[External or internal fixation for arthrodesis of the ankle -- a comparative study of perioperative and long-term results]

Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods

BACKGROUND

Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA.

METHODS

A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation.

RESULTS

We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance.

CONCLUSION

This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA.

LEVEL OF EVIDENCE

Level IIa.

External versus internal fixation for arthrodesis of chronic ankle joint infections - A comparative retrospective study

BACKGROUND

Arthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard. We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.

METHODS

All patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.

RESULTS

Seventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p=0.019), achieved full weightbearing significantly more often (p=0.042) and faster and developed significantly fewer complications (p<0.001). Forty-three patients showed bone fusion without significant differences between the groups.

CONCLUSIONS

Ankle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.

Comparative study of outcomes after ankle arthrodesis shows higher complication rates in cases operated upon by general orthopaedic surgeons

INTRODUCTION

A functional assessment of 38 patients after ankle arthrodesis for the evaluation of the necessity of surgeons-specialisation was carried out by means of clinical evaluation and gait analysis after an average follow up of 30 months.

METHODS

Scores were used to grade ankle function. Gate analysis was examined to determine the effect of arthrodesis on the ankle in relation to the surgeons' experience. Under conditions of normal daily living, we found significant differences in life quality between patients operated upon by experts in orthopaedic foot and ankle surgery (group A) and patients operated by general orthopaedic surgeons (group B).

RESULTS

All patients in group A had orthograde stance. Wrong screw positioning and a failed neutral tibio-talar position were the main problems in group B. Due to this, the re-operation rate was 10%.

CONCLUSION

Our findings may have implications for surgical training programs and for regionalisation of complex surgical procedures.

Arthrodesis for septic arthritis of the ankle: risk factors and complications

INTRODUCTION

Septic ankle joint arthrodesis is a good therapeutic option in cases of infection after trauma or orthopedic surgical procedures. Many different procedures have been described, but external fixation seems to be standard. Aim of this study is to identify risk factors for complications in septic ankle joint arthrodesis with the external AO frame fixator.

MATERIALS AND METHODS

Patients who received septic ankle joint arthrodesis between January 2008 and December 2012 were included in this study. Patients were evaluated clinically and with radiographs or CT scans.

RESULTS

Follow-up of 74 of 79 patients with an external AO frame fixator could be evaluated; follow-up was 411 days (105-991). The mean age at surgery was 57.7 years (19-87). At this time, complications occurred in 41 patients (52 %) with wound healing problems (17 patients, 22 %) and non-union (12 patients, 15 %), and some needed surgical revision. In our collective, men had a significant higher non-union rate (p = 0.031), age or BMI showed no difference. Patients with diabetes and alcohol consumption showed a higher risk for complications (p = 0.049 and p = 0.031, respectively). 62 % of primary arthrodesis showed union, whereas in the case of revision, arthrodesis only 39 % showed union.

CONCLUSIONS

Septic ankle joint arthrodesis with the external AO frame fixator is a probable tool to achieve union. This study showed that there is a high complication rate and some risk factors for complications could be identified. A blinded and prospective study is needed to compare intramedullary nailing and external fixation to evaluate the possible advantage of intramedullary devices in septic ankle arthrodesis.

[Midterm results following denervation of the ankle]

BACKGROUND

Complications related to arthrodesis of the ankle or total ankle replacement require a critical assessment of the indication. Using denervation of the ankle, we have the possibility to delay the above-named surgical treatment for a number of years. The aim of this follow-up study was to review the results of ankle denervation after several years.

METHODS

Within a follow-up examination, we were able to evaluate the results of 45 patients an average of 102 months following ankle denervation.

RESULTS

A total of 82.2% of patients indicated an improvement of pain for an average of 60.9 months; 71.1% of patients reported that the operation was worthwhile. The AOFAS score improved from an average 37.9 (range 26-68) preoperatively to 55.6 (range 24-84) at follow-up.

CONCLUSIONS

Ankle denervation can achieve good ankle pain reduction in the treatment of ankle arthrosis. Denervation should be considered a long-term treatment concept.

Posttraumatic severe infection of the ankle joint - long term results of the treatment with resection arthrodesis in 133 cases

Although there is a clear trend toward internal fixation for ankle arthrodesis, there is general consensus that external fixation is required for cases of posttraumatic infection. We retrospectively evaluated the technique and clinical long term results of external fixation in a triangular frame for cases of posttraumatic infection of the ankle. From 1993 to 2006 a consecutive series of 155 patients with an infection of the ankle was included in our study. 133 cases of the advanced "Gächter" stage III and IV were treated with arthrodesis. We treated the patients with a two step treatment plan. After radical debridement and sequestrectomy the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted in the tibia and in the calcaneus and the gap was temporary filled with gentamicin beads as the first step. In the second step we performed an autologous bone graft after a period of four weeks. The case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues. Mean age at the index procedure was 49.7 years (18-82), 104 patients were male (67,1%). Follow up examination after mean 4.5 years included a standardised questionnaire and a clinical examination including the criteria of the AO-FAS-Score and radiographs. 92,7% of the cases lead to a stable arthrodesis. In 5 patients the arthrodesis was found partly-stable. In six patients (4,5%) the infection was not controllable during the treatment process. These patients had to be treated with a below knee amputation. The mean AOFAS score at follow up was 63,7 (53-92). Overall there is a high degree of remaining disability. The complication rate and the reduced patient comfort reserve this method mainly for infection. Joint salvage is possible in the majority of cases with an earlier stage I and II infection.

Clinical results of resection arthrodesis by triangular external fixation for posttraumatic arthrosis of the ankle joint in 89 cases

The methods for ankle arthrodesis differ significantly, probably a sign that no method is clearly superior to others. In the last ten years there is a clear favour toward internal fixation. We retrospectively evaluate the technique and evaluate the clinical long term results of external fixation in a triangular frame.