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

Posted on October 1, 2011 | Comments Off on Diabetic Limb Salvage in the Septic Ankle: Case Studies of Arthrodesis using the Ilizarov Methodology

by Sutpal Singh, DPM. FACFAS1 , Albert Kim, DPM2, Timothy Dailey, DPM,3
Long Truong, DPM4, Maria Mejia, DPM5

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

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

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

Accepted: September, 2011
Published: October, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0410.0001

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Case Report

Case # 1

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

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

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

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

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

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

Case # 2

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

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

 

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

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

 

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

 

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

 

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

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

  

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

Case # 3

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

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

 

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

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

 

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

 

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

Surgical Technique and Result

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Discussion

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

References

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2. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot & Ankle Surgery 2011 50: 25-30.
3. Schuberth J, Cheung C, Rush S, Blitz N, Roling B. The medial malleolar approach for arthrodesis of the ankle: A report of 13 cases. J of Foot & Ankle Surgery 2005 44:125-132.
4. Easley M. Operative Techniques in Foot and Ankle Surgery. Philadelphia: Lippincott Williams & Wilkins 2011.
5. Coughlin M, Mann R, Saltzman C: Surgery of the Foot and Ankle. Philadelphia. Mosby 2007.
6. Grass R, Rammelt S, Biewener A, Zwipp H: Arthrodesis of the ankle Joint” Clinics Podiatric Medicine Surgery 2004 21:161-178.
7. Karl-Heinz K, Hans-Jörg T, Fusszentrum W. Ankle arthrodesis with an anterior approach. Techniques Foot Ankle Surgery 2007 6: 243-248.
8. Hanson TW, Cracchiolo A 3rd: The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle International 2002 23:704-710.
9. Glick J, Morgan C, Myerson M, Sampson T, Mann J. Ankle arthrodesis an arthroscopic method: Long-term follow-up of 34 Cases. Arthroscopy 1996 12: 428-434.
10. Fragomen AT, Fragomen AT, Meyers KN, Davis N, Shu H, Wright T, Rozbruch SR. A biomechanical comparison of micromotion after ankle fusion using 2 fixation techniques: Intramedullary arthrodesis nail or Ilizarov external fixator. Foot & Ankle International 2008 29: 334-341.
11. Raikin S, Venkat R. An approach to the failed ankle arthrodesis. Foot Ankle Clinics 2008 13:401-416.
12. O’Brien T, Hart T, Shereff M, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis A comparative study. Foot Ankle International 1999 20: 368-373.
13. Hagen RJ. Ankle arthrodesis: problems and pitfalls. Clinical Orthopaedics and Related Research. 1986 202: 152-162.
14. Katsenis D, Bhave A, Paley D. Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus. JBJS 2005 87A: 302–309.
15. Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. JBJS 1985 67A: 546–550.
16. Costigan W, Thordarson D, Debnath U. Operative management of ankle fractures in patients with diabetes mellitus. Foot & Ankle International 2007 28: 32-37.
17. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. JBJS 2005 87B: 489-495.
18. McCormack R.G., Leith J.M.: Ankle fractures in diabetics: Complications of Surgical Management. JBJS1998 80B: 689-692.
19. Wukich D, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot & Ankle International 2011 32:120-30.
20. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot & Ankle International 2009 30:1042-1047.
21. Thordarson, D: Ankle fractures in diabetics. Techniques in Foot and Ankle Surgery. 2004 3: 192-197.
22. Eylon S, Porat S, Bor N, Leibner E. Outcome of Ilizarov ankle arthrodesis. Foot & Ankle International. 2007 28: 873-879.

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

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

© The Foot and Ankle Online Journal, 2011

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Talar and Calcaneal Y-Osteotomy with Distraction Osteogenesis for the Correction of Rigid Equinus

Posted on April 1, 2011 | Comments Off on Talar and Calcaneal Y-Osteotomy with Distraction Osteogenesis for the Correction of Rigid Equinus

by Sutpal Singh, DPM, FACFAS 1 , Albert Kim, DPM 2, Timothy Dailey, DPM 3, Long Truong, DPM 4, Maria Mejia, DPM 5

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

Types of equinus, surgical management for equinus involving the Y- talocalcaneal osteotomy supplementing an external fixation device is presented. A case report is introduced involving surgical correction of a 53 year old male who had a severe equinus flat top talus with mild varus secondary to clubfoot surgery. Treatment included surgical correction utilizing Steindler stripping, Achilles tendon lengthening, and a rather rare Y- osteotomy of the calcaneus and talus with the use of a multiplaner external fixator in an unconstrained system to correct the equinus and varus deformity. Slow distraction was performed in order to decrease the risks of having neurovascular injury, soft tissue injury, and shortening of the foot. After months of follow-up, there was good healing of the osteotomy sites and the patient had a plantigrade foot.

Key words: Clubfoot, Rigid Equinus, Flat top talus, Y-Osteotomy, External fixation, Distraction Osteogenesis, Ilizarov method.

Accepted: March, 2011
Published: April, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0404.0003

Ankle joint equinus can be divided into a three types; soft tissue, osseous and a combination of the two. [1] Soft tissue equinus alone can be easily repaired, but when multiple deformities occur such as clubfoot, it can complicate the treatment.

The etiology of ankle equinus can include trauma, diabetes mellitus, poliomyelitis, osteomyelitis, contracture from burns, neglected or relapsed clubfeet, prolonged immobilization in plantarflexion, as well as neuromuscular disease. [1,3,7]

Traditionally, correction has been managed through arthrodesis and extensive soft tissue release. Treatments for soft tissue ankle equinus include procedures such as splinting, tendo-Achilles lengthening, gastrocnemius recession, and rare deformities such as accessory soleus release. [10,13]  Neurovascular, soft tissue problems and shortening of the foot may occur with traditional techniques. Also, prior surgeries may make the surgical management of the foot deformities more difficult later in life.

An Ilizarov external fixator can be used to correct equinus and it can be applied in two ways; constrained and unconstrained. The constrained technique places the axis of rotation at a planned anatomical axis of the joint. [9]  The constrained technique can correct deformities within the joint unlike the unconstrained that keeps the natural axis of rotation. The unconstrained technique places the axis of rotation around the natural axes of the joint. [9] The unconstrained technique requires distraction of the ankle joint before an attempted correction.

The Ilizarov external fixator can be used to correct equinus without an osteotomy, only when the equinus is soft tissue in nature. Only correcting the soft tissue deformity with an Ilizarov frame has a high recurrence rate. [3]  When dealing with an osseous equinus an osteotomy must be performed and Ilizarov used the process called distraction osteogenesis to correct the deformity. [18] “Gradual distraction of the soft tissues and bones enables reshaping of the foot.” [8]  The Ilizarov technique can fix these deformities with minimal incisions. The downside to this is the patient has an external fixator for several months. During this time the patient may bear weight on the area which has an advantage over internal fixation. Another advantage is during osseous correction it can also correct for soft tissue deformities at the same time.

There are three main types of Ilizarov rearfoot osteotomies including the U, V and Y osteotomies. [9]  The Y- osteotomy is the least published of the three. The Y is an osteotomy through the neck of the talus and an osteotomy of the posterior calcaneus below and parallel to the subtalar joint making an apex in the anterior calcaneus and then an osteotomy plantarly thus creating the shape of a “Y”. [9]  The Y- osteotomy has the same implications as the V- osteotomy except it doesn’t elongate the foot as much. [9] The Y- osteotomy with external fixation allows small changes each day to allow the new bone to form and correct the deformity. This osteotomy allows correction of complicated equinus cases. Which osteotomy is chosen depends greatly on the surgeons’ experience.

Case Report

A 53 year old male was seen in the office due to severe pain around the sub right 4th and 5th metatarsals. The patient had an equinus deformity of the right lower extremity with varus deformity. (Figs.1A and 1B) His past surgical history was significant for club foot surgery when he was 4 years old, which still left him ambulating on the ball of his right foot. The rest of the history was unremarkable.

 

Figure 1A and 1B  Preoperative photo (A) and  radiograph (B) showing ankle equinus deformity.

Physical exam showed that he had scar tissue around the medial, lateral, and posterior heel on the right foot. The positioning of his right lower extremity included a tight contracted Achilles tendon that correlated with a rigid equinus deformity, varus of the foot with subtalar joint stiffness with no range of motion at the mid foot, rear foot and ankle. Also, there were contractures of all the digits. There was no leg length discrepancy noted and the length of the foot was within normal limits. The patient had difficulty wearing shoes and could only wear sandals. There was increased pain under the right 4th and 5th metatarsophalangeal joints due to the excessive pressure while ambulating secondary to the rigid equinus and inversion of the foot. This, in effect, was placing too much pressure on his 4th and 5th metatarsal heads.

The procedure that was performed included a Steindler stripping, an Achilles tendon lengthening, talar and calcaneal Y-osteotomies, plantar tenotomy of all five digits, and the application of an Ilizarov external fixator.

The patient was prepped and draped in the usual standard manner. No tourniquet was applied. A # 15 blade was used to perform a percutaneous tendon lengthening of the Achilles Tendon. The foot was only able to dorsiflex several degrees due to the severity of the deformity from negative 45 to negative 40 degrees. Along the plantar medial calcaneus a Steindler stripping was then performed. This helped release all the fascial and muscular contractions on the plantar foot from the calcaneus. A prophylactic tarsal tunnel release was also performed by transecting the laciniate ligament. Two tibial rings were then applied to the lower leg. One half-ring was applied to the calcaneus and one half-ring was applied to the distal foot. All wires were then tensioned appropriately. The calcaneal half-ring was attached to the posterior tibial ring. The distal foot half-ring was then connected to the anterior tibial ring.

The calcaneal ring was then connected to the distal foot half ring. All connections had distraction capability to correct the foot in three dimensions. Prior to any distraction, using flouroscan a small incision was made at the medial aspect of the talar neck. The incision was deepened to the subcutaneous tissue and then to the periosteum of the talus. A small osteotome was then used to perform a complete osteotomy of the talar neck. Along the lateral aspect of the calcaneus a small incision was made parallel and inferior to the subtalar joint. The incision was deepened to the subcutaneous level and then to the periosteum of the calcaneus. A small osteotome was used to perform a complete osteotomy of the calcaneus 1 cm posterior and inferior to the subtalar joint. Along the anterior aspect of the calcaneus a small incision was made 1 cm proximal to the calcaneal cuboid joint. The incision was deepened to the subcutaneous level and then down to the periosteum of the calcaneus. A small osteotome was inserted down to bone and rotated being careful not to transect the peroneal tendons or sural nerve. A complete osteotomy was then performed at the distal calcaneus. (Fig. 2)

Figure 2  Intra-operative  radiograph of the  Y- osteotomy.   The left side of the Y is the Talar neck osteotomy, the right side of the Y is the calcaneal osteotomy below the subtalar joint and the stem of the Y osteotomy is located at the distal calcaneus.

Note that a void was created while removing the osteotome at the stem of the osteotomy. This eventually healed well due to the vascular nature of the calcaneus. All surgical sites were irrigated with normal saline and bacitracin and sutured with 3-0 Prolene. Attention was then directed to all the plantar toes and plantar flexor tenotomies were then performed and smooth wires were then inserted and attached to the distal half ring. The surgical site was then dressed with Adaptic, gauze and Kerlex . (Figures 3,4,5A, 5B, and 6)

Figure 3  Initial frame placement at the time of the surgery.

Figure 4  Note the rod rotating the distal ring out of varus and dorsiflexing it.

 

Figure 5A and 5B  Note that the forefoot and rearfoot can be manipulated independent of each other.  Note the wires from the toes being attached to the forefoot half ring. (A)  The plantar view showing the percutaneous plantar tenotomies of all the toes with wires going into the metatarsals and attached to the foot half ring. (B)

Figure 6  The post-operative radiograph.

At one week, the following manipulations to the bones in the external fixator were initiated: 1) distraction of the calcaneus towards eversion and inferior displacement, 2) rotation of the distal foot towards eversion and dorsiflexion, 3) distraction of the forefoot from the rearfoot.

The patient was instructed to increase the movements by a total of 1 mm per day achieved by a ¼ turn of the distraction mechanism 4 times per day. The patient was taken back to the OR at week 3 (Fig. 7) and at week 8 (Fig. 8) for the addition of extra rods and bars for greater manipulation and a better line of pull. At week 12, there was good alignment of the foot in a plantigrade position and at week 20, the external fixator was removed (Fig. 9) At 6 months, the patient was ambulating in a custom made AFO. (Fig. 10)

Figure 7   More rods were applied for more distraction at 3 weeks after surgery.

Figure  8   At 8 weeks , the patient had more bars and rods added with frame manipulation.

Figure 9  At 5 months the frame was removed and the patient was placed in a below the knee cast.

Figure 10   At 6 months, the patient had his foot plantigrade and was full weight bearing in a custom made AFO.

Overall, the patient was able to ambulate with the heel on the ground with minimal pain; however, did not have much range of motion at the ankle or foot. All the pain under the lateral forefoot resolved. The patient was satisfied with his plantigrade foot and able to ambulate with a custom AFO.

Discussion

There are multiple surgical procedures available for correction of acquired ankle equinus, soft tissue as well as bone procedures. [1,2,4] When this deformity becomes fixed it poses a challenge to many foot and ankle surgeons due to soft tissue contraction and bony adaption and requires a combination of soft tissue and bone procedures. [1,2,4] Flexible deformities can be treated with manipulation methods thus preventing surgery.

When manipulation methods don’t work then surgery is required. Surgical correction consisting of extensive soft tissue releases with and without arthrodesis for equinus deformity has been well described. [15] Different osteotomies with and without an external fixator have been described in literature for correction of complex foot deformities. [9,11,14,16,17,20]

Correcting deformities such as clubfoot become a challenge especially after failed surgeries due to stiffness of the soft tissues and residual deformities such as equinus. [16,17] There are several osteotomies and a few of the commonly discussed ones are the U (Scythe-shaped), V, and less commonly discussed Y- osteotomy. [16,17]

The scythe-shaped (U) osteotomy is a curved osteotomy that divides the foot into two sections. It starts posterior to the lateral malleolus and runs from 1-1.5 cm below the posterior subtalar joint, then penetrates the floor of the sinus tarsi and emerges at the talar neck. [9,11] This type of osteotomy allows for correction of equinus with a rigid tibio-talar joint. [9]

The V – osteotomy is a combination of oblique cuts that are angled at 60-70 degrees. [9] The osteotomy is performed along the posterior calcaneus and the anterior calcaneal-talar. This type of procedure is indicated for treatment of complex deformity of the hindfoot and the midfoot. [9,11,19,20] The V- osteotomy offers versatility when combined with an external fixator because it has the ability to preserve foot length and perform simultaneous tibial corrections. [20]

The Y – osteotomy is similar to the V – osteotomy in a sense that it allows one to apply differentiated correction between the hindfoot and the forefoot. The osteotomy results in a three ray star that is all 120 degrees apart. The osteotomy is first performed at the oblique posterior aspect of the calcaneus, then a vertical osteotomy of the calcaneus, and finally the calcaneal-talar ostetomy. [9] This type of procedure allows for the same correction as the V – osteotomy but with fewer complications. [9]

The hinges are positioned on the medial and lateral threaded rods of the calcaneal half ring. The equinus is corrected by lowering the calcaneus and raising the forefoot in relationship to the talar body. [9] Correction is achieved through the movement of the fragments of the osteotomy with the majority of correction of the calcaneal and talar equinus. [9,14] The Y – osteotomy does not cause any skeletal lengthening as with the scythe-shaped osteotomy, therefore it offers three advantages. [9] The advantages include faster consolidation because of less bone regeneration, skin alteration is easily contained, and prevention of calcaneocuboid diastasis is unnecessary. [9]

The Ilizarov method with external fixation was chosen for the correction after performing the osteotomy because it enables correction in all three orthogonal planes. [4,9,11,14,17] Using an external fixator is not only minimally invasive, but it also allows the surgeon to stage the treatment appropriately to manipulate the rate and direction of the correction. It can be used as either a constrained or unconstrained hinge system. In the constrained foot frame, forces applied to the foot are directed around the axis. [14] This technique is usually reserved for large joints. In the unconstrained system, joints of the ankle and the foot are used as the fulcrum points for correction and it is usually used with smaller joints or deformities with multiple joint axes. [14]

The Steindler stripping procedure is recommended for patient with significant contractures of the plantar aponeurosis and plantar musculature.[1] The abductor hallucis, flexor digitorum brevis, and abductor digiti quinti are released from the periosteum of the calcaneus. However, this procedure is limited in that it does not correct fixed deformities and only corrects in the sagittal plane. [1]

The complications associated with the use of an external fixator and any type of osteotomy includes tarsal tunnel syndrome, neurovascular symptoms, pin tract infection, flexor contractures, valgus drift, incomplete osteotomy, residual deformity, and recurrence of problem. [4,9,11,14,16,17,19,20]

Due to such complications, it has been recommended that a prophylactic tarsal tunnel release be performed to decrease the likelihood of nerve entrapment secondary to the correction and to minimize the risk of vascular injury. [16] There is a high incidence of nerve injury as a result of acute angular deformity correction. [20] If compressive symptoms of the tibial nerve are experienced during the correction, it can be addressed either by performing a secondary surgical decompression or by decreasing the rate of correction. [11,14] Pin tract infection and flexor contractures are usually secondary to prolonged fixator utilization. [19,20] Pin tract problem are related to skin motion and controlled with local pin site care. Pin tract infections are minor complications that occurs with any type of external fixator but respond very well to oral antibiotics and rarely lead to osteomyelitis requiring pin removal. [17,20] Premature consolidation of the osteotomy before full correction is reached is also not an uncommon complication. To avoid this problem, it is recommended to start distraction routinely on the third postoperative day. [16]

Despite such complications, the Ilizarov technique remains an effective and safe tool for complex lower limb reconstruction surgery. It allows corrections in all planes at a rate that can be tailored to the deformity without the constraints of traditional methods.

When looking back at the literature regarding the Y- osteotomy there is not much to be found. Our case presentation is unique that to our knowledge there are no other journal articles on which a y calcaneal osteotomy is used in conjunction with an Ilizarov distractor. Furthermore there is close to no literature regarding the Y- osteotomy. In the literature the main focus has been on correcting the structural equinus foot by using the V. [16,17] Also there has not been another study in which the y osteotomy is used in conjunction with the Ilizarov distractor. In our case study we found that the Y- osteotomy allows for correction of a severe deformity while minimizing neurovascular and soft tissue complications as well as avoiding excessive shortening of the foot as is many times encountered with traditional techniques.

Traditional methods although successful with certain patients they involve much more cut in the bone which can lead to excessive shortening and soft tissue complications. Our case report helps to illustrate a successful way in which a rigid equinus can be corrected by the use of an under researched osteotomy with gradual distraction of the structures in the foot. In our case the patient was satisfied with his plantigrade foot even though he did not have much range of motion at the ankle or foot. This view is supported by other studies in which patient satisfaction is achieved with improvement in appearance of the foot. [6,16,21]

Conclusion

In this case study, we presented a rigid equinus foot that was corrected with the use of a Y – osteotomy along with the use of Ilizarov methodology. There is not much literature about the usage of the Y – osteotomy even though it has three main advantages which are: faster consolidation, skin alterations are easier to contain, and there is less chance of calcaneal-cuboid diastasis. [1] Furthermore, the Y – osteotomy avoids excessive lengthening of the foot. Correction of severe foot deformities with the Ilizarov method is technically difficult but when used with the Y – osteotomy, differentiated correction between the hindfoot and forefoot can be applied. In the case study it was successfully shown that the Y – osteotomy allows for correction of a severe deformity while minimizing neurovascular and soft tissue complications as well as avoiding excessive shortening of the foot as is many times encountered with traditional techniques. The final result was a plantigrade foot. Thus, the Y – osteotomy through the talus and calcaneus with distraction osteogenesis using the Ilizarov methodolgy is an effective surgical procedure in correcting rigid equino-varus foot deformities.

References

1. Banks AS, Downey MS, Martin DE, Miller SE. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilkins, 2001.
2. Coughlin, Michael J, Roger A. Mann, Charles L. Saltzman. Surgery of the Foot and Ankle. Philadelphia, Mosby 2007.
3. Digiovanni CW, Holt S, Czerniecki JM, Ledoux WR, Sangeorzan BJ. Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov Technique. Strategies Trauma Limb Reconstruction 3: 105-108, 2008.
4. Emara Khaled M, Allam Mohamed Farouk, ElSayed Mohamed Nabil MA, Ghafar Khaled Abd EL. Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov technique. Strat Traum Limb Recon 3:105-108, 2008.
5. Easley, Mark E., Wiesel Sam. Operative Techniques In Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilkins 2011.
6. Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution? J Pediatr Orthop 26:432–437, 2006.
7. Guyton G, Saltzman C. The Diabetic foot. JBJS 83A: 1083-1096, 2001.
8. Ilizarov GA. Transosseous osteosynthesis. Berlin/Heidelberg: Springer-Verlag, 1992.
9. Kirienko Alexander, Villa Angelo, Calhoun Jason H. Ilizarov Technique for Complex Foot and Ankle Deformities. Marcel Dekker, Inc, 2004.
10. Kishta WE, Mansour EH, Ibrahim MM. The accessory soleus muscle as a cause of persistent equinus in clubfeet treated by the Ponseti method : A report of 16 cases. Acta Orthopaedica Belgica 76: 658-662, 2010.
11. Kocaoğlu M, Eralp L, Atalar AC, Bilen FE. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg 41: 30-39, 2002.
12. Laughlin RT, Calhoun MD. Ring fixators for reconstruction of traumatic disorders of the foot and ankle. Orthop Clin North Am 287-294, 1995.
13. Lopez A, Kalish S, Mathew J, Willis FB. Reduction of ankle equinus contracture secondary to diabetes mellitus with dynamic splinting. Foot Ankle Online Journal. 3 (3):2, 2010.
14. Mendicino RW, Murphy L J, Maskill MP, Catanzariti AR, Harry P. Application of a constrained external fixator frame for treatment of a fixed equinus contracture. J Foot Ankle Surg 47: 468-475 , 2008.
15. Galli M , Cimolin V, Crivellini M, Albertini G. Gait analysis before and after gastrocnemius fascia lengthening in children with cerebral palsy. J Appl Biomaterials Biomechanics 3: 98-105, 2005.
16. Segev E, Ezra E, Yaniv M, Wientroub S, Hemo Y. V Osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. J Orthopaedic Surg 16: 215-219, 2008.
17. Shalaby H, Hefny H. Correction of complex foot deformities using the V-osteotomy and the Ilizarov technique. Strat Traum Limb Recon 1: 21-30, 2007.
18. Spielberg Parratt Dheerendra Khan Jennings Marsh. Ilizarov principles of deformity correction. Annals of The Royal College of Surgeons of England 92: 101–105, 2010.
19. Gerhardt S, Vinay S, Bernhard ZE, Uitz C, Wolfgang L. Complex foot deformities associated with soft-tissue scarring in children. Journal Foot Ankle Surg 40: 42-49, 2001.
20. Theis JC, Simpson H, Kenwright J. Correction of complex lower limb deformities by the Ilizarov technique: An audit of complications. J Orthopaedic Surgery 8: 1448-1552, 2000.
21. Utukuri MM, Ramachandran M, Hartley J, Hill RA. Patient-based outcomes after Ilizarov surgery in resistant clubfeet. J Pediatr Orthop B 15:278–84, 2006.

Address correspondence to: Sutpal Singh, DPM, FACFAS, Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, Fellow of the American College of Foot and Ankle Surgeons, Private practice in Southern California.

1 Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, CA.  Fellow American College of Foot and Ankle Surgeons. Private practice in Southern California
2 PM&S 36, R3 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
3 PM&S, R2 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
4 PM&S, R1 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
5 PM&S, R1 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.

© The Foot and Ankle Online Journal, 2011

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Talar Neck Fracture Reduced and Stabilized with an Ilizarov External Fixator: A case report with three year follow up

Posted on July 1, 2010 | Comments Off on Talar Neck Fracture Reduced and Stabilized with an Ilizarov External Fixator: A case report with three year follow up

by Sutpal Singh, DPM, FACFAS, FAPWCA1 , Chih-Hui (Jimmy) Tsai, DPM2,
Albert Kim, DPM3, Timothy Dailey, DPM4

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

The authors report a case of a Grade 3 Tscherne, isolated Hawkins Type III fracture that was treated with open reduction and external fixation. The Ilizarov technique simplified the surgery by allowing the reduction of the diastasis using a tensioned olive wire, providing distraction of fracture bones externally, and aid in reduction of the talus without the need for multiple, extensive dissection. The patient responded very well to the surgery, despite occurrence of avascular necrosis of the talus and three years status post surgery. The patient has good range of motion, is pain-free, and ambulates without difficulty despite having avascular necrosis.

Key words: Talar fracture, Hawkins classification, Hawkins sign, Ilizarov technique, diastasis, avascular necrosis.

Accepted: June, 2010
Published: July, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0307.0001

Talar fractures have been described since the early 1600’s. [1] In early literature, open talar fractures had an 84% mortality rate. [3] Due to the high mortality rate, surgeons advised extreme measures such as below knee amputations or talectomy. [1] Since then, the surgical technique for these fractures has vastly improved. However, these types of fractures, thought not fatal, still prove to be very challenging today. Talar fractures are rare, making up only 3% of all foot fractures.

Talar fractures can be classified as open or closed. The Tscherne soft tissue classification system describes both open and closed fractures. [9,17] (Table 1) For the closed soft tissue injuries, Tscherne uses a grading system from 0-3 and is based on the amount of the injury. Grade 0 is minimal soft tissue damage from indirect violence. Grade 1 is a superficial abrasion or contusion caused by pressure from within. Grade 2 is a deep contaminated abrasion associated with local skin or muscle contusion and may encompass a compartment syndrome. Grade 3 consists of extensive skin contusion or crushing, underlying severe muscle injury, decompensated compartment syndrome, and associated vascular injury. [9]

Table 1  Tscherne Classification.

Talar fractures can be further divided into three anatomical locations: neck, body and head. Talar neck fractures comprised of 50% of all talar fractures. [2] The most commonly used classification system for talar neck fractures is Hawkin’s Classification (Table 2). This classification has four types, which are differentiated by the degree of displacement. Type I is a non-displaced talar neck fracture. Type II is a talar neck fracture with mild displacement and subluxing from the subtalar joint. Type III is displacement of the talar body with dislocation of subtalar and ankle joint. Type IV is a combination of Type III with dislocation of the talonavicular joint. [1] The higher the grade, the greater the risk is for complications.

Table 2  Hawkins Classification. (AVN – avascular necrosis)

Blood supply to the talus may be an issue if one delays reduction or inadequately treats these fractures. [3] Avascular necrosis (AVN) of the talar body and arthrosis after displaced talar neck fractures is quite common; the higher the grade, the larger chance of AVN. In an article by Gholam et al, they described nine cases of Hawkins Type III fractures, and eight of the nine developed arthrosis.3 In Hawkins Type I fractures, it is quite rare to see AVN. However in Hawkins Type II, there is a 15.8%-75% chance. [1] In Hawkins Type III, the chance of AVN increases to 33-75%. [1]

Hawkins Type IV has the highest chance, reaching almost 100% due to the amount of displacement and disruption of the blood supply to the talus. [1] Subchondral atrophy of the talar dome, also called Hawkins Sign, indicates an intact blood supply to the talus. [3] It is essential to be aware of AVN so it can be treated promptly.

Various treatment options exist for talar neck fractures. Some surgeons prefer using a compression screw across the fracture fragment, while others prefer a plate. In a study performed by Charlson, et al., plate fixation and screw fixation were compared. No statistical difference between either method was found. Plate fixation may provide more control of the anatomical alignment, but has no biomechanical advantage over screws alone. [4] There are very few cases reported in the literature of an isolated talar neck fractures treated with external fixation. However, there are many cases of multiple fractures (talus with calcaneus or talus with medial/lateral malleolus) successfully treated with external fixation. The purpose of this paper is to report a Grade 3 Tscherne, isolated and displaced Hawkins Type III talar neck fracture that was specifically treated with open reduction and external fixation. By determining how much soft tissue injury and the extent of talar fracture, external fixation can be more superior to internal fixation. In this case, the Ilizarov technique is ideal when there is soft tissue injury, vascular compromise, and displaced talar neck fracture.

Case Report

The patient is a 40 year-old correctional officer who was riding a recreational vehicle at the time of his injury. (Fig. 1A and B) He reported jumping off the vehicle due to faulty breaks, resulting in a severe talar neck fracture. (Fig. 2A and B). The mechanism of the traumatic injury was that of hyperdorsiflexion of the foot against the tibia in an axial force with impingement of the talar neck.

 

Figure 1A and B  Note the severe contracture of all the toes. (A) Note the contracted hallux and lack of blood flow to the medial ankle where the talar body is compressing the skin and posterior tibial artery. (B)

 

Figure 2A and B Non-weight bearing lateral view.  Note the overlap of the talus onto the calcaneus. (A) Note the fracture fragments in the ankle. (B)

As the force continued, there was a medial and dorsal displacement fracture of the talus, and disruption of the interosseous talocalcaneal ligament. Also, the posterior and subtalar joint capsule were disrupted. As the ankle supinated, there was increased force of the talar neck against the medial malleolus resulting in subluxation of the subtalar joint and ankle joint. It was quite severe such that the medial ankle was blanching and becoming necrotic.

The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons were also contracted, such that the hallux and lesser toes were severely plantarflexed.

The dorsalis pedis artery was palpable, but the posterior tibial (PT) artery was being compressed and not palpable or heard using a Doppler. There was soft tissue damage and vascular supply was compromised. The patient opted to have surgery and informed consent was obtained from him to allow us to study and present this case. An open reduction was performed with the use on an Ilizarov frame immediately.

Surgical Technique

A large curvilinear incision was made on the medial ankle overlying the talus, extending distally and proximally from the area of blanching. (Fig. 3) The incision was deepened to the subcutaneous tissue and then to the deep tissue. The entire talar dome was noted at the incision site. (Fig. 4) The deep tissue was retracted. Once past the deep tissue, we noted that the posterior tibial artery was being compressed by the talar body. The talar body was exposed, and it was completely displaced and rotated out of the ankle and subtalar joint. There was a large hematoma and multiple small fracture fragments in the ankle joint. The hematoma was evacuated, and the small fracture fragments were removed. The wound was also copiously irrigated with bacitracin-impregnated saline. Then, attempt at relocating the dislocated and fractured talus was performed; however, there was much contraction of the tibia onto the calcaneus that it was extremely difficult to retract. Thus an external fixator was employed to distract the tibia from the calcaneus in order to relocate the talus.

Figure 3  1)  Medial surface of the talus.  2) Anterior or distal surface of the talus.  3) Lateral surface of the talus.    4) Posterior process of the talus with entrapped flexor hallucis longus (FHL) and  posterior tibial (PT) tendons and PT artery.   Note that the toes are at the upper left and the leg is at the lower right.

Figure 4  Dislocated and rotated talus.  1) Medial surface of the talus where the deltoid ligament is shown to be torn.  2) The posterior aspect of the talus: The posterior tibial tendon, posterior tibial artery and FHL are entrapped.  3) Lateral surface of the talus.  4) Talar dome.  5) Anterior surface of the talus.

First, two tibial rings were applied to the lower leg. Then a foot plate was applied, and all the wires were appropriately tensioned. Several distraction rods were used to connect the tibial rings to the foot plate, and then the foot was distracted. By distracting the tibia from the calcaneus, it made it much easier to rotate the talus and slide it between the tibia and calcaneus back into anatomical alignment. The fractured talus was anatomically reduced and held in place by an external fixator. Once the fracture was reduced, the severe skin tension on the medial side of the foot decreased.

A Doppler placed over the PT artery now showed good blood flow. Also, the FHL and FDL tendons became more relaxed, and the contracture over the hallux and lesser toes were reduced. A series of photographs shows the alignment of the Ilizarov frame directly after surgery (Figs. 5A and B, 6) and at 3 weeks after surgery. (Figs. 7A and B)

 

Figure 5A and B  Post-operative site with the Ilizarov Frame.

Figure 6  Post-operative reduction of the talar fracture in good alignment.

 

Figure 7A and B  Three weeks post- operative view.

Results

A one year follow-up showed that his hallux range of motion was normal and his ankle healed in good alignment and anatomical position. This was accompanied with good range of motion, without pain, and with normal ambulation. However, despite the proper care and good post operative alignment, there was still sclerosis of the talar body which indicated that there was indeed avascular necrosis present. He remained non-weight bearing for 6 months and then weight bearing using a pneumatic cam walker for an additional 6 months. After this the patient went back to working 8 hours a day as a corrections officer and it was explained to him of the possible collapse and further complications from the osteonecrosis of the talus and to limit any vigorous activities. He was again followed up at 2 years and at 3 years after the initial traumatic event. He did have an increase in plantar flexion, and adequate dorsiflexion towards the end of the follow-up. He had no pain and was satisfied with the surgical outcome. He however, did have sclerosis of the talus but without any evidence of collapse. (Table 3)

Table 3  Patient 3 year follow-up results. (DF – dorsiflexion, PF – plantarflexion, AVN – avascular necrosis)

Discussion

The complex nature of high energy talus fractures can pose complications that can challenge most foot and ankle surgeons. The complexity arises because of the blood supply to the talus being extremely vulnerable after a traumatic injury. [10] Short term complications can result in skin necrosis, wound dehiscence, and infection. [11,12] Additional complications of comminuted fractures involving the talar neck and body carry a risk of AVN due to the retrograde blood supply. [13] Injury to the joints surrounding the talus can cause irreversible osteochondral damage that could lead to possible early post traumatic arthritis or arthrosis. In this report, we have a patient with a closed talar neck fracture with vascular comprise. The case is further complicated by additional factors that included the medial ankle developing blanching and ultimately becoming necrotic, the posterior tibial artery being compressed, and the FHL and FDL tendons being contracted such that the hallux and lesser digits were severely plantarflexed.

Treatment options evolved from reduction and immobilization, to limited fixation, and currently, open reduction internal fixation being performed on most talar fractures. [14] Included in the literature are recommendations for primary arthrodesis or talectomy for severe talar fractures. [15] In this case, an external fixator was applied due to the severe contracture of the tibia onto the calcaneus. The Ilizarov external fixator allowed for distraction of the tibia from the calcaneus and this allowed for reduction and rotation of the talar body in its anatomical location.

Also, because of the volatile nature of the fracture and the additional soft tissue complications and its increased probability for an osteonecrosis sequelae, external fixation was utilized because it is commonly implemented and indicated for compromised soft tissue structures and gross instability. [16]

In this case, the patient was destined to have avascular necrosis due to the talar neck fracture which according to the literature has up to a 75% chance to develop the condition even with the utmost care and precautions. [1,14] This was exacerbated by the ruptured medial deltoid ligaments causing a dislocation of the talus. In examining the talus, it is a unique bone in the foot in that it has no muscular attachments with about 60% of the talus is covered with articular cartilage. These anatomical features make the talus vulnerable to dislocation. Extreme forces can cause dislocation of the talus out of the ankle mortise with disruption of the strong ligamentous attachments and this may have accounted for the medial deltoid ligament ruptures present in this patient.

This dislocation most likely caused tremendous vascular damage to this already intricate arrangement of vessels that are highly vulnerable to injury. The anterior tibial, PT, and perforating peroneal arteries serve as the vascular supply to the talus. The artery of the tarsal canal is a branch of the PT, and it supplies most of the talar body, the medial talar wall, and the undersurface of the talar neck. The artery of the tarsal canal anastamoses with the artery of the sinus tarsi, which is a branch of the perforating peroneal artery, and these vessels supply the inferior aspect of the talar body and neck. [18]

As the talus dislocates from the ankle mortise, there is sequential failure of the talar blood supply. Since the blood supply to bone and soft tissue are so intertwined, it has been noted that osteonecrosis was highest in cases in which no soft tissues remained attached to the talus. [19]

In this patient, this risk of avascular necrosis was increased and seen when the soft tissue along the medial aspect of the foot became de-vascularized and necrotic.

It is recommended that the patient should be non-weight bearing or protected weight bearing until the avascular necrosis resolves, [19,20] however there is no definitive evidence to suggest that full weight bearing with avascular necrosis leads to secondary complications such as collapse of the talar dome and tibiotalar arthritis. [21] This is further exemplified by this case where the patient, even at a three year follow up with avascular necrosis of the body of the talus, shows that his ankle is in good alignment, has not collapsed, shows no evidence of varus or valgus, has good range of motion, no pain, and ambulates normally. (Figs. 8A and B, 9, 10A and B)

 

Figure 8A and B   Six months after surgery.

Figure 9 Three years after the initial injury.

 

Figure 10A and B  Weight-bearing lateral view of the ankle, three years status post-operative, shows AVN of the talus, but good alignment.  There is no pain, no collapse of the talus, and the patient has good ankle range of motion. (A) Weight-bearing anterior posterior view of the ankle, three years status post-operative shows AVN of the talus, but good ankle joint congruity. (B)

By using the Ilizarov External Fixator, the talus was immobilized and held in place such that no axial pressure was placed onto the talus while healing took place.

Conclusion

Talar fractures are very complicated with a high incidence of AVN. We feel that if there is much difficulty in reducing the talar fracture from the tight tibial collapse onto the calcaneal surface, an external fixator is very beneficial in distracting the tibia from the calcaneus. In the above case, we used the multiplaner Ilizarov external fixator. He did have a severe fracture and dislocation of the talus which eventually resulted in AVN. At this moment, the patient states that he is pain free, and examination showed good ankle and subtalar joint range of motion. It is very important to have the patient frequently visit the office to make sure the talus is not collapsing and to explain to the patient that possible future surgeries, such as total ankle joint implant, subtalar joint arthrodesis, triple arthrodesis, or ankle fusion, may be necessary if the talus collapses as a consequence of AVN.

References

1. Banks AS, Downey MS, Martin DE, Miller SJ. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 1, 3rd edition. Philadelphia: Lippincott Williams and Wilkins; 2001.
2. Juliano P, Dabbah M, Harris TG. Talar neck fractures. Foot Ankle Clinics 2004 9: 723-736.
3. Pajenda G, Vecsei V, Reddy B, Heinz T: Treatment of talar neck fractures: Clinical results of 50 patients. J Foot & Ankle Surg 2000 39(6) 365-375.
4. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int 2006 27 (5): 340-343.
5. Marion H. Talar Shift: The stabilizing role of the medial, lateral and posterior ankle structures. Clinical Orthopedics Rel Res 1990 257: 177-183
6. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long term results of displaced talar neck fractures. Clin Orthopedics Rel Res 1985 199: 81-87.
7. Grob D, Simpson LA, Weber BG. Operative treatment of displaced talus fractures. Clin Orthopedics Rel Res 1985 199: 88-96.
8. Greenleaf J, Berkowitz RD, Whitelaw GP, Seidman GD. Hawkins Type III Fracture – Dislocation of the talus and diastasis of the tibiofibular joint without concomitant fracture of the malleolei. Clin Orthopedics Rel Res 1992 279: 254-57.
9. Frank T, Joseph B. Soft-tissue injury associated with closed fractures: Evaluation and management. J Am Academy of Orthopedic Surgeons. 2003 V:11 N:6, 431-438.
10. Baumhauer JF, Alvarez RG. Controversies in treating talus fractures. Orthop Clin North Am 1995 26(2): 335-351.
11. Fulkerson EW, Egol KA: Timing issues in fracture Management: a review of current concepts. Bulletin of the NYU hospital for joint diseases 67(1): 58-67, 2009.
12. Roberts C, Pape H, Jones A, Malkani A, Rodriguez J, Giannoudis P: Damage control orthopaedics evolving concepts in the treatment of patients who have sustained orthopaedic trauma. JBJS 2005 87(2): 434-449.
13. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 2000 21(12):1023-1029.
14. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures: results and outcomes. JBJS 2004 86A(8): 1616-1624.
15. Gunal I, Atilla S, Arac S, Gursoy Y, Karagozlu H: A new technique of talectomy for severe fracture-dislocation of the talus. JBJS 1993 75B (1): 69-71.
16. Sirkin M, Sanders R, DiPasquale T, Herscovici D: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthopaedic Trauma 2004 18 (8 Suppl): S32-38.
17. Tscherne H, Schatzker J (editors). Major Fractures of the Pilon, the Talus, and the Calcaneus: Current Concepts of Treatment. Berlin, Germany: Springer-Verlag, 1993.
18. Schuberth J, Alder D. Talar fractures. In: Banks A, Downey M, Martin D, Miller S editor. McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery. Philadelphia: Lippincott Williams and Wilkins; 2002, 1866-1867.
19. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion: A report of two cases. Foot Ankle Int 1992 13: 473-477.
20. Brewster N, Maffulli N. Reimplantation of the totally extruded talus. J Orthop Trauma 1997 11: 42–45.
21. Vallier H, Barei D, Bernischke S, Sangeorzan B. Surgical treatment of talar body fractures. JBJS 2003 85A: 1716-1724.

Address Correspondence to: Sutpal Singh, DPM. FACFAS. FAPWCA

1  Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, Fellow of the American College of Foot and Ankle Surgeons, Fellow American Professional Wound Care Association. Private practice in Southern California.
2  Doctor of Podiatric Medicine (R3) ,Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
3  Doctor of Podiatric Medicine (R2) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
4  Doctor of Podiatric Medicine (R1) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA

© The Foot and Ankle Online Journal, 2010

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Open Dislocated Bi-Malleolar Ankle Fracture in a Diabetic Treated with the Illizorov Apparatus: A case report in early ambulation and stabilization

Posted on February 1, 2010 | Comments Off on Open Dislocated Bi-Malleolar Ankle Fracture in a Diabetic Treated with the Illizorov Apparatus: A case report in early ambulation and stabilization

by Sutpal Singh, DPM. FACFAS1 , Chih-Hui (Jimmy) Tsai, DPM2, Albert Kim, DPM3,
Timothy Dailey, DPM4

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

The authors describe a case report of a diabetic patient with an open bi-malleolar ankle fracture sustained after a motor vehicle accident that was treated immediately after injury. Treatment included extensive pulse lavage with antibiotic impregnated saline solution and reduction of the fractures using external fixation. Recovery lasted several months, followed by usage of a Pneumatic CAM walker. The external fixator allowed the patient to ambulate throughout the healing process. No internal fixation was utilized. After months of follow-up, there was good healing of the fractures with no infection of the tibia, fibula, and talus. The authors recommend reduction of tibial and/or fibular fracture(s) using the Ilizarov methodology especially in diabetic patients with open fractures and/or contaminated wound.

Key words: Open Ankle Fracture, Gustilo System, Bi-Malleolar ankle fracture, Ilizarov method.

Accepted: January, 2010
Published: February, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0302.0002

Historically, an open ankle fracture commonly equated with much morbidity and mortality. However with more modern therapy, the expected outcome has improved significantly. [1] The purpose of this article will be to describe a report of a diabetic patient with an open dislocated ankle fracture and the significance of treatment with the use of an Illizarov apparatus. In this article, discussion will focus on the classification, complications, and treatment protocols of open fractures to the ankle joint.

The Illizarov apparatus in our case allowed the patient ambulate during the recovery period in attempt to decrease other risks such as infection and osteomyelitis by use of open internal fixation and morbidity associated with prolonged immobility of a limb.

A fracture is considered to be open when there is a disruption of the skin and underlying soft tissues resulting in a communication between the fracture and the outside environment. Open fractures are most commonly classified according to the system developed by Gustilo and Anderson. [1,2]

The classification of open fractures is based on the size of the wound, the amount of soft tissue injury, fracture pattern and correlates with both infection and amputation rates. Type I open fractures are characterized by a clean wound smaller than 1 cm in diameter, appears clean with a simple fracture pattern and no skin crushing. The fracture can be short, oblique, or transverse. Type II presents with a laceration larger than 1 cm without significant soft tissue crushing or skin flaps, with minimal periosteal stripping; however, a more complex fracture pattern may result. Type III features a large crush component with comminution. It is larger than 5 cm, highly contaminated with extensive soft tissue injury. These injuries may also be older than six hours. Type III injuries are subdivided into three types: type IIIA which presents with adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps; type IIIB featuring inadequate soft tissue coverage with extensive periosteal stripping, and finally type IIIC which displays with any open fracture that is associated with vascular injury that requires repair. [2,3]

Patients with open fractures are at risk of complications of acute wound infection and osteomyelitis. The risk of a clinical infection depends on the severity of the injury and ranges from 0% to 2% for type-I open fractures, 2% to 10% for type-II, and 10% to 50% for type-III. [4] The rate of infection of open fractures is associated with the fracture characteristics, antibiotic therapy variables, and host parameters.

Another variable is the location of the open fracture with tibial open fractures resulting in twice the rates of infection than other areas of the body. [4] Other possible complications include inadequate soft tissue coverage or extensive soft tissue damage resulting in the failure to heal or even close. This may be exasperated by a compromised neurovascular status of the injured extremity or the development of a compartment syndrome. [5] Open fractures may also succumb to osseous mal-union or non-union, the loss of function, and even amputation.

Management of the open fracture is dependent upon the following principles: careful and thorough assessment of the patient; initial stabilization; classification of the injury; tetanus prophylaxis; antibiotic therapy; prompt surgical debridement and wound management; fracture stabilization through internal fixation, external fixation, or casting; early bone grafting; timely wound closure; supplemental procedures to achieve healing; and adequate follow-up. [6] In any given situation, the best option for fixation depends on a number of factors, including the bone involved, the fracture site, the wound location, and the condition of the patient. The available evidence supports the current trend toward earlier coverage and closure of open fracture wounds. [7] The ultimate goal of a surgeon when dealing with open fractures is to prevent infection, promote fracture healing, and restore alignment and function.

Case Report

A 33 year-old female who had a motor vehicle accident presents with an acute, open, dislocated, bi-malleolar fracture of the right ankle. She was immediately transferred to the emergency room. Her past medical history was significant for Type II Diabetes, diagnosed over 10 years ago. She has peripheral neuropathy, with numbness up to the mid-leg. The rest of the history and review of systems was unremarkable. The right ankle fracture presents to our service wrapped in gauze which is soaked in blood. She did not have a splint on, and the foot is severely dislocated. There is tremendous swelling, but no fracture blisters. Despite the extent of this high impact open fracture, a hand-held Doppler showed that she has good vascular status to the dorsalis pedis and posterior tibial arteries. Her capillary refill is immediate. The open ankle fracture is on the lateral side with the wound measuring approximately 9 cm x 5 cm. Even though the fibula, talus and distal tibia were exposed, there is enough skin to close the wound. Uniquely, there is no dirt or any gross contamination noted despite the nature of this accident. X-rays of the ankle indicated that she has a severely dislocated bi-malleolar ankle fracture. (Figs. 1A, B and C).

  

Figure 1A, B and C Variable views of the open ankle fracture.

The medial malleolus is comminuted. Since the open fracture is less than 6 hours old, she is taken to the operating room immediately in order to reduce the fracture using the Ilizarov frame. The patient is then allowed to ambulate directly after surgery when indicated.

Surgical Technique

Under general anesthesia, the open wound is cultured for bacterial organism. Afterwards, nine liters of bacitracin and Ancef impregnated saline is used to irrigate the wound. Two tibial rings are applied to the distal tibia and a foot plate is then applied. Both are tensioned appropriately. The foot plate is then manipulated so the fibular fracture and medial malleolar fracture are reduced in anatomical alignment. The foot plate and the tibial rings are then joined together with appropriate rods. Distraction of the foot plate is performed in order to pull the fibula and medial malleolus fractures into better alignment. The fibula is then stabilized using two K-wires while the comminuted medial malleolus is reduced using an olive wire at the largest fragment. The olive wire is inserted from distal-inferior-posterior-medial to proximal-superior-anterior-lateral, attached to the proximal tibial ring and tensioned for compression (Figs. 2A and B). The open wound is then very loosely approximated and packed with iodoform. Several days later, the culture results revealed no bacterial growth. The wound is again irrigated with normal saline and Bacitracin® and then completely closed using 3-0 prolene (Figs. 3A,3B,4,5A and 5B).

 

Figure 2  External fixation at the ankle.  Note the olive wire reducing the comminuted medial malleolar fracture. (A)  Lateral view of the ankle with an External Fixator in place. (B)

 

Figure 3  Ilizaorov Frame medial view (A) and lateral view. (B)

Figure 4  Loose approximation of the open fracture.  The iodoform packing has been removed from the open wound.

 

Figure 5  Medial View of the Ilizarov frame several months later. (A)  The Ilizarov frame several months later. (B)

Discussion

The complexity of open ankle fractures pose a challenge to many foot and ankle surgeons. By definition, an open fracture is considered contaminated or infected after six hours of no treatment. Very often in a high speed motor vehicular accident, there can be fracture of the tibia, fibula, and/or other part of the foot are present along with an open wound. In this report, we have a patient with a large open wound, bi-malleolar ankle fracture, and exposed tibial, fibular, and talus. The case is further complicated by the patient’s diabetes mellitus. However because surgery is performed immediately and the wound is clean with no gross contamination during examination, we were able to utilize the Illizarov apparatus immediately after the accident to fixate and stabilize the open ankle fracture.

An external fixator is recommended when a patient has poor bone stock, poor healing potential, open fractures, or fractures with contaminated wounds. [8] With a high level of morbidity and risk of osteomyelitis, application of internal fixation by itself followed by primary closure of the wound is not indicated. In addition, a larger wound would require a split-thickness skin graft or benefit from healing by secondary intention. Using an external fixator is not only minimally invasive, but it also allows the surgeon to stage the treatment appropriately. The patient can also benefit from being able to bear weight. Any wounds after surgery can easily be viewed and treated with an external fixator. This is of course, contraindicated when using a cast.

The complications associated with the use of an external fixator include pin tract infection and wire failure. These can be mitigated and appropriately treated with antibiotics and pin care to help prevent infection at these sites. The above patient is classified as having a Gustillo type IIIA. She has a large open wound with adequate soft tissue for coverage. She also has a severe ankle dislocation, bi-malleolar ankle fracture, and exposed tibia, fibula and talus. The external fixator was removed after 3 months. She then had a pneumatic cam walker applied. A two year follow-up showed that her ankle healed in an anatomical position with good range of motion (Figs. 6A and B).

 

Figure 6  Anteroposterior (A) and lateral view (B) two years after injury.

Conclusion

This case report shows the advantages to using external fixation for an open ankle fracture secondary to a motor vehicle accident. Use of external fixation has many advantages, as explained previously. The goals of open fracture surgery are to prevent infection, promote fracture healing, and restore function. A detailed history and physical is essential in these type of complicated cases. The surgeon must decide which surgical option is going to meet specific goals.

References

1.Patrick JH, Smelt GJ: Surgical progress-100 years ago. An assessment of Listerism at St. Thomas’s Hospital, London. Ann R Coll Surg Engl 59: 456 – 462, 1977.
2. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg 58A: 453 – 458, 1976.
3. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24: 742 -746, 1984.
4. Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 243: 36 – 40, 1989.
5. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA: Compartment syndrome in open tibial fractures. J Bone Joint Surg 68A: 1348 – 1353, 1986.
6. Zalavras CG, Marcus RE, Levin S, Patzakis MJ: Management of Open fractures and subsequent complications. J Bone Joint Surg Am 89A: 883 – 895, 2007.
7. Okike K, Bhattacharyya T: Current concepts review: Trends in the management of open fractures. J Bone Joint Surg 88A: 2739 – 2747, 2006.
8. Molloy A, Roche A, Narayan B: Treatment of nonunion and malunion of trauma of the foot and ankle using external fixation. Foot and Ankle Clinics Sept: 563 – 587, 2009.

Address correspondence to: Sutpal Singh, DPM. FACFAS. Private practice in Southern California. Email: spsingh@aol.com

1  Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina. Fellow of the American College of Foot and Ankle Surgeons, Private practice in Southern California.
2  Chih-Hui (Jimmy) Tsai, DPM, Doctor of Podiatric Medicine (R3). Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina , (PM&S-36).
3  Albert Kim, DPM, Doctor of Podiatric Medicine (R2), Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36).
4  Timothy Dailey, DPM, Doctor of Podiatric Medicine (R1), Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36).

© The Foot and Ankle Online Journal, 2010

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