Hindfoot Arthrodesis with the Blade Plate: Increased Risk of Complications and Nonunion in a Complex Patient Population

The Outcomes of Isolated Tibiocalcaneal Arthrodesis: A Systematic Review

Background

Tibiocalcaneal arthrodesis (TCA) can be achieved by internal fixation (intramedullary nail or plate), external fixation, or a combination. Evidence for the optimal approach is limited. This systematic review examines the outcomes of these different approaches to guide surgical management.

Methods

A MEDLINE and Oxford SOLO search was performed using "tibiocalcaneal," "ankle," "fusion OR arthrodesis." The primary outcome was union. Secondary outcomes included rates of postoperative complications, weightbearing status, rates of revision surgery, and PROMs. We included any studies with follow-up greater than 6 months that contained our primary outcome and at least 1 secondary outcome.

Results

The initial search yielded 164 articles, of which 9 studies totaling 53 cases met the criteria. The majority of articles were excluded because they were nonsurgical studies, or were not about isolated TCA but were for tibiotalocalcaneal arthrodesis, more complex reconstructions (eg, Charcot), case reports, and/or did not include the predetermined outcome measures.TCA union rate was 86.2% following external fixation, 82.4% for intramedullary nail fixation, and 83.3% for plate fixation. One patient underwent a hybrid of external and internal fixation, and the outcome was nonunion. The rate of complications following TCA was 69.8%.

Conclusion

There is limited evidence on the best operative approach for isolated tibiocalcaneal arthrodesis. Both external and internal fixation methods had comparable union rates. External fixation had frequent complications and a more challenging postoperative protocol. Novel techniques such as 3D-printed cages and talus replacement may become a promising alternative but require further investigation.

Efficacy of supramalleolar osteotomy in the treatment of traumatic ankle joint varus deformity in adolescents

BACKGROUND

Supramalleolar osteotomy (SMOT) has emerged as a valuable treatment for ankle varus deformity; however, there are fewer reports of treatment outcomes in adolescents. The purpose of this study was to investigate the radiologic and clinical outcomes of SMOT for the treatment of traumatic ankle joint varus deformity (TAVD) in adolescents.

METHODS

We reviewed 32 adolescent cases who underwent SMOT between February 2017 and February 2022 for TAVD. Radiologic assessment included tibial anterior surface angle (TAS), talar tilt angle (TT), and tibial lateral surface angle (TLS) preoperatively and at 3 months and 12 months postoperatively, and clinical assessment was performed using American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Scale (VAS) scores, and ankle dorsiflexion-plantarflexion ROM including preoperative and 6 months postoperative and 12 months postoperative.

RESULTS

All 32 patients were followed up completely with a mean follow-up of (20.3 ± 3.2) months. From the radiologic outcomes, the mean preoperative TAS improved from 61.53 ± 3.74 to 88 ± 1.72 at 12 months postoperatively, the mean preoperative TT decreased from 2.25 ± 1.32 to 0.5 ± 0.57 at 12 months postoperatively, the mean preoperative TLS improved from 76.72 ± 0.21 to 79.34 ± 1.52 at 12 months postoperatively, the differences between the above preoperative and 12 months postoperative radiologic outcomes were statistically significant (p < 0.05), the mean preoperative AOFAS score improved from 65.5 ± 9.40 to 92.34 ± 4.00 at 12 months postoperatively, the mean preoperative VAS score decreased from 2.44 ± 1.24 to 0.78 ± 0.75 at 12 months postoperatively, and the mean preoperative range of motion (ROM) of ankle improved from 50.16 ± 7.46 to 55.78 ± 4.77 at 12 months postoperatively. The differences between the above preoperative and 12 months postoperative clinical results were statistically significant (p < 0.05).

CONCLUSION

Our study demonstrated that SMOT was effective in correcting TAVD and significantly improving ankle function in adolescents, and that it is an efficient and successful method for restoring ankle joint congruence and normal hindfoot alignment.

The Fate of Delayed Unions After Isolated Ankle Fusion

BACKGROUND

Nonunion remains the most common major complication of ankle arthrodesis. Although previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. In this retrospective cohort study, we sought to understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography scan (CT) was associated with outcomes.

METHODS

Delayed union was defined as incomplete (<75%) fusion on CT between 2 and 6 months postoperatively. Thirty-six patients met the inclusion criterion: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained including patient satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction. Failure was defined as patients who required revision or reported being not satisfied. Fusion was assessed by measuring the percentage of osseous bridging across the joint on CT. The extent of fusion was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%).

RESULTS

We determined the clinical outcome of 28 (78%) patients with mean follow-up of 5.6 years (range, 1.3-10.2). The majority (71%) of patients failed. On average, CT scans were obtained 4 months after attempted ankle fusion. Patients with minimal or moderate fusion were more likely to succeed clinically than those with "absent" fusion (P = .040). Of those with absent fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed.

CONCLUSION

We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% fusion on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Blade Plate With Autogenous Bone Grafting to Salvage Peri Ankle Nonunions

BACKGROUND

Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures.

METHODS

This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS).

RESULTS

We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P = .009), for the MCS 52 (IQR, 45-60, range 33-62, P = .701), and for the FAOS 73 (IQR, 48-83).

CONCLUSION

In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores.

LEVEL OF EVIDENCE

Level IV, therapeutic.

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.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

Persistent Pain After Hindfoot Fusion

One of the most challenging problems facing orthopedic surgeons is persistent pain after surgery and certainly is just as frustrating following hindfoot fusion. The hindfoot joints consist of the subtalar, talonavicular, and calcaneocuboid (CC) joints. These joints are commonly fused for degenerative changes, deformity correction, inflammatory or neuropathic arthropathy, tarsal coalition, or primarily after trauma. Goals of hindfoot fusion are a painless plantigrade foot capable of fitting in shoes without orthotics or a brace. Many believe that deformity correction is achievable without inclusion of the CC joint. Managing patient expectations is important when counseling a patient especially regarding potential complications.

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.

Takedown of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: A Case Series of 77 Patients

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

Midterm Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft

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.

The circular arc shaped nail for fixing the tibiotalocalcaneal arthrodesis. After clinical results

BACKGROUND

Tibiotalocalcaneal arthrodesis is commonly considered a salvage option for a variety of hindfoot disorders involving the ankle and subtalar joint mostly with concomitant deformity. Retrograde interlocking nailing represents one of the biomechanically most stable fixation modes after reduction of hindfoot geometry. The considerable complications, non-union and revision rates at a moderate outcome reported even with modern retrograde nails underscore the idea that the development of an optimized retrograde nail may be warranted.

METHODS

A novel circular shaped nail was designed with a perfect fit to the reamed canal and the implant geometry which respects physiologic hindfoot anatomy and alignment. The present clinical series reports the experience and the clinical and radiographic outcomes after application of the implant in the first 30 consecutive patients. Assessments included validated versions of the AOFAS Ankle/Hindfoot Score and the Foot Function Index.

RESULTS

Anatomical alignment was achieved and maintained in 29/30 cases with a single case of later loss of reduction due to a technical error which led to surgical reintervention two months after the index procedure. The overall union rate reached 93%. Two non-unions (one ankle, one subtalar joint) were observed without necessitating further surgery. Three superficial surgical site infections were registered which made a local flap coverage necessary in two patients due to local skin break-down. No deep infection occurred. There were 2 implant removals, one was not related to hindfoot nailing. At the time of follow-up, the AOFAS Ankle/Hindfoot Score was 57 (median) from a maximum of 86 points. The self-assessment via the Foot Function Index improved from preoperative 155 points to 62.5 postoperatively (median values, p<0.001, Wilcoxon test).

CONCLUSION

On the basis of our results, which saw a high rate of successful fusion and patient satisfaction and where the hindfoot reduction was maintained until definite healing in the vast majority of cases, the novel circular arc nail represents a viable and safe option for tibiotalocalcaneal arthrodesis with a low complication rate.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BACKGROUND

The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.

METHODS

Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5).

RESULTS

One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.

CONCLUSION

In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.

Role of Extra-articular Tibiotalocalcaneal Arthrodesis and Posterior Approach in Highly Complex Cases

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is a procedure commonly used as salvage surgery for various pathologic processes that compromise the ankle and subtalar joints. It is a reasonably standardized procedure when performed as a primary surgery in advanced stages of TTC arthritis. For such cases, there are several alternative approaches, fixation materials, and bone substitutes that can be used. Most represent valid options with similar results in the literature. However, in highly complex cases requiring TTC arthrodesis, the options for the approach and fixation material can be limited. Understanding the alternative approaches and techniques is of great help to the surgeon when faced with highly complex cases, such as patients with multiple previous operations, lack of bone stock, severe deformities, or compromise of associated soft tissues. In this article, we describe the role of the posterior approach with some technical variation that allows extra-articular arthrodesis in highly complex cases, and we present a series of patients with tibiotalocalcaneal arthrodesis who were operated on using this technique.

METHODS

Retrospective review of all patients who underwent tibiotalocalcaneal arthrodesis via posterior approach between 2008 and 2016. The surgeries were performed by 2 different surgeons with the same technique (posterior approach with sliding graft) but 2 different fixation methods. Radiographs and computed tomographic (CT) studies were reviewed and patient satisfaction was rated using the Coughlin scale. Mean follow-up was 38 months. We identified 20 patients. The mean age was 51.2 years; 11 patients had post-traumatic arthritis whereas the others had other causes of arthritis (inflammatory disease, neurologic deformity, etc).

RESULTS

The arthrodesis was performed using a tibiotalocalcaneal plate in 9 patients and retrograde intramedullary nail in 11 patients. Radiographic fusion was observed at an average of 3.1 months. Four patients had complications and 15 reported good or excellent results after surgery.

CONCLUSION

Our study found a fusion rate comparable to other studies in highly complex cases. There were no operative wound complications. We observed that the posterior approach, with an extra-articular fusion procedure, was a valid option for salvage surgery in highly complex cases that require tibiotalocalcaneal fusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Novel Double Osteotomy Technique of Distal Tibia for Correction of Asymmetric Varus Osteoarthritic Ankle

BACKGROUND

A most challenging condition for balancing a varus arthritic ankle is the presence of a defect in the medial tibial plafond. After our initial results with a medial tibial plafondplasty did not fulfill our expectations of success, we hypothesized that adding a correcting supramalleolar osteotomy of the distal tibia would move the loading force to the tibiotalar joint more medially and move the center of rotation of the talus more laterally. In this study, we analyzed midterm clinical and radiographic outcomes in patients with double tibial osteotomy.

METHODS

Between January 2005 and February 2010, 20 patients were treated with a medial tibial plafondplasty and a medial supramalleolar osteotomy of the distal tibia. The mean age of the patients was 44 ± 12 years (range, 17-60 years). Follow-up averaged 5.9 ± 2.1 years (range, 4-11.2 years). Weight-bearing radiographs were used to assess osteotomy union and hindfoot alignment.

RESULTS

There were no intraoperative or perioperative complications. The average VAS pain score decreased significantly from 7.9 ± 1.3 (range, 6-10) to 1.3 ± 1.6 (range, 0-7). The average AOFAS hindfoot score increased significantly from 49 ± 15 points (range, 36-68) preoperatively to 86 ± 12 points (range, 66-96) postoperatively. The varus tilt improved significantly from 19.4° ± 8.2° (range, 6°-32°) to 6.9° ± 3.9° (range, 1°-12°).

CONCLUSION

The novel double osteotomy was found to be an efficient and successful method to restore tibiotalar joint congruency and to normalize hindfoot alignment.

LEVEL OF EVIDENCE

Level IV, prospective cohort study.

Can a Three-Component Prosthesis be Used for Conversion of Painful Ankle Arthrodesis to Total Ankle Replacement?

BACKGROUND

In patients with painful ankle arthrodesis, the surgical treatment is challenging, and may include takedown of ankle arthrodesis and conversion to a total ankle replacement (TAR). This procedure is technically demanding given the altered anatomy after arthrodesis. Few studies have evaluated TAR in the setting of prior arthrodesis.

QUESTIONS/PURPOSES

(1) What intraoperative and perioperative complications were observed in patients who underwent conversion of an ankle arthrodesis to a TAR? (2) Was durable fixation achieved at short term, and what was the alignment of the components? (3) What subsequent surgical procedures were performed, including revisions? (4) What improvements were observed in pain, tibiotalar range of motion (ROM), and quality of life?

METHODS

Between January 2007 and December 2014, 18 patients with a painful ankle arthrodesis underwent conversion to TAR at our tertiary referral center. During this period, the indications for conversion of ankle arthrodesis to TAR were tibiotalar nonunion or malunion after attempted arthrodesis in patients who declined revision ankle arthrodesis. The goal of revision surgery was to help patients regain hindfoot mobility and to decrease pain. During the study period, all patients who met indications were treated with a conversion procedure. Of the 18 patients included, 14 were men and four were women. The mean age of the patients was 51 ± 7 years. The mean followup was 54 ± 27 months, with no loss to follow up observed. The initial ankle arthrodesis was performed 6 ± 3.5 years before conversion to TAR. In all patients, the conversion to TAR was performed using a nonconstrained cementless three-component prosthesis. Intraoperative and postoperative complications, revision procedures, and prosthesis component loosening were evaluated. Weightbearing radiographs were used to determine the angular alignment of the tibial and talar components using α/β/γ angles and to analyze the bone-implant interface. Osseointegration was defined as visible trabecular structures at the bone-implant interface without radiolucent lines. The criteria for radiographic loosening was defined as subsidence or migration of prosthesis components and/or a cystic lesion with a diameter at least 2 mm. Clinical assessment included pain evaluation, measurement of ankle ROM, and quality of life.

RESULTS

Two of the 18 patients sustained an intraoperative medial malleolar fracture. In three patients, delayed wound healing was observed. At latest followup, four patients had incomplete osseointegration (posterior quarter of the bone-prosthesis interface on the tibial side). None of the 18 patients had prosthesis loosening. In all patients, both components were neutrally aligned. Two patients had painful arthrofibrosis with reduced ROM, which we treated with an open arthrolysis and exchange of mobile-bearing inlay; one other patient is considering a revision for substantial tibial component medial tilt with collapse of the medial arch. At the latest followup, the mean dorsiflexion and plantar flexion were 8.5° ± 3° and 15° ± 5°, respectively. The mean visual analog scale (VAS) score decreased from 9 ± 0.8 to 1.7 ± 1.6 (p < 0.001). The Short Form Health Survey questionnaire (SF-36) physical and mental outcome scores improved from 34 ± 5 to 74 ± 11 (p < 0.001) and from 49 ± 4 to 75.5 ± 7 (p < 0.001).

CONCLUSIONS

Conversion of an ankle arthrodesis to a TAR is a technically challenging procedure. In this small series, it was associated with frequent complications including arthrofibrosis, and functional outcomes including postoperative ROM were lower than reported for primary TAR. However, pain and function did improve. Further studies are necessary to address long-term clinical and radiographic outcomes in this patient cohort.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Tibiotalocalcaneal Arthrodesis for Foot and Ankle Deformities

Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.

[Effectiveness of arthroscopic debridement and release for post-traumatic arthritis of subtalar joint]

Objective

To evaluate the effectiveness of arthroscopic debridement and release for post-traumatic arthritis of subtalar joint.

Methods

Between January 2011 and December 2014, 14 cases of post-traumatic arthritis of the subtalar joint underwent arthroscopic debridement and release, and the clinical data were retrospectively analyzed. All patients were male, aged 42 years on average (range, 32-62 years). Calcaneus fracture was caused by falling from height; 8 cases received conservative treatment and the other 6 cases received open reduction and internal fixation. The mean interval from injury to operation was 3.4 years (range, 2-7 years). The arthroscopic debridement and release were performed through lateral portals. The injury degree of articular cartilage was classified as grade 3 in 4 cases and grade 4 in 10 cases based on Outerbridge rating. The degree of pain was assessed by visual analogue scale (VAS) and the function of joint was assessed by the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Scale.

Results

All incisions healed by first intention and no complication occurred. The follow-up time was 18 months. Pain was relieved obviously; VAS was significantly decreased to postoperative 3.8±0.9 at 18 months from preoperative 7.7±1.2 ( t=9.728, P=0.000), and AOFAS Ankle Hindfoot Scale was significantly increased to postoperative 59.1±8.8 from preoperative 37.6±8.2 ( t=6.688, P=0.000). During follow-up, no patient was given arthrodesis and no worsened sign was found on the postoperative CT and MRI.

Conclusion

Arthroscopic debridement and release for post-traumatic arthritis of the subtalar joint can relieve clinical symptoms and delay subtalar arthrodesis.