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C OPYRIGHT Ó 2013 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

An Eleven-Year Follow-up of a Custom Talar

Prosthesis After Open Talar Extrusion
in an Adolescent Patient
A Case Report
Kuldeep P. Gadkari, MS, MBBS, John G. Anderson, MD, Donald R. Bohay, MD, John D. Maskill, MD,
Michelle A. Padley, BS, CRC, and Lindsey A. Behrend, BS

Investigation performed at Orthopaedic Associates of Michigan, Grand Rapids, Michigan

T
alar extrusion is an extremely rare injury; isolated cases
are reported in most instances1-8. Because of the paucity
of literature pertaining to this injury, no definitive rec-
ommendations exist for treatment. General consensus among
orthopaedic surgeons mandates that this injury be managed by
thorough debridement of the wound and reduction of the
extruded talus, if possible9. When complications like osteone-
crosis and infection occur, the surgeon is left with few options
outside of tibiocalcaneal arthrodesis. Often, this leaves the
patient with a shortened limb and altered gait mechanics10. In
2007, Stevens et al. reported a talar extrusion in a fourteen-
year-old girl who underwent an excision of the native talus
because of infection, followed by replacement with a custom-
made cobalt-chrome talar body prosthesis11. That case report
was unique because of the age of the patient, the use of a metal
implant in a previously infected wound, and the use of a custom-
made metal prosthesis with a novel ‘‘snap-fit’’ design for pur-
chase and stability. In this case report, we describe the same
patient after eleven years of follow-up. The patient was in-
formed that data concerning the case would be submitted for
publication.
Case Report
A fourteen-year-old girl had been involved in a motor ve-
hicle accident. On initial evaluation, there had been total
extrusion of the right talus from a 10-cm lacerated wound on
the lateral aspect of the ankle. The talus appeared intact but
devoid of soft-tissue attachments, with the exception of a few
capsular strands at the neck. The wound had been grossly
contaminated with dirt and grass.
The talus was reduced into the ankle joint in the operating
room. The lateral ligaments of the ankle were reconstructed.

Fig. 1 Fig. 2
Fig. 1 Anterior (left) and lateral (right) radiographs of the right foot six years after implantation. Fig. 2 A lateral radiograph of the right foot nine years
after implantation.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of
the article.

JBJS Case Connect 2013;3:e118 d http://dx.doi.org/10.2106/JBJS.CC.L.00331

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The wound was left open and dressed under sterile condi-
tions. The patient had debridements on days two, four, and
seven after injury. On day seven, a foul odor emanated from
the talar extrusion wound; a culture of the wound revealed
Clostridium bacteremia. Reexamination showed that the
talus had no soft-tissue attachments remaining. A talectomy
was performed, and the native talus was preserved in for-
malin for the purpose of templating a prosthesis. Tobramycin
beads were placed in the wound, followed two days later by a
polymethylmethacrylate spacer. A medial spanning external fix-
ator (A-frame; Synthes, West Chester, Pennsylvania) was applied
Fig. 3 across the ankle, along with a vacuum-assisted closure device.
A lateral radiograph of the right foot eleven years after implantation. Wound closure was accomplished with a skin graft. The
preserved native talus was sent to Smith & Nephew (Memphis,
Tennessee), where computed tomography was used to deter-
mine the exact contour of the talus; a cobalt-chrome prosthesis
was constructed. This prosthesis was implanted into the patient
seven months postinjury. Additionally, the patient underwent a
below-the-knee amputation of the contralateral limb because
of chronic infection from an open pilon fracture during the
postoperative course.

Technique
An anterior incision was made and the extensor hallucis longus
muscle, the neurovascular structures, and the tibialis anterior
muscle were all retracted medially. The antibiotic spacer was
removed, and the cobalt-chrome talar prosthesis was implanted.
Intraoperatively, 10° of dorsiflexion and 50° of plantar flexion
were possible.
At four years postsurgery, the patient had no symptoms
or evidence of instability. The range of motion was 5° of dor-
siflexion to 20° of plantar flexion. She could handle uneven
Fig. 4
surfaces easily while walking, but could not run on uneven sur-
A photograph showing the dorsal aspect of the right foot eleven years after
faces. Radiographs taken at six and nine years postimplantation
implantation.
demonstrated that the prosthesis remained in a good position
(Figs. 1 and 2).
The most recent follow-up took place eleven years after
the talar replacement procedure. The patient had retained a
25° arc of motion in the sagittal plane. The hindfoot was
stiff, and she had no inversion or eversion. She had mild,
occasional pain and was walking outdoors without assistive
devices. She had difficulty walking on uneven terrain. Radio-
graphs showed that the prosthesis was in a slightly plantar
flexed but stable position (Fig. 3). There was minimal osteo-
phyte formation at the anterior distal border of the tibia and
the proximal superior navicular. The American Orthopaedic
Foot & Ankle Society (AOFAS) ankle-hindfoot score was 75
(specifically, 30 points for pain, 30 points for function, and
15 points for alignment). Photographs (Figs. 4 and 5) of the
right foot show a mildly valgus foot with satisfactory wound-
healing.

Discussion
Fig. 5
A photograph showing the lateral aspect of the right foot eleven years after
implantation.
T otal talar extrusion without fracture is an extremely rare
injury1-8. Memisoglu and Hürmeydan reported a talar ex-
trusion in a thirteen-year-old girl: the talus was intact, but there
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was soft-tissue stripping with chondral comminution5. The
talus was reduced, and the chondral fractures were pinned
with Kirschner wires. At the eighteen-month follow-up, she
had full range of motion, and the AOFAS ankle-hindfoot
score was 93 points without evidence of osteonecrosis.
O’Brien described a seventeen-year-old boy in whom the
talus was replaced7. After nine months, the patient had talona-
vicular joint incongruity. The main determinants of a good long-
term outcome of reimplantation are absence of osteonecrosis and
infection. Detenbeck and Kelly12 favored a primary talectomy and
a tibiocalcaneal arthrodesis, whereas Brewster and Maffulli13 fa-
vored replacing the talus. Assal and Stern14 and Palomo-Traver
et al.15 reported that osteonecrosis and infection were infrequent
after talar extrusion. Memisoglu and Hürmeydan reported an
infection rate of 27.3% and an osteonecrosis rate of 18.2%5. In
2006, Smith et al. reported that reimplantation of the talus did
not result in a high infection rate9.
In spite of radiographic changes, the talar body does not
always collapse, and not all patients with a talar body collapse
require surgery. Reimplantation of the extruded talus must
be strongly considered since it restores the joint mechanism,
hindfoot height, and bone stock for future reconstructive
procedures.
Harnroongroj and Vanadurongwan implanted steel talar
prostheses in sixteen patients with osteonecrosis of the talus or
severe crush fractures of the talar body2. The native talar head
was retained, and a peg on the prosthesis fit into a recess on the
native talar neck with bone cement. At fifteen years of follow-
up on nine patients, eight reported a satisfactory result. In the
patient with an unsatisfactory result, the prosthesis had sunk
into the talar neck.
Magnan et al. used a combination of a total ankle arthro-
plasty and a prosthetic talus to treat a forty-five-year-old pro-
fessional athlete4. The talus was fixed to the calcaneus and the
navicular with screws. Tsukamoto et al. reported on total talar
replacement following collapse of the native talus in a patient
with rheumatoid arthritis after total ankle arthroplasty16. They
used an alumina ceramic prosthesis, and their patient reported
remarkable pain relief and improvement in walking capacity.
In our patient, the talus had been replaced in the wound
at the time of the initial debridement because the patient was
young and had no fractures. Subsequently, the talus had to be
excised because of infection. At this point, there were three
possible options: a tibiocalcaneal arthrodesis, a cobalt-chrome
prosthesis milled to the exact dimensions of the native talus,
or a below-the-knee amputation. Arthrodesis would have in-
volved sacrificing the joint, considerable shortening, a stiff
lever for propulsion, and altered gait mechanics. The surgeons
believed that a prosthetic talus was the best option that they
could offer this young patient. Additionally, it would not
eliminate the future option of a tibiocalcaneal arthrodesis or
References
1. Fleming J, Hurley KK. Total talar extrusion: a case report. J Foot Ankle Surg. 2009
Nov-Dec;48(6):e19-23. Epub 2009 Jul 17.
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I N A N A D O L E S C E N T P AT I E N T
an amputation if necessary. Stability to the prosthesis was
provided by its natural shape and contour. The prosthetic
talus had a porous coating material applied at the non-
articular sites to provide a place for scar adherence and added
stability. However, the clinical importance of the applica-
tion of the porous coating material was unknown, and the
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prosthesis. The application of an external fixator and antibiotic
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To the best of our knowledge, this is the longest reported
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ipated the observed gradual reduction in the range of motion, as
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Implants that utilize cement for fixation have also pro-
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The use of a custom talar prosthesis is indicated when
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Talar extrusions without fractures are rare and challenging
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arthrodesis. n
NOTE: The authors thank Kevin T. Weaver for his assistance with this project.
Kuldeep P. Gadkari, MS, MBBS
John G. Anderson, MD
Donald R. Bohay, MD
John D. Maskill, MD
Michelle A. Padley, BS, CRC
Lindsey A. Behrend, BS
Orthopaedic Associates of Michigan,
1111 Leffingwell Avenue NE, Suite 100,
Grand Rapids, MI 49525.
E-mail address for J.G. Anderson: John.Anderson@oamichigan.com
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Am. 1997 Sep;79(9):1313-22.
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