Closed Pantalar Dislocations

Characteristics, Treatment Approaches, and Outcomes

Amir Reza Vosoughi, MD; Heather A. Vallier, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(7):278-287. 

In This Article

Treatment

The main goal of treatment was to achieve a stable anatomic reduction of the talus in the ankle, subtalar, and talonavicular joints besides reduction and fixation, as indicated, of associated fractures. Reduction of closed pantalar dislocation should be done promptly to prevent skin necrosis and to alleviate ongoing neurological or arterial compromise. Controversies exist regarding open versus closed reduction of this type of dislocation;[28] nevertheless, accurate urgent reduction, either closed or open, is advocated.[15]

Previously, primary or secondary talectomy and different types of arthrodesis had been suggested, even for closed pantalar dislocations.[1,2] However, complications which occur after an anatomically reduced talus may be managed more easily than cases after talectomy. Retention of the talus will maintain the length and anatomy of the extremity and will prevent shortening of surrounding soft tissues and tendons.[9] As shown in Table 1, all cases underwent primary talectomy and tibiocalcaneal arthrodesis[1] or tibiotalar arthrodesis[2,14] had fair to poor clinical outcomes. Hence, primary talectomy should no longer be advocated.

Among 40 cases that underwent initial reduction, 24 had successful closed reduction (60%), 11 had unsuccessful closed reduction (27.5%), and 5 underwent open reduction without trying initial closed reduction (12.5%). The successful rate for closed reduction of closed pantalar dislocation would be 68.5% (24 of 35).

Closed Reduction

Mitchell was the first to describe a closed reduction technique in 1936.[6] The closed reduction must be done under sedation to provide muscular relaxation and to alleviate pain. The knee should be kept in flexed position to diminish the Achilles tendon pull. After manual longitudinal traction of the foot and countertraction by grasping the leg, the talus should be pushed by thumbs of the surgeon to its normal position, depending on the position of the dislocated talus.[20] The aim was initially to reduce the tibiotalar joint, often followed by spontaneous reduction of the subtalar and talonavicular joints.[17,28] Sometimes, other maneuvers may be necessary such as inserting a calcaneal pin to improve traction and steerage.[7,19] Moreover, insertion of another pin to the tibia and using a universal distractor could be helpful to reduce the talus in the tight empty space.[5,7]

After reduction, the alignment of tibiotalar, talonavicular, and subtalar joints should be assessed by multiplanar fluoroscopy.[17,25,34] More importantly, CT scan is used to confirm accurate reduction, to diagnose occult fractures, or to discern incarcerated osteochonrdral fragments within the joints.[28] After a successful reduction, non–weight-bearing in below knee cast immobilization is advised for 6 to 12 weeks.[27] Progression to full weight-bearing is recommended at 3 months after the injury.[28]

Fixation may be achieved if indicated, using pins through the subtalar and ankle joints or ankle spanning external fixation for 6 to 12 weeks.[3,13,15,26] Sometimes the talonavicular joint is unstable and requires temporary fixation with a Kirschner wire.[9,13,23,24] In cases with associated displaced fractures, open reduction and stable fixation should be considered with appropriate approach, depending on the fracture. Notably, the outcome of cases with successful closed reduction was excellent or good for all cases, excepting one patient who underwent late triple arthrodesis for pain relief.[14]

Irreducible Dislocation

Attempted closed reduction maneuver more than two times is not recommended because of possible skin slough and further damage to the surrounding soft tissues and the chrondral surfaces.[9,32] Closed reduction may be impossible for some acute cases[1,9,13,19,21,23–25,32,33] or neglected cases after 48 hours.[31] Based on our analysis, among 16 cases that underwent open reduction, 11 (68.7%) had unsuccessful initial closed reduction. Different obstacles exist to prevent closed reduction of the talus and, soft tissues are the most common; however, an associated displaced medial malleolus fracture has also been reported.[33] The talar head may be displaced between flexor hallucis longus and flexor digitorum longus tendons,[19] within interlocking capsuloligamentous structures,[23] lateral to peroneus longus tendon in a case of lateral pantalar dislocation,[2] medial to the tibialis anterior tendon in a medial pantalar dislocation,[2] or anterior to the tibialis posterior tendon in an anterolateral dislocation.[24] Itsiopoulos et al[32] proposed that the anteromedial dislocation of the talus, without malleolus fracture, may be responsible for the unsuccessful closed reduction of a closed pantalar dislocation.

If closed reduction fails, open reduction is essential. For anterolateral pantalar dislocation associated without fracture or with bimalleolar or medial malleolus fracture, open reduction is done through an anterolateral approach[9,21,31] or anteromedial approach.[23] In some cases, both anteromedial and anterolateral are done, even without any associated fractures.[24,25,33] In one case, the authors did dual approaches because of a lateral transverse wound over the dislocated talus.[24] Sometimes, especially for neglected cases, open reduction may be facilitated with reduction aids, such as a calcaneal pin or a distracting external fixator.[31]

Open Reduction

Some authors have preferred open reduction without initial attempt of a closed reduction in several cases with or without associated fractures.[2,10,22] At the last follow-up, of 5 cases, 2 (40%) had postoperative osteonecrosis, 4 (80%) had arthrosis, and one underwent tibiotalar arthrodesis. The outcome was excellent for 1 case, good for 3, and fair for 1 case.

An attempt at closed reduction with adequate sedation and muscle relaxation is recommended, followed by open reduction in cases of unsuccessful closed reduction. During open reduction, careful attention to local anatomy will minimize additional surgical insult to remaining vascularity. Meticulous soft-tissue handling will also mitigate risk for wound and soft-tissue healing complications.

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