Results of Arthroscopic Ankle Arthrodesis with Fixation Using Two Parallel Headless Compression Screws in a Heterogenic Group of Patients

Improvement in clinical outcome and quality of life after arthroscopic ankle arthrodesis in paralytic foot drop

BACKGROUND

Paralytic foot-drop is a disabling deformity that results from nerve or direct muscle injuries. Palliative surgeries such as tendon transfer and ankle arthrodesis are reserved for permanent deformity, with the arthroscopic technique had not been widely studied before. This study aims to evaluate the clinical outcome and quality of life after arthroscopic ankle fusion of paralytic foot-drop deformity.

MATERIALS AND METHODS

The patients who were retrospectively enrolled in this study underwent arthroscopic ankle fusion for paralytic foot-drop deformity between March 2017 and December 2021. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Cumberland Ankle Instability Tool (CAIT) were the measures used for clinical assessment. To judge the union, serial plain radiographs of the ankle were obtained. The preoperative and postoperative means were analyzed utilizing a two-tailed paired t-test, with a p value of less than 0.05 indicating statistical significance.

RESULTS

This study included 21 consecutive patients with a mean follow-up of 35.09 ± 4.5 months and a mean age of 41.5 ± 6.1 years. Highly significant improvements were observed between the preoperative and final follow-up means of the AOFAS score (from 57.6 ± 4.6 to 88.3 ± 2.7) and CAIT (from 12.1 ± 2.2 to 28.9 ± 1.01; p ˂ 0.00001 for both). All patients attained radiographic union and resumed their previous occupations without reporting serious adverse effects.

CONCLUSIONS

Arthroscopic ankle fusion is an effective, minimally invasive palliative surgery for patients suffering from permanent paralytic foot-drop deformity. This technique was shown to provide good functional and radiologic outcomes without significant complications.

LEVEL OF EVIDENCE

Retrospective cohort; level of evidence (IV).

Irritation from metalwork after ankle arthrodesis fixed using screws: a proportional meta-analysis and systematic review

OBJECTIVE

Ankle arthrodesis (AA) is often fixed using cannulated screws. The irritation from metalwork is a relatively common complication, but there is no consensus regarding the need to remove the screws on a systematic basis. The aim of this study was to determine (1) the proportion of screws removed after AA and (2) whether predictors of screw removal could be identified.

METHODS

This PRISMA-compliant systematic review was part of a larger previous protocol registered on the PROSPERO platform. Multiple databases were searched including studies in which patients undergone AA using screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS).

RESULTS

Forty-four series of patients from thirty-eight studies (1990 ankles, 1934 patients) were selected. The average follow-up was 40.8 months (range 12-110). In all studies, hardware was removed due to symptoms reported by patients and related to the screws. The pooled proportion of removal of metalwork was 3% (95% CI 2-4). The pooled proportion of fusion was 96% (95%CI 95-98), while the pooled proportion of complications and reoperations (excluding the removal of metalwork) stood at 15% (95% CI 11-18) and 3% (95% CI 2-4), respectively. The mean mCMS (50.8 ± 8.1, range 35-66) revealed only an overall fair quality of studies. The univariate analysis and the multivariate model showed that the year of publication (R = - 0.004; p = 0.01) and the number of screws (R = 0.08; p = 0.01) were associated with the screw removal rate. Specifically, we found that over time the removal rate decreased by 0.4% per year and that the use of three screws instead of two reduced the risk of removal of metalwork by 8%.

CONCLUSIONS

In this review, removal of metalwork after ankle arthrodesis using cannulated screws was needed in 3% of cases at an average follow-up of 40.8 months. It was indicated only in case of symptoms related to soft tissue irritation from screws. The use of three screws was paradoxically related to a reduced risk of removal of screws as compared to two-screw constructs.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV.

Screw Internal Fixation and Ilizarov External Fixation: A Comparison of Outcomes in Ankle Arthrodesis

The purpose of this study was to compare the mid-term clinical outcomes between screw internal fixation and Ilizarov external fixation in patients who underwent ankle arthrodesis and to elucidate the differences between the 2 fixation methods. This study investigated 43 ankles in 41 patients who underwent ankle arthrodesis at 1 of the 2 study institutions. There were 15 men and 26 women, and their mean age was 66.2 (range 49 to 87) years. The primary disease included osteoarthritis (OA) (79%), rheumatoid arthritis (RA) (16.3%), and Charcot joint (4.7%). Patients were divided into 2 groups depending on the surgical approach: the screw group (S) and the Ilizarov group (I). The following items were evaluated and compared between the 2 groups: patient characteristics, Tanaka-Takakura classification based on preoperative plain X-ray images, duration of surgery, blood loss, surgical complications, time to start weightbearing, and the Japanese Society of Surgery of the Foot (JSSF) standard rating system for the ankle-hindfoot. Duration of surgery was significantly shorter in the S group (162.3 versus 194.9 min), and the amount of blood loss was also significantly lower in the S group (29.2 versus 97.5 ml). Preoperative JSSF scale was significantly lower in the I group (44.8 versus 33), but postoperative JSSF scale was not significantly different between the 2 groups (82.1 versus 77.9). The S group had satisfactory clinical outcomes with a shorter duration of surgery and smaller amount of blood loss than the I group. However, severe patients in the I group achieved similar treatment outcomes.

PRE-PLANNING ANKLE ARTHRODESIS USING 3D RECONSTRUCTED TOMOGRAPHIES

OBJECTIVE

To implement one analysis method of the ankle bone contour that could make a more precise ankle arthrodesis.

METHODS

Twenty tomographies were submitted to 3D reconstruction. Seven points of anatomic interest for ankle arthrodesis with the three screws technique were marked with a triplannar marker. The median of the position of markers was estimated, and the union of the seven median points allow the construction of one median ankle for that population. Using this median ankle, sizes and angles for the screws position were determined.

RESULTS

Two median ankles were reconstructed, left and right. The position of the screw passage were determined considering the anatomical parameters. In the right ankle the lateral to medial screw should enter 4.56 cm and 0.79 above and posterior to lateral malleolus, with one inclination of 17.34° in relation to tibial longitudinal axis; and 0° in relation to tibial axial plane. The position for the other two screws is also described.

CONCLUSION

Our article is the first to presents one precise guide for ankle arthrodesis based on a populational assessment. Level of evidence II, Diagnostic Studies.

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.

Re-arthrodesis after primary ankle fusion: 134/1,716 cases from the Swedish Ankle Registry

Background and purpose - Arthrodesis is the most common treatment of severe ankle arthritis. Large studies on the occurrence of re-arthrodesis are few, especially with information in terms of risk. We used the National Swedish Ankle Registry to assess incidence and risk factors for re-arthrodesis. Patients and methods - In the Registry, we examined the occurrence of re-arthrodesis in 1,716 patients with a primary ankle arthrodesis. We also analyzed associations between the re-arthrodesis risk and sex, diagnosis, and surgical method. Results - The risk of first re-arthrodesis at 2.5 years was 7.4% and the rate at 9 years 7.8%. The risk following arthroscopic surgery with fixation by screws was 15%, which is statistically significantly higher than the 8% following the gold standard technique with open screw fixation, the 5% following fixation by intramedullary nailing, and the 3% following fixation by plate and screws. Patients with either idiopathic osteoarthritis or posttraumatic arthritis had a higher risk of re-arthrodesis than patients with rheumatoid arthritis. We could not find that the risk of re-arthrodesis was associated with sex. Interpretation - In Sweden, the re-arthrodesis risk varied by primary technique and was especially high after arthroscopic surgery. Reasons are unknown but poor surgical technique and/or surgeon inexperience may contribute, as may patient selection.

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

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