Ankle arthrodesis

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Foot and Ankle Surgery 14 (2008) 1–10 www.elsevier.com/locate/fas

Review

Ankle arthrodesis Aneel Nihal M.D., FRCS (Orth.)a, Richard E. Gellman M.D.b,c, John M. Embil M.D., FRCPCd,e, Elly Trepman M.D.e,f,g,* a

Southside Health Service District, Logan Hospital, South Brisbane, Queensland, Australia b Summit Orthopaedics, Portland, OR, USA c Department of Orthopaedics and Rehabilitation, Oregon Health Sciences University, Portland, OR, USA d Section of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada e Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada f Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada g Grand Itasca Clinic & Hospital, Grand Rapids, MN, USA Received 5 March 2007; received in revised form 3 July 2007; accepted 20 August 2007

Abstract Numerous techniques for ankle arthrodesis have been reported since the original description of compression arthrodesis. From the early 1950s to the mid 1970s, external fixation was the dominant technique utilized. In the late 1970s and 1980s, internal fixation techniques for ankle arthrodesis were developed. In the 1990s, arthroscopic ankle arthrodesis was developed for ankle arthrosis with minimal or no deformity. The open technique is still widely used for ankle arthrosis with major deformity. For complex cases that involve nonunion, extensive bone loss, Charcot arthropathy, or infection, multiplanar external fixation with an Ilizarov device, with or without a bone graft, may achieve successful union. The fusion rate in most of the recently published studies is 85% or greater, and may depend on the presence of infection, deformity, avascular necrosis, and nonunion. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Contents 1. 2. 3. 4. 5. 6. 7.

8. 9.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . Evaluation of ankle arthrosis . . . . . . . . . . . . . . . Arthrodesis position and evaluation of deformity . Techniques for ankle arthrodesis . . . . . . . . . . . . 7.1. Arthrodesis in situ . . . . . . . . . . . . . . . . . 7.2. Realignment (open) arthrodesis . . . . . . . . 7.3. Surgical approaches . . . . . . . . . . . . . . . . 7.4. External fixation. . . . . . . . . . . . . . . . . . . 7.5. Internal fixation . . . . . . . . . . . . . . . . . . . 7.6. Role of bone graft in ankle fusion . . . . . . Sequelae of ankle arthrodesis . . . . . . . . . . . . . . Results of treatment with ankle arthrodesis . . . . . 9.1. Arthrosis: open ankle arthrodesis . . . . . . .

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* Corresponding author at: Health Sciences Centre, MS673-820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1R9. Tel.: +1 206 407 3671. 1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2007.08.004

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9.2. Rheumatoid arthritis . . . . . . . . . . 9.3. Arthroscopic ankle arthrodesis . . . 9.4. Complex and revision arthrodesis . Acknowledgement . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . .

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1. Introduction

3. Indications

Ankle arthrosis is one of the common problems for which patients present to the foot and ankle orthopaedic surgeon. The treatment of ankle arthrosis includes nonsurgical and surgical options. Nonsurgical treatment of ankle arthrosis may include limitation and modification of activities, nonsteroidal anti-inflammatory drugs, nutritional supplements including glucosamine and grape seed extract, a cane or crutches, physical therapy including movement reeducation (Feldenkrais method), shoe modification with a rocker bottom sole, a locked ankle-foot orthosis (AFO) with a solid ankle cushion heel (SACH), a custom molded leather ankle brace, or a patellar tendon-bearing AFO [1–3]. Surgical treatment options include arthroscopic debridement [2,3], synovectomy, excision of impinging osteophytes [3], joint distraction [4,5], or arthrodesis [6–11]. Results of debridement for advanced arthrosis may be limited. Total ankle prosthetic replacement for the treatment of ankle arthrosis has been associated with complications and failures including early loosening, subsidence, malalignment of the components, malleolar impingement, soft tissue imbalance, infection, and dislocation [12–15]. Despite recent renewed interest in total ankle arthroplasty [16–20], ankle arthrodesis remains the primary surgical treatment option for disabling ankle arthrosis in most patients.

The painful ankle may result from primary osteoarthritis or arthritis secondary to trauma, rheumatological conditions, or sepsis. Ankle arthrodesis is indicated for severe ankle pain resulting from arthrosis that interferes with standing and walking (Table 1). Deformity of the ankle that interferes with shoe wear and gait, including ankle equinus, valgus, or varus malalignment, may be managed with ankle arthrodesis if other corrective joint-sparing surgery is not feasible. Tibiotalar instability with advanced arthritic changes resulting from recurrent ankle sprain, failed ligament reconstruction, or neurological diseases may be an indication for arthrodesis. Failed total ankle replacement secondary to component loosening or infection may be salvaged with component removal and arthrodesis [14,29,30]. Arthrodesis may also be indicated for salvage of instability and bone destruction resulting from Charcot arthropathy [31,32] or osteomyelitis [33]. The reported frequency of involvement of the ankle and hindfoot in rheumatoid arthritis varies between 9% and 70% [9]. Rheumatoid arthritis of the ankle may be associated with arthritic involvement of the other joints of the foot. Associated hindfoot, midfoot, and forefoot deformities may contribute to pain and functional impairment and will need careful evaluation before proceeding with ankle arthrodesis.

2. History Early ankle arthrodesis [21] was accomplished by removing the articular cartilage from the body of the talus and the mortise. In the early 1900s, arthrodesis was performed for post-poliomyelitis paralysis to stabilize the ankle and foot. In 1951, compression arthrodesis was introduced, using external fixation without bone graft [22]. The advantages of compression included the elimination of both shear forces and gaps between the bony surfaces. Compression arthrodesis was originally described with an anterior transverse incision and transection of the tendons, nerves and vessels [22]. Although the technique of performing ankle fusion has markedly evolved to spare these vital structures, the concept of compression remains a foundation of modern methods of arthrodesis. Compression and direct contact between bony surfaces may be achieved using internal or external fixation [23]. More recently, arthroscopic methods of examining the ankle joint [24–26] have been extended to include arthroscopic debridement and arthrodesis [27,28].

Table 1 Indications for ankle arthrodesis I. Arthritis/arthrosis Primary osteoarthritis of ankle joint Postraumatic arthritis Ankle fracture (bimalleolar, trimalleolar, or pilon) Fracture or avascular necrosis of body of talus Dislocation or fracture-dislocation of ankle Inflammatory arthropathy Rheumatoid arthritis Seronegative arthritis Gout or pseudogout Hemophilic arthropathy Sequela of septic arthritis or posttraumatic infection II. Neurological Poliomyelitis Charcot-Marie-Tooth disease Cerebral paralysis (stroke) Charcot arthropathy III. Miscellaneous Failed total ankle replacement Severe equinus contracture secondary to compartment syndrome of leg

A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

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History and physical examination provide basic information about the etiology of the patient’s ankle arthrosis, severity of the symptoms, and functional impairment. The diagnosis may be confirmed with anteroposterior, mortise, and lateral weight-bearing radiographs of the ankle. Computed tomography (CT) and magnetic resonance imaging (MRI) may provide more detailed information about bone and cartilage involvement. Arthroscopic evaluation is an invasive diagnostic procedure and is usually deferred in arthrosis unless debridement or excision of impinging osteophytes or loose bodies is planned for temporary pain relief and to delay ankle arthrodesis. In cases where the source of pain is equivocal, fluoroscopically guided injection of the ankle or subtalar joint with a local anesthetic drug (lidocaine, 1% or bupivacaine, 0.5%, with no epinephrine), mixed with a contrast agent to confirm intra-articular location of the injection and exclude the potential for communication between the ankle joint and adjacent joints or tendon sheaths, may confirm or exclude the ankle joint as the primary source of pain [34].

Valgus or varus malunion may also result in painful callus at the first and fifth metatarsal, respectively. Valgus malunion can lead to subtalar joint arthrosis and posterior tibial tendon dysfunction that may be treated with realignment subtalar arthrodesis. Limb shortening may occur. Preoperative planning for all ankle arthrodesis cases should include an evaluation of the patient’s mechanical axis and any potential malalignment, especially in the distal tibia or foot that could lead to uneven weight distribution on the foot. Normal alignment in the frontal plane is such that the anatomic axis of the tibia shaft falls just medial to the midbody of the talus and just medial to the weightbearing point of the calcaneus. Normal alignment in the sagittal plane, noted on a lateral radiograph, should show that the anatomic axis of the tibia intersects the lateral talar process. During the arthrodesis, all attempts are made to preserve normal alignment; on the lateral view the foot may be translated slightly posterior to the normal sagittal line to decrease stress on the midfoot joints during gait. Bone loss in the distal tibia or talus that alters these relationships may lead to arthrodesis malunion. Correct alignment is achieved by careful positioning of the talus beneath the distal tibia following resection of cartilage and preparation of the bone surfaces with small osteotomes or drilling the subchondral plate. Areas of avascular bone are excised if possible. In some cases of avascular necrosis of the entire talar body, the talus can be left in place if it remains structurally intact without collapse. Defects are addressed with bone grafts or greater bone resection opposite the defect to create stable and parallel surfaces for arthrodesis. The decision is guided by the degree of deformity and whether there is a focal, contained bone loss or more peripheral, structural bone loss. In general, deformities that would create unacceptable limb shortening from extensive bone resection may be treated with larger bone grafts and supplemental stabilization with an Ilizarov-type multiplanar external fixator. In cases of limb shortening greater than 2.5 cm, limb lengthening with distraction osteogenesis may be considered [35].

6. Arthrodesis position and evaluation of deformity

7. Techniques for ankle arthrodesis

The goal of ankle arthrodesis is to create a pain-free plantigrade foot for weightbearing. Attention to the position and alignment of the foot in relation to tibia and leg is crucial. Ideal alignment includes neutral ankle flexion, 0–58 of valgus, and neutral to slight external rotation position. Malalignment of the foot may have adverse effects on the biomechanics of the lower extremity, leading to persistent pain following a solid arthrodesis. Excessive dorsiflexion may cause heel pain and ulcer, and plantarflexion may cause metatarsalgia and genu recurvatum (‘‘back knee’’) gait. Valgus, varus, internal rotation, or external rotation malunion may be associated with increased stresses and laxity of the collateral ligaments of the knee.

Arthrodesis techniques [36] can be broadly classified into two categories: arthrodesis in situ and realignment arthrodesis. Various surgical approaches and fixation methods may be considered depending on the status of the soft tissues, degree of deformity and bone quality, and experience of the surgeon.

4. Contraindications Ankle arthrodesis is avoided, if possible, in children and adolescents with open growth plates. Progressive, recurrent, or severe complex deformities in the adult may be difficult to correct. Smoking is associated with greater risk of nonunion [7]. Impaired vascular status may contribute to an increased risk of wound complications, infection, and amputation. Medical conditions that place the patient’s life at risk and the presence of peripheral vascular disease are carefully weighed against the potential benefit of the operation. The diabetic, neuropathic foot is no longer considered an absolute contraindication to ankle arthrodesis because the risk of ulceration, infection, and amputation may be greater with an unstable, neuropathic ankle that is not stabilized with fibrous union or bony arthrodesis [32].

5. Evaluation of ankle arthrosis

7.1. Arthrodesis in situ Arthrodesis in situ is indicated for cases with minimal or no deformity, and may done with arthroscopy [37–40] or minimal arthrotomy and percutaneous screw fixation [41]. Surgical exposure is minimized, resulting in decreased

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A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

wound morbidity and smaller scars. Postoperative pain and duration of inpatient hospital stay are decreased compared with open ankle arthrodesis. Minimal soft tissue stripping may contribute to a high frequency of union (greater than 90%), faster time to fusion [41], and greater patient satisfaction. The apparently lower morbidity with in situ arthrodesis may be a result of selection bias for less complex cases that do not require correction of major deformity. A disadvantage of in situ arthrodesis is that major deformity or bony deficiency may not be correctible. However, mild deformity (especially mild equinus) may be corrected, and successful arthrodesis may be achieved in complex cases such as previous nonunion [42]. Arthroscopic ankle arthrodesis requires specialized equipment, instruments, and arthroscopic experience, and the procedure may be technically more demanding than open arthrodesis. After arthroscopic ankle debridement and excision of articular cartilage through anteromedial and anterolateral portals, fixation is achieved using two or three cannulated screws placed separately from the tibia and the fibula to the talus [10,40,43,44]. If additional intraoperative or postoperative fixation is required, a Charnley clamp may be used to supplement tibiotalar screw fixation [38]. Complications may include saphenous, sural, deep peroneal, and superficial peroneal nerve injury [45]. The minimal arthrotomy technique is done using two small anterior (1.5 cm) incisions, one medial to the tibialis anterior tendon and one lateral to the peroneus tertius tendon [41]. The arthrotic tissue and remaining articular cartilage are debrided, and fixation is accomplished with percutaneous tibiotalar lag screws [41].

approach is a common approach used for ankle fusion [46]. A 10–12 cm longitudinal incision is made directly over the distal fibula, with care taken to avoid injury to the sural nerve. The approach is in the interneural plane between the sural nerve (posterior) and the superficial peroneal nerve (anterior). The fibula is osteotomized obliquely approximately 6 cm proximal to the distal tip or 2–4 cm proximal to the level of the tibial plafond. The distal fibula is then removed and may be used as autogenous bone graft. Debridement of the medial side of the joint may be done from either the lateral wound or from a supplemental medial incision about the medial malleolus. The medial approach may used to expose the tibiotalar joint through a longitudinal incision either directly over or anterior to the medial malleolus. The medial malleolus may be excised or retained as a medial buttress [47]. The remaining joint surface is denuded and decorticated. The anterior approach may provide good access to the entire ankle joint, but may place the anterior neurovascular structures at risk. An anterior approach had been used with a transverse incision between the tips of the medial and lateral malleolei, including section of the extensor tendons and neurovascular bundle [22]; however, this approach may cause postoperative adhesions between tendons, numbness, swelling, and vascular compromise [48], and is not recommended. The anterior longitudinal approach involves a slightly curved longitudinal incision, with dissection either between the tibialis anterior and extensor hallucis longus tendons [49] or between the extensor hallucis longus and extensor digitorum longus tendons [50–52]. In both

7.2. Realignment (open) arthrodesis

Table 2 Surgical approaches and fixation for ankle arthrodesis

Realignment arthrodesis is indicated for cases with major deformity or bone loss. This may include ankles with severe varus or valgus deformity or talar collapse resulting from trauma, avascular necrosis, or Charcot arthropathy. Excision of articular cartilage and bony contact are achieved with direct visualization. The major advantage of open arthrodesis over the minimal arthrotomy method is that severe deformities of the ankle may be corrected with appropriate bone cuts, and bone deficiency or loss of height may be improved with a bone graft. Disadvantages of open ankle arthrodesis include the wide surgical exposure and soft tissue stripping that may be associated with greater postoperative pain, delayed wound healing, wound infection, dehiscence, nonunion, and neurovascular injury. Recovery and time to fusion may be more prolonged after open arthrodesis.

Surgical approaches I. Open ankle arthrodesis Anterior approach Transverse incision Longitudinal incision Posterior approach Lateral approach Medial approach Combined medial and lateral approach

7.3. Surgical approaches Several surgical approaches to the ankle may be considered for arthrodesis depending on the deformity, fixation technique, condition of the soft tissues, and the surgeon’s preference and experience (Table 2). The lateral

II. Arthroscopic arthrodesis III. Mini-arthrotomy arthrodesis Methods of fixation I. External fixation Charnley external fixation Calandruccio apparatus Ilizarov frame Hoffman double frame external fixator Triangular external fixator with a metatarsal pin Any other conventional external fixator II. Internal fixation Screws Plates Intramedullary nail III. No fixation (cast immobilization)

A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

instances, the neurovascular bundle is exposed and protected. The anterior longitudinal approach may be used for realignment arthrodesis of the deformed ankle or when anterior plate fixation is done [53,54]. A combined anteromedial and anterolateral longitudinal two-incision approach has also been described. The anteromedial incision is made between the tibialis anterior and extensor hallucis longus tendons and the anterolateral incision is made between the extensor digitorum longus or peroneus tertius and the peroneal tendons. However, with this combined approach there is a risk of skin bridge necrosis between the two incisions. In a posterior approach, the patient is positioned prone and a longitudinal incision is made either medial to the Achilles tendon to avoid injury to the sural nerve [55] or lateral to the Achilles tendon where the sural nerve can be identified and protected. The Achilles tendon is then divided and a Z-plasty lengthening can be done if a preoperative equinus deformity is present. The ankle joint is approached by creating a plane between the peroneal tendons and the medial neurovascular bundle and flexor hallucis longus tendon. Through this approach both the ankle and subtalar joints may be exposed and fused [56–58]. 7.4. External fixation The popularity of external fixation in ankle arthrodesis had declined with improvements in internal fixation instruments and techniques due to the more labor-intensive management of external fixation both intraoperatively and postoperatively. However, external fixation remains useful when extensive soft tissue compromise or bone loss precludes internal fixation or casting. The early techniques of compression arthrodesis with external fixation described by Charnley and Calandruccio provided acceptable fusion rates, but the frames are not as versatile or rigid as current Ilizarov or equivalent devices [22,35,55,59,60]. Other external fixators may be used for ankle arthrodesis, such as the Hoffmann external fixator with anterior sliding tibial bone graft for arthrosis associated with severe posttraumatic equinus deformity [61] and the triangular external fixator with a metatarsal pin [62]. Ankle arthrodesis with the Ilizarov ring external fixator has been used for treatment of nonunion, ongoing sepsis including infected nonunion, malunion, and limb length discrepancy; this may result in solid union with a clinically satisfactory, plantigrade foot, providing an alternative to amputation in some cases [33,35,60,63–65]. Complication rates of greater than 50% with circular wire fixators have been reported, presumably because of the complexity of the underlying pathology of ankles for which this method was indicated [60]. 7.5. Internal fixation Various methods of internal fixation have been described including screws, angled blade plate, T plate, Wolf blade

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plate, intramedullary nail, and compression blade plate [6,36,53,54,66–70]. Some of these internal fixation techniques may not be applicable if ankle anatomy is distorted by deficient bone stock, major deformity, previous failed total ankle replacement, previous osteomyelitis, previous wound problem or plastic surgery flap, associated foot deformity, arthrosis in other joints, osteonecrosis of the talus, or Charcot arthropathy. Preoperative planning is important for proper selection of surgical approach and fixation method to achieve a painless, plantigrade foot for walking. In some cases, ankle arthrodesis is combined with triple arthrodesis (pantalar fusion) for limb salvage as an alternative to amputation [71]. Retrograde intramedullary nail technique may be useful for fusion in Charcot deformities [31,72], rheumatoid patients, and fixed equinus deformity [69,73]. Anterior sliding graft with rigid internal fixation is another option for treatment of pseudarthrosis, arthritis after infection, or talar osteonecrosis, but has a complication rate of 33% [74,75]. 7.6. Role of bone graft in ankle fusion Bone graft may be an important component of an ankle arthrodesis if potential for union may be compromised by factors such as infection [12], osteonecrosis of the talus [70], bone defects [30,71], and previous nonunion [76]. However, a bone graft is not routinely required in primary ankle arthrodesis is the absence of these complicating factors. In Charnley’s primary compression ankle arthrodesis, bone graft was not used [22]. Open transfibular ankle arthrodesis with internal screw fixation may achieve union in greater than 90% of cases without bone graft [36]. Arthroscopic ankle arthrodesis usually does not require a bone graft because of the extensive cancellous surface exposed with minimal soft tissue disruption [44]. Potential sources of autogenous bone graft for ankle arthrodesis may vary depending on the type and amount of graft required. Available bone stock may depend on previous trauma or surgery. The iliac crest is a reliable source of cancellous and cortical bone but is associated with donor site morbidity [77]. Local bone graft may be used from the distal fibula [76,78] or tibia [79,80]. Arthrodesis with an anterior tibial sliding bone graft may avoid the morbidity of iliac crest bone graft [74,81]. If non-structural bone graft is required, the excised distal fibula or medial malleolus may be ground in a bone mill to increase the bony surface area for promotion of union. The distal tibia is an excellent source of cancellous bone graft for procedures in the foot [82], but this site is usually unavailable for ankle arthrodesis because of proximity to the arthrodesis. The proximal tibia may provide adequate cancellous graft for ankle arthrodesis and avoid iliac crest morbidity [42]. Demineralized bone matrix has been used for ankle arthrodesis, with union rates comparable to autogenous bone graft [83].

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A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

complications remain common, including wound infection in 15% and tibial stress fracture in 6% of cases treated with an anterior plate [68]. Factors that may increase the risk of nonunion and other complications include smoking, alcohol abuse, diabetes, drug abuse, psychiatric illness, and a history of either high velocity ankle injury or open ankle fracture [7].

8. Sequelae of ankle arthrodesis Decreased subtalar motion and long-term degenerative changes may occur in the subtalar, talonavicular, calcaneocuboid, naviculocuneiform, tarsometatarsal, and first metatarsophalangeal joints [84–89]. Long-term follow-up at an average of 22 years after ankle arthrodesis showed more activity limitation, pain, and disability with the fused than opposite limb [88]. Appropriate preoperative counseling about the potential development of arthritis in the foot is advised for patient education prior to ankle arthrodesis.

9.2. Rheumatoid arthritis In a small study using the Charnley external fixation method, union was achieved in all 11 rheumatoid patients (Table 4) [99]. Complications included pin track infection in 4 (36%) patients [99]. Compression arthrodesis using pins and clamps may also be limited in rheumatoid patients because of osteopenia [100]. Nonetheless, a union rate of 96% was achieved in 26 rheumatoid ankles (14 tibiotalar arthrodesis and 12 tibiocalcaneal arthrodesis procedures) in which external fixation was used in 20 (77%) ankles, suggesting that external compression arthrodesis may be successful in patients with rheumatoid arthritis [101]. Open ankle arthrodesis in 10 patients from a lateral approach, using the fibula as an onlay graft in 9 cases and a sliding tibial inlay graft in one case, resulted in union in all cases [100]. In another study, union was achieved in all five rheumatoid patients fixed with two longitudinal Steinmann pins in the cast [102]. Compression screw fixation yielded a 92% union rate in 43 patients, of which 38 (88%) were seropositive for rheumatoid factor [9], and a 90% union rate in another study of 20 patients [103]. Intramedullary nail fixation with counter-rotation fins was used for ankle arthrodesis in 15 rheumatoid patients [69], and solid fusion was achieved in all patients. Arthroscopic ankle arthrodesis was performed in 8 rheumatoid patients (10 ankles) and union was achieved in all (100%) ankles by an average of 10 weeks [8].

9. Results of treatment with ankle arthrodesis Although 50% of patients with an ankle arthrodesis may have no handicap in performing activities of daily living, major deficits in physical function, emotional disturbance, and bodily pain have been documented with the Short Form36 Health Survey [90]. Orthopaedic shoes may be helpful in improving gait pattern after ankle arthrodesis [91]. 9.1. Arthrosis: open ankle arthrodesis In the initial report of compression ankle arthrodesis, bony union was achieved in 79% of ankles [22]. Union rate with this and other open ankle arthrodesis techniques may vary from 72% to 100% [7,8,38,69,92,93]. However, numerous studies report union rate greater than 90% (Table 3). Complication rates as high as 48% [87] and 60% [94] have been reported. Nonunion is less frequent with modern compression techniques compared with initial methods with which nonunion rates were as high as 35–40% [50,95]. In one series, complications in 47 arthrodesis procedures with the Charnley compression clamp included infection (19%), nonunion (15%), and amputation (6%) [96]. In another series of 60 arthrodesis procedures with various methods (46 Charnley, 8 modified anterior tibial sliding graft, and 6 other), complications occurred in 48% of patients, including nonunion in 23% of patients [87]. Recent reports of open arthrodesis with an anterior plate [68], cancellous screws [97], and a T-plate with screws [98] have reported union in 93–95% of cases. However,

9.3. Arthroscopic ankle arthrodesis A successful arthroscopic ankle arthrodesis was initially reported over two decades ago [27]. Several studies have shown that arthroscopic ankle arthrodesis is a useful procedure in cases with minimal deformity, resulting in a

Table 3 Results and complications of open ankle arthrodesis Method Charnley compression Charnley compression T plate on lateral side Compression blade plate Screws from talus to tibia Screws from tibia to talus Crossed screws Anterior sliding graft with screws Total

Total

Union

19 47 11 17 18 16 40 27

15 40 10 16 17 16 38 25

195

(79%) (85%) (91%) (94%) (94%) (100%) (95%) (93%)

177 (91%)

Nonunion 4 7 1 1 1 0 2 2

(21%) (15%) (9%) (6%) (6%) (0%) (5%) (7%)

18 (9%)

Malunion

Infection

Pin track infection

Reference

– 2 – 1 1 1 – –

– – – 1 (6%) – – – 2 (7%)

– 9 (19%) 3 (27%) – – – – –

[22] [96] [67] [54] [36] [39] [11] [74]

3 (2%)

12 (6%)

(4%) (6%) (6%) (6%)

5 (3%)

A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

7

Table 4 Results and complications of ankle arthrodesis in patients with rheumatoid arthritis Method Cannulated screws, arthroscopic IM nail with fins Compression clamp Screws Ex.fix 20; Int. fix. 6 Screws Total

Total

Union

10 15 11 10 26 43

10 15 11 10 25 40

115

(100%) (100%) (100%) (100%) (95%) (93%)

111 (97%)

Nonunion

Malunion

Infection

Pin track infection

Reference

– – – – 1 (4%) 3 (7%)

– – – – 1 (4%) 3 (7%)

– – – 1 (10%) – 2 (5%)

– – 4 (36%) – 1 (4%) –

[8] [69] [99] [100] [101] [9]

4 (3%)

4 (3%)

3 (3%)

5 (4%)

IM nail = intramedullary nail; Ex. Fix = external fixation; Int. fix = internal fixation.

high frequency of union with apparently faster union and less postoperative morbidity (pain or wound healing issues) than with open arthrodesis (Table 5) [10,38–40,104–107]. A comparative study of arthroscopic (17 patients) and open (16 patients) arthrodesis showed that the arthroscopic method had a comparable fusion frequency (fusion frequency: arthroscopic 94%; open, 100%) and faster average time to union (arthroscopic, 9 weeks; open, 15 weeks) [39]. Another comparative study of arthroscopic compared with open ankle arthrodesis in 36 patients (19 arthroscopic and 17 open) showed that arthroscopic arthrodesis yielded fusion frequency comparable to open arthrodesis but with significantly less morbidity, shorter operative time, less blood loss, and shorter hospital stay [104]. Postoperative pain and wound problems are less frequent after arthroscopic than open arthrodesis. Several studies have also confirmed time to union of approximately 9 weeks with the arthroscopic method [10,39,44], but a recent larger series was noted for average time to union of 12 weeks [108]. Frequency of union in arthroscopic studies has ranged from 85% to 100% [8,10,38,40,43,44,107,109] (Table 5). Complications of arthroscopic ankle arthrodesis may include nonunion, malunion, superficial infection [40], deep infection [37], neuroma formation, hardware-associated pain that necessitates hardware removal [10], transient synovitis, and drill bit failure (Table 5). Most reports of a small series of cases have few complications (Table 5). However, in a larger series of 42 patients treated with arthroscopic ankle arthrodesis, a 55% complication rate was

noted, including four pin site infections, four patients with pain due to hardware, four painful subtalar joints, three nonunions, two fractures, and one deep infection [37]. In this series, the majority of complications were minor and treatable, and 85% of patients were satisfied with the final results [37]. A recent larger series of 105 ankles was noted for a nonunion rate of 8% and symptomatic hardware removal in 22 (21%) ankles [108]. The arthroscopic fusion technique may result in injury to the neurovascular structures, especially the sural, superficial and deep peroneal and saphenous nerves [45]. 9.4. Complex and revision arthrodesis A major complication of primary ankle arthrodesis is nonunion with or without infection. These cases present a major challenge to the orthopaedist, but the long-term patient satisfaction with limb salvage often is preferable to amputation. In a series of 23 patients with pseudarthrosis following ankle arthrodesis, revision arthrodesis (isolated ankle, 14 patients; tibiocalcaneal, 7 patients; pantalar, 2 patients) was done (average, 1.7 years after the initial procedure) with rigid internal screw fixation, when possible, or an external fixator in limbs with osteoporotic bone [71]. In 14 (61%) patients in whom bone loss was present, autogenous bone graft was used. Twenty-one (91%) patients achieved union at an average of 14 weeks, 19 (83%) patients were satisfied with the revision procedure, and there were no amputations

Table 5 Results and complications of arthroscopic ankle arthrodesisa Method Cannulated screws Cannulated screws Crossed tibiotalar, Charnley clamp Tibiotalar and fibulotalar screws Tibiotalar and fibulotalar screws Tibiotalar and fibulotalar screws Total a

Total

Union

Nonunion

Malunion

1(6%) 1(3%)

2(12%) 1(3%)

17 34

16(94%) 33(97%)

8 16 19 26

8(100%) 16(100%) 17(89%) 22(85%)

2(11%) 4(15%)

120

112 (93%)

8 (7%)

Infection

Other complicationsb 1(3%) 4(50%) 2(12%) 3(16%)

2(8%) 3 (3%)

2 (2%)

Reference [39] [44] [38] [10] [43] [40]

10 (8%)

A recent series of 105 ankles having arthroscopic ankle arthrodesis had complications including symptomatic hardware removal from 22 (21%) ankles, nonunion in 9 (9%) ankles, superficial infection with 3 ankles, deep vein thrombosis and pulmonary emboli with 2 ankles, and revision of fixation, stress fracture, and deep infection each with 1 ankle [108]. b Others: drill broken, removal of hardware, neuroma, transient synovitis.

8

A. Nihal et al. / Foot and Ankle Surgery 14 (2008) 1–10

in this series [71]. In another series of 20 failed ankle fusions (11 nonunions, 7 malunions, 1 infected nonunion, and 1 ankle with talar avascular necrosis) revised with internal compression screw fixation, complications were frequent but fusion was achieved in 17 (85%) ankles at an average of 6 months after surgery; three amputations were done for chronic infection, but three other patients were dissatisfied because of chronic pain [110]. In another study of 18 revision ankle arthrodesis procedures fixed with internal compression screw fixation in 16 ankles, buttress plate in 1 ankle, and an external fixator in 1 ankle, union rate was 94% but clinical results were fair or poor in 12 (67%) ankles [111]. The Ilizarov technique was successfully used in another series of 21 failed ankle fusions (malunion or nonunion with or without infection); solid union and a plantigrade foot were achieved with all ankles, and functional results were excellent in 15 (71%) ankles [35]. Ankle arthrodesis is not contraindicated by the presence of ongoing sepsis. In one series, 28 ankle fusions were performed in 26 patients with ongoing sepsis and were followed over a period of 2 years; functional limb salvage was achieved in 25 (96%) with an overall infection arrest rate of 92% [112]. The Ilizarov external fixator may be useful in the management of complex tibial pathology or failed ankle arthrodesis, with 16 (80%) of 20 treated cases having good results and solid fusion in one series [63] and 7 (88%) of 8 ankles in another [33]. Even in the presence of infected nonunion or osteomyelitis, successful tibiocalcaneal fusion may be achieved using the Ilizarov technique [64]. In a small group of four failed infected ankle fusions, revision with compression using the Ilizarov frame resulted in tibiocalcaneal fusion in three ankles at an average of 7 months with no evidence of residual infection [64]. Arthrodesis of the infected ankle may be particularly challenging because of antimicrobial and wound considerations, and consultations with infectious diseases and plastic surgery specialists may be required [113]. Osteomyelitis may be polymicrobial and associated with open draining sinuses [114]. However, a program of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion may be successful at achieving solid ankle arthrodesis union and limb salvage [114]. Posttraumatic infected ankles with bone loss after pilon fracture may be treated successfully with Ilizarov external fixation and distraction osteogenesis to fill in the bone defect and achieve solid ankle arthrodesis union [115]. Although arthrodesis union and eradication of infection may be achieved after open, infected, complex ankle trauma, treatment morbidity and cost of care may be extensive, and major functional and psychosocial disability may remain [116]. Successful ankle fusion may be achieved despite the presence of avascular necrosis of the talus. In 19 patients with avascular necrosis of the talus who underwent ankle arthrodesis (ankle and subtalar arthrodesis, 16 [84%] patients; isolated ankle arthrodesis, three [16%] patients)

with a variety of techniques (external fixation, 13 [68%]; internal fixation, 4 [21%]; no fixation, 2 [11%]), including bone graft in all ankles, union was achieved in 16 (84%) ankles [70]. In the Charcot ankle for which nonoperative treatment had failed to achieve a stable, plantigrade foot, ankle and hindfoot arthrodesis with a retrograde locked intramedullary nail may be a good alternative to amputation. In Charcot arthropathy, ankle arthrodesis with a retrograde nail in 21 patients resulted in bony union in 19 (90%) patients (followup, 12–31 months) [31]. Morbidity was greater in 6 patients who had marked deformity that necessitated talectomy; in this group, 8 additional operations were required to achieve union [31]. Tibial fracture, tarsal tunnel syndrome, metal failure, and pain or stress fracture at the tip of the nail may occur. Failed total ankle arthroplasty may be salvaged with removal of components and ankle arthrodesis; tricortical iliac crest bone graft with internal plate fixation may be successful, but external fixation may be required if infection is present [117].

Acknowledgments AN acknowledges support from the Paul W. Lapidus Fellowship in Foot and Ankle Surgery and the John Charnley Trust (U.K.) for fellowship training in the United States of America. Editorial support from Kyle Lee Williams, M.A. is gratefully appreciated.

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