Bilateral atraumatic avascular necrosis of the talus with bone infarction of distal tibia and calcaneus after a septic pneumonia and multiorgan failure

Abstract

As discussed in past literatures, most cases of talar necrosis occur following a complex traumatic fracture to the talus.1 Cases of total talar avascular necrosis without a traumatic prehistory are still very rare, unlike the well-documented and up-to-date avascular necrosis of the hip joint. A male in his forties presented with community-acquired bacterial pneumonia and respiratory insufficiency. His condition progressed to respiratory and septic heart failure, kidney failure requiring dialysis, and acute liver failure, necessitating urgent treatment in the intensive care unit. The patient was treated for necrotizing fasciitis of the upper and lower extremities for a further four months, four weeks after recovery from critical sepsis. Approximately 15 months after full recovery, he sustained a minor supination injury to his right ankle with no evidence of post-traumatic ankle effusion, but was diagnosed with diffuse necrosis of the right talus with multifragmentary fracture and infarction of the distal tibia and calcaneus on MRI several days later. The same diagnosis was made on the left ankle a few weeks later. The diffuse bilateral talar necrosis appears to have been caused by a combination of factors, including generalized systemic ischemia during septic shock, catecholamine requiring cardiac failure, and the adverse effects of prolonged high-dose corticosteroid therapy.