Misplaced Talus Fracture

[verslickity]

I have arthritis and AVN of my talus.  The bone healed after it was reduced, but I am barely able to walk now, 2 yrs after I was in a bad car accident.  My foot has turned inwards, putting most my weight on the outer edge of my foot.  My doctor suggests fusion of the joint.  Is there any other treatment that could be more helpful to my mobility?

[DrNavneetMD]

Hello Dear,

The goal of treating fractures of the talus is to maximize the movement of the ankle and subtalar joints, restore the anatomic dimensions of the bone and prevent arthritis of either of the above joints. This is not easy because of the magnitude of the fracture that commonly occurs in the most serious injuries. Arthritis may develop, or even worse, there may be a loss of blood supply to the bone – a condition called avascular necrosis of the talus. This loss of blood supply is one of the more devastating problems associated with fractures of the talus. In order for the bone to survive and heal after a fracture, it needs blood circulation. One of the problems commonly associated with certain severe fractures of the talus is that the blood circulation to this bone is damaged, leading to partial death of the Bone.
Treatment of fractures of the talus is quite varied. This ranges from immobilization of the foot in a cast or boot to surgery. If surgery is performed it is usually done with incisions and then the bone is put back together with a procedure called open reduction and internal fixation. Pins or screws are used to reduce and hold the bone in place. There are surgical procedures that can be performed if avascular necrosis develops to try to improve the blood circulation to the talus bone. Traditionally, when arthritis of the ankle joint occurs after AVN and talus fracture, a fusion of the ankle has been recommended. This fusion is a complicated operation, and the results of the fusion are not always predictable. For this reason, alternative treatments are desirable. In particular, instead of the fusion of both the ankle and the subtalar joint, following a fusion of the subtalar joint, an ankle joint replacement can be performed.

The problem with AVN of the talus, is that blood supply does not always return, and there are very few ways to improve the circulation to the talus.

1.Fusion of the ankle. This consists of “gluing” the ankle together and limits the up and down range of motion permanently. The fusion is not easy to accomplish, and the success rate of this type of surgery can be unpredictable.

2. Total ankle replacement. Total ankle replacement is now an accepted treatment for ankle arthritis, but cannot always be performed if AVN is present. The ankle replacement must have a good bone to sit on, and if the AVN is extensive, it cannot be performed. If a fusion of the subtalar joint is performed first, there is often sufficient bone underneath the talus then to support the ankle prosthesis.

3. Drilling of the talus. There is a lot of evidence that by creating a hole with either a drill or a device that looks like a kitchen tool used to core an apple, that the blood supply to the talus can be increased. The drilling creates little holes and channels that allow tiny little blood vessels to grow and improve the blood supply to the talus.

4. Muscle flap. All muscle has a blood supply to it in order to stay alive. This is a new procedure, and with the short term follow up of these patients, the results seem to be good.

5. Free vascularized bone graft. It is possible to take a tiny blood vessel attached to a piece of bone and using the microscope, transplant this into the talus.

Refer http://www.arthritis-treatment-and-relief.com/avascular-necrosis-talus-treatment.html

Best

[jensmccabe]

I had a similar issue post Hawkins IV talar-fx due to an MVA. My doctor and I treated the deformity (turning inwards) with a calcaneal osteotomy (literally cutting through heel bone, moving it into different position, securing with screws).

This has helped significantly with mobility and reduced the deformity, at least for a time. My doctor and I did discuss that as a result of difference in load/weight-bearing overall, eventually the foot will continue to turn inward and other measures will be needed (I'm 29 now, was 20 at time of injury).

Same thing with arthritis and AVN. Also I've had multiple talar revisions, including revision of the talo-navicular joint.

I've avoided fusion thus far (had spontaneous calcaneal fusion) but am told my case is very unusual.

Good luck!