Failed Ankle Arthrodesis Research Articles

Salvage of Failed Ankle Arthrodesis by Conversion to Total Ankle Arthroplasty: Intermediate Term Results

Category: Ankle; Hindfoot Introduction/Purpose: As ankle arthroplasty has become a reliable treatment for painful ankle arthritis, it has also been employed as a salvage procedure for failed ankle arthrodeses. Published studies of conversion have generally combined patients treated by several surgeons using a variety of different prostheses, with short-term follow-up. Early reports showed failure in patients with an absent distal fibula, and more recently that has been considered a contraindication. Some reports have expressed concerns about doing hindfoot arthrodeses at the same setting. This retrospective study examines the mid-term follow-up of 19 patients treated by a single surgeon using a standard technique with a single prosthesis, and includes patients with a deficient distal fibula and concomitant hindfoot fusions. Methods: Between May 2010 and August 2019, 28 patients underwent conversion of their failed ankle arthrodesis to a total ankle arthroplasty using a prosthesis with an intramedullary tibial component. Nineteen patients (10 males and 9 females) with an average age of 49.8 (45-81) years at the time of surgery were included in the study. Three modes of ankle arthrodesis failure were identified: 1) solid tibial-talar-calcaneal arthrodesis with a painful malposition (n=3); 2) painful pseudarthrosis of the ankle (n=4); and 3) solid ankle fusion with painful adjacent hindfoot arthritis (n=12). The patients in the first two groups were treated with arthroplasty alone, while those in the third group had an arthroplasty and hindfoot fusion. Four patients had a deficient distal fibula. Outcomes were evaluated post-operatively with a Visual Analog Scale, the AOFAS Ankle and Hindfoot Scale, a satisfaction survey, and radiographic assessment of the arthroplasty and any concomitant hindfoot fusions. Results: Mean follow-up was 7.6 (2.6-11.8) years. Complications included fracture with or without subsequent surgery (n=4), subsequent sub-talar fusion (n=1), varus deformity (n=1), and wound dehiscence or infection (n=2). Three patients had revision of their talar components. Postoperative dorsiflexion was 7.8 ± 12.6 degrees and plantarflexion 20.9±13.37 degrees. Two patients developed lucencies about the tibial stem, and two had mild subsidence of the talar components. There were no hindfoot pseudarthroses. Four patients with a deficient distal fibula were all able to be salvaged with an intact ankle arthroplasty. Mean (± SD) VAS Score was 4.6 ± 3.0 and AOFAS score was 71.2±21.7. Sixty-seven percent reported that they were satisfied or very satisfied. Forty-four percent had significant limitations in either activity or ADLs in their ankle function. Conclusion: Total ankle arthroplasty should be considered as a salvage procedure for patients with a failed ankle arthrodesis. With the described techniques it can be combined with concomitant hindfoot arthrodesis procedures and can be used successfully in patients who have a deficient distal fibula. While there can be a high prosthetic retention rate in the medium term, prospective patients must be counseled about potential limitations.

Patient Reported Outcomes Following Revision Ankle Arthrodesis for Ankle Fusion Non-Union

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Ankle arthrodesis (AA) has, for many years, been considered the gold standard procedure for the surgical treatment of end stage ankle arthritis. Non-union following AA surgery is a devastating complication which subsequently requires revision surgery. However, data on outcomes including patient reported outcome measures (PROMs) following revision ankle arthrodesis (RAA) after failed AA is lacking. The aim of this study is to assess the outcome of RAA for symptomatic non-union after AA including PROMs. Methods: Prospectively collected data from a multicenter database of ankle arthritis surgery was analyzed. Demographic data and PROMs including Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) health survey were collected at regular intervals. Surgeries were performed by six fellowship-trained foot and ankle surgeons between January 2003 and July 2015. 336 primary AA cases were identified, of which 27 (8%) underwent revision for symptomatic AA non-union. Results: Mean follow-up of 27 AA non-union cases was 5.3 years (2-10). There were 16 (59%) males and 11 (41%) females, with a mean age of 62 years (44 - 81) and a mean BMI of 32 (26.5 – 45), respectively. At index AA, 12 (44%) cases were performed arthroscopically. Twenty-three (84%) AA non-union patients were actively smoking pre- and post-operatively, and 15 (56%) were diabetic. Overall union-rate following RAA was 85% (23/27). For RAA the pre-operative mean AOS score of 64.9 (38.8-81.5) improved to 49.1 (24.1-73) at latest follow-up. SF-36 PCS score improved from 27.2 (21.3 – 38.3) to 33.3 (19.1-54.2) and SF-36 MCS score improved from 41.2 (17.5-60.9) to 46.2 (29.3-65.9). Overall complication rate of RAA was 22%, with a re-operation rate of 15%. Conclusion: Revision ankle arthrodesis (RAA) for ankle fusion non-union resulted in a successful fusion of the ankle in 85% of patients with modest improvement in AOS and SF-36 scores. Indeed, even after successful RAA, patients report pain and disability levels comparable to that reported by primary AA patients pre-operatively. Additionally, complication and re-operation rates of RAA are high. This data emphasizes on the importance of achieving a primary fusion in AA. The presented patient reported outcomes may help the treating surgeon to counsel patients prior to RAA surgery to better set their expectations.

Fibular Strut Autograft as an Augmented Biological Plate: A New Modified Technique for Tibiocalcaneal Arthrodesis With Intramedullary Nail

Fibular Strut Autograft as an Augmented Biological Plate: A New Modified Technique for Tibiocalcaneal Arthrodesis With Intramedullary Nail

Ankle Arthrodesis With Anterior Plate Fixation in Patients at High Risk for Nonunion.

Between January 1, 2011, and January 1, 2017, an orthopaedic foot and ankle surgeon performed tibiotalar arthrodesis on 221 patients. Thirty-two were included in this study. Inclusion criteria included patients with at least one risk factor for nonunion and/or malunion, isolated anterior ankle arthrodesis with plate fixation, patients older than 18, and a minimum of 1-year follow-up. Risk factors were avascular necrosis of the talus, severe segmental bone defect, smoking, inflammatory arthropathy, coronal deformity greater than 15°, diabetes mellitus, septic nonunion, failed ankle arthrodesis, and body mass index greater than 35. Functional outcome questionnaires (Ankle Osteoarthritis Score [AOS] and Foot Function Index [FFI]) were collected at the latest visit or by phone. Twenty-six (26/32, 81.2%) patients included in the study had computed tomography images available for review at an average of 3.2 months after surgery. The rate of successful arthrodesis was 93.8% (30/32) at an average of 78 days. Overall, 14 patients (14/32, 43.8%) developed a postoperative complication, including 1 patient that had a delayed nonunion and 2 patients that proceeded to nonunion. Twenty-three patients (23/32, 71.9%) completed the functional outcome questionnaires at an average of 26.8 months. Mean AOS and FFI scores improved significantly postoperatively (P < .001). Sagittal tibiotalar and coronal tibiotalar alignment improved significantly in patients with severe preoperative deformity (P < .001). Tibiotalar arthrodesis with anterior plate fixation in a high-risk cohort results in high union rates and significantly improved functional outcomes. Levels of Evidence: Therapeutic, Level IV: Prospective, comparative trial.

Salvage of failed ankle arthrodesis after posttraumatic septic arthritis by Ilizarov external fixator: mid-term results

Background: Failed septic ankle arthrodesis is a challenging problem. This study evaluated the results of salvage revision ankle arthrodesis using Ilizarov external fixation to treat nonunited arthrodesis of posttraumatic septic ankle arthritis and to analyze the functional outcome of this method. Methods: This prospective study included 14 patients with a mean age of 48 yr. Patients had already undergone a mean of 4.43 previous surgeries at a mean of 17.14 mo from primary arthrodesis. Five patients had associated deformity. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 23.93. Meticulous debridement was done and an Ilizarov fixator was applied in compression in a one-stage procedure. Results: The mean follow up period was 41.71 mo with mean external fixation period of 17.29 wk. Successful arthrodesis in perfect alignment was achieved in 13 of 14 patients without additional procedures. One ankle did not go on to union. A chronic discharging sinus persisted in one patient. One infected loose wire was exchanged in two patients. One diabetic patient reported moderate daily diffuse pain. The mean postoperative AOFAS ankle-hindfoot score was 71.57. Patients with successful fusion were satisfied with the procedure. Conclusions: Using an Ilizarov fixator to salvage nonunited septic posttraumatic ankle arthrodesis was effective, with patients reporting a stable ankle and dramatic functional improvement with minimal complications.

Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail with a valgus curve

Objective To investigate the clinical effects of tibiotalocalcaneal arthrodesis (TTCA) using a retrograde intramedullary nail with a valgus curve. Methods At our department, 22 patients underwent TTCA using a retrograde intramedullary nail with a valgus curve from June 2009 to January 2014 and were available for complete follow-up. They were 12 men and 10 women, aged from 46 to 79 years (average, 62.2 years). There were 3 cases of primary ankle osteoarthritis, 9 ones of traumatic arthritis, one of ankle arthritis secondary to severe talar avascular necrosis, 3 ones of progressive subtalar arthritis following failed ankle replacement, 5 ones of progressive subtalar arthritis following failed ankle arthrodesis, and one of arthritis secondary to equinovarus. The outcome measurements included the American Foot and Ankle Society (AOFAS) ankle-hindfoot scale, EQ-5DTM functional score, radiologic assessment and clinical examination. Results The mean follow-up was 21.3 months (range, from 14 to 38 months). A plantigrade foot and bony union were achieved in all the patients after a mean time of 3.9 months (range, from 2.4 to 6.2 months). Postoperative radiologic results showed a good hindfoot alignment in all the patients. Superficial infection oc-curred in one patient and loosening of the distal screw in another who asked for removal. The mean postop-erative EQ-5DTM functional score and AOFAS ankle-hindfoot score were 69.3 (range, from 20 to 90) and 69.9 (range, from 45 to 85), respectively. Conclusion TTCA using a retrograde curved intramedullary nail may lead to solid fusion and good hindfoot alignment. Key words: Foot deformities; Arthrodesis; Bone nail; Arthritis

A Retrospective Study

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure for end-stage pathology of the tibiotalar and subtalar joints including primary arthritis, severe deformity, failed total ankle arthroplasty, failed ankle arthrodesis with subsequent subtalar arthritis, talus avascular necrosis and Charcot arthropathy. Although many different fixation techniques of TTCA have been proposed, there is still no consensus gold standard fixation strategy. The various options include plate and screw constructs, intramedullary nails and external fixator systems. The purpose of this study is to report our experience with rigid fixation using a commercially available 4.5 mm locking plate for TTCA. Methods: We retrospectively reviewed the clinical charts and radiographs of 17 patients who underwent TTCA during the time period of 2012-2014. We used a lateral surgical approach with fibular osteotomy and a 4.5 mm Smith and Nephew™ PERI-LOC ankle fusion plate. Two senior foot and ankle surgeons at our institution performed all surgeries. The main outcomes were postoperative fusion rate and complication rate. Results: Of the 17 patients, 9 were male and 8 were female with a mean age of 53. 29% of patients had diabetes mellitus and 69% were either current or former smokers. The average BMI was 32.9. The average follow up was 17.7 months. The nonunion rate in our patient series was 76%. Nonunion was defined as no radiographic evidence of fusion at 6 months post-surgery. This failure rate is very high in comparison to historical data of nonunion rates in TTCA, which are often reported to be 7-26%. Only four out of 17 patients had a successful arthrodesis using this locked plate construct. Complications included nonunion, hardware failure (with screws and/or plate fracture), deep infection (35% of patients), and pseudoarthrosis. Conclusion: Too rigid of fixation with thick stainless steel plates and locking screw constructs can lead to failure in tibiotalocalcaneal arthrodesis. Increased nonunion rates due to overly rigid fixation has been demonstrated in many other contexts but never in the foot and ankle literature.

Primary vs. Revision Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: The current standard treatment for failed ankle arthrodesis is a revision ankle arthrodesis. However, there is limited literature addressing postoperative outcomes in patients with revision tibiotalar arthrodesis. The objectives of the retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary vs. revision tibiotalar arthrodesis. Methods: Between March 2002 and November 2014, 455 ankle arthrodeses were performed in our institution. There were 234 male and 221 female patients with a mean age of 55.6 ± 15.1 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.3 ± 21.3 kg (46-218), 172.8 ± 13.6 cm (147-208), and 30.2 ± 6.3 kg/m2 (18.9-61.7), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, allograft/autograft use, and use of bone morphogenic protein. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 38.3 ± 27.4 months (12.0-150.4). Results: There were 385 and 70 patients with primary and revision arthrodesis, respectively. Demographics and comorbidities were comparable in both groups. All revision surgeries were open procedures, while 63 of 385 primary ankle arthrodeses were performed arthroscopically. The most common main fixation type in patients with primary ankle arthrodesis was a screw construct, while plates were most common for revisions (P &lt; 0.001). The use of autograft was comparable in both groups (P = 0.886), however allograft was used more frequently in the revision arthrodesis group (P &lt; 0.001). The rate of osseous union was comparable in both groups with 90.4% and 91.4% in patients with primary and revision arthrodesis, respectively (P = 0.735). The complication rate was comparable in both groups. Conclusion: The osseous union rates and complication rates were comparable in both patient groups, with primary and revision ankle arthrodesis.

Primary vs. revision ankle arthrodesis: Comparison of fusion and complication rates

Category:Ankle ArthritisIntroduction/Purpose:The current standard treatment for failed ankle arthrodesis is a revision ankle arthrodesis. However, there is limited literature addressing postoperati...

Applications of the Medial Femoral Condyle Free Flap for Foot and Ankle Reconstruction

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology. A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months). There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively. Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest. Level IV, retrospective case series.

Successful treatment of nonunion with teriparatide after failed ankle arthrodesis for Charcot arthropathy

We describe a case of successful treatment to nonunion after multiple arthrodesis operations for Charcot arthropathy with teriparatide. We describe the case of a 25-year-old woman with severe Type I diabetes mellitus that resulted in nonunion after multiple arthrodesis operations for Charcot arthropathy. The woman sustained a femoral shaft fracture for which she underwent surgery with intramedullary nail fixation. Immediately after surgery, an empiric course of teriparatide was initiated. Femoral shaft fracture healing was observed after 2 weeks, and the woman was able to walk 12 weeks after the surgery, at which point plain film and computed tomography images revealed complete union of the ankle.

Tibiotalocalcaneal Arthrodesis With a Curved, Interlocking, Intramedullary Nail

Tibiotalocalcaneal fusion with a straight rod has a risk of damaging the lateral plantar neurovascular structures and may interfere with maintaining normal heel valgus position.We report the results of a prospective study of tibiotalocalcaneal (TTC) arthrodesis with a short, anatomically curved interlocking, intramedullary nail. Forty-five arthrodesis in 42 patients, performed between Jan 2003 and Oct 2008, were prospectively followed. The mean followup was 48 (range, 10 to 74) months. The main indications for the procedure were failed ankle arthrodesis with progressive subtalar arthritis, failed ankle arthroplasty and complex hindfoot deformity. The outcome was measured by a combination of pre and postoperative clinical examination, AOFAS hindfoot scores, SF-12 scores and radiological assessment. Union rate was 89% (40/45). Eighty-two percent (37/45) reported improvement in pain and 73% (33/45) had improved foot function. Satisfactory hindfoot alignment was achieved in 84% (38/45). Postoperatively there was a mean improvement in the AOFAS score of 37. Complications included a below knee amputation for persistent deep infection, five nonunions, and three delayed unions. Four nails, six proximal and six distal locking screws were removed for various causes. Other complications included two perioperative fractures, four superficial wound infections and one case of lateral plantar nerve irritation. With a short, anatomically curved intramedullary nail, we had a high rate of tibiotalocalcaneal fusion with minimal plantar neurovascular complications. We believe a short, curved intramedullary nail, with its more lateral entry point, helped maintain hindfoot alignment.

Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty

Pain following an ankle arthrodesis continues to be a challenging clinical problem. Recent reports on semiconstrained two-component ankle implants have demonstrated the feasibility of reversing a problematic ankle fusion and converting it to a total ankle arthroplasty. However, the failure rate is high. The objective of the present prospective study was to evaluate the intermediate-term outcome associated with the use of an unconstrained three-component ankle implant after taking down an ankle arthrodesis. Thirty painful ankles in twenty-eight patients (average age, 58.2 years) who were managed with takedown of a fusion and total ankle arthroplasty were followed for a minimum of thirty-six months (average, 55.6 months). The outcome was assessed on the basis of clinical and radiographic evaluations. In twenty-nine ankles in twenty-seven patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 34.1 preoperatively to 70.6 at the time of the latest follow-up. Twenty-four patients (82.7%) were satisfied with the results. While five ankles were completely pain-free, twenty-one ankles were moderately painful, and three remained painful. The average clinically measured range of motion of 24.3 degrees amounted to 55.1% of that of the contralateral, unaffected ankle. Radiographically, the tibial component was stable in all ankles but one. The talar component was found to have migrated in four ankles but was asymptomatic in two of them. One ankle had to be revised to a tibiocalcaneal arthrodesis because of persistent pain and loosening of the talar component. For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. Key factors for the success of this procedure may be the intrinsic coronal plane stability provided by the ankle implants and the use of wider talar implants.

Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty

Pain following an ankle arthrodesis continues to be a challenging clinical problem. Recent reports on semiconstrained two-component ankle implants have demonstrated the feasibility of reversing a problematic ankle fusion and converting it to a total ankle arthroplasty. However, the failure rate is high. The objective of the present prospective study was to evaluate the intermediate-term outcome associated with the use of an unconstrained three-component ankle implant after taking down an ankle arthrodesis.Thirty painful ankles in twenty-eight patients (average age, 58.2 years) who were managed with takedown of a fusion and total ankle arthroplasty were followed for a minimum of thirty-six months (average, 55.6 months). The outcome was assessed on the basis of clinical and radiographic evaluations.In twenty-nine ankles in twenty-seven patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 34.1 preoperatively to 70.6 at the time of the latest follow-up. Twenty-four patients (82.7%) were satisfied with the results. While five ankles were completely pain-free, twenty-one ankles were moderately painful, and three remained painful. The average clinically measured range of motion of 24.3 degrees amounted to 55.1% of that of the contralateral, unaffected ankle. Radiographically, the tibial component was stable in all ankles but one. The talar component was found to have migrated in four ankles but was asymptomatic in two of them. One ankle had to be revised to a tibiocalcaneal arthrodesis because of persistent pain and loosening of the talar component.For patients with pain at the site of a failed ankle arthrodesis, conversion to total ankle arthroplasty with the use of a three-component ankle implant is a viable treatment option that provides reliable intermediate-term results. Key factors for the success of this procedure may be the intrinsic coronal plane stability provided by the ankle implants and the use of wider talar implants.

Takedown of ankle fusion and conversion to total ankle replacement.

The painful ankle arthrodesis is an unsolved clinical problem. In many cases, transtibial amputation may be the best option for functional recovery. Recent reports of early success with second generation ankle implants show takedown of the problematic ankle fusion and conversion to total ankle arthroplasty may be an alternative to amputation. This study is a retrospective review of 23 ankles in 22 patients scheduled to have this procedure. Four patients were lost to followup, leaving 19 ankles in 18 patients at an average followup of 39 months. Three patients chose to have an amputation because of continued pain. In the remaining 16 ankles, the mean AOFAS ankle-hind foot outcome score improved from 42-68. Patients who had a clear source of pain with the ankle arthrodesis (such as subtalar arthrosis) had a better result than patients without a clear source of pain. All the patients who had the lateral malleolus resected during previous arthrodesis had complicated courses after arthroplasty. For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation.

Revision of ankle arthrodesis.

From 1989 to 1996, we treated 18 cases (10 males, eight females; average age 48.2 years) of failed ankle arthrodesis by revision of ankle arthrodesis and followed their progress for at least two years. The average time interval between original surgery and revision was 17.3 months. Revisions were needed due to infection in one case, nonunion in 10 cases, and malalignment in seven cases. The salvage operations included debridement in the infected case, refreshed pseudoarthrosis in nonunion cases, and corrective osteotomy in malalignment cases. Sixteen cases were fixed by crossed screws with internal compression, one infected case was fixed by an external fixator, and one case with bone loss was fixed with buttress plate. The average follow-up period was 40.4 months. There was one nonunion and two delayed unions, with an ultimate fusion rate of 94%. The average AOFAS ankle-hindfoot score was 70.9 at final follow up. There was one excellent result (5.6%), five good results (27.8%), 11 fair results (61%), and one poor result (5.6%), and the overall results were poorer compared with our series of primary arthrodesis. The time to fusion also took longer in the revision cases (average 2.7 months in primary cases and 4.8 months in revision cases). Fusion techniques that ensure solid union in a functional position are essential. If an ankle arthrodesis fails, however, revision is a salvage procedure that can achieve an acceptable result.

Optimal insertion site for intramedullary nails during combined ankle and subtalar arthrodesis

Combined fusion of the ankle and subtalar joints with the insertion of an intramedullary nail from a plantar approach is used as a salvage procedure in certain conditions. These include severe arthritis of the two joints simultaneously, avascular necrosis of the talus, failed ankle arthrodesis, gross ankle or subtalar deformity and unstable ankle fractures. An anatomic study was carried out to ascertain the optimal insertion site for such a nail. Entry sites were made through the heels of six cadaveric limbs which were then dissected to determine any damage to neurovascular structures. The optimal insertion site was found to be lateral to the midline of the heel in order to avoid damage to the lateral plantar artery and nerve. This may mean that a curved rather than a straight nail is more suitable for this procedure.

Ankle arthrodesis with cross screw fixation. Good results in 36/40 cases followed 3-7 years.

Tibiotalar arthrodesis by an anterior approach, using internal compression with cancellous crews, offers wide exposure, good possibilities of correcting deformities, and good bony apposition. From 1987 to 1991, we used this technique in 42 ankle joints (40 patients). The indications were posttraumatic arthrosis, sequelae of septic arthritis, necrosis of the talus and failed ankle arthrodesis. In 13 ankles with severe deformity, a bone graft was also used. 38 patients (40 ankle joints) were available for follow-up after 4 (3-7) years. Solid union was achieved in 38 ankles after an average of 13 weeks. The clinical result was good-to-excellent in 36 ankles. We conclude tha this is a simple and effective method for ankle arthrodesis in both low-risk and, coupled with bone grafting, in properly selected high-risk patients.

Arthrodesis of the Ankle with Lateral Plating

A modification of internal fixation compression arthrodesis for ankle fusion is described using two 6.5-mm cancellous bone screws and a lateral T plate. Using this technique, 20 consecutive arthrodeses by one surgeon were reviewed. Solid union was attained in 19 of 20 patients (95%). Average follow-up was 18 months (range 6-59 months). Time to obtain solid arthrodeses averaged 18 weeks. In 11 patients who returned for follow-up, clinical grading using the Mazur scale score averaged 70 of 90 points. Diagnoses included posttraumatic degenerative arthritis, failed ankle arthrodesis and rheumatoid arthritis (2 each), failed ankle arthroplasty, and post-tuberculous arthritis (1 each). Complications included one malunion and one asymptomatic screw malposition. All patients attaining union were pleased with the procedure.

The Ilizarov Technique in Ankle Fusion

Failed ankle arthrodesis represents a significant challenge to the orthopaedist today. The complexity of this problem is further increased when associated with additional complications, such as osteomyelitis, leg length discrepancy, or concomitant foot deformity. In many instances, the only viable salvage alternative is amputation. The authors report 21 cases of complex distal tibial pathology or failed ankle arthrodesis treated with the Ilizarov external fixator. Of the 20 cases available for follow-up evaluation, 16 (80%) achieved good results with solid ankle arthrodesis and resolution of associated pathology. The Ilizarov fixator may be a viable clinical tool in these difficult cases in which amputation is the alternative.