Complications and Functional Outcomes After Pantalar Dislocation

Boden, Kaeleen A. BA1; Weinberg, Douglas S. MD1; Vallier, Heather A. MD1,a

Journal of Bone & Joint Surgery - American Volume: 19 April 2017 - Volume 99 - Issue 8 - p 666–675
doi: 10.2106/JBJS.16.00986
Scientific Articles
Disclosures

Background: Pantalar dislocations without associated talar fracture are rare and have high risks of complications, including infection, osteonecrosis, and posttraumatic osteoarthrosis. Limited information on later function exists. This study evaluated complications and outcomes following pantalar dislocation without talar fracture.

Methods: Nineteen patients were identified with open (n = 14) or closed (n = 5) pantalar dislocations without talar fracture. Ten male and 9 female patients with a mean age of 39.6 years (range, 19 to 68 years) were included. Open injuries underwent surgical debridement. Sixteen patients had open reduction, and 2 had closed reduction. Fixation was achieved with Kirschner wires (n = 4), external fixation (n = 9), or both (n = 3). Two patients did not have fixation. Another patient had primary transtibial amputation due to nonreconstructible foot trauma. Charts and radiographs were reviewed to identify infection, osteonecrosis, and posttraumatic arthrosis. Data on pain, medications, range of motion, and secondary procedures were collected. After a minimum of 1 year, Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) surveys were administered.

Results: The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems with prolonged drainage, which healed with dressing changes and oral antibiotics, and 1 patient developed cellulitis 4 months after injury, which resolved with intravenous antibiotics. No deep wound infections occurred. Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, 2 with collapse of the talar dome, and 7 (44%) developed arthrosis of ≥1 peritalar articulation. Outcome surveys were obtained for 11 (58%) of the 19 patients, at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 88% (14 of 16) of the patients with radiographic and clinical follow-up reported at least mild pain and 75% (12 of 16) were taking analgesics.

Conclusions: Urgent surgical debridement of open injuries and reimplantation of the talus after pantalar dislocation was not associated with deep infection. Osteonecrosis occurred in the majority of patients, but collapse was uncommon. Persistent pain and functional limitations are frequent after pantalar dislocation, as reflected in extremity-specific and generalized functional outcome scores.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, Ohio

E-mail address for H.A. Vallier: hvallier@metrohealth.org

Article Outline

Open pantalar dislocations are rare and devastating injuries, and only 51 cases, to our knowledge, have been reported1-3. Extreme forces about the ankle are required to displace the talus at its 3 articulations: the subtalar, tibiotalar, and talonavicular joints3.

Treatment remains controversial. Some early reports suggested performing primary talectomies with tibiocalcaneal arthrodesis to minimize risks of infection and osteonecrosis2,4. More recently, talar reimplantation with either internal or external fixation has become accepted. Satisfactory results have been described5, although patients are at risk for infection, osteonecrosis, and posttraumatic osteoarthrosis. Little information exists regarding long-term function after these injuries. Accordingly, we designed a retrospective review to analyze the clinical and functional outcomes of patients who experienced a pantalar dislocation.

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Materials and Methods

The fracture registry of an urban, level-I trauma center was queried for patients with pantalar dislocation between July 2002 and August 2014. Inclusion criteria included disarticulation at the tibiotalar, talonavicular, and subtalar joints. Nineteen patients were identified, including 14 with open injuries and 5 with closed injuries (Table I). Demographic and injury data were collected. Ten men and 9 women with a mean age of 39.6 years (range, 19 to 68 years) were included. The most common mechanism of injury was motor vehicle collision (n = 13). Eleven patients sustained additional ipsilateral lower-extremity injuries, most commonly fractures of the tibia (n = 5) and the calcaneus (n = 4). Five patients sustained contralateral lower-extremity injuries. Seven patients had no additional ipsilateral or contralateral lower-extremity injuries. The mean Injury Severity Score (ISS)6 was 24.9 (range, 9 to 59). Injuries to other body areas included closed head injuries (5 patients), facial fractures (2 patients), multiple rib fractures (8 patients), pneumothorax (2 patients), liver laceration (2 patients), pelvic ring injury (2 patients), upper-extremity fractures (7 patients), and thoracolumbar spine fractures (3 patients).

All patients were managed according to the American College of Surgeons Advanced Trauma Life Support guidelines. For those with open injuries, the talus was initially wrapped with gauze moistened with saline solution and placed adjacent to the injured ankle. Open wounds were covered with saline gauze and bulky dressing, followed by placement of a splint. Intravenous first-generation cephalosporin or equivalent was administered, and tetanus status was updated. Plain ankle radiographs were made. Urgent surgical debridement and irrigation was undertaken, including debridement of any necrotic or foreign material from the talus, and the talus was copiously irrigated with normal saline solution. The mean time from presentation to the emergency department to the start of surgery was 8.2 hours (range, 2.6 to 21.5 hours). Open reduction of the talus was performed. Open wounds were located over the lateral part of the hindfoot and ankle, with talar extrusion lateral to the ankle in 12 cases and with medial wounds and medial extrusion in 2 cases, both with associated calcaneal fractures (Figs. 1-A through 1-F). Closed dislocations were managed urgently with attempted closed reduction, which was successful in 2 cases with either ipsilateral bimalleolar ankle fracture or calcaneal fracture. Open reduction through an anteromedial approach was performed for the other 3 patients (Figs. 2-A through 2-D). One patient with open pantalar dislocation had degloving of the plantar pad and an associated open comminuted calcaneal fracture and was treated primarily with transtibial amputation. Sixteen of the other 18 patients underwent Kirschner-wire fixation of the ankle and subtalar joints (n = 4), ankle-spanning external fixation (n = 9), or both (n = 3). Open reduction and internal fixation of associated malleolar fractures (n = 2) was performed at the time of definitive closure. A second surgical debridement was performed for the first 2 patients in this series with open dislocation; however, the subsequent patients with open injury were treated with a single debridement and primary closure. Antibiotics were administered intravenously for 48 hours after would closure. Wires and external fixation were retained for 8 to 12 weeks, and non-weight-bearing was advised for 12 weeks.

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).

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Statistical Analysis

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.

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Results

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.

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Discussion

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).

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