Ankle arthrodesis using an arthroscopic method: long-term follow-up of 34 cases

Effect of a compression staple on correction of varus deformity during arthroscopic ankle arthrodesis

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) has become popular because of its higher rate of bone union, lower invasiveness, and shorter hospital stays compared to those of open arthrodesis. However, postoperative malalignment is often observed for severe varus deformity, which can cause nonunion, pain, and adjacent joint arthrosis. A compression staple can provide a persistent, strong compressive force on the bone surface. This study aimed to clarify the difference in alignment correction in AAA by comparing a compression staple and screws fixation with screws-only fixation pre- and postoperatively.

METHODS

Seventy ankles in 67 patients undergoing AAA were retrospectively reviewed. AAA with three screws through the distal tibia was performed in 53 ankles, and 17 ankles underwent AAA with a compression staple and two screws. After the preparation of the joint surface arthroscopically, patients in the S group had three canulated cancellous screws inserted through the medial tibia. Patients in the CS group had a compression staple placed at the lateral aspect of the tibiotalar joint and two screws inserted through the medial side. Clinical scores and pre-and postoperative alignment on plain radiographs were compared between the two procedures.

RESULTS

There were no significant differences in the pre-and postoperative Japanese Society for Surgery of the Foot scale. One ankle in the S group exhibited nonunion. There were no significant differences in talar tilt and tibiotalar angles between the groups. The tibial plafond angle in the CS group was significantly lower than that in the S group (p < 0.05). Postoperatively, talar tilt and tibiotalar angles on the coronal image, and the lateral tibiotalar angle in the CS group were significantly lower than those in the S group (p < 0.05).

CONCLUSION

AAA with a compression staple and two-screw fixations could obtain more optimal alignments than AAA with screw-only fixation, even in cases with severe varus deformity.

Small Joint Arthroscopy of the Foot

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.

Arthroscopic Ankle Arthrodesis

Despite the increasing popularity of total ankle replacement, ankle arthrodesis remains the gold standard for the treatment of end-stage ankle arthritis. Historically, open techniques have been utilized for ankle arthrodesis. There have been many variations and techniques described, including transfibular, anterior, medial, and miniarthrotomy. Inherent disadvantages to these open techniques include postoperative pain, delayed or nonunion, wound complications, shortening, prolonged healing times, and prolonged hospital stays. Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to the traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays.

Improvement in clinical outcome and quality of life after arthroscopic ankle arthrodesis in paralytic foot drop

BACKGROUND

Paralytic foot-drop is a disabling deformity that results from nerve or direct muscle injuries. Palliative surgeries such as tendon transfer and ankle arthrodesis are reserved for permanent deformity, with the arthroscopic technique had not been widely studied before. This study aims to evaluate the clinical outcome and quality of life after arthroscopic ankle fusion of paralytic foot-drop deformity.

MATERIALS AND METHODS

The patients who were retrospectively enrolled in this study underwent arthroscopic ankle fusion for paralytic foot-drop deformity between March 2017 and December 2021. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Cumberland Ankle Instability Tool (CAIT) were the measures used for clinical assessment. To judge the union, serial plain radiographs of the ankle were obtained. The preoperative and postoperative means were analyzed utilizing a two-tailed paired t-test, with a p value of less than 0.05 indicating statistical significance.

RESULTS

This study included 21 consecutive patients with a mean follow-up of 35.09 ± 4.5 months and a mean age of 41.5 ± 6.1 years. Highly significant improvements were observed between the preoperative and final follow-up means of the AOFAS score (from 57.6 ± 4.6 to 88.3 ± 2.7) and CAIT (from 12.1 ± 2.2 to 28.9 ± 1.01; p ˂ 0.00001 for both). All patients attained radiographic union and resumed their previous occupations without reporting serious adverse effects.

CONCLUSIONS

Arthroscopic ankle fusion is an effective, minimally invasive palliative surgery for patients suffering from permanent paralytic foot-drop deformity. This technique was shown to provide good functional and radiologic outcomes without significant complications.

LEVEL OF EVIDENCE

Retrospective cohort; level of evidence (IV).

Effectiveness of Arthroscopically Assisted Surgery for Ankle Arthrodesis

Regarding the treatment of ankle arthritis, the choice of arthroscopic ankle arthrodesis (AAA) or open ankle arthrodesis (OAA) remains controversial. To guide clinical decision-making, we conducted a meta-analysis on the optimal treatment of ankle arthrodesis. We identified eligible studies published from June 1, 1969 to June 1, 2020 using the Cochrane Library, PubMed, OVID, Embase, and Medline searched the references of relevant studies. Randomized and non-randomized studies that compared outcomes of AAA and OAA were included. After the methodologic assessment, available data were extracted and statistically reviewed. The primary outcomes were overall complications rate, tourniquet time, length of the hospital stay, non-union rate, and rate to fusion. The secondary outcomes were delayed union and postoperative infection rate. We included 9 studies comparing arthroscopic and open in patients with ankle arthrodesis, comprising 467 participants. AAA had the advantage of demonstrating a lower overall complication rate (odds ratio [OR], 0.44 [95% confidence interval [CI], 0.26-0.73]; p = .002), shorter intraoperative tourniquet time (mean difference [MD], -16.49 [95% CI, -23.51 to -9.46]; p < .001), shorter length of the hospital stay (MD -1.75, 95% CI -1.94 to -1.2, p < .001),lower non-union rate (OR, -0.07 [95% CI, -0.13 to -0.02]; p <.01) and higher rate to fusion (OR, 4.2 [95% CI, 1.96-8.99]; p < .001) in comparison with OAA. Yet, no significant differences were found in delayed union (OR, 0.46 [95% CI, 0.10-2.04]; p = .30) and postoperative infection rate (OR, 0.45 [95% CI, 0.17-1.15]; p = .09) between the groups. Our results suggest that arthroscopic ankle arthrodesis is superior to open ankle arthrodesis alone in the treatment of ankle arthritis based on the overall complication rate, intraoperative tourniquet time, length of the hospital stay, non-union rate and rate to fusion. However, further high-quality randomized controlled trials with appropriate blinding methods are needed to confirm the findings.

Do degree of coronal plane deformity and patient related factors affect union and outcome of Arthroscopic versus Open Ankle Arthrodesis?

BACKGROUND

This study aimed to analyse if union and outcome of Arthroscopic Ankle Arthrodesis (AAA) versus Open Ankle Arthrodesis (OAA) were influenced by the extent of coronal plane deformity and to report if patient related factors influence union.

METHODS

A total of 122 ankle arthrodesis procedures were included in the study. These were divided into two groups; Group A (n = 99) with deformity less than 15° and Group B (n = 23) with deformity greater than or equal to 15°. Data was collected on patient demographics, medical comorbidities (smoking, diabetes, obesity) and time to union. Patient reported outcome measures (PROMs) evaluated were Manchester Oxford Foot Questionnaire, EuroQol-5D and EuroQol visual analogue health thermometer (EQ-VAS).

RESULTS

The mean follow-up in Group A and B was 74.87 and 89.17 months respectively. The average deformity in Group A was 4.9° for AAA and 5.8° for OAA. In Group B it was 18.9° (maximum 28° varus) for AAA and 22.1° (maximum 41° valgus) for OAA. The overall union rate was 95% in Group A (AAA-94%; OAA-100%; [p = 0.20]) and 87% in Group B (AAA-100%; OAA-67%; [p = 0.02]). Mean time to union was 13.2 weeks in Group A (AAA-13.3 weeks; OAA-12.8 weeks; [p = 0.73]) compared to 12.4 weeks for Group B (AAA-12.9 weeks; OAA-11.8 weeks; [p = 0.56]). Irrespective of the extent of deformity and type of surgery, smokers had a 10 times higher likelihood of non-union (p = 0.03). In Group A, none of the PROMs showed significant difference between AAA and OAA. In Group B, EQ-VAS score reached statistical significance (p = 0.03) in favour of AAA whereas other PROMs showed no difference.

CONCLUSION

AAA is reproducible in achieving union in end stage ankle arthritis and good PROMs can be expected even in ankles with larger deformities. Regardless of the type of surgery and extent of deformity, smoking is a significant risk factor for non-union.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Arthroscopic Ankle Arthrodesis

End-stage ankle arthritis typically affects an active younger patient population as compared with hip and knee arthritis. The optimal surgical treatment depends on several patient-specific factors. Open ankle arthrodesis has achieved reliable outcomes for this condition over years; however, arthroscopic techniques seem to be advantageous and feasible even in cases with significant intraarticular deformity. This article describes the surgical technique of arthroscopic ankle arthrodesis and discusses the outcome compared with that of open ankle fusion and total ankle replacement.

Deciding Between Ankle and Tibiotalocalcaneal Arthrodesis for Isolated Ankle Arthritis

After isolated ankle (tibiotalar) arthrodesis, the triceps progressively shifts the subtalar joint into varus thus blocking compensatory motion from the midtarsal joints. In a tibiotalocalcaneal arthrodesis, the subtalar may be fixed with the correct valgus. Comparison between ankle and tibiotalocalcaneal arthrodesis does not clearly favor one over another for pain relief, satisfaction, and gait analysis. Compensatory sagittal plane motion through the midtarsal joints when the subtalar is fixed in valgus may be responsible for these results. Tibiotalocalcaneal arthrodesis has become our procedure of choice over isolated tibiotalar for end-stage ankle arthritis regardless of the radiographic state of the subtalar.

Arthroscopic vs open ankle arthrodesis: A prospective case series with seven years follow-up

BACKGROUND

The osteoarthritis of the ankle, although less common than other joints, is associated with severe functional limitation. Surgical options are ankle arthroscopic debridement, osteotomies, ankle arthrodesis and ankle arthroplasty. Ankle arthroplasty is increasingly used thanks to the new implants design, but ankle arthrodesis still represents the most used technique and it can be performed arthroscopically or with an open procedure.

AIM

To compare mid-term results of arthroscopic vs open ankle arthrodesis of patients affected by end-stage ankle arthritis.

METHODS

This study enrolled 23 patients, which underwent ankle arthrodesis. The patients were divided into 2 groups: group A (open procedure; n = 11) and group B (arthroscopic procedure, n = 12), the two groups were homogeneous with regard to age and body mass index (P = 0.347). The American Orthopaedic Foot and Ankle score (AOFAS), Freiburg Ankle score (FAS) and visual analogue scale for pain intensity were evaluated preoperatively, at six months and at final follow-up of 7.6 years in group A and 7.3 years in group B (P = 0.364).

RESULTS

Patients in the arthroscopic group showed better results at six-month follow-up compared to the open group at the AOFAS (group A, 62.2; group B, 78.5; P < 0.05) and the FAS (group A, 61.1; group B, 70.3; P = 0.015) scores. Pain relief was achieved in both groups at six-month follow-up (group A, 1.4; group B, 0.9; P = 0.162). Both open and arthroscopic groups showed improved clinical outcomes from baseline to final follow-up (P > 0.05). Hospital stay was shorter in group B than in group A (P = 0.001). More complications were reported in the open group than in the arthroscopic group (P = 0.459).

CONCLUSION

The arthroscopic and the open arthrodesis are valid and safe options for the treatment of ankle arthritis on the basis of clinical outcomes at 7 years follow-up. Moreover, the arthroscopic treatment shows faster improvement at six-month follow-up in comparison with the open group.

The Potential of Bone Debris as a Bioactive Composite for Bone Grafting in Arthroscopic Ankle Arthrodesis

Arthroscopic ankle arthrodesis (AAA) has advantages of being less invasive and achieving a high bone union rate. However, there are still some nonunion or delayed union cases, especially those of high-grade deformity. During AAA, curettage of the subchondral bone using an abrader burr provides bone debris, and there is the possibility of bone debris being used as autograft to improve bone union. The purpose of this study is to analyze bone debris histologically, and the effect of its implantation on bone union of AAA. Bone debris from 6 patients was collected during AAA. Bone debris/atelocollagen composite was made and cultured for 4 weeks. Histological analyses were performed before and after culture. Twenty-six patients with AAA were divided into 2 groups with or without bone debris implantation, and the time to union after surgery was evaluated. In histological analysis of bone debris/atelocollagen composite, bone debris contained bone, cartilage and synovium fragment at time 0. After 4 weeks of culture, osteocalcin positive cells migrated and proliferated in the gel. Ki67 positive cells significantly increased after culture. In clinical cases, time to union was significantly shorter in the bone debris group (9.3 ± 1.3 weeks) than that in the control (12.4 ± 3.1 weeks). This study showed that bone debris contained the osteochonductive and osteoinductive properties, and there is the potential for its implantation into the ankle joint to improve bone union in ankle arthrodesis.

Use of External Fixators as a 3-Dimensional Navigation Drill Guide for Arthroscopic Ankle Arthrodesis

In this article, we describe a novel technique using external fixators and cannulated screws to construct a 3-dimensional navigation drill guide to predict the screw trajectory before screw insertion that can prevent screw collision during arthroscopic ankle arthrodesis. Four orthopedic residents who had no prior experience of ankle arthrodesis were instructed on how to use the 3-dimensional navigation drill guide and where to insert the screws for ankle arthrodesis. Each resident inserted 6.5 cannulated screws on 8 sawbone ankle models using the device and the C-arm fluoroscopy. An experienced attending surgeon also inserted the same screws on 2 sawbone ankle models to find out if there is any difference between the experienced and inexperienced surgeons. All four residents and an attending surgeon did not experience any collision of screws for the three cannulated screws. Notably, one resident had collision of the 4th screw on his first sawbone model. On the second saw bone model, all surgeons could insert 5 screws without redrilling. A 3-dimensional navigation drill guide constructed with external fixators can assist surgeons in implementing percutaneous screws for arthroscopic ankle arthrodesis.

Arthroscopic Ankle Arthrodesis Provides Similarly Satisfactory Surgical Outcomes in Ankles With Severe Deformity Compared With Mild Deformity in Elderly Patients

PURPOSE

To evaluate the surgical outcome in terms of radiographic measurements, functional outcomes, and complications following arthroscopic ankle arthrodesis (AAA) in patients 60 years of age or older, and to compare the results of patients with mildly deformed ankle with those of patients with severely deformed ankle.

METHODS

We retrospectively reviewed patients who underwent AAA with 3 cannulated screws between January 2008 and December 2017 and followed postoperatively for at least 24 months. All included patients were 60 years of age or older. Demographic data and radiographic and functional outcomes were compared between patients with coronal deformity of less than 15° (group I) and those with a deformity equal to or greater than 15 degrees (group II).

RESULTS

A total of 41 patients with a mean age of 70.6 years were included (group I, n = 26; group II, n = 15) and mean follow-up was 51.4 months. Group II had significantly more severe preoperative coronal deformity of tibiotalar angle than group I (20.1 ± 2.9 vs 6.6 ± 4.1°, P < .01). Near-normal tibiotalar alignment was achieved postoperatively in both groups (group I, 3.4 ± 3.3 vs group II, 4.7 ± 3.1°, P = .227). Union was achieved in 39 (95.1%) patients with 2 cases in group I experiencing non-union. Union rate, mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and visual analog scale pain scores were not significantly different between the 2 groups at final follow-up.

CONCLUSIONS

AAA is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. In addition, arthroscopic intra-articular malleolar osteotomy was a useful technique for correcting severe coronal deformity in our series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: Arthroscopic Ankle Arthrodesis Requires Intraoperative Deformity Correction: Size of the Deformity Is Not the Primary Determinant of Outcome

Traditional teaching has told us that arthroscopic ankle arthrodesis is reserved for those patients with severe osteoarthrosis but minimal deformity. However, it is not the size of the deformity that matters; rather, it is the ability to correct the deformity intraoperatively that leads to satisfactory results. Preoperative identification of those patients with significant deformity that can be corrected with an arthroscopic approach would allow for improved selection and likely lead to better patient-reported outcomes and fewer complications.

A case of arthroscopic ankle arthrodesis for hemophilic arthropathy of the bilateral ankles

•

We successfully treated hemophilic arthropathy in both ankles with arthroscopic arthrodesis.

•

In surgery for patients with hemophilia, perioperative supplementation of the deficient coagulation factor was necessary.

•

There were many advantages in arthroscopic ankle arthrodesis, compared to open ankle arthrodesis.

Introduction

Hemophilic arthropathy can affect multiple joints including ankle. However, only one report has been published regarding both arthroscopic ankle arthrodesis with hemophilic arthropathy.

Presentation of case

The patient was a 23-year-old man with hemophilia A and a 3-year history of recurrent hemarthrosis in both ankles. We undertook surgery to treat arthropathy. His left ankle was treated first and the right ankle 6 months later. In both ankles, the cartilage was worn and eburnated. The remaining cartilage was removed and more dimples were created to fuse the tibia and talus. The ankle was fixed using 3 cannulated screws. Postoperatively, the patient wore an immobilization cast with no weight-bearing for 2 weeks. Thereafter, weight-bearing was allowed and the cast was removed 4 weeks after surgery.

Discussion

At the 1-year follow-up, bony union was satisfactory, functional outcome was acceptable, and pain relief was good. The Japanese Society for Surgery of the Foot ankle-hindfoot scale score increased from 24 preoperatively to 87 postoperatively.

Conclusion

We report successful treatment with arthroscopic arthrodesis in a case of hemophilic arthropathy in both ankles.

What should we be careful of ankle arthroscopy?

PURPOSE

Ankle arthroscopy has been used as a standard tool by foot and ankle surgeons. To overcome the narrowness of ankle joint, a noninvasive distraction technique is used for the successful visualization in ankle arthroscopy. The aim of this study was to investigate the incidence and type of complications associated with ankle arthroscopy using a noninvasive distraction technique and to report a troublesome complication.

METHODS

We reviewed 514 patients' charts from 2003 to 2011. The same noninvasive distraction technique was used. Patients' demography, duration of follow-up, diagnoses, procedures, and complications related to ankle arthroscopy were analyzed.

RESULTS

There were 388 male and 126 female; mean age was 37.2 years; mean follow-up duration was 33 months. The diagnoses were osteochondral lesion of talus, chronic ankle instability, anterolateral soft tissue impingement syndrome, and anterior bony impingement. We performed arthroscopic synovectomy, osteochondral procedure, bony spur excision, and loose body removal. The mean time of arthroscopic procedure was 47 min. There were neurologic complications (eight cases), skin necrosis of posterior thigh (three cases), instrument breakage (two cases), and superficial wound infection (one case). All complications were well resolved. The total duration of distraction plus tourniquet inflation exceeded 120 min in the three cases of skin necrosis. Skin necrosis was deemed to be resulted from the long tourniquet time.

CONCLUSION

The noninvasive distraction technique is safe and effective for ankle arthroscopy. However, the distraction plus tourniquet requires attention because it can cause high pressure on posterior thigh resulting in soft tissue injury.

Effect of Lateral Gutter Osteophyte Resection on Correction of Varus Deformity in Arthroscopic Ankle Arthrodesis

BACKGROUND

Recently, arthroscopic ankle arthrodesis has been performed for moderate-to-severe varus-deformed ankle osteoarthritis. However, the effect of osteophyte resection in the lateral gutter in arthroscopic ankle arthrodesis has not been clarified. We hypothesized that a varus-deviated ankle with lateral gutter osteophytes can be corrected by osteophyte resection.

METHODS

Thirty-nine ankles of 38 patients were included. The mean age of patients was 70.0 (45-83) years. The patients were divided into the following groups: group with an osteophyte in the lateral gutter (osteophyte) and group with no osteophytes (nonosteophyte). Preoperative and postoperative tibiotalar angle, tibial plafond angle, and tibiotalar angle under valgus stress, as well as the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, were recorded. Twelve ankles underwent lateral gutter osteophyte resection, whereas the other 27 ankles did not require osteophyte resection.

RESULTS

Preoperative tibiotalar angle was higher in the osteophyte group than in the nonosteophyte group (21.8 vs 11.2 degrees, P = .01). The tibiotalar angle in the preoperative valgus stress imaging was higher in the osteophyte group (12.9 vs 5.7, P < .01). However, the postoperative tibiotalar angle was similar between the 2 groups (7.1 vs 5.4, P = .183). JSSF ankle/hindfoot scale improved in both groups.

CONCLUSION

Lateral gutter osteophyte resection enabled correction of the varus malalignment in arthroscopic ankle arthrodesis.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Current concepts in the management of ankle arthritis

Ankle arthritis is a common condition. It causes a significant socioeconomic burden, and is associated with significant morbidity. Patients with ankle arthritis are either elderly with significant co-morbidities, or young adults who have previously suffered with ankle injuries, resulting in post-traumatic arthritis. There is a wide variation in the management of these patients with ankle arthritis. We therefore present an overview of the current evidence based management of patients with symptomatic ankle arthritis.

Postoperative weightbearing following ankle arthrodesis

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Patients and Methods

MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates.

Results

A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis.

Conclusion

Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262

Application of 3D-Printed Personalized Guide in Arthroscopic Ankle Arthrodesis

Objective

To accurately drill the Kirschner wire with the help of the 3D-printed personalized guide and to evaluate the feasibility of the 3D technology as well as the outcome of the surgery.

Methods

Patients' DICM data of ankle via CT examinations were introduced into the MIMICS software to design the personalized guides. Two 2mm Kirschner wires were drilled with the help of the guides; the C-arm fluoroscopy was used to confirm the position of the wires before applying the cannulated screws. The patients who underwent ankle arthrodesis were divided into two groups. The experimental group adopted the 3D-printed personalized guides, while the control group received traditional method, i.e., drilling the Kirschner wires according to the surgeon's previous experience. The times of completing drilling the Kirschner wires to correct position were compared between the two groups. Regular follow-ups were conducted to statistically analyze the differences in the ankle fusion time and AOFAS scores between the two groups.

Results

3D-printed personalized guides were successfully prepared. A total of 29 patients were enrolled, 15 in the experimental group and 14 in the control group. It took 2.2 ± 0.8 minutes to drill the Kirschner wires to correct position in the experimental group and 4.5 ± 1.6 minutes in the control group (p=0.001). No obvious complications occurred in the two groups during and after surgery. Postoperative radiographs confirmed bony fusion in all cases. There were no significant differences in the fusion time (p=0.82) and AOFAS scores at 1 year postoperatively between the two groups (p=0.55).

Conclusions

The application of 3D-printed personalized guide in assisting the accurate drilling of Kirschner wire in ankle arthrodesis can shorten the operation time and reduce the intraoperative radiation. This technique does not affect the surgical outcome.

Trial Registration Number

This study is registered on www.clinicaltrials.gov with NCT03626935.

Arthroscopic Ankle Arthrodesis: A 2-15 Year Follow-up Study

PURPOSE

The purpose of our study was to determine the results of arthroscopic ankle arthrodesis (AAA) and how the procedure affects adjoining joints and functional scores.

METHODS

Between 1993 and 2013, 116 patients (120 ankles) underwent AAA. Nineteen ankles were lost to follow-up due to death, insufficient radiographic studies, or inability to contact, resulting in 97 patients (101 ankles). Mean age at surgery was 61.1 years (range, 35.8-79.6 years); mean follow-up was 86 months (range, 24-247 months). Patients were assessed according to the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Ankle Osteoarthritis Scale (AOS), and Foot and Ankle Outcome Score (FAOS) and underwent comprehensive clinical and radiographic examinations.

RESULTS

A total of 94.6% of patients achieved ankle fusion on radiographs. Mean AOFAS score was 83.3 (standard deviation [SD], 13.2). Mean modified FAOS score was 87.4 (SD, 10.4). The AOS scoring system showed 75% good/excellent results. According to the Kellgren-Lawrence score and van Dijk osteoarthritis grading scale, 85% and 69% of patients had no change in talonavicular or subtalar grade of osteoarthritis, respectively. There were no cases of deep infection or other serious adverse events. All but 4 patients were able to return to work following AAA.

CONCLUSIONS

AAA is an effective operation for treating degenerative ankle disease, even in cases of moderate tibiotalar coronal deformity. At a mean of 86 months postop, nearly three quarters of our patients had good/excellent functional outcomes. Arthritis found in the adjacent hindfoot joints at the time of tibiotalar fusion appears to be a function of preexisting arthritic change and not directly caused by the tibiotalar fusion.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Joystick of the Talus for Correcting Malalignment During Arthroscopic Ankle Arthrodesis: A Surgical Tip

Ankle arthrodesis has been widely reported as an effective solution in treating tibiotalar joint osteoarthritis. The arthroscopic tibiotalar approach for arthrodesis has also been proven to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. Historically, ankle malalignment has represented one of the main contraindications for the arthroscopic procedure, but interestingly some investigators have shown that the coronal joint deformity may be addressed arthroscopically as well. Other investigators have also demonstrated that part of the valgus/varus is due to malrotation of the talus within the mortise; therefore, controlling the talar position becomes crucial for correcting more severe deformities. We present here a technique for correcting tibiotalar malalignment during arthroscopic arthrodesis in varus or valgus ankles, performed through a K-wire used as a joystick to manage the talar position on both the coronal and axial planes.

Effect of Preoperative Deformity on Arthroscopic and Open Ankle Fusion Outcomes

INTRODUCTION

Coronal deformity is considered a relative contraindication for arthroscopic ankle fusion. This study assessed whether preoperative coronal ankle joint deformity influenced the outcome of arthroscopic ankle fusion.

METHODS

Ninety-seven patients had 62 arthroscopic and 35 open ankle fusions between 2005 and 2012. Clinical outcomes were prospectively recorded with use of the Ankle Osteoarthritis Scale (AOS) and Ankle Arthritis Scale (AAS) preoperatively and at 6, 12, and 24 months and final follow-up. Radiological alignment was measured using the tibiotalar angle, the tibial plafond angle, the lateral talar station, and the lateral tibiotalar angle. Both groups had the same demographics.

RESULTS

Preoperative deformity was the same regarding sagittal alignment and overall coronal alignment, but the arthroscopic group had less tibial deformity (tibial plafond angle range 0-19 degrees vs 0-43 degrees). At final follow-up, the mean AOS was 34.2 for arthroscopic (95% confidence interval [CI], 23.3-45.2) vs 33.9 for open (95% CI, 17.8-49.9). The AAS at final follow-up was 26.0 for arthroscopic (95% CI, 21.0-31.0) vs 27.5 for open (95% CI, 19.7-35.2). Both groups had the same tibiotalar angle, lateral talar station, and lateral tibiotalar angle at follow-up. Regression analyses revealed no influence of type of surgery, preoperative deformity, postoperative radiological alignment, age, sex, body mass index, smoking status, etiology of the arthritis, and need for bone grafting on outcome scores (all P > .05).

CONCLUSION

Arthroscopic and open ankle fusion yielded equivalent results for both patient-reported outcome measure and radiographic alignment in patients with coronal and sagittal joint deformity. Patients with higher tibial plafond angles more often underwent open fusion.

LEVEL OF EVIDENCE

III, comparative series.

Arthroscopic Ankle Arthrodesis: An Update

Arthroscopic ankle arthrodesis provides an alternative to open techniques. Advancements in arthroscopic techniques and instrumentation have made the procedure easier to perform. Arthroscopic ankle arthrodesis has demonstrated faster rates of union, fewer complications, reduced postoperative pain, and shorter hospital stays. Sound surgical techniques, particularly with regard to joint preparation, are critical for success. Comorbidities such as increased body mass index, history of smoking, malalignment, and posttraumatic arthritis should be considered when contemplating arthroscopic ankle arthrodesis. Although total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis remains a viable alternative for management of the end-stage arthritic ankle.

Posterior Arthroscopic Tibiotalar Arthrodesis: Anatomic Feasibility Study

Anterior arthroscopic tibiotalar arthrodesis has been well codified. A posterior approach with the patient in prone position is indicated when the anterior approach is precluded by soft tissue issues or for a 1-step procedure associated with posterior subtalar fusion. In an anatomic study, we assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine the arthroscopy entry points, mortise cartilage freshening quality, and risk of osseous, tendinous, vascular, and neural complications. We mapped 22 zones of the fibular tibiotalar mortise from 10 specimens. Medial and lateral para-Achilles arthroscopic approaches were used, with a 4-mm arthroscope at 30°. For chondral resection, we used a motorized burr, curette, and osteotome. The entire plafond of the tibial mortise could be freshened in all cases, but the talar dome could be freshened in its entirety in only 20% of cases. In 80%, only the posterior two thirds could be treated, because the anterior portion descending to the neck of the talus was poorly accessible. More than 50% of the area of the malleolar grooves was freshened. One medial malleolar fracture and one posterior fibular artery lesion developed. Thus, the technique was shown to be feasible, if no frontal hindfoot deformity or tibiotalar equinus is present, which would prevent satisfactory resection of the posterior and anterior talar cartilage. The procedure allows for single-step associated subtalar fusion, requiring 2 complementary arthroscopic approaches, 1 cm distally.

Comparison of compressive forces caused by various cannulated cancellous screws used in arthroscopic ankle arthrodesis

Background

When performing arthroscopic ankle arthrodesis for end-stage ankle arthritis, internal fixation is performed using bone screws after appropriate preparation.

However, optimal characteristics of bone screws have not been examined in terms of pressure force. Objective comparisons of bone-screw performance may provide information on procedures for arthroscopic ankle arthrodesis. The study objectives were to determine whether it was possible to measure compressive force changes using the newly developed device and to infer all screw characteristics from measurement results when used in actual surgeries. In addition, we performed experiments on cadavers to verify whether the experimental results could be applied to the joints of living subjects.

Methods

Three types of screws (S1, S2, and S3) were inserted into the unique measurement device, and the changes in pressure were measured for each 45° turn. Changes in pressure and maximum pressure force were recorded after the application of the screws. After reaching the maximum pressure in the simulated bone, further screw rotations were accompanied by a gradual pressure decrease to 0 MPa. We also measured pressure changes in a similar manner by inserting a miniature pressure sensor into the talocrural joints of cadavers.

Results

The mean maximum pressure ± standard deviation for S1, S2, and S3 were 0.832 ± 0.164 MPa, 0.434 ± 0.116 MPa, and 0.414 ± 0.127 MPa, respectively. Pressure slopes to the maximum did not significantly differ between the screws in the simulated bone, and a subsequent pressure decrease to 0 MPa was significantly more rapid for S1 than for S2 and S3. Although pressure failure after the overtightening of screws was only observed in the simulated bone, patterns of pressure vs. rotation angle were similar in simulated and cadaveric bones. The pressure profile characteristics of three different screw types were determined.

Conclusions

We were able to measure the compressive force changes using the newly developed device when the screws were inserted. On the basis of the measurement results, we were able to infer the characteristics of all screws when used in actual surgery.

Arthroscopic arthrodesis for ankle arthritis without bone graft

Background

Ankle arthrodesis is considered by many to be the standard operative treatment for end-stage ankle arthritis. The purpose of this study was to perform a new technique for ankle joint surface and determine the outcome for the union rates of ankle arthroscopic arthrodesis.

Methods

A total of 68 patients with posttraumatic arthritis, primary osteoarthritis, and rheumatoid arthritis were treated by ankle arthroscopic arthrodesis between May 2007 and December 2012. Our surgical indication was deformity less than 15° measured by weight-bearing radiographs. Firstly, the remaining articular cartilage was removed with different curettes and shavers. Then, the new technique (microfracture) was done at tibiotalar surfaces. Finally, the ankle was fixed with two cannulated percutaneous screws. The wound healing, complications, postoperative radiographs, and American Orthopaedic Foot and Ankle Society (AOFAS) score were evaluated.

Results

The average follow-up time was 32 months (range 25–58 months). There was no bone grafting, and a fusion rate of 100% was achieved. The average fusion time was 12.1 weeks. One patient developed superficial infection at 2 weeks postoperatively and was cured by nonsurgical treatment. No deep infections, deep venous thrombosis, or revision surgery were observed. Screws had been removed in four patients because of prominence. One patient had fusion in the subtalar joint because of arthritis at 5 years postoperatively. At the last follow-up, radiographic signs of developed or progressing arthritis were observed in nine patients at subtalar joint and in four patients at talonavicular joint. At 1-year follow-up, the mean AOFAS ankle/hindfoot score had increased to 84 from a mean preoperative value of 38 (P < 0.01).

Conclusions

Arthroscopic arthrodesis provides surgeons with an alternative to traditional open techniques for the management of severe ankle arthritis. Our data show that preparation of the joint surface with microfracture is an effective technique to increase the union rate of arthroscopic ankle arthrodesis, while bone graft and other promoting substances are not necessary to be routinely used.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-016-0490-y) contains supplementary material, which is available to authorized users.

Ankle arthrodesis: A systematic approach and review of the literature

Ankle arthrodesis is a common treatment used for patients with end-stage ankle arthritis (ESAA). The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus (0°-5°)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain-free plantigrade foot for weightbearing activities. There are many variations in operative technique including deferring approaches (open or arthroscopic) and differing fixation methods (internal or external fixation). Each technique has its advantage and disadvantages. Success of ankle arthrodesis can be dependent on several factors, including patient selection, surgeons’ skills, patient comorbidities, operative care, etc. However, from our experience, the majority of ESAA patients obtain successful clinical outcomes. This review aims to outline the indications and goals of arthrodesis for treatment of ESAA and discuss both open and arthroscopic ankle arthrodesis. A systematic step by step operative technique guide is presented for both the arthroscopic and open approaches including a postoperative protocol. We review the current evidence supporting each approach. The review finishes with a report of the most recent evidence of outcomes after both approaches and concerns regarding the development of hindfoot arthritis.

Percutaneous Hindfoot and Midfoot Fusion

Hindfoot and midfoot fusions can be performed with percutaneous techniques. Preliminary results of these procedures are encouraging because they provide similar results than those obtained with open techniques with less morbidity and quick recovery. The best indications are probably fusions for mild-to-moderate reducible hindfoot and midfoot deformities in fragile patients with general or local bad conditions. The main limit is linked to the surgeon's experience in percutaneous foot surgery because a learning curve with the specific tools is necessary before doing these procedures.

Percutaneous Pediatric Foot and Ankle Surgery

The techniques for performing percutaneous osteotomies in treating deformities of the foot in children are presented along with a detailed description of the operative details. The author's use of minimal-access surgery for tibial, os calcis, and midfoot osteotomies is described using a cooled side-cutting burr that has not previously been described for use in the child's foot. The cancellous nature of the bones in the child are easily cut with the burr and the adjacent soft tissues are not damaged. The early experience of the healing times are not impaired and the complications associated with percutaneous scars seem to be negligible.

Anatomic Feasibility Study of Posterior Arthroscopic Tibiotalar Arthrodesis

BACKGROUND

Operative indications for an anterior arthroscopic tibiotalar arthrodesis are well defined. A posterior approach with the patient in a prone position may be indicated when the anterior approach is precluded by the soft tissue condition or for a 1-step procedure associated with posterior approach subtalar fusion.

METHODS

An anatomic study assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine arthroscopy entry points, mortise cartilage freshening quality, and the risk of osseous, tendinous, vascular, and neural complications. Twenty-two zones of the fibular tibiotalar mortise were mapped from 10 specimens. Medial and lateral para-Achilles arthroscopic portals were used with a 4 mm 30-degree arthroscope. Chondral resection was performed with a motorized burr, curette, and osteotome.

RESULTS

The entire plafond of the tibia could be debrided in all cases, whereas the talar dome was debrided in its entirety in 20% of cases; in 80%, only the posterior two-thirds could be treated with the anterior portion approaching the neck of the talus being poorly accessible. More than 50% of the area of the malleolar grooves was debrided. There was 1 medial malleolar fracture and 1 peroneal artery lesion.

CONCLUSION

The technique was shown to be feasible if there was no frontal hindfoot deformity or tibiotalar equinus preventing satisfactory resection of the posterior and anterior talar cartilage.

CLINICAL RELEVANCE

This study demonstrated that a posterior approach arthroscopic ankle fusion would lead to adequate joint preparation. This procedure reduces the risk of nerve damage.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

BACKGROUND

While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior.

METHODS

A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material.

RESULTS

This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables.

CONCLUSION

Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft.

LEVEL OF EVIDENCE

Level IV.

Ankle arthrodesis in tubercular arthritis using anterior bridge plating: a report of 2 cases

Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results.

Arthroscopic ankle arthrodesis with intra-articular distraction

Arthroscopic ankle arthrodesis has shown high rates of union comparable to those with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments. However, sometimes, standard noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma. In the present report, we describe a technique to distract the ankle joint by inserting a 4.6-mm stainless steel cannula with a blunt trocar inside the joint. The cannula allowed sufficient intra-articular distraction, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patient's position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction.

[Arthrodesis and endoprostheses of the ankle joint: indications, techniques and pitfalls]

If adequate conservative measures for the treatment of end-stage ankle osteoarthritis have failed, surgery may be taken into consideration. After exorbitant failure rates in the beginning of total ankle replacement, nowadays this kind of treatment has regained lot of interest and has become a viable alternative to ankle fusion. The correct indication and a precise explanation of the surgical procedure, outcomes and potential complications provide a solid base for future success.Currently, there is no doubt that total ankle replacement has become an important player in the treatment of symptomatic and debilitating end-stage ankle arthritis. With increasing number of patients who undergo total ankle replacement the experience with this kind of procedure increases too. As a consequence several surgeons have started to stretch indications favoring total ankle replacement. However, it must be mentioned here, despite progress in terms of improved anatomical and biomechanical understanding of the hindfoot and improved surgical techniques and instruments, total ankle replacement and ankle fusion remain challenging and difficult procedures. We provide a review article including an overview of the relevant techniques. This article should serve as rough guide for surgeons and help in decision-making regarding total ankle replacement and ankle fusion.

Arthroscopic ankle arthrodesis in hemophilic arthropathy

BACKGROUND

Ankle arthrodesis is an accepted treatment for patients with advanced disabling tibiotalar arthritis, mostly in osteoarthritis, rheumatoid, and posttraumatic arthritis. No detailed reports have been published regarding the use of arthroscopy for the treatment of the end-stage hemophilic ankle. The purpose of this article is to report the results of arthroscopic ankle arthrodesis in hemophilic arthropathy of the ankle.

METHODS

Ten patients (10 ankle joints) who underwent arthroscopically assisted ankle arthrodesis for the treatment of end-stage hemophilic A arthritis were enrolled in this study. The rate of ankle fusion, incidence of complications, and clinical rating by the Morgan system were analyzed.

RESULTS

In this series, the fusion rate was 100%, and patients achieved bone fusion as shown by radiographs. The average time to fusion was 10.5 weeks. Superficial wound infection occurred in 1 patient. According to the Morgan system, there were 8 (80%) good to excellent results and 2 (20%) fair results. All patients were satisfied with the outcome of the operation.

CONCLUSIONS

Arthroscopic ankle arthrodesis was an effective alternative to open technique with established advantages in hemophilic arthropathy.

LEVEL OF CLINICAL EVIDENCE

Level IV, retrospective case series.

Incidence of nonunion after isolated arthroscopic ankle arthrodesis

PURPOSE

To determine the incidence of nonunion after isolated arthroscopic ankle arthrodesis.

METHODS

Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google, were systematically searched for the terms "arthroscopic ankle arthrodesis" AND "nonunion". Additionally, we manually searched common American, British, and European orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: isolated ankle arthrodesis, greater than 20 ankles, minimum mean follow-up of 12-months, a 2-portal anterior arthroscopic approach, fixation with 2 or 3 large-diameter cannulated cancellous screws, and the nonunion rate with no restriction on cause.

RESULTS

After considering all the potentially eligible articles, 7 (25.9%) met the inclusion criteria. A total of 244 patients (244 ankles)-148 (60.7%) male and 96 (39.3%) female patients, with a weighted mean age of 49.2 years-were included. For those studies that specified the exact follow-up, the weighted mean was 24.1 months. A total of 21 nonunions (8.6%) were reported, with 14 (66.7%) being symptomatic and requiring further intervention.

CONCLUSIONS

The results of this systematic review reveal an acceptable incidence of nonunion of 8.6%. However it is important to recognize that of these nonunions, 66.7% were symptomatic. This supports the belief that regardless of approach, nonunion of an ankle arthrodesis is problematic. In light of this finding, additional prospective studies are warranted to compare directly the incidence of nonunion between open, minimum incision, and arthroscopic approaches with a variety of fixation constructs.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Arthroscopic tibiotalocalcaneal arthrodesis with locked retrograde compression nail

Tibiotalocalcaneal (TTC) arthrodesis is a demanding procedure. Several techniques have been described for successful fusion, including the use of plates, screws, intramedullary nails, and external fixators. Arthroscopic TTC fusion with intramedullary nailing has been recently described as an alternative method to traditional open procedures. The surgical technique and clinical and radiographic outcomes of 2 patients who had undergone arthroscopic TTC arthrodesis with intramedullary nailing are presented. The indication for surgery was symptomatic tibiotalar and subtalar post-traumatic arthritis in 1 patient and distal tibia and fibula nonunion in the other. In both cases, fusion was obtained at approximately 8 weeks postoperatively. At the final follow-up visit at 2 years postoperatively, their American Orthopaedic Foot and Ankle Society score had improved from 31 to 85 points and from 16 to 71 points, respectively. No intra- or postoperative complications developed. Arthroscopic TTC arthrodesis can be an alternative to traditional open procedures, especially in patients with soft tissue concerns or several previous surgeries. Experience with ankle arthroscopy procedures is mandatory to obtain satisfactory results and minimize the risk of complications.

Open ankle arthrodesis with a fibular-sparing technique

BACKGROUND

Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique.

METHODS

A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring.

RESULTS

At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being "completely satisfied" with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment.

CONCLUSION

This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores.

Surgical treatment of the arthritic varus ankle

Within the past several years, the arthritic varus ankle has been addressed extensively in Foot and Ankle Clinics, with numerous excellent reviews by particularly knowledgeable authors. To support these outstanding contributions, this article provides a practical approach to this challenging constellation of foot and ankle abnormalities. Varus ankle arthritis exists on a continuum that prompts the treating surgeon to be familiar with a spectrum of surgical solutions, including joint-sparing realignment, arthroplasty, and arthrodesis. Each of these treatment options is addressed with several expanded case examples and supports the management approaches with the available pertinent literature.

TIBIOTARSAL COMPRESSION ARTHRODESIS USING A LATERAL LOCKING PLATE

OBJECTIVES

Tibiotalar (TT) arthrodesis is still a very important option in the treatment of primary or post-traumatic arthritis of the ankle but persists the controversy regarding the optimal method for the fixation of the arthrodesis site. No matter the implant used, the goal is to obtain a solid, healthy, pain-free fusion. The purpose of the current study is to present the preliminary results of a novel laterally based tibiotalar compression arthrodesis system using a locked plate.

METHODS

Thirteen consecutive patients with tibiotalar arthritis were submitted to an arthrodesis using a new lateral plating system. The average age was 59.7 years (range 36~72); nine patients were male and four female. Using a cutting guide, the remaining articular surfaces of the tibia and talus were removed. A compression device was applied to avoid malalignment of the ankle and a precontoured lateral locking plate was used to achieve the joint fusion.

RESULTS

Both the AOFAS ankle-hindfoot score and the VAS score improved with the surgery. All patients' ankles fused by 6 months. In all patients we found a very good alignment in the sagittal, coronal and transverse planes.

CONCLUSION

We believe that a combination of a bilateral compression, contoured bony cuts, and lateral locked plating offers a novel, accurate and useful technique for ankle arthrodesis.

Arthroscopic ankle arthrodesis: are results reproducible irrespective of pre-operative deformity?

BACKGROUND

Arthroscopic ankle arthrodesis is gaining in popularity. It has been shown to have a shorter time to union and less morbidity than traditional open procedures. The arthroscopic technique has been mainly used for ankles with minimal deformity. Our aim was to find out whether we could reproduce the good results of arthroscopic ankle arthrodesis in both minimally and markedly deformed ankles.

METHODS

We reviewed 62 patients who underwent an arthroscopic ankle arthrodesis for end stage arthritis. The average follow up was 63 months (range 21-92 months). Patients were evaluated subjectively and objectively using the Mazur grading system. 4 patients died before final review and 3 were lost to follow-up leaving 55 patients for evaluation. The pre-operative tibiotalar angle in the coronal plane was between 26° valgus and 24° varus. We divided our patients into 2 groups based on the tibiotalar angle. Group A (n=31) had a varus or valgus deformity of less than 15 and Group B (n=24) had a deformity equal to or more than 15°.

RESULTS

The overall fusion rate was 91%. Fusion occurred in 29 of 31 (94%) ankles in Group A compared to 21 of 24 (88%) in Group B (p=0.64).The overall mean time to union was 10.4 weeks. The time to union in Group A was 8.8 weeks compared to 12.7 weeks for Group B (p=0.001). Using the Mazur ankle grading system, 84% of the cases in Group A had a good to excellent result compared to 79% in Group B (p=0.73). There were 2 superficial infections, 2 cases of deep vein thrombosis and 3 patients required removal of prominent screws.

CONCLUSIONS

We have shown that arthroscopic ankle arthrodesis yields reliable and reproducible results in a District General Hospital setting with high union rates, short time to union and low complication rates. It can be satisfactorily employed for ankles with significant deformity, although this resulted in a longer time to union. The end results remain uniformly good to excellent.

Arthroscopic tibiotalocalcaneal arthrodesis with intramedullary nail with fins: a case series

Arthroscopic arthrodesis of the ankle has several advantages compared with open arthrodesis, including a smaller skin incision, less damage to the soft tissue around the joint, a lower risk of skin necrosis and infection, a lower incidence of postoperative infection and swelling, and better preservation of the contour of the surface of the joint, which maintains a larger contact area between the talus and tibia. We successfully performed arthroscopic arthrodesis of the tibiotalocalcaneal joints with intramedullary nails with fins in 9 ankles of 8 patients. Solid fusion was attained in all cases, except for 1 case of nonunion at the subtalar joint. We also corrected the alignment in 1 patient with a varus deformity. The fixation was strong, even in the case of poor bone quality, such as occurs in rheumatoid arthritis. The intramedullary nails with fins allowed for appropriate compression for bone consolidation without loss of rotational stability. Arthroscopic tibiotalocalcaneal arthrodesis, a less-invasive technique than conventional open surgery, is effective treatment, especially in patients with poor skin conditions secondary to diseases such as rheumatoid arthritis and diabetes mellitus.

Small joint arthroscopy of the foot

The arthroscopic approach to small joints of the foot has made many advances in recent years, which can be directly related to the improvement of the surgical equipment. This improvement has led to more indications for the use of arthroscopy as well as minimizing the complications. Several articles recently have presented experiences in arthroscopic surgery in the small joints of the foot; however, its use is still relatively limited. Approaches to small joints of the foot involve the first metatarsophalangeal joint, tarsometatarsal joint, and Chopart joint, as well as the interphalangeal joint to the great toe and lesser toes.

Arthroscopic ankle arthrodesis

Arthroscopic ankle arthrodesis provides the surgeon with an alternative to traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays. Adherence to sound surgical techniques, particularly with regard to joint preparation, is critical for success. Although total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis remains a viable alternative for the management of end-stage arthritic ankle.

Arthroscopic ankle arthrodesis after tibial pilon open reduction internal fixation

Ankle arthrodesis is an essential tool in the foot and ankle surgeon's armamentarium. Despite the evolving technology and ongoing research in ankle arthroplasty, arthrodesis continues to be a proven and safe option for the majority of patients with ankle arthritis refractory to conservative management. Here, the authors present their technique of an arthroscopic ankle arthrodesis specifically in the setting of a previous open-reduction internal fixation (ORIF) for a tibia plafond type fracture. They have found this to be a reliable technique to achieve a solid ankle arthrodesis while minimizing soft-tissue trauma and dissection in an already compromised soft-tissue envelope.

Treatment of ankle osteoarthritis: arthrodesis versus total ankle replacement

While ankle arthrodesis has remained the gold standard treatment for symptomatic primary, secondary, and posttraumatic ankle arthritis, more recently, total ankle replacement (TAR) has seen considerable improvement in terms of biomechanics, function, and complication rates. However, while in the long-term degeneration of the adjacent joints is almost always found on radiographs after ankle arthrodesis, the longevity of TAR is still insufficient and does not match that of total knee and hip joints. The current review article focuses on the treatment of ankle arthritis by means of arthrodesis and TAR.

Autogenous bone graft harvest using reamer irrigator aspirator (RIA) technique for tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis is a technically demanding procedure that can be associated with a high number of complications, including nonunion. Bone grafting is commonly used in arthrodesis procedures to decrease the risk of nonunion. In this article, we describe a technique that uses a reamer-irrigator-aspirator (RIA) method for procurement of autogenous bone graft for use in tibiotalocalcaneal arthrodesis fixated with a retrograde intramedullary nail. Using the RIA technique, autogenous bone graft can be readily obtained without the need for additional incisions and dissection, thereby minimizing the need for additional sources of bone graft.

Arthroscopic versus open ankle arthrodesis: a retrospective cost analysis

Compared with traditional open arthrodesis, arthroscopic ankle arthrodesis has been associated with similar rates of fusion, decreased time to union, decreased pain, shorter hospital stay, earlier mobilization, reliable clinical results, and fewer complications. The aim of this case-control study was to analyze cost differences between outpatient arthroscopic and inpatient open ankle arthrodesis. To this end, the authors analyzed 20 ankle arthrodesis procedures: 10 performed by one surgeon on an inpatient basis using an open approach, and 10 performed by another surgeon on an outpatient basis arthroscopically. Patient age, body mass index, tourniquet time, length of stay, complications, days to clinical union, and insurance type, as well as charges and reimbursements for the surgeons and the hospital or surgery center were abstracted from the records. Statistically significant differences were observed between the outpatient arthroscopic and inpatient open arthrodesis groups for total site charges ($3898 +/- 0.00 versus $32,683 +/- $12,762, respectively, P < .0001), reimbursement to the surgeon ($1567 +/- $320 versus $1107 +/- $278, respectively, P = .003), and reimbursement to the hospital or ambulatory surgery center ($1110 +/- $287 versus $8432 +/- $2626, respectively); the ratio of hospital/surgery center charges to hospital/surgery center reimbursements was 28.48% for the inpatient arthroscopic group and 25.80% for the inpatient open arthrodesis group. Outpatient arthroscopic ankle arthrodesis, compared with inpatient open ankle arthrodesis, appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.