SLR - July 2017 - Natalia Cardona
Reference: Boden, K.A., Weinberg, D.S. & Vallier, H.A. (2017). Complications and Functional Outcomes After Pantalar Dislocation. The Journal of Bone and Joint Surgery. 2017 April 19; 99(8), 666–675.
Scientific Literature Review
Reviewed By: Natalia Cardona, DPMResidency Program: Northwest Medical Center, Margate, FL
Podiatric Relevance: Pantalar dislocations are not commonly seen by the practicing foot and ankle surgeon, yet they can potentially result in a devastating loss of lower-extremity function. Many authors seek to understand the injury, establish a treatment protocol and measure their complications. Treatments include primary talectomies, talar reimplantation with internal or external fixation and even primary amputation. These injuries notably feature risks of infection, osteonecrosis and posttraumatic arthrosis. This article focuses on the complications and long-term functional outcomes of these complex injuries.
Methods: A level IV retrospective review was used to analyze clinical and functional outcomes of patients who had suffered pantalar dislocations. Data was collected using a fracture registry of an urban, level 1 trauma center of patients treated between July 2002 and August 2014. Nineteen patients were identified, including 14 open injuries and five closed injuries, all without associated talar fracture. Ten male and nine female patients with a mean age of 39.6 years were included. The range of ages was between 19 and 68 years. The mean Injury Severity Score (ISS) was 24.9. The mean time from presentation to the emergency department to start of surgery was 8.2 hours. Sixteen patients had open reduction, and two had closed reduction. Fixation was achieved with Kirschner wires, external fixation or both. Two patients did not have fixation. Data was collected on pain levels, medication usage, range of motion and secondary procedures, with a minimum follow-up of one year. Infection, osteonecrosis and posttraumatic arthrosis were evaluated by reviewing patient charts and radiographs. Outcomes were measured using the Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA).
Results: During the 12-year study period, 19 pantalar dislocations without talar fractures were treated. The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems, and one patient developed cellulitis. No deep wound infections occurred. Fourteen of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis; two with collapse of the talar dome; and seven developed arthrosis of at least one peritalar articulation. Outcome surveys were obtained for 11 of the 19 patients at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 14 of 16 of the patients with radiographic and clinical follow-up reported at least mild pain, and 12 of 16 were taking analgesics.
Conclusions: The authors concluded that urgent surgical debridement of open injuries and reimplantation of the talus after pantalar dislocation was not associated with deep infection. They advocate that primary talectomies should be avoided and only reserved for persistent deep infections and not as initial treatment. Although osteonecrosis occurred in the majority of patients, collapse was uncommon. Persistent pain and functional limitations are frequent after pantalar dislocation, and those patients with collapse or posttraumatic arthrosis may experience worse outcomes. The results of this study may help guide the treatment algorithm of foot and ankle surgeons who manage these complex injuries.