Revisional Surgery of Talar and Ankle Fractures

Revisional Surgery of Talar and Ankle Fractures

Crystal L. Ramanujam, John J. Stapleton, Scott E. Sexton


Most fractures of the talus occur because of high-energy trauma, and they are relatively uncommon constituting less than 1% of all fractures.1 Since the talus contributes to 3 essential joints (ankle, subtalar, and midtarsal joints), malunions or nonunions after displaced talar head, neck, or body fractures may cause significant pain, deformity, and disability.2 In addition, since these fractures occur following high-velocity injuries, they are associated with considerable soft tissue damage. Closed injuries may have elements of internal degloving, which increases the risk for wound healing complications and infections. Open talar fractures occur frequently, accounting for 20% to 25% of injuries, with a greater incidence of fracture displacement, and in these cases, urgent surgical debridement is typically undertaken.3

In contrary, due to a growing population with prolonged life expectancy and increased activity levels, ankle fractures account for many of the foot and ankle injuries that occur throughout the United States each year. A large-scale epidemiological study by Scheer et al found that the most common mechanisms of injury were falls (54.83%) and sports (20.76%).4 With increased life expectancy, there has also been a corresponding increase in patients with significant medical comorbidities undergoing open reduction and internal fixation (ORIF) for unstable ankle fractures such as diabetes mellitus, peripheral vascular disease, and chronic obstructive pulmonary disease.5,6 Unfortunately, when surgical intervention is required, reported adverse outcomes for the fixation of ankle fractures have included infection, failure of fixation, amputation, and potentially death.7

Indications and Contraindications

Indications for revisional surgery of talar and ankle fractures include but are not limited to pain, deformity that is not braceable or impedes ability to ambulate in shoe gear, the presence of nonhealing wound(s), nonunion, malunion, painful hardware, hardware failure, and acute or chronic osteomyelitis recalcitrant to conservative treatment methods such as local wound care and antibiotic therapy.

Contraindications for revisional surgery may include the presence of medical comorbidities that preclude optimization for surgical intervention, uncorrectable peripheral arterial disease, poor bone stock that cannot accommodate reconstruction, severe patient noncompliance, and patient’s refusal of reoperation.

Preoperative Considerations

For all patients undergoing revisional surgery for the consequences of talar or ankle fractures, a thorough history and clinical examination is critical for planning in order to determine any medical comorbidities, which may need to be optimized preoperatively, and to investigate any prior surgical intervention(s), which may contribute to the revisional surgical approach. Bilateral standing radiographs and computed tomography scans with 3-dimensional planar reconstructions should be obtained. To assess the amount of avascular necrosis (AVN) of the talar body, magnetic resonance imaging should be performed. Advanced imaging with nuclear bone scans may be useful for determining extent of bone infection and especially helpful with concomitant Charcot neuroarthropathy of the hindfoot/ankle. Noninvasive vascular testing including ankle brachial indices, toe brachial indices, and Doppler ultrasound with segmental pressures for the lower extremities should be performed in patients with risk of vascular impairment such as those with diabetes mellitus, smoking history, and cardiovascular disease. Vascular surgical consultation may be warranted if evidence of arterial occlusive disease is found. In addition, the patient’s ability to maintain compliance for the postoperative period must be assessed thoroughly during preoperative planning, so that both the patient’s and surgeon’s expectations are clearly discussed and agreed upon.

Figure 25.1 Preoperative radiographic (A and B) views demonstrating a left foot comminuted open peritalar fracture and dislocation of a patient who was transferred from an outside facility with bilateral lower extremity injuries and a contralateral right closed distal tibia pilon fracture. Patient underwent an initial surgical debridement of the left foot open talar fracture with reduction and percutaneous pinning (C) with a closed reduction and splint application of the right pilon fracture. The patient returned to the operating room for a planned staged surgical debridement and delayed primary closure of the left foot surgical wound with an open reduction and internal fixation of the contralateral distal tibia pilon fracture. The retained left foot Steinmann pins were used for definitive fixation as further surgical incision placement(s) to perform an open reduction and internal fixation of the talus was not feasible due to compromised soft tissue envelope. The Steinmann pins were removed at 10 weeks and the patient progressed to a weight-bearing status with a high-tide walking boot for an additional 6 weeks. The patient had continued pain to the left lower extremity as a result of a nonunion of the posterior talus body fracture and posttraumatic arthritis of the subtalar joint (D and E). Patient elected for revisional surgery that consisted of excision of the nonunited posterior talus body fracture fragment which was morselized and utilized for autogenous bone graft and subtalar joint arthrodesis that was performed through a posterior lateral approach (F). The patient was kept non–weight-bearing for 8 weeks then progressed to weight-bearing status as tolerated in a high-tide walking boot for an additional 4 weeks before returning to regular shoe gear. Radiographs at 6 months postoperatively demonstrate successful subtalar joint arthrodesis and alignment (G and H).

Figure 25.2 Preoperative radiographic (A and B) views of a diabetic patient with a high energy open talus and ankle fracture and dislocation that was transferred from an outside facility after an initial surgical debridement and lower extremity spanning external fixation application. Patient underwent a revisional excisional debridement and open reduction of the talus and ankle fractures with external fixation modification which was supplemented with transarticular pin fixation (C and D). Eight weeks later, the spanning external fixator and transarticular pins were removed. Seventeen weeks postoperatively, the patient presented with a cutaneous draining sinus and signs of deep infection. The talar fracture was united but with avascular necrosis, collapse, and evident signs of deep infection of the retained hardware (E and F). Patient underwent a revisional excisional debridement, hardware removal with intraoperative bone and soft tissue cultures to guide parenteral intravenous antibiotic therapy. Five days later, the patient underwent a total talectomy with tibiocalcaneal arthrodesis and application of a multiplane circular external fixator (G-J). The circular external fixator was removed at 4 months postoperatively and the patient was transitioned into a walking cast for 6 weeks. Final postoperative radiographic (K and L) views demonstrating a successful tibiocalcaneal arthrodesis at 14 months follow-up.

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Oct 22, 2022 | Posted by in ORTHOPEDIC | Comments Off on Revisional Surgery of Talar and Ankle Fractures
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