Ankle arthrodesis has long been the traditional

Transcription

1 Originl Artile Trnsfiulr nkle rthrodesis: A novel method for nkle fusion A short term retrospetive study S Muthukumr Blji, V Selvrj, Sthish Devdoss, Annmli Devdoss Astrt Bkground: Ankle rthrodesis hs long een the trditionl opertive tretment for posttrumti rthritis, rheumtoid rthritis, infetion, neuromusulr onditions, nd slvge of filed nkle rthroplsty. It remins the tretment of hoie for ptients in whom hevy nd prolonged tivity is ntiipted. We present our short term followup study of funtionl outome of ptients who underwent trnsfiulr nkle rthrodesis for rthritis of nkle due to vrious inditions. Mterils nd Methods: 29 trnsfiulr nkle rthrodesis in 29 ptients performed etween April 2009 nd April 2014 were inluded in this study. The men ge ws 50 yers (rnge yers). The outome nlysis with minimum of 1-yer postopertive followup were inluded. All the ptients were ssessed with the Amerin Orthopedi Foot nd Ankle Soiety (AOFAS) Hindfoot sle. Results: All ses of nkle fusions (100%) progressed to solid union in men postopertive durtion of 3.8 months (rnge 3 6 months). All ptients hd sound rthrodesis. The men followup period ws months (stndrd devition ± 10.34). The men AOFAS sore ws 74 (pin sore = 32, funtionl sore = 42). We found tht twenty ptients (68.96%) out of 29, hd exellent results, 7 (24.13%) hd good, nd 2 (6.89%) showed fir results. Conlusion: Trnsfiulr nkle rthrodesis is simple nd effetive proedure for nkle rthritis. It hieves high rte of union nd good funtionl outome on midterm followup. Key words: Ankle rthritis, nkle fusion, negleted nkle frtures, tiiotlr ompression srew, trnsfiulr nkle rthrodesis MeSH terms: Arthrodesis, nkle joint, rthritis, nkle injuries, rheumtoid rthritis Introdution Ankle rthrodesis hs long een the trditionl opertive tretment for posttrumti nkle rthritis, rheumtoid rthritis (RA), infetion, neuromusulr onditions, nd slvge of filed totl nkle rthroplsty. 1-3 Ankle fusion remins the tretment of hoie for ptients in whom hevy, nd prolonged tivity is ntiipted nd nkle replement n e only reommended for those with more modest requirements. 4 Deprtment of Orthopedis, Institute of Orthopedi Reserh nd Aident Surgery, Devdoss Multispeility Hospitl, Mduri, Tmil Ndu, Indi Address for orrespondene: Dr. S Muthukumr Blji, No. 1145, Mrdhini Autore Produts, 13 th Cross, Chndr Lyout 1 st Stge, Bengluru , Krntk, Indi. E-mil: mkmk79@gmil.om Quik Response Code: Aess this rtile online Wesite: DOI: / Ankle fusion provides pinless, plntigrde, nd stle foot. Severl different methods hve een desried to hieve the nkle fusion; inluding externl fixtors nd/or internl fixtion, use of fiulr strut grft, interposition one grfting, nd intrmedullry niling However, it is slvge proedure tht uses persistent ltertions in git nd potentil for deteriortion exists due to the risk of developing ipsilterl hindfoot rthritis. 11,12 In our study, the rw surfe of the medil side of fiul ws ompressed using the 4.5 mm ortil srews with lg effet, s strut grft. We present short term funtionl outome of ptients who underwent trnsfiulr nkle rthrodesis for nkle rthritis. This is n open ess rtile distriuted under the terms of the Cretive Commons Attriution-NonCommeril-ShreAlike 3.0 Liense, whih llows others to remix, twek, nd uild upon the work non-ommerilly, s long s the uthor is redited nd the new retions re liensed under the identil terms. For reprints ontt: reprints@medknow.om How to ite this rtile: Blji SM, Selvrj V, Devdoss S, Devdoss A. Trnsfiulr nkle rthrodesis: A novel method for nkle fusion - A short term retrospetive study. Indin J Orthop 2017;51: Indin Journl of Orthopedis Pulished y Wolters Kluwer Medknow 75

2 Mterils nd Methods 29 trnsfiulr nkle rthrodesis in 29 ptients performed etween April 2009 nd April 2014 were inluded in this study. Of the 29 ptients, 16 were mle (55%) nd 13 were femle (44%) (mle to femle rtio = 1.2:1). The men ge t surgery ws 50 yers (rnge yers). The men followup period ws months (stndrd devition ± 10.34). Among the 29 ptients who underwent trnsfiulr rthrodesis, 22 (76%) ptients hd post trumti rthritis (PTA), 5 (17%) ptients hd tuerulr rthritis (TA), nd 2 (7%) hd rheumtoid rthritis (RA). In our study, 18 proedures were done on right nkles (62.07%) nd 11 were on left nkles (37.93%). None of our ptients hd ilterl trnsfiulr nkle rthrodesis. Inlusion riteri were dignosis of rthritis of the nkle of Grde 3 nd ove (posttrumti rthritis [PTA], seondry to tuerulosis, nd seondry to RA) with minimum of 1-yer postopertive followup. Ptients with septi rthritis, filed nkle rthroplsty, nd Chrot s rthritis were exluded from this study. Dt otined from the se sheets inluded ge, gender, indition for surgery, the side ffeted, operting surgeon, periopertive ntiioti use, durtion of surgery, numer of srews used for fixtion, soure of one grft, length of sty in hospitl, surgil omplitions, durtion of postopertive outptient followup, omments on postopertive rdiogrphs in the lini in onjuntion with the rdiologist reports, nd ptient stisftion. Blji, et l.: Trnsfiulr nkle rthrodesis Opertive proedure Under regionl nesthesi nd tourniquet ontrol with ump under the ipsilterl hip, the nkle ws prepred nd drped. Aess to the nkle ws gined through lterl pproh entered on the fiul. The fiul ws osteotomized pproximtely 2 m ove the syndesmosis level nd refleted down nd relesed of ll tthment [Figure 1]. The osteotomized fiul ws then prepred y removing soft tissue nd rtiulr rtilge. A good exposure of the nkle joint for dequte preprtion of the tiil nd tlr rtiulr surfes ws ville. The rtiulr rtilge of the tiil plfond nd the tlr dome were removed prllel to one nother using n osteotome to provide good ontt surfe [Figure 1]. In ses where the exposure ws not dequte, n dditionl exposure y osteotomizing the medil mlleolus ws used nd this ws done in eight ses [Figure 1]. The exised one ws used s n inly grft. Two 6.5 mm 16 mm nellous srews were used to ompress the two rthrodesis surfe with the nkle in neutrl. Two 4.5 mm ortil srews were used to ple the only distl fiul grft in ompression: one s distl tiiofiulr nd the other s tlofiulr [Figure 1d]. The distl fiulr ortex ws over drilled with 4.5 mm drill to hieve good ompression. Postopertive protool Following wound losure, ompression dressing nd ove knee sl were pplied. The lim ws elevted. Wound inspetion ws done on seond nd 4 th postopertive dys. At 12 th postopertive dy, the wound ws inspeted nd Figure 1: () Peropertive photogrph showing osteotomy of the fiul 2 ms ove the nkle joint. () Peropertive photogrph showing omplete removl of the distl fiul fter the osteotomy gives good exposure of the joint. () Peropertive photogrph showing exision of the medil mlleolus through medil inision gives dditionl exposure when needed. (d) Immedite postopertive rdiogrph nteroposterior nd lterl views showing multiple srews used in rthrodesis d 76 Indin Journl of Orthopedis Jnury-Ferury 2017 Vol. 51 Issue 1

3 suture removl ws done. Sl ws onverted into elow knee wlking st. The initil 6 weeks, ptient ws moilized with nonweight ering. At the end of 6 weeks, we llowed weight ering in the wlking st nd plster oot. After 3 months, one union ws sertined y rdiogrphs, the wlking st ws removed, nd ptients were free to moilize to improve the sutlr nd midfoot movements with repe ndge in the dy time. The initil postopertive nteroposterior nd lterl rdiogrph ws tken for eh ptient on the immedite postopertive dy, nd susequent rdiogrphs were tken t eh followup visit in the outptient lini nd were ssessed y rdiologist nd the surgeon. Followup rdiogrphs were exmined for ony union nd implnt position nd inorportion of one grft. Bony union ws onfirmed y the presene of treulr lines etween the tii nd tlus t the point of ontt, nd dispperne of the rdioluent line tht ws present in the initil postopertive rdiogrph. The fiulr grft inorportion usully ourred 1 to 2 yers fter surgery. All the ptients were ssessed with the Amerin Orthopedi Foot nd Ankle Soiety (AOFAS) Ankle-Hindfoot sle. 13 This ws done t finl followup on outptient sis. The min emphsis of this system ws on pin, the funtionl tivities nd hind foot deformity. A norml person would sore 100 points. Beuse of lk of nkle motion, the mximum sore tht the ptient with n nkle fusion ould hve ws 92 sine they ould not ern the 8 points given for the full rnge of motion. A sore of ws onsidered s exellent result, good result, fir result, nd sore less thn 60 ws onsidered s poor result. 11 Results All ses of nkle fusions (100%) progressed to ony union in men postopertive durtion of 3.8 months (rnge 3 6 months). All ptients hd sound nkylosis. All Blji, et l.: Trnsfiulr nkle rthrodesis the ptients were ssessed linilly nd rdiologilly fter men followup of 32 months (rnge months). Four ptients hd superfiil infetion. Two ptients responded stisftorily to orl ntiiotis, nd two ptients were treted y intrvenous ntiiotis (2 PTA, 1 TA, nd 1 RA). Two ptients hd skin mertion nd rek down tht ws treted y deridement nd seondry suturing (1 TA nd 1 RA). None of our ptients hd deep infetion. The inidene of postopertive omplitions ws limited in PTA (n = 2/22) when ompred to TA (n = 2/5) (P < 0.01) nd RA (n = 2/2) (P < 0.001). In our study, the men AOFAS sore ws 74 (pin sore = 32, funtionl sore = 42). We found tht twenty ptients (68.96%) of the 29 hd exellent results, 7 (24.13%) hd good, nd 2 (6.89%) showed fir results. All ptients returned to their preopertive tivities. Of the 22 ses of PTA ptients, 18 ptients (81.81%) hd exellent results nd 4 ptients (18.18%) hd good results [Figures 2 nd 3]. The seond indition ws TA. In five ses of tuerulosis rthritis ptients, two ptients hd exellent results, two ptients hd good results, nd one ptient hd fir results [Figure 4]. RA ws the third indition. Of the two ses of RA ptients, one ptient hd good result nd one ptient hd fir result. Thus, there were etter results mong ptients whose indition for surgery ws PTA (n = 22) when ompred to TA (n = 5) (P < 0.05) nd to RA (n = 2) (P < 0.001) [Tle 1]. Disussion Ankle rthrodesis ws first desried y Alert. 10 Sine then, mny surgil pprohes hve een desried in the Tle 1 : Funtionl outome of ses s per the AOFAS sores Dignosis/Outome Exellent Good Fir Totl Post trumti rthritis Tuerlulr thritis Rheumtoid rthritis Totl Figure 2: X-ry of right nkle joint nteroposterior nd lterl views of 45 yers old femle showing () post trumti mlunited imlleolr frture () immedite postopertive x-rys with trns fiulr nkle rthrodesis () Six months followup x-rys Indin Journl of Orthopedis Jnury-Ferury 2017 Vol. 51 Issue 1 77

4 Blji, et l.: Trnsfiulr nkle rthrodesis Figure 3: X-ry of right nkle joint nteroposterior nd lterl views in 28 yers old mle showing () filed open redution internl fixtion nd mlunited imlleolr frture. () Immedite postopertive X-ry with trnsfiulr nkle rthrodesis. () Six months followup X-rys showing rthrodesis Figure 4: X-ry nkle joint nteroposterior nd lterl views in 61 yers old mle showing () tuerulr rthritis. () Immedite postopertive X-rys with trnsfiulr nkle rthrodesis. () Six months followup X-ry showing rthrodesis literture for nkle fusion inluding the nterior, posterior, nd trnsmlleolr pprohes. The trnsfiulr pproh to nkle fusion ws first desried y Horwitz. 14 Adms desried trnsfiulr nkle rthrodesis y lterl pproh where the distl fiulr frgment ws removed nd prepred for use s n only grft. 15 The grft ws seured y three srews: Two of whih grip the tii nd one the tlus. In this pproh, ler exposure of the rtiulr surfes ws redily otined. The fiulr grft gives sound stility nd provides sffolding for formtion of stout one ridge ross the joint. Close ontt etween the tii nd tlus ws essentil, nd the pking of nellous one hips round the ones ws n dvntge. Fusion ws hieved fusion in 28 out of 30 ses. It is lso generlly understood tht the hnes of union re higher when the fixtion is rigid. However, in our study, 4.5 ortil srews were used to void grft rekge whih is ommon when using 6.5 mm nellous srews. 16,17 The ftors tht re importnt in hieving mximl heling nd nkle fusion inlude rigid internl fixtion, ompression of the fusion surfes, nd good iologil environment. 14,18,19 Vrious strtegies hve een used to redue the inidene of nonunion inluding multiple ompression srews nd lrger dimeter srews to improve mehnil stility nd ompression. Use of multiple nnulted nellous srews (out 2 4) provides mximum ontt nd ompression ross the vile nellous one surfes. Wng et l. used trnsfiulr ompression rthrodesis of nkle y lterl pproh with resetion of distl fiul. 20 They ttined ompression using T plte pled ross the tiiotlr joint with the id of n AO ompression pprtus. They hieved fusion in 10 out of 11 ses. Flükiger nd Weer used multiple lg srews (2 or 3) y trns fiulr pproh for tiiotlr rthrodesis ompression nd used the disseted distl fiul s only grft to tii nd tlus with ortil srews. 21 They hieved solid fusion in ll ses with n verge AOFAS sore eing Akr et l. used trnsfiulr tehnique with sgittl splitting of fiul with internl ompression with multiple nellous srews nd hieved 100% solid union rthrodesis nd sujetive outome with very stisfied results in 54% nd stisfied results in 46%. 22 In our study, we used trns fiulr pproh with osteomized distl fiul eing used s n only grft over tii nd tlus with two ortil srews. Two riss-ross 6.5 mm 16 fillet nellous srews used for tiiotlr rthrodesis for internl ompression. We hieved solid union in ll ses. Our results (100% union) were omprle nd in some prmeters etter thn results from other series. 11,14,17,21,22 78 Indin Journl of Orthopedis Jnury-Ferury 2017 Vol. 51 Issue 1

5 There were no heling-relted prolems in our series. This my e ttriutle to the use of fiul s strut grft nd the lering of rtilge from the distl rtiulr surfe of fiul nd syndesmosis tissues on the medil side of fiul with deortition. Lee et l. in their tehnique of trnsfiulr rthrodesis using metl urr nd urettge nd two trnsrtiulr srews. They reported union rtes similr to our study of 95% (P < 0.05). They onluded tht use of metl urr nd urettge redued the surgery time nd did not signifintly lter the one surfes. 23 The limittion of study is short term followup (men 32 months). Another limittion of this study is tht it ws retrospetive nlysis. There ws no rndomiztion. Finlly, the smple size ws reltively smll ut still lrger thn some previous studies. A long term ssessment nd lrger series of nkle rthrodesis is thus wrrnted to gin sttistilly signifint results. We exluded Chrot s neurorthropthy of the nkle s it independently n influene the overll outome of the proedure nd it is est treted y retrogrde intrmedullry niling. 24 In more omplex trum round the nkle joint, humerl loking plte fixtion tehnique desried y Zhng et l. my e indited. 25 We do not hve experiene with this proedure, nd it ws not indited in ny of our ptients s the fiul ws used s lterl stilizing iologil plte. In our series, of the two ptients with RA, one ptient hd fir result nd the other hd poor result. Ptients with RA nd involvement of nkle my not meet the riteri for n nkle rthrodesis; this my e euse they hve involvement not only of the nkle ut lso of the smll joints of the foot so tht these joints nnot ompenste for the fused nkle. 11,12 However, these ptients hve low funtionl demnd. Therefore, these ptients with RA my e etter ndidtes for the totl nkle rthroplsty. 26 To e onsidered s preferle lterntive to rthrodesis, totl nkle replement (TAR) should give etter results thn those presented here, without other disdvntges. Spirt et l. in their study of totl nkle hd 5-yer survivl rte with reopertion s the end point of 54% only. The 5-yer survivl rte with filure s the end point ws 80% for ll ptients nd 89% for ptients who were more thn 54 yers of ge. 26,27 Younger ge ws found to hve negtive effet on the rtes of reopertion nd filure the funtionl outome of this proedure is unertin. Tiiotlr rthrodesis following filed TAR is n extremely diffiult proedure. 4 We did not enounter suh ptients in our series. Hopgood et l. desried the prolems enountered when trying to restore funtion using tiiotlr rthrodesis following filed TAR. 3 They found tht it ould not e hieved in every se despite miniml mount of one reseted t the time of nkle replement. They Blji, et l.: Trnsfiulr nkle rthrodesis found tht severe one loss develops on the tlr side s the omponent loosens, nd this my extend to the sutlr joint. They suggest tht if there is suffiient tlr one stok, tiiotlr rthrodesis e done. 3,28 This is often the se in ptients with OA, ut rrely for those with RA. If there is signifint loss of one from the tlus or mrkedly rthriti sutlr joint, they reommend tiiotlolnel rthrodesis with n intrmedullry nil. 4 An intrmedullry nil gives firm fixtion oth distlly nd proximlly nd is the method of hoie when tiiotlolnel rthrodesis is indited. They lso found tht most serious outomes ourred, where the lterl mlleolus ws totlly exised in the elief tht it would ssist in otining good, ony pposition nd serve s one grft. Nonunion ourred in suh ptients nd the sene of lterl mlleolus resulted in the nkle eoming grossly unstle. Conlusion Trnsfiulr nkle rthrodesis is novel proedure for tretment of nkle rthritis. It hieves high rte of union nd good funtionl outome on midterm followup. The AOFAS hindfoot sore improves stisftorily following trnsfiulr nkle fusion. This tehnique is n effetive pproh for most primry nd selet revision ses. Finnil support nd sponsorship Nil. Conflits of interest There re no onflits of interest. Referenes 1. Ginnini S, Bud R, Fldini C, Vnnini F, Romgnoli M, Grndi G, et l. The tretment of severe posttrumti rthritis of the nkle joint. J Bone Joint Surg Am 2007;89 Suppl 3: Smmro VJ. Ankle rthrodesis in rheumtoid rthritis: Tehniques, results, nd omplitions. Foot Ankle Clin 2007;12:475-95, vii. 3. Hopgood P, Kumr R, Wood PL. Ankle rthrodesis for filed totl nkle replement. J Bone Joint Surg Br 2006;88: Wood PL, Dekin S. Totl nkle replement. The results in 200 nkles. J Bone Joint Surg Br 2003;85: Slem KH, Kinzl L, Shmelz A. Ankle rthrodesis using Ilizrov ring fixtors: A review of 22 ses. Foot Ankle Int 2006;27: Nielsen KK, Linde F, Jensen NC. The outome of rthrosopi nd open surgery nkle rthrodesis: A omprtive retrospetive study on 107 ptients. Foot Ankle Surg 2008;14: Thoms RL, Sthe V, Hi SI. The use of intrmedullry nils in tiiotlolnel rthrodesis. J Am Ad Orthop Surg 2012;20: Hoover JR, Sntrok RD, Jmes WC 3 rd. Ankle fusion stility: A iomehnil omprison of externl versus internl fixtion. Orthopedis 2011;34:4. Indin Journl of Orthopedis Jnury-Ferury 2017 Vol. 51 Issue 1 79

6 Blji, et l.: Trnsfiulr nkle rthrodesis 9. Nsson S, Shuff C, Plmer D, Owen J, Wyne J, Crr J, et l. Biomehnil omprison of nkle rthrodesis tehniques: Crossed srews vs. lde plte. Foot Ankle Int 2001;22: Alert E. For resetion of the knee joint. Vienn Medil University Journl. 1879;20: Gowd BN, Kumr JM. Outome of nkle rthrodesis in posttrumti rthritis. Indin J Orthop 2012;46: Singh J. Tiiotlr rthrodesis for injuries of the tlus. Indin J Orthop 2008;42: Kitok HB, Alexnder IJ, Adelr RS, Nunley JA, Myerson MS, Snders M. Clinil rting systems for the nkle-hindfoot, midfoot, hllux, nd lesser toes. Foot Ankle Int 1994;15: Horwitz T. The use of the trnsfiulr pproh in rthrodesis of the nkle joint. Am J Surg 1942;60: Colmn AB, Pomeroy GC. Trnsfiulr nkle rthrodesis with rigid internl fixtion: An ssessment of outome. Foot Ankle Int 2007;28: Pk CH, Lee JY, Jeong YJ. Ankle rthrodesis outomes in nkle osteorthritis: Comprison etween nterior pproh nd trnsfiulr pproh. J Koren Foot Ankle So 2014;18: Onoder T, Mjim T, Kshr Y, Tkhshi D, Ymzki S, Ando R, et l. Outome of trnsfiulr nkle rthrodesis with Ilizrov pprtus. Foot Ankle Int 2012;33: Frey C, Hlikus NM, Vu-Rose T, Ermzdeh E. A review of nkle rthrodesis: Predisposing ftors to nonunion. Foot Ankle Int 1994;15: Verhelst MP, Mulier JC, Hoogmrtens MJ, Sps F. Arthrodesis of the nkle joint with omplete removl of the distl prt of the fiul: Experiene with the trnsfiulr pproh nd three different types of fixtion. Clin Orthop Relt Res 1976;118: Wng GJ, Shen WJ, MLughlin RE, Stmp WG. Trnsfiulr ompression rthrodesis of the nkle joint. Clin Orthop Relt Res 1993;289: Flükiger G, Weer M. The trnsfiulr pproh for nkle rthrodesis. Oper Orthop Trumtol 2005;17: Akr GA, Middleton A, Adedpo AO, Finn P. Poplitel lok with trnsfiulr pproh in nkle rthrodesis: A se series. J Med Cse Rep 2010;4: Lee HJ, Min WK, Kim JS, Yoon SD, Kim DH. Trnsfiulr nkle rthrodesis using urring, urettge, multiple drilling, nd fixtion with two retrogrde srews through single lterl inision. J Orthop Surg (Hong Kong) 2016;24: Shh NS, De SD. Comprtive nlysis of uniplnr externl fixtor nd retrogrde intrmedullry niling for nkle rthrodesis in dieti Chrot s neurorthropthy. Indin J Orthop 2011;45: Zhng C, Shi Z, Mei G. Loking plte versus retrogrde intrmedullry nil fixtion for tiiotlolnel rthrodesis: A retrospetive nlysis. Indin J Orthop 2015;49: Shuh R, Hofstetter J, Krismer M, Bevoni R, Windhger R, Trnk HJ. Totl nkle rthroplsty versus nkle rthrodesis. Comprison of sports, reretionl tivities nd funtionl outome. Int Orthop 2012;36: Spirt AA, Assl M, Hnsen ST Jr. Complitions nd filure fter totl nkle rthroplsty. J Bone Joint Surg Am 2004;86- A: DeHeer PA, Ctoire SM, Tulmn J, Borer B. Ankle rthrodesis: A literture review. Clin Poditr Med Surg 2012;29: Indin Journl of Orthopedis Jnury-Ferury 2017 Vol. 51 Issue 1