Implantable Electrical Bone Stimulation for Arthrodeses of the Foot and Ankle in High-Risk Patients: A Multicenter Study

This study assessed arthrodesis procedures performed in the foot and ankle of high-risk patients following implantation of an internal electrical bone stimulator. Criteria defining patients as "high risk" included diabetes, obesity, habitual tobacco and/or alcohol use, immunosuppressive therapy, and previous history of nonunion. Standard arthrodesis protocol of bone graft and internal fixation was supplemented with the implantable electrical bone stimulator. A retrospective, multicenter review was conducted of 26 patients (28 cases) who underwent 28 forefoot and hindfoot arthrodeses from 1998 to 2002. Complete fusion was defined as bony trabeculation across the joint, lack of motion across the joint, maintenance of hardware/fixation, and absence of radiographic signs of nonunion or pseudoarthrosis. Radiographic consolidation was achieved in 24 of the 28 cases at an average 10.3+/-4.0 weeks. Followup averaged 27.2 months. Complications included 2 patients who sustained breakage of the cables to the bone stimulator. Five patients underwent additional surgery. Four of the 5 patients had additional surgery in order to achieve arthrodesis. All 4 went on to subsequent arthrodesis. This study demonstrates how arthrodesis of the foot and ankle may be enhanced by the use of implantable electrical bone stimulation.     

Clinical outcome of tibiotalar arthrodesis utilizing the chevron technique

Tibiotalar arthrodesis remains the gold standard reconstructive procedure for the treatment of disabling ankle arthritis. The purpose of this study was to review the clinical results of tibiotalar arthrodesis utilizing the chevron fusion technique. The results of 46 consecutive patients who underwent ankle arthrodesis utilizing the chevron technique were reviewed. The etiology of the tibiotalar arthritis was posttraumatic in 29 of 46 patients. Of the remaining 17 patients, seven had osteoarthritis, five had talar osteonecrosis, two had rheumatoid arthritis, one had hemophilic arthropathy, one had gouty arthropathy, and one had unrecognized chronic osteomyelitis. Three patients had prior hindfoot arthrodeses, and two patients had bilateral ankle fusions at last follow-up. All patients were followed for a minimum of 2 years. Of the 46 patients, 41 were available for review, with an average follow-up of 7.3 years (range, 2-20 years). Twelve patients had greater than 10-year follow-up. The Mazur ankle score was calculated for all 41 patients. The average Mazur ankle score for the 41 patients available for review was 72.8, out of a maximum possible score of 90. Eighteen patients had excellent results, 11 patients had good results, five patients had fair results, and seven patients had poor results. The most common reasons for fair or poor results were symptomatic subtalar arthritis and multiple medical comorbidities. All patients with postoperative symptomatic subtalar arthritis had preoperative radiographic evidence of subtalar arthrosis. Of the 12 patients with greater than 10-year follow-up, nine had excellent or good results, and an average Mazur ankle score of 76.6. All patients with either prior hindfoot arthrodeses or bilateral ankle fusions had excellent or good results. Of the 41 arthrodeses included in the study, 38 (38/41, 93%) went on to clinical and radiographic union. The chevron technique provides a predictable method to obtain fusion of the tibiotalar joint. Most patients can expect excellent or good results. In the current study, 90% (37/41) of patients were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances.     

Ankle Salvage Surgery with Autologous Circular Pillar Fibula Augmentation and Intramedullary Hindfoot Nail

Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.     

Foot Pressure Changes Before and After Ankle Fusion: A Pedobarograph Study

We performed a case-control study with the purpose of establishing the pressure patterns in the soles of the feet of patients with ankle osteoarthritis, determining whether the pattern changed after treating the arthritis with ankle joint fusion (arthrodesis), and whether the change is significant. We also studied the benefits of ankle fusion with respect to the Short-Form 36-item Health Survey and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The study included 18 participants (9 in the study group and 9 in the control group) to reach statistical significance with a 95% confidence interval (CI). A demonstrable increase was found in both forefoot and hind-foot pressures in the study group preoperatively compared with the control group. Also, a demonstrable increase was found in the pressure in both the forefoot (mean difference 50.56 ± 267.39 kPa) and the hindfoot (mean difference 57.44 ± 160.27 kPa) from preoperatively to postoperatively. This difference was not statistically significant (p = .59 [t(8) = 0.57]; 95% CI 256.10 to ?154.98) for the forefoot pressures and for the hindfoot pressures (p = .31 [t(8) = 1.08]; 95% CI 180.64 to ?65.76). The Short-Form 36-item scores significantly improved from preoperatively to postoperatively (p = .000054 for the physical component and p = .018 for the mental component). The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score also improved significantly (p = .0000005). The foot pressures, as measured by using the insole sensors, showed an increase in forefoot and hindfoot pressures that was not statistically significant.     

Role of Cellular Allograft Containing Mesenchymal Stem Cells in High-risk Foot and Ankle Reconstructions

The use of cellular allograft containing mesenchymal stem cells is gaining popularity as an augmentation to foot and ankle arthrodesis. Those with underlying comorbidities (diabetes mellitus, Charcot osteoarthropathy, smoking, suppressive medication, increased body mass index) are more likely to require surgical revision procedures and typically have a greater rate of nonunion than their healthy counterparts. We believe that the use of a mesenchymal stem cell graft will increase the likelihood of a successful fusion during the primary procedure. The present study reviewed the use of stem cell grafting in hindfoot and ankle surgery and the healing times in high-risk patients. Successful fusion was defined as bridging across 3 cortices. In this patient group, the average interval to radiologic union was 11.1 ± 2.0 (range 8 to 15) weeks. The interval to partial weightbearing was 5.5 ± 1.8 (range 3 to 12) weeks, to full weightbearing was 8.4 ± 1.9 (range 5 to 14) weeks, and to shoe wearing was 13.6 ± 3.0 (range 10 to 20) weeks.     

关节镜监视下踝关节植骨融合术的疗效分析

目的：探讨关节镜辅助下踝关节清理、植骨融合术的手术方法和临床疗效。方法：2001年1月至2009年5月,采用关节镜辅助踝关节植骨融合术治疗踝关节病变25例,男18例,女7例;年龄32～70岁,平均47.5岁;左踝10例,右踝15例;其中创伤后骨关节炎13例,地方性大骨节病10例,类风湿性关节炎2例。手术前后采用疼痛视觉模拟评分（VAS）对踝关节疼痛进行评定,根据美国足踝关节协会评分系统（AOFAS）从疼痛、自主活动、最大步行距离、地面步行、步态、活动度、稳定性及踝关节对线等方面进行评价。结果：25例均获随访,时间20～35个月,平均27.5个月。术后踝关节无疼痛,步态明显改善,无神经血管损伤、感染和固定失败等并发症,平均骨性融合时间为11.7周（8～15周）。术后VAS评分为（1.20±0.82）分,较术前的（8.60±0.96）分明显降低（t=27.326,P=0.000）;术后AOFAS评分中客观项目均较术前改善,术后AOFAS评分为（82.44±4.96）分,较术前的（36.44±9.90）分明显增加（t=-19.178,P=0.000）。结论：关节镜监视下踝关节植骨融合术操作简单,术中创伤小,术后恢复快、并发症少,是踝关节融合的理想方法。     

Tibio-talo-calcaneal fusion after limb salvage procedures—A retrospective study

BackgroundThe treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies.Patients and methodsEight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation + wires (1 case), external fixation + screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented.ResultsIndependent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency.ConclusionTibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects – often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.Level of Evidence: IV, Case series     

踝关节融合治疗创伤后踝关节炎

 目的 探讨踝关节融合治疗创伤后踝关节炎的早期临床疗效。方法 回顾性分析2008年1月至2012年5月,采用踝关节融合治疗并获得随访的47例创伤后踝关节炎患者资料,男28例,女19例;年龄14～72岁,平均44岁;均为Morrey-Wiedeman 3期踝关节炎,其中17例合并距下关节炎;31例有明显足内外翻畸形或马蹄足畸形,16例外观大致正常。采用Kofoed踝关节评分、美国足踝外科协会(American Orthopaedic Foot and Ankle Society, AOFAS)踝与后足评分、Maryland足部评分及视觉模拟评价(visual analogue scale, VAS)评价术前及末次随访时足踝关节功能。结果 47例患者均获得随访,随访时间为5～52个月,平均25个月。末次随访时踝关节均融合,其中1例术后出现感染,经去除内固定及清创后踝关节融合。43例主观满意度为非常满意或满意,4例为一般,满意率为91.5%(43/47)。Kofoed评分,末次随访时平均为(80.96±6.07)分,与术前(48.11±5.00)分比较,差异有统计学意义;AOFAS评分,末次随访时平均为(82.21±4.26)分,与术前(53.38±5.52)分比较,差异有统计学意义;Maryland评分,末次随访时平均为(88.94±5.14)分,与术前(49.74±5.71)分比较,差异有统计学意义;VAS评分,末次随访时平均为(2.28±1.10)分,与术前(7.89±0.87)分比较,差异有统计学意义。踝关节正位X线片中,22例踝融合于中立位,19例外翻< 5°,3例外翻5°～10°,2例内翻< 5°,1例内翻5°～10°;侧位X线片中,32例踝融合于背伸中立位,12例跖屈5°以内,3例跖屈5°～10°。结论 踝关节融合治疗严重的创伤后踝关节炎早期即可纠正畸形、缓解疼痛与重建功能,是治疗创伤后踝关节炎的良好选择。     

Effectiveness of Hindfoot Arthrodesis by Stable Internal Fixation in Various Eichenholtz Stages of Neuropathic Ankle Arthropathy

The optimal time to treat neuropathic (Charcot) arthropathy of the ankle and peritalar joint is controversial because of the various treatment options available and the variable results reported in published studies. We sought to determine the outcome of hind foot arthrodesis with stable internal fixation in patients with different Eichenholtz stages of arthropathy. We prospectively studied patients with substantial disabilities caused by neuropathic arthropathy in deformed, unstable ankle and peritalar joints, with or without ulcerations, who had undergone treatment from July 2007 to December 2012. All patients underwent ankle arthrodesis, autologous iliac crest bone grafting, and subtalar joint arthrodesis, with or without talonavicular joint arthrodesis, fixed internally with an intramedullary hindfoot nail, with or without an additional plate or cancellous screws. Of the 33 enrolled patients, 9 (27.3%) had stage I, 13 (39.4%) had stage II, and 11 (33.3%) had stage III Charcot arthropathy. The cause of arthropathy was diabetes mellitus in 25 (75.8%) patients. The duration of symptoms ranged from 1 to 120 (median 7) months. The mean follow-up period was 40 (range 12 to 76) months and did not differ markedly among the groups. The hindfoot scores, rate of salvage or amputation, or complication rates did not differ significantly across Eichenholtz stage. For the patients with stage I, II, and III, the preoperative hindfoot score was 50, 49, and 48, respectively (p = .9). The corresponding postoperative scores were 68, 68, and 70 (p = .5). We found no evidence that the effectiveness of hindfoot arthrodesis by stable fixation varied across the Eichenholtz stage of Charcot arthropathy involving ankle and peritalar joint. Furthermore, we found that stable internal fixation and bone grafting using a hindfoot nail results in an 84.84% union rate and salvages the unstable and disabled foot in 90.9% of patients with ankle and peritalar Charcot arthropathy.     

Outcomes of Hindfoot Arthrodesis Supplemented With Bioactive Glass and Bone Marrow Aspirate: A Retrospective Radiographic Study

Foot and ankle surgeons continue to explore bone graft alternatives that will be comparable to the reference standard of autologous bone. The purpose of the present study was to consider the outcomes of hindfoot arthrodesis supplemented with bioactive glass in patients at risk of delayed union and nonunion. We performed a retrospective radiographic review of 29 consecutive patients (48 joints) who had undergone arthrodesis of ≥1 joint of the hindfoot (ankle, subtalar, talonavicular, calcaneocuboid). All patients included in the present study had a minimum of 1 documented risk factor for osseous nonunion (history of previous nonunion, trauma, smoking, diabetes, Charcot arthropathy, obesity, age >65 years at surgery). The patients were followed up for a minimum of 24 weeks or until radiographic healing had been achieved. We found 12 (25.0%) nonunions across all 48 joints supplemented with bioactive glass. We found 4 (16.7%) nonunions in the subtalar joint, 1 (11.1%) in the calcaneocuboid joint, and 1 (11.1%) in the talonavicular joint. We found that hindfoot arthrodesis procedures supplemented with bioactive glass resulted in an incidence of union comparable to that with autograft and other bone graft substitutes.     

Ankle Arthrodesis: A Retrospective Analysis Comparing Single Column,Locked Anterior Plating to Crossed Lag Screw Technique

Ankle arthrodesis is performed to eliminate pain due to end-stage osteoarthritis, regardless of etiology. This procedure remains the reference standard treatment for end-stage ankle arthritis, despite recent advancements in total ankle replacement. The objective of the present study was to retrospectively evaluate the radiographic and clinical fusion rates and time to bony fusion for patients who underwent ankle arthrodesis using an anterior approach with a single column locked plate construct versus crossed lag screws. We identified 358 patients who had undergone ankle arthrodesis from January 2003 to June 2013. Of the 358 patients, 83 (23.2%) met the inclusion criteria for the present study. Of the 83 included patients, 47 received locked anterior (or anterolateral) plate fixation, and 36 received crossed lag screw constructs. The overall nonunion rate was 6.0% (n = 5), with 1 nonunion in the anterior plate group (2.1%) and 4 nonunions in the crossed lag screw group (11.1%; p = .217). No differences were identified between the 2 groups for normal talocrural angle [χ² (1) = 0.527; p = .468], normal tibial axis/talar ratio [χ² (1) = 0.004; p = .952], and lateral dorsiflexion angle (p = .565). Based on our findings in similar demographic groups, ankle arthrodesis using locked anterior plate fixation is a safe technique with similar complication rates and radiographic outcomes to those of crossed lag screws.     

Long-term results following ankle arthrodesis for post-traumatic arthritis

BACKGROUND: Ankle arthrodesis is considered by many to be the standard operative treatment for end-stage ankle arthritis; however, the long-term effect of ankle arthrodesis on other lower-extremity joints remains largely unknown. The purpose of this study was to perform a clinical and radiographic review to determine the effect of ankle arthrodesis on the development of osteoarthritis in other lower-extremity joints. METHODS: Twenty-three patients who had had an isolated ankle arthrodesis for the treatment of painful posttraumatic arthritis of the ankle were followed for a mean of twenty-two years (range, twelve to forty-four years) after the operation. Each completed standardized, self-reported outcome questionnaires (the Foot Function Index, Western Ontario and McMaster University Osteoarthritis Index [WOMAC], and Short Form-36 [SF-36]), was examined clinically by two of the investigators, and underwent complete radiographic examination of the knee, ankle, and foot bilaterally. The radiographic grade of osteoarthritis was determined for each joint, and the levels of overall activity limitation, pain, and disability were determined for each patient from the clinical findings and questionnaire information. RESULTS: Osteoarthritis of the ipsilateral subtalar (p<0.0001), talonavicular (p<0.0001), calcaneocuboid (p<0.0001), naviculocuneiform (p = 0.0012), tarsometatarsal (p = 0.0009), and first metatarsophalangeal joints (p = 0.0012) was consistently more severe than the osteoarthritis of those joints on the contralateral side. Osteoarthritis did not develop more frequently in the ipsilateral knee or lesser metatarsophalangeal joints than it did on the contralateral side. Significant differences between the two sides were found with regard to overall activity limitation (p<0.0001), pain (p<0.0001), and disability (p<0.0001), with the involved side consistently more symptomatic. CONCLUSIONS: To our knowledge, the present series represents the longest follow-up study of ankle arthrodesis to date. Our cohort of patients all had isolated post-traumatic ankle arthritis, and each underwent a successful isolated ankle arthrodesis. At a mean of twenty-two years, the majority of the patients had substantial, and accelerated, arthritic changes in the ipsilateral foot but not the knee. They were often limited functionally by foot pain. Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction.     

Expanding Indications of Primary Arthrodesis in Selected Individuals for Managing Complex Hindfoot Trauma During COVID-19 Pandemic

BackgroundDuring the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of outdoor activities, organized sports, and schools/colleges. Neglected hindfoot fractures have emerged as a consequence with increased frequency. Similarly, complex ankle and pilon fractures that require staged management, prolonged hospital stay, and soft-tissue care have emerged as a potential concern as prolonged exposure to healthcare setting adds to risk of acquiring as well as transmitting COVID-19 infection. The authors present their experience with expanding these indications for hindfoot arthrodesis as they encounter a greater number of neglected ankle and hindfoot trauma.MethodsThis was a retrospective observational study of collected data from the trauma unit of our hospital. Inclusion criteria included all trauma classified by the AO/OTA as occurring at locations 43, and who underwent subtalar and ankle arthrodesis. This included distal tibia, malleolar, talus, and calcaneus fractures. These patients were followed up to at least 6 months till complete fracture union.ResultsA total of 18 patients underwent arthrodesis of either the ankle or subtalar joint between March and October 2020. Mean age of patients undergoing arthrodesis of the hindfoot was 69.2 years (43–84 years). Indications for the procedure included Displaced and comminuted intra-articular distal tibia fractures in elderly (6 patients), Malunited ankle fractures (2 patients), Neglected Ankle fractures managed conservatively (3 patients), Calcaneus fractures (5 patients), and neglected Talus body fracture (2 patients). All patients were followed up to at least 6 months and everyone went onto successful painless union between 3 and 6 months of the arthrodesis procedure without any significant complications.ConclusionIn summary, COVID-19 pandemic has led to a change in paradigm of trauma management and foot and ankle management is no different than other musculoskeletal trauma systems. The authors propose an expansion of indications for hindfoot arthrodesis in managing complex hindfoot trauma in pandemic situation.     

Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures

BACKGROUND: The purpose of this study was to report the results of 52 combined subtalar and ankle arthrodesis using an intramedullary nail. METHODS: Retrospective review identified 49 patients who had 52 combined ankle and subtalar arthrodeses with an ACE retrograde locked intramedullary humeral nail (DePuy-Ace), Warsaw, IN). Most procedures included bone grafts from the fibula, proximal tibia, or iliac crest or femoral head allograft. Intraoperative complications included one fractured tibia and one fractured medial malleolus. The procedure was done mainly for the treatment of combined ankle and subtalar arthritis (31) or complex hindfoot deformities (12). Outcome was assessed by a combination of chart review, clinical examination, and telephone questionnaire. Followup averaged 34 (8 to 73) months. RESULTS: At followup 82% of patients were satisfied with the results of surgery, 82% reported improvements in pain levels, and 67% reported improved foot function. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 63. Postoperative complications included deep infection, amputation, stress fracture, nonunion, and prominent hardware. CONCLUSION: Hindfoot arthrodesis with intramedullary nailing is an effective technique for treating complex foot deformities and often is the only alternative to amputation. Patient satisfaction is high, but the procedure is demanding and complications are frequent.     

Effects of teriparatide on fusion rates in patients undergoing complex foot and ankle arthrodesis

BackgroundHere, we determined whether teriparatide treatment would increase fusion rates after foot and ankle arthrodesis by comparing treatment results between patients with high-risk factors for nonunion who received teriparatide against those who did not.MethodsWe retrospectively reviewed 66 consecutive patients who underwent foot and ankle arthrodesis. The inclusion criterion was the presence of at least one of the following risk factors for nonunion after previous foot and ankle arthrodesis: deformity, bone defects, avascular necrosis, and nonunion. Sixteen patients were finally enrolled and divided into 2 groups: 8 patients received teriparatide treatment after fusion surgery (PTH group), and 8 patients did not (control group).ResultsThe fusion rate was significantly greater in the PTH group than in the control group (100% vs 50%). Four patients in the control group developed nonunion, 3 of whom underwent revision fusion; however, all patients received the teriparatide treatment after revision surgery and subsequently achieved union. No significant differences in demographics, fusion sites, and complication rates were found.ConclusionThough the sample size was small, the current study suggests that teriparatide administration may improve fusion rates in patients with high-risk factors for nonunion after foot and ankle arthrodesis.     

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.     

Modified Blair ankle fusion for ankle arthritis

Objective： To investigate the clinical outcome of modified Blair ankle fusion for ankle arthritis. Methods： Between November 2009 and June 2012, 28 patients with ankle arthritis were treated, among whom 11 had obvious foot varus deformity, and 17 were almost normal in appearance. There were 13 males and 15 females with an average age of 49.4 years （range, 23-67 years）. The main symptoms included swelling, pain, and a limited range of motion of the ankles. The ankle joints functions were assessed by American Orthopedic Foot and Ankle Society （AOFAS） ankle and hindfoot score and visual analog scale （VAS） preoperatively and at I year follow-up. Results： Twenty-eight patients were followed up for 19.8 months on average （range, 1-2 years）. Superficial wound infection occurred in 3 cases, and was cured after debridement; the other incisions healed by first intention without complications. All ankles were fused at 1 year follow-up after operation. The symptom was relieved completely in all patients at last follow-up without complication of implant failure, or nonunion. The postoperative AOFAS ankle and hindfoot score was 83.13±3.76, showing significant difference when compared with the preoperative score （45.38±3.21, P〈0.01）. VAS was significantly decreased from 8.01±0.63 to 2.31±1.05 at 1 year follow-up （P〈0.05）. Conclusion： Modified Blair ankle fusion has the advantages of high feasiblity, less cost and rigid fixation. It shows high reliability in pain relief and may obtain a good clinical effectiveness.     

Posttraumatic arthrodesis of the subtalar joint – outcome in workers compensation and rates of non-union

Background: Regardless of the simple surgical technique, the success of the subtalar arthrodesis is limited by the rate of non-unions of the arthrodesis. The functional outcome of workers compensation is known to be poorer compared to patients without pending litigation. The aim of this study was to quantify the rate of non-unions and to determine risk factors leading to failure of the osseous consolidation after arthrodesis of the subtalar joint. The outcome assessed is a general health assessment with the SF-36 questionnaire and more illness specific with the AOFAS hindfoot score. Secondly, the influence of the health insurance status of the patients with or without worker's compensation on the outcome was tested.Methods and results: The inclusive criterion was an arthrodesis of the subtalar joint with and without autologous cancellous bone grafting and screw osteosynthesis. This cohort study included the clinical course of 115 patients with posttraumatic osteoarthritis from 2000 to 2006. The average age of the patients (n = 115) was 47 ± 11.0 years, 83% of the treated patients were men. 68% of the patients suffered of secondary osteoarthritis after calcaneal fracture. The time interval from trauma to presenting at the physician due to therapy resistant pain was in the average 5.5 ± 9.9 years. After primary arthrodesis (n = 101) of the subtalar joint osseous consolidation was proved in 55% cases, consolidation was questionable in 21% and the rate of no consolidation with revision was remarkable high with 24%. The duration of osseous consolidation was proved by plain projection radiography or computer tomography and clinical reduction of pain. For primary arthrodesis osseous consolidation was reached after 6.4 ± 6.3 month, after secondary arthrodesis osseous consolidation was reached after 9.4 ± 13.1 month. After revision surgery 57% of the arthrodesis healed, 12% the osseous consolidation was questionable, and the failure rate was still 12%.Conclusion: The outcome measures of the patients with SF-36 and the more functional related AOFAS hindfoot score showed poor outcome rates after subtalar fusion in posttraumatic osteoarthritis. The AOFAS hindfoot score was 47 ± 24 points after primary arthrodesis and 46 ± 17 points after secondary arthrodesis of the subtalar joint. The patients regained their former ability to work only in 30% after fusion of the subtalar joint. If revision surgery was necessary 8% of the patients got back to their work prior to the injury.     

Comparison and Use of Allograft Bone Morphogenetic Protein Versus Other Materials in Ankle and Hindfoot Fusions

Bone grafting is a common procedure in foot and ankle surgery. Because autogenous graft use results in comorbidity to the patient, the search has been ongoing for the ideal substitute. A novel processing technique for allograft using bone marrow, which retains many of the growth factors, has shown promise in the spinal data and early reports of foot and ankle surgery. We performed a retrospective, comparative study of patients undergoing hindfoot and ankle arthrodesis, with a total of 68 patients included. Of the 68 patients, 29 (42.65%) received a bone morphogenetic protein allograft and 39 (57.35%) did not. The patient demographics and social and medical history were similar between the 2 groups and both groups had a similar time to union (p?=?.581). Of the 29 patients in the bone morphogenetic protein allograft group, 3 (10.3%) experienced nonunion and 4 (13.8%) developed a complication. Of the 39 patients undergoing other treatment, 7 (17.9%) experienced nonunion and 14 (35.9%) developed a complication. The difference for nonunion was not statistically significant (p?=?.5). However, the difference in the overall complication rate was statistically significant (p?=?.04). We found that this novel bone graft substitute is safe and can be used for foot and ankle arthrodesis.     

Use of intramedullary carbon fiber nail in hindfoot fusion: A small cohort study

Background

Current literature on carbon fiber implant use in foot and ankle surgery is scant. The purpose of this paper is to report medium-term outcomes of hindfoot fusion using a carbon fiber intramedullary nail.