What is the management of a patient with an open fracture dislocation of the ankle joint with loss of the talus bone?

Management of Open Fracture Dislocation of Ankle with Loss of Talus

Immediate reimplantation of the extruded talus after thorough debridement should be attempted, as this approach yields satisfactory functional outcomes in the majority of cases and preserves bone stock for potential future procedures if complications arise.

Immediate Emergency Management

Initial Wound Care and Debridement

• Perform urgent irrigation and thorough debridement of the wound and all bony fragments within 6 hours of injury to minimize infection risk 1
• Remove all contaminated soft tissues and foreign material during debridement 2, 3
• Clean the extruded talus thoroughly before reimplantation 3

Antibiotic Prophylaxis

• Administer first-generation cephalosporin (cefazolin 2g IV) immediately, ideally within 3 hours of injury 4
• For beta-lactam allergies, use clindamycin 900mg IV or vancomycin 30mg/kg over 120 minutes 4
• Continue antibiotics for maximum 24 hours perioperatively 4

Definitive Surgical Management

Talar Reimplantation Technique

• Reduce and reimplant the talus even if completely extruded from the wound 2, 3
• Stabilize the reimplanted talus using two Steinmann pins placed from the inferior calcaneus, through the talus, into the inferior tibia 2
• Consider supplemental screw osteosynthesis or percutaneous wire transfixation for additional stability 5
• Apply external fixator to stabilize the entire limb and protect soft tissues 2, 6

Ligamentous Repair

• Repair medial and lateral collateral ligaments using wire anchors during the same procedure 6
• Address any syndesmotic disruption if present 1

Rationale for Reimplantation Over Excision

The evidence strongly supports reimplantation despite the severity of injury. In a series of 9 patients with complete talar extrusion, 6 patients (67%) were free of complications with mean AOFAS score of 82.5 at 21-month follow-up 2. Individual case reports demonstrate AOFAS scores of 83 and Kaikkonen scores of 90 at long-term follow-up 3, 6. Excision with or without tibiocalcaneal fusion should be reserved as a salvage procedure only 3.

Expected Complications and Their Management

Common Complications to Anticipate

• Avascular necrosis of the talus occurs in approximately 39% of cases despite optimal management 5
• Peritalar arthrosis develops in approximately 73% of patients with dislocated talar fractures 5
• Infection risk is present but can be minimized with proper debridement and antibiotic prophylaxis 2, 3
• Compartment syndrome of the foot occurs in 9% of cases and requires immediate fasciotomy 5

Monitoring Protocol

• Monitor for signs of infection during the first 2 weeks postoperatively 6
• Assess for skin necrosis, particularly over pressure points from fixation 6
• Serial radiographs to detect early signs of avascular necrosis (Hawkins sign absence at 6-8 weeks indicates compromised vascularity) 5

Critical Pitfalls to Avoid

• Do not discard the extruded talus - reimplantation provides better outcomes than primary excision and preserves bone stock for future salvage procedures if needed 2, 3
• Do not delay surgical intervention - treatment beyond 6 hours significantly increases infection risk 1
• Do not accept inadequate reduction - anatomical reconstruction is crucial, though bony defects may make this challenging in 48% of cases 5
• Do not underestimate associated injuries - 50% of patients with poor outcomes had additional ipsilateral foot or leg injuries that must be addressed 5

Postoperative Management

Immobilization and Weight-Bearing

• Maintain external fixation until soft tissue healing is complete (typically 2 weeks minimum) 6
• Transition to plaster cast immobilization after external fixator removal 6
• Delay weight-bearing until radiographic evidence of healing and soft tissue stability 2

Long-Term Prognosis

Despite optimal management, only 64% of patients achieve excellent results, with 23% achieving good results 1. The presence of multiple injuries and inability to achieve anatomical reconstruction are negative prognostic factors 5. However, even with the risk of catastrophic complications like avascular necrosis, reimplantation ensures adequate bone stock for subsequent arthrodesis if needed 2.