Revision arthrodesis of the ankle: a 4 cannulated screw compression fixation technique

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

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

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

BACKGROUND

While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior.

METHODS

A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material.

RESULTS

This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables.

CONCLUSION

Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft.

LEVEL OF EVIDENCE

Level IV.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

Indications and considerations of foot and ankle arthrodesis

This article discusses the introductory physiology of bone healing with respect to arthrodesis. The joints of the foot and ankle can suffer many trials and tribulations in an otherwise normal life, and must adapt to instances such as fractures, dislocations, and congenital problems. When adaptation leads to a malformation in the unit structure, surgical intervention is required to restore the foot and ankle complex to a working device. Primary indications for regarding any joint fusion in the human body include deformity, instability, and pain. An overview of the indications for performing joint fusions at the foot and ankle is presented.