Six-year survival of reimplanted talus after isolated total talar extrusion: a case report | Journal of Medical Case Reports

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Total talus extrusion without fracture is an extremely rare and potentially debilitating injury. Few reports have described it [1, 6, 1113]. 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 [14]. 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. [15], Fleming et al. [16], and Breccia et al. [12] applied only external fixation as the definitive method without talar fixation. Karampinas et al. [1] 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. [2] made the fixation construct using two retrograde Kirschner wires, and Apostle et al. [4] 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 [10], 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 [17]. So, our surgical strategy might be useful.

In talus injury, osteonecrosis and arthritis should always be concerns [

18

]. In the past, immediate tibiocalcaneal arthrodesis was usually favored over reimplantation [

19

21

]. However, sporadic reports of favorable outcomes with reimplantation led to the exploration of reimplantation as a first-line treatment [

22

]. In our patient, for surveillance of osteonecrosis progression, serial MRI was performed at 6 months, 1 year, and 5 years after the injury (Fig. 

3

). Because there was no Hawkins sign, which is the only early sign that can be seen with conventional radiography and that can reliably predict the development of avascular necrosis (AVN) [

23

], at 8 weeks after surgery (Fig. 

5

), we were concerned that the abnormal findings of the first MRI might indicate AVN of the talus. However, the abnormality had disappeared on the 5-year follow-up MRI scan. Based on this finding, and considering that these traumatic injuries tend to affect younger patients [

6

], the confirmative diagnosis and management of AVN should be delayed as long as possible owing to the possibility of revascularization.

Fig. 5

a This plain radiograph obtained at 8 weeks postoperatively did not show the Hawkins sign in the reimplanted talus. b After 24 months, the anterior osteophyte appeared without narrowing at the ankle joint surface. c At the last follow-up at 6 years, the reimplanted talus was well positioned in the ankle joint without avascular necrosis

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.

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