Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review

Total Ankle Arthroplasty in Young Patients

With continuing advancements in total ankle arthroplasty (TAA), it is quickly becoming the procedure of choice for older patients with end-stage ankle arthritis. Multiple studies have been conducted on younger patients who have undergone TAA with promising results, but is it the procedure of choice? Considerations of TAA versus ankle arthrodesis, TAA implant longevity, outcomes of revision TAA, and whether patients should be offered an arthrodesis with plans for conversion to arthroplasty may help elucidate whether pursuing ankle arthroplasty in a younger, more active population is the correct approach for surgeons.

Outcomes of Conversion of Ankle Fusion to Total Ankle Arthroplasty

With ankle replacements gaining popularity and documented good functional outcomes, there is an increasing number of patients inquiring about the possibility of converting an ankle fusion to a replacement. This could be due to pain, limited function, or increasing adjacent joint arthritis. There is an increasing body of evidence in the literature that a conversion to a replacement is possible and that the outcomes are positive. There are also absolute contradictions for a conversion. An absent fibula, pain of unknown origin, and recent infection fall in this category. Long-term follow-up is needed to see if conversions of ankle fusions to replacements have the same functional results and longevity as primary replacements.

Tibiotalocalcaneal and Tibiotalar Arthrodesis for Severe Cavovarus Deformity: Tips and Tricks

Cavovarus foot is a complex 3-dimensional deformity. Clinical history, physical examination, and comorbidity assessment are essential for preoperative evaluation. In severe cases, ankle or tibiotalocalcaneal arthrodesis can provide symptomatic relief and result in a plantigrade foot. This article emphasizes the importance of weight-bearing computed tomography for surgical planning and presents the authors' preferred technique for tibiotalocalcaneal, which includes a novel curved anterolateral incision, partial fibular onlay bridging graft, and patient-specific instrumentation for forefoot deformity correction. The tips and tricks aim to assist surgeons in better treating these challenging patients while optimizing preoperative planning.

Talocrural Arthrodesis Increases Osteoarthritis Severity in Adjacent Joints: A Midterm Computed Tomography Follow-Up Study

BACKGROUND

After talocrural arthrodesis, adjacent joints (subtalar, talonavicular, and calcaneocuboid) are often affected by osteoarthritis (OA)). It is unclear if OA is pre-existing to talocrural arthrodesis, or whether it develops after talocrural arthrodesis. This retrospective study is unique because it is the first study with preoperative and follow-up computed tomography (CT). The aim of this study is to investigate whether OA develops in adjacent joints after talocrural arthrodesis or if OA is already pre-existing. In addition, associations between degree of OA and patient-reported outcomes are investigated.

METHODS

Patients were selected from electronic files, and adjacent joint OA was assessed on preoperative CT and bilateral follow-up CT. Patient-reported outcomes were collected.

RESULTS

Twenty-three patients were included with an average follow-up time of 7 years (SD = 2). In participants without pre-existing OA, OA significantly progressed in all adjacent joints. In participants with pre-existing OA, OA progressed in the subtalar joint. Patient-reported outcomes were not correlated to OA.

CONCLUSIONS

Osteoarthritis in the adjacent joints progresses after talocrural arthrodesis, especially in participants without pre-existing OA. The severity of OA is not related to patient-reported outcomes. Therefore, the clinical impact of the progression of OA seems to be limited.

LEVEL OF EVIDENCE

Level III: retrospective.

Arthroscopic ankle arthrodesis in two alkaptonuria patients

Alkaptonuria is a very rare disorder in which homogentisic acid accumulates due to a deficiency in the activity of homogentisic acid 1,2 dioxygenase. This deficiency results in deposition of a yellowish-brown pigment in connective tissue. Such deposition is termed 'ochronosis' and leads to deterioration in the formation and structure of proteoglycans in hyaline cartilage. These actions lead to fragmentation and rapid destructive arthritis. Often, ochronotic arthritis appears at 40-60 years of age, and many patients are treated symptomatically. Here, we report two patients (three ankles) with ochronotic arthritis who were treated with ankle arthrodesis. In all cases, the postoperative clinical score improved, but the time needed for fusion was prolonged and symptomatic subtalar arthropathy developed in the early postoperative period.

Management of Talar Avascular Necrosis with Total Talus

Avascular necrosis (AVN) of the talus is a difficult pathology to treat. Patient-specific factors such as functional status, comorbidities should be considered. Previous standard care for talar AVN was centered around arthrodesis procedures and loss of motion about the joints of the rearfoot and ankle. With the advent of 3D printed talar implants, patients are afforded an option to maintain ankle joint motion. Literature is limited due to the recent development of total talus replacement (TTR) technology. This article aims to review literature, surgical techniques, and pearls to better help foot and ankle surgeons treat cases of talar AVN.

Subtalar Arthrodesis in Patients With Prior Tibiotalar Arthrodesis for Posttraumatic Osteoarthritis

BACKGROUND

The tibiotalar arthrodesis for end-stage ankle osteoarthritis is a surgical procedure that leads to a modification of the kinematics of the adjacent joints and may result in the development of secondary osteoarthritic degeneration of the subtalar joint. It has previously been observed that subtalar arthrodesis in this context shows a lower fusion rate than isolated subtalar arthrodesis. This retrospective study reports the results of subtalar joint arthrodesis with previous ipsilateral tibiotalar arthrodesis and suggests some factors that may compromise the fusion of the joint.

METHODS

Between September 2010 and October 2021, 15 arthrodeses of the subtalar joint with screw fixation were performed in 14 patients, with a fusion of the ipsilateral tibiotalar joint. Fourteen of 15 cases used an open sinus tarsi approach, 13 were augmented with iliac crest bone graft, and 11 had supplemental demineralized bone matrix (DBM). The outcome variables were fusion rate, time to fusion, and revision rate. Fusion was assessed by radiographs and computed tomography scan.

RESULTS

Twelve of the 15 subtalar arthrodeses (80%) fused at the first attempt with an average fusion time of 4.7 months.

CONCLUSION

In this limited retrospective case series, compared to the fusion rate of isolated subtalar arthrodesis reported in the literature, the rate of subtalar fusion in the presence of an ipsilateral tibiotalar arthrodesis was found to be lower.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Total Talar Prosthesis, Learning from Experience, Two Reports of Total Talar Prosthesis after Talar Extrusion and Literature Review

Recently, total talar prosthesis has been proposed to substitute the talus during the management of complex talar lesions such as talar extrusion, comminuted talar fractures, or avascular necrosis. Herein, we report two cases of talar extrusion treated with total talar replacement after a high-intensity trauma. Both cases subsequently required revision surgery due to degenerative changes of the tibial plafond (arthrodesis in the first case, conversion to a total ankle prosthesis in the latter). We report and analyze the literature concerning total talar replacement to discuss strategies that could help improve prosthesis survival and reduce the incidence of osteoarthritis.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA.

METHODS

All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors.

RESULTS

The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively.

CONCLUSION

As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Ankle Arthrodesis: Indications, Outcomes, and Patient Satisfaction

Background

Osteoarthritis of the ankle, which has a prevalence of 3.4% in the general population and affects 70% of candidates post-traumatically, is less common than hip or knee arthritis. Despite the recent progress in ankle arthroplasty surgery, ankle arthrodesis is still considered the gold-standard treatment for severe osteoarthritis of the ankle joint and can achieve impressive improvements in pain and function in the majority of patients. Our objective is to assess the clinical and functional outcomes of ankle arthrodesis, postoperative complications, and patient satisfaction.

Methodology

This was a descriptive cross-sectional study that took place at Future Hospital in Khartoum, Sudan, from July 2015 to July 2022. Our institute performed 102 ankle fusion surgeries; 14 patients were excluded from the study because they did not show up for their follow-up visit, meaning 88 candidates were included. Two cannulated screws (6.5 mm) were used for ankle fixation in all patients. The outcome was assessed two years after surgery. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to assess ankle function before surgery and two years after the procedure. Postoperative complications and patient satisfaction were reported. The primary researcher collected data through direct interviews.

Result

The mean age of the study participants was 52.2 years, with 36.4% being between 40 and 50 years of age. The study consisted of 43 women and 45 men. The male-to-female ratio was almost 1:1. In 56.8% of candidates, the right ankle was involved. The overall rate of complications was 11.4%. Concerning patient satisfaction, 75% of the patients were fully satisfied. Moreover, significant correlations were found between the mean postoperative AOFAS score and age group, diabetes mellitus, complications, and patient satisfaction.

Conclusion

Ankle arthrodesis was demonstrated to be an excellent surgical method for reducing pain and enhancing ankle joint function. The most frequent complications were delayed wound healing, infection, and non-union. The functional outcome and patient satisfaction of this procedure were statistically high; patients with a higher functional score had higher levels of satisfaction. In contrast, diabetic and elderly patients had higher rates of complications.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Biomechanics and Tribology of Total Ankle Replacement

This article discusses the biomechanics and tribology of total ankle replacements considering the influence of implant design and generation on functional outcome, before discussing the interplay between biomechanics and tribology in the clinical success of total ankle replacement. It reflects on what we know and highlights areas for further research, as well as identifying factors to consider in clinical practice.

Subjective and Objective Outcomes of Ankle Joint Arthrodesis with Either Ilizarov or Internal Fixation

After arthroplasty, arthrodesis of the ankle joint is the most common method to treat advanced ankle osteoarthritis. The goal of the study was to assess the subjective and objective outcomes in 2 different types of fixation for ankle joint arthrodesis. We retrospectively assessed 47 patients who had undergone ankle joint arthrodesis with fixation either via an Ilizarov apparatus (group 1) (n = 21) or cannulated screws (group 2) (n = 26). The outcomes were measured by: (1) the quantity of analgesics administered, (2) the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) general patient satisfaction, (4) the patients' decision to undergo the same procedure given another chance, and (5) the necessity of blood transfusion during hospitalization. Data was collected at the last postoperative follow-up visit. The AOFAS scores in group 1 and group 2 patients were 73.9   ± 13 and 72.7  ±  14.3, respectively. In group 1, 17 patients (81%) were very satisfied with the results, while in group 2, 19 patients (73%) were very satisfied with the results (p = .043). Two group 1 patients (10%) and four group 2 patients (15.3%) reported that they were satisfied with the outcomes (p = .035). Two patients (10%) from group 1 and three patients (11%) from group 2 were fairly satisfied. Seventeen patients (81%) after arthrodesis with Ilizarov fixation and 21 patients (81%) after arthrodesis with internal fixation would choose the same procedure given the opportunity to choose again. In group 1 there were no patients who required blood transfusion; in group 2 one patient (4%) required blood transfusion; the difference was statistically significant (p = .039). Nineteen group 1 patients (90%) were administered an analgesic preoperatively, while postoperatively only 6 (29%) required analgesics. In group 2, 24 patients (92%) were administered analgesics preoperatively, with 8 (31%) of them still requiring analgesics postoperatively. Ankle arthrodesis patients from both group 1 and group 2 achieved good subjective and objective results of treatment. We noted slightly better results in the Ilizarov apparatus group.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

The Impact of Concomitant Ipsilateral Knee Pain on Functional Outcomes in Total Ankle Arthroplasty

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival.Levels of Evidence: Level III.

Ankle and Tibiotalocalcaneal Fusion

Arthrodesis of the ankle and/or tibiotalocalcaneal joints is a reliable treatment of arthritic conditions of the ankle and hindfoot. It may be complicated by infection, nonunion, malunion, fracture, wound complications, nerve injury, and adjacent joint degeneration. These complications may be addressed with a variety of techniques but should be done so carefully so as not to lead to more complex problems. A thorough work-up and discussion should take place prior to any surgical intervention and treatment. Several cases are presented to illustrate revision arthrodesis techniques and the management of these complications.

Midterm Survivorship of the INBONE II Total Ankle Arthroplasty

BACKGROUND

The use of total ankle arthroplasty (TAA) in the treatment of ankle arthritis has grown substantially as advancements are made in design and surgical technique. Among the criteria guiding the choice between arthroplasty and arthrodesis, the long-term survival and postoperative outcomes are of crucial importance. Although outcomes of the INBONE I have been published, there is limited midterm survival data for the INBONE II. The purpose of this study was to determine the radiographic and patient-reported outcomes, and survivorship of this prosthesis in patients with a minimum 5-year follow-up.

METHODS

We retrospectively identified 51 ankles (46 patients) from 2010 to 2015 who underwent TAA with the INBONE II prosthesis at our institution. Of these, 44 cases had minimum clinical follow-up of 5 years (mean, 6.4; range 5-9). Median age was 66 years (range 42-81) and median BMI was 27.5 (range 20.1-33.0). A chart review was performed to record the incidence of revision and reoperation. Preoperative and postoperative radiographs were analyzed to assess the coronal tibiotalar alignment (TTA), the talar inclination angle, and the presence of periprosthetic lucencies and cyst formation. Preoperative and minimum 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscales were compared. Survivorship was determined by incidence of revision, defined as removal of a metallic component.

RESULTS

The survivorship at 5 years was 98% and the rate of reoperation was 7.8% (n = 4); 2 patients underwent irrigation and debridement for infection, 1 patient underwent a medializing calcaneal osteotomy, and 1 patient underwent open gutter debridement, 1 patient underwent a revision of a subsided talar component at 3.2 years after index surgery. Average postoperative TTA was 88.6 degrees, with 42 rated as neutral (85-95 degrees), 2 varus (<85 degrees), and no valgus (>95 degrees) ankles. At final follow-up, asymptomatic periprosthetic cysts were observed in 8 patients. All FAOS domain scores improved between preoperative and final follow-up.

CONCLUSION

At midterm follow-up, we observed significant improvement in radiographic alignment and patient-reported outcome scores for the INBONE II total ankle prosthesis. In addition, this cohort has had a relatively low reoperation rate and high survivorship.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Ankle Arthrodesis

End-stage ankle arthritis typically affects an active younger patient population as compared with hip and knee arthritis. The optimal surgical treatment depends on several patient-specific factors. Open ankle arthrodesis has achieved reliable outcomes for this condition over years; however, arthroscopic techniques seem to be advantageous and feasible even in cases with significant intraarticular deformity. This article describes the surgical technique of arthroscopic ankle arthrodesis and discusses the outcome compared with that of open ankle fusion and total ankle replacement.

Deciding Between Ankle and Tibiotalocalcaneal Arthrodesis for Isolated Ankle Arthritis

After isolated ankle (tibiotalar) arthrodesis, the triceps progressively shifts the subtalar joint into varus thus blocking compensatory motion from the midtarsal joints. In a tibiotalocalcaneal arthrodesis, the subtalar may be fixed with the correct valgus. Comparison between ankle and tibiotalocalcaneal arthrodesis does not clearly favor one over another for pain relief, satisfaction, and gait analysis. Compensatory sagittal plane motion through the midtarsal joints when the subtalar is fixed in valgus may be responsible for these results. Tibiotalocalcaneal arthrodesis has become our procedure of choice over isolated tibiotalar for end-stage ankle arthritis regardless of the radiographic state of the subtalar.

[Arthrodesis vs. prosthesis for end-stage osteoarthritis of the ankle joint : A scientific argument]

The gold standard in operative treatment of end-stage ankle osteoarthritis remains controversial even now. Endoprosthetic treatment, which has undergone significant improvements in recent years competes with arthrodesis, which can achieve excellent results particularly in the arthroscopically assisted technique. Both procedures offer specific advantages and disadvantages so that the decision about indications for treatment should always be made individually, taking specific needs and the individual constellation of findings of the patient into consideration.

High Reoperation Rate in Mobile-Bearing Total Ankle Arthroplasty in Young Patients

Background and Objectives: Due to inferior survival rates compared to hip and knee arthroplasty, total ankle arthroplasty (TAA) was previously mainly recommended for older and less active patients. However, given the encouraging survival rates and clinical outcomes of modern generations of TAA, some authors have also advocated TAA in young patients. Thus, the aim of this study was to evaluate age related reoperation, revision and survival rates of third-generation mobile-bearing TAAs. Materials andMethods: In this retrospective study, 224 consecutive TAA patients with a minimum follow up (FU) of 2 years were analyzed. Patients were retrospectively assigned to two study groups (Group A: age < 50 years; Group B: age ≥ 50 years). Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle. Results: After a mean FU of 7.1 ± 3.2 years, the reoperation rate (Group A: 22.2%; Group B: 5.3%; p = 0.003) and revision rate (Group A: 36.1%; Group B: 13.8%; p = 0.003) were higher within Group A. An age of under 50 years at time of surgery was associated with higher reoperation (odds ratio (OR): 6.54 (95% CI: 1.96–21.8); p = 0.002) and revision rates (OR: 3.13 (95% CI: 1.22–8.04); p = 0.018). Overall, lower patient age was associated with higher reoperation (p = 0.009) and revision rates (p = 0.001). Conclusions: The ideal indication for TAA remains controversial, especially regarding patient age. The findings of this study show high reoperation and revision rates in patients aged under 50 years at time of surgery. Therefore, the outcomes of this study suggest that the indication for TAA in young patients should be considered very carefully and that the association between low patient age and high reoperation rate should be disclosed to all eligible patients.

Ankle joint salvage and reconstruction by limited ORIF combined with an Ilizarov external fixator for complex open tibial pilon fractures (AO 43-C3.3) with segmental bone defects

Background

Open pilon fractures combined with sizeable segmental bone defects are rare, difficult to treat, and often result in the loss of ankle joint function. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures and sizeable segmental bone defects treated by limited ORIF combined with an Ilizarov external fixator.

Methods

We conducted a retrospective analysis of open pilon fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy between July 2014 and August 2019. All patients were included for assessments of fracture healing and infection rates. Ankle functional outcomes were assessed in all patients according to the Paley criteria and American Orthopedic Foot and Ankle Society Score (AOFAS) at least 24 months post-injury.

Results

All patients were followed up for a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. According to the Paley evaluation system, the success rate of ankle joint reconstruction was 64% (7/11). The mean score based on the AOFAS functional assessment was 77.73 ± 8.87. Five patients showed posttraumatic arthritis, one of whom required ankle arthrodesis. Three patients developed pin site infections, and one patient developed a deep infection after bone grafting.

Conclusion

The strategy of limited ORIF combined with an Ilizarov external fixator can restore ankle function in most patients with complex open tibial pilon fractures. Ankle stiffness, pin tract infection, and traumatic arthritis were the most common complications associated with this therapy.

Calcaneal Reconstruction With Free Deep Circumflex Iliac Artery Osseocutaneous Flap Following Aggressive Benign Bone Tumor Resection

BACKGROUND

Advances in limb-salvage techniques have made total calcanectomy and primary reconstruction possible in managing calcaneal aggressive benign tumors and selected cases of intraosseous malignant tumors. However, there is still no consensus on the operative approach, oncologic margin, and the best reconstruction method to date. These 2 cases describe our experience in calcaneal reconstruction with the free deep circumflex iliac artery (DCIA) osseocutaneous flap in benign aggressive calcaneal tumors.

METHODS

We reported 2 consecutive male and female patients, with an average age of 25 years (age 19 and 31, respectively), who underwent total calcanectomy and primary calcaneal reconstruction with the free DCIA osseocutaneous flaps for calcaneal chondroblastoma and giant cell tumor. A marginal resection of the entire calcaneus through the subtalar and calcaneocuboid joints (intra-articular approach) was performed in the first case and a wide local resection leaving 1 cm normal calcaneal bone margin anterosuperiorly (intraosseous approach) was performed in the second case.

RESULTS

The follow-up period averaged 48 months. Negative oncologic margins were achieved in both cases. The first case was complicated with venous thrombosis; however, the graft remained viable after emergency reexploration. Normal foot function was restored with good solid osseous union and bony hypertrophy observed. Both patients achieved good short-term functional and aesthetic outcomes with no donor site pain or disability. No local recurrence was reported either.

CONCLUSION

Primary calcaneal reconstruction with the free DCIA osseocutaneous flap can lead to good short-term functional and aesthetic outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

INTRODUCTION

Traumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.

PATIENTS AND METHODS

The subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.

RESULTS

The 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.

CONCLUSION

Intra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

Distal tibial oblique osteotomy for reconstruction of ankle joint congruity and stability

Teramoto distal tibial oblique osteotomy (DTOO) is a joint-preserving surgery for ankle osteoarthritis (AOA). However, there are few articles on the radiological assessment of DTOO. The purpose of this study was to report the clinical outcomes and radiological evaluations of weight-bearing radiographs before and after DTOO. We retrospectively reviewed 52 patients who underwent DTOO between 2007 and 2018. We recorded the Tanaka-Takakura classification, fixation methods, Japanese Society for Surgery of the Foot Ankle/Hindfoot Scale (JSSF scale), and complications. The tibial articular surface angle (TAS), medial malleolar angle (MMA), tibial lateral surface angle (TLS), talar tilt angle (TTA), and tibiotalar surface angle (TTS) were evaluated using weight-bearing ankle radiographs. The median patient age was 66 years, and the mean follow-up duration was 46 ± 23 months. Two stage 2, 9 stage 3a, 30 stage 3b, and 11 stage 4 according to the Tanaka-Takakura classification were performed using DTOO. The JSSF scale improved significantly from 39.9 ± 13.8 before surgery to 87.2 ± 7.5 after surgery. Seven cases were fixed using a locking plate, and 45 cases were fixed using a circular external fixator. The TAS, MMA, TLS, TTA, and TTS significantly changed before and after DTOO. Radiological evaluation indicated that DTOO influences talar behavior during weight-bearing, and improves the clinical outcomes of AOA.

A mouse model of ankle-subtalar joint complex instability induced post-traumatic osteoarthritis

BACKGROUND

Ankle-subtalar joint complex instability is not uncommonly presented in the clinic, but symptoms and signs similar to other conditions can easily lead to its misdiagnosis. Due to the lack of appropriate animal models, research on ankle-subtalar joint complex instability is limited. The aims of the present study were to establish an animal model of ankle-subtalar joint complex instability in mice and to explore its relationship with post-traumatic osteoarthritis (PTOA).

METHODS

Twenty-one male C57BL/6J mice were randomly divided into three groups: SHAM group (sham surgery group), transected cervical ligament + anterior talofibular ligament (CL+ATFL) group, and transected cervical ligament + deltoid ligament (CL+DL) group. Two weeks after surgery, all mice underwent cage running training. Balance beam and gait tests were used to evaluate the changes in self-movement in the mice after ankle-subtalar ligament injury. Micro-CT and histological staining were used to evaluate the progress of PTOA.

RESULTS

Compared with the SHAM group, balance and gait were affected in the ligament transection group. Twelve weeks after surgery, the time required to cross the balance beam in the CL+ATFL group was 35.1% longer and the mice slipped 3.6-fold more often than before surgery, and the mean step length on the right side was 7.2% smaller than that in the SHAM group. The time required to cross the balance beam in the CL+DL group was 32.1% longer and the mice slipped 3-fold more often than prior to surgery, and the average step length on the right side was 5.6% smaller than that in the SHAM group. CT images indicated that 28.6% of the mice in the CL+DL group displayed dislocation of the talus. Tissue staining suggested that articular cartilage degeneration occurred in mice with ligament transection 12 weeks after surgery.

CONCLUSIONS

Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. In addition, as time progressed, the articular cartilage displayed degenerative changes, which affected the ability of animals to move normally.

Midfoot Function Before and After Total Ankle Arthroplasty

BACKGROUND

Information regarding the effect of total ankle arthroplasty (TAA) on midfoot function is extremely limited. The purpose of this study was to characterize midfoot region motion and power during walking in people before and after TAA.

METHODS

This was a prospective cohort study of 19 patients with end-stage ankle arthritis who received a TAA and 19 healthy control group participants. A motion capture and force plate system was used to record sagittal and transverse plane first metatarsal and lateral forefoot with respect to hindfoot motion, as well as sagittal plane midfoot region positive and negative peak power during walking. Parametric or nonparametric tests to examine differences and equivalence across time were conducted. Comparisons to examine differences between postoperative TAA group and control group foot function were also performed.

RESULTS

Involved-limb midfoot function was not different between the preoperative and 6-month postoperative time point in the TAA group (all P ≥ .17). Equivalence testing revealed similarity in all midfoot function variables across time (all P < .05). Decreased first metatarsal and lateral forefoot motion, as well as positive peak power generation, were noted in the TAA group postoperative involved limb in comparison to the control group (all P ≤ .01).

CONCLUSION

The similarity of midfoot function across time, along with differences in midfoot function in comparison to controls, suggests that TAA does not change midfoot deficits by 6 months postoperation.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Application of Negative Pressure Wound Therapy in Total Ankle Replacement

The efficacy and safety of incisional negative pressure wound therapy (iNPWT) was evaluated following total ankle replacement. A retrospective cohort study was conducted in patients who underwent total ankle replacement between January 2010 and June 2018. Following joint replacement, the patients received iNPWT (iNPWT group) or sterile dressings (Control group). Infection rate, wound complication incidence, length of stay, visual analogue scale, American Orthopedic Foot and Ankle Society, and short-form 36 scales, and ankle range of motion were assessed 1 week, 2 weeks, 1 month, 3 months, 6 months, and 12 months postoperatively. Thirty-four patients (n = 13 iNPWT and n = 21 Control) were included. No significant differences were found in baseline data. During follow-up, one Control patient developed a superficial infection at the incision. Wound complications developed in 4 Control patients and 1 iNPWT patient; although this was not statistically significant. Length of stay was similar between the 2 groups. Two weeks after surgery, the range of visual analogue scale (2.1 vs 1.4), American Orthopedic Foot and Ankle Society (13.7 vs 9.7), and short-form 36 scale (9.0 vs 6.5) improvement, and increase of ankle range of motion (9.2 vs 6.1) was significantly larger in the study group than in the control group (p < .05). Three months to 1 year after the surgery, this difference was no longer statistically significant. The application of iNPWT following total ankle arthroplasty helped reduce postoperative pain, improve ankle function, and improve patient quality of life. However, these benefits were no longer statistically significant 3 months to 1 year after surgery.

Assessment of Lower Limb Load Distribution in Patients Treated with the Ilizarov Method for Tibial Nonunion

Background

Successful treatment of tibial nonunion should lead to a complete bone union, lack of pain, and pathological mobility of the lower extremity, as well as to the achievement of satisfactory joint mobility and muscle strength, which in turn improves its biomechanics. The objective of this study was to assess the load placed on the lower limbs in patients subjected to treatment with the Ilizarov method due to aseptic tibial nonunion.

Material/Methods

This research involved 24 participants (average age, 55 years). All were diagnosed with aseptic tibia nonunion and treated with the Ilizarov external fixator between 2000 and 2017. The control group was matched to the treated group in terms of sex and age. This study used pedobarography evaluation to assess lower limb load distribution.

Results

No differences were found in the distribution of the load over the entire foot or of the forefoot and hindfoot of the treated limb in comparison to the non-dominant limb of the controls, or in the healthy limb of the treated group compared to the dominant limb of the control group. Similarly, differences in load distribution between the operated and healthy limbs of the treated group were insignificant.

Conclusions

Patients subjected to treatment with the Ilizarov external fixator for aseptic tibial nonunion show symmetrical load distribution on both lower limbs following treatment, which does not differentiate them in this respect from healthy individuals. Treated patients presented with a symmetrical distribution of the load on the lower extremities over the entire foot surface, including the forefoot and hindfoot. Finally, the Ilizarov external fixator enables restoration of correct static biomechanics of the treated limbs over the period of aseptic tibial nonunion therapy.

Takedown of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: A Case Series of 77 Patients

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years: A Prospective, 3-Dimensional Gait Analysis

BACKGROUND

In vivo gait analysis provides objective measurement of patient function and can quantify that function before and after ankle reconstruction. Previous gait studies have shown functional improvement for up to 4 years following total ankle arthroplasty (TAA), but to date, there are no published studies assessing function at ≥5 years following TAA. We hypothesized that patients who underwent TAA would show significant improvements in walking function at a minimum follow-up of 5 years, compared with their preoperative function, as measured by changes in temporospatial, kinematic, and kinetic gait parameters.

METHODS

Three-dimensional gait analysis with a 12-camera digital motion-capture system and double force plates was utilized to record temporospatial, kinematic, and kinetic measures in 33 patients who underwent TAA with either the Scandinavian Total Ankle Replacement (Stryker; n = 28) or Salto Talaris Ankle (Integra LifeSciences; n = 5). Gait analysis was performed preoperatively and at a minimum follow-up of 5 years (mean, 7.6 years; range, 5 to 13 years).

RESULTS

Significant improvements were observed in multiple gait parameters, with temporospatial increases in cadence (+9.5 steps/min; p < 0.0001), step length (+4.4 cm; p = 0.0013), and walking speed (+0.2 m/s; p < 0.0001), and kinematic increases in total sagittal range of motion (+2.0°; p = 0.0263), plantar flexion at initial contact (+2.7°; p = 0.0044), and maximum plantar flexion (+2.0°; p = 0.0488). Kinetic analysis revealed no loss of peak ankle power, despite patients aging.

CONCLUSIONS

To our knowledge, this is the first study to report 7-year functional outcomes of TAA, quantified by objective, in vivo measurements of patient gait. Patients were shown to have sustained improvement in multiple objective parameters of gait compared with preoperative function.

LEVEL OF EVIDENCE

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

Clinical evaluation of arthrodesis with Ilizarov external fixator for the treatment of end-stage ankle osteoarthritis: A retrospective study

To analyze the efficacy of arthrodesis with Ilizarov external fixator for the treatment of end-stage ankle osteoarthritis.This retrospective study included 88 patients with end-stage (stage-3) ankle osteoarthritis according to Morrey-Wiedeman classification who underwent arthrodesis with Ilizarov external fixator from January 2016 to January 2019. There were 47 males and 41 females with a mean age of (57.21 ± 7.12) years old (range 49-76). Outcomes were measured by the American Orthopaedic Foot and Ankle society (AOFAS) Ankle Hindfoot Scale, Visual Analog Scale (VAS) pain scores, complications, subjective satisfaction, ankle function, correction of deformity, and complications.With an average follow-up of (13.50 ± 5.41) months (range 10-21), all 88 patients returned for final follow-up. All patients achieved bony healing with a success rate of 100%. Mean postoperative healing time (3.56 ± 1.04) months (range 3-6). Two patients developed sinus tract infection, delayed healing in 1 patient, and 2 patients had pain and swelling again in the ankle joint. No serious complications occurred in other patients. All the patients evaluated with the VAS scores and AOFAS scores at final follow-up showed significant improvement (P < .05). Through imaging analysis, medical tibial talar angle (MTTA) improved from (85.76 ± 6.01) degrees to (88.98 ± 1.35) degrees postoperative. Lateral talar station (LTS) decreased from (5.32 ± 3.81) mm to (2.71 ± 2.62) mm after operation (P < .05). The overall satisfaction of patients is 88.64%.In the treatment of end-stage ankle osteoarthritis, arthrodesis with Ilizarov external fixator can achieve good radiological and clinical outcomes with low prevalence of ankle joint malalignment and high fusion rates and satisfaction.

Arthroscopic Ankle Arthrodesis Provides Similarly Satisfactory Surgical Outcomes in Ankles With Severe Deformity Compared With Mild Deformity in Elderly Patients

PURPOSE

To evaluate the surgical outcome in terms of radiographic measurements, functional outcomes, and complications following arthroscopic ankle arthrodesis (AAA) in patients 60 years of age or older, and to compare the results of patients with mildly deformed ankle with those of patients with severely deformed ankle.

METHODS

We retrospectively reviewed patients who underwent AAA with 3 cannulated screws between January 2008 and December 2017 and followed postoperatively for at least 24 months. All included patients were 60 years of age or older. Demographic data and radiographic and functional outcomes were compared between patients with coronal deformity of less than 15° (group I) and those with a deformity equal to or greater than 15 degrees (group II).

RESULTS

A total of 41 patients with a mean age of 70.6 years were included (group I, n = 26; group II, n = 15) and mean follow-up was 51.4 months. Group II had significantly more severe preoperative coronal deformity of tibiotalar angle than group I (20.1 ± 2.9 vs 6.6 ± 4.1°, P < .01). Near-normal tibiotalar alignment was achieved postoperatively in both groups (group I, 3.4 ± 3.3 vs group II, 4.7 ± 3.1°, P = .227). Union was achieved in 39 (95.1%) patients with 2 cases in group I experiencing non-union. Union rate, mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and visual analog scale pain scores were not significantly different between the 2 groups at final follow-up.

CONCLUSIONS

AAA is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. In addition, arthroscopic intra-articular malleolar osteotomy was a useful technique for correcting severe coronal deformity in our series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Arthrodesis of the Upper Ankle and Subtalar Joint - Indication and Technique]

Arthrodesis of the upper ankle and subtalar joint are still frequently used and at the moment the gold standard in the therapy of severe arthritis and deformity of the ankle joint and hindfoot. The spectrum of indications is wide, beginning from posttraumatic or degenerative changes to postinfectious, rheumatoid and diabetic causes of arthritis and as a salvage procedure after failed ankle arthroplasty. The types of arthrodesis have to be differentiated from each other: tibiotalar, subtalar and tibiotalcalcaneal fusion. Soft tissue conditions have to be taken into account; these and individual factors like comorbidities and osseous conditions require an individual planning of the approaches and types of fixation.

Open versus arthroscopic ankle arthrodesis: a systematic review and meta-analysis

Background

Osteoarthritis (OA) is a growing health concern that affects approximately 27 million people in the USA and is associated with a $185 billion annual cost burden. Choosing between open surgery and arthroscopic arthrodesis for ankle arthritis is still controversial. This study compared arthroscopic arthrodesis and open surgery by performing a systematic review and meta-analysis.

Methods

For the systematic review, a literature search was conducted in 4 English databases (PubMed, Embase, Medline and the Cochrane Library) from inception to February 2020. Three prospective cohort studies and 7 retrospective cohort studies, enrolling a total of 507 patients with ankle arthritis, were included.

Results

For fusion rate, the pooled data showed a significantly higher rate of fusion during arthroscopic arthrodesis compared with open surgery (odds ratio 0.25, 95% CI 0.11 to 0.57, p = 0.0010). Regarding estimated blood loss, the pooled data showed significantly less blood loss during arthroscopic arthrodesis compared with open surgery (WMD 52.04, 95% CI 14.14 to 89.94, p = 0.007). For tourniquet time, the pooled data showed a shorter tourniquet time during arthroscopic arthrodesis compared with open surgery (WMD 22.68, 95% CI 1.92 to 43.43, p = 0.03). For length of hospital stay, the pooled data showed less hospitalisation time for patients undergoing arthroscopic arthrodesis compared with open surgery (WMD 1.62, 95% CI 0.97 to 2.26, p < 0.00001). The pooled data showed better recovery for the patients who underwent arthroscopic arthrodesis compared with open surgery at 1 year (WMD 14.73, 95% CI 6.66 to 22.80, p = 0.0003).

Conclusion

In conclusion, arthroscopic arthrodesis was associated with a higher fusion rate, smaller estimated blood loss, shorter tourniquet time, and shorter length of hospitalisation than open surgery.

Preliminary Experience With SPECT/CT to Evaluate Periarticular Arthritis Progression and the Relationship With Clinical Outcome Following Ankle Arthrodesis

BACKGROUND

Single photon emission computed tomography combined with computed tomography (SPECT/CT) could potentially aid in diagnosing periarticular arthritis/activity and progression, facilitate effective treatment options, and evaluate the effect surgery has on the clinical outcome of patients with ankle arthritis. The goal of our study was to assess SPECT/CT activity in the ankle and periarticular joints before and after ankle fusion surgery and determine whether it was associated with clinical pain and function scores.

METHODS

Thirty-four patients recruited into this study underwent either arthroscopic or open ankle fusion. X-ray (XR) and SPECT/CT imaging was obtained as well as completion of patient Ankle Osteoarthritis Scale (AOS) and 36-item Short Form Survey (SF-36) questionnaires preoperatively and at 6 months postoperatively. Ankle, subtalar, and talonavicular joint arthritis grading on XR and CT, along with SPECT/CT activity, was evaluated by 2 nuclear medicine radiologists. Data were assessed for normality and analyzed with the appropriate comparative test. P value was set at <.05. Thirty patients (31 ankles) completed follow-up and were analyzed.

RESULTS

SPECT/CT activity showed no significant difference in the ankle joint at 6 months postoperatively while periarticular joint activity significantly increased (P < .05). Six months postoperatively, patients had significant improvements in their AOS and SF-36 scores (P < .05). SPECT/CT grading of all joints analyzed, however, was not associated with AOS or SF-36 scores preoperatively or at 6 months postoperatively.

CONCLUSION

In this study, intensity of activity as evaluated by SPECT/CT in periarticular hindfoot joints in patients who had ankle arthrodesis was not associated with clinical/functional scores at 6 months postoperatively.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Arthroscopic ankle fusion only has a limited advantage over the open operation if osseous operation type is the same: a retrospective comparative study

Background

A great deal of research suggests that arthroscopic ankle fusion (AAF) has advantages over open ankle fusion (OAF), but these outcomes would be imprecise because of a selection bias. The purpose of this study is to verify which is better for ankle fusion, AAF or OAF. We regrouped the OAF group into two subgroups according to whether the osseous operation type is the same as AAF group. The goal is to minimize the impact of disease severity, thereby reducing selection bias to some extent.

Methods

We retrospectively analyzed the data of ankle fusion in our hospital between July 2015 and October 2018. Forty-three patients were enrolled and divided into AAF group (n = 17) and OAF group (n = 26). In order to eliminate selection bias, we divided OAF group into complex osseous operation subgroup (COO subgroup) (n = 15) and simple osseous operation subgroup (SOO subgroup) (n = 11). The osseous operation type of SOO subgroup is the same as AAF group. Then, we compared the differences between these groups. All patients were followed up at least 1 year after operation. We analyzed data, including etiology composition, surgical time, intra-op blood loss, reduction of albumin, total hospital stays, union time, fusion situation, complications, radiological examination, functional score, and questionnaire survey. Then we performed statistical analyses.

Results

We found that the etiological components of AAF group and OAF group were different; the etiological components of AAF group and SOO subgroup were similar. We found that AAF group has advantages over OAF group and COO subgroup in general. However, except in terms of surgical trauma, hospital stays, and short-term complications occurred, the AAF group has not obvious advantages over SOO subgroup, including intra-op blood loss, fusion condition, postoperative function score, and postoperative patient satisfaction; and AAF group need more surgical time than the SOO subgroup.

Conclusions

The arthroscopic ankle fusion can bring a good curative effect; however, if the osseous operation type is the same, the arthroscopic ankle fusion only has a limited advantage over the traditional open operation in perioperative soft tissue protection and enhanced recovery after surgery.

Biomechanical Considerations in Rearfoot Fusions

This article discusses rearfoot fusions for foot and ankle surgeons. It establishes normal foot and ankle function primarily in the stance phase of gait. The foot is greatly affected by external and internal forces, which contribute to normal function or the need for compensatory mechanisms. As a result of compensation, many symptoms develop, often leading to debilitating disorders such as degenerative joint disease. The interaction of the ankle, subtalar, and midtarsal joints are outlined. Congenital deformities, trauma and abnormal compensation are reviewed along with corresponding sequelae. Surgery is often indicated to reduce symptoms, improve position, and help stabilize the foot.

Secondary Subtalar Joint Osteoarthritis Following Total Ankle Replacement

BACKGROUND

An advantage of total ankle replacement (TAR) compared to ankle fusion is that by maintaining motion, the occurrence of hypermobility of adjacent joints may be prevented. This could affect the development of symptomatic subtalar joint osteoarthritis (OA). The aim of the study was to determine the incidence of subtalar joint fusion and the progression of subtalar joint OA following TAR.

METHODS

Secondary subtalar joint fusion rate was determined from a cohort of 941 patients receiving primary TAR between 2000 and 2016. The indication for fusion, the time interval from primary TAR to fusion, and the union rate were evaluated. To assess the progression of subtalar joint OA, degenerative changes of the subtalar joint were classified in 671 patients using the Kellgren-Lawrence score (KLS) prior to TAR and at latest follow-up.

RESULTS

In 4% (37) of the patients, a secondary subtalar joint fusion was necessary. The indication for fusion was symptomatic OA in 51% (19), hindfoot instability in 27% (10), osteonecrosis of the talus in 19% (7), and cystic changes of the talus in 3% (1) of the patients. Time from primary TAR to subtalar joint fusion due to progressive OA was 5.0 (range, 0.3-10) years and for other reasons 1.6 (range, 0.2-11.6) years (P = .3). In 68% (456) of the patients, no progression of subtalar joint OA was observed.

CONCLUSION

The incidence of secondary subtalar joint fusion was low. The most common reason for subtalar joint fusion following TAR was symptomatic OA.

LEVEL OF EVIDENCE

Level IV, case series.

Ankle joint reconstruction by circular frame external fixator for a severely comminuted and contaminated open tibial pilon fracture (AO 43-C3.3). Case report

A severely comminuted and contaminated open tibial pilon fracture is one of the most challenging fractures we face. Although nowadays conducting multiple operations over various stages is a common treatment option taking into account the possibility of soft tissue damage, a gold standard protocol for severe pilon fractures has not yet been established. This case concerns a 56-year-old gentleman who suffered a severely comminuted and contaminated Gustilo 3b open tibial pilon fracture (AO 43C3.3) that was successfully treated using a circular frame external fixator without flap. Two years six months after the injury, there were no indications of any skin conditions at the site of the open wound, the range of ankle motion had been maintained and independent walking was possible. The score under the JSSF (Japanese Society of Surgery of the foot) ankle/hind foot scale was 81. This indicates that use of a circular frame external fixator is a useful treatment method in the event of a severe open pilon fracture where there is a large osteochondral bone defect.

Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation

Background

Ankle arthrodesis may have internal or external stabilization.

We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Methods

We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007–2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Results

Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458).

Conclusions

Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.

Evolution in Management of Tibial Pilon Fractures

PURPOSE OF REVIEW

Tibial plafond, or pilon, fractures can be some of the most difficult fractures to manage. As they are often associated with high-energy trauma, both the soft tissue involvement and the comminuted fracture pattern pose challenges to fixation. Furthermore, the complex anatomy and trauma to the cartilage at the time of injury predispose pilon fractures to poor functional outcomes and high rates of posttraumatic arthritis. This review will discuss the recent developments in the treatment of tibial pilon fractures.

RECENT FINDINGS

Historically, surgical management of pilon fractures has been associated with high rates of complications, including wound complications, infections, nonunions, and even the need for amputation. In response, staged protocols were created. However, recent studies have called this into question, demonstrating low wound complications with early definitive fixation. Additional studies are evaluating adjuvants to minimize wound complications, including the use of vancomycin powder and oxygen supplementation, while another study challenges the 7-cm myth regarding the distance needed between skin incisions. Additional research has been focused on alternative methods of managing these complex, and sometimes non-reconstructable, injuries with the use of external fixation, minimally invasive internal fixation, and primary arthrodesis. Tibial pilon fractures remain difficult to treat for even the most skilled orthopedic trauma surgeons. With improvements in surgical techniques and implants, complication rates have declined and outcomes have improved; however, the overall prognosis for these injuries often remains poor.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads.

METHODS

Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.

RESULTS

In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant.

CONCLUSIONS

Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

Clinical and Radiological Mid- to Long-term Outcomes Following Ankle Fusion

BACKGROUND

The aims of this study were to establish the likelihood of additional surgery after ankle fusion, determine the interval for developing osteoarthrosis in the ipsilateral subtalar or Chopart joints, and evaluate its clinical relevance.

MATERIAL AND METHODS

A retrospective clinical and radiological study with a minimum follow-up of 24 months was performed. Short-Form 36 Heath Survey, Foot Function Index, American Orthopaedic Foot and Ankle Society Score (AOFAS) and a visual analog scale (VAS) were used to evaluate pain level and quality of life in at least 62 adult patients.

RESULTS

A total of 57% of our patients developed osteoarthrosis in at least one of the related joints and 28% of them required additional surgery due to pain. Patients who received workers' compensation had significantly lower AOFAS and higher VAS pain values.

CONCLUSION

More than half of the study cohort developed osteoarthrosis in the related joints after ankle fusion, but fewer than one-third required further joint fusion surgery as a consequence.