Total Ankle Replacement in the Varus Ankle

Authors:  Shock, R., Christensen, J., Schuberth, J. (2011). 

Reviewed by:  James Johnston, DPM

The Journal of Foot and Ankle Surgery. Scientific Literature Review: 50, 5-10. June 2011

This is a retrospective study of patients with more than 5º of ankle varus arthrosis who underwent total ankle replacement before October 2007.  Patient preoperative, immediate postoperative and most recent post operative weight bearing films were evaluated.  The degree of varus deformity was determined by measurement of the long axis of the tibia to a perpendicular axis of the talar dome on AP and mortise views.

Results:
A total of 26 patients with preoperative varus ankle deformity of greater than 5 degrees were reviewed in the study.  Patient ages ranged from 63.85 ± 9.33 years, with 7 females and 19 males.  The average follow up was 16.69 ± 7.26 months.  The average varus deformity was 18.3º ± 6.4º on the AP preoperative radiograph and 16.8º ±6.79º on the mortise projection.  The immediate postoperative radiographs were measured and showed correction of 19º on the AP and 17º on mortise projections.  All corrections where within 1º of postoperative films at follow up. There was a significant change in coronal plane correction of varus deformity on both AP and mortise views indicating either one can be used for preoperative planning.  The sequence of corrective maneuvers for varus deformity was:  Ancillary pedal procedures including but not limited to subtalar arthrodesis, ankle ligament reconstruction and talonavicular arthrodesis.  A standard incisional approach was used followed by a medial deltoid sleeve release, lateral gutter resection, talar deformity reduction, tibial-talar preparation, component insertion and lateral ligament placation.

Conclusions:
At the time of review there has been no standard surgical approach to the varus ankle TAA in foot and ankle literature.  This article demonstrates a stepwise approach to management of the rearfoot deformity and presents a convincing although limited case review for the indication of TAR in the varus ankle.  The article points out that the varus ankle deformity frequently involves ligamentous imbalance with leads to a maladaptive joint.  Previous literature has provided us with the suggestion that moderate to severe (10 º to 20 º) coronal plane deformity of the tibiotalar complex may be a contraindication to TAA.  This article argues that with proper soft tissue balancing and the reestablishment of the plantigrade foot with a neutral ankle mortise, success can be found at least in the intermediate follow up.

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle

Aysha Rajeev, MBBS, FRCS1, Shanaka Senevirathna, MRCS2, Sarkhell Radha, MRCS3, N.S. Kashayap, FRCS4

The Journal of Foot and Ankle Surgery: June 2011

The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range, 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.

Level of Clinical Evidence: 4

Keywords: funtional outcome, internal fixation, surgery, trauma

1 Associate Specialist, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom

2 Junior Clinical Fellow, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom

3 Senior Clinical Fellow, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom

4 Consultant Orthopaedic Surgeon, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom

Treatment of Displaced Intra-Articular Calcaneal Fractures with Closed Reduction and Percutaneous Screw Fixation

T. Tomesen, J. Biert and J.P.M. Frölke. 

Journal of Bone and Joint Surgery AM: 2011 May; 93(10):920-8

Surgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.

METHODS:

All patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated.

RESULTS:

We reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters.

CONCLUSIONS:

We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

LEVEL OF EVIDENCE:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Minifragment Plate Fixation of High-Energy Navicular Body Fractures

Jason Evans, MD; Daphne M. Beingessner, MD; Julie Agel, MA; Stephen K. Benirschke, MD

Foot & Ankle International: May 2011 (Vol.32 #5) May 1, 2011

The purpose of this study was to assess the ability of miniplate

fixation in navicular fractures to restore medial column stability,

maintain reduction, and determine the impact this approach may have on

the development of avascular collapse of the navicular. We hypothesized

that comminuted fractures of the navicular can be safely reduced and

maintained to union with minifragment plate fixation with a low

incidence of avascular collapse. Materials and Methods: A retrospective

chart review was performed on 24 patients with navicular

fractures treated with open reduction and internal fixation with

minifragment plate fixation at a level one trauma center over a period

of 6 years. Results: All fractures united. No patient developed a deep

infection. There was no loss of reduction. Isolated broken screws were

evident in three patients (12.5%), with no plate breakage, and no

implant failure by pullout. Four patients (17%) underwent plate removal

for painful prominent hardware following fracture healing. Four

patients (17%) developed radiographic arthrosis of the talonavicular

joint. One patient (4%) had radiographic avascular collapse evident at

6 months and was treated with plate removal and an

orthotic device. Conclusion: Minifragment fixation was a good

alternative to independent lag screws for rigid stabilization of

navicular body fractures

Level of Evidence: IV, Retrospective Case Series

Key Words: Navicular; Avascular Necrosis; Talonavicular Arthritis;

Midfoot Injuries; High-Energy

STAR™ Ankle: Long-Term Results

Jeffrey A. Mann, MD; Roger A. Mann, MD; Eric Horton, MD

Foot & Ankle International: May 2011 (Vol.32 #5) May 1, 2011

There has been a resurgence of interest in total ankle replacement

(TAR) due to improved results with newer prostheses. However, long-term

survivorship data has been limited. The STAR™ Ankle prosthesis is the

first three-part prosthesis approved for use in the United States.

Materials and Methods: Eighty-four total ankle replacements were

performed in 80 patients using the STAR™ Ankle prosthesis and followed

prospectively. Postoperatively, patients were evaluated with the AOFAS

score for pain and function, and serial radiographs were evaluated for

stability and alignment of the prosthesis. Implant failure, secondary

procedures, and complications were recorded. Results: Ninety-one

percent of prostheses remain implanted at an average followup of 9.1

years. The probability of implant survival was 96% at 5 years and 90%

at 10 years. An average 39-point improvement in the AOFAS

ankle-hindfoot score was noted, from a mean of 43 to a mean of 82

points. We noted a statistically significant increase in both average

pain and function sub-scores. Postoperative range of motion averaged

4.5 degrees of dorsiflexion and 35 degrees of plantarflexion. Ninetytwo

percent of the patients were satisfied with their outcome. Ten patients

(13%) developed concerning osteolytic lesions. Change in prosthetic

alignment and adjacent joint arthritis were similar to previous

reports. We report 21 complications, which included 14 additional

surgical procedures. Conclusion: The first U.S. prospective long-term

survivorship data with the STAR™ Ankle prosthesis found it to be an

excellent long-term option for the treatment of ankle arthritis.

Level of Evidence: IV, Case Series

Key Words: Ankle Arthroplasty; Ankle Arthritis; Scandinavian Total

Ankle Replacement; STAR Ankle  

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Hardware Related Pain and Hardware Removal after Open Reduction and Internal Fixation of Ankle Fractures

Johan H. Pot, Remco J.A. van Wensen, Jan G. Olsman 

The Foot and Ankle Online Journal 4 (5): 1 May 2011

Fractures of the distal tibia and fibula are one of the most common types of fractures in adults. [1] Whereas stable and non or minimally displaced fractures can be treated with cast immobilization, unstable dislocated ankle fractures require open reduction and internal fixation (ORIF) with plate and screws.

Long term functional outcome is satisfying in most patients, but a number of patients have persistent ‘hardware related’ complaints and tenderness that ‘require’ elective hardware removal. Aside from painful hardware, some asymptomatic patients also want their hardware removed for other reasons. Although hardware removal is frequently undertaken, it is not without risk and the results are often unpredictable. [2]

The more commonly reported risks of hardware removal are iatrogenic (nerve) injury, infections, delay in wound healing and re-fractures. In addition to medical considerations there is also an economic impact such as physician costs, hospital fees, patient loss of work and productivity. [2] Reports in literature are not consistent concerning the incidence of painful hardware and the outcome and pain relief after hardware removal. [3-5] This study was designed to document the incidence of late pain after ORIF of ankle fractures and to analyse the outcome, expectations and complications after hardware removal.

Key words: Ankle, Ankle Fracture, FAOS, Hardware, ORIF Ankle

See all of your internal and external fixation options for Ankle Fracture, Fibular Fracture, Medial Malleolar Fracture, and Pilon Fracture. 

Retrograde Ankle Arthrodesis Using an Intramedullary Nail: A Comparison of Patients with and without Diabetes Mellitus

Dane K. Wukich, MD1, James Y.C. Shen, MD2, Claudia P. Ramirez, BS2, James J. Irrgang PhD, PR, ATC3

The Journal of Foot and Ankle Surgery: Volume 50, Issue 3, Pages 299-306 (May 2011)

Tibiotalocalcaneal arthrodesis (TTCA) has been used for the salvage of severe deformity involving the ankle and hindfoot. The purpose of this study was to evaluate the results of retrograde intramedullary nailing (IMN) for severe ankle/hindfoot pathology in a group of patients with diabetic neuropathy and compare them with a cohort of nondiabetic patients. Our working hypothesis was that patients with diabetes mellitus (DM) and neuropathy would experience inferior outcomes and more postoperative complications than patients who did not have DM. Forty consecutive patients (17 with DM and 23 without DM) who had a minimum follow-up of 1 year were retrospectively reviewed. The mean follow-up was 33 months and the mean AOFAS Ankle Hindfoot Score significantly improved form 19 to 55. Patients with DM improved on average from 24 to 55 and patients without DM improved from 16 to 55. Although a postoperative complication was experienced in 59% of patients with DM compared with 44% of patients without DM, this difference did not reach statistical significance with the numbers available. More patients with DM used a brace at final follow-up than patients without DM. Those patients who had a history of preoperative skin ulceration had higher rates of infection than those patients who did not have skin ulcers. We did not find any significant postoperative differences in AOFAS Ankle Hindfoot Scores between those patients with DM versus patients without DM. On average, patients with DM demonstrated an improvement of 129% and patients without diabetes improved by 243%. With the numbers available, we were not able to confirm our hypothesis that patients with DM experienced significantly lower clinical outcomes than patients without DM. A study of 100 patients in each group would be necessary to achieve adequate power to conclusively state that DM had no impact on the final outcome.

Level of Clinical Evidence: 2

Keywords: ankle, arthrodesis, diabetes, nail

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1 Chief, Division of Foot and Ankle Surgery; Associate Professor of Orthopaedic Surgery; and Assistant Program Director, Orthopaedic Surgery Residency, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

2 Medical Student, University of Pittsburgh School of Medicine, Pittsburgh, PA

3 Associate Professor of Orthopaedic Surgery and Director of Clinical Research, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA