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Tibiocalcaneal Arthrodesis Using a Simple External Fixator
The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Tibiocalcaneal Arthrodesis Using a Simple External Fixator Ravichand Ismavel, MS (Ortho) 1, Sait S. Azad, Dilpoma (Ortho) 2, Daniel V. Viju, MS (Ortho) 1, Alfred J. Daniel, MS (Ortho) 3 1 2 3
Associate Professor, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Postgraduate Registrar, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Diplomate of National Board Professor and Head, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
a r t i c l e i n f o
a b s t r a c t
Keywords: ankle calcaneus external fixation hindfoot talus tibia
Tibiocalcaneal arthrodesis has been a salvage option for conditions with extensive loss of the talar body. In conditions that preclude the use of internal fixation, external compression arthrodesis has been the preferred technique to achieve fusion about the hindfoot. Since Sir John Charnley elucidated the technique of compression arthrodesis using compression clamps, various modifications and techniques of external compression arthrodesis have been described. Various clinical and biomechanical studies have established the superiority of triangular transfixation in external compression arthrodesis. We have described a simple technique of compression arthrodesis after the principle of triangular transfixation using easily available hardware from Ilizarov instrumentation. This technique is relatively inexpensive in terms of the cost of the materials, uses a modular construct, and allows multiplanar correction of the hindfoot. It can be used intraoperatively to distract the hindfoot joints, especially in the presence of fibrosis and poor skin conditions. We believe this device can be a reasonable alternative to the conventional external fixation techniques for tibiocalcaneal arthrodesis. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Tibiocalcaneal arthrodesis has been a salvage option often used for conditions with extensive loss of the talar body such as advanced neuropathic arthropathy of the hindfoot, failed ankle arthroplasty, and open ankle injury with talar loss (1,2). To achieve fusion around the hindfoot, various internal and external fixation techniques have been described. External compression arthrodesis has been the preferred technique when poor bone quality, compromised soft tissue, and infection preclude the use of internal fixation (3,4). Sir John Charnley first described compression arthrodesis in 1951 using an external compression device transfixed on either sides of the ankle (5). The inability to resist rotatory forces and the high nonunion rates using Charnley’s external compression device led to modification of external fixation techniques (6,7). Compression arthrodesis using triangular external fixators improved triplanar stability, decreased movement at the arthrodesis site, and increased the union rates (8,9).
We have devised a technique of compression arthrodesis in accordance with the principle of triangular transfixation (8,10) using easily available standard components from Ilizarov instrumentation (Fig. 1). Our technique is relatively inexpensive, uses a modular construct, and allows multiplanar correction of the hindfoot. It can be used intraoperatively to distract the hindfoot, especially in the presence of fibrosis and poor skin conditions.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Ravichand Ismavel, MS (Ortho), Department of Orthopaedics, Unit 3, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India. E-mail address: [email protected] (R. Ismavel).
1. A 2-hole RanchoÔ cube is threaded and locked against a nut at 1 end of the threaded rod. This will form the distal end of the CD limb. 2. The proximal end of the CD limb is assembled by threading a square nut into position a few centimeters down the other end of
Surgical Technique The device primarily consists of 4 compression–distraction (CD) limbs. The CD limbs are preassembled and sterilized. The components required to assemble 1 CD limb include one 150-mm-long fully threaded connecting rod, two 2-hole RanchoÔ cubes (Smith & Nephew, Andover, MA), one 10-mm hexagonal nut, and 2 square nuts. The CD limb should be assembled as follows (Fig. 2):
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.010
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R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. The components required to assemble the fixator included three 4.5-mm Steinmann pins, four 150-mm fully threaded rods, eight 2-holed RanchoÔ cubes, four 10-mm hexagonal nuts, eight 10-mm square nuts, and eight 10-mm short bolts.
the threaded rod. A RanchoÔ cube is then slid after the nut through 1 of its nonthreaded holes. A second square nut is threaded down the rod after it. Next, the RanchoÔ cube can be freely slid along the rod between these square nuts. This configuration of the square nuts and the RanchoÔ cube will form the CD motor (adjusting) unit of the limb. Tightening these square nuts against the cube will lock the cube in the final desired position. Four such preassembled CD limbs, three 4.5-mm Steinmann pins, and 8 short bolts form the final construct (Fig. 3). Procedure
Fig. 3. The construct consists of 4 CD limbs (marked A to D) affixed on three 4.5-mm Steinmann pins using 10-mm short bolts (marked “S”).
similar manner. The proximal end of the second CD limb is placed on to the tibial Steinmann pin through the threaded hole of its RanchoÔ cube, such that the threaded rod of this CD limb lies anterior to the tibial pin (Figs. 3 and 4B), creating a crossed configuration of the threaded rods. Similarly, a crossed triangular construct is built on the lateral side of the ankle and hindfoot using another pair of CD limbs (Figs. 3 and 4C and 4D). The CD limbs should be secured to the Steinmann pins using 10-mm short bolts threaded through the adjacent threaded hole of the RanchoÔ cubes (Fig. 3). Once the external fixation construct has been positioned as described, the joint can be compressed or distracted by turning the CD
The patient was placed supine on a radiolucent table, and the diseased hindfoot joints were visualized and debrided using an anterolateral or a lateral approach. With image intensifier guidance, 1 Steinmann pin was passed through the calcaneus anteriorly and another pin posteriorly, such that they were parallel to each other and to the plane of arthrodesis. A third Steinmann pin was passed through the distal tibia, approximately 10 cm proximal to its distal end and parallel to the plane of arthrodesis. The CD limbs should be attached to these Steinmann pins as follows. On the medial side, the distal end of 1 CD limb is placed on the anterior calcaneal Steinmann pin through the distal nonthreaded hole of the RanchoÔ cube. The proximal end of this CD limb is passed onto the tibial Steinmann pin through the threaded hole of its RanchoÔ cube such that the threaded rod of the CD limb lies posterior to the tibial Steinmann pin (Figs. 3 and 4A). A second CD limb is positioned on the posterior calcaneal Steinmann pin through its distal end in a
Fig. 2. Assembling the compression device (CD) limb. The distal end of the CD limb (marked as “D”) is assembled by locking a 2-holed RanchoÔ cube against a nut at 1 end of the threaded rod. The proximal end of the CD limb (marked as “P”) consists of 2 square nuts and 1 RanchoÔ cube. This forms the CD motor unit.
Fig. 4. The final assembly provides triangular transfixation, with crossed rods situated medially and laterally about the arthrodesis.
R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
motor unit on the proximal end of the CD limbs. Intraoperative distraction using the device can be helpful for making congruous bone cuts through a minimal skin incision. Once the cuts have been made, the CD motor units can be turned to compress the tibia to the hindfoot. After applying compression, residual coronal and sagittal plane misalignment can be corrected by differential compression of the CD limbs. The simple external fixator we have described can be slightly overcompressed in the corrected position until the Steinmann pins have bent toward each other, imparting elastic compression that will compensate for subsequent resorption or subsidence of bone at the arthrodesis site or pin migration through poor quality bone. A retrograde, axial, calcaneotibial Steinmann pin can also be added to provide better translational control in cases in which severe incongruity of the 2 surfaces has been encountered. The serial radiographs of a case treated using this simple fixator has been shown in Fig. 5A–C. Discussion A biomechanical study by Bennett et al (11) concluded that the maximum stability of hindfoot arthrodesis will be conferred by the use of 3 crossed 6.5-mm cancellous screws. However, the holding power of the screws will be directly related to the bone density (12,13). However, many of the chronic conditions afflicting the hindfoot will be complicated by localized osteoporosis resulting from compromised circulation, disuse osteopenia, Charcot neuroarthropathy, or reflex sympathetic dystrophy, all of which demand augmentation of fixation to achieve successful osteosynthesis (13–16). Arthrodesis using external fixators can effectively address the issue of poor bone stock (3), and the use of a triangular or ring external compression arthrodesis construct will confer stability and provide an alternative to internal fixation with comparable, or even superior, results (8,10,17,18). The modularity and easy availability of the components used in the device we have described in our report makes this simple fixator a surgeon-friendly device. The device provides compression by way of a triangular construct, with additional stability provided by the crossed configuration. The advantage of this fixator is the ability to use it in a distraction mode to aid osseous and articular resections, which will be especially useful in patients with fibrosed joints and scarred soft tissue, because intraoperative distraction will enhance the surgeon’s visualization through a minimal skin incision. Moreover, the simple device we have described is adjustable, such that multiaxial deformity correction can be achieved by compressing or distracting the different limbs of the fixator. Furthermore, postoperative compression and adjustment of the residual deformity can be addressed, and the stability of the construct will allow for early mobilization with weight bearing in selected patients. For all these reasons, we believe that this device can be a reasonable alternative to the conventional external fixation techniques for tibiocalcaneal arthrodesis. We also realize that without direct comparisons of this simple form of external fixation to other devices, we cannot make any claims regarding its superiority in terms of successful arthrodesis and foot-related quality of life. Thus, prospective cohort studies and randomized controlled trials are necessary to know whether 1 method will be better than another. Similarly, a detailed assessment of the cost-effectiveness (defining incremental cost differences in terms of quality-of-life units) of different forms of fixation for tibiocalcaneal arthrodesis would be required to know whether 1 method of fixation would be better in terms of costs. References Fig. 5. (A) Preoperative anteroposterior (Left) and lateral (Right) radiographs of a case of post-traumatic arthropathy of the ankle and hindfoot. (B) Postoperative anteroposterior radiograph after application of the external fixation construct. (C) Follow-up radiographs of hind foot fusion.
1. Myerson MS, Alvarez RG, Lam PW. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 21:643–650, 2000. 2. Huang P-J, Fu Y-C, Lu C-C, Wu W-L, Cheng Y-M. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci 23:120–127, 2007.
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R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3. Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Foot Ankle Clin 7:207–254, 2002. 4. Fabrin J, Larsen K, Holstein PE. Arthrodesis with external fixation in the unstable or misaligned Charcot ankle in patients with diabetes mellitus. Int J Low Extrem Wounds 6:102–107, 2007. 5. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 33B:180–191, 1951. 6. Hagen RJ. Ankle arthrodesis: problems and pitfalls. Clin Orthop Relat Res 202:152–162, 1986. 7. Scranton PE Jr, Fu FH, Brown TD. Ankle arthrodesis: a comparative clinical and biomechanical evaluation. Clin Orthop Relat Res 151:234–243, 1980. 8. Berman AT, Bosacco SJ, Parks BG, Israelite CL, Austin DK, Farrell ED, Quartararo LG. Compression arthrodesis of the ankle by triangular external fixation: biomechanical and clinical evaluation. Orthopedics 22:1129–1134, 1999. € rgens C, Paech A. Clinical results of resection 9. Kiene J, Schulz AP, Hillbricht S, Ju arthrodesis by triangular external fixation for posttraumatic arthrosis of the ankle joint in 89 cases. Eur J Med Res 14:25–29, 2009. 10. Thordarson DB, Markolf KL, Cracchiolo A III. External fixation in arthrodesis of the ankle: a biomechanical study comparing a unilateral frame with a modified transfixion frame. J Bone Joint Surg Am 76:1541–1544, 1994.
11. Bennett GL, Cameron B, Njus G, Saunders M, Kay DB. Tibiotalocalcaneal arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 26:530–536, 2005. 12. Ramaswamy R, Evans S, Kosashvili Y. Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: are all screws created equal? Injury 41:179–183, 2010. 13. Thordarson DB, Markolf KL, Cracchiolo A III. Arthrodesis of the ankle with cancellous-bone screws and fibular strut graft: biomechanical analysis. J Bone Joint Surg Am 72:1359–1363, 1990. 14. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 30B:506–511, 1948. 15. Lance EM, Paval A, Fries I, Larsen I, Patterson RL Jr. Arthrodesis of the ankle joint: a follow-up study. Clin Orthop Relat Res 142:146–158, 1979. 16. Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 62:777–784, 1980. 17. Thordarson DB, Markolf K, Cracchiolo A III. Stability of an ankle arthrodesis fixed by cancellous-bone screws compared with that fixed by an external fixator: a biomechanical study. J Bone Joint Surg Am 74:1050–1055, 1992. 18. Ogut T, Glisson RR, Chuckpaiwong B, Le ILD, Easley ME. External ring fixation versus screw fixation for ankle arthrodesis: a biomechanical comparison. Foot Ankle Int 30:353–360, 2009.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Tibiocalcaneal Arthrodesis Using a Simple External Fixator Ravichand Ismavel, MS (Ortho) 1, Sait S. Azad, Dilpoma (Ortho) 2, Daniel V. Viju, MS (Ortho) 1, Alfred J. Daniel, MS (Ortho) 3 1 2 3
Associate Professor, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Postgraduate Registrar, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Diplomate of National Board Professor and Head, Department of Orthopaedics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
a r t i c l e i n f o
a b s t r a c t
Keywords: ankle calcaneus external fixation hindfoot talus tibia
Tibiocalcaneal arthrodesis has been a salvage option for conditions with extensive loss of the talar body. In conditions that preclude the use of internal fixation, external compression arthrodesis has been the preferred technique to achieve fusion about the hindfoot. Since Sir John Charnley elucidated the technique of compression arthrodesis using compression clamps, various modifications and techniques of external compression arthrodesis have been described. Various clinical and biomechanical studies have established the superiority of triangular transfixation in external compression arthrodesis. We have described a simple technique of compression arthrodesis after the principle of triangular transfixation using easily available hardware from Ilizarov instrumentation. This technique is relatively inexpensive in terms of the cost of the materials, uses a modular construct, and allows multiplanar correction of the hindfoot. It can be used intraoperatively to distract the hindfoot joints, especially in the presence of fibrosis and poor skin conditions. We believe this device can be a reasonable alternative to the conventional external fixation techniques for tibiocalcaneal arthrodesis. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Tibiocalcaneal arthrodesis has been a salvage option often used for conditions with extensive loss of the talar body such as advanced neuropathic arthropathy of the hindfoot, failed ankle arthroplasty, and open ankle injury with talar loss (1,2). To achieve fusion around the hindfoot, various internal and external fixation techniques have been described. External compression arthrodesis has been the preferred technique when poor bone quality, compromised soft tissue, and infection preclude the use of internal fixation (3,4). Sir John Charnley first described compression arthrodesis in 1951 using an external compression device transfixed on either sides of the ankle (5). The inability to resist rotatory forces and the high nonunion rates using Charnley’s external compression device led to modification of external fixation techniques (6,7). Compression arthrodesis using triangular external fixators improved triplanar stability, decreased movement at the arthrodesis site, and increased the union rates (8,9).
We have devised a technique of compression arthrodesis in accordance with the principle of triangular transfixation (8,10) using easily available standard components from Ilizarov instrumentation (Fig. 1). Our technique is relatively inexpensive, uses a modular construct, and allows multiplanar correction of the hindfoot. It can be used intraoperatively to distract the hindfoot, especially in the presence of fibrosis and poor skin conditions.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Ravichand Ismavel, MS (Ortho), Department of Orthopaedics, Unit 3, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004 India. E-mail address: [email protected] (R. Ismavel).
1. A 2-hole RanchoÔ cube is threaded and locked against a nut at 1 end of the threaded rod. This will form the distal end of the CD limb. 2. The proximal end of the CD limb is assembled by threading a square nut into position a few centimeters down the other end of
Surgical Technique The device primarily consists of 4 compression–distraction (CD) limbs. The CD limbs are preassembled and sterilized. The components required to assemble 1 CD limb include one 150-mm-long fully threaded connecting rod, two 2-hole RanchoÔ cubes (Smith & Nephew, Andover, MA), one 10-mm hexagonal nut, and 2 square nuts. The CD limb should be assembled as follows (Fig. 2):
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.010
2
R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. The components required to assemble the fixator included three 4.5-mm Steinmann pins, four 150-mm fully threaded rods, eight 2-holed RanchoÔ cubes, four 10-mm hexagonal nuts, eight 10-mm square nuts, and eight 10-mm short bolts.
the threaded rod. A RanchoÔ cube is then slid after the nut through 1 of its nonthreaded holes. A second square nut is threaded down the rod after it. Next, the RanchoÔ cube can be freely slid along the rod between these square nuts. This configuration of the square nuts and the RanchoÔ cube will form the CD motor (adjusting) unit of the limb. Tightening these square nuts against the cube will lock the cube in the final desired position. Four such preassembled CD limbs, three 4.5-mm Steinmann pins, and 8 short bolts form the final construct (Fig. 3). Procedure
Fig. 3. The construct consists of 4 CD limbs (marked A to D) affixed on three 4.5-mm Steinmann pins using 10-mm short bolts (marked “S”).
similar manner. The proximal end of the second CD limb is placed on to the tibial Steinmann pin through the threaded hole of its RanchoÔ cube, such that the threaded rod of this CD limb lies anterior to the tibial pin (Figs. 3 and 4B), creating a crossed configuration of the threaded rods. Similarly, a crossed triangular construct is built on the lateral side of the ankle and hindfoot using another pair of CD limbs (Figs. 3 and 4C and 4D). The CD limbs should be secured to the Steinmann pins using 10-mm short bolts threaded through the adjacent threaded hole of the RanchoÔ cubes (Fig. 3). Once the external fixation construct has been positioned as described, the joint can be compressed or distracted by turning the CD
The patient was placed supine on a radiolucent table, and the diseased hindfoot joints were visualized and debrided using an anterolateral or a lateral approach. With image intensifier guidance, 1 Steinmann pin was passed through the calcaneus anteriorly and another pin posteriorly, such that they were parallel to each other and to the plane of arthrodesis. A third Steinmann pin was passed through the distal tibia, approximately 10 cm proximal to its distal end and parallel to the plane of arthrodesis. The CD limbs should be attached to these Steinmann pins as follows. On the medial side, the distal end of 1 CD limb is placed on the anterior calcaneal Steinmann pin through the distal nonthreaded hole of the RanchoÔ cube. The proximal end of this CD limb is passed onto the tibial Steinmann pin through the threaded hole of its RanchoÔ cube such that the threaded rod of the CD limb lies posterior to the tibial Steinmann pin (Figs. 3 and 4A). A second CD limb is positioned on the posterior calcaneal Steinmann pin through its distal end in a
Fig. 2. Assembling the compression device (CD) limb. The distal end of the CD limb (marked as “D”) is assembled by locking a 2-holed RanchoÔ cube against a nut at 1 end of the threaded rod. The proximal end of the CD limb (marked as “P”) consists of 2 square nuts and 1 RanchoÔ cube. This forms the CD motor unit.
Fig. 4. The final assembly provides triangular transfixation, with crossed rods situated medially and laterally about the arthrodesis.
R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
motor unit on the proximal end of the CD limbs. Intraoperative distraction using the device can be helpful for making congruous bone cuts through a minimal skin incision. Once the cuts have been made, the CD motor units can be turned to compress the tibia to the hindfoot. After applying compression, residual coronal and sagittal plane misalignment can be corrected by differential compression of the CD limbs. The simple external fixator we have described can be slightly overcompressed in the corrected position until the Steinmann pins have bent toward each other, imparting elastic compression that will compensate for subsequent resorption or subsidence of bone at the arthrodesis site or pin migration through poor quality bone. A retrograde, axial, calcaneotibial Steinmann pin can also be added to provide better translational control in cases in which severe incongruity of the 2 surfaces has been encountered. The serial radiographs of a case treated using this simple fixator has been shown in Fig. 5A–C. Discussion A biomechanical study by Bennett et al (11) concluded that the maximum stability of hindfoot arthrodesis will be conferred by the use of 3 crossed 6.5-mm cancellous screws. However, the holding power of the screws will be directly related to the bone density (12,13). However, many of the chronic conditions afflicting the hindfoot will be complicated by localized osteoporosis resulting from compromised circulation, disuse osteopenia, Charcot neuroarthropathy, or reflex sympathetic dystrophy, all of which demand augmentation of fixation to achieve successful osteosynthesis (13–16). Arthrodesis using external fixators can effectively address the issue of poor bone stock (3), and the use of a triangular or ring external compression arthrodesis construct will confer stability and provide an alternative to internal fixation with comparable, or even superior, results (8,10,17,18). The modularity and easy availability of the components used in the device we have described in our report makes this simple fixator a surgeon-friendly device. The device provides compression by way of a triangular construct, with additional stability provided by the crossed configuration. The advantage of this fixator is the ability to use it in a distraction mode to aid osseous and articular resections, which will be especially useful in patients with fibrosed joints and scarred soft tissue, because intraoperative distraction will enhance the surgeon’s visualization through a minimal skin incision. Moreover, the simple device we have described is adjustable, such that multiaxial deformity correction can be achieved by compressing or distracting the different limbs of the fixator. Furthermore, postoperative compression and adjustment of the residual deformity can be addressed, and the stability of the construct will allow for early mobilization with weight bearing in selected patients. For all these reasons, we believe that this device can be a reasonable alternative to the conventional external fixation techniques for tibiocalcaneal arthrodesis. We also realize that without direct comparisons of this simple form of external fixation to other devices, we cannot make any claims regarding its superiority in terms of successful arthrodesis and foot-related quality of life. Thus, prospective cohort studies and randomized controlled trials are necessary to know whether 1 method will be better than another. Similarly, a detailed assessment of the cost-effectiveness (defining incremental cost differences in terms of quality-of-life units) of different forms of fixation for tibiocalcaneal arthrodesis would be required to know whether 1 method of fixation would be better in terms of costs. References Fig. 5. (A) Preoperative anteroposterior (Left) and lateral (Right) radiographs of a case of post-traumatic arthropathy of the ankle and hindfoot. (B) Postoperative anteroposterior radiograph after application of the external fixation construct. (C) Follow-up radiographs of hind foot fusion.
1. Myerson MS, Alvarez RG, Lam PW. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 21:643–650, 2000. 2. Huang P-J, Fu Y-C, Lu C-C, Wu W-L, Cheng Y-M. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci 23:120–127, 2007.
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R. Ismavel et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3. Cooper PS. Application of external fixators for management of Charcot deformities of the foot and ankle. Foot Ankle Clin 7:207–254, 2002. 4. Fabrin J, Larsen K, Holstein PE. Arthrodesis with external fixation in the unstable or misaligned Charcot ankle in patients with diabetes mellitus. Int J Low Extrem Wounds 6:102–107, 2007. 5. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 33B:180–191, 1951. 6. Hagen RJ. Ankle arthrodesis: problems and pitfalls. Clin Orthop Relat Res 202:152–162, 1986. 7. Scranton PE Jr, Fu FH, Brown TD. Ankle arthrodesis: a comparative clinical and biomechanical evaluation. Clin Orthop Relat Res 151:234–243, 1980. 8. Berman AT, Bosacco SJ, Parks BG, Israelite CL, Austin DK, Farrell ED, Quartararo LG. Compression arthrodesis of the ankle by triangular external fixation: biomechanical and clinical evaluation. Orthopedics 22:1129–1134, 1999. € rgens C, Paech A. Clinical results of resection 9. Kiene J, Schulz AP, Hillbricht S, Ju arthrodesis by triangular external fixation for posttraumatic arthrosis of the ankle joint in 89 cases. Eur J Med Res 14:25–29, 2009. 10. Thordarson DB, Markolf KL, Cracchiolo A III. External fixation in arthrodesis of the ankle: a biomechanical study comparing a unilateral frame with a modified transfixion frame. J Bone Joint Surg Am 76:1541–1544, 1994.
11. Bennett GL, Cameron B, Njus G, Saunders M, Kay DB. Tibiotalocalcaneal arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 26:530–536, 2005. 12. Ramaswamy R, Evans S, Kosashvili Y. Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: are all screws created equal? Injury 41:179–183, 2010. 13. Thordarson DB, Markolf KL, Cracchiolo A III. Arthrodesis of the ankle with cancellous-bone screws and fibular strut graft: biomechanical analysis. J Bone Joint Surg Am 72:1359–1363, 1990. 14. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 30B:506–511, 1948. 15. Lance EM, Paval A, Fries I, Larsen I, Patterson RL Jr. Arthrodesis of the ankle joint: a follow-up study. Clin Orthop Relat Res 142:146–158, 1979. 16. Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 62:777–784, 1980. 17. Thordarson DB, Markolf K, Cracchiolo A III. Stability of an ankle arthrodesis fixed by cancellous-bone screws compared with that fixed by an external fixator: a biomechanical study. J Bone Joint Surg Am 74:1050–1055, 1992. 18. Ogut T, Glisson RR, Chuckpaiwong B, Le ILD, Easley ME. External ring fixation versus screw fixation for ankle arthrodesis: a biomechanical comparison. Foot Ankle Int 30:353–360, 2009.