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High failure with the dowel technique for fusion of rheumatoid ankles
The Foot (19981 8. l-17-149 B 1998 Harcourt Brace &Co
ORIGINAL
Ltd
ARTICLE
High failure with the dowel technique for fusion of rheumatoid ankles H. Lauge-Pedersen, S. Odenbring,‘” K. Knutson, U. Rydholm Department qf Orthopuedics, Lund University Hospital, and “Department Hospital, Sweden
of Orthopaedics Kvistianstad County
SUMMARY. Twelve patients (12 ankles) with rheumatoid arthritis were treated with arthrodesls using the dowel technique described by Baciu. Only five of 12 ankles obtained bony fusion. The technique is unsuitable for patients with rheumatoid arthritis.
malleolus, the distal end of the tibia and proximal surface of the talus, and the distal tibiofibular joint to the medial portion of the lateral malleolus, leaving its lateral cortex intact (Fig, 1). The cylindrical bone graft was expelled from the cutter. It was then introduced in reverse so that the medial end of the bone graft was placed in the lateral malleolus; it was also rotated through 90” so that the original surface of the joint was vertical (Fig. 1). In Lund, the technique was somewhat modified. The quality of the bone cylinder was often poor and would only fill the cavity to 50-75%. In order to solve this problem two cylindrical bone grafts were taken from the iliac crest with a Cloward cutter, its inner diameter being the same as the outer diameter of the milling cutter. The cylindrical bone grafts were introduced in addition to the cylindrical bone graft from the ankle. After the operation the ankle was splinted in a neutral position. The average casting time was 11(6-l 5) weeks.
INTRODUCTION Many different techniques have been suggested for ankle arthrodesis, each with its advantages and disadvantages.‘.’ In 1986, Baciu described a simple technique for arthrodesis of the ankle.; He designed a milling cutter with an expulsion piston, the milling cutter being a hollow cylinder 170 mm long with an 18 mm diameter. The cutter was successfully used in patients with post-traumatic osteoarthritis. We report the result of using a similar instrument for patients with rheumatoid arthritis.
MATERIALS
AND METHODS
From October 1987 to March 1992, 12 patients (12 ankles) with rheumatoid arthritis were operated on with the technique described by Baciu. Seven patients were treated in Kristianstad County Hospital and five patients in Lund University Hospital. The average age at operation was 55 (43-72) years. Follow-up time was 16 (3-48) months. One patient had a fixed valgus deformity of his ankle of approximately 15”. In all the other patients, the ankle could be reduced to a functional position. With an image intensifier and the patient supine a Kirchner wire was introduced from the middle of the base of the medial malleolus through the joint space of the ankle and through the lateral malleolus. A 5 cm long vertical skin incision was made centered over the Kirchner wire. The periosteum was freed from the bone and the milling cutter was progressively passed through the medial
Correspondence to Henrik Lauge-Pedersen MD, Department Orthopaedics, University Hospital, S-22185 Lund, Sweden. Fax: +46 46130732. Tel.: +46 46172399.
RESULTS Five patients had painless bony fusion (Fig. 2) and were satisfied with the operation. Seven patients did not obtain bony fusion (Fig. 3). Three of these patients had no further surgery due to low level of functional activity, two of them claimed to be satisfied and painless in spite of no radiographic or clinical evidence of fusion. Three patients were operated on again with an open technique and screw fixation, this time with success. One patient had a deep infection; after surgery, with removal of necrotic tissue including the bony cylinder, the wound healed and the patient had spontaneous fusion of the ankle joint. One patient had a subcutaneous infection which healed after a period of antibiotic treatment (Table 1).
of
147
148
The Foot
C A Fig. l-(A) K-wire through the jomt (AP view). (B) Position of the cylinder (lateral view). (C) The cylindrical bone graft expelled from the cutter. (D) Reinsertion of the cylindrical bone graft
DISCUSSION Baciu reported successful bony fusion in 58 of 62 patients using the dowel technique.3 The indication for surgery was mainiy post-traumatic osteoarthritis; none of the patients had rheumatoid arthritis. The advantages of the technique were short operating time, minimal surgical exposure and the ease of positioning the ankle. In addition, no foreign material was needed. The technique seemed to be suitable for the rheumatoid patient. However, it proved impossible to create a well-fitting bony cylinder, because of the poor bone quality and because the milling cutter must have a smaller inner than outer diameter. Adding cylindrical bone graft with the same outer diameter did not seem to improve the healing rate. Stranks et al’ reported fusion in eight out of eight ankles in patients with rheumatoid arthritis using a dowel graft method with cross-screw fixation, so that stability appears to be crucial for obtaining bony fusion. The casting time was in some cases short, a minimum of 10 weeks in failed cases, which could contribute to the poor results. The reported rates of successful arthrodesis of the ankle vary widely; for compression arthrodesis, from 65%5 to 95%6 and for the transfibular technique’ and internal fixation, from 95OL$to 100%.9 However, most of the patients in those studies did not have rheumatoid arthritis. Few studies have been restricted to patients with rheumatoid arthritis. Cracchiolo et allo reported successful arthrodesis in 15 out of 19 ankles with compression arthrodesis, and 10 out of 13 with internal fixation. Adam and Ranawat” described 21 ankle arthrodeses and 7 pantalar arthrodeses, performed with six different techniques. Failure of fusion was noted in 5 patients. Smith and Wood” reported fusion in 11 out of 11 ankles using the Charnley The Foot(1998)
8, 147-149
B Fig. &Ankle Immediately
ape :rated on with the dowel techmque. (A) after operation and (B) after bony fusion. 0 1998
Harcourt
Brace
& Co. Ltd
Rheumatoid Table
1
Case
Clinical
characteristics
Diagnosis
1 2 3 4 5 6 I 8 9 10 11 12
RA RA RA RA RA RA RA RA RA RA RA RA
ankle fusion
149
and results
Sex
Age W-1
Side
Casting time (weeks)
F F F F F F F F M F M F
54 55 61 63 41 59 44 46 12 43 55 66
Left Left Left Right Right Left Left Left Right Left Right Left
10 9 10 12 12 10 10 14 6 15 13 11
Angle of fusion Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Flexion Neutral Valgus Neutral
Add bone graft
5” 15”
No Yes Yes No No Yes Yes Yes No No No No
Reoperation
Yes Yes
Yes Yes
Satisfied No Yes Yes Yes Yes No No Yes Yes No No Yes
Postoperatlve complications No No No No No Subcut infection No No No No Deep infection No
Fusion No Yes Yes No Yes No No No Yes No No Yes
techniques. Adding bone graft from the iliac crest did not improve the results. Also, the quality of the bone cylinder may not be sufficient in the rheumatoid patient to reliably lock all motion during healing. If the dowel technique is used in the rheumatoid patient we suggest additional fixation with screws or external fixator. The high success rate using either the Charnley compression technique or even percutaneous screw fixationI without dowels make the dowel technique superfluous as a minimally invasive arthrodesis technique in rheumatoid arthritis. REFERENCES
Fig. 3-Failed technique.
arthrodesis
after
operation
with
the dowel
compression technique. Using the simple ankle fusion technique described by Baciu,? we obtained fusion in only five of 12 ankles. The results in this small series are clearly inferior to those of more conventional
0 1998
Harcourt
Brace
& Co.
Ltd
1. Smith E J, Ward A J. Ankle arthrodesls. The Foot 1992; 1: 61-65. 2. Stranks G J, Cecil T. Jeffery I T A. Anterior ankle arthrodesls with cross-screw fixation J Bone Joint Surg (Br) 1994; 76-B: 943-946. Bacm C C. A simple technique for arthrodesis of the ankle. J Bone Joint Surg (Br) 1986: 68-B: 266-267. Stranks G J. Cecil T, Jeffrey I T A. Anterior ankle arthrodesis with cross-screw fixation. J Bone Joint Surg (Br) 1994: 76B. 943-946 Hagen R J. Ankle arthrodesis: problems and pitfalls Chn Orthop 1986; 202, 152-162. Charnley J. Compression arthrodesis of the ankle and shoulder J Bone Joint Surg (Br) 1951; 33-B(2): 180-191. Adams J C. Arthrodesis of the ankle joint. Experiences with the transfibular approach. J Bone Joint Surp (Br) 1948; 30B(3): 506-S 11. Morgan C D. Henke J A, Bailey R W, Kaufer H. Long-term results of tibiotalar arthrodesis J Bone Joint Surg (Am) 1985; 67-A. 546-550. Scranton P E. Use of Internal compression in arthrodesis of the ankle. J Bone Joint Surg (Am) 1985; 67-A: 550-555 Cracchiolo A III, Cmnno W R. Lian G. Arthrodesis of the ankle in patients who have rheumatoid arthritis. J Bone Joint Surg (Am) 1992; 74A: 903-909. Adam W, Ranawat C. Arthrodesls of the hmdfoot in rheumatoid arthritis. Orthop Chn N Am 1976; 7: 827-840. Smith E J. Wood P L R Ankle arthrodesls m the rheumatoid patient. Foot Ankle 1990; 10: 252-256. Lauge-Pedersen H, Knutson K, Rydholm U. Percutaneous ankle arthrodesis m the rheumatoid patient without debridement of the joint. The Foot 1998. in press
The Foot
(1998)
8, 147-l
49
ORIGINAL
Ltd
ARTICLE
High failure with the dowel technique for fusion of rheumatoid ankles H. Lauge-Pedersen, S. Odenbring,‘” K. Knutson, U. Rydholm Department qf Orthopuedics, Lund University Hospital, and “Department Hospital, Sweden
of Orthopaedics Kvistianstad County
SUMMARY. Twelve patients (12 ankles) with rheumatoid arthritis were treated with arthrodesls using the dowel technique described by Baciu. Only five of 12 ankles obtained bony fusion. The technique is unsuitable for patients with rheumatoid arthritis.
malleolus, the distal end of the tibia and proximal surface of the talus, and the distal tibiofibular joint to the medial portion of the lateral malleolus, leaving its lateral cortex intact (Fig, 1). The cylindrical bone graft was expelled from the cutter. It was then introduced in reverse so that the medial end of the bone graft was placed in the lateral malleolus; it was also rotated through 90” so that the original surface of the joint was vertical (Fig. 1). In Lund, the technique was somewhat modified. The quality of the bone cylinder was often poor and would only fill the cavity to 50-75%. In order to solve this problem two cylindrical bone grafts were taken from the iliac crest with a Cloward cutter, its inner diameter being the same as the outer diameter of the milling cutter. The cylindrical bone grafts were introduced in addition to the cylindrical bone graft from the ankle. After the operation the ankle was splinted in a neutral position. The average casting time was 11(6-l 5) weeks.
INTRODUCTION Many different techniques have been suggested for ankle arthrodesis, each with its advantages and disadvantages.‘.’ In 1986, Baciu described a simple technique for arthrodesis of the ankle.; He designed a milling cutter with an expulsion piston, the milling cutter being a hollow cylinder 170 mm long with an 18 mm diameter. The cutter was successfully used in patients with post-traumatic osteoarthritis. We report the result of using a similar instrument for patients with rheumatoid arthritis.
MATERIALS
AND METHODS
From October 1987 to March 1992, 12 patients (12 ankles) with rheumatoid arthritis were operated on with the technique described by Baciu. Seven patients were treated in Kristianstad County Hospital and five patients in Lund University Hospital. The average age at operation was 55 (43-72) years. Follow-up time was 16 (3-48) months. One patient had a fixed valgus deformity of his ankle of approximately 15”. In all the other patients, the ankle could be reduced to a functional position. With an image intensifier and the patient supine a Kirchner wire was introduced from the middle of the base of the medial malleolus through the joint space of the ankle and through the lateral malleolus. A 5 cm long vertical skin incision was made centered over the Kirchner wire. The periosteum was freed from the bone and the milling cutter was progressively passed through the medial
Correspondence to Henrik Lauge-Pedersen MD, Department Orthopaedics, University Hospital, S-22185 Lund, Sweden. Fax: +46 46130732. Tel.: +46 46172399.
RESULTS Five patients had painless bony fusion (Fig. 2) and were satisfied with the operation. Seven patients did not obtain bony fusion (Fig. 3). Three of these patients had no further surgery due to low level of functional activity, two of them claimed to be satisfied and painless in spite of no radiographic or clinical evidence of fusion. Three patients were operated on again with an open technique and screw fixation, this time with success. One patient had a deep infection; after surgery, with removal of necrotic tissue including the bony cylinder, the wound healed and the patient had spontaneous fusion of the ankle joint. One patient had a subcutaneous infection which healed after a period of antibiotic treatment (Table 1).
of
147
148
The Foot
C A Fig. l-(A) K-wire through the jomt (AP view). (B) Position of the cylinder (lateral view). (C) The cylindrical bone graft expelled from the cutter. (D) Reinsertion of the cylindrical bone graft
DISCUSSION Baciu reported successful bony fusion in 58 of 62 patients using the dowel technique.3 The indication for surgery was mainiy post-traumatic osteoarthritis; none of the patients had rheumatoid arthritis. The advantages of the technique were short operating time, minimal surgical exposure and the ease of positioning the ankle. In addition, no foreign material was needed. The technique seemed to be suitable for the rheumatoid patient. However, it proved impossible to create a well-fitting bony cylinder, because of the poor bone quality and because the milling cutter must have a smaller inner than outer diameter. Adding cylindrical bone graft with the same outer diameter did not seem to improve the healing rate. Stranks et al’ reported fusion in eight out of eight ankles in patients with rheumatoid arthritis using a dowel graft method with cross-screw fixation, so that stability appears to be crucial for obtaining bony fusion. The casting time was in some cases short, a minimum of 10 weeks in failed cases, which could contribute to the poor results. The reported rates of successful arthrodesis of the ankle vary widely; for compression arthrodesis, from 65%5 to 95%6 and for the transfibular technique’ and internal fixation, from 95OL$to 100%.9 However, most of the patients in those studies did not have rheumatoid arthritis. Few studies have been restricted to patients with rheumatoid arthritis. Cracchiolo et allo reported successful arthrodesis in 15 out of 19 ankles with compression arthrodesis, and 10 out of 13 with internal fixation. Adam and Ranawat” described 21 ankle arthrodeses and 7 pantalar arthrodeses, performed with six different techniques. Failure of fusion was noted in 5 patients. Smith and Wood” reported fusion in 11 out of 11 ankles using the Charnley The Foot(1998)
8, 147-149
B Fig. &Ankle Immediately
ape :rated on with the dowel techmque. (A) after operation and (B) after bony fusion. 0 1998
Harcourt
Brace
& Co. Ltd
Rheumatoid Table
1
Case
Clinical
characteristics
Diagnosis
1 2 3 4 5 6 I 8 9 10 11 12
RA RA RA RA RA RA RA RA RA RA RA RA
ankle fusion
149
and results
Sex
Age W-1
Side
Casting time (weeks)
F F F F F F F F M F M F
54 55 61 63 41 59 44 46 12 43 55 66
Left Left Left Right Right Left Left Left Right Left Right Left
10 9 10 12 12 10 10 14 6 15 13 11
Angle of fusion Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Flexion Neutral Valgus Neutral
Add bone graft
5” 15”
No Yes Yes No No Yes Yes Yes No No No No
Reoperation
Yes Yes
Yes Yes
Satisfied No Yes Yes Yes Yes No No Yes Yes No No Yes
Postoperatlve complications No No No No No Subcut infection No No No No Deep infection No
Fusion No Yes Yes No Yes No No No Yes No No Yes
techniques. Adding bone graft from the iliac crest did not improve the results. Also, the quality of the bone cylinder may not be sufficient in the rheumatoid patient to reliably lock all motion during healing. If the dowel technique is used in the rheumatoid patient we suggest additional fixation with screws or external fixator. The high success rate using either the Charnley compression technique or even percutaneous screw fixationI without dowels make the dowel technique superfluous as a minimally invasive arthrodesis technique in rheumatoid arthritis. REFERENCES
Fig. 3-Failed technique.
arthrodesis
after
operation
with
the dowel
compression technique. Using the simple ankle fusion technique described by Baciu,? we obtained fusion in only five of 12 ankles. The results in this small series are clearly inferior to those of more conventional
0 1998
Harcourt
Brace
& Co.
Ltd
1. Smith E J, Ward A J. Ankle arthrodesls. The Foot 1992; 1: 61-65. 2. Stranks G J, Cecil T. Jeffery I T A. Anterior ankle arthrodesls with cross-screw fixation J Bone Joint Surg (Br) 1994; 76-B: 943-946. Bacm C C. A simple technique for arthrodesis of the ankle. J Bone Joint Surg (Br) 1986: 68-B: 266-267. Stranks G J. Cecil T, Jeffrey I T A. Anterior ankle arthrodesis with cross-screw fixation. J Bone Joint Surg (Br) 1994: 76B. 943-946 Hagen R J. Ankle arthrodesis: problems and pitfalls Chn Orthop 1986; 202, 152-162. Charnley J. Compression arthrodesis of the ankle and shoulder J Bone Joint Surg (Br) 1951; 33-B(2): 180-191. Adams J C. Arthrodesis of the ankle joint. Experiences with the transfibular approach. J Bone Joint Surp (Br) 1948; 30B(3): 506-S 11. Morgan C D. Henke J A, Bailey R W, Kaufer H. Long-term results of tibiotalar arthrodesis J Bone Joint Surg (Am) 1985; 67-A. 546-550. Scranton P E. Use of Internal compression in arthrodesis of the ankle. J Bone Joint Surg (Am) 1985; 67-A: 550-555 Cracchiolo A III, Cmnno W R. Lian G. Arthrodesis of the ankle in patients who have rheumatoid arthritis. J Bone Joint Surg (Am) 1992; 74A: 903-909. Adam W, Ranawat C. Arthrodesls of the hmdfoot in rheumatoid arthritis. Orthop Chn N Am 1976; 7: 827-840. Smith E J. Wood P L R Ankle arthrodesls m the rheumatoid patient. Foot Ankle 1990; 10: 252-256. Lauge-Pedersen H, Knutson K, Rydholm U. Percutaneous ankle arthrodesis m the rheumatoid patient without debridement of the joint. The Foot 1998. in press
The Foot
(1998)
8, 147-l
49