Avascular necrosis talus treatment
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The talus is a bone that forms part of two ankle joints.
It connects the leg to the foot and is responsible for the upward and downward movement (dorsiflexion and plantarflexion) of the ankle. This joint is called the tibial-talar joint.
Also, it sits on top of the heel bone (calcaneus) where it is responsible for the majority of the inward and outward movement (inversion and eversion) of the foot. This is called the subtalar joint.
Disorders of the talus can affect both the tibial talar ankle joint and the subtalar ankle joint. This means that multiple planes of movement of the foot and ankle can be altered. The major injury that can affect the talus is a fracture.
The goal of treating fractures of the talus is to maintain movement of the ankle and subtalar joints and restore normal anatomic relationships in order to prevent the development of arthritis.
In addition to arthritis, another condition that can cause damage to the talus is after fracture is loss of blood supply to the bone – a condition called avascular necrosis (AVN) of the talus. This loss of blood supply is a devastating problem associated with fracture of the talus because it causes death and the collapse of the bone.
Treatment of fractures of the talus can vary from simple immobilization of the foot in a cast or boot to surgery. Surgery is usually an open (meaning an incision is made) reduction and internal fixation. Pins and/or screws are used to hold the bone in place.
Recovery from a talar fracture can take a long time.
Avascular necrosis of the talus can be a devastating problem leading to total loss of the ankle joint with arthritis, deformity and pain. The blood supply is cut off by certain fracture types.
When the talus dislocates from the ankle joint, the incidence of AVN approaches 100%.
Here are some treatment measures:
In the past, when arthritis of the ankle joint occurred after AVN and talus fracture, a fusion of the ankle was recommended. Fusion eliminates pain but at the expense of marked limited range of motion as well as transfer of forces to other weight-bearing areas of the limb. For this reason, alternative treatments are desirable. One approach that shows promise is instead of the fusion of both the ankle and the subtalar joint, a fusion of the subtalar joint is followed by an ankle joint replacement of the tibial talar joint.
Total ankle replacement cannot always be performed if AVN is present. The ankle replacement must have good bone to sit on, and if the AVN is extensive, it cannot be performed. If a fusion of the subtalar joint is performed first, there is often sufficient bone underneath the talus to support the ankle prosthesis.
Drilling of the talus creates small holes and channels that improve the blood supply to the talus.
A free vascularized bone graft is a procedure where a small blood vessel attached to a piece of bone is implanted into the talus.
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