Ankle arthrodesis with an anterior tension plate

The incidence of complications associated with arthrodesis of the ankle has remained high, especially in wound complications and infections. A new method to achieve arthrodesis of the ankle that utilizes an anterior surgical approach and an anterior tension plate was assessed in 17 patients. This method transforms the potentially deforming force of the tendoachilles into a compressive and corrective force and facilitates realignment of the ankle in all planes. Also, dissection and subperiosteal elevation is minimized while soft tissue coverage of the hardware is maximized. Whereas the predominant preoperative diagnosis was posttraumatic degenerative joint disease, others included failed ankle arthroplasty, failed arthrodesis, and a fixed equinus deformity. A solid arthrodesis was achieved in 82% of the patients. Although complications occurred and two patients required reoperations, there were no problems with respect to wound healing or infection, which is a marked contrast to other series. This technique is recommended as a simple, safe, and effective method to achieve an arthrodesis of the ankle joint.     

A Modified Anterior Approach to the Ankle

The anterior approach to the ankle is frequently used in fracture fixation, ankle arthroplasty, and various tendon reconstructive procedures. However, wound complications and trauma may lead to scarring and a suboptimal anterior ankle soft tissue envelope for healing. The author presents a modified approach to the anterior ankle in cases where scarring and soft tissue injury preclude a direct anterior incision.     

Anterior Ankle Incision Healing Complications With and Without Tourniquet Use: A Retrospective Comparative Cohort Study

Anterior ankle incisions and tourniquet use in foot and ankle surgery have both been associated with increased incidence of incisional healing complications. Although a tourniquet is commonly used for procedures such as total ankle replacement and ankle arthrodesis that utilize an anterior ankle incision, it is possible to avoid tourniquet use while preserving adequate visualization with atraumatic layered dissection and closure, appropriate use of electrocautery, and ligation of vessels as needed. The primary aim of this study is to report rates of anterior ankle incisional healing complications both with and without tourniquet use. A retrospective chart review was performed on consecutive patients undergoing total ankle replacement or ankle arthrodesis through a multi-provider foot and ankle surgery practice between 2013 and 2018. A total of 121 patients, 58 (47.9%) in the tourniquet group and 63 (52.1%) in the no-tourniquet group, were included in this study with a median follow-up period of 36 (range 2-96) months. There was a higher rate of incisional healing complications for the tourniquet group (5.2%) compared to the no-tourniquet group (3.2%), however this did not reach statistical significance (p = .670). There was no significant difference in operative time between the tourniquet and no-tourniquet group (p = .405). The overall incisional healing complication rate was 4.1%. Although avoiding tourniquet use alone does not appear to significantly reduce anterior ankle incisional healing complications, the described technique has yielded an overall lower rate of incisional complications compared to those commonly reported in the literature.     

Factors Associated with Nonunion,Delayed Union,and Malunion in Foot and Ankle Surgery in Diabetic Patients

The incidence of bone healing complications in diabetic patients is believed to be high after foot and ankle surgery. Although the association of hyperglycemia with bone healing complications has been well documented, little clinical information is available to show which diabetes-related comorbidities directly affect bone healing. Our goal was to better understand the risk factors associated with poor bone healing in the diabetic population through an exploratory, observational, retrospective, cohort study. To this end, 165 diabetic patients who had undergone arthrodesis, osteotomy, or fracture reduction were enrolled in the study to assess the risk factors associated with nonunion, delayed union, and malunion after elective and nonelective foot and/or ankle surgery. Bivariate analyses showed that a history of foot ulcer, peripheral neuropathy, and surgery duration were statistically significantly associated with bone healing complications. After adjusting for other covariates, only peripheral neuropathy, surgery duration, and hemoglobin A1c levels >7% were significantly associated statistically with bone healing complications. Of the risk factors we considered, peripheral neuropathy had the strongest association with bone healing complications.     

Ankle fusion in patients with chronic hepatitis C

BackgroundIt appears that both the incidence and survival of patients infected with hepatitis C have recently demonstrated a significant increase. The goal of this investigation was to determine the associated perioperative risks associated with ankle arthrodesis in this growing population.MethodsThe Healthcare Cost and Utilization Project State Inpatient Databases identified patients with chronic hepatitis C infection who underwent ankle arthrodesis between January 2009 and December 2013. International Classification of Diseases, Ninth Revision, codes were used to define the primary composite outcome of death or postoperative complication. Logistic models with frequency weights were used to compare propensity matched groups.Results7339 patients met inclusion criteria. Of these, 157 patients had a history of chronic Hepatitis C infection. After performing a propensity score match, the final analytic cohort was 157 in the Hepatitis C group and 386 in the non-Hepatitis C group. There was no statistically significant differences in complications between patients with chronic Hepatitis C undergoing ankle fusion and those without Hepatitis C at any post-operative time point (inpatient, 30 days, or 90 days).DiscussionPatients with chronic hepatitis C infection undergoing ankle arthrodesis are not at an elevated risk of inpatient, thirty, and ninety day postoperative complications compared to patients without chronic HCV infections. Patients with chronic hepatitis C did not have an increased risk of surgical site infection or mortality at any time point.Level of evidencePrognostic Level III.     

Minimally Invasive Plate Osteosynthesis for Treatment of Ankle Fractures in High-Risk Patients

Wound healing problems are the most common complication after open reduction with internal fixation (ORIF) of unstable ankle fractures. The incidence is especially high among elderly patients with medical comorbidities and patients with compromised soft tissues. Minimally invasive plate osteosynthesis (MIPO) might provide a safer alternative to ORIF by preventing extensive soft tissue dissection and preserving the blood supply. We conducted a retrospective review of 44 consecutive patients who had undergone MIPO of unstable ankle fractures. All patients had a minimum 1-year follow-up (mean 82 weeks); 80% were aged ≥60 years, 52% had diabetes, and 45% had a compromised soft tissue envelope. Immediate postoperative radiographs were evaluated for the quality of reduction, and clinical records were analyzed for the complication rate. Good to excellent anatomic reduction was achieved in 89% of the patients. The overall complication rate was 27%, including 25% surgical wound dehiscence, 9% infection, and 11% loss of reduction. No patient experienced nerve injury. Those with a history of ankle fracture dislocation and a compromised soft tissue envelope preoperatively had a significantly greater incidence of surgical wound dehiscence and complications overall compared with those without (p?=?.016 and p?=?.035; p?=?.045 and p?=?.009, respectively). Peripheral vascular disease was a statistically significant predictor of surgical wound dehiscence (p?=?.010). The overall complication rate in our study was comparable to that seen in similar populations treated with conventional ORIF. In conclusion, our results suggest that MIPO in high-risk patients is a safe alternative, with predictable outcomes, comparable to those of traditional open techniques.     

The Effects of Tibialis Anterior Tenotomy on Wound Complications and Functional Outcomes After Anterior Fusion Plating for Severe Ankle Arthritis

Nonunion is known to be a relatively common complication following ankle arthrodesis. Various fixation techniques have been introduced to enhance the stability and to improve fusion rate. With the use of anterior plate supplementation, postoperative wound problems have been frequently reported despite better fusion rate. This study was performed to determine the effects of tibialis anterior (TA) tenotomy on wound complications and functional outcomes after anterior fusion plating for severe ankle arthritis. Forty-six patients who underwent ankle arthrodesis using anterior fusion plate were followed for more than 2 years. TA tenotomy was performed prior to wound closure in all patients. As a control group, 38 patients who underwent arthrodesis without TA tenotomy were analyzed. Functional outcomes were evaluated with Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure. Wound complication rate, time to fusion, fusion rate, time to pain relief were evaluated. Mean Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure scores significantly improved to 32.6 and 69.4 points at final follow-up, respectively. As compared to control group (33.8 and 67.7 points), there were no significant differences in functional outcomes. As postoperative wound complications, there were 1 case of wound dehiscence and 1 case of superficial wound infection. TA tenotomy group showed a significantly lower wound complication rate (4.3%) than control group (23.7%) (p < .001). While there were no significant differences in fusion rate, time to fusion, and time to pain relief between both groups, control group needed higher rate of implant removal. Ankle arthrodesis using anterior fusion plate in conjunction with TA tenotomy appears to be an effective surgical option for end-stage ankle arthritis, with excellent fusion rate and less wound complication rate. Although there were no specific functional deficits related to absence of TA tendon, further studies are needed to determine long-term effects of TA tenotomy in patients with a fused ankle.     

Complications Associated with Uni-portal Endoscopic Gastrocnemius Recession in a Diabetic Patient Population: An Observational Case Series

The purpose of this article was to report the complications associated with uni-portal endoscopic gastrocnemius recession for surgical treatment of pathologic soft tissue ankle equinus contracture in diabetic patients. This is an observational case series involving a retrospective review of prospectively collected data of 23 uni-portal endoscopic gastrocnemius recessions used to treat pathologic soft tissue ankle equinus contracture in 18 consecutive diabetic patients between November 2006 and January 2009. Each patient underwent uni-portal endoscopic gastrocnemius recession under general or spinal anesthesia with thigh tourniquet control in combination with soft tissue and/or osseous reconstructive foot and/or ankle surgery. Patients were kept non–weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 9 male and 9 female patients with a mean age ± SD of 69.0 ± 7.4-years (range: 47.0 to 71.0 years). There were 11 right and 12 left lower limbs involved, with 5 procedures performed bilateral. Complications included 3 conversions to an open incision secondary to difficulty dissecting through excessive adipose tissue, delayed healing of 3 incision sites in patients with uncontrolled diabetes mellitus at the time of surgery, and 3 undercorrections in patients with spastic contractures. The remainder of the procedures were deemed successful with no saphenous nerve, sural nerve, or lesser saphenous vein related injuries occurring. When properly performed, uni-portal endoscopic gastrocnemius recession represents a safe, reliable, and minimally invasive technique useful for correcting pathologic soft tissue ankle equinus contracture in patients with diabetes. A percutaneous tendo-Achilles lengthening should be performed in patients who have marginal arterial inflow that precludes tourniquet use or have a spastic contracture. An open rather than endoscopic gastrocnemius recession should be performed in patients with excessive adipose tissue. Before surgery, the risk of delayed wound healing should be discussed with patients who have uncontrolled diabetes mellitus and in-patient management with tight glycemic control considered.     

Protective Approach for Anatomical Structures at Risk in Total Ankle Replacement

Currently, total ankle replacement (TAR) is an alternative to arthrodesis in selected patients, with the anterior approach being the most widely used to carry it out. Regardless of the type of implant used, the pins for bone resection guides, chisels, and the saw for distal tibial resection can endanger the neurovascular and tendon structures that lie in intimate proximity to the posterior aspect of the ankle. Additionally, there is a documented complication rate of up to 15.3% in such surgery. We have implemented a protective posteromedial approach that complements the anterior approach to reduce this risk of intraoperative iatrogenic injury. Using this method we introduce a protective instrument that separates the posterior anatomical structures from the posterior cortex of the tibia. This article describes the surgical technique used to carry out TAR through an anterior approach in a safer way, without increasing complications or the duration of real-time surgery.     

Application of Negative Pressure Wound Therapy in Total Ankle Replacement

The efficacy and safety of incisional negative pressure wound therapy (iNPWT) was evaluated following total ankle replacement. A retrospective cohort study was conducted in patients who underwent total ankle replacement between January 2010 and June 2018. Following joint replacement, the patients received iNPWT (iNPWT group) or sterile dressings (Control group). Infection rate, wound complication incidence, length of stay, visual analogue scale, American Orthopedic Foot and Ankle Society, and short-form 36 scales, and ankle range of motion were assessed 1 week, 2 weeks, 1 month, 3 months, 6 months, and 12 months postoperatively. Thirty-four patients (n = 13 iNPWT and n = 21 Control) were included. No significant differences were found in baseline data. During follow-up, one Control patient developed a superficial infection at the incision. Wound complications developed in 4 Control patients and 1 iNPWT patient; although this was not statistically significant. Length of stay was similar between the 2 groups. Two weeks after surgery, the range of visual analogue scale (2.1 vs 1.4), American Orthopedic Foot and Ankle Society (13.7 vs 9.7), and short-form 36 scale (9.0 vs 6.5) improvement, and increase of ankle range of motion (9.2 vs 6.1) was significantly larger in the study group than in the control group (p < .05). Three months to 1 year after the surgery, this difference was no longer statistically significant. The application of iNPWT following total ankle arthroplasty helped reduce postoperative pain, improve ankle function, and improve patient quality of life. However, these benefits were no longer statistically significant 3 months to 1 year after surgery.     

Perioperative Complications of a Modular Stem Fixed-bearing Total Ankle Replacement with Intramedullary Guidance

Despite improved total ankle replacement outcomes, investigators have demonstrated that the incidence of complications after total ankle replacement is a function of the surgeon’s experience with the technique. We hypothesized that the use of an intramedullary guide during a modular stem fixed-bearing total ankle replacement would decrease the incidence of perioperative complications and produce a similar incidence of complications across time. Because all patients were mobilized early, we also evaluated the influence of early mobilization on wound development. The medical records were reviewed to identify complications, and the radiographs were evaluated to determine the component alignment of the initial 58 consecutive ankles. Major wound complications were defined as complications requiring soft tissue coverage by a plastic surgeon. Minor wound complications were defined as those that could be treated without a return to the operating room. The procedures were separated into 2 groups: the initial 29 procedures (group A) and latter 29 procedures (group B). Eight ankles (14%) had wound complications. The incidence of complications was similar across time [r_s (56) = ?0.06, p = .64]. The incidence of complications and component misalignment was similar for groups A and B (p ≥ .19). All wounds were diagnosed within 15 days of surgery. None of the ankles developed wounds after physical therapy began. These results have demonstrated that the modular stem fixed-bearing total ankle replacement with intramedullary guidance can produce a similar incidence of complications over time, regardless of surgeon experience. Additionally, early mobilization did not appear to influence the incidence of wound complications and should be advocated, when appropriate.     

Ankle arthrodesis: combined internal-external fixation

This report documents the experience of using combined internal and external fixation in ankle arthrodesis. During the period from 1992 to 2000 a single surgeon used this method of fixation on 26 ankle fusions in 26 consecutive patients without exclusions. There were no nonunions and no delayed unions. The median time to union was 10.3 weeks and the mean time was 11.3 weeks (range, 7.4 to 23.2 weeks). Complications specific to this procedure included 3 (12%) minor pin tract infections which cleared with oral, out-patient antibiotics, 4 (15%) skin irritations from internal fixation pins sufficiently bothersome to require pin removal after union was obtained, and 1 (4%) painful pin tract which cleared spontaneously. Most of these complications occurred early in the series and subsequent changes in technique considerably decreased their incidence. This fixation technique produced excellent results. Combined internal and external fixation is recommended as a useful option in arthrodesis of the ankle.     

The Porcine Small Intestinal Submucosa (SIS) Patch in Foot and Ankle Reconstruction

We undertook a retrospective cohort study of 54 patients who underwent foot and ankle soft tissue reconstructive surgery augmented with a porcine small intestinal submucosal (SIS) patch. The mean patient age was 44 (range 17 to 68) years, there were 21 (38.89%) males in the cohort, and the mean follow-up duration was 1080 (range 365 to 1943) days. Clinical outcomes were considered excellent in 46 (85.19%) patients, good/fair in 3 (5.56%) patients, and poor in 5 (9.26%) patients; and no adverse events attributable to the xenograft were observed. Direct SIS patch failure, resulting in stretching of the repair, re-tear, or tendon stenosis, occurred in 3 (5.56%) patients, and delayed incision healing occurred in 6 (11.11%) patients. Based on our observations, we concluded that the porcine SIS xenograft, when used to augment cellular and vascular in-growth, is a viable adjunct to musculoskeletal reconstructions of the foot and ankle.     

Ankle fusion for definitive management of non-reconstructable pilon fractures

BACKGROUND: Highly comminuted pilon fractures, especially with a compromised soft tissue envelope, present a challenging treatment scenario. This study presents our results for patients managed with ankle fusion rather than ORIF. MATERIALS AND METHODS: Fourteen patients with ankle joint incongruence after non-reconstructable tibia pilon fractures were treated with primary tibiotalar arthrodesis using a fixed-angle cannulated blade plate. Delayed metaphyseal unions due to bone defects were treated concurrently. The subtalar joint was preserved in all cases. RESULTS: Metaphyseal healing and stable arthrodesis was obtained in each case. There was one case of blade plate breakage in a patient who still achieved successful arthrodesis without reoperation. Union was achieved at an average of 15 weeks. No secondary procedures were required to obtain union. All 14 patients were ambulatory at last followup. Average followup was 39 weeks. CONCLUSION: Primary ankle arthrodesis can be achieved using a cannulated blade plate to address a non-reconstructable articular surface and metaphyseal bone defects in complex tibia pilon fractures.     

Treatment of Isolated Ankle Osteoarthritis with Arthrodesis or the Total Ankle Replacement: A Comparison of Early Outcomes

Background

Ankle arthrodesis and replacement are two common surgical treatment options for end-stage ankle osteoarthritis. However, the relative value of these alternative procedures is not well defined. This study compared the clinical and radiographic outcomes as well as the early perioperative complications of the two procedures.

Methods

Between January 2, 1998 and May 31, 2002, 138 patients were treated with ankle fusion or replacements. Seventy one patients had isolated posttraumatic or primary ankle arthritis. However, patients with inflammatory arthritis, neuropathic arthritis, concomitant hind foot fusion, revision procedures and two component system ankle replacement were excluded. Among them, one group of 42 patients had a total ankle replacement (TAR), whereas the other group of 29 patients underwent ankle fusion. A complete follow-up could be performed on 89% (37/42) and 73% (23/29) of the TAR and ankle fusion group, respectively. The mean follow-up period was 4.2 years (range, 2.2 to 5.9 years).

Results

The outcomes of both groups were compared using a student''s t-test. Only the short form heath survery mental component summary score and Ankle Osteoarthritis Scale pain scale showed significantly better outcomes in the TAR group (p < 0.05). In the radiographic evaluation, there was no significant difference in preoperative and postoperative osteoarthritis between the TAR and fusion groups.

Conclusions

The clinical results of TAR are similar to those of fusion at an average follow-up of 4 years. However, the arthroplasty group showed better pain relief and more postoperative complications that required surgery.     

A Review of 399 Total Ankle Replacements: Analysis of Ipsilateral Subtalar Joint Arthrodesis and Associated Talar Component Subsidence

Total ankle replacement (TAR) is an accepted treatment for end-stage ankle arthritis. When concurrent subtalar joint pathologic features exist, ipsilateral subtalar joint arthrodesis (STJA) can be performed either simultaneous with TAR or as a staged procedure. Limited data exist on the effect of talar component subsidence and prosthesis survivorship. The present study purpose was to evaluate the effect of STJA on talar component subsidence after primary TAR and its effect on TAR survivorship. All patients, a minimum of 18 years old, from a single institution with modern-generation TAR and 1-year minimum follow-up data available were evaluated. The study group included patients who had also undergone STJA, and the control group (no STJA) was matched 1:1 by age, gender, and prosthesis. The initial postoperative weightbearing and most recent weightbearing radiographs were compared for talar component subsidence. We reviewed 399 primary TARs from 2004 to 2012. A total of 33 patients with ipsilateral STJA met the inclusion criteria and had an appropriate control group match. In the study group, 8 patients required a return to the operating room for 4 revisions and 4 reoperations at a median follow-up point of 24.3 months. Of the controls, 9 patients required a return to the operating room, with 4 revisions and 5 reoperations at a median follow-up point of 38.4 months. No statistically significant radiographic differences were found between the 2 groups. Primary TAR and ipsilateral STJA were infrequently required (41 of 399; 10.3%). TAR did not result in decreased survivorship when performed with ipsilateral STJA at an early follow-up point. Further study is warranted to determine any differences among previous, simultaneous, and subsequent STJA with ipsilateral TAR, and a matched longitudinal analysis is needed to determine longer term survivorship.     

Primary Ankle Arthrodesis for Neglected Open Weber B Ankle Fracture Dislocation

Primary ankle arthrodesis used to treat a neglected open ankle fracture dislocation is a unique decision. A 63-year-old man presented to the emergency department with a 5-day-old open fracture dislocation of his right ankle. After thorough soft tissue debridement, primary arthrodesis of the tibiotalar joint was performed using initial Kirschner wire fixation and an external fixator. Definitive soft tissue coverage was later achieved using a latissimus dorsi free flap. The fusion was consolidated to salvage the limb from amputation. The use of primary arthrodesis to treat a compound ankle fracture dislocation has not been previously described.     

Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.     

Incidence of ankle arthrodesis and total ankle replacement between 1997 and 2018: A nationwide registry study in Finland

BackgroundSurgical treatment options for end-stage ankle osteoarthritis (OA) include ankle arthrodesis (AA) and total ankle replacement (TAR). We investigated the national incidence of AA and TAR and assessed trends in the surgical management of ankle OA in Finland between 1997 and 2018.MethodsThe Finnish Care Register for Health Care was used to calculate the incidence of AA and TAR based on sex and different age groups.ResultsThe mean age (SD) of patients was similar, 57.8 (14.3) years for AA and 58.1 (14.0) for TAR. TAR showed a 3-fold increase from 0.3 per 100 000 person-years in 1997 to 0.9 per 100 000 person-years in 2018. The incidence of AA operations decreased during the study period from 4.4 per 100 000 person-years in 1997 to 3.8 per 100 000 person-years in 2018. TAR utilization increased notably at the expense of AA between 2001 and 2004.ConclusionTAR and AA are both widely used procedures in the treatment of ankle OA, with AA being the favored option for most patients. The incidence of TAR has remained constant for the past 10 years, indicating appropriate treatment indications and utilization.