Is there a role for low intensity pulsed ultrasound (LIPUS) in delayed or nonunion following arthrodesis in foot and ankle surgery?

BackgroundDelayed union and nonunion following foot and ankle arthrodesis is a disabling complication for patients. There are no clinical studies looking at whether there is a role for use of low-intensity pulsed ultrasound (LIPUS) following this. The aim of this study is to investigate the efficacy of LIPUS in this cohort of patients in our centre.MethodsThis was a retrospective observational study reviewing the use of LIPUS in patients who had arthrodesis of a number of different foot and ankle joints diagnosed with delayed or non-union.ResultsOver a 5 year period, 18 patients (71st MTPJ fusion, 2 subtalar joints, 2 triple fusion, 4 ankle fusions and 3 isolated midfoot joint) with radiologically confirmed delayed union, were treated with a standardised LIPUS therapy. Twelve patients (67%) were treated successfully with full radiological union confirmed. 4 patients required further surgical revision surgery while 2 were treated conservatively. Isolated small foot joints demonstrated a higher incidence of fusion (9/10; 90%) after LIPUS in comparison to larger or multiple joint arthrodesis (3/8; 38%).ConclusionsThere may be a role for the use of LIPUS as a treatment option in delayed union of isolated, small foot joint arthrodesis. However, we would not recommend its use in large or multiple F&A joint arthrodesis. Large multicentre series are required to confirm our findings.     

Results of Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy - A retrospective analysis of 44 patients

BackgroundThe role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy.Study designA retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre.Patients and methodsIn a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction).ResultsThere were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%).ConclusionDespite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.     

Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle?

This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5–84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.     

Radiographic Outcomes of Isolated Subtalar Joint Arthrodesis With Varying Fixation Technique

Subtalar joint (STJ) arthrodesis is a well-established and accepted surgical procedure utilized for the treatment of various hindfoot conditions including primary or posttraumatic subtalar osteoarthritis, hindfoot valgus deformity, hindfoot varus deformity, complex acute calcaneal fracture, symptomatic residual congenital deformity, tarsal coalition, and other conditions causing pain and deformity about the hindfoot. Union rates associated with isolated subtalar joint arthrodesis are generally thought to be favorable, though reports have varied significantly, with non-union rates ranging from 0 to 46%. Various fixation constructs have been recommended for STJ arthrodesis. The purpose of this study was to compare radiographic union in a 2-screw fixation technique to a 3-screw fixation technique for patients undergoing primary isolated STJ arthrodesis. To this end, we retrospectively reviewed 54 patients; 26 in the 2-screw group and 28 in the 3-screw group. We found the median time to radiographic union to be 9 weeks for the 2-screw cohort and 7 weeks for the 3-screw cohort. Additionally, we found that the 2-screw fixation cohort had a radiographic non-union rate of 26.9% while the 3-screw cohort had no non-unions. We conclude that the use of a 3-screw construct for isolated STJ arthrodesis has a lower non-union rate and time to union when compared to the traditional 2-screw construct and should be considered as a fixation option for STJ arthrodesis.     

Range of motion of foot joints following total ankle replacement and subtalar fusion

BackgroundIn severe cases of ankle and subtalar arthritis, arthrodesis of the subtalar joint is performed in combination with ankle arthroplasty. In these special cases gait analysis reveals real motion at the replaced tibiotalar joint.MethodsTwenty-three patients affected by ankle and subtalar arthritis, treated either with a 3-component or a 2-component prosthesis in combination with subtalar arthrodesis, were clinically evaluated preoperatively and at a minimum of 1-year follow-up. Gait analysis was performed postoperatively using a multi-segment foot protocol. Foot kinematics were compared to corresponding data from a healthy control group.ResultsClinical scores significantly improved from preoperative to follow-up. The clinically measured passive ankle dorsiflexion/plantarflexion significantly improved at the follow-up. Patients’ normalized walking speed and stride length were significantly lower than those in control. With exception of the ankle frontal-plane motion, sagittal-plane mobility of foot joints was about 50% than that in healthy joints.ConclusionsImprovement in clinical scores was found for both prostheses. Normal spatio-temporal parameters were not restored. In these patients, fusion of the subtalar joint appeared to be compensated by larger frontal-plane motion at the tibiotalar joint.Level of evidenceLevel III- retrospective comparative study.The study was approved by the local Ethics Committee as protocol MAT (protocol registration at clinicaltrials.gov NCT03356951).     

High Union Rates and Function Scores at Midterm Followup With Ankle Arthrodesis Using a Four Screw Technique

When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8–7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.     

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.     

Changes in the subtalar joint alignment after supramalleolar osteotomy for varus ankle arthritis

BackgroundThe subtalar joint may compensate for tibio-talar deformity, but what would happen to the joint after the deformity was corrected is not well known. Supramalleolar osteotomy (SMOT) is an effective procedure for the treatment of varus deformity of ankle arthritis. The objective of this study was to investigate the subtalar joint alignment pre and postoperatively following SMOT, and the factors which influenced the alignment of the subtalar joint.MethodsThirty-one patients with varus ankle arthritis (Takakura stage 2, 3a and 3b) who were treated using SMOT were retrospectively reviewed. The subtalar and ankle joint alignment was measured on weightbearing radiograph and weightbearing computerized tomography (WBCT).ResultsThe foot and ankle offset (FAO), tibial articular surface angle (TAS), tibio-talar surface angle (TTS), and subtalar vertical angle (SVA) were significantly corrected (P＜0.05). The subtalar inclination angle (SIA) decreased in 19 patients and increased in the other 12 cases after the SMOT (P＜0.001). The shift of subtalar joint (ΔSIA) showed an inverse correlation with the preoperative FAO (P＜0.001, r = −0.621).ConclusionsThe shift of subtalar joint after SMOT could maintain the neutral position of the hindfoot and showed a negative correlation with the preoperative FAO. The ΔSIA was greater in the severer preoperative hindfoot deformity.Level of evidenceLevel IV, case series.     

Retrospective Analysis of the Rate and Interval to Union for Joint Arthrodesis of the Foot and Ankle

Arthrodesis is a common procedure indicated for surgical treatment of end-stage degenerative joint disease of the foot and ankle. Many published studies have reviewed the union rate, focusing on specific technique or fixation. However, studies reporting on the average period required to achieve fusion, irrespective of the type of fixation or surgical method used, have been lacking. We report on the union rate and interval to fusion in patients who had undergone primary arthrodesis of various joints of the foot and ankle. A retrospective review of the medical records of 135 patients was performed. The specific joints studied were ankle, and the subtalar, triple, first tarsometatarsal, first metatarsophalangeal, and hallux interphalangeal joints. Our results showed that the average interval for complete fusion was significantly less for the joints in the forefoot, with the subtalar joint, ankle, and triple arthrodesis requiring a longer period to achieve complete fusion. The nonunion rate was also greater when the fusion involved the joints of the rearfoot. Our results have refuted the idea that 6 weeks is the minimum period required to achieve fusion in the foot and ankle. The results of our study support the need for additional education of the patients and surgeons that the interval required for recovery after foot and ankle fusion depends on the location and surface area that has been fused.     

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.     

Technique and early experience with posterior arthroscopic subtalar arthrodesis

BACKGROUND: Subtalar arthrodesis is a reliable procedure for pain relief and improved function in patients with isolated subtalar arthritis. Arthroscopic subtalar arthrodesis (ASTA) was designed to improve upon traditional methods by using a minimally invasive technique. However, posterior arthroscopic subtalar arthrodesis (PASTA) has not been described. The purpose of the present study was to investigate the early results of PASTA. METHODS: A retrospective review of 11 feet in 10 patients (one bilateral) that had PASTA was conducted. Inclusion criteria were isolated subtalar arthritis with no or minimal deformity and no significant bone loss. Exclusion criteria included patients requiring adjunctive open procedures or who had significant deformity. The technique involved prone positioning, two posterolateral portals and one posteromedial portal, posterior talocalcaneal facet debridement, percutaneous cancellous allografting and internal screw fixation. Outcome measures included patient satisfaction, the modified American Orthopaedic Foot and Ankle Society (AOFAS) score, union rate, time to union, and postoperative complications. RESULTS: All patients were discharged the day of surgery or stayed one night in the hospital. Eight patients were very satisfied, one satisfied, and one patient not satisfied with the results of their surgery. The average modified AOFAS score (maximum 94 points) improved from 36 points preoperatively to 86 points postoperatively. Ten joints fused by 10 weeks postoperatively, and one patient developed a nonunion. No other postoperative complications occurred. CONCLUSIONS: For surgeons familiar with posterior ankle or subtalar arthroscopy, PASTA offers superior exposure of the posterior talocalcaneal facet, high patient satisfaction, an excellent fusion rate, and less postoperative morbidity for patients with subtalar arthritis.     

Immunoreactivity of NOS, CGRP, PACAP, SP and VIP in the trigeminal nucleus caudalis and in the cervical spinal cord C1 and C2 of the cat

Abstract Background:   This retrospective study discusses the results of 16 years of follow-up for 32 ankle arthrodesis treatments that were performed between January 1977 and December 1994. Patients and Methods:   All patients were treated by external fixation. Not only the radiologic results but also the clinical and subjective assessment of pre- and postoperative individual outcomes were of interest. Results:   Radiologic assessment showed complete bony union in 82% of cases; 18% of patients revealed a bony union of two thirds. In the subtalar joint, a distinct arthrosis formation was generated. Clinical and subjective outcome was satisfactory. The patient collective achieved an average of 67 points in the Mazur grading score. Conclusion:   A comparison of the clinical examination and the radiologic assessment revealed that external fixation is a suitable surgical procedure for ankle arthrodesis.     

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.     

Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment

BACKGROUND: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. METHOD: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. RESULTS: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. CONCLUSIONS: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.     

Tibiotalocalcaneal fusion with a retrograde intramedullary nail: clinical and functional outcomes

Severe arthrosis and deformity of the ankle and subtalar joints are debilitating problems that can be difficult to treat. We retrospectively reviewed and functionally assessed 15 patients who had undergone tibiotalocalcaneal fusion with a retrograde intramedullary nail. The procedure had been a salvage procedure for severe arthrosis and deformity of the ankle and subtalar joints. Minimum follow-up was 2 years. Solid fusion was achieved in 14 of 15 patients. Mean time to union was 16.5 weeks. Ankle-Hindfoot Scale scores showed excellent pain relief at union. Subjective gait disturbances were common postoperatively, though patient satisfaction and the return-to-work rate were high (93% and 80%, respectively). The 12 complications included nonunion, malunion, skin problems, plantar pain, infection, and painful hardware. We advocate using a retrograde nail as a salvage technique in complex posttraumatic or postsurgical settings.     

Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report.

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.     

Use of circular external fixation for combined subtalar joint fusion and ankle distraction

The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, with potentially promising long-term results.     

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     

Arthroscopic ankle arthrodesis: Are results reproducible irrespective of pre-operative deformity?

BackgroundArthroscopic ankle arthrodesis is gaining in popularity. It has been shown to have a shorter time to union and less morbidity than traditional open procedures. The arthroscopic technique has been mainly used for ankles with minimal deformity. Our aim was to find out whether we could reproduce the good results of arthroscopic ankle arthrodesis in both minimally and markedly deformed ankles.MethodsWe reviewed 62 patients who underwent an arthroscopic ankle arthrodesis for end stage arthritis. The average follow up was 63 months (range 21–92 months). Patients were evaluated subjectively and objectively using the Mazur grading system. 4 patients died before final review and 3 were lost to follow-up leaving 55 patients for evaluation.The pre-operative tibiotalar angle in the coronal plane was between 26° valgus and 24° varus. We divided our patients into 2 groups based on the tibiotalar angle. Group A (n = 31) had a varus or valgus deformity of less than 15? and Group B (n = 24) had a deformity equal to or more than 15°.ResultsThe overall fusion rate was 91%. Fusion occurred in 29 of 31 (94%) ankles in Group A compared to 21 of 24 (88%) in Group B (p = 0.64).The overall mean time to union was 10.4 weeks. The time to union in Group A was 8.8 weeks compared to 12.7 weeks for Group B (p = 0.001). Using the Mazur ankle grading system, 84% of the cases in Group A had a good to excellent result compared to 79% in Group B (p = 0.73). There were 2 superficial infections, 2 cases of deep vein thrombosis and 3 patients required removal of prominent screws.ConclusionsWe have shown that arthroscopic ankle arthrodesis yields reliable and reproducible results in a District General Hospital setting with high union rates, short time to union and low complication rates. It can be satisfactorily employed for ankles with significant deformity, although this resulted in a longer time to union. The end results remain uniformly good to excellent.