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Arthroscopically Assisted Ankle Fusion in Patients With End-Stage Tuberculosis
Arthroscopically Assisted Ankle Fusion in Patients With End-Stage Tuberculosis Kang-lai Tang, M.D., Ph.D., Qi-hong Li, M.D., Ph.D., Guang-xin Chen, M.D., Lin Guo, M.D., Gang Dai, M.D., Ph.D., and Liu Yang, M.D., Ph.D.
Purpose: Our purpose was to evaluate the clinical outcomes of arthroscopically assisted ankle fusion in patients with end-stage tuberculosis. Methods: Ten patients, all with end-stage tuberculosis, were operated on by arthroscopically assisted ankle fusion, and a half-ring sulcated external fixator was used. Partial weight-bearing was started on the fourth day. The clinical results were assessed with the American Orthopaedic Foot & Ankle Society score. Ankle fusion was proved by radiographs. Results: At the mean follow-up of 23 months, all fusions were healed; the mean time to radiologic healing was 14.5 weeks. The final American Orthopaedic Foot & Ankle Society score was 66 points. Conclusions: Arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications. Level of Evidence: Level IV, therapeutic case series. Key Words: Arthroscopy— External fixation—Ankle—Tuberculosis—Arthrodesis.
A
rthroscopically assisted ankle arthrodesis, used in osteoarthritis and rheumatoid arthritis, has been adopted by more and more orthopaedists.1-9 Traditionally, surgical treatment of ankle tuberculosis (TB) mainly involved open debridement and arthrodesis with relatively poor healing of soft tissues and many postoperative complications.10-13 To our knowledge, the use of arthroscopy for the treatment of end-stage ankle TB has not been reported.14 Patients with end-stage ankle TB have a low rate of fusion with a high incidence of complications; thus we tried to find a safe and effective solution for such patients. Our specific hypothesis was that arthroscopically assisted ankle fusion with an exter-
From the Centre for Joint Surgery, Orthopaedics Department, Southwest Hospital, Third Military Medical University, Chongqing, China. The authors report no conflict of interest. Address correspondence and reprint requests to Kang-lai Tang, M.D., Ph.D. Centre for Joint Surgery, Orthopaedics Department, Southwest Hospital, Third Military Medical University, Gaotanyan St 30, Chongqing 400038, China. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America 0749-8063/07/2309-6418$32.00/0 doi:10.1016/j.arthro.2007.04.004
nal fixator would increase the rate of ankle fusion and decrease the incidence of complications.
METHODS Patients Only patients who had undergone arthroscopically assisted ankle arthrodesis for the treatment of endstage ankle joint TB were included in the study. In addition, we included only those who had undergone arthrodesis by use of a half-ring external fixator and who had at least 6 months of follow-up. Any patient who had any ankle deformity and large bone defects in any part of the joint was excluded. There were 10 patients (6 men and 4 women; mean age, 33 years [range, 28 to 56 years]; mean duration of illness, 13 months [range, 8 to 23 months]). Of these, 5 were diagnosed as having ankle TB before the operation, based on patient history, radiographs, magnetic resonance imaging, and polymerase chain reaction testing. The other 5 patients were misdiagnosed preoperatively as having rheumatic arthritis, suppurative arthritis, and gouty arthritis but were then proved to have TB by operative synovial fluid polymerase
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 9 (September), 2007: pp 919-922
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chain reaction testing or pathologic analysis of biopsy specimens (or both). The diagnosis in all patients was confirmed by postoperative pathology. On the basis of radiographs and magnetic resonance imaging, all patients had some classical characteristics, including severe joint destruction and, eventually, sclerosis, fibrous ankylosis, central and peripheral erosions, various degrees of osteoporosis, obscure subcartilaginous bone plates or small amounts of articular hydrops, abscesses, bone chips, and articular cartilage damage. Before surgery, all patients received anti-TB drug therapy for at least 3 weeks, until the erythrocyte sedimentation rate (ESR) became normal or was stable. Surgical Technique Patients were placed in the supine position and received lumber plexus and sciatic nerve block anesthesia. A tourniquet was used on the upper leg (pressure of 280 mm Hg). By use of a self-made ankle joint retractor with pads, arthroscopic surgery was conducted with water inflow under pressure (100 to 120 mm Hg). A 30° ankle arthroscope (2.8 or 4 mm in diameter) (Smith & Nephew Endoscopy, Andover, MA) was used. Standard anterolateral, anteromedial, and posterolateral approaches were adopted. Articular cavity lavage was carried out with large volumes of physiologic saline solution, all hyperplastic synovial membrane was removed with a shaver, and damaged articular cartilage was removed with a shaver and trimmer. Articular cartilage was removed systematically with the aid of a mechanical shaver, high-speed bur, and angled curettes, down to subchondral bleeding bone. The subchondral surface was smooth without any grooves. After clearing and buffing, isoniazid and streptomycin were injected into the articular cavity. The incision was closed, with fixation of the joint via a half-ring sulcated external fixator. Two pairs of Kirschner wires (2.5 mm) were inserted in crisscross fashion and parallel with the ankle joint line at the distal tibia, 6 to 8 cm away from the ankle joint surface, and at the calcaneus midpoint. Kirschner wires were linked to the half-ring sulcated external fixator, and compression fixation was then performed. The external fixation apparatus was adjusted to maintain the ankle joint in the neutral position. Postoperative Management and Assessment Immediately after surgery, all patients received anti-TB drug therapy, with rifampin (900 mg/d), isoniazid (300 mg/d), and ethambutol (750 mg/d) for 12
to 18 months; pyrazinamide (1,500 mg/d) for 6 months; and intramuscular streptomycin treatment for 1 to 3 months. Patients could walk with partial weightbearing 4 days postoperatively. All patients were assessed both clinically and radiologically. The American Orthopaedic Foot & Ankle Society (AOFAS) score was used to evaluate clinical results. Serial radiographs were obtained once every 2 weeks until union was achieved. The external fixation apparatus was adjusted according to joint space as shown by radiographs until the surfaces of the joint were in complete contact (Fig 1). The external fixator was removed after union was proved on radiographs. RESULTS All patients were observed postoperatively, with a mean follow-up of 23.2 months (range, 6 to 46 months). All patients achieved bone fusion as shown by radiographs (Fig 2). The mean time to radiographic bone fusion was 14.5 weeks (range, 8 to 20 weeks). In two patients bony callus began to form at 6 weeks and bone fusion was completed 8 weeks postoperatively. One of them was lost to follow-up because the patient felt well and did not want to return for follow-up after 6 months. Another patient was also lost to follow-up for the same reason after 9 months. The other 8 patients were followed up for at least 12 months. AOFAS scores were determined and averaged 66 points (range, 58 to 82 points) at the patients’ last follow-up. The ESR and C-reactive protein level returned to normal in all patients by 3 months postoperatively. There was no TB metastasis, diffusion, skin sinus tract, or TB recurrence. DISCUSSION Ankle TB is frequently overlooked, and its early diagnosis is not easy because of the lack of characteristic symptoms, signs, and imaging manifestations.10-15 The classical characteristics in the end stage of joint TB include severe joint destruction and, eventually, sclerosis and fibrous ankylosis.11-13 In this group, all patients had these features and were proved to be in the end stage of ankle TB. It is very difficult to treat end-stage ankle TB with conservative therapy. Traditionally, the ankle needs to be opened and debrided to perform an ankle fusion.11 For simple synovial membrane TB and in the early stage of total ankle TB, Titov et al.14 reported debridement of TB under arthroscopy with good results. However, for total ankle TB with severe damage in the end stage, debride-
ANKLE FUSION IN TUBERCULOSIS PATIENTS
FIGURE 1. Postoperative anteroposterior and lateral radiographs showing excellent apposition of tibiotalar surfaces.
ment and tibiotalar arthrodesis should be considered. Significant varus and valgus deformities cannot be corrected effectively under arthroscopy. So, arthroscopically assisted debridement and fusion are not advisable for any patient who had any ankle deformity and large bone defects in any part of the joint. In our arthroscopic surgeries, we used anteromedial, anterolateral, and posterolateral approaches. Anteromedial and anterolateral approaches were used to debride the joint space. Sometimes, we used the posterolateral approach to debride the back of the ankle. These 3 approaches were usually sufficient for broad debridement of the ankle joint. Complete and effective bone contact between the tibial concavity and the talar dome is the key to successful tibiotalar arthrodesis. Traditionally, ankle joint TB was treated by open debridement, which has the following drawbacks: significant trauma, extensive incision and stripping of periosteum and soft tissue, and limited operative field exposure, particularly at the back of the joint (making radical clearing of the articular cavity difficult).11-13 The arthroscopically assisted debridement of TB under traction allows for clear exposure of lesions and broad removal of affected synovial tissues, stripping cartilage and subcartilaginous bone.10,14 Hence, compared with open surgery, arthroscopically assisted debridement of ankle joint TB results in a small incision, fast recovery, radical debridement, matching of bone surfaces, and preservation of the ankle mortise as outlined. It was recently reported that arthroscopically assisted ankle arthrodesis with ankle screws or spongy bone screws was used in traumatic osteoarthritis and rheumatoid arthritis.1,5,6 Internal fixation with these screws should not be considered for infectious ankle
921
joint destruction.7 External fixation pins do not pass through the lesions and thus minimize the possibility of TB dissemination. Ankle arthrodesis with a halfring sulcated external fixator has some advantages: (1) providing various modes of mechanical action, compression fixation, stable fixation, and late elastic fixation, which are performed depending on ankle joint apposition after debridement; (2) fixation away from the affected site, avoiding TB dissemination; (3) small wounds causing the biologic environment for bone fusion; and (4) adjustment postoperatively to correct remnant axial deviation or position alteration of the ankle as a result of early functional exercise. In this study we performed tibiotalar arthrodesis by inserting Kirschner wires between the tibia and calcaneus, instead of between the tibia and talus, which may affect subtalar joint movement. This is a relative disadvantage of this procedure; however, limitations of subtalar joint movement may partially recover with walking exercise after removal of the external fixator. In our patient group, the radiologic fusion rate was 100%. The mean time to radiographic bone fusion was 14.5 weeks (range, 8 to 20 weeks). In their review, Winson et al.8 reported on 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean time to union was 12 weeks (range, 6 to 20 weeks). Nonunion occurred in 9 cases (7.6%). The fusion rate in our study was much better than in the former studies. However, the time to fusion may be slightly longer because of ankle joint TB. Furthermore, we also obtained good clinical outcomes. The mean postoperative AOFAS score in our study was somewhat low at the patients’ last follow-up. However, the ESR and C-reactive protein level were restored to normal in all patients 3 months postoperatively. No recurrences or other complications occurred
FIGURE 2. Good ankle fusion shown on radiographs (anteroposterior and lateral) after removal of external fixator.
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during the follow-up period. How could we obtain such good outcomes? In addition to the reasonable and complete debridement, as well as stable external fixation, the standard anti-TB drug therapy before and after surgery was also very important. As for the low AOFAS scores, they may be related to multiple factors, including the long period during which the patients had not received any reasonable treatment, poor rehabilitation as a result of economic factors, and so on. However, this study was based on a small sample size and short period of follow-up and was not a randomized, controlled study. In addition, the mean postoperative AOFAS score was low but could not be compared with preoperative scores, which were not obtained. Hence, a large, controlled, long-term clinical follow-up study is required to elucidate the efficacy and safety of the present method. CONCLUSIONS Arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications. Acknowledgment: The authors thank James K. DeOrie, M.D., and Clifford L. Jeng, M.D., for manuscript correction in language.
REFERENCES 1. Cameron SE, Ullrich P. Arthroscopic arthrodesis of the ankle joint. Arthroscopy 2000;16:21-26.
2. Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthrodesis. Foot Ankle Int 2005;26:275-280. 3. Fitzgibbons TC. Arthroscopic ankle debridement and fusion: Indications, techniques, and results. Instr Course Lect 1999; 48:243-248. 4. Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using an arthroscopic method: Long-term follow-up of 34 cases. Arthroscopy 1996;12:428-434. 5. Karladani A, Digas G, Ekstrom L, Swanpalmer J, Styf J, Hansson T. Ankle arthrodesis using dowel bone graft and cancellous-bone screws: A mechanical study in cadavers. Acta Orthop Scand 2004;75:471-476. 6. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res 1991:84-95. 7. O’Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis: A comparative study. Foot Ankle Int 1999;20:368-374. 8. Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 2005;87:343-347. 9. Zvijac JE, Lemak L, Schurhoff MR, Hechtman KS, Uribe JW. Analysis of arthroscopically assisted ankle arthrodesis. Arthroscopy 2002;18:70-75. 10. Cai D, Chen Y, Rong L. Arthroscopy in diagnosis and treatment of tuberculous synovitis. Zhonghua Jie He He Hu Xi Za Zhi 1998;21:276-277 (in Chinese). 11. Dhillon MS, Nagi ON. Tuberculosis of the foot and ankle. Clin Orthop Relat Res 2002:107-113. 12. Sequeira W, Co H, Block JA. Osteoarticular tuberculosis: Current diagnosis and treatment. Am J Ther 2000;7:393-398. 13. Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop Relat Res 2002:11-19. 14. Titov AG, Nakonechniy GD, Santavirta S, Serdobintzev MS, Mazurenko SI, Konttinen YT. Arthroscopic operations in joint tuberculosis. Knee 2004;11:57-62. 15. Titov AG, Vyshnevskaya EB, Mazurenko SI, Santavirta S, Konttinen YT. Use of polymerase chain reaction to diagnose tuberculous arthritis from joint tissues and synovial fluid. Arch Pathol Lab Med 2004;128:205-209.
Purpose: Our purpose was to evaluate the clinical outcomes of arthroscopically assisted ankle fusion in patients with end-stage tuberculosis. Methods: Ten patients, all with end-stage tuberculosis, were operated on by arthroscopically assisted ankle fusion, and a half-ring sulcated external fixator was used. Partial weight-bearing was started on the fourth day. The clinical results were assessed with the American Orthopaedic Foot & Ankle Society score. Ankle fusion was proved by radiographs. Results: At the mean follow-up of 23 months, all fusions were healed; the mean time to radiologic healing was 14.5 weeks. The final American Orthopaedic Foot & Ankle Society score was 66 points. Conclusions: Arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications. Level of Evidence: Level IV, therapeutic case series. Key Words: Arthroscopy— External fixation—Ankle—Tuberculosis—Arthrodesis.
A
rthroscopically assisted ankle arthrodesis, used in osteoarthritis and rheumatoid arthritis, has been adopted by more and more orthopaedists.1-9 Traditionally, surgical treatment of ankle tuberculosis (TB) mainly involved open debridement and arthrodesis with relatively poor healing of soft tissues and many postoperative complications.10-13 To our knowledge, the use of arthroscopy for the treatment of end-stage ankle TB has not been reported.14 Patients with end-stage ankle TB have a low rate of fusion with a high incidence of complications; thus we tried to find a safe and effective solution for such patients. Our specific hypothesis was that arthroscopically assisted ankle fusion with an exter-
From the Centre for Joint Surgery, Orthopaedics Department, Southwest Hospital, Third Military Medical University, Chongqing, China. The authors report no conflict of interest. Address correspondence and reprint requests to Kang-lai Tang, M.D., Ph.D. Centre for Joint Surgery, Orthopaedics Department, Southwest Hospital, Third Military Medical University, Gaotanyan St 30, Chongqing 400038, China. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America 0749-8063/07/2309-6418$32.00/0 doi:10.1016/j.arthro.2007.04.004
nal fixator would increase the rate of ankle fusion and decrease the incidence of complications.
METHODS Patients Only patients who had undergone arthroscopically assisted ankle arthrodesis for the treatment of endstage ankle joint TB were included in the study. In addition, we included only those who had undergone arthrodesis by use of a half-ring external fixator and who had at least 6 months of follow-up. Any patient who had any ankle deformity and large bone defects in any part of the joint was excluded. There were 10 patients (6 men and 4 women; mean age, 33 years [range, 28 to 56 years]; mean duration of illness, 13 months [range, 8 to 23 months]). Of these, 5 were diagnosed as having ankle TB before the operation, based on patient history, radiographs, magnetic resonance imaging, and polymerase chain reaction testing. The other 5 patients were misdiagnosed preoperatively as having rheumatic arthritis, suppurative arthritis, and gouty arthritis but were then proved to have TB by operative synovial fluid polymerase
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 9 (September), 2007: pp 919-922
919
920
K-L. TANG ET AL.
chain reaction testing or pathologic analysis of biopsy specimens (or both). The diagnosis in all patients was confirmed by postoperative pathology. On the basis of radiographs and magnetic resonance imaging, all patients had some classical characteristics, including severe joint destruction and, eventually, sclerosis, fibrous ankylosis, central and peripheral erosions, various degrees of osteoporosis, obscure subcartilaginous bone plates or small amounts of articular hydrops, abscesses, bone chips, and articular cartilage damage. Before surgery, all patients received anti-TB drug therapy for at least 3 weeks, until the erythrocyte sedimentation rate (ESR) became normal or was stable. Surgical Technique Patients were placed in the supine position and received lumber plexus and sciatic nerve block anesthesia. A tourniquet was used on the upper leg (pressure of 280 mm Hg). By use of a self-made ankle joint retractor with pads, arthroscopic surgery was conducted with water inflow under pressure (100 to 120 mm Hg). A 30° ankle arthroscope (2.8 or 4 mm in diameter) (Smith & Nephew Endoscopy, Andover, MA) was used. Standard anterolateral, anteromedial, and posterolateral approaches were adopted. Articular cavity lavage was carried out with large volumes of physiologic saline solution, all hyperplastic synovial membrane was removed with a shaver, and damaged articular cartilage was removed with a shaver and trimmer. Articular cartilage was removed systematically with the aid of a mechanical shaver, high-speed bur, and angled curettes, down to subchondral bleeding bone. The subchondral surface was smooth without any grooves. After clearing and buffing, isoniazid and streptomycin were injected into the articular cavity. The incision was closed, with fixation of the joint via a half-ring sulcated external fixator. Two pairs of Kirschner wires (2.5 mm) were inserted in crisscross fashion and parallel with the ankle joint line at the distal tibia, 6 to 8 cm away from the ankle joint surface, and at the calcaneus midpoint. Kirschner wires were linked to the half-ring sulcated external fixator, and compression fixation was then performed. The external fixation apparatus was adjusted to maintain the ankle joint in the neutral position. Postoperative Management and Assessment Immediately after surgery, all patients received anti-TB drug therapy, with rifampin (900 mg/d), isoniazid (300 mg/d), and ethambutol (750 mg/d) for 12
to 18 months; pyrazinamide (1,500 mg/d) for 6 months; and intramuscular streptomycin treatment for 1 to 3 months. Patients could walk with partial weightbearing 4 days postoperatively. All patients were assessed both clinically and radiologically. The American Orthopaedic Foot & Ankle Society (AOFAS) score was used to evaluate clinical results. Serial radiographs were obtained once every 2 weeks until union was achieved. The external fixation apparatus was adjusted according to joint space as shown by radiographs until the surfaces of the joint were in complete contact (Fig 1). The external fixator was removed after union was proved on radiographs. RESULTS All patients were observed postoperatively, with a mean follow-up of 23.2 months (range, 6 to 46 months). All patients achieved bone fusion as shown by radiographs (Fig 2). The mean time to radiographic bone fusion was 14.5 weeks (range, 8 to 20 weeks). In two patients bony callus began to form at 6 weeks and bone fusion was completed 8 weeks postoperatively. One of them was lost to follow-up because the patient felt well and did not want to return for follow-up after 6 months. Another patient was also lost to follow-up for the same reason after 9 months. The other 8 patients were followed up for at least 12 months. AOFAS scores were determined and averaged 66 points (range, 58 to 82 points) at the patients’ last follow-up. The ESR and C-reactive protein level returned to normal in all patients by 3 months postoperatively. There was no TB metastasis, diffusion, skin sinus tract, or TB recurrence. DISCUSSION Ankle TB is frequently overlooked, and its early diagnosis is not easy because of the lack of characteristic symptoms, signs, and imaging manifestations.10-15 The classical characteristics in the end stage of joint TB include severe joint destruction and, eventually, sclerosis and fibrous ankylosis.11-13 In this group, all patients had these features and were proved to be in the end stage of ankle TB. It is very difficult to treat end-stage ankle TB with conservative therapy. Traditionally, the ankle needs to be opened and debrided to perform an ankle fusion.11 For simple synovial membrane TB and in the early stage of total ankle TB, Titov et al.14 reported debridement of TB under arthroscopy with good results. However, for total ankle TB with severe damage in the end stage, debride-
ANKLE FUSION IN TUBERCULOSIS PATIENTS
FIGURE 1. Postoperative anteroposterior and lateral radiographs showing excellent apposition of tibiotalar surfaces.
ment and tibiotalar arthrodesis should be considered. Significant varus and valgus deformities cannot be corrected effectively under arthroscopy. So, arthroscopically assisted debridement and fusion are not advisable for any patient who had any ankle deformity and large bone defects in any part of the joint. In our arthroscopic surgeries, we used anteromedial, anterolateral, and posterolateral approaches. Anteromedial and anterolateral approaches were used to debride the joint space. Sometimes, we used the posterolateral approach to debride the back of the ankle. These 3 approaches were usually sufficient for broad debridement of the ankle joint. Complete and effective bone contact between the tibial concavity and the talar dome is the key to successful tibiotalar arthrodesis. Traditionally, ankle joint TB was treated by open debridement, which has the following drawbacks: significant trauma, extensive incision and stripping of periosteum and soft tissue, and limited operative field exposure, particularly at the back of the joint (making radical clearing of the articular cavity difficult).11-13 The arthroscopically assisted debridement of TB under traction allows for clear exposure of lesions and broad removal of affected synovial tissues, stripping cartilage and subcartilaginous bone.10,14 Hence, compared with open surgery, arthroscopically assisted debridement of ankle joint TB results in a small incision, fast recovery, radical debridement, matching of bone surfaces, and preservation of the ankle mortise as outlined. It was recently reported that arthroscopically assisted ankle arthrodesis with ankle screws or spongy bone screws was used in traumatic osteoarthritis and rheumatoid arthritis.1,5,6 Internal fixation with these screws should not be considered for infectious ankle
921
joint destruction.7 External fixation pins do not pass through the lesions and thus minimize the possibility of TB dissemination. Ankle arthrodesis with a halfring sulcated external fixator has some advantages: (1) providing various modes of mechanical action, compression fixation, stable fixation, and late elastic fixation, which are performed depending on ankle joint apposition after debridement; (2) fixation away from the affected site, avoiding TB dissemination; (3) small wounds causing the biologic environment for bone fusion; and (4) adjustment postoperatively to correct remnant axial deviation or position alteration of the ankle as a result of early functional exercise. In this study we performed tibiotalar arthrodesis by inserting Kirschner wires between the tibia and calcaneus, instead of between the tibia and talus, which may affect subtalar joint movement. This is a relative disadvantage of this procedure; however, limitations of subtalar joint movement may partially recover with walking exercise after removal of the external fixator. In our patient group, the radiologic fusion rate was 100%. The mean time to radiographic bone fusion was 14.5 weeks (range, 8 to 20 weeks). In their review, Winson et al.8 reported on 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean time to union was 12 weeks (range, 6 to 20 weeks). Nonunion occurred in 9 cases (7.6%). The fusion rate in our study was much better than in the former studies. However, the time to fusion may be slightly longer because of ankle joint TB. Furthermore, we also obtained good clinical outcomes. The mean postoperative AOFAS score in our study was somewhat low at the patients’ last follow-up. However, the ESR and C-reactive protein level were restored to normal in all patients 3 months postoperatively. No recurrences or other complications occurred
FIGURE 2. Good ankle fusion shown on radiographs (anteroposterior and lateral) after removal of external fixator.
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K-L. TANG ET AL.
during the follow-up period. How could we obtain such good outcomes? In addition to the reasonable and complete debridement, as well as stable external fixation, the standard anti-TB drug therapy before and after surgery was also very important. As for the low AOFAS scores, they may be related to multiple factors, including the long period during which the patients had not received any reasonable treatment, poor rehabilitation as a result of economic factors, and so on. However, this study was based on a small sample size and short period of follow-up and was not a randomized, controlled study. In addition, the mean postoperative AOFAS score was low but could not be compared with preoperative scores, which were not obtained. Hence, a large, controlled, long-term clinical follow-up study is required to elucidate the efficacy and safety of the present method. CONCLUSIONS Arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications. Acknowledgment: The authors thank James K. DeOrie, M.D., and Clifford L. Jeng, M.D., for manuscript correction in language.
REFERENCES 1. Cameron SE, Ullrich P. Arthroscopic arthrodesis of the ankle joint. Arthroscopy 2000;16:21-26.
2. Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthrodesis. Foot Ankle Int 2005;26:275-280. 3. Fitzgibbons TC. Arthroscopic ankle debridement and fusion: Indications, techniques, and results. Instr Course Lect 1999; 48:243-248. 4. Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using an arthroscopic method: Long-term follow-up of 34 cases. Arthroscopy 1996;12:428-434. 5. Karladani A, Digas G, Ekstrom L, Swanpalmer J, Styf J, Hansson T. Ankle arthrodesis using dowel bone graft and cancellous-bone screws: A mechanical study in cadavers. Acta Orthop Scand 2004;75:471-476. 6. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res 1991:84-95. 7. O’Brien TS, Hart TS, Shereff MJ, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis: A comparative study. Foot Ankle Int 1999;20:368-374. 8. Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 2005;87:343-347. 9. Zvijac JE, Lemak L, Schurhoff MR, Hechtman KS, Uribe JW. Analysis of arthroscopically assisted ankle arthrodesis. Arthroscopy 2002;18:70-75. 10. Cai D, Chen Y, Rong L. Arthroscopy in diagnosis and treatment of tuberculous synovitis. Zhonghua Jie He He Hu Xi Za Zhi 1998;21:276-277 (in Chinese). 11. Dhillon MS, Nagi ON. Tuberculosis of the foot and ankle. Clin Orthop Relat Res 2002:107-113. 12. Sequeira W, Co H, Block JA. Osteoarticular tuberculosis: Current diagnosis and treatment. Am J Ther 2000;7:393-398. 13. Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop Relat Res 2002:11-19. 14. Titov AG, Nakonechniy GD, Santavirta S, Serdobintzev MS, Mazurenko SI, Konttinen YT. Arthroscopic operations in joint tuberculosis. Knee 2004;11:57-62. 15. Titov AG, Vyshnevskaya EB, Mazurenko SI, Santavirta S, Konttinen YT. Use of polymerase chain reaction to diagnose tuberculous arthritis from joint tissues and synovial fluid. Arch Pathol Lab Med 2004;128:205-209.