Complications of ankle and tibiotalocalcaneal arthrodesis

Outcomes after total ankle arthroplasty with an average follow-up of 10 years: A systematic review and meta-analysis

BACKGROUND

The literature demonstrating positive outcomes after total ankle arthroplasty (TAA) is mounting. However, the long-term outcomes of TAA (≥ 10 years) remain minimally reported. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics over multiple TAA studies with greater than 10 years of average follow-up.

METHODS

TAA studies were searched in Medline, Embase, and Scopus from the date of inception to September 12, 2022. Inclusion criteria included 1) studies of patients that underwent uncemented TAA, and 2) studies with an average follow-up time of at least ten years. Manuscripts in non-English languages and isolated abstracts were excluded. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta-analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation.

RESULTS

Our data included approximately 3651 patients (3782 ankles). Of the 25 studies with an average follow-up of 10 years included in the systematic review, 5 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre-and post-operative AOFAS and VAS scores was -40.36 (95% CI -47.24 to -33.47) and 4.52 (95% CI: 2.26-6.43), respectively. The risk of bias was low to moderate for the included studies.

CONCLUSION

Outcomes following TAA are favorable and indicate patient-reported outcome improvement over long-term follow-up. However, a significant amount of heterogeneity exists between studies. Future, prospective, randomized research should focus on standardizing outcome measures, survivorship, and complication reporting methodologies to allow for pooled meta-analyses of these important outcome metrics.

Comparison of different fibula procedures in tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a mid-term retrospective study

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures.

METHODS

We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded.

RESULTS

Fifty-eight patients with an average age of 53.2 (range, 32-69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60-78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1 min) was longer than that of FO (119.3 ± 11.7 min) and FS (112.2 ± 12.6 min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters.

CONCLUSIONS

TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP.

LEVEL OF CLINICAL EVIDENCE

Level 3.

Preservation of the Subtalar Joint Determines Outcomes in a 10-Year Evaluation of Ankle Arthrodesis

Posttraumatic osteoarthritis may lead to surgical fusion of the ankle joint if non-surgical therapy fails. The indication for a fusion of the joint is based on the pain and disability of the patient, radiographic imaging, and surgeon experience, with no strict guidelines. We aimed to compare outcomes after tibiotalocalcaneal arthrodesis (TTCA) and tibiotalar arthrodesis (TTA) to highlight the functional importance of the subtalar joint. In total, 432 patients with ankle arthrodesis were retrospectively enrolled. Group A (n = 216) underwent TTCA; group B (n = 216) underwent TTA. Demographics, Olerud & Molander Ankle Score (OMAS), Foot Function Index (FFI-D), and Short Form-12 Questionnaire (SF-12) were recorded at a mean follow-up of 6.2 years. The mean OMAS was 50.7; the mean FFI-D was 68.9; the mean SF-12 physical component summary was 39.1. These scores differed significantly between the groups (p < 0.001). The overall revision rate was 18%, primarily for revision of non-union and infection (p < 0.001). Approximately 16% of group A and 26% of group B were able to return to previous work (p < 0.001). Based on significantly worse clinical scores of TTCA compared to TTA and the prolonged downtime and permanent incapacity, the indication for a generous subtalar joint arthrodesis with planned ankle arthrodesis should always be critically examined.

Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT

Background

We aimed to compare the clinical effectiveness, cost-effectiveness and complication rates of total ankle replacement with those of arthrodesis (i.e. ankle fusion) in the treatment of end-stage ankle osteoarthritis.

Methods

This was a pragmatic, multicentre, parallel-group, non-blinded randomised controlled trial. Patients with end-stage ankle osteoarthritis who were aged 50-85 years and were suitable for both procedures were recruited from 17 UK hospitals and randomised using minimisation. The primary outcome was the change in the Manchester-Oxford Foot Questionnaire walking/standing domain scores between the preoperative baseline and 52 weeks post surgery.

Results

Between March 2015 and January 2019, 303 participants were randomised using a minimisation algorithm: 152 to total ankle replacement and 151 to ankle fusion. At 52 weeks, the mean (standard deviation) Manchester-Oxford Foot Questionnaire walking/standing domain score was 31.4 (30.4) in the total ankle replacement arm (n = 136) and 36.8 (30.6) in the ankle fusion arm (n = 140); the adjusted difference in the change was -5.6 (95% confidence interval -12.5 to 1.4; p = 0.12) in the intention-to-treat analysis. By week 52, one patient in the total ankle replacement arm required revision. Rates of wound-healing issues (13.4% vs. 5.7%) and nerve injuries (4.2% vs. < 1%) were higher and the rate of thromboembolic events was lower (2.9% vs. 4.9%) in the total ankle replacement arm than in the ankle fusion arm. The bone non-union rate (based on plain radiographs) in the ankle fusion arm was 12.1%, but only 7.1% of patients had symptoms. A post hoc analysis of fixed-bearing total ankle replacement showed a statistically significant improvement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score (-11.1, 95% confidence interval -19.3 to -2.9; p = 0.008). We estimate a 69% likelihood that total ankle replacement is cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over the patient's lifetime.

Limitations

This initial report contains only 52-week data, which must therefore be interpreted with caution. In addition, the pragmatic nature of the study means that there was heterogeneity between surgical implants and techniques. The trial was run across 17 NHS centres to ensure that decision-making streams reflected the standard of care in the NHS as closely as possible.

Conclusions

Both total ankle replacement and ankle fusion improved patients' quality of life at 1 year, and both appear to be safe. When total ankle replacement was compared with ankle fusion overall, we were unable to show a statistically significant difference between the two arms in terms of our primary outcome measure. The total ankle replacement versus ankle arthrodesis (TARVA) trial is inconclusive in terms of superiority of total ankle replacement, as the 95% confidence interval for the adjusted treatment effect includes both a difference of zero and the minimal important difference of 12, but it can rule out the superiority of ankle fusion. A post hoc analysis comparing fixed-bearing total ankle replacement with ankle fusion showed a statistically significant improvement of total ankle replacement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score. Total ankle replacement appears to be cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over a patient's lifetime based on long-term economic modelling.

Future work

We recommend long-term follow-up of this important cohort, in particular radiological and clinical progress. We also recommend studies to explore the sensitivity of clinical scores to detect clinically important differences between arms when both have already achieved a significant improvement from baseline.

Trial registration

This trial is registered as ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 5. See the NIHR Journals Library website for further project information.

Risk Factors for Nonunion Following Ankle Arthrodesis: A Systematic Review and Meta-analysis

BACKGROUND

Nonunion is a postoperative complication after ankle arthrodesis (AA), which leads to increased morbidity and revision rates. Previous studies have identified risk factors for nonunion following AA, but no meta-analysis has been performed to stratify risk factors based on strength of evidence.

METHODS

Abstracts and full-text articles were screened by 2 independent reviewers. Relevant data were extracted from the included studies. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results.

RESULTS

Database search yielded 13 studies involving 987 patients were included, and 37 potential risk factors for nonunion. Meta-analysis found 5 significant risk factors for nonunion post-AA. Strong evidence supports male gender (OR: 1.96; 95% CI: 1.13-3.41), smoking (OR: 2.89; 95% CI: 1.23-6.76), and history of operative site infection prior to arthrodesis (OR: 2.40; 95% CI: 1.13-5.09) as predictors for nonunion following AA. There was moderate evidence supporting history of open injury (OR: 5.95; 95% CI: 2.31-15.38) and limited evidence for preoperative avascular necrosis (OR: 13.16; 95% CI: 2.17-79.61) as possible risk factors for nonunion.

CONCLUSION

The results of our meta-analysis suggest that male gender, smoking, and history of operative site infection have strong evidence and that history of open injury and avascular necrosis also have evidence as risk factors for nonunion. Surgeons should be cognizant of these risks when performing AA and closely follow up with patients with the aforementioned risk factors to ensure postoperative success.

LEVELS OF EVIDENCE

Level V: Systematic review of cohort and case-control studies.

Tibiotalocalcaneal Arthrodesis in Severe Hindfoot Deformities

Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies--weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.

Distraction arthroplasty in the management of osteoarthritis of the ankle: A systematic review

BACKGROUND

This study aimed to evaluate the use of distraction arthroplasty for ankle osteoarthritis, with respect to patient reported outcome measures (PROMs), complications, range of motion and radiographic outcomes.

METHODS

A computer-based search was performed in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Two reviewers independently performed title/abstract and full-text screening. Quality assessment was performed using The Methodological Index for Non-Randomised Studies (MINORS) and Joanna Briggs Institute criteria.

RESULTS

Whilst all studies evaluating PROMs reported significant (P < 0.05) improvement, these were either below or only slightly above the minimally clinically important difference. The rate of conversion to arthrodesis or total ankle arthroplasty was high, with failure rates of up to 52% reported.

CONCLUSION

Due to the inconsistent improvements in PROMs, which are likely overestimated due to substantial bias, and the high failure rate, this review suggests that distraction arthroplasty is not currently an effective treatment option for ankle arthritis.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.

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.

Combined Transfibular and Anterior Approaches Increase Union Rate and Decrease Non-Weight-Bearing Periods in Ankle Arthrodesis: Combined Approaches in Ankle Arthrodesis

The transfibular approach is a widely used method in ankle arthrodesis. However, it is difficult to correct coronal plane deformity. Moreover, it carries a risk of nonunion and requires long periods of non-weight-bearing because of its relatively weak stability. We hypothesized that the transfibular approach combined with the anterior approach in ankle arthrodesis wound yield a higher fusion rate and shorter non-weight-bearing period. This study was performed to evaluate the clinical and radiographic results and postoperative complications in ankle arthrodesis using combined transfibular and anterior approaches in end-stage ankle arthritis. Thirty-five patients (36 ankles) with end-stage ankle arthritis were consecutively treated using ankle arthrodesis by combined transfibular and anterior approaches. The subjects were 15 men and 20 women, with a mean age of 66.5 years (46-87). Clinical results were assessed using the visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) scores, and the ankle osteoarthritis scale (AOS) preoperatively and at the last follow-up. Radiographic results were assessed with various radiographic parameters on ankle weight-bearing radiographs and hindfoot alignment radiographs. All clinical scores significantly improved after surgery. Union was obtained in all cases without additional surgery. Talus center migration (p = 0.001), sagittal talar migration (p < 0.001), and hindfoot alignment angle (p = 0.001) significantly improved after surgery. One partial skin necrosis, two screw penetrations of the talonavicular joint, and four anterior impingements because of the bulky anterior plate occurred after surgery. In conclusion, combined transfibular and anterior approaches could be a good method to increase the union rate and decrease the non-weight-bearing periods in ankle arthrodesis.

Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis

Posttraumatic osteoarthritis of the ankle and hindfoot is a common and frequently debilitating disorder. 70% to 90% of ankle osteoarthritis is related to prior trauma that encompasses a spectrum of disorders including fractures and ligamentous injuries that either disrupt the articular surface or result in instability of the joint. In addition to clinical evaluation, imaging plays a substantial role in the treatment planning of posttraumatic ankle and hindfoot osteoarthritis. Imaging evaluation must be tailored to specific clinical scenarios and includes weight bearing radiography that utilizes standard and specialty views, computed tomography which can be performed with a standard or a weight bearing technique, magnetic resonance imaging, and ultrasound evaluation. This review article aims to familiarize the reader with treatment rationale, to provide a brief review of surgical techniques and to illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis, such as joint-preserving procedures, ankle fusion, subtalar fusion, tibiotalarcalcaneal fusion and ankle arthroplasty. Preoperative findings will be discussed along with the expected postoperative appearance of various procedures in order to improve detection of their complications on imaging and to provide optimal patient care.

Risk factors of ankle osteoarthritis in the treatment of critical bone defects using ilizarov technique

Background

Distraction osteogenesis using the Ilizarov external circular fixator has been applied in lower limb reconstructive surgery widely. The increasing ankle osteoarthritis (OA) progression and severity are often associated with the period of external fixator and the greater relative instability of the ankle joint, but few studies have quantified risk factors directly during this technique.

Methods

The study was conducted on 236 patients who underwent bone transport surgery for tibias using the Ilizarov external circular fixator from 2008 to 2018. The cumulative incidence of ankle OA diagnoses in patients after the Ilizarov technique treatment was calculated and stratified by risk factors from preoperative and postoperative management. After the data were significant through the Mann-Whitney U test analyzed, odds ratios were calculated using logistic regression to describe factors associated with the OA diagnosis including gender, age, BMI, location of bone defect, diabetes, hypertension, osteoporosis, the history of metal allergy and glucocorticoid intake, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-HF scale scores, defect size (DS), the type of bone transport, the bone union time, external fixator time (EFT), and external fixator index (EFI).

Results

There were 199 males and 37 females with a mean age of 47 years (range 28–59 years). Out of 236 patients, 49 had an additional treatment for ankle OA after the Ilizarov technique treatment of bone defects (average follow-up time 2.1 years, range 1.6–4.2 years). The incidence of postoperative ankle OA was 20.8 %, with 19 patients classified as K&L grade 3 and seven patients as grade 4. The top five risk factors included double-level bone transport (OR3.79, P = 0.005), EFI > 50days/cm (OR3.17, P = 0.015), age > 45years (OR2.29, P = 0.032), osteoporosis (OR1.58, P < 0.001), BMI > 25 (OR1.34, P < 0.001). Male, BMI > 25, diabetes, osteoporosis, and AOFAS ankle-HF scale scores are the independent risk factors.

Conclusions

Ilizarov external circular fixator is a safe and effective method of treatment for critical bone defects. The double level bone transport, EFI > 50days/cm, age > 45years, osteoporosis, BMI > 25 are the top five relevant risk factors of ankle OA. The probability of developing ankle OA among patients having three or more risk factors is 50–70 %.

Osteotomy combined with lateral ligament reconstruction in treating osteochondral lesion in patients with talar injury and varus ankle

This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results.

The "Ball in Basket" Technique for Tibiotalocalcaneal Fusion

Tibiotalocalcaneal arthrodesis (TTCA) in severe bone deficit represents a complex challenge for expert orthopedic surgeons also. This study aims to illustrate a surgical technique, defined as “ball in basket”, that facilitates the fitting of the structural bone graft (femoral head from bone bank) and its placement, in order to fill the bone gap during instrumented arthrodesis. The proposed technique includes the preparation of the recipient bone surfaces with acetabular convex reamers and of concave reamers to shape the bone graft from bone bank. This preparation guarantees a maximum congruence of the bone surfaces and a greater stability of the bone graft during the placement of the fixation devices to optimize the bone fusion and to provide a good patient clinical outcome. The preliminary results obtained for two patients, initially presenting with severe anatomical deformity associated with severe bone gap, are described. Patients underwent clinical and radiographic follow-up evaluations (respectively at 4 and 30 months of follow-up) showing radiographic healing and good functional recovery. The results are encouraging, although long-term studies and a wider cohort of patients are necessary to consider this technique a reliable aid in case of severe bone deficit. (www.actabiomedica.it)

A Safety and Cost Analysis of Outpatient Versus Inpatient Hindfoot Fusion Surgery

Background. Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost savings of these procedures compared with the risks and benefits has not been clearly investigated. The objective of this study was to compare patient characteristics, costs, and short-term complications between inpatient and outpatient procedures. Methods. This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures by a single surgeon, at 1 academic institution, from 2013 to 2017. Data collected included demographics, operative variables, comorbidities, complications, costs, and subsequent reencounters. Results. Of 124 procedures, 34 were inpatient and 90 were outpatient. Between procedural settings, with the numbers available, there was no significant increase in complication rate or frequency of reencounters within 90 days. There were no significant differences in the number of patients with reencounters related to the index procedure within 90 days (P = .43). There were 30 reencounters within 90 days after outpatient surgery versus 4 after inpatient surgery (P = .05). The total number of emergency room visits in the outpatient group within 90 days was significantly higher compared with the inpatient group (P = .04). The average cost for outpatient procedures was US$4159 less than inpatient procedures (P < .0001). Conclusion. Outpatient hindfoot fusion may be a safe alternative to inpatient surgery, with significant overall cost savings and similar rate of short-term complications. On the basis of these findings, we believe that outpatient management is preferable for the majority of patients, but further investigation is warranted. Levels of Evidence: Level III.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BACKGROUND

The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.

METHODS

Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5).

RESULTS

One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.

CONCLUSION

In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.

Simultaneous Intraoperative Measurement of Cadaver Ankle and Subtalar Joint Compression During Arthrodesis With Intramedullary Nail, Screws, and Tibiotalocalcaneal Plate

BACKGROUND

Suboptimal tibiotalocalcaneal arthrodesis (TTCA) fusion rates may result from inadequate compression that increases motion and interferes with bony bridging. The aim of this study was to evaluate compressive forces at the ankle and subtalar joints with 3 contemporary TTCA constructs.

METHODS

Thirty fresh-frozen cadaveric lower extremity specimens were divided into 3 groups of 10 each: 3 partially threaded cannulated screws, hindfoot nail, and lateral plate. Specimens were mounted to a testing apparatus, and compression was independently measured at the tibiotalar and talocalcaneal interfaces. Statistical analysis included paired Student t tests, analysis of variance, and Tukey post hoc tests.

RESULTS

Mean forces at the ankle joint for the screws, nail, and plate constructs were 331 ± 86, 479 ± 137, and 548 ± 199 N, respectively, with plates providing significantly more compression than screws ( P < .01). Similarly, subtalar compressive forces demonstrated 319 ± 105 N in the screws group, 466 ± 125 N, in the nail group, and 513 ± 181 N in the plate group, with plate compression greater than that achieved with screws ( P < .01). No differences were identified in compression between ankle and subtalar joints within specimens in any group.

CONCLUSIONS

Lateral TTCA plates provided increased compressive forces at the ankle and subtalar joint compared with screws-only constructs. Hindfoot nails did not demonstrate significant differences in either of these parameters compared with plates or screws in this study.

CLINICAL RELEVANCE

Hindfoot nail and lateral plate options should be strongly considered when aiming to maximize compression in patients undergoing TTCA.

Anterior Approach for Ankle Arthrodesis

End-stage ankle arthritis may be treated successfully with either an ankle arthrodesis or arthroplasty. Both surgical interventions have demonstrated success with regard to pain relief and function. Ankle arthrodesis is indicated for patients with recalcitrant ankle pain despite appropriate nonoperative intervention. Patients who have a history of posttraumatic arthritis from a high-energy injury, soft-tissue compromise, limited range of motion, or deformity may be superior candidates for arthrodesis. The surgical technique can be undertaken with either an open or an arthroscopic approach. An open anterior approach with an anatomic precontoured locking plate is ideal for patients with deformity and/or bone loss. Additionally, the use of a precontoured plate assists with achieving a neutral alignment in both the coronal and the sagittal plane, which is critical to the long-term success of the procedure. No hardware, however, substitutes for appropriate surgical technique, which is the focus of this video article. The procedure includes the following steps:An anterior extensile incision is made immediately lateral to the anterior tibial tendon, extending to the level of the talonavicular joint.Dissection is taken with care to avoid the superficial peroneal nerve in the distal aspect of the incision. The extensor retinaculum is incised either longitudinally or in a z-shaped fashion to facilitate closure.Deep dissection may be taken through the sheath of the anterior tibial tendon, which substantially decreases the risk of injury to the deep neurovascular bundle. Alternatively, dissection may be taken through the extensor hallucis longus (EHL) to avoid violation of the anterior tibial tendon sheath. The neurovascular bundle is directly posterior to the EHL at the level of the ankle joint.The ankle joint is exposed, with the removal of tibial and talar osteophytes.The joint surfaces are prepared.The precontoured ankle arthrodesis plate, which is used to improve alignment, is positioned and placed.Compression is achieved using the "Achilles tension band technique," which furthers compression through the ankle.An additional transarticular screw is placed. The expected outcome of the procedure, based on recent clinical outcomes, is osseous union, and the rate of union has been reported to range from 91% to 96%. Improvement in function and pain relief are associated with a successful arthrodesis. Despite a slow deterioration of functional outcomes and radiographic progression of arthritis, clinical improvement with a high rate of patient satisfaction has been noted at a mean of 9 years postoperatively.

Effectiveness of Hindfoot Arthrodesis by Stable Internal Fixation in Various Eichenholtz Stages of Neuropathic Ankle Arthropathy

The optimal time to treat neuropathic (Charcot) arthropathy of the ankle and peritalar joint is controversial because of the various treatment options available and the variable results reported in published studies. We sought to determine the outcome of hind foot arthrodesis with stable internal fixation in patients with different Eichenholtz stages of arthropathy. We prospectively studied patients with substantial disabilities caused by neuropathic arthropathy in deformed, unstable ankle and peritalar joints, with or without ulcerations, who had undergone treatment from July 2007 to December 2012. All patients underwent ankle arthrodesis, autologous iliac crest bone grafting, and subtalar joint arthrodesis, with or without talonavicular joint arthrodesis, fixed internally with an intramedullary hindfoot nail, with or without an additional plate or cancellous screws. Of the 33 enrolled patients, 9 (27.3%) had stage I, 13 (39.4%) had stage II, and 11 (33.3%) had stage III Charcot arthropathy. The cause of arthropathy was diabetes mellitus in 25 (75.8%) patients. The duration of symptoms ranged from 1 to 120 (median 7) months. The mean follow-up period was 40 (range 12 to 76) months and did not differ markedly among the groups. The hindfoot scores, rate of salvage or amputation, or complication rates did not differ significantly across Eichenholtz stage. For the patients with stage I, II, and III, the preoperative hindfoot score was 50, 49, and 48, respectively (p = .9). The corresponding postoperative scores were 68, 68, and 70 (p = .5). We found no evidence that the effectiveness of hindfoot arthrodesis by stable fixation varied across the Eichenholtz stage of Charcot arthropathy involving ankle and peritalar joint. Furthermore, we found that stable internal fixation and bone grafting using a hindfoot nail results in an 84.84% union rate and salvages the unstable and disabled foot in 90.9% of patients with ankle and peritalar Charcot arthropathy.

New Technique for Tibiotalar Arthrodesis Using a New Intramedullary Nail Device: A Cadaveric Study

Introduction. Ankle arthrodesis is performed in a variety of methods. We propose a new technique for tibiotalar arthrodesis using a newly designed intramedullary nail. Methods. We proposed development of an intramedullary device for ankle arthrodesis which spared the subtalar joint using a sinus tarsi approach. Standard saw bones models and computer assisted modeling and stress analysis were used to develop different nail design geometries and determine the feasibility of insertion. After the final design was constructed, the device was tested on three cadaveric specimens. Results. Four basic nail geometries were developed. The optimal design was composed of two relatively straight segments, each with a different radius of curvature for their respective tibial and talar component. We successfully implemented this design into three cadaveric specimens. Conclusion. Our newly designed tibiotalar nail provides a new technique for isolated tibiotalar fusion. It utilizes the advantages of a tibiotalar calcaneal nail and spares the subtalar joint. This design serves as the foundation for future research to include compression options across the tibiotalar joint and eventual transition to clinical practice.

Tibiotalocalcaneal arthrodesis by using proximal humeral locking plate

Objectives

The aim of this study was to evaluate the short-term clinical and radiological results of tibiotalocalcaneal arthrodesis (TTCA) with proximal humeral locking plate.

Material and methods

Eight patients (7 female, 1 male; average age 53 years (range: 24–67)) who underwent TTCA with proximal humeral locking plate between 2009 and 2011, were retrospectively evaluated with AOFAS hindfoot scale and Maryland foot score system. The mean follow up was 32.6 months (range: 23–54).

Results

Complete fusion was achieved in 7 patients. Soft tissue infection was observed in 2 patients and reflex sympathetic dystrophy in 3 patients. All patients recovered with medical treatment. At the final follow-up, mean AOFAS Hindfoot score was 60 (range: 41–81) and Maryland Foot Score was 67.8 (range: 41–85). The satisfactory rates of AOFAS and MFS were found as 12.5% (1/8) and 50% (4/8), respectively. One patient had an incomplete union with 5 degrees of heel varus deformity and 5 degrees of equinus deformity was observed in another. There were no implant failure or deformation of the plate during the follow-up period.

Conclusion

Our study suggests that proximal humeral plate may be an alternative for fixation in tibiotalocalcaneal fusion surgery.

The epidemiology of thoracolumbar trauma: A meta-analysis

PURPOSE

To describe the epidemiology of thoracolumbar fractures and associated injuries in blunt trauma patients.

METHODS

A systematic review and metaanalysis was performed based on a MEDLINE database search using MeSH terms for studies matching our inclusion criteria. The search yielded 21 full-length articles, each sub-grouped according to content. Data extraction and multiple analyses were performed on descriptive data.

RESULTS

The rate of thoracolumbar fracture in blunt trauma patients was 6.90% (±3.77, 95% CI). The rate of spinal cord injury was 26.56% (±10.70), and non-contiguous cervical spine fracture occurred in 10.49% (±4.17). Associated injury was as follows: abdominal trauma 7.63% (±9.74), thoracic trauma 22.64% (±13.94), pelvic trauma 9.39% (±6.45), extremity trauma 18.26% (±5.95), and head trauma 12.96% (±2.01). Studies that included cervical spine fracture with thoracolumbar fracture had the following rates of associated trauma: 3.78% (±5.94) abdominal trauma, 21.65% (±16.79) thoracic trauma, 3.62% (±1.07) pelvic trauma, 18.36% (±4.94) extremity trauma, and 15.45% (±11.70) head trauma. A subgroup of flexion distraction injuries showed an associated intra-abdominal injury rate of 38.70% (±13.30). The most common vertebra injured was L1 at a rate of 34.40% (±15.90). T7 was the most common non-junctional vertebra injured at 3.90% (±1.09). Burst/AO type A3 fractures were the most common morphology 39.50% (±16.30) followed by 33.60% (±15.10) compression/AO type A1, 14.20% (±8.08) fracture dislocation/AO type C, and 6.96% (±3.50) flexion distraction/AO type B. The most common etiology for a thoracolumbar fracture was motor vehicle collision 36.70% (±5.35), followed by high-energy fall 31.70% (±6.70).

CONCLUSIONS

Here we report the incidence of thoracolumbar fracture in blunt trauma and the spectrum of associated injuries. To our knowledge, this paper provides the first epidemiological road map for blunt trauma thoracolumbar injuries.

Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss

Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and for the management of severe planar deformities of the ankle and hindfoot. Although the procedure results in a rigid ankle and hindfoot, it is often the only means of providing patients with a stable and painless foot and ankle for ambulation. Some patients who require the procedure have substantial bone loss that can be managed with a variety of autograft and allograft options. Options for tibiotalocalcaneal fixation include both internal and external devices, the selection of which depends on the underlying pathology, amount of bone loss, and type of bone graft selected. Relatively high complication rates associated with tibiotalocalcaneal fusion have been reported, with complications ranging from superficial infection to ultimate amputation; however, proper patient selection and careful graft and fixation planning can minimize the postoperative complications of the procedure.

Use of a Proximal Humeral Locking Plate for Complex Ankle and Hindfoot Fusion

Arthrodesis of the ankle and hindfoot in the setting of major deformity is challenging and associated with substantial risks. Patients often have significant comorbidities that lead to unforgiving soft tissues, poor vascularity, and poor bone quality. This creates the high-risk scenario of poor wound healing and poor implant fixation. Complications can be devastating, leading to loss of the limb and sepsis. The use of locking plate technology might provide biomechanical and operative technique advantages in such patients. We retrospectively assessed the results of the modified use of the PHILOS(™) (Synthes(®), Zuchwil, Switzerland) proximal humeral locking plate in 21 patients (11 males, 10 females; mean age 56.1 years, range 25 to 74 years) who had undergone complex fusions, including tibiotalar (n = 4), tibiocalcaneal (n = 7), or tibiotalocalcaneal (n =10) fusions. The average follow-up period was 14.6 (median 10, range 6 to 49) months. Of the 21 fusions, 18 achieved union (85.7%) at an average period of 4.8 (median 4.3, range 3 to 12) months. The overall deep infection rate was 14.3%. Overall, 17 of the 21 patients (81%) were satisfied with the result (good to excellent), 1 reported the result was fair (4.8%), and 3 patients developed nonunion and were dissatisfied with the procedure (14.3%). The present study is the largest series to date of patients undergoing complex ankle and hindfoot arthrodesis with the use of a proximal humeral locking plate and confirms previous findings that the technique is reliable with union, satisfaction, and complication rates comparable to those of other techniques.

Complex ankle arthrodesis: Review of the literature

Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.

Complex ankle arthrodesis: Review of the literature

Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients’ outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.

Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review

Introduction. End-stage ankle osteoarthritis is a debilitating condition. Traditionally, ankle arthrodesis (AA) has been the surgical intervention of choice but the emergence of total ankle replacement (TAR) has challenged this concept. This systematic review aims to address whether TAR or AA is optimal in terms of functional outcomes. Methods. We conducted a systematic review according to PRISMA checklist using the online databases Medline and EMBASE after January 1, 2005. Participants must be skeletally mature and suffering from ankle arthrosis of any cause. The intervention had to be an uncemented TAR comprising two or three modular components. The comparative group could include any type of ankle arthrodesis, either open or arthroscopic, using any implant for fixation. The study must have reported at least one functional outcome measure. Results. Of the four studies included, two reported some significant improvement in functional outcome in favour of TAR. The complication rate was higher in the TAR group. However, the quality of studies reviewed was poor and the methodological weaknesses limited any definitive conclusions being drawn. Conclusion. The available literature is insufficient to conclude which treatment is superior. Further research is indicated and should be in the form of an adequately powered randomised controlled trial.

Surgical correction of severe deformity of the ankle and hindfoot by arthrodesis using a compressing retrograde intramedullary nail

BACKGROUND

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail is a widely used surgical technique for the treatment of concomitant tibiotalar and subtalar arthritis and correction of accompanying deformity. This study was undertaken to evaluate the union rate, deformity correction, and clinical outcomes achieved using a compressing retrograde intramedullary nail.

METHODS

Thirty tibiotalocalcaneal arthrodeses with an osseous compressing arthrodesis nail system were studied with a mean follow-up of 26 months. Radiographic data were collected on deformity correction and union rate, and clinical outcomes were evaluated using the Visual Analogue Scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle/Hindfoot Score, and the Short Form-36 (SF-36) health survey. Records were reviewed for complications and concomitant procedures.

RESULTS

Thirteen of 30 operated limbs had a preoperative coronal plane deformity exceeding 15 degrees. Mean magnitude of correction was 13.2 degrees (range, 0-32 degrees, standard deviation ±9.6). In total, 76% of limbs (23/30) had postoperative coronal deformity of less than 5 degrees. Union was achieved in 96.6% of patients. There were 3 cases of tibial stress reaction, 3 cases of transient plantar nerve irritation, and 3 cases of wound infection. Clinical outcomes demonstrated a reduction in mean VAS score from 6.5 to 1.3 (P < .01), an increase in mean AOFAS Ankle/Hindfoot Scores from 29.7 to 74.3 (P < .01), and an increase in mean total SF-36 scores from 85.6 to 98.8 (P < .01).

CONCLUSION

A compressing retrograde intramedullary nail was effective in achieving deformity correction, a high union rate, and improvement in clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimal incision surgery for tibiotalocalcaneal arthrodesis

BACKGROUND

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure for severe diseases involving ankle and subtalar joints. However, this procedure is often associated with postoperative complications related to preoperative comorbidities. The purpose of this study was to present the clinical and functional outcomes of a consecutive series of TTCA using an original operative approach based on minimal incision surgery (MIS).

METHODS

Forty patients were followed prospectively for a mean (SD) of 31 (12.5) months. Clinical data, which included x-rays, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, SF-36 scores, and a patient satisfaction survey, were collected. A further 25 patients were examined retrospectively.

RESULTS

In the prospective group (n = 40), the mean AOFAS score improved by 44.8 points 1 year after the intervention (95% confidence interval [CI], 40.6-48.9), and the SF-36 improved by a mean of 17.5 points (95% CI, 1.4-20.9) in the mental component summary (MCS) score and 11.5 points (95% CI, 8.3-14.7) in the physical component summary (PCS) score. In the prospective group, postsurgical pain correlated with MCS score (r = 0.47, P < .001). In the entire group, bony union (defined as radiographic consolidation and absence of clinical symptoms) was observed in 86% of cases. Two deep infections, 2 nonunions in patients with preoperative persistent ulcers, and 7 delayed unions were the major complications observed in the entire group. One patient required amputation. No cases of superficial infection, wound dehiscence, or deep venous thrombosis were recorded.

CONCLUSION

To our knowledge, the present series represents the largest study on TTCA using MIS. The data obtained in the present study showed clinical and functional improvement after surgery and similar bony union rates as previously reported in the literature but with fewer complications related to the surgical wounds.

LEVEL OF EVIDENCE

Level IV, case series.

Anterior ankle arthrodesis

Ankle arthrodesis is a common procedure that resolves many conditions of the foot and ankle; however, complications following this procedure are often reported and vary depending on the fixation technique. Various techniques have been described in the attempt to achieve ankle arthrodesis and there is much debate as to the efficiency of each one. This study aims to evaluate the efficiency of anterior plating in ankle arthrodesis using customised and Synthes TomoFix plates. We present the outcomes of 28 ankle arthrodeses between 2005 and 2012, specifically examining rate of union, patient-reported outcomes scores, and complications. All 28 patients achieved radiographic union at an average of 36 wk; the majority of patients (92.86%) at or before 16 wk, the exceptions being two patients with Charcot joints who were noted to have bony union at a three year review. Patient-reported outcomes scores significantly increased (P < 0.05). Complications included two delayed unions as previously mentioned, infection, and extended postoperative pain. With multiple points for fixation and coaxial screw entry points, the contoured customised plate offers added compression and provides a rigid fixation for arthrodesis stabilization.

Fusion following failed total ankle replacement

Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement. The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.

Outcome of arthrodesis of the hindfoot as a salvage procedure for complex ankle pathology using the Ilizarov technique

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

Tibiotalocalcaneal arthrodesis

Combined arthrodesis of the ankle and subtalar joint is a challenging but potentially rewarding procedure for certain patients. The author discusses multiple aspects of the procedure from patient counseling to postoperative complications.

Tibiotalocalcaneal arthrodesis with combined retrograde intramedullary nail and lateral L-plate

Achieving stable fixation when performing tibiotalocalcaneal or tibiocalcaneal arthrodesis can be challenging. Patients undergoing these procedures often have osteopenia, poor bone stock, fragmentation of the bones of the foot and ankle, joint subluxation, or even dislocation. The author describes a technique of tibiotalocalcaneal arthrodesis with intramedullary nail fixation augmented by lateral plating through the transfibular approach. This can provide excellent exposure of the ankle and subtalar joints, morselized bone for grafting, and better construct stability.

Limb salvage: revision of failed intramedullary nail in hindfoot and ankle surgery in the diabetic neuropathic patient

Herein, we illustrate an operative technique to attain limb salvage after a failed intramedullary nail in the diabetic Charcot neuropathic patient. The use of the blade plate, or T-plate, in combination with external fixation, fastened into the body of the calcaneus allows for greater bone capture. Our experience has shown that this provides for a stable, long-lasting construct.

Tibiotalocalcaneal arthrodesis using a femoral locking plate

The goal of a tibiotalocalcaneal arthrodesis is to create a pain-free, stable hindfoot and ankle. Although a reserved procedure, it is useful when simultaneous ankle and subtalar joint pathology exists. Numerous complications have been reported after tibiotalocalcaneal arthrodesis, most importantly nonunion. Locking plates have proved to be a more stable construct than alternative forms of arthrodesis. In the inverted positions, the hybrid plating of the femoral locking plate structurally aligns with the anatomy of the hindfoot. This provides an anatomically sound construct, while allowing for both locking and lag screw insertion. We describe a new technique using a 4.5-mm condylar plate for tibiotalocalcaneal arthrodesis.

Advances in intramedullary nail fixation in foot and ankle surgery

Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.

Posterior approach using anterior ankle arthrodesis locking plate for tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.

Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement

BACKGROUND

Major modifications in the design and techniques of total ankle replacement have challenged the perception that ankle arthrodesis is the treatment of choice for end-stage ankle arthritis. High complication and revision rates have been reported after both procedures.

METHODS

We performed radiographic evaluations at a mean of thirty-nine months following 114 total ankle replacements done with use of commonly used implants and at a mean of thirty-seven months following forty-seven ankle arthrodeses. The mean age was sixty-four years for the patients (fifty-one female and sixty-three male) who underwent total ankle replacement and fifty-nine years in the patients (fifteen female and thirty-two male) who underwent ankle arthrodesis. The impact of complications was analyzed with use of the Ankle Osteoarthritis Scale (AOS), a validated outcome instrument.

RESULTS

Both groups had significant improvement in the mean AOS score (p < 0.001). There was no significant difference in the mean improvement between the two groups (p = 0.96). The complication rate was 54% following total ankle replacement and 26% following ankle arthrodesis, which was a significant difference (p = 0.003). The impact of major complications on the AOS outcome score was significant in both the total ankle replacement group (p = 0.031) and the ankle arthrodesis group (p = 0.02).

CONCLUSIONS

At the time of follow-up, at a minimum of two years postoperatively, the outcomes of total ankle replacement and ankle arthrodesis, with regard to pain relief and function, were comparable. While the rate of complications was significantly higher following total ankle replacement, the impact of complications on outcome was clinically relevant in both groups.

Biomechanical investigation of a novel ratcheting arthrodesis nail

Background

Knee or tibiotalocalcaneal arthrodesis is a salvage procedure, often with unacceptable rates of nonunion. Basic science of fracture healing suggests that compression across a fusion site may decrease nonunion. A novel ratcheting arthrodesis nail designed to improve dynamic compression is mechanically tested in comparison to existing nails.

Methods

A novel ratcheting nail was designed and mechanically tested in comparison to a solid nail and a threaded nail using sawbones models (Pacific Research Laboratories, Inc.). Intramedullary nails (IM) were implanted with a load cell (Futek LTH 500) between fusion surfaces. Constructs were then placed into a servo-hydraulic test frame (Model 858 Mini-bionix, MTS Systems) for application of 3 mm and 6 mm dynamic axial displacement (n = 3/group). Load to failure was also measured.

Results

Mean percent of initial load after 3-mm and 6-mm displacement was 190.4% and 186.0% for the solid nail, 80.7% and 63.0% for the threaded nail, and 286.4% and 829.0% for the ratcheting nail, respectively. Stress-shielding (as percentage of maximum load per test) after 3-mm and 6-mm displacement averaged 34.8% and 28.7% (solid nail), 40.3% and 40.9% (threaded nail), and 18.5% and 11.5% (ratcheting nail), respectively. In the 6-mm trials, statistically significant increase in initial load and decrease in stress-shielding for the ratcheting vs. solid nail (p = 0.029, p = 0.001) and vs. threaded nail (p = 0.012, p = 0.002) was observed. Load to failure for the ratcheting nail; 599.0 lbs, threaded nail; 508.8 lbs, and solid nail; 688.1 lbs.

Conclusion

With significantly increase of compressive load while decreasing stress-shielding at 6-mm of dynamic displacement, the ratcheting mechanism in IM nails may clinically improve rates of fusion.

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.

[The Taylor Spatial Frame. Correction of posttraumatic deformities of the tibia and hindfoot]

INTRODUCTION

Posttraumatic deformities in the lower limb are mainly multidirectional, with angulation, translation, and rotatory deformities. Acute corrections with internal fixation are often not possible due to the soft tissue damage and the extent of the deformity. The Taylor Spatial Frame (TSF) allows correction in a virtual hinge with 6 axes, thus enabling the correction of multidirectional deformities simultaneously.

METHODS

From February 2003 until December 2006, we applied 31 TSFs to 20 patients with a posttraumatic deformity of the tibia and hindfoot. The mean patient age was 41 years (range 12-73). 9 patients had a nonunion of the tibia with deformity, 6 had a malunion of the lower tibia and ankle, 3 had an angular deformity after ankle fusion, and 2 had malaligned Ilizarov bone segment transports. The mean follow-up time was 25.3 months (range 10-82).

RESULTS

In all 20 patients, full correction of the deformity was achieved. The mean time for correction was 29 days (range 5-82). On average, the frame was worn (time to healing) 164.2 days (80-300) and the mean distraction rate was 1.1 mm/day (0.5-2.0). The Web-based planning was done two times per case for full deformity correction. Complications were 3 pin-site infections, 2 insufficient callus formations and 1 pinhole stress fracture.

CONCLUSIONS

The main advantage of the TSF compared with other external frames is the ability to perform simultaneous correction of angular, axial, translational, and rotatory deformities. This enables a reduced correction time and increased patient comfort.

Tibiotalocalcaneal arthrodesis for salvage of severe ankle degeneration

Tibiotalocalcaneal arthrodesis is a successful and proven surgical procedure for patients who have significant arthritic changes, deformity, and failed previous operations. Surgical technique varies depending on the type of fixation. Basic surgical principles should not be violated. Correction of the deformity with appropriate joint preparation and stable fixation is important for a good outcome. Other adjunctive materials, such as bone growth stimulators and orthobiologics, should be used appropriately to ensure adequate primary arthrodesis.

Brace management for ankle arthritis

Management of ankle arthritis can be difficult for the physician and patient. Conservative options are limited but should be exhausted in an effort to prolong ankle arthrodesis. Custom braces can provide an effective means to alleviate pain, improve quality of life, and prolong ankle arthrodesis in patients affected by advanced ankle arthritis with or without deformity.

Ankle fusion for bone loss around the ankle joint using the Ilizarov technique

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site.

Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.