability after this procedure, but it has the disadvantages of widening the hind part of the foot and shortening the foot, both of which make shoe fitting difficult. [4]

In 1970, Hawkins proposed a very useful classification of talar neck fractures. In Group I, the vertical fracture of the neck must be undisplaced. In Group II, the fracture is displaced and the subtalar joint is subluxated or dislocated, and the ankle joint normal. In Group III, the fracture fragments are displaced and the body of the talus is dislocated from both the ankle and subtalar joints. [5] Incidence of avascular necrosis of body of talus is different in each type.

Group I undisplaced fractures of talar neck are usually not complicated with avascular necrosis. [5,6,7] Fractures of the neck associated with subtalar subluxation or dislocation had an incidence of avascular necrosis of 36 per cent in Kenwright and Taylor’s series. [7] Hawkins series acknowledged avascular necrosis in 42 per cent of his Group-II fracture-dislocations, but union of the fracture took place in all. [5] Incidence of avascular necrosis in Group III fracture-dislocation ranges from 75 [7] to 100 [8] per cent. According to Watson-Jones avascular necrosis is almost inevitable in fractures of the talar neck with dislocation of the body. So avascular necrosis following fracture of the neck of the talus is a very common incidence, hence, it is a challenging subject for the orthopaedic or podiatric surgeon.

Harry D. Morris and associates, in1971, did modify Blair method of tibio-talar fusion and added a cortical screw through the graft up to posterior cortex of the distal end of the tibia and a Steinmann pin through calcaneus into the Tibia to stabilize the Ankle. [9] The present paper reports five almost such operations with follow-up of two years. In this series part of the body of talus was not excised. It was positioned in between calcaneus and tibia with cancellous bone graft taken from bed of sliding cortical graft with the idea that inter positioned cortical and cancellous bone would make sound ankylosis of ankle with maintenance of heel height.

This reported series has shown the results of the treatment of five cases of fracture of talar neck with dislocation of body after primary Blair’s method of fusion modified by Morris, et al,. Cases were followed up for more than two years.

Subjects and Methods

In our series, five cases with fracture of the neck of the talus with talar body dislocation were included. It was of Group III according to Hawkins classification. Study was conducted from the year 2006 to 2010. (i.e. for four years) Out of five patients, four were male and one was female. Median age was approximately thirty years. (range 24 – 40 years) Right ankle was injured in four cases. Median follow-up was up to 28.6 months. (range 24 – 35 months) In one case, the fracture was of compound type. Initially wound was debrided and sensitive intravenous antibiotic continued for two weeks before final surgery. (i.e. tibio-talar fusion)

Primary Blair fusion modified after Morris, et al., was the preferred option in the reported series. Ethical committee permission was taken for this study.

In all cases, surgery was delayed routinely to provide time for swelling to subside. Absence or reduction of swelling helped to do thorough, meticulous dissection along the tissue planes.

Figures 1-3 shows the first example of a case of a modified Blair fusion in a group III – Hawkins fracture dislocation. Here, the dislocated part of the body of the talus was excised. The gap between calcaneus and tibia was filled with cancellous bone taken from lower tibia, anterior surface from the bed of sliding cortical graft and ipsilateral iliac crest. Remaining steps of the surgical procedure were almost same like those of Morris modification of Blair fusion i.e. one cortical screw was used to fix the sliding graft and thick K-wire of 2.5mm diameter was used instead of Steinmann pin.

Figure 1 Example 1 – Case 1 (see table 1): Fracture of the neck of the talus with dislocation of the body (i.e. Group -3, Hawkins fracture with no neurovascular deficit.)

Figure 2  Example 1 – Case 1:  Radiograph shows that the talar body was excised and Ankle fused with a 2.5mm K-wire and a 4.5 mm cortical screw, passed through a sliding tibial graft and up to posterior cortex of tibia. (Modified Blair fusion)

Figure 3 Example 1 –  Case 1:  The patient now stands on the floor with both feet on the ground and shape of left foot is well maintained after Modified Blair fusion.

The operation was performed by exposing the ankle through `universal incision’ to foot and ankle (i.e. antero-lateral approach.) Incision was started at the upper end from eight to ten centimeters above the ankle joint and extended distally and end at the base of the fourth metatarsal. Incision was made over the fascia and the superior and inferior extensor retinacula down to the periosteum of the tibia and the capsule of the ankle joint. This dissection usually divides the anterolateral malleolar and lateral tarsal arteries.

Cutaneous nerves were identified and protected. Extensor digitorum brevis muscle was detached from its origin and reflected distally. Extensor tendons, the dorsalis pedis artery and the deep peroneal nerve were retracted medially and the capsule was incised to expose the ankle.

With the joint widely exposed, dislocated talar body was excised with an osteotome or nibbled out and the head and neck was left undisturbed. The talonavicular joint and anterior and medial portions of the talocalcaneal joint were untouched. A sliding graft 2.0 by 6.0 centimeters was sliced from the distal anterior portion of the tibia with the help of a thin power saw. This graft was placed into a notch of approximately two centimeters deep made into the neck of the talus. The ankle was held in roughly 10 to 15 degrees of plantarflexion while the graft was fit into the neck of the talus. The graft was fixed with a cortical screw of 4.5mm diameter with lower tibia and a thick K-wire of 2.5mm diameter was inserted through the plantar aspect of the heel traversing the calcaneus and extending into the medullary canal of the tibia for 10 – 12 centimeters.

Cancellous graft was packed around the fusion site. Graft was harvested from bed of the sliding graft or ipsilateral iliac crest. Subjects have given informed consent, and that the study has been approved by an institutional review board. A below knee plaster slab was applied after surgery for better soft tissue healing. Cast was substituted after stitch removal and K-wires were routinely taken out after four weeks of surgery. (Figures 4, 5A, 5B, 6A and 6B) Non –weight bearing crutch walking was continued up to almost 12 weeks after surgery. They were followed up at monthly interval for one year.

Figure 4 Example 2 – Case 4 (see table 1):  Post operative photograph shows the Steinmann pin introduced from plantar surface of heel which is removed prior to cast application.

 

Figure 5A and 5B Example 2 – Case 4 (see table 1):  Post operative radiographs show advanced fusion and nice graft incorporation lateral (A) and anteroposterior (B) views.

 

Figure 6A and 6B Example 2 –  Case 4 (see table 1):  Post operative Photographs shows healed Antero-Lateral incision, anterior view (A) and lateral view (B), started   8 to 10 cm above the ankle and extended downwards over the joint and in the line of fourth metatarsal bone more distally over foot.

From second year onwards patients were followed up at every six months in Outpatient Department. The operated ankle was assessed with serial roentgenograms to look for progress of fusion with proper bony alignment and measurement of tibiopedal movement. Tibiopedal motion is defined as the curve of motion between maximum dorsiflexion and maximum plantarflexion of ankle and the angles were subtended by the long axis of the tibia and that of the foot in the lateral projection. The range of tibiopedal motion was measured with use of a goniometer between the axis of the tibia and the foot in positions of maximum dorsiflexion and plantarflexion.

In our study, results were considered excellent if the patient had completely asymptomatic foot and ankle and comfortable in Activities of Daily Life (ADL) and if tibiopedal movement ranged from 15 to 20 degrees. If there was occasional discomfort which caused no restriction in ADL and tibiopedal movement ranged from 10 to 15 degrees, then results were considered good. Poor result was with less than 10 degree tibiopedal movement and painful ankle to limit ADL.

Results

According to the above mentioned protocol all five patients were followed up and evaluated after surgery. Mean age of patients in this series was twenty nine years. Right sided ankles were more commonly affected here (4:1). Roughly 4 months was required for bony fusion to take place. (range 3 – 6months)
Three cases out of five were considered as with excellent outcome, two were with good outcome after follow up according to the mentioned criteria.

Tibiopedal movement was 15 to 20 degrees in three cases and 10 to 15 degrees in one case and lower than 10 degree in one case. Sound fusion took place in four cases. In one case fusion was not sound, so it was painful on walking. It was with poor outcome. Another case with good result had occasional discomfort in ankle though there was solid bony fusion. Patient who had compound Group- III fracture dislocation had poor outcome in follow up. It was possibly due to formation of fibrosis from infected tissues inside even after thorough primary wound clearance and formation of pseudoarthrosis at fusion site. But heel height and shape was maintained in all cases. Inversion and eversion was partially restricted in all patients.

Antero lateral incision easily and widely exposed the ankle without any neurovascular injury. It could be freely extended upwards or downwards to fulfill the requirement during surgery. In one case posterolateral exposure was also necessary for removal of posteriorly dislocated body of the talus in addition to standard anterolateral incision. Table 1 shows the details of all five cases of this series.

Table 1 This table compares basic descriptive information of five cases with a Hawkins Group III fracture–dislocation of neck of talus treated with Modified Blair arthrodesis. They were followed up for two to three years. Three out of five patients had an excellent result.

Discussion

Fracture of the neck of the talus, treated with Blair fusion or with its different modifications, has been published in few journals in different times. But it has not been discussed and published at many places as it deserves .In the reported series five cases of Hawkins Group III were operated with modified Blair’s fusion.

In 1943, Blair used a distal tibial sliding cortical graft without fixation in two patients with acute fracture of the neck of the talus. At the time of follow-up (minimum, four months), both fractures had united in follow-up (minimum, four months).3 Morris et al., in 1971 modified the procedure .They used a cortical screw up to posterior cortex of tibia to fix the sliding graft and a Steinmann pin introduced through planter surface of heel traversing calcaneus into the tibia by 10 to 12 centimeters. Four of their ten patients had a talar fracture with avascular necrosis, and six had an acute fracture. Seven had an excellent result and three, a good result.9 Later, Morris reported a series of four patients with a minimum two months follow-up after modified Blair procedure for the treatment of a fracture and osteonecrosis.10 Result was excellent in those two cases.

MD Dennis and HS Tullos, in 1980 ,performed a retrospective clinical and roentgenographic study on seven patients who underwent Blair tibiotalar arthrodesis with the average follow-up was 3.9 years. Results were good in five patients, fair in one, and poor in one. In two patients, pseudoarthrosis developed: painful in one and asymptomatic in one. [11]

In 1982, Lionberger, et al., described arthrodesis of the distal aspect of the tibia to the talar neck with use of a pediatric hip-compression screw. Five patients were treated and followed up for a mean of one year, one developed a delayed union. [12] Canale and Kelly reported a series of seventy-one fractures through the neck of the talus. Blair procedure was used for two fractures but both had poor result. [13]

In the reported series five cases were included. All five cases were categorized as Hawkins Group- III. (i.e. fracture of neck of the talus with dislocation of talo-tibial joint and subtalar joint, full displacement of the body of the talus from ankle) Fractures were treated with primary modified Blair arthrodesis because there was 75 to 100 percent chance of development of avascular necrosis of the body of the talus after this type of fracture-dislocation according to several reports.

Morris and associates, in 1971 advocated immediate excision of the extruded body for patients with comminuted fractures of the talar body as well as those with closed Group- III fracture-dislocation of talar neck since avascular necrosis occurs in over 90 per cent of these injuries. In this reported series, the modification was also after those of Morris. (i.e. one cortical screw and one thick k-wire were used)
In contrary to the modification presented by Morris, the body of the talus was partially excised in this study group with the hope that remained cortical bone with added cancellous bone from lower tibia would make sound fusion with maintenance of height of the heel. K-wire inserted through calcaneus into the tibia enhanced the stabilization of ankle construct for first four weeks. That helped the fusion process to take place initially.

Most of our patients had a successful clinical result with high rate of union, in spite of the complex nature of their problems. Three cases out of five (60%) were considered as excellent, one was with good (20%) and one (20%) was with poor outcome after follow up of almost two years. Tibiopedal movement was 15 to 20 degrees in three cases and 10 to 15 degrees in one and less than 10 degrees in one case. Fusion took place in all cases. Two cases had occasional discomfort in ankle though there was solid bony fusion. Heel height and shape was maintained in all cases.

In essence, a modified Blair arthrodesis may be opted for patients who have Hawkin’s Group III fracture- dislocation. It has the advantage over tibiocalcaneal arthrodesis of giving a normal-appearing foot, producing no shortening, and allowing motion to remain at the talonavicular and anterior subtalar joints thus helping the patients to walk with comfort.

Conclusion

Modified Blair fusion may be recommended for fracture of the neck of the talus with dislocation of talar body, as it is a relatively easy way out of a complex problem around the ankle. As avascular necrosis of talar body after Group III fracture- dislocation takes place in almost all cases, primary osteosynthesis has practically no role in management. Postoperative tibiopedal movement also helps the patient to walk more physiologically. Above all, heel height and shape is maintained after Blair fusion, so patients usually enjoy well fitted shoe.

References

1. Miller 0L, Baker LD. Fracture and fracture-dislocation of the astragalus. Southern Med J 1939 32: 125-136.
2. Schrock RD, Johnson HE, Waters CH, Jr. Fractures and fracture-dislocations of astragalus (talus). JBJS 1942 24A: 560-573.
3. Blair HC. Comminuted fractures and fracture dislocations of the body of the astragalus. Operative treatment. Am J Surg1943. 59: 37-47.
4. Detenbeck LC, Kelly PJ. Total dislocation of the talus. JBJS 1969 51A: 283-288.
5. Hawkins LG. Fractures of the neck of the talus. JBJS 1970 52A: 991-1002.
6. Colart WD. “Aviator’s Astragalus”. JBJS 1952 34B: 545-566.
7. Kenwright J, Taylor R0. Major injuries of the talus. JBJS 1970 52B: 36-48.
8. Pennal GF. Fractures of the talus. Clin Orthop1963 30: 53-63.
9. Morris HD, Hand WL, Dunn AW. The modified Blair fusion for fractures of the talus. JBJS 1971 53A: 1289-1297.
10. Morris HD. Aseptic necrosis of the talus following injury. Orthop Clin North America 1974 5: 177-189.
11. Dennis MD, Tullos HS. Blair tibiotalar arthrodesis for injuries to the talus. JBJS 1980 62A: 103-107.
12. Lionberger DR, Bishop JO, Tullos HS. The modified Blair fusion. Foot and Ankle 1982. 3: 60-62.
13. Canale ST, Kelly, FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. JBJS 1978 60A: 143-156.


Address correspondence to: Dr Arunangsu Bhattacharyya,MS(ORTHO)
A-8/4,Bidhan Abasan,Block-FB,Sector-3,Saltlake,Kolkata-700097.West
Bengal,India. Email: orthoarunangsu@yahoo.com

Assistant Professor. ,Dept. of Orthopaedics, Medical College,Kolkata.
Assistant Professor, Dept. Of Orthopaedics, North Bengal Medical College & Hospital,West Bengal.
Medical Officer. North Bengal Medical College & Hospital.

© The Foot and Ankle Online Journal, 2010

Fresh Osteochondral Allografting in the Treatment of Osteochondritis Dissecans of the Talus

by Ali Abadi DPM,MS1 , Raymond Ferrara DPM2

The Foot and Ankle Online Journal 3 (7): 3

A 42 year-old female with persistent ankle pain secondary to trauma of the right ankle is presented. Magnetic resonance imaging revealed an osteochondral lesion of the medial equatorial aspect of the talar bone. After exhausting several type of conservative treatments, such as pain management, ice therapy, NSAID, injection and immobilization, surgical intervention was necessary to treat the osteochondritis dissecans.

Key words: Osteochondritis Dissecans, Osteochondral Allograft, Articular cartilage transplantation, talus.

Accepted: June, 2010
Published: July, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0307.0003


Osteochondritis Dissecans (OCD) was initially described by Alexander Monro (primus) in 1738. [1] In 1870, James Paget described the disease process for the first time, but it was not until 1887 that Franz König published a paper on the cause of loose bodies in the joint. [2] König named the disease “osteochondritis dissecans”, [3] describing it as a subchondral inflammatory process of the knee, resulting in a loose fragment of cartilage from the femoral condyle. In 1922, Kappis described this process in the ankle joint. [4] On review of all literature describing transchondral fractures of the talus, Berndt and Harty developed a classification system for staging of osteochondral lesions of the talus (OLTs). [5]

In 2001, Scranton and McDermott added a fifth stage to the Berndt and Harty classification system in order to describe the cases of patient in whom the cartilage cap is intact with the lesion involving a subchondral cyst within the talar dome. [6] The term osteochondritis dissecans has persisted, and has since been broadened to describe a similar process occurring in many other joints, including the knee, hip, elbow, and metatarsophalangeal joints.

Case Report

A 42 year-old female presented with history of sever right ankle pain. The patient stated that she has deep ankle pain and repeatedly “twists her ankle”. On physical examination the region of pain was localized along the anteromedial aspect of the right talus. The area was tender to direct pressure. There was evidence of swelling at the right medial malleolar, but no signs of acute trauma, or bruising were noted. The ankle range of motion is preserved. Weight bearing radiographs of the ankle revealed osteochondral lesions.

Magnetic resonance imaging (MRI) of the right ankle revealed an osteochondral defect involving the medial talar dome, without associated subchondral collapse. There is a T2 hyperintense and T1 hypointense osteochondral defect, measures 5 mm in transverse extent x 6 mm in cranicaudal extent. (Fig.1A and B)

 

Figure 1A and B Magnetic resonance imaging demonstrating the osteochondral defect. A) The axial view, B) coronal view.

The ankle mortis is symmetric. There is a surrounding bone marrow edema along the superomedial talar dome. It also revealed mild fluid within the retrocalcaneal bursae and minor tenosynovitis of the medial and lateral ankle tendons. Laboratory examination included corpuscular blood count with differential count, white blood cell count, rheumatoid factor, C-reactive protein, erythrocyte sedimentation rate, and serum uric acid are all unremarkable. Osteochondral allograft was obtain from thirteen year old fresh cadaver and supplied by Arthrex Inc. [7]

Surgical Technique

The surgical procedure was performed under Monitored anesthesia care (MAC) combined with local infiltrative nerve block. The patient was positioned supine on the operating table. Pre-operative antibiotic (2 grams Cefazolin ) were given at the beginning of the case. A pneumatic ankle tourniquet is placed on the mid-calf and inflated to 250mmHg. The skin was prepped and draped from toes to mid calf.

A 6 cm longitudinal incision was made directly over the medial malleolus. (Fig. 2) The incision was then carried down through the subcutaneous tissue using sharp and blunt dissection. Care was taken to avoid all vital neurovascular structures. The talar dome and tibial plafond was located and marked on the skin utilizing the intraoperative fluoroscopy. (Fig. 3) The medial malleolus is predrilled with two 0.045 pins at a slightly divergent angles to help prevent proximal slippage of the medial malleolus during screw insertion. These pins are overdrilled with Arthrex 3.4 mm cannulated Trim-It Drill Bit across the medial malleolus and into the tibial plafond. The holes are then tapped. (Fig. 4) A V-shaped osteotomy was performed and medial malleolus carefully pulled inferiorly to expose the talus. (Fig. 5)

Figure 2  A 6cm longitudinal incision is made along the medial malleolus.

Figure 3 intraoperative  fluoroscopic view showing the tibial plafond.

Figure 4 The medial malleolus is marked at the tibial plafond and the Arthrex 3.4 mm cannulated Trim-It wire is then placed in the tibia.

Figure 5 An intraoperative photograph demonstrating the V-shaped osteotomy on medial malleolus to gain exposure to the OCD lesion.

The posterior tibialis and the flexor hallucis longus tendons are protected with small retractors. The talar lesion is drilled perpendicularly and centrally with the 2.4 mm guide pin. The guide pin is advanced to a depth of 15-20mm. The guide pin is then overdrilled with the appropriate size cannulated Headed Reamer to a depth of at least 12 mm. (Fig. 6) The cannulated OATS Alignment Rod is introduced over the guide pin, which measures the diameter and depth of the pilot hole. At this point we covered the surgical site with saline soaked gauze and directed our attention to the Allograft bone. (Fig. 7) After matching the defected cartilage site to the donor site the Arthrex OATS 6 mm donor harvester was used.

Figure 6 After placement of guide wire, the defect is then reamed.

Figure 7  Fresh donor cadaver bone of the talus.

We drove the harvester into to the donor talus, at 90 degrees, and twisted it clockwise 90 degrees under pressure and then full counter clockwise revolution. (Fig. 8) The tube and the raft were then withdrawn. Then we inserted the graft into the recipient hole in the talus. We utilized the large end of the tamp for tapping the graft into the graft site and made sure there is no protrusion. (Fig. 9 A – C)

Figure 8  The Arthrex OATS 6 mm donor harvester is being twisted clockwise and counterclockwise to secure the donor graft.

  

Figure 9A,B and C  The 6 mm donor plug is harvested from the talus (A),  12mm of bone plug is removed (B) and then transferred to the patient’s talus. (C)

The medial malleolus is replaced back to its anatomical position. The Arthrex 0.045 pins re-inserted back into the cannulated holes. Two 4.5mm cannulated screws were driven up the holes while the medial malleolus is held in a position of anatomic reduction. (Fig. 10 A and 10B)

 

Figure 10A and B  The graft is tapped into the talus. (A)  Intra-operative fluoroscopic view showing the two 4.5mm cannulated screw fixation of medial malleolus after graft implantation. (B)

Discussion

Articular cartilage disease can eventually lead to debilitating injury because of the body’s inability to repair this important tissue. OCD is a pathologic process in which a fragment of subchondral bone becomes avascular and can separate from the surrounding tissue.

Although most lesions are thought to have a traumatic origin, other possible causes include defect of ossification, repetitive mechanical stress, and ischemia. [8,9] The main indication for allografting includes talar defects that are 10 mm or greater. The lesions are often missing articular cartilage, or the remaining cartilage is soft and fibrillated. In the Brendt and Harty classification, these are usually stage III or IV leisons. [10] Surgery is offered when the pain is unresponsive to non-operative treatment that includes medication, cast immobilization, bracing and physiotherapy. Contraindications to allografting are few in number. The major reasons are osteoarthritis of tibiotalar joint, reflex sympathetic dystrophy and avascular necrosis of the talus. [11]

There is extensive evidence in support of autograph and allograft replacement of osteochondritis dissecans. Hangody, et al., were the first to report their early and intermediate results. They used the ipsilateral knee as a donor site and found good to excellent long term success in 34 out of 36 patients at an average of 4.2 years. [12] Al-Shaikh, et al., reports their results using the OATS procedure for treatment of the large OCD lesions of talus. Seventeen out of nineteen patients (89%) were satisfied with their results. [13]

Gross, et al., were the first to use fresh osteochondral allografts in the treatment of large OCD lesions of talus. They had 9 patients who underwent fresh osteochondral allograft transplantation from the tali of fresh human cadaver. Six grafts remain in situ with a mean survival of 11 years. [14] According to Gross, et al., the most common complication of fresh osteochondral allografting is resorption and failure of the graft to incorporate, which results in subchondral collapse and fragmentation of the graft.

Post operative management includes non-weight bearing for period of 12 weeks, but range of motion exercises are started once the incision is healed. After three months, patients begin protected weight bearing in a cam boot for 1 month. Full activity is allowed by 6 months.

References

1. Munro A. Part of the cartilage of the joint separated and ossified. Medical Essays and Observations 1973 4: 19. Cited in Burns RC. Osteochondritis dissecans. CMAJ 1939 41 (3): 232-235.
2. Garrett JC (July 1991). Osteochondritis dissecans. Clin J Sports Med 10 (3): 569-593.
3. Barrie HJ. Osteochondritis dissecans 1887-1987. A centennial look at König’s memorable phrase. JBJS 1987 69B (5): 693-695.
4. Kappis M. Weitere beitrage zur traumatisch-mechanischen entstehung der “spontanen” knorpela biosungen (German). Deutsche Zeitschrift für Chirurgie 1922 171: 13-29.
5. Berndt AL, Harty M. (June 2004). Transchondral fractures (osteochondritis dissecans) of the talus. JBJS 2004 86A (6): 1336.
6. Scranton PE Jr, McDermott JE. Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autograft. Foot ankle Int 2001 22: 380-384.
7. Arthrex Med. Inst. GmbH. Single use osteochondral Autograft Transfer System (OATS) and Small Joint OATS Sets, www.artherax.com (accessed 28th June 2010).
8. Obedian RS, Grelsamer RP. Osteochondritis dissecans of the distal femur and patella. Clin Sports Med 1997 16:1 57-174.
9. Steadman JR, Rodkey WG,Rodrigo JJ. Microfracture :surgical technique and rehabilitation to treat chondral defects. Clin Ortho Relat Res 2001 391: 362-336
10. Brendt AL, Harry M. Transchondral fractures of the talus. JBJS 1959 41A: 988-1018.
11. Meehan RE, Brage ME. Fresh osteochondral allografting for osteochondral defect of the talus. Techniques Foot Ankle Surg 2004 54: 53-61.
12. Hangody L. Kish G, Kárpáti Z, Szerb I, Eberhardt R. Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique. Foot Ankle Int 1997 18: 628-634.
13. Al-sheikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteochondral grafting for talar cartilage defect. Foot Ankle Int 2002 23: 381-389.
14. Gross AE, Agnidis Z, Hutchinson CR. Osteochondral defect of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int 2001 22: 385-391.


Address correspondence to: Dr. Ali Abadi , Virtua hospital ,West jersey, 101 Carnie Blvd. Voorhees NJ 08043 Email:aa78@Georgetown.edu .

Dr. Ali Abadi , Virtua hospital ,West jersey, 101 Carnie Blvd. Voorhees NJ 08043.
Dr Raymonfd Ferrera attending at Virtua Hosital, West jersey, 101 Carnie Blvd. Voorhees NJ 08043.

© The Foot and Ankle Online Journal, 2010

Talar Neck Fracture Reduced and Stabilized with an Ilizarov External Fixator: A case report with three year follow up

by Sutpal Singh, DPM, FACFAS, FAPWCA1 , Chih-Hui (Jimmy) Tsai, DPM2,
Albert Kim, DPM3, Timothy Dailey, DPM4

The Foot and Ankle Online Journal 3 (7): 1

The authors report a case of a Grade 3 Tscherne, isolated Hawkins Type III fracture that was treated with open reduction and external fixation. The Ilizarov technique simplified the surgery by allowing the reduction of the diastasis using a tensioned olive wire, providing distraction of fracture bones externally, and aid in reduction of the talus without the need for multiple, extensive dissection. The patient responded very well to the surgery, despite occurrence of avascular necrosis of the talus and three years status post surgery. The patient has good range of motion, is pain-free, and ambulates without difficulty despite having avascular necrosis.

Key words: Talar fracture, Hawkins classification, Hawkins sign, Ilizarov technique, diastasis, avascular necrosis.

Accepted: June, 2010
Published: July, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0307.0001


Talar fractures have been described since the early 1600’s. [1] In early literature, open talar fractures had an 84% mortality rate. [3] Due to the high mortality rate, surgeons advised extreme measures such as below knee amputations or talectomy. [1] Since then, the surgical technique for these fractures has vastly improved. However, these types of fractures, thought not fatal, still prove to be very challenging today. Talar fractures are rare, making up only 3% of all foot fractures.

Talar fractures can be classified as open or closed. The Tscherne soft tissue classification system describes both open and closed fractures. [9,17] (Table 1) For the closed soft tissue injuries, Tscherne uses a grading system from 0-3 and is based on the amount of the injury. Grade 0 is minimal soft tissue damage from indirect violence. Grade 1 is a superficial abrasion or contusion caused by pressure from within. Grade 2 is a deep contaminated abrasion associated with local skin or muscle contusion and may encompass a compartment syndrome. Grade 3 consists of extensive skin contusion or crushing, underlying severe muscle injury, decompensated compartment syndrome, and associated vascular injury. [9]

Table 1  Tscherne Classification.

Talar fractures can be further divided into three anatomical locations: neck, body and head. Talar neck fractures comprised of 50% of all talar fractures. [2] The most commonly used classification system for talar neck fractures is Hawkin’s Classification (Table 2). This classification has four types, which are differentiated by the degree of displacement. Type I is a non-displaced talar neck fracture. Type II is a talar neck fracture with mild displacement and subluxing from the subtalar joint. Type III is displacement of the talar body with dislocation of subtalar and ankle joint. Type IV is a combination of Type III with dislocation of the talonavicular joint. [1] The higher the grade, the greater the risk is for complications.

Table 2  Hawkins Classification. (AVN – avascular necrosis)

Blood supply to the talus may be an issue if one delays reduction or inadequately treats these fractures. [3] Avascular necrosis (AVN) of the talar body and arthrosis after displaced talar neck fractures is quite common; the higher the grade, the larger chance of AVN. In an article by Gholam et al, they described nine cases of Hawkins Type III fractures, and eight of the nine developed arthrosis.3 In Hawkins Type I fractures, it is quite rare to see AVN. However in Hawkins Type II, there is a 15.8%-75% chance. [1] In Hawkins Type III, the chance of AVN increases to 33-75%. [1]

Hawkins Type IV has the highest chance, reaching almost 100% due to the amount of displacement and disruption of the blood supply to the talus. [1] Subchondral atrophy of the talar dome, also called Hawkins Sign, indicates an intact blood supply to the talus. [3] It is essential to be aware of AVN so it can be treated promptly.

Various treatment options exist for talar neck fractures. Some surgeons prefer using a compression screw across the fracture fragment, while others prefer a plate. In a study performed by Charlson, et al., plate fixation and screw fixation were compared. No statistical difference between either method was found. Plate fixation may provide more control of the anatomical alignment, but has no biomechanical advantage over screws alone. [4] There are very few cases reported in the literature of an isolated talar neck fractures treated with external fixation. However, there are many cases of multiple fractures (talus with calcaneus or talus with medial/lateral malleolus) successfully treated with external fixation. The purpose of this paper is to report a Grade 3 Tscherne, isolated and displaced Hawkins Type III talar neck fracture that was specifically treated with open reduction and external fixation. By determining how much soft tissue injury and the extent of talar fracture, external fixation can be more superior to internal fixation. In this case, the Ilizarov technique is ideal when there is soft tissue injury, vascular compromise, and displaced talar neck fracture.

Case Report

The patient is a 40 year-old correctional officer who was riding a recreational vehicle at the time of his injury. (Fig. 1A and B) He reported jumping off the vehicle due to faulty breaks, resulting in a severe talar neck fracture. (Fig. 2A and B). The mechanism of the traumatic injury was that of hyperdorsiflexion of the foot against the tibia in an axial force with impingement of the talar neck.

 

Figure 1A and B  Note the severe contracture of all the toes. (A) Note the contracted hallux and lack of blood flow to the medial ankle where the talar body is compressing the skin and posterior tibial artery. (B)

 

Figure 2A and B Non-weight bearing lateral view.  Note the overlap of the talus onto the calcaneus. (A) Note the fracture fragments in the ankle. (B)

As the force continued, there was a medial and dorsal displacement fracture of the talus, and disruption of the interosseous talocalcaneal ligament. Also, the posterior and subtalar joint capsule were disrupted. As the ankle supinated, there was increased force of the talar neck against the medial malleolus resulting in subluxation of the subtalar joint and ankle joint. It was quite severe such that the medial ankle was blanching and becoming necrotic.

The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons were also contracted, such that the hallux and lesser toes were severely plantarflexed.

The dorsalis pedis artery was palpable, but the posterior tibial (PT) artery was being compressed and not palpable or heard using a Doppler. There was soft tissue damage and vascular supply was compromised. The patient opted to have surgery and informed consent was obtained from him to allow us to study and present this case. An open reduction was performed with the use on an Ilizarov frame immediately.

Surgical Technique

A large curvilinear incision was made on the medial ankle overlying the talus, extending distally and proximally from the area of blanching. (Fig. 3) The incision was deepened to the subcutaneous tissue and then to the deep tissue. The entire talar dome was noted at the incision site. (Fig. 4) The deep tissue was retracted. Once past the deep tissue, we noted that the posterior tibial artery was being compressed by the talar body. The talar body was exposed, and it was completely displaced and rotated out of the ankle and subtalar joint. There was a large hematoma and multiple small fracture fragments in the ankle joint. The hematoma was evacuated, and the small fracture fragments were removed. The wound was also copiously irrigated with bacitracin-impregnated saline. Then, attempt at relocating the dislocated and fractured talus was performed; however, there was much contraction of the tibia onto the calcaneus that it was extremely difficult to retract. Thus an external fixator was employed to distract the tibia from the calcaneus in order to relocate the talus.

Figure 3  1)  Medial surface of the talus.  2) Anterior or distal surface of the talus.  3) Lateral surface of the talus.    4) Posterior process of the talus with entrapped flexor hallucis longus (FHL) and  posterior tibial (PT) tendons and PT artery.   Note that the toes are at the upper left and the leg is at the lower right.

Figure 4  Dislocated and rotated talus.  1) Medial surface of the talus where the deltoid ligament is shown to be torn.  2) The posterior aspect of the talus: The posterior tibial tendon, posterior tibial artery and FHL are entrapped.  3) Lateral surface of the talus.  4) Talar dome.  5) Anterior surface of the talus.

First, two tibial rings were applied to the lower leg. Then a foot plate was applied, and all the wires were appropriately tensioned. Several distraction rods were used to connect the tibial rings to the foot plate, and then the foot was distracted. By distracting the tibia from the calcaneus, it made it much easier to rotate the talus and slide it between the tibia and calcaneus back into anatomical alignment. The fractured talus was anatomically reduced and held in place by an external fixator. Once the fracture was reduced, the severe skin tension on the medial side of the foot decreased.

A Doppler placed over the PT artery now showed good blood flow. Also, the FHL and FDL tendons became more relaxed, and the contracture over the hallux and lesser toes were reduced. A series of photographs shows the alignment of the Ilizarov frame directly after surgery (Figs. 5A and B, 6) and at 3 weeks after surgery. (Figs. 7A and B)

 

Figure 5A and B  Post-operative site with the Ilizarov Frame.

Figure 6  Post-operative reduction of the talar fracture in good alignment.

 

Figure 7A and B  Three weeks post- operative view.

Results

A one year follow-up showed that his hallux range of motion was normal and his ankle healed in good alignment and anatomical position. This was accompanied with good range of motion, without pain, and with normal ambulation. However, despite the proper care and good post operative alignment, there was still sclerosis of the talar body which indicated that there was indeed avascular necrosis present. He remained non-weight bearing for 6 months and then weight bearing using a pneumatic cam walker for an additional 6 months. After this the patient went back to working 8 hours a day as a corrections officer and it was explained to him of the possible collapse and further complications from the osteonecrosis of the talus and to limit any vigorous activities. He was again followed up at 2 years and at 3 years after the initial traumatic event. He did have an increase in plantar flexion, and adequate dorsiflexion towards the end of the follow-up. He had no pain and was satisfied with the surgical outcome. He however, did have sclerosis of the talus but without any evidence of collapse. (Table 3)

Table 3  Patient 3 year follow-up results. (DF – dorsiflexion, PF – plantarflexion, AVN – avascular necrosis)

Discussion

The complex nature of high energy talus fractures can pose complications that can challenge most foot and ankle surgeons. The complexity arises because of the blood supply to the talus being extremely vulnerable after a traumatic injury. [10] Short term complications can result in skin necrosis, wound dehiscence, and infection. [11,12] Additional complications of comminuted fractures involving the talar neck and body carry a risk of AVN due to the retrograde blood supply. [13] Injury to the joints surrounding the talus can cause irreversible osteochondral damage that could lead to possible early post traumatic arthritis or arthrosis. In this report, we have a patient with a closed talar neck fracture with vascular comprise. The case is further complicated by additional factors that included the medial ankle developing blanching and ultimately becoming necrotic, the posterior tibial artery being compressed, and the FHL and FDL tendons being contracted such that the hallux and lesser digits were severely plantarflexed.

Treatment options evolved from reduction and immobilization, to limited fixation, and currently, open reduction internal fixation being performed on most talar fractures. [14] Included in the literature are recommendations for primary arthrodesis or talectomy for severe talar fractures. [15] In this case, an external fixator was applied due to the severe contracture of the tibia onto the calcaneus. The Ilizarov external fixator allowed for distraction of the tibia from the calcaneus and this allowed for reduction and rotation of the talar body in its anatomical location.

Also, because of the volatile nature of the fracture and the additional soft tissue complications and its increased probability for an osteonecrosis sequelae, external fixation was utilized because it is commonly implemented and indicated for compromised soft tissue structures and gross instability. [16]

In this case, the patient was destined to have avascular necrosis due to the talar neck fracture which according to the literature has up to a 75% chance to develop the condition even with the utmost care and precautions. [1,14] This was exacerbated by the ruptured medial deltoid ligaments causing a dislocation of the talus. In examining the talus, it is a unique bone in the foot in that it has no muscular attachments with about 60% of the talus is covered with articular cartilage. These anatomical features make the talus vulnerable to dislocation. Extreme forces can cause dislocation of the talus out of the ankle mortise with disruption of the strong ligamentous attachments and this may have accounted for the medial deltoid ligament ruptures present in this patient.

This dislocation most likely caused tremendous vascular damage to this already intricate arrangement of vessels that are highly vulnerable to injury. The anterior tibial, PT, and perforating peroneal arteries serve as the vascular supply to the talus. The artery of the tarsal canal is a branch of the PT, and it supplies most of the talar body, the medial talar wall, and the undersurface of the talar neck. The artery of the tarsal canal anastamoses with the artery of the sinus tarsi, which is a branch of the perforating peroneal artery, and these vessels supply the inferior aspect of the talar body and neck. [18]

As the talus dislocates from the ankle mortise, there is sequential failure of the talar blood supply. Since the blood supply to bone and soft tissue are so intertwined, it has been noted that osteonecrosis was highest in cases in which no soft tissues remained attached to the talus. [19]

In this patient, this risk of avascular necrosis was increased and seen when the soft tissue along the medial aspect of the foot became de-vascularized and necrotic.

It is recommended that the patient should be non-weight bearing or protected weight bearing until the avascular necrosis resolves, [19,20] however there is no definitive evidence to suggest that full weight bearing with avascular necrosis leads to secondary complications such as collapse of the talar dome and tibiotalar arthritis. [21] This is further exemplified by this case where the patient, even at a three year follow up with avascular necrosis of the body of the talus, shows that his ankle is in good alignment, has not collapsed, shows no evidence of varus or valgus, has good range of motion, no pain, and ambulates normally. (Figs. 8A and B, 9, 10A and B)

 

Figure 8A and B   Six months after surgery.

Figure 9 Three years after the initial injury.

 

Figure 10A and B  Weight-bearing lateral view of the ankle, three years status post-operative, shows AVN of the talus, but good alignment.  There is no pain, no collapse of the talus, and the patient has good ankle range of motion. (A) Weight-bearing anterior posterior view of the ankle, three years status post-operative shows AVN of the talus, but good ankle joint congruity. (B)

By using the Ilizarov External Fixator, the talus was immobilized and held in place such that no axial pressure was placed onto the talus while healing took place.

Conclusion

Talar fractures are very complicated with a high incidence of AVN. We feel that if there is much difficulty in reducing the talar fracture from the tight tibial collapse onto the calcaneal surface, an external fixator is very beneficial in distracting the tibia from the calcaneus. In the above case, we used the multiplaner Ilizarov external fixator. He did have a severe fracture and dislocation of the talus which eventually resulted in AVN. At this moment, the patient states that he is pain free, and examination showed good ankle and subtalar joint range of motion. It is very important to have the patient frequently visit the office to make sure the talus is not collapsing and to explain to the patient that possible future surgeries, such as total ankle joint implant, subtalar joint arthrodesis, triple arthrodesis, or ankle fusion, may be necessary if the talus collapses as a consequence of AVN.

References

1. Banks AS, Downey MS, Martin DE, Miller SJ. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 1, 3rd edition. Philadelphia: Lippincott Williams and Wilkins; 2001.
2. Juliano P, Dabbah M, Harris TG. Talar neck fractures. Foot Ankle Clinics 2004 9: 723-736.
3. Pajenda G, Vecsei V, Reddy B, Heinz T: Treatment of talar neck fractures: Clinical results of 50 patients. J Foot & Ankle Surg 2000 39(6) 365-375.
4. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int 2006 27 (5): 340-343.
5. Marion H. Talar Shift: The stabilizing role of the medial, lateral and posterior ankle structures. Clinical Orthopedics Rel Res 1990 257: 177-183
6. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long term results of displaced talar neck fractures. Clin Orthopedics Rel Res 1985 199: 81-87.
7. Grob D, Simpson LA, Weber BG. Operative treatment of displaced talus fractures. Clin Orthopedics Rel Res 1985 199: 88-96.
8. Greenleaf J, Berkowitz RD, Whitelaw GP, Seidman GD. Hawkins Type III Fracture – Dislocation of the talus and diastasis of the tibiofibular joint without concomitant fracture of the malleolei. Clin Orthopedics Rel Res 1992 279: 254-57.
9. Frank T, Joseph B. Soft-tissue injury associated with closed fractures: Evaluation and management. J Am Academy of Orthopedic Surgeons. 2003 V:11 N:6, 431-438.
10. Baumhauer JF, Alvarez RG. Controversies in treating talus fractures. Orthop Clin North Am 1995 26(2): 335-351.
11. Fulkerson EW, Egol KA: Timing issues in fracture Management: a review of current concepts. Bulletin of the NYU hospital for joint diseases 67(1): 58-67, 2009.
12. Roberts C, Pape H, Jones A, Malkani A, Rodriguez J, Giannoudis P: Damage control orthopaedics evolving concepts in the treatment of patients who have sustained orthopaedic trauma. JBJS 2005 87(2): 434-449.
13. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 2000 21(12):1023-1029.
14. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures: results and outcomes. JBJS 2004 86A(8): 1616-1624.
15. Gunal I, Atilla S, Arac S, Gursoy Y, Karagozlu H: A new technique of talectomy for severe fracture-dislocation of the talus. JBJS 1993 75B (1): 69-71.
16. Sirkin M, Sanders R, DiPasquale T, Herscovici D: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthopaedic Trauma 2004 18 (8 Suppl): S32-38.
17. Tscherne H, Schatzker J (editors). Major Fractures of the Pilon, the Talus, and the Calcaneus: Current Concepts of Treatment. Berlin, Germany: Springer-Verlag, 1993.
18. Schuberth J, Alder D. Talar fractures. In: Banks A, Downey M, Martin D, Miller S editor. McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery. Philadelphia: Lippincott Williams and Wilkins; 2002, 1866-1867.
19. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion: A report of two cases. Foot Ankle Int 1992 13: 473-477.
20. Brewster N, Maffulli N. Reimplantation of the totally extruded talus. J Orthop Trauma 1997 11: 42–45.
21. Vallier H, Barei D, Bernischke S, Sangeorzan B. Surgical treatment of talar body fractures. JBJS 2003 85A: 1716-1724.


Address Correspondence to: Sutpal Singh, DPM. FACFAS. FAPWCA

1  Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, Fellow of the American College of Foot and Ankle Surgeons, Fellow American Professional Wound Care Association. Private practice in Southern California.
2  Doctor of Podiatric Medicine (R3) ,Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
3  Doctor of Podiatric Medicine (R2) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
Doctor of Podiatric Medicine (R1) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA

© The Foot and Ankle Online Journal, 2010

Talar Osteochondral Defect Grafting with Nexa Orthopedics OsteoCure™ Bone Graft Plug

by Jonathan Sharpe, DPM1, Mark A. Hardy, DPM, FACFAS2

The Foot & Ankle Journal 1 (6): 1

Osteochondritis dessicans of the ankle is a condition often encountered by the foot and ankle physician. Many treatments have been described in the literature including cast immobilization, arthroscopic debridement, open debridement, and autogenous grafting. The NEXA OsteoCure™ bone graft plug allows for immediate lesion excision while avoiding the morbidity associated with obtaining an autograft. The authors provide a brief review of talar dome lesions including staging and classification and their experience and technique involved for utilizing NEXA Orthopedics OsteoCure™ bone graft plugs.

Key words: Osteochondritis dessicans, Talus, Talar dome lesions, NEXA Orthopedics OsteoCure™ bone graft plugs

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: May 2008
Published: June 1st, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0106.0001

Osteochondral defects of the talar dome, aka osteochondritis dissecans, are common pathological entities encountered by the podiatric physician. Although trauma is thought to play a primary role in the genesis of these lesions, idiopathic osteonecrosis may also be a cause. Subjectively, these patients frequently present complaining of a deep, aching, non-descript pain in the ankle joint that worsens with activity.

Clinical examination may reveal joint line tenderness, effusion, as well as pain upon ankle joint range of motion. Diagnosis is frequently made with imaging after high clinical suspicion, and the lesions are typically seen anterolaterally or posteromedially. (Fig. 1)

Figure 1   Diagnosis of osteochondral defects are often made with CT scans.  The lesions are typcially seen anterolaterally and posteromedially.

Insight into the morphology and mechanism of action of these lesions was illustrated in a retrospective study of thirty-one ankles in twenty-nine patients with osteochondral lesions by Canale, et al. [1] It was found that lateral lesions were associated with inversion or inversion-dorsiflexion trauma and that these lesions are morphologically shallow and anteriorly located on the talar dome. Lateral lesions were more likely to become displaced in the joint and to have persistent symptoms. Medial lesions were both traumatic and atraumatic in origin, morphologically deep, located more posteriorly on the talar dome, and less symptomatic. These typically occurred with a plantarflexion and inversion type of injury. [1]

With an acute injury, the osteochondral lesion may not be visible on the initial radiographs. If there is a high index of suspicion, repeat radiographs in two to four weeks should be obtained or one should consider more advanced imaging. In a study by Anderson, et al., it was found that when plain radiographs of the ankle are relied on for the diagnosis of an osteochondral fracture of the talus, many lesions remain undiagnosed. [2] Stage-I osteochondral fractures show no diagnostic changes on plain radiographs, and Stage-II lesions are usually subtle and, therefore, are often overlooked by both radiologists and clinicians. The most commonly used classification system for these injuries was created by Berndt and Harty. [3]

A type I lesion represents a small area of compression. A type II lesion is a partially detached osteochondral lesion. When the lesion becomes completely detached, but remains in its anatomical location, it is a type III lesion. A detached lesion with any movement or migration is classified as type IV. A CT may offer more accurate staging of the lesion, although classification may not correlate with intraoperative findings. (Fig. 2)

Figure 2   The CT may offer more accurate staging of the lesion, although classification may not correlate with intraoperative findings.  

Pettine, et al., evaluated seventy-one osteochondral fractures of the talus for an average of 7.5 years after the onset of symptoms to determine which factors influenced the final result. It was found that the type of fracture was the most important factor and that delay in treatment also affected the results adversely. [4]

In the study by Canale, et al., using the classification system of Berndt and Harty, it appeared that Stage-I and Stage-II lesions should be treated non-operatively, regardless of location. Stage-III medial lesions should be treated non-operatively initially but if symptoms persist, surgical excision and curettage are indicated. Stage-III lateral lesions and all Stage-IV lesions should be treated surgically and early. Long-term results indicated that few lesions unite when treated non-operatively. Degenerative changes in the ankle joint, whether symptomatic or not, were common regardless of the type of treatment. [1]

Non-operative treatment of these lesions includes casting and immobilization. There is no evidence, however, that these patients need to be immobilized if they are kept non-weight bearing. There is also no evidence that a non-weight bearing cast offers better results than a weight bearing cast.

A retrospective study of 22 ankles in 22 patients with osteochondral talar dome lesions between 1975 and 1983 indicated that surgical treatment yields superior results to conservative therapy. [5] Many of these lesions are treated surgically with arthroscopic joint examination and debridement of the lesion. This process may be aided by an external joint distracting device. Anterolateral lesions are typically more amenable to arthroscopic debridement than posteromedial lesions because of their anatomical location. In a study by Kumai, et al., the authors found good clinical results in arthroscopic debridement and k-wire drilling of lesions in patients who were younger than sixty years old.6 Posteromedial lesions typically necessitate an osteotomy of the medial malleolus for exposure, with open reduction and internal fixation and subsequent prolonged non weight-bearing. (Fig. 3)

Figure 3   Posteromedial lesions typically necessitate an osteotomy of the medial malleolus for exposure.  Here,  ORIF screws are placed through the medial malleolus following the procedure.  

We have employed the NEXA Orthopedics OsteoCure™ Bone Graft Plug with success for surgical repair of talar osteochondral lesions. The OsteoCure™ Plug is a cylindrical implant ideal for filling defects in bone.

The implant is a resorbable, porous scaffold, which allows the in-growth of new healing tissue. The implant is sized for cylindrical defects with a minimum depth of 5 mm and a maximum depth of 12 mm. Careful pre-operative planning should be taken to ensure adequate visualization of the defect to be grafted. An osteotomy may need to be employed to ensure sufficient access to the lesion.

Surgical Technique

The following described technique has been outlined from NEXA’s surgical technique literature. The OsteoCure™ Plug Implant Kit contains the cylindrical implant, the delivery device, and a trimming knife. This is to be used with the accompanying OsteoCure™ Plus Site Preparation Kit. (Fig. 4)

Figure 4    The OsteoCure™ Plug Implant Kit contains the cylindrical implant, the delivery device and the trimming knife.  This is to be used with the accompanying OsteoCure™ Plus Site Preparation Kit.  

The standard implant depths range from 5 mm to 12 mm, but longer implants are available. The implants also come in a variety of diameters to suit the varying sizes of these lesions. The color-coded instrument set comes in 5, 7, 9, and 11 mm to correspond to the accompanying OsteoCure™ implant sizes. Once adequate visualization and access of the talar lesion has been obtained, a thin walled drill sleeve is introduced to the talar dome, taking care to encompass the entire lesion. (Figs. 5-7)

  

Figures 5,6,7   Once the osteochondral defect is identified, a thin walled sleeve drill is introduced to the talar dome.

Prior to insertion, an appropriately sized obturator is introduced into the handle of the drill sleeve for ease of insertion. The drill sleeve is then gently introduced through the cartilaginous surface by pronating and supinating the device. Once the drill sleeve has been slightly advanced, remove the obturator from the drill sleeve. The depth can easily be measured on the drill sleeve, which is calibrated in millimeter measurements. Care must be taken to insert the drill sleeve in a manner perpendicular to the articular surface to ensure that the graft lies flush after insertion. Next, the metallic cap is removed while maintaining the drill sleeve at the desired depth. The corresponding drill is then introduced into the drill sleeve and the lesion is drilled to the desired depth. (Fig. 8)

Figure 8   Care is taken to insert the drill sleeve and drill in a manner perpendicular to the articular surface to ensure that the graft will lie flush after insertion.  

Continue drilling until the drill stop contacts the drill sleeve. The drill and drill sleeve are then both removed from the surgical field. (Fig. 9)

Figure 9   The talar dome defect is now drilled and prepared for grafting.

Next, the cylindrical graft is prepared. The graft comes housed in a delivery device. The device has a plunger on the opposite end of the graft. The plunger end should be introduced into the lesion and pressed firmly into place. This will force the graft out of the proximal end of the delivery device, effectively sizing the implant. (Fig. 10)

Figure 10   The plunger end of the device is introduced, effectively sizing the implant.

The delivery device is then removed from the field and the redundant overhanging graft is trimmed with the knife included in the kit. (Fig. 11)

  

Figures 11,12,13   The redundant portion of graft is trimmed.  (Fig. 11)  The graft is introduced (Fig. 12) and gently tamped into place.  Gently contour the graft as needed with a scalpel. (Fig. 13)

The delivery device is then reintroduced to the lesion with the graft now facing distally toward the lesion. It is helpful to advance the graft a few millimeters to help introduce it into the drilled defect. The plunger on the proximal end of the delivery device is then firmly advanced, seating the graft into the defect. (Fig. 12)

It can be gently tamped with a mallet. The graft should sit flush with the articular surface. If there is a small step-off deformity, gently contour the graft with a scalpel. (Fig. 13)

Once the graft has been placed, commence with ORIF of osteotomy if necessary and standard wound closure. (Fig. 14)

Figure 14   The graft is seated in place.  ORIF of the malleolus is then performed with appropriate closure of the surgical site.

According to NEXA, immediately following implantation the scaffold allows blood, marrow and progenitor cells to be transported into the pores. The scaffold provides a porous and mechanically protected environment for healing, tissue in-growth and cellular development. The calcium sulfate dissolves within 6 weeks to 6 months. New tissue forms within the pores. Between 6 months and 12 months, the polymer undergoes resorbtion and is gradually replaced with tissue as well. After 12 months the polymer is predominantly resorbed and the defect will contain new tissue.

Our post-operative treatment protocol consists of non-weight bearing for 2 weeks, followed by active range-of-motion, usually, once the incisions have healed. Partial weight bearing is then employed for 2 weeks, in a fracture boot, with progression to full weight bearing for an additional 2 weeks.

At 6-8 weeks the patient is then enrolled into a formal physical therapy program.

References

1. Canale-ST; Belding-RH Osteochondral lesions of the talus JBJS-Am. 62(1): 97-102, Jan. 1980.
2. Anderson IF, et al: Osteochondral fractures of the dome of the talus JBJS – Am. 71(8):1143-52, Sept. 1989.
3. Brendt, AL, Harty, M. Transchondral fractures (osteochondritis dissecans) of the talus. JBJS. Vol 41-A. 988-1020, 1959.
4. Pettine KA. Morrey BF. Osteochondral fractures of the talus. A long-term follow-up. JBJS – British 69(1):89-92, Jan. 1987.
5. Flick AB. Gould N. Foot & Ankle. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. [JC:f3x] 5(4):165-85, Jan-Feb 1985.
6. Kumai T, Takakura Y, Higashiyama I, Tamai S. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 81(9):1229-35, Sept, 1999.


 
Address correspondence to: Mark A. Hardy, DPM, FACFAS, Kaiser Permanente Foundation Department of Podiatric Surgery
12301 Snow Road Parma, OH 44130
Email: markhardy@sbcglobal.net

1Senior Resident, Kaiser Permanente/Cleveland Clinic Foundation Residency Program, Cleveland, Ohio.

2Director, Cleveland Clinic/Kaiser Permanente. Foot & Ankle Residency Program. Director, Foot and Ankle Trauma Service. Kaiser Permanente – Ohio Region

© The Foot & Ankle Journal, 2008