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Six-year survival of reimplanted talus after isolated total talar extrusion: a case report
© The Author(s). 2017
Received: 2 April 2017
Accepted: 20 November 2017
Published: 15 December 2017
Open total extrusion of the talus without concomitant fracture is an extremely rare injury. We present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation.
A 55-year-old Asian man who had a totally extruded talus without fracture underwent immediate reimplantation surgery. A spanning external fixator with single antegrade K-wire fixation was applied to maintain the reimplanted talus. During 6 years of follow-up, he could walk without aids and could squat, corresponding to an American Orthopaedic Foot and Ankle Society score of 85. We found that the suspect lesion that was evident at 6 months after surgery had disappeared at 12 months postoperatively on the basis of sequential follow-up magnetic resonance imaging. There was no evidence of osteonecrosis of the dislocated talus at the final follow-up.
In patients with a totally extruded talus, a surgical strategy including immediate reimplantation of the talus and a temporary spanning fixator with single K-wire fixation might be useful to allow early mobilization around the ankle joint and to prevent additional damage of the foot without significant complications.
Open total extrusion of the talus without concomitant fracture is an extremely rare injury, accounting for 0.06% of all dislocations and 2% of all talar injuries [1–3]. Very few sporadic cases have been reported in the English literature, and there is no definite consensus concerning management. Primary ankle fusion was once recommended as the initial procedure. More recently, reimplantation of a completely extruded talus through the wound has been more recommended, and results have been satisfactory [4–8]. However, fixation constructs that are needed to maintain the reimplanted talus have not been well established. Therefore, we present 6-year follow-up data of a patient treated using a temporary spanning external fixator and less invasive single K-wire fixation. A good clinical outcome featuring revascularization of the extruded talus was attained.
Total talus extrusion without fracture is an extremely rare and potentially debilitating injury. Few reports have described it [1, 6, 11–13]. Despite the absence of a congruent evidence-based strategy, immediate reimplantation has been considered the first-line treatment. Once the talus is extruded over the skin, surgeons should focus on prevention of infection and fixation constructs, as mandated in the management of open fracture, and the additional risk of osteonecrosis due to talus vascularity . In our patient, the totally extruded talus was managed by immediate reimplantation and minimization of soft tissue damage. The approach produced an excellent outcome and complete revascularization at the 6-year follow-up.
Concerning the fixation constructs for a reimplanted talus, Van Opstal et al. , Fleming et al. , and Breccia et al.  applied only external fixation as the definitive method without talar fixation. Karampinas et al.  used two Steinmann pins placed from the inferior aspect of the calcaneus through the talus into the inferior aspect of the tibia with a circular external fixator. However, Turhan et al.  made the fixation construct using two retrograde Kirschner wires, and Apostle et al.  used a single provisional Kirschner wire. Their outcomes could not be verified, because postoperative radiographs were not included.
No clear strategy for use of fixation constructs has been established. Considering their many advantages, including the elimination of gross movement at the fracture site, improved blood flow, and reduced postoperative edema , in one study a spanning external fixator was applied as a temporary option to maintain the joint space around the reimplanted talus to prevent complications, including pin-site infections and joint contracture. In this approach, half-pins were inserted into the distal tibia and calcaneus with careful attention paid to avoid overdistraction. To directly maintain the position of the talus, a single K-wire was placed in an antegrade direction from the proximal medial to the distal lateral aspect of the ankle joint.
Through this less invasive technique, we could prevent additional damage in the plantar area of the foot and open wound, and the patient achieved partial weight bearing before removal of the K-wire. The ankle was actively mobilized as much as possible from 3 weeks postoperatively, and the patient started ambulating with toe-touch walking with crutches after 7 weeks. Despite the early exercise protocol, the patient had no significant pain around the ankle. Prolonged immobilization and offloading is not indicated in cases of asymptomatic osteonecrosis and may lead to a delay of remineralization . So, our surgical strategy might be useful.
To our knowledge, there has been no report on the revascularization of a completely extruded talus with clear proof by serial MRI. Our findings revealed the possibility of revascularization and change with time of the extruded talus. Our less invasive surgical strategy with early motion exercise, which consists of a temporary spanning external fixator and single antegrade K-wire fixation, might be useful in preventing additional damage of soft tissue around the ankle joint and limb disability due to prolonged immobilization.
Immediate reimplantation of a totally extruded talus is a well-known salvage procedure. For this surgical strategy, a fixation construct featuring temporary spanning external fixator and less invasive K-wire fixation can avoid soft tissue damage around the ankle.
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GHJ designed and controlled all the processes for this study and performed the surgery. JMK collected information related to the study as the main drafter of the manuscript. SKH participated in the design and coordination of this case report and helped to collect information. All authors read and approved the final manuscript.
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