Complex ankle arthrodesis: Review of the literature

Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail

PURPOSE

With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively.

METHOD

Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated.

RESULTS

The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients.

CONCLUSION

Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Incidence of Vitamin D Deficiency in Foot and Ankle Arthrodesis Nonunions

Background Vitamin D has been found to be crucial in musculoskeletal health. The role of vitamin D levels in orthopedic patients has become a growing area of interest given its negative impact on fracture healing which can contribute to the development of nonunion following surgery. We sought to investigate the incidence of hypovitaminosis D in a cohort of patients who experienced a nonunion following a foot and ankle arthrodesis procedure. Methodology Patients who underwent a major elective foot and ankle arthrodesis procedure and developed a nonunion were given the opportunity to obtain serum vitamin D levels. All vitamin D levels were reported from percutaneous venous blood samples and compared to our institution's range of accepted normal values (25-80 ng/mL). Results A total of 13 patients who developed a nonunion agreed to have a vitamin D level obtained, and 11 of 13 patients had a low vitamin D level (average = 14.6 ng/mL, range = 9-24 ng/mL). Five patients underwent revision arthrodesis after normalization of vitamin D levels, and four out of five patients went on to successful union. Conclusions Hypovitaminosis D may be a modifiable risk factor for nonunion following a major foot and ankle arthrodesis procedure. Orthopedic surgeons should consider vitamin D screening and supplementation in patients undergoing elective arthrodesis procedures.

Simultaneous tibio-talar fusion and tibial lengthening for end-stage ankle arthritis

PURPOSE

Arthrodesis of the ankle joint is an accepted treatment option in patients with end-stage ankle arthritis. The goal is to achieve fusion between the tibia and the talus, thereby stabilizing the joint and alleviating pain. There might be associated limb length discrepancy, especially in post-traumatic and post-infectious cases. These patients require limb lengthening and arthrodesis. The purpose of this study is to report our experience with simultaneous ankle arthrodesis and lengthening using external fixation in adolescent and young adult patients.

METHODS

This retrospective case series included all patients treated in our hospital by concomitant ankle arthrodesis and tibial lengthening procedures on the same limb, using ring external fixation system. All surgeries included distal tibial joint surface resection and the talar dome, thereby correcting any associated deformity at the ankle. The arthrodesis was fixed and compressed using ring external fixator. A concurrent proximal tibial osteotomy was done, and limb lengthening, or bone transport was performed.

RESULTS

Eight patients operated between the years 2012-2020 were included in this study. Median patient age was 20.4 years (range 4-62 years), 50% women. Median limb lengthening was 20 mm (range 10-55 mm), and median final leg length discrepancy (LLD) was 7.5 mm (range 1-72 mm). The most common complication recorded was pin tract infection, which resolved with empiric antibiotics in all cases.

CONCLUSION

Based on our experience, combined arthrodesis and proximal tibial lengthening is efficient solution that provides stable ankle and restores length of the tibia even in complex and challenging situations.

Tibiotarsal Arthrodesis with Retrograde Intramedullary Nail and RIA Graft: A Salvage Technique

Ankle arthrodesis is a commonly used salvage procedure in the management of post-traumatic ankle fractures, which often result in severe disability and may require the amputation of the distal third of the leg. Successful ankle arthrodesis relies on a thorough assessment of local and systemic risk factors to ensure optimal results. Failure to accurately assess these factors may lead to unsatisfactory results. High-energy trauma causing bone defects and soft tissue necrosis often results in osteomyelitis, a condition that poses a significant threat to the success of the arthrodesis procedure. It is important to apply a standardised surgical protocol to minimise the possibility of superficial and deep infection and limit damage to the neighbouring soft tissues. Therefore, it is critical to undertake surgical lavage and debridement and administer systemic and local antibiotic therapy, along with the use of a spacer, to eradicate infection prior to performing arthrodesis. In this study, we present our experience in the recovery of limbs with post-traumatic complications via tibio-astragalic or tibio-calcaneal arthrodesis using a retrograde intramedullary nail technique. The approach involves a multi-step procedure using a previous antibiotic spacer implant and an autologous bone graft (RIA). This study spanned a period from January 2014 to December 2021 and included 35 patients (12 women and 23 men) with a mean age of 47.8 ± 20.08 years (range: 22-85 years). Among the patients, 18 had osteomyelitis following AO 43 C3 fractures, and 9 of them had previous exposure and bone loss at the time of injury. The remaining cases included 10 patients with AO 44 C fracture outcomes and 7 patients with AO 44 B fracture outcomes. Our results emphasise the importance of the meticulous management of local and systemic risk factors in ankle arthrodesis procedures. The successful eradication of infection and subsequent arthrodesis can be achieved via the implementation of surgical lavage, debridement, and systemic and local antibiotic therapy using spacers. This surgical protocol implemented by us has yielded excellent results, saving affected limbs from post-traumatic complications and avoiding the need for amputation. Our study contributes to the existing knowledge supporting the use of retrograde arthrodesis with intramedullary nails in severe cases where limb salvage is the primary goal. However, further research and long-term follow-up studies are needed to validate these results and evaluate the effectiveness of this technique in a larger patient population.

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.

Low Preoperative Albumin Associated With Increased Risk of Superficial Surgical Site Infection Following Midfoot, Hindfoot, and Ankle Fusion

BACKGROUND

This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years.

RESULTS

Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups.

CONCLUSION

This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection.

LEVELS OF EVIDENCE

Level III, Retrospective cohort study.

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.

Comparing Rates of Fusion and Time to Fusion in Viable Cellular Allograft and Autograft

BACKGROUND

Autograft or allograft frequently are used to enhance bone union in foot and ankle surgery. Viable cellular bone allograft uses viable cells and bone scaffolding in a gel base, but uncertainty remains around allograft's greater efficacy than autograft regarding rates of fusion (ROF) and time to fusion (TTF).

METHODS

Autograft, viable cellular allograft, and viable cellular allograft with autograft were compared in 199 forefoot, midfoot, and hindfoot arthrodeses performed over a 6-year period. Data collected from electronic medical records and radiographs were analyzed to determine ROF and TTF as well as rates of revision surgery for delayed or nonunion and compared among groups.

RESULTS

Eighty-seven patients comprised the autograft group, 81 the allograft group, and 31 the combined group. No significant differences were noted in patient demographics among the groups. No statistically significant differences in ROF were noted among the 3 groups, with 86% (75 of 87) fusion in the autograft group, 93% (75 of 81) in the allograft group, and 84% (26 of 31) in the combined group (P = .20). After conducting a multivariate analysis, we found no statistically significant difference for allograft or combined graft on TTF (P = .1379 and .2311, respectively). No significant difference was found in rate of revision surgery for nonunion, which was 1.2% (1 of 81) in the allograft group, 3.4% (3 of 87) in the autograft group, and 6.5% (2 of 31) in the combined group (P = .3).

CONCLUSION

No significant difference was found in ROF, TTF, or rate of revision surgery when comparing viable cellular allograft to autograft or combined allograft-autograft. Viable cellular allograft may be a reasonable alternative to the gold standard of autograft and should be considered an option in patients undergoing arthrodesis in foot and ankle surgery.

LEVEL OF EVIDENCE

Level III, therapeutic.

How to assess consolidation after foot and ankle arthrodesis with computed tomography. A systematic review

PURPOSES

Many studies have been performed that investigate consolidation after arthrodesis of foot and ankle joints. Consolidation in foot and ankle joints is best assessed by computed tomography (CT). However, no golden-standard methodology exists for radiological consolidation assessment from CT after ankle and foot arthrodesis. The aim of this review is to present an overview of the radiological methodologies for consolidation assessment, outcomes on reliability and validity and to advise which methodology should be used.

METHOD

Scientific databases were systematically searched. Eligible studies were studies that 1) performed foot or ankle arthrodesis, 2) mentioned radiological or CT follow-up in abstract, 3) performed postoperative CT in > 50% of patients. Two authors selected eligible studies and performed a risk of bias assessment with the COSMIN tool.

RESULTS

Risk of bias assessment showed that most studies (80%) were at high risk of bias due to poor methodology. The most popular method for consolidation assessment is by subjectively categorizing consolidation into consolidation groups, with a substantial reliability score. Another popular method is to calculate the fusion ratio and then apply a fusion threshold, to distinguish between fused and non-fused joints. This method had an excellent reliability score. In most studies a fusion threshold of 50% is used. However, four studies in this review showed that a 30% fusion threshold may by more valid.

CONCLUSION

Based on the results of this review we would advise to calculate fusion threshold and apply a 30% fusion threshold to distinguish fused from non-fused foot and ankle joints.

The talar body prosthesis treated end-stage ankle arthritis with talar body deficient: a 6-13 years of follow-up outcomes and 6-year survivorship

INTRODUCTION

Talar body deficient provides a unique challenge for ankle arthritis treatment. We studied the clinical-radiographic outcomes at 6 to 13 years and 6 year prosthesis survivorship of patients treated for ankle arthritis with poor talar body bone stock using a talar body prosthesis (TBP).

MATERIALS AND METHODS

Between 2008 and 2015, we treated 32 consecutive end-stage ankle arthritis patients with talar body deficiency by TBP implantation and fascia interposition. One patient was excluded with a diagnosis of inflammatory arthritis. We assessed visual analogue scale (VAS) of ankle pain, sagittal range of motion, American Orthopaedics Foot and Ankle Society (AOFAS) ankle-hindfoot score, Foot Ankle Ability Measure (FAAM) of activity daily living (ADL), prosthesis tibiotalar surface angle, radiographic prosthesis loosening, adjacent joint arthritis and complication. Pre-operative to last follow-up outcomes (at 6-13 years) were compared. Prosthesis survivorship was analyzed at 6 year follow-up. p < 0.05 was considered a significant difference.

RESULTS

There was statistically significant improvement of median VAS ankle pain, as 8.0 (IQR 1.0) to 1.0 (IQR 2.0), AOFAS ankle-hindfoot score from 48 (IQR 21) to 80 (IQR 7.0), FAAM of ADL from50.0 (28.0) to 88.0 (IQR 15.0), and sagittal ROM from 20^o (IQR 19°) to 33° (IQR 14°), p < 0.05. The median tibiotalar surface angle was statistically significant improved from 85.0° (IQR 8.0°) to 89.0° (IQR 3.0°), p < 0.001. No radiographic prosthesis loosening or adjacent talonavicular-calcaneocuboid joint arthritis. The 6 year prosthesis survivorship was 93.5% (95% CI 84.9-100.0%). End of survivorship was observed in 2 patients due to progressive valgus tilting at 16° and 18°, respectively. No prosthesis was revised.

CONCLUSIONS

TBP implantation with fascia replacing the articular end of distal tibia provided significant better pre- to post-operative clinical outcomes and had 6 year survivorship as 93.5% for the treatment of ankle arthritis with talar body deficient.

LEVEL OF EVIDENCE

IV.

Management of Elderly Traumatic Ankle Arthritis with Ilizarov External Fixation

Objective

To evaluate the clinical curative effect of Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.

Methods

From June 2013 to August 2019, 72 patients with elderly traumatic ankle arthritis were treated with arthrodesis through Ilizarov external fixation technique in our institution. Conventional double‐feet standing X‐ray films were taken before and after operation. The tibiotalar angle on X‐ray image was measured to evaluate the degree of talipes varus and valgus. The Foot and Ankle pain score of American Orthopaedics Foot and Ankle Society (AOFAS) and Visual Analog Scale (VAS) were compared by using paired t‐test to evaluate the functional recovery.

Results

All of the patients acquired effective postoperative 18–49 months follow‐up, with an average of 31.5 months. All patients were included in the analysis, among which 38 cases were males and 34 cases were females, with an average of 65.4 years (ranging from 60 to 74). All ankles achieved bony fusion; the clinical healing time was 12.7 weeks on average (11–18 weeks). The AOFAS score was 45.36 ± 6.43 preoperatively and 80.25 ± 9.16 at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The VAS score was 8.56 ± 1.85 on average preoperatively and 2.72 ± 0.83 at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The tibiotalar angle was 101.93° ± 4.12° preoperatively and 94.45° ± 2.37° at 12 months post‐operation, with a statistically significant difference (p < 0.0001). The results of the functional evaluation indicated that 44 patients (61.1%) had excellent results, 18 (25%) had good results, and 10 (13.9%) had fair results.

Conclusion

Our study demonstrated that it is possible to obtain satisfactory outcome with Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.

Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing

Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.

Simultaneous Limb Lengthening With Ankle Fusion Using an Internal Lengthening Nail

We reviewed 18 limbs in 17 patients who underwent ankle fusion with simultaneous tibial lengthening with a magnetic internal lengthening nail. All patients had preoperative limb length discrepancy (LLD) (mean 4.9 cm (2.6-7.6 cm)) with ankle deformity. The ankle was fused from medial or lateral approaches using screws/plate constructs placed adjacent to the retrograde Precise nail. Lengthening was carried out by a distal 1/3 tibial osteotomy. Clinical and radiographic measures were performed after a mean follow-up of 20 months (12-37 months). The mean amount of lengthening performed was 4 cm (1.8-7.2 cm). The final mean LLD was 1 cm (0.7-1.1 cm), which was statistically significant (p<0.01) as compared to preoperative. The foot was plantigrade in all cases. The mean foot rotation was 10° (5-15°) external, relative to the knee. At final follow-up all patients reported minimal to no pain, and all claimed to be walking more functionally than before surgery. Ankle fusion and limb lengthening was achieved in all cases. Combining both treatments by using an internal lengthening nail was very effective and avoided leaving patients with a dysfunctional LLD or of having a separate limb lengthening procedure. This is the first report of such a combined treatment of ankle fusion with internal tibial lengthening nail.

Double Versus Triple Arthrodesis Fusion Rates: A Systematic Review

Hindfoot arthrodesis is often required for end-staged deformities, such as posterior tibial tendon dysfunction, osteoarthritis, or rheumatoid arthritis. Although the need for hindfoot arthrodesis is generally accepted in severe deformities, there is a debate whether a double or triple arthrodesis should be performed. The aim of our systematic review is to review the fusion rates and mean time to fusion in double and triple arthrodesis. A total of 184 articles were identified using the keyword search through the database of articles published from 2005 to 2017. After review by 3 physicians, a total of 13 articles met the eligibility criteria. The reason for double or triple arthrodesis within the studies were posterior tibial tendon dysfunction, tarsal coalition, degenerative joint disease, osteoarthritis, rheumatoid arthritis, Charcot Marie Tooth, Multiple Sclerosis, Polio, neuromuscular disorder, cerebral palsy, acrodystrophic neuropathy, clubfoot, post-traumatic, and seronegative arthropathy (spondyloarthritis). Within these 13 studies, there were a total of 343 (6-95) subjects extremities operated on. The overall fusion rate for double arthrodesis was 91.75% (289/315) compared to 92.86% (26/28) triple arthrodesis fusion rate, p value .8370. The mean time to fusion for double arthrodesis was 17.96 ± 7.96 weeks compared to 16.70 ± 8.18 weeks for triple arthrodesis, p value = .8133. There are risks associated with triple arthrodesis including increased surgical times, lateral wound complications, residual deformity, surgical costs and peri-articular arthritis. Given the benefits of double arthrodesis over triple arthrodesis and the nearly equivalent fusion rates and time to fusion, double arthrodesis is an effective alternative to triple arthrodesis. The authors of this systematic review recommend double arthrodesis as the hindfoot fusion procedure of choice.

Ilizarov Ankle Arthrodesis: A Simple Salvage Solution for Failed and Neglected Ankle Fractures

BACKGROUND

Infection around the ankle joint after fracture fixation, or septic arthritis with active discharging sinuses is often challenging to manage with conventional procedures of arthrodesis. The Ilizarov method of arthrodesis gives a better alternative for salvage in such cases.

METHODS

This was a retrospective study including 20 patients who were subjected to tibiotalar arthrodesis with Ilizarov method. The major pathologies included internal fixation of ankle fractures complicated by infection, posttraumatic infected ankle arthritis, and osteomyelitis. The patients were evaluated on the basis of Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. The aim of the surgery was to achieve plantigrade, stable, and painless foot with no signs of infection.

RESULTS

A total of 20 patients were operated and reviewed at our institute. The study comprised of 15 male and 5 female patients with a mean age of 43.9 years (range 33-55 years). Out of 20 patients, 4 patients had complications of pin-tract infection and one had wire breakage of the forefoot ring. According to the ASAMI criteria, 17 patients had excellent bone scores and 18 patients had good functional scores. Union was achieved in all patients with resolution of infection and the mean limb length discrepancy was 1.92 cm (range 1-2.5 cm).

CONCLUSIONS

The Ilizarov fixator for ankle arthrodesis provides an excellent way for strong bone fusion, infection eradication, early weight-bearing, and the added benefits of compression at the arthrodesis site post-operatively.

Vitamin D Deficiency and Outcomes After Ankle Fusion: A Short Report

BACKGROUND

Vitamin D deficiency has been postulated as a cause for impaired bone healing and remodeling. The purpose of this study was to assess the potential association between low vitamin D levels and reoperation for nonunion following ankle fusion surgery.

METHODS

All adult patients (aged ≥18 years) who underwent ankle fusion procedures at a tertiary referral center from January 2010 to January 2019 with available vitamin D levels within 12 months preoperatively were retrospectively reviewed (n = 47). Patients were categorized as vitamin D deficient (<30 ng/mL) vs normal (31-80 ng/mL). The primary outcome was the incidence of reoperation secondary to nonunion. Secondary outcomes included incidence of reoperation not related to nonunion and the need for repeat reoperation.

RESULTS

The average level in the vitamin D-deficient group (n = 17; 36.2%) was 16.9 vs 46.4 ng/mL in the normal group (n = 30; 63.8%). All recorded reoperations for nonunion occurred exclusively in the vitamin D-deficient cohort (4/17 [23.5%]; P = .013). There were similar reoperation rates for causes other than nonunion (2/17 [11.8%] vs 4/30 [13.3%]; P > .99) and repeat reoperation rates (3/17 [17.6%] vs 1/30 [3.3%]; P = .128) among vitamin D-deficient vs normal patients.

CONCLUSION

Vitamin D deficiency may be associated with an increased risk of reoperation for nonunion after ankle fusion.

Soft Tissue and Osseous Substitutes for the Diabetic Foot

Several soft tissue and osseous substitutes have become widely available for consideration in diabetic foot and ankle reconstruction. Although autogenous skin and bone grafts remain the gold standard, the diabetic foot often presents with challenging clinical scenarios in which these options are limited or contraindicated. Selection of the appropriate substitute depends on the patient's medical status, type and extent of soft tissue and bone loss, and expected function of the given site. This article reviews several of the specific advanced orthobiologics and their clinical indications.

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.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion

BACKGROUND

The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis.

METHODS

Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up.

RESULTS

TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2).

CONCLUSION

In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems.

LEVEL OF EVIDENCE

Level IV, case series.

The Role of Distraction Arthroplasty in Managing Ankle Osteoarthritis

Ankle distraction arthroplasty (DA) is a joint-preserving option for the treatment of ankle osteoarthritis. The ideal patient is a young, active person who is compliant with follow-up and understands that clinical improvements may not be fully evident until 1 year after surgery. The procedure promotes cartilage healing and regeneration by removing mechanical stress at the joint surface through the application of a joint-spanning external fixator. There is an array of adjuvant procedures commonly performed to optimize healing potential-including microfracture, osteophyte removal, osteotomies, and soft tissue balancing procedures. Short- and intermediate-term studies have been promising, though there is a wide variance in reported failure and complication rates.

Risk factors for nonunion following tibiotalocalcaneal arthrodesis: A systematic review and meta-analysis

BACKGROUND

The goal of this study is to review the literature to identify risk factors for nonunion after tibiotalocalcaneal arthrodesis (TTCA) and stratify them based on strength of evidence.

METHODS

Five databases were searched from inception to May 17th, 2020. Abstracts and full-text articles were screened for those that included risk factors predictive of nonunion following TTCA.

RESULTS

Eight studies involving 624 patients were included and 33 potential risk factors for nonunion were identified. Strong evidence supported prior peripheral neuropathic conditions as risk factors for nonunion following surgery (OR: 2.86, 95% CI: 1.56-5.23).

CONCLUSION

TTCA is an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior peripheral neuropathic conditions have strong evidence for failure to achieve union. Surgeons should be cognizant of these risks when performing TTCA and carefully monitor patients with the aforementioned comorbidity to achieve successful results.

Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis

BACKGROUND

Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications.

METHODS

We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period.

RESULTS

Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2.

CONCLUSION

Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control and clinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD: ±11.3) versus 71.7 (SD: ±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.

Limited Evidence for Biological Adjuvants in Hindfoot Arthrodesis: A Systematic Review and Meta-Analysis of Clinical Comparative Studies

BACKGROUND

The purpose of the present study was to evaluate the efficacy of biological adjuvants in patients managed with hindfoot arthrodesis.

METHODS

A systematic review of the PubMed and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with use of specific search terms and eligibility criteria. Assessment of evidence was threefold: level of evidence by criteria as described in The Journal of Bone & Joint Surgery, quality of evidence according to the Newcastle-Ottawa scale, and conflicts of interest. Meta-analysis was performed with fixed-effects models for studies of low heterogeneity (I2 < 25%) and with random-effects models for studies of moderate to high heterogeneity (I2 ≥ 25%).

RESULTS

A total of 1,579 hindfeet were recruited across all studies, and 1,527 hindfeet were recorded as having completed treatment and follow-up visits. The duration of follow-up ranged from 2.8 to 43 months. Twelve of the 17 included studies comprised patients with comorbidities associated with reduced healing capacity. Based on the random-effects model for nonunion rates for autograft versus allograft, the risk ratio was 0.82 (95% CI, 0.13 to 5.21; I2 = 56%; p = 0.83) in favor of lower nonunion rates for autograft. Based on the random-effects model for rhPDGF/β-TCP versus autograft, the risk ratio was 0.90 (95% CI, 0.74 to 1.10; I2 = 59%; p = 0.30) in favor of lower nonunion rates for rhPDGF/β-TCP.

CONCLUSIONS

There is a lack of data to support the meaningful use of biological adjuvants as compared with autograft/allograft for hindfoot arthrodesis. The meta-analysis favored the use of autograft when compared with allograft but favored rhPDGF/β-TCP when compared with autograft in the short term.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous septic arthrodesis of the tibiotalar and subtalar joints with the Ilizarov external fixator-an analysis of 13 patients

Purpose

Treatment of joint destruction of the tibiotalar and subtalar joints caused by acute or chronic infections in compromised hosts is a challenging problem. In these cases, simultaneous septic arthrodesis with the use of the Ilizarov external fixator represents a possible alternative to amputation. This case series presents the results and complications of patients with acute or chronic infection of the tibiotalar and subtalar joints.

Methods

Between 2005 and 2015, 13 patients with acute or chronic infections were treated by simultaneous single-stage debridement/arthrodesis of the tibiotalar and subtalar joints. In seven patients, there was a florid infection with fistula formation and soft tissue defects, and in six patients, there was chronic osteomyelitis with closed soft tissue. In addition to the demographic data, the time spent in the fixator, the major and minor complications and the endpoint of consolidation were reviewed.

Results

The mean time spent in the fixator was 18 (min 15, max 26) weeks. The mean follow-up time for nine patients was 100 (min 3, max 341) weeks. Complete osseous consolidation of both the tibiotalar and subtalar joints was achieved in 10 patients (77%). In three (23%) patients, there was complete consolidation of one of the joints and partial consolidation of the other joint.

Conclusion

The Ilizarov external fixator allows for simultaneous arthrodesis of the tibiotalar and subtalar joints in septic joint destruction. However, the healing rates are below the rates reported in the literature for isolated tibiotalar or tibiocalcaneal arthrodesis in comparable clinical situations.

Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

BACKGROUND

Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis.

METHODS

In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon's logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes.

RESULTS

Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection (P = .05) and bone stimulator use (P < .001). Among smokers, there was a trend toward slower union with heavier smoking (P = .004).

CONCLUSION

This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Revision Surgery for Failed Total Ankle Replacement

Revision surgery for failed total ankle replacement is a challenge to the revision surgeon. Deformity, presence of infection, segmental bone defects, patient comorbidities, and soft tissue compromise all are significant considerations when determining appropriate procedures. Revision total ankle replacement, explant and fusion with or without lengthening, use of a trabecular metal cage, placement of an antibiotic cement spacer, grafting, and amputation all are viable options to treat patients with failed ankle arthroplasty.

Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system

BACKGROUND

Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hindfoot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors.

METHODS

A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails. The electronic database of PubMed/Medline/Cochrane Library was explored using specific search terms. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded.

RESULTS

A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies.

CONCLUSION

Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice.

Agonizing and Expensive: A Review of Institutional Costs of Ankle Fusion Nonunions

Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m². Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].

Outcomes of Tibiocalcaneal Arthrodesis in High-Risk Patients: An Institutional Cohort of 18 Patients

INTRODUCTION

Tibiocalcaneal (TC) arthrodesis is commonly performed in patients with severe hindfoot disease. These include severe Charcot deformities, ankle malformations, chronic osteomyelitis (COM), and avascular necrosis (AVN). The talar vascular becomes disrupted to the point that the bone can no longer be salvaged. The procedure involves performing a talectomy and fusing the tibia to the calcaneus. This helps in preserving the remaining hindfoot anatomy, while allowing the patient to regain function and mobility. Our study highlights certain risk factors that influence the rate of postoperative complication after tibiocalcaneal surgery.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 18 patients from a single institution who underwent tibiocalcaneal between the years of 2011 and 2019. Preoperative diagnoses, comorbidities, and post-operative outcomes were noted among all patients. Then, the rates of non-union, below-knee amputations, revision surgeries, postoperative infections, and hardware failure were recorded. These data were then analyzed to determine which preoperative and perioperative factors affected postoperative outcomes for patients after tibiocalcaneal arthrodesis surgery.

RESULTS

Nonunion was the most commonly reported complication in this series. Eight of the eighteen patients were documented to have nonunion including three patients with stable pseudarthrosis. Diabetic patients had a slightly higher incidence of nonunion (4 of 7 patients) compared to those without diabetes (4 of 11 patients). Of the nine patients diagnosed with Charcot arthropathy, five had nonunion. Three of the five individuals with a BMI ranging from 25 to 30, and four of the six individuals with a BMI of greater than 30 had a nonunion. Infection was a post-operative complication for four of the eighteen patients. Two of the four patients had multiple comorbidities in addition to chronic infections in the joint which were recurrent after surgery.

CONCLUSION

In conclusion, TC arthrodesis provides a viable option for high-risk patients with complicated ankle pathology who have not had successful outcomes from previous treatment. It is not without complications considering the comorbidities the patients present with before requiring this procedure. Further studies are necessary to validate the trends of outcomes and comorbidities of patients with TC arthrodesis.

The need for a paradigm shift in the rehabilitation of elective foot and ankle reconstructive surgery patients? An annotation

Current surgeon established protocols encourage late weight bearing and prolonged immobilisation after ankle, hind- and mid-foot fusion surgery. There is no universal guidance regarding early mobilisation and rehabilitation after this type of surgery. There is a paucity of research in this area but early mobilisation may be beneficial in terms of improved clinical and patient reported outcome measures, whilst still offering good union and very few complications. Feasibility work prior to a full-scale trial is now needed to explore the efficacy of early functional mobilisation, prior to any adoption within clinical practice. A paradigm shift in the early post-operative management of this patient group has the potential to improve outcomes for patients and decrease the socioeconomic burden on the health service.

What Is the Treatment "Algorithm" for Infection After Ankle or Hindfoot Arthrodesis?

RECOMMENDATION

There is no universal algorithm for addressing the infected ankle or subtalar arthrodesis. A potential algorithm created by consensus is.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

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.

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.

Staged distraction osteogenesis followed by arthrodesis using internal fixation as a form of surgical treatment for complex conditions of the ankle

Aims

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique.

Patients and Methods

Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS).

Results

A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery.

Conclusion

The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755–60.

Clinical assessment of 115 cases of hindfoot fusion with two different types of graft: Allograft+DBM+bone marrow aspirate versus autograft+DBM

INTRODUCTION

Nonunion is a common complication (15%) of hindfoot and ankle arthrodesis. Autograft can improve the fusion rate because of its osteoconductive, osteoinductive and osteogenic properties. However, autograft harvesting is a source of morbidity. One alternative is to combine allograft with demineralized bone matrix (DBM) and iliac bone marrow aspirate (BMA). This combination graft has similar biological properties to healthy bone. When used alone, allograft has osteoconductive and sometimes structural properties. DBM provides osteoinduction and improves the osteconductivity. BMA adds cells and thereby osteogenic potential.

HYPOTHESIS

Given its intrinsic properties, allograft-DBM-BMA is as effective as autograft-DBM treatment while simplifying the clinical practice.

MATERIAL AND METHODS

One hundred and fifteen cases of ankle and hindfoot arthrodesis were studied in 82 patients divided in two groups: autograft-DBM vs allograft-DBM-BMA. Treatment effectiveness was assessed using clinical (time to fusion, fusion rate) and radiological (trabecular bone bridge, disappearance of joint space) criteria. A CT scan was done in 60% of cases when fusion could not be confirmed using the clinical and radiological criteria.

RESULTS

There was no significant difference between the two groups in terms of fusion rate, time to fusion, number of heterotopic ossifications, revision rate and quantity of DBM used. The nonunion rate was 18% in the autograft group and 13% in the allograft group. The infection rate was 11% in the autograft and 4% in the allograft group.

DISCUSSION

Allograft-DBM-BMA is an alternative to autograft-DBM that provides similar effectiveness without increasing the number of nonunion or complications. Osteonecrosis and surgical revision are risk factors.

LEVEL OF EVIDENCE

III retrospective study.

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.

Complex ankle arthrodesis with step-cut osteotomy in Charcot arthropathy with bone loss

We report a case of a complex limb salvage ankle arthrodesis in a patient with Charcot arthropathy. A step-cut osteotomy was performed in order to tackle the issues of anterior tibial bone loss; worsening leg length discrepancy; soft tissue contraction; joint instability and high risk of non-union. The construct formed by the step-cut allowed for the preservation of good bone stock; avoidance of further limb shortening; increased torsional stability and increased surface area for bony union. This resulted in a patient with a stable, plantigrade foot appropriate for footwear. We use this case to highlight this technique as an option in the operative management of complex ankle fusions with sagittal or coronal plane deformity with bone loss and subluxation of the ankle joint.

Limb Salvage After Failed Initial Operative Management of Bimalleolar Ankle Fractures in Diabetic Neuropathy

BACKGROUND

Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population.

METHODS

This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months.

RESULTS

The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures.

CONCLUSION

This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Arthroscopic arthrodesis for ankle arthritis without bone graft

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

The Biology of Bone and Ligament Healing

This review describes the normal healing process for bone, ligaments, and tendons, including primary and secondary healing as well as bone-to-bone fusion. It depicts the important mediators and cell types involved in the inflammatory, reparative, and remodeling stages of each healing process. It also describes the main challenges for clinicians when trying to repair bone, ligaments, and tendons with a specific emphasis on Charcot neuropathy, fifth metatarsal fractures, arthrodesis, and tendon sheath and adhesions. Current treatment options and research areas are also reviewed.

Contribution of G.A. Ilizarov to bone reconstruction: historical achievements and state of the art

Methodological solutions of Prof. G.A. Ilizarov are the core stone of the contemporary bone lengthening and reconstruction surgery. They have been acknowledged in the orthopaedic world as one of the greatest contributions to treating bone pathologies. The Ilizarov method of transosseous compression–distraction osteosynthesis has been widely used for managing bone non-union and defects, bone infection, congenital and posttraumatic limb length discrepancies, hand and foot disorders. The optimal conditions for implementing distraction and compression osteogenesis were proven by numerous experimental studies that Prof. G.A. Ilizarov organized and supervised at a large orthopaedic research institute in Kurgan. The tension stress effect on regeneration and growth of tissues was thoroughly investigated with radiographic, histological and biochemical methods. The impact of the Ilizarov method on the progress of bone lengthening and reconstruction surgery could be called revolutionary.