Tag Archives: arthrodesis

Intramedullary rodding of a toe – hammertoe correction using an implantable intramedullary fusion device – a case report and review

by Christopher R. Hood JR, DPM, AACFAS1, Jason R. Miller, DPM, FACFAS2pdflrg

The Foot and Ankle Online Journal 9 (4): 1

Development of a hammertoe is a commonly encountered problem by the foot and ankle surgeon. In long-standing deformity, the pathologic toe becomes fixed with patient complaints of pain, corns, and calluses and, in the immunocompromised patient, ulceration with potential infection and amputation. A common correction of the deformity is through lesser toe interphalanageal arthrodesis, commonly performed at the proximal joint. There are numerous techniques and new devices on the market to help assist in holding position until fusion is achieved.  The author demonstrates a case report utilizing a fixation device that has characteristics similar to that of an intramedullary rod. Additionally, a retrospective, observational study involving 35 toes that have undergone an arthrodesis procedure of the proximal interphalangeal joint using an intramedullary fusion device to stabilize the fusion site is reviewed. This device imparts its stability in a manner similar to that of intramedullary rods in long bone fixation.

Keywords: ArrowLokTM, arthrodesis, digit(al), fusion, hammertoe, implantable device, intramedullary, surgery, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0001

1 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Malvern, PA
2 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Fellowship Director, Pennsylvania Intensive Lower Extremity Fellowship, and Residency Director, Phoenixville Hospital PMSR/RRA, Phoenixville, PA
* – Corresponding author: Christopher R. Hood JR, DPM, AACFAS, crhoodjr12@gmail.com


The hammertoe deformity is one of the most common presenting problems and surgical corrections encountered and performed by the foot and ankle surgeon [1,2]. Correction through lesser interphalangeal (proximal interphalangeal joint, PIPJ, or distal interphalangeal joint, DIPJ) resection and fusion was first described by Soule in 1910 [1]. Since then many modifications have been made to the procedure from various methods of bone preparation at the fusion site to extramedullary (EM) Kirschner wires (KW) and intramedullary (IM) fusion devices (IMFD) to stabilize the fusion site until osseous healing has been achieved [1, 3-6].

The choice to adapt fixation from EMKW to IMFD buried inside the bone stemmed from the desire to improve surgical outcomes, namely decreasing surgical site infection (SSI) rates among other inherent problems with KW use [5]. Since their introduction onto the market, many of these new have held true in decreasing these complication rates, achieving similar outcomes regarding fusion rates, with the bonus of higher patient satisfaction and a decreased (almost eliminated) infection rate [2, 7-10].

Here we present an example of an IMFD, different in construct than others on the market, which has not yet been reported on. This device gives another option to the surgeon when it comes time for digital fusion procedures with the added versatility of various lengths when multiple digital joints need to be fused simultaneously. The construct of this device, unlike others, garners its strength and stability from its length, purchasing the subchondral bone plate and acting in a manner similar to an intramedullary rod used in other orthopaedic fixations scenarios.

Methods

Case Report

Our patient, a 49 year-old female, presented with a chief complaint of a right second toe deformity. Conservative measures of strapping, padding, and shoe modifications were attempted, but ultimately failed. She elected to proceed with arthrodesis of the digit. She was followed at post-op weeks 2, 4, and 8. At week 8, osseous bridging was noted across the osteotomy site (Figure 1). The patient had no complaints and was discharged. She returned to the office 2 years later for a different complaint and x-rays revealed fusion across the PIPJ with no loss in hardware fixation (Figure 2).

fig1a fig1b

Figure 1 Case report patient at (left) 2 weeks and (right) 8 weeks post-operation. Note fusion on medial side of arthrodesis site at 8 weeks.

fig2

Figure 2 Case report patient seen 2 years later. Complete fusion with no loss of fixation.

 

Surgical Technique

A #15 blade is used to make an incision across the PIPJ of the digit. This is dissected down to the deep capsule taking care to create a surgical plane between the superficial and deep fascial layers. Retraction is utilized to protect neurovascular structures located around the digit. A transverse tenotomy of the long extensor is performed just proximal to the PIPJ and soft tissues are freed up from the proximal phalanx head and middle phalanx base. Cartilage resection is performed with a sagittal saw at the head of the proximal phalanx and base of the middle phalanx.

Implantation of the IMFD is performed per the devices surgical technique guide. First, the IM canals of the proximal and middle phalanx are reamed with the supplied 1.6mm diameter reaming device down to but not through the subchondral plate into the adjacent joint. This position is checked on fluoroscopy and length is measured off of the wire, summing the proximal and middle phalanx measurements and choosing the sized implant available. Next the proximal phalanx is broached with the supplied 2.7mm broaching device. The depth of the broach is noted per the ruler on the device (7-10mm depth). The appropriate implant is positioned at the corresponding proximal phalanx reaming depth and placed within the proximal phalanx IM canal. The digit is then grasped and manipulated to place the distal end of the implant into IM canal of the middle phalanx. Once inserted, the implant can be released and the bones are manually compressed across the resection point. Closure consists of re-approximation of the extensor tendon and capsule around the fusion site for extra-medullary stability, and layered closure of the superficial fascia and skin.

Patient Audit

A CPT code audit of 28285 (correction hammertoe, eg. Interphalangeal fusion, partial, or total phalangectomy) from March 1, 2011, to July 15, 2015, was performed. Over that time period, the resulting search yielded 60 patients who had 89 digital surgeries. Patients that had arthroplasty, arthrodesis not performed with the studied device, the studied device plus KW, or isolated DIPJ arthrodesis were excluded. Ultimately, 35 toes in 23 patients had isolated PIPJ fusions using this technique.

Results

The case patient was seen at post-operation weeks 2, 4, and 8. Signs of fusion were noted at week 4 and complete fusion was noted at week 8 radiographically. No loss of fixation was noted at any point. Patient satisfaction was high at discharge.

The CPT audit identified 35 toes that underwent PIPJ arthrodesis using the studied device. Average follow-up was 110 days. There was zero (0%) cases of hardware failure noted. In a single instance (2.8%), the device appeared to have rotated 90 degrees on its long axis, but fixation was still maintained. Two toes (5.7%) were misaligned with  slight medial angulation of the digit. There were zero occurrences of either a superficial or deep incisional infection as defined by the CDC [11]. No patient required revision surgery or a return to the operating room for a complication secondary to the index digital arthrodesis procedure.

Discussion

One of the biggest problems with arthrodesis of the PIPJ can be attributed to the use of EMKW for temporary stabilization across the fusion site until osseous union is achieved. The use of KW for fixation was first described by Taylor in 1940 [1]. Since that time, surgeons have battled against the complications of this technique such as pin-tract infections, digital edema, delayed or non-union of the arthrodesis site due to lack of compression, rotational instability, bent or broken wires, and patient dissatisfaction and apprehension due to the protruding wire and its impending removal [2,10]. External wire exposure infection rates range from 0-18% [1,5,12]. Studies have reported 40% of the wire infections were related to external factors through irritation at the skin-pin interface secondary to trauma and water-contamination [5]. Because of this, Creighton et al (1995) first presented a new technique of the single buried KW in digital fusion [5]. In more recent times, various IMFDs have been manufactured to give the surgeon options of fixation other than the aging gold standard KW. Canales et al (2014) in a recent paper noted 68 IMFDs on the market as of February 1, 2014 [6]. Normal incidence of surgical site infection after foot and ankle surgery has been reported between 1% and 5.3% [13, 14]. Creighton et al (1955) reported an infection rate of 3.5% with his buried KW technique while more recent fusion products have reported similar results ranging from 0%-5% [2,5,7,10]. Our results were similar with a 0% superficial or deep infection rate for the 35 toes at average patient follow-up of 110 days.  No patient at any point or length of follow-up presented for care of digital infection.

One such product for IM digital fusion is the Arrow-LokTM Hybrid implant (Arrowhead Medical Device Technologies, LLC., Collierville, TN) and is the specific implant used by the senior author and reviewed in this article. The implant is made of one solid piece of ASTM F-138 stainless steel, has a core diameter of 1.5mm (0.059”) with a proximal 3-dimensional (3-D) barbed arrow-shaped head 3.0mm by 3.5mm or 2.5mm and distal 3-D arrow-shaped head 3.0mm by 3.5mm. It comes in variable lengths ranging between 13mm and 50mm and in 0° and 10° plantar bend angles [15-17] (Figure 3). There is no special handling or pre-operative storage restriction placing a handling time limitation on implementation [17]. Its use in various clinical situations (PIPJ and DIPJ arthrodesis) as well as surgical tips and tricks have been published on, but to the authors best knowledge no literature exists on loss of correction and infection rates [15,18].

fig3

Figure 3 Intramedullary fusion device comes in straight (top) or 10° angulation (bottom). Key regions include (A)overall length, 13-50-mm; (B) distal tip diameter, 3.5-mm; (C) proximal tip diameter, 2.5-mm or 3.5mm; (D) length of proximal angle segment, variable 6-9-mm; (E) length of proximal angle segment, variable 10-26-mm.

 

The theory of construct of the ArrowLokTM is similar to that of an intramedullary rod (IMR) in fracture care (Figure 4). One of the biggest benefits of the ArrowLokTM device is due to the various available lengths ranging from 13mm to 50mm, the largest identifiable span on the market. Both transfer loads across a break in long bones, whether it be a fusion (ArrowLokTM) or fracture (IMR) site [19]. This IM position is closer to the anatomic axis of the bone and aids to resist bending while the circular round construct resists loads equally in all planes. Mechanical load testing at a quarter of a million cycles at up to 89N showed no signs of wear or fatigue of the ArrowLokTM  or bone [16]. Furthermore, in instances where both PIPJ and DIPJ fusion is needed, one longer device can be used versus two separate devices to be squeezed into a tight space [15]. This results in a location of potential stress riser in the middle phalanx between the distal and proximal ends of the two implants as described in the above situation. This is important when a common results regarding digital fusion (either implanted devices and percutaneous k-wires), the bulk of the non-osseous fusions are made up of fibrous unions which rarely impact the outcome of the surgery and are still considered a surgical success [7,8]. When osseous fusion is not achieved and weaker fibrous tissue fills the fusion interface, much of the strength of the fusion lies in the inherent strength of the implant device.

fig4a fig4ab fig4c

Figure 4 Like an IM rod (left), the ArrowLokTM device (right) garners its strength through its length spanning the osteotomy site to transfer loads and end arrow tips acting as a locking screw, preventing rotation, shortening and gapping, all reasons for failure of fixation.

 

figure-5

Figure 5 DIPJ arthrodesis with the ArrowLokTM device.

The 3-D arrow-ends of the ArrowLokTM act similar to proximal and distal locking screws in IMRs. This secures the device and prevents rotation, compression, shortening, or gapping, resulting in loss of fixation. Compared to a standard 1.6mm  (0.0062”) EMKW, the ArrowLokTM has comparable resistance to bending, increased resistance to pull-out (21x more resistant), and increased resistance to rotational forces (12x more resistant) [16]. These problems are inherent to EMKW use due to the design lacking IM compressive purchase and inability to prevent rotation, leading to potential non-solid fusion and mal- or non-union.

IMRs bending rigidity is based off of diameter and in solid, circular nails, is proportional to nail diameter to the third power [20]. Diameter also affects nail fit with a well fitting nail, reducing movement between the nail and bone, friction between the two maintaining reduction [20]. Reaming with the initial KW and broach help increase this contact relationship. With a 1.5mm core diameter, the ArrowLokTM is a tight fit within the phalangeal canal and increases bending rigidity and construct strength. The long, solid, one-piece design differs from others on the market in not having regions of thinner diameter metal and having two pieces that snap together at the junction of the fusion site – both which lead to sites of potential breakdown [9]. One study demonstrated a 20.7% rate in fracture at internal fixation site using Smart Toe® (Stryker Osteosythesis, Mahwah, NJ) versus 7.1% in 0.062-inch buried IMKW use [9].

Conclusion

The recent literature has demonstrated that utilization of these newer devices like the ArrowLokTM for correction of the hammertoe deformity provide a safe method with low complication rates similar to other products on the market.8 Furthermore, with the decrease and almost elimination of infection rates, despite the higher cost of the implant compared to a KW, the potential for infection complications and the associated cost is avoided. In our retrospective case review, ArrowLokTM showed a lack of hardware failure, zero infection rate, and high patient satisfaction. Due to its available lengths, IMR type construct, and ability to cross two fusion sites at once, this device offers another option for the surgeon in digital fusion.

Conflict of Interest

Dr. Jason R. Miller is a consultant for Arrowhead Medical. Arrowhead Medical Device Technologies had no knowledge or influence in study design, protocol, or data collection related to this report.

References

  1. Zelen CM, Young NJ. Digital arthrodesis. Clin Podiatr Med Surg. 2013;30(3):271-282. doi:10.1016/j.cpm.2013.04.006.
  2. Angirasa AK, Barrett MJ, Silvester D. SmartToe® implant compared with kirschner wire fixation for hammer digit corrective surgery: a review of 28 patients. J Foot Ankle Surg. 2012;51(6):711-713. doi:10.1053/j.jfas.2012.06.013.
  3. Lamm BM, Ribeiro CE, Vlahovic TC, Bauer GR, Hillstrom HJ. Peg-in-hole, end-to-end, and v arthrodesis. A comparison of digital stabilization in fresh cadaveric specimens. J Am Podiatr Med Assoc. 2001;91(2):63-67.
  4. Miller JM, Blacklidge DK, Ferdowsian V, Collman DR. Chevron arthrodesis of the interphalangeal joint for hammertoe correction. J Foot Ankle Surg. 2010;49(2):194-196. doi:10.1053/j.jfas.2009.09.002.
  5. Creighton RE, Blustein SM. Buried kirschner wire fixation in digital fusion. J Foot Ankle Surg. 1995;34(6):567-570; discussion 595. doi:10.1016/S1067-2516(09)80080-X.
  6. Canales MB, Razzante MC, Ehredt DJ, Clougherty CO. A simple method of intramedullary fixation for proximal interphalangeal arthrodesis. J Foot Ankle Surg. 2014;53(6):1-8. doi:10.1053/j.jfas.2014.03.017.
  7. Basile A, Albo F, Via AG. Intramedullary fixation system for the treatment of hammertoe deformity. J Foot Ankle Surg. 2015:1-7. doi:10.1053/j.jfas.2015.04.004.
  8. Catena F, Doty JF, Jastifer J, Coughlin MJ, Stevens F. Prospective study of hammertoe correction with an intramedullary implant. Foot Ankle Int. 2014;35(4):319-325. doi:10.1177/1071100713519780.
  9. Scholl A, McCarty J, Scholl D, Mar A. Smart toe® implant versus buried kirschner wire for proximal interphalangeal joint arthrodesis: A comparative study. J Foot Ankle Surg. 2013;52(5):580-583. doi:10.1053/j.jfas.2013.02.007.
  10. Scott RT, Hyer F. The protoe intramedullary hammertoe device: an alternative to kirschner wires. Foot Ankle Spec. 2013;6 (3)(June):2013-2015. doi:10.1177/1938640013487891.
  11. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):247-278. doi:10.1016/S0196-6553(99)70088-X.
  12. Kramer WC, Parman M, Marks RM. Hammertoe correction with k-wire fixation. Foot Ankle Int. 2015;36(5):494-502. doi:10.1177/1071100714568013.
  13. Feilmeier M, Dayton P, Sedberry S, Reimer R a. Incidence of surgical site infection in the foot and ankle with early exposure and showering of surgical sites: a prospective observation. J Foot Ankle Surg. 2014;53(2):173-175. doi:10.1053/j.jfas.2013.12.021.
  14. Saxena A, Fournier M, Cooper J, Spurgeon L. Rate of surgical site infection following the implementation of an antibiotic prophylaxis protocol for foot and ankle surgery. J Am Soc Podiatr Surg. 2014;(2):1-6.
  15. Brown BC, Cohen RK, Miller JR, Roman SR. Correcting hammertoe deformities utilizing an intramedullary device: case reports. Pod Inst.:51-60. http://www.podiatryinstitute.com/pdfs/Update_2013/2013-11.pdf. Accessed July 7, 2015.
  16. Arrowhead medical device technologies, LLC. 2011. http://arrowheaddevices.com/. Accessed July 7, 2015.
  17. Moon JL, Kihm CA, Perez DA, Dowling LB, Alder DC. Digital arthrodesis: current fixation techniques. Clin Podiatr Med Surg. 2011;28(4):769-783. doi:10.1016/j.cpm.2011.07.003.
  18. Roman SR. Surgical tips and tricks when correcting hammertoe deformities utilizing an intramedullary device for proximal interphalangeal fusion. Pod Inst.:59-62. http://www.podiatryinstitute.com/pdfs/Update_2012/2012_13.pdf. Accessed July 11, 2015.
  19. Eveleigh RJ. A review of biomechanical studies of intramedullary nails. Med Eng Phys. 1995;17(5):323-331. doi:10.1016/1350-4533(95)97311-C.
  20. Bong MR, Kummer FJ, Koval KJ, Egol K a. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97-106.

Implant arthroplasty versus arthrodesis for end stage hallux rigidus

by Anita Patel DPM1, Steven F Boc DPM FACFAS FACFAO2pdflrg

The Foot and Ankle Online Journal 7 (3): 1

End stage arthritis of the first metatarsophalangeal joint (MTPJ) is a debilitating condition that affects thousands of patients yearly. The treatments for it has been well known and studied for many years, however, controversy still remains with the different surgical options available. Arthrodesis has always been considered the mainstream treatment for advanced hallux rigidus, but with newer technologies and development of more functional implants, implant arthroplasty has become more popular and may someday surpass arthrodesis. The purpose of this paper is to review the two procedures and provide a literature-based comparison of the overall outcomes. Three retrospective studies with variable methods were reviewed and used to compare the two procedures and their results. Utilizing this data, it was concluded that arthrodesis produces overall superior results with better patient satisfaction and fewer complications, but has lower functionality as it does not restore the first MTPJ motion.

Key words: Hallux rigidus, arthrodesis, implant arthroplasty.

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0001

Address correspondence to: Anita Patel, DPM PGY-3
e-mail: anitap1084@gmail.com

1 Hahnemann University Hospital. Podiatric Medicine and Surgery/Reconstructive Rearfoot and Ankle Surgery
2 Director, Podiatric Medicine and Surgery/ Reconstructive Rearfoot and Ankle Surgery
Assistant Professor, Department of Surgery, Drexel University College of Medicine


End stage arthritis of the first metatarsophalangeal joint is a painful condition that results in significant limitation of motion of the joint. The condition has been well documented and studied over the years, however, surgical treatment still remains controversial. There are numerous surgical options which can be categorized into joint destructive and joint sparing procedures. Our main focus is to compare arthrodesis and implant arthroplasty for the treatment of end stage hallux rigidus.

Etiology

There are two main causes of hallux rigidus; congenital or adult-acquired. The congenital form has an onset during the teenage years caused by an underlying structural deformity such as an abnormally long hallux proximal phalanx or a long first metatarsal. The adult acquired form typically affects patients in their 40’s or 50’s due to high impact activities such as running or dancing. Abnormal biomechanics of the foot contribute to hallux rigidus which includes excessive pronation, hypermobile first ray, or metatarsal primus elevatus. Hallux rigidus is most commonly seen bilaterally, however, it can be seen unilaterally in cases when trauma is the cause of the pathology.  Other causes include neuromuscular imbalance, metabolic disorders, or post-surgical complications.

Clinical Presentation

Initially, the patient will present with a painful and stiff big toe joint specifically with weight-bearing forces or increased during activity. Activities that require excessive extension of the first MTPJ will exacerbate the symptoms [3]. They will complain of pain at the first MTPJ when wearing high heeled shoes. Patients may complain of pain with certain shoes due to soft tissue irritation from rubbing of the shoe gear. In earlier stages of the arthritis, pain will mainly be present with palpation to the dorsal aspect of the first metatarsal head with a possible palpable dorsal exostosis on physical exam. As the condition progresses, pain will be present during passive end range of motion of the metatarsophalangeal joint. With severe arthritis, there will be crepitus and pain during midrange motion of the joint. Gait alteration or compensatory changes may also cause lateral metatarsalgia [3]. Other common clinical findings include plantar hyperkeratotic lesions specifically at the plantar aspect of the hallux IPJ.

Classification

Today, the most widely used classification for hallux rigidus remains the Regnauld Classification as described below [1]:

  • Grade I: Mild limitation of dorsiflexion, mild dorsal spurring, pain, no sesamoid involvement, subchondral sclerosis, mild sesamoid enlargement.
  • Grade II: Broadening and flattening of the metatarsal head and base of the proximal phalanx, focal joint space narrowing, structural first ray elevatus, osteochondral defect, sesamoid hypertrophy.
  • Grade III: Worsening loss of joint space, near ankylosis, extensive osteophyte formation, osteochondral defects, extensive sesamoid hypertrophy, with or without joint mice.

Treatment for hallux rigidus can be divided into 2 groups: joint sparing versus joint destructive procedures. Joint sparing procedures include cheilectomy, first metatarsal osteotomy, and phalangeal osteotomy.

fig1

Figure 1 Radiographic evaluation of hallux rigidus as described by Regnauld. Images A/B corresponds with Grade I/II Regnauld. Images C/D corresponds with Grade III. Images E/F corresponds with Grade IV.

Surgical Treatment

Joint destructive procedures include excisional arthroplasty, implant arthroplasty, and arthrodesis. The procedure chosen is determined by the underlying deformity or the stage of hallux rigidus. In the earlier stages, cheilectomy or a decompression osteotomy of the first metatarsal is sufficient to relieve patient symptoms. However, the patient should be made aware that hallux rigidus is a progressive disorder and further surgical intervention in the future may be necessary. For the later stages of hallux rigidus, implant arthroplasty and arthrodesis are the most viable available options. Prior to any procedure, every surgeon must take into consideration each patient’s biomechanical factors, lifestyle, age, activity level, as well as their overall short-term or long-term expectations to the surgery [2]. Surgeons must also consider their own past outcomes as well as experience and comfort level with the types of procedures proposed [2].

Implant arthroplasty

Implant arthroplasty for the first MTPJ was first introduced in the 1950’s, however, it became more mainstream in the early 1970’s when Dow Cornings’ Swanson-Silastic hemi- implant gained widespread use and acceptance [4]. Within a few years of its use, however, various complications resulted from the implant such as reactive synovitis, fractures of the material, fibrous hyperplasia, and lymphadenitis which discredited these implant [4]. In the late 1970’s to early 1980’s, a variety of new designs created by Swanson, LaPorta, Lawrence, Sgarlato, and Hetal aimed to eliminate these complications by creating new hinged, non-articulating silicone implants with the addition of grommets [4]. These implants were later referred to as second generation first MTPJ implants. The 1990’s brought about different materials such as metallic hemi-implants (unipolar) or total joint implants (bipolar) which reduced the complications from the traditional silicone implants and are still used today.

These newer implants are referred to as third generation first MTPJ implants [5]. The development of these third-generation implants was a result of advancements in technologies and an improvement in the properties of silicone elastomers. [4]. Lawrence et al published a study in March 2013 which discusses the success of these new third-generation implants in 54 patients with 70 implants having an average follow up period of 66.4 months. Patients had an average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score of 88.2 and an average VAS score of 8.5 with 10 being the highest [4].  Very little data is published in the long term success for some of the latest designs, but technology continues to evolve with new advancements in foot and ankle orthopedic biologics being made every day.  Although implants have been around since the 1950’s, they are still evolving and changing, and therefore considered investigational in the minds of some surgeons.

Arthrodesis

Arthrodesis remains the gold standard surgical treatment for end stage 1st MTPJ arthritis with predicable outcomes and patient satisfaction. The procedure was first described in 1984 for the treatment of hallux valgus. Although  joint functionality is decreased since the motion is completely eliminated, the procedure provides stability through the medial column for a plantigrade foot during ambulation and a stable lever arm for propulsion [3]. Therefore, this procedure is often indicated for patients with an active lifestyle allowing them to return to their daily recreational activities without painful motion at the joint [1].

The main focus for a successful procedure and better overall outcome is not so much the technique used but rather the position of the fusion. The sagittal plane position is determined by the normal declination of the first metatarsal relative to the floor and transverse plane position is based relative to the lesser toes [3]. The hallux should be positioned in 10⁰ of dorsiflexion relative to the weightbearing surface and 15 to 20⁰ of abduction ensuring that the hallux does not impinge against the second toe [6]. In addition, the frontal plane and rotational correction should be maintained in a neutral position making sure the toenail faces straight upward [6]. Fixation is based on surgeon preference but most commonly used with the greatest success are dorsal plates or crossed cannulated screws. Non-union rates for arthrodesis range from 0-23% with union rates ranging from 91-100% [1].

Data

Multiple studies on arthrodesis and implant arthroplasty have been performed with sufficient long term follow-up comparing the two procedures. We reviewed three recent articles describing results from both procedures in attempts to compare outcomes of 1st MTPJ arthrodesis and implant arthroplasty. One study published in 2012 by Kim et al looked at 158 patients (105 female and 53 male). The patients had undergone one of three procedures: arthrodesis, hemi-implant or resectional arthroplasty. The patients were followed for an average of 159 weeks. Function, alignment and subjective assessment of pain were evaluated and their outcomes determined were successful procedure versus need for further intervention. Out of the 158 patients, 51 underwent arthrodesis, 52 hemi-implants and 55 resectional arthroplasty. There were three revisional surgeries performed, two with bone graft and one without.

In the arthrodesis group, complications included non-union, malunion, metatarsalgia and continued first MTPJ pain. Complications in the hemi-implant category included radiolucency around the implant, bony overgrowth into the joint, migration into the joint, dorsal drift of the hallux, cystic changes to the implant, metatarsalgia, elevation of the first ray, subsidence of the implant and continued first MTPJ pain. Two revisional surgeries were performed for this category with removal of implant and resectional arthroplasty. Complications of the arthroplasty group included floating hallux, metatarsalgia, sesamoiditis and remodeling of the first metatarsal head. There were no revisional surgeries required for this group. No statistical significant difference was found when comparing the procedures for function, alignment and subjective pain with an average follow up of 3 years.
A second study published by Raikin et al, in 2008 performed 21 hemi-arthroplasties and 27 arthrodesis in 46 patients. The patients were followed for an average of 79 months. The patient satisfaction rates were quantified in four categories: excellent, good, fair and poor. The outcomes for the hemiarthroplasty were excellent or good for 12 cases, fair in two cases and poor or failed in seven.  The mean pains score level was 2.4 out of 10. There were five hemiarthroplasties that failed, four were revised into arthrodesis and one into revisional hemiarthroplasty. The fusion rate was 100% for the 27 arthrodesis and no revisional surgery was required. The patients were followed for a mean of 30 months and the outcomes for the arthrodesis group was twenty-two excellent or good, four fair, and one poor. The mean pain score level was 0.7 out of 10.

The most recent study conducted by Erdil et al, published in 2013 reviewed 38 patients who had a total joint replacement, hemiarthroplasty or arthrodesis and were followed for at least two years. Out of the 38 cases, 12 were total joint replacement (group A), 14 were hemiarthroplasties (Group B) and 12 were arthrodesis (Group C). Complications of the procedures included one superficial soft tissue infection (Group A), One non-displaced first metatarsal fracture due to non-compliance (Group A), metatarsalgia (Two in group A, Two in group B and Three in group C) and delayed union. There were no major complications that required revisional surgical intervention and were resolved with conservative treatment. Functional outcomes were evaluated using American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal interphalangeal  (AOFAS-HMI) scale and Visual analog scale (VAS). With regards to AOFAS-HMI score there was no significant difference between groups A and B. Group C had a significantly lower AOFAS-HMI score which was expected due to the lack of range of motion.  With regards to the VAS score there was also no significance between groups A and B. The VAS score was also decreased in group C.

Discussion

First metatarsophalangeal joint implant arthroplasty versus arthrodesis in hallux rigidus is a controversial topic and most often depends on each individual case presentation. The studies mentioned above cover multiple methods to quantify each procedure. The first study focused on function, alignment and subjective pain. The second looked at patient satisfaction, and the third study looked at orthopaedic functionality and scoring post surgically. This variety allows us to best analyze the outcomes of each procedure.

The first study by Kim et al. indicated similar long term overall patient satisfaction with both arthrodesis and hemi-implant. The arthrodesis had the least amount of complications and revisional surgical intervention needed but this did not affect the final results as there was no statistical significance in the patient subjective scores. In the study by Raikin et al. where patient satisfaction and pain level were evaluated, arthrodesis supersedes hemiarthroplasty. There were fewer complications with arthrodesis as seen in the other two studies. The study by Erdil et al. also revealed that fewer complications were seen in the arthrodesis group, although the biomechanical functionality is decreased. The total joint and hemiarthroplasties were also successful procedures in this study so they suggested that arthrodesis be considered a salvage procedure if functionality needs to be preserved.

In conclusion, arthrodesis in cases of advanced hallux rigidus is the most successful and reliable procedure when every criteria is taken into consideration. Besides low functionality and maintaining the integrity of the joint, it provides fewer overall complications, lower revisional rates, and higher patient satisfaction. Nonetheless, hemi-arthroplasty and total joint replacement are also viable options that need to be considered in every case, specifically for patients that are less active and wish to maintain their first MTPJ motion.

References

  1. Peace RA, Hamilton GA. End-stage hallux rigidus: cheilectomy, implant, or arthrodesis? Clin Podiatr Med Surg. 2012;29 (3): 341-53. doi:10.1016/j.cpm.2012.04.002Pubmed citation
  2. Perler AD, Nwosu V, Christie D et-al. End-stage osteoarthritis of the great toe/hallux rigidus: a review of the alternatives to arthrodesis: implant versus osteotomies and arthroplasty techniques. Clin Podiatr Med Surg. 2013;30 (3): 351-95. doi:10.1016/j.cpm.2013.04.011Pubmed citation
  3. Vanore JV, Christensen JC, Kravitz SR et-al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: Hallux rigidus. J Foot Ankle Surg. 42 (3): 124-36. doi:10.1053/jfas.2003.50037Pubmed citation
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  5. Kim PJ, Hatch D, DiDominico LA et-al. A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint implant, and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus. J Foot Ankle Surg. 51 (1): 50-6. doi:10.1053/j.jfas.2011.08.009Pubmed citation
  6. Raikin SM, Ahmad J. Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. Surgical technique. J Bone Joint Surg Am. 2008;90 Suppl 2 Pt 2 : 171-80. doi:10.2106/JBJS.H.00368Pubmed citation
  7. Erdil M, Elmadağ NM, Polat G et-al. Comparison of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in the treatment of advanced hallux rigidus. J Foot Ankle Surg. 52 (5): 588-93. doi:10.1053/j.jfas.2013.03.014Pubmed citation

Diabetic Limb Salvage in the Septic Ankle: Case Studies of Arthrodesis using the Ilizarov Methodology

by Sutpal Singh, DPM. FACFAS, Albert Kim, DPM2, Timothy Dailey, DPM,3
Long Truong, DPM4, Maria Mejia, DPM5

The Foot and Ankle Online Journal 4 (10): 1

Diabetic patients usually have multiple comorbidities resulting in higher complication rates after ankle fractures. In many cases, the patient, through diabetic complications of peripheral neuropathy, may mistakenly ambulate resulting in dislocation or hardware failure if only internal fixation is utilized. Also, impaired wound healing, infection, non-union, mal-union and development of Charcot foot and ankle arthropathy may ensue. This article will present several cases in which open reduction and internal fixation in diabetic ankle fractures failed which then lead to osteomyelitis. This infection with the presence of diabetic neuropathy results in an increased risk for loss of limb. These cases were ultimately salvaged with septic ankle arthrodesis using the Ilizarov Method.

Key words: Diabetic ankle fracture, osteomyelitis, Limb Salvage, Septic Ankle Arthrodesis, Ilizarov Methodology.

Accepted: September, 2011
Published: October, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0410.0001


Treating diabetic ankle fractures is a very complex task and many times lead to multiple complications. The majority of diabetic patients have comorbidities such as peripheral vascular disease, osteoporosis with poor bone stock that can lead to poor healing potential and complications. A few of the complications encountered are ulcerations and wound dehiscence.

It has been well documented in the literature that diabetic patients with ankle fractures who underwent open reduction and internal fixation developed complications of wound infections, below the knee amputations, Charcot arthropathy, malunions, wound necrosis requiring plastic surgery, and deep sepsis. [1,2] When complications are encountered, often, salvage is managed by ankle arthrodesis. Our treatment protocol is to fuse the ankle using the Ilizarov Method.

When performing an ankle fusion there are a variety of different open surgical approaches to exposing the ankle for fusion as well as arthroscopic ankle fusions.

The open surgical approaches are more commonly used than the arthroscopic option. Of the many different open approaches the more common ones are the medial transmalleolar, lateral transmalleolar, anterior, and posterior approaches. A discussion on the various types of ankle arthodesis will be presented followed by the Ilizarov Method in septic ankle joint arthrodesis.

The medial approach is performed by using an osteotome or oscillating saw to create a transverse medial malleolar osteotomy at the level of the distal tibial articular surface. Next, the medial malleolus is reflected distally on the deltoid hinge, exposing the ankle joint. A power saw is used to resect the tibial plafond perpendicular to long axis of the tibia. Temporary fixation with Steinmann pins can be utilized to maintain the plantigrade position. [3]

The medial approach provides better visualization of the tibiotalar articulation [3,4,5], the surgical exposure obtained is more subcutaneous and gives better access for preparation of the articular surfaces. Neurovascular complications are also decreased by this approach. Finally, the medial approach allows for visualization in placement of a posterior screw which has to be placed blindly when using the lateral approach. [3]

In the lateral approach of ankle arthrodesis, an osteotomy is performed approximately 2 cm proximal to the level of the ankle joint. In this approach care must be taken not to sever the sural nerve. [3,4,5,6] The lateral approach is preferred over an anterior approach in cases with moderate to severe deformity. Therefore in cases where a severe deformity of the ankle joint is not present, an anterior approach is indicated.

In regards with the anterior approach, care is taken to avoid any damage to the terminal branches of the superficial peroneal nerve, the intermediate and the medial dorsal cutaneous nerves due to the course of these nerves under the incision site. [7] The fixation indicated for the anterior approach is composed of at least 2 screws inserted at 30 degrees with respect to the long axis of the tibia. These screws should cross proximal to the fusion site to maximize stability. In certain cases a third screw can be placed to improve sagittal plane stability. [7] A major advantage of the anterior approach is that the osteotomy of the lateral and medial malleoli is avoided. The other approach which is used but is not discussed in the literature as frequently is the posterior approach.

For the posterior approach, Hanson et al., concluded that using a posterior approach with a 95 degree blade plate is effective in large patients with a mild to moderate hindfoot deformity. [8]

In addition to the open techniques, an ankle fusion can be performed with arthroscopy. In the arthroscopic technique various abraders, curettes and other arthroscopic instrument are used to remove the cartilage from the joint surfaces using a camera and small portals through the ankle joint. After removing the cartilage the ankle is reduced into proper position and finally fixated internally with two transmalleolar screws. With arthroscopic fusion it has been shown that the average time to fusion is significantly less, whereas this produces a faster recovery period. The shorter time to fusion is likely a result of the minimal soft tissue stripping that is performed during the procedure. [4,9]

Regardless of whether an open or an arthroscopic fusion is performed, the position of the foot for fusion is the same. In the literature the correct position for fusion is valgus of the posterior foot varying from 0 to 5 degrees with an external rotation of 5 to 10 degrees, sloping slightly posterior talus relative to tibia and neutral flexion position. [1,2,4,5,6] In order to prevent malposition, the foot should be compared to the rest of the leg and the contralateral limb before fusing it.

Once the proper position is found the next concern is fixation. There are various methods of fixation such as compression with an external fixator, internal fixation using plates and screws, intramedullary fixation, and arthroscopic ankle fusion. [1,2]

In difficult cases of ankle arthrodesis and limb salvage the preferred fixation methods are Intramedullary (IM) nail and external fixation. [1,4,5,10,11] Obtaining a solid fusion can be challenging in compromised bony interfaces, and standard techniques of tibiotalar fixation such as crossed lag screws are often inadequate. An advantage that the Ilizarov technique has over IM nailing and the other internal fixation options is it can be used in cases of infection. [3,4] The Ilizarov method also spares the subtalar joint.

Post operative care is comparably the same in almost all the surgical procedures with non weightbearing in a posterior splint followed with a cast for at least 6 weeks, removal of casts depends on healing noted and once healing progresses the patient is placed in a CAM boot. [4,5]

For patients that were treated using the Ilizarov Method, early weight bearing is permitted. When comparing open arthrodesis with arthroscopic fusions, the arthroscopic patients were hospitalized for an average of 1.6 (1-4 day range) days whereas the open group was hospitalized for average of 3.4 days (1-6 day range). [12]

As discussed earlier, complications include malposition, neurovascular complications. Nonunions and amputations can also occur as a complication depending on the surgical approach. Initially they can be treated with prolonged periods of immobilization and minimal weightbearing. In addition, an external bone stimulator can be used. [11] If prolonged immobilization does not help then bone grafting and external fixation are recommended. [1,4,5,11,13,14,15] In cases in which non unions are painful and they are not able to be resolved with repeated surgical options an amputation is many times the only option. [11,13] Also superficial infection of the surgical incision or the pin sites in external fixation methods has been reported as occurring in 40% to 50% in which local wound care is usually sufficient enough. In cases of deeper infections where osteomyelitis is involved the rate of amputation is as high as 50% which happens more so in the case of fusions performed in an existing septic process. [11] This article will present failed open reduction internal fixation (ORIF) in diabetic patients that were salvaged in case of septic ankle fusion using the Ilizarov method in which both medial and lateral incisions were used.

Case Report

Case # 1

The first case is that of a 70 year-old diabetic, neuropathic, cardiomyopathic, liver transplant patient on dialysis. He had a bimalleolar ankle fracture stabilized with internal fixation. (Figs. 1 and 2) He was referred to our service after undergoing multiple surgeries including wound care and skin graft. He had a large ulcer on the medial and lateral ankle on the left lower extremity. His fibular plate was severely bent and the tibia was exposed on the medial side due to noncompliance and ambulation. An external fixator with several tibial screws and one calcaneal transfixation screw was used to temporarily hold the deformity. This was done prior to being transferred to our service. Cultures revealed Methicillin-resistant Staphylococcus aureus (MRSA) with osteomyelitis at the ankle and the patient was on intravenous (IV) antibiotics. After consulting with infectious disease, internal medicine, cardiology and vascular surgery, the patient was given clearance for limb salvage. The patient had only two choices at the time: (1) below the knee amputation or (2) limb salvage. He chose the latter. The treatment plan included wound care, debridement of the ulcer and removal of the necrotic and infected bone and soft tissue. This was performed 1 week prior to surgery. The patient then underwent a septic ankle arthrodesis using the Ilizarov frame as well as rotational flap to close the ulcer. (Figs. 3-5)

Figure 1  Pre-operative radiograph of failed internal fixation in case #1.

Figure 2  Clinical photograph of the exposed distal tibia and calcaneus in case # 1.

Figure 3   Application of the external fixator, closure of the calcaneal ulcer with a Graft Jacket, and rotational flap to cover the tibial wound at the ankle in case #1.

Figure 4  Showing lateral approach in case #1 with the external fixator.  The anteroposterior radiograph (A),  Lateral radiograph (B) and lateral radiograph after removal of wires from the subtalar joint (C) in case # 1.   All radiographs showing complete consolidation of the tibial talar joint.

Figure 5   Clinical photographs 4 months after surgery showing limb salvage with all wound healed with solid bone consolidation in case #1.

Case # 2

This patient is a 380lb, diabetic, neuropathic, cardiomyopathic patient with a malunion. (Fig. 6) He had an unstable ankle fracture at the fibula with complete rupture of the deltoid ligament. (Fig. 7A and 7B) He was stabilized with open reduction and internal fixation. He ambulated several days after the surgery resulting in malunion and widening of the tibial talar joint. He was seen by our service several months after the initial surgery. He had a large open wound down to the medial tibia with purulent drainage coming from the ankle joint. He presented with osteomyelitis of the ankle. Again, he was cleared for limb salvage.

Figure 6   Clinical photographs of open distal tibia with osteomyelitis in case # 2. (Close-up in inset)

 

Figure 7A and 7B   Anteroposterior  (A)  and lateral (B) radiographic views of a failed internal fixation resulting in a diabetic septic ankle.  (Case # 2)

The treatment plan again included wound care, debridement of the ulcer and removal of the necrotic and infected tissue. One week later, he had a septic ankle arthrodesis and subtalar joint arthrodesis using the Ilizarov frame as well as a rotational flap to close the ulcer at the ankle. (Figs. 8A, 8B, 9A, 9B, 10A, 10B, 11 and 12)

 

Figure 8A and 8B   Clinical photographs of septic ankle arthrodesis using the Ilizarov frame.  Medial view: Note closure of the ankle using a rotational flap (A) and anterior view.  This is the second day after surgery for case #2.

 

Figure 9A and 9B   Lateral (A) and anteroposterior (B) radiographic views 2 days after surgery showing ankle and subtalar joint arthrodesis compressed with an Ilizarov circular external fixator in case # 2.

 

Figure 10A and 10B  Medial (A) and lateral (B) views 3 months after tibial-talar-calcaneal fusion with the Ilizarov frame.  The skin on the medial side has completely healed with the rotational flap in case # 2.

Figure 11   The ulcer has completely healed and the Ilizarov external fixator has been removed in case #2.  The foot is very stable and completely fused at the tibial-talar-calcaneal joint.

  

Figures 12  Post operative radiographs showing complete arthrodesis of the tibial-talar-calcaneal joint and stabilization using percutaneous 6.5 mm fusion Synthes bolts after the Ilizarov frame was removed in case #2.

Case # 3

This patient is a 70 year old diabetic, neuropathic who suffered a severe ankle and foot fracture. She is a chronic tobacco abuser smoking 2 packs per day. She had an ORIF of the right ankle and foot. The patient developed a postoperative infection. She was referred to our service for limb salvage. On initial presentation the patient had a tremendous amount of putrid smelling brown pus coming from the medial ankle. (Fig. 13, 14A and 14B) Culture and sensitivity revealed MRSA. She was on IV Vancomycin. She was taken to the OR and an incision and drainage was performed. The necrotic bone and tissue as well as the hardware at the ankle were removed. The wound was then packed with iodoform and she had daily wound care. One week later, when the infection was controlled, she had a septic ankle arthrodesis using the Ilizarov Method. (Figs. 15, 16A, 16B, 17A, 17B)

Figure 13  Clinical photograph showing the diabetic open septic ankle joint.  The toes are to the upper right and the knee is to the upper left.  (Case #3)

 

Figure 14A and 14B   Severe foot and ankle deformity with sepsis at the tibial talar joint and failed hardware. (A) Note the probe in the medial ankle. (B) Putrid smelling brown pus was noted coming from the medial ankle and tracking across the ankle to the lateral mid leg area in  case #3.

Figure 15  Lateral radiographic view of the septic ankle arthrodesis using the Ilizarov frame several weeks after surgery.  There is good alignment of the tibial talar complex.  There is placement of antibiotic beads in the ankle/lower leg area.  (Case #3)

 

Figure 16A and 16B   There is a valgus rotation of the calcaneus relative to the long axis of the tibia.  (A) The forefoot was in neutral position without any varus or valgus. (B) All incisions have healed.  (Case # 3)

 

Figure 17A and 17B  After removal of the external fixator, insertion of internal splinting with Synthes metaphyseal plate, and calcaneal osteotomy with medial translation.  This shows good alignment of the lower extremity.  The tibial talar joint is completely fused. (A)  Lower leg, ankle and hind foot are in good alignment after the medial calcaneal slide osteotomy. (B) (Case #3)

Surgical Technique and Result

Case # 1: Three tibial rings, each 180 mm with several smooth 1.8 mm wires were applied to the proximal tibial segment. Also two half pins were also inserted and attached to the tibial rings. Then a foot plate was applied using the 1.8 mm wires. Note that the tibial rings and foot plate were not connected at this time. An incision was made on the lateral side. The hardware and the distal fibula were removed. On the medial side, the hardware and distal medial tibia were removed. The ulcer on the medial side was debrided and all necrotic tissue was removed. Then the tibial talar joint was resected until there was good apposition and bleeding. The wound was copiously irrigated with 3 liters of normal saline and bacitracin. The foot plate was manipulated to hold the tibial talar joint in good apposition with the second toe in line with the tibial tuberosity. There was no varus, valgus, dorsiflexion or plantar flexion noted. The tibial talar joint was in neutral position. The foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Several 0.062 Kirschner wires were inserted to hold the tibial talar joint. (Figs. 3 and 4)

Rods were then applied to the foot plate and tibial rings. Compression was applied in an axial direction. There was good alignment and good compression. Another incision was made above the ulcer and a full thickness rotational flap was performed to close the ulcer where the tibia was exposed. There were also two other ulcers noted which were created by the prior transfixation screw through the calcaneus. These ulcers were debrided to good bleeding tissue and then covered with Graft Jacket and sutured with 3-0 ProleneTM. The rest of the surgical sites were closed using 3-0 VicrylTM for deep tissue and 3-0 ProleneTM for the skin as well as skin staples.

The external fixation was left on for three months until consolidation was seen on radiograph. Then the external fixation was removed and the wires going into the subtalar joint was removed. A CROW boot was then dispensed to the patient to protect the limb. The patient then began ambulating with a walker. At six month and one year follow-up, the patient is still ambulating and without any recurrence. (Fig. 5)

Case # 2: Three 200 mm tibial rings were applied to the patient proximal to the open wound on the lower leg. Then 1.8 mm smooth wires were inserted and tensioned appropriately. Then 4 tibial half pins were inserted into the tibia and attached to the tibial rings.

Then a foot plate was applied to the foot with wires and tensioned appropriately. The tibial rings and the foot plate were not connected. Then an incision was made on the medial and lateral ankle. All the necrotic bone, tissue and the hardware were then removed. The tibia and the talus were then resected to good bleeding tissue and good apposition. The lateral incision was also extended to the subtalar joint and the subtalar joint was then denuded of cartilage. The large ulcer on the medial side was debrided and all necrotic tissue was removed. There was an even larger opening on the medial side after the debridement. The surgical site was irrigated with 3 liters of normal saline with bacitracin. The foot plate with the foot was then manipulated in a manner in which the tibia and second toe was in line. The tibial talar joint was in neutral position without varus or valgus. There was no varus, valgus, dorsiflexion or plantar flexion noted. The tibial talar joint was in neutral position. The foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Then several 0.062 Kirschner wires were inserted from the calcaneus, through the talus and then into the tibia.

Rods were then used to connect the foot plate to the tibial rings and this was then compressed to fuse the tibial-talar-calcaneal joint. Attention was then directed to the medial large ulcer. Another incision was made at the ulcer and a rotational flap was performed so as to close the ulcer. The surgical site was closed with 3-0 vicryl for the deep tissue, and 3-0 ProleneTM and skin staples for the skin.

The external fixator was left in place for three months until good consolidation was noted. The K wires were removed. Because he was morbidly obese, internal splinting with percutaneous 6.5 bolt screws from Synthes were inserted from plantar calcaneus to the tibia. He was also given custom AFO. (Figs. 8A,8B, 9A, 9B, 10A, 10B, 11 and 12) At six month and one year follow-up, the patient is still ambulating and without any recurrence.

Case # 3: The patient had severe abscess at the medial left ankle with the pus tracking laterally up the leg. (Fig. 13) An incision and drainage was performed on the medial and lateral ankle. The infected tissue, bone and hardware were all removed as well at the distal fibula. The surgical site was irrigated copiously with three liters of normal saline and bacitracin using a pulse lavage system. The surgical site was loosely approximated with 3-0 ProleneTM and skin staples. She then had wound care every day including the use of Betadine® soaked iodoform as well as irrigation with one liter of normal saline and bacitracin for 5 days. Once the infection was controlled, she was then taken back to the OR for a septic ankle arthrodesis.

The patient was taken back to the OR and three 180 mm tibial rings were applied to the left lower leg proximal to the infected area. (Fig. 15) The wires were tensioned appropriately and then 2 half pins were applied. Then a foot plate was applied and tensioned appropriately. The tibial talar joint was then resected and then placed in a neutral position without any varus or valgus. There was no varus, valgus, dorsiflexion or plantar flexion noted at the tibial talar joint. Also note that the foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Her tibial talar joint was in neutral position. This was then stabilized with several 0.062 K wires. The foot plate with the foot was then connected to the tibial rings with several rods. These were then tightened to compress the tibial talar joint. She did have a valgus tilt of the subtalar joint with the heel being laterally located. (Figs. 16A and 16B) Because of the complexity of the deformity, it was decided to perform a medial calcaneal slide osteotomy at a different time until there was complete consolidation of the tibial talar joint. Antibiotic beads of 1 gm of Vancomycin were made and inserted into the lower leg ankle area.

The external fixator was left in place for four months until good consolidation was noted. The K wires were removed. At this time, because of the severe deformity and possibility of recurrence and BKA, internal splinting with a 10-hole 3.5 mm metaphyseal plate and screws spanning the tibial-talar-calcaneal complex was performed. Also, a medial calcaneal slide osteotomy was also performed to have a more rectus foot and in better alignment of the leg and hindfoot. This was performed by making an incision on the lateral calcaneal area. The incision was deepened to the subcutaneous tissue and then to bone. A sagittal saw was used to perform the osteotomy and the calcaneus was translated medially approximately 2 cm and stabilized with several crossing K wires. (Figs. 17A and 17B)

Two months later, the wires in the calcaneus were removed and a custom Arizona brace was dispensed and she was able to ambulate with a walker.

After six months, she developed an ulcer on the plantar right foot. She had a Charcot foot prior to the severe infection on the left foot. This ulcerated after six months but with proper wound care, this ulcer completely healed. She was also dispensed another Arizona brace for the right lower extremity. At two year follow-up, she is doing well and has both of her legs and feet. (Figs. 18,19)

 

Figures 18  Two years after surgery, the radiographs show good alignment and complete arthrodesis of the tibial-talar-calcaneal bones.   The wires in the posterior calcaneus have all been removed in case #3.

Figure 19   Complete healing of the calcaneal osteotomy in anatomic good position after removal of the internal fixation wires in case #3.

Discussion

Multiple studies have noted that open reduction internal fixation in acute diabetic ankles fracture can be devastating. [16,17,18,19,20] Patients with complications associated with diabetes are at an increased risk for higher rates of in hospital mortality, in hospital post operative complications, length of stay and non-routine discharges. [19] Previous studies has shown mortality rate as high as 8.5% and deep infection of 17% associated with complications of diabetic ankle fracture. [18] Even after anatomical reduction with stable internal fixation, the diabetic neuropathic patients may experience complications such as breaking or bending the fibular plate, malunion, nonunion, and charcot arthropathy. After repeat ORIF of the ankle with stacked one-third tubular plates and several syndesmotic screws, failure can occur. It is noted in previous studies that diabetic neuropathic patients are 5 times more likely to need revision surgery when comparing to patient with uncomplicated diabetes. [20] Salvage by tibiotalocalcaneal fusion with intramedullary rod in this population group also failed due to non compliance. This can ultimately resulted in a below the knee amputation. [2,21] In revisions surgery, the fusion rate is noted to be lower than in primary arthrodesis. [22]

Thus, in our case reports, our protocol is to perform ORIF and then to stabilize the lower extremity with an Ilizarov frame. If the patient has peripheral vascular disease, the Ilizarov frame was applied with
very minimal to no internal fixation. If the patient is severely medically compromised, the surgery was performed under IV sedation using a popliteal block, common peroneal block at the neck of the fibula and saphenous nerve block at the level of the tibial tuberosity.

Several surgical techniques are currently accepted for performing primary ankle arthrodesis. These techniques include compression with an external fixator, internal fixation using plates and screws, intramedullary fixation, and arthroscopic ankle fusion. [1,22]

The Ilizarov technique offers several advantages that “traditional” fusion does not offer in patients with complex ankle pathology such as infection, limb-length discrepancy, mal-union, Charcot joints, talar osteonecrosis, and talar absence. [22] Internal fixation and arthroscopic techniques are not suitable methods for infection, bone loss, severe deformities, or failed procedures. [1] Post-operatively, the Ilizarov method allows for adjustments in mechanical control throughout the treatment period that is otherwise impossible with nails, screws, or plates. [1,22]

Potential limitations that can be associated with this technique include pin track problem, the cumbersome frame, and complexity associated with application of the frame. [22]

Pin track infections do occur but usually are managed locally with pin site care and oral antibiotics. However, the advantages outweigh these downfalls. These advantages prove even more invaluable when application is planned for revisions and complex situations. [1]

The Ilizarov technique provides stable fixation and allows application of primary and continuous forces along any axis and direction. [1,22] The dynamic axial fixation maintains bone contact without additional bone grafting and allows excellent bending, shearing, and torsional stability that allows early weightbearing. [1,22] Most patients are bearing partial weight immediately, therefore earlier compression is noted across the surgical site, enhancing fusion rate. [22]

Additionally, due to early ambulation, there is noted improvement in proprioception and reduction in complications such as deep vein thrombosis and deconditioning. [22]

The Ilizarov technique also enables correction in a single plane or in multiple planes. [1,2,22] A well aligned fusion ensures a near normal gait. It is recommended that fusion be position with valgus of the posterior foot varying from 0 to 5 degrees with an external rotation of 5 to 10 degrees, sloping slightly posterior and neutral flexion position. [1,2]

Ankle arthrodesis can be divided by approach as anterior, transmalleolar, or posterior or by method of fixation as external or internal. [1] However, when planning the proper procedure for the high risk diabetic patient, many techniques become less appropriate with frequent complications and difficult to achieve fusion site. In our case reports in this article, we performed septic ankle arthrodesis using the Ilizarov Method for limb salvage. All patients were told that a BKA was eminent. We were able to salvage the limb by the Ilizarov Methodology. It has been noted by Gabriel Ilizarov that osteomyelitis burns in the fury of osteogenesis. Osteogenesis occurs by compression and immobilization of bone using the Ilizarov Methodology. In the presence of infection of the tibiotalar joint, arthrodesis is a reasonable treatment option and in some cases may be the way to prevent amputation at a more proximal level. [2]

Conclusion

The previous cases of diabetic ankle fractures which were fixed with open reduction and internal fixation went on to septic ankle joints. Septic ankle joint is a difficult condition to treat with two viable options limb salvage ankle arthrodesis or below knee amputation. Patients must be aware that ankle arthrodesis may still end up in a BKA. Many different ankle arthrodesis surgical techniques exist with the salvage option.

Each surgeon has his or her preference as to their procedure of choice with each having their advantages and disadvantages. The author’s systematic approach to diabetic ankle fractures is to cast if they are non-displaced, and ORIF with an Ilizarov frame if ankle fracture is displaced. If they go on to a septic ankle joint then the area is debrided and internal hardware is removed and an Ilizarov method is used for ankle arthrodesis. In the authors experience the biggest complication with the Ilizarov frame is pin tract irritations and or infections but these are easily treated by removing the pin and placing a new one. The Ilizarov method is a good option in providing adequate compression and in allowing the patient to bear weight. It is important to follow these patients frequently to make sure the arthrodesis site is healing well and free of infections to prevent a BKA.

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19. Wukich D, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot & Ankle International 2011 32:120-30.
20. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot & Ankle International 2009 30:1042-1047.
21. Thordarson, D: Ankle fractures in diabetics. Techniques in Foot and Ankle Surgery. 2004 3: 192-197.
22. Eylon S, Porat S, Bor N, Leibner E. Outcome of Ilizarov ankle arthrodesis. Foot & Ankle International. 2007 28: 873-879.


Address correspondence to: Sutpal Singh, DPM. FACFAS, FAPWCA, Chief Ilizarov Surgical Instructor at Doctors Hospital, West Covina, California.

1  Chief Ilizarov Surgical Instructor at Doctors Hospital, West Covina, California. Private practice in Southern California.
 Resident, Doctors of Podiatric Medicine (R3),
 Resident, Doctors of Podiatric Medicine (R2),
4,5  Residents, Doctors of Podiatric Medicine (R1).
All residents : Doctors Hospital of West Covina (PM&S-36).

© The Foot and Ankle Online Journal, 2011

Giant Cell Tumor of Talus: A case report of late presentation with extensive involvement

by Mohan Kumar J.1 , Narayan Gowda2

The Foot and Ankle Online Journal 4 (1): 1

Giant cell tumor (GCT) of bone, or osteoclastoma, is classically described as a locally invasive tumor that occurs close to the joint of a mature bone. It is generally considered to be a benign tumor. In our rural setup, a substantial proportion of patients seek traditional means of treatment before medical consultation. A case of GCT in a 20 year-old boy which had led to extensive destruction of the talus is reported. In view of the extensive involvement, total talectomy along with tibio – calcaneal arthrodesis was performed. At 6 months of follow-up, the patient had a painless and well arthrodesed ankle. There was no evidence of recurrence at 18 months of follow-up.

Key words: GCT, osteoclastoma of the talus ,tibiocalcaneal ,arthrodesis.

Accepted: December, 2010
Published: January, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0401.0001


In the talus, giant cell tumor (GCT) of bone is an infrequent primary bone tumor that can present late with extensive involvement of soft tissue and articular surface changes often making the joint preservation difficult or impossible. [1] GCT account for approximately 5-8% of all primary bone tumors. [2,3,4] The authors report a GCT which had led to destruction of the entire talus in a 20 year-old boy. In view of the extensive involvement, total talectomy along with tibiocalcaneal arthrodesis was performed with the aim of achieving a stiff but painless joint.

Case presentation

A 20 year-old boy presented with chief complaints of insidious onset pain in the left ankle since the last two years, swelling in the left ankle since the last six months and inability to bear weight on right side since the last six months. The patient was treated elsewhere with intralesional steroid. There was no history of fever, loss of appetite, loss of weight, similar complaints in other joints or history of similar complaints in the past. The family, occupational, recreational and drug histories were not significant. The general physical and systemic examinations were within normal limits. On local examination, the attitude of the limb was neutral. There was a 5 × 4 cm swelling over medial and anterior aspect of left ankle joint. (Fig. 1)

Figure 1 Clinical photo of the left ankle.

There were no visible veins, sinus or discharge from the swelling. There was hypopigmentation and the swelling was tender. All movements at the ankle joint were painfully restricted. Serum biochemistry studies were within normal limits. Anterior posterior (AP) and lateral radiographs of the ankle showed a radiolucent lesion occupying the whole talus. (Fig. 2) The magnetic resonance scan (MRI) revealed an expansible soft tissue mass in the talus causing cortical destruction and extension into soft tissues. (Fig. 3) A fine needle aspiration of the mass was performed and a provisional diagnosis of GCT was rendered.

Figure2 Radiograph showing the lesion (left ankle).

Figure 3 Preoperative MRI showing GCT extensive involvement of the left ankle.

The condition, its prognosis and various treatment modalities were discussed with the patient and his family. Because of extensive involvement of talus, total talectomy with tibiocalcaneal arthrodesis was planned. The patient was a manual labourer and therefore opted for a stiff but painless joint. Total talectomy was performed through an anterolateral approach. (Fig. 4) Fusion was achieved by autologous iliac crest graft and stabilization with a Steinmann pin and Chamley’s clamp. (Fig. 5) The patient was advised non weight bearing on the affected limb for 8 weeks and mobilized in a short leg walking cast thereafter.

Figure 4 Intraoperative image showing the lesion.

Figure 5 Immediate post-operative radiograph showing complete talectomy and pan talar fusion using external fixator.

At 6 months of follow-up (Fig. 6), the patient had a smooth healed scar with a painless and well arthrodesed ankle and no evidence of recurrence. He had shortening of 2 cms which he managed with a shoe rise. There was no evidence of recurrence at 18 months of follow-up.

Figure 6 Clinical photo 6 months after surgery.

Discussion

GCT, also known as osteoclastoma, is a fairly common bone tumor accounting for 5% of all the primary bone tumors. It is a benign tumor with a tendency for local aggressiveness and high chances of recurrence. GCT is most commonly seen in the distal femur proximal tibia, distal radius and the proximal humerus in descending order of frequency. [5]

The foot is an unusual site of presentation and GCTs involving hand and foot bones appear to occur in a younger age group and tend to be multicentric. [6] The clinical picture is that of insidious onset pain, which in many cases may be mismanaged as ankle sprain. A history of preceding trivial trauma may be present. Other features are non specific. Radiologically; the tumor appears as an eccentric lytic lesion with cortical thinning and expansion. There is absence of reactive new bone formation. The tumor may erode the cortex and invade the joint. Pathological fracture may also be seen. [7] MRI scanning permits accurate delineation of the tumor extent and helps in deciding the line of management i.e. (curettage versus talectomy).

Many authors have reported satisfactory results with intralesional curettage and bone grafting. [8] However, curettage alone has a high rate of recurrence and adjuvants like Methylmethacrylate (bone cement), cryotherapy and phenol have been suggested.

Partial or total talectomy may be contemplated in cases where there is extensive involvement of the talus. Arthrodesis may or may not be done, but it is said that arthrodesis is essential after resection of all tarsal bones except calcaneum. [9]

Fresh frozen osteochondral allograft reconstruction has also been described for an aggressive GCT of talus but there is paucity of literature on this particular modality of treatment. [10] The trend is towards limb salvage and amputation is reserved for recurrences and only rarely done. In conclusion, in a case of GCT of talus presenting late with extensive involvement and in a manual labourer, total excision and tibiocalcaneal arthrodesis is an valuable treatment option.

References

1. Ng ES, Saw A, Sengupta S. Giant cell tumour of bone with late presentation: review of treatment and outcome Journal of Orthopaedic Surgery 2002: 10(2): 120–128.
2. Huvos AG Bone Tumours: Diagnosis, Treatment and Prognosis. 1979, 1st Edition, Saunders, Philadelphia p265.
3. Schajowicz F. Tumors and Tumor Like Lesions of Bone and Joints. New York, NY: Springer; 1981.p 205.
4. Dahlin DC. Bone Tumours: General Aspects and Data on 6221 cases. 1981, 3rd Edition. Charles C Thomas Publisher, Springfield p99.
5. Stoker DJ. Bone tumors (1): general characteristics benign lesions. In: Grainger RG, Allison DJ (Editors). Diagnostic radiology a textbook of medical imaging. 3rd Edition. New York: Churchill Livingston; 1997. p. 629–1660,
6. Wold LE, Swee RG. Giant cell tumor of the small bones of the hand and feet. Semin Diagn Pathol 1984, 1:173-184.
7. Carrasco CH, Murray JA. Giant cell tumours. Orthop Clin North Am 1989, 20: 395- 405.
8. Bapat MR, Narlawar RS, Pimple MK, Bhosale PB. Giant cell tumour of talar body. J Postgrad Med 2000, 46:110.
9. Dhillon MS, Singh B, Gill SS, Walker R, Nagi ON. Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature. Foot Ankle 1993, 14(5):265-272.
10. Schoenfeld AJ, Leeson MC, Grossman JP. Fresh-frozen osteochondral allograft reconstruction of a giant cell tumor of the talus. J Foot Ankle Surg 2007, 46(3):144-148.


Address correspondence to: Department of Orthopaedics PESIMSR. Kuppam AP India 517425

1 Assistant professor, Dept of Orthopaedics PESIMSR.
2 Assistant professor, Dept of Orthopaedics PESIMSR.

© The Foot and Ankle Online Journal, 2011

Primary Modified Blair Arthrodesis for Group-III Hawkins Fracture-Dislocation: A Series of Five Cases

by Arunangsu Bhattacharyya, MS(Ortho)1 , Dibyendu Biswas, MS(Ortho)2 , Rajat Ghosh,M.B.B.S. 3

The Foot and Ankle Online Journal 3 (10): 1

Background: Fracture of the neck of the talus with dislocation of talo-tibial joint and subtalar joint might be one of the worst injuries that can happen around the ankle joint. Almost all cases are complicated with avascular necrosis of the body of the talus and takes years to be revascularized even after prolonged non weight bearing. Different types of arthrodesis has been advocated by several authors. In the reported series, Blair fusion is the opted procedure because of several merits.
Methods and Material: Five patients with Hawkins Group III were selected in this series. (4 male, 1 female) One patient had compound fracture-dislocation. They were treated with Blair arthrodesis and followed up for more than two years with serial radiographs and assessment of tibiopedal movement.
Results: Three patients (60%) recovered with excellent result with range of Tibiopedal movement was 15 to 20 degrees and it was painless and one had good result (20%) with occasional pain and range of movement was 10 to 15 degrees. One patient had pain on walking and the outcome was graded as poor (20%) and range of movement was less than 10 degrees. Heel shape and heel height were maintained after surgery.
Conclusions: Blair fusion may be recommended as it is a relatively easy way out of a complex problem around the ankle. Remained tibiopedal movement helps the patient to walk more physiologically

Key words: Fracture talar neck, Hawkins fracture-dislocation, Dislocation of body, Primary Modified Blair fusion, arthrodesis.

Accepted: September, 2010
Published: October, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0310.0001


Fracture of the neck and the body of the talus is one of the most devastating injuries around the ankle. Fractures are very often complicated with dislocation of talo-navicular or subtalar or talo-tibial joint.

Fractures that create difficulty in management are fractures of the talar neck with or without dislocation; dislocations of the body of the talus; and fractures with loss of a segment of the body of the talus because those are commonly complicated with avascular necrosis of the talus. There are different opinions on suitable treatment of this type of injury. Talar neck fracture and talar body dislocation can occur due to forced dorsiflexion of the talus against the anterior edge of the tibia. Non-displaced fracture of the body of the talus, subtalar or talonavicular subluxation or dislocation can be treated with closed manipulation and plastering.

In 1939, Miller and Baker recommended subtalar or pantalar fusion for the fractures with poor reductions. [1] Triple or subtalar arthrodesis as treatment of improperly reduced fracture dislocation of talus was suggested by Schrock, et al.,. [2]

In 1943, Blair described a type of tibiotalar fusion in which the body of the talus was excised and a sliding cortical bone graft was positioned between the anterior aspects of the tibia and the head of the talus. [3]

In 1969, Detenbeck and Kelley recommended talectomy and tibiocalcaneal compression arthrodesis as the primary treatment for fracture-dislocation of the talus. They reported no significant functional disability after this procedure, but it has the disadvantages of widening the hind part of the foot and shortening the foot, both of which make shoe fitting difficult. [4]

In 1970, Hawkins proposed a very useful classification of talar neck fractures. In Group I, the vertical fracture of the neck must be undisplaced. In Group II, the fracture is displaced and the subtalar joint is subluxated or dislocated, and the ankle joint normal. In Group III, the fracture fragments are displaced and the body of the talus is dislocated from both the ankle and subtalar joints. [5] Incidence of avascular necrosis of body of talus is different in each type.

Group I undisplaced fractures of talar neck are usually not complicated with avascular necrosis. [5,6,7] Fractures of the neck associated with subtalar subluxation or dislocation had an incidence of avascular necrosis of 36 per cent in Kenwright and Taylor’s series. [7] Hawkins series acknowledged avascular necrosis in 42 per cent of his Group-II fracture-dislocations, but union of the fracture took place in all. [5] Incidence of avascular necrosis in Group III fracture-dislocation ranges from 75 [7] to 100 [8] per cent. According to Watson-Jones avascular necrosis is almost inevitable in fractures of the talar neck with dislocation of the body. So avascular necrosis following fracture of the neck of the talus is a very common incidence, hence, it is a challenging subject for the orthopaedic or podiatric surgeon.

Harry D. Morris and associates, in1971, did modify Blair method of tibio-talar fusion and added a cortical screw through the graft up to posterior cortex of the distal end of the tibia and a Steinmann pin through calcaneus into the Tibia to stabilize the Ankle. [9] The present paper reports five almost such operations with follow-up of two years. In this series part of the body of talus was not excised. It was positioned in between calcaneus and tibia with cancellous bone graft taken from bed of sliding cortical graft with the idea that inter positioned cortical and cancellous bone would make sound ankylosis of ankle with maintenance of heel height.

This reported series has shown the results of the treatment of five cases of fracture of talar neck with dislocation of body after primary Blair’s method of fusion modified by Morris, et al,. Cases were followed up for more than two years.

Subjects and Methods

In our series, five cases with fracture of the neck of the talus with talar body dislocation were included. It was of Group III according to Hawkins classification. Study was conducted from the year 2006 to 2010. (i.e. for four years) Out of five patients, four were male and one was female. Median age was approximately thirty years. (range 24 – 40 years) Right ankle was injured in four cases. Median follow-up was up to 28.6 months. (range 24 – 35 months) In one case, the fracture was of compound type. Initially wound was debrided and sensitive intravenous antibiotic continued for two weeks before final surgery. (i.e. tibio-talar fusion)

Primary Blair fusion modified after Morris, et al., was the preferred option in the reported series. Ethical committee permission was taken for this study.

In all cases, surgery was delayed routinely to provide time for swelling to subside. Absence or reduction of swelling helped to do thorough, meticulous dissection along the tissue planes.

Figures 1-3 shows the first example of a case of a modified Blair fusion in a group III – Hawkins fracture dislocation. Here, the dislocated part of the body of the talus was excised. The gap between calcaneus and tibia was filled with cancellous bone taken from lower tibia, anterior surface from the bed of sliding cortical graft and ipsilateral iliac crest. Remaining steps of the surgical procedure were almost same like those of Morris modification of Blair fusion i.e. one cortical screw was used to fix the sliding graft and thick K-wire of 2.5mm diameter was used instead of Steinmann pin.

Figure 1 Example 1 – Case 1 (see table 1): Fracture of the neck of the talus with dislocation of the body (i.e. Group -3, Hawkins fracture with no neurovascular deficit.)

Figure 2  Example 1 – Case 1:  Radiograph shows that the talar body was excised and Ankle fused with a 2.5mm K-wire and a 4.5 mm cortical screw, passed through a sliding tibial graft and up to posterior cortex of tibia. (Modified Blair fusion)

Figure 3 Example 1 –  Case 1:  The patient now stands on the floor with both feet on the ground and shape of left foot is well maintained after Modified Blair fusion.

The operation was performed by exposing the ankle through `universal incision’ to foot and ankle (i.e. antero-lateral approach.) Incision was started at the upper end from eight to ten centimeters above the ankle joint and extended distally and end at the base of the fourth metatarsal. Incision was made over the fascia and the superior and inferior extensor retinacula down to the periosteum of the tibia and the capsule of the ankle joint. This dissection usually divides the anterolateral malleolar and lateral tarsal arteries.

Cutaneous nerves were identified and protected. Extensor digitorum brevis muscle was detached from its origin and reflected distally. Extensor tendons, the dorsalis pedis artery and the deep peroneal nerve were retracted medially and the capsule was incised to expose the ankle.

With the joint widely exposed, dislocated talar body was excised with an osteotome or nibbled out and the head and neck was left undisturbed. The talonavicular joint and anterior and medial portions of the talocalcaneal joint were untouched. A sliding graft 2.0 by 6.0 centimeters was sliced from the distal anterior portion of the tibia with the help of a thin power saw. This graft was placed into a notch of approximately two centimeters deep made into the neck of the talus. The ankle was held in roughly 10 to 15 degrees of plantarflexion while the graft was fit into the neck of the talus. The graft was fixed with a cortical screw of 4.5mm diameter with lower tibia and a thick K-wire of 2.5mm diameter was inserted through the plantar aspect of the heel traversing the calcaneus and extending into the medullary canal of the tibia for 10 – 12 centimeters.

Cancellous graft was packed around the fusion site. Graft was harvested from bed of the sliding graft or ipsilateral iliac crest. Subjects have given informed consent, and that the study has been approved by an institutional review board. A below knee plaster slab was applied after surgery for better soft tissue healing. Cast was substituted after stitch removal and K-wires were routinely taken out after four weeks of surgery. (Figures 4, 5A, 5B, 6A and 6B) Non –weight bearing crutch walking was continued up to almost 12 weeks after surgery. They were followed up at monthly interval for one year.

Figure 4 Example 2 – Case 4 (see table 1):  Post operative photograph shows the Steinmann pin introduced from plantar surface of heel which is removed prior to cast application.

 

Figure 5A and 5B Example 2 – Case 4 (see table 1):  Post operative radiographs show advanced fusion and nice graft incorporation lateral (A) and anteroposterior (B) views.

 

Figure 6A and 6B Example 2 –  Case 4 (see table 1):  Post operative Photographs shows healed Antero-Lateral incision, anterior view (A) and lateral view (B), started   8 to 10 cm above the ankle and extended downwards over the joint and in the line of fourth metatarsal bone more distally over foot.

From second year onwards patients were followed up at every six months in Outpatient Department. The operated ankle was assessed with serial roentgenograms to look for progress of fusion with proper bony alignment and measurement of tibiopedal movement. Tibiopedal motion is defined as the curve of motion between maximum dorsiflexion and maximum plantarflexion of ankle and the angles were subtended by the long axis of the tibia and that of the foot in the lateral projection. The range of tibiopedal motion was measured with use of a goniometer between the axis of the tibia and the foot in positions of maximum dorsiflexion and plantarflexion.

In our study, results were considered excellent if the patient had completely asymptomatic foot and ankle and comfortable in Activities of Daily Life (ADL) and if tibiopedal movement ranged from 15 to 20 degrees. If there was occasional discomfort which caused no restriction in ADL and tibiopedal movement ranged from 10 to 15 degrees, then results were considered good. Poor result was with less than 10 degree tibiopedal movement and painful ankle to limit ADL.

Results

According to the above mentioned protocol all five patients were followed up and evaluated after surgery. Mean age of patients in this series was twenty nine years. Right sided ankles were more commonly affected here (4:1). Roughly 4 months was required for bony fusion to take place. (range 3 – 6months)
Three cases out of five were considered as with excellent outcome, two were with good outcome after follow up according to the mentioned criteria.

Tibiopedal movement was 15 to 20 degrees in three cases and 10 to 15 degrees in one case and lower than 10 degree in one case. Sound fusion took place in four cases. In one case fusion was not sound, so it was painful on walking. It was with poor outcome. Another case with good result had occasional discomfort in ankle though there was solid bony fusion. Patient who had compound Group- III fracture dislocation had poor outcome in follow up. It was possibly due to formation of fibrosis from infected tissues inside even after thorough primary wound clearance and formation of pseudoarthrosis at fusion site. But heel height and shape was maintained in all cases. Inversion and eversion was partially restricted in all patients.

Antero lateral incision easily and widely exposed the ankle without any neurovascular injury. It could be freely extended upwards or downwards to fulfill the requirement during surgery. In one case posterolateral exposure was also necessary for removal of posteriorly dislocated body of the talus in addition to standard anterolateral incision. Table 1 shows the details of all five cases of this series.

Table 1 This table compares basic descriptive information of five cases with a Hawkins Group III fracture–dislocation of neck of talus treated with Modified Blair arthrodesis. They were followed up for two to three years. Three out of five patients had an excellent result.

Discussion

Fracture of the neck of the talus, treated with Blair fusion or with its different modifications, has been published in few journals in different times. But it has not been discussed and published at many places as it deserves .In the reported series five cases of Hawkins Group III were operated with modified Blair’s fusion.

In 1943, Blair used a distal tibial sliding cortical graft without fixation in two patients with acute fracture of the neck of the talus. At the time of follow-up (minimum, four months), both fractures had united in follow-up (minimum, four months).3 Morris et al., in 1971 modified the procedure .They used a cortical screw up to posterior cortex of tibia to fix the sliding graft and a Steinmann pin introduced through planter surface of heel traversing calcaneus into the tibia by 10 to 12 centimeters. Four of their ten patients had a talar fracture with avascular necrosis, and six had an acute fracture. Seven had an excellent result and three, a good result.9 Later, Morris reported a series of four patients with a minimum two months follow-up after modified Blair procedure for the treatment of a fracture and osteonecrosis.10 Result was excellent in those two cases.

MD Dennis and HS Tullos, in 1980 ,performed a retrospective clinical and roentgenographic study on seven patients who underwent Blair tibiotalar arthrodesis with the average follow-up was 3.9 years. Results were good in five patients, fair in one, and poor in one. In two patients, pseudoarthrosis developed: painful in one and asymptomatic in one. [11]

In 1982, Lionberger, et al., described arthrodesis of the distal aspect of the tibia to the talar neck with use of a pediatric hip-compression screw. Five patients were treated and followed up for a mean of one year, one developed a delayed union. [12] Canale and Kelly reported a series of seventy-one fractures through the neck of the talus. Blair procedure was used for two fractures but both had poor result. [13]

In the reported series five cases were included. All five cases were categorized as Hawkins Group- III. (i.e. fracture of neck of the talus with dislocation of talo-tibial joint and subtalar joint, full displacement of the body of the talus from ankle) Fractures were treated with primary modified Blair arthrodesis because there was 75 to 100 percent chance of development of avascular necrosis of the body of the talus after this type of fracture-dislocation according to several reports.

Morris and associates, in 1971 advocated immediate excision of the extruded body for patients with comminuted fractures of the talar body as well as those with closed Group- III fracture-dislocation of talar neck since avascular necrosis occurs in over 90 per cent of these injuries. In this reported series, the modification was also after those of Morris. (i.e. one cortical screw and one thick k-wire were used)
In contrary to the modification presented by Morris, the body of the talus was partially excised in this study group with the hope that remained cortical bone with added cancellous bone from lower tibia would make sound fusion with maintenance of height of the heel. K-wire inserted through calcaneus into the tibia enhanced the stabilization of ankle construct for first four weeks. That helped the fusion process to take place initially.

Most of our patients had a successful clinical result with high rate of union, in spite of the complex nature of their problems. Three cases out of five (60%) were considered as excellent, one was with good (20%) and one (20%) was with poor outcome after follow up of almost two years. Tibiopedal movement was 15 to 20 degrees in three cases and 10 to 15 degrees in one and less than 10 degrees in one case. Fusion took place in all cases. Two cases had occasional discomfort in ankle though there was solid bony fusion. Heel height and shape was maintained in all cases.

In essence, a modified Blair arthrodesis may be opted for patients who have Hawkin’s Group III fracture- dislocation. It has the advantage over tibiocalcaneal arthrodesis of giving a normal-appearing foot, producing no shortening, and allowing motion to remain at the talonavicular and anterior subtalar joints thus helping the patients to walk with comfort.

Conclusion

Modified Blair fusion may be recommended for fracture of the neck of the talus with dislocation of talar body, as it is a relatively easy way out of a complex problem around the ankle. As avascular necrosis of talar body after Group III fracture- dislocation takes place in almost all cases, primary osteosynthesis has practically no role in management. Postoperative tibiopedal movement also helps the patient to walk more physiologically. Above all, heel height and shape is maintained after Blair fusion, so patients usually enjoy well fitted shoe.

References

1. Miller 0L, Baker LD. Fracture and fracture-dislocation of the astragalus. Southern Med J 1939 32: 125-136.
2. Schrock RD, Johnson HE, Waters CH, Jr. Fractures and fracture-dislocations of astragalus (talus). JBJS 1942 24A: 560-573.
3. Blair HC. Comminuted fractures and fracture dislocations of the body of the astragalus. Operative treatment. Am J Surg1943. 59: 37-47.
4. Detenbeck LC, Kelly PJ. Total dislocation of the talus. JBJS 1969 51A: 283-288.
5. Hawkins LG. Fractures of the neck of the talus. JBJS 1970 52A: 991-1002.
6. Colart WD. “Aviator’s Astragalus”. JBJS 1952 34B: 545-566.
7. Kenwright J, Taylor R0. Major injuries of the talus. JBJS 1970 52B: 36-48.
8. Pennal GF. Fractures of the talus. Clin Orthop1963 30: 53-63.
9. Morris HD, Hand WL, Dunn AW. The modified Blair fusion for fractures of the talus. JBJS 1971 53A: 1289-1297.
10. Morris HD. Aseptic necrosis of the talus following injury. Orthop Clin North America 1974 5: 177-189.
11. Dennis MD, Tullos HS. Blair tibiotalar arthrodesis for injuries to the talus. JBJS 1980 62A: 103-107.
12. Lionberger DR, Bishop JO, Tullos HS. The modified Blair fusion. Foot and Ankle 1982. 3: 60-62.
13. Canale ST, Kelly, FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. JBJS 1978 60A: 143-156.


Address correspondence to: Dr Arunangsu Bhattacharyya,MS(ORTHO)
A-8/4,Bidhan Abasan,Block-FB,Sector-3,Saltlake,Kolkata-700097.West
Bengal,India. Email: orthoarunangsu@yahoo.com

Assistant Professor. ,Dept. of Orthopaedics, Medical College,Kolkata.
Assistant Professor, Dept. Of Orthopaedics, North Bengal Medical College & Hospital,West Bengal.
Medical Officer. North Bengal Medical College & Hospital.

© The Foot and Ankle Online Journal, 2010

Immediate Ambulation after a First Metatarsophalangeal Joint Fusion using a Locking Plate: Technique and case reports

by Robert M Greenhagen, DPM1 , Shelly A Wipf, DPM1, Adam R Johnson, DPM2,
Patrick J Nelson, DPM3, Nicholas J Bevilacqua, DPM4

The Foot and Ankle Online Journal 3 (4): 2

Purpose: Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a predictable procedure to relieve pain and dysfunction of the first MTPJ. Many fixation techniques have been described. The authors present two cases in which a locking plate was successfully used for first MTPJ fusion. The patients began immediate weight-bearing post-operatively without a delay in union, hardware failure, or malalignment.
Methods: A retrospective chart and radiographic review of a 53 year-old male and a 59 year-old female was performed. Serial radiograph was taken to assess fusion at the arthrodesis site.
Procedures: Cartilage was resected from the head of the first metatarsal and base of the proximal phalanx preserving the curvature of the joint. The joint was placed in the desired position and interfragmental compression was obtained using a cannulated 4.0-millimeter partially threaded screw from proximal medial to distal lateral with all threads crossed the fusion site. A locking plate was then placed on the dorsal aspect of the joint and secured with locking screws proximal and distal.
Results: The patients began ambulating immediately post-operatively with a post-operative shoe. Both patients had successful fusion by 8 weeks with good alignment and intact fixation. Patients returned to regular shoe gear once trabeculation was noted.
Conclusion: These 2 case reports suggest excellent results and immediate ambulation with compression screws and locking plates. This clinical report shows promise in regards to early ambulation using locking plate fixation technique and further studies are encouraged.

Key words: Arthrodesis, first metatarsophalangeal joint, MTPJ fusion, locking plate.

Accepted: March, 2010
Published: April, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0304.0002


Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a predictable procedure to relieve pain and dysfunction of the first MTPJ. The indications for this common procedure include hallux rigidus, rheumatoid arthritis, revision of failed bunion surgery, implant arthroplasty, and Keller procedures, and deformities secondary to neuromuscular disease such as cerebral palsy and poliomyelitis. [1] Fixation techniques vary from crossed Kirschner wires [1], intramedullary Steinman pins [2], intramedullary screws [3-5], crossed lag screws [6], external fixation [7], and plate fixation with interfragmentary screw. [2-8]

Protocols for post-operative ambulation have varied throughout the literature, and there have been numerous reports of early weight-bearing with favorable union rates, albeit most of these studies reported patients ambulating in a rigid post-op shoe or short leg walking cast that eliminated the propulsive phase of gait.2,9-12 To our knowledge, there are currently no reported cases evaluating the use of locking plates for first MTPJ fusion. The purpose of this report is to examine results with immediate ambulation after first MTPJ with compression screws and locking plates.

Case Report 1

A 59 year-old female presented to the foot and ankle clinic with severe pain to the right first MTPJ. She had undergone an Austin bunionectomy previously, and now presented with severely limited and painful joint range of motion. Radiographs were consistent with asymmetric joint space narrowing and degenerative joint disease. (Fig. 1) The patient was informed of the risk, benefits and complications of both the procedure and the new post-operative protocol.

 

Figure 1  Pre-operative radiographs show severe joint space narrowing and sclerotic subchondral changes. (A)  Radiographs at seven weeks show full trabeculation and intact hardware. (B)

Figure 4  The cup portion of the reamer is used first to remove all cartilage from the metatarsal head. (A)

The phalanx is reamed with the cone reamer. By performing the metatarsal head first, more room is made for cumbersome cone reamer. (B) (Illustration by Patrick Nelson, DPM©) 

Informed consent was obtained and the patient underwent a first MTPJ arthrodesis with a compression screw and a four-hole locking plate. Seven weeks after surgery, the patient presented for follow-up in normal footwear with pain free ambulation. Radiographs revealed trabeculation across the fusion site, with good alignment and intact fixation. (Fig. 2)

Case Report 2

A 53 year-old male presented with localized severe pain to his right first MTPJ. The patient had minimal range of motion and radiographs showed significant degeneration and non-uniform narrowing of the joint space. (Fig 2A) The patient exhausted conservative care and desired surgical management. The patient was informed of the risk, benefits and complications of both the procedure and the new post-operative protocol. Informed consent was obtained and the patient underwent a first MTPJ arthrodesis with a compression screw and a four-hole locking plate. (Fig. 2B)

 

Figure 2  Pre-operative radiographs show severe hallux rigidus with diffuse joint space narrowing and flattening of the metatarsal head. (A) Postoperative week eight, osseous union is noted with no signs of hardware failure. (B)

Post-operatively, the patient was placed in a surgical shoe and instructed to ambulate as tolerated. Eight weeks after surgery, the patient presented in normal shoe gear and pain free ambulation. Radiographs showed trabeculation, excellent alignment and intact fixation.

Technique

A dorsal medial incision was made and layered dissection was continued down to the level of the joint. (Fig. 3) Cartilage was resected from the head of the first metatarsal and base of the proximal phalanx preserving the curvature of the joint using a cup and cone reamer. (Fig. 4) The joint was placed in the desired position (slight dorsiflexion and abduction) and interfragmental compression was obtained using a 4.0-millimeter partially threaded cannulated screw. The screw was placed from proximal medial to distal lateral being sure that all threads crossed the joint. (Fig. 5) The alignment of the joint and position of the screw was directly visualized using intra-operative fluoroscopy. The locking plate was placed on the dorsal aspect of the joint and secured with locking screws proximal and distal. (Fig. 6) The wound is closed in layers and a dressing is applied.

Figure 3 A dorsal medial approach is made which allows reaming of the proximal phalanx and first metatarsal head.

 

Figure 4  The cup portion of the reamer is used first to remove all cartilage from the metatarsal head. (A) The phalanx is reamed with the cone reamer. By performing the metatarsal head first, more room is made for cumbersome cone reamer. (B) (Illustration by Patrick Nelson, DPM©)

Figure 5 An interfragmentary screw can be placed from proximal medial to distal lateral. This provides both compression and fixation that does not interfere with the dorsal plate.  We recommend the use of a cannulated screw for simplicity. (Illustration by Patrick Nelson, DPM©)

Figure 6 Dorsal plating of the joint provides rigid fixation of the fusion site.

Patients are placed in a post-operative shoe and instructed to ambulate as tolerated. Patients are transitioned to normal footwear once clinical and radiographic signs of healing are appreciated.

Discussion

Many fixation techniques have been described for first MTPJ arthrodesis. [2-4,6-8,13] The ideal fixation technique for MTPJ arthrodesis should maintain stability and position of the fusion site while osseous union occurs.

A review of the literature favors interfragmentary screw fixation as the strongest construct. Neufeld and colleagues compared memory compression staples, cannulated screws, and a five-hole, one-third tubular plate contoured to fit the arthrodesis site in 21 matched fresh-frozen cadaver specimens. [14]

Each specimen was loaded to failure in a cantilever fashion and an extensometer was used to measure gapping across the arthrodesis site, with failure defined as a 2-mm gap. They found that the crossed cannulated screws and the dorsal plate constructs failed at significantly higher loads than the two compression staples (p<0.029 and p<0.002, respectively). [14] The dorsal plate failed due to bending of the plate in 79% of specimens. While the crossed cannulated screws provided the greatest amount of rigidity, failure occurred when the screw fractured the metatarsal head at the screw-bone interface in all but one specimen.

Curtis and colleagues found interfragmentary screws to be superior to plate fixation due to bending of the plate. [15] They suggested that adding a screw or K wire placed obliquely to the axis of the MTPJ might improve stability. Politi, et al., used synthetic bone models to demonstrate that the most stable technique was an oblique interfragmentary lag screw with a dorsal plate. [16]

There are several problems with conventional plate application. The stability of a plate relies on compression between the plate and the cortical bone, potentially disrupting the periosteal blood supply and inducing porosity of the bone. [17] To apply a screw to a conventional plate, it must be tightened with an axial traction of 1000-2000 Newtons (N), which produces up to 2400 N of friction in a 4-hole plate (co-efficient of friction between metal and bone = 0.4). [18] In addition, plate application to the first MTPJ is fraught with biomechanical disadvantages. The AO (Arbeitsgemeinschaft für Osteosynthesefragen) group recommends that a plate be positioned on the tension side of a bone to create dynamic compression in accordance with the tension band principle.1 In a loaded first MTPJ, the tension side is the convex plantar surface of the joint. Due to the position of the sesamoids, soft tissue structures, and potential complications of plantar incisions, the ideal placement of the plate on the tension side of the joint is not feasible, and the plate must be placed on the concave dorsal or compression side of the joint. Since the plate thus applied cannot supply tension band fixation, it will instead serve a neutralization function to protect the lag screw from shearing, bending, and torsional forces.

The locking plate design overcomes several of the disadvantages of conventional plate fixation and when combined with the use of an interfragmentary lag screw for compression, may provide a construct sufficiently stable to allow early weight-bearing and successful arthrodesis. The screw holes of the locking plate have threads that match the conically threaded undersurface of the screw heads, locking the screw head to the plate and negating the need for the plate to be compressed against the bone, thus minimizing the potential for disruption of the periosteal blood supply. [18,20] The locking mechanism between the screw and the plate prevents toggle and screw back out which may result from micromotion of up to 90% body weight that could be transferred onto the first MTPJ during gait. [21] In addition, the locking properties of the plate and screws render failure impossible unless there is simultaneous pullout of all the screws. [22] Gallentine and colleagues reported the use of locking plate fixation of proximal metatarsal chevron osteotomies, finding that the locking plate was successful in maintaining alignment and position of the first ray in patients who were allowed to bear weight on their heel immediately postoperatively. [23] In a study of synthetic calcaneal fracture models, the stability of plates with locking screws and conventional plates without locking screws was compared. [24] It was shown that the locking plates provided greater stability than the conventional plates with high cyclic loading simulating full weight-bearing.

In an in-vitro study of first metatarsocuneiform arthrodesis, Cohen, et al., argued that one of the shortcomings of the locking plate is that while it is rigid at the screw to plate to bone interface, it provides no compression at the arthrodesis site. [25] The authors of the current case report assert that the addition of the interfragmentary screw at the fusion site allows for compression, obviating the need for compression by the biomechanically disadvantaged plate. In this way, the plate functions to neutralize weight-bearing forces, while avoiding the aforementioned failure at the screw-bone interface by the intrinsic properties of the locking mechanism.

Allowing immediate ambulation after first MTPJ arthrodesis decreases the morbidity of the procedure by reducing disuse atrophy and osteopenia, the risk of deep thrombosis/pulmonary embolism, and inconvenience to the patient. When fixated with adequate internal fixation, the first MTPJ arthrodesis is a stable construct which allows the patient to ambulate immediately postoperatively. This notion has received support throughout the literature. In his early description of first MTPJ fusion in 1952, McKeever recommended weight-bearing in a cut-out shoe at the third or fourth post-operative day, though he noted that he cautioned the patient “very strongly” against placing full weight on the toe for six weeks. [5] Immediate ambulation in a wooden-soled postoperative shoe or short walking boot is the standard of care reported in a major orthopaedic text. [26]

In a retrospective review of 47 first MTPJ arthrodeses, Dayton reported a 100% fusion rate when allowing immediate post-operative ambulation with a standard surgical shoe, restricting weight to the heel or lateral aspect of the foot. [9] A randomized, prospective study of 61 cases found a 97% fusion rate for the early weightbearing group and a 93% fusion rate for the delayed weightbearing group, suggesting no difference in radiographic union or clinical outcome between patients who began ambulating two to four days post-operatively and those who remained non-weightbearing for four weeks. [12] Most authors recommend the use of a post-operative shoe or a CAM boot to eliminate the propulsive phase of gait, thus decreasing the chance for fixation failure. Young and colleagues compared three types of post-operative boots with a fiberglass cast in a cadaver model using strain gauges in the first MTPJ joint and simulated weightbearing. [27] They found that the removable cast boots provided the same, and in one type, even more reduction of force across the arthrodesis site than a traditional fiberglass cast.

The exact amount of force that a first MTPJ arthrodesis site can tolerate before failing is still unknown. The authors recognize that in certain situations, the force to failure may be reduced, such as revision arthrodeses utilizing bone grafts, cases in which less than optimal fixation is achieved, or large patient habitus. In such cases, an early weightbearing protocol may not be appropriate.

Further limitations of this case report include the small number of cases, selection and evaluation bias. The small number is due to the fact that all patients were directly seen by the junior authors. The senior author may have had other patient’s that would have satisfied the selection criteria, but were not included. This may have lead to an unintended selection bias. All patients and radiographs were evaluated by the senior author. Evaluation bias may have also occurred. The patients’ digital radiographs are included to address this concern. While the authors recognize these limitations, we do not advocate a change in the standard of care based solely on limited case studies alone and further studies are needed.

Conclusion

The authors have presented 2 cases of early ambulation following first MTPJ arthrodesis with a successful result using a locking plate with an interfragmentary screw. This clinical report shows promise for first MTPJ with regard to early and immediate ambulation following first MTPJ fusions.

References

1. Yu GV, Shook, JE. Arthrodesis of the first metatarsophalangeal joint. Current recommendations. JAPMA 1994 84(6): 66-80.
2. Smith RW, Joanis TL, Maxwell PD. Great toe metatarsophalangeal joint arthrodesis: a user-friendly technique. Foot Ankle 1992 13(7): 367-77.
3. Hansen ST. Functional reconstruction of the foot and ankle. 2000, Philadelphia: Lippincott Williams & Wilkins. xviii, 525
4. Castro MD, Klaue K. Technique tip: Revisiting an alternative
method of fixation for first MTP joint arthrodesis. Foot Ankle Int 2001 22(8): 687-688.
5. McKeever DC. Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. JBJS 1952 34A(1): 129-134.
6. Turan I, Lindgren U. Compression-screw arthrodesis of the first metatarsophalangeal joint of the foot. Clin Orthop Rel Res 987 (221): 292-295.
7. Harrison MHM, Harvey FJ. Arthrodesis of the first metatarsophalangeal joint for hallux valgus and ridigus. JBJS 1963 45A (3): 471-480.
8. Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: A prospective study. Foot Ankle Int 2006 27(11): 869-876.
9. Dayton P, McCall A. Early weightbearing after first
Metatarsophalangeal joint arthrodesis: a retrospective observational case analysis. J Foot Ankle Surg 2004 43(3): 156-159.
10. Sage RA, Lam AT, Taylor DT. Retrospective analysis of
first metatarsal phalangeal arthrodesis. J Foot Ankle Surg 1997 36(6): 425-429 (discussion 467).
11. Flavin R, Stephens MM. Arthrodesis of the first
metatarsophalangeal joint using a dorsal titanium contoured plate. Foot Ankle Int 2004 25(11): 783-787.
12. Lampe HIH, Fontijne P, van Linge B. Weight bearing
after arthrodesis of the first metatarsophalangeal joint. A randomized study of 61 cases. Acta Orthop Scand, 1991 62(6): 544-555.
13. Coughlin MJ, Mann RA. Arthrodesis of the first
metatarsophalangeal joint as salvage for the failed Keller procedure. JBJS 1987 69A(1): 68-75.
14. Neufeld SK, Parks BG, Naseef GS, Melamed EA, Schon LC. Arthrodesis of the first metatarsophalangeal joint: a biomechanical study comparing memory compression staples, cannulated screws, and a dorsal plate. Foot Ankle Int 2002 23(2): 97-101.
15. Curtis MJ, Myerson M, Jinnah RH, Cox QG, Alexander I. Arthrodesis of the first metatarsophalangeal joint: a biomechanical study of internal fixation techniques. Foot Ankle, 1993 14(7): 395-399.
16. Politi J, John H, Njus G, Bennett GL, Kay DB. First metatarsal-phalangeal joint arthrodesis: A biomechanical assessment of stability. Foot Ankle Int 2003 24(4): 332-337.
17. Perren SM, Cordey J, Rahn BA, Goutier E, Schneider E. Early temporary porosis of bone induced by internal fixation implants. A reaction to necrosis, not to stress protection? Clin Orthop Rel Res 1988 (232): 139-151.
18. Perren SM. Evolution of the internal fixation of long bone
fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. JBJS 2002 84B (8): 1093-1110.
19. Müller ME, Allgoewer M, Schneider R, Willenegger H. Manual of internal fixation : techniques recommended by the AO-ASIF Group. 3rd Ed. 1991, Berlin ; New York: Springer-Verlag. xxviii, 750.
20. Rüedi TP, Murphy WM. AO principles of fracture management. 2000, Stuttgart ; New York; Davos Platz, [Switzerland]: Thieme; AO Pub. 864.
21. Wyss UP, McBride I, Murphy L, Cooke TD, Olney SJ. Joint reaction forces at the first MTP joint in a normal elderly population. J Biomech 1990 23(10): 977-984.
22. Kim T, Ayturk UM, Haskell A, Miclau T, Puttlitz CM. Fixation of osteoporotic distal fibula fractures: A biomechanical comparison of locking versus conventional plates. J Foot Ankle Surg 2007 46(1): 2-6.
23. Gallentine JW, Deorio JK, Deorio MJ. Bunion surgery using locking-plate fixation of proximal metatarsal chevron osteotomies. Foot Ankle Int 2007 28(3): 361-368.
24. Richter M, Gosling T, Zech S, Allami M, Geerling J, Droste P, Krettek C. A comparison of plates with and without locking screws in a calcaneal fracture model. Foot Ankle Int 2005 26(4): 309-319.
25. Cohen DA, Parks BG, Schon LC. Screw fixation
compared to H-locking plate fixation for first metatarsocuneiform arthrodesis: a biomechanical study. Foot Ankle Int 2005 26(11): 984-989.
26. Coughlin MJ, Mann RA, Saltzman CL. Surgery of the
Foot and Ankle. 8th Edition. 2007, Philadelphia: Mosby.
27. Young D, Stone NC, Molgaard J, Duford D. A biomechanical study in cadavers of cast boots
used in the early postoperative period after first metatarsophalangeal joint arthrodesis. Can J Surg 2003 46(3): 183-186.


Address correspondence to: Robert M. Greenhagen, DPM, UPMC Podiatric Residency Program, Pittsburgh, PA.

Podiatric Residents, UPMC Podiatric Residency Program, Pittsburgh, PA
Podiatric Resident, Hennepin County Medical Center, Minneapolis, MN
Podiatric Resident, Saint Vincent Charity Hospital, Cleveland, OH
Associate Medical Director, Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, CA

© The Foot and Ankle Online Journal, 2010

First Metatarsalphalangeal Joint Arthrodesis in Rheumatoid Arthritis: A Case Report of Non-Union

by Evan F. Meltzer, MS, DPM, FACFAS1

The Foot & Ankle Journal 1 (4): 3

The author presents a case report of an attempted arthrodesis of the first metatarsophalangeal joint in a patient with rheumatoid arthritis. Reasons for non union were explored. These include the primary disease process and associated medical and surgical complications. There is conflicting data regarding any direct correlation of patients with rheumatoid arthritis and ethnicity affecting the outcome of surgical arthrodesis.

Key words: Non-Union, rheumatoid arthritis, arthrodesis

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org

Published: April 1, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0104.0003

Rheumatoid arthritis (RA) affects people worldwide with a consistent prevalence of 1%. It is most prevalent in highly developed countries such as the United States, England, and Scandinavia. [1] The prevalence of the disease varies in some populations, and may exceed 5% in several Native American tribes such as the Yakima, Chippewa and Pima tribes of the United States. [1,2] In contrast, RA is less common in Japan and Hong Kong and relatively rare in Indonesia and sub-Saharan Africa. [1] This case report illustrates a surgical non union 8 months following an arthrodesis procedure in a patient with rheumatoid arthritis.

Case Report

A 35 year old female with a history of rheumatoid arthritis presented to the podiatry clinic with a chief complaint of pain in the right great toe for the previous 6 months. Her systemic disease was adequately controlled by her primary physician with Etanercept (Enbrel®), 25 mg injected subcutaneously twice per week. The patient was also taking Alendronate (Foxamax®)70mg by mouth weekly. We also prescribed naproxen, 500 mg twice per day, and hydrocodone, 5mg with acetaminophen 500 mg as needed for breakthrough pain. The patient’s primary provider also prescribed a baseline daily dose of prednisone, 10 mg daily, in addition to an increase, then tapering schedule with an endpoint of 20 mg daily.

The patient is a non-smoker and did not have diabetes or peripheral neuropathy. Medical treatment failed to provide pain relief, and shoe therapy combined with corticosteroid arthrocentesis was recommended. The patient’s symptoms progressed and she was presented with several surgical options.

The patient underwent a first MTP arthrodesis procedure using the CHARLOTTE™ MTP Fusion System (Wright Medical Technology, Inc.). The surgery was uneventful, and radiographs taken 7 weeks postoperatively demonstrate adequate correction (Figs 1, 2).

Figure 1  The 7 week postoperative anteroposterior radiograph demonstrating satisfactory placement of the CHARLOTTE MTP plate with screw fixation.  The CHARLOTTE Multi-Use Compression screw is also visible from medial distal to lateral proximal.

Figure 2    The 7 week postoperative lateral radiograph illustrating the low profile of the construct, with good purchase of all screw threads.

The patient was kept immobilized for 3 months, ambulating in a cam walker for that entire time, and was subsequently discharged from postoperative care. Shortly after discharge, the patient relocated to another city in Montana.

The patient returned to the podiatry clinic 8 months later with a screw head percutaneously visible. There were no complaints of pain other than the concern over a visible screw head and associated dorsal edema. There was no reported history of trauma to the affected foot during the intervening time. Subsequent radiographs demonstrated loosening of the other screws and a failed union of the first MTP joint (Figs 3, 4).

Figure 3     The 8 month postoperative anteroposterior radiograph clearly showing the non union, exuberant bone medial to the plate, and lucency of bone around the screws.

Figure 4    The 8 month postoperative lateral radiograph demonstrating the position of the percutaneous screw and loosening of the entire construct.  The dorsal edema and visible screw head prompted the patient to return to the clinic.

The percutaneous screw was easily removed in the clinic with a hemostat. The patient returned to the operating room where all hardware was removed except for the initial transverse screw. The region of the non union and first metatarsal shaft was remodeled with demineralized bone matrix using Allomatrix® DR (Wright Medical Technology, Inc.). This was applied within the pseudo joint space along with another CHARLOTTE™ Multi-Use Compression screw.

An Orthofix bone growth stimulator was fitted and dispensed to promote bone healing. Radiographs taken prior to the author’s relocation indicated adequate progression of primary bone healing of the revised surgical site.

Discussion

The incidence of non union following arthrodesis of painfully diseased joints in rheumatoid arthritis patients is not unusual. [3,4] However, there is conflicting data suggesting a direct correlation between RA and surgical non union. [9,10] Maenpaa et al [9] state that non unions are more common among patients with severe deformity and osteoporosis (RA, neuromuscular arthropathy). In contradiction to the previous statement, Bogoch and Moran [10] state that the relatively rapid and reliable bone healing and arthrodesis in RA may be attributable to the preexisting rapid turnover of bone with an increase in osteogenesis. These authors speculate that the phase of induction of osteogenesis initiated by surgical arthrodesis is enhanced by the preconditioned state of bone formation in this patient group. Other possible primary surgical approaches to consider in this case were hemi or total first implant arthroplasty verses resection arthroplasty (Keller procedure). This patient desired a rigid fusion. Another approach to revision could have been to remove all hardware and leave the non union alone, since she had no pain. Some studies show that non unions are not always painful. [5] If successful, first MTP arthrodesis is a satisfactory procedure with good long-term results. [5,6] The effects of poor bone healing with the use of oral prednisone are widely recognized. [7] This may be considered a causative factor in this surgical result, but is purely speculative. The effect of an intra-articular corticosteroid injection in the final result of this case is also unknown. It is unlikely that joint injection with corticosteroid would have such a widespread effect on the massive failure of the entire construct.

What is known is the increased risk of non union due to the patient’s comorbidity of rheumatoid arthritis. The literature [1,2] supports the notion that the incidence of rheumatoid arthritis in certain Native American tribes exceeds 5%. While this author could not locate a specific reference to the incidence of RA in the Blackfeet Tribe of Montana, obeservations by two family doctors on this reservation over a 20 year period concur a similar incidence of the disease in the Blackfeet members they have treated. [8] The pharmacy budget at the Blackfeet Community Hospital is significantly impacted by the cost of RA mitigating drugs.

In addition to medical morbidities, the foot and ankle surgeon must recognize rheumatoid arthritis as a factor that may impact the outcome of planned surgical procedures. High risk patients should be adequately counseled regarding risk factors and benefits verses possible adverse results. This should be carefully considered during the informed consent process. There seems to be a general consensus among foot and ankle surgeons that patients with RA have a higher risk of non union following surgical arthrodesis. The possibility of the increased risk of non union associated with RA in conjunction with ethnic ancestry cannot be positively correlated by this report and may merit further study of bone healing and genetic background.

References

1. Cush, JJ, Kavanaugh, A. Rheumatoid Arthritis: Early Diagnosis and Treatment. Professional Communications, Inc., p 29. 2005.
2. Peschken, CA, Esdaile, JM. Rheumatic diseases in North America’s indigenous peoples. Seminars in Arthritis and Rheumatism 28 (6), pp.368-391. 1999.
3. Anderson, T, Maxander, P, Rydholm, U, Besjakov, J, Carlsson, A. Ankle arthrodesis by compression screws in rheumatoid arthritis: Primary nonunion in 9/35 patients. Acta Orthopaedica 76 (6), pp. 884-890. 2005.
4. Salai, M, Hakerem, D, Pritch, M, Chechick, A, Goshen, E. Non-union of undisplaced radial neck fracture in a rheumatoid patient. Archives of Orthopaedic and Trauma Surgery 119 (1-2), pp.119-120. 1999.
5. Goucher, NR, Coughlin, MJ. Hallux Metatarsophalangeal joint Arthrodesis using dome-shaped reamers and dorsal plate fixation: A prospective study. Foot and Ankle International 27 (11), pp. 869-876. 2006.
6. Brodsky, JW, Passmore, RN, Pollo, FE, Shabat, S. Functional outcome of Arthrodesis of the first metatarsalphalangeal joint using parallel screw fixation. Foot and Ankle International 26 (2), pp. 140-146. 2005.
7. Waters, RV, Gamradt, SC, Asnis, P, Vickery, BH, Avnur, Z, Hill, E, Bostrom, MPG. Systemic corticosteroids inhibit bone healing in a rabbit ulnar osteotomy model. Acta Orthopaedica Scandinavica 71 (3), pp. 316-321. 2000.
8. Personal communication, R. Rottenbiller, MD and R. Odegaard, MD. Blackfeet Community Hospital, Browning, Montana. 2007.
9. Maenpaa, H, Lehto, MUK, Belt, EA. Why Do Ankle Arthrodeses Fail in Patients with Rheumatic Disease? Foot & Ankle International 22 (5), pp403-408. 2001.
10. Bogoch, ER, Moran, EL. Bone Abnormalities in the Surgical Treatment of Patients with Rheumatoid Arthritis. Clin. Orthop., 366, pp8-21. 1999.


Address correspondence to: Evan F. Meltzer, MS, DPM, FACFAS
G.V. (Sonny) Montgomery VA Medical Center, Surgical Service (112)
1500 Woodrow Wilson Drive, Jackson, MS 39216

1G.V. (Sonny) Montgomery VA Medical Center, Surgical Service (112), 1500 Woodrow Wilson Drive, Jackson, MS 39216

© The Foot & Ankle Journal, 2008

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