Subject: Extruded Talus
Date: Thu, 17 Apr 2003 21:45:18 -0700
From: John Ruth
We have a 20 year old patient who presented today with an open talar neck fracture with complete extrusion of the talar body(laying on the bed next to patients ankle). Wound clean with no significant contamination. Would anyone recommend replacing the talar body with fixation of the neck and pinning of the body to maintain reduction in the mortise or should we discard the body fragment, temporaily ex fix across the ankle and plan to do a tibiocalcaneal fusion when the wound has healed?
Date: Fri, 18 Apr 2003 15:09:55 -0700
From: Muhammad Amin Chinoy
IF i remember correctly, someone did present a case similar to this about a year back, and there was a long dicussion on it. I'm sure the list gurus would be able to guide us to those archives, and may be we could also get a one year followup on this.
Dr. M. Amin Chinoy
Date: Fri, 18 Apr 2003 06:53:58 -0700
From: John T. Ruth
I actually reviewed the previous talus cases. There was a case with an extruded talar body, but the body fragment was lost at the scene of the injury. There was also very little discussion on the subject.
Date: Fri, 18 Apr 2003 07:13:53 -0500
From: Sciadini, Marcus
I have replaced completely extruded open pan-talar dislocations with good results but have no experience with the same situation and an associated talar neck fracture. Although I can't remember the exact reference, I believe there was a lengthy discussion of this at one of the recent OTA meetings with the consensus being to preserve the fragment.
Marcus F. Sciadini, M.D.
Date: Fri, 18 Apr 2003 07:54:10 -0700
Subject: Re: Extruded Talus
About 6 years ago, I had a similar case. A 32 year old manual labourer came to me with the extruded part of the talus in a bottle. The body of the talus was intact. I did a wound debridement and applied a posterior plaster slab. The extruded talus was not replaced. Approximately 4 weeks later after the wound had healed, I did a Blair fusion. A few months ago, I was able to review the patient. Except for difficulty in walking on uneven ground, the patient was satisfied.He continues to work as a manual labourer. I admit this is a single case and one cannot make any conclusions on it, but I do not think there is a large series of such cases.
I will post the pictures of this patient in a few days.
Dr. George Thomas,
Date: Fri, 18 Apr 2003 13:41:14 EDT
In the situation you describe I would be tempted to replace the extruded talus fragment, although recognizing that you are taking risk of major infection.
There are clearly case reports (e.g. 1, 2) of successful re-implantation of both totally extruded talus and totally extruded talus body with talar neck fractures. (One of this site a year ago) People point to those cases and the theoretical appeal to support replacing the fragment.
Marsh has a series (17) of severe talus fracture published in JOT circa 1995. There were several (?3) BKA's, all in patients who developed severe infection after replacement of an extruded talus so he recommended NOT replacing. I think it was 3/?3 where fragments were replaced.
Date: Fri, 18 Apr 2003 19:07 EST
From: Bill Burman
> Marsh has a series (?30) of severe talus fracture published in JBJS circa 1995. There were several (?3) BKA's, all in patients who developed severe infection after replacement of an extruded talus so he recommended NOT replacing.
Here are some links to case reports of successful reimplantation of an extruded talus. you mentioned
However, I find the Marsh series (JOT 1995) you mentioned (which recommends primary talectomy) to be confusing.
There were 18 high energy, severe (Hawkins III or total dislocations) open talar injuries in 17 patients - 12 with talar extrusions. They reimplanted 12. Reimplanted extruded talar bodies had a high infection rate (7/12). The infected cases were frequently associated with poor outcome scores and subsequently treated with talectomy (not BKA).
The authors conclude it would have been better if all the reimplanted extrusion cases had a primary talectomy. They did only one primary talectomy on a non-extruded talus and it got infected. As for the 5 non-infected talar extrusion reimplants, they write:
"Unfortunately, we do not know whether the patients that had replacement of the extruded body and did not develop infection had improved outcome because of the preservation of the talar body."
If you told me I had a nearly 50% chance to save my talus and that the worst thing that could happen to me is that I might lose it later, I think I would opt for a reimplant.
Maybe I am reading this wrong and Larry Marsh or someone else can help correct me.
Date: Sat, 19 Apr 2003 01:26:47 -0700
From: George Thomas
Here are the 6 year follow-up pictures of the pt. with a fracture through the neck of the talus with extrusion for whom I had done a Blair fusion as a secondary procedure. My reasoning:
I would be interested in the long-term (over 5 years) result of reimplantation.
Dr. George Thomas,
Date: Sat, 19 Apr 2003 11:40:28 +0600
From: Alexander Chelnokov
JTR> the mortise or should we discard the body fragment, temporaily ex fix across the ankle and plan to do a tibiocalcaneal fusion when the wound has healed?
To our experience the second option has smooth course and more predictable outcome.
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sat, 19 Apr 2003 13:33:47 -0400
From: James Carr
Hope I am not too late for this... I have written on talus a bunch, reviewed the literature, and treated a fair amount myself- we had about 20+/ year in Virginia. I think its worth the effort to save it. If it gets by without infection, the patient is much better off than some type of salvage (repeat- salvage). To me AVN has always been overated as a problem, at least in our practice life. By that I mean it may give rise to problems later, but worry about that later, and then address specific problems. Use rigid screw fixation, go for aggressive coverage, and if it gets infected, you are then left with talectomy/Blair fusion/etc. Once a talus like this gets infected, its trouble. My preferred salvage is commonly a Syme's amputation, with the exact solution tailored to the individual patient
From: Marsh, J Lawrence
Date: Mon, 21 Apr 2003 08:49:13 -0500
Regarding extruded talus these are unusual injuries so most information must be based on opinion but a little can be learned from reported series, ours and others: the best results follow successful replacement combined with avoiding complications (infection, body collapse and post traumatic arthritis). Unfortunately the worst results are those injuries complicated by infection and the risk is not insignificant and is increased by replacement. Infection leads to extended treatment and our data indicated it compromised the final result. Total dislocation of the talus is dramatic but seems to have less risks and a potentially better outcome than talar neck or body fracture dislocations with extrusion. I would therefore lean toward replacement in younger healthy patients, isolated injuries, short time interval, good skin, little contamination, partial rather than total extrusion, total dislocation vs fracture dislocation. Exactly which combination of the above would lead me to not replace the extruded talus must be individualized. JOT 11, 1997, p 42-48 has a good discussion of the issues. Thanks.
Date: Tue, 22 Apr 2003 15:44:35 -0700
From: Johh Ruth
Thanks Larry, I read your article and it was very informative. This patient's injury involves a fracture of the neck with complete open extrusion of the body fragment. The wound was clean and the reduction good. It was replaced and fixed with 2 PA fully threaded (some medial comminution) cannulated screws. I will let you know what happens.