ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10040-1181 |
Management of Neglected Medial Peritalar Dislocations: A Preliminary Report with Clinical and Radiological Analysis of 10 Cases
1Department of Orthopedics, Wachche Hospital, Solapur, Maharashtra, India
2,3Department of Orthopedics, Dr VM Government Medical College, Solapur, Maharashtra, India
Corresponding Author: Gurunath S Wachche, Department of Orthopedics, Wachche Hospital, Solapur, Maharashtra, India, Phone: +91 9822195087, e-mail: wgurunathan@yahoo.com
ABSTRACT
Aim and objective: To study the functional outcome of neglected medial peritalar dislocations treated with open reduction and k-wire fixation and assess the clinical and radiological outcome of these neglected cases.
Materials and methods: A prospective study was performed on 10 patients between June 2016 and July 2020. All the cases were treated with open reduction and internal fixation with k-wire fixation in the Department of Orthopedics and private setup. We graded these injuries according to the AOFAS ankle hindfoot scale.
Results: In our study, all the patients had closed injury and presented to us between 4 weeks and 8 weeks after injury without taking any primary treatment. The mean age-group was 21-58 years of age with male predominance (60%). Road traffic accident (RTA) is the most common mode of injury (80%). Five (50%) of the patient had right side involvement and five (50%) left-sided. Four (40%) patients had excellent outcomes, four (40%) good, and two (20%) fair. Three patients had complications like superficial skin infection, broken k-wire, and persistent pain due to missed calcaneocuboid subluxation preoperatively.
Conclusion: All chronic neglected peritalar dislocations need open reduction and K-wire fixation. Preoperative computed tomography (CT) scan, proper operative planning, if needed use of distractor for reduction is useful in some cases. Meticulous soft tissue handling is key factor for better outcome. Long-term follow-up is needed to know about the talus osteonecrosis and post-traumatic arthritis.
How to cite this article: Wachche GS, Handralmath S, Dhamoji P. Management of Neglected Medial Peritalar Dislocations: A Preliminary Report with Clinical and Radiological Analysis of 10 Cases. J Foot Ankle Surg (Asia Pacific) 2022; 9(2):81-85.
Source of support: Nil
Conflict of interest: None
Keywords: Neglected medial peritalar dislocations, Open reduction and transarticular fixation, Subtalar joint, Talonavicular joint
INTRODUCTION
Peritalar dislocation is an uncommon injury involving the talocalcaneal and talonavicular joints. It often results from high-velocity trauma such as fall from height, motor vehicle accidents, and athletic injuries.1 It was first reported in the year 1811.2 Peritalar dislocations represent around 1-2% of all traumatic dislocations and 15% of all talar injuries. Most affected patients are young males in the third decade of life.3-5
The rarity of these injuries can be attributed to the presence of strong ligaments connecting the talus and calcaneus, the strong biomechanical properties of the ankle, and the tight joint capsule.6 The basic mechanics of this particular injury lies in the direction of deforming forces on a plantarflexed foot.7
Four traditional classifications of dislocation are described in the literature as medial, lateral, posterior, and anterior. Medial dislocations, which result from various contexts and are considered an inversion/rotational injury, are the most common type, accounting for up to 80% of presentations. Lateral dislocations, which are caused by high energy trauma and eversion, are the second most common type, accounting for 17% of the presentation. Posterior dislocations account for 2.5% and anterior dislocations are rarely described.8
Subtalar dislocations commonly have other associated injuries in the ankle. The tibia, fibula, talus calcaneus, and navicular are the most commonly fractured bones, but the cuboid, cuneiforms, and metatarsals are at risk as well. One study demonstrated that ~88% of all patients with a subtalar dislocation had an associated foot or ankle injury.9,10
The prompt diagnosis followed by closed reduction and immobilization in a plaster cast is the recommended treatment but when closed reduction is failed or in cases of neglected dislocations, open reduction and internal fixation may be required due to soft tissue interposition and minimize further soft tissue and neurovascular compromise.11
We present our preliminary report of chronic neglected medial peritalar dislocations with clinical and radiological results.
MATERIALS AND METHODS
Ethical permission and informed patient consent were obtained for the study. Ten patients of both sexes belonging to the adult age-group presenting with, neglected peritalar dislocations admitted to the orthopedic department of VM Medical College and Wachche Hospital, Solapur, from June 2016 to July 2020.
In our case series, we prospectively evaluated patients with neglected peritalar dislocation presenting between 4 weeks and 8 weeks post-injury. All these cases had medial peritalar dislocations only.
Out of 10 patients, 8 patients were associated with posterior process talus fracture, 1 patient with severely comminuted coronal fracture of the body of talus and lateral malleolus fracture, 1 patient with calcaneocuboid subluxation and posterior process fracture.
A detailed history of all the cases was taken to rule out other systemic injuries. A thorough clinical examination of the affected limb was done and vascularity was distally assessed. Radiological examination like X-rays (Fig. 1) and computed tomography (CT) scan (Fig. 2) was carried out to support the diagnosis and for better understanding of fracture configuration.
Figs 1A and B: Preoperative X-ray lateral view showing dislocation of subtalar joint and dislocation of talonavicular dislocation
Fig. 2: Preoperative CT scan showing talonavicular dislocation with indentation of talar neck
Surgical Technique
After routine blood examination and pre-op anesthetic work-up, patients were posted for surgical procedures after taking consent. All the patients were operated on under spinal anesthesia. Prophylactic antibiotics was given before the incision.
Position of the Patient
The patient was placed in a supine position on an operating table, a pneumatic tourniquet was applied to mid-thigh. The affected foot was scrubbed, prepped, and draped with betadine solution up to the knee.
Skin Incision
An anteromedial S-shaped incision was taken in all cases and the talus was exposed (Fig. 3). In all the cases, the reduction was the difficult task due to chronicity of the pattern. The reduction was difficult due to lot of soft tissue fibrosis, buttonholing of talus head with extensor retinaculum and extensor digitorum brevis muscle. The articular surface of the naviculum and talar head was normal in nine cases. In one case, the talus head was intended at navicular surface. Identification of the structure was difficult in all cases due to lot of fibrous tissue.
Fig. 3: Intraoperative photograph showing dislocated talus head with k-wires positioned as Joystick
All the cases had a lot of fibrous tissue which was removed. In three cases, there was buttonholing of the extensor retinaculum, which was levered out and the talus was reduced. In two cases, distraction was done to assist the reduction. After reduction, talocalcaneal and talonavicular joints were fixed with 2.5 mm k-wires. Closure done with 3-0 ethilon suture. The patient was immobilized with the below-knee slab.
Postop IV antibiotics given for 3-5 days. Average hospital stay was 5-7 days. The below-the-knee splint was maintained for 4 weeks, beginning with passive ankle dorsiflexion and plantar flexion exercises after the removal of the cast and later with partial weight bearing followed by full weight bearing in the 10th week after reduction. K wires removed after 6 weeks. In one case there was breakage of the talonavicular k-wire (Fig. 4) due to lost follow-up we could not remove the k-wire in time. In this patient, we removed the k-wire after 18 months of the surgery (Tables 1 to 5).
| Age (years) | Number of cases | Percentage |
|---|---|---|
| 21-30 | 5 | 50 |
| 31-40 | 3 | 30 |
| 41-60 | 2 | 20 |
| Total | 10 | 100 |
Most common age-group involved was between 21 years and 30 years (50%)
| Sex | Number of cases | Percentage |
|---|---|---|
| Male | 6 | 60 |
| Female | 4 | 40 |
| Total | 10 | 100 |
Male patients were dominant (60%) compared to female patients (40%)
| Mode of injury | Number of cases | Percentage |
|---|---|---|
| RTA | 8 | 80 |
| Fall from height | 2 | 20 |
| Total | 10 | 100 |
Most common mode of injury was RTA (80%), followed by fall (20%)
| Side | Number of cases | Percentage |
|---|---|---|
| Right | 5 | 50 |
| Left | 5 | 50 |
| Total | 10 | 100 |
The right foot (50%) was more commonly involved than left foot (50%)
| Results | Number of cases | Percentage |
|---|---|---|
| Excellent | 4 | 40 |
| Good | 4 | 40 |
| Fair | 2 | 20 |
| Poor | 0 | 0 |
pain, and 10 points to alignment. Score ≥90 excellent, 80-89 good, 70-79 fair, and <70 poor.
Fig. 4: An 18-month follow-up X-ray showing broken K-wire In situ, no signs of arthritis
The patient was followed up for 1 year and at the end of 1 year, the patient was pain free while performing his daily activities of weight bearing. The radiograph of the ankle at 1 year revealed normal tibiotalar and subtalar spaces. There were no signs of avascular necrosis of the talus. The patients were assessed clinically and radiologically. In all cases, we have done CT scan pre- and postoperatively (Fig. 5). The longest follow-up is 2 years and minimum follow-up is 3 months.
Fig. 5A and B: An 18-month follow-up CT scan showing reduced joints with no signs of arthritis
Clinical results (Fig. 6) were graded on 100 points AOFAS ankle-hind foot score: 50 points were assigned to function, 40 points to pain, and 10 points to alignment. Score ≥90 excellent, 80-89 good, 70-79 fair, and <70 poor.
Figs 6A and B: Clinical photographs with healed incision and with residual heel varus
RESULTS
In our case study of 10 patients, all the patients had closed injury and were diagnosed with chronic neglected medial peritalar dislocations with duration of 4 to 8 weeks. Eight patients were associated with posterior process talus fracture, one patient with severely comminuted coronal fracture of body of talus and lateral malleolus fracture, one patient with calcaneocuboid subluxation and posterior process fracture. The reason for late presentation is mainly due to missed diagnosis, ignorance and local treatment by quacks.
Three patients had complications including one with breakage of k-wire due to lost follow-up for almost 1 year which was removed after 18 months. One patient with a superficial wound problem was treated with oral antibiotics. One patient had persistent pain due to missed calcaneocuboid subluxation which was missed preoperatively.
In all the cases, open reduction with dorsomedial incision was performed. Two patients needed intraoperative differential distraction to reduce the dislocations.
As all cases were chronic, neglected >4 weeks the reduction was difficult due to posttraumatic fibrosis of soft tissue buttonholing of talar head through the extensor retinaculum and extensor digitorum brevis muscle.
Operative Complications
In our study, we encountered complications in three patients. One patient had a superficial infection which was managed with cleaning and dressing on alternative days and oral antibiotics, which resolved in due course of time. One patient had varus malalignment of the subtalar joint. One patient we lost his follow-up for one year, he presented to us with a broken k-wire which was removed subsequently after 18 months of surgery. None of the 10 patients had talar necrosis or redislocation till now.
DISCUSSION
In the literature, we have found many case reports of management of medial peritalar dislocations; however, there were no case series of neglected medial peritalar dislocations >4 weeks of durations.
We submit our preliminary reports of clinico-radiological and functional outcome of series of 10 cases of chronic neglected medial peritalar dislocations which are initially untreated or mismanaged by quacks.
In India, the patients usually present with neglected conditions due to many factors. Peritalar dislocations are rare lesions, caused by the torsional mechanism which usually involves high energy.
The medial dislocation is the most common type also known as “acquired clubfoot,” is the result of forceful inversion of the forefoot which applies stress on the lateral collateral ligament when the foot is in plantar flexion. Talus pivot on sustentaculum tali and if the strong talocalcaneal and talonavicular ligaments rupture, talus remains in his normal position at the ankle joint, and subtalar joint dislocation occurs. Lateral dislocation, also known as “acquired flatfoot,” the mechanical pattern of injury is similar to the medial pattern but instead of inversion, applied forces on the medial side cause eversion of the foot and leads to rupture of deltoid ligament, interosseous ligament, and dorsal talonavicular ligament. The talus pivots on the anterior calcaneus process.12-14
Posterior and anterior dislocation occurs when forces applied on the dorsum of the foot result in forceful extreme plantar flexion of the forefoot. Both medial and lateral collateral ligaments along with interosseous ligament are torn in both dislocations.14,15
Most fractures affect talonavicular and subtalar joint surfaces, producing small osteochondral or cartilaginous fragments that may eventually go unnoticed on pre- or post-reduction simple X-rays. Those hidden fractures occur in all lateral and posterior dislocations and in around 12-38% of medial peritalar dislocations.
Early diagnosis, anatomical stable reduction, stable fixation of peritalar joint surfaces, and resection of small, free osteochondral fragments are decisive factors for the prevention of early post-traumatic arthritis which in turn may cause pain, joint stiffness, and an unsatisfactory final result.
The most common cause of irreducible medial dislocation is buttonholing of the extensor retinaculum or the extensor digitorum brevis, entrapment of the talus in the talonavicular capsule, or talocalcaneal impingement by fractures of their articular surfaces and tibialis posterior tendon. The most frequent cause of irreducible lateral dislocation is entrapment of the posterior tibialis tendon as subluxes over the medial malleolus.16,17
Fractures of the posterior process of the talus have not attracted much attention. The posterior talocalcaneal joint comprises the basal surface of the posterior tubercle that is facing plantarlaterally. This explains why fracture will occur if the calcaneum is forced medially as this will cause avulsion of the tubercle.18 Talar fractures can be diagnosed with radiographs but fractures associated with the dislocations are difficult to diagnose. Computed tomography is important for the complete evaluation of the fracture, their configuration, and better surgical planning and outcome.19
Peritalar dislocation is a potentially devastating injury in which the complications range from chronic pain from subtalar arthritis to talar avascular necrosis. The literature suggests that closed reduction is the most common and appropriate method of treatment for medial dislocations, but those with neglected peritalar dislocations, need open reduction and internal fixation because of their irreducibility.20,21
Subtalar stiffness and early onset subtalar arthritis are primary causes of poor functional outcomes in dislocation. Optimal post-reduction immobilization period and post-reduction weight-bearing protocol can improve the functional outcome after an isolated subtalar dislocation.
In our study of 10 patients, all the patients had closed injury and were diagnosed with medial peritalar dislocation. Most commonly, young age-group was affected (21-30 years) with the average age of 24.8.
In our study, dislocations were more common in males 6 (60%) and less common in females 4 (40%). Male predominance in our study could be because of the involvement of males in outdoor activities and road traffic accidents. Out of 10 patients with dislocation, 5 (50%) had a right-sided injury and 5 (50%) had left-sided.
In our study, eight patients (80%) had a history of road traffic accidents (RTA) and two (20%) with a history of falls. Out of these eight patients with a history of RTA, four patients had a fracture of the posterior process of the talus which was treated conservatively.
In one patient, we found a fracture of the body of the talus in the coronal plane, lateral malleolus fracture with severe swelling. In one patient, we found subluxation of calcaneocuboid joint with associated posterior process fracture talus. We missed the calcaneocuboid dislocation which is diagnosed in the follow-up post-op CT scan which was left untreated.
The functional outcome of 10 patients was graded according to the AOFAS score. Four patients had excellent results, four had good results, and two with fair results. Patient with excellent result had no pain or limp, unrestricted daily routine activity, complete range of motion and well aligned. Patient with good results had occasional pain and those with fair results had occasional pain with difficulty in walking on uneven surface with partial restriction of motion.
We encountered complications in three patients. In one patient, breakage of k-wire due to lost follow-up of the patient and he started walking with full weight bearing. We removed the broken k-wire after 18 months post-op. The remaining part in body talus not removed and kept like that only. None of our patients had talar necrosis or degenerative arthritis of subtalar joint.
CONCLUSION
Neglected foot and ankle fractures are very common in India. The management of chronic neglected peritalar dislocations is reported very rarely in the literature.
The management is mainly depending on the duration of the fracture, age and need of the patient, and condition of the joint. Precise imaging study, such as a CT scan, to be done to rule out associated fractures. Open reduction with gentle soft tissue handling and transarticular k-wire fixation with early rehabilitations gives good results in chronic neglected peritalar dislocations. The limitation of our study is short follow-up and small sample size. We need still long follow up and adequate sample size to know about the osteonecrosis and post-traumatic arthritis.
ORCID
Gurunath S Wachche https://orcid.org/0000-0003-0813-4225
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