A 27-year-old man was brought into the emergency department after a motorbike accident. No wounds were reported other than the total extrusion of the right talus (Fig. ). The bone pedicle appeared severely damaged, whereas the talar bone was intact and was stored in a bone bank. Irradiation was employed to preserve and sterilize the bone.
X-ray shows the absence of talus without any fracture of the surrounding bones
A culture was obtained and empiric antibiotic therapy with teicoplanin and amikacin was started. The lacerated wound was copiously irrigated, cleansed with povidone iodine, and debrided. The talar void was filled with properly modeled gentamicin/clindamycin-loaded cement spacer in order to reduce the risk of articular talar space loss and infection while waiting the cultural results (Figs. , ). An external fixator, with pins inserted in the tibia and calcaneus, was applied to stabilize the joint. Vascularization of the foot appeared intact; tendons and muscles did not display damage; no neurological deficit was reported; and the skin defect was closed primarily.
Properly modeled antibiotic cement was employed to fill the talar void (left). An external fixator was employed to stabilize the joint; the wound was closed primarily (right)
Intraoperative X-rays after application of antibiotic cement
After 2 weeks, the cutaneous margins of the wound and the surrounding skin displayed necrosis. The patient was referred to our department of plastic surgery. The cultures gave negative results. After debridement of the necrotic tissue, the cutaneous defect measured 6 × 5 cm. The antibiotic cement was removed, and two polyvinyl alcohol sponges were placed in the articular void in order to prevent any damage to the articular cartilages. During the same surgical time, a distally based sural fasciocutaneous flap measuring 8 × 6 cm was harvested and applied to the defect. Split-thickness skin grafts were employed to cover the flap pedicle. Twenty-five days later, the external fixator was removed and the original talus was placed, with a dorsal incision 2 cm above the flap margin. Arthrodesis was performed percutaneously using two screws in the anterior subtalar joint and two in the posterior subtalar joint (Fig. ).
Arthrodesis with two screws in the anterior subtalar joint and in the posterior subtalar joint. Anteroposterior and lateral X-ray projections after 2 years of follow-up. No signs of avascular necrosis are observed
Mobilization of the ankle without weight bearing was allowed after removal of the external fixator. Literature is rather unforthcoming in suggesting guidelines due to the rarity of missing talus lesions. We opted to precociously allow careful movements without weight bearing in order to avoid atrophy and to restore talus and surrounding tissues. Weight bearing was then gradually introduced at 3–4 months after the final surgery, and after 6 months, full weight bearing was achieved. At the 4-year follow-up, the joint showed no signs of avascular necrosis, neither plantarflexion nor dorsiflexion showed impairment, and ambulation was regular (Fig. ).
Final result after 4 years. Movements are not impaired; ambulation is regular