Ankle arthrodesis using a modified Masquelet induced membrane technique for open ankle fracture with a substantial osteochondral defect: A case report of novel surgical technique

Reconstruction of a bone defect using the Masquelet induced membrane technique has been well described. However, there are few reports of arthrodesis using this technique. In this case report, we describe a modified Masquelet technique for ankle arthrodesis with nailing. The patient was a 32-year-old man who sustained an open fracture of the right ankle with a substantial osteochondral defect as a result of a fall. Immediately after the injury, a staged procedure using the Masquelet technique was planned. The bone defect was filled with bone cement in the acute stage, but replacement of the cement was needed 6 months after the injury because of a prolonged inflammatory reaction. Ten months after the injury, the bone cement was removed, and ankle arthrodesis was performed using an IM nail with a combination of autologous and artificial bone. As a modification of the Masquelet technique, the anterior surface of the transplant site was covered with a large but thin layer of cortical bone instead of suturing the incised membrane. At 1 year postoperatively, firm bony union was achieved and the implant was removed. At follow-up 3 years after his injury, the patient is able to walk, undertake physical work, and has no clinical signs of infection. Our experience suggests that a modified induced membrane technique may be useful when treating an open limb fracture with an extensive osteochondral defect where preservation of the joint is difficult and arthrodesis is considered.     

Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics

BackgroundUnstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained.MethodsOver a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis.ResultsEight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12–136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture.ConclusionIn spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture.Level of evidence: Level IV retrospective case series.     

Prinzipien der OSG-Arthrodese bei Gelenkinfekt

A chronic empyema of the ankle joint often develops after an open fracture or surgery. In the case of the destruction of the joint due to an infection, an arthrodesis should be performed.Normally we use an external fixator with two bone-nails placed into the calcaneus and two into the tibia. The arthrodesis is distracted and Septopal is permanently implemented. At 4-6 weeks after surgery the Septopal is removed, with distraction being reduced and a cancellous bone-graft taken from the dorsal iliac crest is performed to fill the bony defect. After bone healing, the external fixator is removed and the patient mobilized in a brace. Initially, weight-bearing is limited to 10 kg but is increased gradually to full weight. The brace is used for 6-9 months; later the patient is mobilized in orthopaedic shoes. In difficult cases, also in combination with a malposition which has to be corrected or a lengthening of the lower limb, we use the Ilizarov fixator. From 1993 to 2003 we performed arthrodeses of the ankle joint due to infectious destruction in 107 cases. In 82.2%, the empyema was caused by a fracture of the ankle joint and the following treatment. In 58% of the patients, we saw associated diseases such as obesity, alcohol abuse, diabetes and malposition of the foot. In 55% we found Staphylococcus aureus. In 86%, we used the external AO-fixator, in 14% the Ilizarov fixator. The patient retained the fixator for an average of 128 days. In our study, 92.1% of the 101 patients who had completed therapy showed a good stability an average of 4.5 years after the arthrodesis. In 5% we found partial stability, while three patients had to be amputated. In 57 patients (56.4), an arthrosis of the tarsal bones was found, and 38 patients (54.3%) of the 70 patients who at the time of the arthrodesis were still working could return to work.     

Arthroscopic ankle arthrodesis

Surgical options are limited for the patient who has symptomatic severe ankle joint degeneration that is unresponsive to nonoperative treatment. Arthrodesis of the tibiotalar joint is a procedure that can produce a pain-free ankle that can withstand the rigors of daily life, even in a young, high-demand, working individual. Minimally invasive orthopedic techniques have been applied to ankle arthrodesis, and arthroscopic ankle fusion has been shown to be an effective technique to achieve tibiotalar arthrodesis, with high rates of fusion and low rates of complication. This article covers indications, contraindications, and procedural techniques for arthroscopic ankle arthrodesis. Results of arthroscopic versus open ankle arthrodesis are compared.     

Technic and results of covered ankle joint arthrodesis with autocompression angle plates

In 1973, Mittelmeier introduced a new technique of arthrodesis of the ankle joint by internal osteosynthesis using an autocompression plate with additional compression screwing of fibula to tibia and talus in order to avoid the disadvantages of previous operative methods of arthrodesis by bone splinting or external fixation (longer cast immobilisation, handicap by external fixator, danger of bone hole osteomyelitis a.o.). Regarding this new technique, the fibula works as a petiolated well vascular bone chip which bridges the joint. Representation of the special operative technique of covered autocompression arthrodesis of the upper ankle joint rsp. - in case of special indication - the combined arthrodesis of the upper and lower ankle joint. Representation of our casuistry of 43 patients who underwent this operation. With the exception of one case (osteomyelitis recidivation with following pseudarthrosis) a fast bony consolidation of the arthrodesis was achieved. In the meantime the osteosynthesis material is removed in 35 cases. One third of the patients gets along with conventional shoes.     

Arthrodesis of the upper ankle joint. Indications, technique, results]

From 1984 to 1990 a total of 119 arthrodesis of the upper ankle joint were performed at the Hospital of Accident Surgery of the Trade Association in Frankfurt am Main. The results of 98 patients after an arthrodesis of the upper ankle joint are documented by an x-ray control series and patient files, including the expertise on the medical status of pensioners plus a follow-up examination of 34 patients. The indications and the results are discussed on the basis of the various procedures. The results confirm the method of a compressions arthrodesis with an extension screw in case of a posttraumatic arthrosis of the upper ankle joint, while a fixateur externe should be used in case of chronical osteomyelitis, osteoporotic bones, extensive tissue swellings and after a pilon or talus fragment fracture.     

Fine wire frame arthrodesis for the salvage of severe ankle pathology

Ankle arthrodesis is an accepted method of treatment for severe ankle pathology, but no single method of treatment is universally successful. Compression is usually applied across the ankle joint and maintained with either internal or external fixation; both are associated with complications such as infection, non-union and pain. We present our experience of 13 difficult cases managed by fine wire external frames, and describe the surgical technique used.A sound arthrodesis was achieved in 12 out of 13 cases, though one case required a repeat procedure, giving a union rate of 92% of cases or 86% of procedures. The mean period of fixation was 24 weeks (range 12-82), followed by a mean period of cast immobilisation of 7 weeks (range 0-10). Using Mazur's functional ankle score there were seven good results, four fair, one poor and one failure, which resulted in a below knee amputation.We believe this method represents a significant improvement on previously published results, but accept that it requires considerable experience and should not be considered for primary ankle arthrodesis. We would recommend its usage for the salvage of failed arthrodesis or severe fracture non-union, particularly in the presence of infection.     

Syndesmotic Ligament Allograft Reconstruction for Treatment of Chronic Diastasis

Chronic diastasis after a syndesmotic injury can lead to ankle joint instability and loss of joint congruence. Failure to restore the fibula into the proper anatomic position within the incisura increases the focal stress on the talus and can accelerate degenerative joint destruction. In the case of failed syndesmotic repair, fixation options are limited. If promptly diagnosed, the syndesmosis may be amenable to open debridement and subsequent fixation with 2 interosseous screws. If latent diastasis is found, however, syndesmotic fusion by bone block arthrodesis is recommended. We present a syndesmotic allograft repair technique for surgical reconstruction of chronic unstable syndesmotic ruptures.     

Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

Introduction Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported. Materials and methods A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities. Conclusions Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.     

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.     

Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy

Charcot osteoarthropathy with severe ankle instability and deformity is often managed with below-the-knee amputation if deformity and cutaneous compromise result in osteomyelitis. Recently, some surgeons have reported satisfactory outcomes with ankle arthrodesis in the coalescence or remodeling (subacute and chronic) stages of the disease before the onset of joint instability, severe deformity, and ulcer formation. This observational study describes the clinical outcomes of ankle arthrodesis in a cohort of 45 diabetic patients who underwent unilateral ankle arthrodesis for Charcot neuroarthropathic ankle deformity before the development of ulceration and bone infection. Two (4.44%) of the patients were lost to follow-up, whereas 2 (4.44%) others underwent below-the-knee amputation shortly after the ankle arthrodesis because of postoperative infection. After a mean follow-up duration of 5 ± 2.85 years, 39 (86.67%) patients returned to independent ambulation wearing custom-made shoes with molded insoles, whereas 2 (4.44%) others required pneumatic casts for ambulation.     

Ilizarov ankle arthrodesis.

Six consecutive patients, four with failed infected ankle fusions and two with posttraumatic degenerative ankle arthritis, were treated by monofocal compression arthrodesis using the Ilizarov external fixator. The average age was 48 years (range, 33-74 years). The average preoperative duration after failed infected ankle fusion was 18 months and for posttraumatic arthritis after fracture, 23 months. Infected failed pseudarthroses had significant fixed valgus deformity of the foot, bilateral draining sinuses, and near complete destruction and loss of the talus. Compression was dynamically applied during treatment. Custom foot plates were secured to the frame, and weight bearing as tolerated was allowed throughout the treatment period. Tibiocalcaneal fusion was obtained in three of four infected failed ankle fusions at an average of seven months (range, five to nine months). There was no evidence of infection at follow-up evaluation in these patients. One patient did not tolerate the frame and developed a fibroarthrosis. One patient sustained a refracture of the fusion at six months. Successful tibiocalcaneal fusion was obtained with reapplication of the frame and a Pappineau graft. Two primary ankle fusions healed with tibial talar fusion at an average of 3.5 months. Overall follow-up time averaged 26 months (range, 19-30 months). Six wires broke, requiring simple replacement. Four of these six were 1.5-mm wires. The Ilizarov frame may have several advantages in primary ankle arthrodesis and in the salvage of infected failed ankle fusions.     

Intramedullary Compressive Nail Fixation for the Treatment of Severe Charcot Deformity of the Ankle and Rear Foot

Involvement of the ankle joint in Charcot osteoarthropathy may be associated with severe instability and fracture or collapse of the talus. Recalcitrant ulceration may result over the lateral malleolus, increasing the risk of major amputation. This study evaluated ankle arthrodesis with a compressive intramedullary nail in 14 patients with diabetes affected by Charcot of the ankle. The mean patient age was 58 +/- 12 years, and the mean duration of diabetes was 17 +/- 5 years. Transcutaneous oxygen pressures were > or = 50 mm Hg in all patients, indicating a good distal blood supply. A below-knee amputation had previously been suggested because of severe ankle joint instability. None of the patients were able to walk without a brace. Four patients had an ulceration that had healed before the index procedure. All procedures were performed in the quiescent phase of the disease. After a mean follow-up of 18 +/- 4 months, 10 patients (71.4%) achieved a solid arthrodesis, returning to walking with protective shoes. Three patients (21.4%) developed breakage of the calcaneus screws, necessitating removal of the screws in 2 cases and removal of the entire nail in 2 cases. These 3 patients went on to fibrous union that allowed walking with a brace. One patient (7.2%) required a below-knee amputation because of postoperative osteomyelitis of the distal tibia. The data from our study demonstrate a high rate of limb salvage (92.8%), suggesting that this device is safe and effective in the treatment of Charcot arthropathy of the ankle.     

Sp?tinfektion nach Osteosynthese am oberen Sprunggelenk

A 63-year-old patient suffering from diabetes mellitus and arterial occlusive disease sustained a displaced fracture of the upper ankle joint. The fracture was treated by open reduction and internal fixation (ORIF) but 6 months later a delayed infection developed. Partial implant removal and a single lavage were performed. With persistent signs of infection full implant removal and subsequently debridement and lavage were carried out 3.5 months later followed by arthrodesis of the upper ankle joint. The arbitration board decided that the treatment applied after diagnosing the delayed infection was not sufficient which led to a delay in appropriate treatment. However, whether the arthrodesis of the upper ankle joint could have been prevented could not be proven.     

Use of the Taylor Spatial Frame in Compression Arthrodesis of the Ankle: A Study of 10 Cases

Ankle fusion is a well established way of managing a variety of recalcitrant ankle pathologies including severe osteoarthritis and infected malunion of ankle fractures. Compression arthrodesis has been a widely accepted surgical means of achieving ankle fusion. The authors describe compression arthrodesis of the tibiotalar joint in 10 cases using the Taylor-Spatial Frame (TSF). From 2003 to 2005, 10 patients (9 male and 1 female) aged between 48 and 71 years (median age 61 years) underwent application of the TSF to achieve compression arthrodesis of 10 ankle joints. The TSF is an external fixator system supported by a computer program. After input of the radiological deformities referenced to one of the rings, the computer provides the detailed strut adjustments necessary to bring about gradual correction. The underlying pathology was severe posttraumatic arthritis (2 cases), malunion (1 case), nonunion of pilon fracture (1 case), and infected ankle (1 case). Five cases presented with previous failed surgical arthrodesis. Clinical, subjective, objective, and radiological analyses were performed regularly and at the end of an average follow-up of 16.7 months (range 12–26 months). Solid fusion in anatomical alignment with return to a fully functional status was obtained in 10 out of 10 ankles. The TSF has shown encouraging results as a simple, effective and versatile means of achieving compression arthrodesis of the ankle joint.     

Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer

Forty-two consecutive patients with chronic osteomyelitis complicating persistent tibial nonunion and chronic osteomyelitis complicating tibial fracture with segmental bone loss were treated from January 1979 through December 1986 using a protocol including either open cancellous bone grafting (Friedlaender-Papineau technique), posterolateral bone grafting (Harmon technique), or local or microvascular soft-tissue transfer before cancellous bone grafting. Each patient had undergone surgical debridement and intravenous antibiotic therapy before inclusion in this study. Patients were classified using a staging system which included consideration of anatomic location of the infection within the bone; extent of bone involvement; quality of soft-tissue envelope and vascular integrity; and generalized host status. The overall success rate for arresting the osteomyelitis and healing the nonunion was 62% (26/42). If the six patients who refused additional bone graft surgery, the one patient who represented poor patient selection, and the patient who refused ankle arthrodesis are eliminated, the success rate for healing of the nonunion and resolving the osteomyelitis in this difficult patient population is: open bone cell graft, 66% (12/18); soft-tissue transfer 87.5%, (7/8); and posterolateral bone grafting, 87.5% (7/8). Use of a standardized classification system allows comparison of treatment results. Adequate debridement is crucial in treating osteomyelitis complicating established long bone fractures and nonunions. Determining the extent of debridement has proven to be the single most difficult aspect technically. Patient selection and pretreatment education are crucial. Caring for these patients is not only labor intensive and demanding of personnel and hospital resources, but demanding of the patients as well.     

A case of ankle osteoarthritis associated with lateral premalleolar bursitis caused by chronic ankle instability

IntroductionLateral premalleolar bursitis develops on the dorsolateral aspect of the foot anterior to the lateral malleolus, distinct from lateral malleolar bursitis located just around the lateral malleolus.Presentation of caseA 71-year-old woman visited an orthopedic clinic about 40 years after an episode of ankle sprain and was diagnosed with lateral premalleolar bursitis and osteoarthritis of the left ankle. Stress radiography revealed left ankle anterolateral malleolar bursitis with varus and anterior instability. We opted for less invasive arthroscopic ankle arthrodesis over open resection to stop the communication of the bursitis with the ankle joint. The lateral premalleolar bursitis was located just over the anterolateral portal. The remaining cartilage in the talotibial joint was removed and the subchondral surface was exposed and curetted down to a bleeding surface by ankle arthroscopy. The talotibial joint was fixed with 3 6.0-mm cannulated cancellous screws. The foot and ankle were immobilized by cast for 4 weeks. Bony union was achieved about 8 weeks postoperatively. The patient could perform daily activities without pain and with no recurrence of the lateral premalleolar bursitis at the 1.5-year follow-up.DiscussionTo our knowledge, this is the first report on arthroscopic arthrodesis for ankle osteoarthritis with recalcitrant lateral premalleolar bursitis caused by the check valve mechanism of chronic ankle instability after old ankle sprain.ConclusionWe report a case of arthroscopic arthrodesis for osteoarthritis of the ankle associated with lateral premalleolar bursitis caused by the check valve mechanism of chronic ankle instability after old ankle sprain.     

Management of failed total ankle replacement with a retrograde short femoral nail: a case report

Arthrodesis of the ankle joint after failed total ankle replacement using internal fixation with plates and screws is problematic because of the significant bone loss. An external fixator has the disadvantage of prolonged treatment until complete consolidation, frequently complicated by pin track infections. Recently an intramedullary fixation has been described for tibio-talo-calcaneal arthrodesis for posttraumatic osteoarthritis of the ankle joint. We report on the use of this technique plus bone graft in a case of failed total ankle replacement complicated by cystic talus degeneration and a massive bony defect. The advantages include early mobilization and weightbearing provided by the stability of the fixation.     

Arthrodese – Pseudarthrosen am Sprunggelenk Die fehlgeschlagene Arthrodese

Non-unions after fracture dislocation of the ankle joint are extremely rare with predominantly operative treatment. In contrast, after fractures of the tibial plafond (pilon fractures) infections are seen in the literature in 37 % and non-unions are seen in 27 % after open reduction and internal fixation, requiring secondary ankle arthrodesis in about one quarter of all cases. In contrast to aseptic non-union or arthrosis, which can be salvaged with screw arthrodesis, with prevailing infection and severe osteoporosis external fixation (either one- or two-sided) is the treatment of choice. In isolated non-unions of the malleoli, either plate osteosynthesis with 3.5 low-contact dynamic compression plate or tension banding with autologous bone graft interposition, or alternatively sliding graft technique, is performed with good results.     

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.