Stress fracture of the tibia following extensive hindfoot and ankle arthrodesis: a report of three cases

Tibial Stress Fracture Following Ankle Arthrodesis

BACKGROUND

End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential.

METHODS

A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study.

RESULTS

A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up.

CONCLUSION

In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Tibiotalocalcaneal arthrodesis using a straight intramedullary nail

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is a proven solution for severe hindfoot arthropathy that reestablishes stability for plantigrade gait and alleviates pain, while correcting deformity. Intramedullary nailing is an effective option for fixation. The aim of this study was to determine clinical outcome, analyze the fusion rate, and determine final hindfoot alignment in a consecutive series of patients using a single-design straight intramedullary nail.

METHODS

This study evaluated 63 patients treated between 2006 and 2010 with at least 36 months of follow-up. Ten patients were excluded because of study inclusion criteria, and 4 were lost to follow-up, leaving 49 patients available for review. The average follow-up was 70.7 ± 15.1 months.

RESULTS

The American Orthopaedic Foot and Ankle Society score improved from 29.7 ± 15.1 before arthrodesis to 65.8 ± 14.6 after (P < .001) with 83.7% (41/49) of patients stating they were satisfied or very satisfied with the outcome. The hindfoot angle improved from -3 ± 15 degrees (varus) before the arthrodesis to 3.5 ± 4 degrees (valgus) after; the tibiotalar angle averaged 103 ± 4.2 degrees after the arthrodesis. Fusion occurred in both joints in 86% (42/49) of patients and in 93% (91/98) of all joints. The average time to fusion was 4.5 ± 2 months. Current smokers had a significantly (P = .03) higher risk of complications. Use of an allograft, with or without bone morphogenetic protein 2, led to comparable results even in the presence of a large bone defect.

CONCLUSION

These results are comparable to previously published studies using intramedullary nailing to achieve tibiotalocalcaneal arthrodesis. The complication concerns typically associated with straight nails were not found. We recommend using a retrograde intramedullary nail for the fixation of TTC arthrodesis and adding an allograft in cases of significant bone loss.

LEVEL OF EVIDENCE

Level IV, consecutive case series.

Periprosthetic fracture after femoral intramedullary nail use in two cases of tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis using intramedullary nail fixation is a technically demanding procedure. Periprosthetic fracture in association with tibiotalocalcaneal arthrodesis is a rare occurrence, with relatively few instances reported. The present report describes 2 such instances that occurred after tibiotalocalcaneal arthrodesis using retrograde femoral intramedullary nail fixation. Studies have suggested that a longer nail might decrease the incidence of periprosthetic fracture. Other factors could also have an influence, including the proximal screw orientation and the presence of medical comorbidities, such as osteopenia.

Revisional hindfoot arthrodesis

Salvage of a failed hindfoot arthrodesis is an extensive undertaking for the surgeon and patient. With increased morbidity and postoperative convalescence and complications, patients must understand the risk involved in this type of revisional surgery. This article provides a systematic approach to revisional hindfoot arthrodeses, focusing on patient evaluation, surgical technique, and postoperative treatment.

Charcot of the calcaneus

Charcot of the calcaneus, although not as prolific as midfoot deformation, still results in significant morbidity. Current treatment centers on methods proven effective for other joints in the foot. Most neuropathic conditions of the calcaneus can be managed reasonably nonoperatively. In cases of severe deformity or ulceration, surgical management may be the more conservative approach. The surgical principles of proper soft tissue balancing and handling are critical. As the diabetic population continues to increase, the incidence of Charcot of the calcaneus will concomitantly increase. Further research into methods of arthrodesis and osteotomy with external fixation seem to be the direction of the future.

Participation in sports after arthrodesis of the foot or ankle

Currently no data or guidelines exist for the surgeon on how to advise patients about returning to sports participation after arthrodesis within the foot or ankle. Sequelae of inappropriate activity after arthrodesis includes periarticular arthrosis, arthrodesis failure and stress fracture. Some arthrodeses will preclude certain sports because it limits the patient's ability to perform movement vital to the game, for example, ankle arthrodesis preventing basketball players from jumping. Questionnaires were sent to members of the American Orthopaedic Foot and Ankle Society (AOFAS) and to trainers of professional basketball and American football teams. This paper reports on the responses of orthopaedic foot and ankle surgeons about return to sports participation, after arthrodeses within the foot and ankle, and suggests guidelines for sports participation after an arthrodesis of the lower extremity. A selective sports participation policy is advised. Patients with an ankle or triple fusion should avoid high-impact sports, while those with more distal arthrodeses should be monitored for arthrosis and stress fracture.

Treatment of ankle arthrosis

Patients with arthrosis of the ankle are seen routinely in the practice of orthopaedic surgery. Although the etiologies of the arthrosis may be varied, the treatment options are similar. These options vary with the severity of the symptoms, the findings on examination and radiographs, and the physical demands of the patients. Although there are many different conservative and surgical options available, it generally is accepted that arthrodesis of the ankle is the surgical treatment of choice for patients with significant symptoms that do not respond to conservative measures. Although ankle arthrodeses have been performed for more than 100 years, there is still little agreement as to the best method to achieve the best results. Various treatment options, conservative and surgical, available to treat patients with arthrosis of the ankle are reviewed.