Revision ankle 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.

Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis

Ankle arthrodesis has become a common surgical procedure for individuals with end-stage ankle arthritis, chronic infection, and bony misalignment. Although arthrodesis is typically managed with arthrodesis in situ or realignment, reconstruction may be utilized for patients with more complicated cases that involve metatarsal defects. Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes.

Extracorporal shock wave therapy for the treatment of arthrodesis non-unions

INTRODUCTION

Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions.

PATIENTS AND METHODS

In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm², 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment.

RESULTS

24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001).

CONCLUSION

Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief.

LEVEL OF EVIDENCE

Level IV.

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.

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).

Outcomes of Salvage Arthrodesis and Arthroplasty for Failed Osteochondral Allograft Transplantation of the Ankle

BACKGROUND

Osteochondral allograft (OCA) transplantation is a useful treatment for posttraumatic ankle arthritis in young patients, but failure rates are high and reoperations are not uncommon. The aim of this study was to evaluate the outcomes of failed ankle OCA transplantation converted to ankle arthrodesis (AA) or total ankle arthroplasty (TAA).

METHODS

We evaluated 24 patients who underwent salvage procedures (13 AA and 11 TAA) after primary failed ankle OCA transplantation. Reoperations were assessed. Failure of the salvage procedure was defined as an additional surgery that required a revision AA/TAA or amputation. Evaluation among nonfailing ankles included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), pain, and satisfaction.

RESULTS

In the salvage AA cohort, 3 patients were classified as failures (2 revision AA and 1 amputation). The 10 nonfailing patients had a mean follow-up of 7.4 years. Eighty-eight percent were satisfied with the procedure, but 63% reported continued problems with their ankle (eg, pain, swelling, stiffness). Mean pain level was 1.9 and AAOS-FAM core score was 83±13. In the salvage TAA cohort, 2 patients were classified as failures (both revision TAA). The 9 nonfailing patients had a mean follow-up of 3.8 years. Fifty percent were satisfied with the procedure, but 40% reported continued problems with their ankle. The mean pain level was 1.3, and the median AAOS-FAM core score was 82±26.

CONCLUSION

Revision and reoperation rates for salvage procedures following failed OCA transplantation of the ankle are higher compared to published data for primary AA and TAA procedures. However, we believe OCA transplantation can serve as an interim procedure for younger patients with advanced ankle joint disease who may not be ideal candidates for primary AA or TAA at the time of initial presentation.

LEVEL OF EVIDENCE

Level IV, case series.

Ankle Arthrodesis for Talar Avascular Necrosis and Arthrodesis Nonunion

This article reviews the surgical treatment of talar avascular necrosis. Specifically, arthrodesis for this complex entity and potential treatment of nonunions are discussed. The hallmarks of treatment are evolving and can range from nonoperative measures to amputations. Nonoperative treatment and the results of current arthrodesis techniques for late-stage avascular necrosis are reviewed. Surgical correction requires an understanding of the condition's natural history, utilization of structural and nonstructural bone grafting techniques, and stable fixation. Although the methods described follow standard orthopedic principles, high-quality evidence and outcome studies are limited for treatment of this challenging and often disabling condition.

Long-term Follow-up of Revision Osteochondral Allograft Transplantation of the Ankle

BACKGROUND

Osteochondral allograft (OCA) transplantation is a useful alternative for treatment of posttraumatic ankle arthritis in young patients but has a relatively high failure rate and further procedures are often required. The purpose of this study was to evaluate outcomes of patients who underwent revision OCA transplantation of the ankle after failed primary OCA transplantation.

METHODS

Twenty patients underwent revision OCA transplantation of the ankle between 1988 and 2015. Mean age was 44 years, 55% (11 of 20) were female. The mean time from primary to revision OCA was 3.0 ± 1.7 years. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM) and questionnaires evaluating pain and satisfaction. Failure of the revision OCA was defined as a conversion to arthroplasty, arthrodesis, or amputation.

RESULTS

Ten of 20 ankles required further surgery, of which 30% (6 of 20) were considered OCA revision failures (4 arthrodeses, 1 arthroplasty, and 1 amputation). The mean time to failure was 6.7 (range, 0.6-13.1) years. Survivorship of the revision OCA was 84% at 5 years and 65% at 10 years. The 14 patients with grafts remaining in situ had an average follow-up of 10.3 years; mean AAOS-FAM Core Score was 70.5 (range, 42.3-99). Of the patients who answered the follow-up questions, 4 of 7 reported moderate to severe pain, and 5 of 12 were satisfied with the results of the procedure.

CONCLUSION

Although the results of revision ankle OCA transplantation are not inferior to primary OCA transplantation, the high rates of persistent pain, further surgery, and graft failure suggest that the indications for OCA as a revision procedure should be carefully evaluated, with proper patient selection. Considering the treatment alternatives, revising a failed OCA transplantation can be a useful treatment option, especially for young and active patients who wish to avoid arthrodesis or arthroplasty.

LEVEL OF EVIDENCE

Level IV, case series.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Arthrodesis for septic arthritis of the ankle: risk factors and complications

INTRODUCTION

Septic ankle joint arthrodesis is a good therapeutic option in cases of infection after trauma or orthopedic surgical procedures. Many different procedures have been described, but external fixation seems to be standard. Aim of this study is to identify risk factors for complications in septic ankle joint arthrodesis with the external AO frame fixator.

MATERIALS AND METHODS

Patients who received septic ankle joint arthrodesis between January 2008 and December 2012 were included in this study. Patients were evaluated clinically and with radiographs or CT scans.

RESULTS

Follow-up of 74 of 79 patients with an external AO frame fixator could be evaluated; follow-up was 411 days (105-991). The mean age at surgery was 57.7 years (19-87). At this time, complications occurred in 41 patients (52 %) with wound healing problems (17 patients, 22 %) and non-union (12 patients, 15 %), and some needed surgical revision. In our collective, men had a significant higher non-union rate (p = 0.031), age or BMI showed no difference. Patients with diabetes and alcohol consumption showed a higher risk for complications (p = 0.049 and p = 0.031, respectively). 62 % of primary arthrodesis showed union, whereas in the case of revision, arthrodesis only 39 % showed union.

CONCLUSIONS

Septic ankle joint arthrodesis with the external AO frame fixator is a probable tool to achieve union. This study showed that there is a high complication rate and some risk factors for complications could be identified. A blinded and prospective study is needed to compare intramedullary nailing and external fixation to evaluate the possible advantage of intramedullary devices in septic ankle arthrodesis.

Total Ankle Arthroplasty for the Treatment of Symptomatic Nonunion Following Tibiotalar Fusion

Background Nonunion of an ankle arthrodesis is associated with significant pain and morbidity. Revision arthrodesis presents greater short-term morbidity and long-term sequelae. 1-6 Recent reports have demonstrated the feasibility of converting a symptomatic nonunion of an ankle arthrodesis to a total ankle arthroplasty.7-9 The objective of the present study was to evaluate the short-term outcome associated with take down of symptomatic nonunions of ankle arthrodeses and conversion to a fixed bearing, intramedullary total ankle arthroplasty. Methods Five patients with symptomatic, aseptic tibiotalar arthrodesis nonunions (average age, 62.2 years), who underwent conversion to a total ankle arthroplasty were retrospectively identified and assessed at a prospective office visit. Minimum follow-up was 12 months (average, 21.3 months). Clinical outcomes were assessed on the basis of the American Foot and Ankle Society (AOFAS) ankle-hindfoot score10 and the Foot Function Index.11,12 Radiographic analysis, patient satisfaction and pain levels were also evaluated. Results The average post-operative AOFAS ankle-hindfoot score was 82.6, while the FFI was 28.2%. The average clinical range of motion was 35 degrees. Visual analog scale (VAS) pain scores averaged 31.1 out of 100. Four out of the five patients were very satisfied or satisfied. Radiographically, the tibial and talar components were stable in all patients without evidence of loosening, migration, or subsidence. There were no complications requiring additional procedures. Conclusions Patients undergoing ankle arthrodesis that is complicated by an aseptic nonunion pose a difficult clinical problem. Conversion to a total ankle arthroplasty with a fixed bearing, intramedullary implant is a viable treatment option with reliable short-term results.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Clinical and Operative Factors Related to Successful Revision Arthrodesis in the Foot and Ankle

BACKGROUND

Arthrodesis is a common operative procedure used to manage arthritis and deformity in the foot and ankle. Nonunion is a possible and undesirable outcome in any arthrodesis surgery. Rates of nonunion in the foot and ankle literature range from 0% to 47% depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including location, fixation method, tobacco use, diabetes, infection, and others.

METHODS

The case logs of 3 foot and ankle surgeons were reviewed from January 2007 to September 2014 to identify nonunion arthrodesis revision cases. The patient factors reviewed included diabetes, inflammatory arthropathy, tobacco use, history of infection, nonunion elsewhere, neuropathy, Charcot arthropathy, posttraumatic arthritis, and prior attempt at revision arthrodesis at the same site. Operative records were reviewed to identify location of the nonunion, instrumention, use of allograft or autograft bone, use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union on the final radiograph during follow-up. Eighty-two cases of revision arthrodesis were identified with an average follow-up of 16 months.

RESULTS

The overall nonunion rate was 23%. Neuropathy and prior attempts at revision were identified as significant risks (P <.05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8-fold increase in the risk of failure for each attempt at revision.

CONCLUSION

Revision arthrodesis for nonunion in the foot and ankle was successful (77%) under a variety of patient and operative conditions. Neuropathy was a significant patient risk factor for persistent nonunions, and we believe it is important to identify even in the nondiabetic patient. As the number of attempts at revisions increases, there is a subsequent 3-fold increase in the risk of persistent nonunion.

LEVEL OF EVIDENCE

Level IV, case series.

Complex ankle arthrodesis: Review of the literature

Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.

Complex ankle arthrodesis: Review of the literature

Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients’ outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.

A Unique Treatment for Talar Osteonecrosis: Placement of an Internal Bone Stimulator: A Case Report

CASE

There are many treatment options for talar osteonecrosis without collapse, ranging from restricted weight-bearing to arthrodesis. We present a patient with talar osteonecrosis without evidence of collapse. After conservative treatment had failed, she was treated successfully with arthroscopic drilling, bone-grafting, and placement of an internal bone stimulator.

CONCLUSION

Talar osteonecrosis is a challenging entity to treat. Despite our increased knowledge of the complex talar vascular anatomy, etiologies, and treatment options, poor outcomes remain all too common. A combination of bone-grafting and an internal bone stimulator was effective for relief of symptoms in our patient in the short-term.

Healing in the new millennium: bone stimulators: an overview of where we've been and where we may be heading

Electromagnetic fields and their uses in bone healing have been fairly well studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of nonunions and as an adjunctive device in arthrodeses, particularly in high-risk populations. There are varying data and a significant variety of quality in the current research and publications concerning the use of electrical bone stimulation in the treatment of the foot and ankle. Thus, there is a definite need for further investigation and high-quality study designs to determine the most effective treatment modalities and pathologies best used with bone stimulation. Bone stimulation should be viewed as an adjunctive procedure in which the surgeon optimizes the high-risk patient both medically or surgically whenever possible. But when used appropriately, bone stimulation has the potential to influence outcomes and aid in bone healing when complications arise and in high-risk populations.

Applications of the medial femoral condyle free flap for foot and ankle reconstruction

BACKGROUND

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology.

METHODS

A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months).

RESULTS

There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively.

CONCLUSIONS

Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Predictive risk assessment for major amputation after tibiotalocalcaneal arthrodesis

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage.

METHODS

One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created.

RESULTS

There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: e(x) /(1 + e(x) ) where x is a factor of age, diabetes, revision, and ulceration.

CONCLUSION

TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation.

LEVEL OF EVIDENCE

Level II, prognostic.

Union rate of tibiotalocalcaneal nails with internal or external bone stimulation

INTRODUCTION

The use of bone growth stimulation has been reported in the application of hindfoot and ankle arthrodesis. Most studies have been retrospective case series with few patients. The authors present a comparative analysis of patients undergoing tibiotalocalcaneal (TTC) arthrodesis via a retrograde intramedullary arthrodesis nail to evaluate the influence of internal versus external bone stimulation in this population.

METHODS

One hundred fifty-four patients were treated with retrograde intramedullary nailing. A comprehensive chart and radiographic review was performed from a database of patients who underwent TTC fusion with or without bone stimulation. Ninety-one patients with retrograde TTC nailing were treated with direct current internal bone stimulation at the time of the index procedure (internal group) and 63 were treated with combined magnetic field external bone stimulation (external group). The primary end point was fusion with potential variables evaluated for influence on fusion rates.

RESULTS

Demographically the cohorts were similar groups in age and comorbidities. Surgical and outcome data were examined, and there were few statistically significant differences between the two groups. There was no statistically significant difference in rate of union (52.7% and 57.1%, p = .63) or rate of complications between the internal and external groups. Overall, the success rate for achieving a stable, functional limb for the groups was 81.3% (74/91 patients) and 82.5% (52/63 patients) in the internal and external groups, respectively (p = .62).

CONCLUSION

The authors demonstrated there were no statistically significant differences between the union and complication rate when comparing these types of internal and external bone stimulation in this patient population. Consideration of these results may help guide physicians when considering bone stimulation as an adjunct to TTC fusions with a retrograde intramedullary nail.

The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database

The use of bone morphogenetic protein-2 (BMP-2) has been recommended for high-risk fusions and nonunion. Patients undergoing revisional tibiotalocalcaneal (TTC) arthrodesis via a retrograde arthrodesis nail to evaluate the influence of BMP-2 on rate of fusion in this high-risk population are presented. A retrospective chart and radiographic review were performed on 23 patients with failed prior fusion attempts at the ankle treated with retrograde intramedullary nailing. Sixteen patients were treated without BMP-2 (None group) and 7 were treated with BMP-2 (BMP group). The primary and secondary end-points were successful fusion, and time to fusion, respectively, with a variety of variables evaluated for influence. Other than the use of BMP-2, there were no statistical differences in the patient population. Overall, 11 of 16 ankles (68.8%) in the None group and 5 of 7 ankles (71.4%) in the BMP group resulted in a stable, functional limb. Rate of complication was similar between the 2 groups (p > .05). Time to radiographic ankle union was 115.2 and 184.0 days in the None and BMP groups (p > .05). The effect of BMP-2 on revisional TTC fusions with retrograde nails is reported here. The overall result as a stable, functional limb was 69.6%, which suggests that revision surgery in this high-risk population is a reasonable consideration. Even though this study was unable to demonstrate statistically significant differences, biologic augmentation with BMP-2 did not increase the complication rate and showed a slightly enhanced salvage rate for revision TTC fusions with an intramedullary nail.

[Tibiocalcaneal arthrodesis using retrograde insertion of a compression nail]

OPERATION GOAL: Arthrodesis of the upper and lower ankle joint because of problematic bone positioning or failed arthrodesis. Osteosynthesis procedure using a retrograde compression nail. To achieve stable, fully weight-bearing osteosynthesis for early, pain-free mobilization.

INDICATIONS

Rearthrodesis because of failure of the conventional arthrodesis technique and development of osteoarthritis of the lower ankle joint. Painful osteoarthritis of the upper ankle joint because of inadequate perfusion or a major bone defect because of sclerosis or necrosis. Primary arthrodesis because of facture of the lower leg (pilon tibial) with joint involvement and preexisting osteoarthritis.

CONTRAINDICATIONS

Acute osteitis/osteomyelitis, sclerosis in the marrow of the distal tibia, malalignment of the distal tibial shaft and local soft tissue inflammation.

SURGICAL TECHNIQUE

Preparation of the articular surface of the upper and lower ankle for arthrodesis using a transfibular approach. If necessary, correction of bone defects with iliac crest spongiosa. Stabile osteosynthesis by retrograde insertion of a compression nail.

POSTOPERATIVE MANAGEMENT

A split lower leg cast on the 2nd postoperative day, mobilization of the patient with underarm crutches with floor contact for 2 weeks, then with application of a lower leg walking cast for 8 weeks with partial weight-bearing for 4 weeks and full weight-bearing for the last 4 weeks of cast fixation. X-ray controls immediately postoperatively, then after 6 and 12 weeks.

RESULTS

From 2006 to 2008, 12 patients (7 men, 5 women; mean age 59 years) with various indications were treated with retrograde insertion of a compression nail. All patients were routinely controlled radiologically and clinically after 2, 4, 8 and 12 weeks. Follow-up was carried out at 6, 12 and 24 months. All arthrodeses showed osseous consolidation 16 weeks postoperatively. Ten patients were able to use full weight-bearing without pain after 12 weeks. Two patients reported experiencing pain after walking for 2 h. In total three complications occurred: one hindfoot healed with varus malalignment; one patient fell, fracturing the lower leg above the nail; one distal locking screw loosened.

Decreasing bacterial colonization of external fixation pins through nitric oxide release coatings

OBJECTIVE

Bacterial infection of the pin tract represents the most common complication associated with external fixation. This study was designed to evaluate the antibacterial activity of nitric oxide (NO)-releasing xerogel films applied to commercially pure titanium pins in a rat model.

METHODS

Pins were coated with xerogel solution through a dip-coating procedure. Half of the xerogel-coated implant pins were modified into NO donors and served as the NO-releasing group, whereas the remaining pins were left unmodified to serve as non-NO-releasing xerogel-coated controls. Acid-etched pins served as uncoated controls. Animal selection was randomized and every rat had one pin from each of the three groups randomly allocated to the third, fourth, or fifth tail vertebrae. Quantification of bacterial infection was performed 48 days postoperatively and the tissue-implant interface was inspected for clinical signs of infection on Days 14 and 28 postimplantation.

RESULTS

Pin tract bacterial colony counts of the NO-releasing group (170,000 ± 181,000) were significantly lower than both the xerogel-coated group (677,000 ± 675,000) and the control group (1,181,000 ± 2,717,000) 48 days postoperatively (P < 0.05). No significant difference in colony counts was observed between the xerogel-coated group and the control group. The NO-releasing group also had significantly fewer clinical signs of infection than both the coated and the control groups on postoperative Day 28 (P < 0.05).

CONCLUSION

The application of NO-releasing xerogel coatings can inhibit bacterial colonization of external fixation pins both during the initial postsurgical period and up to 48 days postimplantation.

Bone and wound healing in the diabetic patient

Impaired soft tissue regeneration and delayed osseous healing are known complications associated with diabetes mellitus with regard to orthopedic surgery, making the management and treatment of diabetic patients undergoing foot and ankle surgery more complex and difficult. At the moment several options are available to address the known issues that complicate the clinical outcomes in these high-risk patients. Using a multifaceted approach, with close attention to intraoperative and perioperative considerations including modification of surgical technique to supplement fixation, local application of orthobiologics, tight glycemic control, administration of supplementary oxygen, and biophysical stimulation via low-intensity pulsed ultrasound and electrical bone stimulation, the impediments associated with diabetic healing can potentially be overcome, to yield improved clinical results for diabetic patients after acute or elective foot and ankle surgery.

Nanotextured titanium surfaces for enhancing skin growth on transcutaneous osseointegrated devices

A major problem with transcutaneous osseointegrated implants is infection, mainly due to improper closure of the implant-skin interface. Therefore, the design of transcutaneous osseointegrated devices that better promote skin growth around these exit sites needs to be examined and, if successful, would clearly limit infection. Due to the success already demonstrated for orthopedic implants, developing surfaces with biologically inspired nanometer features is a design criterion that needs to be investigated for transcutaneous devices. This study therefore examined the influence of nanotextured titanium (Ti) created through electron beam evaporation and anodization on keratinocyte (skin-forming cell) function. Electron beam evaporation created Ti surfaces with nanometer features while anodization created Ti surfaces with nanotubes. Conventional Ti surfaces were largely micron rough, with few nanometer surface features. Results revealed increased keratinocyte adhesion in addition to increased keratinocyte spreading and differences in keratinocyte filopodia extension on the nanotextured Ti surfaces prepared by either electron beam evaporation or anodization compared to their conventional, unmodified counterparts after 4h. Results further revealed increased keratinocyte proliferation and cell spreading over 3 and 5days only on the nanorough Ti surfaces prepared by electron beam evaporation compared to both the anodized nanotubular and unmodified Ti surfaces. Therefore, the results from this in vitro study provided the first evidence that nano-modification techniques should be further researched as a means to possibly improve skin growth, thereby improving transcutaneous osseointegrated orthopedic implant longevity.

Bone growth stimulation for foot and ankle nonunions

During the last few decades, electrical current stimulation has gone from an investigational modality to an accepted method of treatment to assist with bone healing. This article provides an overview of electrical bone stimulation for nonunions in the foot and ankle.

Revisional hindfoot arthrodesis

Salvage of a failed hindfoot arthrodesis is an extensive undertaking for the surgeon and patient. With increased morbidity and postoperative convalescence and complications, patients must understand the risk involved in this type of revisional surgery. This article provides a systematic approach to revisional hindfoot arthrodeses, focusing on patient evaluation, surgical technique, and postoperative treatment.

Hindfoot salvage with external fixation

Hindfoot salvage procedures by definition present circumstances requiring extraordinary measures to prevent or limit damage or destruction. Although this technique is used at some centers as the only means of correcting and fixating foot and ankle deformities, it is an expensive procedure. Other available methods may be more expeditious depending on the circumstances. However, the benefits of external fixation in certain circumstances are invaluable. Circular frame external fixators are important tool for the foot and ankle surgeon.

Use of implantable bone growth stimulation in Charcot ankle arthrodesis

BACKGROUND

The purpose of this study was to review the results of arthrodesis of the Charcot hindfoot when an implantable bone growth stimulator was added to the procedure. Arthrodesis of the Charcot hindfoot has a high nonunion and complication rate.

METHODS

Ten patients (ages 50 to 69 years) with Charcot neuroarthropathy of the ankle, hindfoot, or both had arthrodesis with use of rigid internal fixation and an implantable bone growth stimulator. There were six tibiotalocalcaneal, two pantalar, and two tibiocalcaneal arthrodeses. An intramedullary nail was used in nine patients and a blade plate was used in one patient. All but one patient was diabetic. Four of the ten patients had preoperative osteomyelitis or postoperative infection. Another patient had purulent drainage, although cultures were negative. Four patients had a preoperative ulceration. Five patients had a two-stage procedure for debridement of infected bone, removal of hardware, and placement of antibiotic beads. Autogenous bone graft from the distal fibula or proximal tibia was used in all patients.

RESULTS

One patient with a preoperative osteomyelitis developed a stable ankle pseudarthrosis. The other nine patients fused at an average of 3.7 months after surgery for a fusion rate of 90%. There were two major complications and eight minor complications. There were no amputations. All patients were ambulatory in a double upright brace or shoes for diabetic patients and were free of ulceration at the time of followup. Average American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score improved from 21 preoperatively to 59 postoperatively.

CONCLUSIONS

The adjunctive use of an implantable bone growth stimulator in conjunction with rigid internal fixation, autogenous bone grafting, and sound operative technique may enhance the outcome and fusion rate in patients undergoing arthrodesis for Charcot neuroarthropathy of the ankle and hindfoot.

Bioadjuvants for complex ankle and hindfoot reconstruction

Many reconstructive options exist for symptomatic hindfoot and ankle problems. Hindfoot and tibiotalar fusions are reliable procedures with consistent results. Unfortunately, many potential complications have been cited throughout the literature. Although the most important aspect in any fusion surgery is meticulous technique, advances in technology, including PRP, bone stimulators, and BMPs seem to be useful additions in the quest to achieve solid fusions with decreased complications.

The role of electrical stimulation in bone repair

Electric and electromagnetic fields regulate extra-cellular matrix synthesis and stimulate repair of fractures and nonunions. Studies of electric and electromagnetic fields suggest they (1) regulate proteoglycan and collagen synthesis and increase bone formation in models of endochondral ossification, (2) accelerate bone formation and repair, (3) increase union rates in fractures previously refractory to healing, and (4) produce results equivalent to bone grafts. Electric and electromagnetic fields regulate the expression of genes in connective tissue cells for extra-cellular matrix proteins, which results in an increase in cartilage and bone. They also increase gene expression for and synthesis of growth factors, which may be an intermediary mechanism of activity and may amplify field effects through autocrine and paracrine signaling.

Electrical bone stimulation: an overview and its use in high risk and Charcot foot and ankle reconstructions

Since early work done in the 1950s on the "piezoelectricity of bone," a growing body of basic science and clinical evidence suggests the use of electrical bone stimulation as an adjunct in the treatment of foot and ankle nonunions, fusions, and Charcot arthropathy. Both implantable designs (that allow for direct constant stimulation of bone) and nonimplantable (such as pulsed and combined electromagnetic fields) devices have been studied. Ongoing research continues to support the potential usefulness of these modalities.

Die Rückfußarthrodese durch retrograde Marknagelung

BACKGROUND

Simultaneous arthrodesis of the ankle and subtalar joints and correction of axial malalignment of the hindfoot in cases of bony defects and/or circulatory disturbances of the talus after multiple previous interventions. Internal stabilization with a short distal femur nail. Restoration of pain-free weight bearing. Failure of arthrodesis of the ankle and subtalar joint in patients with severely altered bone structure particularly at the level of the talar dome. Malalignment of hind- and/or forefoot after previous arthrodesis of the ankle and subtalar joint. Poor skin or soft-tissue condition. Acute osteitis/osteomyelitis.

METHODS

Posterolateral approach. Resection of the articular cartilage and the areas of sclerosis of the ankle and posterior facet of the subtalar joint. Interposition of bone grafts harvested from the posterior iliac crest. Correction of malalignment of the hind- and forefoot. Locked nailing with a short distal femur nail.

RESULTS

All 21 prospectively enrolled patients were followed-up clinically and radiographically at an average of 1.2 years (0.6-2.1 years) postoperatively. The average age of the 4 women and 17 men at the time of surgery was 53.4 years (38.9-73.7 years). The goal of the surgery was achieved in all patients. Subjective assessment was good in 14 patients and satisfactory in 3 patients. Complications occurred in 5 patients; these included loss of nail purchase (2), dislocation of locking screw (1), breakage of locking screw (1), and nonunion (1).

The role of cyclooxygenase-2 inhibition in foot and ankle arthrodesis

Cyclooxygenase-2 (COX-2) inhibitors are an important adjunct in controlling postoperative pain. Concerns exist regarding the use of NSAIDs for postoperative pain management because of the possible deleterious impact on bone healing in patients undergoing hindfoot arthrodesis. Orthopedic surgeons are concerned with: (1) a multimodal approach for postoperative pain control, and (2) bone healing following arthrodesis, fracture repair with rigid internal fixation, and cementless implants. The use of COX-2 inhibitors has been shown to be an important component of a pain control strategy but questions about their effects on bone healing have inhibited their use. This article discusses the laboratory and clinical data available on the use of COX-2 inhibitors on bone healing and their effects on foot and ankle arthrodesis procedures.

The use of circular wire external fixation in the treatment of salvage ankle arthrodesis

The authors retrospectively reviewed their experience with circular wire external fixation in the treatment of salvage ankle arthrodesis during the past 9 years. The results of 43 cases in a difficult patient population are presented with an average follow-up of 27.0 months. Thirty-three patients (80.5%) went on to achieve a solid fusion or stable pseudarthrosis. A minimum of a 4-ring frame construct was applied for an average of 96.1 days. The major complication rate was 51.2%, including 3 below-knee amputations (7.3%), 7 unstable nonunions (17.1%), 7 cases of osteomyelitis and/or deep-space infection (16.3%), 3 malunions (7.3%), and 2 tibial stress fractures (4.7%). The incidence of complications occurred similarly in patients with Charcot arthropathy, failed total ankle arthroplasty, septic fusion, posttraumatic deformity, or avascular necrosis of the talus, whereas it was relatively higher in patients who were diabetics, smokers, or had an increased body mass index. In addition, the incidence of a nonunion tended to increase with longer follow-up, suggesting that early presumption of a solid union may be erroneous. Based on our defined criteria of a stable, well-aligned fusion without severe pain or activity restrictions, 28 patients (68.3%) had a good result. Circular wire external fixation can be a viable treatment for complex ankle salvage pathology; however, it is difficult to predict the prospects of success or failure.

PEMF as treatment for delayed healing of foot and ankle arthrodesis

BACKGROUND

Arthrodesis is the most common surgical treatment for foot and ankle arthritis. In adults, these procedures are associated with a 5% to 10% rate of nonunion. Pulsed electromagnetic field (PEMF) stimulation was approved by the Federal Drug Administration (FDA) for treatment of delayed unions after long-bone fractures and joint arthrodesis. The purpose of this study was to examine the results of PEMF treatment for delayed healing after foot and ankle arthrodesis.

METHODS

Three hundred and thirty-four foot and ankle arthrodeses were done. Nineteen resulted in delayed unions that were treated with a protocol of immobilization, limited weightbearing, and PEMF stimulation for a median of 7 (range 5 to 27) months. All patients were followed clinically and radiographically.

RESULTS

The use of PEMF, immobilization, and limited weightbearing to treat delayed union after foot and ankle arthrodesis was successful in 5 of 19 (26%) patients. Of the other 14 patients with nonunions, nine had revision surgery with autogenous grafting, continued immobilization, and PEMF stimulation. Seven of these eventually healed at a median of 5.5 (range 2 to 26) months and two did not heal. One patient had a below-knee amputation, and four refused further treatment.

CONCLUSIONS

The protocol of PEMF, immobilization, and limited weightbearing had a relatively low success rate in this group of patients. We no longer use this protocol alone to treat delayed union after foot and ankle arthrodesis.

Revision arthrodesis of the foot and ankle

Previously failed procedures with less than optimal outcomes always are distressing to the patient and surgeon. The revisional arthrodesis may require a higher level of surgical technique and skill than the original procedure from which it was derived. Another level of difficulty is added when the original procedure was deemed to have failed secondary to poor patient compliance. The basic tenets of successful revisional arthrodesis include a motivated and educated patient, adherence to basic surgical principles and techniques, and the ability to extrapolate those principles and techniques into ideas that are born from thinking along the lines of necessity.

Treatment of nonunions with electric and electromagnetic fields

Electric and electromagnetic fields are, collectively, one form of biophysical technique which regulate extracellular matrix (ECM) synthesis and may be useful in clinically stimulating repair of fractures and nonunions. Preclinical studies have shown that electric and electromagnetic fields regulate proteoglycan (PG) and collagen synthesis in models of endochondral ossification, and increase bone formation in vivo and in vitro. A substantial number of clinical studies have been done that suggest acceleration of bone formation and healing, particularly osteotomies and spine fusions, by electric and electromagnetic fields. Many of these studies have used randomized, placebo controlled designs. In osteotomy trials, greater bone density, trabecular maturation, and radiographic healing were observed in actively treated, compared with placebo-treated patients. In spine fusions, average union rates of 80% to 90% were observed in actively treated patients across numerous studies compared with 65% to 75% in placebo-treated patients. Uncontrolled, longitudinal cohort studies of delayed and nonunions report mean union rates of approximately 75% to 85% in fractures previously refractory to healing. The few randomized controlled studies in delayed and nonunions suggest improved results with electric and electromagnetic fields compared with placebo treatment, and equivalent to bone grafts.

External fixation use in arthrodesis of the foot and ankle

The use of external fixation in foot and ankle arthrodesis can be beneficial. Its advantages, disadvantages, and indications were reviewed in this article. External fixation offers the surgeon an opportunity to treat complex foot and ankle deformities, trauma, chronic infections, pseudoarthroses, soft tissue contractures, and limb length discrepancies in ways that were unavailable before its advent. The Ilizarov technique requires considerable experience and patient compliance for the best postoperative outcome. An understanding of musculoskeletal physiology and the biomechanics of bone and soft tissue are essential for the competent application of external fixators in general and Ilizarov frames in particular. The surgeon should be aware of all the surgical options before the application of an external complex apparatus.

Die Technik der tibiotalaren Arthrodese mit Kompressionsmarknagel

Tibiotalar arthrodesis still remains the primary choice of treatment for disabling ankle arthropathy since the results of ankle arthroplasty are not yet convincing. Numerous operative techniques have been described, with an increasing trend towards the use of internal fixation and compression. Using an intramedullary compression nailing technique, 137 tibiotalar fusions were performed at our hospital. The special design of the nail allows distal interlocking in the talus and dynamic axial compression with high primary stability. With correct joint axis, only the cartilage joint surfaces were removed. For axis correction the corresponding bony joint surfaces were also resected. We also performed a dowel technique with bone grafting from the lateral malleolus. We examined 110 of the 137 patients during follow-up. A primary union could be achieved in 99 cases (90.0%). A further six cases (5.5%) healed after recompression and bone grafting. Nonunion remained in five cases (4.5%). Operative complications included one tibial shaft fracture and one hematoma. Septic complications were three superficial and eight deep infections. Sufficient pain relief after arthrodesis was reported by 70 (63.6%) patients; in 37 (33.6%) patients the symptoms remained unchanged and 3 (2.7%) patients found their pain to be worse than before the procedure. Intramedullary compression nailing is shown to be an effective technique for tibiotalar arthrodesis in severe ankle arthropathy. The main advantages of the technique are limited soft tissue damage in the ankle area and high primary stability allowing early weight bearing.