a 19-year - old man injured his left foot in a motorcycle accident . during the fall , the foot was forcibly twisted .
a clinical examination showed that the foot was supinated and severely contaminated on the anterolateral side .
initial radiographs of the ankle revealed complete absence of the talus and fractures of the lateral malleolus and anterior process of the calcaneus ( fig .
the patient was shifted to the operating room , and wound irrigation and debridement were performed , followed by internal fixation of the lateral malleolus and calcaneus . because of the void created by the absent talus , a temporary antibiotic impregnated polymethyl - methacrylate cement spacer was inserted in the talar space , and a triplanar external fixator was placed across the ankle joint ( fig .
, the extruded talus was found in a trash basket near the site of the accident and was transferred to the hospital . it was heavily contaminated and scratched with soil and rubbish .
we thoroughly cleaned the talus by pulsatile lavage in the operating room , and it was kept frozen . a reverse fasciocutaneous flap from the calf muscle
was used for coverage of a palm - sized soft tissue defect of the anterolateral aspect of the ankle .
the cement spacer was removed 4 months later , and tibiocalcaneal fusion with bone grafts was performed instead of reimplantation of the frozen talus .
we packed the defect tightly with a cancellous bone graft from the anterior superior iliac spine and a frozen allograft of the femoral head .
antibiotic - impregnated cement beads were inserted after removing the bone grafts and aggressive curettage of the talar space .
compressive tibiocalcaneal fusion using an ilizarov external fixator and an additional autogenous iliac bone graft were reperformed ( fig .
3 ) . we achieved fusion 21 months after the injury followed by proximal tibial lengthening with the ilizarov external fixator for the 4 cm leg length discrepancy .
the patient is walking with full weight - bearing without any aids for regular activities of daily living 8 years after the injury .
solid fusion between the tibia , calcaneus , and navicular was observed on a lateral radiograph ( fig .
4 ) . a 45-year - old man sustained a fall from 5 m while rock - climbing .
the patient sustained a pantalar dislocation with a > 10 cm sized transverse open wound on the medial aspect of the ankle ( fig .
initial radiographs showed complete absence of the talus and a tip fracture of both malleoli .
the totally extruded talus was found on site but was severely contaminated with gravel , soil , and mud .
we had anticipated an inevitable avascular necrosis of the talus , as it was completely deprived of a blood supply ; therefore , we planned to perform an initial subtalar fusion expecting revascularization from the calcaneus followed by ankle arthroplasty .
the talus was temporarily fixed using multiple kirschner wires after massive wound debridement and irrigation because of the high risk for infection .
a primary subtalar fusion was performed 4 days later , with reimplantation of the extruded talus and internal fixation with cannulated screws .
6 ) . radiographs taken 6 months after the trauma , showed osteolysis on the distal tibial articular surface and loosening of the screws ( fig .
7 ) . with suspicion of infection , curettage of the talar body was performed and an antibiotic impregnated cement spacer was inserted . however , the biopsy result revealed granulation tissue without significant neutrophil infiltration , with necrotic bone and marrow fibrosis .
the ankle was fused using multiple screws , and a femoral head allograft was used to fill the talar defect 12 months after the trauma .
two years after the injury , the preserved talonavicular joint made mid - foot motion possible and tibio - talar - calcaneal fusion was achieved ( fig .
the patient has had a good functional outcome with the ability to enjoy a 4 hour course of tracking twice per 
 week .
a 19-year - old man injured his left foot in a motorcycle accident . during the fall , the foot was forcibly twisted .
a clinical examination showed that the foot was supinated and severely contaminated on the anterolateral side .
initial radiographs of the ankle revealed complete absence of the talus and fractures of the lateral malleolus and anterior process of the calcaneus ( fig .
the patient was shifted to the operating room , and wound irrigation and debridement were performed , followed by internal fixation of the lateral malleolus and calcaneus . because of the void created by the absent talus , a temporary antibiotic impregnated polymethyl - methacrylate cement spacer was inserted in the talar space , and a triplanar external fixator was placed across the ankle joint ( fig .
, the extruded talus was found in a trash basket near the site of the accident and was transferred to the hospital . it was heavily contaminated and scratched with soil and rubbish .
we thoroughly cleaned the talus by pulsatile lavage in the operating room , and it was kept frozen . a reverse fasciocutaneous flap from the calf muscle
was used for coverage of a palm - sized soft tissue defect of the anterolateral aspect of the ankle .
the cement spacer was removed 4 months later , and tibiocalcaneal fusion with bone grafts was performed instead of reimplantation of the frozen talus .
we packed the defect tightly with a cancellous bone graft from the anterior superior iliac spine and a frozen allograft of the femoral head .
antibiotic - impregnated cement beads were inserted after removing the bone grafts and aggressive curettage of the talar space .
compressive tibiocalcaneal fusion using an ilizarov external fixator and an additional autogenous iliac bone graft were reperformed ( fig .
3 ) . we achieved fusion 21 months after the injury followed by proximal tibial lengthening with the ilizarov external fixator for the 4 cm leg length discrepancy .
the patient is walking with full weight - bearing without any aids for regular activities of daily living 8 years after the injury .
solid fusion between the tibia , calcaneus , and navicular was observed on a lateral radiograph ( fig .
a 45-year - old man sustained a fall from 5 m while rock - climbing .
the patient sustained a pantalar dislocation with a > 10 cm sized transverse open wound on the medial aspect of the ankle ( fig .
initial radiographs showed complete absence of the talus and a tip fracture of both malleoli .
the totally extruded talus was found on site but was severely contaminated with gravel , soil , and mud .
we had anticipated an inevitable avascular necrosis of the talus , as it was completely deprived of a blood supply ; therefore , we planned to perform an initial subtalar fusion expecting revascularization from the calcaneus followed by ankle arthroplasty .
the talus was temporarily fixed using multiple kirschner wires after massive wound debridement and irrigation because of the high risk for infection .
a primary subtalar fusion was performed 4 days later , with reimplantation of the extruded talus and internal fixation with cannulated screws . additional reduction and fixation of the fractured medial malleolus
6 ) . radiographs taken 6 months after the trauma , showed osteolysis on the distal tibial articular surface and loosening of the screws ( fig .
7 ) . with suspicion of infection , curettage of the talar body was performed and an antibiotic impregnated cement spacer was inserted . however , the biopsy result revealed granulation tissue without significant neutrophil infiltration , with necrotic bone and marrow fibrosis .
the ankle was fused using multiple screws , and a femoral head allograft was used to fill the talar defect 12 months after the trauma .
two years after the injury , the preserved talonavicular joint made mid - foot motion possible and tibio - talar - calcaneal fusion was achieved ( fig .
the patient has had a good functional outcome with the ability to enjoy a 4 hour course of tracking twice per 
 week .
a total talar extrusion associated with a high energy injury is rare and is frequently complicated by soft tissue injuries and fractures .
this type of injury is prone to infection , avascular necrosis , secondary arthritis , and poor functional outcome .
there is also controversy about the initial surgical treatment . both primary talectomy and salvage of the talus
have been recommended , but a primary talectomy in cases in which the talus has been extruded through the wound and contaminated has a high likelihood of infection .
smith et al.9 ) and assal and stern1 ) reported that a totally extruded talus should be managed with thorough cleaning and debridement of the wound followed by reimplantation .
if the extruded talus is available and replaced , the survival of the talus probably depends on avoiding infection and avascular necrosis , and the existence of residual soft tissue attachment retaining a blood supply to the talus .
some authors have reported that reimplantation of an extruded talus with some retaining soft tissue attachments has relatively good clinical results.7,8,9 ) however , in cases without any soft tissue attachments , the result of reimplantation of a likely avascular and contaminated talus , which may act as a sequestrum , is questionable .
in contrast , reimplantation and wound closure can make it difficult to perform appropriate wound care that may require debridement and cleaning . only nine cases in six reports have documented complete extrusion of the talus without any soft tissue attachments.1,2,4,5,6,9 ) reimplantations were performed in five of the nine cases , and no subsequent infection or avascular necrosis were detected in the replaced talus . only three cases developed osteoarthritis ( table 1 ) .
these results seem to be contradictory to our conception and are unusually excellent , even compared with those after fractures of the talar body or neck .
the causes of the poorer results were considered failure of infection control in case 1 and progressive bone resorption in case 2 .
palomo - traver et al.7 ) reported that the talus should be replaced unless it is totally extruded or grossly contaminated .
it was suggested that impaired circulation related to trauma of the surrounding vascular and lymphatic structures leads to a nonhealing condition and subsequent infection ; thus , predisposing the patient to acute and chronic bone infection.4,10 ) the cause of infection even after talectomy in case 1 seemed to be the unrepairable , contaminated open wound and the dead space created by the absent talus that made it difficult to control the infection . in case 1 , we were worried about infection , and the talus was not available for reimplantation , whereas the talus in case 2 was contaminated but was available , and we replaced it after a thorough wash .
we expected that avascular necrosis of the talus was inevitable and planned a primary subtalar fusion and revision ankle arthroplasty .
we achieved the subtalar fusion , but had to perform massive debridement for unclearly progressive osteolysis around the ankle joint and then conducted a tibio - talar fusion with an allograft .
we presumed that the repeated debridement and cleaning of the wound prevented the infection , but the cause of osteolysis may have been due to poor viability of the deep frozen talus . both of our patients were treated without initial reimplantation to prevent infection .
nevertheless , they had complications such as infection and unclearly progressive osteolysis and a long period of disability before achieving fusion .
it is a reasonable option to replace an extruded talus as soon as possible after thorough debridement unless the talus is contaminated , because an open wound usually occurs from inside to outside .
 total talar extrusion without a soft tissue attachment is an extremely rare injury and is rarely reported . 
 appropriate treatment remains controversial . 
 we describe the long - term outcomes of two patients who had complete talar extrusion without remaining soft tissue attachment treated with arthrodesis . both of our patients had complications such as infection and progressive osteolysis . 
 we suggest reimplantation of the extruded talus after thorough debridement as soon as possible as a reasonable option unless the talus is contaminated or missing , because an open wound may arise from inside to outside . 
CASE REPORT
Case 1
Case 2
DISCUSSION