Ankle Fixation Research Articles

Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases

Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results.

Intraoperative Radiation Use by Trainees During Ankle Fracture Fixation

Orthopedic trainees are assessed during training regarding their use of radiological screening during operative procedures. The authors investigated whether orthopedic trainees' use of fluoroscopic screening during ankle fixation operations varied with the 2 variables of consultant supervision and trainee experience. Data from operative fixation of isolated Weber B ankle fractures were reviewed. The intraoperative radiation dose was retrieved from radiographers' data. Operations performed by consultants were used as a control group (n=25 patients). Trainee supervision was assessed as "trainer in operating room (OR)" and "trainer out of OR." Regarding experience, the patients were divided into those operated on primarily by trainees in their first (n=36 patients) and in their last (n=34 patients) 3 years of formal specialist training. All trainee groups used more radiation than consultants. Supervision did not affect the radiation use of senior trainees (P<.05). Senior trainees used less radiation than their junior peers (P<.02). Junior trainees supervised by a trainer in the OR used less radiation than junior trainees supervised by a trainer outside of the OR (P<.05). During open reduction and internal fixation of ankle fractures, junior orthopedic trainees use less intraoperative radiation when they are supervised by a trainer in the OR. The more experience a surgeon has, the less fluoroscopic screening is used during operative ankle fixation.

Foot &amp; ankle

The December 2012 Foot &amp; ankle Roundup360 looks at: correcting the overcorrected club foot; syndesmotic surgery; autograft for osteochondral defects; sesamoidectomy after fracture in athletes; complications in ankle replacement; the arthroscope as a treatment for ankle osteoarthritis; whether da Vinci was a modern foot surgeon; and a popliteal block in ankle fixation.

Post operative management of ankle fixation: How many radiographs do we need?

Post operative management of ankle fixation: How many radiographs do we need?

The treatment of severe open Pilon fractures

Objective To discuss the operative methods, timing and outcomes of severe open Pilon fractures. Methods From April 2003 to July 2008, 21 patients with open Pilon fractures were admitted. All the patients were type C fracture according to AO/OTA classification, including 17 cases of type C2 and 4 cases of type C3. According to Gustilo classification, there were 18 cases of type Ⅱ, 2 cases of type ⅢA, 1 case of type ⅢB. The patients were treated in two different ways: one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with transarticular external fixation of the ankle (19 cases),which included 16 cases of Gustilo Ⅱ AO/OTA C2, 2 cases of type Gustilo Ⅱ AO/OTA C3 and 1 case of type Gustilo ⅢA AO/OTA C2. Formal open reconstruction of the articular surface by plating and external fixation was performed when the condition of soft tissue had improved (2 cases), which included 1 cases of type Gustilo ⅢA AO/OTA C3 and 1 cases of type Gustilo Ⅲ B AO/OTA C3. Results All the patients were followed up from 6 to 48 months, with the mean of 24 months. The outcome of reduction was evaluated by the Burwell-Charnley score. Anatomical reduction was found in 6 cases, function reduction was in 14 cases and poor reduction was 1 case. The heal-time ranged from 2.5 to 11 months, with the mean of 4.7 months. The delayed union occurred in 2 cases. The rate of delayed union was 9.5%. Two patients experienced skin superficial necrosis. There were superficial infection in 2 cases and deep infection in 1 case. The infection rate was 14.3%. Eight cases experienced early traumatic arthritis. The incidence of this complication was 38.1%.According to American Orthopedic Foot Ankle Society (AOFAS) scale for ankle joint, the result of the treatment was 66-94, with an average of 85.2. Conclusion It is important to have the optimal timing of surgery and reliable fixation according to fracture classification, the condition of soft tissue and time after injury. It is the key to evaluate the condition of soft tissue and protect the blood supply. Key words: Tibia; Fractures, open; Fracture fixation, internal; External fixators

Anticoagulation management in patient undergoing elective and emergency orthopaedic procedures

INTRODUCTION Warfarin remains the treatment of choice for the majority of patients with venous thromboembolism, atrial fibrillation and valvular heart disease or valve replacement unless contraindicated. Poor management of patients on warfarin often leads to delay in surgery, life threatening bleeding during or after operation and unnecessary delay in discharge from hospitals in United Kingdom. METHODS We carried out a prospective study on patients who were on warfarin and underwent elective and emergency orthopaedic procedures during period of study- August 2007 to April 2008. All patients included in the study were identified from admission notes during period of study. All data regarding indications for warfarin, pre and post procedures INR, elective or emergency orthopaedic procedures and complications were collected using a standard proforma. RESULTS 18 patients, 12 male and 6 female were included into the study. Patients9 age ranged from 47-87 with mean of 76. The indications for warfarin therapy were atrial fibrillation in 12 patients, deep vein thrombosis in 5 patients and left ventricular aneurysm in 1 patient. 18 procedures, 10 elective and 8 emergency orthopaedic procedures were carried out during period of study. Elective procedures - 7 primary joint arthroplasty, 1 revision hip arthroplasty, 1 removal of metalwork and 1 metatarsophalangeal joint fusion. Emergency procedures - 4 hip hemiarthroplasty, 2 dynamic hip screw fixation, 1 external fixator application and 1 open reduction and internal fixation of ankle. All elective admission patients were pre-assessed in clinic prior to admission and were advised to stop warfarin based on their INR level. Patients with INR 2-3 had their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 had their warfarin stopped 5 days prior to surgery. This group of patients had their INR check on admission and ranged from 1.1-1.5. This group of patients had no reversal therapy and no cancellations were made to their operation. 8 emergency admission patients had INR of 1.4-4.7 on admission with mean of 2.7. 5 patients had reversal therapy while 3 patients had no reversal therapy. Pharmacological methods used to reduce the INR were fresh frozen plasma in 1 patient and Vitamin K in 4 other patients. 2 patients that received reversal therapy had operation on day 1, 2 on day 3 and 1 on day 5. 1 patient that had no reversal therapy was operated on day 1, 1 on day 3 and 1 on day 5. Patient that received no reversal therapy and operated on day 5 of admission died post-operatively from medical complications. Mean delay for patient that had reversal therapy was 2.2 days compared to 3 days in patient with no reversal therapy. All patients in this study had prophylactic low molecular weight heparin while off warfarin. Patients were recommenced on their normal dose of warfarin the day after their operation. DISCUSSION & CONCLUSIONS We conclude that patients on warfarin with INR 2-3 should have their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 should stop their warfarin 5 days prior to elective surgery. Trauma patients on warfarin requiring operation should have their INR reversed on admission to shorten delay in waiting time and improve outcomes.

Compression Forces of Internal and External Ankle Fixation Devices with Simulated Bone Resorption

Internal and external fixation techniques have been developed to provide rigidity and stability to a fusion site such as in tibiotalocalcaneal (TTC) arthrodesis. Compression of the fusion site plays an integral role in primary bone healing, though little work has been done to quantify the compressive force values of ankle fixation devices. Using synthetic and cadaveric bone models, a Newdeal/Integra PantaNail and DePuy VersaNail were tested as compressive intramedullary (IM) nails while an Encore True/Lok and an Ace-Fischer frame were tested as external fixators. The PantaNail experienced maximum compressive loads of 1898 and 1255 N in synthetic and cadaveric constructs, respectively. The VersaNail experienced max compressive loads 388 N during installation. All IM nails tested experienced decreased compressive loads after removal of the external guide and instrumentation. The external fixators were loaded to approximately 1200 N in both synthetic and cadaveric constructs. The decrease in compressive load was recorded as a function of simulated fusion site bone resorption for all devices. The IM nails experienced a 90% reduction in load with less than 1 mm of resorption, while the external fixators held 50% load for over 4 mm of resorption. These data were verified using a simple constitutive model of IM nails and external fixators. Intramedullary nails are capable of generating compression, however, are unable to provide sustained compression for any considerable amount of resorption. External fixators are inherently capable of applying and sustaining greater amounts of compression. Surgeons who perform TTC arthrodesis procedures should be aware of a device's ability to generate and sustain compression with respect to bone resorption.

Ankle fixation need not increase the energetic cost of human walking

We tested whether the metabolic energy cost of walking with the ankles immobilized can be comparable to normal walking. Immobilization of any lower extremity joint usually causes greater energy expenditure. Fixation of the ankle might be expected to eliminate the work it normally performs, to detrimental effect. But fixation using lightweight boots with curved rocker bottoms can also bring some benefits, so that the overall energetic effect might be quite small. We measured oxygen consumption, kinematics, and ground reaction forces in six ( N = 6) able-bodied human volunteers walking at 1.25 m/s in three conditions: normal walking in street shoes, walking with ankles immobilized by walking boots, and normally with ankles free but also weighted to match the mass of the walking boots. We estimated metabolic energy expenditure, joint work, and overall work performed on the body center of mass as a function of ankle fixation. Ankle fixation with walking boots caused the total rate of energy expenditure for walking to increase by 4.1% compared to normal ( P = 0.003), but differed by an insignificant amount (0.4% less, P = 0.78) compared to walking with equivalent ankle weight. Compared to normal walking, ankle fixation can reduce ankle torque and work during the stance phase, most notably during late stance. This apparently makes up for the loss of ability to push-off as normal. With a suitably lightweight apparatus and curved rocker bottom surface, loss of ankle motion need not increase energy expenditure for walking.

Transarticular versus Extraarticular Ankle Pin Fixation: A Biomechanical Study

Transarticular pin fixation for ankle stabilization has drawbacks, including ankle joint arthrosis. An extraarticular technique could help avoid these problems. We compared stiffness under minimal dorsiflexion loading with transarticular versus extraarticular fixation. Cadaveric specimens from ten lower extremity matched pairs were randomized to receive transarticular or extraarticular fixation. For transarticular fixation, axial pins were passed retrograde through the plantar heel, calcaneus, subtalar joint, talar body, and ankle joint. For extraarticular fixation, the first pin was inserted antegrade from the anterior distal tibia to the posterolateral aspect of the calcaneus tuberosity. The second pin was inserted percutaneously antegrade from the distal medial tibial metaphysis to the dorsal navicular, passing anterior to the ankle and dorsal to the talonavicular joint. Each specimen was subjected to 1000 cycles at 5 mm/s to 100 N. After testing, the extraarticular specimens were dissected to establish the distance of the pin from the flexor hallucis longus (FHL) tendon. There was no significant difference in stiffness between the transarticular and the extraarticular group (mean+/-standard error of the mean) (17.93 N/mm+/-1.0 N/mm and 18.61 N/mm+/-1.07 N/mm, respectively). The lateral pin was 4.2+/-1.4 mm (range, 2.5 to 6.0 mm) from the FHL. Fixation stiffness with extraarticular crossed antegrade pins was not different from that of transarticular fixation and did not disrupt the ankle or the plantar skin. Extraarticular ankle fixation may help avoid the complications found with the joint, cartilage, and plantar skin disruption associated with transarticular fixation.

Ankle Arthrodesis Using Ilizarov Ring Fixators: A Review of 22 Cases

Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.

The comparison of the effects on osteoarthritis of the knee between the insole with figure 8 elastic ankle fixation band and the insole without ankle fixation

The comparison of the effects on osteoarthritis of the knee between the insole with figure 8 elastic ankle fixation band and the insole without ankle fixation

Surgical treatment for pilon fracture of the ankle-open reduction and internal fixation.

From 1991 to 1994, 39 ankles of 38 patients underwent surgical open reduction and internal fixation for pilon fractures. These patients included 29 males and 9 females with an average age of 38.6 y/o (range 28 y/o-58 y/o). The follow up and evaluation period averaged 31.7 months (range 22Ms-44Ms), during which time a standing x-ray for arthrosis grading and functional scale was used for clinical evaluation. Complications included 1 case of infection, 1 case of loss reduction, 2 cases of partial skin necrosis and 2 cases of delayed union. Post-traumatic arthritis occurred in 23 ankles (59%) but only 4 ankles of grade 4 arthrosis resulted in poor functional scale and the overall satisfactory rate was 82%. It was found that anatomic reduction, rigid fixation and early motion exercise are important to successful treatment of ankle fractures. Regarding pilon fracture, specifically the severity of fracture pattern and delay of reduction are important problems to overcome to ensure successful results. Therefore, adequate surgical approach for entire view of ankle joint, reduction and fixation of fibula, sufficient bone graft for articular support, intraoperative x-ray check and postoperative immobilization are essential for the achievement of better clinical results.

Comparison of Passive Stiffness Variables and Range of Motion in Uninvolved and Involved Ankle Joints of Patients Following Ankle Fractures

The purpose of this study was to quantify several variables of ankle stiffness and dorsiflexion (DF) range of motion (ROM) in the casted (fractured) and noncasted ankles of humans after cast removal. Thirty subjects (mean age = 32.4 years, SD = 15.8) with malleolar ankle fractures were tested within 4 days of cast removal but before they began physical therapy. A torque motor system generated torque-versus-displacement graphs by recording angular displacement and resistive torque during a 6 0/s passive cycling of the ankle from 10 degrees of plantar flexion to the limit of DF ROM: Maximum passive DF ROM, passive torque, and passive elastic stiffness at the neutral position and energy loss were measured. Testing was performed in the absence of triceps surae muscle electromyographic activity. For analysis, subjects were separated into two groups based on fracture severity. There was no difference in passive torque between the fractured ankles and the matched noncasted ankles. There was a small difference in passive elastic stiffness between the more severely fractured ankles and the matched noncasted ankles. The fractured ankles were different in terms of energy loss from the matched noncasted ankles. For maximum passive DF ROM, there was a large difference between the fractured ankles (more severe: mean = 4.4 degrees; less severe: mean = 6.8 degrees) and the matched noncasted ankles (more severe: mean = 15.1 degrees; less severe: mean = 19.1 degrees). Altered length-tension relationships and neuromuscular mechanisms have been suggested to produce postimmobilization joint contractures. The results of this study on humans are consistent with both possibilities and support the theory that changes that occur during immobilization result in protection from overstretching of the fragile calf musculature after a period of ankle fixation. The time course of normalization of stretch reflexes warrants investigation.

Experimental rapid sarcomere loss with concomitant hypoextensibility.

Slow soleus muscle in guinea pigs was actively shortened by constant electrical stimulation of the sciatic nerve for 12 hours. At the end of this period, hypoextensibility and a 25% decrease in the numbers of sarcomeres were observed. When a 36- or 48-hour period was allowed to elapse after the end of stimulation, some recovery occurred, and the sarcomere numbers were then found to be diminished by only 5%. If the stimulation was performed when the muscle was prevented from shortening (by ankle fixation in dorsiflexion), there was no decrease in sarcomere numbers and no hypoextensibility after neuroaxis lesions, when abnormal contractions maintain lasting shortening of the muscle.