Total extruded talus is a rare subtype of total dislocation of the talus that involves an open wound without associated fractures. When the talus is completely extruded from the body with or without minimal remnant soft tissue attachments, there is a complete disruption of the talar blood supply and a high risk of vascular compromise. ^, The optimal treatment approach for this injury remains controversial because of its rarity and high incidence of complications, including deep infection, avascular necrosis, and arthrosis. ^,,, Although several recent reports of primary reimplantation for total extruded talus have exhibited good functional outcomes, talar vascularity after reimplantation remains unclear, and the middle- and long-term outcomes are not well understood. ^,,,,,

We present the case of a 30-year-old man who underwent primary talar reimplantation for total extruded talus with a small strand of soft tissue attachments. The patient was followed up for 5 years after reimplantation with clinical evaluation, radiography, and magnetic resonance imaging (MRI) to detect the development of avascular necrosis and revascularization of the talus.

A 30-year-old man sustained a sprain in his right ankle while working at a construction site. The patient was immediately transported to our hospital and treated in the emergency room. Physical examination revealed a 10-cm open wound over the lateral ankle, and the talus was completely extruded through the skin with only a small strand of adipose tissue attached ( Fig. 1 -A). The extruded talus was not associated with significant fracture or cartilage damage. The neurovascular status of the extremity was not compromised. Radiographic examination upon injury revealed total dislocation of the talus without significant associated fractures ( Fig. 1 -B and 1 -C). The patient was administered 1-g cefazolin within 1 h of presentation, with subsequent doses administered every 8 h for 5 days.

Photograph at the time of injury revealed total extruded talus without significant fracture. Fig. 1-B and Fig. 1-C Radiographs at the time of injury.

The patient was transported to the operating room within 2 h of the initial presentation. The extruded talus and open wound were thoroughly irrigated and debrided, and the small strand of adipose tissue attached to the talus was carefully preserved. The talus was reduced through the open wound without difficulty, and the open wound was primarily closed. An external fixator was then applied to stabilize the right ankle with pins in the proximal tibia, and a transosseous pin was applied through the calcaneus ( Fig. 2 -A and 2 -B). The open wound healed uneventfully, and no signs of infection were observed postoperatively. The external fixator was removed 6 weeks after surgery.

and Fig. 2-B Radiographs following emergency surgery revealed that the dislocated talus was reduced. Fig. 2-C and Fig. 2-D Radiographs obtained 5 years after reimplantation revealed no evidence of avascular necrosis of the talus and no evidence of arthrosis around the talus.

The patient began partial weight-bearing 12 weeks after surgery and progressed to full weight-bearing 6 months after surgery. On the final physical examination, the patient exhibited 15° of ankle dorsiflexion, 50° of ankle plantarflexion, 25° of subtalar inversion, and 20° of subtalar eversion. The ankle and subtalar joint were stable. The patient exhibited a return to his preinjury activity level and demonstrated minimal ankle disability. Postoperative radiographic examination performed 5 years after the injury revealed no signs of arthrosis or avascular necrosis of the talus ( Fig. 2 -C and 2 -D). The patient underwent MRI at 3 months, 1 year, and 5 years after injury to monitor the development of avascular necrosis and revascularization of the reimplanted talus. T1-weighted MRI at 3 months after injury revealed normal marrow signal intensity, and fat-suppressed MRI revealed a focal high-signal-intensity area within the talar body, indicating bone marrow edema ( Fig. 3 ). MRI at 1 and 5 years after injury revealed normal bone marrow signal within the talus and no signs of avascular necrosis ( Figs. 4 and 5 ). These findings indicated that the total extruded talus was spared from avascular necrosis and underwent complete revascularization 5 years after reimplantation.

T1-weighted MRI obtained 3 months after reimplantation revealed normal marrow signal intensity. Fig. 3-B Fat-suppressed MRI revealed focal high-signal-intensity area within the talar body, indicating bone marrow edema.

T1-weighted MRI obtained 1 year after reimplantation. Fig. 4-B Short tau inversion recovery (STIR) MRI at 1 year after reimplantation. Both MR images revealed a normal bone marrow signal within the talus and no evidence of avascular necrosis.

T1-weighted MRI obtained 5 years after reimplantation. Fig. 5-B STIR MRI at 5 years after reimplantation. Both MR images revealed a normal bone marrow signal within the talus and no evidence of avascular necrosis.