Tag Archives: external fixation

Management of a dislocated talar dome fracture with ankle arthrodiastasis and open reduction internal fixation: A case report

by Charles A. Sisovsky, DPM, AACFAS1*; Carl A. Kihm, DPM, FACFAS2

The Foot and Ankle Online Journal 13 (4): 7

Osteochondral lesions of the talus (OLT) can be acute or chronic with mechanisms of injury and treatment protocols that have been well-described. Current treatment options for OLT depend on severity and chronicity. Treatment options for OLT consist of bracing, steroid injections, arthroscopic debridement with microfracture, osteochondral transfer, structural allograft, arthrodiastasis, arthrodesis or total ankle arthroplasty. Although mechanisms are similar, talar dome fractures have been less frequently presented in our literature. Displaced intra-articular fractures often require operative management although these procedures have not been detailed in the literature due to the rarity of the injury. This case report describes the surgical management of a 19-year-old male who sustained a dislocated and rotated lateral talar dome fracture after an inversion ankle injury while playing basketball. Long-term follow-up of our patient show an excellent, asymptomatic outcome without limitations at his 18-month follow-up visit.

Keywords: arthrodiastasis, external fixation, osteochondritis, syndesmosis, talus fracture, transchondral fracture

ISSN 1941-6806
doi: 10.3827/faoj.2020.1304.0007

1 – Fellowship-trained Foot and Ankle Surgeon, American Health Network, OptumCare, Department of Foot and Ankle Surgery, 2108 State Street, New Albany, IN 47150
2 – Attending surgeon at Norton Audubon Hospital, Faculty of the Kentucky Podiatric Residency Program, Private Practice, 3 Audubon Plaza Drive Suite 320, Louisville, KY 40217
* – Corresponding author: csisovsk@gmail.com


Osteochondral lesions of the talus (OLT) have been thoroughly discussed throughout the literature and describe pathologies to include transchondral lesions, osteochondral lesions, and talar dome fractures. These lesions typically involve the talar cartilage and subchondral bone and are typically caused by a single or multiple traumatic events, leading to partial or complete detachment of the fragment [1]. These fractures comprise approximately 0.1-0.85% of all fractures and most occur as a result of high-energy trauma, such as motor vehicle accidents [2-3]. Talar dome lesions or osteochondritis dissecans were first described by Berndt and Harty in the ankle in 1959 [4]. Current treatment options for OLT range from non-surgical treatment with cast immobilization to surgical excision and microfracturing. Newer techniques include osteochondral autograft transplantation and autologous chondrocyte implantation. The goal of these treatments is to restore the anatomic alignment of the articular surfaces in order to diminish long-term pain and swelling, and to improve function. The surgical management of large, displaced talar dome fractures is difficult in that with the tight joint confines, anatomic reduction may require ankle joint distraction to achieve proper reduction. Both arthroscopic and open exposures are considered regardless of whether ankle arthrodiastasis is utilized. Then, once reduced, optimal fixation placement is also challenging due to the tight joint confines and since fixation must not be detrimental to the articular surfaces or prominent or impinge the ankle joint.

In this case, we present the surgical management we utilized to achieve open reduction internal fixation of a dislocated lateral talar dome fracture with external fixation arthrodiastasis. Since anatomic reduction was achieved and our patient had an excellent long-term outcome, here, we present the surgical technique employed which may be useful in similar, future displaced lateral talar dome cases as these are rarely described in our literature [5-6]. Our case is unique in that we described the surgical management of a completely dislocated talar dome fracture with the use of bioabsorbable pins and ankle joint distraction.

Case Report

A healthy 19-year-old male inverted his ankle while playing basketball, when landing after jumping. Immediately afterwards, he was unable to bear weight. He went to the emergency department where radiographs demonstrated a dislocated lateral talar dome fracture (Figure 1). A CT scan was ordered which confirmed that the fracture segment, which measured 2.2 x 1.3 x 0.6 cm, was dislocated and rotated 180 degrees (Figure 2). The patient was made non-weight bearing while soft tissues were managed for 2 weeks.

Surgical management of the lateral talar dome fracture dislocation started with application of a delta frame external fixation construct to manually distract the ankle joint and maintain distraction during the postoperative period. The tibial tuberosity was palpated and four fingerbreadths were measured and this was the entry point of the first trans-tibial pin (Arthrex, Naples, FL). A 1 cm longitudinal skin incision was made using a #15 blade. Blunt dissection was then carried down to the level of bone using a curved hemostat. Next, the tibia was pre-drilled and a 5.0 mm tibial Schanz pin was inserted using a T-handle. The multi-pin clamp was then applied to the tibial Schanz pin and used as a drill guide to insert the second tibial Schanz pin which was inserted next. Utilizing fluoroscopic imaging, the trans-tibial pins were noted to be bi-cortical and of appropriate length and orientation. Next, attention was directed to the medial aspect of the calcaneus where 1 cm longitudinal skin incision was made using a #15 blade.

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Figure 1 Preoperative radiograph showing a completely displaced talar dome fracture.

Blunt dissection was carried down to the level of bone using a curved hemostat. Utilizing fluoroscopic imaging, a 6.0 mm trans-calcaneal pin was then inserted. The tibial and calcaneal clamps were then connected with carbon fiber bars. While the ankle was maximally distracted, with manual distraction of the transcalcaneal pin, the assistant surgeon locked the construct into place.

Next, an open incisional approach allowed for visualization, reduction and fracture stabilization. We created a 10 cm longitudinal skin incision over the anterolateral ankle gutter. The incision started 2 cm proximal to the syndesmosis, traversing the ankle joint, and curving medially over the lateral border of the talus. As expected, the superficial peroneal nerve and its terminal divisions were encountered and subsequently protected throughout the entirety of the case. Next, the deep fascia was incised utilizing dissection scissors. The extensor digitorum longus tendon was retracted laterally and a capsular incision was made into the ankle joint, exposing the displaced talar dome fracture fragment. The fragment was then excised and prepared for reinsertion (Figure 3).

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Figure 2 CT scan showing dislocated talar dome fracture.

Fracture hematoma and any loose, overhanging soft tissues were excised. The ankle was then flushed with copious amounts of sterile saline. The fragment was reinserted into the ankle joint, and delicately placed in its anatomical position. Two 18 mm x 1.3 mm bioabsorbable poly-L-lactic acid Chondral Darts (Arthrex, Naples, FL) were then inserted in the anterior and posterior aspects of the fracture. With the limited access in the ankle joint, the pins were still placed in a diverging manner to provide greater capture and stability (Figure 4).

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Figure 3 Excised fragment measuring approximately 2.5 cm x 1.5 cm.

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Figure 4 Fragment re-implanted and fixated with bioabsorbable pins.

Intraoperative imaging confirmed clinical findings that the fracture was reduced and the talar dome restored.

Preoperative radiographs were suspicious for a distal tibiofibular diastasis which could not be ruled out given the rotational mechanism of injury. We tested the stability of the syndesmosis intra-operatively utilizing the Cotton hook test [7].

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Figure 5 Successful application of suture button and external fixator.

This was done by applying a laterally-directed force on the fibula with a towel clamp which resulted in lateral translation of the fibula with respect to the tibia. Therefore, we made an intraoperative decision to transfix the syndesmosis. First, a periarticular clamp was placed perpendicular to the axis of the ankle joint, reducing the syndesmosis which was confirmed on fluoroscopy. Next, the syndesmosis was stabilized using knotless, trans-syndesmotic Tightrope® fixation (Arthrex, Naples, Florida).

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Figure 6 Radiograph 12 weeks postoperative.

Figure 7 Radiograph 16 weeks postoperative.

Final images were taken and the ankle was noted to be maintained in distraction, the syndesmosis reduced with the Suture Button system applied appropriately and the fragment restored to anatomic position (Figure 5). The incision was closed with vicryl sutures and stability was maintained through the external fixation.

He went on to heal uneventfully, without soft tissue complications, paresthesias or limitations in range of motion. The external fixator was removed after 6 weeks. Immediately thereafter, the patient began home physical therapy with ankle strengthening and range of motion exercises. By postoperative week 9, he started placing more pressure on his foot, partial-weight bearing in a pneumatic boot as he transitioned off crutches. By 12 weeks, he was completely off crutches and partial weight bearing in his boot.

Radiographs demonstrated progression of bone consolidation and maintained alignment (Figure 6). At 16 weeks he was back in his shoes and without pain or limitations. Radiographs appear normal but bony exostoses were beginning to form at the medial malleolus and medial talus.

There were no restrictions of motion upon physical exam (Figure 7). At the 18-month follow-up he stated he had been back to his regular daily activities, including basketball, with no reports of pain. Radiographs show excellent restoration of the talar dome and ankle mortise. Bony exostoses are noted but incidental and asymptomatic (Figure 8). According to the AOFAS Ankle-Hindfoot Scale (AHS) the patient scored 100 points and the patient is very pleased with his outcome, lack of pain and level of function.

Discussion

Osteochondral lesions (OCLs) of the talus are rare in terms of overall fracture type in the lower extremity, however, they can be present in more ways than one might think. Lambers et al. retrospectively reviewed data of a prospective cohort of 59 patients and showed the prevalence of OCLs of the talus in ankle fractures with syndesmotic instability was 14% with most lesions located on the lateral talar dome [8]. This is consistent with the mechanism of injury and location of fracture of the case presented. Conversely, Raikin, et al., reviewed 428 ankle MRIs and found that the medial talar dome was most involved 62% of the time and, of those, the medial and mid zone was affected 53% [9]. Whereas these lesions are typically more superficial, the case presentation here focused on a dislocated, larger fracture segment of the lateral talar dome and this has not been explained much in our literature.

Figure 8 Radiographs one year postoperative.

Diagnosis of OCLs may be elusive during the early stages of patient complaints and can result in a delayed diagnosis [10]. In our case, the patient had a completely detached and 180-degree rotated large fracture so diagnosis was clear and straightforward. In addition to the standard preoperative radiographs, we ordered a CT scan to get a more accurate depiction of the lesion. CT scans can help identify the amount of bone involvement in an OCL and help in determining ideal fixation methods [10].

Multiple treatment options are available for OCLs of the talus and arthrodiastasis is among the preferred options. Arthrodiastasis has been shown to benefit patients significantly in the short- and long-term in prevention of post-traumatic ankle arthritis. However, ankle arthrodiastasis is considered a salvage procedure and most often a last-ditch effort prior to fusion or ankle implant arthroplasty [11-12]. Although the present case did not have a patient with ankle arthritis, we used this option to slow the progression of future osteoarthritis.

Joint distraction is not only used in the ankle, it is also used in the hip and knee with good long-term outcomes [13-14]. Furthermore, joint distraction is also used in other aspects of the foot and ankle. Dayton, et al., published a review describing a percutaneous technique for calcaneal fractures. They concluded that their patients’ return to function was similar or better than after open reduction, and their soft tissue complication rate was much lower [15]. In ankle joint distraction, it’s recommended to obtain at least 5 mm of distraction [11]. We achieved 2.7 mm of joint distraction which was measured from the calibrated from the postoperative radiographs via the PACS program.

Arthrodiastasis is based on the theory that osteoarthritic cartilage has healing capacity. The chondrocyte repair is nourished by intra-articular fluid pressure changes within the joint by movement with the use of hinges in the external fixator or by allowing the patient to walk with the frame in place. This allows intermittent increases in hydrostatic pressure, creating a supportive environment for cartilage repair [11]. In our case we used a static external fixator and made the patient non-weight bearing due to the fact that the patient had a displaced talus fracture that was reduced using open reduction internal fixation. The arthrodiastasis effect is difficult to evaluate individually. The authors believe the external fixation provided added benefit of maximal ankle immobilization as the bioabsorbable pins maintained position but did not affect much compression or maximum fracture stability.

In conclusion, our case report describes the use of open reduction and internal fixation of a large, completely dislocated lateral talar dome fracture fixated with bioabsorbable fixation and further stabilized with external fixation ankle arthrodiastasis. Valderrabano, et al., completed a study of 390 patients and found that talus fractures accounted for 2% of patients acquiring post traumatic ankle arthritis [17]. Lastly, Nakasa, et al., showed favorable outcomes utilizing bioabsorbable PLLA pins even in those patients who had disruption of the subchondral plate (18). We supplemented our fixation with a delta frame in order to provide the patient with greater stability and to allow for ankle joint distraction. We felt that this was appropriate for a patient of his age to slow the progression of ankle osteoarthritis. At 1.5 years postoperative assessment, our patient is without pain, functioning without limitation and pleased. This treatment approach may be beneficial in patients presenting with similar pathology. Further research investigating the risk of post traumatic ankle arthritis is needed to better understand long-term outcomes with this procedure.

References

  1. Zenegrink M, Struijs PA, Tol J, van Dijk C. Treatment of Osteochondral Lesions of the Talus: A Systematic Review. Knee Surg, Sports Traumat, Arthroscopy 8(2):238-246, 2010.
  2. Fortin, P. and Balazsy, J. Talus Fractures: Evaluation and Treatment. Journal American Acad of Ortho Surgeons 9(2):114-127, 2001.
  3. Higgins, T. and Baumgaertner, M. Diagnosis and Treatment of Fractures of the Talus: A Comprehensive Review of the Literature. Foot Ankle Int 20(9):595-605, 1999.
  4. Berndt, A. and Harty, M. Transchondral Fractures (Osteochondritis Dissecans) of the Talus. The J Bone Joint Surg Am 41(7):988-1020, 1959.
  5. D’Angelantonio AM, Schick FA. Ankle Distraction Arthroplasty Combined with Joint Resurfacing for Management of an Osteochondral Defect of the Talus and Concomitant Osteoarthritis: A Case Report. J Foot and Ankle Surg 52(1):76-79, 2013.
  6. Belczyk R, Stapleton JJ, Zgonis T, Polyzois VD. A Case Report of a Simultaneous Local Osteochondral Autografting and Ankle Arthrodiastasis for theTreatment of a Talar Dome Defect 26:335-342, 2009.
  7. Cotton FJ. Fractures and Joint Dislocations p 549. WB Saunders, Philadelphia, 1910.
  8. Lambers KA, Saarig A, Turner H, Stufkens SA. Prevalence of Osteochondral Lesions in Rotational Type Ankle Fractures With Syndesmotic Injury. Foot Ankle Int 40(2):159-166, 2019.
  9. Raikin SM, Elias I, Zoga AC, Morrison WB, Besser MP, Schweitzer ME. Osteochondral Lesions of the Talus: Localization and Morphologic Data from 424 Patients Using a Novel Anatomical Grid Scheme. Foot Ankle Int 28(2):154-61, 2007.
  10. Talusan PG, Milewski MD, Toy JO, Wall EJ. Osteochondritis Dissecans of the Talus: Diagnosis and Treatment in Athletes. Clin Sports Med 33:267-284, 2014.
  11. Kluesner AJ, Wukich DK. Ankle Arthrodiastasis. Clin Podiatr Med Surg 26:227-244, 2009.
  12. Labovitz JM. The Role of Arthrodiastasis in Salvaging Arthritic Ankles. Foot Ankle Spec 3(4):201-204, 2010.
  13. Hosny GA, El-Deeb K, Fadel M, Laklouk M. Arthrodiastasis of the Hip, J Pediatr Orthop 31(2):S229-234, 2011.
  14. Jansen MP, Besselink NJ, van Heerwaarden RJ, Custer RJ, Emans PJ, Spruijt S, Mastbergen SC, Lafeber FP. Knee Joint Distraction Compared with High Tibial Osteotomy and Total Knee Arthroplasty: Two-Year Clinical, Radiographic, and Biochemical Outcomes of Two Randomized Controlled Trials. Cartilage, 2019.
  15. Dayton P, Feilmeier M, Hensley NL. Technique for minimally invasive reduction of calcaneal fractures using small bilateral external fixation. J Foot Ankle Surg. 53(3):376–82, 2014.
  16. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of Ankle Osteoarthritis. Clin Orthop Relat Res 467(7): 1800-1806, 2009.
  17. van Valburg AA, van Roermund PM, Lammens J, van Melkebeek J, Verbout AJ, Lafeber EP, et al. Can Ilizarov joint distraction delay the need for an arthrodesis of the ankle? A preliminary report. J Bone Joint Surg Br. 77(5):720–5, 1995.
  18. Nakasa T, Ikuta Y, Tsuyuguchi Y, Ota Y, Kanemitsu M, Adachi N. Fixation Technique Using PLLA Pins Gives Good Clinical Results Regardless of Bone Condition in Osteochondral Lesion of Talar Dome. Foot & Ankle Orthopaedics. 2019 Oct 1;4(4):2473011419S0031.

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Limb salvage in Charcot deformity correction: A case series of 20 limbs

by Jordan James Ernst, DPM, MS, FACPM1*; Dalton Ryba, DPM2; Alan Garrett, DPM, FACFAS3

The Foot and Ankle Online Journal 13 (4): 4

Charcot arthropathy is a disabling complication of peripheral neuropathy, with progressive osseous destruction often necessitating operative intervention to prevent ulceration and even amputation. The prospect of a stable, plantigrade foot is one that is best sought through timely intervention. While a host of procedures and techniques for Charcot reconstruction have been described in the literature, no clear consensus has been reached on a superior method or modality, nor on what factors most significantly affect outcomes and complications. We present a case series of 18 patients (20 limbs) operatively treated at our institution and followed for an average of 3 years for Charcot deformity. Reconstructive efforts consisted of both internal and internal fixation, and combinations thereof. To date, 1 patient has received a below-knee amputation. At 3 years (range 12-50 months), 80% of our limbs have shown that our interventions have provided lasting correction and defense against future ulceration and other undue sequelae. Three limbs remain affected by ulceration. In total, 95% of limbs have avoided major amputation. Our results appear comparable with the available literature. While successful results are being achieved in this endeavor, many questions remain unanswered, awaiting higher levels of empirical evidence to aid in their resolution.

Keywords: diabetic foot, arthrodesis, reconstruction, external fixation, beaming, tibiotalocalcaneal fusion, arthropathy

ISSN 1941-6806
doi: 10.3827/faoj.2020.1304.0004

1 – Fellowship-Trained Foot and Ankle Surgeon, Texas Institute of Orthopedic Surgery and Sports Medicine, Grapevine, TX
2 – Foot and Ankle Surgeon, Lone Star Orthopaedic and Spine Specialists
3 – John Peter Smith Hospital, Foot and Ankle Surgery, Dept. of Orthopedics, Acclaim Bone and Joint Institute
* – Corresponding author: jordanj.ernst88@gmail.com


Charcot arthropathy, a potentially disabling complication of peripheral neuropathy, often demands surgical intervention due to the progressive nature of osseous destruction, which, when left unabated, may lead to deformity susceptible to ulceration, infection, and ultimately, amputation. Surgical intervention is often necessary to create a stable, plantigrade foot that is less prone to ulceration. While a host of procedures and techniques for Charcot reconstruction have been described in the literature, no clear consensus has been reached on a superior method or modality, nor has a deformity-specific correction algorithm been established.

In addition to procedural selection, operative timing with respect to stage of deformity has not been clearly defined. Despite this, failed conservative management, recalcitrant ulceration, continued pain secondary to residual bony deformity, and as a final effort to avoid amputation remain the primary surgical indications [1].

The insensate foot is one that is prone to recurrent, unperceived trauma. Continued ambulation, coupled with neuropathic joint relaxation and hypotonia, allows for progressive osseous destruction that compromises the pedal architecture. Loss of vasomotor tone, as a result of autonomic neuropathy, allows shunting within the Haversian system, increasing bone perfusion with subsequent demineralization and, eventually, osteopenia. The resultant abnormal bone is ill equipped to protect the vulnerable joints from the aforementioned neuropathic destruction and deformity. As each case of Charcot deformity is unique, largely due to patient physiology and pattern of destruction, direct comparison of fixation techniques and patient cohorts may not be feasible. Despite this lack of standardization, sound understanding of the principles of each surgical technique remains the mainstay of enabling a surgeon to devise a construct that will have the most effectual outcome.

The aim of our study was to review, at midterm follow up, the outcomes of 20 limbs post Charcot deformity correction. We deemed a successful outcome as a stable, ulceration free limb allowing for ambulation. A limb with remaining wound or ulceration, or one that underwent major amputation, was regarded as an unsuccessful outcome.

Case Series

From February 2010 to July 2017, 26 limbs in 24 patients were treated consecutively at our institution for Charcot deformity of the midfoot, rearfoot, and ankle, or combinations thereof, with at least 12 months of follow up available. Our institutional review board approved this retrospective case series. Of these patients, we excluded one patient who was treated at an outside institution between treatments at our institution, one patient who died due to unrelated causes, and 4 others who were lost to follow up as they had not been seen at our institution in over 1.5 years. Inclusion for operative reconstruction included recurrent ulceration despite conservative measures. We prefer to avoid surgical intervention in those with a closed soft tissue envelope though deformities that were deemed unbraceable and neuropathic fractures/dislocations that were complicated by Charcot destruction were also included. We did not elect to perform a reconstruction for any patient who would have clearly been better served with a proximal amputation. In deciding between conservative and surgical intervention, we carefully weighed the risks and benefits of each potential treatment including the location and magnitude of deformity, patient willingness and ability to comply with post-operative instructions, comorbid conditions, glycemic control, vascular status, family support, social issues, wound presence with or without concurrent infection, and others. Notably, reliance on casting/bracing to contain the deformity, skin breakdown, deep vein thrombosis, and contralateral Charcot development are of special concern in patients undergoing conservative approaches. In total, 20 limbs in 18 patients met our study criteria.

In some patients, after successful Charcot reconstruction at a given anatomic location, the patient later incurred a Charcot event at a separate site within the same extremity. In these instances, for calculating wound duration preoperatively and time in external fixation, the total time for all patients combined was divided by the total number of “Charcot events” (and thus reconstructions) rather than number of limbs. This was performed to avoid artificially higher average time intervals that would have been produced by attributing the pre-operative wound time and external fixation time for multiple surgeries to one limb. In total, 24 reconstructions were performed as 4 of the 20 limbs underwent surgical correction of a repeat Charcot event.

A complete review of the medical charts including radiographs were performed to gather the data for our study. In addition to demographic information, the following variables and parameters were recorded: the location(s) of the deformity, primary and adjunctive procedures performed, date of index and subsequent surgeries, presence of wound(s) and osteomyelitis, time to wound healing, wound duration prior to surgery, percentage of patients obtaining a Charcot Restraint Orthotic (CRO) walker post operatively, complications, comorbid conditions, tobacco use, Hg A1C%, prior pedal amputations, date of last follow up, and total follow up time.

Of the 20 limbs, 6 had Charcot deformity of the ankle (Brodsky 3A), 5 had deformity in the rearfoot/Chopart’s joint (Brodsky 2), 17 demonstrated abnormality at the midfoot/Lisfranc joint (Brodsky 1), and 1 patient developed a Charcot process to the calcaneal tuber (Brodsky 3B). Additionally, 5 of these patients presented with combined Brodsky 1 and 2 deformities.

Our patients, on average, were afflicted by 4.3 comorbid conditions. Diabetes was responsible for the neuropathic process in 14 patients, idiopathic causes in 2, spinal stenosis in 1, and Lupus in 1. Eight patients had a history of cardiac disease, 1 of CVA, 3 of COPD, 2 of chronic kidney disease (1 ESRD), 2 of psychiatric disorders, and 3 of hepatitis. Peripheral vascular disease affected 1 patient. Ten patients had a history of tobacco use. The average A1C value in those with diabetes preoperatively was 9.3%.

The average patient age was 55.7 years, there were 9 females and 9 males. Average BMI measured 34.6kg/m2.

Operative Procedures

All procedures were performed by the senior author. Two reconstructions were performed during the acute phase of the disease (Eichenholz I), and the remainder were performed during the inert phase (Eichenholz stage II/III), all after distal perfusion had been deemed appropriate.

The index procedures were performed at the location of existing deformity, with subsequent surgery (subsequent Charcot event) performed at the new location of deformity.

Seven patients underwent columnar beaming (example in Figure 4), one medial column plating and screw fixation, one medial double screw fusion, and one medial column screw fusion. All but one of these constructs was augmented with application of a static circular frame. Three underwent plantar midfoot planing with placement of external fixation alone.

One patient underwent bilateral beaming in a staged fashion. The other patient who underwent bilateral procedures was treated for a calcaneal avulsion fracture on the right side with fragment excision, achilles tendon reattachment via anchors, and flexor hallucis longus transfer. Contralaterally, he developed midfoot, and then, ankle deformity, treated sequentially with external fixation and planning and TTC fusion respectively.

Regarding the 5 tibiotalocalcaneal (TTC) fusions, 3 underwent intramedullary nailing. In one such case, nailing initially proved effective but was compromised by late infection. Limb salvage was achieved with the use of a titanium cage after temporization with an antibiotic nail (Figure 1). The other 2 patients underwent lateral TTC plate and screw fixation (Figure 3) constructs respectively, as prior hardware precluded intramedullary nailing. In 4/5 TTC fusions, a static circular frame was applied over the respective fusion construct. Two intramedullary nails were placed after arthroscopic ankle preparation. In these cases, there was not yet flagrant malalignment necessitating an open approach. With open approaches, we formally prepare the subtalar joint with our constructs. The necessity for this has been debated [2].

Two patients underwent medial Lisfranc fusion with external fixation utilizing olive wires and no additional hardware. These were performed for severe dislocations in the acute phase that threatened soft tissue integrity. No limbs underwent concomitant TTC fusion and midfoot bolting as we did not treat a patient with simultaneous deformity. However, 4 patients that received midfoot reconstruction subsequently underwent treatment for deformity at the ankle. An additional patient, who was treated for midfoot disease and then later developed ankle pathology, underwent a below-knee amputation (BKA) for concomitant ankle abscess and systemic sepsis (Figure 2).

The remaining patient underwent ankle fusion by way of external fixation alone given the attendant joint sepsis.

Cases of soft tissue infection were treated with thorough irrigation and debridement with appropriate antibiotic therapy. Osteomyelitis was treated with bone resection as necessary with infectious disease consultation to manage prolonged antibiotic therapy.

Results

Eighteen patients for a total of 20 limbs (2 patients with bilateral reconstructions) were operatively treated at our institution and followed for an average of 3 years for Charcot deformity. Given the 20% rate of a repeat Charcot reconstruction, 24 reconstructions were performed in total (4 repeat Charcot reconstructions for patients who developed ankle disease after midfoot surgery). To date, 1 patient has received a BKA. Overall, 80% of our limbs have obtained a successful outcome. Three limbs remain affected by ulceration, 2 of which had wounds preoperatively. In total 95% of limbs have been salvaged or remain salvageable.

With respect to primary midfoot/hindfoot reconstruction, there were 17 such cases. As mentioned, 5 developed subsequent disease of the ankle, with 3 out of 4 attempted ankle reconstructions obtaining salvage, and in the remaining patient salvage not attempted due to emergent infection (BKA). Of the remaining 12 primary midfoot/hindfoot reconstructions, 10 limbs were salvaged. One patient in this group underwent bilateral midfoot reconstructions in a staged fashion.

Figure 1 This patient incurred separate Charcot events at both the midfoot and then the ankle, approximately 3.5 years apart. Panels a, b show his presentation after his ankle Charcot event. He had been treated by our team with external fixation and planing after a failed midfoot fusion several years prior at another facility. His midfoot hardware was removed and the ankle addressed with TTC nail fusion (c,d), the tract of which can still be appreciated within the tibial medullary canal (k,l). The nail was removed due to a chronic non-union with superimposed late infection (e,f), and a titanium cage was placed (i,j) after temporary fixation with an antibiotic nail (g,h). At last follow-up, a pseudoarthrosis is appreciated about the titanium cage (k,l). Clinical view of patient (m,n,o): A stable, plantigrade foot is demonstrable, despite the pseudoarthrosis, which has been maintained with his CRO Walker. We see him periodically in the clinic for surveillance exams.

Figure 2 This patient underwent Charcot reconstruction of his midfoot during the acute phase of the destructive process, clinical photo in panel a. Deformity appeared isolated to the LisFranc complex but was grossly unstable as evidenced by the divergent pattern of dislocation seen on his ED radiographs (b,c). Given the tenuous soft tissue, we elected to utilize an external fixation only construct to reposition the gross malalignment of the midfoot via olive wires (d,e). The patient coalesced successfully in an acceptable position (f,g). He ambulated ulceration free for 4 months before presenting to the ED with an ankle abscess and in a septic state. No open wounds were present but soft tissue emphysema was seen on x-ray over an area of the medial ankle where an obvious abscess was present (h). An emergent bedside incision and drainage was performed in the ED (i) before he was taken to the operative theater for a guillotine BKA. It appears that when he presented in sepsis he was undergoing a Charcot process about the ankle (h). The relationship of the Charcot event to the abscess is unclear, although we have encountered Charcot flares complicated by abscess without open wounds previously. This example highlights that with Charcot correction, success is never absolute.

Figure 3 This patient was initially treated for a Charcot deformity with plantar planing and external fixation application for a midfoot prominence and resultant ulceration (a). After successfully healing his ulceration and removal of the external fixator, he presented back to the clinic a few months later with a gross varus deformity at the ankle, and lateral malleolar wound, after a period of admitted unprotected ambulation. Radiographs revealed a pathologic bimalleolar fracture and severe varus deformity of the ankle (b,c). As a broken half pin from his prior external fixator obstructed the tibial canal, he underwent TTC fusion via large diameter cannulated screws. The wound was excised through a lateral approach that entailed fibular takedown, subtalar and ankle joint preparation, and corrective cuts to the tibia and talus to realign the rearfoot and ankle to the leg. An external fixator was placed to extend the area of stability beyond the fusion sites (d,e). Radiographs at final follow-up reveal good osseous union to the ankle and subtalar joints with maintained deformity correction (f,g).

Figure 4 Example of medial column bolting. A midfoot Charcot process in the quiescent phase as demonstrated by the partial coalescence and lack of bony fragmentation (a,b). Note the plantar subluxation of the midfoot on the rearfoot, most demonstrable at the talonavicular joint (b). Significant osseous resorption is seen at the intermediate cuneiform which is displaced medially along with the medial column (a). Medial column bolting was utilized to restore stability and correct deformity. This was enhanced with the application of a static external fixator to extend fixation beyond the joint segments affected by the neuropathic process (c,d). Radiographs at final follow up reveal maintained correction (e,f). The joints were not formally prepared in this instance, though it has become our preferred technique to do so.

As stated, the 4 repeat Charcot reconstructions were patients who developed disease of the ankle after undergoing midfoot reconstruction. Three of these limbs were ultimately salvaged, with 1 afflicted with persisting ulceration. In total, of the 7 patients with ankle deformity, 5 were salvaged. These include the 3 that were successfully reconstructed subsequent to midfoot reconstruction and 2 primary ankle salvages. The 2 remaining patients were the patient relegated to BKA and the patient with failed ankle salvage after prior midfoot surgery.

In 1 patient, calcaneal avulsion repair with FHL transfer was performed successfully on one side with primary ankle salvage performed on the contralateral side at a later date (1 of 2 patients with primary ankle salvage).

In total, there were 20 primary limb reconstructions, 17 of the midfoot/hindfoot, 2 of the ankle, and 1 of the calcaneal tuber.

The average A1C value in those with diabetes preoperatively was 9.3%. The average A1C in those still with unsuccessful outcomes was 8.3%, while in those with successful outcomes averaged 9.7%. Four patients had a history of amputation within the forefoot. Total time in the external fixation device averaged 2.8 months. Twelve limbs (60%) had ulcerations preoperatively, 3 wounds were complicated by underlying osteomyelitis. At the time of frame removal, 10 of the wounds had healed. The other 2 patients with preoperative wounds have maintained their limbs but are still with wounds, 1 with prior osteomyelitis. Average wound time prior to surgery was 11.2 months. Pin tract infections occurred in 6 frames, wires broke in 2, one of which with concomitant infection that prompted premature frame removal. Other complications included 1 abscess formation, 1 case of non-pin tract cellulitis, 1 incision dehiscence, and 1 decubitus ulceration. Descriptive characteristics of the study population can be seen in Table 1.

Ulcer Free Limbs:

16 Limbs

15 Patients

Limbs with Ulceration/BKA:

4 Limbs

4 Patients

Total study population:

20 Limbs

18 Patients

Gender 6 M, 8 F 3 M, 1 F 9 M, 9 F
Age (years) 56.8 51.5 55.7
Follow – Up (months) 37.2 32.3 36.4
Laterality 9 R, 5 L 3 R, 1 L 12 R, 8 L
BMI (kg/m2) 35.2 32.3 34.6
Diabetes-related neuropathy (limbs) 12 3 15
A1C 9.7% 8.3% 9.3%
PVD 0 1 1
Comorbid Conditions (Avg #) 4.1 5 4.3
Tobacco Use 60% 50% 55.6%
Cardiac disease 6 3 8
ESRD 0 1 1
Number of pre-operative wounds and duration 10 Limbs

10.6 months

2 Limbs

14 months

12 Limbs

11.2 months

Osteomyelitis (limbs) 2 1 3
Time In External Fixation per Events (months) 2.8 2.9 2.8
Repeat Charcot Events

(Limbs)

3 2 5
Prior Forefoot Amputations (limbs) 2

1 ipsilateral

2

2 ipsilateral

4

3 ipsilateral

Location of Deformity
Ankle/Hindfoot 5 2 7
Midfoot/Hindfoot 13 4 17
Procedures Performed
TTC/TC/Ankle Fusion 5 1 6
Midfoot and Combined Midfoot/Rearfoot Fusions 7 3 10
Midfoot Fracture-Dislocation Correction with External Fixation Alone 1 1 2
Planing with ex-fix alone 5 0 5
Calcaneal Avulsion Repair 1 0 1

Table 1 Descriptive summary of patient population averages. *Note the number of patients with a salvaged limb and those with an unsalvaged limb do not equal the total number of patients as one patient had successful reconstruction on one side and failure of the contralateral extremity (both midfoot reconstructions).

Discussion

Limb salvage rates in patients undergoing Charcot reconstruction are reported with great variability in the literature. With any of these data points, it is important to consider that each surgeon has an individualized selection bias to their respective patient population. While certain indications for Charcot correction have been developed, each cohort is ultimately that surgeon’s unique population deemed appropriate for surgical intervention. As such, there is likely heterogeneity when comparing patient populations undergoing Charcot reconstruction. As previously mentioned, the choice to attempt reconstruction in a patient with Charcot deformity is multifaceted, and often difficult. Zgonis has described the choice between conservative measures and surgical intervention in Charcot patients as the “lesser of two evils” given the significant complications in each [3]. In addition to deciding between reconstruction and non-operative care, amputation is an alternative in many patients. Clearly, limb salvage should not be undertaken in those whose medical status or limited functional capacity would preclude them from ever realizing the benefits of limb salvage. In these patients, this choice can become complex however, as in some patients, the magnitude of the contribution of comorbid conditions versus the limb deformity itself, to lack of function, cannot be easily discerned. No patient in our series requested a below knee amputation, although all patients with Charcot joint disease are made aware from initial diagnosis that the limb is at risk for this outcome. As no patient with emergent infection underwent reconstruction, the procedures could be seen as elective.

Domek, et al., demonstrated that among diabetic patients undergoing elective surgery, the average A1C value of those with postoperative complications was 6.29%, compared with 6.11% for those who did not. Each 1% increase portended a 5% increase in complication risk [4]. Though A1C based risk stratification for diabetic patients undergoing elective procedures has been clearly illustrated, these guidelines are not necessarily best interpreted as concrete “cut off” points when deciding to offer a patient Charcot reconstruction, but rather as a valuable prognostic tool to be considered in the entirety of the clinical situation. Furthermore, bracing in the face of severe deformities is impractical. Ramanujam, et al., have shown that in a cohort of 116 patients with Charcot of the foot and/or ankle treated with external fixation, A1C was not associated with risk of amputation or mortality [5]. A1C Averaged 8.16% in their series, somewhat lower than our average. While not an ideal average, the surgeon must contemplate which scenario offers the best propensity for healing; a wound with an underlying structural abnormality in a patient with an A1C of 9%, or a wound without underlying prominence in that same patient. Those in our study with successful outcomes trended towards higher A1C values. Keeping this in mind, there are undoubtedly patients whose comorbid conditions lack a level of control so great that surgical reconstruction is doomed to failure. The diabetic host with ESRD is one such patient that is often cited as being ill-equipped to convalesce successfully after Charcot reconstruction, given the devastating effects of renal disease on bone metabolism [6] and the sheer mortality associated with the disease [7].

With respect to prior amputations, our results showed that half of those with an unsuccessful outcome had a history of prior forefoot amputation. A greater sample size could ascertain whether prior forefoot amputation is truly an independent risk factor for amputation, or rather a reflection of more severe disease processes in these patients.

Increased morbidity has been reported in Charcot reconstructions in the face of ulceration [5], and internal fixation is often avoided in these cases [8].

Regarding wound presence in our cohort, 10/12 (83.3%) patients with preoperative wounds obtained successful outcomes compared to the overall success rate of 80%. Of the 3 patients who remained with ulceration or wound at the end of our study period, 2 had wounds preoperatively.

In considering the success of our interventions, 80% of these patients ultimately achieved the goals of reconstruction, a plantigrade and functional extremity without a predilection for re-ulceration. In measuring the merit of our interventions however, we must also examine the effect of our interventions on those in whom reconstruction has not attained the desired outcome. One patient underwent major amputation as a result of infection not directly related to our intervention. In assessing the 3 patients in whom wound healing has not been achieved, 2 had wounds pre-operatively. The one postoperative wound developed from non-compliance from the patient wedging her external fixator around her wheelchair footrests to create a decubitus heel ulceration. No wounds were complicated with infection at last follow up. We feel that while 100% success has not been obtained, we have stayed true to the bioethic of non-maleficence or “Primum non nocere”. All 3 of these limbs remain salvageable, and a non-healing wound was never created by our surgical approach.

While the risk of contralateral Charcot after an initial event is well documented in the literature [3], less information has been assembled on the risk of a Charcot event within the same limb at a secondary location. In our series, 5 patients (25% of limbs) developed ankle Charcot deformity after having undergone treatment for breakdown at the midfoot level, comprising 5/17 of all patients treated for midfoot disease. One had been treated with bolting of the midfoot, 3 with external fixation alone, and 1 with plating. Of these 5 patients, 4 admitted to a period of non-compliance with their CRO walker, and 1 had declined CRO walker fitting and instead ambulated in a custom-made gauntlet AFO. On average, the Charcot events were separated by 2.3 years. Given our sample size, we cannot speculate on the potential risk for a repeat Charcot event within the same limb. Clearly, it would stand to reason that if one segment of the pedal framework is fused, the adjacent segments are placed under increased demand, and thus at increased risk for overload and collapse. To what extent this is true and the relationship between various anatomical zones remains to be seen [9]. Increased understanding of ipsilateral Charcot events could potentially affect future fixation methods. To our knowledge, the percentage of this occurrence has not been documented. Our rate of 25%, while seemingly high, does not have a reference standard for us to compare our outcomes. Perhaps our results are an aberration, or non-compliance was the culprit, or perhaps our follow up of 3 years was simply long enough to realize a potentially underreported sequela. The rate of contralateral Charcot has been reported to be approximately 25%, [10] matching our value for ipsilateral deformity. In our population, 2 patients were surgically treated for contralateral deformity, however more potentially had contralateral Charcot deformities that were treated conservatively, so we did not attempt to compare rates of contralateral versus ipsilateral Charcot in our own series. One of our patients with bilateral deformity at the midfoot level was treated successfully on one side, but remains with an ulceration on the contralateral extremity.

While we routinely obtained radiographs after Charcot reconstruction, we did not include rates of union in our series. LaFontaine has described the abnormal character and cellularity of this bone [11]. This type of bone not only demands more robust fixation, but also has suboptimal reparative capacity. At times, unconventional fixation is required, as in our TC fusion with a titanium cage. This method is touted to facilitate osseous formation through structural mechanics rather than through copious biologics. Via load transfer and its open architecture allowing for graft incorporation, the device is said to actively participate in the healing process [12]. In the absence of radiographic evidence of hardware failure or frank peri-implant fracture, we deem clinical union to be of greater importance in determining weight bearing progression in Charcot patients. Wiewiorsky, et al., elaborated that complete osseous union is not a definite prerequisite for stability [9]. All wound-free patients in our series were instructed to advance to weight bearing in a CRO walker once clinically stable. All but 3 of our wound free patients obtained a CRO walker device. At our institution, we routinely have patients fitted for a CRO walker in the post anesthesia unit after frame removal. Coordination of this effort preoperatively with the prosthetist is key to minimizing the patient’s time to obtaining the device, and therefore their risk of collapse. While waiting for their custom device to be manufactured, a fracture boot is utilized for weight bearing in a controlled environment such as the home or a rehabilitation facility.

With regard to fixation options, progress has been made to discern the general trends and outcomes with various fixation methods, but also to develop and refine techniques for improved success.

Dayton, et al., in their systematic review comparing internal and external fixation for Charcot deformity, presented general concepts of fixation methods [8]. They elaborate that internal fixation has a greater degree of comfortability, being a technique surgeons are most often more familiar with and perceive as being more straightforward. External fixation, while potentially more technically demanding, offers a less invasive approach that ultimately yields a platform for soft tissue preservation while allowing an adjustable design with a wide range of stability.

Their results elucidated several trends in fixation choice. They noted internal fixation tended to be the method of choice when ulceration or osteomyelitis were absent. In contrast, external fixation was most often employed when osteomyelitis or wounds were present. This method was also often staged to afford limb salvage and allowed for earlier weight bearing. Overall, the odds of success with internal fixation was 0.52 times as likely as with external fixation, despite the higher usage of external fixation in more complicated cases.

While internal and external fixation each have merits of their own [1,5] combining the two methods may provide a more favorable outcome [13,14]. Hagewald, et al., in a series of 22 patients with Charcot deformity without osteomyelitis, were able to attain a 91% incidence of short term (58 weeks) limb-salvage utilizing a combined approach. Flap closure was used for wound coverage in the 8 patients with ulcerations [14].

Lamm and colleagues obtained impressive results with a novel two-stage approach to midfoot Charcot deformity correction [15]. Their protocol first obtains correction through gradual distraction and realignment with a Taylor Spatial Frame. Prior to application, a percutaneous Gigli saw osteotomy is performed across the coalesced midfoot to allow for manipulation of the forefoot on a fixed hindfoot, utilizing wires affixed to the frame on either side of the osteotomized segment. This correction is successively maintained with a minimally invasive arthrodesis technique consisting of percutaneously inserted partially threaded, cannulated, intramedullary metatarsal screws after frame removal. The guidewires are used to stabilize the foot before the frame is removed.

All patients underwent Ilizarov external fixation, with additional internal fixation at the location(s) of deformity and bone resection as needed. The authors contend this approach may be especially beneficial in those patients with bone quality insufficient to rely solely on internal fixation, thus requiring stabilization away from the internal site of correction. While the results of dual fixation appear promising, a recent systematic review did not reveal any added benefit of combined fixation [16].

One of the tenants of the Charcot reconstruction “superconstruct” is to extend the area of fixation beyond the osseous segments affected by the neuropathic process [17]. In many of our constructs, a static circular fixator fulfilled this objective whether in isolation or combined with internal fixation. Combined fixation was utilized in 14/24 (58%) of our reconstructions.

In a review of the Charcot literature in the last 5 years, it would seem that the most common location of deformity undergoing operative intervention is that of the hindfoot and ankle [16]. There appears to be a reduced trend for surgical treatment of midfoot Charcot deformity. Lamm advocates primarily for non-operative care in Charcot deformities limited to affliction at the Lisfranc complex, given the inherent anatomic stability at this location [18]. In our current study, two patients with isolated Lisfranc deformity were treated surgically. The remaining patients with Lisfranc degeneration also had pathology at the more proximal midfoot and Chopart’s joints that warranted remedial alignment with fixation.

Our study had a number of limitations. The most notable methodological weakness is the retrospective nature of the design. Two authors were responsible for gathering, compiling, and analyzing data from the patient medical records. This could have inadvertently increased the potential for bias in our results. Additionally, this method is somewhat limited by the accuracy and quality of documentation. However, the patient records were thoroughly reviewed by each of the two reviewing authors independently, and a unified agreement was reached regarding any discrepancies. Given our sample size and the diversity of fixation methods and deformities, we could not set out to correlate various patient factors, types of fixation, and deformity level, to the obtained outcomes. The heterogeneity of Charcot deformity both in pattern of deformity and temporality of presentation, together with each unique host, render such undertakings of outcome based comparisons arduous, requiring a multitude of patients. Rather, we contend we have shown that in a high risk patient population affected by Charcot deformity, limb salvage efforts are effective and without undue sequelae. Indeed, high quality randomized controlled trials are not likely warranted or ethical [19]. The systematic review of Schneekloth appears to agree with this sentiment [16]. The authors report that while the overall quality of literature regarding this topic has improved greatly in recent years, evidence concerning the timing of treatment and the use of different fixation methods remains inconclusive. As a whole, they found that approximately 9% of patients undergoing Charcot reconstruction will undergo major amputation.

In summary, 80% of our limbs have obtained successful outcomes at a follow-up of 3 years, providing vivid examples of how Charcot deformity is amenable to, and even mandates a diverse surgical repertoire to obtain a stable, ulceration free limb. In this approach, the utility of external fixation cannot be understated given the increased propensity for limb salvage [8]. We theorize that this approach, together with more aggressive soft tissue coverage, will offer the highest potential for success. Further research may provide the surgeon with greater knowledge with which to temper their decisions rather than to develop an accepted protocol or gold standard of treatment [19]. Increased understanding of the risk for a secondary Charcot event after reconstruction may be a pivotal factor as well. Given these methods and findings, we hope to better arm the reconstructive surgeon for this formidable task. With ongoing treatment, patient recruitment, and analysis, we aspire to develop this work into one which can more clearly aid the limb salvage specialist in their decision making amongst a host of surgical options.

References

  1. Grant WP, Garcia-Lavin SE, Sabo RT, Tam HS, Jerlin E. A retrospective analysis of 50 consecutive Charcot diabetic salvage reconstructions. J Foot Ankle Surg 48:30-83, 2009
  2. Mulhern JL, Protzman NM, Levene MJ, et al. Is subtalar joint cartilage resection necessary for tibiotalocalcaneal arthrodesis via intramedullary nail? A multicenter evaluation. J Foot Ankle Surg 55:572-77, 2016.
  3. Zgonis T, Roukis TS, Lamm BM. Charcot foot and ankle reconstruction: current thinking and surgical approaches. Clin Podiatr Med Surg 24:505-17, 2007.
  4. Domek N, Dux K, Pinzur M, Weaver F, Rogers T. Association between hemoglobin A1c and surgical morbidity in elective foot and ankle surgery. J Foot Ankle Surg 55:939-43, 2016.
  5. Ramanujam CL, Han D, Zgonis T. Lower extremity amputation and mortality rates in the reconstructed diabetic Charcot foot and ankle with external fixation: data analysis of 116 patients. Foot Ankle Spec 9:113-26, 2016
  6. Miller PD. Chronic kidney disease and the skeleton. Bone Res 2:140-44, 2014.
  7. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013. Chapter Five: Mortality, Volume 2.
  8. Dayton P, Feilmeier M, Thompson M, Whitehouse P, Reimer RA. Comparison of complications for internal and external fixation for Charcot reconstruction: a systematic review. J Foot Ankle Surg 54:1072-75, 2015.
  9. Wiewiorski M, Yasui T, Miska M, Frigg A, Valderrabano V. Solid bolt fixation of the medial column in Charcot midfoot arthropathy. J Foot Ankle Surg 52:88-94, 2013
  10. Caputo GM, Ulbrecht J, Cavanagh PR, Juliano P. The Charcot foot in diabetes: six key points. Am Fam Physician 57:2705–10, 1998.
  11. La fontaine J, Shibuya N, Sampson HW, Valderrama P. Trabecular quality and cellular characteristics of normal, diabetic, and Charcot bone. J Foot Ankle Sur 50:648-53, 2011.
  12. Olivares-navarrete R, Hyzy SL, Slosar PJ, Schneider JM, Schwartz Z, Boyan BD. Implant materials generate different peri-implant inflammatory factors: poly-ether-ether-ketone promotes fibrosis and microtextured titanium promotes osteogenic factors. Spine 40:399-404, 2015.
  13. Capobianco CM, Ramanujam CL, Zgonis T. Charcot foot reconstruction with combined internal and external fixation: case report. J Orthopaedic Surg Res 11:5-7, 2010.
  14. Hegewald KW, Wilder ML, Chappell TM, Hutchinson BL. Combined internal and external fixation for diabetic Charcot reconstruction: A retrospective case series. J Foot Ankle Surg 55:619-27, 2016.
  15. Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to charcot diabetic foot reconstruction. J Foot Ankle Surg. 49:517-22, 2010.
  16. Schneekloth BJ, Lowery NJ, Wukich DK. Charcot Neuroarthropathy in Patients With Diabetes: An updated systematic review of surgical management. J Foot Ankle Surg 55:586-90, 2016.
  17. Sammarco VJ. Superconstructs in the treatment of Charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin. 14:393-407, 2009.
  18. Lamm BM. Surgical reconstruction and stepwise approach to acute Charcot neuroarthropathy. In: Zgonis T, editor. Surgical reconstruction of the diabetic foot and ankle, Philadelphia: Wolters Kluwer; 2009, p. 223-29.
  19. Shazadeh Safavi P, Jupiter DC, Panchbhavi V. A systematic review of current surgical interventions for Charcot neuroarthropathy of the midfoot. J Foot Ankle Surg 56:1249-52, 2017.

Distraction osteogenesis for treatment of a shortened first metatarsal after failed first metatarsophalangeal joint arthroplasty

by Tyler Reber DPM1*; Lindsey Hjelm , DPM2; Mallory Schweitzer, DPM, AACFAS3; Craig E Clifford, DPM, MHA, FACFAS, FACPM4

The Foot and Ankle Online Journal 13 (3): 9

Distraction osteogenesis is well documented in the literature as a viable treatment option for large bony defects and brachymetatarsia. Few studies have examined the use of this technique after failed arthrodesis or arthroplasty of the 1st metatarsophalangeal joint (MPJ). Acute correction with autograft is typically the procedure of choice for treatment of defects of the 1st MPJ. However, the amount of length that can be achieved is limited in acute correction and distraction osteogenesis should be considered for larger defects. This case study presents our treatment of a failed first MPJ arthroplasty that resulted in a defect at the 1st MPJ of greater than 2 centimeters and our technique of using external fixation followed by internal fixation to regain desired length and minimize time in the external fixator.

Keywords: Distraction osteogenesis, external fixation, monolateral rail, mini rail, failed 1st metatarsal arthroplasty, infected implant

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0009

1 – Resident Physician, PGY-2, Franciscan Foot & Ankle Institute, Federal Way, WA
2 – Resident Physician, PGY-2, Franciscan Foot & Ankle Institute, Federal Way, WA
3 – Fellow Physician, CHI Franciscan Health Advanced Foot & Ankle Reconstructive Surgery Fellowship, Burien, WA,
4 – Residency Director, Franciscan Foot & Ankle Institute, Federal Way, WA
* – Corresponding author: rebertyler@gmail.com


Failed arthrodesis or arthroplasty of the first MPJ can often leave the revision surgeon with limited surgical options. The literature recommends, when possible, acute correction of bony defect over distraction osteogenesis due to decreased complication rates, faster time to healing, and reduced psychological strain that an external fixator can potentially cause a patient [1-3]. However, acute correction is limited by the soft tissues with potential neurovascular compromise. In these instances, distraction osteogenesis should be considered as it allows for the soft tissues to adapt as the bone lengthens [4].

Distraction osteogenesis by external fixation has been widely used and studied since Dr. Ilizarov first described his technique in the 1950’s. Dr. Illizarov described two main phases: the first being distraction where he determined the ideal rate was 1 mm per day and the second being consolidation wherein the newly formed regenerate gains strength [5-7]. In the standard technique, the patient spends the entire consolidation period in the external fixator and this can more than double the amount of time the patient spends in the fixator. A new technique that is gaining popularity is the conversion of the external fixation to internal fixation to limit the duration the patient spends in the fixator, and this technique was used in this case [8-9].

This case study presents our treatment of a failed first MPJ arthroplasty from deep infection after a failed first MPJ arthrodesis due to a non-union that left a defect at the 1st MPJ of 22 millimeters.

https://lh4.googleusercontent.com/5bnygpI1Ghf8MjT7-gUvUB51hSJklyjVtp3kD_klZeNma3XlUigLNCJSNpkFjTZQe75PeiawZxcX-1lbeD2IO3t3DYMM5GhWMe5dVKm0c5637bkcXZFhcohASHvyglR8BTx2A4pei_E https://lh4.googleusercontent.com/D8lVo-bSk6WO4ECc1wxueQVKAzC-KW2LfQlwVtjNdT7PWy-0fDxWppfX9tU4rKRiKnViAZ13HLkZVkqDwo-47JbUojLFpHSUXAO6Sn7zt0ceOi9CimViepjrNS9GjUOcGZF0337XQYI

Figure 1 (A) Preoperative clinical photo (B) Preoperative X-ray with antibiotic spacer.

The objective of this case study is to present our surgical technique for lengthening of the first metatarsal by distraction osteogenesis with external fixation to show its use as a viable treatment option for a shortened first metatarsal.

Case Study

A case is presented of a 52-year-old female who failed all conservative care for 1st MPJ arthritis of the left foot and underwent a 1st MPJ fusion. The 1st MPJ fusion failed due to a non-union and the decision was made to convert to a first MPJ arthroplasty. Infection of the implant with osteomyelitis was subsequently diagnosed with MRI at 3 months post-arthroplasty. The implant was removed at 3 months postoperative and was replaced by an antibiotic spacer and the patient was able to tolerate the spacer for two years (Figure 1). The area eventually became painful and removal of the antibiotic spacer was deemed necessary. Labs were obtained for vitamin D, prealbumin, comprehensive metabolic panel, parathyroid, and thyroid panel which were all within normal range. The length able to be achieved with acute correction was not felt to be adequate to restore proper function of the first ray, so distraction osteogenesis was selected as the treatment option. After removal of the antibiotic spacer, a mono-lateral external fixator was applied and used to lengthen the first metatarsal 22 millimeters of length, which was achieved after 26 days of distraction.

https://lh3.googleusercontent.com/zMuv_t3pOvBlUJL3IzVE1cTiKX4sePxiRFFbC4lJ4jUdvvrclQDKMQjcV18zBzxs9jjXfnZXipfmV389-yr9fJYbEBsvDSAZa2bKOKSdzgpAYImtQryXOKFz3b9X5IUO6yBCIZldEyc https://lh6.googleusercontent.com/lk9Ksc7-dsMJSDjdU1oCNCL3HRCyfqNGFpeP8fZHQ1rtWPGdxEV9x691XdWQu3gaGMpDHy7YcQ9_eSDu_5tQd_FnFhJCHQHNycR-Hn50qKXdyib66RxZI4gpR-t3_vQTYhkDtedF3tQ https://lh4.googleusercontent.com/dM9ngSpoCOSE6huTfVoEMMl4w0PvbLGxThXoInM52wJhFToe-pJ2oImKEhPj8Bu1u1_e3VupJxCt939m6plP4IOhVQfeNVW9hTT5qJKLEUDw48DM6TcX-_CmVrKnZdqTuQOJ4UH4JP4 https://lh6.googleusercontent.com/wOqg2On9WrwutLiv8LtYiX8hWOblFdNMAddGvkfMBndOPusZaLqOxMWs_stK6ISV11bsmTNJIov49hpOD6ZxDp-48h8TgBRN99PVaEBzZVxNzN8-FdZQgWAzr1okq3fhkhv0RLg_Z9A

Figure 2 (A)Intraoperative, Closure with External fixator application (B) Immediate postoperative with compression at corticotomy site (C) X-ray after 26 days distraction, 22mm of lengthening (D) Consolidation period post external fixator removal and internal fixation.

The external fixator remained on for an additional month to allow consolidation of the regenerate, but was removed at the patients request and was replaced with a locking plate. After five months, the locking plate was removed due to hardware irritation. A CT confirmed partial union of the first MPJ prior to hardware removal and the fusion site was stressed intraoperatively and found to be stable. The locking plate and screws were then removed. The patient was able to ambulate in tennis shoes without pain and was able to perform activities of daily living 1 year postoperatively.

Surgical Technique

A longitudinal incision was made medially over the 1st metatarsocuneiform joint extending distally to the medial hallux interphalangeal joint. Layered dissection was carried along the length of the incision down to the level of the antibiotic spacer within the 1st metatarsophalangeal joint site.

https://lh3.googleusercontent.com/RuMJ4cuyrMv5JKWZBA3qbWr0nmt9Uju9kkbVfv4jnb8CO5NfF-uAqxKQlqFCMvwPPvV01F0UGaJc3jEDOcl2e9ooJ4WJMNhtT-I3QXDJLWappVXCWvEKwxSPP-QA-sVdNmYC1cD-IRE https://lh5.googleusercontent.com/0OS6MdqMER0XlpB89zo-9ar41xlK4hH6ox8XCfGoSRd_nP12H5a3pzifA59U2nlD0UW2AUNlsXojOhoWcGNsfkufJqFceYc7bDrPKuJ0EDRL0adeGh7kCkVGQuA-fILEt0tgRXrdfso

Figure 3 (A) CT scan 14 weeks status post 1st MTPJ fusion showing osseous consolidation at the first MPJ (B) Immediate post-op hardware removal.

The spacer was removed and the nonunion margins were curetted and fenestrated down to healthy bleeding bone. Orthobiologics were used to augment the fusion site. A 0.062” K-wire was inserted through the tip of the distal hallux, crossing the hallux interphalangeal joint, and into the 1st metatarsophalangeal nonunion site. Correct placement of this K-wire is key to help guide the axis of regenerate formation as the bone is lengthened.

An osteotomy was made 1 centimeter distal to the base of the first metatarsal by perforating the bone with a k-wire and then completing the osteotomy with an osteotome. Intraoperative fluoroscopy was used to confirm the completion of the osteotomy.

Thereafter, a monolateral external fixator was applied to the dorsal aspect of the foot with 3 proximal pins within the medial cuneiform, 1 pin in the base of the first metatarsal, and 2 distal pins in the midshaft of the metatarsal. The osteotomy site was then compressed utilizing the external fixator and the 0.062” K-wire was driven across the osteotomy and into the base of the first metatarsal.

The patient began lengthening at POD #12 at a distraction rate of 0.25 millimeters four times per day. After 26 days of distraction, there was 22 millimeters of length achieved and distraction was discontinued. One month into the consolidation phase the external fixator and K-wire were removed at the patients request. The metatarsal was docked to the proximal phalanx at this time after fenestrating the opposing bony surfaces and a locking plate was used to span the regenerate and provide stability (Figure 3).

Discussion

This case study supports the current literature that distraction osteogenesis is a viable option for treatment of a large bony defect at the 1st MPJ. The patient was able to gain 22 millimeters of length through distraction osteogenesis and was able to undergo a successful fusion at the 1st MPJ with a stable fusion site and regenerate bone at the time of hardware removal. Placement of the K-wire so that it parallels the first metatarsal in both the sagittal and transverse planes is key in order to avoid malalignment of the newly formed regenerate. Although the patient did require removal of her hardware, she was able to return to normal shoe gear without pain and was able to perform her activities of daily living that had previously been limited at her one-year follow-up.

The literature currently supports single-stage procedures over distraction osteogenesis when possible. Jones, et al., in 2015 performed a systematic review of the literature comparing single stage vs distraction osteogenesis in the treatment of brachymetatarsia. They found that the overall major complication rate of distraction osteogenesis was 12.62% compared to 3.72% with single stage procedures and the minor complications rate was 39.18% for distraction osteogenesis compared to 15.76% for single stage. They also found that distraction osteogenesis is associated with a greater time to heal with an average of 2.31 months for every centimeter gained compared to 1.9 month per centimeter with a single stage procedure [1].

Even with these disadvantages, distraction osteogenesis does have a major advantage over single stage bone grafting in that much greater length can be achieved and donor site complications can be avoided. Recommendations have been made that no more than 15 millimeters or 25% of the original length of the bone be attempted with a bone graft. With callus distraction, the recommendation has been that the metatarsal can be increased in length up to 40% of its original length [11-12].

This case study also supports the conversion to internal fixation at the time of external fixation removal during the consolidation period. This allows for the benefits of external fixation in being able to gain greater lengths of correction while also limiting the time the patient spends in the external fixator. This technique is well supported in the literature and can help make external fixation more tolerable for the patient [8-9].

In any patient with a history of a non-union it is important to rule out any underlying conditions that may have caused the non-union. There are a variety of different causes for a non-union from improper joint preparation, improper/loss of fixation, smoking, low vitamin D levels, underlying metabolic disorders, among others [14-15]. It is important to order the appropriate labs pre-operatively and medically optimize the patient before considering return to the OR for surgical intervention. The protocol for ruling out underlying metabolic bone conditions for the senior author in our study (C.C.) is to order labs for vitamin D, prealbumin, a comprehensive metabolic panel, parathyroid, and a thyroid panel. In our patient these labs all came back normal indicating they most likely did not contribute to the patient’s original non-union.

In conclusion, bony defects too large for acute correction in the 1st MPJ provide difficult challenges to the surgeon but distraction osteogenesis is a viable option. Converting the external fixation to internal fixation can also help make distraction osteogenesis more tolerable to patients that are hesitant to spend extended periods of time in an external fixator.

References

  1. Jones MD, Pinegar DM, Rincker SA. Callus Distraction Versus Single-Stage Lengthening With Bone Graft for Treatment of Brachymetatarsia: A Systematic Review. J Foot Ankle Surg. 2015 Sep-Oct;54(5):927-31. doi:10.1053/j.jfas.2015.02.013. Epub 2015 May 19. Review. PubMed PMID: 25998479.
  2. Oh CW, Satish BR, Lee ST, Song HR. Complications of distraction osteogenesis in short first metatarsals. J Pediatr Orthop. 2004 Nov-Dec;24(6):711-5. PubMed PMID: 15502575.
  3. Mather R, Hurst J, Easley M, Nunley J. (2008). First Metatarsal Lengthening. Techniques in Foot & Ankle Surgery. 7. 25-30. 10.1097/BTF.0b013e318165c21c.
  4. Choi IH, Chung MS, Baek GH, Cho TJ, Chung CY. Metatarsal lengthening in congenital brachymetatarsia: one-stage lengthening versus lengthening by callotasis. J Pediatr Orthop. 1999 Sep-Oct;19(5):660-4. PubMed PMID: 10488871.
  5. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989 Jan;(238):249-81. PubMed PMID: 2910611.
  6. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues:Part II. The influence of the rate and frequency of distraction. Clin OrthopRelat Res. 1989 Feb;(239):263-85. PubMed PMID: 2912628.3. Skirving AP, Newman JH. Elongation of the first metatarsal. J Pediatr Orthop.3:508-510. 1983.
  7. Skirving AP, Newman JH. Elongation of the first metatarsal. J Pediatr Orthop. 1983 Sep;3(4):508-10. PubMed PMID: 6630498.
  8. Oh CW, et al. Submuscular plating after distraction osteogenesis in children. J Pediatr Orthop B. 2008;17(5):265–269. doi:10.1097/BPB.0b013e32830688d8
  9. Harbacheuski R, Fragomen AT, Rozbruch SR. Does lengthening and then plating (LAP) shorten duration of external fixation?. Clin Orthop Relat Res. 2012;470(6):1771–1781. doi:10.1007/s11999-011-2178-2
  10. Bartolomei FJ. Surgical correction of brachymetatarsia. J Am Podiatr Med Assoc. 1990;80(2):76–82. doi:10.7547/87507315-80-2-76
  11. Kim HT, Lee SH, Yoo CI, Kang JH, Suh JT. The management of brachymetatarsia. J Bone Joint Surg Br. 2003;85(5):683–690.
  12. Lee WC, Suh JS, Moon JS, Kim JY. Treatment of brachymetatarsia of the first and fourth ray in adults. Foot Ankle Int. 2009;30(10):981–985. doi:10.3113/FAI.2009.0981
  13. Harbacheuski R, Fragomen AT, Rozbruch SR. Does lengthening and then plating (LAP) shorten duration of external fixation?. Clin Orthop Relat Res. 2012;470(6):1771–1781. doi:10.1007/s11999-011-2178-2
  14. Moore KR, Howell MA, Saltrick KR, Catanzariti AR. Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study. J Foot Ankle Surg. 2017;56(3):457–462. doi:10.1053/j.jfas.2017.01.011
  15. DeFontes K, Smith JT. Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery. Orthop Clin North Am. 2019;50(2):259–267. doi:10.1016/j.ocl.2018.10.008

 

Limb salvage for calcaneal osteomyelitis with pin to bar external fixation 

by Aaron Chokan, DPM, FACFAS1; Les P. Niehaus, DPM, FACFAS2; Joseph Albright, DPM, AACFAS3; David Bishop, DPM, AACFAS3; Frederick Garland, DPM3

The Foot and Ankle Online Journal 13 (3): 6

The prevalence of heel ulcers is as high as 18% in hospitalized patients. Due to lack of underlying muscle, protective fat pad, and constant pressure, poor tissue perfusion to the area inhibits healing. Concomitant comorbidities such as diabetes, neuropathy, and peripheral arterial disease provide added challenges to limb salvage. The incidence of surgical intervention in a diabetic patient with foot ulcers is 97%, with 71% going on to some form of amputation. Our study includes 10 patients with underlying calcaneal osteomyelitis who were treated with partial calcanectomy with primary flap closure and offloading pin to bar external fixation. Primary closure was achieved in 100% of patients with an average time of 106 days (ranging from 43 to 205 days), with no pin tract infections, revisional bone debridement, or subsequent BKA/AKA. Average follow-up time was 20.9 months (ranging 12 to 45 months).  Partial calcanectomy with offloading pin to bar fixation allows for cost-effective fixation, accelerated healing, and a satisfying functional result in true limb salvage cases.

Keywords: Limb salvage, calcaneal osteomyelitis, external fixation, infection

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0006

1- Ohio Foot & Ankle Center, Stow, OH
2- Alliance Foot and Ankle Center, Alliance, OH
3- Aultman Alliance Community Hospital, PGY-3, Alliance, OH


Pressure ulcers to the heel are recognizably difficult to treat due to their anatomic location, and the prevalence of heel ulcers is as high as 18% in hospitalized patients [1]. The plantar and posterior aspects of the calcaneus are constant areas of pressure in both the sedentary or standing position. The lack of underlying muscle and common atrophy of its protective fat pad hinders tissue perfusion to the area. The associated diagnoses including diabetes, neuropathy, and arterial disease inhibits normal healing. Calcaneal ulcers are also accompanied by higher costs and have proven to be two to three times less likely to heal in comparison to forefoot ulcers [2]. Many of these patients are quickly consulted for a below knee amputation as a definitive treatment. Patients are able to use a prosthesis for a quick return to function, however, a BKA amputation increases energy expenditure by 25% and 33% of BKA amputees do not survive beyond two years [3,4].

Calcaneal osteomyelitis can be classified based on route of infection. The Waldvogel  classification includes hematogenous, direct or contiguous, and chronic osteomyelitis [5-7].  Hematogenous osteomyelitis results in bacteria disseminated into the bloodstream emanating from an identifiable focus of infection or developing during transient bacteremia unrelated to infection. Direct or contiguous osteomyelitis is caused by spread from adjacent sources or contact between bacteria and tissue and may be traumatically or surgically induced. Chronic osteomyelitis is the result of the coexistence of infected, nonviable tissues and an ineffective host response [8]. The attempt of preserving the calcaneus is beneficial for functionality but is much more difficult to fully eradicate the infection. The utilization of a static external fixator frame enables both stabilization and immobilization to achieve complete offloading through the final maturation stage of wound healing. The SALSAstand has been introduced for this purpose and its construct prevents any unwanted tension on skin edges as well as pressure-induced ischemia due to weight bearing [9].

Excluding case studies, there is lack of literature evaluating the combination of partial calcanectomy with primary closure and external fixation. Our study aims to provide a reproducible surgical approach to the treatment of heel ulcers with underlying calcaneal osteomyelitis. Partial calcanectomy with primary flap closure and offloading pin to bar external fixation allows for cost-effective fixation, accelerated healing, and a satisfying functional result in true limb salvage cases.

Patients and Methods

Patients diagnosed with osteomyelitis of the calcaneus were treated with radical resection of the calcaneus with primarily closure and with utilization of SALSAstand pin to bar external fixation. All patients were treated by a single surgical attending from January 2016 to May 2019.  The inclusion criteria included patients with type 1 or 2 diabetes mellitus, those with at least a Wagner stage 3 ulceration to the heel, patients who had been diagnosed with osteomyelitis of the calcaneus with MRI advanced imaging or white blood labelled indium scans if patient was unable to have MRI, over 20% involvement of the calcaneus, and a minimum follow up of 6 months after achievement of primarily closure.

In our experience these patients had multiple co-morbidities requiring a multi-specialty medical approach. Consults for infectious disease, cardiology, vascular, endocrinology, anesthesiology, physical therapy and internal medicine were used for safety and to increase efficacy of the operative procedure.  Additionally, patient demographics were examined.

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Figure 1 A – Plantar lateral wound probing directly to calcaneus. B – Posterosuperior Flap from achilles area rotated plantarly. C – Sutured flap over deficit, knots tied outside flap.

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Figure 2 Planned resection of calcaneus with section taken. 0.5 cm margin using MRI guided resection.

Risk factors included obesity, hemoglobin A1C, peripheral vascular disease, history of tobacco use, and end stage renal disease. Other significant findings evaluated included history of attempted surgical treatment, number of operations required, and number of re-hospitalizations following the initial procedure.

Surgical Technique

The patients were placed under general anesthesia and were initially placed in the prone position. Thigh tourniquets were used unless a patient had recently undergone vascular intervention. A combination of two incisional approaches were utilized based on the location of the heel ulcer. Straight elliptical excisions for plantar wounds and a posterosuperior flap for posterior calcaneal ulcers (Figure 1). Full-thickness incisions were created with meticulous dissection to not harm the skin flaps. Once the flap was freed from attachments and the primary wound excised, the Achilles tendon was completely resected at its insertion. Utilizing a large saw, the calcaneus was resected from proximal superior to distal inferior in an oblique fashion (Figure 2).

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Figure 3 SALSAstand method for offloading. Two half pins into tibia and two half pins into midfoot.

A margin of 0.5 cm of bone was resected from the involved bone via diagnostic advanced imaging. All the rough edges of bone were then smoothed down. Portions of the bone were sent to both microbiology and pathology. A combination of 2-0 Prolene vertical mattress technique and staples were utilized to ensure closure.

After proper closure of the flap, tourniquets were deflated and then the patient was flipped to supine position with care to prevent shearing forces or pressure on the flap. A pin to bar external fixation frame was then applied to the leg for offloading of the posterior flap. In safe zone 4, just distal to the midshaft of the tibia, using a parallel guide and clamp, two 5-0 half pins were placed into the tibial crest [10]. Two 45 degree elbows were placed in the tibial clamp and 2 bar frames were then extended toward the level of the forefoot and the heel.  Two more 5-0 half pins were then inserted medially and laterally separately into the navicular and the cuboid to help construct the offloading frame. Fluoroscopy was employed to ensure placement. Pin to bar mechanism was then utilized to connect the two bars from the elbow to the midfoot pins as well as a large offloading “U” frame that went posterior around the heel (Figure 3). The “U” frame kept the patient from externally rotating the leg and forcing any pressure on the calcaneal flap. All the pin sites were covered with xeroform and dry dressing was applied to the leg.

All patients were still placed on intravenous antibiotics for 6 week depending on microbiology results. All patients were kept non-weight bearing to the operative leg until closure of the surgical wound. After complete healing, the external fixation device was removed and the patient was casted for custom solid AFO.

Results

A total of 12 patients were identified. Two patients were excluded due to one inadequate follow-up and one patient who was deceased before adequate follow-up, leaving 10 patients that met the inclusion criteria. Of those who met the inclusion criteria, 30% (3/10) were active tobacco smokers, 50% (5/10) were diagnosed with ESRD, 70% (7/10) had a history of PVD, previous surgical intervention occurred in 90% (9/10),  average BMI among the 10 patients was 31 and average hemoglobin A1C was 7.5%.  Demographic and medical history is seen in Table 1.

Patient Characteristics Median or no. (percentage)
Patient Age 64
Gender
Male 7
Female 3
BMI 31.3
HbA1C 7.6
Diabetes Mellitus 10 (100%)
ESRD 5 (50%)
PVD 7 (70%)
Current Tobacco Use 3 (30%)
Previous Surgical Intervention 9 (90%)
Follow up (months)
Mean 15.9
Range 7 to 42

Table 1 Patient Demographics (N=10).

Complication n
Dehiscence 3 (30%)
Flap necrosis 2 (20%)
Recurrent ulcer 2 (20%)

Table 2 Complications.

Variable
Wound Size 6.4 x 5.6 cm (35.8 cm2)
Average duration of wound 38 weeks (4 to 204)
Calcaneus resection size 122 cm3
Time to healing 106 days (43 to 205)
Time in external fixation 41 days (15 to 77)

Table 3 Pre and post operative results.

Mean wound size preoperatively was 6.4 cm x 5.6 cm (35.8 cm2), mean size of calcaneal bone resected was 6.6 cm x 4.9 cm x 3.6 cm (116.4 cm3). Average time to primary closure was 106 days (ranging 43 to 205 days), average days in external fixation devices was 41 days (ranging 15 to 77 days), and number of operating room visits following initial procedure was 1.5 visits (ranging from 1 to 3 visits). Complications encountered included partial wound dehiscence in 3/10 patients, flap necrosis in 2/10 patients, and re-ulceration in 2/10 patients.

Re-ulceration occurred at an average of 5 weeks post op (ranging 4 weeks to 6 weeks). Due to complications, subsequent adjunctive grafting occurred in 6 patients to aid in healing and 2 patients required rehospitalization. No pin tract infection, revisional bone debridement, or subsequent BKA/AKA was observed. Average follow up time was 20.9 months (ranging 12 to 45 months).

Discussion

A similar study by Akkurt, et al, utilized MRI guided debridement with application of Ilizarov external fixation for patients with pedal ulcers and concomitant calcaneal osteomyelitis.[11] The mean size of calcaneal osteomyelitis was 8.73 cm3 (range 3–18 cm3) and the authors advocated for a preoperative MRI-guided resection plus a maximum 0.5 cm of resection in depth as far as healthy osseous tissue was sufficient in all patients.  The authors recommendations is the same guideline we utilized for our resection. The wounds healed in 18 of the 23 patients (78%), partial recovery occurred and subsequent flap operation was performed in three patients (13%), and below-the-knee amputation was performed in two patients (9%). Pin tract infections were the most common complication seen in 16 patients (69.5%).[11]  Our study showed complete healing in 100% of patients with no below-knee-amputations or pin tract infection as a result. Pin tract infection was a common complication possibly due to the complexity of the frames in the study by Akkurt, et al.[11] We hypothesize utilizing a four half-pin fixation construct decreases the chance for pin tract infection and subsequent amputation. There is less chance of loosening and pistoning without smooth wire fixation. Bollinger, et al., performed partial calcanectomies and evaluated the functional status of their patients. Thirteen of the 22 patients had confirmed osteomyelitis. Eighteen patients were available for follow-up. Twelve had delayed wound healing that required either a split thickness skin graft or serial debridements.  Nine patients had diabetes and all had delayed wound healing with an average follow up time of 27 months. They found that ulcers larger than 7 cm would not allow for a tension-free closure. They also recommended casting in plantar flexion for a minimum of 4 weeks post-operative. This study resulted in 100%  satisfaction rates of its subjects. However over 50% had delayed wound healing with the need of additional surgical treatment [12]. Our experience saw similar results in delayed healing with subsequent grafting at 60%. A combination of biologics and split thickness skin grafts were utilized depending on size of surgical wound. With our average wound size of 35.8 cm2, we found that even with larger deficits, utilizing a rotational flap allowed for tension free initial closure of skin.

Vac therapy is also a conservative option to attempt and close these long standing ulcers. However, the frequency of dressing changes, time needed, and prolonged non-weight bearing make the negative pressure therapy a very involved task. Nather et al., looked at wound vac therapy for diabetic foot wounds in 11 patients and administered VAC therapy for an average of 23.3 ± 10.3 days.  Initial wound sizes ranged from 6.9 to 124.0 cm2 and post therapy had an average reduction of 10.1 cm2 with an average reduction of 24.9%, which was not statistically significant [13]. The use of wound vac therapy alone in diabetics cost an average of $13,262 for a 12 week therapy course [14]. Conservative treatment through vac therapy, debridements, and serial grafting increases both cost to patient and chance of infection. Our patient population only required 1.5 visits to the OR after the initial procedure where at least one of the visits involved was to remove the external fixation device. The average healing time after calcanectomy and primary closure was about 15 weeks where the average duration of the wound being present was 38 weeks. This procedure allows for complete eradication of infected bone and tissue, properly offloading, and primary tissue healing for practical and functional results.

Dalla Paola, et al., used a combination of the treatments discussed. They enrolled 18 consecutive patients with large heel ulcers complicated by osteomyelitis. Treatment was performed in a two-step manner, first including MRI guided resection of  the infected calcaneus, application of circular external fixator, and negative pressure wound therapy  with dermal substitute. The second stage included application of split thickness skin graft over the wound. Complete healing was achieved in all patients with mean time of 69+/- 64 days. Total time for maintenance of the circular frame was 78.2 +/- 31.5 days [15]. Another surgical alternative is the use of myofascial flaps to cover soft tissue deficits in the heel. The robust nature of the muscle belly aids in bone healing and increased antibiotic deliverance to the site of infection. Abductor hallucis, reverse sural artery, and saphenous flaps are all viable options depending on the size of muscle needed for coverage. However, these surgical procedures are technically demanding and require attentive wound care. Increased risk of flap breakdown may be attributed to the high pressure area they weren’t designed for.  Flap rejection is cited from 5% to 25% while diabetics have an increased rate of necrosis at 32% [16].

References

  1. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implica- tions for the future. Adv Skin Wound Care 2001; 14:208-15.
  2. Jacobs TS, Kerstein MD. Is there a difference in outcome of heel ulcers in diabetic patients and non-diabetic patients? Wounds 2000; 12(4):96-101.
  3. Cuccurullo, Sara J. Physical Medicine and Rehabilitation Board Review. 2nd ed. New York: Demos Medical, 2010.
  4. Pinzur MS. Amputation level selection in the diabetic foot. Clin Orthop. 1993; 296:68-70
  5. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (first of three parts) N Engl J Med. 1970 Jan 22;282(4):198–206.
  6. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (Second of Three Parts) N Engl J Med. 1970 Jan 29;282(5):260–266.
  7. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (Third of Three Parts) N Engl J Med. 1970 Feb 5;282(6):316–22.
  8. Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often? Postgrad Med J. 2000 Aug; 76(898):479-83.
  9. Clark J, Mills JL, Armstrong DG. A method of external fixation to offload and protect the foot following reconstruction in high-risk patients: the SALSAstand. Eplasty. 2009;9:e21. Published 2009 Jun 4.
  10. Cooper P, Polysois V, Zgonis T. External Fixators Of The Foot And Ankle. Wolters Kluwer Health, Chapter 2. Published 2015.
  11. Akkurta MO, Ismail  D, Öznur A. Partial  calcanectomy  and Ilizarov external fixation may reduce amputation need in severe diabetic calcaneal ulcers. Diabetic Foot Ankle, 2017 8(1), 1264699
  12. Bollinger M, Thordarson DB. Partial calcanectomy: an alternative to below knee amputation. Foot Ankle Int. 2002;23(10):927-932.
  13. Nather A, Chionh SB, Han YY, Chan PL, Nambiar A. Effectiveness of Vacuum-assisted Closure (VAC) Therapy in the Healing of Chronic Diabetic Foot Ulcers. Ann Acad Med Singapore.  2010;39:353–8
  14. Driver V, Blume P. Evaluation of Wound Care and Health-Care Use Costs in Patients with Diabetic Foot Ulcers Treated with Negative Pressure Wound Therapy versus Advanced Moist Wound Therapy. Journal of the American Podiatric Medical Association: 2014;104(2):147-153.
  15. Dalla Paola L, Brocco E, Ceccacci T, Ninkovic S, Sorgentone S, Marinescu MG, Volpe A. Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation. Foot Ankle Int 30:1065–1070, 2009.
  16. Germann G. Invited discussion: the simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps. Plast Reconstr Surg 2003; 111:761–2.

Ankle arthrodiastasis in conjunction with treatment for acute ankle trauma

by Nunzio Misseri, DPM¹; Hayley Iosue, DPM¹; Elizabeth Sanders, DPM¹; Amber Morra, DPM¹; Mark Mendeszoon, DPM2,3

The Foot and Ankle Online Journal 13 (3): 3

Arthrodiastasis has been described as an alternative joint sparing procedure for more advanced stages of arthritis. The use of joint distraction has been gaining popularity in foot and ankle surgery, especially with regards to post-traumatic ankle arthritis. Less is known about the effects of arthrodiastasis in cases of acute ankle trauma. This case series presents four cases of intra-articular ankle trauma that were treated with arthrodiastasis using external fixation along with reduction with/without internal fixation. The external fixators were kept on for at least 6 weeks with follow-up of at least 1-2 years for each case. These cases represent high impact injuries that were destined for post-traumatic arthritis that would eventually result in a joint destructive procedure. The results were promising in all cases, by at least delaying the need for a joint fusion or replacement in one case and foregoing the need for such procedures in the other 3 cases within our follow-up period.

Keywords: Arthrodiastasis, ankle, diastasis, arthritis, trauma, post traumatic, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0003

1 – University Hospitals Regional Hospitals, Surgical Fellow
2 – University Hospitals Regional Hospitals, Fellowship Director; faculty
3 – Precision Orthopaedic Specialities Inc.


The incidence of people with post-traumatic arthritis accounts for nearly 12% of those with symptomatic lower extremity arthritis [1]. Among those with ankle joint osteoarthritis, previous trauma is the most common etiology ranging from 20% to 78% incidence [2-4]. These patients usually end up with joint destructive procedures such as joint fusion or replacement.

Arthrodiastasis is an innovative treatment for ankle arthritis to enhance ankle joint range of motion, diminish pain, and potentially delay or forego ankle joint destructive procedures. Arthrodiastasis of the ankle has been described as an alternative and/or adjunctive salvage procedure for arthritis in patients not amenable to ankle joint replacement or arthrodesis [5]. The procedure is not technically demanding for the surgeon and, long-term, can cost less than arthrodesis or arthroplasty.

Various theories exist to explain how arthrodiastasis has a positive effect on joints. A theory by Gavril Ilizarov suggests applying tension to tissues with distraction increases micro-vascularity to articular cartilage, therefore assisting in cartilage repair [6]. This tension creates a hypervascular state which increases synthesis of nutrients, proteoglycans and in turn helps stimulate chondrocyte formation [6].

Lafeber described a theory in which joint unloading with resulting fluctuations in intra-articular pressure from joint distraction along with concomitant weight bearing, the activity of chondrocytes increases which creates proteoglycans that have the ability to repair articular cartilage and stimulate pluripotent mesenchymal cells to differentiate into articular cartilage [7,8]. This concept of mechanical offloading with continuing pressure changes was shown to increase proteoglycan synthesis by 50% in osteoarthritis knee condyles undergoing arthrodiastasis [7,9]. This process also decreases the inhibition of proteoglycan synthesis by mononuclear inflammatory cells, decreases production of catabolic cytokines and provides increased nutrition delivery to chondrocytes [7].

Both theories predicate the notion that osteoarthritic ankle cartilage is capable of regeneration. Arthrodiastasis has been used over the years with chronic osteoarthritis of the ankle with good results. A review by Dr. Rodriguez-Merchan published in 2017 looked at 14 articles that included patients with end stage osteoarthritis undergoing ankle joint distraction. A total of 249 patients were included in this review with follow up ranging from 1-12 years. Overall 73-91% of patients had good results within their follow up and 6.2-44% of patients ended up with either a joint fusion or replacement [10]. This review serves as a good foundation on the results of ankle joint arthrodiastasis in chronic cases of osteoarthritis, however little is known on its effects during its application in acute trauma. We present a series of acute ankle trauma in which we employ external fixation for arthrodiastasis. In these cases studies, each patient suffered from an intra articular ankle fracture. In the acute setting, the fractures were reduced and an external fixator was applied. Ankle joint diastasis of 5-10mm was applied to the ankle joint utilizing the external fixator. The external fixators were left in place for six to eight weeks.

Case 1

A 30 year-old male sustained an open bimalleolar fracture while operating his horse-drawn lawn mower. Upon presentation to the emergency department, he was evaluated and subsequently taken to the operating room for wound washout, flap closure, application of a delta frame for stability with percutaneous kirschner wire fixation to the medial malleolus. Once the soft tissue envelope was stable nine days later, open reduction and internal fixation was performed. The same delta frame remained intact and the ankle joint was distracted in an attempt to preclude ankle arthritic changes. The frame remained in place for six weeks allowing for ankle joint arthrodiastasis during this time. The patient was seen in the office 1.5 years after surgery and was clinically doing well. He is ambulating without orthoses and able to perform his daily activities without issues. Radiographic images revealed a healed fracture with the ankle mortise in good alignment, without signs of degenerative arthritis.

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Figure 1 Open bimalleolar fracture of a 21-year-old Amish male sustained while operating a horse-drawn lawn mower. Case 1.

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Figure 2 Post-operative radiographs status-post wound washout and closure, open bimalleolar fracture reduction, percutaneous fixation, application of delta frame. Status-post bimalleolar fracture open reduction and internal fixation, syndesmotic repair, and re-application of delta frame to obtain arthrodiastasis at the ankle joint.

image5.png

Figure 3 Six weeks status-post bimalleolar fracture open reduction and internal fixation, postoperative day 0 of delta frame removal.

Case 2

A 56-year-old female presented after a motor vehicle accident where she sustained a right closed comminuted talar fracture. Radiographs and a CT scan revealed a Hawkins type IV talus fracture. She was subsequently taken to the operating room after full evaluation in the emergency department. Closed reduction was attempted with a calcaneal pin but was not possible. Therefore, a lateral sinus tarsi approach incision was made from the tip of the fibula extending dorsally over the 4th metatarsal to expose the talus. The talus was reduced and fixed percutaneously with Kirschner wires and a delta frame was applied.

Eleven days later, after the soft tissue envelope improved, she was taken back to the operating room for subtalar and talonavicular joint arthrodesis in an attempt to maintain blood supply to the talus. The deltoid ligament was repaired and a modified Brostrom augmentation was performed. A ring external fixator was placed to achieve stability as well as arthrodiastasis at the ankle joint. The external fixator was removed two months postoperatively. Minor medial ankle arthritis was noted on postoperative radiographic images which worsened over the years. Two years postoperatively the patient is contemplating joint destructive procedures.

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Figure 4 Radiographs and CAT scan of a Hawkins type IV severely comminuted talus fracture. Case 2.

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Figure 5 Intraoperative findings of a severely comminuted talus fracture. Postoperative clinical photos and radiographs of open reduction and external fixation of a comminuted talus fracture, stabilization with percutaneous Kirschner wires and circular external fixator.

Case 3

A 34-year-old male patient was admitted from an outside hospital two days after a trauma where a car he was repairing fell on his left lower limb. He was noted to have a closed dislocated fracture of the left talus, Hawkins type III, and displaced medial malleolus fracture. Closed reduction and splinting was performed at the previous hospital. After full evaluation at our facility, open reduction of the talus and closed reduction of the medial malleolus was performed followed by the application of a ring external fixator. After adequate reduction, approximately a half centimeter of distraction of the ankle joint was produced. This frame was left in place for four months. Following frame removal, the patient continued physical and functional treatment aimed at strengthening the tibial and foot muscles and was encouraged to increase range of motion of the ankle. The patient was able to return to his normal daily activities and return to work. At his two year follow-up he has not needed to go on to further joint destructive procedures and continues to be able to perform his activities of daily living without issue.

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Figure 6 Radiographs on admission. Case 3.

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Figure 7 Radiographs following Ilizarov frame application and during treatment.

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Figure 8 Radiographs following Ilizarov frame removal 80 days status-post reduction and external fixation of talus fracture.

Case 4

A 15-year-old male patient who presented with chief complaint of right foot and ankle injury sustained after a fall while riding a BMX bike. The patient did have a history of a previous talus fracture 3 years prior to this presentation which was treated non-surgically. Radiographic images revealed a Hawkins type III talar neck fracture which was confirmed and evaluated on CT scan. The patient underwent open reduction with internal fixation of the talus fracture with two cannulated screws from posterior to anterior and application of an external fixation with approximately 6-mm of joint distraction.

The external fixator was removed after 6 weeks and the patient was gradually transitioned from a walking boot and into well-supportive sneakers while undergoing physical therapy. He was able to return to his daily activities, sports and BMX bike. The patient was seen in the office 1.5 years after surgery without any clinical or radiographic signs of post traumatic arthritis.

image9.png

Figure 9 Preoperative radiographs and CT scan images; post operative radiographs pre and post removal of external fixation.

Discussion

Acute ankle arthrodiastasis with concomitant ankle fracture, open reduction with internal and/or external fixation, should be considered in an attempt to preclude post-traumatic ankle arthritis. This becomes more crucial in cases of intra-articular ankle trauma, where the rate of post-traumatic arthritis increases. With arthrodiastasis, the changes in hydrostatic pressure provide an environment for chondrocyte repair and regeneration thus decreasing the chances for post-traumatic arthritis and the potential need for a joint fusion or replacement. The combination of mechanical offloading along with the microangiogenesis that is produced with increased tension to the soft tissue structures have shown to aid this process of repair.

Vito, et al., distracted 65 arthritic ankles using the Ilizarov frame for 6 weeks with distraction of 5-10 mm [11]. The patients had marked reduction in pain at 12 months for all patients except two: those two went on to arthrodesis. Valburg, et al., reported an average of two years pain relief following three months of arthrodiastasis with an Ilizarov frame [12]. Ploegmakers, et al., assessed the use of arthrodiastasis in 22 patients and reported 73% of the patients had significant improvement at seven years [13]. Although these series were not in the acute setting, one can assess the benefit these series showed with arthrodiastasis of the ankle joint.

This case series showcased four different cases of intra-articular ankle trauma where ankle diastasis was employed as part of the fixation in the acute setting. Successful outcomes were noted in three patients thus far at one to two years of follow up. One of the patients will require a joint fusion or replacement after 2 years. With the widening list of indications for arthrodiastasis, we believe there are benefits of using joint distraction in acute intra-articular trauma to either forgo or delay post-traumatic arthritis. This review serves as a foundation to pursue further indications for arthrodiastasis, however it does have limitations. The sample size is small at this time due to lack of extended follow-up. The follow-up time period listed for these four cases is 1-2 years. The results may prove to be different in the future with extended follow-up, however ankle joint diastasis remains a viable option in patients with intra-articular trauma to possibly reduce or delay the need for arthrodesis in the future

References

  1. Thomas AC, Hubbard-Turner J, Wikstrum EA, Palmieri-Smith RM. Epidemiology of Posttraumatic Arthritis. Journal of Athletic Training. 2017;52(6):491-496.
  2. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006;20(10):739–744.
  3. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-46.13.
  4. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009; 467(7):1800-1806.
  5. Labovitz, J. The Role of Arthrodiastasis in Salvaging Arthritic Ankle. Foot & Ankle Specialist. 2010; 3(4):201-204.
  6. Ilizarov GA. Transosseous Osteosynthesis. Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue, Chapter 11, Non-operative Correction of Foot Deformities. 547-581. Springer-Verlag, Heidelberg, 1992.
  7. Lafeber FP, Intema F, van Roermund PM, et al. Unloading joints to treat osteoarthritis, including joint distraction. Curr Opin Rheum. 2006. 18:519 – 525.
  8. Vito G, et al. Point-Counterpoint: Is Arthrodiastasis A Viable Option For Ankle Arthrosis. Podiatry Today. 2008;21(10).
  9. Kluesner AJ, Wukich DK. Ankle Arthrodiastasis. Clin Podiatr Med Surg. 2009 Apr;26(2):227-44.
  10. Rodriguez-Merchan EC. Joint Distraction in Advanced Osteoarthritis of the Ankle. Arch Bone Jt Surg. 2017;5(4):208-212.
  11. Vito G, Pacheco F, Southerland C, Rodriguez E, Thompson S. A New Solution for the Arthritic Ankle. Podiatry Today. 2005. 18(12):36-43.
  12. Van Valburg AA, van Roermund PM, Marijnissen AC, van Melkebeek J, Lammens J, Verbout AJ, Lafeber FP, Bijlsma JW. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage. 1999 Sep;7(5):474-9.
  13. Ploegmakers JJ, et al. Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Osteoarthritis Cartilage. 2005;13(7):582-588

 

Staged correction of equinovarus in a diabetic patient: A case report

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

The Foot and Ankle Online Journal 12 (2): 1

A rigid equinovarus deformity in the diabetic patient is a challenge for many surgeons. The utilization of a single stage, acute correction of the deformity can lead to soft tissue compromise and neurovascular complications. Using gradual correction by means of external fixation, with subsequent internal fixation for arthrodesis, provides a viable option for limb salvage in this difficult patient cohort.

Keywords: Reconstructive surgery, diabetes, external fixation, lower extremity 

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Research Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author- akamery@kent.edu


The diabetic patient with a rigid equinovarus deformity subsequent to soft tissue contracture is a unique and challenging patient [1]. Limb salvage options for this patient population are limited and complex. The utilization of gradual correction with external fixation proves to be an adequate treatment option that has less complications and leads to a stable and functional foot in this at risk group [1]. Single stage acute correction is another viable option, however, this can lead to limb length discrepancy due to significant bone resection or neurovascular compromise [2,3]. Longstanding soft tissue contracture of the medial ankle can lead to a rigid equinovarus deformity, in this setting acute correction is not a viable option due to the risk of neurovascular compromise and the delicate soft tissue envelope [4].

Case Report

A 59 year-old female presented to the clinic with a rigid equinovarus deformity secondary to multiple medial malleolar wound debridement. The patient developed this deformity over several months of wound care, which resulted in soft tissue contracture to the medial ankle. She presented to our service non-ambulatory and unbraceable due to progression of the deformity (Figure 1). She subsequently developed a wound on the lateral malleolus. 

Staged surgical correction was planned due to severe contracture and questionable medial neurovascular and soft tissue compromise. It was felt that a single stage correction would not be ideal in this particular patient. A dynamic circular frame was placed for gradual correction (Figure 2). Five days post initial procedure, the patient was educated on how to perform distraction with a total of 2 degrees of angular correction daily. The patient was non-weight bearing during the correction process. 

After 42 days, approximately 84 degrees of correction was obtained (Figure 3). At this point, a clinical decision was made to proceed with a Tibio-talo-calcaneal (TCC) fusion. 

Figure 1 Pre-operative AP foot radiograph showing severe equinovarus deformity.

Figure 2 Intra-operative clinical picture.  

Figure 3 Clinical picture after 42 days of correction.

It was determined that enough correction had occurred to relax the medial soft tissue envelope. The patient was returned to the operating room for the secondary procedure. This included external fixator removal and TCC arthrodesis with an intramedullary nail.  The patient remained non-weight bearing for 6 weeks until bony consolidation was seen on x-ray (Figure 4). 

The patient was then transitioned to protected weight bearing for 2 weeks in a controlled ankle motion (CAM) boot. The patient eventually successfully transitioned into a Charcot restraint orthotic walker (CROW) (Figure 5). The patient has remained ambulatory in a CROW for 6 months.

Figure 4 Six-week post secondary procedure. 

Figure 5 Clinical picture six weeks post secondary procedure.

Discussion

The diabetic patient with a severe lower extremity deformity and soft tissue compromise presents a challenging case for foot and ankle surgeons. Staged correction of these deformities utilizing gradual correction by external fixation and subsequent internal fixation with arthrodesis proves to be a viable option to help with limb preservation in these patients. Our case presentation demonstrates the efficacy of staged correction in these challenging patients and that limb salvage and return to ambulation in a CROW can be obtained and maintained. 

References

  1. Cuttica DJ, Decarbo WT, Philbin TM. Correction of rigid equinovarus deformity using a multiplanar external fixator. Foot Ankle Int. 2011;32(5):S533-9.
  2. Mirzayan R, Early SD, Matthys GA, Thordarson DB. Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity. Foot Ankle Int. 2001;22(3):209-13.
  3. Paley, D., Herzenberg, JE. Ankle and Foot Considerations In: Principles of Deformity Correction. 2002. 571-646.
  4. Bellamy JL, Holland CA, Hsiao M, Hsu JR. Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device. Strategies Trauma Limb Reconstr. 2011;6(3):173-6.

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

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

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

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

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

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0006

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


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

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

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

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

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

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

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

Case Report

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

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

 

References

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

Acknowledgements: None

Conflicts of Interest: None

Communications Author: Sham Persaud

Level of Evidence: Level IV Therapeutic Study

Early mobilization in bilateral talar fractures

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

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

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

Key words: talar fracture, early mobilization, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0009


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

1 Jackson North Medical Center in North Miami, Florida


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

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

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

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

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

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

Case Report

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

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

Talar1

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

Talar2

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

Talar3

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

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

Talar4

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

Talar5

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

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

Talar6

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

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

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

Talar7a Talar7b

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

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

Talar8a Talar8b Talar8c

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

Discussion

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

References

  1. Morgan A, Kim PS, Christman RA. Radiographic anatomy of the talus. J Am Podiatr Med Assoc. 93 (6): 449-80. – Pubmed
  2. Jimenez AL, Morgan JH. Talar fractures: three case studies. J Am Podiatr Med Assoc. 2001;91 (8): 415-21. – Pubmed
  3. Taraz-jamshidi MH, Shapari O, Shiravani R et-al. Simultaneous bilateral fracture dislocation of the talus: a case report. Trauma Mon. 2013;18 (2): 90-4.  –Pubmed
  4. Ohl X, Harisboure A, Hemery X et-al. Long-term follow-up after surgical treatment of talar fractures: Twenty cases with an average follow-up of 7.5 years. Int Orthop. 2011;35 (1): 93-9. – Pubmed
  5. Ogut T, Seyahi A, Aydingoz O et-al. A two-portal posterior endoscopic approach in the treatment of a complex talus fracture: a case report. J Am Podiatr Med Assoc. 99 (5): 443-6. – Pubmed
  6. Ebraheim NA, Patil V, Owens C et-al. Clinical outcome of fractures of the talar body. Int Orthop. 2008;32 (6): 773-7. – Pubmed
  7. Kilic A, Kabukcuoglu Y, Sokucu S. The treatment of talar body fractures with compression screws: a case series. Cases J. 2009;2 : 7953. – Pubmed
  8. Hollawell, S. SIDEKICK® Mini Fixator: Surgical technique. Wright Medical Technology, Inc. 2013. – link

Calcaneal Intraosseous Lipoma treated with External Fixation: A case report and review of the literature

by James Losito, DPM1, Victor L. Herrera, DPM2, Riquel Gonzalez, DPM3, Thomas Merrill, DPM4

The Foot and Ankle Online Journal 5 (8): 1

A case report is presented of an intraosseous lipoma. Diagnosis was made with the help of Magnetic Resonance Imaging and histopathologic analysis, after which the patient was treated by means of curettage and packing with bone graft substitute. Surgical, histologic features and a staging classification for intraosseous lipoma are presented in this case report. This article also discusses the use of external fixation in a patient with high risk of calcaneal fracture and to promote early weight bearing and early recovery. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain such as plantar fasciitis, retrocalcaneal bursitis, gout and stress fracture, it should be kept in mind as a possible diagnosis in cases of unresolved pain to the heel.

Key Words: Intraosseous lipoma, external fixation, heel pain, bone tumor.

Accepted: July, 2012

Published: August, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0508.0001


Intraosseous lipomas are rare benign bone tumors. This benign neoplasm has been reported to occur in the calcaneus as well as the proximal femur [1,6,7]. In the past, the relative absence of symptoms and radiographic similarity to a bone cyst has accounted for under diagnosis of intraosseous lipoma [2,3]. Intraosseous lipomas are derived from mature lipocytes mostly seen at the metaphysis of the long bones in men [5,6]. Foot and heel pain are the common symptoms of calcaneal intraosseous lipoma [5].

Non-surgical options such as NSAIDs, cold compression, use of non-weight bearing devices such as cane, use of silicone sole plate and preventive measures for pathological fractures are the most commonly used treatment modalities for this condition. Surgery is indicated in the presence of pain resistant to conservative treatment methods, impending or pathological fractures and when a histopathological differential diagnosis is required for aneurismal bone cyst, giant cell tumor, pseudo cyst formation or unicameral bone cyst. Although surgical treatment with curettage and autogenous bone grafting has been reported as a treatment choice, only small case series have been reported thus far [10]. In this study, we present one calcaneal intraosseous lipoma in a patient treated with curettage, autogenous bone grafting and Ilizarov external fixator.

Case Report

A 23 year-old male presents with the complaint of a dull, aching pain in his right heel of 2 years of duration. The pain was noted to increase after strenuous walking, long time of standing or other rigorous activities involving the right foot. The pain has been increasing steadily over the 3-4 months period. Patient stated the pain is persistent and worse at the end of the day. The pain is ranked (7 out of 10) on pain scale with 0 no pain, and 10 severe pain. There is associated swelling observed of the right foot.

 

Figures 1A and 1B Lateral plain x-rays (A) and antero-posterior views (B) with well-circumscribed bone lesion.

On gross examination, the patient walked with an antalgic gait. There is a small soft tissue palpable fluent mass on the right medial arch below the medial malleolus compatible with a possible superficial soft tissue lipoma. No scars, sinuses or venous prominences overlying the affected area, and the right ankle and subtalar joint motions were normal.

There is pain on palpation to the right heel and ankle. There is no past medical history that would increase the likelihood of bone infarction, such as corticosteroid use, infection, previous irradiation, lipid storage disease, collagen-vascular disease, or lympho-proliferative disorder.

Diagnosis

Plain radiographs revealed the presence of a well-circumscribed radio-mixed lesion with a thin sclerotic rim, interspersed with trabeculations in the antero-inferior portion of the left calcaneus underlying the subtalar joint. (Figs.1A and 1B) A preoperative magnetic resonance imaging (MRI) scan of the Right foot reveals the presence of a 2.3 x 2.0 cm circumscribed mass to the neck and body of the calcaneus. Predominant fat signal is seen on all pulse sequences. There is an eccentric component of fluid signal within the lateral aspect of the mass (Figs. 2A, 2B, 2C and 2D). The appearance of the mass is compatible with an intraosseous lipoma. There is prominent fatty tissue seen in the plantar, medial aspect of the right hindfoot most likely represents a prominent lobule of subcutaneous fat. It is at this point that the surgical option was discuses with the patient and he agreed to undergo surgical approach of his condition.

   

Figures 2A, 2B, 2C and 2D T1/T2 sagittal images shows fluid signal within the lateral aspect of the mass. (A and B) T1/T2 coronal images with well demarcated mass in the calcaneus. (C and D)

Surgical Approach

Based on the clinical and diagnostic image findings, intraosseous lipoma is diagnosed and operative decompression of the cyst is subsequently undertaken. Prior to the operation, the lesion is localized fluoroscopically and its localization is marked on the skin. Under tourniquet control, a straight lateral skin incision is performed over the lesion and the periosteum is incised longitudinally. The lesion and a portion of the adjacent normal tissue were exposed at one end of the lesion using a 1cm×1 cm rectangular cortical window. The cortex overlying the cyst is exposed on the inferior and lateral aspects. Using an oscillating saw and osteotome the cortex is opened and the lesion is totally curetted out with angled curettes through the cortical window.

As the cyst is decorticated, a greasy-yellow intraosseous lipoma is identified and evacuated from the osseous cavity. The soft tissue contents of the intraosseous cyst were removed along with the greasy fluid and the entire specimen is sent for histopathologic diagnosis. The cavity of the calcaneus is lavaged with normal saline before cancellous allograft bone is used to pack the cavity. After filling the cavity, the wound is closed in anatomic layers and a sterile dressing applied, followed by application of an Ilizarov ring external fixator for the initial postoperative period to allow for weight-bearing ambulation (Figs. 3A and 3B). Postoperative radiographs show the orientation of the external fixator to allow for early amputation after surgery (Figs. 4A and 4B).

 

Figures 3A and 3B Ring External Fixation system applied after the excised the bone tumor.

 

Figures 4A and 4B Lateral and A-P views of Post-Op X-Rays evaluation.

Subsequent histopathologic analysis reveals fragments of bone which include a few fragments of necrotic bone and fibroadipose tissue which shows foci of fat necrosis and necrosis of other soft tissue-types. The morphology suggests a possible fracture site or tendon avulsion. There is no evidence of neoplasm. These findings are consistent with the diagnosis of intraosseous lipoma. The patient’s heel pain subsided almost immediately after the operation, with the exception of surgical wound pain, which subsided in normal fashion.

A postoperative magnetic resonance imaging (MRI) scan of the right] foot is done 3 months after surgery once the fixator is removed. This reveals the resection of the previously described intra-osseous fatty mass in the neck and body of the calcaneus. Intermediate signal intensity tissue now fills this region of the calcaneus. There is no calcaneal fracture identified (Figs. 5A, 5B, 5C and 5D).

   

Figures 5A, 5B, 5C and 5D MRI shows T1/T2 sagittal views. (A and B) T1/T2 axial views of 12weeks MRI follow up evaluation shows bone graft uptake and reduced size of the bone cavity without fluid signal. (C and D)

Two weeks following suture removal, the patient is mobilized with instructions for partial weight bearing in the following 3 weeks, followed thereafter by weight bearing as tolerated. Clinical and radiological examinations are performed on the first postoperative day, at 6weeks, at 12weeks and every other month thereafter, until there is radiological confirmation of graft consolidation (Figs. 6A, 6B, 6C and 6D).

   

Figures 6A, 6B, 6C and 6D Clinical examinations at 12weeks post-op, without External Fixation. There is now good and adequate ankle range of motion.

Discussion

Milgram’s classification system is used for staging the lesions: In stage 1, the lesion is a solid lipoma composed of viable fat cells; in stage 2, part of the lesion is necrotized, forming focal calcification; and in stage 3, most of the tumor tissue has died, with variable degrees of cyst formation, calcification, and reactive new bone formation [19].

Histopathologic analysis of our (specimen) reveals fragments of bone which include a few fragments of necrotic bone and fibroadipose tissue showing foci of fat necrosis and necrosis of other soft tissue-types. The morphology suggests a possible fracture site or tendon avulsion. There is no evidence of neoplasm. These findings were consistent with the diagnosis of stage 2 intraosseous l intraosseous.

The need for surgical treatment is controversial. Curettage with bone grafting is the treatment of choice when surgical intervention is needed. Most lipomas, however, can be managed conservatively. Some surgeons feel that in asymptomatic cases with no signs of an impending pathologic fracture or suspicion of malignancy that a non-operative treatment with clinical and radiological follow-up is indicated. Malignant transformation is rare. While some surgeons think that biopsy is unnecessary because radiological features are characteristic, others believe that the lesion must be diagnosed histologically. However, reports stating that biopsy is required usually predate the common and efficient use of MRI, when an accurate radiological diagnosis was almost impossible.

We believe that pain alone is not an indication for surgical intervention or any other invasive treatment, including biopsy. The cause of pain in the patient with intraosseous lipomas is unclear, but it may be mechanical due to expansile remodeling of bone. It may be related to the ischemic changes that frequently accompany these lesions. It is also possible that the pain is referable from nearby joint disease and that the an intraosseous lesion is incidentally discovered. It is reported that symptoms may recur after surgical treatment or resolve spontaneously on conservative treatment, thus suggesting that many intraosseous lipomas are incidental findings and that patients may have another, unidentified cause of symptoms. Microtrabecular fracture in areas of weakened bone following episodes of minor trauma may be one cause of pain. Areas of diffuse increased signal were observed on MRI within the lipoma in some series, which may represent a stress response.

Asymptomatic intraosseous lipomas of the calcaneus should not require surgical intervention, since the tumor always occurred in the region of Ward’s triangle, which is a non weight-bearing region. In fact, in healthy individuals it is a region with bone paucity. A pathological fracture seems to be unlikely and has not been previously reported in the calcaneus.

Small cysts that are not located in the pressure-bearing trabecular area of the calcaneus are usually asymptomatic and can be treated conservatively. A “critical-size cyst” has been defined as an intraosseous lipoma extending the full breadth of the calcaneus laterally to medially in the coronal plane, and occupying at least 30% of the length of the calcaneus anteroposterior. Since the presence of a pathological fracture through a calcaneal cyst makes the operative procedure more complex and healing less predictable, the authors believe that large symptomatic calcaneal cysts should be managed surgically to reduce morbidity.

The decision to operate on a calcaneal cyst should be based on its size and location, the provisional diagnosis, associated symptoms, and the activity level and health of the patient. Although intraosseous lipoma is a benign lesion, Milgram [19] described four cases of intraosseous lipoma that underwent malignant transformation. Liposarcoma and malignant fibrous histiocytoma have also been found adjacent to benign lipomas.

Treatment of intraosseous lipomas is still controversial. Hirata, et al.[30], suggested that surgical treatment is not necessary owing to the potential for spontaneous regression and very low rate of malignant transformation. However, according to Weinfeld, et al.[21], curettage and grafting is the best choice of treatment. Schneider stated that the need for surgical treatment relies on the risk of malignant transformation [23]. Bertram reported a 33% rate of accidental diagnosis among 54 patients and surgery was only required when the patient was clinically symptomatic [24].

Gonzalez’s conclusion was similar to Bertram and stated that the majority of calcaneal intraosseous lipomas are seen in Ward’s triangle [10]. According to Mollin, et al.[28], curettage and grafting is a good choice for permanent treatment and can be performed if the patient is symptomatic. In the present case report, we operated on a symptomatic patient. He was resistant to conservative treatment for the previous 3 to 6 months. He underwent surgery due to the pain, incapacity to perform any sport activity and a suspicion for risk of pathological fracture due to his athletic ability.

Our patient started weight bearing just after surgery with an external fixator. He recovered with full benefit after nine months, and increased his sport activities without any complaint. Since intraosseous lipoma is an uncommon bone tumor, there is a need to familiarize physicians with the radiographic and MRI features of this lesion for the correct diagnosis and treatment.

References

1.  Kapukaya A, Subasi M, Dabak N, Ozkul E. Osseous lipoma: eleven new cases and review of the literature. Acta Orthop Belg 2006 72: 603-614. [PubMed]
2.  Radl R, Leithner A, Machacek F, Cetin E, Koehler W, Koppany B, Dominkus M, Windhager R. Intraosseous lipoma: retrospective analysis of 29 patients. Int Orthop 2004 28: 374-378. [PubMed]
3.  Campbell RS, Grainger AJ, Mangham DC, Beggs I, Teh J, Davies AM. Intraosseous lipoma: report of 35 new cases and a review of the literature. Skeletal Radiol 2003 32: 209-222. [PubMed]
4.  Reig-Boix V, Guinot-Tormo J, Risent-Martinez F, Aparisi-Rodriguez F, Ferrer-Jimenez R. Computed tomography of intraosseous lipoma of os calcis. Clin Orthop Relat Res 1987 (221): 286-291. [PubMed]
5.  Yildiz HY, Altinok D, Saglik Y. Bilateral calcaneal intraosseous lipoma: a case report. Foot Ankle Int 2002 23: 60-63.  [PubMed]
6.  Buckley SL, Burkus JK. Intraosseous lipoma of the ilium. A case report. Clin Orthop Relat Res 1988 (228): 297-301. [PubMed]
7.  Arslan G, Karaali K, Cubuk M, Senol U, Lüleci E. Intraosseous lipoma of the frontal bone. A case report. Acta Radiol  2000 41: 320-321. [PubMed]
8.  Kapukaya A, Subasi M, Dabak N, Ozkul E. Osseous lipoma: eleven new cases and review of the literature. Acta Orthop Belg 2006 72: 603-614. [PubMed]
9.  Chow LT, Lee KC. Intraosseous lipoma. A clinicopathologic study of nine cases. Am J Surg Pathol 1992 16: 401-410. [PubMed]
10.  Gonzalez JV, Stuck RM, Streit N. Intraosseous lipoma of the calcaneus: a clinicopathologic study of three cases. J Foot Ankle Surg 1997 36: 306-310. [PubMed]
11.  Propeck T, Bullard MA, Lin J, Doi K, Martel W. Radiologic-pathologic correlation of intraosseous lipomas. AJR Am J Roentgenol2000 175: 673-678.  [PubMed]
12.  Kamekura S, Nakamura K, Oda H, Inokuchi K, Iijima T, Ishida T. Involuted intraosseous lipoma of the sacrum showing high signal intensity on T1-weighted magnetic resonance imaging (MRI). J Orthop Sci 2001 6:183-186. [PubMed]
13.  Levin MF, Vellet AD, Munk PL, McLean CA. Intraosseous lipoma of the distal femur: MRI appearance. Skeletal Radiol 1996 25: 82-84.  [PubMed]
14.  Blacksin MF, Ende N, Benevenia J. Magnetic resonance imaging of intraosseous lipomas: a radiologic-pathologic correlation. Skeletal Radiol1995 24: 37-41. [PubMed]
15.  Rosenblatt EM, Mollin J, Abdelwahab IF. Bilateral calcaneal intraosseous lipomas: a case report. Mt Sinai J Med 1990
57: 174-176. [PubMed]
16.  Ketyer S, Brownstein S, Cholankeril  J.  CT diagnosis of intraosseous lipoma of the calcaneus. J Comput Assist Tomogr 1983 7: 546-547. [PubMed]
17.  Kozlowski K, Welshman R. What is it? Intraosseous lipoma in a 13-year-old boy. Br J Radiol 1991 64: 855-856. [PubMed]
18.  Lagier R. Case report 128. Skeletal Radiol 1980 5: 267-269, 1980. [PubMed]
19.  Milgram JW. Intraosseous lipomas. A clinicopathologic study of 66 cases. Clin Orthop 1988 231: 277-230. [PubMed]
20.  Poussa M, Holmstrom T. Intraosseous lipoma of the calcaneus. Report of a case and a short review of the literature.  Acta Orthop Scand 1976 47: 570-574. [PubMed]
21.  Weinfeld GD, Yu GV, Good JJ. Intraosseous lipoma of the calcaneus: a review and report of four cases. J Foot Ankle Surg 2002 41: 398-411.  [PubMed]
22.  Schneider O, Mischo J, Puschel W. Intraosseous lipoma of the calcaneus. Chirurg 1994 65: 74-76. [PubMed]
23.  Bertram C, Popken F and Rutt J. Intraosseous lipoma of the calcaneus. Congen Arch Surg 2001 386: 313-317. [PubMed]
24.  Langenbecks, Tejero A, Arenas AJ and Sola R. Bilateral intraosseous lipoma of the calcaneus. A case report. Acta Orthop Belg 1999 65: 525-527.  [PubMed]
25.  Rosenblatt EM, Mollin J and Abdelwahab IF. Bilateral calcaneal intraosseous lipomas: a case report. Mt Sinai J Med 1990 57: 174-176.  [PubMed]
26.  Ramos A, Castello J, Sartoris DJ, Greenway GD, Resnick D, Haghighi P. Osseous  lipoma: CT appearance. Radiology  1985 157: 615-619. [PubMed]
27.  Bruni L. The “cockade” image: a diagnostic sign of calcaneum intraosseous lipoma. Rays 1986 11: 51-54.  [PubMed]
28.  Reig-Boix V, Guinot-Tormo J, Risent-Martinez F, Aparisi-Rodriguez F, Ferrer-Jimenez R. Computed tomography  of intraosseous lipoma of os calcis. Clin Orthop 1987 221:286-291. [PubMed]
29.  Hirata M, Kusuzaki K and Hirasawa Y. Eleven cases of intraosseous lipoma of the calcaneus. Anticancer Res 2001 21:  4099-4103. [PubMed]


Address correspondence to: Victor Herrera, DPM email: herreragioco@bellsouth.net

1Diplomate, American Board of Podiatric Surgery, American Academy Podiatric Sports Medicine.
2Senior Resident at Barry University/ Mercy Hospital, Miami, Florida
3Resident at Barry University/ Mercy Hospital, Miami, Florida
4Diplomate, American Board of Podiatric Surgery.

© The Foot and Ankle Online Journal, 2012

Arthrodiatasis in the Treatment of Ankle Arthritis: A Case Series

by Edgardo Rodriguez, DPM1, Byron Hutchinson, DPM2, Craig Clifford, DPM3, Kevin McCann, DPM4

The Foot and Ankle Online Journal 5 (7): 2

Ankle arthritis that has failed conservative treatment warrants a more aggressive approach. Most treatments for ankle arthritis are primarily joint destructive, with a high probability for long term negative sequelae. The option to attempt surgical treatment with a less invasive procedure is appealing for both the surgeon and the patient. The purpose of this study is to demonstrate the efficacy of ankle arthrodiatasis with the use of external fixation as an alternative treatment for ankle arthritis. Eighty-two patients were evaluated preoperatively and postoperatively for pain, function, and complications with the Maryland foot score. Twenty patients (24%) experienced excellent results, forty-five (55%) good results, twelve patients (12%) had fair results, and five patients (6%) had poor results. Of the five poor results, four patients underwent an ankle replacement and one patient underwent ankle arthrodesis. The authors consider the use of ankle distraction with ankle arthroplasty as a viable alternative to previously accepted treatments for severe ankle arthritis. The hallmark benefit of this procedure is its joint sparing properties. Decreased soft tissue dissection associated with the use of external fixation makes this less invasive treatment available to a wide range of patients. Ankle arthrodiatasis is a viable treatment option for the treatment of advanced ankle arthritis.

Key Words: Arthrodiatasis, Ankle Distraction, Distraction Arthroplasty, External Fixation, Ankle Arthritis

Accepted: June, 2012

Published: July, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0507.0002


Articular damage to the ankle joint has a broad range of etiologic processes including traumatic arthritis, primary degenerative osteoarthritis, neuropathic arthropathy, inflammatory arthritis, and infectious arthritis.

Because of pain when ambulating or inability to bear weight, these ankle arthritides can be exceedingly debilitating. The most common causes of degenerative changes in the ankle joint are previous trauma to the joint and abnormal ankle mechanics [1]. Unlike the larger, more proximal joints of the lower extremity, primary idiopathic osteoarthritis is not the leading cause of damage to ankle joint articular cartilage.

It has been previously shown that up to 70% of symptomatic ankle arthritis is associated with past rotational ankle fractures or other previous trauma, with only 7% manifesting as primary (idiopathic) osteoarthritis [2].

Ankle arthritis may be evaluated both clinically and radiographically. On examination, patients may present with painful and limited joint motion, tenderness, variable degrees of inflammation, joint crepitus, and osseous deformity. Evidence of joint space narrowing, osteophyte formation, subchondral cystic lesions, and osseous erosions are often visible radiographically (Figs 1A and 1B). Early symptoms of ankle arthritis can be treated successfully with several conservative therapies. Pharmacologic agents, such as non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular steroidal injections, and visco-supplementation with sodium hyaluronate injection may be beneficial in reducing symptoms [3]. Lifestyle changes, which include weight reduction and the use of bracing devices such as Ankle-Foot Orthoses have shown to decrease symptoms as well. When conservative measures fail and symptoms persist a more aggressive approach is warranted, which includes operative intervention.

 

Figure 1A and 1B Preoperative anterior-posterior radiograph of arthritic ankle joint (A). Preoperative lateral radiograph of arthritic ankle joint showing extensive tibial hypertrophy (B).

To date, ankle arthrodesis for the treatment of end-stage ankle arthritis has yielded good short- and intermediate-term results. Several reports [4,5,6] have suggested that primary arthrodesis relieves symptoms in approximately 80% of treated individuals by providing a stable, plantigrade, and ideally a painless foot. Yet even when performed appropriately, this procedure has its inherent complications, including malalignment, abnormal biomechanics, painful retained hardware, and most importantly premature arthritis of adjacent joints. With advances in joint replacement technology, new generation ankle prostheses are designed to more accurately mimic the true anatomy and biomechanics of the ankle. Unlike early counterparts, these second generation implants have exhibited promising results [7]. Ankle joint replacement however, is a difficult procedure to master, and fraught with the possibility of long term complications and eventual implant failure. With a high technical learning curve, these procedures should only be performed by skilled surgeons with adequate procedural volume. Salvage procedures after failed ankle replacement may include revision, arthrodesis, and even amputation [8].

The term “arthrodiatasis” was coined in 1979 in Verona, Italy. Its origin stems from the Greek words for “joint” (arthros), “through” (dia), and “to stretch out” (tasis) [9]. In 1975, Volkov and Oganesian first reported the use of joint distraction in the knee and elbow [10]. Only recently has literature started to surface which studies distraction for the treatment of arthritic ankles. The first documented case of ankle arthrodiatasis was published in 1978 [9,11], but the majority of work with ankle distraction began in the 1990’s. Van Valburg et al. reported on joint distraction utilizing an Ilizarov apparatus in 11 patients, resulting in increased joint space as well as decreased pain and improved mobility for a mean of two years. Van Roermund, van Valburg, and their team in the Netherlands have led much of the research on ankle distraction [12-18].

Ankle arthrodesis and implant arthroplasty are both joint destructive procedures with a high possibility for long term negative sequellae [19].

Ankle arthrodiatasis with the use of an external fixator carries the primary benefit of being non-destructive to the ankle joint, which retains for the younger patient the possibility of later implant arthroplasty or arthrodesis. The purpose of this study is to demonstrate the efficacy of ankle arthrodiatasis with the use of external fixation as an alternative treatment for ankle arthritis.

Methods

Eighty-two distractions were performed in 82 non-consecutive patients from 1998 to 2010, with a mean age of 49 years of age, and follow-up ranging from one to 12 years. Of these, 45 were male and 37 female. Thirty-seven (45%) of patients had a deformity correction (i.e. midfoot, calcaneal, or supramalleolar osteotomy) and twenty-three (28%) underwent an Achilles tendon lengthening. Seventy-Eight of 82 patients (95%) underwent an open ankle arthrotomy at the time of frame application to remove any impinging anterior osteophytes and improve ankle joint range of motion (Figs. 2A and 2B). All patients had arthritis of the ankle joint secondary to trauma and were recommended for an arthrodesis by other treating physicians after failing conservative treatment. All patients had either slight or marked decrease in range of motion at the ankle as compared to accepted normal values with none of the ankles being graded as ankylosed.

 

Figure 2A and 2B Open arthrotomy with visible osteophyte formation (A). Open arthrotomy following resection of anterior tibia (B).

All patients were assessed by one of the two senior authors (ER or BH) both preoperatively and postoperatively using the Maryland foot score [20].

Patient Preparation and Additional Procedures

Operative procedures were performed in the supine position under general anesthesia with a thigh tourniquet. If indicated, adjunctive procedures were performed at the time of frame application. A percutaneous tendoAchilles lengthening was performed to correct ankle joint equinus. An osteotomy was performed in the calcaneus to correct for a varus deformity, or in the tibia to correct for a procurvatum deformity if indicated.

Aggressive ankle debridement at the time of ankle distraction was performed from either an open anterior medial approach or arthroscopically to increase intraoperative range of motion and remove osteophytic blocks and soft tissue impingement. An accessory anterior lateral incision was necessary as well in some cases. After performing the necessary ancillary procedures, incision sites were closed appropriately via the surgeon’s preference, and the pneumatic thigh tourniquet was deflated.

Frame Preparation and Wire Placement

The authors utilized a multi-planar ring external fixation system for arthrodiatasis. Three main objectives of frame design for ankle distraction are: providing stability, allowing sufficient room for soft tissue clearance, and permitting weight bearing as soon as possible. The frame was pre-built in order to minimize intraoperative anesthesia time. It was generally comprised of two proximal rings, which were attached to the tibia, and a distal foot plate or one-third ring, which was attached to the foot. The two tibial rings and the distal foot plate or one-third ring were separated by threaded rods, which varied in length depending on patient size. Three or four threaded rods separated each tier of the frame. Ring size was chosen to allow two finger-breadths between the ring and the leg at any point. Rings that are too large provide less rigid fixation, but it is essential that there is enough space to allow for postoperative swelling [20].

The proximal ring was positioned perpendicular to the axis of the tibial shaft and the limb was centered within the ring. The ankle joint was placed at 90 degrees, with the foot in a neutral position. The distal one-third ring or foot plate was placed parallel to, but not distal to the plantar surface of the foot, so that patients were able to bear weight directly on the plantar foot with minimal interference from the distal frame. Smooth wires were utilized to attach the frame to the extremity, consisting of two crossing wires through the calcaneus distal to the neurovascular bundle, and two crossing wires at each tibial ring level. A third wire was placed at each tibial ring if the patient weighed more than 200 pounds. All wires were secured and tensioned to their corresponding ring.

Distraction Technique

Distraction was accomplished by tightening nuts along threaded rods or with telescoping rods connecting the foot plate to the distal tibial ring for six millimeters of acute distraction. Fluoroscopic imaging was utilized to verify distraction length. Vascular supply and small vessel integrity were evaluated after distraction via palpation of pedal pulses and capillary refill time. In postoperative recovery if the patient was unable to tolerate the distraction, the amount of distraction was reduced until the patient was comfortable.

Gradual distraction was accomplished at a rate of one millimeter per day in four separate daily adjustments until the desired amount of distraction was obtained.

Postoperative Management

The space between the skin and the fixator rings was packed with a bulky bolster dressing in an effort to control postoperative edema. This is particularly important in the ankle and heel region where swelling is most severe after this type of procedure. Postoperative dressings remained in place for three to seven days. Distraction was confirmed radiographically at the first postoperative visit. (Figs. 3A and 3B) At time of dressing change, pin sites were cleansed with isopropyl alcohol. After approximately two weeks postoperatively, patients began daily self-care of the pin sites with the use of isopropyl alcohol. Sutures and staples remained intact until the frame was removed. Patients were allowed to begin wetting the frame in the shower after approximately two weeks, when the pin sites were dry and stable.

 

Figure 3A and 3B Postoperative anterior-posterior radiograph depicting arthrodiatasis (A). Postoperative lateral radiograph depicting arthrodiatasis (B).

Patients began partial weightbearing as soon as possible after the procedure. Under most circumstances, the patients were encouraged to begin touchdown weight bearing on the first postoperative day as tolerated. Physical therapy was started while patients were in the hospital to instruct the patient with gait utilizing an assistive device, usually a walker.

The ring fixator was removed under general anesthesia after 10 to 12 weeks if a corresponding osteotomy had been performed, and after approximately six weeks if no osteotomy was performed. In most cases, the ankle joint was arthroscopically debrided, and lateral ligamentous laxity of the joint was assessed and repaired if necessary. Radiographs were taken at the time of frame removal (Fig. 4). The patients began weight bearing immediately after the frame was removed with a fracture walker. Patients were able to bear full weight with the use of the fracture walker, but often required a gait assistive device such as a cane or crutch for a period ranging from several weeks to about two months after the frame was removed. Transition to regular shoe gear occurred at two to four weeks, depending upon whether or not ligamentous repair was necessary.

Figure 4 Same patient as in Figure 1, following arthrodiatasis and frame removal.

Results

Patients were evaluated preoperatively for pain and function, and at most recent follow-up for pain, functional outcome, and complications. A retrospective chart review was performed, and patients were assigned to outcomes groups of excellent, good, fair, or poor based on the modified Maryland foot score. All patients rated their cosmetic results as acceptable postoperatively.

Twenty patients (24%) had an excellent outcome. These patients reported minimal pain and were able to walk unlimited distances. These patients did not experience weakness, and did not require a supportive device.

They related the ability to ambulate in any shoes, or shoes with only mild concessions. They also related the ability to ambulate on any terrain and climb stairs normally without difficulty. The 45 patients (55%) with good results experienced mild to moderate pain and were only slightly limited in walking distance. They experienced mild weakness not requiring a supportive device. They related the ability to ambulate in shoes with minor concessions or with orthotics. These patients experienced difficulty ambulating on rocks and hills. Several also reported requiring a banister or other method of assistance when climbing stairs.

Twelve patients (15%) had fair results, and usually related moderate pain and were slightly to moderately limited in walking distance. They typically experienced mild to moderate weakness with only one patient requiring a supportive device. They were able to ambulate in shoes with orthotics, experienced difficulty ambulating on rocks and hills, and reported requiring some method of assistance when climbing stairs. Finally, five of the patients (6%) had a poor outcome following distraction. Four of these patients ultimately required an ankle replacement and one required ankle arthrodesis.

The most common complication encountered was pin site irritation or infection in 12 patients (15%), which is commonly seen with external fixation. Clinical signs of local infection were treated successfully with use of aggressive cleansing of pin sites and with oral antibiotics if necessary. One patient (1.2%) developed acute osteomyelitis which was resolved with intravenous antibiotics. One patient (1.2%) was removed from the multiplanar ring fixator in four weeks secondary to psychological intolerance to the device. Ligamentous laxity after distraction occurred with two patients (2.4%), and was corrected with either bracing or lateral ligament repair. One patient (1.2%) developed a deep vein thrombosis, leading to a pulmonary embolism. This was treated and completely resolved via anticoagulant therapy. One patient (1.2%) developed Charcot neuroarthropathy of the midfoot. Fortunately, this development was identified and treated promptly, and did not change the patient’s overall functional outcome.

Discussion

Advanced arthritis of the ankle joint can be one of the most difficult and debilitating pathologies treated by the foot and ankle specialist. Although no single treatment is appropriate for every patient, the authors consider the use of ankle distraction with arthroplasty as a viable alternative to previously accepted treatments. Decreased soft tissue dissection associated with the use of the external fixation device as compared to more aggressive procedures make this treatment available to a wide range of patients. It has been advocated [9] for patients under the age of 50, to delay arthrodesis procedures by five to ten years and opt for other operative procedures. Stress placed on adjacent joints following ankle arthrodesis often leads to arthritic changes in these joints as well. It follows therefore that arthrodesis of the ankle joint should be avoided in younger patients. The non-destructive nature of arthrodiatasis creates an additional option to delay arthrodesis provided the patients are proper candidates for the procedure and understand the possible need for a more aggressive procedure later on in life.

Few studies have been published on the use of ankle distraction as treatment for severe ankle arthritis. In 1995, van Valburg et al. [17] reported on joint distraction utilizing an Ilizarov apparatus in 11 patients with posttraumatic arthritis. Improvement in pain and mobility were noted. Ankle range of motion increased by 55% and joint space widening was seen in 50% of the patients radiographically. Van Valburg, et al,. [15] published a two year prospective follow up in 17 patients, indicating that 66% continued to have symptomatic relief. In 1998, van Roermund, et al,. [16] presented three cases of joint distraction for arthritis. The joints distracted in this case study were the interphalangeal joint of the thumb, the patellofemoral joint, and the ankle joint. Van Roermund et al. [14] later implied that joint distraction in the case of severe ankle osteoarthritis may be a treatment of choice. In 2002, Marijnissen, et al,. [13] reported significantly better results with ankle distraction than with debridement alone. Marijnissen, et al,. [12] then advocated the use of ankle joint distraction as the treatment of choice in patients of a relatively young age with severe ankle arthritis.

In a study reporting the effects of joint distraction in a canine model, van Valburg reported that in the arthritic canine knee joint distraction produced a return to control levels of abnormal cartilage proteoglycan as well as a decrease in local inflammation, suggesting a change in cartilage metabolism [18]. Chiodo and McGarvey advocated further study of ankle distraction due to its minimally invasive nature, combined with the fact that it is not joint-destructive [23]. Even if joint distraction provides only temporary relief and clinical results slowly deteriorate over time, more definitive and committed procedures can potentially be postponed for a considerable period of time. Ploegmakers, et al,. reported six of 22 patients (73%) treated with ankle distraction showed significant improvement in symptoms at seven years postoperatively [24]. Most recently, Paley and Lamm have performed 20 ankle joint distractions using a hinged external fixator, allowing for range of motion within the ankle joint [9]. Eighteen of the distracted joints were rated good or excellent, with a follow up ranging from two to 17 years.

In theory, distraction of the ankle joint allows for maintenance of intermittent intra-articular fluid pressure, thereby promoting cartilage reparative processes [10]. Damage to the ankle joint is further diminished by offloading contact between the joint surfaces. Subchondral sclerosis is reduced during distraction, which decreases the mechanical stresses on the cartilage during loading of the joint and allows for greater absorption of stresses during ambulation [9,13,14,23].

As noted previously, there is a much lower incidence of primary osteoarthritis in the ankle compared to the knee. Studies performed by Cole, et al,. [25] compared the cartilage between the human talocrural and tibiofemoral joint. They were able to demonstrate that the ankle joint had better reparative processes compared to the knee joint. The biochemical composition of the ankle joint has a more dense extracellular matrix, which resists loading and is less prone to damage [25,26,27]. This may cause a shift in the distracted joint, favoring cartilage synthesis rather than degradation.

The ability of ankle cartilage to repair itself along with the documented clinical benefits of ankle distraction has caused increased interest in this particular joint sparing operative procedure.

As is the case with almost all operative procedures, proper patient selection is a key component to increasing the chance for a successful outcome. Radiographic criteria, concurrent lower extremity deformities, the age and overall health of the patient, and the patient’s motivation and willingness to comply with instructions are all key factors to consider when deciding whether ankle distraction is appropriate for a patient.

Before considering patients for ankle distraction, the surgeon must evaluate and address any adjacent lower extremity deformities. Additional procedures may be indicated to create a stable, plantigrade foot, which is necessary for a successful outcome after ankle distraction. The surgeon must also be prepared to address any talar dome lesions that may be present, either arthroscopically or with open arthrotomy.

Standard weight bearing radiographs of the foot and ankle provide sufficient preoperative imaging for most distraction procedures. Hindfoot alignment views or other imaging modalities may be necessary to evaluate more complex deformities. Common findings among post-traumatic arthritic joints, which are most prevalent with ankle arthritis, include joint space narrowing, subchondral sclerosis, osseous erosions, and osteophyte formation. Relative radiographic contraindications to performing an ankle distraction include flattening of the talar dome, presence of greater than five degrees of valgus or varus deformity of the hindfoot, midtarsal joint degenerative joint disease, severe forefoot abnormalities, and severe equinus deformity.

Generally, ankle arthrodiatasis is indicated for younger or more active patients experiencing pain, instability, and deformity but seeking alternatives to ankle arthrodesis and replacement. Patient age is less important than the individual’s overall health, compliance, motivation, and ability to tolerate rigorous post-distraction rehabilitation and physical therapy.

Distraction procedures have been shown to produce slow, progressive improvement over a period of many months with most patients noticing the greatest amount of functional and symptomatic improvement approximately one year after surgery [14].

Contraindications to performing this procedure include medical co-morbidities that preclude the patient from undergoing an elective operative procedure, severe osteoporosis, infection, non- reconstructable malalignment of the lower extremity, severe peripheral vascular disease and neuroarthropathy. Psychosocial issues must also be addressed prior to frame placement.

The most common complication associated with external fixation procedures is pin-tract infections [28]. Fortunately, these infections are usually superficial and localized, making them manageable to treat. The infections often begin as a cellulitis secondary to Staphylococcus aureus, and they respond quickly to oral antibiotics [29]. If the infection involves deeper tissues and/or bone, the patient may require intravenous antibiotic therapy, with or without wire removal [31]. Pin-site care opinions differ, but a study by Davies, et al., showed that pin-sites and wires managed with the technique used by the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics were less likely to develop pin tract infections [29]. This technique focuses on avoiding thermal injury and local formation of hematoma during surgery and utilizing alcoholic antiseptic and occlusive pressure dressings postoperatively.

Neurovascular injury during pin placement can generally be avoided with proper planning and a firm grasp of the cross sectional anatomy in each region of wire placement. Posterior tibial nerve traction injuries and tarsal tunnel syndrome are also possible complications associated with ankle distraction procedures [30]. Gradual distraction of the ankle can sometimes prevent this complication. Another option for prevention is to perform a prophylactic tarsal tunnel release at the time of ankle distraction. The posterior tibial nerve is at risk for traction injuries during acute or gradual correction of hindfoot deformities.

The addition of this procedure has been shown to relieve a considerable amount of postoperative nerve traction and tarsal tunnel symptoms [31,32].

Venous thrombosis is always a risk after procedures in which external fixators are applied, and the surgeon should use prophylactic measures to prevent this. Low molecular weight heparin (LMWH) is started approximately 12 to 24 hours after surgery and continued for 28 to 42 days following the procedure, depending upon the patient’s other risk factors. LMWH is advantageous in that it can be given at a constant dose without any laboratory monitoring. Randomized clinical trials comparing LMWH with unfractionated heparin in general surgical patients have found that LMWH given once or twice daily are as effective or more effective in preventing thrombosis [33,34]. Warfarin has also been compared with LMWH, and most studies show a superior benefit with LMWH [35,36]. The patient should be encouraged to start moving the lower extremities as soon as possible postoperatively. Intermittent sequential compression devices (SCDs) for prophylaxis against deep vein thrombosis (DVT) on the contralateral limb is important while the patient is still in the hospital.

Hardware failure in the form of wire breakage will occasionally occur, more frequently with the wires in the foot. This is usually because of excessive strain in the foot during walking with a fixed ankle [12]. If this occurs, the wire can be removed and replaced with a new wire if necessary. It is important to check and adjust tension of all wires at postoperative visits. For patients over 200 pounds, it is recommended to place three wires across the tibia at each level of the tibial rings. This will aide in prevention of hardware failure.

It is important to check for ligamentous laxity and instability immediately after the frame is removed intra-operatively. If ligament damage is present, repair of the lateral ankle ligaments is often necessary. If the patient is complaining of symptoms related to this condition postoperatively when the frame is removed, these symptoms can usually be managed successfully with physical therapy and functional bracing.

Failure of the ankle distraction procedure to relieve pain is always a possibility. Ankle arthrodiatasis is generally performed on patients who have advanced, debilitating arthritis, and the patient must go into the procedure with the understanding that an arthrodesis or an implant may be necessary in the future. After ankle distraction there is often a period of increased pain and stiffness for two to four months, and it can take as long as six to twelve months to see improvement. During this time, the patient should continue with aggressive physical therapy and non-impact activities [31]. Radiographic improvements are sometimes seen for as long as five years after arthrodiatasis, indicating that ankle distraction benefits are progressive in nature [12]. It is the author’s belief that the benefit of ankle arthrodiastasis outweighs the mild and infrequent nature of the complications encountered with this procedure.

Ankle distraction with ankle arthroplasty should be considered a viable treatment for severe ankle arthritis for its minimal dissection and joint-sparing properties. Future treatment for ankle arthritis will likely involve ankle distraction in conjunction with newer methods in cartilage repair, such as autologous chondrocyte transplantation, autologous osteochondral transfer, and allografts. With new advances and developments, further studies will be required to study the efficacy of these procedures.

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Address correspondence to: Craig Clifford, DPM, Federal Way Orthopedic Associates, Federal Way, WA 98003
Email: CraigClifford@fhshealth.org

1Director: Chicago Foot & Ankle Deformity Correction Center; 233 East Erie, Ste 702, Chicago, Illinois 60611
2Director: Franciscan Foot & Ankle Institute; 34509 9th Ave S., Ste 306, Federal Way, WA 98003.
3Federal Way Orthopedic Associates, Federal Way, WA 98003.
4St. Cloud Orthopedics, St. Cloud, Minnesota.

© The Foot and Ankle Online Journal, 2012