Excision, reimplantation of talus can help reduce infections

Two studies found promise in the extrusion and salvage of the talus as treatment for debilitating injuries.

Issue: January 2005

Treatment of open fractures of the talus has traditionally been complicated by a high incidence of infection, and excision of the talus has been recommended to decrease that risk. Two studies presented at the Orthopaedic Trauma Association 20th Annual Meeting found that a scrupulous surgical technique can decrease the risk of infection while maintaining outcomes. Excision, however, may be warranted in some cases such as a severe soft tissue injury or contamination.

Bradley D. Dresher, MD, of the University of Tennessee Campbell Clinic in Memphis, presented a study that compared the incidence of infection in open talar fractures and dislocations treated with partial or total talectomy vs. those in which the talus was preserved. The study was a retrospective review of injuries treated between November 1999 and December 2003.

The study included 28 patients; there were 25 open fractures and three open dislocations. Eighty-nine percent of patients had additional injuries. Twelve patients had Gustilo type II fractures; five, Gustilo type IIIA; and 11, Gustilo type IIIB. Three patients needed skin grafting for wound closure. Four other patients needed flaps for wound closure.

Treatment began with emergent debridement and irrigation, with antibiotics for all patients. Twenty-four patients then underwent open reduction internal fixation, three had partial talectomies and one a total talectomy. Three of the four talectomies were for type III open fractures.

radiograph
These images show the extruded talus of an 18-year-old male who fell 40 feet in a dirt bike accident. He had an ipsilateral open tibia fracture, midfoot fractures and a medial malleolus fracture but no talus fracture. His talus was completely extruded through a lateral wound. It was safely implanted without evidence of avascular necrosis.

COURTESY OF CARLA S. SMITH

Infections common

Deep infection occurred in five of 28 patients for an incidence of 18%, Dresher said. All five infections occurred in type IIIB open injuries treated with talar preservation for an incidence of 50% in the subgroup. There were two below-knee amputations of infected patients: one at four months and one at six months after injury. There were two delayed talectomies.

Two patients had superficial infections, and no infections occurred in the four talar excisions.

Other complications were common as well, with osteonecrosis occurring in 12 of 28 patients with at least partial talar preservation, for an incidence of 44%. Avascular necrosis (AVN) occurred in all three talar dislocations, and seven of 12 patients with AVN needed additional surgery.

Dresher noted that the 18% incidence of infection is somewhat lower than in previously published studies. The difference may be due to advances in wound care, he said. Although the number of excisions was small, the study showed a trend that excision of the talus might be a good option vs. ORIF, which had a very high infection rate.

ï¿½This study shows an especially high risk of infection in type IIIB open fractures and a trend toward decreased infection with a partial talar or total excision,ï¿½ Dresher said. ï¿½The retrospective nature of this study and relatively small numbers [prevent] any definitive recommendations.ï¿½

Allison Paige Whittle, MD, also at the Campbell Clinic, was the lead author of the study. ï¿½The contaminated injuries are the ones most prone to infections, the type IIIB injuries,ï¿½ she told Orthopedics Today in a phone interview. ï¿½Iï¿½d probably try to preserve a type II and type IIIA, as well, at this point; I would probably not excise it.ï¿½

These figures show injury films and one-year follow-up after fracture dislocation with healing of the fracture and some sclerosis.

COURTESY OF CARLA S. SMITH

Reimplantation

The second study, presented by Carla S. Smith, MD, PhD, of the Orthopedic and Neurosurgical Center of the Cascades in Bend, Oregon, and Harborview Medical Center in Seattle, focused on the reimplantation of extruded tali.

ï¿½Historically, treatment of open talar injuries has been unrewarding,ï¿½ Smith said. ï¿½There are few large series ï¿½ one to date ï¿½ and a recent trend toward successful reimplantation in isolated case studies. The overall 40% infection rate has led several authors to warn against the dangers of reimplantation, largely due to the risk of infection and the sequelae thereof.ï¿½

Researchers retrospectively reviewed 558 talar injuries from a single trauma center and found 27 with documentation of a complete extrusion and reimplantation of the talus or talar body. Nineteen of those achieved a follow-up of greater than one year, with an average of 30 months.

The average age of patients was 36; most of the injuries were from motor vehicle crashes. Six of the injuries were isolated, but 78% had associated injuries, and half of those were either ipsalateral or contralateral foot injuries.

Good functional outcomes

ï¿½The take-home lesson is that if you are very scrupulous and if you preserve viable soft tissue and if you debride very thoroughly, then you can be successful.ï¿½
ï¿½ Carla S. Smith

Smithï¿½s study found a substantially lower infection rate. ï¿½By and large, our study was blunt trauma, and I think [Dresherï¿½s study] included penetrating trauma. Additionally, this difference is likely due to strict adherence to an institutional protocol observing aggressive debridement, soft tissue handling and antibiotic use,ï¿½ Smith told Orthopedics Today in a phone interview.

Of the patients with long-term follow-up, one of 19 had a secondary infection after a fourth operative procedure (calcaneal osteotomy), but the infection was localized in the calcaneus. Patients averaged 1.9 initial procedures and 0.56 secondary procedures. Over half of the 13 patients with available X-ray follow-up had AVN with at least some collapse. Another 23% had osteoarthritis of the subtalar or ankle joint; only three had normal X-rays.

Functional follow-up was available on all patients. All were ambulatory on the affected leg, and there were no late talectomies or amputations. ï¿½The average MFA for these patients was 28.2, and I point out that the average published value for isolated hindfoot injuries is 22 and 9. Overall these patients have functional impairments but they are ambulatory in the injured extremities,ï¿½ Smith said.

Researchers compared the results to previously published studies of talar injuries and determined that reimplantation of the extruded talus is a viable option in appropriate patients.

Whittle said that she would still be cautious with reimplanting the talus in many patients. ï¿½Certainly some people have done it successfully, but I would lean toward not putting it back if it were severely contaminated,ï¿½ she said. ï¿½I would lean toward not reimplanting it in anybody with medical conditions that would predispose to infection like diabetes or peripheral vascular disease or things of that nature, or people that arenï¿½t very functional. I would try to reimplant it more in healthy, younger people with cleaner wounds.ï¿½

Smith said the study showed that the procedure can be done safely. ï¿½Many patients have abnormal radiograms at follow-up, and many need to undergo secondary procedures; however, overall theyï¿½re ambulatory and with comparable MFA and functional scores,ï¿½ she said in her presentation. ï¿½The take-home lesson is that if you are very scrupulous and if you preserve viable soft tissue and if you debride very thoroughly, then you can be successful.ï¿½

For more information:
Whittle AP, Dresher BD, Giel T. Open fractures and dislocations of the talus. #3.
Smith CS, Nork SE, Sangeorzan BJ. The extruded talus: results of reimplantation. #4. Both presented at the Orthopaedic Trauma Association 20th Annual Meeting. Oct. 8-10, 2004. Hollywood, Fla.