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Harnroongroj T, Arunakul M, Reingrittha P, Chuckpaiwong B, Angthong C, Tharmviboonsri T, Lertwattanachai P. Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study. Foot Ankle Int 2024; 45:435-443. [PMID: 38501708 DOI: 10.1177/10711007241231966] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT. METHODS A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant. RESULTS The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023. CONCLUSION Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT. LEVEL OF EVIDENCE Level III, retrospective cohort comparative study.
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Affiliation(s)
- Thos Harnroongroj
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Marut Arunakul
- Department of Orthopedic Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Pissanu Reingrittha
- Department of Orthopedic Surgery, Buddhachinaraj Phitsanulok Hospital, Phitsanulok, Thailand
| | - Bavornrit Chuckpaiwong
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Chayanin Angthong
- Department of Orthopedic Surgery, Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Thailand
| | - Theerawoot Tharmviboonsri
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
| | - Penpun Lertwattanachai
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
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Abstract
BACKGROUND Three-dimensional custom cages can be used to treat complex ankle and hindfoot pathology and bone loss with potentially better patient satisfaction and higher fusion rates than tibiotalocalcaneal (TTC) fusion alone or in combination with bulk femoral head allograft. Yet there is limited literature to support this procedure. The purpose of this study is to objectively quantify the clinical and radiologic outcomes of patients undergoing patient-specific 3D-printed custom cage implantation to fill large defects around the ankle joint region as part of a limb-salvaging TTC fusion. METHODS This is a retrospective review of 21 patients (mean age 59.3 years) who underwent custom cage implantation with a TTC retrograde fusion nail by a single surgeon for massive bone loss of the ankle and hindfoot. Patient charts were reviewed for pain and functional outcomes, complications, and various demographics, including number of previous surgeries to the ipsilateral ankle. Mean follow-up was 32 months. All 21 patients had preoperative and postoperative pain and function scores available for analysis. RESULTS A total of 20 (95.2%) of the 21 patients had their cage in situ at final follow-up. Overall, with the numbers available, visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, and the 12-Item Short Form Health Survey (SF-12) mental and physical health scores significantly improved from preoperative to final follow-up. However, when compared to the overall US population of age-matched 55- to 64-year-old individuals, patients still remained relatively disabled. There were 2 failures, one of which required amputation and the other was treated nonoperatively with bracing. CONCLUSION In conclusion, in this relatively small, single-surgeon series, we found that 3D-printed custom cage technology offered a viable option for complex TTC fusion procedures performed in the presence of significant bone loss, with good fusion rates, however relatively modest improvement in functional outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - Jared Raikin
- Syndey Kimmel Medical College, Philadelphia, PA, USA
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Kim DH, Kim W, Choi Y. Management of talar lesions with cement augmentation and autologous bone graft. J Orthop Surg (Hong Kong) 2022; 30:10225536221131159. [PMID: 36176213 DOI: 10.1177/10225536221131159] [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: 11/17/2022] Open
Abstract
BACKGROUND Treatment of bone lesions involved with the articular cartilage at the talus is challenging. We report the management of talus lesions, particularly tumors and avascular necrosis (AVN), at the articular surface through treatment with cement augmentation and autologous bone graft. METHODS Eight benign bone tumors and three cases of AVN were reviewed retrospectively at a mean follow-up of 56 months (range, 12-162). The mean age of all patients was 36.1 years old (range, 15-73) when assessed between February 2005 and November 2021. Curettage of tumorous and necrotic lesions resulted in significant bone defects filled with bone cement augmentation. Cartilage defects of the talar dome were supported with autologous cancellous bone graft. Tolerable weight-bearing ambulation was permitted immediately after surgery. Radiological and functional evaluations were recorded. RESULTS We observed an increase in the average The American Orthopaedic Foot and Ankle Score (AOFAS) (p = .003) and a decrease in the average Visual Analogue Scale pain score (p = .003). There was no statistically significant decrease in ROM before or after surgery (p = .114). Additionally, no talus collapse of the ankle joint occurred. Talar dome status did not aggravate before or after surgery, except for one patient. Despite no radiographic osteoarthritis exacerbation before or after surgery in six patients, five patients had osteoarthritic change. CONCLUSION Cement implantation and autologous bone graft performed simultaneously for benign bone tumors with joint cartilage damage and AVN are technically simple, have good outcomes, and may be a suitable alternative to standard treatments.
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Affiliation(s)
- Do Hun Kim
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wanlim Kim
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Youngrak Choi
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Deformity Correction of the Midfoot/Hindfoot/Ankle. Clin Podiatr Med Surg 2022; 39:233-272. [PMID: 35365325 DOI: 10.1016/j.cpm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The correction of the deformed arthritic foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible bony procedures and arthrodesis that maybe performed. The appropriate work up and understanding of the pathomechanics is vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection is done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct deformity of the midfoot, hindfoot, and ankle. This article will also discuss the authors' technique and pearls.
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Zhang H, Fletcher AN, Scott DJ, Nunley J. Avascular Osteonecrosis of the Talus: Current Treatment Strategies. Foot Ankle Int 2022; 43:291-302. [PMID: 34753345 DOI: 10.1177/10711007211051013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Avascular osteonecrosis (AVN) of the talus (AVNT) is a painful and challenging clinical diagnosis. AVNT has multiple known risk factors and etiologies and presents at different stages in severity. Given these unique factors, the optimal treatment solution has yet to be determined. Both joint-preserving and joint-sacrificing procedures are available, including core decompression and arthrodeses. Recently, new salvage and replacement techniques have been described including vascularized pedicle bone grafts and total talus replacement using patient-specific prosthesis; however, evidence remains limited. This review examines the current trends AVNT treatment and the emerging data behind these novel techniques.
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Affiliation(s)
- Hanci Zhang
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel J Scott
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Rabiu AR, Mart JPS, Reichert ILH, Ahluwalia R. The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects-Results of a New Technique in Tibiotalocalcaneal Arthrodesis. J Foot Ankle Surg 2021; 60:1301-1307. [PMID: 34362653 DOI: 10.1053/j.jfas.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/13/2021] [Indexed: 02/03/2023]
Abstract
Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m2. All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.
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Affiliation(s)
- Abdul-Rasheed Rabiu
- Surgical Registrar, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Jean-Pierre St Mart
- Surgical Registrar, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Ines L H Reichert
- Consultant Trauma & Orthopaedic Surgeon, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Raju Ahluwalia
- Consultant Foot and Ankle Surgeon, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom.
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Kadakia RJ, Akoh CC, Chen J, Sharma A, Parekh SG. 3D Printed Total Talus Replacement for Avascular Necrosis of the Talus. Foot Ankle Int 2020; 41:1529-1536. [PMID: 32806936 DOI: 10.1177/1071100720948461] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend on disease severity and functional goals. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study was to evaluate outcomes following TTR with a custom 3D printed metal implant. METHODS Patients who underwent TTR were retrospectively reviewed over a 3-year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog scale (VAS) scores, Foot and Ankle Outcome Scores (FAOSs), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre- and postoperatively. Twenty-seven patients underwent TTR for talar AVN with a mean follow-up of 22.2 months. RESULTS Ankle range of motion remained unchanged postoperatively. VAS pain scores improved postoperatively from 7.1 to 3.9 (P < .001). FAOSs improved postoperatively with regard to pain (P < .001), symptoms (P = .001), quality of life (P < .001), and activities of daily living (P < .001). There were 3 complications requiring reoperation in this cohort. CONCLUSION 3D printed TTRs represent a unique surgical option for patients with severe talar AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and AVN. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Rishin J Kadakia
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Craig C Akoh
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Akhil Sharma
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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8
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Fenwick A, Kröger N, Jovic S, Hölscher-Doht S, Meffert R, Jansen H. Pedobarography shows no differences in gait after talar fractures. Technol Health Care 2020; 28:85-92. [PMID: 31104035 DOI: 10.3233/thc-191667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Fractures of the talus often lead to permanent restrictions of the affected limb. Possible alterations after these fractures in gait have not been evaluated yet. OBJECTIVE To evaluate possible alterations of gait by pedybarography after talar fractures. METHODS We conducted a retrospective single-centre study at a level I trauma center. Twenty patients with operatively treated talar fractures were followed up. Objective and subjective function of the ankle was measured using range of motion, clinical scores and dynamic pedobarography (emed-M; Novel, Germany). RESULTS There were 11 talar neck and 9 talar body fractures. All patients received screw fixation. There was a significant reduction in range of motion. The outcome was moderate to satisfying and the severity of the injury correlated with the clinical outcome and the range of motion. The presence of posttraumatic arthritis and joint incongruity lead to a decreased function of ankle and subtalar joint and resulted in a worse clinical outcome. AVN rate was associated to initial displacement. Dynamic pedobarography showed no significant changes in gait pattern. CONCLUSIONS Fractures of the talus lead to dissatisfaction, pain and malfunction. However, a change in gait pattern could not be proved.
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9
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Abstract
The talus is unique in having a tenuous vascular supply and 57% of its surface covered by articular cartilage. Fractures of the head, neck, or body regions have the potential to compromise nearby joints and impair vascular inflow, necessitating surgical treatment with stable internal fixation in many cases. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Percutaneous screw fixation has also demonstrated success in certain patterns. Despite this modern technique, osteonecrosis and osteoarthritis remain common complications. A variety of new treatments for these complications have been proposed, including vascularized autograft, talar replacement, total ankle arthroplasty, and improved salvage techniques, permitting some patients to return to a higher level of function than was previously possible. Despite these advances, functional outcomes remain poor in a subset of severely injured patients, making further research imperative.
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10
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Velasco BT, Briceño J, Miller CP, Ye MY, Savage-Elliott I, Ellington JK, Kwon JY. Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system. Injury 2020; 51:1497-1508. [PMID: 32389394 DOI: 10.1016/j.injury.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hindfoot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors. METHODS A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails. The electronic database of PubMed/Medline/Cochrane Library was explored using specific search terms. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded. RESULTS A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies. CONCLUSION Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice.
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Affiliation(s)
- Brian T Velasco
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA 18510, United States.
| | - Jorge Briceño
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile.
| | - Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, United States.
| | - Michael Y Ye
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, United States.
| | - Ian Savage-Elliott
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - J Kent Ellington
- Department of Orthopaedic Surgery, OrthoCarolina, 250 N Caswell Rd, Charlotte, NC 28207, United States.
| | - John Y Kwon
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States.
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Del Vecchio JJ, Chemes LN, Bertollotti L, Ghioldi ME, Dealbera ED, Galli Serra M, Parizzia W. Patient-specific three-dimensional printed hemi talar prostheses for the treatment of talar osteonecrosis, case report and literature review. SAGE Open Med Case Rep 2020; 8:2050313X20919223. [PMID: 32537160 PMCID: PMC7268162 DOI: 10.1177/2050313x20919223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/23/2020] [Indexed: 11/16/2022] Open
Abstract
We present the case of a 43-year-old boy who presented with progressive pain as a result of history of lateral avascular necrosis of the talus secondary to traumatic open ankle luxation 20 years ago. Conservative treatment (12-month period) prior to surgery failed. It consisted of physiokinetic treatment, insoles and analgesic medication. A diagnostic injection was used in the ankle (positive) and subtalar joint (negative) in order to recognize origin of pain. Hemilateral avascular necrosis of the talus is rare. There are no prior reported cases of the use of hemi-implants. This case highlights the potential use of a patient-specific three-dimensional printed Ti6Al4V prosthesis presented in a complex scenario.
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Affiliation(s)
- Jorge Javier Del Vecchio
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine.,Department of Kinesiology and Physiatry, Universidad Favaloro, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lucas Nicolás Chemes
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | | | - Mauricio Esteban Ghioldi
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Eric Daniel Dealbera
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Marcos Galli Serra
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Walter Parizzia
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
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Wang C, Xu C, Li M, Li H, Wang L, Zhong D, Liu H. Arthroscopic ankle fusion only has a limited advantage over the open operation if osseous operation type is the same: a retrospective comparative study. J Orthop Surg Res 2020; 15:80. [PMID: 32102674 PMCID: PMC7045598 DOI: 10.1186/s13018-020-01599-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/13/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Chenggong Wang
- Department of Foot and Ankle Surgery, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China.,Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Can Xu
- Department of Foot and Ankle Surgery, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China.,Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Mingqing Li
- Department of Foot and Ankle Surgery, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China.,Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Hui Li
- Department of Foot and Ankle Surgery, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China.,Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Long Wang
- Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Da Zhong
- Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Hua Liu
- Department of Foot and Ankle Surgery, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China. .,Department of Orthopedics, Xiangya Hospital Central South University, No.87 Xiangya Road, Changsha, 410008, Hunan, China.
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13
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Sultan AA, Mont MA. Core Decompression and Bone Grafting for Osteonecrosis of the Talus: A Critical Analysis of the Current Evidence. Foot Ankle Clin 2019; 24:107-112. [PMID: 30685004 DOI: 10.1016/j.fcl.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Several operative treatments have been explored to treat patients with progressive or symptomatic osteonecrosis of the talus, aiming to alleviate pain and restore mobility. Because most affected patients are typically younger and more active individuals, joint preservation techniques have received increasing attention. Core decompression, either through an open or percutaneous drilling approach has been used. Similarly, nonvascularized and vascularized bone grafts have been used in clinical practice with varying results. Owing to the relative paucity of studies, in this review we aimed to investigate the use of (1) core decompression and (2) bone grafting for treating osteonecrosis of the talus.
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Affiliation(s)
- Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Strategic Initiatives, Lenox Hill Hospital, 100 E 77th Street, New York, NY 10075, USA.
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14
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Abstract
This article reviews the surgical treatment of talar avascular necrosis. Specifically, arthrodesis for this complex entity and potential treatment of nonunions are discussed. The hallmarks of treatment are evolving and can range from nonoperative measures to amputations. Nonoperative treatment and the results of current arthrodesis techniques for late-stage avascular necrosis are reviewed. Surgical correction requires an understanding of the condition's natural history, utilization of structural and nonstructural bone grafting techniques, and stable fixation. Although the methods described follow standard orthopedic principles, high-quality evidence and outcome studies are limited for treatment of this challenging and often disabling condition.
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Affiliation(s)
- Jonathon D Backus
- Cornerstone Orthopaedics and Sports Medicine, 3 Superior Drive, Suite 225, Superior, CO 80027, USA.
| | - Daniel L Ocel
- Cornerstone Orthopaedics and Sports Medicine, 3 Superior Drive, Suite 225, Superior, CO 80027, USA
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Abstract
Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.
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16
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Abstract
Avascular necrosis (AVN) of the talus bone is a progressive and debilitating consequence of trauma or exposure to a variety of risk factors. The Ficat classification describes current understanding of the natural history of AVN, including preclinical, preradiographic, precollapse, postcollapse, and arthritic stages. The size and location of the avascular region likely determines risk of progression; however, symptoms do not correlate with stage. Patients may be minimally symptomatic despite diffuse involvement for long periods. Joint-sparing strategies have shown promise but do not universally prevent progression of the disease. When bone structure fails, joint-sacrificing strategies may be required.
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Affiliation(s)
- Andrew Haskell
- Departments of Orthopedic Surgery and Sports Medicine, Palo Alto Medical Foundation, 301 Industrial Road, San Carlos, CA 94070, USA.
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17
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Gross CE, Sershon RA, Frank JM, Easley ME, Holmes GB. Treatment of Osteonecrosis of the Talus. JBJS Rev 2018; 4:01874474-201607000-00002. [PMID: 27509328 DOI: 10.2106/jbjs.rvw.15.00087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis. Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis. In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Sershon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan M Frank
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - George B Holmes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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18
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Griffin MJ, Coughlin MJ. Evaluation of Midterm Results of the Panta Nail: An Active Compression Tibiotalocalcaneal Arthrodesis Device. J Foot Ankle Surg 2018; 57:74-80. [PMID: 29268906 DOI: 10.1053/j.jfas.2017.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Indexed: 02/03/2023]
Abstract
A tibiotalocalcaneal intramedullary rod is a powerful construct often reserved for difficult and salvage cases. The Panta Nail (Integra LifeSciences, Plainsboro, NJ) is a second-generation rod that offers active axial compression compared with previous rod designs. We characterized our experience with this device and identified factors associated with nonunion. We retrospectively identified 19 patients receiving the Panta Nail during a 4-year period with a mean follow-up period of 16 months. We used a consecutive series approach toward inclusion. Fusion, asymptomatic fibrous union, or nonunion was determined for each ankle and subtalar joint as the primary endpoint. Patients were grouped as follows: group A, successful outcome; group B, successful outcome after dynamization; group C, no successful outcome. Secondary data were tested for association with the probability of first-attempt fusion. The Panta Nail resulted in a first-attempt fusion rate of 65% at the ankle and subtalar joints. With implementation of dynamization (31% of cases) at an average of 28 weeks after insertion (groups A and B), the bony fusion rate was 88% and 77% at the ankle and subtalar joint, respectively. Inclusion of 3 asymptomatic fibrous unions with final visual analog scale scores <4 (1 ankle; 2 subtalar) as successful outcomes resulted in 94% and 88% success rates for the ankle and subtalar joints (groups A and B). Salvaged total ankle arthroplasties with the Panta Nail device as a subgroup had an 83% fusion rate, with a 50% dynamization rate. No predictors of nonunion were found. The Panta Nail is a second-generation tibiotalocalcaneal arthrodesis device capable of providing good success rates for fusion. Also, dynamization is an appropriate and frequent augmentation method.
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Affiliation(s)
- Matthew J Griffin
- Orthopaedic Surgeon, The Coughlin Clinic of Saint Alphonsus Hospital, Boise, ID.
| | - Michael J Coughlin
- Professor and Orthopaedic Surgeon, The Coughlin Clinic of Saint Alphonsus Hospital, Boise, ID
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19
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Abstract
Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.
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Affiliation(s)
- Mandeep S Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Balvinder Rana
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Inayat Panda
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Sandeep Patel
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Sandeep Patel, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail:
| | - Prasoon Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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20
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Mulligan RP, Adams SB, Easley ME, DeOrio JK, Nunley JA. Comparison of Posterior Approach With Intramedullary Nailing Versus Lateral Transfibular Approach With Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis. Foot Ankle Int 2017; 38:1343-1351. [PMID: 28952355 DOI: 10.1177/1071100717731728] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. The intramedullary (IM) nail and lateral, fixed-angle plating are commonly used because of ease of use and favorable biomechanical properties. A lateral, transfibular (LTF) approach allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PATS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either a PATS approach with IM nailing or LTF approach with fixed-angle plating. METHODS A retrospective review was performed on all patients who underwent simultaneous TTC arthrodesis with minimum 1 year clinical and radiographic follow up. Patients were excluded if they underwent TTC arthrodesis through an approach other than PATS or LTF, and received fixation without an IM nail or fixed-angle plate. Primary outcomes examined were union rate, revisions, and complications. Thirty-eight patients underwent TTC arthrodesis with a PATS approach and IM nailing, and 28 with a LTF approach and lateral plating. RESULTS The overall union rate was 71%; 76% (29 of 38 patients) for the PATS/IM nail group, and 64% (18 of 28) for LTF/plating group ( P = .41). Symptomatic nonunion requiring revision arthrodesis occurred in 16% (6 of 38) of the PATS/IM nail group versus 7% (2 of 28) in the LTF/lateral plating group ( P = .45). There were no significant differences in individual tibiotalar or subtalar union rates, superficial wound problems, infection, symptomatic hardware, stress fractures, or nerve irritations. CONCLUSION Union, revision, and complication rates were similar for TTC arthrodesis performed with a PATS approach and IM nail compared with an LTF approach and fixed-angle plate in a complex patient population. Both techniques were adequate, especially when prior incisions, preexisting hardware, or deformity preclude options. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ryan P Mulligan
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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21
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Abd-Ella MM, Galhoum A, Abdelrahman AF, Walther M. Management of Nonunited Talar Fractures With Avascular Necrosis by Resection of Necrotic Bone, Bone Grafting, and Fusion With an Intramedullary Nail. Foot Ankle Int 2017; 38:879-884. [PMID: 28587485 DOI: 10.1177/1071100717709574] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The presence of nonunion of a talar fracture with displacement, together with complete avascular necrosis, is a challenging entity to treat. METHODS Twelve patients, 8 men (66.7%) and 4 women (33.3%), with nonunited talar fractures and extensive avascular necrosis of the talus were included. The average age was 27.7 years (range, 19-38 years). After exclusion of infection, the patients underwent resection of necrotic bone, bulk autograft, and fusion using an intramedullary nail. The posterior approach was used in 11 patients and the anterior approach in 1 patient. The primary outcome was solid osseous union at the ankle and subtalar level and between the talar head anteriorly and the posterior construct, as evidenced by computed tomographic examination. Functional assessment was performed with the American Orthopaedic Foot & Ankle Society score and subjective patient satisfaction Results: After a mean follow-up duration of 23 months (range, 12-60 months), solid osseous union was achieved in 8 patients (66.7%). Stable fibrous union was seen in 1 patient (8.3%). Three patients (25%) required reoperation, and osseous fusion was finally achieved. American Orthopaedic Foot & Ankle Society score improved from a mean of 39.3 (range, 12-56) preoperatively to 76.6 (range, 62-86) at last follow-up. Subjective patient satisfaction was graded good or excellent in all cases. CONCLUSION Resection of necrotic talar body and bulk autograft with tibiotalocalcaneal fusion by an intramedullary nail through a posterior approach was a reasonable option for the management of type IV posttraumatic talar deformity. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Ahmed Galhoum
- 2 Schmerzklinik Kirschgarten, Orthopedics Surgery Hirschgasslein, Basel, Switzerland
| | | | - Markus Walther
- 3 Shoen Klinic Harlaching, Orthopedic Surgery, Munich, Germany
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22
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Abstract
Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.
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Affiliation(s)
- Patrick R Burns
- Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, 1515 Locust Street #350, Pittsburgh, PA 15219, USA.
| | - Augusta Dunse
- PGY-2, Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15217, USA
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23
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Watanabe K, Teramoto A, Kobayashi T, Ogon I, Sakakibara Y, Kamiya T, Suzuki T, Yamashita T. Tibiotalocalcaneal Arthrodesis Using a Soft Tissue-Preserved Fibular Graft for Treatment of Large Bone Defects in the Ankle. Foot Ankle Int 2017; 38:671-676. [PMID: 28552043 DOI: 10.1177/1071100717696252] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pathogenesis of ankle disorders with a large bone defect is varied and treatment for those problems is challenging for orthopaedic surgeons. The aims of this study were to present an operative technique of arthrodesis for the reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue-preserved fibular strut graft and to report outcomes of consecutively treated patients. METHODS Twelve feet from 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening, were treated. Bone defects were filled using iliac bone and/or resected fibula and tibiotalocalcaneal arthrodesis was performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint while preserving the lateral to posterior skin and soft tissues on the fibula. The periods of bony fusion and outcomes were radiographically and clinically evaluated. The mean follow-up period was 33.4 months. RESULTS Bony fusion was achieved within 3 months in all cases. Coronal and sagittal alignments were acceptable, and the mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded their results of treatment as "satisfied." CONCLUSION This procedure did not require special techniques and it should be applicable to complicated cases with large bone defects. High fusion rates that we believe are due to preserving blood supply to the fibular graft can be expected with preservation of the hindfoot height. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Kota Watanabe
- 1 Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Hokkaido, Japan
| | - Atsushi Teramoto
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Takuma Kobayashi
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Izaya Ogon
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Yuzuru Sakakibara
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Tomoaki Kamiya
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Tomoyuki Suzuki
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Toshihiko Yamashita
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
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24
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Evers J, Schulze M, Gehweiler D, Lakemeier M, Raschke MJ, Wähnert D, Ochman S. A modified and enhanced test setup for biomechanical investigations of the hindfoot, for example in tibiotalocalcaneal arthrodesis. BMC Musculoskelet Disord 2016; 17:318. [PMID: 27472925 PMCID: PMC4966560 DOI: 10.1186/s12891-016-1177-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/28/2016] [Indexed: 11/12/2022] Open
Abstract
Background Tibiotalocalcaneal arthrodesis (TTCA) using intramedullary nails is a salvage procedure for many diseases in the ankle and subtalar joint. Despite “newly described intramedullary nails” with specific anatomical shapes there still remain major complications regarding this procedure. The following study presents a modified biomechanical test setup for investigations of the hindfoot. Methods Nine fresh-frozen specimens from below the human knee were anaysed using the Hindfoot Arthrodesis Nail (Synthes) instrument. Quasi-static biomechanical testing was performed for internal/external rotation, varus/valgus and dorsal/plantar flexion using a modified established setup (physiological load entrance point, sledge at lever arm to apply pure moments). Additionally, a 3D optical measurement system was added to allow determination of interbony movements. Results The mean torsional range of motion (ROM) calculated from the actuator data of a material testing machine was 10.12° (SD 0.6) compared to 10° (SD 2.83) as measured with the Optotrak® system (between tibia and calcaneus). The Optotrak showed 40 % more rotation in the talocrural joint. Mean varus/valgus ROM from the material testing flexion machine was seen to be 5.65° (SD 1.84) in comparison to 2.82° (SD 0.46) measured with the Optotrak. The subtalar joint showed a 70 % higher movement when compared to the talocrural joint. Mean ROM in the flexion test was 5.3° (SD 1.45) for the material testing machine and 2.1° (SD 0.39) for the Optotrak. The movement in the talocrural joint was 3 times higher compared to the subtalar joint. Conclusion The modified test setup presented here for the hindfoot allows a physiological biomechanical loading. Moreover, a detailed characterisation of the bone-implant constructs is possible.
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Affiliation(s)
- Julia Evers
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Schulze
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dominic Gehweiler
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Lakemeier
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dirk Wähnert
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Sabine Ochman
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.
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25
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Hernigou P, Flouzat-Lachaniette CH, Daltro G, Galacteros F. Talar Osteonecrosis Related to Adult Sickle Cell Disease: Natural Evolution from Early to Late Stages. J Bone Joint Surg Am 2016; 98:1113-21. [PMID: 27385685 DOI: 10.2106/jbjs.15.01074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the rate of, and factors affecting, progression of talar osteonecrosis related to sickle cell disease. Adult patients with sickle cell disease who presented with hip osteonecrosis were evaluated for talar osteonecrosis with radiographs and magnetic resonance imaging (MRI). Forty-five of them (75 tali) were diagnosed with talar osteonecrosis, and this group was evaluated for factors influencing the progression of the disease. METHODS Forty-five patients with sickle cell disease and osteonecrosis of the talus were identified with radiographs and MRI between 1985 and 1995. Seven of these patients were homozygous for hemoglobin S (S/S genotype), 26 had hemoglobin S/hemoglobin C, and 12 had hemoglobin S/beta-thalassemia. The talar osteonecrosis was graded with radiographs and MRI. The patients were followed with clinical examination and radiographs every 6 months until talar collapse and every year after the collapse. RESULTS The osteonecrosis was unilateral in 15 patients and bilateral in 30 at the time of the initial examination. Forty-five ankles were asymptomatic and 30 were symptomatic at the initial evaluation. MRI performed at the time of the most recent follow-up, and compared with MRI performed at diagnosis, did not show partial or total regression of the osteonecrosis in any of the patients, even those with asymptomatic stage-I osteonecrosis. At the time of the most recent follow-up (mean, 20 years; range, 15 to 25 years), pain and collapse had developed in all except 12 ankles. The stage of the osteonecrosis at the initial visit, pain, the genotype of the sickle cell disease, and the extent and location of the lesion in the talus were risk factors for progression of the disease. CONCLUSIONS In the majority of the patients with sickle cell disease, osteonecrosis of the talus should be expected to show relevant clinical and radiographic evidence of progression over a long period. LEVEL OF EVIDENCE Prospective Level II. See Instructions for Authors for a complete description of levels of evidence.
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Tibiotalocalcaneal arthrodesis using an intramedullary nail: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24:1316-25. [PMID: 25715850 DOI: 10.1007/s00167-015-3548-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Tibiotalocalcaneal arthrodesis is aimed to block the ankle joint motion in cases of severe osteoarthritis, avascular necrosis of the talus and/or failure of arthroplasty operations. This systematic review was carried out to evaluate the clinical outcome after tibiotalocalcaneal arthrodesis using intramedullary nail either open and arthroscopically assisted. Focus was on the success rate of the procedure in terms of union and complications and on the comparison between the techniques. METHODS The databases PubMed (Medline), EMBASE and Cochrane Library were searched in order to retrieve relevant studies. All therapeutic level 1-4 studies involving humans with intramedullary nail fixation technique were included. Only studies written in English, Italian, French, Spanish and German were included. Data related to the type of surgery, complications and clinical outcomes were extracted and analysed. RESULTS A total of 83 studies were identified, of which 32 studies were eligible for inclusion; 31 case series and one randomized controlled trial. The main reported outcome score was the American Orthopaedic Foot and Ankle Society scale. Almost, all the included studies reported higher than 50% union rates and a significant improvement in terms of the clinical and mechanical ankle function after treatment. CONCLUSIONS Results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal arthrodesis using intramedullary nailing. Low complication rates contribute to make this a safe procedure. No comparison can be done between arthroscopic and open technique, due to the lack of scientific works on the first one. LEVEL OF EVIDENCE IV.
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27
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Kodama N, Takemura Y, Shioji S, Imai S. Arthrodesis of the ankle using an anterior sliding tibial graft for osteoarthritis secondary to osteonecrosis of the talus. Bone Joint J 2016; 98-B:359-64. [DOI: 10.1302/0301-620x.98b3.36154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aims This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus. Patients and Methods We reviewed the clinical and radiological outcomes of 27 patients who underwent arthrodesis with either vascularised or non-vascularised (conventional) grafts, comparing the outcomes (clinical scores, proportion with successful union and time to union) between the two groups. The clinical outcome was assessed using the Mazur and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. The mean follow-up was 35 months (24 to 68). Results The mean outcome scores increased significantly in both groups. In the vascularised graft group, the mean Mazur score improved from 36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. In the conventional arthrodesis group, the mean Mazur score improved from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. Complete fusion was achieved in 13 patients (76%) in the vascularised group, but only four (40%) in the conventional group. The clinical outcomes and proportion achieving union were significantly better in the vascularised group compared with the conventional arthrodesis group, although time to union was similar in the two groups. Take home message: Vascularised sliding tibial grafts may be used to achieve arthrodesis in patients with OA of the ankle secondary to osteonecrosis of the talus. Cite this article: Bone Joint J 2016;98-B:359–64.
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Affiliation(s)
- N. Kodama
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Y. Takemura
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Shioji
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Imai
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
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28
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Taylor J, Lucas DE, Riley A, Simpson GA, Philbin TM. Tibiotalocalcaneal Arthrodesis Nails: A Comparison of Nails With and Without Internal Compression. Foot Ankle Int 2016; 37:294-9. [PMID: 26472084 DOI: 10.1177/1071100715611891] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hindfoot arthrodesis with tibiotalocalcaneal (TTC) intramedullary nails is used commonly when treating ankle and subtalar arthritis and other hindfoot pathology. Adequate compression is paramount to avoid nonunion and fatigue fracture of the hardware. Arthrodesis systems with internal compression have demonstrated superior compression to systems relying on external methods. This study examined the speed of union with TTC fusion nails with internal compression over nails without internal compression. METHODS A retrospective review was performed identifying nail type and time to union of the subtalar joint (STJ) and tibiotalar joint (TTJ). A total of 198 patients were included from 2003 to 2011. RESULTS The median time to STJ fusion without internal compression was 104 days compared to 92 days with internal compression (P = .044). The median time to TTJ fusion without internal compression was 111 days compared to 93 days with internal compression (P = .010). Adjusting for diabetes, there was no significant difference in fusion speed with or without internal compression for the STJ (P = .561) or TTJ (P = .358). Nonunion rates were 24.5% for the STJ and 17.0% for the TTJ with internal compression, and 43.4% for the STJ and 42.1% for the TTJ without internal compression. This difference remained statistically significant after adjusting for diabetes for the TTJ (P = .001) but not for the STJ (P = .194). CONCLUSION The intramedullary hindfoot arthrodesis nail was a viable treatment option in degenerative joint disease of the TTC joint. There appeared to be an advantage using systems with internal compression; however, there was no statistically significant difference after controlling for diabetes. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y. A new form of surgical treatment for patients with avascular necrosis of the talus and secondary osteoarthritis of the ankle. Bone Joint J 2015; 97-B:802-8. [PMID: 26033060 DOI: 10.1302/0301-620x.97b6.34750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.
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Affiliation(s)
- N Kodama
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - Y Takemura
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - H Ueba
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - S Imai
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - Y Matsusue
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
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Abstract
BACKGROUND Avascular necrosis (AVN) of the talus is a painful condition leading to destruction of the ankle-hindfoot complex. Moderate outcomes and high complication rates are reported in small numbers of advanced disease treated with tibiotalocalcaneal fusion, which has the additional disadvantage of sacrificing both the ankle and subtalar joints. The blood supply of the talus is tenuous, and open procedures risk further talar collapse by disrupting extraosseous vessels. This article reports the outcome of arthroscopic ankle fusion for late-stage AVN of the talus. Our hypothesis was that arthroscopic ankle fusion would relieve symptoms of advanced talar AVN, prevent collapse of the talus, and preserve the subtalar joint. METHODS A cohort study was performed on 16 patients with talar AVN treated with arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included perioperative complications, ongoing pain, and further operative intervention. All radiologic investigations were reported independently by a senior radiologist. The average age of the patients was 53.5 years. The presumed causes of talar AVN were steroids, trauma, hematologic disorders, and alcoholism. The etiology was unknown in 7 patients. One patient was lost to follow-up. RESULTS Clinical and radiologic fusion at the ankle joint was confirmed in 15 of 15 available patients. Thirteen patients reported resolution of pain at follow-up. Three patients had ongoing pain and underwent a subsequent successful subtalar fusion. CONCLUSIONS Arthroscopic ankle fusion was a safe and reliable treatment of symptomatic advanced talar AVN. It was a minimally invasive procedure with minimal complication rate, preserving the talus and sparing the subtalar joint. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Adrian R Kendal
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Paul Cooke
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Robert Sharp
- Foot and Ankle Orthopaedic Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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Tenenbaum S, Stockton KG, Bariteau JT, Brodsky JW. Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft. Foot Ankle Int 2015; 36:282-7. [PMID: 25377390 DOI: 10.1177/1071100714558506] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis. METHODS Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire. RESULTS Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection. CONCLUSION Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.
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Affiliation(s)
- Shay Tenenbaum
- Baylor University Medical Center, Dallas, TX, USA Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Jason T Bariteau
- Department of Orthopedics, Emory University School Medicine, Atlanta, GA, USA
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Wukich DK, Mallory BR, Suder NC, Rosario BL. Tibiotalocalcaneal Arthrodesis Using Retrograde Intramedullary Nail Fixation: Comparison of Patients With and Without Diabetes Mellitus. J Foot Ankle Surg 2015; 54:876-82. [PMID: 26015305 PMCID: PMC5664154 DOI: 10.1053/j.jfas.2015.02.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 02/03/2023]
Abstract
Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis is a salvage procedure reserved for severe cases of deformity. The aim of the present study was to compare the outcomes of this technique in patients with and without diabetes mellitus (DM). A total of 61 patients with and 56 without DM underwent retrograde intramedullary nailing and had a minimum follow-up period of 12 months. The overall incidence of complication was 45.2%; however, the overall incidence of complications between those with and without DM was not significantly different (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.38 to 1.65, p = .54). Patients with DM had a significantly greater rate of superficial infections (OR 8.3, 95% CI 1.01 to 68.67, p = .03). However, no difference was seen in the rate of deep infection (OR 0.90, 95% CI 0.34 to 2.46, p = .83) or noninfectious complications (OR 0.50, 95% CI 0.23 to 1.13, p = .09). Successful limb salvage was achieved for 96.8% of the patients with DM and 94.7% of those without DM (p = .66). A femoral head allograft was used in 32 (27.4%) of 117 patients to substitute for an osseous void. Of the 32 patients who required a femoral head allograft, 21 (67.7%) experienced a complication compared with 32 (37.6%) of 85 patients who did not require a femoral head allograft (OR 3.16, 95% CI 1.35 to 7.41, p = .008). The incidence of patient satisfaction was 80% for patients with DM and 72% for those without DM (p = .36). Despite a high incidence of complications, limb salvage was accomplished in approximately 95% of patients with complicated deformities. Four patients (6.56%) with DM experienced a tibia fracture; therefore, we now routinely use a 300-mm-long nail for this reconstruction.
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Affiliation(s)
- Dane K. Wukich
- Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Professor of Orthopaedic Surgery, University of Pittsburgh Medical Center Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA
| | - Brady R. Mallory
- Resident in Podiatry, University of Pittsburgh Medical Center Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA
| | - Natalie C. Suder
- Graduate Student in Biostatistics and Epidemiology, Department of Epidemiology and Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Bedda L. Rosario
- Clinical Faculty in Biostatistics and Epidemiology, Department of Epidemiology and Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Tenenbaum S, Coleman SC, Brodsky JW. Improvement in gait following combined ankle and subtalar arthrodesis. J Bone Joint Surg Am 2014; 96:1863-9. [PMID: 25410503 DOI: 10.2106/jbjs.m.01448] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study assessed the hypothesis that arthrodesis of both the ankle and the hindfoot joints produces an objective improvement of function as measured by gait analysis of patients with severe ankle and hindfoot arthritis. METHODS Twenty-one patients with severe ankle and hindfoot arthritis who underwent unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail were prospectively studied with three-dimensional (3D) gait analysis at a minimum of one year postoperatively. The mean age at the time of the operation was fifty-nine years, and the mean duration of follow-up was seventeen months (range, twelve to thirty-one months). Temporospatial measurements included cadence, step length, walking velocity, and total support time. The kinematic parameters were sagittal plane motion of the ankle, knee, and hip. The kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths on the affected and unaffected sides. RESULTS There was significant improvement in multiple parameters of postoperative gait as compared with the patients' own preoperative function. Temporospatial data showed significant increases in cadence (p = 0.03) and walking speed (p = 0.001) and decreased total support time (p = 0.02). Kinematic results showed that sagittal plane ankle motion had decreased, from 13.2° preoperatively to 10.2° postoperatively, in the operatively treated limb (p = 0.02), and increased from 22.2° to 24.1° (p = 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p = 0.007), and knee motion increased from 56° to 60° (p = 0.054). Kinetic results showed significant increases in ankle moment (p < 0.0001) of the operatively treated limb, ankle power of the contralateral limb (p = 0.009), and hip power on the affected side (p = 0.005) postoperatively. There was a significant improvement in gait symmetry (p = 0.01). CONCLUSIONS There was a small loss of sagittal plane motion in the affected limb postoperatively. There were marked increases in gait velocity, ankle moment, and hip motion and power, documenting objective improvements in ambulatory function. The data showed that preoperative ankle motion was greatly diminished. This may suggest that pain is more important than stiffness in asymmetric gait.
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Affiliation(s)
- Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel. E-mail address:
| | - Scott C Coleman
- Baylor University Medical Center, 411 North Washington Avenue, Suite 2100, Dallas, TX 75246. E-mail address for S.C. Coleman: . E-mail address for J.W. Brodsky:
| | - James W Brodsky
- Baylor University Medical Center, 411 North Washington Avenue, Suite 2100, Dallas, TX 75246. E-mail address for S.C. Coleman: . E-mail address for J.W. Brodsky:
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Lamm BM, Issa K, Kapadia BH, Naziri Q, Jones LC, Mont MA. Percutaneous Drilling for Early-Stage Osteonecrosis About the Ankle. JBJS Essent Surg Tech 2014; 4:e21. [PMID: 30775128 DOI: 10.2106/jbjs.st.m.00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The mid-term clinical, patient-reported, and radiographic outcomes of percutaneous drilling to treat early-stage osteonecrosis (without joint collapse) of the distal part of the tibia or of the talus are promising. Step 1 Preoperative Planning for a Lateral Talar Lesion Obtain anteroposterior and lateral ankle radiographs as well as magnetic resonance imaging (MRI) studies of the ankle to evaluate the stage of the osteonecrotic disease. Step 2 Percutaneous Pin Insertion Lateral Talar Lesion Insert a 1.8-mm Steinmann pin or Ilizarov wire percutaneously under biplanar fluoroscopic visualization. Step 3 Percutaneous Drilling Make one, two, or three passes with a 3.2-mm cannulated drill bit over the pin into the lesion(s). Step 4 Backfilling the Bone Tunnel Optional Infiltrate the defect with demineralized bone matrix to backfill the drill track and the deep necrotic bone defect. Step 5 Postoperative Management The patient bears weight as tolerated in a removable short leg rigid boot for the first four weeks and avoids high-impact activities for at least ten months. Results In our study, there were significant improvements in the mean American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score (p = 0.001), University of California Los Angeles (UCLA) activity score (p = 0.025), and visual analog scale (VAS) pain score (p = 0.001) at a mean of five years (range, two to nine years) postoperatively.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Bradley M Lamm
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Kimona Issa
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
| | - Qais Naziri
- SUNY Downstate Medical Center, Department of Orthopaedic Surgery and Rehabilitation, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203
| | - Lynne C Jones
- The Johns Hopkins Medical Institution, 733 North Broadway, Baltimore, MD 21287
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for B.M. Lamm: . E-mail addresses for M.A. Mont: ,
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Abstract
INTRODUCTION Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature. METHODS We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. RESULTS 19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is "very low". Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN. DISCUSSION Given the "very low" GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Bryan Haughom
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jaskarndip Chahal
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - George B Holmes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Bussewitz B, DeVries JG, Dujela M, McAlister JE, Hyer CF, Berlet GC. Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis. Foot Ankle Int 2014; 35:706-11. [PMID: 24719399 DOI: 10.1177/1071100714531231] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. METHODS The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). RESULTS Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). CONCLUSION This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. LEVEL OF EVIDENCE Level IV, case series.
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Issa K, Naziri Q, Kapadia BH, Lamm BM, Jones LC, Mont MA. Clinical characteristics of early-stage osteonecrosis of the ankle and treatment outcomes. J Bone Joint Surg Am 2014; 96:e73. [PMID: 24806019 DOI: 10.2106/jbjs.m.00888] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purposes of this study were to describe the clinical manifestations of osteonecrosis involving the distal tibia and talus, to identify risk factors associated with the disease, and to evaluate the efficacy of percutaneous drilling for the treatment of ankles with early-stage symptomatic osteonecrosis. METHODS One hundred and one ankles in seventy-three patients with symptomatic osteonecrosis of the talus and/or distal tibia treated with percutaneous drilling were identified. There were eighty-one ankles in fifty-nine patients treated only at our institution and twenty ankles in fourteen patients with a failed prior core decompression at outside institutions. The parameters evaluated included demographics, disease characteristics, clinical outcomes including the American Orthopaedic Foot & Ankle Society score, Short-Form-36 scores, University of California Los Angeles activity scores, and visual analog scale pain scores, and radiographic outcomes at a mean follow-up duration of five years (range, two to nine years). RESULTS Eighty-five ankles had isolated talus osteonecrosis, eleven ankles had involvement of the distal tibia and talus, and five ankles had isolated distal tibial disease. Twenty-nine patients (40%) had initially presented with symptomatic osteonecrosis of another joint, most commonly the knee (37%), the hip (29%), and the shoulder (25%). The most common identifiable risk factors included chronic corticosteroid use (49.3%), alcohol abuse (35.6%), tobacco use (29%), and hypertension (20.5%). Overall, 83% of ankles did not demonstrate further disease progression after the procedure. There were significant improvements (p < 0.05) in clinical and patient-reported outcomes after surgical treatment. The presence of human immunodeficiency virus and sickle cell disease was associated with a higher odds ratio of disease progression to joint collapse. CONCLUSIONS Osteonecrosis of the distal tibia and talus was usually part of multifocal disease, and concurrent knee osteonecrosis was more common than hip osteonecrosis. The results of the present study suggest that early-stage ankle osteonecrosis can be treated successfully with percutaneous drilling.
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Affiliation(s)
- Kimona Issa
- Seton Hall University, School of Health and Medical Sciences, 400 South Orange Avenue, South Orange Village, NJ 07079
| | - Qais Naziri
- SUNY Downstate Medical Center, Department of Orthopaedic Surgery and Rehabilitation, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203
| | - Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont: ;
| | - Bradley M Lamm
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont: ;
| | - Lynne C Jones
- The Johns Hopkins Medical Institution, 733 North Broadway, Baltimore, MD 21287
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont: ;
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Brodsky JW, Verschae G, Tenenbaum S. Surgical correction of severe deformity of the ankle and hindfoot by arthrodesis using a compressing retrograde intramedullary nail. Foot Ankle Int 2014; 35:360-7. [PMID: 24505043 DOI: 10.1177/1071100714523270] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail is a widely used surgical technique for the treatment of concomitant tibiotalar and subtalar arthritis and correction of accompanying deformity. This study was undertaken to evaluate the union rate, deformity correction, and clinical outcomes achieved using a compressing retrograde intramedullary nail. METHODS Thirty tibiotalocalcaneal arthrodeses with an osseous compressing arthrodesis nail system were studied with a mean follow-up of 26 months. Radiographic data were collected on deformity correction and union rate, and clinical outcomes were evaluated using the Visual Analogue Scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle/Hindfoot Score, and the Short Form-36 (SF-36) health survey. Records were reviewed for complications and concomitant procedures. RESULTS Thirteen of 30 operated limbs had a preoperative coronal plane deformity exceeding 15 degrees. Mean magnitude of correction was 13.2 degrees (range, 0-32 degrees, standard deviation ±9.6). In total, 76% of limbs (23/30) had postoperative coronal deformity of less than 5 degrees. Union was achieved in 96.6% of patients. There were 3 cases of tibial stress reaction, 3 cases of transient plantar nerve irritation, and 3 cases of wound infection. Clinical outcomes demonstrated a reduction in mean VAS score from 6.5 to 1.3 (P < .01), an increase in mean AOFAS Ankle/Hindfoot Scores from 29.7 to 74.3 (P < .01), and an increase in mean total SF-36 scores from 85.6 to 98.8 (P < .01). CONCLUSION A compressing retrograde intramedullary nail was effective in achieving deformity correction, a high union rate, and improvement in clinical outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier P, Friscia DA, Hansen ST, Schaser K, Ljungqvist J, Sands AK. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int 2013; 34:1245-55. [PMID: 23613330 DOI: 10.1177/1071100713487526] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. METHODS Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons-Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. RESULTS The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. CONCLUSIONS The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Stefan Rammelt
- Department of Trauma & Reconstructive Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
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Jeng CL, Campbell JT, Tang EY, Cerrato RA, Myerson MS. Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle. Foot Ankle Int 2013; 34:1256-66. [PMID: 23650649 DOI: 10.1177/1071100713488765] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect. METHODS Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion. RESULTS Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation. CONCLUSIONS Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Clifford L Jeng
- Institute for Foot and Ankle Reconstruction, Mercy Medical Center, Baltimore, MD, USA
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DeVries JG, Berlet GC, Hyer CF. Predictive risk assessment for major amputation after tibiotalocalcaneal arthrodesis. Foot Ankle Int 2013; 34:846-50. [PMID: 23391623 DOI: 10.1177/1071100712472488] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. METHODS One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. RESULTS There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: e(x) /(1 + e(x) ) where x is a factor of age, diabetes, revision, and ulceration. CONCLUSION TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. LEVEL OF EVIDENCE Level II, prognostic.
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Affiliation(s)
- Randall C Marx
- The San Antonio Orthopedic Group, 2829 Babcock Road, Suite #700, San Antonio, TX 78229, USA
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