Outcome of transfibular ankle arthrodesis with Ilizarov apparatus

Posttraumatic Avascular Necrosis of the Talus: Prevention, Course, and Treatment Options

Avascular necrosis (AVN) of the talus in a posttraumatic setting describes a condition of temporary or permanent bone death of a different extent, initiated by a circulatory disturbance. It is estimated that about 75% of all talar AVNs are caused by a prior trauma. The incidence of posttraumatic AVN rises with higher energy of injury, severity of talar body or neck displacement, fracture comminution, and injury to the soft tissues and major vessels in the lower leg and ankle region. These conditions are often seen in open fractures, fracture dislocations, and pure dislocations.

Subjective and Objective Outcomes of Ankle Joint Arthrodesis with Either Ilizarov or Internal Fixation

After arthroplasty, arthrodesis of the ankle joint is the most common method to treat advanced ankle osteoarthritis. The goal of the study was to assess the subjective and objective outcomes in 2 different types of fixation for ankle joint arthrodesis. We retrospectively assessed 47 patients who had undergone ankle joint arthrodesis with fixation either via an Ilizarov apparatus (group 1) (n = 21) or cannulated screws (group 2) (n = 26). The outcomes were measured by: (1) the quantity of analgesics administered, (2) the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) general patient satisfaction, (4) the patients' decision to undergo the same procedure given another chance, and (5) the necessity of blood transfusion during hospitalization. Data was collected at the last postoperative follow-up visit. The AOFAS scores in group 1 and group 2 patients were 73.9   ± 13 and 72.7  ±  14.3, respectively. In group 1, 17 patients (81%) were very satisfied with the results, while in group 2, 19 patients (73%) were very satisfied with the results (p = .043). Two group 1 patients (10%) and four group 2 patients (15.3%) reported that they were satisfied with the outcomes (p = .035). Two patients (10%) from group 1 and three patients (11%) from group 2 were fairly satisfied. Seventeen patients (81%) after arthrodesis with Ilizarov fixation and 21 patients (81%) after arthrodesis with internal fixation would choose the same procedure given the opportunity to choose again. In group 1 there were no patients who required blood transfusion; in group 2 one patient (4%) required blood transfusion; the difference was statistically significant (p = .039). Nineteen group 1 patients (90%) were administered an analgesic preoperatively, while postoperatively only 6 (29%) required analgesics. In group 2, 24 patients (92%) were administered analgesics preoperatively, with 8 (31%) of them still requiring analgesics postoperatively. Ankle arthrodesis patients from both group 1 and group 2 achieved good subjective and objective results of treatment. We noted slightly better results in the Ilizarov apparatus group.

EXPERIMENTAL SUBSTANTIATION OF THE BIOMECHANICAL EFFICIENCY OF THE ANTERIOR PLATE COMBINED WITH TWO SPONGIOUS SCREWS FOR ANKLE ARTHRODESIS

Актуальность. Несмотря на существующее значительное количество разнообразных методик, применяемых для артродеза голеностопного сустава, ряд авторов указывают на определенные технические сложности указанных операций, потерю коррекции заданного положения таранной и большеберцовой костей в процессе анкилозирования, несращения. Проблема совершенствования методики фиксации при артродезе голеностопного сустава требует новых решений. Цель провести сравнительный биомеханический анализ стабильности фиксации при артродезе голеностопного сустава тремя спонгиозными винтами и разработанной пластиной, комбинируемой с двумя спонгиозными винтами, методом конечных элементов. Материалы и методы. Методом конечных элементов выполнена оценка биомеханических характеристик трех вариантов систем фиксации голеностопного сустава при артродезе: три спонгиозных винта, разработанная пластина, комбинируемая с двумя спонгиозными винтами, проксимальный винт в пластине кортикальный, а также разработанная пластина, комбинируемая с двумя спонгиозными винтами, проксимальный винт в пластине с угловой стабильностью. Изучены напряжения и деформации при приложении различных видов нагрузок. Результаты. В модели фиксации голеностопного сустава передней пластиной, комбинируемой с двумя спонгиозными винтами и проксимальным кортикальным винтом, имплантаты и таранная кость испытывали наименьшие напряжения по сравнению с двумя другими моделями. Так, максимальное эквивалентное напряжение в имплантатах при втором варианте составило 68-124 МПа, при первом варианте 92-147 МПа, при третьем 130-331 МПа. Эквивалентное напряжение в таранной кости во втором варианте фиксации составило от 20 до 46 МПа, в первом и третьем вариантах 28-58 МПа и 47-65 МПа, соответственно. Показатели максимального контактного давления на границе большеберцовой и таранной костей оказались наибольшими в первом варианте по сравнению с двумя другими моделями (34 МПа, 31 МПа и 31 МПа соответственно). Заключение. Среди изученных систем фиксации голеностопного сустава для артродеза, применение передней пластины, комбинируемой с двумя спонгиозными винтами и проксимальным кортикальным винтом, является наиболее предпочтительным с точки зрения биомеханики.

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 %.

Screw Internal Fixation and Ilizarov External Fixation: A Comparison of Outcomes in Ankle Arthrodesis

The purpose of this study was to compare the mid-term clinical outcomes between screw internal fixation and Ilizarov external fixation in patients who underwent ankle arthrodesis and to elucidate the differences between the 2 fixation methods. This study investigated 43 ankles in 41 patients who underwent ankle arthrodesis at 1 of the 2 study institutions. There were 15 men and 26 women, and their mean age was 66.2 (range 49 to 87) years. The primary disease included osteoarthritis (OA) (79%), rheumatoid arthritis (RA) (16.3%), and Charcot joint (4.7%). Patients were divided into 2 groups depending on the surgical approach: the screw group (S) and the Ilizarov group (I). The following items were evaluated and compared between the 2 groups: patient characteristics, Tanaka-Takakura classification based on preoperative plain X-ray images, duration of surgery, blood loss, surgical complications, time to start weightbearing, and the Japanese Society of Surgery of the Foot (JSSF) standard rating system for the ankle-hindfoot. Duration of surgery was significantly shorter in the S group (162.3 versus 194.9 min), and the amount of blood loss was also significantly lower in the S group (29.2 versus 97.5 ml). Preoperative JSSF scale was significantly lower in the I group (44.8 versus 33), but postoperative JSSF scale was not significantly different between the 2 groups (82.1 versus 77.9). The S group had satisfactory clinical outcomes with a shorter duration of surgery and smaller amount of blood loss than the I group. However, severe patients in the I group achieved similar treatment outcomes.

Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion

Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.

Salvage arthrodesis for infected ankle fractures with segmental bone-loss using Ilizarov concepts: a prospective study

PURPOSE

Complex ankle fractures accompanied with infection and segmental bone loss are a worrying issue. This prospective study was conducted to explore the effectiveness of using Ilizarov concepts in achieving salvage arthrodesis and reconstructing post-debridement defects in such complicated scenarios.

METHODS

A total of 44 consecutive patients (mean age 35.61 ± 8.57 years, 30 males, 44 feet) of post-traumatic infected ankle fractures, who met our selection criteria, were enrolled and subjected to radical debridement and salvage arthrodesis using the bifocal bone transport concepts of Ilizarov. All patients were treated between 2012 and 2017 either by acute shortening compression of the arthrodesis site with re-lengthening (ASRL) through the created proximal metaphyseal osteotomy (group I, n = 20) or by gradual bone transport (BT) through the proximal osteotomy with gradual closure of the distal ankle defect (group II, n = 24). Plain-radiographs were used for radiological assessment. Clinically, the outcomes were objectively graded according to the Hawkins criteria, while subjectively the patients reported their satisfaction on a 1-5 points acceptance scale.

RESULTS

The mean follow-up was 37.16 ± 5.31 (30-48 months). Successful fusion was achieved in 43/44 patients, with a significantly (P < 0.05) lesser needs for bone-grafting in favour of group II. The results were good in 32 cases, fair in 11, and poor in a single case with no significant difference between the two groups. The acceptance scores were significantly (P < 0.05) superior in group II (3.08 ± 1.1 points) than that group I (2.25 ± 1.4 points).

CONCLUSIONS

Bifocal bone transport is effective in salvaging troublesome infected ankle fractures with bone loss. BT is more comprehensive and acceptable than ASRL with lesser needs for bone grafting.

Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation

Background

Ankle arthrodesis may have internal or external stabilization.

We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Methods

We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007–2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Results

Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458).

Conclusions

Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.

A New Classification for Ankle Arthrodesis When Using an External Fixator

Background

We have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively.

Materials and methods

Thirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I—no bone defect, no or mild deformity; type II—no bone defect, severe deformity; type III—bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV—bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport.

Results

All patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one.

Conclusion

We have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases.

How to cite this article

Matsubara H, Watanabe K, Takata M, et al. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019;14(3):148–154.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads.

METHODS

Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.

RESULTS

In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant.

CONCLUSIONS

Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

Assessment of the distribution of load on the lower limbs and balance before and after ankle arthrodesis with the Ilizarov method

Ankle arthrodesis with the Ilizarov method is an accepted form of treatment of advanced degenerative changes of the ankle joint. Incorrect balance and load distribution on the lower limbs may result in pain and dysfunction. The aim of the study was to assess the change of balance and load distribution in lower extremities in patients before and after ankle arthrodesis with the Ilizarov method. Between 2013 and 2016, ankle arthrodesis using the Ilizarov method was performed on 21 patients. The evaluation of balance and percentage of load in each lower limb was performed before the surgery and during the follow-ups. The evaluation was performed using a Zebris pedobarographic platform. Before the surgery, the patients exhibited an average load of 41.9% of body weight in the affected limb, whereas the load in the healthy limb was 58.1%. The difference was statistically significant (p = 0,000031). In two years follow-up, the average load in the treated limbs was 48.19%, whereas the healthy limbs were subjected to an average load of 51.81%. In preoperative tests, the average path length of the center of gravity was 161.55 cm; postoperatively, the average path length of the center of gravity was 129.7 cm (p = 0.00003206). Preoperatively, the average area of the center of gravity was 18.85 cm²; it decreased to 6.19 cm² (p = 0.000032) postoperatively. Arthrodesis of the ankle with the Ilizarov method improved the statics of the musculoskeletal system by improving the distribution of loads in the lower limbs as well as balance. However, it failed to restore the parameters of a healthy person. Advanced degenerative changes of the ankle disturb the biomechanics of the entire lower limb.

Radiological evaluation of ankle arthrodesis with Ilizarov fixation compared to internal fixation

INTRODUCTION

We asked whether the type of ankle joint arthrodesis stabilization will affect: (1) rate of union, (2) rate of adjacted-joint arthritis, (3) malalignment of the ankle joint.

MATERIAL AND METHODS

We retrospectively radiological studied 62 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1,n=29) or internal stabilization (group 2,n=33) from 2006 to 2015. Radiologic outcomes were mesure by: (1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test,Mann-Whitney U test and Students t-test were used to the statistical analyses.

RESULTS

Ankle fusion was achieved in 100% of patients treated with external fixation and in 88% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 76% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 85% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 27(81.8%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 33 patients from group 2.

DISCUSION

Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization.

Transfibular ankle arthrodesis: A novel method for ankle fusion - A short term retrospective study

BACKGROUND

Ankle arthrodesis has long been the traditional operative treatment for posttraumatic arthritis, rheumatoid arthritis, infection, neuromuscular conditions, and salvage of failed ankle arthroplasty. It remains the treatment of choice for patients in whom heavy and prolonged activity is anticipated. We present our short term followup study of functional outcome of patients who underwent transfibular ankle arthrodesis for arthritis of ankle due to various indications.

MATERIALS AND METHODS

29 transfibular ankle arthrodesis in 29 patients performed between April 2009 and April 2014 were included in this study. The mean age was 50 years (range 22-75 years). The outcome analysis with a minimum of 1-year postoperative followup were included. All the patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot scale.

RESULTS

All cases of ankle fusions (100%) progressed to solid union in a mean postoperative duration of 3.8 months (range 3-6 months). All patients had sound arthrodesis. The mean followup period was 32.52 months (standard deviation ± 10.34). The mean AOFAS score was 74 (pain score = 32, functional score = 42). We found that twenty patients (68.96%) out of 29, had excellent results, 7 (24.13%) had good, and 2 (6.89%) showed fair results.

CONCLUSION

Transfibular ankle arthrodesis is a simple and effective procedure for ankle arthritis. It achieves a high rate of union and good functional outcome on midterm followup.

Transfibular ankle arthrodesis using burring, curettage, multiple drilling, and fixation with two retrograde screws through a single lateral incision

PURPOSE

To review the outcome of 23 ankle arthrodeses using burring, curettage, multiple drilling, and fixation with 2 retrograde screws through a single lateral incision.

METHODS

Records of 22 consecutive patients aged 39 to 79 (mean, 62.4) years who underwent 23 ankle arthrodeses for end-stage ankle arthritis were reviewed. Through a single lateral incision, articular cartilage was removed using burring and curettage, and multiple holes were drilled using a Kirschner wire, followed by fixation with 2 retrograde screws. The resected distal fibula was fixed to the distal part of the talus and tibia. The position of the ankle and subtalar joint arthrosis was assessed by 2 orthopaedic specialists. Pre- and post-operative American Orthopaedic Foot and Ankle Society (AOFAS) scores were evaluated.

RESULTS

The mean operating time was 122 minutes. The mean follow-up period was 41 months. The mean postoperative ankle alignment was suboptimal: 2.7º varus, 6.7º plantar flexion, and 2.9º internal rotation. The mean AOFAS score improved from 30 to 71 (p<0.01). The postoperative varus ankle alignment was not associated with the AOFAS score (r= -0.13, p=0.569). Of the 23 cases, one was nonunion and 22 achieved bone union after a mean of 5.4 (range, 2-16) months; 3 of them were delayed union. Despite bone union, 7 patients complained of persistent pain; 4 of them had progressive arthrosis of the adjacent subtalar joints (n=2) or subtalar and talonavicular joints (n=2).

CONCLUSION

Ankle arthrodesis using burring, curettage, multiple drilling, and fixation with 2 retrograde screws achieved a high union rate and acceptable functional score without serious complications.

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.

Complications of tibio-talar-calcaneal fusion using intramedullary nails

BACKGROUND

Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications following the use of hindfoot nails at our institution.

METHODS

We identified patients from a retrospective database. All underwent hindfoot nailing under the care of the senior author. Details of complications were recorded.

RESULTS

We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18-69). Forty patients achieved ankle fusion and 36 subtalar joint fusion. Complications included prominent metalwork in 13 patients, CRPS in five and one peri-prosthetic fracture. Nine developed deep infection, and of these limb salvage was achieved in six patients by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. The remaining three patients underwent below knee amputation.

CONCLUSION

Significant complications can occur, although limb preservation was possible in most cases of deep infection. Hindfoot nailing should be reserved as salvage procedure.

Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction

BACKGROUND

Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options.

METHODS

An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications.

RESULTS

In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values.

CONCLUSIONS

Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy.