Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle

Use of a spinal cage for creating stable constructs in ankle and subtalar fusion

In complicated foot surgery with reconstruction of the hindfoot, a gap will sometimes be present between the bones that must be filled and stabilized. Bone grafting with structural bone graft is 1 alternative; however, it can collapse and must be stabilized with screws or a nail. A locking intramedullary nail can be used but could lead to nonunion owing to distraction. Newer nails include a compression device but that can result in shortening. We developed a technique that includes distraction of the fusion area with a spinal cage and then compression of the construct by inserting a compression screw through the cage. We present our experience with this technique.We reviewed the data from 7 patients who had undergone surgery using this technique. The technique included distraction of the fusion area and insertion of a titanium cylindrical spinal cage filled with autologous cancellous bone graft. A cannulated compression screw was then inserted through the cage, creating compression of the fusion area against the cage and achieving stabilization of the fusion area. Postoperatively, a non-weightbearing cast was applied for 3 months, followed by a full weightbearing cast until radiographic fusion was apparent. Complete radiographic union was observed in all 7 patients within 6 to 12 months postoperatively. At the latest follow-up visit, the mean American Orthopaedic Foot and Ankle Society scale score was 54 ± 16 (range 30 to 71) points. The use of a cylindrical titanium cage with a local bone graft and stabilization by distraction and compression provided a stable construct, avoided shortening, and led to good fusion. In addition, donor site complications and unpredictable strength loss and lysis of bone allograft were avoided.

The management of infection following total ankle replacement: demographics and treatment

BACKGROUND

Little has been published on the management of infected total ankle replacements. This study reviewed our experience with this difficult clinical problem.

METHODS

From 2002 to 2011 we retrospectively evaluated patients requiring prosthesis removal for infection following primary or revision total ankle replacement. Infections were classified as acute postoperative, late chronic, or remote hematogenous. The demographics, treatment, and outcome of the infected replacements were evaluated.

RESULTS

Of 613 replacements performed during this time period, 15 infections occurred at our institution and 4 from other institutions were treated. These 19 cases included 15 late chronic infections, 3 early postoperative infections, and 1 acute hematogenous infection. Fourteen of the infections occurred in a subset of 433 prostheses (3.2%) placed between 2002 and 2009 when we used an implant with a unique design that necessitated a tibiofibular syndesmosis fusion for the tibial component support (Agility, Depuy). One infection occurred out of 139 other prostheses (0.7%) between 2009 and 2011 when we switched to an anatomic design fixed bearing implant system. Prosthesis salvage was attempted in the 3 early postoperative and 1 acute hematogenous cases, however they all required subsequent removal of the prosthesis. Mean time to removal of the prosthesis after the index arthroplasty was 18 months. Mean follow-up was 19 months from the time of prosthesis removal. Three of the 19 patients underwent successful revision with replacement, 6 with arthrodesis, 7 with a permanent antibiotic spacer, and 3 patients required a transtibial amputation.

CONCLUSION

Only a limited number of patients who develop a deep infection following primary or revision total ankle arthroplasty can expect to undergo successful joint-preserving revision ankle arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis

BACKGROUND

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.

METHODS

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).

RESULTS

Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%).

CONCLUSION

This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases.

LEVEL OF EVIDENCE

Level IV, case series.

Ankle salvage surgery with autologous circular pillar fibula augmentation and intramedullary hindfoot nail

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.