Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

Authors: Sarah Shogren, DPM , Sara Zelinskas, DPM , Byron Hutchinson, DPM , Vineet Kamboj, DPM

Journal: The Foot and Ankle Online Journal 4 (8): 3

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Current Concepts Review: Results of Total Ankle Arthroplasty

Authors: Mark E. Easley, MD; Samuel B. Adams, MD; W. Chad Hembree, MD; James K. DeOrio, MD

Journal: J Bone Joint Surg Am. 2011; 93: 1455-1468

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence.

Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis.

On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years.

Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange.

A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Key words: N/A

Locked Versus Nonlocked Plate Fixation For Hallux MTP Arthrodesis

Authors: Kenneth J. Hunt, MD; J. Kent Ellington, MD, MS; Robert B. Anderson, MD; Bruce E. Cohen, MD.

Foot & Ankle International: July 2011 (Vol.32 #7)

Dorsal plate fixation is used commonly for arthrodesis of the hallux

first metatarsophalangeal (MTP) joint. Custom dorsal plates

incorporating locking technology have been developed recently for

applications in the foot to provide relative ease of application and

theoretically superior mechanical properties. The purpose of this study

is to compare the radiographic and clinical outcomes of patients

undergoing hallux MTP joint arthrodesis using a locked plate, or a

nonlocked plate. Materials and Methods: We compared consecutive

patients who underwent hallux MTP arthrodesis for a variety of

diagnoses with either a precontoured locked titanium dorsal plate

(Group 1) or a precontoured, nonlocked stainless steel plate (Group 2).

All patients were evaluated with radiographs, visual analog pain scale,

American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a

detailed patient satisfaction survey. Results: There were 73 feet in

Group 1 and 107 feet in Group 2. There was a trend toward a higher

nonunion rate in Group 1 compared to Group 2. When considering

only patients without rheumatoid arthritis (RA), the union rate was

significantly higher in Group 2 compared to Group 1. Hardware failure

and the overall complication rate was equivalent between the two

Groups. Conclusion: As locked plate technology continues to gain

popularity for procedures in the foot, it is important that clinical

outcomes are reported. Locked titanium plates were associated with

higher nonunion rates. Improved plate design, patient selection, and an

understanding of plate biomechanics in this unique loading environment

may optimize future outcomes for hallux MTP arthrodesis.

Level of Evidence: III, Retrospective Comparative Study

Key Words: Hallux Arthrodesis; Hallux Valgus; Hallux Rigidus; Locked

Plate; Arthritis

Lapidus Arthrodesis with a Single Lag Screw and a Locking H-Plate

Authors:  Christopher R.D. Menke, DPM; Michael C. McGlamry, DPM; Craig A. Camasta, DPM

The Journal of Foot and Ankle Surgery: Vol: 50, No. 4, 377-382. July 2011

The aim of this pilot study was to assess if using an interfragmental lag screw and a Darco® locking H-plate for the modified Lapidus arthrodesis in the treatment of hallux abducto valgus deformity (1) would allow for earlier weight bearing than previously described and (2) would indicate whether any changes would occur radiographically with the earlier weight bearing. Twenty-one metatarsocuneiform arthrodeses, in 18 patients, were retrospectively evaluated through chart review and postoperative radiographs. Original diagnoses included painful hallux abducto valgus and osteoarthritis of the first metatarsocuneiform joint. The mean age of the patients was 48 (range, 16 to 70) years. The mean follow-up duration was 38.5 (range, 29 to 60) months. The overall radiographic osseous union rate was 90.5% (19/21 feet), although there were 2 asymptomatic nonunions. There were no cases of fixation failure, and the surgical correction was preserved on follow-up radiographs. Overall, the mean time to full weight bearing was 4.7 (range, 3 to 7.5) weeks, and it was a mean of 8 (range, 7 to 10) weeks before the patient was back to wearing comfortable shoes. The authors concluded that metatarsocuneiform arthrodesis fixated with 1 interfragmentary lag screw and a Darco® locking H-plate provides sufficient stability to allow earlier weight bearing than has been previously described with other internal fixation constructs.

Level of Clinical Evidence: 4

Keywords: bunionectomy, fixation, foot, hallux abducto valgus, surgery

Posterior Approach Using Anterior Ankle Arthrodesis Locking Plate for Tibiotalocalcaneal Arthrodesis

Authors:  Lawrence A. DiDomenico, DPM; Paul Sann, DPM

 

The Journal of Foot and Ankle Surgery: Online Only July 8th, 2011

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.

Correction of Moderate to Severe Coronal Plane Deformity with the STAR Ankle Prosthesis

Authors:  Rogor A. Mann, MD; Jeffrey A. Mann; Sudheer C. Reddy

Foot & Ankle International: July 2011 (Vol.32 #7)

Prior studies have demonstrated a correlation between the degree of

preoperative coronal plane deformity and failure following ankle

replacement. We reviewed all of our patients who underwent ankle

replacement utilizing the STAR prosthesis from 2000 to 2009 to evaluate

the outcome of those with moderate (10 to 19 degrees) and severe (20

degrees or greater) coronal plane deformity. Materials and Methods: Out

of 130 consecutive patients, 43 patients had at least 10 degrees of

preoperative coronal plane deformity. Twenty-five ankles had 10 to 19

degrees degrees of deformity and 18 ankles had 20 degrees

or greater deformity. Average age was 66 years. Average length of

followup was 41 (range, 12 to 98) months. Results: Average talar

preoperative deformity was 17.9 (range, 10 to 29) degrees, while

average initial talar postoperative deformity was 3.5 (range, 0 to 12)

degrees. Average final talar postoperative deformity was 4.7 (range, 0

to 14) degrees. Preoperative and final correction of deformity was

statistically significant (p <0.01), but there was no significant

difference between initial and final postoperative correction. Overall,

recurrence of the preoperative coronal plane deformity occurred in six

of 43 patients (14%). All three patients who had deformities over 25

degrees developed recurrences. Correction of the coronal plane

deformities was achieved by using intraoperative soft-tissue balancing,

including deltoid ligament release in 12 patients

and lateral ligament reconstruction in one patient. Deltoid ligament

release was found to be necessary for all patients with greater than 18

degrees of varus plane deformity. Conclusion: Correction of moderate to

severe coronal plane deformity with the STAR prosthesis was achievable

with only soft-tissue balancing procedures with predictable results

especially for deformities less than 25 degrees.

Level of Evidence: IV, Retrospective Case Series

Key Words: STAR; STAR Ankle; Scandinavian Total Ankle Replacement;

Ankle Replacement; Coronal Plane Deformity; Valgus; Varus; Deltoid

Release

Impaired Wound-Healing, Local Eczema, and Chronic Inflammation Following Titanium Osteosynthesis in a Nickel and Cobalt-Allergic Patient: A Case Report and Review of the Literature

Peter Thomas, MD¹; Manfred Thomas, MD²; Burkhard Summer, PhD¹; Karin Dietrich, MD¹; Melanie Zauzig³; Erwin Steinhauser, PhD³; Veit Krenn, MD⁴; Hans Arnholdt, MD⁵; Michael J. Flaig, MD¹ 


The Journal of Bone & Joint Surgery, Volume 93, Issue 11


Patients known to develop allergic reactions to nickel (Ni), cobalt (Co), or chromium (Cr) often develop eczema in association with items of daily use such as jewelry, earrings, or watchbands. The overall sensitization rates to these metals may range between 1.1% (chromium) and 13% (nickel) in the general population, with further differences based on age and sex¹. Chromium-cobalt alloys and stainless steel are widely used as orthopaedic implants and may release nickel, chromium, or cobalt into the surrounding tissues as a consequence of either wear or corrosion². Some patients with a metal allergy may develop dermatitis in association with orthopaedic implants, and the prevalence of dermal sensitivity in patients with a joint replacement, particularly a failed implant, is higher than that in the general population³. Metal sensitivity rates to nickel, cobalt, or chromium may be as high as 43% in orthopaedic patients with well-functioning implants and as high as 71% in patients with poorly functioning implants³. In contrast, because of their excellent biocompatibility, titanium (Ti)-based materials are not considered to provoke allergic reactions. Our patient developed eczema and impaired wound-healing following the fixation of an ankle fracture with titanium-based implants. Histological analysis of the tissue around the implant demonstrated inflammation primarily with lymphocytes, and a contact allergy to nickel and cobalt was found in the absence of titanium hyperreactivity, raising the question of a prior unknown nickel exposure as the source of the complications. The patient was informed that data concerning this case would be submitted for publication, and she consented.


Investigation performed at the Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Munich; the Department of Precision- and Micro-Engineering/Engineering Physics, Munich University of Applied Sciences, Munich; the Department of Foot Surgery, Hessingpark-Clinic, Augsburg; and the Institute of Pathology, Augsburg, Germany