踝关节外侧入路T型接骨板固定在胫距关节融合中的应用

背景:目前踝关节融合仍是治疗踝关节创伤后关节炎的金标准。踝关节融合术后不愈合发生率较高。距骨外后侧坏死者往往难以清理。目的:探讨踝关节外侧入路腓骨下段截骨、胫距关节融合T型接骨板固定治疗踝关节创伤后关节炎的临床疗效。方法:回顾性分析2013年6月至2016年6月采用踝关节外侧入路腓骨截骨、胫距关节融合T型接骨板固定的30例创伤后关节炎患者资料。男18例,女12例,年龄56~75岁,平均67.3岁。根据Morrey-Wiedeman分期,均为3期关节炎。记录患者术后主观满意度,采用美国足踝外科协会(AOFAS)踝功能评分评价末次随访时足踝部功能。结果:30例患者随访时间12~24个月,平均20.0个月。AOFAS评分末次随访时平均为(77.9±6.5)分,与术前(51.2±9.8)分比较,差异有统计学意义(P<0.05)。末次随访时胫距关节均融合,其中1例患者损伤腓肠神经,神经相应支配区出现感觉障碍,经营养神经治疗半年后症状缓解;1例由于早期活动融合处延迟愈合,经石膏固定、口服药物后愈合;1例由于融合时距骨向踝关节前侧稍移位,行走时鞋容易脱落。27例患者对手术效果非常满意,3例一般,满意率为90%。结论:踝关节外侧入路腓骨截骨、胫距关节融合T型接骨板固定治疗创伤后关节炎创伤小,术中获取植骨来源充分,操作方便,伤口风险小,患者术后满意度高,能纠正畸形、缓解疼痛,值得临床推广。     

全踝关节置换治疗创伤性踝关节炎

目的 探讨全踝关节置换治疗创伤性踝关节炎的早期临床疗效.方法 2005年1月至2010年1月采用全踝关节置换治疗55例创伤性踝关节炎患者,其中52例获得随访,男28例,女24例;平均年龄56.2岁(36～79岁).手术采用STAR假体.52例患者术前和末次随访时均行Kofoed踝关节评分和美国足踝外科协会(AOFAS)踝与后足评分,并对比术前与末次随访时的评分结果. 结果 52例患者术后获6～60个月(平均32个月)随访.3例患者术后出现切口皮缘浅表坏死,经换药后愈合;4例术中截骨时发生内、外踝骨折;1例术后出现假体滑动半月板失效断裂.末次随访时踝关节活动度较术前增加0～10°.52例患者末次随访时Kofoed踝关节评分平均为(86.0±9.3)分,与术前[(51.0±13.5)分]比较差异有统计学意义(t=28.10,P=0.000);AOFAS踝与后足评分平均为(88.0±8.2)分,与术前[(66.0±13.5)分]比较差异有统计学意义(t=21.60,P=0.000).52例患者中,术后无疼痛19例,轻度疼痛27例,中度疼痛6例.42例患者表示满意或一般,10例表示不满意,满意率为80.8%. 结论 全踝关节置换治疗创伤性踝关节炎在减轻疼痛等方面取得了令人鼓舞的结果,但在临床使用上尚存争议.     

Prosthetic Replacement of the Ankle in Posttraumatic Arthrosis

Background: As a result of numerous failed implantations of cemented ankle prostheses since the early 70s, ankle arthrodesis represented the "gold standard" in the treatment of ankle arthrosis. Due to a change to cementless implantations in the 90s it came to a remarkable reduction in early loosening, bone necrosis and sintering of the prosthesis which were the main reasons for former failures. In cooperation with ESKA Implants, Lübeck, we have developed a cementless anatomic ankle prosthesis. Patients and Methods: At our hospital, the ESKA prosthesis has been implanted in 56 patients (72% posttraumatic) since 1990. In our study, we report the examination results of 40 out of these 56 patients at least 1 year post implantation (21 of them more than 5 years). For evaluation, we used the Kofoed ankle score, which allows an easier comparison with other studies. This score showed an average improvement from 34.75 points preoperatively to 91.25 points postoperatively. Results: The persistent preoperative pain had completely disappeared in all patients; only twelve patients complained of intermittent pain under fairly heavy loading. 23 patients were able to walk > 2km and 13 > 5 km without pain. The overall range of motion was 40-60° in 14 patients, 25-40° in 21, and < 25° in only five. We did not see any kind of secondary arthrosis in the adjacent joints. An arthrodesis which posed no problems had to be performed only three times: in two cases in 1991, during the 1st postoperative year, with both patients showing infections of the prosthesis; in the third case, the prosthesis had to be changed after 9 years. Conclusions: According to our good results and those of other studies on cementless ankle prostheses, we consider a cementless upper ankle prosthesis, implanted by a highly experienced surgeon, the preferable alternative to upper ankle arthrodesis.     

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BackgroundThe aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.MethodsSix patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4 ± 1.9 years (range 1.0–6.5).ResultsOne patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.ConclusionIn the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.     

Short-term results of our first 49 Scandanavian total ankle replacements (STAR)

BACKGROUND: Forty-seven consecutive patients treated for ankle arthritis with a Scandinavian total ankle replacement (STAR) by one surgeon were investigated retrospectively. MATERIALS AND METHODS: A modification of the Foot Function Index (FFI), which scores pain and task difficulties, was followed prospectively. Patients were assessed clinically and radiologically. Failure was defined as revision of the prosthesis or arthrodesis for any reason. RESULTS: In 47 patients (16 male, 31 female) 49 total ankle replacements were carried out between May 1999 and June 2004. Indication for surgery was end stage arthritis for rheumatoid arthritis in 29 cases, post-traumatic arthritis in 12, osteoarthritis in five and arthritis secondary to degenerative flatfoot in three. Mean followup time was 28 (12 to 67) months. The modified FFI (range, 0 to 100, a high score meaning more pain and disability) improved significantly from 59 before to 35 after surgery. The mean postoperative Kofoed ankle score was 68. Sixteen procedures were complicated by fractures or temporary neurological damage. At the time of followup, 45 prostheses survived, while four replacements had failed. Radiological examination at followup showed radiolucent lines, osteolysis, and malposition of the components in 31 cases. CONCLUSION: Our results are comparable with those reported in the literature. The clinical outcome improved significantly. Due to aseptic and septic loosening, 8.2% of the prosthesis failed.     

Analysis of arthroscopically assisted ankle arthrodesis

Purpose: Evaluation of an arthroscopically assisted ankle arthrodesis technique for clinical and radiographic union, function, and patient satisfaction. Type of Study: Retrospective analysis and review of the literature. Methods: Twenty-one patients with a mean age of 52.7 years who underwent arthroscopic ankle arthrodesis were examined at an average follow-up time of 34 months. The mean duration of symptoms was 4.4 years. The most common diagnosis for patients who underwent arthrodesis was post-traumatic arthritis (19 of 21) with 1 patient having a diagnosis of avascular necrosis of the talus and the other patient having rheumatoid arthritis. All patients described severe mechanical pain as the most important reason for undergoing the procedure. Results: Fusion occurred in 20 of 21 patients. The average time to clinical and radiographic union was 8.9 weeks. Nine patients were graded as excellent; no pain, limp, or occupational restriction, and a stable fusion. Eleven were graded as good; mild pain, occasional limp, or occupational restriction with a stable fusion. One was graded as poor; failed union and pain. The failure had extensive avascular necrosis involving approximately 50% of the talus as a preoperative diagnosis. Conclusions: The advantages of the arthroscopic technique include a high fusion rate, decreased time to fusion, and decreased cost. There are considerable advantages to the arthroscopic technique in appropriately selected patients with no or mild angular deformity and no avascular necrosis greater than 30% of the talus. There is a substantial reduction in time to fusion in the arthroscopic procedure compared with published reports on open procedures for ankle arthrodesis. While this procedure is not indicated in all instances, selected patients with disabling ankle arthrosis may be more appropriately treated with an arthroscopic arthrodesis than by open surgery.     

Revisionsarthroplastik des oberen Sprunggelenks

In the last 20?years total ankle replacement has become a viable alternative to arthrodesis for end-stage osteoarthritis of the ankle. Numerous ankle prosthesis designs have appeared on the market in the past and attracted by the encouraging intermediate results reported in the literature, many surgeons have started to perform this procedure. With increased availability on the market the indications for total ankle replacement have also increased in recent years. In particular, total ankle replacement may now be considered even in younger patients. Therefore, despite progress in total ankle arthroplasty the number of failures may increase. Up to now, arthrodesis was considered to be the gold standard for salvage of failed ankle prostheses. Because of extensive bone loss on the talar side, in most instances tibiocalcaneal fusion is the only reliable solution. An alternative to such extended hindfoot fusions would be revision arthroplasty. To date, however, there are no reported results of revision arthroplasty for salvage of a failed ankle replacement.Based on our experience prosthetic components with a flat undersurface are most likely to be able to find solid support on remaining bone stock. The first 83 cases (79?patients, 46 males, 33 females, average age 58.9 years, range 30.6-80.7?years) with a average follow-up of 5.4 years (range 2-11 years) showed excellent to good results in 69 cases (83%), a satisfactory result in 12 cases (15%) and a fair result in 2 cases (2%) and 47?patients (56%) were pain free. Primary loosening was noted in three cases and of these two cases were successfully revised by another total ankle replacement and in one case with arthrodesis. Another case with hematogenous infection was also revised by arthrodesis. At the last follow-up control two components were considered to be loose and the overall loosening rate was thus 6%.This series has proven that revision arthroplasty can be a promising option for patients with failed total ankle prosthesis. The most challenging issue is the solid anchoring of available components on residual bone. More experience is needed, however, to better define the possibilities and limitations of revision arthroplasty.     

Knee arthrodesis using a customized intramedullary nail: 14 cases

We report our experience with knee arthrodesis using a customized intramedullary nail implanted in 14 patients. Indications for knee arthrodesis were: recurrent prosthesis infection (n=11), post-traumatic septic arthritis (n=1), aseptic loosening of a hinge prosthesis (n=1), and nonunion (n=1). A two-stage procedure was used for the 12 patients with infected joints. Mean follow-up was 19 months. Weight bearing began during the first week after arthrodesis in 13 patients. First intention bone healing was achieved in 13 patients. Mean time to healing was three months. All patients rapidly recovered full independence. Complications were: one misinsertion of the tibial stem, one nonunion which fused after repeated grafting, and two recurrent infections (controlled chronic fistulae) which required skin flaps for cover. We have found that this customized nail is a useful method for achieving bone fusion in patients with difficult indications for arthrodesis, particularly recurrent prosthesis infection.     

Results of the treatment of basal thumb osteoarthritis by Rubis II prosthesis after more than 5 years. A retrospective study of 118 cases

ObjectivesThe goal of the work was to evaluate the mid-term results of the Rubis II^® trapeziometacarpal prosthesis for the treatment of basal thumb osteoarthritis.MethodsFrom 1997 to 2003, 118 trapeziometacarpal prostheses Rubis II^® were implanted at Saint-Quentin's Hospital. Seventy-seven have been clinically and radiologically reviewed. The average follow-up was of 88 months. Sixteen patients were reviewed by phone. Fourteen patients were lost to contact and two died (13.5% of cases). Nine prostheses were removed (7.6% of cases).ResultsAmong the reviewed prostheses, 76.6% of patients had no pain, the others had moderate pain. Postoperatively, the average opposition according to Kapandji's scale was 9.52. The average key-pinch force was similar on both sides. All reviewed patients were satisfied or very satisfied. No radiological loosening was noted. Nine removals were necessary; for post-traumatic dislocation in six cases, post-traumatic fracture of the trapezium in two cases, and inflammatory reaction with no infection in one case. The survival rate of the prosthesis was 93% at five years.ConclusionsThe Rubis II^® prosthesis presents a satisfactory survival rate after five years and good clinical results. The design of the implant could explain the absence of loosening. The main risk of the Rubis II prosthesis seems to be the post-traumatic dislocation occurring mostly during the first two years after surgery.     

Arthroscopic arthrodesis of the shoulder: Fourteen-year follow-up

Shoulder arthrodesis is indicated in infections, brachial paralysis, irreparable rotator cuff tears, osteoarthritis without indication of prosthesis, rescue after arthroplasty, or after surgery for cancer. Arthroscopic arthrodesis is exceptional. Our aim is presenting our result after 14 years of follow-up of one patient. We present a case report of a 17-year-old male patient. He suffered fracture of left scapula (type V, Ideberg), fracture of left clavicle (type I, Craig), and fracture of left distal ulna. We realized osteosynthesis of clavicle (plate and screws) with the aim of treating this floating shoulder. Electromyography showed partial axonotmesis of axilar nerve. After 7 months of follow-up, axonotmesis was still present. We realized arthroscopic shoulder arthrodesis (three cannulated screws). Fourteen years later, shoulder movement was as follows: Flexion, 0-90°; maximum abduction, 40° with shoulder atrophy; Constant, 47 points; and UCLA, 17 points, without pain. Arthrodesis with screws reaches a subjective benefit in 82% of patients. Percentage of pseudarthrosis is less than in patients treated with plates, although the risks of infections, fractures, and material removal are greater than in patients treated with plates. Shoulder arthroscopic arthrodesis is exceptional, but it allows minimal surgical aggression.     

关节镜辅助踝关节融合术治疗晚期创伤性踝关节炎

 目的 探讨关节镜辅助踝关节融合术对保守治疗无效的晚期创伤性踝关节炎的治疗价值。方法 2007年7月至2010年12月,采用关节镜辅助踝关节融合术治疗晚期创伤性踝关节炎21例,男14例,女7例;年龄21～68岁,平均(37±13)岁。均为单侧手术。首次踝关节外伤至踝关节融合术的时间为1~41年,平均12.6年。患者术前均接受保守治疗无效,疼痛明显。术中彻底清除关节面软骨,行关节端“微骨折”处理,初步复位后以克氏针临时固定;“C”型臂X线机透视确认位置,拧入空心螺钉固定。2例同期行关节镜辅助距下关节融合术。术后石膏固定6~10周,部分负重锻炼直至骨性愈合。结果 全部患者获得随访,随访时间1～4年,平均1.8年。术后10~16周骨性愈合,平均12周。步态均得到改善,无切口愈合不良和感染等早期并发症。3例单纯踝关节融合患者术后出现距下关节炎伴疼痛,2例经保守治疗后症状缓解、1例行开放距下关节融合术后症状缓解。术前疼痛视觉模拟评分平均(8.1±1.5)分,术后1年平均(2.7±1.1)分,差异有统计学意义(t=3.153,P=0.005)。结论 对晚期创伤性踝关节炎,关节镜辅助踝关节融合术创伤小、切口小、融合率高,但对设备条件要求高,掌握该技术需要一定的学习曲线。     

The Stanmore knee arthrodesis prosthesis

Knee arthrodesis is most commonly performed for failed total knee arthroplasty. Conventional arthrodesis techniques are associated with a high incidence of complications and are unsuitable in cases with extensive bone loss. We report our medium-term results using a custom-made cemented knee arthrodesis prosthesis in 10 patients with a mean follow-up of 56.4 months (range, 15-199 months). The prosthesis was implanted as a 1- or 2-stage procedure for infected revision knee arthroplasty or tumor endoprosthesis in 9 patients and as a primary procedure in 1 patient with angiosarcoma involving the knee extensor mechanism. The average combined femoral and tibial bone deficit was 170 mm (range, 56-220 mm). Implant survivorship was 90%. All patients with retained prosthesis had no evidence of residual infection or loosening and were able to mobilize independently. One prosthesis was revised though retained following a prosthetic fracture, and 1 patient underwent above-knee amputation for uncontrolled infection. We conclude that the Stanmore knee arthrodesis prosthesis provides reliable fusion in an otherwise difficult-to-treat group of patients.     

Cervical disc prosthesis in humans: first failure

STUDY DESIGN: Prospective preliminary trial of a cervical disc prosthesis. OBJECTIVE: To study the feasibility, efficacy in maintaining intervertebral mobility, and complications of a low-profile disc prosthesis implanted after single-level cervical discectomy. SUMMARY OF BACKGROUND DATA: Since studies reported by Baba et al, there is fear that degeneration of the intervertebral disc levels adjacent to cervical arthrodesis may be exacerbated by this arthrodesis. For this reason, several cervical prostheses have been designed as an alternative to arthrodesis. None of these prostheses, some of which are bulky, has been shown to be efficacious. METHODS: Five women and five men (average age, 36 years) underwent implantation of the present disc prosthesis after single-level discectomy. The discectomy was performed for cervical disc herniation that resulted in cervicobrachial pain for more than 3 months. None of the patients exhibited intervertebral instability on bending films. Preoperative magnetic resonance studies showed a noncontained disc herniation in all 10 patients and osteophytes in 2 of the patients. RESULTS: The cervicobrachial pain resolved in all 10 patients. Intense neck pain developed in 1 patient who underwent revision surgery to remove the prosthesis and perform an arthrodesis. Another patient developed neck pain but refused the proposed revision operation. Bending films showed mobility of the intervertebral space containing the prosthesis in both of these patients. In the 8 patients who remained pain free after the operation, lateral bending films at follow-up found no mobility of the implanted disc level. Five of these eight patients had circumferential fusion, 2 had posterior fusion, and 1 had anterior fusion. CONCLUSION: This prosthesis failed to achieve the desired effect because the intended mobility failed to persist in 8 of the 10 patients and pain developed in the other 2 patients, in whom the mobility persisted.     

Die HINTEGRA-Sprunggelenkprothese

The HINTEGRA ankle was developed as an attempt to specifically address the needs of minimal bone resection, extended bone support, proper ligament balancing, and minimal contact stresses within and around the prosthesis. The purpose of this article was to present the design and rationale of this prosthesis, and to analyze the clinical and radiological short- to mid-term results particularly with respect to the revisions and learning curve.Of the 278 total ankle replacements (between 2000 and 2004) with the HINTEGRA ankle, 271 ankles [patients: 261, males: 133, females: 128, age: 58.4 years (range: 25-90 years)] were clinically and radiographically assessed after 36.1 months (range: 12-64 months). The preoperative diagnosis was post-traumatic osteoarthrosis in 206 cases (76.0%), systemic arthritis in 34 cases (12.5%), and a primary osteoarthrosis in 31 cases (11.5%). Beside 4 perioperative and 19 early postoperative complications, a late complication occurred in 40 cases (14.8%). Of these, 22 complications (8.2%) were not related to implants, and 18 complications (6.6%) were related to implants. In all, 39 cases (14.4%) were revised; of these, 5 cases (1.8%) were revised to ankle arthrodesis. All other 34 revision arthroplasties were successful and did not evidence any differences in the outcome to the non-revised ankles. The AOFAS hindfoot score improved from 40.3 (range: 14-61) to 85.0 (range: 44-100) points at last follow-up. Radiographically, the tibial component was stable in all remaining 266 ankles, and no tilting of the component occurred since surgery. The talar component was positioned too posteriorly in 12 ankles (4.4%).The concept of minimal bone resection and wide bony support was shown to be successful on the tibial and talar sides. Most complications occurred in the early cases of this series, and the learning curve was found to be short and steep. Despite the high amount of post-traumatic cases with limited soft tissue quality, the obtained function, pain relief, and patient satisfaction were promising and, compared with other devices, the results mostly were superior. This may support the belief that anatomically shaped surfaces, as is the case in the HINTEGRA ankle, may advance success in total ankle replacement.     

Reconstruction of infected post-traumatic bone defects of the distal femur with the CompressⓇ implant. Preliminary results of a staged non-biological strategy

IntroductionInfected post-traumatic distal femur defects remain a therapeutic challenge. Non-biological reconstruction offers an option for avoiding complex biological knee arthrodesis procedures. The Compress^Ⓡ implant is an alternative to the traditional distal femur stemmed megaprosthesis. The aim of this study is to analyse the first patients treated with a distal femur Compress^Ⓡ prosthesis to manage massive infected post-traumatic defects of the distal femur with joint involvement.MethodsWe retrospectively reviewed all patients with massive infected defects of the distal femur where this implant was used in a two-stage strategy, together with an antibacterial coating hydrogel (DAC^Ⓡ). The specific protocol, microbiological data, clinical and radiological results, complications, functional results and prosthesis survivorship were determined. Follow-up was for a minimum of 12 months, or until implant removal.ResultsTen patients (11 Compress^Ⓡ implants) with a mean age of 52 years (range 35-73) were included. On average, patients had undergone 4.4 previous surgical procedures before index surgery. The mean bone defect was 14 cm (range 8-21). After a median follow-up of 27 months (range 12-50 months) no patient had presented with recurrence of the infection, and limb salvage was achieved in all cases. Two patients suffered aseptic loosening which required revision of the femoral component. The short-term survivorship of the implant in our series was 81.8% at 4 years, with all failures occurring in the first 7 months. After this 7-month time threshold, we encountered no further loosening. Regarding functional outcomes, patients had a mean knee ROM of -4/86, expressed high overall satisfaction with the procedure according to the SAPS scale, and had an average LEFS of 52.5% (40-72.5%).ConclusionNon-biological reconstruction of the distal femur with the Compress^Ⓡ implant is a valid option in selected patients with massive infected defects with joint involvement. Survivorship was high, with all loosening occurring in the first months after surgery—representing a failure in the osseointegration of the implant.     

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。     

利用胫骨滑移植骨进行胫距关节融合

目的了解行胫骨滑移植骨的胫距关节融合效果。 方法分析2015年1月至2018年12月在青岛市黄岛区第三人民医院骨科行胫距关节融合的病例资料。用疼痛视觉模拟评分法(VAS)和Mazur评分，评估踝关节融合后的疼痛及功能改善；并了解胫距关节融合情况和并发症情况。采用配对样本的Wilcoxon符号秩检验进行比较。 结果根据纳入、排除标准，共纳入11例研究对象，术前VAS评分5～8分，术后18个月VAS评分1～3分，术后疼痛明显改善(Z＝-2.684，P<0.05)；术前Mazur评分21～77分，术后18个月Mazur评分69～86分，较术前明显改善(Z＝-2.666，P<0.05)。术后12个月后，所有患者的胫距关节均融合，随访期间均未发现感染。有1例59岁的终末期骨关节炎患者术后出现外侧足背皮肤浅感觉减退。 结论采用胫骨滑移植骨联合空心螺钉进行胫距关节融合对踝关节疼痛及功能改善明显，并发症少、融合率高。     

Knee arthroplasty in octogenarians: results at 10 years

The purpose of this study was to assess the long-term results of total knee arthroplasty (TKA) in octogenarians. Between 1976 and 1989, 1 surgeon at our institution performed 110 TKAs in 90 patients who were 80 years of age or older. No patients were lost to follow-up monitoring; all living patients underwent a minimum of 10 years (range, 10-19 years) followup care. There were 5 (3.4%) surgical complications, but at final follow-up examination, no implants had failed because of aseptic loosening. Of all patients, 96% experienced complete pain relief and 91% showed an excellent knee score (> or = 85) at final follow-up examination. Only 14% of patients had an excellent function score. The 88% death rate for our patient population, the fact that only 14% of patients had an excellent function score after surgery, and the lack of aseptic implant failure by the time of final follow-up examination after an average of 8 years with a conventional TKA raise the question of whether using expensive newer-design implants cost-effectiveness is in octogenarians.     

The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis

Various types of internal fixation have been used to achieve arthrodesis of both the ankle and subtalar joints. We have investigated the use of a standard 95 degree angled blade plate as a method of more rigid internal fixation to achieve arthrodesis of these joints. The purpose of this retrospective study was to review our clinical and radiographic results in adults using a blade plate applied through a posterior approach to fuse the ankle and subtalar joints. METHODS: Between April 1995 and June 2000, 10 tibiotalocalcaneal arthrodeses were performed using a posterior approach and a blade plate for internal fixation. There were 10 adults (five men and five women) whose average age was 64 years (range, 42 to 80 years). The indication for the procedure was severe pain which was unresponsive to nonoperative management in patients with arthritic joints. Preoperative diagnoses included six patients with post-traumatic arthritis, two with primary degenerative arthritis, one with rheumatoid arthritis, and one with post-polio deformity. An average of 1.7 previous operations had been performed on the affected ankle. RESULTS: Clinical and radiographic follow-up was performed for all patients at an average of 37 months (range, 12 to 71 months) postoperatively. All 10 patients achieved a solid fusion. The mean time to radiographic fusion was 14.5 weeks (range, 9 to 26 weeks). The operation resulted in plantigrade feet in all patients with an average tibia-floor angle of 2.3 degrees of dorsiflexion and an average of 5 degrees of hindfoot valgus. Patients had excellent pain relief, however function did not improve as much. Complications occurred in three patients. One patient required a small split-thickness skin graft for wound healing, one experienced a transient posterior tibial nerve neuropraxia, and one developed a deep venous thrombosis in the nonoperative leg at six weeks postoperatively. Three patients required removal of the blade plate because of discomfort, which promptly cleared. CONCLUSIONS: Arthrodesis provides excellent pain relief for patients with painful arthritic deformities of the ankle and subtalar joints. Using a posterior approach, a blade plate for internal fixation and bone grafts resulted in a solid fusion for all our patients. This method is particularly effective in large patients with a mild-moderate hindfoot deformity.     

Treatment of late recurring idiopathic clubfoot deformity in adults

Late recurrence of idiopathic clubfoot deformity in adults after prior successful surgery in childhood remains a rarity and only case reports exist. No study has yet clarified the results of triple arthrodesis in such cases. Complete clinical and radiological review of 7 patients (7 feet) after a follow-up time of 43 months following triple arthrodesis was undertaken. The time interval between the last surgical intervention and the triple arthrodesis averaged 27 years. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used as an outcome measure. Average age at time of review was 36 years (range 18-45). All patients were examined clinically and radiologically. The AOFAS-score improved from 43 points preoperatively to 61 points at follow-up (p = 0.004). If adjusted by excluding subtalar motion, the relative score improved by 19% (from 46% to 65%; p = 0.0043). Although not significantly altered (p = 0.1), pain scores remained fair (25 points) but were improved compared with the preoperative evaluation (13 points). Ankle motion was not changed. Although statistically not significant, there was an increase in degree of ankle arthritis in 67% of patients (one patient had ankle fusion) and mid- and forefoot degenerative changes in 57%. Hindfoot alignment remained fair after surgical intervention. Triple arthrodesis is a palliative means to correct recurrent deformity in patients with idiopathic clubfoot. Despite residual symptoms and degenerative changes at the ankle, 86% of all patients were satisfied with the postoperative result.