An approach to the failed ankle arthrodesis

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.

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.

Takedown of Ankle Fusions and Conversion to Total Ankle Replacements

BACKGROUND

With ankle replacements gaining credibility, there is a small subset of patients who might benefit from a conversion of an ankle fusion to a replacement. The objective of this study is to present clinical and radiographic results of patients who had their ankle fusion converted to total ankle arthroplasty (TAA).

METHODS

Patients presented to the senior author with ongoing ankle pain following fusion or increasing pain after a period of relative comfort after an ankle fusion. Outcomes were evaluated preoperatively and postoperatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) pain scale. A patient satisfaction survey was also distributed.

RESULTS

All ankle fusion conversions between April 2010 and December 2019 were included. Fifty-one patients (30 females) with the mean age of 62.6 (range, 37-83) years were followed. Mean follow-up was 4.2±2.3 (range, 2-11.5) years. Two patients were lost to follow-up (1 is deceased). Pre- and postoperative mean patient-reported outcome scores were all significantly different between groups except VR-12 mental subscale scores. VR-12 physical scores improved from 28.7±8.9 preoperatively to 38.9±9.9 (P < .001) postoperatively; VR-12 mental score was stable. AOS pain and disability subscales similarly improved: 55.9±24.4 to 27.9±25.4 (P < .001) and 61.7±21.1 to 31.1±25.7 (P < .001), respectively. VAS pain improved from a mean of 64.5±27.3 to 29.4±27.7 (P < .001). There was no tibiotalar dorsiflexion or plantarflexion with the ankle fusion. Initial postoperative visit revealed that average dorsiflexion was 10.9±5.93 degrees and average plantarflexion was 14.1±5.22 degrees. At the latest follow-up, dorsiflexion improved significantly to 15.5±6.33 degrees (P < .001), with no significant improvement in plantarflexion (P = .980).

CONCLUSION

In this single-surgeon longitudinal study of 51 patients with a painful, malaligned, or nonhealed ankle fusion treated with an ankle replacement, we found highly satisfactory functional outcomes at an average of 4.2 years. Continued long-term follow-up will reveal whether the longevity of these replacements is comparable to primary replacements.

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.

Revision of the Malaligned Ankle Arthrodesis

A malaligned ankle arthrodesis is a painful and complicated pathology. Deformities may be present in the frontal, sagittal, or transverse plane or a combination of planes. Thorough preoperative evaluation of the deformity and the patient as a whole is crucial to successful revision. Surgical site for revision should be based on center of rotation of angulation, when possible. Revision commonly is performed through opening wedge osteotomy. Closing wedge and focal dome osteotomies, however, are excellent options. Revision also may be performed through external fixation or total ankle replacement. Although the literature is not rich with data, the options discussed provide favorable results.

External versus internal fixation for arthrodesis of chronic ankle joint infections - A comparative retrospective study

BACKGROUND

Arthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard. We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.

METHODS

All patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.

RESULTS

Seventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p=0.019), achieved full weightbearing significantly more often (p=0.042) and faster and developed significantly fewer complications (p<0.001). Forty-three patients showed bone fusion without significant differences between the groups.

CONCLUSIONS

Ankle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.

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).

Comparison of Monolateral External Fixation and Internal Fixation for Skeletal Stabilisation in the Management of Small Tibial Bone Defects following Successful Treatment of Chronic Osteomyelitis

Background

To compare the salvage rate and complication between internal fixation and external fixation in patients with small bone defects caused by chronic infectious osteomyelitis debridement.

Methods

125 patients with chronic infectious osteomyelitis of tibia fracture who underwent multiple irrigation, debridement procedure, and local/systemic antibiotics were enrolled. Bone defects, which were less than 4 cm, were treated with bone grafting using either internal fixation or monolateral external fixation. 12-month follow-up was conducted with an interval of 3 months to evaluate union of bone defect.

Results

Patients who underwent monolateral external fixation had higher body mass index and fasting blood glucose, longer time since injury, and larger bone defect compared with internal fixation. No significant difference was observed in incidence of complications (23.5% versus 19.3%), surgery time (156 ± 23 minutes versus 162 ± 21 minutes), and time to union (11.1 ± 3.0 months versus 10.9 ± 3.1 months) between external fixation and internal fixation. Internal fixation had no significant influence on the occurrence of postoperation complications after multivariate adjustment when compared with external fixation. Furthermore, patients who underwent internal fixation experienced higher level of daily living scales and lower level of anxiety.

Conclusions

It was relatively safe to use internal fixation for stabilization in osteomyelitis patients whose bone defects were less than 4 cm and infection was well controlled.

Open ankle arthrodesis with a fibular-sparing technique

BACKGROUND

Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique.

METHODS

A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring.

RESULTS

At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being "completely satisfied" with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment.

CONCLUSION

This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores.

Versatility of Ilizarov technique in difficult cases of ankle arthrodesis and review of literature

BACKGROUND

Ankle arthrodesis is a well-established procedure that has been successfully used for treatment of end stage arthritis of the ankle for well over a century. Internal fixation for ankle arthrodesis is adequate in most of the cases. However, surgeons and patients are occasionally confronted with cases in need for ankle arthrodesis but do not lend itself well to the ideal position and/or internal fixation. These cases may even contraindicate internal fixation. The aim of this study is to assess the results of ankle arthrodesis using different modalities of Ilizarov techniques and demonstrating its high versatility in treating such difficult cases.

PATIENTS AND METHODS

This is a prospective study. Thirty cases of ankle fusion for end stage arthritis or instability were performed in the period between January 2002 and December 2007 at the Health Insurance Reference Hospitals, Alexandria, Egypt. Tibiotalar fusion was done in 22 cases and tibiocalcaneal fusion in 8 cases using different modalities of Ilizarov technique. The mean follow up period was 5.5 years (range 4-8, SD 1.9).

RESULTS

Sound and painless fusion was achieved in all the cases except one (97%). The difference between the mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) was found to be statistically highly significant (t=10.1, p=0.001). Many minor complications were encountered during the course of treatment in the form of: pin tract infections, wound dehiscence, cellulitis that was managed effectively with local wound care, oral antibiotics.

CONCLUSION

The versatility of the combinations of assemblies afforded by Ilizarov fixator was found to be endless. This makes the Ilizarov fixator to be an effective and versatile mean of treating difficult cases of ankle arthrodesis.

Hállux Rígidus: prospective study of joint replacement with hemiarthroplasty

OBJECTIVE:

To report the results of medium-term follow-up after deploying Arthrosurface-HemiCap^(r) in patients with diagnosis of Hállux Rigidus (HR).

METHOD:

Eleven patients underwent partial Arthroplasty of the first metatarsal-phalangeal joint. Six women and five men with an average age 51.9 years (46 to 58 years) and average postoperative follow-up of 3.73 years (3-4 years); were classified through the Kravitz system and evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) scales for hállux, Visual Analogical Scale (VAS) - analog functional pain - and range of motion in the first metatarsal joint in preoperative, postoperative after six months and present post-operative.

RESULTS:

The results show significant improvement of the three analyzed parameters, both for overall analysis and for pre and post-operative comparisons individually. The comparative analysis of each variable in the six months and the current postoperative periods do not show statistically significant differences, indicating maintenance of parameters during this interval.

CONCLUSION:

hemiarthroplasty of first metatarsophalangeal joint is a reproducible and safe option for the surgical treatment of hállux rigidus II and III, with significant improvement of the evaluated parameters for the studied population. Level of Evidence IV, Case Series.

Revision of failed ankle implants

Total ankle joint replacement (TAR) has been offered as an alternative to ankle joint arthrodesis since the 1970s. TAR offers the benefit of perseveration of joint motion, with potential decreased occurrence of adjacent joint degeneration, and a more expedient path to weight bearing. Since their introduction, TAR devices have undergone a variety of modifications, specifically in regards to the number and type of components used.

Surgical treatment of hallux rigidus using a metatarsal head resurfacing implant: mid-term follow-up

The treatment of advanced hallux rigidus remains controversial, with many authors discussing arthrodesis versus arthroplasty. The purpose of this study is to report mid-term outcomes after implantation of a motion-preserving metatarsal head-resurfacing prosthetic and to present our technical considerations and modifications to the published technique to further enhance the clinical benefit of the procedure. Thirty-two implantations were performed in 30 patients. Twenty-three patients were women, 9 men. The average age was 62.8 years (range, 39-86 years). Patients were graded at baseline according to Hattrup and Johnson and completed the American Orthopaedic Foot & Ankle Surgery metatarsophalangeal clinical rating system preoperatively and postoperatively and a patient satisfaction question at final follow-up. Seventy-two percent of implantations were grade III hallux rigidus and 28% were grade II. The average follow-up was 27.3 months (range, 12-43 months). The mean change score for the overall American Orthopaedic Foot & Ankle Surgery scale was 236.8% (SD = 146.62, confidence interval [CI] = 186-287.6). A similar result was achieved between grade II (250.9%, SD = 240.3, CI = 93.9-407.9) and grade III (231.3%, SD = 95.83, CI = 195.14-270.46). No implants were revised or removed, and all patients stated that they were happy with their outcome and would repeat the procedure again if needed. In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus. Salvage arthrodesis remains an option if future revisions are indicated.

Use of bone morphogenetic proteins in arthrodesis: clinical results

Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints.