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Sequelae of subtalar joint dislocations at two level 1 trauma centers: A case series and literature review

Open AccessPublished:June 14, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100217

      Abstract

      Traumatic incidences of subtalar joint dislocations are rare, occurring in approximately less than 1% of all traumatic dislocations. These injuries, however, often require prompt treatment due to involvement of skin tenting, open injury, and/or neurovascular compromise. Additionally, functional outcomes may be hampered by high rates of post-traumatic osteoarthritis. Due to the rarity of subtalar joint dislocations, cases are not often reported. A total of 6 acute traumatic subtalar joint dislocations over a 5-year period were included in this case series. Four were caused by high-energy trauma, and two were due to ground level falls. Five (5/6) were medial dislocations and one (1/6) lateral. Three patients had concomitant injuries: one had a posterior process fracture of the talus and two had distal fibular fractures. All six patients had a closed reduction in the operating room under monitored anesthesia care with a standardized post-operative protocol. Three patients were male. Mean patient age, body mass-index, and follow-up was 40.5 years (STD ± 18.7), 32.6 (STD ± 7.6), and 17.7 months (STD ± 9.7), respectively. Average hospital stay was 10.3 days (STD ± 7.9). Five post-operative complications were encountered in 4 patients (66.7%), including post-traumatic arthritis of the subtalar joint in half of the patients (3/6), talonavicular joint arthritis in one patient, and deep wound dehiscence with infection in another patient. All returned to their pre-injury level of work and reactional activity without functional limitations. The recent literature was also reviewed, further emphasizing the lack of data in circulation.

      Keywords

      Introduction

      Traumatic incidences of subtalar joint (STJ) dislocations are rare, occurring in approximately less than 1% of all traumatic dislocations.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      Subtalar joint dislocations are defined by dislocations of the talocalcaneal and talonavicular joints without involvement of the ankle joint.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      • Liu P
      • Chen K
      • Wang S
      • Hua C
      • Zhang H
      • Yu J
      A mouse model of ankle-subtalar joint complex instability induced post-traumatic osteoarthritis.
      The etiology of these injuries are most commonly high energy trauma, such as motor vehicle accidents or falls from height. Low energy etiologies are less common, but they can occur with sports, ground level falls, or other eversion/inversion injuries of the foot.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      Malgaigne and Buerger expanded on Broca's classification and emphasized four types of STJ dislocations based on the position of the foot relative to the talus. A medial dislocation is the most common, occurring at a rate of 80-85% of all cases, while lateral dislocations account for 15-20%.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Teo AQA
      • Han F
      • Chee YH
      • O'Neill GK
      Unstable Open Posterior Subtalar Dislocation Treated With a Ring External Fixator: A Case Report and Review of the Literature.
      The other two types, anterior and posterior dislocations, are extremely rare and only account for <1% and 2.5% of incidents, respectively.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      ,
      • Rammelt S
      • Goronzy J
      Subtalar dislocations.
      All types of STJ dislocations often require prompt treatment due to involvement of skin tenting, open injury, and/or neurovascular compromise.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Rammelt S
      • Goronzy J
      Subtalar dislocations.
      The severity of these injuries and their deleterious effects are a cause for concern in management . Additionally, functional outcomes may be hampered by high rates of post-traumatic osteoarthritis (OA).
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      • Liu P
      • Chen K
      • Wang S
      • Hua C
      • Zhang H
      • Yu J
      A mouse model of ankle-subtalar joint complex instability induced post-traumatic osteoarthritis.
      • Prada-Canizares A.
      • Aunon-Martin I.
      • Vila y Rico J.
      Pretell-Mazzini. Subtalar Dislocation: Management and Prognosis for an Uncommon Orthopaedic Condition.
      Due to the rarity of the pathology, cases of subtalar joint dislocations are not often reported. Hence, the question remains whether modern complication rates are as great as those reported historically. The aim of the present study was to evaluate the epidemiology and complication rates of STJ dislocations over a 5-year period in order to determine if current treatment techniques are viable as well as to improve discussion with patients regarding expectations.

      Methods

      Institutional review board approval was obtained, and retrospective chart review was undertaken. Inclusion criteria included patients who sustained a STJ dislocation with or without polytrauma, being greater than 18 years of age, and presentation between April 1, 2017 to April 1, 2022. Exclusion criteria included vulnerable patient populations (i.e. prisoners), those who sustained a concomitant talar neck or body fracture, those with a concomitant ankle joint dislocation, and those with less than 9 months of follow up. We identified 9 cases of STJ dislocations at our two Level 1 Trauma Centers (Scripps Healthcare, San Diego, CA) through current procedural terminology (CPT) coding (28435 and 28445). Among the 9 cases of isolated acute traumatic STJ dislocations, 6 patients met both inclusion and exclusion criteria.
      Patient demographic information was collected and plain film radiographs were reviewed. On chart review, International Classification of Diseases (ICD) 9 or 10 codes were used for diagnosis of complications. Radiographic OA was further evaluated according to the classification of Kellgren-Lawrence (Table 2).
      • Kohn MD
      • Sassoon AA
      • Fernando ND
      Classifications in brief: Kellgren-Lawrence classification of osteoarthritis.
      Radiographic outcome was recorded at latest follow up, as was potential return to pre-injury recreational activities and work status. Need for surgical intervention status post dislocation was also recorded.
      All 6 patients had a closed reduction in the operating room under general anesthesia. This was after at least two failures of closed reduction in the Emergency Department. Reduction technique was identical to that as previously described.
      • Sharma S
      • Patel S
      • Dhillon MS
      Subtalar Dislocations.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      ,
      • Rammelt S
      • Goronzy J
      Subtalar dislocations.
      First, the knee is flexed to diminish the strain from the gastrocnemius-soleus complex. Secondly, for lateral dislocations, the foot is brought into dorsiflexion and eversion. Conversely, the foot is placed in plantarflexion and inversion for medial dislocations. Next, the foot is pulled distally to aid in release of the talar head and navicular. One hand is then placed on the heel, and the other hand on the tibia for counter pressure. For lateral dislocations, a plantar flexion and inversion force is applied alongside medial stress on the talar head. Inversely for medial dislocations, a dorsiflexion and eversion force are aggressively applied alongside lateral stress to the talar head. Post reduction position is demonstrated in Fig. 1. One patient required the use of percutaneous pinning. All were placed in a posterior leg splint with stirrups for 2-4 weeks, followed by a short leg cast for 4 weeks. After the short leg cast, the 3 patients with isolated STJ dislocations were placed in a controlled ankle motion boot and the 3 patients with concomitant injuries were placed in a walking cast for 4 weeks.
      Fig. 1
      Fig. 1A 60 year old male who sustained an Left medial subtalar joint dislocation secondary to a fall form height, anteroposterior (A) and lateral (B) ankle views.

      Results

      Nine cases of STJ dislocations were identified between 2017 and 2021. Three patients were lost to follow-up, leaving 6 acute traumatic subtalar joint dislocations for analysis, which are illustrated in Table 1. Five (5/6) were medial dislocations and one (1/6) lateral. Four were caused by high-energy trauma, and two were due to ground-level falls. Three patients had associated concomitant injuries: one patient had a posterior process talar fracture, and two experienced ankle fractures. Two were open dislocations. Computed tomography (CT) scans were not obtained in two dislocations.
      Table 1Patient demographics, complications, and radiographic outcomes.
      PatientAge (years)SexBody-mass-indexLateralityDislocation TypeCT ScanFollow-up (mo)Associated Fracture(s)Percutaneous PinningSubtalar Osteoarthritis GradeTalonavicular Osteoarthritis GradeSubtalar Joint Motion (percent of contralateral)
      160M25.49LeftMedialYes12Steida processNo10Conserved
      271F30.52RightLateralNo19AnkleNo00Conserved
      325M37.5RightMedialYes17AnkleNo20Reduced (80%)
      426M26.6RightMedialNo38NoneNo00Conserved
      539F47.2LeftMedialYes11NoneNo00Conserved
      622M28.2LeftLateralYes9NoneYes11Reduced (90%)
      Mean40.5 ± 18.7-32.6 ± 7.6---17.7 ± 9.7---0-
      Table 2Modified Kellgren-Lawrence classification of osteoarthritis.
      GradeRadiographic Findings
      0No radiographic evidence of arthritis
      1Possible osteophytic lipping
      2Osteophytes, possible narrowing of joint, possible sclerosis of subchondral bone
      3Moderate osteophytes, definite narrows, pseudocystic formation
      4Altered morphology of articular margins, severe osteophytes and marked narrowing
      Three patients were male. Mean patient age, body mass index, and follow-up was 40.5 years (STD ± 18.7), 32.6 kg/m (STD ± 7.6), and 16.2 months (STD ± 11.0, range 9-35), respectively. Average hospital stay was 10.3 days (STD ± 7.9). Five complications were encountered in 4 patients (66.7%), including post-traumatic arthritis of the subtalar joint in half of the patients (3/6), one including the talonavicular joint arthritis, and another suffering a deep wound dehiscence with infection. The latter wound, occuring in an open injury and seen in Fig. 2, healed after 6 weeks of intravenous antibiotics and further surgery. Of patients with radiographic OA, none reported pain at the most recent follow up. Two patients reported stiffness. Range of motion of the STJ at last follow-up was within 80% of the contralateral limb in all patients.
      Fig. 2
      Fig. 2Patient who suffered wound necrosis after open lateral subtalar joint dislocation and ankle fracture variant. X-Rays on presentation (A-B) and 17 months post-operatively (C). Wound at 5 weeks (D), and after debridement and prior to wound vac application and eventual split thickness skin grafting (E).

      Discussion and literature review

      Despite reviewing cases at two level 1 trauma centers, only 9 cases of subtalar joint dislocations were identified without talar neck or body fracutures. This underscores the scarcity of STJ dislocations and the need for studies to evaluate treatment protocols and outcomes. Furthermore, no anterior or posterior dislocations were identified. Anterior and posterior STJ dislocations continue to be demonstrated on a case report level.
      • Teo AQA
      • Han F
      • Chee YH
      • O'Neill GK
      Unstable Open Posterior Subtalar Dislocation Treated With a Ring External Fixator: A Case Report and Review of the Literature.
      • Gaba S
      • Kumar A
      • Trikha V
      • Das S
      • Agrawal P
      Posterior Dislocation of Subtalar Joint without Associated Fracture: A Case Report and Review of Literature.
      To the authors knowledge, the largest series of subtalar joint dislocations is that of Bibbo and colleagues in 2003.
      • Bibbo C
      • Anderson RB
      • Davis WH
      Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases.
      With 25 cases, they were capable of correlating injury characteristics to clinical and radiographic outcomes at a mean follow up of 5 years. They illustrated 89% rate of radiographic changes to the STJ, and 88% of cases with concomitant injury. Interestingly, this group reported symptomatic OA of the STJ to be less than one-third of the total prevalence of radiographic OA. Previously, the same group had emphasized the importance of CT imaging to uncover concomitant occult injuries.
      • Bibbo C
      • Lin SS
      • Abidi N
      • Berberian W
      • Grossman M
      • Gebauer G
      • Behrens FF
      Missed and associated injuries after subtalar dislocation: the role of CT.
      More recently, Ruhlmann and colleagues reviewed 13 cases of isolated acute traumatic dislocations, similar to the present study.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      With a mean follow up of 6 years, they noted a 46.1% and 23.1% rate of OA of the STJ and TNJ, respectively. Patients with conserved STJ range of motion (ROM) were associated with improved AOFAS scores. However, they did not grade or quantify the OA, which could preclude the greater rates of OA seen in our data despite the considerably shorter follow up. Another contributor is our inclusion of Kellgren-Lawrence Grade 1 as significant STJ OA.
      In 2019, a group in Italy discussed 3 cases of closed medial dislocations in volleyball players. With 4 weeks of immobilization and early physical rehabilitation, they demonstrated impressive AOFAS scores of 96.6 at 48 months of follow up.
      • Biz C
      • Ruaro A
      • Giai Via A
      • Torrent J
      • Papa G
      • Ruggieri P
      Conservative management of isolated medial subtalar joint dislocations in volleyball players: a report of three cases and literature review.
      Similarly, De Luna and colleagues noted successful conservative treatment of a closed medial dislocation.
      • De Luna V
      • Caterini A
      • Petrungaro L
      • Barosso M
      • De Maio F
      • Farsetti P
      Medial subtalar dislocation from a low-energy trauma. A case report and review of the literature.
      Camarda et al. found that patients with other peritalar injuries had lower AOFAS scores at final follow up.
      • Camarda L
      • Abruzzese A
      • La Gattuta A
      • Lentini R
      • D'Arienzo M
      Results of closed subtalar dislocations.
      This series included a total of 13 cases and a follow up of 76 months.
      Presently, we found that all STJ dislocations were irreducible at bedside in the emergency room, including at least one attempt under conscious sedation without paralytics. Two of these patients' first reductions were at a rural medical center prior to transfer to our facility. This highlights the difficulty in reducing STJ dislocation patterns. Also, this may emphasize the need for urgent treatment in the operating room in favor of putting a patient through multiple reduction attempts. Such protocol may decrease risk of ischemic damage due to skin tenting at the prominence of the talar head.
      • Ruhlmann F
      • Poujardieu C
      • Vernois J
      • Gayet LE
      Isolated acute traumatic subtalar dislocations: review of 13 cases at a mean follow-up of 6 years and literature review.
      There are various limitations to this study. For one, there are the limitations inherent to its retrospective case study-based nature, including the absence of clinical or patient reported outcomes. Although, clinical outcome has been associated negatively to the level of osteoarthritis.
      • Rammelt S
      • Goronzy J
      Subtalar dislocations.
      • Bibbo C
      • Anderson RB
      • Davis WH
      Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases.
      The short-term follow up is also a cause for concern, and may be a primary reason why subtalar joint motion was preserved and maintained at least 80% of the STJ motion of the contralateral limb in all patients. Two patients reported stiffness and exhibited less STJ range of motion than the contralateral limb. Also, occult injuries were likely missed in patients who did not obtain CT imaging.
      • Bibbo C
      • Lin SS
      • Abidi N
      • Berberian W
      • Grossman M
      • Gebauer G
      • Behrens FF
      Missed and associated injuries after subtalar dislocation: the role of CT.
      Nevertheless, all patients reported returning to their activities at pre-injury levels. Namely, all returned to manual labor and recreational activities without pain or loss of function, although two patients complained of general stiffness. One novel discovery was the greater progression of OA in the patient who underwent closed reduction and percutaneous pinning, which includes the only case of talonavicular OA. The authors surmise that additional injury to the STJ cartilage may have occurred with the 2.0 mm Steinmann pins in addition to the confounding factor of a more severe injury necessitating pin placement to hold the reduction.
      The authors do recommend taking STJ dislocations to the operating room with general anesthesia. Given that all 6 cases, as well as the other 3 without adequate follow-up, were not reducible with conscious sedation in the emergency department. This method may be judicious to expedite reduction with less chance of iatrogenic cartilaginous or neurovascular damage. Overall, the small number of patients and short term follow up does not allow us to draw any conclusions. The amount of case series in the literature is limited, demonstrating the need for further study.

      Author contribution statement

      The authors confirm contribution to the paper as follows: study conception and design: Ramez Sakkab. Data collection: Ramez Sakkab, Anne He. Analysis and interpretation of results: Ramez Sakkab, Stephanie Dal Porto-Kujanpaa, Brittany Rice. Draft manuscript preparation: Ramez Sakkab, Stephanie Dal Porto-Kujanpaa, Anne He, Brittany Rice. All authors reviewed the results and approved the final version of the manuscript.

      Informed patient consent

      The authors declare that informed patient consent was not provided for the following reason Institutional Review Board approval was obtained, and informed patient consent was waived.

      Declaration of Competing Interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper

      Funding statement

      This research was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award number UL1TR002550 . The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

      Acknowledgements

      The authors would like to thank Donald Green, DPM, FACFAS for their help with the scientific research process.

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