Category Archives: external fixation

Staged surgical intervention in the treatment of septic ankle arthritis with autologous circular pillar fibula augmentation: A case report

by Sham J. Persaud DPM, MS1*; Colin Zdenek DPM2; Alan R. Catanzariti DPM3

The Foot and Ankle Online Journal 10 (3): 6

Surgical management of chronic septic arthritis of the ankle joint is a challenging problem. Failure to initiate appropriate antibiotic therapy and perform incision and drainage within the first 24 to 48 hours of onset can result in subchondral bone loss and permanent joint dysfunction. Patients with chronic infection are not only at risk for loss of joint function, but also limb loss. This case report presents a staged procedure for limb salvage of patients with chronic septic arthritis of the ankle joint. Our technique includes use of both internal and external fixation, along with infection control and autologous pillar grafts. Though our case study is limited, the results are comparable to previous studies. This approach appears to be reasonable for limb salvage in end-stage degenerative joint disease following septic ankle arthritis.

Keywords: Septic arthritis, ankle, pillar graft, internal fixation, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0006

1 – West Penn Hospital, The Foot and Ankle Institute, Pittsburgh, PA 15224
2 – Silicon Valley Reconstruction Foot and Ankle Fellow, Palo Alta Medical Foundation, Mountain View, CA 94040
3 – Director of the Residency Training Program, West Penn Hospital, The Foot and Ankle Institute, Pittsburgh, PA 15224
* – Corresponding author: Sham Persaud, shamjoseph.persaud@ahn.org


Surgical management of chronic septic arthritis of the ankle joint is a challenging problem. Failure to initiate appropriate antibiotic therapy and perform incision and drainage within the first 24 to 48 hours of onset can result in subchondral bone loss and permanent joint dysfunction. Joint function after Staphylococcus aureus (S. aureus) septic arthritis is generally lost 25-50% of the time [1-4]. The mortality rate for septic arthritis has been reported as high as of 10-15% [1-2, 5-8].

Internal ankle arthrodesis techniques are reported to have between 88% to 100% primary fusion rates in patients with aseptic arthritis [9-12]. However the fusion rate for ankle arthrodesis in the setting of sepsis is roughly 71% to 93% [13-19].

Surgical management of septic arthritis requires debridement of all non-viable infected soft tissue and bone in order to eradicate infection [14-15, 20]. In addition to debridement, the use of local antibiotic delivery through polymethylmethacrylate (PMMA) has been shown to be an effective adjunct in treating infection [21-24]. Bactericidal levels of antibiotics from PMMA spacers are achieved through the process of elution where high concentrations of antibiotic are released locally, with minimal systemic effect, and limited risk to the patient. Peak antibiotic concentrations are mostly reached within the first week after placement; however, some studies have shown antibiotics may still be released at effective concentrations even after 4-6 weeks of implantation [25-30].

The use of long term intravenous (IV) or suppressive oral antibiotic therapy in conjunction with debridement is an important part of treatment. A 2-6 week course of IV antibiotic therapy is recommended depending on the severity of the infection and host immunity [14, 15, 20, 31].   

Fixation techniques for arthrodesis of the diseased ankle secondary to septic arthritis have been controversial. External fixation has been shown to provide adequate torsional stability, but is less effective in maintaining sagittal plane stability. On the other hand, internal fixation has been shown to provide excellent sagittal plane stability, but limited torsional stability. [19] Some authors believe a combination of both fixation techniques lead to optimal outcomes [12, 14, 15, 19, 20].

A concern with arthrodesis is following septic arthritis is loss of limb length. Cancellous bone graft has been shown to be effective in aiding with small defects [15, 20, 31]. Free vascularized bone graft has also been shown to be effective with large bony defects [14, 15, 20]. Use of allograft or synthetic bone grafts have rarely been mentioned in the literature [32]. One technique which has been described in aseptic ankle joint arthrodesis is the use of fibular pillar grafts as structural grafts to maintain length [33].

Patients with chronic infection are not only at risk for loss of joint function, but also limb loss. Cierny et al. related a 25% amputation rate for patients with arthrodesis of septic ankle joints [15]. This case report presents a staged procedure for limb salvage of patients with chronic septic arthritis of the ankle joint.

Case Report

A 54-year-old female with chronic right septic ankle arthritis for 6 months presented for evaluation. The patient had undergone arthrocentesis with corticosteroid, I&D with washout and long-term IV antibiotic therapy. She was offered a below knee amputation elsewhere but was reluctant to proceed and sought a second opinion. Her pre-operative radiographs can be seen in Figure 1 A-C and pre-operative MRI may be seen in Figure 2 A-B.  The patient chose to proceed with staged surgical approach for limb salvage.

Figure 1 Pre-operative radiographs; Mortise view, AP view, and Lateral view.

Figure 2 Pre-operative MRI; T1 Sagittal view, T2 Sagittal view.

The patient underwent needle biopsy of the tibia and talus with arthroscopic debridement. Arthroscopy was performed in standard fashion using a 2.7mm 30-degree arthroscope, utilizing a burr and shaver for ankle joint debridement.  Arthroscopic evaluation of the ankle joint revealed destruction of both tibial and talar articular surfaces.  Cartilage of both articular surfaces was degraded and granular in nature.  Cultures recovered S. aureus infection of the tibia.

Thirteen days later, open arthrotomy of the ankle joint with extensive debridement of the tibia and talus, as well as insertion of a Vancomycin cement spacer was performed.  The arthrotomy was performed using a lateral approach with a fibular osteotomy. The fibula was sent for pathology evaluation and culture, which were shown to be free of any bacterial infection.  Debridement was performed through osteotomies of both the tibia and talus which included the articular cartilage and subchondral plate (Figure 3). The joint was then pulse lavaged with 3L of normal saline-bacitracin mixture and a Vancomycin PMMA spacer was placed within the current ankle joint (Figure 4). This was then stabilized with a monolateral external fixator. The patient was placed on 6 weeks of antibiotic therapy by Infectious Disease including IV Cephazolin and PO Rifampin.

Figure 3 Intra-op radiograph status post fibula take down and wide excisional debridement of tibia and talus.

Figure 4 Intra-op radiographs and picture of Vancomycin PMMA spacer.

Ten weeks later, the patient underwent intramedullary (IM) nail tibiotalocalcaneal arthrodesis (TTC) (Figure 5). The original lateral incision was utilized to access the ankle joint.  The Vancomycin spacer was removed and soft-tissue specimens from the tibia and talus, which were sent for frozen section evaluation by pathology, were negative for infection. The bony surfaces were then prepared for arthrodesis in standard fashion using curettes, osteotomes, and drills. The subtalar joint was prepared in a similar fashion. The ankle was grafted with morselized femoral head combined with bone morphogenic proteins to provide osteoconduction and osteoinduction, as well as fibular pillar grafts to provide structural support and maintain length.  Fixation was accomplished with an IM nail. The patient remained non-weight bearing for 3 months.  She was then transitioned into a fracture boot for an additional month and then into a sneaker. No major or minor complications were noted throughout her recovery process. The patient has continued to improve throughout the post-operative course and is able to bear weight without assistance in standard foot gear. Serial radiographs have demonstrated complete union of all involved joints (Figure 6).

Figure 5 Intra-op radiographs (axial view, AP view, and lateral view) of IM nail with fibular pillar grafts.

Figure 6 Final radiographs showing consolidation (AP ankle, oblique ankle, lateral view) of IM nail with fibular pillar grafts.

Discussion

The fusion rate within the literature varies dramatically. Hawkins showed a variation between 71-94% depending on the control of infection within the joint [13]. Richter also reported a fusion rate of 86.6% for septic ankles [14]. Cierny et al reported results of 83% to 100%. Cierny believed this was secondary to the quality of the surrounding soft tissues. These cases used either external, or hybrid fixation techniques for their fusion [15].

Treatment of S. aureus septic ankle arthritis should include immediate lavage and debridement of the joint with culture and sensitivity driven antibiotic therapy [14, 15, 20].  However, this treatment alone leaves the patient predisposed to continued pain and discomfort secondary to sequela of septic arthritis. Therefore, ankle arthrodesis should be considered as a long-term option following resolution of the infection [4].

External fixation or a hybrid of external and internal fixation has been recommended for arthrodesis following septic ankle arthritis. We used a solitary IM nail for fixation in our cases. Klouche et al. discussed the use of internal fixation in a one-stage procedure using two cross screws through a lateral approach. There technique provided a cure rate of 85% and a consolidation rate of 89.5% at 4.8 months. Empiric antibiotics were administered to all patients and were modified based on culture and sensitivity results obtained at the time of surgery. No local antibiotics were used with their technique [34]. We used IV antibiotics before and after our definitive procedure, as well as, a Vancomycin loaded cement spacer following debridement of the infected bone.

Though our case study is limited, the results have been comparable to previous studies. This approach appears to be reasonable for limb salvage in end-stage degenerative joint disease following septic ankle arthritis. An evidence based study with increased numbers of patients and long term follow up would be beneficial in further accessing this technique for the treatment of septic arthritis of the ankle.

 

References

  1. Cooper C, Cawley MID. Bacterial arthritis in an English health district: a 10 year review. Ann Rheum Dis. 1986; 45:458-463.
  2. Peters RHJ, Rasker JJ, Jacobs JWG, Prevo RL, Karthaus RP. Bacterial arthritis in a district hospital. Clin Rheumatol. 1992; 11:351-355.
  3. Youssef PP, York JR. Septic arthritis: a second decade of experience. Aust N Z J Med. 1994; 24:307-311.
  4. Kaandorp CJE, Krunen P, Bernelot Moens HJ, Habbema JDF, Van Schaardenburg D. The outcome of bacterial arthritis: A prospective community-based study. Arthritis Rheum. 1997; 40(5):884-92.
  5. Meijers KAE, Dijkmans BAC, Hermans J, van den Broek PJ, Cats A. Non-gonococcal infectious arthritis: a retrospective study. J Infect. 1987; 14:13-20.
  6. Yu LP, Bradley JD, Hugenberg ST, Brandt KD. Predictors of mortality in non-postoperative patients with septic arthritis. Scand J Rheumatol. 1992; 21:142-144.
  7. Mathews C. J., Weston V. C., Jones A., Field M., Coakley G. Bacterial septic arthritis in adults. The Lancet.2010; 375(9717):846-855.
  8. Miller A, Abduljabbar F, Jarzem P. Polyarticular Septic Arthritis in an Immunocompetent Adult: A Case Report and Review of the Literature. Case Rep Orthop. 2015; 2015:602137.
  9. Scranton PE Jr. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am. 1985; 67:550–555.
  10. Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int. 1998; 19:3–9.
  11. Zwipp H, Grass R, Rammelt S, Dahlen C. Arthrodesis: non-union of the ankle—arthrodesis failed. Chirurg. 1999; 70:1216–1224.
  12. Kollig E, Esenwein SA, Muhr G, Kutscha-Lissberg F. Fusion of the septic ankle: experience with 15 cases using hybrid external fixation. J Trauma. 2003 Oct;55(4):685-91.
  13. Hawkins BJ, Langerman RJ, Anger DM, Calhoun JH. The Ilizarov technique in ankle fusion. Clin Orthop. 1994; 303:217–225.
  14. Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Ostermann PA. Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases. J Trauma. 1999; 47:1072–1078.
  15. Cierny G III, Cook WG, Mader JT. Ankle arthrodesis in the presence of ongoing sepsis: indications, methods, and results. Orthop Clin North Am. 1989;20:709–721.
  16. Johnson EE, Weltmer J, Lian GJ, Cracchiolo A III. Ilizarov ankle arthrodesis. Clin Orthop. 1992; 280:160–169.
  17. Lonner JH, Koval KJ, Golyakhovsky V, Frankel VH. Posttraumatic nonunion of the distal tibial metaphysis: treatment using the Ilizarov circular external fixator. Am J Orthop. 1995; suppl: 16–21.
  18. Stasikelis PJ, Calhoun JH, Ledbetter BR, Anger DM, Mader JT. Treatment of infected pilon nonunions with small pin fixators. Foot Ankle. 1993; 14:373–379.  
  19. Thordarson DB, Patzakis MJ, Holtom P, Sherman R. Salvage of the septic ankle with concomitant tibial osteomyelitis. Foot Ankle Int. 1997; 18:151–156.  
  20. Cierny G, Zorn EZ. Arthrodesis of the tibiotalar joint for sepsis. Foot Ankle Clin 1996; 1:177– 97.  
  21. Chen NT, Hong HZ, Hooper DC, May JW. The effect of systemic antibiotic and antibiotic impregnated polymethylmethacrylate beads on the bacterial clearance in wounds containing contaminated dead bone. Plastic Reconst Surg 1993; 97(2):1305–11.
  22. Donati D, Biscaglia R. The use of antibiotic impregnated cement in infected reconstructions after resection for bone tumours. J Bone Joint Surg Br 1998; 80(6):1045– 50.
  23. Popham GJ, Mangino P, Seligson D, et al. Antibiotic impregnated beads: Part II: factors in antibiotic selection. Orthop Rev 1991; 20:331–7.
  24. Ostermann PA, Henry SL, Seligson D. The role of local antibiotic therapy in the management of compound fractures. Corr 1993; 295:102– 11.
  25. Antrum RM, Solomkin JS. A review of antibiotic prophylaxis for open fractures. Orthop Rev 1987; 16:81–9.
  26. Eckman JB Jr, Henry SL, Manginio PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop 1988; 237:213–5.
  27. Lerner RK, Esterhai JL, Polomono RC, et al. Psychological, functional, and quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower extremity amputation. Arch Phys Rehab 1991; 72:122–6.
  28. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures.   J Bone Joint Surg Am 1974; 56:532– 41.
  29. Schentag JJ, Lasezkay G, Plant ME, et al. Comparative tissue accumulation of gentamycin and tobramycin in patients. J Antimicrob Chemother 1979; 4(SupplA):23–30.
  30. Seligson D, Popham GJ, Voos K, Henry SL, Faghri M. Antibiotic-leaching from polymethylmethacrylate beads. J Bone Joint Surg Am 1993; 75:714– 20.
  31. Stuart MJ, Morrey BF. Arthrodesis of the diabetic neuropathic ankle joint. Clin Orthop 1990; 253:209– 11.  
  32. Esterhai JL Jr, Sennett B, Gelb H, et al. Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft tissue transfer. Trauma 1990; 30:49–54.
  33. Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Ankle salvage surgery with autologous circular pillar fibula augmentation and intramedullary hindfoot nail. J Foot Ankle Surg. 2014 Sep-Oct; 53(5):601-5.
  34. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot Ankle Surg. 2011 Jan-Feb; 50(1):25-30.

Acknowledgements: None

Conflicts of Interest: None

Communications Author: Sham Persaud

Level of Evidence: Level IV Therapeutic Study

Early mobilization in bilateral talar fractures

by Mario Cala DPM1, Kristina Barreiro DPM1, Hany Jeffry DPM1.pdflrg

The Foot and Ankle Online Journal 7 (2): 9

Bilateral fractures of the talus can be considered extremely rare. The appropriate treatment suggested by most experts includes permanent anatomical reduction with fixation. Open surgical approaches to the hindfoot can be associated with major complications. Some of these complications include vascular damage, soft tissue and surgical wound-healing problems due to the poor blood supply to the posterior ankle region. To avoid these complications, fluoroscopy assisted closed reduction and percutaneous fixation has been recommended in the treatment of less displaced fractures in some of the literature. This is a case report in which bilateral talar fractures were treated percutaneously resulting in early mobilization.

Key words: talar fracture, early mobilization, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0009


Address correspondence to: Kristina Barreiro, DPM
Jackson North Medical Center in North Miami, Florida
Email: barreirokristina@gmail.com

1 Jackson North Medical Center in North Miami, Florida


The talus is a very important bone in the lower extremity. The body of the talus is divided into five surfaces: superior, medial, lateral, posterior, and inferior. The anterior surface is attached to the neck. The neck of the talus has four surfaces: superior, medial, lateral, and inferior. The head of the talus is entirely articular, consisting of three articular surfaces; the largest being the talonavicular articulation [1]. It is highly vascularized with three main arteries supplying its blood supply. The anterior tibial artery, posterior tibial artery, and peroneal artery all give branches that supply the talus. Due to its high vascularity, the talus has a high healing rate, if vascularity is not compromised. A positive Hawkins sign is seen in talar fractures 4-8 weeks after the injury at the subcortical bone of the talar dome due to the washing out of the subchondral bone and subsequent osteopenia. This indicates bone remodeling. It is highly predictive of a revitalization of the talar body after a fracture [1].

Talar fractures can vary in site of fracture: from an osteochondral talar dome fracture to a dislocated talar neck fracture to talar body fracture. Each type of fracture has its own outcome in terms of treatment plan due to its mechanism of injury. The mechanism of injury for talar body fractures typically involves hyperdorsiflexion of the foot with impingement of the talar neck against the anterior edge of the tibial plafond [2]. Another mechanism of injury resulting in fracture of the body of the talus is a fall from height, in which an axial compression of the talus between the tibial plafond and the calcaneus results. Fractures of the talar body, while uncommon, present a harsh prognosis due to its greater risk for avascular necrosis than talar neck fractures [1]. Talar dome fractures are caused by two mechanisms of injury: medial lesions were caused by inversion and plantar flexion of the foot with external rotation of the tibia on the talus, while lateral lesions were caused by inversion and dorsiflexion of the foot with internal rotation of the tibia on the talus. Talar neck and head fractures are more common than talar body fractures [3].

Bilateral fractures of the talus can be considered extremely rare. The appropriate treatment suggested by most experts includes permanent anatomical reduction with fixation [3].  One study found a patient with a left talar neck fracture of the lateral process and right talar body fractures with bilateral subtalar and talonavicular dislocations. Treatment was bilateral internal fixation. This case resulted in permanent pain and limitation in movement [3].

The use of plain films and magnetic resonance imaging can help in the diagnosis and staging of these lesions as well as aid in treatment planning. Conservative treatment for nondisplaced talar fractures is common, but displaced fractures require stable fixation and early physical therapy [4]. Classical treatment for talar fractures is open reduction and internal fixation. In the past, crossed k-wires have been used to correct the fractures, as well as cannulated screws, and combinations of k-wires and screws in the talus. Rare cases used mini-plates. Patients who received internal fixation where typically immobilized in a non-weight bearing cast in neutral alignment for a period of twelve weeks [4]. Following the period of non-weight bearing, progressive weight-bearing combined with physiotherapy is usually started.

Arthroscopic treatment may be used in the management of transchondral dome fractures [5]. Following excision of the talar dome fracture fragment, the exposed subchondral bone should be drilled with multiple small drill-holes to promote migration of fibroblasts to the surface for the production of fibrocartilage [6]. Arthroscopically assisted internal fixation of talar body fractures using anterior portals has been noted [5].

Open surgical approaches to the hind foot can be associated with higher complications. Some of these include surgical wound-healing problems due to the poor blood supply to the posterior ankle region. To avoid vascular damage and soft-tissue problems, fluoroscopy assisted closed reduction and percutaneous fixation has been recommended in the treatment of minimally displaced fractures in at least one source [5]. In our case report, in order to minimize complications, we used bilateral mini-rails. The SIDEKICK® Mini Fixator from Wright Medical was utilized in our case. It is indicated to stabilize multiple fracture fragments ranging from open and/or comminuted fractures to infected non-unions, fractures with length discrepancies, fusions and corrective osteotomies of the metacarpal, metatarsal, ulnar, and calcaneal bones [8]. This mini-rail allows early weight-bearing and decreases the risk of avascular necrosis.

Case Report

The patient is a 20-year-old male with no significant past medical history was brought to the emergency department following a motor vehicle accident at 75 MPH. The patient was complaining of ankle pain and swelling, along with left sided chest pain which appeared skeletal.

After a complete series of x-rays and CT scans, he was found to have closed transverse fractures of the body of the talus of right foot (Figures 1, 2, and 5). He also was found to have a minimally displaced fracture of the neck of the talus of left foot that was graded type 1 on Hawkins classification (Figures 3, 4, and 5). No other fractures were seen, and no organ damage was detectable on CT imaging. His physical exam was normal, except for edema and tenderness with limited range of motion of both ankles.

Talar1

Figure 1 Coronal CT view of right rear foot showing comminuted fracture of talar body.

Talar2

Figure 2 Sagittal CT view of right rear foot showing fracture of the talar body.

Talar3

Figure 3 Coronal CT view of left rear foot showing comminuted fracture of talar neck.

Initial management involved pain medication, and immobilization of bilateral ankles utilizing posterior splints with application of modified Jones compressions to control swelling. After medical clearance, surgical intervention was planned for close reduction of the talar fractures of the bilateral feet utilizing mini-rail external fixators.

Talar4

Figure 4 Sagittal CT view of left rear foot showing talar neck fracture.

Talar5

Figure 5 Transverse CT view of bilateral rear foot showing right talar body fracture and left talar neck fracture.

The external fixator was applied to the dorsomedial aspect of the right foot with six half pins (two were inserted into the proximal fragment, two were inserted into the distal fragment, and for more stabilization, one pin into the navicular and one pin into the medial cuneiform bone) (Figure 6). For the left foot, the external fixator was applied to the dorsomedial aspect as well, with two half pins inserted into the proximal fragment, two inserted into the distal fragment, and two pins into the navicular bone to achieve more stabilization (Figure 6). Compression of both tali was achieved by turning the mini-rail bringing the fractured fragments together. Fluoroscopy imaging confirmed good alignment of both tali.

Talar6

Figure 6 Post-operative X-ray of bilateral foot in AP view showing achievement of anatomical alignment of the fractured tali with the assistance of the mini-rail compression and fixation.

The patient received antibiotic before and after the surgery. Postoperatively, we continued with posterior splint and modified Jones compression with non-weight bearing to bilateral foot, assisted with wheelchair. Medications for pain and DVT prophylaxis were prescribed on discharge.

One week after surgery, the patient reported minimal pain to right foot.  He reported walking on his feet disregarding our instructions. Seven weeks after the surgery, the patient reported no pain. X-rays of bilateral feet revealed healing of the talar fractures. He was allowed to bear weight partially assisted with a walker and resume physical activity moderately (Figure 7).

Talar7a Talar7b

Figure 7A & B Clinical pictures of the patient 7 weeks after the surgery date with partial weight bearing and mini-rails bilateral foot.

At nine weeks post operatively, the hardware was removed. Patient tolerated walking without pain and was tolerating physical therapy the week after removing the hardware. X-rays taken one month after removing the mini-rails demonstrated complete resolution of the fracture sites (Figure 8A, B, and C).

Talar8a Talar8b Talar8c

Figure 8A, B, & C Bilateral Foot X-Rays in Lateral and AP views demonstrating complete resolution of bilateral talar fractures post removal of the mini-rail fixator.

Discussion

Because of the young age of the patient, in the hope of achieving earlier weight-bearing with a better chance to be able to return to work, we chose mini-rail as a minimally invasive approach.  Conventional therapies, such as Kirschner wires, would delay early weight-bearing. Our choice of mini-rails also avoided the vascular and wound healing complications that are commonly associated with an open approach to the rear foot. This patient had a chance to heal with no complications, in a shorter time, and was able to ambulate earlier than conventional internal fixation would allow.

References

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  8. Hollawell, S. SIDEKICK® Mini Fixator: Surgical technique. Wright Medical Technology, Inc. 2013. – link