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Salvage Tibiotalocalcaneal Arthrodesis Augmented With Fibular Columns and Iliac Crest Autograft: A Technical Note
Abstract
Failure of ankle arthrodesis or total ankle replacement (TAR) results in a challenging clinical situation and may take the form of symptomatic nonunion following arthrodesis and aseptic or infective loosening following TAR. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required, with use of bone grafting to maintain length and reduce disability. Fibular strut grafting in the form of pillars or columns, potentially supplemented by tricortical and iliac graft, may be used in association with intramedullary TTC nailing or lateral plating and has demonstrated encouraging fusion rates. In this technical note, we review the history of this technique and report indications and surgical approach. Furthermore, of 6 cases (mean age 69.8 years) treated at our institution and followed at 13 months (range, 8 to 20 months), 5 (83%) were clinically and radiologically united, and patients were satisfied with the outcome of surgery. One patient with a background of chronic kidney disease remained dissatisfied with no union achieved, persistent pain, and awaiting a below-the-knee amputation. No other complications were observed. TTC fusion augmented with fibular columns and iliac crest autograft is an option to treat combined ankle and subtalar joint pathologies with significant talar bone loss.
Levels of Evidence: Level V (technical note)
... There have been several studies on TTC arthrodesis [14][15][16]; however, to the best of our knowledge, none have focused on how to handle the fibula intraoperatively to achieve better results. Fibular osteotomy (FO) [15], fibular strut (FS) [17], and fibular preservation (FP) [13] are likely to be more feasible than other treatment options; however, the relative results remain unknown. This study aimed to evaluate the effects of fibular procedures during TTC arthrodesis using retrograde intramedullary nails in adults. ...
... Although TTC arthrodesis using a retrograde intramedullary nail is a well-established procedure, the best option as a fibular procedure remains uncertain. All of FO, FS and FP have been reported in the existing literature, but no one has focused whether the choice of different fibula management would make a difference in TTC arthrodesis surgical outcomes [13,15,17]. Shah et al. introduced a surgical procedure that involves inserting a FS graft intramedullary using adjuvant hardware fixation, reporting that the FS was beneficial to bone fusion and the intraoperative use of autologous bone grafts helped reduce infection rates [29]. ...
Background
Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures.
Methods
We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded.
Results
Fifty-eight patients with an average age of 53.2 (range, 32–69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60–78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1 min) was longer than that of FO (119.3 ± 11.7 min) and FS (112.2 ± 12.6 min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters.
Conclusions
TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP.
Level of clinical evidence
Level 3.
... They sectioned the distal fibular fragment into 3 or 4 columns and placed them in the ankle joint to regain the height and fill the void. 5 Derek Ley and Hassan 3 used a fibular biological plate for augmentation of tibiocalcaneal arthrodesis with This study was supported by Shahid Beheshti University of Medical Sciences, Tehran, Iran. ...
Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies--weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.
Background
We investigated the association between hindfoot residual malalignment assessed on weightbearing computed tomography (WBCT) images and the development of periprosthetic cysts (PPCs) after total ankle replacement (TAR). We hypothesized that PPCs would be found predominantly medially in the varus configuration and laterally in the valgus configuration.
Methods
Cases of primary TAR with available WBCT imaging of the ankle were included in this retrospective study. The location of the PPC was marked and the following volumes were calculated: total (TCV), medial (MCV), central (CCV), and lateral (LCV) cyst volumes. Hindfoot alignment was measured as Foot and Ankle Offset (FAO), with 95% confidence intervals (95% CIs) calculated to define varus (<95% CI) and valgus (>95% CI) groups. Cyst volumes were compared between these 2 groups. The American Orthopaedic Foot & Ankle Society (AOFAS) score at the time of the WBCT was also retrieved. Receiver operating characteristic (ROC) curves were used to determine FAO thresholds for predicting an increased risk of PPC.
Results
Forty-eight TARs (mean follow-up, 44.6 months) were included, 81% of which had at least 1 PPC. The mean FAO was 0.12% (95% CI, –1.12 to 1.36). Patients with greater residual malalignment ( P < .001) and those with longer follow-up ( P < .001) presented with increased TCV. In varus cases, the MCV was greater than the LCV ( P = .042), with a threshold FAO value of −2.75% or less predicting an increased MCV. In valgus cases, the LCV was greater than the MCV ( P = .049), with a FAO threshold value of 4.5% or more predicting an increased LCV.
Conclusion
In this series, the PPC volume after primary TAR significantly correlated with postoperative hindfoot malalignment and longer follow-up.
Level of Evidence
Level III, retrospective comparative series.
Bone allografts are widely being used in clinical practice for bone reconstruction. They are considered to be the most preferred alternative to bone autografts, mainly due to their availability and the elimination of donor site morbidity. The risk of bacterial and viral disease transmission, albeit low, is one of the major concerns associated with bone allograft transplant. This review focuses on the epidemiologic and microbiologic aspects of bone allograft infections and the current prevention and treatment options. It also discusses the role of the regulatory authorities in ensuring the safety and efficacy of bone allografts.
Bone substitutes are being increasingly used in surgery as over two millions bone grafting procedures are performed worldwide per year. Autografts still represent the gold standard for bone substitution, though the morbidity and the inherent limited availability are the main limitations. Allografts, i.e. banked bone, are osteoconductive and weakly osteoinductive, though there are still concerns about the residual infective risks, costs and donor availability issues. As an alternative, xenograft substitutes are cheap, but their use provided contrasting results, so far. Ceramic-based synthetic bone substitutes are alternatively based on hydroxyapatite (HA) and tricalcium phosphates, and are widely used in the clinical practice. Indeed, despite being completely resorbable and weaker than cortical bone, they have exhaustively proved to be effective. Biomimetic HAs are the evolution of traditional HA and contains ions (carbonates, Si, Sr, Fl, Mg) that mimic natural HA (biomimetic HA). Injectable cements represent another evolution, enabling mininvasive techniques. Bone morphogenetic proteins (namely BMP2 and 7) are the only bone inducing growth factors approved for human use in spine surgery and for the treatment of tibial nonunion. Demineralized bone matrix and platelet rich plasma did not prove to be effective and their use as bone substitutes remains controversial. Experimental cell-based approaches are considered the best suitable emerging strategies in several regenerative medicine application, including bone regeneration. In some cases, cells have been used as bioactive vehicles delivering osteoinductive genes locally to achieve bone regeneration. In particular, mesenchymal stem cells have been widely exploited for this purpose, being multipotent cells capable of efficient osteogenic potential. Here we intend to review and update the alternative available techniques used for bone fusion, along with some hints on the advancements achieved through the experimental research in this field.
Background: Tibiotalocalcaneal (TTC) arthrodesis implementing adjunctive allografts is a method of limb salvage for patients with complex hindfoot osseous deficits, though outcome results are limited. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors. Methods: The authors reviewed 24 TTC arthrodesis procedures with bulk femoral head allografts performed by a single surgeon from 2004 to 2016. Radiographic union at the ankle and subtalar joints along with stability of the allograft were assessed. Patients who had clinically successful arthrodeses were contacted to score the Foot and Ankle Ability Measure—Activities of Daily Living (FAAM-ADL) questionnaire, Visual Analog Scale (VAS) for pain, and Short Form-12 (SF-12) at a mean of 58.0 months (range, 28-102) postoperatively. Results: Complete radiographic union of involved joints was achieved in 15 patients (63%) and in 75% (36/48) of all joints; 21 ankles (88%) were assessed to be radiographically stable at final follow-up. Three patients (13%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 21 patients (88%) did not require additional surgery as of final follow-up. Patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P < .001). The mean VAS for pain significantly improved from 77.2 to 32.9 (P < .001). Male sex (P = .08) and a lateral operative approach (P = .03) both resulted in worse outcomes. Conclusion: Use of a femoral head allograft with TTC arthrodesis can offer improved functional scores and sustained radiographic outcomes.
Level of Evidence: Level IV: Case series
Background
Total ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA.
Aim
This analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA.
Patients and methods
A multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively.
Results
Mean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51–49.69, p < 0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084–0.173), all cause revision was 0.185 (95%CI: 0.131–0.256), unplanned reoperation was 0.288 (95%CI: 0.204–0.390) and all infection was 0.033 (95%CI: 0.021–0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118–0.325), all cause revision was 0.305 (95%CI: 0.191–0.448), unplanned reoperation was 0.422 (95%CI: 0.260–0.603) and all infection was 0.029 (95%CI: 0.013–0.066).
Conclusion
Despite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.
Introduction:
In the treatment of osteoarthritis of the ankle, controversy persists between advocates of arthrodesis and of joint replacement.
Hypothesis:
Results of total ankle replacement (TAR) are equivalent to those of ankle arthrodesis (AA).
Material and methods:
A single-center continuous retrospective series included 50 patients (25 TAR, 25 AA) operated on by a single surgeon. TAR used the standard Salto® mobile-bearing prosthesis, and arthrodesis used screws or plates. Results were assessed clinically on AOFAS score, visual analog scale (VAS) and satisfaction questionnaire, and radiologically on X-ray and CT. Survivorship in the 2 procedures was estimated on the Kaplan Meier method.
Results:
At a mean 67 months' follow-up (range, 40-105 months), mean AOFAS and VAS scores were significantly better in the AA group (74.1 and 1.9, respectively) than in the TAR group (67 and 3.5, respectively) (p<0.001). In the AA group, 80% of patients were satisfied or very satisfied, compared to 64% after TAR. Five-year survival without revision for non-union (AA) or implant removal (TAR) was similar between groups: AA, 96%; TAR, 90% (p=0.72). In contrast, survival with no revision procedures was significantly better with AA (96%) than TAR (75%) (p=0.03).
Discussion:
At 5 years, surgical revision rates were significantly greater than after standard Salto® mobile-bearing TAR than for arthrodesis, notably due to onset of cysts; we therefore decided to abandon this implant.
Level of evidence:
IV, comparative retrospective study.
Aims:
The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail.
Patients and methods:
A total of 23 TAAs, in 22 patients, were revised for aseptic loosening and balloon osteolysis to a hindfoot fusion by a single surgeon (NH) between January 2012 and August 2014. The procedure was carried out without bone graft using the Phoenix, Biomet Hindfoot Arthrodesis Nail. Preoperative investigations included full blood count, CRP and ESR, and radiological investigations including plain radiographs and CT scans. Postoperative plain radiographs were assessed for fusion. When there was any doubt, CT scans were performed.
Results:
The mean follow-up was 13.9 months (4.3 to 37.2). Union occurred at the tibiotalar joint in 22 ankles (95.6%) with one partial union. Union occurred at the subtalar joint in 20 ankles (87%) of cases with two nonunions. The nail broke in one patient with a subtalar nonunion and revision was undertaken. The only other noted complication was one patient who suffered a stress fracture at the proximal aspect of the nail, which was satisfactorily treated conservatively.
Conclusion:
This study represents the largest group of patients reported to have undergone revision TAA to fusion of the hindfoot with good results Cite this article: Bone Joint J 2018;100-B:475-9.
Background:
The purpose of this study was to assess the outcomes of distal tibial structural allograft to obtain a stable TTC fusion.
Methods:
Retrospectively, ten patients were carried out with a minimum one year follow-up. The median age was 72 (33-81). The median BMI was 28 (24-33). Indications for TTC arthrodesis included failed total ankle arthroplasty (n=7 patients), prior nonunion (n=2 patients), and a trauma injury.
Results:
Union rate was 80%. The median initial height of the distal tibial allograft was 19mm (14-24mm). In seven cases the allograft did not lose height. The AOFAS score median was 69 (31-84). SF-12 median physical component was 39 (30-53), and 59 (23-62) for mental component. The VAS median was 2 (0-8).
Conclusions:
TTC using distal tibial allograft shows a lower rate of collapse than other structural grafts and provides a fusion rate higher or in accordance with the literature.
Level of evidence:
Level IV, retrospective case series.
Introduction:
One of the reasons for revision of total ankle replacement (TAR) implants is loosening due to subchondral cysts. Reconstruction and fusion of the ankle is often the first choice for revision procedures due to the large bone defects, which are typically filled with autograft and/or allograft. Filling the defect with a trabecular metal tantalum implant is a potential alternative given the biomechanical properties of this component.
Hypothesis:
Using tantalum as a spacer provides primary stability and contributes to fusion of the ankle joint after removal of failed TAR implants.
Methods:
Eleven patients underwent arthrodesis an average of 6.9 years after TAR. The mean height of the bone defect was 32mm. It was filled with a specially designed quadrangular implant (Trabecular Metal™, Zimmer/Biomet) combined with an iliac crest graft. Ten patients underwent tibiotalocalcaneal (TTC) arthrodesis fixed with an angled retrograde nail and one patient underwent talocrural arthrodesis fixed with two plates (anterolateral and anteromedial). The clinical, functional (AOFAS and SF36 scores), and radiological (plain X-rays and CT scan) outcomes were determined.
Results:
At a mean follow-up of 19.3 months, the mean total AOFAS score was 56 (21-78) and the mean SF36 score was 60.5 (19-84). One patient was lost to follow-up and four patients still had pain. The tantalum implant was integrated in six patients. Five patients achieved fusion of the subtalar joint and 8 achieved fusion of the talocrural joint. Three patients required surgical revision.
Discussion:
Our hypothesis was not confirmed. The clinical outcomes after more than 1 year of follow-up are disappointing, as was the large number of nonunion cases and the lack of tantalum integration. These technical failures can be explained by insufficient construct stability and/or insufficient implant porosity.
The use of total ankle arthroplasty (TAA) for the treatment of end-stage ankle arthritis is on the rise. Aseptic loosening and subsidence represent the most common complications leading to failure following TAA and can be associated with a significant amount of bone loss. Revision TAA has become a more viable treatment option but the management of bone loss in the tibia and talus remains a challenge. There is a paucity of literature regarding the success of revision TAA in the setting of surrounding bone loss. Published outcomes are mixed and complications can be quite serious. More recent implant designs, particularly of the talar component, allow for less bony resection during a primary ankle replacement and offer promise for the future. Frequent clinical and radiographic monitoring following a primary TAA is key to preventing the development of significant periprosthetic bone loss.
Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Reoperation rates are higher in total ankle arthroplasties (TAAs) compared with ankle arthrodesis. Infection rates for primary TAAs are 1.4% to 2.4%. The survival rate of TAA is approximately 75% to 90% at 10 years. Arc of motion is maintained with TAAs compared with ankle arthrodesis. Ankle arthrodesis increases arc of motion through the talonavicular joint. Several factors are strong reasons to favor ankle fusion rather than TAA. TAA and ankle arthrodesis are effective treatments of end-stage ankle arthritis but the choice must be tailored to individual patients.
Background:
The treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies.
Patients and methods:
Eight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation+wires (1 case), external fixation+screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented.
Results:
Independent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency.
Conclusion:
Tibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects - often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.
Level of evidence:
IV, Case series.
Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.
Background:
Surgical strategies to address deformities of the ankle and hindfoot in patients with Charcot arthropathy include the use of retrograde intramedullary nails and ring fixators. The literature has not shown superiority of one technique over the other. This study presents a single surgeon's case series of Charcot arthropathy patients treated with either a ring fixator or retrograde intramedullary nail to achieve tibiotalocalcaneal arthrodesis.
Methods:
We performed a retrospective analysis of 27 consecutive patients with Charcot arthropathy who underwent a tibiotalocalcaneal arthrodesis using either a retrograde intramedullary (IM) nail (n = 16 patients) or a ring fixator (RF) (n = 11 patients) by a single surgeon. We report the rates of limb salvage complications requiring secondary surgery and fusion in both groups. The patient demographics and presence of medical comorbidities known to increase the risk of surgical complications were similar between groups. The mean duration of follow-up for the retrograde nail group was 3.6 years and 2.2 years for the ring fixator group.
Results:
The mean time to discharge from the hospital after the index surgical procedure was 2.7 days for the IM group and 4.6 days for the RF group. For the patients treated with a ring fixator, the mean time to removal of the frame after the initial application was 13.3 ± 1.8 weeks. The limb salvage rate for the RF group was 9 of 11 patients whereas it was 15 of 16 in the IM group. Complications including deep infection, hardware failure, and symptomatic nonunion requiring revision surgery were common in the IM group, with 11 of 16 patients requiring further surgery. Seven patients in the IM group required removal of the implant at a mean of 117.2 weeks after the index procedure because of the development of deep infection or nail cutout. In the RF group, only 1 patient required revision surgery. Fusion rates were similar between both groups, with 10 of 16 patients fusing in the IM group and 7 of 11 in the RF group.
Conclusion:
Use of a retrograde intramedullary rod or ring fixator resulted in high rates of successful limb salvage when used for tibiotalocalcaneal arthrodesis in patients with Charcot arthropathy. However, in this study, the need for revision surgery was more frequent in the retrograde nail group compared to the ring fixator group.
Level of evidence:
Level III, retrospective comparative series.
Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.
Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature.
The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265).
Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%).
This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases.
Level IV, case series.
Bone grafting has been aFSn integral part of orthopaedic surgery for more than 100 years. In the field of foot and ankle surgery, with its focus on reconstruction, fusions of the joints of the foot are a common procedure, and these often require supplemental graft material. Although many synthetic and allograft products are now available for this purpose, autogenous bone's osteoinductive and osteoconductive qualities are unmatched by commercial bone substitutes. Our experience with bone graft harvest from the iliac crest has been favorable, despite a recent trend to avoid harvest of iliac crest bone because of perceived morbidity and lengthened operative time. This paper presents a surgical technique that has low morbidity, adds minimal operative time, and provides autogenous bone graft material for procedures involving the foot and ankle.
OperationszielWiederherstellung einer schmerzfreien Belastbarkeit der unteren Extremität durch Versteifung des Sprunggelenks nach Prothesenfehlschlägen.
IndikationenSprunggelenkprothesenlockerung.
Mutilierende Sprunggelenkdestruktion mit schwerer Achsfehlstellung bei rheumatoider Arthritis.
Schwere Arthrosen im oberen und unteren Sprunggelenk.
KontraindikationenSeptische Prothesenlockerung.
Schwere arterielle Verschlusskrankheit.
OperationstechnikTransfibularer Zugang zum oberen und unteren Sprunggelenk. Osteotomie und Resektion der distalen Fibula 7–8 cm oberhalb der
Fibulaspitze. Entfernen der Prothesenkomponenten, Synovektomie und Anfrischen der verbliebenen Knochenflächen. Entknorpelung
der talokalkanearen Gelenkfläche. Bestimmung der Defektgröße. Defektfüllung mit horizontal oder vertikal platzierten Knochenspänen
und Spongiosachips aus dem Fibularesektat und nötigenfalls aus dem ipsilateralen ventralen Beckenkamm. Tibiotalokalkaneare
Arthrodese mit einem retrograd eingebrachten Verriegelungsnagel. Schichtweiser Wundverschluss. Gespaltener Unterschenkelliegegipsverband.
WeiterbehandlungMobilisation im Unterschenkelliegegipsverband unter Entlastung für 6 Wochen. Dynamisierung des Marknagels. Teilbelastung mit
pneumatischer Gehschiene mit 20 kg für weitere 6 Wochen. Stufenweise Steigerung der Belastung nach Maßgabe der Röntgenverlaufskontrolle.
Orthopädischer Maßschuh bzw. Schuhzurichtung mit Sohlenversteifung und Mittelfußrolle.
ErgebnisseIm Zeitraum von Januar 2003 bis September 2006 wurden 15 Patienten mit aseptischen Prothesenfehlschlägen (sechs Thompson-Richards-Prothesen,
acht S.T.A.R.-Prothesen, eine Saltoprothese) versorgt. In allen Fällen wurde eine tibiotalokalkaneare Interpositionsarthrodese
mit retrograd eingebrachtem Femurmarknagel durchgeführt. Der AOFAS-Score (American Orthopaedic Foot and Ankle Society) betrug
postoperativ durchschnittlich 57,9 Punkte (35–81 Punkte). Ein Patient entwickelte eine Pseudarthrose und wird sich einer Revisionsarthrodese
unterziehen müssen. Ein weiterer Patient musste aufgrund einer ausgedehnten Wundheilungsstörung plastisch versorgt werden.
ObjectiveRestoration of painless function to the lower limb by ankle fusion after failure of total ankle arthroplasty.
IndicationsLoose total ankle replacement.
Severe ankle destruction and axial deviation in rheumatoid patients.
Severe osteoarthritis in the subtalar and ankle joints.
ContraindicationsInfected total ankle replacement.
Severe arterial occlusive disease of the affected extremity.
Surgical TechniqueTransfibular approach to the subtalar and ankle joints. Osteotomy and resection of the distal fibula 7–8 cm proximal to the
tip of the lateral malleolus. Removal of the prosthetic components, synovectomy, and revitalization of the remaining bone
surface. Removal of any residual articular cartilage from the subtalar joint surfaces. Determination of the extent of bone
loss and defect filling with horizontally or vertically placed tricortical and cancellous bone graft from the resected fibula
and, if necessary, from the ipsilateral anterior iliac crest. Tibiotalocalcaneal arthrodesis by retrograde insertion of a
retrograde locking nail. Wound closure in layers. Split below-knee cast.
Postoperative ManagementMobilization with below-knee cast without weight bearing for 6 weeks. Dynamic locking of the intramedullary nail. Partial
weight bearing with a walker up to 20 kg for an additional 6 weeks. Gradual increase in weight bearing in accordance with
radiologic evidence of consolidation. Fitted orthopedic shoe with rocker-bottom sole, and made to measure insoles.
ResultsFrom January 2003 to September 2006, 15 patients with infected ankle prosthesis loosening (six Thompson-Richards prostheses,
eight S.T.A.R. prostheses, and one Salto prosthesis) were treated. All patients underwent tibiotalocalcaneal interposition
arthrodesis with femoral nailing in retrograde technique. The average AOFAS (American Orthopaedic Foot and Ankle Society)
Score was 57.9 points (35–81 points) postoperatively. One patient developed a nonunion and revision surgery will have to be
performed. Another patient with delayed wound healing and skin necrosis needed plastic surgery.
Tibiotalocalcaneal (TTC) arthrodesis is a salvage operation to treat a difficult problem; normal function is not expected with arthrodesis of these 2 major joints. However, in properly selected patients, TTC arthrodesis using intramedullary nailing is an effective technique to reduce pain and improve function. It allows load sharing, provides anatomic alignment, and has the advantage of being able to simultaneously arthrodese both the joints with 1 device. Its use is not without risks, and care must be taken when choosing the insertion site to reduce the risk of neurovascular insult.
Internal and external fixation techniques have been developed to provide rigidity and stability to a fusion site such as in tibiotalocalcaneal (TTC) arthrodesis. Compression of the fusion site plays an integral role in primary bone healing, though little work has been done to quantify the compressive force values of ankle fixation devices.
Using synthetic and cadaveric bone models, a Newdeal/Integra PantaNail and DePuy VersaNail were tested as compressive intramedullary (IM) nails while an Encore True/Lok and an Ace-Fischer frame were tested as external fixators.
The PantaNail experienced maximum compressive loads of 1898 and 1255 N in synthetic and cadaveric constructs, respectively. The VersaNail experienced max compressive loads 388 N during installation. All IM nails tested experienced decreased compressive loads after removal of the external guide and instrumentation. The external fixators were loaded to approximately 1200 N in both synthetic and cadaveric constructs. The decrease in compressive load was recorded as a function of simulated fusion site bone resorption for all devices. The IM nails experienced a 90% reduction in load with less than 1 mm of resorption, while the external fixators held 50% load for over 4 mm of resorption. These data were verified using a simple constitutive model of IM nails and external fixators.
Intramedullary nails are capable of generating compression, however, are unable to provide sustained compression for any considerable amount of resorption. External fixators are inherently capable of applying and sustaining greater amounts of compression.
Surgeons who perform TTC arthrodesis procedures should be aware of a device's ability to generate and sustain compression with respect to bone resorption.
In 20 patients the following 3 techniques have been used for ankle fusion, all with a lateral transfibular approach: (1) fibular grafting; (2) lateral removal of the distal fibula and fixation with 3 Blount staples; (3) removal of the distal fibular and fixation with Charnley compression clamps. The compression technique, through a lateral approach, was found to be superior as it avoids section of tendons. Removal of the distal portion of the fibular eliminates the risk of drainage and problems with wound healing due to the presence of a large bone graft immediately underneath the skin. Fusion is obtained more rapidly with the third than the first and second techniques. Pain seems to be related to osteoarthritis of the surrounding joints. The gait pattern depends not only on pain, but also on the position of the foot and on the posterior displacement of the talus. Less osteoarthritis as a result of shorter immoblizaition is the most favorable factor, notwithstanding the longer preoperative period in the third than in the first two methods.
The efficacy of total ankle replacement compared with that of ankle fusion continues to be one of the most debated topics in foot and ankle surgery. The purpose of this study was to determine whether there are sufficient objective cumulative data in the literature to compare the two procedures. A systematic review of the literature addressing the intermediate and long-term outcomes of interest in total ankle arthroplasty and ankle arthrodesis was performed.
A comprehensive search of MEDLINE for all relevant articles published in English from January 1, 1990, to March 2005 was conducted. Additionally, relevant abstracts from the 2003 and 2004 annual proceedings of major orthopaedic meetings were eligible. Two reviewers evaluated each study to determine whether it was eligible for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two procedures. The analysis of the outcomes focused on second-generation ankle implants.
The systematic review identified forty-nine primary studies, ten of which evaluated total ankle arthroplasty in a total of 852 patients and thirty-nine of which evaluated ankle arthrodesis in a total of 1262 patients. The mean AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 78.2 points (95% confidence interval, 71.9 to 84.5) for the patients treated with total ankle arthroplasty and 75.6 points (95% confidence interval, 71.6 to 79.6) for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% (95% confidence interval, 69.0% to 87.6%) and the ten-year survival rate was 77% (95% confidence interval, 63.3% to 90.8%). The revision rate following total ankle arthroplasty was 7% (95% confidence interval, 3.5% to 10.9%) with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% (95% confidence interval, 5.5% to 11.6%), with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group.
On the basis of these findings, the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion.