Tag Archives: arthritis

The vacuum phenomenon in the ankle joint: Air bubbles on CT

by Christopher R. Hood JR. DPM1*, Wesley A. Jackson DPM2, Robert C. Floros DPM3, David A. Bernstein, DPM4

The Foot and Ankle Online Journal 11 (2): 2

Gas or air bubbles in a joint space are most commonly associated with the “vacuum phenomenon,” a collection of gas that has precipitated out of solution to take up a gaseous state within a joint. This phenomenon was unbeknown to us upon a patient presentation, seen on computed tomography scan, and so further academic investigation was performed to define this pathology. Because of this lack of awareness, a PubMed® literature review was performed to analyze the rate of incidence in foot and ankle. Additionally, we present a case example of the vacuum phenomenon in the ankle joint of a 50-year old patient presenting with degenerative ankle joint pain symptoms. Further, a review of the condition as well as differentials is discussed in an attempt to raise awareness of this differential diagnosis for gas bubbles within a joint.

Keywords: Air bubbles, ankle, arthritis, CT, computed tomography, foot, gas bubbles, gaseous degeneration, vacuum phenomenon

ISSN 1941-6806
doi: 10.3827/faoj.2018.1102.0002

1 – Fellowship-Trained Foot and Ankle Surgeon, Premier Orthopaedics and Sports Medicine, Malvern PA.
2 – Resident, PGY-2, Bryn Mawr Hospital PMSR/RRA, Bryn Mawr PA.
3 – Private practice, Ocean County Foot & Ankle Surgical Associates, P.C., Toms River NJ and The Foot and Ankle Center, Haverford PA.
4 – Residency Director, Bryn Mawr Hospital PMSR/RRA, Bryn Mawr PA and Private Practice, Wayne PA.
* – Corresponding author: crhoodjr12@gmail.com


The presence of gas or air bubbles in a joint was first described by Fick in 1910 when he noticed gas bubbles in hand joints on radiograph (XR) evaluation while under traction [1-3]. Later this radiographic finding was coined the “vacuum phenomenon” (VP) by Magnusson in 1937 [2]. On imaging modalities such as computed tomography (CT) where it is most often visualized, it appears as a dark radiolucent pattern that can be shaped anywhere between a singular, linear bubble to confluence of bubbles within the confines of a joint space [2]. The shape is classically defined as a crescentic lucency paralleling a joint when found articular [3].

Gas bubbles were first thought to be associated with joint traction or trauma, but has since been found in situations of degenerative changes to joints [1,2]. Other associated gas bubble presenting pathologies include fracture-dislocation (e.g. traction injuries, open injuries introducing free air), ligament injury, metastasis, infection (e.g., abscess, osteomyelitis), cancer (e.g., multiple myeloma), intervertebral disc herniation/Schmorl’s nodes, abdominal or thoracic free air (e.g., digestive tract perforation, pneumothorax, air embolism), decompression sickness, and iatrogenic causes (e.g., surgical introduction of air, arthroscopy) [2,4].

Related to degenerative disease, its presence is most often cited to the sacroiliac (SI) joints (i.e., joint, facets, intervertebral discs) but also has been found in the pubic symphysis, lumbosacral space, and the joints of the temporomandibular, wrist, hand, hip, shoulder, knee, ankle (AKJ), subtalar (STJ), and calcaneocuboid (CCJ) [1-4]. Analysis of the gas in the SI location has found it to be predominantly nitrogen (> 90%) based , but oxygen and carbon dioxide among other gases are also present at much lower concentrations [2].

The purpose of this report was twofold: to determine the rate of occurrence of foot and/or ankle VP in the literature through a keyword search and present a case example of the VP to the AKJ in an end-stage degeneration clinical situation.

Methods

A PubMed® advanced keyword search was performed on May 1, 2017,  using the term combinations of “air bubble,” “bubble,” “gaseous degeneration,” “vacuum phenomenon,” with “foot” or “ankle.” The search had no restriction parameter fields applied. (Table 1) The returned abstracts were reviewed to determine their validity whether relevant to the primary search goal of obtaining articles demonstrating the VP from the ankle joint, distally. A table was then created counting the published instances of the VP in the foot and/or ankle.

Case Report

A 50-year old male patient presents to the senior author’s office after referral from a previous podiatrist due to his primary complaint of ankle pain. The patient described the pain as a progressive pain upon ambulation. The patient is very active and enjoys running and mountain climbing in particular. He states he can walk up to 8 miles until he can’t bare the pain anymore. He states his pain has been progressing in the ankle for 8 years now. Only rest has been able to alleviate his symptoms to this point in time. He has not sought any formal medical treatment prior to presentation.

Figure 1 50 year-old male, sagittal CT scan of the ankle. Note the gas formation in the joint as well as presence within the subchondral bone region. Associated talar dome arthritic changes. Images are left to right, lateral to medial.

Figure 2 50 year-old male, coronal CT scan of the ankle. Note the gas formation centered around, and within the cystic changes to the medial talar dome. Images are left to right, anterior to posterior.

Figure 3 50-year-old male, axial CT scan of the ankle. Note the gas formation is positioned with the lower-lying cartilage defect space. Images are left to right, superior to inferior slices.

Ankle Foot
  • “air bubble” / “ankle”
  • “air bubble” / “foot”
  • “bubble” / “ankle”
  • “bubble” / “foot”
  • “gaseous degeneration” / “ankle”
  • “gaseous degeneration” / “foot”
  • “vacuum phenomenon” / “ankle”
  • “vacuum phenomenon” / “foot”

Table 1 Key Word Search Parameters for Study Identification – Vacuum Phenomenon to the Foot and/or Ankle.

Ankle Foot
  • “air bubble” / “ankle” = 0
  • “air bubble” / “foot” = 1
  • None related to topic
  • “bubble” / “ankle” = 3
  • None related to topic
  • “bubble” / “foot” = 21
    • 1 discussing foot drop  developed 10 days post-op disc surgery, secondary to nerve root gas bubble (Kloc et al., 1998)(6)
    • 1 discussing STJ ROM using a bubble inclinometer
    • 1 discussing diabetic foot bullosis diabeticorum
  • “gaseous degeneration” / “ankle” = 0
  • “gaseous degeneration” / “foot” = 2
    • 1 discussing foot drop  developed 10 days post-op disc surgery, secondary to nerve root gas bubble (Kloc et al., 1998)(6)
  • “vacuum phenomenon” / “ankle” = 4
    • 1 related to dislocated joint/trauma of STJ and CCJ (Ahmad et al., 2007)(5)
    • 1 related to STJ and AKJ (Lee et al., 1994)(1)
    • 2 discussing lumbar pathology
  • “vacuum phenomenon” / “foot” = 2
    • 1 related to STJ and AKJ (Lee et al., 1994)(1)
    • 1 discussing foot drop  developed 10 days post-op disc surgery, secondary to nerve root gas bubble (Kloc et al., 1998)(6)

Table 2 Study Search Resulted Literature – Vacuum Phenomenon to the Foot and/or Ankle.

The patient’s past medical history consists of hemochromatosis. There is no known past surgical history to the foot or ankle. There is no known family history of foot or ankle pathologies at this time. Medications consist of hydrochlorothiazide and a baby aspirin daily.

The patient’s physical exam findings show limited dorsiflexion at the ankle joint and pain upon end range of motion in dorsiflexion at the ankle joint with a hard stop. His neurovascular status was grossly intact. There were no subjective complaints or objective findings of an infectious process based on the history and physical exam. He had no complaints of any other arthritic or painful joints. No other abnormalities were noted to his problem based exam.

A CT scan of the ankle exhibited degenerative joint disease to the talotibial joint along with a large anterior osteophyte of the distal tibia and talar neck at the ankle joint level. The CT scan also exhibited intra-articular gas centrally within the joint (Figures 1-3). Upon discussion with the reading radiologist it was declared that the gas was related to the VP. Further discussion with multiple facility radiologists where the study was performed revealed that the gas is due to nitrous oxide from surrounding synovial tissues, but can also be due to positioning of the ankle joint at the time of the study. From their experience, most VPs noted by these radiologists occur primarily in the lumbar spine and shoulders. None of them have seen such a finding in the ankle until this particular case.

Discussion of treatment options with the patient included less impacting exercises, an anterior ankle joint arthroplasty, and the need for a possible ankle joint replacement in the long term future. The patient was in favor of the anterior ankle arthroplasty procedure but would take time to think about his options moving forward. No treatments have been rendered to date and he has not returned to the senior authors’ facility.

Results

From the PubMed® literature search, 33 articles resulted in total. After reviewing titles, abstracts, and database tags, removing irrelevant and duplicate entries, only two articles were relevant to this literature review of identifying examples of the VP in the foot and/or ankle (Table 2). This included a retrospective institutional review of CT imaging over two years evaluating the presence of gas bubbles in the lower extremity joints (i.e., AKJ, STJ, CCJ) and a case example of the VP in the STJ and CCJ after a trauma [1,5]. A third study found discussed a drop foot secondary to epidural gas formation and nerve root compression was not counted due to the distance location of the gas bubbles from the foot [6].

Discussion

The VP is a combination of anatomy and physics, calling into play both Henry’s Law and Boyle’s Law through hydrodynamic cavitation [2,4]. Simply put, gas precipitates out of solution through a negative intra-articular pressure when a joint is distended (e.g. traction) or collapses. The newly created free space within the joint capsule needs to be filled, and is done so by gas (primarily nitrogen) [2,3]. In this situation it is often by a gaseous element that precipitates out of the local tissue or synovial fluid due to changes in pressure [1,2,4]. Gohil et al (2014) and Yanagawa et al (2016) provide detailed explanations of this phenomenon. Normally, this gas goes back into solution when the joint returns to its normal volume and pressure. However in situations of arthritis, a thickened or fibrotic/scarred joint capsule does not allow the gas to dissolve out. Furthermore, excess joint space due to the presence of cartilage loss and subchondral cysts allows the gas to remain out of solution to fill that “extra” space [1]. In situations of traction or trauma to a joint,  the blood gas nitrogen precipitates out of solution to fill the excess free intra-articular space from the joints’ distention [5]. In open fractures, the outside air fills the spaces within the extremity, and is not a true VP.

The presence of the VP may be seen as something no more than an academic finding when present on a CT scan of a lower extremity joint. It has been documented in instances related to trauma (i.e. sprain; joint dislocation; rapid joint distention,) degenerative disease, osteochondrosis, osteonecrosis, idiopathic, osteomyelitis / infection, or conditions specific to the joint found in [1,2,5]. Its finding is most often related to degenerative disease to a joint, easily seen on CT due to its greater sensitivity  with higher resolution compared to XR or magnetic resonance imaging (MRI) [1,2,4]. Associated pathology such as narrowed space, subchondral cyst, sclerosis, hypertropic degeneration to the joint may be seen along with the gas bubbles in degenerative situations across each imaging modality. In acute trauma, the presence of gas would suggest intact joint capsule and the associated intra-capsular ligaments however reports in the knee have shown otherwise [2].

When found, one important point is to correlate the finding to the presenting pathology through the patient history and physical exam so to not over or under diagnose the true pathology at hand [2,3]. This is most important when wanting to rule out any potential infectious processes such as septic joint, open fracture-dislocation, or penetrating joint trauma. Joint gas and spinal infection has been associated with bacteria such as obligate anaerobes or facultative organisms such as clostridia, Peptococcus, and E. coli [1,7]. Patterns of gas formation have been cited with different pathology from a linear formation in more benign pathology while bubble-like multi-lobulated patterns suggest infection [2]. In closed injuries, the presence may suggest a recent joint dislocation that otherwise may not be visible on imaging [5].

Specific to the lower extremity, Lee et al. (1994) performed an institutional retrospective review of CT scans over a two year period  to determine the incidence of gas within the STJ and/or AKJ [1]. It was documented in 12 cases (n = 495, 2.4%) on CT, none of which were related to infection. Of these, 11 were in situations of arthritis (post-traumatic, 10; non-traumatic, 1), 10 cases in the STJ, and although the XR did not show gas or air in the joints, degenerative changes were present and visible on both XR and CT. In the only other example, Ahmad et al. (2007) demonstrated the VP in a single case of an acute, closed STJ and CCJ fracture-dislocation [5]. One final unrelated  but interesting case included epidural gas collection secondary to vertebral disc degeneration causing nerve root compression and a drop foot [6]. Ultimately, surgical decompression resulted in resolution of the drop foot.

The VP is very under-reported in the literature and in radiology reports [2]. In the SI joint where the finding is most common, one study found only a 16% reported rate [2]. For the case presented here, the finding was not mentioned in the radiologists report. Only in calling the radiologist who performed the evaluation did we get an explanation of the gas finding seen on CT. The condition may be unfamiliar to physicians other than radiologist, as was in this instance, where more awareness would be important for the ordering physician to add the VP to their differential diagnosis of gas in a joint without jumping directly to infection [2,7].

The authors surmised the VP finding in the lower extremity may not be seen in high percentages due to two more reasons. These are based on the physics of the VP and some speculation [2]. The first is that the VP is most sensitive on CT imaging. In instances of acute trauma to the lower extremity such as traction injuries (i.e. sprains) that are often evaluated, diagnoses, and treated in the outpatient setting, an MRI is often the modality used if advanced imaging is required. In these traumatized joints, by the time imaging is performed, the gas has possibly gone back into solution and fluid fills any remaining excess intra-articular space. In acute injury settings such as joint dislocations, it has been suggests that gas bubbles may be routinely seen within 4 hours of dislocation while occasionally seen after 48 hours on CT scan [8]. Another multi-joint study found, after inducing a transient traction-VP, the gas bubbles to disappear within 10 minutes [3]. If acute fracture-dislocations present in the emergent setting and the more sensitive CT is ordered, the VP finding may often be overlooked due to the more pressing osseous trauma that requires urgent treatment or be attributed to a concomitant open injury and free air. Second relates to the duration of gas presence in a joint, other than the aforementioned points. In situations of chronic degenerative disease, over time the gas within the joint achieves a new solubility equilibrium and will dissolve back into solution and not be visible. The time to reach equilibrium was not found in any report.

Conclusion

The VP is a finding consisting of gas or air bubbles on CT within a joint space. Its finding is under represented in the lower extremity joints with only two citations to date (not including this report). The presence should not be alarming when seen in a non-infectious presentation. Although its finding to date is not correlated with a more advanced joint degeneration to the lower extremity, the finding can be another example of degeneration in addition to visible cartilage loss, subchondral cysts, and scarred joint capsules. This example adds to the literature base of VP to the lower extremity and provides another mode of bringing awareness to physicians who treat the lower extremity.

Financial Disclosures / Funding Declaration

None

Conflict of Interest

None

Acknowledgements

None

References

  1. Lee TH, Wapner KL, Mayer DP, Hecht PJ, D M. Computed tomographic demonstration of the vacuum phenomenon in the subtalar and tibiotalar joints. Foot Ankle Int. 1994;15(7):382–5.
  2. Gohil I, Vilensky JA, Weber EC. Vacuum phenomenon: clinical relevance. Clin Anat. 2014;27:455–62.
  3. Balkissoon ARA. Radiologic interpretation of vacuum phenomena. Crit Rev Diagn Imaging. 1996;37(5):435–60.
  4. Yanagawa Y, Ohsaka H, Jitsuiki K, Yoshizawa T. Vacuum phenomenon. Emerg Radiol [Internet]. Emergency Radiology; 2016;23:377–82. Available from: http://dx.doi.org/10.1007/s10140-016-1401-6
  5. Ahmad R, Annamalai S, Radford M, Cook C. Vacuum phenomenon in a dislocated joint. Emerg Med J. 2007;24:862.
  6. Kloc W, Wasilewski W, Imieliński B, Karwacki Z. Epidural gas aggregation in the course of gaseous degeneration of lumbar intervertebral disk as a cause of foot paresis. Neurol Neurochir Pol. 1998;32(3):699–704.
  7. Nagashima T, Minota S. Air bubbles in the knee joint. J Clin Rheumatol. 2016;22(2):94–5.
  8. Fairbairn KJ, Mulligan ME, Indication A, Fairbairn KJ, Murphey MD, Resnik S. Gas bubbles in the hip joint on ct: an indication of recent dislocation. Am J Roentgenol. 1995;164(May):931–4.

A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report

by Rajesh Kumar Chopra1, Narendran Pushpasekaran2*, Sathyamurthy Palanisamy2, Balu Ravi2

The Foot and Ankle Online Journal 10 (4): 5

Closed midfoot dislocations are not uncommon injuries. The key to good functional outcomes is stable concentric reduction by understanding the injury pattern and early intervention to maintain the biomechanics of the foot. We report on a 20-year-old male, the presentation of a complex pattern of closed traumatic dislocation of the midfoot, managed by open reduction and internal fixation with Kirschner wires for six weeks. He did not show any evidence of instability or arthritis and had a foot function index of 94% at 14 months. The unique presentation of this midfoot dislocation is the separation of naviculocuneiform and calcaneocuboid joints. An entity that requires reporting in literature as it remains unclassified and to add to the spectrum of injuries caused by the deforming forces of foot.

Keywords: foot injuries, tarsal bones, open reduction, arthritis, foot function index

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0005

1 – M.S.(Ortho), professor, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
2 – M.S.(Ortho), resident, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
* – Corresponding author: drnaren247ortho@gmail.com


Closed traumatic dislocations of the midfoot are common injuries in level 1 and 2 trauma care [1]. Apart from the common Lisfranc, Chopart and talonavicular dislocations, swivel-type dislocations of the medial column involving the talus, navicular and cuneiforms, and lateral columns involving the calcaneus and cuboid bones have rarely been reported [2-4]. The proposed injury mechanisms to cause such injuries are dorsiflexion, plantar flexion, abduction and adduction forces or a combination of them [5]. However, involvement of both columns in the form of complete disruption of the naviculocuneiform and calcaneocuboid joints has been infrequently reported in the literature. We report this complex presentation sustained following a supination-abduction force.

Case report

A 20-year-old male, presented to the emergency department after a motor vehicle collision. He sustained a supination-abduction injury in a dorsiflexed foot and developed pain, deformity and swelling in the right foot. The forefoot was depressed and supinated in relation to the hindfoot with mild contusion and skin necrosis over the talonavicular prominence. An abnormal prominence was noted dorsally and medially at the naviculocuneiform joint. (Figures 1A and B). Distal pulses, toe movements and neurological examination were normal. There were no associated injuries in the body. The patient had no medical illness or neuropathies. Radiographs of the foot and ankle showed complete dislocation between the naviculo-cuneiform and calcaneocuboid joints with disruption of the calcaneo-navicular articulation. (Figures 2A and B). This pattern of injury has not been included in any classifications  available in literature.

Figure 1 showing the deformities-step at the naviculocuneiform  junction, forefoot supinated in relation to hindfoot. Pressure necrosis is seen over the navicular site.

Figure 2 Anteroposterior and Oblique views of right foot and ankle showing dislocation of the naviculocuneiform and calcaneocuboid joints (white arrow). Chip fracture of the navicular (black arrow), the site of attachment of calcaneonavicular ligament.

Under general anaesthesia, closed reductions were attempted with the knee flexed and the ankle in 15 degree plantar flexion. The deformity was initially exaggerated and reduction attempted by traction and manipulation opposite to the deforming forces. However, incongruent reduction required an open reduction through Ollier’s approach. The dorsal midtarsal ligament, lateral and plantar cuboideonavicular ligaments were found to be ruptured. Congruent stable reduction was achieved and secured with two 2mm Kirschner wires (K-wires) stabilizing the calcaneocuboid joint and two k wires fixating the medial two cuneiforms and the navicular under image intensifier control (Figures 3A and B). The ruptured ligaments were meticulously repaired. Additional immobilisation by below knee cast and non weight bearing was maintained for 6 weeks. With the removal of the K-wires, physiotherapy, partial weight bearing, medial arch support and controlled ankle motion boot were instituted. The patient had full weight bearing and a plantigrade foot at his 4 month follow-up. The patient had a mild restriction of subtalar motion and restriction of dorsiflexion by 5 degrees. He had no clinical or radiological signs of instability or arthritis and foot function index of 94% at 14 months (Figures 4A and B).

Figure 3 AP and oblique views of the foot and ankle. The navicular, the three cuneiforms and calcaneocuboid joints are concentrically reduced and fixed with K-wires.

Figure 4 Anteroposterior and oblique views of foot and ankle at 14 months follow-up showing normal alignment of arches and no arthritis.

Discussion

Closed midfoot dislocations are not uncommon presentations in level 1 or 2 trauma centers [1]. Apart from the common complex dislocations of Lisfranc and Chopart, isolated and swivel-type fractures and dislocations involving the medial column (talus, navicular and cuneiforms) and lateral column (calcaneus and cuboid) have rarely been reported [2-4]. However, the midfoot dislocations involving the separation of naviculocuneiform and calcaneocuboid joints are rare pattern of injuries infrequently reported in the literature (Table 1).

  Report Patient details Mode of injury Pattern Treatment Follow up Outcomes
1 Q. Choudry et al in 2007 [6]. 34/ male Fall of motorized palate over foot Naviculo- cuneiform subluxation and calcaneocuboid dislocation Closed reduction and immobilization for 6 weeks 15 weeks Good
2 y. chen et al in 2012 [7]. 64/ male Run over by car cuboid, medial and intermediate cuneiform fractures with naviculo-cuneiform and calcaneocuboid dislocation Open reduction and internal fixation of fractures 6 months Good
3 y. chen et al in 2012 [7]. 59/female Car accident left navicular, medial cuneiform and calcaneal fractures with calcaneal–cuboid, navicular–cuneiform and first tarsometatarsal joint dislocations Open reduction and internal fixation 3 months Chronic pain due to calcaneo cuboid instability
4 Our patient 20/male Fall from bike Isolated calcaneal–cuboid, navicular–cuneiform dislocation Open reduction and stabilization 14 months Good

Table 1 Review of reported naviculocuneiform and calcaneocuboid disruptions.

Main and Jowett had extensively studied the mechanisms of midtarsal injuries and proposed the various deforming forces causing the midtarsal fractures and dislocations [5] (Table 2).

Deforming forces Spectrum of midfoot injuries
1 Medial Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular).
2 Longitudinal In plantar flexed foot- navicular fractures.

In dorsiflexed foot- talus fractures, dorsal navicular dislocations.

3 Lateral Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular or naviculocuneiform with intact calcaneo-cuboid).
4 Plantar Fracture-sprains, fracture- subluxations or dislocations (chopart), plantar swivel dislocations.
5 Crush Fractures of mid tarsals.

Table 2 Mechanism of midfoot injuries [5].

Our case presents an unusual and complex pattern of injury in which plantar-abduction force at the midfoot caused the injury path through naviculocuneiform joint and calcaneocuboid joints causing complete dislocation of the three cuneiforms and cuboid articulations. This extends the spectrum of injury pattern caused by abduction deforming forces.

Obtaining concentric and stable reduction is of paramount importance to restore the biomechanics of the foot and prevent debilitating arthritis [8]. The management and prognosis of such complex midtarsal injuries in the literature have not been elaborated, except for a few case reports favoring open reduction and internal fixation [9]. In our case, the patient had good outcomes treated by open reduction and Kirschner wire fixation.

Conclusion

We report this case of traumatic closed dislocation of naviculocuneiform and calcaneocuboid joints following supination abduction deforming forces. Such injuries require further reporting to understand the spectrum of midfoot injuries. Congruent and stable fixation is of paramount importance to maintain proper biomechanics of foot.

References

  1. Hanlon DP. Leg, ankle, and foot injuries: Emerg Med Clin North Am 2010; 28(4):885-905.
  2. Davis CA, Lubowitz J, Thordarson DB. Midtarsal Fracture-Subluxation; Case Report and Review of the Literature: Clin Orthop Relat Res 1993; 292: 264-268.
  3. Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries?: J Bone Joint Surg [Br] 1999; 81:881-885.
  4. Kollmansberger A, De Boer P. Isolated calcaneocuboid dislocation: a brief report: JBJS [Br] 1970; 71:323-325.
  5. Main BJ, Jowett RL. Injuries of the midtarsal joint: JBJS [Br] 1975; 57:89–97.
  6. Choudry Q, Akhtar S, Kumar R. Calcaneocuboid and naviculocuneiform dislocation: An unusual pattern of injury: J Foot Ankle Surg 2007;13:48–50.
  7. Cheng Y, Yang H, Sun Z, Ni L, Zhang H. A Rare Midfoot Injury Pattern: Navicular–Cuneiform and Calcaneal– Cuboid Fracture–Dislocation: J Int Med Res 2012; 40(2):824-31.
  8. Richter M, Wippermann B, Krettek C, Schratt HE, Huefner T, Thermann H: Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001; 22:392–8.
  9. Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C: Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int 2004; 25:340–8.

Ankle arthrodesis as a salvage procedure: A case of secondary ankle arthritis using Charnley’s compression device

by Narayana B.S. Gowda, D Ortho, DNB Ortho, MNAMS, Mohan J. Kumar, MS Ortho

The Foot and Ankle Online Journal 5 (2): 1

Ankle arthrodesis is commonly considered to be the standard operative treatment for end stage ankle arthritis. The purpose of this study was to perform a clinical and radiographic review to determine functional outcome for a group of patients in whom an ankle arthrodesis had been performed using Charnley’s compression device. A functional assessment of fifteen patients after ankle arthrodesis for post traumatic arthritis was carried out by means of an extensive clinical evaluation after an average follow up of 2 years and 8 months.

Key words: Ankle arthrodesis, ankle arthritis, Charnley’s compression device, secondary arthritis ankle.

Accepted: January, 2012
Published: February, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0502.0001


Ankle arthrodesis is considered by many to be the standard operative treatment for end stage ankle arthritis. [1] A patient with ankle arthritis and deformity can experience severe pain and functional disability. Treatment options include the use of walking aids, orthotic devices, intra-articular steroids, open rather than arthroscopic debridement, periarticular osteotomy, and arthroplasty, all of which have provided inconsistent relief. Ankle arthrodesis has been accepted by many as yielding good long term clinical results. [2]

Since 1879, when Albert first described arthrodesis of the ankle [8], more than thirty different techniques have been described. The open technique with compression and internal fixation is still widely used for ankle arthrodesis with major deformity. [9] Ankle arthrodesis is an alternative for cases with intact subtalar joint. [10] This study presents intermediate term follow up functional outcome of patients with ankle arthrodesis performed using Charnley’s compression device.

Materials and methods

We reviewed fifteen patients, 10 males and 5 females, who had undergone ankle arthrodesis between January 2006 to December 2009 at the People’s Education Society (PES) Medical College and Research Center, Kuppam, Andhra Pradesh (AP), India (6 cases of post traumatic AVN talus (Fig. 1), 4 cases malunited bimalleolar fracture, 3 cases of distal tibial plafond fractures, 2 cases of medial malleoli non-union). All the fifteen patients who had secondary ankle arthritis have undergone open ankle fusion with anterolateral approach (Fig. 2) in supine position under tourniquet control and spinal anaesthesia.

Figure 1  Preoperative radiograph right ankle showing arthritic changes secondary to non union talar neck fracture.

Figure 2  Intraoperative photo showing anterolateral approach to ankle.

Compression was achieved using Charnley’s compression device and a calcaneotibial Steinman pin was applied to maintain the alignment and to increase the stability of fixation (Figs. 3 and 4). Suction drain was removed after 48 hours and the patient was made ambulant with non weight on operated site. All the patients were evaluated clinically and radiologically at 6 weeks and tibiocalcaneal Steinman pin was removed and the patients were allowed to bear weight as tolerated. All the fixators were removed after 12 weeks once the arthrodesis site was united radiologically. We had 3 cases of cellulitis of ankle and foot which was treated successfully with antibiotics, and 5 cases of superficial pin tract infection which were healed completely after fixator removal. None of these pin tract infections caused osteomyelitis. The mean age at the time of surgery was 40.52 years (24 – 56 years) and the time interval between the date of fusion and date of follow up examination ranged from 1 year to 5 years and 7 months, the average being 2 years 8 months.

Figure 3  Immediate post operative radiograph showing Charnley’s compression device.

Figure 4  Clinical photo showing Charnley’s compression device.

Clinical Evaluation

The clinical evaluation was based on a personal interview and physical examination. The patients were questioned as to their pain during daily activities such as running or walking on the level ground and going up and down the hills and stairs. A complete orthopaedic examination evaluated stance, gait, limb length discrepancy, circumference, range of motion of the knees, ankles, and subtalar joints; neurovascular status muscle strength and presence or absence of tenderness and swelling. Special attention was directed to the position of the fused ankle and the motion of the subtalar and mid tarsal joints. Any valgus or varus deformities of the heel and the presence of the callosities were also determined. The contralateral extremity was used as a control. Ankle anterior posterior and lateral radiographs were taken to assess the fusion and position of the arthrodesis (Fig. 5).

Figure 5   Two year follow up radiographs shows solid union at the arthrodesis site.

To quantitate the results of the clinical examination the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used. The main emphasis of this system was on pain and the functional activities. A normal person would score 100 points. Because of lack of ankle motion, the maximum score that the patient with an ankle fusion could have was 92, since they could not earn the 8 points given for the full range of motion.

A score of 80 to 92 was considered an excellent result: 70 to 79, a good result; 60 to 69, a fair result; and score less than 60 was considered a poor result.

Results

All patients studied had a solidly fused ankle and had no complications related to the surgery (Fig 6). They were all improved as a result of ankle fusion and returned to their pre injury activities. Wearing shoes with appropriate heels, all the patients could walk on level ground without support. All the patients stated that they could walk up and down the stairs without much difficulty. Limb length discrepancies were insignificant (0.5 to 1.5 cm) except in one patient who had 2.5 cm secondarily due to distal tibial plafond fracture. The radiographs showed that 6 cases showed some evidence of degenerative changes in the subtalar joints which did not correlate with the symptoms.

Figure 6  Two year follow up clinical photo of right ankle arthrodesis showing very litte difference compared to left normal side.

Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that eleven of the 15 had excellent results; two good; and two fair results. All of them could walk with relatively good velocity and with a consistently rhythmic gait.

Discussion

The patients with solid ankle fusion in this study functioned very well during the activities of normal daily living. All of them could walk on the level ground without pain. The fusion had permitted them to return to their former occupations and recreational activities. On this basis all the patients could be classified as having very satisfactory results.

Based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, these patients had appreciable limitations when walking barefoot but only mild to moderate limitations when wearing proper footwear. Patients were assessed not only under normal conditions but also under stressful conditions such as walking long distances, climbing up and down the stairs, and running. Six of the 15 could not run. Three had some minor discomfort after walking long distance.

When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [9] As a fused ankle provides a painless ankle joint with limited functional disability, ankle arthrodesis is still the treatment of choice for most disabling ankle arthritis. [10]

Charnley’s compression devise is still a simple, cost effective and excellent external fixator which can be used easily by every orthopaedic surgeon. After removal of the fixator, there is no indication for additional surgery to remove the implant compared to internal fixation. There are no hardware problems as all the hardware was removed. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis using Charnley’s compression device, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis. [11] Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction. [12-13] In studies ranging in size from 12 to 101 patients, rates of successful primary ankle fusion of 80% to 100% have been reported earlier. [14-18] However an average follow up time of 2 years and 8 months is relatively short to comment on the future secondary osteoarthritic changes in the subtalar and mid foot joints.

To be considered as an alternative preferable to arthrodesis, a total ankle replacement should give better results than those presented here, without other disadvantages. Patients with rheumatoid arthritis and involvement of ankle may not meet the criteria for an ankle arthrodesis may be because they have involvement not only of the ankle but also of the small joints of the foot, so that these joints cannot compensate for the fused ankle. Therefore, patients with rheumatoid arthritis may be better candidates for the total ankle replacement. [19]

Conclusion

Subjectively and objectively, the patients with ankle fusion function quite well in activities of daily living provided that, they have enough compensatory motion in the Chopart’s and Lisfranc joints of the foot, the other ankle has a normal range of motion, they wear footwear with appropriate height. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function; however, it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of ipsilateral hindfoot arthritis. Charnley’s compression device can still be considered as the fixator of choice compared to other modalities available with respect to cost, simplicity and good outcome.

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Address correspondence to: Asst Professor, Dept of Orthopaedics, PES Medical College, Kuppam, Chittore dist, Andra Pradesh, India, 517425. Email: drnarayan999@yahoo.com, Mob: 00 91 7702990696

1  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.
2  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.

© The Foot and Ankle Online Journal, 2012