The modified Blair fusion

Identifying Risk Factors for Osteonecrosis After Talar Fracture

OBJECTIVE

To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors.

METHODS

DESIGN

Retrospective chart review.

SETTING

21 US trauma centers and 1 UK trauma center.

PATIENT SELECTION CRITERIA

Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes.

RESULTS

In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions.

CONCLUSIONS

Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Talar Replacement for Idiopathic Osteonecrosis of the Talus: Investigation of Clinical Outcomes, Pain, ADL, QOL

Background

Treatment of osteonecrosis of the talus is challenging. Nonoperative management includes nonweightbearing treatment. Various types of hindfoot fusion procedures have been performed, but delayed union and shortening of the operated leg have reportedly occurred. In contrast, talar body prosthesis is a surgical procedure with potential that relieves pain, restores ankle joint function, and is not associated with leg-length discrepancy. The aim of this study was to investigate postoperative pain, clinical outcomes, activities of daily living (ADL), and quality of life (QOL) after total talar replacement in patients with osteonecrosis of the talus.

Methods

Ten ankles in 10 patients with idiopathic osteonecrosis of the talus who were treated with a total talar replacement between 2007 and 2015 were included in the investigation. Scores according to the visual analog scale (VAS), Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale, Functional Independence Measure (FIM), and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were assessed.

Results

The VAS score significantly improved from a mean of 80 ± 8 points before surgery to 18 ± 22 points after surgery (P < .01). The JSSF ankle-hindfoot scale score significantly improved from a mean of 53 ± 12 points before surgery to 89 ± 7 points after surgery (P < .01). The FIM score significantly improved from a mean of 122 ± 1 points before surgery to 125 ± 1 points after surgery (P < .01). The mean postoperative SAFE-Q scores were as follows: 81 ± 10.3 points for pain, 78 ± 14.7 points for physical function, 90 ± 12.4 points for social function, and 83 ± 15.4 points for shoe-related.

Conclusion

Total talar replacement is a useful treatment for patients with osteonecrosis of the talus. This replacement surgery preserves the function of the ankle and subtalar joints, and improves pain, ADL, and QOL.

Level of Evidence

Level IV, case series.

The Long-Term Clinical Results of Total Talar Replacement at 10 Years or More After Surgery

BACKGROUND

Total talar replacement has been reported to have favorable short-term and intermediate-term results for the treatment of osteonecrosis of the talus. The purpose of this study was to evaluate the long-term clinical results of total talar replacement for a minimum of 10 years after the surgical procedure.

METHODS

From October 2005 to April 2011, 19 ankles in 18 patients (1 male and 17 female) were treated using a total talar prosthesis for osteonecrosis of the talus. The median follow-up period was 152 months (interquartile range [IQR], 138, 160 months). The Ankle Osteoarthritis Scale (AOS) score, the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale score, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at the final follow-up. Subsidence of the prosthesis was also assessed at the earliest opportunity for full weight-bearing and the final follow-up. The postoperative range of motion of the ankle was assessed at the final follow-up.

RESULTS

The median scores for all subscales of the AOS significantly improved. The median JSSF Ankle-Hindfoot Scale score significantly improved from 58 (IQR, 55, 59.5) to 97 (IQR, 87, 99.5). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20, 20) to 40 (IQR, 30, 40), and the median function score improved from 28 (IQR, 26, 30.5) to 47 (IQR, 47, 50). The median postoperative range of motion of the ankle was 45° (IQR, 42.5°, 55°). Subsidence of the implant was not recognized at the final follow-up (p = 0.083). Proliferation of osteophytes and degenerative changes in the adjacent joints did not affect the overall results.

CONCLUSIONS

The customized alumina ceramic total talar prosthesis produced stable clinical outcomes over 10 years, and the patients treated with total talar replacement showed favorable clinical results over this time frame.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Avascular Osteonecrosis of the Talus: Current Treatment Strategies

Avascular osteonecrosis (AVN) of the talus (AVNT) is a painful and challenging clinical diagnosis. AVNT has multiple known risk factors and etiologies and presents at different stages in severity. Given these unique factors, the optimal treatment solution has yet to be determined. Both joint-preserving and joint-sacrificing procedures are available, including core decompression and arthrodeses. Recently, new salvage and replacement techniques have been described including vascularized pedicle bone grafts and total talus replacement using patient-specific prosthesis; however, evidence remains limited. This review examines the current trends AVNT treatment and the emerging data behind these novel techniques.

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.

An Alumina Ceramic Total Talar Prosthesis for Avascular Necrosis of the Talus

Avascular necrosis tends to occur in the talus because of poor blood supply caused by the extended coverage to the articular cartilage on its surface. Treatment is conservative in the earlier stage of this disease; however, surgical treatment is usually indicated in the advanced stage. Nonunion, leg length discrepancy, or hindfoot instability may occur in patients treated with ankle or tibio-talo-calcaneal fusion. Arthroplasty using a customized total talar prosthesis designed using the computed tomography image of contralateral talus has the potential advantages of weightbearing in the earlier postoperative phase, prevention of lower extremity discrepancy, and maintenance of joint function.

Treatment of Osteonecrosis of the Talus

More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis. Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis. In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.

Management Options in Avascular Necrosis of Talus

Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

Early results of a novel technique: Hindfoot fusion in talus osteonecrosis prior to ankle arthroplasty: A case series

BACKGROUND

The purpose of this study was to evaluate the clinical outcome of a two staged approach of subtalar arthrodesis followed by TAR for patients with ankle arthritis and AVN talus.

METHODS

Out of total 210 TARs performed at our institute; 7 patients underwent a two staged procedure between 2006 and 2010. All patients had over 3 years of follow up (except one). The clinical results were assessed using AOFAS, WOMAC, SF-36 and patient satisfaction scores.

RESULTS

The mean follow up was 3 years. There was significant improvement in AOFAS and WOMAC (pain and stiffness) from pre-op to 3 years post-op (P<0.05). SF 36 scores improved from pre-op to 3 years post-op for 6/8 domains. 5 patients were satisfied at 3 years for overall surgical outcomes, 4 were satisfied with pain relief. Radiological signs of talar subsidence were noted in 2 patients at year 1. This did not progress at 3 years and did not deteriorate clinical outcome.

CONCLUSION

We recommend our two staged approach to deal with this difficult clinical problem. We believe this approach is safe for TAR surgery where talar vascularity and bone quality is questionable leading to reduced talar subsidence, ischaemic pain and improvement in longevity of TAR.

LEVEL OF EVIDENCE

Evidence IV (Retrospective case series).

An Alumina Ceramic Total Talar Prosthesis for Osteonecrosis of the Talus

BACKGROUND

Treatment of osteonecrosis of the talus is challenging. Total talar replacement has the potential to restore the function of the ankle joint without an associated leg-length discrepancy. The purpose of the present study was to investigate postoperative function and pain after total talar replacement in patients with osteonecrosis of the talus.

METHODS

Fifty-five ankles in fifty-one consecutive patients with osteonecrosis of the talus who were treated with a total talar replacement from 2005 to 2012 were included in the investigation. Scores according to the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and the Ankle Osteoarthritis Scale (AOS) were assessed before surgery and at the final follow-up evaluation.

RESULTS

According to the JSSF ankle-hindfoot scale, the score for pain improved from a mean (and standard deviation) of 15 ± 9.4 points (range, 0 to 20 points) to 34 ± 5.6 points (range, 20 to 40 points); the score for function, from 21.2 ± 9.7 points (range, 4 to 38 points) to 45.1 ± 4.0 points (range, 37 to 50 points); the score for alignment, from 6.0 ± 2.8 points (range, 5 to 10 points) to 9.8 ± 0.9 points (range, 5 to 10 points); and the total score, from 43.1 ± 17.0 points (range, 11 to 68 points) to 89.4 ± 8.4 points (range, 76 to 100 points). According to the AOS scale, the score for "pain at its worst" improved from a mean of 6.1 ± 3.3 points (range, 0 to 9.9 points) to 2.0 ± 1.7 points (range, 0 to 6.3 points).

CONCLUSIONS

Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function.

A new form of surgical treatment for patients with avascular necrosis of the talus and secondary osteoarthritis of the ankle

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.

Treatments for avascular necrosis of the talus: a systematic review

INTRODUCTION

Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature.

METHODS

We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations.

RESULTS

19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is "very low". Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN.

DISCUSSION

Given the "very low" GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

LEVEL OF EVIDENCE

Level II.

The use of a ceramic talar body prosthesis in patients with aseptic necrosis of the talus

The purpose of this study was to evaluate the clinical results of a newly designed prosthesis to replace the body of the talus in patients with aseptic necrosis. Between 1999 and 2006, 22 tali in 22 patients were replaced with a ceramic prosthesis. A total of eight patients were treated with the first-generation prosthesis, incorporating a peg to fix into the retained neck and head of the talus, and the remaining 14 were treated with the second-generation prosthesis, which does not have the peg. The clinical results were assessed by the American Orthopaedic Foot and Ankle Society ankle/hindfoot scale. The mean follow-up was 98 months (18 to 174). The clinical results of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. There were, however, radiological signs of loosening, prompting a change in design. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favourable radiological appearances. Revision was required using a total talar implant in four patients, two in each group. Although the second-generation prosthesis produced better results, we cannot recommend the use of a talar body prosthesis. We now recommend the use of a total talar implant in these patients.

Technique tip: open ankle athrodesis using locking compression plate combined with anterior sliding bone graft

Level of Evidence: V, Expert Opinion

Technique and short-term results of ankle arthrodesis using anterior plating

Clinical and biomechanical trials have shown that rigid internal fixation during ankle arthrodesis leads to increased rates of union and is associated with a reduced infection rate, union time, discomfort and earlier mobilisation compared with other methods. We describe our technique of ankle arthrodesis using anterior plating with a narrow dynamic compression plate (DCP). Between 2004 and 2007, 29 patients with a mean age of 24.4 years (range 18-42) had ankle arthrodesis using an anteriorly placed narrow DCP. Twenty-two patients were post-traumatic and seven were paralytic (five after spine fracture and two after common peroneal nerve injury). Follow-up was between 12 and 18 months (average 14 months). A rate of fusion of 100% was achieved at an average of 12.2 weeks. According to the Mazur ankle score, 65.5% had excellent, 20.7% good and 13.8% fair results. Ankle arthrodesis using an anteriorly placed narrow DCP is a good method to achieve ankle fusion in many types of ankle arthropathies.

Ankle arthrodesis

Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early 1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion, extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of infection, deformity, avascular necrosis, and nonunion.

The use of fibular autograft and ankle arthrodesis for aggressive giant cell tumor in the distal tibia: a case report

The case describes successful distal tibial resection, fibular autograft, and ankle arthrodesis in two patients who had giant cell tumor in the distal tibia. At long-term followup, the patients had no pain and no limitation in daily or low-impact recreational activities. In conclusion, due to the large resection that is often necessary for aggressive tumors, fibular autograft and ankle arthrodesis may be a useful method in the distal tibia.

Post talus neck fracture reconstruction

Talar neck fractures are interesting fractures that require careful ORIF if the patient factors allow. The long-term sequelae of these fractures can be severe regardless of the quality of the reconstruction. Posttraumatic arthritis and avascular necrosis are devastating complications that are unfortunately common. Malunion and nonunion of talar neck fractures need to be evaluated carefully with attention to adjacent joints. A full workup is needed to fully evaluate the patient and fracture factors. If the patient has failed nonoperative treatment then reconstruction or salvage is considered. Reconstruction of ununited and malunited talar neck fractures can be successful if the patient is well selected. Corrective fusion is a viable alternative for those patients who have posttraumatic arthritis. Combined ankle replacement and subtalar fusion remains another motion-conserving procedure.

Use of talectomy in modern foot and ankle surgery

Talectomy is a procedure that is undertaken rarely in modern orthopedic surgery; however, it has been performed for many years. Talectomy has been used most commonly in pediatric orthopedics with some degree of success in severe clubfoot deformity, arthrogryposis multiplex congenita, myelomeningocele, tuberculosis, and tumors. In adults, talectomy has been used in salvage procedures that involve nonunion of ankle fusions, failed total ankle arthroplasty, inflammatory arthropathy, neuroarthropathy, failed talar prostheses, failed pantalar fusions, adult neglected clubfoot, posttraumatic avascular necrosis talus, and deformities that are due to sciatic nerve palsy and compartment syndrome. This article consider what place talectomy has in modern adult foot and ankle surgery.

Avascular necrosis of the talus: current treatment options

AVN of the talus is a challenging disease process with respect to patho-physiology and treatment. We believe that our algorithm is a legitimate approach to aid the orthopedic surgeon in initiating a promising treatment. It is divided into different levels and allows to change between some. This is not the only way to proceed but it seems promising, especially if the long-term results with the vascularized bone grafts show revascularization of the talus. As always in medicine, the treatment needs to be individualized. Arthrodesis always should be the last option and is a challenging procedure.

Functional outcome after modified Blair tibiotalar arthrodesis for talar osteonecrosis

BACKGROUND

Osteonecrosis of the talar body is a challenging problem for both patient and surgeon. One reconstruction option is an arthrodesis of the tibia to the talar neck, as described by Blair, which has the theoretical advantages of salvaging some hindfoot height and motion of the subtalar joint. A few case series have been published describing outcome after modified Blair fusions, none with validated functional outcomes. The purpose of this article is to describe a modification of Blair's original technique, and report the functional outcomes in a series of patients undergoing this procedure.

METHOD

A retrospective review of seven patients with talar osteonecrosis undergoing modified Blair tibiotalar arthrodesis was performed. The median patient age was 51 (range, 39-78). Median follow-up was 20 months (range, 12-112). Two patients required a repeat procedure for delayed/nonunion, with subsequent uneventful union. In all patients the procedure included compression screw fixation of the talar head to the anterior distal tibia, with the two repeat procedures and the most recent patient having an additional anterior compression plate and bone graft. Functional outcome measures using both the AOFAS ankle-hindfoot score and the SF-36 global health outcome measure were obtained at latest follow-up. In addition, radiographic assessment of bone union and time to union was determined.

RESULTS

Median SF-36 physical and mental component scores were 46 and 61, respectively. The median AOFAS ankle-hindfoot score was 67 out of 100. Median visual analog scales for postoperative pain and function were 7.1 and 6.0 respectively, out of a best possible score of 10.

CONCLUSION

Functional outcome scores after modified Blair arthrodesis are lower than similar scores after conventional tibiotalar fusion, and much lower than "normal" values; however, the procedure has similar, if not lower, complication rates to alternative complex hindfoot reconstructions, and this procedure is a valuable alternative in the management of talar osteonecrosis with arthrosis.

Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature

Fractures of the head, neck, and body of the talus present difficult treatment challenges. The vulnerable blood supply and abundant articular surfaces may lead to long-term problems with osteonecrosis and osteoarthrosis. Previous studies of these relatively rare injuries have been mostly small, inconsistent, or anecdotal, leading to confusion and controversy regarding the optimum treatment of various types of talus fractures. The surgeon who treats these injuries must be prepared to address meticulous reduction and fixation, maintain attentive follow-up, and manage the complications that may result despite appropriate treatment. This review summarizes the findings of the literature on each type of talus fracture to provide a clearer picture of their recommended management.

Revision ankle fusion using internal compression arthrodesis with screw fixation

We reviewed 20 revision ankle fusions performed using internal compression arthrodesis with screw fixation. Clinical, functional, and radiographic results were measured at an average follow-up of 30 months (range, 12-50 months). The reasons for the index procedures were nonunion in 11, malunion in 7, infected nonunion in 1, and nonunion associated with avascular necrosis of the talus in 1 case. Fusion occurred in 15 of 20 patients. Two additional patients obtained fusion after subsequent procedures, for a final union rate of 85%. The average time to fusion was 6 months (range, 2-32 months). Nineteen additional operations were necessary in 12 patients, including three amputations for chronic infection (two infected nonunions and one chronic osteomyelitis). All but one patient had a plantigrade limb at follow-up. Seventeen of 20 patients were satisfied with their ultimate outcome, including all three patients with amputations. The three dissatisfied patients were bothered by chronic pain. Revision ankle fusion for nonunion or malunion using internal compression arthrodesis with screw fixation is beneficial for most patients. It is a technically demanding procedure that is associated with a high complication rate. Many patients can be expected to have residual pain. We emphasize the need for accurate alignment and early, aggressive treatment of infectious complications. Amputation should be considered a viable option to improve functional outcome in patients with solid, well-aligned fusions who are disabled by severe chronic pain.

Tibiotalocalcaneal arthrodesis with an intramedullary device

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.

Ankle arthroplasty by excision of the talar body: subtotal talectomy

We carried out the ankle arthroplasty by excision of the talar body (subtotal talectomy) on 10 ankles of nine patients with talar body tumor, paralytic talipes equinovarus, talipes varus due to spinal injury, or comminuted fracture of the talar body. Talar body excision was initiated by lateral incision and subsequent osteotomy of the fibula. The fibula was everted, leaving the lateral ligament (calcaneofibular ligament) intact. After the talus was exposed, the talar body was excised, leaving about 1.5 cm of head unresected. Subsequently, the fibula was shortened slightly, and the tibia was pulled down to the level of the calcaneus to form a joint, instead of arthrodesis being performed. After surgery, the joint formed by the tibia and calcaneus was mobile in seven of the 10 feet and immobile (arthrodesis) in the remaining three feet. The average follow-up period was 6 years. Although postoperative x-ray revealed slight osteoarthritic changes of Chopart's joint and the tibiocalcaneal joint, none of the patients showed ankle pain that impaired activities of daily living. Subtotal talectomy allows correction of talipes equinus without Achilles tendon lengthening.

Talar neck fractures

Talar neck fractures represent a serious injury, and a review of the literature reveals the controversies surrounding the treatment options. In spite of the differences, there are many aspects of management where little disagreement exists. Anatomic reduction is the goal in situations where a primary salvage procedure is not performed. If closed treatment is chosen, careful follow-up is necessary to prevent unrecognized displacement as swelling subsides in the cast. Weight-bearing should be delayed until radiographic signs of fracture healing are obvious. There is a growing tendency toward open reduction and internal stabilization of talar neck fractures. Results suggest improved maintenance of reduction, decreased time to union, and a better end result. Prior to attempting any type of salvage procedure, careful assessment of both the tibiotalar and subtalar complex is necessary. The incidence of poor results following a talar neck fracture is disappointingly high. Additional studies of the pathoanatomy and biomechanics may improve our understanding. Controlled prospective clinical series will help clarify the advantages of specific treatment approaches and lead to better clinical results.

Ankle arthrodesis: a long-term study

Few studies of ankle arthrodesis have assessed tarsal mobility. This study was performed to evaluate radiographically the effect of ankle arthrodesis on tarsal motion. Thirty patients (31 ankles) returned for clinical and radiographic examination, review of charts, and completion of questionnaire forms. Radiographs were evaluated for success of fusion, position of fusion, tarsal motion, hindfoot position, and subtalar and midtarsal arthritis. The median follow-up time was 7.0 years (range 2-20 years). Results showed that fusion was achieved in 22 patients (71%). The evaluation score based on the grading system of Mazur et al. correlated with success of fusion and patient satisfaction. However, no correlation existed between evaluation score and tarsal motion or position of fusion in the sagittal or coronal planes. Radiographic evaluation showed no significant difference between tarsal motion of the fused side and the unfused side. Tarsal mobility was not affected by ankle arthrodesis or by the techniques performed to achieve fusion.