97 © 2015 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd
REVIEW ARTICLE
A Systematic Review of Total Dislocation of the Talus John T. Weston, MD, Xiaochen Liu, BS, Meghan E Wandtke, MS, Jiayong Liu, MD, Nabil E Ebraheim, MD Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
This review summarizes the treatment and resulting outcomes for total talar dislocation. The PubMed database was searched for articles about humans with total talar dislocation published in the English language in the last twenty years. The following data were entered into a Microsoft Excel spreadsheet: type of dislocation, nature of associated fractures (if any), type of reduction/fixation utilized, immobilization, weight-bearing status, outcome, complications and average follow-up time. Thirty-nine articles reporting a total of 86 cases of total talar dislocation are included in this review. Seventy-three of these were open injuries and 13 closed. Forty-three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. The talus was preserved in the initial management of 74 cases, whereas the remaining 12 cases were managed by primary talectomy. The mean duration of follow-up was 32 months. Twenty-two cases required a secondary arthrodesis or another additional procedure. A good outcome was achieved in 35% of cases, a fair outcome in 37% and a poor outcome in 27%. The complication of avascular necrosis (AVN) occurred in 22 cases and 14 subjects developed clinically significant osteoarthritis. Generally, the outcome of current treatments associated with total talar dislocation is not ideal, only 1/3 of cases achieving good outcomes. So far, preservation of the talus is the best treatment option. AVN is still a relatively common complication even in the absence of fracture or postoperative infection.
Key words: Avascular necrosis; Dislocation; Fracture; Talar; Talus
Introduction otal talar dislocation is defined as dislocation of the talus from the tibiotalar, talocalcaneal and talonavicular joints1,2. It most commonly occurs secondary to a high-energy impact to an inverted, plantar-flexed foot1,3–6. Total dislocation of the talus is a rare injury that is thought to account for only 0.06% of all dislocations and only 2% of talar injuries7. It is usually the result of high-energy trauma such as a fall from a height or motor vehicle accident1,8. Because of the limited blood supply of the talus, its numerous articulations and the frequency of open injuries, dislocations of the talus are difficult to repair and are often associated with complications, including avascular necrosis (AVN), infection and osteoarthritis2,9–13. Numerous techniques have been used to repair total talar dislocations, ranging from primary talectomy with arthrodesis2,14–16, to immediate reduction and fixation,
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even in the case of total talar extrusion1,8,12,13,17,18. To our knowledge there have been no systematic reviews of dislocations of the talus to date, published reports being limited to case reports and small case series. The purpose of this review was to summarize data about this rare injury, treatment approaches and related outcomes. Materials and Methods sing the PubMed database, we conducted an electronic search of articles about humans published in the English language within the last twenty years. We used the search terms “talar dislocation” and “talus” as a simple text search with the filters listed above. We included case reports of total talar dislocation with and without associated fractures of the talus, foot, and ankle in this review. The exclusion criteria for this review were as follows: chronic talar dislocation, pediatric
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Address for correspondence Jiayong Liu, MD, Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA, 3065 Arlington Avenue, Toledo, Ohio, USA 43614 Tel: 001-419-3835361; Fax: 001-419-3833526; Email: [email protected] Disclosure: The authors declare that they have no conflicts of interest. No benefits in any form have been, or will be, received from any commercial party related directly or indirectly to the subject of this article. Received 5 August 2014; accepted 3 March 2015
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Orthopaedic Surgery 2015;7:97–101 • DOI: 10.1111/os.12167
98 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
Total Talar Dislocation
TABLE 1 Summary of data for 86 cases of total talar dislocation (cases [%]) Type of dislocation Open (n = 73)
Closed (n = 13)
Fractures Any associated fracture
Talus fracture
Reduction 43 (50)
32 (37)
Open
83 (97)
Closed
cases and case series in which data for cases of total talar dislocation were grouped with data for other types of talar dislocation. We classified abstracts as definitely include, unsure or definitely exclude and reassessed those classified as unsure once the full text of the article was available. We entered the following data from the included cases into a Microsoft Excel spreadsheet: type of dislocation, nature of fractures (if any), type of reduction/fixation utilized, immobilization, weightbearing status, outcome and complications. Statistical analysis of the variables above was done by calculating percentages in Microsoft Excel. Because the information reported about patient outcomes was highly variable, we established the following criteria for categorizing the outcomes: good = full weightbearing with near full range of motion, minimal pain, and minimal activity restriction; fair = full weight-bearing with moderate restriction of activity because of restricted range of motion or pain; poor = partial weight-bearing or severe restriction of activity caused by pain, or pain/instability that was so severe it required arthrodesis or another corrective procedure. Results e included 39 articles reporting a total of 86 cases of total talar dislocation in this review (see Table 1). Seventy-three of these were open injuries and 13 closed1. Forty-three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. Closed reduction was performed in only three cases, the remaining 83 requiring open reduction. An external fixator was used at least
W
Fixation
3 (3)
Complications
Internal fixation K-wires
25 (29) 15 (17)
Screws Pins
13 (15) 1 (1)
External fixation
24 (28)
Arthrodesis
22 (26)
Avascular necrosis Radiographic evidence of osteoarthritis Clinical osteoarthritis
22 (26) 19 (22)
Infection Deep Superficial
10 (12) 8 (9) 2 (2)
14 (16)
temporarily in 24 cases and internal fixation in 25 cases. The management of 15 cases involved K-wires, of 13 involved screws and of one a Steinman pin. The mean duration of follow-up was 32 months. Twenty-two cases required a secondary arthrodesis or another additional procedure. AVN occurred in 22 cases. Nineteen patients developed radiographic evidence of osteoarthritis, this being clinically significant in 14 patients. Ten cases were complicated by infection; eight with deep infections involving the ankle joint, and two with superficial wound infections. Sufficient information about outcome to allow stratification according to our criteria listed above was reported in only 51 of the 83 cases. Of these 51 cases, 18 (35%) achieved good outcomes, 19 (37%) fair outcomes and 14 (27%) poor outcomes. Isolated Total Talar Dislocation We also analyzed total talar dislocation with no associated fractures of the talus, foot, or ankle, for which we used the term “isolated total talar dislocation” (see Table 2). Some case series included both cases of isolated dislocation and fracturedislocations and did not separate the outcome data for these two groups. We therefore did not include these cases of isolated total talar dislocation in this separate analysis, leaving 29 cases of isolated dislocation available for analysis. Twenty-one of these dislocations were open and eight closed. Closed reduction was achieved in two cases whereas 27 required open reduction. Ten cases were managed using internal fixation and ten with external fixation. Eight cases of isolated total talar dislocation required a secondary arthrodesis, or another palliative procedure because of pain, instability or deformity. AVN
TABLE 2 Summary of data for 29 cases of isolated total talar dislocations (cases [%]) Type of dislocation
Reduction
Open (n = 21)
Open
Closed (n = 8)
Closed
Fixation
Complications
27 (93)
Internal fixation K-wires Screws Pins
10 (34) 4 (14) 3 (10) 1 (3)
Avascular necrosis Radiographic osteoarthritis Clinical osteoarthritis
7 (24) 6 (21) 3 (10)
2 (7)
External fixation Arthrodesis
10 (34) 8 (28)
Infection Deep Superficial
3 (10) 3 (10) 0 (0)
99 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
Total Talar Dislocation
TABLE 3 Summary of data for 12 cases managed by primary talectomy (cases [%]) Type of dislocation Open (n = 12)
Closed (n = 0)
Reduction Open
Closed
4 (33.3)
4 (33.3)
Fixation
Complications
Primary arthrodesis Tibiocalcaneal pseudoarthrosis
9 (75) 2 (16.7)
Talar prosthesis with total ankle arthroplasty
1 (8.3)
External fixation Secondary salvage procedure
9 (75) 3 (25)
occurred in seven cases. At final follow-up, radiographic evidence of osteoarthritis was noted in six cases, three of whom reported clinically significant osteoarthritis. Sufficient information about outcome to allow stratification according to our criteria was available for 25 cases of isolated talar dislocation. Of these 25 cases, nine achieved good outcomes, eight fair outcomes and eight poor outcomes. Total Dislocation of the Talus with Associated Fracture As mentioned above, cases of total talar dislocation with and without associated fractures of talus and adjacent bones were included in several of the case series reviewed; however, the authors did not provide separate data for outcome and complications for these two groups1,19–21. Therefore, we were unable to accurately analyze data on the specific subset of fracturedislocation of the talus. Primary Talectomy Twelve of the reviewed cases were treated by primary talectomy (see Table 3), meaning that the talus was not reimplanted or preserved in the original surgical management. In several cases, this was because the talus had been completely extruded during the initial trauma and not recovered14,15,22. In other cases, the talus was discarded because of concerns regarding contamination or comminution9,16,23–25. All 12 of these cases involved open injuries and four had talar fractures. External fixation was utilized to temporarily maintain leg length and alignment in nine cases. The strategies used for initial management (following appropriate wound care) included the following: primary arthrodesis with or without bone graft (nine cases), primary talectomy without reconstruction or arthrodesis leading to tibiocalcaneal pseudoarthrosis (two cases)23,25 and talar prosthesis and total ankle arthroplasty (one case)22. Three cases required a secondary salvage procedure. In two of these cases, the original arthrodesis had failed to unite and had to be revised9,24. In the third case, the patient had developed a varus heel deformity requiring a calcaneal osteotomy9. One patient who had been managed by creation of a tibiocalcaneal pseudoarthrosis developed degenerative arthritis of the ankle. Two of the 12 cases managed with primary talectomy were complicated by infection. Avascular Necrosis The complication of AVN occurred in 22 cases of the reviewed cases. On the basis of the information provided, we
Avascular necrosis Radiographic evidence of Osteoarthritis Clinical osteoarthritis
0 (0) 1 (8.3)
Infection Deep Superficial
2 (16.7) 2 (16.7) 0 (0)
1 (8.3)
know that at least 13 of the 22 cases of AVN had no associated talar fracture. As stated above, in all 29 of the reviewed cases of talar dislocation had no associated fracture. AVN developed in seven of these 29 cases of isolated talar dislocation, yielding a 24% incidence of AVN in this subgroup, which is comparable to the 26% incidence of AVN in all reviewed cases of total talar dislocation. Three of the 22 cases of AVN were complicated by infection (two deep and one superficial infection). Discussion he talus consists of a head, neck and body and is situated deep in the hindfoot (see Fig. 1). It is bordered by the tibial plafond superiorly, the calcaneus inferiorly, the medial malleolus medially, the lateral malleolus laterally and the naviculus anteriorly1,13,26. The entire weight of the body is transferred from the tibia to the talus and thus distributed to the hindfoot. The talus forms three joints—the tibial-talar joint, which allows dorsi- and plantar-flexion, the talo-navicular joint, which allows adduction/abduction, and the talocalcaneal joint, which allows inversion/eversion10,12,13. Together, these joints allow for pronation (plantar flexion, eversion, and abduction) and supination (dorsi flexion, inversion, and adduction) of the ankle. Because of its numerous articulations, over 60% of the talus is covered by hyaline articular cartilage and ligamentous attachments, leaving a limited surface area for its blood supply12,13,26–29. The talar neck and head are supplied by branches of the dorsalis pedis artery and anastomoses from the peroneal arteries (see Fig. 1). The talar body is supplied inferiorly by the tarsal canal and sinus tarsi arteries, which are formed by anastomoses between the posterior tibial artery and the perforating branch of the peroneal artery26,30. Superiorly, the talar body is supplied by the deltoid artery, which is formed by anastomoses between the posterior tibial and dorsalis pedis arteries12. This tenuous blood supply is easily disrupted by dislocation of the talus, potentially leading to AVN, especially if the post-operative course is complicated by infection20,26. Fractures complicate dislocation of the talus by further disrupting the blood supply. The majority of talar fractures are intra-articular, contributing to the risk for osteoarthritis. In addition, 97% of the cases in our review were open injuries and therefore at great risk of infection.
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100 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
Total Talar Dislocation
Fig. 1 Position and blood supply of the talus.
Historically, total talar dislocation has been managed by primary talectomy and tibiocalcaneal arthrodesis with the aim of mitigating the risk of the complications described above2. However, the results of our review suggest that talectomy does not decrease the rate of complications: two of twelve cases of primary talectomy developed infections and three of twelve required a secondary procedure. These ratios are very similar to the overall incidence of infection of 10%, and the 26% of cases that required a salvage procedure. In addition, the functional outcomes of patients managed by primary talectomy were worse than those of the group as a whole, none of the former cases achieving a good outcome. Many of the reviewed articles recommended attempting to preserve the talus, even in cases of total extrusion with significant contamination, preservation having a better chance for a good outcome and a similar risk of complications3,31–38. We defined isolated total talar dislocation as dislocation from all three articulations of the talus without associated fractures of the talus or adjacent bones39,40. Not surprisingly, the occurrence of open injury and the need for open reduction were slightly lower in this subgroup (see Tables 1 and 2). At 24% and 26%, respectively, the rate of AVN associated with isolated total talar dislocation was comparable to that for all cases of talar dislocation. However, at 10% the rate of clinically significant osteoarthritis in patients with isolated talar dislocation was somewhat lower than the 16% incidence for all cases of total talar dislocation. Overall outcomes for isolated total talar dislocation were quite similar to those of the group as a whole (compare Tables 1 and 2). Avascular necrosis of the talus is the most feared complication of total talar dislocation2,41, often resulting in poor outcomes and the need for arthrodesis. Other authors have reported that infection20 and fractures of the talus (especially Hawkins type III/IV fractures) both increase the risk of
AVN1,12,20. However, our review shows that at least 59% of cases of AVN occurred in injuries with no associated talar fracture and that only 14% of cases of AVN were complicated by postoperative infection. These results suggest that clinicians should maintain a high index of suspicion for AVN even in the absence of fracture or infection. This study has several limitations, which should be acknowledged. Because of the low incidence of talar dislocation, all of the articles reviewed were either case studies or case series with no controls. In addition, we were limited by the varying amounts of information reported by different authors. For example, some authors reported outcomes using the American Orthopaedic Foot and Ankle Society anklehindfoot scale, but many only commented on pain, range of movement and ability to return to usual activities. Some authors gave details of surgical approach, fixation methods, weight-bearing status and rehabilitation, whereas others gave only general information regarding treatment. This paper is limited by the broad nature of this topic and the information presented is generalized as a result. In addition, some of our data are based on analysis of a combination of patients with isolated talar dislocation and with fracturedislocations of the talus and dislocations of the talus with fractures of surrounding bones. That these are not equal injuries this may limit the generalizability of our data. Lastly, PubMed was the only database used to collect data on total talar dislocation. Conclusion ur review supports the modern approach of immediate reduction and fixation of total talar dislocation. Preservation of the talus achieves a better ratio of good, fair, and poor outcomes than primary talectomy, with similar rates of infection and need for secondary procedures. AVN is still a relatively
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101 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
common complication even in the absence of talar fracture or postoperative infection. Therefore, we recommend clinicians maintain a high index of suspicion for this complication even when fracture and postoperative infection are not present.
Total Talar Dislocation
Acknowledgements Special thanks to Nathan Elkins (Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA) for assistance with the figure drawing.
References 1. Burston JL, Isenegger P, Zellweger R. Open total talus dislocation: clinical and functional outcomes: a case series. J Trauma, 2010, 68: 1453–1458. 2. Detenbeck LC, Kelly PJ. Total dislocation of the talus. J Bone Joint Surg Am, 1969, 51: 283–288. 3. Fujii T, Yajima H, Tanaka Y, Takakura Y. Total talar dislocation and fracture treated with a vascularized bone graft: a case report. Foot Ankle Int, 2004, 25: 159–163. 4. Heylen S, De Baets T, Verstraete P. Closed total talus dislocation: a case report. Acta Orthop Belg, 2011, 77: 838–842. 5. Lee J, Hamilton G. Complete talar extrusion: a case report. J Foot Ankle Surg, 2009, 48: 372–375. 6. Segal D, Wasilewski S. Total dislocation of the talus. Case report. J Bone Joint Surg Am, 1980, 62: 1370–1372. 7. Pavic´ R. Talocalcaneal transfixation in total dislocation of the talus and subtalar dislocations. Mil Med, 2009, 174: 324–327. 8. Sayegh FE, Nikolaides AP, Anagnostidis KS, Kapetanos GA. Simultaneous bilateral fracture-dislocation of the talus: a case report. Foot (Edinb), 2009, 19: 125–129. 9. Jaffe KA, Conlan TK, Sardis L, Meyer RD. Traumatic talectomy without fracture: four case reports and review of the literature. Foot Ankle Int, 1995, 16: 583–587. 10. Kleiger B. Injuries of the talus and its joints. Clin Orthop Relat Res, 1976, 121: 243–262. 11. Pereles TR, Koval KJ, Feldman DS. Fracture-dislocation of the neck of the talus in a ten-year-old child: a case report and review of the literature. Bull Hosp Jt Dis, 1996, 55: 88–91. 12. Rammelt S, Zwipp H. Talar neck and body fractures. Injury, 2009, 40: 120–135. 13. Wagner R, Blattert TR, Weckbach A. Talar dislocations. Injury, 2004, 35 (Suppl 2): SB36–SB45. 14. Joshi AK, Joshi C, Singh S, Singh V. Traumatic loss of talus: a rare injury. Foot (Edinb), 2012, 22: 319–321. 15. Koller H, Assuncao A, Kolb K, Holz U. Reconstructive surgery for complete talus extrusion using the sandwich block arthrodesis: a report of 2 cases. J Foot Ankle Surg, 2007, 46: 493–498. 16. Schuberth JM, Jennings MM. Reconstruction of the extruded talus with large allograft interfaces: a report of 3 cases. J Foot Ankle Surg, 2008, 47: 476–482. 17. Turhan Y, Cift H, Ozkan K, Ozkut A, Eren A. Closed total talar extrusion after ankle sprain. Foot Ankle Spec, 2012, 5: 51–53. 18. Van Opstal N, Vandeputte G. Traumatic talus extrusion: case reports and literature review. Acta Orthop Belg, 2009, 75: 699–704. 19. Garofalo R, Moretti B, Ortolano V, et al. Peritalar dislocations: a retrospective study of 18 cases. J Foot Ankle Surg, 2004, 43: 166–172. 20. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the talus. J Orthop Trauma, 1995, 9: 371–376. 21. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations. Long-term results. J Bone Joint Surg Am, 1995, 77: 1075–1079.
22. Magnan B, Facci E, Bartolozzi P. Traumatic loss of the talus treated with a talar body prosthesis and total ankle arthroplasty. A case report. J Bone Joint Surg Am, 2004, 86: 1778–1782. 23. Maris JS, Theodoratos G, Papanikolaou A. Primary talectomy after open total dislocation of the talus: a case report with 13 years follow-up. J Orthop Trauma, 2006, 20: 223–226. 24. Montoli C, De Pietri M, Barbieri S, D’Angelo F. Total extrusion of the talus: a case report. J Foot Ankle Surg, 2004, 43: 321–326. 25. Papaioannou NA, Kokoroghiannis CG, Karachalios GG. Traumatic extrusion of the talus (missing talus). Foot Ankle Int, 1998, 19: 590–593. 26. 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: 120–123. 27. Burston JL, Brankov B, Zellweger R. Reimplantation of a completely extruded talus 8 days following injury: a case report. J Foot Ankle Surg, 2011, 50: 104–107. 28. Citak M, Koulalis D, Haentjes J, et al. Complete dislocation of the talus: a case report using intraoperative 3D fluoroscopy. Technol Health Care, 2010, 18: 123–128. 29. Ely EE, Konstantakos EK, Laughlin RT, Johnson RM, Binski JC. Total dislocation of the talus and the navicular: a case report. J Orthop Trauma, 2009, 23: 546–549. 30. Katz BE, Yang E. Complete closed posterior talus dislocation without fracture. Orthopedics, 2000, 23: 846–848. 31. Apostle KL, Umran T, Penner MJ. Reimplantation of a totally extruded talus: a case report. J Bone Joint Surg Am, 2010, 92: 1661–1665. 32. Assal M, Stern R. Total extrusion of the talus. A case report. J Bone Joint Surg Am, 2004, 86: 2726–2731. 33. Brewster NT, Maffulli N. Reimplantation of the totally extruded talus. J Orthop Trauma, 1997, 11: 42–45. 34. Fleming J, Hurley KK. Total talar extrusion: a case report. J Foot Ankle Surg, 2009, 48: 690. e19–e23. 35. Gerken N, Yalamanchili R, Yalamanchili S, Penagaluru P, Md EM, Cox G. Talar revascularization after a complete talar extrusion. J Orthop Trauma, 2011, 25: e107–e110. 36. Giannini S, Vannini F, Lisignoli G, Facchini A. Traumatic extrusion of the talus-delayed re-implantation with autologous bone marrow mononuclear cell addition: a case report. Foot Ankle Int, 2008, 29: 101–104. 37. 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: 172–175. 38. Vaienti L, Maggi F, Gazzola R, Lanzani E. Therapeutic management of complicated talar extrusion: literature review and case report. J Orthop Traumatol, 2011, 12: 61–64. 39. Gursu S, Sahin V, Demir B, Yildirim T. Closed total dislocation of talus without any accompanying fractures. J Am Podiatr Med Assoc, 2013, 103: 73–75. 40. Taymaz A, Gunal I. Complete dislocation of the talus unaccompanied by fracture. J Foot Ankle Surg, 2005, 44: 156–158. 41. El Ibrahimi A, Shimi M, Elidrissi M, Daoudi A, Elmrini A. A case of closed total dislocation of talus and literature review. Am J Emerg Med, 2011, 29: 475. e1–e3.
REVIEW ARTICLE
A Systematic Review of Total Dislocation of the Talus John T. Weston, MD, Xiaochen Liu, BS, Meghan E Wandtke, MS, Jiayong Liu, MD, Nabil E Ebraheim, MD Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
This review summarizes the treatment and resulting outcomes for total talar dislocation. The PubMed database was searched for articles about humans with total talar dislocation published in the English language in the last twenty years. The following data were entered into a Microsoft Excel spreadsheet: type of dislocation, nature of associated fractures (if any), type of reduction/fixation utilized, immobilization, weight-bearing status, outcome, complications and average follow-up time. Thirty-nine articles reporting a total of 86 cases of total talar dislocation are included in this review. Seventy-three of these were open injuries and 13 closed. Forty-three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. The talus was preserved in the initial management of 74 cases, whereas the remaining 12 cases were managed by primary talectomy. The mean duration of follow-up was 32 months. Twenty-two cases required a secondary arthrodesis or another additional procedure. A good outcome was achieved in 35% of cases, a fair outcome in 37% and a poor outcome in 27%. The complication of avascular necrosis (AVN) occurred in 22 cases and 14 subjects developed clinically significant osteoarthritis. Generally, the outcome of current treatments associated with total talar dislocation is not ideal, only 1/3 of cases achieving good outcomes. So far, preservation of the talus is the best treatment option. AVN is still a relatively common complication even in the absence of fracture or postoperative infection.
Key words: Avascular necrosis; Dislocation; Fracture; Talar; Talus
Introduction otal talar dislocation is defined as dislocation of the talus from the tibiotalar, talocalcaneal and talonavicular joints1,2. It most commonly occurs secondary to a high-energy impact to an inverted, plantar-flexed foot1,3–6. Total dislocation of the talus is a rare injury that is thought to account for only 0.06% of all dislocations and only 2% of talar injuries7. It is usually the result of high-energy trauma such as a fall from a height or motor vehicle accident1,8. Because of the limited blood supply of the talus, its numerous articulations and the frequency of open injuries, dislocations of the talus are difficult to repair and are often associated with complications, including avascular necrosis (AVN), infection and osteoarthritis2,9–13. Numerous techniques have been used to repair total talar dislocations, ranging from primary talectomy with arthrodesis2,14–16, to immediate reduction and fixation,
T
even in the case of total talar extrusion1,8,12,13,17,18. To our knowledge there have been no systematic reviews of dislocations of the talus to date, published reports being limited to case reports and small case series. The purpose of this review was to summarize data about this rare injury, treatment approaches and related outcomes. Materials and Methods sing the PubMed database, we conducted an electronic search of articles about humans published in the English language within the last twenty years. We used the search terms “talar dislocation” and “talus” as a simple text search with the filters listed above. We included case reports of total talar dislocation with and without associated fractures of the talus, foot, and ankle in this review. The exclusion criteria for this review were as follows: chronic talar dislocation, pediatric
U
Address for correspondence Jiayong Liu, MD, Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA, 3065 Arlington Avenue, Toledo, Ohio, USA 43614 Tel: 001-419-3835361; Fax: 001-419-3833526; Email: [email protected] Disclosure: The authors declare that they have no conflicts of interest. No benefits in any form have been, or will be, received from any commercial party related directly or indirectly to the subject of this article. Received 5 August 2014; accepted 3 March 2015
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Orthopaedic Surgery 2015;7:97–101 • DOI: 10.1111/os.12167
98 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
Total Talar Dislocation
TABLE 1 Summary of data for 86 cases of total talar dislocation (cases [%]) Type of dislocation Open (n = 73)
Closed (n = 13)
Fractures Any associated fracture
Talus fracture
Reduction 43 (50)
32 (37)
Open
83 (97)
Closed
cases and case series in which data for cases of total talar dislocation were grouped with data for other types of talar dislocation. We classified abstracts as definitely include, unsure or definitely exclude and reassessed those classified as unsure once the full text of the article was available. We entered the following data from the included cases into a Microsoft Excel spreadsheet: type of dislocation, nature of fractures (if any), type of reduction/fixation utilized, immobilization, weightbearing status, outcome and complications. Statistical analysis of the variables above was done by calculating percentages in Microsoft Excel. Because the information reported about patient outcomes was highly variable, we established the following criteria for categorizing the outcomes: good = full weightbearing with near full range of motion, minimal pain, and minimal activity restriction; fair = full weight-bearing with moderate restriction of activity because of restricted range of motion or pain; poor = partial weight-bearing or severe restriction of activity caused by pain, or pain/instability that was so severe it required arthrodesis or another corrective procedure. Results e included 39 articles reporting a total of 86 cases of total talar dislocation in this review (see Table 1). Seventy-three of these were open injuries and 13 closed1. Forty-three cases had an associated foot or ankle fracture, 32 of those cases specifically having a fracture of the talus. Closed reduction was performed in only three cases, the remaining 83 requiring open reduction. An external fixator was used at least
W
Fixation
3 (3)
Complications
Internal fixation K-wires
25 (29) 15 (17)
Screws Pins
13 (15) 1 (1)
External fixation
24 (28)
Arthrodesis
22 (26)
Avascular necrosis Radiographic evidence of osteoarthritis Clinical osteoarthritis
22 (26) 19 (22)
Infection Deep Superficial
10 (12) 8 (9) 2 (2)
14 (16)
temporarily in 24 cases and internal fixation in 25 cases. The management of 15 cases involved K-wires, of 13 involved screws and of one a Steinman pin. The mean duration of follow-up was 32 months. Twenty-two cases required a secondary arthrodesis or another additional procedure. AVN occurred in 22 cases. Nineteen patients developed radiographic evidence of osteoarthritis, this being clinically significant in 14 patients. Ten cases were complicated by infection; eight with deep infections involving the ankle joint, and two with superficial wound infections. Sufficient information about outcome to allow stratification according to our criteria listed above was reported in only 51 of the 83 cases. Of these 51 cases, 18 (35%) achieved good outcomes, 19 (37%) fair outcomes and 14 (27%) poor outcomes. Isolated Total Talar Dislocation We also analyzed total talar dislocation with no associated fractures of the talus, foot, or ankle, for which we used the term “isolated total talar dislocation” (see Table 2). Some case series included both cases of isolated dislocation and fracturedislocations and did not separate the outcome data for these two groups. We therefore did not include these cases of isolated total talar dislocation in this separate analysis, leaving 29 cases of isolated dislocation available for analysis. Twenty-one of these dislocations were open and eight closed. Closed reduction was achieved in two cases whereas 27 required open reduction. Ten cases were managed using internal fixation and ten with external fixation. Eight cases of isolated total talar dislocation required a secondary arthrodesis, or another palliative procedure because of pain, instability or deformity. AVN
TABLE 2 Summary of data for 29 cases of isolated total talar dislocations (cases [%]) Type of dislocation
Reduction
Open (n = 21)
Open
Closed (n = 8)
Closed
Fixation
Complications
27 (93)
Internal fixation K-wires Screws Pins
10 (34) 4 (14) 3 (10) 1 (3)
Avascular necrosis Radiographic osteoarthritis Clinical osteoarthritis
7 (24) 6 (21) 3 (10)
2 (7)
External fixation Arthrodesis
10 (34) 8 (28)
Infection Deep Superficial
3 (10) 3 (10) 0 (0)
99 Orthopaedic Surgery Volume 7 · Number 2 · May, 2015
Total Talar Dislocation
TABLE 3 Summary of data for 12 cases managed by primary talectomy (cases [%]) Type of dislocation Open (n = 12)
Closed (n = 0)
Reduction Open
Closed
4 (33.3)
4 (33.3)
Fixation
Complications
Primary arthrodesis Tibiocalcaneal pseudoarthrosis
9 (75) 2 (16.7)
Talar prosthesis with total ankle arthroplasty
1 (8.3)
External fixation Secondary salvage procedure
9 (75) 3 (25)
occurred in seven cases. At final follow-up, radiographic evidence of osteoarthritis was noted in six cases, three of whom reported clinically significant osteoarthritis. Sufficient information about outcome to allow stratification according to our criteria was available for 25 cases of isolated talar dislocation. Of these 25 cases, nine achieved good outcomes, eight fair outcomes and eight poor outcomes. Total Dislocation of the Talus with Associated Fracture As mentioned above, cases of total talar dislocation with and without associated fractures of talus and adjacent bones were included in several of the case series reviewed; however, the authors did not provide separate data for outcome and complications for these two groups1,19–21. Therefore, we were unable to accurately analyze data on the specific subset of fracturedislocation of the talus. Primary Talectomy Twelve of the reviewed cases were treated by primary talectomy (see Table 3), meaning that the talus was not reimplanted or preserved in the original surgical management. In several cases, this was because the talus had been completely extruded during the initial trauma and not recovered14,15,22. In other cases, the talus was discarded because of concerns regarding contamination or comminution9,16,23–25. All 12 of these cases involved open injuries and four had talar fractures. External fixation was utilized to temporarily maintain leg length and alignment in nine cases. The strategies used for initial management (following appropriate wound care) included the following: primary arthrodesis with or without bone graft (nine cases), primary talectomy without reconstruction or arthrodesis leading to tibiocalcaneal pseudoarthrosis (two cases)23,25 and talar prosthesis and total ankle arthroplasty (one case)22. Three cases required a secondary salvage procedure. In two of these cases, the original arthrodesis had failed to unite and had to be revised9,24. In the third case, the patient had developed a varus heel deformity requiring a calcaneal osteotomy9. One patient who had been managed by creation of a tibiocalcaneal pseudoarthrosis developed degenerative arthritis of the ankle. Two of the 12 cases managed with primary talectomy were complicated by infection. Avascular Necrosis The complication of AVN occurred in 22 cases of the reviewed cases. On the basis of the information provided, we
Avascular necrosis Radiographic evidence of Osteoarthritis Clinical osteoarthritis
0 (0) 1 (8.3)
Infection Deep Superficial
2 (16.7) 2 (16.7) 0 (0)
1 (8.3)
know that at least 13 of the 22 cases of AVN had no associated talar fracture. As stated above, in all 29 of the reviewed cases of talar dislocation had no associated fracture. AVN developed in seven of these 29 cases of isolated talar dislocation, yielding a 24% incidence of AVN in this subgroup, which is comparable to the 26% incidence of AVN in all reviewed cases of total talar dislocation. Three of the 22 cases of AVN were complicated by infection (two deep and one superficial infection). Discussion he talus consists of a head, neck and body and is situated deep in the hindfoot (see Fig. 1). It is bordered by the tibial plafond superiorly, the calcaneus inferiorly, the medial malleolus medially, the lateral malleolus laterally and the naviculus anteriorly1,13,26. The entire weight of the body is transferred from the tibia to the talus and thus distributed to the hindfoot. The talus forms three joints—the tibial-talar joint, which allows dorsi- and plantar-flexion, the talo-navicular joint, which allows adduction/abduction, and the talocalcaneal joint, which allows inversion/eversion10,12,13. Together, these joints allow for pronation (plantar flexion, eversion, and abduction) and supination (dorsi flexion, inversion, and adduction) of the ankle. Because of its numerous articulations, over 60% of the talus is covered by hyaline articular cartilage and ligamentous attachments, leaving a limited surface area for its blood supply12,13,26–29. The talar neck and head are supplied by branches of the dorsalis pedis artery and anastomoses from the peroneal arteries (see Fig. 1). The talar body is supplied inferiorly by the tarsal canal and sinus tarsi arteries, which are formed by anastomoses between the posterior tibial artery and the perforating branch of the peroneal artery26,30. Superiorly, the talar body is supplied by the deltoid artery, which is formed by anastomoses between the posterior tibial and dorsalis pedis arteries12. This tenuous blood supply is easily disrupted by dislocation of the talus, potentially leading to AVN, especially if the post-operative course is complicated by infection20,26. Fractures complicate dislocation of the talus by further disrupting the blood supply. The majority of talar fractures are intra-articular, contributing to the risk for osteoarthritis. In addition, 97% of the cases in our review were open injuries and therefore at great risk of infection.
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Total Talar Dislocation
Fig. 1 Position and blood supply of the talus.
Historically, total talar dislocation has been managed by primary talectomy and tibiocalcaneal arthrodesis with the aim of mitigating the risk of the complications described above2. However, the results of our review suggest that talectomy does not decrease the rate of complications: two of twelve cases of primary talectomy developed infections and three of twelve required a secondary procedure. These ratios are very similar to the overall incidence of infection of 10%, and the 26% of cases that required a salvage procedure. In addition, the functional outcomes of patients managed by primary talectomy were worse than those of the group as a whole, none of the former cases achieving a good outcome. Many of the reviewed articles recommended attempting to preserve the talus, even in cases of total extrusion with significant contamination, preservation having a better chance for a good outcome and a similar risk of complications3,31–38. We defined isolated total talar dislocation as dislocation from all three articulations of the talus without associated fractures of the talus or adjacent bones39,40. Not surprisingly, the occurrence of open injury and the need for open reduction were slightly lower in this subgroup (see Tables 1 and 2). At 24% and 26%, respectively, the rate of AVN associated with isolated total talar dislocation was comparable to that for all cases of talar dislocation. However, at 10% the rate of clinically significant osteoarthritis in patients with isolated talar dislocation was somewhat lower than the 16% incidence for all cases of total talar dislocation. Overall outcomes for isolated total talar dislocation were quite similar to those of the group as a whole (compare Tables 1 and 2). Avascular necrosis of the talus is the most feared complication of total talar dislocation2,41, often resulting in poor outcomes and the need for arthrodesis. Other authors have reported that infection20 and fractures of the talus (especially Hawkins type III/IV fractures) both increase the risk of
AVN1,12,20. However, our review shows that at least 59% of cases of AVN occurred in injuries with no associated talar fracture and that only 14% of cases of AVN were complicated by postoperative infection. These results suggest that clinicians should maintain a high index of suspicion for AVN even in the absence of fracture or infection. This study has several limitations, which should be acknowledged. Because of the low incidence of talar dislocation, all of the articles reviewed were either case studies or case series with no controls. In addition, we were limited by the varying amounts of information reported by different authors. For example, some authors reported outcomes using the American Orthopaedic Foot and Ankle Society anklehindfoot scale, but many only commented on pain, range of movement and ability to return to usual activities. Some authors gave details of surgical approach, fixation methods, weight-bearing status and rehabilitation, whereas others gave only general information regarding treatment. This paper is limited by the broad nature of this topic and the information presented is generalized as a result. In addition, some of our data are based on analysis of a combination of patients with isolated talar dislocation and with fracturedislocations of the talus and dislocations of the talus with fractures of surrounding bones. That these are not equal injuries this may limit the generalizability of our data. Lastly, PubMed was the only database used to collect data on total talar dislocation. Conclusion ur review supports the modern approach of immediate reduction and fixation of total talar dislocation. Preservation of the talus achieves a better ratio of good, fair, and poor outcomes than primary talectomy, with similar rates of infection and need for secondary procedures. AVN is still a relatively
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common complication even in the absence of talar fracture or postoperative infection. Therefore, we recommend clinicians maintain a high index of suspicion for this complication even when fracture and postoperative infection are not present.
Total Talar Dislocation
Acknowledgements Special thanks to Nathan Elkins (Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio, USA) for assistance with the figure drawing.
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