Masquelet Technique for Hindfoot Fusion of Gustilo IIIA Open Ankle Dislocation with Complete Talar Extrusion and Loss

CATEGORY: Hindfoot, Trauma, Ankle INTRODUCTION/PURPOSE: Complete talar extrusion is a rare injury resulting from high-energy trauma, with dissociation of the talus from surrounding bony and soft-tissue structures. Complications after complete talar extrusion include infection, osteonecrosis, posttraumatic osteoarthritis, and leg-length discrepancy. There is a lack of consensus on the optimal treatment algorithm for complete talar extrusion, due in part to high complication rates associated with injury and treatment. Thus, we report a staged treatment method utilizing the Masquelet Technique with temporary cement spacer, followed by bone grafting with use of femoral shaft autograft and bulk cancellous allograft. METHODS: 44-year-old male status post high-speed motorcycle collision presented with left ankle Gustilo IIIC open fracture dislocation with complete talar extrusion and loss, concomitant ipsilateral tibial plateau fracture and metatarsal shaft fractures. Twelve weeks post-injury, after multiple staged debridements, external fixation and extensive wound vac treatments, removal of the left leg multi-planar external fixator was performed with left distal tibial, fibular, navicular and calcaneal articular and subchondral bone debridement in preparation for Masquelet procedure and pantalar fusion. Open reduction and realignment of left ankle and foot with intramedullary fixation with hindfoot fusion nail was performed, with placement of antibiotic cement spacer for development of secondary reactive periosteal membrane. After nine weeks, intramedullary bone reaming aspiration tool was utilized for removal of left femur intramedullary bone marrow for autograft. Hindfoot pantalar fusion was performed using ipsilateral femoral shaft autograft and bulk cancellous allograft in place of antibiotic spacer. RESULTS: Patient went on successfully to fusion and had one transfixation screw removed during the course of his recovery. Patient was also treated using a long leg ankle foot orthosis brace as a stress shielding device during heavy labor. Patient returned back to work and heavy labor as a landscaper and has had no residual pain. At 24 months postoperative, patient achieved an AOFAS ankle-hindfoot score of 83/100 (good). CONCLUSION: To our knowledge, this is the first case of complete talar extrusion treated with a Masquelet procedure with ipsilateral femoral shaft autograft and bulk cancellous allograft. While chronic pain is reported in as many as 75% of patients post- complete talar extrusion, and infection rates as high as 88%, our patient reports no residual pain and did not experience a postoperative infection. This technique represents a reasonable approach and warrants consideration for the treatment of this rare, complex injury.