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Besor O, Eidelman M, Kotlarsky P. Simultaneous tibio-talar fusion and tibial lengthening for end-stage ankle arthritis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3501-3509. [PMID: 37198500 DOI: 10.1007/s00590-023-03579-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 05/10/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Arthrodesis of the ankle joint is an accepted treatment option in patients with end-stage ankle arthritis. The goal is to achieve fusion between the tibia and the talus, thereby stabilizing the joint and alleviating pain. There might be associated limb length discrepancy, especially in post-traumatic and post-infectious cases. These patients require limb lengthening and arthrodesis. The purpose of this study is to report our experience with simultaneous ankle arthrodesis and lengthening using external fixation in adolescent and young adult patients. METHODS This retrospective case series included all patients treated in our hospital by concomitant ankle arthrodesis and tibial lengthening procedures on the same limb, using ring external fixation system. All surgeries included distal tibial joint surface resection and the talar dome, thereby correcting any associated deformity at the ankle. The arthrodesis was fixed and compressed using ring external fixator. A concurrent proximal tibial osteotomy was done, and limb lengthening, or bone transport was performed. RESULTS Eight patients operated between the years 2012-2020 were included in this study. Median patient age was 20.4 years (range 4-62 years), 50% women. Median limb lengthening was 20 mm (range 10-55 mm), and median final leg length discrepancy (LLD) was 7.5 mm (range 1-72 mm). The most common complication recorded was pin tract infection, which resolved with empiric antibiotics in all cases. CONCLUSION Based on our experience, combined arthrodesis and proximal tibial lengthening is efficient solution that provides stable ankle and restores length of the tibia even in complex and challenging situations.
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Affiliation(s)
- Omri Besor
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel.
| | - Mark Eidelman
- Pediatric Orthopedics, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Pavel Kotlarsky
- Pediatric Orthopedics, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
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2
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Tay KS, Langit M, Fenton C, Grupping R, Muir R, Moulder E, Sharma H. Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction. Foot Ankle Int 2023; 44:403-414. [PMID: 36942403 DOI: 10.1177/10711007231157710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure. METHODS A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed. RESULTS 47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. CONCLUSION Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication. LEVEL OF EVIDENCE Level III, prognostic.
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Affiliation(s)
| | - Mickhael Langit
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
| | - Carl Fenton
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
| | - Rachael Grupping
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
| | - Ross Muir
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
| | - Elizabeth Moulder
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
| | - Hemant Sharma
- Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, United Kingdom
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3
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Monteagudo M, Martínez-de-Albornoz P. Deciding Between Ankle and Tibiotalocalcaneal Arthrodesis for Isolated Ankle Arthritis. Foot Ankle Clin 2022; 27:217-231. [PMID: 35219367 DOI: 10.1016/j.fcl.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Manuel Monteagudo
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud Madrid, Faculty Medicine UEM Madrid, Calle Diego de Velazquez 1, Pozuelo de Alarcon, 28223 Madrid, Spain.
| | - Pilar Martínez-de-Albornoz
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud Madrid, Faculty Medicine UEM Madrid, Calle Diego de Velazquez 1, Pozuelo de Alarcon, 28223 Madrid, Spain
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Fuentes P, Cuchacovich N, Gutierrez P, Hube M, Bastías GF. Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis. Foot Ankle Int 2021; 42:1525-1535. [PMID: 34142580 DOI: 10.1177/10711007211018201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications. METHODS We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period. RESULTS Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2. CONCLUSION Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Patricio Fuentes
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Santiago, Chile
| | - Natalio Cuchacovich
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador-Clinica Las Condes, Santiago, Chile
| | - Paulina Gutierrez
- Department of Emergency Medicine, Clinica Las Condes, Santiago, Chile
| | - Maximiliano Hube
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador-Clinica Indisa, Santiago, Chile
| | - Gonzalo F Bastías
- Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador-Clinica Las Condes, Hospital San Jose-Universidad de Chile, Santiago, Chile
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Teramoto A, Nozaka K, Kamiya T, Kashiwagura T, Shoji H, Watanabe K, Shimada Y, Yamashita T. Screw Internal Fixation and Ilizarov External Fixation: A Comparison of Outcomes in Ankle Arthrodesis. J Foot Ankle Surg 2021; 59:343-346. [PMID: 32131001 DOI: 10.1053/j.jfas.2019.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Atsushi Teramoto
- Assistant Professor, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan.
| | - Koji Nozaka
- Assistant Professor, Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Tomoaki Kamiya
- Assistant Professor, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Takeshi Kashiwagura
- Orthopaedic Surgeon, Department of Orthopedic Surgery, Akita City Hospital, Akita, Akita, Japan
| | - Hiroaki Shoji
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kota Watanabe
- Professor, Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Hokkaido, Japan
| | - Yoichi Shimada
- Professor, Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Toshihiko Yamashita
- Professor, Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Rozis M, Benetos I, Afrati SR, Polyzois VD, Pneumaticos SG. Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion. J Foot Ankle Surg 2021; 59:337-342. [PMID: 32131000 DOI: 10.1053/j.jfas.2019.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/01/2019] [Accepted: 05/19/2019] [Indexed: 02/03/2023]
Abstract
Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.
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Affiliation(s)
- Meletis Rozis
- Orthopaedic Resident, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece.
| | - Ioannis Benetos
- Orthopaedic Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Spyridoula-Roberta Afrati
- Anesthesiologist Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Vasilios D Polyzois
- Orthopaedic Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Spyros G Pneumaticos
- Orthopaedic Professor, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
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7
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Wirth SH, Viehöfer AF, Tondelli T, Hartmann R, Berli MC, Böni T, Waibel FWA. Mid-term walking ability after Charcot foot reconstruction using the Ilizarov ring fixator. Arch Orthop Trauma Surg 2020; 140:1909-1917. [PMID: 32170454 DOI: 10.1007/s00402-020-03407-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Failed conservative treatment and complications are indications for foot reconstruction in Charcot arthropathy. External fixation using the Ilizarov principles offers a one-stage procedure for deformity correction and resection of osteomyelitic bone. The aim of this study was to determine whether external fixation with an Ilizarov ring fixator leads reliably to walking ability. MATERIALS AND METHODS 29 patients treated with an Ilizarov ring fixator for Charcot arthropathy were retrospectively analyzed. Radiologic fusion at final follow up was assessed separately on conventional X-rays by two authors. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher's exact test. RESULTS Mean follow up was 35 months (range 5.3-107) months; mean time of external fixation was 113 days. Ten patients (34.5%) reached fusion, but 19 did not (65.5%). Two patients needed below knee amputation. 26 of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of osteomyelitis at the time of reconstruction and from the presence of fusion. CONCLUSION Foot reconstruction with an Ilizarov ring fixator led to limb salvage in 93%. The vast majority (96.3%) of patients with successful limb salvage was ambulatory, independent from radiologic fusion, and presence of osteomyelitis at the time of reconstruction. These findings encourage limb salvage and deformity correction in this difficult-to-treat disease, even with underlying osteomyelitis.
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Affiliation(s)
- Stephan H Wirth
- Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Arnd F Viehöfer
- Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Timo Tondelli
- Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Rebecca Hartmann
- Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin C Berli
- Divison of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Thomas Böni
- Divison of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Felix W A Waibel
- Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland. .,Divison of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
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Simultaneous Total Knee Arthroplasty and Ankle Arthrodesis for Charcot Neuroarthropathy. Case Rep Orthop 2019; 2019:6136409. [PMID: 31885983 PMCID: PMC6925794 DOI: 10.1155/2019/6136409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Charcot neuroarthropathy is a progressive, deforming pathology of the bone and joints, especially affecting the knees and ankles. Although it is rare, it leads to considerable morbidity. The treatment of Charcot arthropathy of the knee and ankle remains controversial. Many authors suggest that knee involvement is an absolute contraindication to total knee arthroplasty. In recent years, however, several studies have shown satisfactory results for total knee arthroplasty. In the ankle, external fixators have recently been advocated by many authors. Their main advantages are that they permit monitoring of soft tissue healing and avoidance of more invasive surgery. Simultaneous Charcot knee and ankle joint surgery involving total knee arthroplasty (TKA) and ankle arthrodesis is rare and challenging and can lead to major complications if not addressed appropriately. Case Presentation The case of a 71-year-old woman who underwent simultaneous total knee arthroplasty and ankle arthrodesis for severe neurosyphilitic Charcot arthropathy (Eichenholtz classification stage III) and was evaluated three years after surgery is reported. Deformities of the left knee joint and ankle developed. The left leg was shorter by 20 mm, with a functional leg length discrepancy. The patient was limping, and marked varus instability of the left ankle was observed during the stance phase of walking. Postoperatively, the patient was able to walk without assistance, confirming improvement of mobility. Conclusion To the best of our knowledge, this is the first report of combined, simultaneous neurosyphilitic Charcot knee and ankle joint surgery involving TKA and ankle arthrodesis. It was an effective surgical method that maintained leg length and achieved satisfactory alignment without an autologous iliac bone graft.
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Abstract
Ankle arthritis is a major source of morbidity impacting a younger working age population than hip and knee arthritis. Unlike the hip and knee, more than 70% of ankle arthritis cases are post-traumatic, with the remainder being inflammatory or primary arthritis. Nonoperative treatment begins with lifestyle and shoe-wear modifications and progresses to bracing, physical therapy, anti-inflammatory medications, and intra-articular injections. Ankle arthrodesis and total ankle arthroplasty are the 2 main surgical options for end-stage ankle arthritis, with debridement, realignment osteotomy, and distraction arthroplasty being appropriate for limited indications.
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Affiliation(s)
- Vu Le
- Department of Orthopaedics, University of British Columbia, Faculty of Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Andrea Veljkovic
- Department of Orthopaedics, University of British Columbia, Faculty of Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Peter Salat
- Department of Radiology, University of Calgary, Alberta, Canada
| | - Kevin Wing
- Department of Orthopaedics, University of British Columbia, Faculty of Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Murray Penner
- Department of Orthopaedics, University of British Columbia, Faculty of Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Alastair Younger
- Department of Orthopaedics, University of British Columbia, Faculty of Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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Matsubara H, Watanabe K, Takata M, Nomura I, Tsuchiya H. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019; 14:148-154. [PMID: 32742431 PMCID: PMC7368357 DOI: 10.5005/jp-journals-10080-1436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background We have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively. Materials and methods Thirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I—no bone defect, no or mild deformity; type II—no bone defect, severe deformity; type III—bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV—bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport. Results All patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one. Conclusion We have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases. How to cite this article Matsubara H, Watanabe K, Takata M, et al. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019;14(3):148–154.
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Affiliation(s)
- Hidenori Matsubara
- Department of Orthopaedic Surgery, Kanazawa University, Takaramachi, Kanazawa, Japan
| | - Koji Watanabe
- Department of Orthopaedic Surgery, Kanazawa University, Takaramachi, Kanazawa, Japan
| | - Munetomo Takata
- Department of Orthopaedic Surgery, Kanazawa University, Takaramachi, Kanazawa, Japan
| | - Issei Nomura
- Department of Orthopaedic Surgery, Kanazawa University, Takaramachi, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University, Takaramachi, Kanazawa, Japan
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Ewalefo SO, Dombrowski M, Hirase T, Rocha JL, Weaver M, Kline A, Carney D, Hogan MV. Management of Posttraumatic Ankle Arthritis: Literature Review. Curr Rev Musculoskelet Med 2018; 11:546-557. [PMID: 30327933 PMCID: PMC6220012 DOI: 10.1007/s12178-018-9525-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Trauma is the principle cause of osteoarthritis in the ankle, which is associated with significant morbidity. This review highlights the current literature for the purpose of bringing the reader up-to-date on the management of posttraumatic ankle arthritis, describing treatment efficacy, indications, contraindications, and complications. RECENT FINDINGS Recent studies on osteoarthritis have demonstrated variability among anatomic locations regarding the mechanisms and rates of development for posttraumatic osteoarthritis, which are attributed to newly discovered biological differences intrinsic to each joint. Regarding surgical management of posttraumatic ankle arthritis, osteochondral allograft transplantation of the talus, and supramalleolar osteotomies have demonstrated promising results. Additionally, the outpatient setting was found to be appropriate for managing pain following total ankle arthroplasty, associated with low complication rates and no readmission. Management for posttraumatic ankle arthritis is generally progressive. Initial treatment entails nonpharmacologic options with surgery reserved for posttraumatic ankle arthritis refractory to conservative treatment. Patient demographics and lifestyles should be carefully considered when formulating a management strategy, as outcomes are dependent upon the satisfaction of each set of respective criteria. Ultimately, the management of posttraumatic ankle arthritis should be individualized to satisfy the needs and desires, which are specific to each patient.
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Affiliation(s)
- Samuel O Ewalefo
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Texas A&M College of Medicine, Bryan, TX, USA.
| | - Malcolm Dombrowski
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Takashi Hirase
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Jorge L Rocha
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mitchell Weaver
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Kline
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dwayne Carney
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Salvage of failed ankle arthrodesis after posttraumatic septic arthritis by Ilizarov external fixator: mid-term results. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. Most often it is the residual effect of a previous traumatic injury. Nonsurgical treatment of end-stage arthritis of the ankle includes bracing, shoe-wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each has its proponents. Although no ideal treatment of ankle arthritis exists, high-quality studies can help guide treatment in patients of varying demographics. Inherent risks are linked with each treatment option, but those of greatest concern are early implant loosening that requires revision following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis.
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Onodera T, Majima T, Kasahara Y, Takahashi D, Yamazaki S, Ando R, Minami A. Outcome of transfibular ankle arthrodesis with Ilizarov apparatus. Foot Ankle Int 2012; 33:964-8. [PMID: 23131442 DOI: 10.3113/fai.2012.0964] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Both transfibular ankle arthrodesis with fibular onlay grafting and ankle arthrodesis using the Ilizarov apparatus have resulted in acceptable fusion rates. This study analyzed outcomes in the authors' practice for all patients who underwent transfibular ankle arthrodesis with fibular onlay grafting using the Ilizarov apparatus. MATERIALS AND METHODS A retrospective review was conducted of all patients who experienced severe ankle pain associated with osteoarthritis, rheumatoid arthritis, talar osteonecrosis, or septic arthritis and underwent transfibular ankle arthrodesis with an Ilizarov apparatus between 1995 and 2010. Postoperative clinical outcomes were evaluated for 42 consecutive patients (43 feet) who received primary or revision ankle arthrodesis using the Ilizarov technique at two centers. Mean duration of follow-up was 4.1 (range, 1.5 to 13) years. Outcomes were assessed using the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society. RESULTS All ankles fused successfully. Mean clinical outcome improved significantly from 36.2 (range, 8 to 64) preoperatively to 77.4 (range, 0 to 86; p < .05) postoperatively. CONCLUSION Transfibular ankle arthrodesis using the Ilizarov external fixation system and fibular onlay strut grafting can achieve a very high rate of bony union and lead to general improvements in clinical outcome. Forefoot stabilization with a forefoot ring achieved rigid stabilization resulting in a shorter duration of external fixation.
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Affiliation(s)
- Tomohiro Onodera
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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Complex ankle arthrodesis using the Ilizarov method yields high rate of fusion. Clin Orthop Relat Res 2012; 470:2864-73. [PMID: 22777590 PMCID: PMC3441986 DOI: 10.1007/s11999-012-2470-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 06/22/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ankle arthrodesis may be achieved using the Ilizarov method. Comorbidities, such as diabetes, Charcot neuroarthropathy, osteomyelitis, leg length discrepancy, and smoking, can make an ankle fusion complex and may be associated with lower rates of healing. QUESTIONS/PURPOSES We asked if (1) smoking and other comorbidities led to lower fusion rates, (2) time wearing the frame affected outcome, and (3) simultaneous tibial lengthening improved fusion rates. METHODS We retrospectively studied 101 patients who underwent complex ankle fusion using the Ilizarov technique. The median time wearing the frame was 25 weeks (range, 10-65 weeks). Twenty-four patients had simultaneous tibial lengthening. The minimum followup for 91 of the 101 patients was 27 months (median, 65 months; range, 27-134 months). RESULTS Fusion was achieved in 76 of 91 patients. Smoking was associated with a 54% rate of nonunion. Fifteen of 19 patients with Charcot neuroarthropathy achieved union but had a high rate of subsequent subtalar joint failure. Time wearing the frame did not affect union rates. Tibial lengthening did not improve ankle fusion rates. CONCLUSION Smokers should be warned of the high risk of nonunion and we recommend they quit smoking. We also recommend surgeons recognize the higher nonunion rate in patients with Charcot neuroarthropathy. We believe tibial lengthening should not be performed to enhance healing at the fusion site. LEVEL OF EVIDENCE Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Lowery NJ, Woods JB, Armstrong DG, Wukich DK. Surgical management of Charcot neuroarthropathy of the foot and ankle: a systematic review. Foot Ankle Int 2012; 33:113-21. [PMID: 22381342 DOI: 10.3113/fai.2012.0113] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the foot and ankle is an extremely challenging clinical dilemma and surgical management can be highly complicated. The current literature on this topic is comprised of manuscripts that are retrospective case series and expert opinions. Furthermore, surgery in patients with CN of the foot and ankle is guided by studies with low levels of evidence to support our current surgical practices. METHODS A Medline/CINAHL search was performed and a systematic review of articles discussing the surgical management of CN was undertaken. RESULTS Ninety-five articles fit the inclusion criteria for our study. As hypothesized, all reports detailing the surgical management of Charcot neuroarthropathy constituted Level IV or V evidence. CONCLUSION Surgical algorithms for the treatment of CN of the foot are based almost entirely on level four or five evidence. Uncontrolled retrospective case series and case reports guide the use of exostectomy, fusion, and Achilles tendon lengthening for CN. There is inconclusive evidence concerning timing of treatment and use of different fixation methods. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.
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Abstract
The principles of fusion of a Charcot joint arise from the assertion that successful fusion requires removal of all cartilage, debris, and sclerotic bone. The authors believe that reconstruction can prevent amputation in patients who have unbraceable or unstable deformities, or recurrent ulcerations. The goal with any Charcot reconstruction procedure is to achieve a plantigrade foot free of ulceration, and to prevent any future collapse, deformity, or ulcerations. The authors strongly believe arthrodesis of unstable joints of the Charcot neuropathic foot can lead to limb salvage and better quality of life.
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Affiliation(s)
- Panagiotis Panagakos
- Foot and Ankle Care Associates, LLC, Hahnemann University Hospital, Overlook Hospital, Staten Island, NY 10305, USA
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Espinosa N, Klammer G. Treatment of ankle osteoarthritis: arthrodesis versus total ankle replacement. Eur J Trauma Emerg Surg 2010; 36:525-35. [PMID: 26816307 DOI: 10.1007/s00068-010-0058-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 10/07/2010] [Indexed: 01/15/2023]
Abstract
While ankle arthrodesis has remained the gold standard treatment for symptomatic primary, secondary, and posttraumatic ankle arthritis, more recently, total ankle replacement (TAR) has seen considerable improvement in terms of biomechanics, function, and complication rates. However, while in the long-term degeneration of the adjacent joints is almost always found on radiographs after ankle arthrodesis, the longevity of TAR is still insufficient and does not match that of total knee and hip joints. The current review article focuses on the treatment of ankle arthritis by means of arthrodesis and TAR.
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Affiliation(s)
- N Espinosa
- Department of Orthopaedic Surgery, University of Zurich Hospital, University of Zurich, Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - G Klammer
- Department of Orthopaedic Surgery, University of Zurich Hospital, University of Zurich, Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
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Abstract
Ankle arthrodesis is by no means a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of ankle positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to recognize important patient factors and to determine which type of ankle arthrodesis is most appropriate for that specific patient.
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