Ankle arthrodesis for failed total ankle replacement

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.     

Arthrodese des Sprunggelenks mit Kompressionsmarknagel

The extended indications for intramedullary nailing with the ICN (interlocking compression nail) for arthrodesis of the ankle joint are presented, and the indications and techniques applied and the results obtained in 147 cases within a 7-year period are reported. After open surgery with a lateral access to remove the cartilage, internal fixation is achieved with ICNs. The special compression screw device allows primary compression between tibia and talus, which means immobilization in a plaster cast is unnecessary. The specially designed distal nail locking option allows secure fixation in the talus. Compression nailing has proved to be highly effective for ankle arthrodesis when correctly carried out, affording sparing treatment of soft tissue, early stability and an excellent fusion rate.     

Tibiotalocalcaneal arthrodesis: a biomechanical comparision of multiplanar external fixation with intramedullary fixation

BACKGROUND: Methods of achieving tibiotalocalcaneal arthrodesis include intramedullary nailing, crossed lag screws, blade plates, and external fixation. While reports in the orthopaedic literature have compared the biomechanical properties of some of these fixation techniques, to our knowledge none has evaluated multiplanar external fixation. The purpose of this study was to compare the biomechanical properties of intramedullary nail fixation and external ring fixation for tibiotalocalcaneal arthrodesis. MATERIALS AND METHODS: Tibiotalocalcaneal arthrodesis was performed on ten matched pairs of fresh-frozen human cadaveric legs. A ring fixator stabilized the arthrodesis in one leg from each pair and a 10 mm x 150 mm nail inserted retrograde across the subtalar and ankle joint stabilized the arthrodesis in the contralateral leg. The bending stiffness of the resulting constructs was quantified in plantarflexion, dorsiflexion, inversion, and eversion, and torsional stiffness was measured in internal and external rotation. RESULTS: No difference in bending stiffness between the two constructs was identifiable in any of the four bending directions (p > 0.05). Torsional stiffness was approximately two-fold greater in both internal and external rotation in specimens with the ring fixator arthrodesis than in those with the intramedullary nail (p = 0.002). CONCLUSION: The ring fixator provides a stiffer construct than a 10 mm x 150 mm intramedullary nail in torsion, but no difference in bending stiffness was demonstrable. Both techniques can provide satisfactory fixation; however, the ring fixator may better minimize rotational joint motion. CLINICAL RELEVANCE: This study provides a basis for selecting an arthrodesis method that offers optimized fixation.     

Intramedullary nailing in tibiotalocalcaneal arthrodesis

Tibiotalcalcaneal arthrodesis is still the treatment of choice for disabling arthrosis of the upper and lower ankle joint, although replacement of the upper ankle joint is widely accepted. Numerous techniques have been described, with increasing use of internal fixation and compression. In 20 patients tibiotalocalcaneal arthrodesis was performed using a retrograde femur nail inserted through the heel, whereas in 20 patients combined arthrodesis of the upper and lower ankle joint was performed using a distal tibia nail through an anterograde approach. Patients were evaluated in a standardized examination using criteria of SF 36 focussing on approach, osseous consolidation, and quality of life.Both techniques demonstrated good results: bony consolidation was achieved after follow-up time of 19 months in 85% of the anterograde group and 95% of the retrograde group. In 78% pain was reduced effectively using the intramedullary nail arthrodesis and quality of life improved drastically. In four cases pseudarthrosis occurred, two implant failures were reported, and there were two infections. Using the anterograde as well as the plantar approach, tibiotalocalcaneal intramedullary nail arthrodesis is an appropriate technique. In this study both groups demonstrated good results regarding bony consolidation, reduction of pain, and improved quality of life. Advantage of the retrograde technique is the noninvasiveness of the proximal tibia. Heel pain or plantar infections were not observed.We see limits of the presented technique in severe malalignment and septic history of the patient.     

Knee arthrodesis

Arthrodesis is one of the last options available to obtain a stable, painless knee in a patient with a damaged knee joint that is not amenable to reconstructive measures. Common indications for knee arthrodesis include failed total knee arthroplasty, periarticular tumor, posttraumatic arthritis, and chronic sepsis. The primary contraindications to knee fusion are bilateral involvement or an ipsilateral hip arthrodesis. A variety of techniques has been described, including external fixation, internal fixation by compression plates, intramedullary fixation through the knee with a modular nail, and antegrade nailing through the piriformis fossa. Allograft or autograft may be necessary to restore lost bone stock or to augment fusion. For the carefully selected patient with realistic expectations, knee arthrodesis may relieve pain and obviate the need for additional surgery or extensive postoperative rehabilitation.     

Anterograde intramedullary tibio-talo calcaneus arthrodesis (aIMTCA) with spongiosaplasty in pseudarthrosis

Pseudarthrosis occur in 65% of all ankle joint arthrodesis. From the therapeutical point of view we make a distinction between vital (hypertrophic) and avital (hypotrophic) respectively stable and instable pseudarthrosis. The hypotrophic forms demand an additional cancellous or bone grafting. Especially instable pseudarthrosis have to be treated with a biological osteosynthesis. In the hindfoot the so called compression arthrodesis made one's way. But there is still a discussion about the best method, intern or extern fixation. We report about a case of hypotrophic pseudarthrosis with a mal-position occurring after an ankle joint arthrodesis with a Charnley-Fixateur. A fusion of the ankle joint could be carried out with a proximal respectively anterograde intramedullary nail and allogene cancellous graft.     

Periprosthetic fracture after femoral intramedullary nail use in two cases of tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis using intramedullary nail fixation is a technically demanding procedure. Periprosthetic fracture in association with tibiotalocalcaneal arthrodesis is a rare occurrence, with relatively few instances reported. The present report describes 2 such instances that occurred after tibiotalocalcaneal arthrodesis using retrograde femoral intramedullary nail fixation. Studies have suggested that a longer nail might decrease the incidence of periprosthetic fracture. Other factors could also have an influence, including the proximal screw orientation and the presence of medical comorbidities, such as osteopenia.     

肱骨干骨折内固定的选择及应注意的问题

目的正确选择肱骨干骨折手术内固定.方法对107例肱骨干骨折分别进行交锁髓内钉(34例)、加压钢板(29例)、Y型钢板(38例)、螺钉(6例)等内固定,并随访比较分析. 结果所有病例均得到随访,平均随访6.3个月.交锁髓内钉、螺钉内固定组全部愈合;加压钢板内固定组愈合26例,伴桡神经损伤2例;Y型钢板内固定组全部愈合,伴肘关节僵硬2例. 结论根据肱骨干骨折的部位和类型选用适当的内固定方法,骨折愈合良好,可有效的减少并发症的发生.     

Tibiotalocalcaneal Arthrodesis with Combined Retrograde Intramedullary Nail and Lateral L-plate

Achieving stable fixation when performing tibiotalocalcaneal or tibiocalcaneal arthrodesis can be challenging. Patients undergoing these procedures often have osteopenia, poor bone stock, fragmentation of the bones of the foot and ankle, joint subluxation, or even dislocation. The author describes a technique of tibiotalocalcaneal arthrodesis with intramedullary nail fixation augmented by lateral plating through the transfibular approach. This can provide excellent exposure of the ankle and subtalar joints, morselized bone for grafting, and better construct stability.     

Knee fusion--a new technique using an old Belgian surgical approach and a new intramedullary nail

Knee arthrodesis is a useful procedure in difficult cases such as failed total knee arthroplasty, severe articular trauma, bone tumors, and infected knee joints. The most common techniques for knee fusion include external fixation and intramedullary nailing. Küntscher's nail is driven antegrade from the intertrochanteric region into the knee. We describe a new technique for knee arthrodesis using a new intramedullary nail and an old Belgian surgical approach to the knee joint published by Lambotte in 1913. This approach provides excellent exposure for the implantation of the nail by osteotomizing the patella vertically. The nail is implanted using HeyGroves method, whereby the nail is inserted retrograde into the femur and pulled distally anterograde into the tibia. We now use this technique as our standard procedure for knee fusion.     

可膨胀自锁式髓内钉固定胫骨干骨折的力学测试

目的了解Fixion IM可膨胀自锁式髓内钉在胫骨干骨折中的力学特性。方法对Fixion IM可膨胀自锁式髓内钉行抗轴向压缩、抗弯曲、抗扭转强度及应力遮挡力学测评,并与其他用于胫骨干骨折不同方式内固定器械相对比。结果 Fixion IM可膨胀自锁式髓内钉在轴向压缩、抗弯曲强度、抗扭转强度及应力遮挡方面,所测出的实验性材料力学结果表明,其性能优于目前普遍应用于临床的国产交锁髓内钉及标准加压钢板。结论 Fixion IM可膨胀自锁式髓内钉的材料是一种力学性能比较优秀的植入性材料,能较好地适应国人胫骨干髓腔,是一种理想的新型内固定器械。     

Advances in intramedullary nail fixation in foot and ankle surgery

Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.     

Biomechanical comparison of intramedullary nail and blade plate fixation for tibiotalocalcaneal arthrodesis

OBJECTIVE: Tibiotalocalcaneal arthrodesis is used to manage severe bone loss, arthritis, and/or instability. The goal is to relieve pain through a stable, well-aligned hindfoot and ankle. The purpose of this study was 2-fold: to biomechanically compare 1) initial stability, and 2) the effect of bone density on the stability of intramedullary nail and blade plate fixation in tibiotalocalcaneal arthrodesis. DESIGN: Biomechanical study using anatomic specimens. METHODS: Ankle and subtalar joint capsules were exposed for 7 pairs of fresh-frozen anatomic specimens. One ankle from each pair was instrumented with an interlocked intramedullary nail inserted retrograde across the subtalar and ankle joint while the contralateral hind foot was stabilized with a lateral cannulated blade plate. Specimen stability was tested in plantar/dorsiflexion and inversion/eversion to a maximum bending moment of 12 Nm and in internal/external rotation to a maximum torque of 7 Nm. Physical measurements of bone density were made to determine its effect on stability. MAIN OUTCOME MEASURES: Maximum angular displacement of the constructs in plantarflexion, dorsiflexion, inversion, eversion, internal rotation, and external rotation. RESULTS: No significant differences were observed between the plated and nailed constructs in the 3 loading configurations (Power = 0.77). Only 6 pairs were included in the results because of fixation failures. A small but significant reduction in internal rotation alone of 1.8 degrees was found with the plated compared with the nailed construct (P = 0.045). Reduced stability was associated with lower bone density in torsion and inversion/eversion in the plated constructs (r = 0.67- 0.87) with a similar trend seen in torsion in the nailed constructs (r = 0.5). CONCLUSION: Initial construct stabilities and the effect of reduced bone density were found to be similar between the blade plate and the intramedullary nail in tibiotalocalcaneal arthrodesis, thus implant choice may be based on other clinical factors, such as surgeon preference or soft-tissue status.     

Biomechanical evaluation of primary stiffness of tibiotalar arthrodesis with an intramedullary compression nail and four other fixation devices

BACKGROUND: Many techniques of tibiotalar arthrodesis have been described. Screw fixation is widely used. At our center, intramedullary compression nailing has been successfully used for over 10 years. The question to be answered by this study was whether tibiotalar arthrodesis with a compressed intramedullary nail was superior, in terms of primary stiffness and fusion-site compression, to selected other techniques. METHODS: Plane fusion surfaces were machined in third-generation synthetic composite tibiae and the bodies of anatomically correct tali; fixation was with a compressed external fixator (cEF), an uncompressed interlocking nail (uIN), a compressed interlocking nail (cIN), and two different three-screw techniques (ST1 and ST2); three specimens per construct were tested. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as a percent of the available fusion-site area. Construct stiffness was tested in dorsiflexion/plantar flexion (D/P), varus/valgus (V/V), and internal rotation/external rotation (I/E), analyzing 20 cycles per loading mode. RESULTS: Compressed surface area: cIN 80% +/- 10.7; cEF 60% +/- 8.6; ST2 59% +/- 4.4; ST1 55% +/- 6.1; uIN no discernible compression. The greatest primary stiffness in D/P was obtained with the cIN (p < 0.001), followed by ST1. In V/V, ST1 and the cIN had the greatest primary stiffness; the two techniques did not differ significantly. Stabilization with the cEF was significantly better (p < 0.001) than with ST2. In I/E, the cIN produced the greatest primary stiffness (p < 0.001), followed by the two screw techniques, which did not differ significantly between themselves. The uIN had the least primary stiffness in all directions tested. CONCLUSIONS: In this biomechanical study, the cIN and ST1 were superior, in terms of primary stiffness in tibiotalar arthrodesis, to the other techniques tested. In D/P and I/E, the cIN construct was significantly stiffer than the ST1 construct, whose I/E rigidity might, however, be enhanced by a fourth, horizontal screw. CLINICAL RELEVANCE: Intramedullary compression nailing offers stable tibiotalar arthrodesis fixation with a large bony contact area and may enhance the likelihood of successful tibiotalar arthrodesis.     

Kniearthrodesen

When arthrodesis of the knee is indicated, the operative procedure selected for fixation depends on the condition of the soft tissues, the bone stock, whether infection is present, and the age of the patient and his or her capacity for partial weight-bearing. In young patients with no infection or soft tissue problems, when adequate bone stock is present compression plating or the use of an intramedullary nail is possible and allows stable fixation. Soft tissue problems with defect(s) or infection are a good indication for the use of an external fixator. The most common indication for knee arthrodesis is a failed total knee prosthesis that has become infected. Deficient bone stock with osteopenic bone or a defect after failed total knee arthroplasty are problems that can be solved by the use of modular fusion nail systems, especially in older patients. These systems are more comfortable for the patient than external fixation devices and allow early full weight-bearing.     

ARTHRODESIS OF THE DISTAL INTERPHALANGEAL JOINT USING A BIOABSORBABLE ROD AS AN INTRAMEDULLARY NAIL

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

三种内固定在股骨干骨折中的应用

目的观察股骨干骨折三种内固定的疗效。方法股骨干骨折,以外侧入路,分别予交锁髓内钉、梅花钉、加压钢板螺钉内固定。结果随访6～144个月,术后畸形愈合、延迟愈合及不愈合率:交锁髓内钉组3.1%、梅花钉组6.0%、加压钢板螺钉组10.6%;内固定失效率:交锁髓内钉组0%、梅花钉组4.5%、加压钢板螺钉组17.0%;术后患肢关节功能优良率:交锁髓内钉组81.3%、梅花钉组70.1%、加压钢板螺钉组59.6%。结论交锁钉治疗股骨干骨折近远期疗效满意,梅花钉次之,加压钢板螺钉最差。     

Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail.

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

交锁髓内钉和加压接骨板治疗下肢长干骨骨折的疗效

目的比较交锁髓内钉和加压接骨板治疗下肢长干骨骨折的临床疗效。方法对87例采用交锁髓内钉和加压接骨板治疗的下肢长干骨骨折手术患者随访4～24个月,对两种方法的临床情况、术后并发症进行比较分析。结果交锁髓内钉组患者的临床愈合时间、术后并发症均少于加压接骨板组,临床疗效优于加压接骨板组。结论交锁髓内钉治疗下肢长干骨骨折的临床疗效优于加压接骨板。     

Arthrodesis after failed total ankle replacement

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.