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He W, Zhou H, Li Z, Zhao Y, Xia J, Li Y, Chen C, Huang H, Zhang Y, Li B, Yang Y. Comparison of different fibula procedures in tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a mid-term retrospective study. BMC Musculoskelet Disord 2023; 24:882. [PMID: 37957652 PMCID: PMC10644431 DOI: 10.1186/s12891-023-07025-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures. METHODS We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded. RESULTS Fifty-eight patients with an average age of 53.2 (range, 32-69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60-78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1 min) was longer than that of FO (119.3 ± 11.7 min) and FS (112.2 ± 12.6 min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters. CONCLUSIONS TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP. LEVEL OF CLINICAL EVIDENCE Level 3.
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Affiliation(s)
- Wenbao He
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Haichao Zhou
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Zhendong Li
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Youguang Zhao
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Jiang Xia
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Yongqi Li
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Cheng Chen
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Hui Huang
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Yi Zhang
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Bing Li
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China.
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yunfeng Yang
- Department of Orthopedics, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China.
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Martínez-de-Albornoz P, Monteagudo M. Tibiotalocalcaneal Arthrodesis in Severe Hindfoot Deformities. Foot Ankle Clin 2022; 27:847-866. [PMID: 36368801 DOI: 10.1016/j.fcl.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies--weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.
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Affiliation(s)
- Pilar Martínez-de-Albornoz
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud, Madrid, Spain; Faculty Medicine UEM, Madrid, Spain.
| | - Manuel Monteagudo
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud, Madrid, Spain; Faculty Medicine UEM, Madrid, Spain
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Campbell ML, Lenz AL, Peterson AC, DeKeyser GJ, Haller JM, O'Neill DC. Dual Approach to Talar Dome Increases Access for Fracture Care Without Osteotomy. Foot Ankle Int 2022; 43:1474-1481. [PMID: 36000204 DOI: 10.1177/10711007221115719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no consensus surgical treatment algorithm for talar body fractures, with authors recommending both soft tissue-only and osteotomy-based approaches. This study evaluates talar dome access via dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches. METHODS Ten cadaveric legs (5 matched pairs) were included. An mPM approach, between flexor hallucis longus and Achilles tendon, and an ATL approach, utilizing the anterolateral interval with transection of anterior talofibular ligament and calcaneofibular ligament, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4 mm of tibiotalar distraction using an external fixator. Specimens were analyzed by computed tomography (CT). Primary outcome was accessible DSA. Student t tests compared DSA accessed by different exposure methods. RESULTS An initial mPM approach exposed 25.6% and 33.6% of DSA without and with distraction (P = .002). An initial ATL approach accessed 47.0% and 58.1% of DSA without and with distraction, respectively (P = .003). Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach (P = .96 and .37, respectively). The central talar dome was inaccessible in an almond-shaped area, tapered at the medial and lateral ends. Anterior, lateral, and posterior articular margins were able to be fully exposed, often with overlapping exposure between posterior and anterior approaches, with distraction reliably improving lateral visualization. CONCLUSION Dual approaches provided access to greater than 70% and 85% of talar DSA without and with distraction, respectively. Order of approach did not significantly affect exposure and thus should be determined by surgeon discretion. These results may promote soft tissue-only treatment strategies in talar body fracture care with an extensile exposure of the talar dome surface. Careful preoperative planning optimizes the advantages of this approach. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Megan L Campbell
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Amy L Lenz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Andrew C Peterson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Washington, Seattle, WA, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Dillon C O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Ivanov S, Stefanov A, Zderic I, Rodemund C, Schepers T, Gehweiler D, Dauwe J, Pastor T, Makelov B, Raykov D, Richards G, Gueorguiev B. Percutaneous fixation of intraarticular joint-depression calcaneal fractures with different screw configurations - a biomechanical human cadaveric analysis. Eur J Trauma Emerg Surg 2022; 48:3305-3315. [PMID: 35254460 DOI: 10.1007/s00068-022-01901-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/30/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to assess the biomechanical performance of different screw configurations for fixation of Sanders type II B joint-depression calcaneal fractures. METHODS Fifteen human cadaveric lower limbs were amputated and Sanders II B fractures were simulated. The specimens were randomized to three groups for fixation with different screw configurations. The calcanei in Group 1 were treated with two parallel longitudinal screws, entering superiorly the Achilles tendon insertion, and two screws fixing the intraarticular posterior facet fracture line. In Group 2 two screws entered the tuberosity inferiorly to the Achilles tendon insertion and two transverse screws fixed the posterior facet. In Group 3 two screws were inserted along the bone axis, one transverse screw fixed the posterior facet and one oblique screw was inserted from the posteroplantar part of the tuberosity supporting the posterolateral part of the posterior facet. All specimens were biomechanically tested to failure under progressively increasing cyclic loading. RESULTS Initial stiffness did not differ significantly between the groups, P = 0.152. Cycles to 2 mm plantar movement were significantly higher in both Group 1 (15,847 ± 5250) and Group 3 (13,323 ± 4363) compared with Group 2 (4875 ± 3480), P ≤ 0.048. No intraarticular displacement was observed in any group during testing. CONCLUSIONS From a biomechanical perspective, posterior facet support by means of buttress or superiorly inserted longitudinal screws results in less plantar movement between the calcaneal tuberosity and the anterior fragments. Inferiorly inserted longitudinal screws are associated with bigger interfragmentary movements.
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Affiliation(s)
- Stoyan Ivanov
- AO Research Institute Davos, Davos, Switzerland. .,Medical University Varna, Varna, Bulgaria.
| | - Aleksandar Stefanov
- AO Research Institute Davos, Davos, Switzerland.,University Multiprofile Hospital for Active Treatment and Emergency Medicine 'N. I. Pirogov', Sofia, Bulgaria
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | - Tim Schepers
- Trauma Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Jan Dauwe
- University Hospitals Leuven, Leuven, Belgium
| | - Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland.,Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Biser Makelov
- Medical University Varna, Varna, Bulgaria.,University Multiprofile Hospital for Active Treatment 'S. Kirkovitch', Stara Zagora, Bulgaria
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DeKeyser GJ, O'Neill DC, Sripanich Y, Lenz AL, Saltzman CL, Haller JM, Barg A. Talar Dome Access Through Posteromedial Surgical Intervals for Fracture Care. Foot Ankle Int 2022; 43:223-232. [PMID: 34384278 DOI: 10.1177/10711007211036720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction. METHODS Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro-computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals. RESULTS The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02). CONCLUSION The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially. LEVEL OF EVIDENCE Level V, Cadaveric Study.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Dillon C O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Yantarat Sripanich
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Tung Phayathai, Ratchathewi, Bangkok, Thailand
| | - Amy L Lenz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Charles L Saltzman
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Alexej Barg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. Hamburg, Germany
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DeKeyser GJ, Sripanich Y, O'Neill DC, Lenz AL, Haller JM, Saltzman CL, Barg A. Mapping of Posterior Talar Dome Access Through Posteromedial Versus Posterolateral Approaches. J Orthop Trauma 2021; 35:e463-e469. [PMID: 33724965 DOI: 10.1097/bot.0000000000002113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction. METHODS A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals. RESULTS The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach. CONCLUSION The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Yantarat Sripanich
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Tung Phayathai, Ratchathewi, Bangkok, Thailand ; and
| | - Dillon C O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Amy L Lenz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Charles L Saltzman
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Alexej Barg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chinnakkannu K, McKissack HM, He JK, Alexander B, Wilson J, Viner GC, Shah A. Mini-open vs. Transfibular Approach for Ankle Arthrodesis, Which Approach is Superior in Joint Preparation: A Cadaver Study. Indian J Orthop 2021; 55:135-141. [PMID: 34122766 PMCID: PMC8149565 DOI: 10.1007/s43465-020-00244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/20/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Arthrodesis is considered the gold standard for end-stage ankle arthritis in patients who fail conservative management. Achieving union is paramount while minimizing complications. An essential item for successful union is preparation of the articular surface. Our study aims to evaluate the difference in joint preparation between direct lateral and dual mini-open approaches. MATERIALS AND METHODS Ten below knee fresh-frozen specimens were used for this study. Five were prepared through lateral approach, and five using dual mini-incisions. After preparation, all ankles were dissected and images of tibial plafond and talar articular surfaces were taken. Surface areas of articulating facets and unprepared cartilage of talus, distal tibia, and distal fibula were measured and analyzed. RESULTS A greater amount of total surface area was prepared with the mini-open approach in comparison to the transfibular approach. Percentage of prepared surface area of total articulating surface (including talus and tibia/fibula), talus, tibia, and fibula with the transfibular approach were 76.9%, 77.7%, and 75%, respectively. Percentages were 90.9%, 92.9%, and 88.6% with the mini-open approach. When excluding medial gutter, there was no significant difference between techniques (83.94% vs. 90.85%, p = 0.1412). CONCLUSION Joint preparation with the mini-open approach is equally efficacious as the transfibular approach for the tibiotalar joint. The mini-open approach does provide superior preparation of the medial gutter and inferior tibial surface which may help to increase union rates and decreased complications. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Karthikeyan Chinnakkannu
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Haley M. McKissack
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Jun Kit He
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Bradley Alexander
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - John Wilson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Gean C. Viner
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
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Sripanich Y, Dekeyser G, Steadman J, Rungprai C, Haller J, Saltzman CL, Barg A. Limitations of accessibility of the talar dome with different open surgical approaches. Knee Surg Sports Traumatol Arthrosc 2021; 29:1304-1317. [PMID: 32596777 DOI: 10.1007/s00167-020-06113-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/11/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE The aim of this study is to systematically review the current, relevant literature and provide a thorough understanding of the various open surgical approaches utilized to gain access to the talar dome for treatment of osteochondral lesions. Realizing the limits of access from soft tissue exposures and osteotomies, with and without external distraction, will help surgeons to select the appropriate approach for each individual clinical situation. METHODS A literature search was performed using three major medical databases: PubMed (MEDLINE), Scopus, and Embase. The Quality Appraisal for Cadaveric Studies (QUACS) scale was used to assess the methodological quality of each included study. RESULTS Of 3108 reviewed articles, nine cadaveric studies (113 limbs from 83 cadavers) evaluating the accessibility of the talar dome were included in the final analysis. Most of these (7/9 studies) investigated talar dome access in the context of treating osteochondral lesions of the talus (OLTs) requiring perpendicular visualization of the involved region. Five surgical approaches (anteromedial; AM, anterolateral; AL, posteromedial; PM, posterolateral; PL, and direct posterior via an Achilles tendon splitting; DP), four types of osteotomy (anterolateral tibial, medial malleolar, distal fibular, and plafondplasty), and two methods of distraction (Hintermann retractor and external fixator) were used among the included studies. The most commonly used methods quantified talar access in the sagittal plane (6/9 studies, 66.7%). The greatest exposure of the talar dome can be achieved perpendicularly by performing an additional malleolar osteotomy (90.9% for lateral, and 100% for medial). The methodological quality of all included studies was determined to be satisfactory. CONCLUSION Gaining perpendicular access to the central portion of the talar dome, measured in the sagittal plane, has clear limitations via soft tissue approaches either medially or laterally from the anterior or posterior aspects of the ankle. It is possible to access a greater talar dome area in a non-perpendicular fashion, especially from the posterior soft tissue approach. Various types of osteotomies can provide greater accessibility to the talar dome. This systematic review can help surgeons to select the appropriate approach for treatment of OLTs in each individual patient preoperatively. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Yantarat Sripanich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.,Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - Graham Dekeyser
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Jesse Steadman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Chamnanni Rungprai
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - Justin Haller
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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Yang M, Xie M, Gong J, Zhou B, Mu M, Chen Y, Tang K. [Effectiveness of tibio-talo-calcaneal arthrodesis with full thread headless compression screws via combined minimal incisions]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1297-1301. [PMID: 30215500 PMCID: PMC8414157 DOI: 10.7507/1002-1892.201806048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/09/2018] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of tibio-talo-calcaneal arthrodesis with full thread headless compression screws via combined minimal incisions. Methods Between January 2012 and December 2016, 36 patients (36 feet) with ankle diseases underwent tibio-talo-calcaneal arthrodesis with parallel double thread headless compression screws via minimal anterior and lateral oblique incisions. There were 14 males and 22 females with an average age of 53.8 years (range, 18-76 years). There were 19 cases of left feet and 17 cases of right feet. There were 21 cases of talar necrosis, 7 cases of post-traumatic arthritis, 3 cases of rheumatoid arthritis, 2 cases of tuberculosis infection (inactive), 1 case of talar absence, 1 case of Charcot’s disease, and 1 case of pigmented villonodular synovitis of ankle and subtalar joints. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score were 53.7±2.5 and 5.9±0.2, respectively. The operation time was recorded and the wound healing and complications were observed. The bone healing was assessed by X-ray film and CT scanning. The function and pain of joint were evaluated by AOFAS and VAS scores. Results The mean operation time was 49.8 minutes (range, 33-82 minutes). Incision infection occurred in 1 patient (2.8%) at 3 weeks after operation, and recovered after debridement. The other incisions healed by first intention without complications. Thirty-five patients were followed up with an average of 18.5 months (range, 12-29 months). Imaging examination showed fusion of the ankle and subtalar joints with an average fusion time of 10.9 weeks (range, 8-15 weeks). After 1 year, the AOFAS score (84.7±0.6) and VAS score (0.3±0.1) were significantly higher than preoperative scores ( t=12.596, P=0.000; t=30.393, P=0.000). Conclusion It is an effective surgical method of tibio-talo-calcaneal arthrodesis with full thread headless compression screws via combined minimal incisions for end-stage ankle disease because of the less complications incidence and the higher postoperative fusion rate.
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Affiliation(s)
- Mingyu Yang
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Meiming Xie
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Jicheng Gong
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Binghua Zhou
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Miduo Mu
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Yonghua Chen
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038, P.R.China
| | - Kanglai Tang
- Department of Orthopedics/Sports Medicine Center, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing, 400038,
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10
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Abstract
Surgical access to the subtalar joint is required in a plethora of pathologic conditions of the hindfoot. The conventional lateral approach can give excellent access to subtalar joint; however, in hindfoot valgus deformities, there can be unacceptable risks of wound problems and incomplete deformity corrections. The medial approach offers good access to the subtalar joint with an increasing evidence base for its use, especially with double fusions in pes planus deformities. The authors review the current evidence in the use of the medial approach for the subtalar joint.
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Affiliation(s)
- James Widnall
- Trauma and Orthopaedic Department, Aintree University Hospital, Lower Lane, Liverpool, L9 7AL, UK
| | - Lyndon Mason
- Trauma and Orthopaedic Department, Aintree University Hospital, Liverpool University, Liverpool, UK
| | - Andrew Molloy
- Trauma and Orthopaedic Department, Aintree University Hospital, Liverpool University, Liverpool, UK.
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11
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Klos K, Gueorguiev B, Carow JB, Modabber A, Nebelung S, Kim BS, Horst K, Weber CD, Knobe M. Soft tissue microcirculation around the healthy Achilles tendon: a cross-sectional study focusing on the Achilles tendon and dorsal surgical approaches to the hindfoot. J Orthop Surg Res 2018; 13:142. [PMID: 29880004 PMCID: PMC5992692 DOI: 10.1186/s13018-018-0850-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023] Open
Abstract
Background Dorsal approaches to the hindfoot are frequently used. Furthermore, the vascular supply is discussed as a possible cause for ruptures and degeneration of the Achilles tendon. The aim of this study was to evaluate the microperfusion of three possible posterior approaches to the hindfoot and different areas of the Achilles tendon. Methods In 111 subjects, a laser Doppler/white light spectroscopy was used to measure microperfusion in terms of blood flow (Flow) and capillary venous oxygen saturation (SO2) in the hindfoot and Achilles tendon. Measurements were performed at two measurement points (MP, proximal and distal) of three dorsal approaches (medial, lateral and central) and inside the Achilles tendon. Results Microperfusion differed partially between the surgical approaches. The medial and the lateral approaches were significantly superior to the central approach with regard to Flow in both MP (p < 0.001), while SO2 was significantly higher at the proximal measurement point (MP 1; p < 0.001). In this area, the lateral approach was significantly superior to the medial approach regarding Flow (MP 1; p = 0.012). The Achilles tendon exhibited a significantly reduced microperfusion 5 cm proximal to the calcaneal tubercle (SO2 p = 0.001; Flow p = 0.048). Demographic factors, such as body mass index and age, had different effects. Microcirculation was partially superior in men and negatively affected by smoking. Conclusions Soft tissue microcirculation on the lateral and medial side of the healthy Achilles tendon was better than centrally on the tendon. Proximally, the lateral approach was better than the medial approach. These circumstances could provide advantages regarding the surgical approach. The Achilles tendon exhibited significantly reduced microperfusion at the typical side of degeneration and rupture. This circumstance could be a possible cause of degenerative processes.
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Affiliation(s)
- Kajetan Klos
- Department of Foot and Ankle Surgery, Catholic Hospital Mainz, Mainz, Germany
| | | | - John Bennet Carow
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University of Aachen Medical Center, Aachen, Germany
| | - Sven Nebelung
- Department of Radiology, University of Aachen Medical Center, Aachen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery, Reconstructive and Hand Surgery, University of Aachen Medical Center, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Christian David Weber
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany.
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12
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Mulligan RP, Adams SB, Easley ME, DeOrio JK, Nunley JA. Comparison of Posterior Approach With Intramedullary Nailing Versus Lateral Transfibular Approach With Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis. Foot Ankle Int 2017; 38:1343-1351. [PMID: 28952355 DOI: 10.1177/1071100717731728] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. The intramedullary (IM) nail and lateral, fixed-angle plating are commonly used because of ease of use and favorable biomechanical properties. A lateral, transfibular (LTF) approach allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PATS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either a PATS approach with IM nailing or LTF approach with fixed-angle plating. METHODS A retrospective review was performed on all patients who underwent simultaneous TTC arthrodesis with minimum 1 year clinical and radiographic follow up. Patients were excluded if they underwent TTC arthrodesis through an approach other than PATS or LTF, and received fixation without an IM nail or fixed-angle plate. Primary outcomes examined were union rate, revisions, and complications. Thirty-eight patients underwent TTC arthrodesis with a PATS approach and IM nailing, and 28 with a LTF approach and lateral plating. RESULTS The overall union rate was 71%; 76% (29 of 38 patients) for the PATS/IM nail group, and 64% (18 of 28) for LTF/plating group ( P = .41). Symptomatic nonunion requiring revision arthrodesis occurred in 16% (6 of 38) of the PATS/IM nail group versus 7% (2 of 28) in the LTF/lateral plating group ( P = .45). There were no significant differences in individual tibiotalar or subtalar union rates, superficial wound problems, infection, symptomatic hardware, stress fractures, or nerve irritations. CONCLUSION Union, revision, and complication rates were similar for TTC arthrodesis performed with a PATS approach and IM nail compared with an LTF approach and fixed-angle plate in a complex patient population. Both techniques were adequate, especially when prior incisions, preexisting hardware, or deformity preclude options. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ryan P Mulligan
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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13
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Pellegrini MJ, Schiff AP, Adams SB, DeOrio JK, Easley ME, Nunley JA. Outcomes of Tibiotalocalcaneal Arthrodesis Through a Posterior Achilles Tendon-Splitting Approach. Foot Ankle Int 2016; 37:312-9. [PMID: 26578482 DOI: 10.1177/1071100715615398] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A number of operative approaches have been described to perform a tibiotalocalcaneal (TTC) arthrodesis. Here we present the largest reported series of a posterior Achilles tendon-splitting approach for TTC fusion. METHODS With institutional review board approval, a retrospective review of the TTC fusions performed at a single academic institution was carried out. Orthopedic surgeons specializing in foot and ankle surgery performed all procedures. Eligible patients included all those who underwent a TTC fusion via a posterior approach and had at least a 2-year follow-up. Forty-one patients underwent TTC arthrodesis through a posterior Achilles tendon-splitting approach. Mean age at surgery was 56.9±15.0 years. There were 21 female and 20 male patients. Preoperative diagnoses included arthritis (n = 13 patients), failed total ankle arthroplasty (9), avascular necrosis of the talus (9), prior nonunion of the ankle and/or subtalar joint (6), Charcot neuro-arthropathy (2), and stage IV flatfoot deformity (2). In 37 patients (90.2%), a hindfoot intramedullary arthrodesis nail was used, with posterior plate or supplemental screw augmentation in 17 patients. Posterior plate stabilization alone was utilized in 4 cases (9.8%). RESULTS The fusion rate was 80.4%. Eight patients developed a nonunion of the subtalar, tibiotalar, or both joints. Complications were observed in 17 patients (41.4%). Of these, ankle nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial wound breakdown (9.7%), subtalar nonunion (4.8%), and TTC malunion (2.4%) were the most frequently identified. One patient eventually underwent amputation (2.4%). CONCLUSION We believe that posterior Achilles tendon-splitting approach for tibiotalocalcaneal arthrodesis was a safe and effective method, with similar union and complications rates to some previously described techniques. We believe the posterior approach is advantageous as it provides simultaneous access to both the ankle and subtalar joints and allows for dissection to occur between angiosomes, which may preserve blood supply to the skin. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Manuel J Pellegrini
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - Adam P Schiff
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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14
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Napiontek M, Jaszczak T. Ankle arthrodesis from lateral transfibular approach: analysis of treatment results of 23 feet treated by the modified Mann’s technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1195-9. [DOI: 10.1007/s00590-015-1663-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/21/2015] [Indexed: 12/25/2022]
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15
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Yu T, Li B, Yang YF, Chen DW, Yu GR. Limitations of minimal incision technique for tibiotalocalcaneal arthrodesis. Foot Ankle Int 2014; 35:529. [PMID: 24786374 DOI: 10.1177/1071100714529766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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