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Nsekpong TB, Amin AS, Ali SR, Beasley BJ, Panchbhavi V, Jupiter DC. Comparative Analysis of Secondary Outcomes in Treatment of Charcot Neuropathy: A Systematic Review. Foot Ankle Spec 2025; 18:144-150. [PMID: 35778875 DOI: 10.1177/19386400221106635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) is commonly associated with diabetic neuropathy and can predispose patients to amputations. Management remains a challenge, with no definitive treatment. This study examines major postoperative complications associated with open reduction with internal (intramedullary) nails, fixation, external fixation, or combined internal and external fixation for correction of the deformity. METHODS We reviewed available literature using PubMed, OvidSP, Scopus, and Cochrane and searched bibliographies of the included studies to identify additional pertinent references. After review and agreement among 4 raters, a total of 15 studies were included in this analysis. RESULTS Hardware removal rates were 0.133 for intramedullary nails, 0.007 for external fixators, and 0.050 for combined fixation. Rates of hardware complication were 0.182 for intramedullary nails and 0.007 for external fixators. Wound dehiscence occurred at rates of 0.059 for intramedullary nails and 0.216 for combined fixation. The rate of deep infections was 0.031 for intramedullary nails, 0.032 for external fixators, and 0.113 for combined fixation. The rate of irrigation and debridement was 0.007 for external fixators. CONCLUSION Rates of hardware removal (13.3%) and complications (18.2%) were high with intramedullary nails. Dehiscence (21.6%) and deep infection (11.3%) were high in combined fixation. Other complications occurred relatively rarely. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Atish S Amin
- The University of Texas Medical Branch, Galveston, Texas
| | - Shahrukh R Ali
- The University of Texas Medical Branch, Galveston, Texas
| | | | - Vinod Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Daniel C Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, Texas
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Fadle AA, El-Adly W, Fekry MA, Osman AE, Khalifa AA. Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2549-2556. [PMID: 38693347 PMCID: PMC11291572 DOI: 10.1007/s00590-024-03947-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/02/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures. METHODS We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented. RESULTS Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws. CONCLUSION Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Amr A Fadle
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | - Wael El-Adly
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | | | - Ahmed E Osman
- Department of Orthopedic, Assiut University Hospital, Assiut, Egypt
| | - Ahmed A Khalifa
- Department of Orthopedic, Qena Faculty of Medicine and University Hospital, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, 83523, Egypt.
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Abaydi A, Radi J, Tbatou A, Lahrach K, Boutayb F. Tibio-Talo-Calcaneal Arthrodesis: Evaluation of the Effectiveness of a Specific Surgical Technique in 17 Cases. Cureus 2024; 16:e62014. [PMID: 38887747 PMCID: PMC11182152 DOI: 10.7759/cureus.62014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Ankle arthrodesis is a crucial surgical intervention for advanced hindfoot conditions, aiming to restore plantigrade walking and alleviate pain. This study evaluates the effectiveness of a specific surgical approach for tibiotalocalcaneal arthrodesis (TTCA), focusing on rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, and assesses the outcomes of this approach in terms of bone fusion and reduction of postoperative complications. MATERIALS AND METHODS This retrospective analysis includes 17 patients who underwent TTCA in a trauma-orthopedic department over seven years. Data were collected from medical records, the HOSIX software, and patient consultations. Preoperative assessments, surgical techniques, postoperative care, and follow-up evaluations were documented. RESULTS The mean age of patients was 42.4 years, with a male predominance. Surgical indications included post-traumatic arthropathy (53%), inflammatory arthropathy, ankle infectious pathologies, and Charcot foot and ankle prosthesis failures. All patients underwent standard preoperative evaluations and received corticocancellous grafts. An angled retrograde femoral nail in the sagittal plane was used for internal fixation. Postoperative immobilization lasted 6 to 8 weeks, with subsequent rehabilitation. The bone fusion rate was 100%, with a low complication rate (23.5%). DISCUSSION Our study showed a younger patient population with a male predominance, different from some previous studies. Surgical techniques, including the anterior approach combined with a lateral subtalar approach, were consistent with some studies but differed from others. Corticocancellous grafts and the angled retrograde femoral nail in the sagittal plane demonstrated favorable outcomes in terms of fusion. Complication rates were lower compared to some previous reports, highlighting potential improvements in postoperative management. CONCLUSION The surgical approach described for TTCA, emphasizing rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, led to satisfactory bone fusion and reduced postoperative complications. These results underscore the importance of this approach in achieving optimal functional outcomes in ankle arthrodesis.
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Affiliation(s)
- Anass Abaydi
- Orthodontics, University Hospital Center Hassan II, Fès, MAR
| | - Jihad Radi
- Traumatology and Orthopedic Surgery Department A, University Hospital Center Hassan II, Fès, MAR
| | - Amine Tbatou
- Traumatology and Orthopedic Surgery Department A, University Hospital Center Hassan II, Fès, MAR
| | - Kamal Lahrach
- Traumatology and Orthopedic Surgery Department A, University Hospital Center Hassan II, Fès, MAR
| | - Fawzi Boutayb
- Traumatology and Orthopedic Surgery Department A, University Hospital Center Hassan II, Fès, MAR
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Araujo-Monsalvo VM, Toledo-Romo MF, Rodríguez-Castro GA, Vázquez-Escamilla J, Domínguez-Hernández VM, Meneses-Amador A, Cortés-García JR, Martínez-Coria E. Comparative study of two retrograde locked intramedullary nail designs for ankle arthrodesis: A finite element analysis. Proc Inst Mech Eng H 2024; 238:198-206. [PMID: 38193256 DOI: 10.1177/09544119231221191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Ankle arthrodesis is the gold standard for treatment of end-stage arthritis. The goal of ankle arthrodesis is to obtain bony union between the tibia and the talus. Retrograde intramedullary nailing is typically reserved for ankle and subtalar joints arthrodesis. The purpose of this study is to evaluate the effect of two different materials, two locking pin configurations and two nail designs of a retrograde locked intramedullary nail used for ankle arthrodesis. Using the finite element analysis, a numerical study of ankle arthrodesis was developed to evaluate the effect of materials: TI-6Al-4V and stainless steel AISI 316 LVM; two locking pin configurations: five and six pins, on two intramedullary nails: Ø10 × 180 mm and Ø11 × 200 mm. A model of a healthy foot was created from tomographic scans. It was found that the mechanical stimulus required to achieve bone fusion were higher for Ø10 × 180 nails (6.868 ± 0.047) than the Ø11 × 200 nails (5.918 ± 0.047; p < 0.001; mean ± SEM). We also found that six-pin configuration had a higher mechanical stimulus (6.470 ± 0.047) than the five-pin configuration (6.316 ± 0.046; p = 0.020). Similarly, it was higher for titanium (6.802 ± 0.047) than those for stainless steel (5.984 ± 0.046; p < 0.001). Finally, the subtalar zone presented higher values (7.132 ± 0.043) than the tibiotalar zone (5.653 ± 0.050; p < 0.001). The highest mechanical stimulus around the vicinity of tibiotalar and subtalar joint was obtained by Ø10 × 180 nails, made of titanium alloy, with 6P.
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Affiliation(s)
- Víctor Manuel Araujo-Monsalvo
- Laboratorio de Biomecánica, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra," Mexico City, Mexico
| | | | | | - Jesús Vázquez-Escamilla
- Deformidades Neuromusculares, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra," Mexico City, Mexico
| | | | - Alfonso Meneses-Amador
- Departamento de Ingeniería Mecánica, SEPI-ESIME, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Juan Ricardo Cortés-García
- Deformidades Neuromusculares, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra," Mexico City, Mexico
| | - Elisa Martínez-Coria
- Tomografía Computada, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra," Mexico City, Mexico
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Muacevic A, Adler JR. Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing. Cureus 2022; 14:e28036. [PMID: 36120283 PMCID: PMC9473675 DOI: 10.7759/cureus.28036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.
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Phillips M, Bullock G, Scott A. Use of the Straight Retrograde Intramedullary Nail for Tibiotalocalcaneal Arthrodesis: A Single-Institution, Single-Surgeon, Single-Implant Retrospective Series. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221123804. [PMID: 36185348 PMCID: PMC9523874 DOI: 10.1177/24730114221123804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The hindfoot fusion nail has become a popular implant for tibiotalocalcaneal (TTC) arthrodeses given its rigidity, ease of insertion, and potential for less invasive surgical approaches. The purpose of this study was to evaluate fusion and complication rates following the use of a straight, retrograde intramedullary nail for TTC arthrodeses, and the influence of diabetes and smoking on these results. Methods: A review of patient cases performed by a single surgeon at a single institution was performed. Variables included age, comorbidities, smoking history, BMI, hemoglobin A1c, preoperative and postoperative visual analog scale pain scores, assessment of healing, and complications. Relative and absolute risk were assessed for smoking, diabetes, fusion, and surgical complications through risk ratios. Cox proportional hazards survival analyses were performed to assess the effects of smoking and diabetes on fusion rates and complications. Linear regressions were performed to investigate the effects of smoking and diabetes on patient-reported pain levels. Results: Of 103 patients, there were 37 cigarette smokers and 30 diabetic patients. Eighty-three patients achieved union of all involved joints and 19 patients achieved union of 1 or 2 joints. Smokers demonstrated a 1.46 (risk ratio) (95% CI 1.03-2.07) times greater risk of nonunion but were not at an increased risk of experiencing surgical complications (0.86, 95% CI 0.56-1.33). Diabetic patients did not demonstrate an increased risk of nonunion (0.86, 95% CI 0.56-1.33) or complications (1.18, 95% CI 0.76-1.83). Conclusion: Because of increased nonunion risk, patients undergoing elective tibiotalocalcaneal arthrodesis should be counseled increased nonunion risks associated with smoking. In this series, we did not find a relationship between diabetes and complications or nonunion. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- McLeod Phillips
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Aaron Scott
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Galhoum AE, Abd-Ella MM, Zahlawy HE, Tejero S, Valderrabano V, Trivedi V, ElGebeily M. Infected unstable Charcot ankle neuroarthropathy, any hope before amputation? A prospective study. INTERNATIONAL ORTHOPAEDICS 2022; 46:1481-1488. [PMID: 35449479 DOI: 10.1007/s00264-022-05400-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures, and instability. In this study, we present the results of salvage procedure of the ankle Charcot neuroarthropathy using aggressive debridement and Ilizarov frame fusion with early weight bearing. METHODS Twenty-three patients with severely infected ulcerated and unstable Charcot neuroarthropathy of the ankle were treated between 2013 and 2018. The mean age was 63.5 ± 7.9 years; 16 males and seven females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, was performed followed by external fixation with an Ilizarov frame along with early weight-bearing. The primary outcome was a stable plantigrade infection-free foot and ankle that allows weight-bearing in accommodative footwear. RESULTS Limb salvage was achieved in 91.3% of cases at the end of a mean follow-up time of 19 months (range: 17-29). Fifteen (71.4%) solid bony unions evident clinically and radiographically were achieved, while six (28.5%) patients developed stable painless pseudarthrosis. Two patients had below-knee amputations due to uncontrolled infection. CONCLUSION Aggressive debridement and arthrodesis using ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing, and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection.
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Affiliation(s)
- Ahmed E Galhoum
- George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK.
| | | | | | - Sergio Tejero
- Hospital Virgen del Rocío, University of Seville, Seville, Spain
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Management of Ankle Charcot Neuroarthropathy: A Systematic Review. J Clin Med 2021; 10:jcm10245923. [PMID: 34945220 PMCID: PMC8707751 DOI: 10.3390/jcm10245923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes. Repetitive trauma from standing and walking provides a neuro-traumatic stimulus that leads to dislocation, or peri-articular fracture, or both, within the ankle. This review concentrates on the management protocols regarding the ankle only. Methods: A Pubmed search for clinical trials performed to manage ankle Charcot neuroarthropathy and a systematic review of these articles were undertaken. Results: Twenty papers met the inclusion criteria: four of them describe non-surgical management, while the rest show different surgical management options of ankle Charcot neuroarthropathy. Conclusions: Surgical algorithms for the treatment of CN of the ankle are based almost entirely on level four. There is inconclusive evidence concerning the timing of treatment and the use of different fixation methods. Instability and ulceration are the main precursors for surgical interventions. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.
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Rana B, Patel S. Results of Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy - A retrospective analysis of 44 patients. J Clin Orthop Trauma 2021; 23:101637. [PMID: 34824972 PMCID: PMC8600528 DOI: 10.1016/j.jcot.2021.101637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/26/2021] [Accepted: 10/08/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy. STUDY DESIGN A retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre. PATIENTS AND METHODS In a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction). RESULTS There were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%). CONCLUSION Despite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.
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Affiliation(s)
- Balvinder Rana
- Max Super Specialty Hospital, Press Enclave Marg, Saket, New Delhi and Max Hospital, B Block, Sushant Lok, Gurgaon, Haryana, 122001, India,Corresponding author.
| | - Sandeep Patel
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160012, India
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Powers NS, Leatham PR, Persky JD, Burns PR. Outcomes of Tibiotalocalcaneal Arthrodesis with a Femoral Nail. J Am Podiatr Med Assoc 2021; 111:466723. [PMID: 34144596 DOI: 10.7547/19-151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters. METHODS We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated. RESULTS At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection-related complications. CONCLUSIONS Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.
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El-Tantawy A, Atef A, Samy A. Trans-calcaneal retrograde nailing for secondary-displaced traumatic ankle fractures in diabetics with insensate feet: a less-invasive salvage-arthrodesis technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:37-46. [PMID: 33687556 DOI: 10.1007/s00590-021-02898-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Secondary displacement of traumatic ankle fractures with subsequent soft-tissue breakdown is a troublesome issue after inappropriate conservative treatment among non-compliant diabetic patients with severe peripheral neuropathy. This study was conducted to evaluate the results of a less-invasive arthrodesis procedure as an alternative to osteosynthesis in these complex scenarios. METHODS A total of 46 diabetics, who underwent fluoroscopy-assisted trans-calcaneal retrograde nailing-based ankle arthrodesis between 2012 and 2018 for salvaging secondary-displaced diabetic ankle fractures in their insensate feet, were evaluated in this retrospective study. All fractures were associated with uninfected mechanical ulcers overlying malleoli, without Charcot changes, after failed conservative cast immobilization. The patients (mean age: 52.52 ± 3.70 years; 18 males; 46 feet) were evaluated radiologically for union and clinically for limb salvage, modified American Orthopedic Ankle and Foot Scale (AOAFS), and the overall subjective patients' satisfaction. RESULTS The mean follow-up was 29.5 ± 3.1 months. All ulcers have healed with local care only with 100% limb salvage. Four patients experienced minor wound healing problems at posterior heel, and another one developed acute Charcot changes that was successfully managed by offloading and repeat surgery. Forty patients (86.96%) had fully consolidated fusions with a mean time to fusion 15.78 ± 2.58 weeks, while the other six cases had stable fibrous-union. At the final follow-up, the mean modified-AOFAS was 76.85 ± 6.0 from 86 total points. All, but four patients (91.30%) were completely satisfied while the other four patients were partially satisfied. CONCLUSIONS The presented less-invasive arthrodesis technique is reproducible and effective alternative for salvaging unstable diabetic ankle fractures in the insensate feet when standard surgical procedures would be more risky. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Ahmad El-Tantawy
- Orthopedic and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Ashraf Atef
- Orthopedic and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Samy
- Orthopedic and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Rozis M, Benetos I, Afrati SR, Polyzois VD, Pneumaticos SG. Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion. J Foot Ankle Surg 2021; 59:337-342. [PMID: 32131000 DOI: 10.1053/j.jfas.2019.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/01/2019] [Accepted: 05/19/2019] [Indexed: 02/03/2023]
Abstract
Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.
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Affiliation(s)
- Meletis Rozis
- Orthopaedic Resident, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece.
| | - Ioannis Benetos
- Orthopaedic Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Spyridoula-Roberta Afrati
- Anesthesiologist Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Vasilios D Polyzois
- Orthopaedic Consultant, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
| | - Spyros G Pneumaticos
- Orthopaedic Professor, 3rd Orthopaedic Clinic, University of Athens, KAT Hospital, Athens, Greece
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Powers NS, Brandao RA, St John JM, Burns PR. Outcomes and Management of Infected Intramedullary Nails After Tibiotalocalcaneal Arthrodesis in Limb Salvage: A Retrospective Case Series. J Foot Ankle Surg 2021; 59:431-435. [PMID: 32131017 DOI: 10.1053/j.jfas.2018.11.036] [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: 07/08/2018] [Revised: 10/26/2018] [Accepted: 11/05/2018] [Indexed: 02/03/2023]
Abstract
Retrograde intramedullary nails are often used for tibiotalocalcaneal arthrodesis to correct severe hindfoot deformities in high-risk patient populations. The purposes of the current study are to report outcomes of patients undergoing staged management of infection after intramedullary nail fixation for tibiotalocalcaneal arthrodesis and to review the surgical approach to management of this limb-threatening complication. The authors reviewed patients who underwent hindfoot intramedullary nailing with subsequent revision for infection between January 2006 and December 2016. Staged protocol with antibiotic nail for the management of deep infection was used in 19 patients. The mean follow-up was 115.87 ± 92.80 (range 2.29 to 341.86) weeks. Twelve of the patients had diabetes, 10 had Charcot neuroarthropathy, and 7 had arthrodesis for equinovarus deformity. Sixteen had peripheral neuropathy and 13 had history of ulceration on the operated extremity. Limb salvage with the use of this protocol was achieved in 14 (73.68%) of 19 patients. Five (26.32%) patients had proximal amputation with 3 (15.79%) deaths within the follow-up period. Amputation was more likely in the nonsmoking (p = .01) and insulin-dependent (odds ratio = 22, p = .02) patient cohorts, whereas death was associated only with higher body mass index (p = .03). Time to revision was greater in patients with external bracing postoperatively as well (p = .004). Outcomes, including total number of procedures and retained antibiotic rods, were not associated with any of the preoperative variables or indications. In high-risk patient populations, the presented staged management of infected intramedullary hindfoot nails showed promising outcomes for limb preservation.
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Affiliation(s)
- Nicholas S Powers
- Resident, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center Mercy, Pittsburgh, PA.
| | | | | | - Patrick R Burns
- Assistant Professor, Podiatric Medicine and Surgery Residency, Department of Orthopedic Surgery, University of Pittsburgh Medical Center Mercy, University Pittsburgh School of Medicine, Pittsburgh, PA
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Kowalski C, Stauch C, Callahan R, Saloky K, Walley K, Aynardi M, Juliano P. Prognostic risk factors for complications associated with tibiotalocalcaneal arthrodesis with a nail. Foot Ankle Surg 2020; 26:708-711. [PMID: 31543311 DOI: 10.1016/j.fas.2019.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis with a nail can be an effective salvage procedure for several foot and ankle pathologies, but has a relatively high complication rate. The purpose of this study is to investigate risk factors associated with complications after TTC arthrodesis with a nail. METHODS Clinical and radiographic outcomes for 82 patients from 2012 to 2016 who underwent TTC arthrodesis with a nail were retrospectivelyevaluated to determine if patient or surgeon specific variables offered prognostic value in predicting negative outcomes. RESULTS Diabetes, diabetic neuropathy, high (>2) American Society of Anesthesiologists (ASA) classification, and Charcot neuroarthropathy all were predictive of developing a nonunion in either the subtalar ortibiotalar joints (p<0.05). Diabetic neuropathy was predictive ofreoperation, and along with HbA1C >7.5 was also predictive of hardwarefailure. The odds ratio (OR) for diabetic neuropathy was 2.99 (p<0.05)for nonunion in the tibiotalar or subtalar joints, 3.46 (p<0.05) for reoperation,and 4.11 (p<0.05) for hardware failure. High ASAclassification had an odds ratio of 3.93 (p<0.05) for nonunion in the tibiotalar or subtalar joints as well. Diabetes had an odds ratio of 2.57 (p<0.05) for nonunion. CONCLUSIONS Patients with diabetic neuropathy, Charcot neuroarthropathy, elevated HbA1C, and ASA classification >2 demonstrated a higher complication rate in patients undergoing TTC arthrodesis with a nail.
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Affiliation(s)
- Chris Kowalski
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States.
| | - Chris Stauch
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Ryan Callahan
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Kaitlin Saloky
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Kempland Walley
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Michael Aynardi
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Paul Juliano
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
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Cianni L, Bocchi MB, Vitiello R, Greco T, De Marco D, Masci G, Maccauro G, Pitocco D, Perisano C. Arthrodesis in the Charcot foot: a systematic review. Orthop Rev (Pavia) 2020; 12:8670. [PMID: 32913602 PMCID: PMC7459387 DOI: 10.4081/or.2020.8670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.
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Affiliation(s)
- Luigi Cianni
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Maria Beatrice Bocchi
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Raffaele Vitiello
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Tommaso Greco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Davide De Marco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Università Cattolica del Sacro Cuore, Rome
| | - Dario Pitocco
- Diabetes Care Unit, Institute of Endocrinology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Perisano
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
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16
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Ersin M, Demirel M, Chodza M, Bilgili F, Kiliçoglu OI. Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy. Acta Orthop 2020; 91:336-340. [PMID: 32233910 PMCID: PMC8023973 DOI: 10.1080/17453674.2020.1746605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.
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Affiliation(s)
- Mehmet Ersin
- Department of Orthopaedics and Traumatology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Mehmet Chodza
- Department of Orthopaedics and Traumatology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Fuat Bilgili
- Department of Orthopaedics and Traumatology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey
| | - Onder Ismet Kiliçoglu
- Department of Orthopaedics and Traumatology, İstanbul School of Medicine, İstanbul University, İstanbul, Turkey,Correspondence:
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Ha J, Hester T, Foley R, Reichert IL, Vas PR, Ahluwalia R, Kavarthapu V. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma 2020; 11:357-368. [PMID: 32405193 PMCID: PMC7211810 DOI: 10.1016/j.jcot.2020.03.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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Affiliation(s)
- Joon Ha
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Thomas Hester
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Robert Foley
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Ines L.H. Reichert
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Prashanth R.J. Vas
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
- King’s Diabetic Foot Clinic, King’s College College Hospital, London
| | - Raju Ahluwalia
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Venu Kavarthapu
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
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Yammine K, Assi C. Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: A meta-analysis of comparative studies. J Orthop Surg (Hong Kong) 2020; 27:2309499019836012. [PMID: 30894064 DOI: 10.1177/2309499019836012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Ankle Charcot neuroarthropathy presents a great challenge for treatment. While conservative treatments yield poor results, arthrodesis is considered the treatment of choice for unstable Charcot ankles. There are two methods used for ankle fusion: retrograde intramedullary nail (IMN) and external fixator (EF). Literature reports inconclusive results on which method is better for arthrodesis. METHODS The aim of this meta-analysis is to look for significant difference between the two techniques in terms of fusion rate and complications. Four comparative studies including 117 patients (117 interventions) were located and analyzed. RESULTS IMN was found to yield double fusion rate than EF ( p = 0.2) with 5 weeks less time to heal ( p = 0.4). While no significance was noted for revision surgery and amputation rates, EF yielded higher rates of hardware infection ( p = 0.01) and wound infection ( p = 0.01). The IMN method seems to offer quicker and better fusion rate when compared to EF with significantly lower postoperative infection rates. CONCLUSION In the clinical context of high-risk patients such as the diabetic population, IMN technique could be a better option in the case of ulcer-free ankles/feet or in the presence of medial/lateral ulcers. In case of presence of plantar ulcers, EF might be a better choice to avoid the plantar approach for nail insertion. Future research with bigger sample sized and randomized studies are warranted for validation.
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Affiliation(s)
- Kaissar Yammine
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,4 Diabeti Foot Clinic, Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon
| | - Chahine Assi
- 1 Department of Orthopedics, Lebanese American University Medical Center-Rizk Hospital, Achrafieh, Beirut, Lebanon.,2 School of Medicine, Lebanese American University, Byblos, Lebanon.,3 Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
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19
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Love B, Alexander B, Ray J, Halstrom J, Barranco H, Solar S, Singh M, Shah A. Outcomes of Tibiocalcaneal Arthrodesis in High-Risk Patients: An Institutional Cohort of 18 Patients. Indian J Orthop 2020; 54:14-21. [PMID: 32257014 PMCID: PMC7093629 DOI: 10.1007/s43465-020-00048-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/18/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Tibiocalcaneal (TC) arthrodesis is commonly performed in patients with severe hindfoot disease. These include severe Charcot deformities, ankle malformations, chronic osteomyelitis (COM), and avascular necrosis (AVN). The talar vascular becomes disrupted to the point that the bone can no longer be salvaged. The procedure involves performing a talectomy and fusing the tibia to the calcaneus. This helps in preserving the remaining hindfoot anatomy, while allowing the patient to regain function and mobility. Our study highlights certain risk factors that influence the rate of postoperative complication after tibiocalcaneal surgery. MATERIALS AND METHODS We retrospectively reviewed the charts of 18 patients from a single institution who underwent tibiocalcaneal between the years of 2011 and 2019. Preoperative diagnoses, comorbidities, and post-operative outcomes were noted among all patients. Then, the rates of non-union, below-knee amputations, revision surgeries, postoperative infections, and hardware failure were recorded. These data were then analyzed to determine which preoperative and perioperative factors affected postoperative outcomes for patients after tibiocalcaneal arthrodesis surgery. RESULTS Nonunion was the most commonly reported complication in this series. Eight of the eighteen patients were documented to have nonunion including three patients with stable pseudarthrosis. Diabetic patients had a slightly higher incidence of nonunion (4 of 7 patients) compared to those without diabetes (4 of 11 patients). Of the nine patients diagnosed with Charcot arthropathy, five had nonunion. Three of the five individuals with a BMI ranging from 25 to 30, and four of the six individuals with a BMI of greater than 30 had a nonunion. Infection was a post-operative complication for four of the eighteen patients. Two of the four patients had multiple comorbidities in addition to chronic infections in the joint which were recurrent after surgery. CONCLUSION In conclusion, TC arthrodesis provides a viable option for high-risk patients with complicated ankle pathology who have not had successful outcomes from previous treatment. It is not without complications considering the comorbidities the patients present with before requiring this procedure. Further studies are necessary to validate the trends of outcomes and comorbidities of patients with TC arthrodesis.
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Affiliation(s)
- Bridgette Love
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Bradley Alexander
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Jessyca Ray
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Jared Halstrom
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Hannah Barranco
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Spaulding Solar
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
| | - Maninder Singh
- grid.464889.f0000 0004 1800 5096Indian Spinal Injuries Center, New Delhi, India
| | - Ashish Shah
- grid.265892.20000000106344187Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205 USA
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20
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Harkin EA, Schneider AM, Murphy M, Schiff AP, Pinzur MS. Deformity and Clinical Outcomes Following Operative Correction of Charcot Ankle. Foot Ankle Int 2019; 40:145-151. [PMID: 30526048 DOI: 10.1177/1071100718805076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Deformity associated with Charcot foot arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following operative correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot foot arthropathy involving the ankle joint. METHODS: Fifty-six consecutive patients underwent operative reconstruction of Charcot foot deformity involving the ankle joint by a single surgeon over a 14-year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single-stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years. RESULTS: One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty-eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between pre- or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome. CONCLUSIONS: Operative correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly comorbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques. LEVEL OF EVIDENCE: Level IV, case series.
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Affiliation(s)
- Elizabeth A Harkin
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Andrew M Schneider
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | | | - Adam P Schiff
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- 1 Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Tomczak C, Beaman D, Perkins S. Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle. Foot Ankle Int 2019; 40:48-55. [PMID: 30264587 DOI: 10.1177/1071100718800836] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The severely deformed, infected, and unstable neuroarthropathic ankle is challenging to treat. We evaluated our preliminary experience and results of combined internal and external ring fixation for a complex neuropathic population. METHODS: We retrospectively reviewed medical records and radiographs for 8 patients with unilateral severely deformed ankle neuroarthropathy associated with infection and ulceration. Treatment included single-stage reconstruction arthrodesis with an interlocked intramedullary nail coated with antibiotic-containing cement combined with ring fixation. Taylor Spatial Frame™ technology was used when the deformity was not amenable to acute correction (5 patients). Protected postoperative weightbearing was permitted. Their mean age averaged 55.6 (range, 42-66) years with an average body mass index of 38.4 (range, 28.7-49.6) kg/m2. RESULTS: Seven patients achieved limb preservation. Average time for fusion healing was 15.2 (range, 12.2-22.2) weeks, frame time was 17.7 (range, 12.2-23.0) weeks, and follow-up was 34.1 (range, 24.1-68.8) months. All presenting wounds and infection successfully resolved. Reinker and Carpenter scale was excellent for 2 patients, good for 2 patients, and fair for 3 patients. Foot and Ankle Ability Measure averaged 59.0% (range, 39.3%-87.5%). One patient developed a recalcitrant calcaneal ulcer with osteomyelitis that required a transtibial amputation 17 months after successful ankle arthrodesis. CONCLUSIONS: Combined use of interlocked intramedullary nail and ring external fixation for neuroarthropathic ankle arthrodesis achieved a functional and clinically stable salvaged lower limb for most patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
| | | | - Serene Perkins
- 2 Legacy Institute for Surgical Education & Innovation, Legacy Research Institute, Portland, OR, USA
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22
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Lee M, Choi WJ, Han SH, Jang J, Lee JW. Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail. Foot Ankle Surg 2018; 24:542-548. [PMID: 29409267 DOI: 10.1016/j.fas.2017.07.006] [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] [Received: 02/16/2017] [Revised: 06/04/2017] [Accepted: 07/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) fusion using a retrograde intramedullary (IM) nail is an effective salvage option for terminal-stage hindfoot problems. However, as many patients who receive TTC fusion bear unfavorable medical comorbidities, the risk of nonunion, infection and other complications increases. This study was performed to identify the factors influencing outcomes after TTC fusion using a retrograde IM nail. METHODS Between September 2008 and February 2012, 34 consecutive patients received TTC fusion using a retrograde IM nail for limb salvage. All patients had a minimum follow-up of two years. Throughout follow-up, standard ankle radiography was performed along with clinical outcome assessment using a visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society Ankle-Hind Foot Scale (AOFAS A/H scale) and the Foot and Ankle Outcome Score (FAOS). For the retrospective analysis, demographic factors, preoperative medical status, laboratory markers, and etiology were comprehensively reviewed using medical records. The success of the index operation was determined using clinical and radiological outcomes. Finally, the effect of each factor on failure after the operation was analyzed using univariate logistic regression. RESULTS In a mean of seven months, 82% (28/34) achieved union, as evaluated by standard radiography. All clinical outcome parameters improved significantly after the operation, including VAS, AOFAS A/H scale, and FAOS (P<0.001). At the last follow-up, five cases of nonunion with less than AOFAS A/H scale of 80 and two cases of below knee amputation due to uncontrolled infection were determined to be failures. None of the factors (etiology, demographics, laboratory markers and medical status) significantly influenced failures. However, uncontrolled DM significantly increased the failure rate with an odds ratio of 10 (P=0.029). CONCLUSIONS TTC fusion with a retrograde intramedullary nail is a successful treatment for complicated hindfoot problems such as traumatic osteoarthritis, Charcot arthropathy and failed TAA. However, it should be used judiciously in patients with uncontrolled DM, as the risk of failure increases. DESIGN Retrospective cohort study.
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Affiliation(s)
- Moses Lee
- Department of Orthopaedic Surgery, Gwangmyeong Sungae Hospital, Republic of Korea
| | - Woo Jin Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Jinyoung Jang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea.
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23
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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: 0.9] [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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24
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Abstract
Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073.
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Affiliation(s)
- Önder İ. Kılıçoğlu
- Department of Orthopaedics and Traumatology, İstanbul University, Istanbul Faculty of Medicine, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, İstanbul University, Istanbul Faculty of Medicine, Turkey
| | - Şamil Aktaş
- Department of Underwater and Hyperbaric Medicine, İstanbul University, Istanbul Faculty of Medicine, Turkey
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25
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El-Mowafi H, Abulsaad M, Kandil Y, El-Hawary A, Ali S. Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy. Foot Ankle Int 2018; 39:93-98. [PMID: 29035584 DOI: 10.1177/1071100717735074] [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 Ankle fusion is difficult to achieve in the diabetic Charcot ankle Brodsky type 3a because of the poor quality of the bone and the inability to achieve a stable biomechanical construct. The aim of this study was to report the outcome of ankle fusion using a combination of an intramedullary nail and a circular external fixator in patients with diabetic Charcot arthropathy. METHODS We prospectively studied 24 patients with diabetic Charcot arthropathy of the ankle who were treated by fusion of the tibiotalar joint using a combined retrograde intramedullary nail and Ilizarov external fixator. Their mean age was 50.7 ± 6.9 (range, 43-62) years. The mean follow-up after surgery was 36.4 ± 5.8 (range, 24-98) months. RESULTS Twenty-two patients (92%) achieved clinical and radiographic solid bony fusion. No patients in this series needed amputation. All the patients were pain free, and the mean American Orthopaedic Foot & Ankle Society Score (AOFAS) improved significantly from 34.6 ± 6.8 to 66.4 ± 4.5 at the last follow-up. Two patients developed an ulcer over the heel due to a prominent nail. The ulcer healed after nail removal. Eight patients developed pin tract infection. CONCLUSION We report a successful outcomes of ankle fusions using combined intramedullary nail locked only proximally and ring external fixator (hybrid fixation) in patients with diabetic Charcot arthropathy. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Hani El-Mowafi
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Mazen Abulsaad
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Yasser Kandil
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Ahmed El-Hawary
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
| | - Samer Ali
- 1 Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Eldakahlia, Egypt
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26
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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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27
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Ramanujam CL, Stapleton JJ, Zgonis T. Operative Fixation Options for Elective and Diabetic Ankle Arthrodesis. Clin Podiatr Med Surg 2017; 34:347-355. [PMID: 28576194 DOI: 10.1016/j.cpm.2017.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Ankle arthrodesis remains one of the most definitive treatment options for end-stage arthritis, paralysis, posttraumatic and postinfectious conditions, failed total ankle arthroplasty, and severe deformities. The general aims of ankle arthrodesis are to decrease pain and instability, correct the accompanying deformity, and create a stable plantigrade foot. Several surgical approaches have been reported for ankle arthrodesis with internal fixation options. External fixation has also evolved for ankle arthrodesis in certain clinical scenarios. This article provides a comprehensive analysis of midterm to long-term outcomes for ankle arthrodesis using internal and/or external fixation each for elective and diabetic conditions.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
| | - John J Stapleton
- Foot and Ankle Surgery, Lehigh Valley Hospital, 1250 South Cedar Crest Boulevard, Suite 110, Allentown, PA 18103, USA; Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
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28
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Booth S, Ballal M, Pillai A. Complex ankle arthrodesis with step-cut osteotomy in Charcot arthropathy with bone loss. Foot Ankle Surg 2017; 23:e5-e7. [PMID: 28159052 DOI: 10.1016/j.fas.2016.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/24/2016] [Accepted: 08/31/2016] [Indexed: 02/04/2023]
Abstract
We report a case of a complex limb salvage ankle arthrodesis in a patient with Charcot arthropathy. A step-cut osteotomy was performed in order to tackle the issues of anterior tibial bone loss; worsening leg length discrepancy; soft tissue contraction; joint instability and high risk of non-union. The construct formed by the step-cut allowed for the preservation of good bone stock; avoidance of further limb shortening; increased torsional stability and increased surface area for bony union. This resulted in a patient with a stable, plantigrade foot appropriate for footwear. We use this case to highlight this technique as an option in the operative management of complex ankle fusions with sagittal or coronal plane deformity with bone loss and subluxation of the ankle joint.
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Affiliation(s)
- Sean Booth
- University Hospital South Manchester, Manchester, UK.
| | - Moez Ballal
- University Hospital South Manchester, Manchester, UK
| | - Anand Pillai
- University Hospital South Manchester, Manchester, UK
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29
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Richman J, Cota A, Weinfeld S. Intramedullary Nailing and External Ring Fixation for Tibiotalocalcaneal Arthrodesis in Charcot Arthropathy. Foot Ankle Int 2017; 38:149-152. [PMID: 27698177 DOI: 10.1177/1071100716671884] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical strategies to address deformities of the ankle and hindfoot in patients with Charcot arthropathy include the use of retrograde intramedullary nails and ring fixators. The literature has not shown superiority of one technique over the other. This study presents a single surgeon's case series of Charcot arthropathy patients treated with either a ring fixator or retrograde intramedullary nail to achieve tibiotalocalcaneal arthrodesis. METHODS We performed a retrospective analysis of 27 consecutive patients with Charcot arthropathy who underwent a tibiotalocalcaneal arthrodesis using either a retrograde intramedullary (IM) nail (n = 16 patients) or a ring fixator (RF) (n = 11 patients) by a single surgeon. We report the rates of limb salvage complications requiring secondary surgery and fusion in both groups. The patient demographics and presence of medical comorbidities known to increase the risk of surgical complications were similar between groups. The mean duration of follow-up for the retrograde nail group was 3.6 years and 2.2 years for the ring fixator group. RESULTS The mean time to discharge from the hospital after the index surgical procedure was 2.7 days for the IM group and 4.6 days for the RF group. For the patients treated with a ring fixator, the mean time to removal of the frame after the initial application was 13.3 ± 1.8 weeks. The limb salvage rate for the RF group was 9 of 11 patients whereas it was 15 of 16 in the IM group. Complications including deep infection, hardware failure, and symptomatic nonunion requiring revision surgery were common in the IM group, with 11 of 16 patients requiring further surgery. Seven patients in the IM group required removal of the implant at a mean of 117.2 weeks after the index procedure because of the development of deep infection or nail cutout. In the RF group, only 1 patient required revision surgery. Fusion rates were similar between both groups, with 10 of 16 patients fusing in the IM group and 7 of 11 in the RF group. CONCLUSION Use of a retrograde intramedullary rod or ring fixator resulted in high rates of successful limb salvage when used for tibiotalocalcaneal arthrodesis in patients with Charcot arthropathy. However, in this study, the need for revision surgery was more frequent in the retrograde nail group compared to the ring fixator group. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- James Richman
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
| | - Adam Cota
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
| | - Steven Weinfeld
- 1 Department of Orthopaedics, Mount Sinai Hospital, New York, NY, USA
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30
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Sundararajan SR, Srikanth KP, Nagaraja HS, Rajasekaran S. Effectiveness of Hindfoot Arthrodesis by Stable Internal Fixation in Various Eichenholtz Stages of Neuropathic Ankle Arthropathy. J Foot Ankle Surg 2017; 56:282-286. [PMID: 28110796 DOI: 10.1053/j.jfas.2016.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Indexed: 02/03/2023]
Abstract
The optimal time to treat neuropathic (Charcot) arthropathy of the ankle and peritalar joint is controversial because of the various treatment options available and the variable results reported in published studies. We sought to determine the outcome of hind foot arthrodesis with stable internal fixation in patients with different Eichenholtz stages of arthropathy. We prospectively studied patients with substantial disabilities caused by neuropathic arthropathy in deformed, unstable ankle and peritalar joints, with or without ulcerations, who had undergone treatment from July 2007 to December 2012. All patients underwent ankle arthrodesis, autologous iliac crest bone grafting, and subtalar joint arthrodesis, with or without talonavicular joint arthrodesis, fixed internally with an intramedullary hindfoot nail, with or without an additional plate or cancellous screws. Of the 33 enrolled patients, 9 (27.3%) had stage I, 13 (39.4%) had stage II, and 11 (33.3%) had stage III Charcot arthropathy. The cause of arthropathy was diabetes mellitus in 25 (75.8%) patients. The duration of symptoms ranged from 1 to 120 (median 7) months. The mean follow-up period was 40 (range 12 to 76) months and did not differ markedly among the groups. The hindfoot scores, rate of salvage or amputation, or complication rates did not differ significantly across Eichenholtz stage. For the patients with stage I, II, and III, the preoperative hindfoot score was 50, 49, and 48, respectively (p = .9). The corresponding postoperative scores were 68, 68, and 70 (p = .5). We found no evidence that the effectiveness of hindfoot arthrodesis by stable fixation varied across the Eichenholtz stage of Charcot arthropathy involving ankle and peritalar joint. Furthermore, we found that stable internal fixation and bone grafting using a hindfoot nail results in an 84.84% union rate and salvages the unstable and disabled foot in 90.9% of patients with ankle and peritalar Charcot arthropathy.
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Affiliation(s)
- Silvampatty R Sundararajan
- Consultant Orthopaedic and Arthroscopic Surgeon, Department of Orthopaedics, Ganga Hospital, Coimbatore.
| | - Kanchana P Srikanth
- Senior Registrar, Department of Orthopaedics, Ganga Hospital, Coimbatore, Tamil Nadu, India
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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: 54] [Impact Index Per Article: 6.0] [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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32
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Tibiocalcaneal arthrodesis as a limb salvage procedure for complex hindfoot deformities. Arch Orthop Trauma Surg 2016; 136:457-62. [PMID: 26887665 DOI: 10.1007/s00402-016-2420-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Tibiocalcaneal (TC) arthrodesis is a limb salvage method for patients with severe deformities combined with necrosis and/or luxation of the talus. The aim of this study was to examine the clinical and radiological outcome of TC arthrodesis. MATERIALS AND METHODS This retrospective study identified 12 patients with luxation and/or necrosis of the talus, due to charcot neuroarthropathy (83.3 %) or traumatic injuries (16.7 %). All patients underwent TC arthrodesis by an external fixator or nail arthrodesis. The mean follow up was 18 (6-36) months with a mean age of 51.3 (30-66) years. The data were collected using the AOFAS score as well as clinical and radiological examination during regular follow up. RESULTS Seven (58.3 %) patients were treated with an external fixator, four (33.3 %) with nail arthrodesis and one (8.3 %) patient rejected both fixation methods. Four (100 %) patients achieved radiological and clinical bone union after nail arthrodesis and four (57.1 %) patients after external fixation. Three (42.9 %) patients treated by an external fixator showed a radiological moderate bone fusion, but a stable, asymptomatic non-union. One (8.3 %) case ended up in transfemoral amputation. Eleven patients (91.7 %) regained independent mobilization. The mean AOFAS score improved from 24.3 preoperatively to 66.7 postoperatively (p < 0.05). The postoperative satisfaction rate was good to excellent in 83.3 %. CONCLUSION TC arthrodesis is a promising and effective method for the treatment of severe ankle deformities with talus luxation. It allows patient's return to mobility with good to excellent patient satisfaction.
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Ettinger S, Plaass C, Claassen L, Stukenborg-Colsman C, Yao D, Daniilidis K. Surgical Management of Charcot Deformity for the Foot and Ankle-Radiologic Outcome After Internal/External Fixation. J Foot Ankle Surg 2016; 55:522-8. [PMID: 26898396 DOI: 10.1053/j.jfas.2015.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Indexed: 02/03/2023]
Abstract
Charcot neuropathy (CN) is a severe joint disease that makes surgical planning very challenging, because it is combined with ankle instability, serious deformities, and recurrent ulceration. The aim of the present study was to examine the rate of bone fusion after external or internal fixation in patients with CN. We retrospectively examined 58 patients with CN who had undergone reconstruction of the ankle either with tibiotalocalcaneal or tibiocalcaneal arthrodesis. The mean age was 59.1 (range 26 to 81) years at surgery. Of the 58 patients, 38 were treated using intramedullary nail arthrodesis and 19 using an external fixator (1 patient received neither). At a mean follow-up period of 31.3 (range 12 to 57) months, limb salvage and bone fusion had been achieved in 94.83%. The mean time to bone fusion was 12 (range 6 to 18) months. Three patients (5.2%) required a more proximal amputation. All but these 3 patients gained independent mobilization in custom feet orthoses or off the shelf orthoses. Of the 58 patients in the present cohort, 56 (96.6%) would undergo surgery again. In conclusion, internal and external fixation both lead to promising results in the treatment of CN. Internal fixation should be preferred when no indications of ulcer or infection are present.
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Affiliation(s)
- Sarah Ettinger
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany.
| | - Christian Plaass
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Leif Claassen
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | | | - Daiwei Yao
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Kiriakos Daniilidis
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
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Hartig N, Krenn S, Trnka HJ. [Surgical treatment of the Charcot foot : long-term results and systematic review]. DER ORTHOPADE 2016; 44:14-24. [PMID: 25586504 DOI: 10.1007/s00132-014-3058-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established. OBJECTIVES The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method. MATERIALS AND METHODS In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment. RESULTS After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented. CONCLUSION Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.
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Affiliation(s)
- N Hartig
- Abteilung für Kinderorthopädie und Fußchirurgie, Orthopädisches Krankenhaus Speising, Speisingerstraße 109, 1130, Wien, Österreich,
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35
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Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:292-6. [PMID: 26452590 DOI: 10.1002/dmrr.2748] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. SURGICAL MANAGEMENT The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. CONCLUSION Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.
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MESH Headings
- Ankle/pathology
- Ankle/surgery
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/pathology
- Arthropathy, Neurogenic/rehabilitation
- Arthropathy, Neurogenic/surgery
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Decision Trees
- Diabetic Foot/complications
- Diabetic Foot/pathology
- Diabetic Foot/rehabilitation
- Diabetic Foot/surgery
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/rehabilitation
- Diabetic Neuropathies/surgery
- Evidence-Based Medicine
- External Fixators/adverse effects
- External Fixators/trends
- Foot Deformities, Acquired/complications
- Foot Deformities, Acquired/pathology
- Foot Deformities, Acquired/rehabilitation
- Foot Deformities, Acquired/surgery
- Heel/pathology
- Heel/surgery
- Humans
- Internal Fixators/adverse effects
- Internal Fixators/trends
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Precision Medicine
- Preoperative Care/adverse effects
- Preoperative Care/trends
- Quality of Life
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - David Sadoskas
- Fellow Reconstruction and Limb Salvage Surgery UPMC Mercy Hospital, Pittsburgh, PA, USA
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36
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Abstract
Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.
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Affiliation(s)
- Daniel J Gehling
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States.
| | - Beata Lecka-Czernik
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Department of Physiology and Pharmacology, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States; Center for Diabetes and Endocrine Research, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
| | - Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, United States
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Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
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Affiliation(s)
- Remy V Rabinovich
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - Amgad M Haleem
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - S Robert Rozbruch
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
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Rabinovich RV, Haleem AM, Rozbruch SR. Complex ankle arthrodesis: Review of the literature. World J Orthop 2015; 6:602-613. [PMID: 26396936 PMCID: PMC4573504 DOI: 10.5312/wjo.v6.i8.602] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/22/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023] Open
Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients’ outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
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39
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Lareau CR, Deren ME, Fantry A, Donahue RMJ, DiGiovanni CW. Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature. Foot Ankle Surg 2015; 21:150-9. [PMID: 26235852 DOI: 10.1016/j.fas.2015.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior. METHODS A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material. RESULTS This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables. CONCLUSION Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Craig R Lareau
- Department of Orthopaedics, OrthoCarolina Foot and Ankle Institute, Charlotte, NC, United States
| | - Matthew E Deren
- Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States
| | - Amanda Fantry
- Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States.
| | - Rafe M J Donahue
- Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Avenue South S-2323 Medical Center North, Nashville, TN 37232, United States
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 3300, 3F, Boston, MA 02114, United States
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40
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Percutaneous injection of bone marrow mesenchymal stem cells for ankle non-unions decreases complications in patients with diabetes. INTERNATIONAL ORTHOPAEDICS 2015; 39:1639-43. [PMID: 25795249 DOI: 10.1007/s00264-015-2738-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/03/2015] [Indexed: 12/11/2022]
Abstract
PURPOSE Clinical studies in diabetic patients have demonstrated that there is a high incidence of complications in distal tibia and ankle fracture treatments. One strategy to mitigate issues with wound healing and infection in diabetic patients is to use a percutaneous technique in which autologous, bone marrow-derived, concentrated cells are injected at the site of non-unions. METHODS Eighty-six ankle non-union in diabetic patients were treated with bone marrow mesenchymal stem cells (BM-MSCs) delivered in an autologous bone marrow concentrate (BMC). Clinical outcomes of the 86 diabetic non-union patients treated with BMC were compared with 86 diabetic matched non-unions treated with a standard bone iliac crest autograft. RESULTS Treatment with BMC promoted non-union healing in 70 among 86 diabetic patients (82.1 %) with a low number of complications. Of the 86 diabetic patients treated with iliac bone graft, 53 (62.3 %) had healing; major complications were observed: 5 amputations, 11 osteonecroses of the fracture wound edge and 17 infections. CONCLUSIONS In diabetic patients with ankle non-unions, treatment with BM-MSCs from bone marrow concentrate may be preferable in view of the high risks of major complications after open surgery and iliac bone grafting, and improved healing rates compared with standard iliac bone autograft treatment.
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41
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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: 4.3] [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: 3.3] [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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Crespo AM, Rautenberg AF, Siev N, Saadeh P, Egol KA. Fibulectomy, tibial shortening, and ankle arthrodesis as an alternative treatment of nonhealing wounds following open ankle fracture in compromised elderly adults. Foot Ankle Int 2015; 36:103-7. [PMID: 25201329 DOI: 10.1177/1071100714550653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alexander M Crespo
- Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, USA
| | | | - Noam Siev
- Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, USA
| | - Pierre Saadeh
- Plastic Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth A Egol
- Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, USA Jamaica Hospital Medical Center, Jamaica, NY, USA
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Siebachmeyer M, Boddu K, Bilal A, Hester TW, Hardwick T, Fox TP, Edmonds M, Kavarthapu V. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J 2015; 97-B:76-82. [DOI: 10.1302/0301-620x.97b1.34542] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2015;97-B:76–82.
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Affiliation(s)
- M. Siebachmeyer
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - K. Boddu
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - A. Bilal
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. W. Hester
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. Hardwick
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - T. P. Fox
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - M. Edmonds
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
| | - V. Kavarthapu
- King’s College Hospital NHS Foundation
Trust, London SE5 9RT, UK
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45
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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: 2.5] [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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46
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Dominic Marley W, Tucker A, McKenna S, Wong-Chung J. Pre-requisites for optimum centering of a tibiotalocalcaneal arthrodesis nail. Foot Ankle Surg 2014; 20:215-20. [PMID: 25103711 DOI: 10.1016/j.fas.2014.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/08/2014] [Accepted: 05/20/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Purpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths. METHODS We conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs. RESULTS Angles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails. Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p=0.01). CONCLUSIONS Both nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.
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Affiliation(s)
- William Dominic Marley
- Department of Trauma & Orthopaedics, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB, Northern Ireland, UK
| | - Adam Tucker
- Department of Trauma & Orthopaedics, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB, Northern Ireland, UK
| | - Sean McKenna
- Department of Trauma & Orthopaedics, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB, Northern Ireland, UK
| | - John Wong-Chung
- Department of Trauma & Orthopaedics, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB, Northern Ireland, UK.
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47
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LaPorta GA, Nasser EM, Mulhern JL. Tibiocalcaneal arthrodesis in the high-risk foot. J Foot Ankle Surg 2014; 53:774-86. [PMID: 25154654 DOI: 10.1053/j.jfas.2014.06.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 02/03/2023]
Abstract
The present case series outlines the history and surgical treatment of 6 patients who underwent tibiocalcaneal arthrodesis from April 2002 to May 2012, all with external fixation as the primary or secondary fixation. Surgical intervention was performed by the same surgeon at the same facility. The indication for surgery was a nonbraceable Charcot deformity in 5 (83.3%) patients and bone and soft tissue infection complicating previous intramedullary hindfoot fusion in 1 (16.7%) patient. Talectomy was performed in 2 (33.3%) patients secondary to widespread osteomyelitis of the talus and in 4 (66.7%) patients secondary to avascular necrosis and/or disintegration and fragmentation of the remaining talus. The postoperative complications have been discussed in detail and their management outlined. At the most recent follow-up visit, all patients were independently ambulating on a braceable limb with or without the use of an assistive device. In conclusion, tibiocalcaneal arthrodesis is a reasonable option for limb salvage to produce community ambulators in the high-risk population. We emphasize that although multiple fixation options are available for tibiocalcaneal arthrodesis, a combination of internal and external fixation is vital to its success.
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Affiliation(s)
- Guido A LaPorta
- Chief, Podiatric Medicine and Surgery, and Residency Director, Geisinger Community Medical Center, Scranton, PA; and Fellowship Director, Limb Salvage and Reconstructive Surgery Fellowship Program, Northeast Regional Foot and Ankle Institute, Dunmore, PA
| | - Ellianne M Nasser
- Fellow, Limb Salvage and Reconstructive Surgery Fellowship Program, Northeast Regional Foot and Ankle Institute, Dunmore, PA.
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48
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Aikawa T, Watanabe K, Matsubara H, Nomura I, Tsuchiya H. Tibiocalcaneal Fusion for Charcot Ankle With Severe Talar Body Loss: Case Report and a Review of the Surgical Literature. J Foot Ankle Surg 2014; 55:247-51. [PMID: 25116233 DOI: 10.1053/j.jfas.2014.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Indexed: 02/03/2023]
Abstract
Severe bone loss resulting from talar body necrosis in the Charcot ankle can be challenging to treat. In particular, the Charcot ankle will demonstrate progressive instability and deformity, causing protrusion of the medial or lateral malleolus, which will mostly lead to skin ulcers or osteomyelitis and, in some cases, will ultimately require transtibial amputation. Problems such as bone fragility, poor compliance with load-bearing restrictions, susceptibility to infection, and circulatory disorders cause difficulties in the surgical treatment of the Charcot ankle. We believe that tibiocalcaneal fusion is a reliable method to obtain satisfactory outcomes in these difficult cases. However, no study has reported on the use of a locking plate for tibiocalcaneal fusion. Therefore, we report on tibiocalcaneal fusion using a locking plate in 3 patients with Charcot ankle and severe talar body loss. All patients achieved bony union with a plantigrade foot and without any skin complications. We have concluded that a locking plate provides rigid fixation and easier insertion of additional screws, when necessary.
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Affiliation(s)
- Takao Aikawa
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Koji Watanabe
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan; Chief, Orthopaedic Trauma Center, Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Ishikawa, Japan.
| | - Hidenori Matsubara
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Issei Nomura
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
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49
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Kane JM, Raikin SM. Addressing hindfoot arthritis with concomitant tibial malunion or nonunion with retrograde tibiotalocalcaneal nailing: a novel treatment approach. J Bone Joint Surg Am 2014; 96:574-80. [PMID: 24695924 DOI: 10.2106/jbjs.m.00010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibial malunions and nonunions are associated with degenerative changes about the ankle. A comprehensive literature review revealed no articles discussing treatment options for patients with tibial shaft malunion and ipsilateral ankle arthritis. The aim of our study was to evaluate a series of patients in whom tibial osteotomy and retrograde tibiotalocalcaneal nailing were used to treat both tibial deformity and ankle osteoarthritis. METHODS Twenty-five patients underwent retrograde tibiotalocalcaneal nailing with concomitant realignment tibial osteotomy with takedown of the nonunion or malunion in a single procedure. All surgical procedures were performed by a single surgeon at a single institution. Baseline patient characteristics (age, sex, body mass index [BMI], preoperative diagnosis, and prior surgical procedures) were recorded. Data including visual analog scale (VAS) pain scores (0 to 10, with 0 indicating no pain and 10 indicating worst pain) and American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores were prospectively collected at the preoperative evaluation and the time of final follow-up, and patients were asked about their final satisfaction. Preoperative VAS scores averaged 8.3 (range, 7 to 10) of 10, which improved to an average of 2.8 (range, 0 to 6) at the time of final follow-up (p < 0.01). The preoperative AOFAS-AH scores averaged 43 (range, 18 to 62) of 100 and improved to 76 (range, 57 to 84) at the time of follow-up (p = 0.022). Twenty-one patients (84%) stated that they were extremely satisfied with the result of the procedure, three patients (12%) were satisfied, and one patient (4%) with a poor result was unsatisfied. CONCLUSIONS Tibial malunion or nonunion with concomitant hindfoot arthritis can be addressed with a single-stage procedure consisting of tibial osteotomy and retrograde intramedullary nailing for correction of the angular deformity and hindfoot fusion. This procedure provides a viable alternative to multiplanar external fixation or a staged procedure addressing the nonunion or angular deformity and the hindfoot arthritis separately.
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Affiliation(s)
- Justin M Kane
- Department of Orthopedics, Thomas Jefferson University Hospital, Curtis Building #801, 1015 Walnut Street, Philadelphia, PA 19107
| | - Steven M Raikin
- Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address:
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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: 46] [Impact Index Per Article: 4.2] [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 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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