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Ankle Arthrodesis Using an Anterior Titanium Dual Locked Plating Construct
The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Ankle Arthrodesis Using an Anterior Titanium Dual Locked Plating Construct Wesley W. Flint, MD 1, Christopher B. Hirose, MD 2, Michael J. Coughlin, MD 2 1 2
Foot and Ankle Orthopaedic Surgery Fellow, Coughlin Clinic, Saint Alphonsus Medical Group, Boise, ID Foot and Ankle Orthopaedic Surgeon, Coughlin Clinic, Saint Alphonsus Medical Group, Boise, ID
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Ankle arthrodesis is currently the reference standard treatment for end-stage tibiotalar arthrosis. The fusion rates have varied in the published data from 59% to 100%. We reviewed 60 cases of consecutive anterior ankle arthrodesis using an anterior dual locked plating construct with respect to the fusion rate, time to fusion, pain relief, and complications. The patients were followed up for a mean of 1.1 years (range 16 weeks to 4 years). We found that our fusion rate was 97% for ankles not requiring structural allograft. The mean interval to fusion was 11.7 weeks, excluding those with a structural allograft. The mean visual analog scale pain scores decreased from 7 preoperatively to 2 at the final follow-up visit. Anterior ankle arthrodesis with dual locked plating provides excellent results with respect to the fusion rate with a low complication rate. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle arthrodesis ankle fusion locked plating tibiotalar arthrodesis tibiotalar fusion
Ankle arthrodesis has proved to be a reliable procedure to treat end-stage ankle arthrosis and is currently the reference standard technique to treat end-stage arthrosis of the tibiotalar joint. Despite the advent of total ankle arthroplasty, ankle arthrodesis remains the best option, except for the specific indications for total ankle arthroplasty. In patients with end-stage tibiotalar arthrosis, ankle arthrodesis has been shown to improve the patient’s ability to ambulate on flat ground and uneven surfaces and even to navigate stairs (1). Technique and implants have evolved to improve patient outcomes. Ankle arthrodesis was performed previously using external fixation, screw fixation, intramedullary nailing, an anterior tibial sliding graft, and various internal fixation plating constructs or a combination of methods. In previous investigations, the fusion rates have varied widely from 59% to 100% (2–12). The improved techniques, the recognition of patients at a high risk of nonunion, and advances in implant design have led to greater fusion rates. In the present study, we retrospectively reviewed the patient outcomes and the fusion rate of anterior ankle arthrodesis cases using a dual anterior locked plating system.
Financial Disclosure: None reported. Conflict of Interest: Dr. Coughlin has received research funding for other investigations and royalties for surgical devices, none of which pertain to the investigation or the implants described in the present report. W.W. Flint is currently at Orthopaedic Institute of Henderson, 10561 Jeffrey’s Street, Suite 230, Henderson, NV 89052. Address correspondence to: Wesley W. Flint, MD, Orthopaedic Institute of Henderson, 10561 Jeffrey’s Street, Suite 230, Henderson, NV 89052. E-mail address: wesley.fl[email protected] (W.W. Flint).
Patients and Methods From November 2009 to February 2015, 2 surgeons from our group (M.C., C.H.) performed 62 anterior ankle arthrodesis procedures on 60 successive patients using an anterior dual locked titanium plating system (TibiaxysÒ Ankle Fusion Plating System; Integra Lifesciences Corp, Plainsboro, NJ). A retrospective medical record review was conducted to analyze the recorded data, which included the cause of arthritis, weight, comorbidities, age, concomitant procedures, and postoperative complaints. The preoperative and postoperative imaging studies were reviewed by a fellowship-trained foot and ankle surgeon (W.F.) to assess for evidence of bony fusion, the interval to fusion, and the presence of advancing arthritic change in adjacent joints and hardware complications. Fusion was defined by contiguous bony trabeculae seen on anteroposterior and lateral radiographs across the arthrodesis site (Figs. 1 and 2) (13,14). The data were also collected and analyzed by 1 of us not involved in the surgical procedures (W.F.). Of the 60 ankle arthrodeses, 45 were in males and 15 in females. The mean age at surgery was 60 (range 84 to 29) years. The average weight was 97 (range 50 to 159) kg. Of the 60 ankles, 44 (73%) had post-traumatic arthritis and 8 (13%) had primary osteoarthritis implicated as the cause of ankle arthrosis (Table 1). Seventeen ankles had coronal deformities 10 . One case was removed from the study, because the patient had a Charcot ankle, and 1 patient was lost to follow-up. For the purposes of our analysis, we included 58 patients with 60 cases of ankle arthrodesis. The patients were followed up radiographically until bony union was achieved and were subsequently followed up clinically as needed. The average final follow-up visit was just >13 (range 3.7 to 48) months postoperatively. Each patient before operative management had exhausted nonoperative therapies, including anti-inflammatory medications, if indicated, bracing, and corticosteroid injections (15). Those who were candidates for total ankle arthroplasty were also presented with that option.
Operative Technique The procedure was performed using a thigh tourniquet, with the patient positioned supine and a bump placed beneath the ipsilateral hip. A 10-cm longitudinal anterior incision was centered anteriorly at the tibiotalar joint and extended distally just past
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.10.019
2
W.W. Flint et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 1. Preoperative anteroposterior and lateral weight-bearing radiographs of a patient with post-traumatic ankle arthrosis.
the talonavicular joint. The extensor retinaculum was incised sharply, and the tibialis anterior and extensor hallucis tendons were translated medially. The extensor digitorum longus was retracted laterally. The neurovascular bundle was carefully exposed and was either retracted medially or laterally, depending on which position had the least amount of tension after freeing these structures from the adjacent soft tissue. The periosteum was then sharply elevated off the bone at the distal tibia and talar neck. Anterior osteophytes were then removed to expose the anterior talar dome. The articular surfaces were then meticulously debrided of cartilage and dense subchondral bone, maintaining the shape of the talar dome and tibial plafond. Deformities were corrected through bony resection at the arthrodesis site. The joint surfaces were then heavily feathered with a small osteotome and/or perforated with a 2.5-mm drill. Bone autograft or iliac crest aspirate was then placed into the joint. Intraoperatively, the arthrodesis was augmented with local bone graft in 41 patients, an iliac crest bone graft in 2, iliac crest aspirate in 31, and an allograft bone in 10 patients. A large Hintermann compressor was then placed on the medial and lateral sides of the ankle after placing two 3-mm smooth Steinman pins transversely across the distal tibia and the neck of the talus. This was compressed maximally, and fluoroscopic images were then obtained to confirm the adequacy of the tibiotalar position and compression. We also visually assessed the dorsiflexion position and alignment of the heel. The alignment goals were neutral dorsiflexion/plantarflexion, with the heel at 0 to 5 of valgus and rotation similar to that of the contralateral ankle. Anterior ankle plates were then selected according to fit. We placed the anterolateral plate first. We drilled and placed the screws in the talar head and neck first, followed by the tibial screws and, finally, the oblique compression screw. The anteromedial plate was then positioned and placed in a similar fashion. After closure, the extremity was placed into a 3-sided plaster splint in the operating room. It was then changed to a below-the-knee cast on postoperative day 2. The sutures were removed 3 weeks after surgery. The patients remained in a non-weightbearing cast for 6 weeks, followed by a below-the-knee weightbearing cast for another 6 weeks. The mean follow-up was 1.1 (range 0.3 to 4) years.
Statistical Analysis For continuous outcomes, the mean differences between the postoperative and preoperative values were tested with a paired t test. The null hypothesis was that the mean difference was 0. A negative mean difference represents a reduction in the outcome relative to the preoperative level. When an outcome was missing for 1
patients at a time point, temporal comparisons were made with the pairwise-complete outcomes data. A group difference in unpaired outcomes (e.g., subtalar arthritis versus no subtalar arthritis) were tested with Welch’s t test. Odds ratios were tested with Fisher’s exact test. For continuous outcomes, analysis of variance was used to compare 3 patient groups. The Saint Alphonsus Regional Medical Center (Boise, ID) institutional review board approved the present study.
Results In our review of 60 cases of ankle arthrodesis, 57 (95%) had healed radiographically. The mean interval to fusion was 10.9 weeks for the patients who healed without a structural allograft. We observed 3 nonunions. One was a failed total ankle arthroplasty that required a structural allograft bone graft; when this case was excluded from the study, the fusion rate increased to 97%. This patient was also removed from their cast early and had a history of diabetes mellitus and hypothyroidism. Of the remaining 2 nonunions, 1 patient had a fibrous union that was painless. The remaining patient had a history of osteonecrosis and tobacco use and the ankle subsequently healed after revision arthrodesis augmented with 2 headless compression screws with retention of the anterior plates. One of the 3 patients with nonunion had diabetes mellitus. In contrast, 13 (21.7%) of the 60 patients in the entire study had diabetes. Only 3 patients had workers compensation claims, and 4 of the 60 patients used tobacco products, including the 1 patient with treatment failure and a history of osteonecrosis. The average visual analog scale (VAS) pain score preoperatively was 7.4 of 10. Postoperatively, the VAS pain score had decreased to 2.6 at 1 year and 2.1 at the final follow-up visit (n ¼ 38; mean difference in VAS pain score 4.8; p < .001). The mean VAS pain scores for those with post-traumatic arthritis were 7.7 preoperatively (n ¼ 45) and 2.1
W.W. Flint et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
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Fig. 2. Postoperative anteroposterior and lateral radiographs of a patient after ankle arthrodesis using dual locked compression plates.
at the final follow-up visit (n ¼ 45; mean difference in VAS pain score 5.6; p < .001). For those with post-traumatic arthrosis and previous open reduction internal fixation procedures at the ankle or distal tibia had a preoperative mean VAS pain score of 7.1 (n ¼ 11) and a final follow-up postoperative mean VAS pain score of 3 (n ¼ 11, mean difference in VAS pain score 4.1; p < .001). Ankles with primary osteoarthritis of the ankle had a mean VAS pain score of 8.0 preoperatively (n ¼ 8) and 1.0 at the final follow-up visit (n ¼ 8; mean difference in VAS pain score 7.0; p < .001) compared with a mean VAS pain score of 2.3 at the final follow-up visit for the patients without primary arthrosis (mean difference 1.3; p ¼ .026). The ankles with coronal plane malalignment 10 preoperatively had a mean VAS pain score of 7.3 preoperatively (n ¼ 17) and 2.1 at the latest follow-up visit (n ¼ 17; mean difference in VAS pain score 5.2; p < .001; Table 2). The mean preoperative VAS pain score did not differ significantly among the arthritis subtypes. Postoperatively, 12 (20%) of 60 ankles had subtalar arthritis and 5 (8%) had plantar fasciitis. Ankles with subtalar arthritis had a mean
Table 1 Causes of ankle arthrosis in our study population Cause of Arthrosis
Ankles (n)
Post-traumatic Primary Posterior tibial tendon dysfunction, stage IV Osteochondritis dissecans Failed total ankle arthroplasty Failed resurfacing allograft Infected total ankle arthroplasty Unknown Total
44 8 2 2 1 1 1 1 60
Data in parentheses are percentages.
(73.3) (13.3) (3.3) (3.3) (1.6) (1.6) (1.6) (1.6) (100)
VAS pain score of 8.0 preoperatively and 4.3 at the final follow-up visit (n ¼ 12; mean difference in VAS pain score 3.7; p ¼ .001) compared with a mean VAS pain score of 1.6 for patients without subtalar arthritis (mean difference in VAS pain score 2.8; p ¼ .001; Table 2). Subtalar arthrosis was more common in the post-traumatic ankles (24%; 11 of 45) than in those with primary arthritis (12.5%; 1 of 8) but the difference in prevalence was not statistically significant (odds ratio 4.4; p ¼ .262). Postoperative radiographs demonstrated talonavicular overhang of the plates in 15 patients. These patients had a mean VAS pain score at the final follow-up visit of 2.1, which was equal to the mean for the group of patients without the condition. One patient in the series underwent a subtalar arthrodesis during the study period. On further medical record review, we noted that 9 (15%) of 60 patients had complained of painful hardware or ankle pain postoperatively. Of these 9 patients, 7 (12% of 60) had continued hindfoot pain and 3 (5% of 60) had midfoot pain. Three (5%) patients had anterior fusion plates removed because of suspected painful hardware. Postoperative complications developed in 6 (10%) patients who had delayed wound healing not requiring surgery. Two patients required split-thickness skin grafts for wound healing issues. One patient was readmitted to receive parenteral antibiotics, and 1 patient required deep debridement for infection. One patient in the cohort developed chronic regional pain syndrome. Despite these wound healing complications and infection, the patients subsequently experienced successful tibiotalar bony fusion.
Discussion Ankle arthrodesis using an anterior locked plating construct is an excellent treatment option for patients with severe ankle arthrosis.
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W.W. Flint et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Table 2 Mean preoperative and final VAS pain scores Subgroup
All ankles Post-traumatic arthritis Coronal malalignment >10 Subtalar arthritis Previous ORIF Primary arthritis
Patients (n)
60 44 17 12 11 8
VAS Score
Final VAS Score
Preoperative
Final
Mean Difference
p Value
Those Without Condition
Difference Between Those With and Without Condition
p Value
7.4 7.7 7.3 8.0 7.1 8.0
2.1 2.1 2.1 4.3 3.0 1.0
5.3 5.6 5.2 3.7 4.1 7.0
<.001 <.001 <.001 .001 <.001 <.001
NA 2.1 2.1 1.6 2.1 2.3
NA 0.0 0.1 2.8 0.9 1.3
NA .421 .902 .001 .421 .026
Abbreviations: NA, not applicable; ORIF, open reduction internal fixation; VAS, visual analog scale.
In our study, we demonstrated a 97% fusion rate using this construct on native bone. Our findings were similar to those reported by Plaass et al (2). They reported a remarkable 100% fusion rate in 29 patients using the same dual anterior locking plate construct (2). The interval to fusion was 12.3 weeks in 16 ankles without an interposed allograft bone. Of their 29 patients, 13 had received interposition grafts, of which, 9 were a structural allograft. They also reported that 41% of their patients smoked. Postoperatively, they allowed immediate weightbearing in those without a bone graft (2). Our study included twice as many cases, and our group was not involved in the development or design of this implant. Anterior ankle arthrodesis is a preferred method for obtaining fusion at the tibiotalar joint, because it uses an approach familiar to most foot and ankle surgeons and allows for preparation of the ankle gutters through a single approach. The distal fibula does not require osteotomy as in a lateral approach, making it advantageous for possible conversion to total ankle arthroplasty in the future through the same approach (16). Biomechanically, anterior plating creates a tension-band construct that converts distraction at the ankle into compression applied by the ankle plantarflexors (17). We prefer dual anterior plates, because they are well-contoured and the position can be easily modified to fit the bony anatomy. The use of plates in the fusion construct adds significantly greater stability. In 1994, Dohm et al (18) in a biomechanical study compared a fibular strut, crossed screws, and 2 AO T plates and found the AO plating construct to be much stiffer than that of the other methods. Tarkin et al (19) observed that adding an anterior reconstruction plate to 3 crossed screws increased the sagittal rigidity of their arthrodesis construct. Clifford et al (20) evaluated single locked plates with and without compression screws and 3 crossed compression screws. They reported that the locked plate with the compression screw through the plate was the stiffest construct; however, the single plate without the compression screw had stiffness comparable to that of the 3 compression screws (20). Betz et al (21) in a biomechanical study using cadavers demonstrated that using the same dual anterior locked plates used in our study had an average load to failure that was 5 times greater than that seen with the 3-screw construct. Stiffness was also 5 times greater with the dual plates compared with that with 3 screws. Kestner et al (22) evaluated the stiffness comparing a single locked stainless steel plate and the same dual locking titanium plates used in our study. They found that the dual plating was significantly stiffer when torsional and bending forces were applied in a cadaveric model (22). Kakarala and Rajan (11) compared ankle arthrodesis with 2 crossed screws versus 2 crossed screws plus an anterior molded plate and found a greater fusion rate with the addition of the anterior plate. In 25% of the postoperative radiographs, a varying degree of plate overhang was found at the talonavicular joint. This could potentially lead to impingement at the joint and cause pain, although we did not observe increased VAS scores in our study. The risk of this can be reduced by carefully assessing the intraoperative images of the
talonavicular joint and ensuring that the talar dome is centered beneath the tibial shaft. Confirming that the anterior tibial osteophyte has been adequately resected will also prevent the occurrence of talonavicular overhang. Our results have also demonstrated that patients with subtalar arthritis will continue to have pain after tibiotalar fusion that is significantly worse than the pain experienced by those without subtalar arthrosis. Although the exact cause is unknown, it might be related to compensatory motion at the subtalar joint that can worsen the underlying degenerative changes and become more symptomatic after fusion (23). Pedowitz et al (24) in a radiographic evaluation after tibiotalar arthrodesis found a significantly greater sagittal range of motion through the mid- and hindfoot joints compared with the motion found in patients after total ankle arthroplasty. It is imperative to carefully evaluate the adjacent joints preoperatively for degenerative joint disease to adequately treat the patient and prevent ongoing discomfort despite successful ankle fusion. The postoperative pain scores at the final follow-up visit were significantly lower for those undergoing arthrodesis for primary osteoarthritis. This might have resulted from the less degenerative changes to the adjacent joints compared with those changes in the post-traumatic ankles, because the surrounding joints might also have been damaged at the time of the ankle injury and progress to adjacent joint arthrosis. The strengths of the present study included a respectable number of patients evaluated in the series, the greatest number to date reported using dual locked ankle fusion plates. Our patient population is also generalizable to most practitioners with an average body weight of 97 kg, 22% of patients with diabetes, and 7% with active tobacco use during the perioperative period. We also do not possess a conflict of interest with the implant manufacturer. The limitations of the present study included the retrospective nature and that some of the patients did not return for follow-up examinations after successful bony fusion and symptom relief. The assumption was made that if patients were experiencing increased pain, they would have returned for further evaluation. This might have negatively biased our results, because patients with continued pain or other complaints related to their surgery will tend to return for follow-up examinations, and those doing well have little reason to return. The patients were not required to return for follow-up examinations once bony fusion had occurred and if they had no concerns regarding their ankle. If the subjects had been actively followed up for a longer period, we might potentially see increased VAS pain scores as the adjacent joints develop arthrosis (23). Another limitation was that we evaluated the union of the arthrodesis site primarily using plain radiographs, which might not be as accurate as if we had routinely used computed tomography (13,25). In our study, we did not routinely obtain computed tomography studies postoperatively to assess for bony union unless compelled by the patient’s history or physical examination findings owing to the expense of advanced
W.W. Flint et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
imaging procedures and the potential risk of unnecessary ionizing radiation exposure. In conclusion, anterior dual locked plating offers a biomechanically stiff construct leading to outstanding fusion rates, which has been demonstrated in previous studies and in our present case review. Using an anterior approach allows for preparation of the entire joint without the need for an accessory approach and might lend itself to later conversion to total ankle arthroplasty at a later date. Acknowledgments We thank Alicia Trakas and Richard Remington for their research support. References 1. Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int 36:11–17, 2015. 2. Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Foot Ankle Int 30:631–639, 2009. 3. Gharehdaghi M, Rahimi H, Mousavian A. Anterior ankle arthrodesis with molded plate: technique and outcomes. Arch Bone Jt Surg 2:203–209, 2014. 4. Slater GL, Sayres SC, O’Malley MJ. Anterior ankle arthrodesis. World J Orthop 5:1–5, 2014. 5. Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg Br 81:113–116, 1999. 6. Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop Relat Res 268:21–28, 1991. 7. Guo C, Yan Z, Barfield WR, Hartsock LA. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int 31:492–498, 2010. 8. Mohamedean A, Said HG, El-Sharkawi M, El-Adly W, Said GZ. Technique and shortterm results of ankle arthrodesis using anterior plating. Int Orthop 34:833–837, 2010. 9. Gordon D, Zicker R, Cullen N, Singh D. Open ankle arthrodeses via an anterior approach. Foot Ankle Int 34:386–391, 2013. 10. Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop Relat Res 361:178–185, 1999.
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11. Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 72:716–721, 2006. 12. Coughlin MJ, Nery C, Baumfeld D, Jastifer J. Tibiotarsal compression arthrodesis using a lateral locking plate. Rev Bras Ortop 47:611–615, 2012. 13. Coughlin MJ, Grimes JS, Traughber PD, Jones CP. Comparison of radiographs and CT scans in the prospective evaluation of the fusion of hindfoot arthrodesis. Foot Ankle Int 27:780–787, 2006. 14. Coughlin MJ, Smith BW, Traughber P. The evaluation of the healing rate of subtalar arthrodeses, part 2: the effect of low-intensity ultrasound stimulation. Foot Ankle Int 29:970–977, 2008. 15. Hayes BJ, Gonzalez T, Smith JT, Chiodo CP, Bluman EM. Ankle arthritis: you can’t always replace it. J Am Acad Orthop Surg 24:e29–338, 2016. 16. Pellegrini MJ, Schiff AP, Adams SB Jr, Queen RM, DeOrio JK, Nunley JA II, Easley ME. Conversion of tibiotalar arthrodesis to total ankle arthroplasty. J Bone Joint Surg Am 97:2004–2013, 2015. 17. Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior tension plate. Clin Orthop Relat Res 268:70–77, 1991. 18. Dohm MP, Benjamin JB, Harrison J, Szivek JA. A biomechanical evaluation of three forms of internal fixation used in ankle arthrodesis. Foot Ankle Int 15:297–300, 1994. 19. Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 28:219–223, 2007. 20. Clifford C, Berg S, McCann K, Hutchinson B. A biomechanical comparison of internal fixation techniques for ankle arthrodesis. J Foot Ankle Surg 54:188–191, 2015. 21. Betz MM, Benninger EE, Favre PP, Wieser KK, Vich MM, Espinosa N. Primary stability and stiffness in ankle arthrodesdcrossed screws versus anterior plating. Foot Ankle Surg 19:168–172, 2013. 22. Kestner CJ, Glisson RR, DeOrio JK, Nunley JA II. A biomechanical analysis of two anterior ankle arthrodesis systems. Foot Ankle Int 34:1006–1011, 2013. 23. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 83:219–228, 2001. 24. Pedowitz DI, Kane JM, Smith GM, Saffel HL, Comer C, Raikin SM. Total ankle arthroplasty versus ankle arthrodesis: a comparative analysis of arc of movement and functional outcomes. Bone Joint J 98-B:634–640, 2016. 25. Jones CP, Coughlin MJ, Shurnas PS. Prospective CT scan evaluation of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int 27:229–235, 2006.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Ankle Arthrodesis Using an Anterior Titanium Dual Locked Plating Construct Wesley W. Flint, MD 1, Christopher B. Hirose, MD 2, Michael J. Coughlin, MD 2 1 2
Foot and Ankle Orthopaedic Surgery Fellow, Coughlin Clinic, Saint Alphonsus Medical Group, Boise, ID Foot and Ankle Orthopaedic Surgeon, Coughlin Clinic, Saint Alphonsus Medical Group, Boise, ID
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Ankle arthrodesis is currently the reference standard treatment for end-stage tibiotalar arthrosis. The fusion rates have varied in the published data from 59% to 100%. We reviewed 60 cases of consecutive anterior ankle arthrodesis using an anterior dual locked plating construct with respect to the fusion rate, time to fusion, pain relief, and complications. The patients were followed up for a mean of 1.1 years (range 16 weeks to 4 years). We found that our fusion rate was 97% for ankles not requiring structural allograft. The mean interval to fusion was 11.7 weeks, excluding those with a structural allograft. The mean visual analog scale pain scores decreased from 7 preoperatively to 2 at the final follow-up visit. Anterior ankle arthrodesis with dual locked plating provides excellent results with respect to the fusion rate with a low complication rate. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle arthrodesis ankle fusion locked plating tibiotalar arthrodesis tibiotalar fusion
Ankle arthrodesis has proved to be a reliable procedure to treat end-stage ankle arthrosis and is currently the reference standard technique to treat end-stage arthrosis of the tibiotalar joint. Despite the advent of total ankle arthroplasty, ankle arthrodesis remains the best option, except for the specific indications for total ankle arthroplasty. In patients with end-stage tibiotalar arthrosis, ankle arthrodesis has been shown to improve the patient’s ability to ambulate on flat ground and uneven surfaces and even to navigate stairs (1). Technique and implants have evolved to improve patient outcomes. Ankle arthrodesis was performed previously using external fixation, screw fixation, intramedullary nailing, an anterior tibial sliding graft, and various internal fixation plating constructs or a combination of methods. In previous investigations, the fusion rates have varied widely from 59% to 100% (2–12). The improved techniques, the recognition of patients at a high risk of nonunion, and advances in implant design have led to greater fusion rates. In the present study, we retrospectively reviewed the patient outcomes and the fusion rate of anterior ankle arthrodesis cases using a dual anterior locked plating system.
Financial Disclosure: None reported. Conflict of Interest: Dr. Coughlin has received research funding for other investigations and royalties for surgical devices, none of which pertain to the investigation or the implants described in the present report. W.W. Flint is currently at Orthopaedic Institute of Henderson, 10561 Jeffrey’s Street, Suite 230, Henderson, NV 89052. Address correspondence to: Wesley W. Flint, MD, Orthopaedic Institute of Henderson, 10561 Jeffrey’s Street, Suite 230, Henderson, NV 89052. E-mail address: wesley.fl[email protected] (W.W. Flint).
Patients and Methods From November 2009 to February 2015, 2 surgeons from our group (M.C., C.H.) performed 62 anterior ankle arthrodesis procedures on 60 successive patients using an anterior dual locked titanium plating system (TibiaxysÒ Ankle Fusion Plating System; Integra Lifesciences Corp, Plainsboro, NJ). A retrospective medical record review was conducted to analyze the recorded data, which included the cause of arthritis, weight, comorbidities, age, concomitant procedures, and postoperative complaints. The preoperative and postoperative imaging studies were reviewed by a fellowship-trained foot and ankle surgeon (W.F.) to assess for evidence of bony fusion, the interval to fusion, and the presence of advancing arthritic change in adjacent joints and hardware complications. Fusion was defined by contiguous bony trabeculae seen on anteroposterior and lateral radiographs across the arthrodesis site (Figs. 1 and 2) (13,14). The data were also collected and analyzed by 1 of us not involved in the surgical procedures (W.F.). Of the 60 ankle arthrodeses, 45 were in males and 15 in females. The mean age at surgery was 60 (range 84 to 29) years. The average weight was 97 (range 50 to 159) kg. Of the 60 ankles, 44 (73%) had post-traumatic arthritis and 8 (13%) had primary osteoarthritis implicated as the cause of ankle arthrosis (Table 1). Seventeen ankles had coronal deformities 10 . One case was removed from the study, because the patient had a Charcot ankle, and 1 patient was lost to follow-up. For the purposes of our analysis, we included 58 patients with 60 cases of ankle arthrodesis. The patients were followed up radiographically until bony union was achieved and were subsequently followed up clinically as needed. The average final follow-up visit was just >13 (range 3.7 to 48) months postoperatively. Each patient before operative management had exhausted nonoperative therapies, including anti-inflammatory medications, if indicated, bracing, and corticosteroid injections (15). Those who were candidates for total ankle arthroplasty were also presented with that option.
Operative Technique The procedure was performed using a thigh tourniquet, with the patient positioned supine and a bump placed beneath the ipsilateral hip. A 10-cm longitudinal anterior incision was centered anteriorly at the tibiotalar joint and extended distally just past
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.10.019
2
W.W. Flint et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 1. Preoperative anteroposterior and lateral weight-bearing radiographs of a patient with post-traumatic ankle arthrosis.
the talonavicular joint. The extensor retinaculum was incised sharply, and the tibialis anterior and extensor hallucis tendons were translated medially. The extensor digitorum longus was retracted laterally. The neurovascular bundle was carefully exposed and was either retracted medially or laterally, depending on which position had the least amount of tension after freeing these structures from the adjacent soft tissue. The periosteum was then sharply elevated off the bone at the distal tibia and talar neck. Anterior osteophytes were then removed to expose the anterior talar dome. The articular surfaces were then meticulously debrided of cartilage and dense subchondral bone, maintaining the shape of the talar dome and tibial plafond. Deformities were corrected through bony resection at the arthrodesis site. The joint surfaces were then heavily feathered with a small osteotome and/or perforated with a 2.5-mm drill. Bone autograft or iliac crest aspirate was then placed into the joint. Intraoperatively, the arthrodesis was augmented with local bone graft in 41 patients, an iliac crest bone graft in 2, iliac crest aspirate in 31, and an allograft bone in 10 patients. A large Hintermann compressor was then placed on the medial and lateral sides of the ankle after placing two 3-mm smooth Steinman pins transversely across the distal tibia and the neck of the talus. This was compressed maximally, and fluoroscopic images were then obtained to confirm the adequacy of the tibiotalar position and compression. We also visually assessed the dorsiflexion position and alignment of the heel. The alignment goals were neutral dorsiflexion/plantarflexion, with the heel at 0 to 5 of valgus and rotation similar to that of the contralateral ankle. Anterior ankle plates were then selected according to fit. We placed the anterolateral plate first. We drilled and placed the screws in the talar head and neck first, followed by the tibial screws and, finally, the oblique compression screw. The anteromedial plate was then positioned and placed in a similar fashion. After closure, the extremity was placed into a 3-sided plaster splint in the operating room. It was then changed to a below-the-knee cast on postoperative day 2. The sutures were removed 3 weeks after surgery. The patients remained in a non-weightbearing cast for 6 weeks, followed by a below-the-knee weightbearing cast for another 6 weeks. The mean follow-up was 1.1 (range 0.3 to 4) years.
Statistical Analysis For continuous outcomes, the mean differences between the postoperative and preoperative values were tested with a paired t test. The null hypothesis was that the mean difference was 0. A negative mean difference represents a reduction in the outcome relative to the preoperative level. When an outcome was missing for 1
patients at a time point, temporal comparisons were made with the pairwise-complete outcomes data. A group difference in unpaired outcomes (e.g., subtalar arthritis versus no subtalar arthritis) were tested with Welch’s t test. Odds ratios were tested with Fisher’s exact test. For continuous outcomes, analysis of variance was used to compare 3 patient groups. The Saint Alphonsus Regional Medical Center (Boise, ID) institutional review board approved the present study.
Results In our review of 60 cases of ankle arthrodesis, 57 (95%) had healed radiographically. The mean interval to fusion was 10.9 weeks for the patients who healed without a structural allograft. We observed 3 nonunions. One was a failed total ankle arthroplasty that required a structural allograft bone graft; when this case was excluded from the study, the fusion rate increased to 97%. This patient was also removed from their cast early and had a history of diabetes mellitus and hypothyroidism. Of the remaining 2 nonunions, 1 patient had a fibrous union that was painless. The remaining patient had a history of osteonecrosis and tobacco use and the ankle subsequently healed after revision arthrodesis augmented with 2 headless compression screws with retention of the anterior plates. One of the 3 patients with nonunion had diabetes mellitus. In contrast, 13 (21.7%) of the 60 patients in the entire study had diabetes. Only 3 patients had workers compensation claims, and 4 of the 60 patients used tobacco products, including the 1 patient with treatment failure and a history of osteonecrosis. The average visual analog scale (VAS) pain score preoperatively was 7.4 of 10. Postoperatively, the VAS pain score had decreased to 2.6 at 1 year and 2.1 at the final follow-up visit (n ¼ 38; mean difference in VAS pain score 4.8; p < .001). The mean VAS pain scores for those with post-traumatic arthritis were 7.7 preoperatively (n ¼ 45) and 2.1
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Fig. 2. Postoperative anteroposterior and lateral radiographs of a patient after ankle arthrodesis using dual locked compression plates.
at the final follow-up visit (n ¼ 45; mean difference in VAS pain score 5.6; p < .001). For those with post-traumatic arthrosis and previous open reduction internal fixation procedures at the ankle or distal tibia had a preoperative mean VAS pain score of 7.1 (n ¼ 11) and a final follow-up postoperative mean VAS pain score of 3 (n ¼ 11, mean difference in VAS pain score 4.1; p < .001). Ankles with primary osteoarthritis of the ankle had a mean VAS pain score of 8.0 preoperatively (n ¼ 8) and 1.0 at the final follow-up visit (n ¼ 8; mean difference in VAS pain score 7.0; p < .001) compared with a mean VAS pain score of 2.3 at the final follow-up visit for the patients without primary arthrosis (mean difference 1.3; p ¼ .026). The ankles with coronal plane malalignment 10 preoperatively had a mean VAS pain score of 7.3 preoperatively (n ¼ 17) and 2.1 at the latest follow-up visit (n ¼ 17; mean difference in VAS pain score 5.2; p < .001; Table 2). The mean preoperative VAS pain score did not differ significantly among the arthritis subtypes. Postoperatively, 12 (20%) of 60 ankles had subtalar arthritis and 5 (8%) had plantar fasciitis. Ankles with subtalar arthritis had a mean
Table 1 Causes of ankle arthrosis in our study population Cause of Arthrosis
Ankles (n)
Post-traumatic Primary Posterior tibial tendon dysfunction, stage IV Osteochondritis dissecans Failed total ankle arthroplasty Failed resurfacing allograft Infected total ankle arthroplasty Unknown Total
44 8 2 2 1 1 1 1 60
Data in parentheses are percentages.
(73.3) (13.3) (3.3) (3.3) (1.6) (1.6) (1.6) (1.6) (100)
VAS pain score of 8.0 preoperatively and 4.3 at the final follow-up visit (n ¼ 12; mean difference in VAS pain score 3.7; p ¼ .001) compared with a mean VAS pain score of 1.6 for patients without subtalar arthritis (mean difference in VAS pain score 2.8; p ¼ .001; Table 2). Subtalar arthrosis was more common in the post-traumatic ankles (24%; 11 of 45) than in those with primary arthritis (12.5%; 1 of 8) but the difference in prevalence was not statistically significant (odds ratio 4.4; p ¼ .262). Postoperative radiographs demonstrated talonavicular overhang of the plates in 15 patients. These patients had a mean VAS pain score at the final follow-up visit of 2.1, which was equal to the mean for the group of patients without the condition. One patient in the series underwent a subtalar arthrodesis during the study period. On further medical record review, we noted that 9 (15%) of 60 patients had complained of painful hardware or ankle pain postoperatively. Of these 9 patients, 7 (12% of 60) had continued hindfoot pain and 3 (5% of 60) had midfoot pain. Three (5%) patients had anterior fusion plates removed because of suspected painful hardware. Postoperative complications developed in 6 (10%) patients who had delayed wound healing not requiring surgery. Two patients required split-thickness skin grafts for wound healing issues. One patient was readmitted to receive parenteral antibiotics, and 1 patient required deep debridement for infection. One patient in the cohort developed chronic regional pain syndrome. Despite these wound healing complications and infection, the patients subsequently experienced successful tibiotalar bony fusion.
Discussion Ankle arthrodesis using an anterior locked plating construct is an excellent treatment option for patients with severe ankle arthrosis.
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Table 2 Mean preoperative and final VAS pain scores Subgroup
All ankles Post-traumatic arthritis Coronal malalignment >10 Subtalar arthritis Previous ORIF Primary arthritis
Patients (n)
60 44 17 12 11 8
VAS Score
Final VAS Score
Preoperative
Final
Mean Difference
p Value
Those Without Condition
Difference Between Those With and Without Condition
p Value
7.4 7.7 7.3 8.0 7.1 8.0
2.1 2.1 2.1 4.3 3.0 1.0
5.3 5.6 5.2 3.7 4.1 7.0
<.001 <.001 <.001 .001 <.001 <.001
NA 2.1 2.1 1.6 2.1 2.3
NA 0.0 0.1 2.8 0.9 1.3
NA .421 .902 .001 .421 .026
Abbreviations: NA, not applicable; ORIF, open reduction internal fixation; VAS, visual analog scale.
In our study, we demonstrated a 97% fusion rate using this construct on native bone. Our findings were similar to those reported by Plaass et al (2). They reported a remarkable 100% fusion rate in 29 patients using the same dual anterior locking plate construct (2). The interval to fusion was 12.3 weeks in 16 ankles without an interposed allograft bone. Of their 29 patients, 13 had received interposition grafts, of which, 9 were a structural allograft. They also reported that 41% of their patients smoked. Postoperatively, they allowed immediate weightbearing in those without a bone graft (2). Our study included twice as many cases, and our group was not involved in the development or design of this implant. Anterior ankle arthrodesis is a preferred method for obtaining fusion at the tibiotalar joint, because it uses an approach familiar to most foot and ankle surgeons and allows for preparation of the ankle gutters through a single approach. The distal fibula does not require osteotomy as in a lateral approach, making it advantageous for possible conversion to total ankle arthroplasty in the future through the same approach (16). Biomechanically, anterior plating creates a tension-band construct that converts distraction at the ankle into compression applied by the ankle plantarflexors (17). We prefer dual anterior plates, because they are well-contoured and the position can be easily modified to fit the bony anatomy. The use of plates in the fusion construct adds significantly greater stability. In 1994, Dohm et al (18) in a biomechanical study compared a fibular strut, crossed screws, and 2 AO T plates and found the AO plating construct to be much stiffer than that of the other methods. Tarkin et al (19) observed that adding an anterior reconstruction plate to 3 crossed screws increased the sagittal rigidity of their arthrodesis construct. Clifford et al (20) evaluated single locked plates with and without compression screws and 3 crossed compression screws. They reported that the locked plate with the compression screw through the plate was the stiffest construct; however, the single plate without the compression screw had stiffness comparable to that of the 3 compression screws (20). Betz et al (21) in a biomechanical study using cadavers demonstrated that using the same dual anterior locked plates used in our study had an average load to failure that was 5 times greater than that seen with the 3-screw construct. Stiffness was also 5 times greater with the dual plates compared with that with 3 screws. Kestner et al (22) evaluated the stiffness comparing a single locked stainless steel plate and the same dual locking titanium plates used in our study. They found that the dual plating was significantly stiffer when torsional and bending forces were applied in a cadaveric model (22). Kakarala and Rajan (11) compared ankle arthrodesis with 2 crossed screws versus 2 crossed screws plus an anterior molded plate and found a greater fusion rate with the addition of the anterior plate. In 25% of the postoperative radiographs, a varying degree of plate overhang was found at the talonavicular joint. This could potentially lead to impingement at the joint and cause pain, although we did not observe increased VAS scores in our study. The risk of this can be reduced by carefully assessing the intraoperative images of the
talonavicular joint and ensuring that the talar dome is centered beneath the tibial shaft. Confirming that the anterior tibial osteophyte has been adequately resected will also prevent the occurrence of talonavicular overhang. Our results have also demonstrated that patients with subtalar arthritis will continue to have pain after tibiotalar fusion that is significantly worse than the pain experienced by those without subtalar arthrosis. Although the exact cause is unknown, it might be related to compensatory motion at the subtalar joint that can worsen the underlying degenerative changes and become more symptomatic after fusion (23). Pedowitz et al (24) in a radiographic evaluation after tibiotalar arthrodesis found a significantly greater sagittal range of motion through the mid- and hindfoot joints compared with the motion found in patients after total ankle arthroplasty. It is imperative to carefully evaluate the adjacent joints preoperatively for degenerative joint disease to adequately treat the patient and prevent ongoing discomfort despite successful ankle fusion. The postoperative pain scores at the final follow-up visit were significantly lower for those undergoing arthrodesis for primary osteoarthritis. This might have resulted from the less degenerative changes to the adjacent joints compared with those changes in the post-traumatic ankles, because the surrounding joints might also have been damaged at the time of the ankle injury and progress to adjacent joint arthrosis. The strengths of the present study included a respectable number of patients evaluated in the series, the greatest number to date reported using dual locked ankle fusion plates. Our patient population is also generalizable to most practitioners with an average body weight of 97 kg, 22% of patients with diabetes, and 7% with active tobacco use during the perioperative period. We also do not possess a conflict of interest with the implant manufacturer. The limitations of the present study included the retrospective nature and that some of the patients did not return for follow-up examinations after successful bony fusion and symptom relief. The assumption was made that if patients were experiencing increased pain, they would have returned for further evaluation. This might have negatively biased our results, because patients with continued pain or other complaints related to their surgery will tend to return for follow-up examinations, and those doing well have little reason to return. The patients were not required to return for follow-up examinations once bony fusion had occurred and if they had no concerns regarding their ankle. If the subjects had been actively followed up for a longer period, we might potentially see increased VAS pain scores as the adjacent joints develop arthrosis (23). Another limitation was that we evaluated the union of the arthrodesis site primarily using plain radiographs, which might not be as accurate as if we had routinely used computed tomography (13,25). In our study, we did not routinely obtain computed tomography studies postoperatively to assess for bony union unless compelled by the patient’s history or physical examination findings owing to the expense of advanced
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imaging procedures and the potential risk of unnecessary ionizing radiation exposure. In conclusion, anterior dual locked plating offers a biomechanically stiff construct leading to outstanding fusion rates, which has been demonstrated in previous studies and in our present case review. Using an anterior approach allows for preparation of the entire joint without the need for an accessory approach and might lend itself to later conversion to total ankle arthroplasty at a later date. Acknowledgments We thank Alicia Trakas and Richard Remington for their research support. References 1. Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int 36:11–17, 2015. 2. Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Foot Ankle Int 30:631–639, 2009. 3. Gharehdaghi M, Rahimi H, Mousavian A. Anterior ankle arthrodesis with molded plate: technique and outcomes. Arch Bone Jt Surg 2:203–209, 2014. 4. Slater GL, Sayres SC, O’Malley MJ. Anterior ankle arthrodesis. World J Orthop 5:1–5, 2014. 5. Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg Br 81:113–116, 1999. 6. Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop Relat Res 268:21–28, 1991. 7. Guo C, Yan Z, Barfield WR, Hartsock LA. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int 31:492–498, 2010. 8. Mohamedean A, Said HG, El-Sharkawi M, El-Adly W, Said GZ. Technique and shortterm results of ankle arthrodesis using anterior plating. Int Orthop 34:833–837, 2010. 9. Gordon D, Zicker R, Cullen N, Singh D. Open ankle arthrodeses via an anterior approach. Foot Ankle Int 34:386–391, 2013. 10. Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop Relat Res 361:178–185, 1999.
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