Tag Archives: Ilizarov

Case Report: Intra-articular calcaneal fracture reduced with minimal open reduction, external fixation with the use of balloon kyphoplasty technique

by Sutpal Singh, DPM, FACFAS, FAPWCA1, Jennifer S. Chen, DPM, MPH2, W. Scott Davis, DPM2, Yulia Ilyasova, DPM2, Babak Alavynejad, DPM, FACFAS3pdflrg

Calcaneal fractures may be difficult to reduce and there are many possible complications of the standard open reduction and internal fixation.  This case study illustrates use of the Ilizarov method combined with a balloon kyphoplasty technique as an additional approach to reduce these complex fractures with a minimal incision. This innovative technique not only minimize risk of infection, but also offers an alternative approach to patients who would otherwise be poor candidates for the standard calcaneal fracture requiring an open reduction internal fixation.

Key words: Balloon Kyphoplasty, calcaneal fracture, Ilizarov

ISSN 1941-6806
doi: 10.3827/faoj.2015.0802.0007

Address correspondence to: Sutpal Singh
Chief Ilizarov instructor for Doctors Hospital West Covina residency (PMSR+ RRA). drsutpalsingh@gmail.com

1. Chief Ilizarov instructor for Doctors Hospital West Covina residency (PMSR+ RRA)
2. Podiatric Residents from Doctors Hospital West Covina (PMSR + RRA)
3. Residency Director of Doctors Hospital West Covina residency (PMSR + RRA)


The calcaneus is the most common fracture of the tarsal bones, usually sustained by high-energy trauma such as a motor vehicle accident or a fall from a great height [4,7]. Calcaneal fractures account for approximately 60% of all foot fractures, with 70-75% of calcaneal fractures being intra-articular [8].

The decision regarding operative versus non-operative treatment of calcaneal fractures is reported to be controversial in literature with consideration given to the severity of fracture and whether or not the patient is an appropriate surgical candidate [1]. A 2013 study indicated that while operative treatment was unsuccessful at managing displaced intra-articular calcaneal fractures at the one year follow up, at the eight to twelve year follow up, operative treatment was shown to be beneficial with decreased prevalence in posttraumatic arthritis [1].

Non-operative treatment is usually indicated in patients with non-displaced fractures and patients who are poor surgical candidates [7].  This treatment method generally involves below the knee casting with early range of motion exercises or closed reduction with percutaneous pinning and casting [3].

The open reduction internal fixation approach to calcaneal fractures involves a large lateral L type incision allowing for exposure and maneuverability to reduce and fixate the fracture. Careful dissection is needed avoiding the peroneal tendons and sural nerve [7]. The lateral wall is dissected, mobilized, and the remaining fracture patterns are reduced to as close to anatomic position as possible, with care noted especially to the articular surfaces [7]. The fracture is typically fixated using screws and a low profile lateral neutralization plate [7]. Though this technique is currently the standard for displaced intra-articular calcaneal fractures, it is not without its inherent risks. Because of the large extensile incision needed with the use of plates and screws, there is risk of infection, wound dehiscence, and osteomyelitis. A 2001 study of 183 patients with calcaneal fractures treated by open reduction internal fixation resulted in 7 patients with infections (3.2%), 1 of which went on to osteomyelitis of the calcaneus and eventually a below the knee amputation [4].

An additional method described is use of external ring fixation for calcaneal fractures [3]. A 2004 study of 23 patients described a methodology allowing for that patients to weight bear the first postoperative day with few complications noted other than superficial skin infections and no deep infections [8].

The aim of this paper is to present a case presentation detailing the use of an Ilizarov external fixator in conjunction with a balloon kyphoplasty technique in the reduction of an intra-articular calcaneal fracture as an alternative means of approach that uses a minimal incision to reduce fracture fragment and maintain heel height.

Technique

The patient was placed in a supine position and prepped with Betadine.  Two tibial rings were placed on the tibia and then tensioned appropriately.  A 5/8 ring was then applied to the calcaneus with one or two tensioned wires.  Several other thin wires were placed as half pins (the wire has one entry point and no exit point) to help prevent medial or lateral translation and remained for the duration of the frame.  The 5/8 ring was placed in slight equines.  Two rods were then placed from the tibial block ring to the 5/8 ring to distract the subtalar joint and ankle joint. The 5/8 ring was also used to manipulate the calcaneus out of varus and to translate it medially.   After the distraction, the rods were tightened. Fluoroscopy was used to identify the subtalar joint and identify the fracture site.  A 2 cm incision was made on the lateral foot at the area of the subtalar joint.   A small periosteal elevator was placed under the depressed fracture fragment and through the lateral wall.  Note that the lateral wall was not removed or dissected out. Then a size 15 balloon with a 4 cc filling capacity from the kyphoplasty device (Figure 17) was placed through the lateral wall and above the periosteal elevator from lateral to medial.  A calcaneal axial image was taken using fluoroscopy, which confirmed the balloon was in the center of the calcaneus.  The balloon was then inflated.  The elevator was inferior to the balloon so that as it was inflated, the fractured fragment would only go superior without any expansion inferiorly.  After the fragment was elevated, the subtalar joint was re-evaluated.  After noting good anatomic position, several wires were inserted to hold the fragment in position.  Care must be taken while inserting wires to prevent puncturing of the inflated balloon. The balloon was then removed.  The lateral blowout wall was then manually compressed and held with wires.  The large void that occurred was filled with calcium sulfate xenograft (PRO-DENSE, Wright Medical Technology, Memphis, TN).  The incision was then closed with 3-0 prolene.  No deep sutures were used.  Immediate weight bearing was allowed as tolerated.

Case # 1

The patient is a 71 year-old male with a history of chronic smoking who was on a ladder and fell.  He had an intra-articular calcaneal fracture. There was a joint depression fracture with a decreased Bohler’s angle.  Figures 1-9 show the progression of the surgery, realignment and healing of the fracture.

image2

Figure 1 Preoperative image showing joint depression-type calcaneus fracture with a decrease in Bohler’s angle.

 image3

Figure 2 Intraoperative image of  calcaneal fracture with the subtalar joint and ankle joint distracted.  The posterior facet is still depressed.

image4

Figure 3 Intraoperative image of calcaneal fracture being elevated using balloon kyphoplasty technique from the lateral side

 image5

Figure 4 Intraoperative image of calcaneal fracture reduction showing the balloon from calcaneal axial view.

image6

Figure 5 Intraoperative image of calcaneal fracture with elevated posterior fragment held in place with pro-dense and wire attached to the frame immediately after surgery.  Note the fracture line above the PRO-DENSE (Wright Medical Technology, TN).

image7 

Figure 6 Postoperative image of calcaneal fracture with elevated posterior fragment held in place with PRO-DENSE (Wright Medical Technology, TN) and wire attached to the frame. Six weeks status post surgery.  Note the fracture line has healed.

image8

Figure 7 Postoperative image of patient with the frame on.  Note the small incision on the lateral foot.

image9 

Figure 8 Final postoperative calcaneal axial image after external fixator has been removed.

image10

Figure 9 Final posteroperative lateral image after external fixator has been removed.

Case # 2

The patient is a 64 year-old male who also fell from a ladder.  He had an intra-articular calcaneal fracture. There was a joint depression fracture with a negative Bohler’s angle and a lateral wall blowout.  Figures 10-16 show the progression of the surgery, realignment and healing of the fracture.

image11

Figure 10 Preoperative calcaneal axial image

image12

Figure 11 Preoperative lateral image. Note the calcaneal bone impingement on the posterior talus.

image13

Figure 12 Intraoperative image showing the incision site.

image14

Figure 13  Postoperative lateral image several weeks after application of the external fixator with balloon kyphoplasty.

image15

Figure 14 Postoperative image three months after surgery with good restoration of heel height.  There is some arthrosis but minimal to no pain.

image16

Figure 15 Postoperative calcaneal axial image showing good alignment.

image17

Figure 16  Postoperative image. Healed minimal incision in at 3 months.

image18 image19 image20

Figure 17 Kyphoplasty instruments. A: Pump connected to catheter. B: Deflated balloon. C: Balloon inflated with dye.

Discussion

This paper demonstrates a novel approach in the reduction of calcaneal fractures with a minimally invasive technique using balloon kyphoplasty, calcium phosphate bone cement and Ilizarov method.

Balloon kyphoplasty was originally used for vertebral body fractures and has been used in over 600,000 cases [4]. In this paper, the same technique was applied for the reduction of the calcaneal fractures. Acting as a reduction tool, a size 15 balloon was percutaneously inserted into the calcaneal body under the fluoroscopic control and then inflated to reduce the fracture and impact cancellous bone. Bone cement is inserted into the bone void in order to support the fracture reduction and maintain the vertebral body height [4].

The large void that occurred after the balloon was removed was filled with calcium sulfate xenograft (PRO-DENSE, Wright Medical Technology, Memphis, TN). The calcium sulfate of the implant resorbs first, revealing a porous calcium phosphate scaffold conducive to vascular infiltration. Calcium phosphate bone cement was used because it has isothermic properties allowing for quick set up in a wet environment, osteoconductive properties allowing for new bone development while simultaneously becoming resorbed, and is readily available. Moreover, it permits for the avoidance of autogenous bone graft and its associated complications, such as having an additional surgical site and possibility of infection [2]. PMMA, DBM or any bone void filler would also be sufficient as well.

This technique allows for a minimal incision through any angle [5]. This approach may be beneficial in providing a novel technique in calcaneal fractures in situations where a large skin incision may not be a viable option, such as when there is little skin of feasible quality [5]. Furthermore, a 2011 case series study using balloon reduction reported an excellent outcome at three year follow up, suggesting that percutaneous balloon reduction and cement fixation of calcaneal fractures may be a promising technique [9].

The Ilizarov apparatus was used in order to maintain the desired reduction with minimal complications. During the application, any varus or valgus deformity is corrected, congruency of articular surfaces is upheld, and restoration of calcaneal height and width with improved Böhler and Gissane’s angles are sustained [1]. The most common complication with the Ilizarov apparatus is superficial skin infection at wire insertion sites, therefore care is necessary to prevent pintract [pin tract] infections [6]. A 2004 study compared fixation of calcaneal fractures utilizing external fixation versus internal fixation [3]. Both groups had similar functional and radiographic outcomes, however the internal fixation group had a higher complication rate due to wound complications relating to the lateral extensile incision [3]. A 2005 restrospective study in Finland had wound complications in 35 cases (24%), 20 of which needed additional operative treatment (10). Again, another 2009 study cited a 17% wound complication rate [11]. Moreover, with the Ilizarov technique there are no plates or screws left inside the foot once the Ilizarov device is removed. This reduces the risk of wound problems, deep infection, hardware penetration, or peroneal tendon irritation by hardware [4]. The Ilizarov apparatus for reduction or calcaneal fractures is a safe and effective alternative, while providing comparable results to the traditional ORIF approach [3].

Conclusion

In patients with calcaneal fractures, reduction can be difficult, and surgical treatment often requires large incisions with many potential complications. The procedure described here, combining the Ilizarov technique with the use of kyphoplasty, is a viable option for reduction and fixation of calcaneal fractures. It affords the use of a reduction using a minimal incision therefore decreasing all the risks of a large incision as in the classic open reduction internal fixation technique including infection and skin necrosis. It also offers an alternative technique to patients who are not a viable candidate for large incisions. Furthermore, there is little literature on this technique as a means for reducing  displaced calcaneal fractures therefore presenting a novel approach in which more research needs to be performed.

References

  1. Agren, P.H., Wretenberg, P., & Sayed-Noor, A.S. (2013). Operative versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures: A Prospective, Randomized, Controlled Multicenter Trial. The Journal of Bone & Joint Surgery, 95(15), 1351-1357. PubMed
  2. Buckley, Ross Leighton, Thomas A. Russell, Sune Larsson and Mohit Bhandari, Sohail S. Bajammal, Michael Zlowodzki, Amy Lelwica, Paul Tornetta, III, Thomas A. Einhorn, Richard (2008). The Use of Calcium Phosphate Bone Cement in Fracture Treatment. Journal of Bone Joint Surgery (American Version). 90(6), 1186-1196.  PubMed
  3. Emara, K.M., & Allam, M.F. (2005). Management of Calcaneal Fracture Using the Ilizarov Technique. Clinical Orthopaedics and Related Research, 439, 215-220. PubMed
  4. Harvey E.J., Grujic, L., Early, J.S., Benirschke, S.K., & Sangeorzan B.J. (2001). Morbidity Associated with ORIF of Intra-articular Calcaneus Fractures using a Lateral Approach. Foot & Ankle International, 22(11) 868-873. PubMed
  5. Heiney J.P., O’Connor J.A. (2012). Balloon Reduction and Minimally Invasive Fixation (BRAMIF) for Extremity Fractures with the Application of Fast-Setting Calcium Phosphate. Journal of Orthopedics. 7(2)8. (Link)
  6. Rose, R. (2013). Pin site care with the Ilizarov circular fixator. The Internet Journal of Orthopedic Surgery. 16(1). (Link)
  7. Sanders R.W. & Clare, M.P. (2007). Fractures of the Calcaneus (M. Coughlin, R. Mann, & C. Saltzman, Eds.). In Surgery of the Foot and Ankle Vol. II (pp. 2017-2073). Philadelphia, PA: Mosby Elsevier.
  8. Talarico, L.M., Vito, G.R., & Zyranov. (2004). Management of Displaced Intraarticular Calcaneal Fractures by Using External Ring Fixation, Minimally Invasive Open Reduction, and Early Weightbearing. The Journal of Foot and Ankle Surgery, 43(1), 43-50. PubMed
  9. Jacquot, F., Atchabahian, A. (2011). Balloon Reduction and Cement Fixation in Intra-articular Calcaneal Fractures: a Percutaneous Approach to Intra-articular Calcaneal Fractures. International Orthopaedics (SICOT). 35,1007–1014. PubMed
  10. Koski, A., Kuokkanen, H., Tukiainen, E. (2005). Postoperative Wound Complications after Internal Fixation of Closed Calcaneal Fractures: a Retrospective Analysis of 126 Consecutive patient with 148 Fractures. Scandinavian Journal of Surgery. 94,243-245. (PubMed)
  11. Rak, V., Ira, D., Masek, M. (2009). Operative Treatment of Intra-articular Calcaneal Fractures with Calcaneal Plates and its Complications. Indian Journal of Orthopedics. 43(3), 271-280. (PubMed)

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.

References

1. Salem KH, Kinzl L, Schmelz A. Ankle arthrodesis using Ilizarov ring fixators: A review of 22 cases. Foot & Ankle International 2006 27:764-70.
2. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot & Ankle Surgery 2011 50: 25-30.
3. Schuberth J, Cheung C, Rush S, Blitz N, Roling B. The medial malleolar approach for arthrodesis of the ankle: A report of 13 cases. J of Foot & Ankle Surgery 2005 44:125-132.
4. Easley M. Operative Techniques in Foot and Ankle Surgery. Philadelphia: Lippincott Williams & Wilkins 2011.
5. Coughlin M, Mann R, Saltzman C: Surgery of the Foot and Ankle. Philadelphia. Mosby 2007.
6. Grass R, Rammelt S, Biewener A, Zwipp H: Arthrodesis of the ankle Joint” Clinics Podiatric Medicine Surgery 2004 21:161-178.
7. Karl-Heinz K, Hans-Jörg T, Fusszentrum W. Ankle arthrodesis with an anterior approach. Techniques Foot Ankle Surgery 2007 6: 243-248.
8. Hanson TW, Cracchiolo A 3rd: The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle International 2002 23:704-710.
9. Glick J, Morgan C, Myerson M, Sampson T, Mann J. Ankle arthrodesis an arthroscopic method: Long-term follow-up of 34 Cases. Arthroscopy 1996 12: 428-434.
10. Fragomen AT, Fragomen AT, Meyers KN, Davis N, Shu H, Wright T, Rozbruch SR. A biomechanical comparison of micromotion after ankle fusion using 2 fixation techniques: Intramedullary arthrodesis nail or Ilizarov external fixator. Foot & Ankle International 2008 29: 334-341.
11. Raikin S, Venkat R. An approach to the failed ankle arthrodesis. Foot Ankle Clinics 2008 13:401-416.
12. O’Brien T, Hart T, Shereff M, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis A comparative study. Foot Ankle International 1999 20: 368-373.
13. Hagen RJ. Ankle arthrodesis: problems and pitfalls. Clinical Orthopaedics and Related Research. 1986 202: 152-162.
14. Katsenis D, Bhave A, Paley D. Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus. JBJS 2005 87A: 302–309.
15. Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. JBJS 1985 67A: 546–550.
16. Costigan W, Thordarson D, Debnath U. Operative management of ankle fractures in patients with diabetes mellitus. Foot & Ankle International 2007 28: 32-37.
17. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. JBJS 2005 87B: 489-495.
18. McCormack R.G., Leith J.M.: Ankle fractures in diabetics: Complications of Surgical Management. JBJS1998 80B: 689-692.
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

Correction of Traumatic Ankle Valgus and Procurvatum using the Taylor Spatial Frame: A Case Report

by Thurmond Lanier DPM, MPH , Erik Lilja DPM, FACFAS 

The Foot and Ankle Online Journal 4 (5): 3

Injuries about the ankle joint can have devastating consequences when left untreated or undertreated, and treatment is especially important in the pediatric population. Physeal injury may occur that can result in abnormal growth patterns. External fixation can be used to correct ankle and tibial deformities, and the Taylor Spatial Frame (TSF) can be used to more easily correct triplane deformities. A case study is presented to demonstrate the use of the TSF in correction of ankle valgus and tibial procurvatum.

Key words: Epiphysis, Ilizarov frame, External fixation, CORA

Accepted: April, 2011
Published: May, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0405.0003


Injuries about the ankle joint such as fractures, chronic ligamentous injuries, and osteochondral lesions can result in post-traumatic arthritis. These injuries are more devastating when they are left untreated or undertreated. When injuries of this nature happen in the pediatric population, special considerations must be taken to preserve physeal growth plates and prevent the occurrence of future growth disturbances. When a disturbance does occur at the epiphysis, depending how severe the deformity, surgical correction may be indicated. Internal fixation may be used to accomplish correction, but external fixation may be preferred if the deformity is severe which may result in soft tissue compromise if corrected acutely.

Ilizarov circular frames have had widespread use in the correction of angular deformities. [1] With more complex deformities (such as those in multiple planes), Ilizarov frames may be used but the application of hinges are needed and more complex pre-operative planning as well as more intricate post-operative manipulation is needed. With the advent of the Taylor Spatial Frame (TSF), deformities can be reduced in all three planes simultaneously. The TSF has two rings and six struts that are expandable. [2] The deformity parameters are measured by the surgeon and are introduced into the TSF software in which a prescription is printed. [3] We present a case report of a pediatric case where a TSF was utilized for correction of a multiplanar ankle deformity.

Case Report

A 14 year-old patient presented to clinic with complaints of right ankle pain. The patient related having a history of a right ankle fracture which happened 4 years prior. The patient states that he was making a jump on his quad and ended up catching the right foot on the top of the rear tire and felt a snap. The patient was diagnosed with an ankle fracture and was treated conservatively in a cast for approximately six weeks. The patient removed his own cast at that time and began weight bearing. The patient continued to have lateral ankle pain and noticed that his foot was in an abnormal position relative to his ankle. Radiographs were obtained 2 years after the initial injury which showed collapse of the lateral portion of the epiphysis and shortening with lateral displacement of the fibula with an increase in medial clear space. (Figs. 1A and 1B) This also resulted in valgus position of the ankle joint. The patient was given conservative treatment for approximately two years until his growth plates were closed and operative intervention was then initiated.

 

Figures 1A and 1B  Lateral pre-operative radiograph displaying tibial procurvatum and relatively narrow joint space. (A)  The anterior posterior (AP) and mortise pre-operative radiographs demonstrating significant valgus of the mortise and increased medial clear space. Also note decreased tibia-fibula overlap. (B)

Operative Technique/Post-operative care

The TSF consisted of two tibial rings connected by six struts. The proximal ring was applied to the tibia via two half pins. The half pins were applied perpendicular to the posterior crest of the tibia and confirmed with fluoroscopy. The distal ring was placed with two wires and a half pin and was placed distal to where the proposed osteotomy would be. The distal ring was placed in relative malalignment with the distal tibia so when the deformity was corrected the frame would be in a neutral position. An incision was then made along the anteromedial aspect of the tibia. Layered dissection was taken down to the tibia shaft and a through and through osteotomy was made with a sagittal saw. The osteotomy was made as distal in the tibia shaft as possible as the center of rotation of angulation (CORA) was located within the ankle joint. The CORA represents the apex of the deformity and in most cases is the optimal location to place the osteotomy.

If the CORA is located within a joint, generally the osteotomy is made proximal to the CORA within bone with good blood supply. A lateral incision was then made over the fibula with dissection taken down to the shaft. Utilizing a sagittal saw a transverse osteotomy was made. The final frame construction was made sure to be orthogonal to the tibia. (Fig. 2) Post-operatives radiographs were taken to ensure proper alignment of the frame. (Figs. 3 and 4) Adjustments were started approximately 10 days after surgery. Radiographs were taken on a weekly basis. The only complication that occurred was a pin tract infection which resolved with antibiotics. The frame was removed in 3 months when bony consolidation of the osteotomy was identified on radiographs. (Figs. 5 and 6)

Figure 2  Intra-operative image showing application of the Taylor Spatial Frame (TSF).

Figure 3  Immediate AP post-operative radiograph. Note distal ring with built-in deformity to match deformity at ankle joint.

Figure 4   Immediate lateral post-operative radiograph showing fibular osteotomy.

Figure 5  Final lateral post-operative radiograph showing healed osteotomy sites and decrease tibial procurvatum.

Figure 6  Final AP post-operative radiograph showing healed osteotomy sites with decrease in valgus position of the ankle.

Discussion

The use of the TSF has been described in numerous cases in the literature. The frame has been utilized in accomplishing ankle arthrodesis in patients with and without ankle and tibial deformities. Thiryayi, et al., described ankle fusion using the TSF in 10 patients. [2] The patients stayed in the fixator for an average of 24 weeks.

All patients demonstrated bony union. They reported having 7 cases of superficial pin tract infections which were resolved with oral antibiotics. Tellisi, et al., describe applying a TSF for limb lengthening and ankle fusion simultaneously. [4] The authors applied the TSF for ankle fusion and then brought patients back to the operating room for tibial lengthening. The surgeons performed the tibial osteotomy just distal to the tibial tuberosity. The authors also performed a fibular osteotomy to prevent tethering and angular deformity at the tibial lengthening site. The authors had 53 ankle fusions in which 12 underwent simultaneous tibial lengthening. 84% went on to complete fusion with two patients having significant non-unions (these patients were smokers). The average time in the fixator was 8.4 months with all patients having completely healed osteotomy sites. No significant pin tract infections were reported.

A case study was reported by Mabit, et al., where a TSF was placed on a young girl with ankle varus that resulted from a malunited ankle fracture. [5] The authors chose to correct her deformity gradually with a TSF preassembled and with the tibial rings oriented 30 degrees in the coronal plane matching the deformity. A tibial osteotomy was performed and distraction took place on the fourth post-operative day. The patient stayed in the TSF for 2.5 months. The patient went on to successful healing.

Feldman, et al., describe using the TSF for tibial malunions and nonunions. They had 18 patients in their study that had a TSF applied. The average time in the frame was 18.5 weeks. All patients went on to successful healing except one who developed a varus deformity through the healing fracture in the tibia. Fifteen of the 18 patients returned to preinjury activities at last follow-up. [3] Matsubara, et al., describe application of a TSF for 3 patients due to ankle ankylosis. [6] All patients had limb length discrepancy and angulation deformity. The average time in the fixator was 216 days. All patients were able to walk normally with a plantigrade foot.

Conclusion

The TSF is a useful tool for the surgeon to correct complex multiplane deformities of the lower extremity. Pre-operative parameters combined with the computer software make the TSF a simpler system as compared to traditional external fixators. There are various studies in the literature that demonstrate the usefulness and ease of this technique. Our patient was able to adjust the frame with ease and deformity correction was more precise using the computer software.

References

1. Chaudhary M. Taylor spatial frame-software-controlled fixator for deformity correction – The early Indian experience. Indian J Orthop 2007 41: 169-174.
2. Thiryayi WA, Naqui Z, Khan SA. Use of the Taylor Spatial Frame in Compression arthrodesis of the ankle: A study of 10 cases. J Foot Ankle Surg 2010 49: 182-187.
3. Feldman DS, Shin SS, Madan S, Koval KJ. Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame. J Orthop Trauma 2003 17: 549-554.
4. Tellisi N, Fragomen TA, Ilizarov S, Rozbruch SR. Limb salvage reconstruction of the ankle with fusion and simultaneous tibial lengthening using Ilizarov/Taylor Spatial Frame. Hospital Special Surgery, 2008 4:32-42.
5. Mabit C, Pecout C, Arnaud JP. Ilizarov’s technique in correction of ankle malunion. J Orthop Trauma 1994 8: 520-523.
6. Matsubara H, Tsuchiya H, Takato K, Tomita K. Correction of ankle ankylosis with deformity using the Taylor Spatial Frame: A report of three cases. Foot Ankle Int 2007 28: 1290-1294.


Address correspondence to: Thurmond Lanier, DPM, MPH, Swedish Medical Center, 747 Broadway, Seattle, WA, 98122.

1  PGY 2, Swedish Medical Center, 747 Broadway, Seattle, WA, 98122
2  Attending physician, Swedish medical center, 747 Broadway, Seattle, WA, 98122, Private practice, 9501 5th Ave. NE, Seattle, WA, 98115.

© The Foot and Ankle Online Journal, 2011