Tibiotalar Arthrodesis Research Articles

Tibiotarsal compression arthrodesis using a lateral locking plate

OBJECTIVES: Tibiotalar (TT) arthrodesis is still a very important option in the treatment of primary or post-traumatic arthritis of the ankle but persists the controversy regarding the optimal method for the fixation of the arthrodesis site. No matter the implant used, the goal is to obtain a solid, healthy, pain-free fusion. The purpose of the current study is to present the preliminary results of a novel laterally based tibiotalar compression arthrodesis system using a locked plate. METHODS: Thirteen consecutive patients with tibiotalar arthritis were submitted to an arthrodesis using a new lateral plating system. The average age was 59.7 years (range 36~72); nine patients were male and four female. Using a cutting guide, the remaining articular surfaces of the tibia and talus were removed. A compression device was applied to avoid malalignment of the ankle and a precontoured lateral locking plate was used to achieve the joint fusion. RESULTS: Both the AOFAS ankle-hindfoot score and the VAS score improved with the surgery. All patients' ankles fused by 6 months. In all patients we found a very good alignment in the sagittal, coronal and transverse planes. CONCLUSION: We believe that a combination of a bilateral compression, contoured bony cuts, and lateral locked plating offers a novel, accurate and useful technique for ankle arthrodesis.

TIBIOTARSAL COMPRESSION ARTHRODESIS USING A LATERAL LOCKING PLATE

Objectives: Tibiotalar (TT) arthrodesis is still a very important option in the treatment of primary or post-traumatic arthritis of the ankle but persists the controversy regarding the optimal method for the fixation of the arthrodesis site. No matter the implant used, the goal is to obtain a solid, healthy, pain-free fusion. The purpose of the current study is to present the preliminary results of a novel laterally based tibiotalar compression arthrodesis system using a locked plate. Methods: Thirteen consecutive patients with tibiotalar arthritis were submitted to an arthrodesis using a new lateral plating system. The average age was 59.7 years (range 36~72); nine patients were male and four female. Using a cutting guide, the remaining articular surfaces of the tibia and talus were removed. A compression device was applied to avoid malalignment of the ankle and a precontoured lateral locking plate was used to achieve the joint fusion. Results: Both the AOFAS ankle-hindfoot score and the VAS score improved with the surgery. All patients’ ankles fused by 6 months. In all patients we found a very good alignment in the sagittal, coronal and transverse planes. Conclusion: We believe that a combination of a bilateral compression, contoured bony cuts, and lateral locked plating offers a novel, accurate and useful technique for ankle arthrodesis.

Spontaneous tibiotalar arthrodesis as a complication of acute tibial osteomyelitis due to Panton-Valentine leukocidin-producing Staphylococcus aureus: a case report

IntroductionStrains of Panton-Valentine leukocidin-producing Staphylococcus aureus producing a new pattern of disease have emerged worldwide. Infection with these bacteria typically presents as a life-threatening infection of soft tissues and bones, and may cause potentially devastating consequences.Case presentationWe report a case of osteoarticular infection caused by Panton-Valentine leukocidin-producing Staphylococcus aureus. A 12-year-old Caucasian girl presented with acute osteomyelitis of the tibia associated with toxic shock syndrome, which was complicated by an unexpected spontaneous ankle arthrodesis.ConclusionsOsteoarticular infections due to Panton-Valentine leukocidin-producing Staphylococcus aureus appear to be severe, and are characterized by their tendency to evolve towards serious complications. This case highlights the need for early and aggressive surgical procedures in conjunction with appropriate antimicrobial therapy and regular long-term follow-up.

Moving on with the Distraction

Commentary The surgical treatment of severe ankle arthritis continues to be challenging and somewhat controversial. Although ankle arthrodesis is thought to be the “gold standard,” this procedure definitely carries with it the risk of hindfoot arthroses on radiographs with the passage of time1. Interest in ankle replacement has increased in recent years, but studies have shown a relatively high rate of revision arthroplasty at the time of early follow-up2. The surgical treatment of degenerative joint disease of the ankle becomes even more taxing for younger patients. The risk of adjacent-joint arthritis will definitely increase with the passage of time after a tibiotalar arthrodesis. Similarly, the risk of requiring a repeat surgical procedure will increase when an ankle replacement is implanted into a younger patient. Thus, clinicians continue to search for other “joint-sparing” surgical modalities to help to effectively treat ankle arthritis, such as realignment osteotomies, allograft ankle reconstructions, and distraction arthroplasty. The article by Dr. Saltzman et al. is a welcome and important contribution to the literature. It meets the rigid criteria for a prospective, randomized trial, and the authors should be congratulated for their diligence. Their inclusion criterion of selecting patients under the age of sixty years is also important as most clinicians would perform either an ankle arthrodesis or a total ankle replacement in patients with severe ankle arthritis over the age of sixty years. This report also serves to validate many of the European studies on the efficacy of distraction arthroplasty and shows the importance of motion when this technique is used3. One of the concerns about this study, duly acknowledged by the authors, is the relatively “short” follow-up of two years for this patient population. This procedure is not for patients (or clinicians) who are looking for a simple and fast solution. This type of surgical treatment requires a substantial commitment on the part of both the patient and the clinician. In fact, patients in this study had the external fixator in place for approximately three months and did not progress toward full weight-bearing without support until six months. Therefore, it would be very interesting to see if these results continue to improve with time, say, at five or ten years, or begin to wane. With that important information, it would be easier for patients to make the decision to proceed with the lengthy treatment protocol associated with distraction arthroplasty. Also, although outcome information is the priority in this article, the mechanism by which distraction arthroplasty actually works is still largely conjectural4. Nevertheless, this article does provide important information and support for distraction ankle arthroplasty. It also serves to cultivate interest in joint-sparing procedures for ankle arthritis. Hopefully, further studies with longer follow-up will show us how distraction arthroplasty with motion can truly “buy us time” in the treatment of our younger patients who have severe ankle arthritis.

Comparative analysis of uniplanar external fixator and retrograde intramedullary nailing for ankle arthrodesis in diabetic Charcot’s neuroarthropathy

Background:Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. This is a retrospective nonrandomized comparative study assessing the outcomes of tibio-talar arthrodesis for Charcot's neuroarthropathy treated by uniplanar external fixation assisted by external immobilization or retrograde intramedullary interlocked nailing.Materials and Methods:Records of the authors′ institution were reviewed to identify those patients who had undergone ankle fusion for diabetic neuroarthropathy from January 1998 to December 2008. A total of11 patients (six males and five females) with a mean age of 56 year and diabetes of a mean duration of 15.4 years with ankle tibio-talar arthrodesis using retrograde nailing or external fixator for Charcot's neuroarthropathy were enrolled for the analysis. Neuropathy was clinically diagnosed, documented and substantiated using the monofilament test. All procedures were performed in Eichenholz stage II/III.Six patients were treated with uniplanar external fixator, while the remaining five underwent retrograde intramedullary interlocking nail. The outcomes were measured for union radiologically, development of complications and clinical follow-up, according to digital archiving systems and old case notes.Results:All five (100%) patients treated by intramedullary nailing achieved radiological union on an average follow-up of 16 weeks. The external fixation group had significantly higher rate of complications with one amputation, four non unions (66.7%) and a delayed union which went on to full osseous union.Conclusion:The retrograde intramedullary nailing for tibio-talar arthrodesis in Charcot's neuroarthropathy yielded significantly better outcomes as compared to the use of uniplanar external fixator.

Surgical Reconstruction of a Crush Injury of the Talar Body

Fractures of the talar body can have devastating results despite treatment. While talar body fractures are uncommon, they have worse outcomes than do other fractures of the talus, including more osteonecrosis and posttraumatic arthritis1,2. Crush injuries are the most difficult to treat as a result of a very constrained anatomy, the comminution of the fracture fragments, and articular cartilage damage. These fractures are challenging to reconstruct and stabilize and often have poor outcomes3. Conservative treatment does not appear to be better than operative treatment for talar body fractures4. For crush injuries, very aggressive techniques such as primary fusion of the talocrural joint, primary tibiotalar arthrodesis and subtalar arthrodesis, and salvage ankle fusion techniques with structural bone blocks are usually used3,5,6. There have been isolated reports of surgical treatment for crush injuries of the talar body with open reduction and internal fixation; however, these procedures either have had unsatisfactory outcomes2 or were used when there was comminution of only part of the talar dome7. It is generally accepted that severe crush fractures cannot be treated satisfactorily with open reduction and fixation5,8. We describe a case of a severely comminuted talar body and neck fracture treated effectively with surgical reconstruction with a satisfactory result. The patient gave permission for this information to be submitted for publication. A twenty-three-year-old man injured the right ankle in a high-speed motorcycle accident. At the time of admission, the patient had local swelling and varus deformity of the ankle, severe pain, and an inability to actively and passively move the ankle and subtalar joints. He had no neurovascular deficit, tension of the surrounding soft tissue was noted, and there was no open skin lesion. Anteroposterior and …

Plantar pressure distribution after tibiotalar arthrodesis

Introduction Arthrodesis is a well-established treatment option for end-stage osteoarthritis of the ankle. Osteoarthritis of the ankle can alter plantar pressure distribution. However, surprisingly little is known about the effect of ankle arthrodesis to alter plantar pressure distribution. The purpose of this study was to determine plantar pressure distribution in a selected group of patients with unilateral arthrodesis of the ankle joint. Methods 20 patients with an average age of 60 years who underwent isolated unilateral ankle arthrodesis using a 3-crossed screw technique by a single surgeon were included. After a mean of 25 months (range 12–75 months) post surgery plantar pressure distribution was determined in five regions of the foot. The outcome was evaluated clinically, using the American Orthopaedic Foot and Ankle Society hindfoot score, as well as radiographically. The contralateral normal foot was used as a control. Findings Comparing the foot that underwent tibiotalar arthrodesis to the contralateral normal foot, differences were found in the peak pressure and maximum force in the toe region and the lateral midfoot region. In addition, a decrease in the contact time in the forefoot region and a decrease of the contact area in the toe region of the operated foot were identified. The other regions did not show a significant difference. The mean American Orthopaedic Foot and Ankle Society score of the operated leg was 79 (range 46–92) at the last follow up, and the mean fixation angle of the arthrodesis on lateral weight bearing radiographs was 90° (range 86°–100°). Interpretation Our results indicate that arthrodesis of the ankle joint can provide high levels of function with minimal changes in the plantar pressure distribution.

Tibiotalar arthrodesis by distraction osteogenesis with a circular external fixator over an intramedullary nail

Tibiotalar arthrodesis by distraction osteogenesis with a circular external fixator over an intramedullary nail

Arthrodesis with Internal Fixation of the Infected Ankle

Arthrodesis may be necessary to avoid amputation when treating an infected tibiotalar joint. In such cases, external or hybrid fixation is usually used. In this retrospective study, we report our experience in treating tibiotalar joint infection by arthrodesis with internal fixation. From March 1992 to October 2005 (13 years, 7 months), 20 patients underwent septic ankle arthrodesis with internal fixation. The mean duration of infection before fusion was 2.5 ± 6.7 years. Arthrodesis was performed with the Méary technique in 9 (45%) cases and with the Crawford-Adams technique in 11 (55%) cases. Internal fixation consisted of screw fixation, staple fixation, or a combination of both. The mean duration of antibiotic treatment was 97.5 ± 37.5 days, and the mean follow-up was 64 ± 36 months, with no patient lost to follow-up. Patients were considered cured if no clinical, biological, or radiologic signs of infection were present at a minimum of 2 years follow-up. The incidence of cure was 85.0% (91.0% with Crawford-Adams and 77.8% with Méary techniques). Radiographic fusion was identified in 89.5% of the cases (91.0% with Crawford-Adams and 87.5% with Méary techniques) at a mean of 4.8 ± 2.4 (range 3 to 11) months postoperative. Tibiotalar arthrodesis in the presence of sepsis can be performed with internal osteosynthesis only under certain conditions. In our experience, this treatment produced satisfactory fusion in 89.5% of patients and eradicated infection in 85.0% of cases.

Die Arthrodese des Sprunggelenks in Infektsituationen: Ergebnisse mit dem Ilizarov-Ringfixateur

The treatment of severe bacterial infections of the ankle joint is difficult and complex. In the case of a chronic infection with destruction of the ankle joint, a tibiotalar arthrodesis with external fixation is the treatment of choice. In this study the results of ankle arthrodesis due to bacterial infection using the Ilizarov external fixator are presented. Between 2001 and 2004 37 patients (10 female, 27 male, mean age 58 years) were treated with a tibiotalar arthrodesis using the Ilizarov fixator. All patients had a confirmed infection in the course of their disease. Active infection was present in 20 patients at the time of the operation. Most secondary ankle arthritides (81 %) were caused post-traumatically after various internal fixation procedures. Previous ankle arthrodeses were tried in 14 cases (12 cases with internal fixation, two cases with external monolateral fixation). Patients were treated with a four-ring Ilizarov frame (in two cases with a five-ring frame) and stainless steel wires. All patients could be included at a mean follow-up of 46 (12-49) months. A modified AOFAS score was used for the functional outcome. The operation took 141 minutes at an average ranging from 90 to 252 minutes. The inpatient treatment lasted between 10 and 63 days (mean 26 days). The time spent in the fixator was 116.7 (69-245) days. All patients were mobilised under full weight bearing with the external fixator. Surgical revision was necessary in 13 patients: four patients needed wound revisions due to ongoing infection, six patients needed wire exchange due to deep infection in three cases and wire breakage in three cases, one patient needed additional wires because of an initially instable frame configuration and two patients needed secondary skin grafting. Bony consolidation was achieved in 32 patients (86.5 %). With a re-arthrodesis performed in four patients using the Ilizarov fixator, the overall fusion rate was 94.6 %. Infection was persistent in two cases with one solid ankle fusion and one ankle pseudarthrosis. At the time of follow-up 35 patients were able to walk under full weight loading with orthopaedic shoe modifications, four patients needed support of a cane and three patients wore an ankle-foot orthesis. The two patients with persistent pseudarthrosis were mobilised in a lower-leg orthesis after declining another surgical revision. The positioning of the hindfoot showed in seven cases an equinus of 10°, in one case a varus of 10° and in two cases a valgus positioning of 10°. A plantigrade foot positioning or with minimal degrees of deviation could be achieved in all other cases. The modified AOFAS score at the time of the follow-up examination ranged from 19 to 86 with an average score of 67.9 points. All patients except three were satisfied or rather satisfied with the treatment procedure and its results. The Ilizarov external fixator is a safe method for ankle fusion in cases of infection. The advances are a possible application at acute infection and immediate mobilisation at full weight bearing. However, it remains a time-consuming and stressful procedure for the patient.

Metabolic cost and mechanical work during walking after tibiotalar arthrodesis and the influence of footwear

Background This study examined metabolic energy cost and external mechanical work for step-to-step transitions after tibiotalar arthrodesis, and the effect of MBT rocker bottom shoes. Methods Oxygen uptake, forceplate and kinematic data were recorded in 18 controls and 15 patients while walking at a fixed speed of 1.25 m/s in three walking conditions: barefoot, normal walking shoes and MBT rocker bottom shoes. Metabolic energy cost, external mechanical work, and the roll-over shape of the ankle–foot complex were analyzed. Findings Tibiotalar arthrodesis leads to higher metabolic energy cost during walking. During step-to-step transitions positive work during push-off with the impaired ankle was decreased but negative work during collision was not affected. The roll-over shape of the ankle–foot complex did not differ between groups and shoe conditions. However, both in patients and controls rocker bottom shoes did lead to decreased positive work at push-off and increased negative work at collision and consequently higher metabolic energy cost of walking. Interpretation External mechanical work for step-to-step transitions is not different between patients and controls and could not account for the higher metabolic energy cost in patients. Apparently, patients adopt a different walking strategy that limits step-to-step transition cost but nevertheless induces a higher metabolic energy cost. Despite restricted ankle movement, patients retain a normal roll-over shape of the ankle–foot complex. MBT shoes do not affect roll-over shape and appear to have a counterproductive effect on step-to-step transition cost and walking economy.

Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery

Ankle arthrodesis is commonly used for the treatment of osteoarthritis or failed arthroplasty. Screw fixation is the predominant technique to perform ankle arthrodesis. Due to a considerable frequency of failures research suggests the use of an anatomically shaped anterior double plate system as a reliable method for isolated tibiotalar arthrodesis. The purpose of the present biomechanical study was to compare two groups of ankle fusion constructs – three screw fixation and an anterior double plate system – in terms of primary stability and stiffness.Six matched-pairs human cadaveric lower legs (Thiel fixated) were used in this study. One specimen from each pair was randomly assigned to be stabilized with the anterior double plate system and the other with the three-screw technique. The different arthrodesis methods were tested by dorsiflexing the foot until failure of the system, defined as rotation of the talus relative to the tibia in the sagittal plane. Experiments were performed on a universal materials testing machine. The force required to make arthrodesis fail was documented. For calculation of the stiffness, a linear regression was fitted to the force–displacement curve in the linear portion of the curve and its slope taken as the stiffness.For the anatomically shaped double-plate system a mean load of 967 N was needed (range from 570 N to 1400 N) to make arthrodesis fail. The three-screw fixation method resisted a mean load of 190 N (range from 100 N to 280 N) (p = 0.005). In terms of stiffness a mean of 56 N/mm (range from 35 N/mm to 79 N/mm) was achieved for the anatomically shaped double-plate system whereas a mean of 10 N/mm (range from 6 N/mm to 18 N/mm) was achieved for the three-screw fixation method (p = 0.004).Our biomechanical data demonstrates that the anterior double-plate system is significantly superior to the three-screw fixation technique for ankle arthrodesis in terms of primary stability and stiffness.

Tibiocalcaneal arthrodesis: a new arthroscopic procedure

Tibiocalcaneal arthrodesis is considered an aggressive and technically demanding procedure that can be used to treat severe deformities of the hindfoot, and it is rarely performed. The indications for ankle arthroscopy are increasing, and arthroscopic tibiotalar arthrodesis is a common and successful procedure, but arthroscopic tibiocalcaneal arthrodesis has not been previously reported in the literature. A case of extensive talus necrosis with severe hindfoot deformity treated by means of an arthroscopic tibiocalcaneal arthrodesis is presented.

Anterior Double Plating for Rigid Fixation of Isolated Tibiotalar Arthrodesis

Arthrodesis is the most common procedure used to treat end-stage osteoarthritis of the ankle, particularly in patients with difficult conditions such as poor bone quality. While many techniques are available to fuse the ankle, current recommendations favor the use of internal fixation with screws and/or plates. Despite of progress, the complication rate remains a major concern. Non-union is one difficult problem especially with difficult bone conditions, particularly the loss of bone stock on the talar side. Therefore, fusion of the tibiotalar joint is often extended to the talocalcaneal joint to provide sufficient stability. To preserve the subtalar joint, an anterior double plate system for rigid fixation of isolated tibiotalar arthrodesis was developed. This is a preliminary report on the clinical and radiological outcome with this technique. Twenty-nine patients (15 men, 14 women; one ankle per patient) were treated from October 2006 to September 2007. We converted 16 ankles with osteoarthritis and difficult bone conditions, four non-united ankle arthrodeses, and nine failed total ankle replacements to an isolated tibiotalar arthrodesis using anterior double plating. If necessary, we used solid allograft to fill bony defects. Outcomes included bone union as assessed by radiographs, pain as indicated by the American Orthopaedic Foot and Ankle Society scores, and patient satisfaction. Solid arthrodesis was achieved after an average of 12.3 (eight to 26) weeks in the 16 ankles without bone graft interposed between the tibia and talus, and 14.3 (range, 8 to 26) weeks in the 13 ankles with interpositional bone allograft. Radiographs showed that the position of arthrodesis obtained at the time of surgery did not change in any patient up to one year after surgery. The mean American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score increased from 37 (range, 20 to 63) preoperatively to 68 (range, 50 to 92) at the last followup. Twenty-seven patients (93%) were satisfied with their outcome and indicated they would have the operation again. No complications were noted. The anterior double plating system was shown be a reliable method to achieve solid isolated tibiotalar arthrodesis, even in ankles with difficult conditions such as loss of bone stock due to failed total ankle arthroplasty.

Ankle Fusion for Definitive Management of Non-Reconstructable Pilon Fractures

Highly comminuted pilon fractures, especially with a compromised soft tissue envelope, present a challenging treatment scenario. This study presents our results for patients managed with ankle fusion rather than ORIF. Fourteen patients with ankle joint incongruence after non-reconstructable tibia pilon fractures were treated with primary tibiotalar arthrodesis using a fixed-angle cannulated blade plate. Delayed metaphyseal unions due to bone defects were treated concurrently. The subtalar joint was preserved in all cases. Metaphyseal healing and stable arthrodesis was obtained in each case. There was one case of blade plate breakage in a patient who still achieved successful arthrodesis without reoperation. Union was achieved at an average of 15 weeks. No secondary procedures were required to obtain union. All 14 patients were ambulatory at last followup. Average followup was 39 weeks. Primary ankle arthrodesis can be achieved using a cannulated blade plate to address a non-reconstructable articular surface and metaphyseal bone defects in complex tibia pilon fractures.

Ankle fractures in diabetic neuropathic arthropathy

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.

Revision Tibiotalar Arthrodesis

Contemporary recommendations for primary and revision ankle arthrodesis favor internal compression techniques involving the use of screw and/or plate fixation. While tibiotalocalcaneal arthrodesis with internal fixation may be a suitable method of salvage for the treatment of a failed tibiotalar arthrodesis in selected patients, ring external fixation has been reported as an alternative. We reviewed our experience with revision tibiotalar arthrodesis, with a focus on ring external fixation. Forty-five consecutive patients underwent revision tibiotalar arthrodesis with use of repeat internal fixation (eleven patients), ring external fixation (twenty-two patients), or tibiotalocalcaneal arthrodesis (twelve patients). Union rates were assessed radiographically, and functional outcome was determined with use of preoperative and postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scores. All forty-five patients were available for follow-up at an average of 50.3 months. The average ankle-hindfoot score improved from 31.1 points preoperatively to 65.8 points at the time of the most recent follow-up. At the time of the most recent follow-up, the union rate was 88.9% (forty of forty-five). Fusion was achieved with revision tibiotalar arthrodesis in thirty-six (80%) of forty-five patients, including eight of the eleven patients in the repeat internal fixation group, nineteen of the twenty-two patients in the ring external fixation group, and nine of the twelve patients in the tibiotalocalcaneal arthrodesis group. Re-revision led to union in four of five patients. The overall union rate for ring external fixation, including revision and re-revision tibiotalar arthrodeses, was 84.6% (twenty-two of twenty-six). The five patients with persistent nonunion following revision ankle arthrodesis opted for transtibial amputation. Revision tibiotalar arthrodesis leads to satisfactory limb salvage in a majority of patients. Ring external fixation may facilitate clinically acceptable limb salvage in complex cases when methods of internal fixation are limited or even contraindicated.

Tibiotalar arthrodesis for injuries of the talus

Background:Fracture-dislocation of the talus is one of the most severe injuries of the ankle. Opinion varies widely as to the proper treatment of this injury. Since Blair's original description of the tibiotalar fusion in 1943, there is little mention in the literature of his method. The present study reports the results of tibiotalar arthrodesis with modification in Blair's technique.Materials and Methods:Eleven cases of modified Blair's tibiotalar arthrodesis were retrospectively studied. The average age was 32.4 years (range, 26-51 years). Six patients had posttraumatic avascular necrosis; five had neglected fracture-dislocation of the talus.Results:The mean followup is 8 years (range 3-12 years). Tibiotalar fusion was achieved in all the ankles at an average of 20.5 weeks (range 16-28 weeks). Nine cases having 15°-20° tibiopedal motion had excellent results and two ankles having 10°-15° of tibiopedal motion had good result.Conclusion:We achieved good long term results with tibiotalar arthrodesis with modification in Blair technique. The principal modification in the present study is retention of the talar body while performing arthrodesis with anterior sliding graft. The retention of the talar body provides intraoperative stability and in the long term, the retained talar body shares the load transmitted to the anterior and middle subtalar joints thus resulting in improved hind foot function and gait.

Treatment of Recalcitrant Distal Tibial Nonunion Using the Descending Genicular Corticoperiosteal Free Flap

Recalcitrant nonunions of the distal tibia without bone defect are severe problems whose treatment is difficult. Stable internal fixation and osteogenetic enhancement are required. The thin corticoperiosteal flap based on the descending genicular artery has been previously described to treat nonunions in the upper extremity without bone defect. The use of this flap to treat distal tibial nonunions is reported in the present article. Twenty-five patients with recalcitrant nonunion of the distal tibial metaphysis without segmental bone defect or evidence of infection were treated with revision of the internal fixation and a corticoperiosteal free flap from the medial condyle of the femur. The number of previous surgical procedures was two to five. The flaps were compound, including muscle or fat, for wound coverage in seven cases. All compound flaps survived. Bony union was achieved in all cases, with bone formation at the nonunion site by the fourth month in all cases but one. In this case bone union took 7 months. Donor morbidity was negligible. Two tibiotalar arthrodeses were performed secondarily for posttraumatic osteoarthritis. Treatment of recalcitrant distal tibial nonunions without bone defect with removal of previous hardware, stable internal fixation, and free corticoperiosteal flap transfer is safe and effective in noninfected cases.

Tibiotalar Arthrodesis Using a Custom Blade Plate

The purpose of this study was to evaluate the clinical and radiographic outcomes of patients who underwent tibiotalar arthrodesis between 1997 and 2003 for tibiotalar arthritis. The cause was predominantly posttraumatic arthritis secondary to tibial plafond fracture (n = 15) or talar body fracture (n = 2). We retrospectively evaluated a consecutive series of 20 patients with 21 arthritic tibiotalar joints. Radiographs, clinical notes, scheduled visits, and telephone interviews were used to obtain outcome data after tibiotalar arthrodesis using a custom blade plate. The American Orthopedic Foot and Ankle Society Ankle Hindfoot Score quantified clinical outcomes in this study. Sixteen patients with 17 ankle arthrodeses were available after a mean follow-up period of 37.3 months. There were no postoperative wound complications or infections. There were no nonunions identified within the study. The mean American Orthopedic Foot and Ankle Society Ankle Hindfoot Score was 78.25 (range, 65-92). The average time to fusion was 3.9 months. Tibiotalar arthrodesis using a custom blade plate and a lateral approach is a reliable therapy for aseptic posttraumatic arthritis.