An original fibular shortening osteotomy technique in tibiotalar arthrodesis

Dedicated locking plate reduces non-union risk in open ankle fusion in obese patients

INTRODUCTION

Obesity is a growing public health concern. In ankle osteoarthritis, non-conservative treatment in advanced stages consists in ankle fusion, or else total ankle replacement, for which obesity is a relative contraindication. One of main complications of ankle fusion is non-union. Devascularization, obesity and fixation material are all factors involved in postoperative non-union, and have to be taken into account in surgical strategy for reliable results. The objective of this study was to compare the rate of ankle non-union in obese patients using quadruple screwing or a dedicated locking plate. The hypothesis was that the locking plate limits the risk of non-union in this population.

METHODS

All patients were obese (BMI>30kg/m2) and presented ankle osteoarthritis with>10° intra-articular deformity. The approach and joint preparation were performed via an anteromedial approach. Group S was composed of 32 patients, operated on by quadruple screwing; group P comprised 10 patients operated on using a dedicated locking plate. The main endpoint was a significant difference in the rate of non-union between the 2 groups. The secondary endpoint was improvement in pre- and 6-month postoperative AOFAS score.

RESULTS

Group S presented 31% non-union (10/32) and group P 0% (0/10) (p<0.05). Postoperative AOFAS score was significantly higher in group P: 67.8±10.4 [range, 40-92] vs. 83.1±8.0 [range, 64-92] (p<0.05).

CONCLUSION

The dedicated anterior locking plate is a technique of choice for ankle fusion in obese patients with intra-articular deformity>10°, to limit the risk of non-union.

LEVEL OF EVIDENCE

IV; retrospective study.

Comparisons of ankle arthrodesis with different internal fixation methods in the treatment of post-traumatic osteoarthritis

BACKGROUND

The aim of this study was to explore the clinical efficacy of ankle arthrodesis with different internal fixation methods in the treatment of post-traumatic osteoarthritis.

METHODS

We collected 85 patients with post-traumatic osteoarthritis who underwent different ankle arthrodesis between December 2015 and December 2020. The operation performance, complication rate, hindfoot alignment, talus tilt angle, visual analogue scale (VAS), and American Orthopedic Foot and Ankle Society (AOFAS) score were preoperatively and postoperatively evaluated.

RESULTS

In an anterior approach, the locking plate-fixation exhibited a similarity in operation time, incision length, postoperative drainage, bone fusion, hindfoot alignment, and talus tilt angle with fibula support compression screw-fixation, but it was better in increasing postoperative AOFAS. The locking plate-fixation in the anterior approach had lower operation time, incision length, and postoperative drainage than that in the lateral approach. In addition, the lateral locking plate combined with posterolateral compression screw fixation (LLPPCSF) presented shorter bone fusion time, higher AOFAS score, and lower complication rate than either plate- or screw-fixation alone.

CONCLUSION

Lateral locking plate fixation was better than fibula support compression screw fixation in relieving postoperative pain. Anterior locking plate fixation was more time-saving and less invasiveness than lateral locking plate fixation, but its application was limited in low degree of ankle deformation. LLPPCSF was the most effective in improving bone fusion and postoperative pain, considering an optimal option for the treatment of post-traumatic osteoarthritis.

Does a fibula-sparing approach improve outcomes in tibiotalocalcaneal arthrodesis?

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is considered a salvage procedure for either complex deformity or arthritis about the hindfoot, and can be performed via fibula-resection (FR) or fibula-sparing (FS) approaches. The primary aim of this study was to investigate differences in outcomes in FR versus FS TTC arthrodeses.

METHODS

This was a retrospective cohort study reviewing outcomes of TTC arthrodesis at a single institution. Patients who underwent a TTC arthrodesis from 2005 to 2017 and had minimum two-year follow-up were included. Preoperative diagnosis, pre- and post-operative radiographic coronal alignment, fixation methods, and complications were compared between groups.

RESULTS

107 patients (110 ankles) underwent TTC arthrodesis, with a mean age of 57.0 years (sd, 14.0 years). The mean clinical follow-up was 50.7 months (range, 24-146) and mean radiographic follow-up was 45.8 months (range, 6-146 months). Pre-operative diagnoses included arthritis (N = 40), prior non-union (N = 21), Charcot neuro-arthropathy (N = 15), failed total ankle arthroplasty (N = 15) and avascular necrosis of the talus (N = 19). Sixty-nine ankles comprised the FS group and 41 comprised the FR group. There was no significant difference in the non-union rate between groups (29% FR vs 38% FS, p = 0.37), complication rate (59% FR vs 64% FS, p = 0.59), or post-operative coronal standing radiographic alignment (89.6 degrees FR, 90.5 degrees FS, p = 0.26). Logistic regression analyses demonstrated a pre-operative diagnosis of failed TAA was associated with post-operative nonunion (OR:3.41,CI:1.13-11.04,p = 0.03). Pre-operative indication for TTC arthrodesis of arthritis alone was associated with a decreased risk of non-union (OR:0.27,CI:0.11-0.62,p = 0.002).

CONCLUSION

TTC arthrodesis is a successful surgical option for complex hindfoot deformity, arthritis, and limb salvage regardless of surgical approach. We did not detect a difference in the union rate, incidence of complications, or coronal plane radiographic alignment in fibula-sparing versus fibula-resection constructs. Patients with a pre-operative indication for surgery of arthritis may be at decreased risk of developing non-union.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Revision tibiotalar arthrodesis with posterior iliac autograft after failed arthroplasty: A matched comparative study with primary ankle arthrodeses

INTRODUCTION

Tibiotalar arthrodeses performed after failed ankle arthroplasties are known to be complex procedures with often disappointing functional outcomes. This study reports the results of a revision technique using a posterior iliac crest autograft.

HYPOTHESES

We hypothesized that: (1) revision tibiotalar arthrodeses (RTTAs) had functional outcomes which were similar to those of a reference cohort of primary tibiotalar arthrodeses (TTAs) and that (2) the union rate was satisfactory.

MATERIALS AND METHODS

This retrospective study compared 16 RTTAs performed for failed arthroplasties that caused pain and a functional disability (4 aseptic loosening, 4 massive progressive periprosthetic cysts, 5 malpositioning of implants, and 3 cases of unexplained mechanical pain) with a series of 16 primary TTAs performed for painful ankle osteoarthritis. The groups were matched at a 1:1 ratio for age, sex, side and body mass index. The preoperative workup included a physical exam, the American Orthopaedic Foot and Ankle Society (AOFAS) score, weight bearing radiographs, CT and SPECT scans. Outcomes were assessed both clinically (AOFAS score) and radiographically (X-rays and scans). The mean duration of the procedure (DP), average length of stay (LOS), fusion and complication rates, and time to union were also compared.

RESULTS

At the mean follow-up of 30 months (range, 12-88) for the RTTA group and 59 months (range, 23-94) for the TTA group (p=.001), the AOFAS score increased from 27 to 70.8 points (p<.001) and from 29.8 to 76.2 points (p<.001), respectively; values were similar at the last follow-up (p=.442). Both groups had similar fusion (94%) and complication rates (12%). The DP was 196.9±33.6min (range, 179-213) vs. 130±28.4min (range, 118-141) (p<.001) and the LOS was 3.8 days (range, 2-6) vs. 3.9 days (range, 2-6) (p<.445) for both groups (RTTA vs. TTA).

CONCLUSION

This RTTA technique using a posterior iliac crest allograft for filling bone defects was validated by the quality of the functional outcomes obtained.

LEVEL OF EVIDENCE

IV; Comparative retrospective study.

Effectiveness of Ilizarov Ankle Arthrodesis in the Treatment of End-Stage Varus Ankle Osteoarthritis: A Retrospective Study

Objective

To evaluate the outcomes of Ilizarov ankle arthrodesis in the treatment of end‐stage varus ankle osteoarthritis (OA).

Methods

This was a retrospective study of 63 patients with varus ankle OA who underwent Ilizarov ankle arthrodesis between June 2013 and December 2018. There were 24 males and 39 females with an average age of 56.57 ± 4.45 years (range, 47–64 years). Thirty‐six cases were affected on the left side, and 27 were affected on the right side. The patients' mean body mass index (BMI) was 25.18 ± 2.93 kg/m². According to the modified Takakura staging criteria, there were 18 cases of stage 3b (28.57%) and 45 cases of stage 4 (71.43%). Nine patients were primary (14.29%), 48 were traumatic (76.19%), and six were caused by rheumatoid OA (9.52%). Functional assessments were performed according to the American Orthopedic Foot and Ankle Society (AOFAS) ankle‐hindfoot score, Ankle Osteoarthritis Scale (AOS), and visual analogue scale (VAS). The tibial anterior surface angle (TAS), coronal plane tibial‐talar angle (CPT), talar tilt angle (TT), deformity angle (DA), and tibial lateral surface angle (TLS) were assessed on X‐ray films.

Results

The average operation time was 147.84 ± 13.67 min (range, 135–168 min). The average follow‐up time was 34.24 ± 8.72 months (range, 24–61 months). Bony fusion was achieved in all ankles, and the fusion time was 12.43 ± 1.99 weeks on average. The average AOFAS score at the final follow‐up increased from 42.14 ± 8.66 to 80.90 ± 6.80. The average VAS score and AOS pain and disability scores at the final follow‐up decreased from 7.29 ± 1.27 to 2.24 ± 0.94, from 67.94 ± 7.68 to 27.92 ± 5.82, and from 71.64 ± 9.37 to 41.32 ± 8.99, respectively. The average TAS, CPT, and TLS at the final follow‐up increased from 77.76° ± 4.44° to 89.81° ± 1.25°, from 69.04° ± 3.73° to 90.43° ± 1.80°, and from 82.14° ± 3.77° to 88.67° ± 2.50°, respectively. The average TT and DA at the final follow‐up decreased from 8.76° ± 4.30° to 2.05° ± 1.28° and from 20.95° ± 3.73° to 1.57° ± 0.93°, respectively. Three patients developed superficial pin tract infections, all settled with local dressing and antibiotic treatment. Two patients were found to have subtalar arthritis and underwent conservative treatment.

Conclusion

Ankle arthrodesis using the Ilizarov technique is efficient in treating end‐stage varus ankle OA.

Postoperative weightbearing following ankle arthrodesis

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Patients and Methods

MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates.

Results

A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis.

Conclusion

Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262

Distal fibula osteotomies improve tibiotalar joint compression: A biomechanical study in a cadaveric model

BACKGROUND

Successful tibiotalar joint fusion relies on adequate compression. Compression following joint preparation may be affected by the extent to which the fibula holds the joint out to anatomical length. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression.

METHODS

Eight adult cadaveric lower extremity specimens with an intact ankle joint and syndesmotic complex were evaluated. The ankle joint cartilage was denuded to subchondral bone. The fibula was surgically modified with three progressing procedures including an oblique fibula osteotomy, 1 cm resection, and distal fibula resection. A transducer was utilized to measure tibiotalar joint force, contact area, and peak pressure values while compressive forces of 30 N, 50 N, and 100 N were applied to the proximal tibia/fibula.

FINDINGS

Distal fibula resection significantly increased tibiotalar joint force, contact area, and peak pressure the most of all fibula conditions tested compared to intact fibula control (p < .05). Tibiotalar joint force and peak pressures were significantly increased with a distal fibula oblique osteotomy, 1 cm resection, and complete resection under both 30 and 50 N applied compressive force (p < .05).

INTERPRETATION

Complete distal fibular resection results in higher tibiotalar joint force, contact area, and peak pressure which may improve clinical rates of successful ankle fusion.

Comparison of 25 ankle arthrodeses and 25 replacements at 67 months' follow-up

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.

Joystick of the Talus for Correcting Malalignment During Arthroscopic Ankle Arthrodesis: A Surgical Tip

Ankle arthrodesis has been widely reported as an effective solution in treating tibiotalar joint osteoarthritis. The arthroscopic tibiotalar approach for arthrodesis has also been proven to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. Historically, ankle malalignment has represented one of the main contraindications for the arthroscopic procedure, but interestingly some investigators have shown that the coronal joint deformity may be addressed arthroscopically as well. Other investigators have also demonstrated that part of the valgus/varus is due to malrotation of the talus within the mortise; therefore, controlling the talar position becomes crucial for correcting more severe deformities. We present here a technique for correcting tibiotalar malalignment during arthroscopic arthrodesis in varus or valgus ankles, performed through a K-wire used as a joystick to manage the talar position on both the coronal and axial planes.

Fibular Intra-articular Resection During Arthroscopic Ankle Arthrodesis: The Surgical Technique

Ankle arthrodesis is still considered the gold standard in the treatment of advanced painful ankle osteoarthritis. More than 3 decades ago, it was performed under arthroscopy; thereafter, many authors have reported excellent results and a low complication rate. Despite the significant improvements in surgical techniques, nonunion remains a problematic and relatively frequent event. This is one of the reasons the research is constantly active in this field. Ten years ago, a fibular resection during ankle arthrodesis was, for the first time, described in the literature as a means to correct malalignment in varus cases. Nowadays, we perform a similar technique during all arthroscopic ankle arthrodeses, regardless of the kind of preoperative deformity (varus, valgus, or normal alignment). In this article, we describe the arthroscopic technique to perform a fibular intra-articular resection during arthroscopic ankle arthrodesis, joining the benefits of arthroscopic minimal invasiveness to the full joint contact gained after such a fibular osteotomy. In our opinion, this would be the only way through which full contact between the talar and tibial surfaces may be achieved.