Tag Archives: Trauma

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 – Foundation 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.

Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

by Amanda Kamery DPM1*, Craig Clifford DPM MHA FACFAS FACFAOM2

The Foot and Ankle Online Journal 11 (3): 1

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients.

Keywords: ankle fracture, trauma, geriatric, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2018.1103.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Residency Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author: akamery@kent.edu


Geriatric patients are at an increased risk for sustaining ankle fractures due to increased fall rate and decreased bone density. Surgical repair for such injuries is often complex, due to the standard large incision and relatively bulky fixation which is necessary in the geriatric patient due to their generally poor bone stock [1]. This traditional form of fixation carries a complication rate of up to 30% [2]. Additionally, wound healing complications and hardware irritation is more common in this population due to a poor soft tissue envelope, with wound infection rates ranging from 26-40% [3]. Commonly, subsequent surgeries are necessary to remove hardware or to perform wound debridements [4]. As it is well documented that surgical morbidity increases in this population, it is important to utilize techniques and fixation methods that limit subsequent encounters. In this case report, we present intramedullary fixation for distal fibular fractures as a viable option for the geriatric population.

Case  Report

The patient is a 94-year-old male who presented 5 days after a fall with a Weber B, slightly comminuted, left distal fibular fracture (Figure 1a). Due to the unstable nature and slight displacement of the fracture, surgical intervention with an intramedullary fibular rod was chosen. Intra-operatively under general anesthesia, excellent anatomic reduction was noted after placement of the rod and one syndesmotic screw (Figure 1b).

At 2 weeks postoperatively, the posterior splint and skin staples were removed. The patient transitioned to protected heel touch weight-bearing for 4 weeks. He resumed regular activity and normal shoe wear at 6 weeks postoperatively. There were no wound healing complications or hardware irritation noted throughout the postoperative course. At 12 months follow up, patient reported no ankle pain or limitations in activities of daily living (Figures 2a-b).

 

Figure 1 AP ankle radiograph showing Weber B fracture with slight comminution and displacement (a). Two weeks postoperative AP radiograph showing excellent anatomic reduction with fibular rod and syndesmotic screw (b).

 

Figure 2 Twelve months post operative AP (a) and lateral (b) radiographs showing excellent bony consolidation of fracture fragments and adequate anatomic reduction.

Discussion

Treatment of distal fibular fractures in geriatric patients have an increased risk for postoperative complications which can lead to wound healing issues and subsequent surgeries. It is important to utilize techniques and fixation methods that limit subsequent encounters in order to decrease surgical morbidity in this cohort. The intramedullary fibular rod is an excellent alternative to traditional ORIF in the geriatric population. Our case example demonstrates an ideal patient for this technique, including successful anatomic realignment and uneventful postoperative course.

References

  1. Mitchell JJ, Bailey JR, Bozzio AE, Fader RR, Mauffrey C. Fixation of distal fibula fractures: an update. Foot Ankle Int. 2014;35(12):1367-1375.
  2. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502)
  3. Höiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642-648.
  4. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop 2007;31:817–821.

 

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

Incorporating Platelet Rich Plasma and Platelet Poor Plasma into Open Reduction Internal Fixation of Closed Calcaneus Fractures to Reduce Wound Complication: A Case Study

by Travis A. Motley, DPM, FACFAS1 , John Randolph Clements, DPM, FACFAS2 ,
J. Kalieb Pourciau, DPM3

The Foot and Ankle Online Journal 2 (11): 1

Background: Calcaneal fractures are high energy injuries. There is some debate with the advantages and disadvantages of treating calcaneal fractures with open reduction and internal fixation based on surgical complication rates.
Methods: We describe the management of 12 patients who presented to our emergency department with 14 closed intra-articular calcaneal fractures (7 Sanders Class III fractures, 7 Sanders class IV fractures). These 14 fractures were treated with open reduction and internal fixation. We describe a technique using platelet rich plasma and platelet poor plasma in the closing of the soft tissues after open reduction of calcaneal fractures.
Results: While complications with open reduction of calcaneal fractures include poor wound healing and infection and can range between 26 and 60 percent, we observed no complications in our small series.
Discussion: Wound complications are the most common and potentially threatening consequence of open reduction and internal fixation of calcaneal fractures. The purpose of this case study is to offer the addition of platelet rich plasma (PRP) and platelet poor plasma (PPP) in the treatment of these complicated injuries. The study also attributes the low complication rate to application of pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach and “hands off” retraction. As well as low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting. Our series matched that of previous studies without a single wound complication.

Key Words: Trauma, calcaneal fractures, Algower-Donati suture technique, platelet rich plasma (PRP), platelet poor plasma (PPP).

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 and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0001


The calcaneus is the most commonly fractured tarsal bone constituting 60% of all major tarsal injuries, but only 2% of all fractures of the body. [1] Calcaneus fractures are high energy injuries [2] and most commonly occur with a fall from a height. [1]

A study by Lance, et al.,[3] has recorded calcaneal fractures from falls ranging three to fifty feet with an average of 14 feet. There is debate over the appropriate treatment for closed calcaneal fractures. The majority of this debate deals with complication rates and functional outcomes of conservative versus surgical management.

Complications of open reduction internal fixation (ORIF) include, but are not limited to, wound complications (dehiscence, hematoma, erythema, cellulitis, and infection), thromboembolism (deep venous thrombosis and pulmonary embolus), malreduction, compartment syndrome, nerve conditions (entrapment, numbness, reflex sympathetic dystrophy), osteomyelitis, and shoewear modifications. Subsequent operations may be required such as fasciotomy, secondary arthrodesis, peroneal nerve neurolysis, hardware removal, exostectomy, and irrigation and debridements for deep surgical site infections. [4,5] Several predisposing factors contribute to wound complications. Furthermore, the Sanders classification [6] can be predictive of complication rates. A previous study reported Sanders Class II calcaneal fractures have an overall complication rate of 27%, Class III fractures are 26%, and Class IV fractures are 60%. [4] The overall complication rate with ORIF of all closed calcaneal fractures is between 0% and 25% with wound complications being between 0% and 16%. [4,5]

Soft tissue and bone healing are mediated by a cascade of intra- and extracellular events. These events are regulated by signaling proteins and specific healing stages. Wound healing has three overlapping stages: inflammation, proliferation, and remodeling. Inflammation is the initial response to tissue injury. The main goal of the inflammatory phase is to provide rapid hemostasis and begin the sequence of events that leads to regeneration of tissue. During the proliferative phase, the damaged, necrotic tissue that is being removed via phagocytosis starts to be replaced with living tissue that is specific to the local tissue environment. During remodeling, the newly generated tissue reshapes and reorganizes to more closely resemble the original tissue. [7]

Platelets play a prominent role as one of the first responders during the acute inflammatory phase. In response to tissue damage, platelets are activated resulting in the formation of a platelet plug and blood clot for hemostasis. The alpha granules of activated platelets contain numerous proteins that influence wound healing. These include platelet derived growth factor, transforming growth factor, insulin-like growth factor, and Factor V, among others. In the presence of calcium, Factor V binds to activated factor X to produce prothrombin activator which converts prothrombin to thrombin. Thrombin then converts fibrinogen to fibrin which binds to platelet surface receptors. This activates another series of factors which are involved in activating factor X via the intrinsic pathway. [7] These proteins from platelet degranulation are partly responsible for cellular chemotaxis, proliferation, and differentiation. This includes removal of tissue debris, angiogenesis, establishing the extracellular matrix, and regeneration of the appropriate type of tissue.

Platelet rich plasma (PRP) is, by definition, a volume of the plasma fraction of autologous blood having a platelet concentration above baseline. [8] Therefore, PRP has the full complement of clotting factors and higher concentration of platelets. The portion of plasma that remains deficient in platelets is known as platelet poor plasma (PPP). PPP has clinical roles as fibrin sealant for hemostasis. Platelet concentrations in PRP range from 2 – 8.5 times that of normal plasma. [7]

Methods

Each patient enrolled in our study was stabilized by one of the three authors in our emergency department. The optimal time for operation was determined by soft tissue indicators: absence of fracture blisters, positive skin wrinkle test, and restoration of elastic properties within the area of incision. Preoperatively, all patients received one gram of Cephalexin, or one gram of Vancomycin if patient had an allergy to penicillin, intravenously 30 minutes prior to the procedure.

Patients were placed in a lateral decubitus position depending on the operative side. A pneumatic thigh cuff was used for hemostasis. The operative foot was supported with a Seattle pillow. The operative leg was then prepped and draped using aseptic technique. The leg was elevated and exsanguinated and the tourniquet was then inflated. A surgical marking pen was then used to draw an L-shaped lateral extensile incision over the lateral aspect of the calcaneus as to maximally preserve the blood supply to the lateral subperiosteal flap as described by Borelli. [9] The horizontal arm was 2 cm superior to the plantar fat pad, the vertical arm of this incision was 1 cm anterior to the Achilles tendon. Each arm of the “L” measured approximately 8 cm in length. The incisions were initially made to the level of the bone. The subperiosteal flap, including the peroneal tendons and the sural nerve, was elevated from the lateral wall of the calcaneus superiorly and retracted with Kirschner wires in the fibula, talus, and cuboid. (Fig. 1) This allowed visualization of the lateral calcaneal body, the calcaneocubiod joint and the subtalar joint.

Figure 1 Extensile lateral approach with Kirschner wires retracting full-thickness skin flap.

After reduction of the articular surfaces, calcaneal body and the lateral calcaneal wall, a low profile titanium perimeter plate and screws (ACE-Depuy®, Warsaw, Indiana) was utilized for fixation.

The wound was copiously irrigated with normalized saline using bulb syringe. A 4-mm flat Jackson-Pratt facial drain was then placed exiting dorsally and sutured into place. Next, PRP derived from the Gravitational Platelet Separation System (GPS® III, Biomet®, Inc., Warsaw, Indiana) was then applied to any body defects and the operative field. The wound was then carefully closed in layers using 2-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) for deep tissue, 3-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) subcutaneously, and 4-0 Ethilon (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) to reapproximate the skin using the horizontal Allgower – Donati suture technique. [10] (Fig. 2)

Figure 2 Closed extensile lateral approach with Allgower-Donati suture technique. Drain exit site is beyond region of the elevated flap.

Platelet poor plasma from the GPS® III system was then applied above the incision. The wound was bandaged with sterile gauze, kling, and a bulky Curity™ Lakeside™ cotton roll (The Kendall Company, Boston, Massachusetts) compressive posterior splint. The tourniquet was deflated and there were typical hyperemic responses to all the digits. Patients were admitted for postoperative pain management. Drain output was recorded until it produced 30 cc or less in 24 hours. Then, the drain was removed. All patients received one gram of Cephalexin every eight hours or one gram of Vancomycin every 12 hours post operatively until discharged.

Patients were discharged home when their pain was managed appropriately with oral medication. Utilizing this technique, none of our patients had wound complications. Each patient healed the surgical site without incident.

Results

We report on open treatment of 14 calcaneal fractures from 12 patients. Thirteen of the fourteen were sole ORIF of intra-articular calcaneal fractures. One of the fourteen had a primary subtalar joint arthrodesis in addition to reduction of the calcaneus. This patient was included in the study because the surgical approach and timing resembled the other patient who received ORIF. Eleven patients were male, one was female. One patient sustained bilateral injury, and received bilateral repair. Ten of our patients had no pertinent past medical history. One male had a past medical history of transient ischemic attacks, hypertension, and hypothyroidism. One female had a history of numerous psychiatric disorders. Fifty percent (6 of 12) of our patients had social histories significant for tobacco use. There were seven right and seven left calcaneal fractures. Average follow up time period was 11.4 months (range 7-18 months). Average patient age was 35.25 (range from 21 – 69). There were no wound complications in our series utilizing our technique.

Discussion

Calcaneal fractures are high energy injuries with reported complications after ORIF of 0 – 25%.4,5 There is still debate regarding ORIF compared conservative treatment of closed calcaneal fractures based on these complications. In a prospective randomized trial comparing open reduction and internal fixation with non-operative treatment, Howard, et al., [4] reported complication rates of 25% in ORIF of 226 intra-articular calcaneus fractures.

This was then subcategorized into 16% wound complications, 5.8% malpositions of fixation, 1.2% thromboembolisms, 1.6% compartment syndromes, and 0.4% deep infections. All surgeons used the lateral extensile approach in their study.

According to a literature review done by Benirschke and Kramer5, serious infections (those requiring more than oral antibiotic therapy) after ORIF of closed calcaneus fractures range from 0% to 20%. They site three studies that claim 0% complication rates [11-13] and one study with a 20% complication rate. [14] The authors questioned the utility of these findings citing small sample sizes, short follow up times, multiple surgeons, and multiple approaches as concerns. To address those issues they reported on 341 closed calcaneal fractures treated by the senior author (Bernischke) with ORIF via an extensile lateral approach and a two layer closure. He reported only 1.8% of his subjects required further intervention. These finding were comparable to the largest study in their literature review which reported three deep infections in 114 fractures for a rate of 2.6%. [15] Benirschke cited non-compliance as the primary factor of his complications although smoking and predisposing medical conditions also contributed. Other authors have also found smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications, and consideration should be given to nonsurgical management. [16]

As previously concluded by Pietzrak and Eppley [7], platelets direct wound healing. They appear almost immediately at the site of soft tissue injury and create a local environment conducive to tissue generation by secretion of proteins from their alpha granules. Basic science supports the hypothesis of enhancing healing by the placement of a supraphysiologic concentration of autologous platelets at the site of soft tissue injury.

So far, PRP has been applied to the following areas of medicine: cardiopulmonary bypass, mandibular bone augmentation for dental implants, diabetic foot ulcers, periodontal, lumbar spine fusion, and cutaneous ulcers, bone grafting, and cardiovascular surgery with documented success. [17-24]

Wound complications are the most common and potentially threatening consequence of ORIF of calcaneal fractures. There have been previous papers describing techniques to help lower this complication. Our series matched that of previous studies without a single wound complication. While our series is limited to 14 fractures, several important points can be made. Most series of high energy injuries refer to several factors that can influence complication rates: energy of the injury, surgeon experience, soft tissue handling, medical history, patient compliance, social habits, and nutritional status. It can be said with some certainty that constant experience with calcaneal fractures leads to a decreased complication rate. Although the purpose of this case study is to offer the addition of PRP and PPP to the treatment of these complicated injuries, we believe that our low complication rate is multifactorial. This includes pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach, “hands off” retraction, low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting.

References

1. Ruch JA, Taylor GC: Calcaneal Fractures. In Comprehensive Textbook of Foot Surgery 2nd Edition, p1543, edited by ED McGlamry, AS Banks, MS Downey, Williams & Wilkins, Baltimore, 1992.
2. DiGiovanni CW, Benirschke SK, Hansen ST: Foot Injuries. In Skeletal Trauma 3rd Edition, pp 2406 – 2417, edited by BD Browner, JB Jupiter, AM Levine, PG Trafton. WB Saunders, Philadelphia, 2003.
3. Lance EM, Carey EJ: Fractures of the os calcis: a followup study. J Trauma 4: 15 – 56, 1964.
4. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R: Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 17(4): 241 –249, 2003.
5. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 18(1): 1 – 6, 2004.
6. Sanders R, Fortin P, DiPasquale T, Walling A: Operative treatment in 120 displaced intraarticular calcaneus fractures. Results Using a Prognostic Computed Tomographic Scan Classification. Clin Orthop Rel Res 290: 87 – 95, 1993.
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8. Marx RE: Platelet rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 10: 225 – 228, 2001.
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13. Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH: Outcome of foot injuries in multiple injured patients. Orthop Clin North Am. 32:193 – 204, 2001.
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17. Del Rossi AJ, Cernaianu AC, Vertrees RA, Wacker CJ, Fuller ST, Cilley Jr JH, Baldino WA: Platelet-rich plasma reduces postoperative blood loss after cardiopulmonary bypass. J Thorac Cardiovasc Surg 100: 281 – 286, 1990.
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Address correspondence to: Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com

Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com
J. R. Clements, DPM, FACFAS, The Carilion Clinic,Department of Orthopaedics, Three Riverside Place, Roanoke, VA 24014. jrclements@carilion.com
J. Kalieb Pourciau, DPM, Acadian Medical Center, 3521 Hwy 190 East, Suite U, Eunice, LA 70535. kpourciau@gmail.com

© The Foot and Ankle Online Journal, 2009