The Publications Book
The Heidari Publications
94 publications · 23 years of research · click or drag a page corner to turn
Royal College
British Orthopaedic
AO Trauma
Churchill
Limb Recon
Specialist Reg.
Jha S, Atkinson K, McFegan MR, Patel A, Vris A, Heidari N, Parker L, Jeyaseelan LA, Malagelada F.
Category: Ankle; Hindfoot; Trauma Introduction/Purpose: Open talar dislocations with complete or partial extrusion of the talus are rare, high energy injuries associated with major complications including infection, avascular necrosis and post-traumatic arthritis. These are debilitating injuries with significant long-term effects including avascular necrosis and post traumatic arthritis. Functional outcome data in the literature is limited and predominantly consists of case reports and few single centre case series. Historically these injuries have been treated with talectomy and tibiocalcaneal arthrodesis, however there has been a subsequent trend towards debridement and reimplantation with preservation of the extruded talus. Our aim was to evaluate mid-term functional outcomes, assess complication profile and need for secondary surgery in a single-centre series of cases treated with reimplantation. Methods: All talar extrusion injuries presenting between January 2015 and January 2018 were identified from the trauma database search at our major trauma centre. Inclusion criteria was defined as open talar dislocations associated with either complete or partial extrusion of the talus. Case-note review was performed collecting baseline demographic data including age, gender, injury mechanism, associated injuries, Gustilo-Anderson grade, smoking and diabetes status, and method and timing of surgical management. Twelve patients were identified with a mean follow-up of 3 years (minimum 26 months). Primary outcome measure was functional outcome assessed using the Manchester-Oxford Foot Questionnaire (MOxFQ). Results for each of the three domains were converted to a 0-100 scale for comparison. Secondary outcomes included complication rate and all cause re- operation rates Results: Mean age was 37.8 years (17-74 years). Five patients (42%) had total talar extrusion without fracture and 7/12 (58%) sustained fracture-dislocation with partial talar extrusion. All were Gustilo-Anderson grade III. All underwent successful reimplantation with 8/12 (67%) treated with single stage surgery, and 4/12 (33%) in two stages. The mean MOxFQ scores for total talar extrusions versus partial talar extrusions with fracture were 79 (range 9-18) vs 41 (range 0-86) for walking domain, 65 (range 45-80) vs 42 (range 0-90) for pain domain, and 63 (range 38-75) vs 48 (range 19-51) for social domain. One patient (8%) developed avascular necrosis, 3/12 (25%) developed infection and 1/12 (8%) patient eventually required below knee amputation. One (8%) patient underwent secondary surgery fusion for post-traumatic arthritis. Conclusion: Our series demonstrates the serious ramifications of sustaining talar extrusions. Patients who sustain these injuries should expect persistent functional deficit and pain at mid-term follow-up. Functional outcomes are relatively poor. The data demonstrates a trend towards better functional outcomes in patients who have partial extrusion of the talar dome with associated fractures, compared to ligamentous total talar extrusion injuries. The incidence of avascular necrosis, deep infection and secondary surgery in our cohort supports reimplantation as an effective treatment strategy.
What did we look at?
How patients fare in the medium term — pain, walking, return to normal life — after suffering a rare and severe ankle injury called talar extrusion, where the talus (the keystone bone of the ankle) is forced partly or completely out of the foot through the skin. We followed twelve patients treated at a major trauma centre.
Why did we look at it?
Talar extrusion is a high-energy injury (typically a serious car accident or fall from height) and was historically treated by removing the bone and fusing the joint. More recently, surgeons have moved towards cleaning the extruded bone and putting it back — reimplantation — in the hope of preserving more function. The evidence base for this newer approach is small, mostly individual case reports.
What did we find?
All twelve patients underwent successful reimplantation of the talus. Patients with partial extrusions and associated fractures tended to do better in walking, pain and social-life scores than patients whose ligaments had failed completely and the bone had come out cleanly. One patient developed avascular necrosis (loss of blood supply to the bone), three developed infection, and one eventually required below-knee amputation. Most retained their reimplanted talus and avoided fusion in the medium term.
What does this mean for patients?
Talar extrusion remains a serious injury with persistent deficits at mid-term follow-up — patients should be counselled honestly that they will likely have lasting pain and walking limitations. Even so, our results support reimplantation, rather than removal of the bone, as a reasonable treatment approach in most cases. Larger multi-centre studies are still needed to refine which patients benefit most.
Foot & Ankle Orthopaedics 2022. doi:10.1177/2473011421s00266