Ankle Arthrodesis Research Articles

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p=.001 and p=.01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

Ankle arthritis: joint-preserving surgery and total ankle arthroplasty

Ankle arthritis affects approximately 1% of the adult population worldwide and represents a serious global disease burden. However, compared with hip arthritis and knee arthritis, the clinical understanding and treatment of ankle arthritis are still in their infancy. For end-stage ankle arthritis, ankle arthrodesis was considered as the "gold standard" in the past. However, ankle arthrodesis will result in loss of joint mobility, altered gait, limited daily activities, and accelerated degeneration of adjacent joints. Therefore, how to preserve the range of motion of the ankle joint while relieving pain is the key to the treatment of ankle arthritis. Currently, the surgical treatment of ankle arthritis includes arthroscopic debridement, periarticular osteotomies, osteochondral transplantation, ankle distraction arthroplasty, ankle arthrodesis, and total ankle arthroplasty. The choice of treatment should be individualized and based on various factors such as the patient's symptoms, signs, imaging performance, complaints, and financial situation. However, there are no guidelines that give clear treatment recommendations. Therefore, it is necessary to conduct extensive and in-depth discussions on the diagnosis and treatment of ankle arthritis.

The stability of ankle joint fixation during arthrodesis: a comparative study

ABSTRACT. The stability of fixation of the tibia and talus during ankle arthrodesis remains a subject of scientific research. Finding the optimal method for fixing the tibiotalar joint is a pressing issue in traumatology and orthopedics. This study compares the stability of ankle joint fixation during arthrodesis using three spongy screws and an anterior plate combined with two spongy screws. Biomechanical characteristics of ankle joint fixation systems were evaluated on polyurethane foam models in two experimental series: the firs model utilized three spongy screws, and the second model employed a developed plate combined with two spongy screws. The stability of fixation of the ankle joint during arthrodesis was compared between these two approaches. Under minimum cyclic load (20 N), the displacement amplitude was 0.012 mm for the first variant and 0.008 mm for the second variant. Under maximum cyclic load (800 N), the displacement amplitude was 0.106 mm for the first variant and 0.03 mm for the second variant. The study revealed that fixation of the ankle joint during arthrodesis with a plate and two spongy screws provides greater stability compared to fixation with three spongy screws. This suggests that the proposed plate and screws create better conditions for the formation of ankle joint ankylosis. Given the positive biomechanical results, it is recommended to further test this method in clinical conditions.

Radiographic Measurements of the Foot and Ankle After Ankle Arthrodesis.

Ankle arthrodesis is an established treatment for ankle arthritis. For patients with ankle arthritis, the position of the talus during ankle arthrodesis may affect the radiographic parameters of the foot. The purpose of this study is to assess the radiographic relationship between talar alignment and the longitudinal arch of the foot before and after ankle arthrodesis. We retrospectively reviewed a single-surgeon series of 30 patients who had undergone ankle arthrodesis. Measured parameters included the lateral tibiotalar angle (LTTA), lateral talometatarsal angle (LTMA), lateral talocalcaneal angle (LTCA), cuneiform height (CH), and calcaneal pitch (CP). Additional data collected included demographics, fusion construct type, and visual analog scale (VAS) measurements. LTTA was increased from 68.2 ± 7.4 degrees preoperatively to 75.0 ± 6.4 degrees postoperatively (P = .001), LTMA increased from -2.0 ± 10.7 degrees to 4.0 ± 10.1 degrees (P < .001), CH increased from 20.1 ± 7.5 mm to 26.1 ± 8.4 mm (P < .001), LTCA and CP had no statistically significant change. VAS score decreased from 5.7 ± 2.7 to 1.3 ± 1.9 (P < .001). Correcting the talar alignment in the sagittal plane during ankle arthrodesis improved the radiographic parameters of the foot, contributing to restoration of the longitudinal arch. The clinical significance of these findings is that in patients undergoing ankle arthrodesis, the surgeon should be aware that the alignment of the foot will be altered at the time of ankle arthrodesis and should be considered in preoperative planning. Further research is needed to determine the effect of ankle arthrodesis in patients determined to have pes planus preoperatively. Level III, retrospective cohort study.

Hindfoot fusion with various auxiliary techniques in Charcot’s management

Abstract Introduction: Management of Charcot’s arthropathy of the hindfoot (Sanders/Frykberg Type IV) is a challenging situation to address. Complex deformities linked with ankle/hindfoot Charcot’s disease are frequently multiplanar. Due to the collapse of the distal tibia and the two bones of the hindfoot, the talus, and calcaneus, the limb frequently shortens when the skeletal architecture is damaged. A varus ankle or heel results in increased lateral column plantar pressure of the foot due to changed foot pressure loading, predisposing the patient to develop lateral foot ulceration. Collapse and secondary avascular necrosis of the talus; additional stress on the injured bone exacerbates these deformities and contributes to ulcers in the foot, instability during walking, and limb-length discrepancy. Management: The primary indication for surgical ankle stabilization is a foot that cannot be braced and is unstable during walking. Other surgical indications include imminent ulceration, nonhealing ulcers, recurring ulcers, osteomyelitis, and/or severe pain. Achieving ankle and/or hindfoot arthrodesis and correcting these complex multiplanar deformities in this location stabilizes the hindfoot. Various auxiliary techniques that can be combined with Tibio-talo-calcaneal (TTC) are tricortical iliac crest graft and femoral head allograft to build hindfoot, plate augmentation, distally mobilized fibula as biological augmentation and multiple 6.5-mm screws. The choice between internal or exterior fixation is mostly determined by the presence or absence of an active infection and the quality of the bone. Conclusion: Surgical stabilization with TTC nail for Charcot’s arthropathy of the ankle and hindfoot is associated with good clinical outcomes. Despite the high likelihood of complications, limb salvage rates are between 80% and 90%. A meticulous selection of cases, a diligent multimodal strategy, and an experienced team are required to attain this result. Assessment of vascular status, glycemic control, optimum foot care, use of protective footwear during the acute inflammatory phase to prevent inadvertent trivial foot injuries, correction of calcium and vitamin D deficiencies, and cessation of tobacco and alcohol use are preoperative factors that can improve outcomes. Various auxiliary techniques can be combined with TTC nailing for optimum results.

Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study".

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Therapeutic Level III, retrospective cohort.

The results of surgical treatment of the ankle joint in patients with different body mass index

Objective: to assess the possible effect of excess body weight on the results of surgical treatment of osteoarthritis of the ankle. Material and methods. 134 patients with moderate to advanced ankle osteoarthritis who underwent supramallear osteotomy or ankle arthrodesis. Patients were divided into 4 groups according to Body Mass Index: A) underweight (BMI≤18.5 kg / m2), B) normal weight (18.5&lt;BMI≤25 kg / m2), C) overweight (25&lt;BMI ≤30 kg / m2) and D) obese (BMI&gt;30 kg / m2). All patients were followed up for more than 6 months. All patients were evaluated physically, as well as by VAS (Visual Analog Scale) and AOFAS (American Orthopaedic Foot and Ankle Society). Results. The AOFAS and VAS at 3 months and 6 months after surgery were significantly better in all four groups compared to the preoperative scores. A comparison of the preoperative AOFAS and VAS scores showed no significant difference between the four groups (p=0.505, p=0.779). A comparison of the AOFAS and VAS 6 months after surgery revealed no significant difference between the four groups (p=0.313, p=0.711). Conclusions. For the middle and late stages of osteoarthritis, regardless of the level of the patient’s Body Mass Index, supramalleolar osteotomy, as well as ankle arthrodesis, showed the greatest effectiveness. During the early rehabilitation period, an increase in Body Mass Index had no negative effect on pain and functional recovery after ankle surgery.

Reliability and validity of the Forgotten Joint Score-12 for total ankle replacement and ankle arthrodesis.

This study evaluated the reliability and validity of the Forgotten Joint Score-12 (FJS-12)-a measure of patients' ability to forget their joints in daily life-in patients who underwent total ankle replacement (TAR) or ankle arthrodesis (AA). Patients who underwent TAR or AA were recruited from seven hospitals. The patients completed the Japanese version of FJS-12 twice, at an interval of two weeks, at a minimum of one year postoperatively. Additionally, they answered the Self-Administered Foot Evaluation Questionnaire and EuroQoL 5-Dimension 5-Level as comparators. The construct validity, internal consistency, test-retest reliability, measurement error, and floor and ceiling effects were evaluated. A total of 115 patients (median age, 72 years), comprising 50 and 65 patients in the TAR and AA groups respectively, were evaluated. The mean FJS-12 scores were 65 and 58 for the TAR and AA groups, respectively, with no significant difference between groups (P = 0.20). Correlations between the FJS-12 and Self-Administered Foot Evaluation Questionnaire subscale scores were good to moderate. The correlation coefficient ranged from 0.39 to 0.71 and 0.55 to 0.79 in the TAR and AA groups, respectively. The correlation between the FJS-12 and EuroQoL 5-Dimension 5-Level scores was poor in both groups. The internal consistency was adequate, with Cronbach's α greater than 0.9 in both groups. The intraclass correlation coefficients of test-retest reliability was 0.77 and 0.98 in the TAR and AA groups, respectively. The 95% minimal detectable change values were 18.0 and 7.2 points in the TAR and AA groups, respectively. No floor or ceiling effect was observed in either group. The Japanese version of FJS-12 is a valid and reliable questionnaire for measuring joint awareness in patients with TAR or AA. The FJS-12 can be a useful tool for the postoperative assessment of patients with end-stage ankle arthritis.

The Fate of Delayed Unions After Isolated Ankle Fusion.

Nonunion remains the most common major complication of ankle arthrodesis. Although previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. In this retrospective cohort study, we sought to understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography scan (CT) was associated with outcomes. Delayed union was defined as incomplete (<75%) fusion on CT between 2 and 6 months postoperatively. Thirty-six patients met the inclusion criterion: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained including patient satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction. Failure was defined as patients who required revision or reported being not satisfied. Fusion was assessed by measuring the percentage of osseous bridging across the joint on CT. The extent of fusion was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). We determined the clinical outcome of 28 (78%) patients with mean follow-up of 5.6 years (range, 1.3-10.2). The majority (71%) of patients failed. On average, CT scans were obtained 4 months after attempted ankle fusion. Patients with minimal or moderate fusion were more likely to succeed clinically than those with "absent" fusion (P = .040). Of those with absent fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% fusion on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion. Level IV, retrospective cohort study.

The utilization of a perioperative muscle free flap in total ankle arthroplasty: A case report and brief review of the literature

Ankle arthrodesis and total ankle arthroplasty (TAA) are both approaches to surgical treatment of ankle arthroses, with the latter becoming increasingly popular as it maintains ankle mobility. TAA has been associated with complications, including wound persistence, periprosthetic osteolysis, infection, and implant failure, which can be attributed to the area's poor vascularization and soft-tissue quality. In particular, the anterior compartment - solely supplied by the anterior tibial artery – explains the heightened risk of poor outcomes in ankle surgery. The effect of a secondary reconstructive procedure, such as a skin graft or a muscle flap for prosthesis salvage, has been well described in the literature. Muscle flaps are indicated in soft tissue reconstructive procedures because they provide a reliable blood supply and significant tissue volume where there is dead space. Here we outline a case where a 53-year-old male patient received a gracilis muscle free flap after TAA to improve outcomes and as an alternative orthoplastic procedure for patients who otherwise would undergo limb amputation. After several months of physical therapy, the patient is pain-free and active. With this, it can be concluded that a free muscle flap has the potential to be used perioperatively in higher-risk patients to improve TAA outcomes and as an alternative to other procedures that can reduce a patient's quality of life, such as ankle arthrodesis or amputation.

Conversion of Symptomatic Ankle Arthrodesis Nonunion to Total Ankle Arthroplasty Using Patient-specific Instrumentation and Computer-assisted Surgery Guides: A Case Report

A 69-year-old woman developed a painful ankle fusion nonunion and underwent conversion to a total ankle replacement. Preoperative navigation was performed using a computed tomography scan and computer modeling system to develop patient-specific instrumentation and surgery guides. We described the navigation process of a fixed-bearing, computer-guided total ankle implant when performing an ankle arthrodesis takedown due to symptomatic nonunion and converting to a total ankle arthroplasty. The use of this technology is relatively new, and, in this case, preoperative navigation allowed for precise implant planning while accounting for the osseous deformities from previous implants, which already fixated the ankle joint. Level of Evidence: Level IV.

Outcomes following acute versus staged fixation of complete articular tibial plafond fractures.

To determine outcomes following acute versus staged fixation of complete articular tibial plafond fractures. Retrospective cohort study. Single Level 1 Trauma center. 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had minimum 6 month follow up. Acute (aORIF) versus staged (sORIF) definitive fixation. Rates of wound dehiscence/necrosis and deep infection. Acute (N=40) versus staged (N=58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs 0%, p<0.001), which correlated with higher ASA scores (>ASA 3: 37.5% vs 13.8%, p=0.02). Both groups achieved anatomic/good reductions, as determined by post-operative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs sORIF: 121 vs 146 minutes, p=0.02). Post-operatively, both groups had similar rates of wound dehiscence (2.5% vs 6.9%, p=0.65), superficial (10% vs 17.2%, p=0.39), and deep (10% vs 8.6%, p=0.99) infections. While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs sORIF:12.5% vs 25.9%, p=0.13). In select patients managed by fellowship trained Orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes.

Pilon fractures: Consensus and controversy.

Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.

Comparative results of arthroscopic ankle arthrodesis vs. open arthrodesis in patients with diabetes-associated Charcot Neuro-Arthropathy

BackgroundSeveral studies demonstrated a considerable complication rate for open ankle or TTC arthrodesis in patients with diabetes, revision surgery and ulceration. Extensive approaches in combination with multimorbide patients have been suggested as the rationale behind the increased complication rate.MethodsSingle-centre, prospective case-control study compared arthroscopic vs. open ankle arthrodesis in patients with Charcot Neuro-Arthropathy of the foot. 18 patients with septic Charcot Neuro-Arthropathy Sanders III–IV received an arthroscopic ankle arthrodesis with TSF (Taylor Spatial Frame®) fixation combined with different additional procedures required for infect treatment and hindfoot realignment. The ankle arthrodesis was required for the realignment of the hindfoot in Sanders IV patients, arthritis or in case of infection. 12 patients were treated with open ankle arthrodesis and TSF fixation combined with various additional procedures.ResultsA significant improvement has been shown in radiological data in both groups. A significant lower complication rate has been registered in arthroscopic group. A significant correlation was seen between major complications and therapeutic anticoagulation as well as smoking.ConclusionIn high-risk patients with diabetes and plantar ulceration excellent results could be demonstrated in arthroscopically performed ankle arthrodesis with midfoot osteotomy using TSF as fixation devise.

Comparison of Total Ankle Replacement and Ankle Arthrodesis for Ankle Arthropathy in Patients With Bleeding Disorders: A Systematic Review and Meta-Analysis.

There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population. This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool. Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA. Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population.

The German Association for Foot and Ankle (D.A.F.) registry on treatment of end-stage total ankle arthritis-what is its clinical impact?

Initially established as avoluntary prosthesis register for total ankle replacement, the registry now enables analysis of revisions, complications, and clinical and functional outcomes-including patient-reported outcome measures-based on a period spanning more than 10years. To allow analyses of the outcomes of ankle arthrodesis and supramalleolar osteotomies for treatment of end-stage arthritis in the future, the registry was extended by structured capturing of these procedures in 2018. While descriptive and analytical statistical evaluations of total ankle replacement are already possible today, the number of datasets on arthrodesis and supramalleolar osteotomies is still too small to support these analyses or comparative evaluations.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion.

Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA. All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors. The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively. As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options. Level III, retrospective cohort study.

Simultaneous tibio-talar fusion and tibial lengthening for end-stage ankle arthritis.

Arthrodesis of the ankle joint is an accepted treatment option in patients with end-stage ankle arthritis. The goal is to achieve fusion between the tibia and the talus, thereby stabilizing the joint and alleviating pain. There might be associated limb length discrepancy, especially in post-traumatic and post-infectious cases. These patients require limb lengthening and arthrodesis. The purpose of this study is to report our experience with simultaneous ankle arthrodesis and lengthening using external fixation in adolescent and young adult patients. This retrospective case series included all patients treated in our hospital by concomitant ankle arthrodesis and tibial lengthening procedures on the same limb, using ring external fixation system. All surgeries included distal tibial joint surface resection and the talar dome, thereby correcting any associated deformity at the ankle. The arthrodesis was fixed and compressed using ring external fixator. A concurrent proximal tibial osteotomy was done, and limb lengthening, or bone transport was performed. Eight patients operated between the years 2012-2020 were included in this study. Median patient age was 20.4years (range 4-62years), 50% women. Median limb lengthening was 20mm (range 10-55mm), and median final leg length discrepancy (LLD) was 7.5mm (range 1-72mm). The most common complication recorded was pin tract infection, which resolved with empiric antibiotics in all cases. Based on our experience, combined arthrodesis and proximal tibial lengthening is efficient solution that provides stable ankle and restores length of the tibia even in complex and challenging situations.

ANKLE ARTHRODESIS USING TTC (TIBIOTALOCALCANEAL) NAIL IN THE TREATMENT OF NEGLECTED TRIMALLEOLAR FRACTURES OF ANKLE WITH EARLY ARTHRITIS; CASE REPORT

Introduction: Patients rst consult traditional healers and it is when the signs persist that they consult the surgeon for a swollen and painful ankle. Initially we always performed anatomical repairs with osteosynthesis, but the majority of patients still complained of pain and disability. We therefore performed an arthrodesis on neglected post-traumatic ankles. The objective of our study was to describe the result of arthrodesis ankle using TTC (tibiotalocalcaneal) nail on a neglected post-traumatic ankle and to propose a therapeutic indication in the face of any neglected ankle fracture. This was a case of 38/m with 3 months old neglected trimalleolar ankle fr Material and Method: acture with early arthritis treated with ankle arthrodesis using ttc nail. Follow up taken over 3 months by serial x-rays and clinical evaluation. The average follow-up was 3 months and our results were satisfactory radiologically and Results: clinically. Discussion: Arthrodesis with ttc nail appears here as an important alternative in the treatment of neglected ankle fractures with early changes of arthritis

Does the Number of Screws Influence the Union Rate in Ankle Arthrodesis? A Meta-analysis and Systematic Review.

The purpose of this study was to determine whether the number of cannulated screws used during ankle arthrodesis (AA) might influence the union and complication rate. In this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant PROSPERO-registered systematic review, multiple databases were searched including studies in which patients undergone AA using cannulated screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion, and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Two groups were built (arthrodeses fixed with 2 screws [group 1, G1] vs arthrodeses fixed with 3 screws [group 2 G2]) and compared. Fifteen series of patients from 15 studies (667 ankles) were selected (G1 = 458 ankles and G2 = 209). The pooled proportion estimate revealed a similar nonunion rate in the 2-screw group as compared with the 3-screw group (4% vs 3%; P = .68). The pooled proportion of complications was higher in G1 (19%) than in G2 (8%), but it was not significantly different either (P = .45). After exclusion of "symptomatic hardware and screw removal," the difference was still not significant (P = .28) although it resulted lower in G1 than in G2 (4% vs 8%, respectively). Using 3 cannulated screws during AA as compared with a 2-screw construct does not significantly reduce the risk of nonunion nor the risk of complications. Level IV, Systematic review of level IV.