All clinical and radiographic records were reviewed by trained researchers, including 1 surgeon, not involved in the patients’ care. Complications included wound-healing problems, infection, osteonecrosis, and posttraumatic osteoarthrosis. Infection was defined as purulent wound drainage and erythema. Osteonecrosis was defined as any relative increased density of the talar dome on radiography; collapse was noted as loss of articular integrity in the zone of osteonecrosis. Arthrosis was defined as a decrease in joint space or the presence of osteophytes, subchondral cysts, and/or sclerosis. Clinical data including the presence and location of pain, use of pain medications, and ankle range of motion were recorded from medical records. Clinical follow-up averaged 45.1 months postoperatively (range, 3.2 to 157.3 months). All patients returned for a minimum of 3 postoperative visits.
After a minimum of 1 year, patients were contacted by a clinical researcher or physician not involved in their care. The Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) surveys were administered. Both have been previously evaluated for their reliability and validity7-11. Eleven patients completed surveys; 1 declined and 2 were incarcerated. The other 5 patients could not be reached. The mean time of survey completion was 62 months after injury (range, 24 to 152 months).
Normality was assessed with the Shapiro-Wilk test. Quantile-quantile (Q-Q) plots were generated. Comparisons between categorical variables were made with the chi-square or Fisher exact test, and continuous variables were compared with correlations, the independent-samples t test, or the Mann-Whitney U test, where appropriate. Associations between age, sex, ISS, and the presence or absence of an ipsilateral injury were compared with clinical complications including infection, osteonecrosis, and posttraumatic arthrosis. Each of the clinical outcomes was analyzed against both functional outcomes scores, the MFA and FFI.
Nineteen pantalar dislocations without talar fracture were identified and treated during the 12-year study period. With the exception of 1 patient who was treated primarily with transtibial amputation, the talus was reimplanted in all open injuries, and all 18 patients have retained the talus as of this writing. All patients returned for at least 3 subsequent outpatient appointments (minimum of 3 months) and their surgical and traumatic wounds had healed by the time of the most recent visit. Sixteen of the patients had a minimum of 11 months of radiographic follow-up (mean, 29.1 months; range, 11.0 to 80.3 months).
Two patients had superficial wound-healing problems and presented with serous drainage at 6 and 16 weeks postoperatively (Table II). Both resolved with dressing changes and oral antibiotics. No patient developed a deep wound infection. One patient presented with a suture abscess postoperatively and was prescribed oral antibiotics. She developed cellulitis 4 months after injury, which was successfully treated with use of intravenous antibiotics. All infections occurred after open dislocations.
Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, at a mean of 9.3 months after injury (Table II). Two of these patients had collapse of the talar dome, at 10 and 13 months after surgery. Both had sustained open injuries. The use of non-narcotic pain medications and orthotics, and activity modification to alleviate symptoms, were encouraged. The remaining patients had eventual resolution of the osteonecrosis without collapse (range, 5 to 17 months); normal appearance of the osseous integrity of the talus was noted on radiographs. Seven (44%) of the 16 patients developed posttraumatic arthrosis at a mean of 22.8 months (range, 8 to 53 months) after injury, including the tibiotalar (n = 3), subtalar (n = 6), and talonavicular articulations (n = 2). Four patients had arthrosis at >1 articulation. On the basis of the numbers available, infection, osteonecrosis, and posttraumatic arthrosis were not related to age, open injury, ISS, or the presence of an ipsilateral injury. No patient has undergone a secondary surgical procedure to our knowledge, although 1 patient with osteonecrosis and collapse was considering an arthrodesis procedure for pain relief.
Ankle range of motion was documented by the treating surgeon for 14 patients at the most recent follow-up. After a mean of 45.1 months, the mean plantar flexion was 25° (range, 10° to 40°) and the mean dorsiflexion was 11° (range, 0° to 25°). Fourteen (88%) of the 16 patients reported at least mild injury-related pain. Twelve of the 16 were taking pain medication, including 6 intermittently using narcotic medication. Nine patients were taking over-the-counter analgesics.
The mean MFA score was 30.3 (range, 19 to 45). An MFA reference value of 22.1 has been reported for patients with history of hindfoot injury10. Mean scores for patients with and without arthrosis were 30.2 and 30.5, respectively. The mean total FFI score was 25.3 (range, 5 to 58) with subscale averages of 41 for pain, 35 for disability, and 18 for activity. Normal FFI reference values indicate an average score of 12, with subscores of 11 for pain, 15 for disability, and 10 for activity11. Patients with posttraumatic arthrosis had a mean FFI score of 31.2 compared with 18.0 among those without arthrosis.
Six of the 10 patients who completed the FFI reported employment at the time of survey completion, 3 reported unemployment, and 1 was retired. Of the 3 patients reporting unemployment, 2 were either extremely bothered (5 of 5 on a Likert scale) or quite bothered (4 of 5) by their unemployment status, while the other was not bothered at all (0 of 5). Of the 6 patients with employment, 3 reported work being more difficult, 2 reported needing more time to complete tasks, and 2 reported requiring more breaks since returning after injury. Three reported making no changes in work on the basis of their injury.
Pantalar dislocations are rare injuries with potentially devastating loss of function. Properly informing patients regarding expectations remains an important goal for orthopaedic surgeons. However, this may prove challenging for injuries for which small sample sizes and various treatment strategies limit the understanding of the natural history and recovery. To our knowledge, this study represents the largest single cohort of patients sustaining pantalar dislocations without talar fracture treated by a common algorithm of urgent debridement of open injuries and urgent reduction of the talus (Table III). We evaluated the most common complications (infection, osteonecrosis, and posttraumatic arthrosis) and assessed functional outcomes.
Three patients developed infection; however, only 1 was hospitalized, receiving intravenous antibiotics for cellulitis. None required a secondary procedure for infection or pain relief. Other cohort studies had similar rates of infection12,13. These data suggest that, even in open injuries with gross contamination, infection is infrequent with timely surgical debridement and reimplantation. In contrast, Marsh et al. previously argued that talectomies should be the primary surgical strategy to avoid infections and poor outcomes associated with open injuries4. They reported infection in 38% of injuries, including pantalar dislocations and fracture-dislocations, and patients with deep infection required talectomy and/or arthrodesis. Given our lower rate of infection and success in treating infections, we advocate that primary talectomies should be avoided and should be reserved only for persistent deep infection and not as an initial treatment. Urgent debridement and talar reimplantation is our preferred alternative. A single surgical debridement with primary closure may be sufficient to minimize the risk of infection after open injury; however, this determination should be made at the discretion of the treating surgeon.
Unlike infection, osteonecrosis occurred in 83% (10 of 12) of our patients with open dislocations and 88% (14 of 16) of all patients, with 2 developing collapse of the talar dome. In the current literature, a 28% rate of osteonecrosis has been reported after open pantalar dislocation without talar fracture (Table III). The reason for our increased rate of osteonecrosis is unknown but may be related to longer follow-up. When the talus is completely dislocated, avulsion of the blood supply would be anticipated, especially with open injuries in which the talus is visibly not attached to the extremity. Notably, all but 2 patients demonstrated return of normal radiodensity of the talus without collapse within 17 months after injury. This phenomenon has been described previously and occurs in approximately half of patients with talar neck fractures, providing valuable prognostic information for counseling patients5,14,15. Posttraumatic arthrosis was another complication that arose in 44% (7 of 16) of our cases. This percentage is more than the aggregate rate of 28% from other literature (Table III). Again, we noticed a higher rate after open injuries (5 open versus 2 closed), suggesting open injuries are associated with greater morbidity.
We obtained functional outcome data on more than half of our patients after a mean of 5.2 years of follow-up. Smith et al. reported a mean MFA score of 29.8 for patients who had sustained pantalar dislocation with and without fractures5. Our sample set, which excluded talar fractures, reflected a similar mean score of 30.3, demonstrating profound limitation compared with an uninjured reference population score of 9.310. However, many of the patients in this retrospective cohort study had other injuries, which would likely impact the overall MFA results. Our results are similar to a mean MFA score of 26.4 found after tibial plafond fracture16. Using the MFA, the presence or absence of osteonecrosis or arthrosis did not appear to influence scores. Given our low rate of infection, we cannot comment on how it specifically may influence long-term outcomes, but Marsh et al. predicted poorer outcomes in patients who developed infection (38%) using the Boston Children’s Hospital grading system4.
The FFI responses showed more differences in the setting of complications than found for the MFA, likely reflective of the extremity-specific nature of the FFI survey. Our mean FFI score was 25.3, with higher mean scores of 30 and 31 seen after osteonecrosis and posttraumatic arthrosis, respectively. Lower mean scores of 14 and 18 were obtained for patients who did not develop osteonecrosis and posttraumatic arthrosis, respectively. Similar to the MFA, mean FFI scores show a marked difference compared with the uninjured FFI reference value of 127,11. However, tibial plafond fractures and talar neck fractures have been associated with similar mean FFI scores of 28 and 31.7, respectively16,17.
The management of pantalar dislocations has evolved over time, and controversy still exists over the best strategy. Coltart first commented regarding the options of tibiocalcaneal or tibiotalocalcaneal arthrodesis to achieve functional results, while avoiding osteonecrosis and posttraumatic arthrosis as sequelae2. Detenbeck and Kelly echoed the recommendation for talectomy given poor outcomes with high rates of infection, poor healing, and long-term disability18. More recently, others have agreed with the strategy of primary talectomy for open pantalar dislocation due to frequent deep infection and eventual talectomy as a secondary procedure4. However, most other authors have recommended retention of the talus as the preferred initial treatment5,12,13,19-24. Talar reimplantation provides preservation of ankle height and peritalar articulations, with potential for better mobility, and is our preferred strategy.
Our data provide a uniform sample of patients who sustained complete pantalar dislocation, all lacking associated fracture of the talus, and 14 of the 19 had open injuries. We propose that favorable outcomes can be achieved with surgical debridement, talar reimplantation, and temporary fixation, ideally performed on an urgent basis, depending on the timing of patient presentation and ability to tolerate surgery. Acceptable outcomes were achieved with this strategy, with low rates of infection. Despite nearly universal radiographic evidence of osteonecrosis and/or posttraumatic arthrosis, talar collapse was infrequent, and no secondary reconstructive procedures have been undertaken to date.
Despite the relatively sizeable data set presented here, we acknowledge that limitations of our study exist. First, given the rarity of pantalar dislocations without talar fracture, our study was not powered to demonstrate significant differences between variables. Additionally, obtaining high follow-up rates proved difficult for a subset of our patients with our retrospective study design. Whether this was due to social issues, such as incarceration, or technical issues, such as outdated contact information, more complete patient follow-up would have enhanced our results.
In summary, pantalar dislocation without talar fracture remains an exceedingly rare injury for which clinical and functional outcomes have not previously been well described. We present, to our knowledge, the largest group of patients treated with use of a similar algorithm involving reimplantation and longitudinal follow-up and including several clinical and functional measures. Our results suggest continued impairment despite, as demonstrated by most patients, improvement of talar vascularity without collapse. Those with collapse and/or posttraumatic arthrosis may experience worse outcomes.
Investigation performed at MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, Ohio
Disclosure: No external funding was received for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/C259).
1. Schuind F, Andrianne Y, Burny F, Donkerwolcke M, Saric O, Body J, Copin G, De Clerq D, Opdecam P, de Marneffe R. Fractures et luxations de l’astragale. Revue de 359 cas. Acta Orthop Belg. 1983;49(6):652–89.
2. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br. 1952 ;34(4):545–66.
3. Leitner B. The mechanism of total dislocation of the talus. J Bone Joint Surg Am. 1955 ;37(1):89–95.
4. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the talus. J Orthop Trauma. 1995;9(5):371–6.
5. Smith CS, Nork SE, Sangeorzan BJ. The extruded talus: results of reimplantation. J Bone Joint Surg Am. 2006 ;88(11):2418–24.
6. Baker SP, O’Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974 ;14(3):187–96.
7. Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44(6):561–70.
8. Engelberg R, Martin DP, Agel J, Obremsky W, Coronado G, Swiontkowski MF. Musculoskeletal Function Assessment instrument: criterion and construct validity. J Orthop Res. 1996 ;14(2):182–92.
9. Martin DP, Engelberg R, Agel J, Snapp D, Swiontkowski MF. Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument. J Orthop Res. 1996 ;14(2):173–81.
10. Engelberg R, Martin DP, Agel J, Swiontkowski MF. Musculoskeletal Function Assessment: reference values for patient and non-patient samples. J Orthop Res. 1999 ;17(1):101–9.
11. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 ;83(2):219–28.
12. Burston JL, Isenegger P, Zellweger R. Open total talus dislocation: clinical and functional outcomes: a case series. J Trauma. 2010 ;68(6):1453–8.
13. Karampinas PK, Kavroudakis E, Polyzois V, Vlamis J, Pneumaticos S. Open talar dislocations without associated fractures. Foot Ankle Surg. 2014 ;20(2):100–4. Epub 2014 Jan 3.
14. Gerken N, Yalamanchili R, Yalamanchili S, Penagaluru P, Md EM, Cox G. Talar revascularization after a complete talar extrusion. J Orthop Trauma. 2011 ;25(11):e107–10.
15. Vallier HA. Fractures of the talus: state of the art. J Orthop Trauma. 2015 ;29(9):385–92.
16. Harris AM, Patterson BM, Sontich JK, Vallier HA. Results and outcomes after operative treatment of high-energy tibial plafond fractures. Foot Ankle Int. 2006 ;27(4):256–65.
17. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004 ;86(8):1616–24.
18. Detenbeck LC, Kelly PJ. Total dislocation of the talus. J Bone Joint Surg Am. 1969 ;51(2):283–8.
19. Hosny H. Open complete medial talar dislocation without fracture of the talus or the malleoli. JBJS Case Connect. 2014;4(4):e117.
20. Fleming J, Hurley KK. Total talar extrusion: a case report. J Foot Ankle Surg. 2009 ;48(6):690.e19–23. Epub 2009 Jul 17.
21. Lee J, Hamilton G. Complete talar extrusion: a case report. J Foot Ankle Surg. 2009 ;48(3):372–5. Epub 2009 Apr 8.
22. Schiffer G, Jubel A, Elsner A, Andermahr J. Complete talar dislocation without late osteonecrosis: clinical case and anatomic study. J Foot Ankle Surg. 2007 ;46(2):120–3.
23. Brewster NT, Maffulli N. Reimplantation of the totally extruded talus. J Orthop Trauma. 1997 ;11(1):42–5.
24. Ritsema GH. Total talar dislocation. J Trauma. 1988 ;28(5):692–4.
25. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion (missing talus): report of two cases. Foot Ankle. 1992 ;13(8):473–7.
26. Palomo-Traver JM, Cruz-Renovell E, Granell-Beltran V, Monzonís-García J. Open total talus dislocation: case report and review of the literature. J Orthop Trauma. 1997 ;11(1):45–9.
27. Krasin E, Goldwirth M, Otremski I. Complete open dislocation of the talus. J Accid Emerg Med. 2000 ;17(1):53–4.
28. Huang PJ, Fu YC, Tien YC, Lin GT, Lin SY, Cheng YM, Huang CY, Huang CK, Hsu CY. Open total talar dislocation—report of two cases. Kaohsiung J Med Sci. 2000 ;16(4):214–8.
29. Assal M, Stern R. Total extrusion of the talus. A case report. J Bone Joint Surg Am. 2004 ;86(12):2726–31.
30. Hardy MA, Stella Chuida DP. Open extrusion of the talus: a case report. Foot Ankle. 2008;12(1).
31. Mnif H, Zrig M, Koubaa M, Jawahdou R, Hammouda I, Abid A. Reimplantation of a totally extruded talus: a case report. J Foot Ankle Surg. 2010 ;49(2):172–5. Epub 2009 Dec 16.
32. Vaienti L, Maggi F, Gazzola R, Lanzani E. Therapeutic management of complicated talar extrusion: literature review and case report. J Orthop Traumatol. 2011 ;12(1):61–4. Epub 2011 Feb 25.
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