Transfibular Approach Research Articles

Survival and complications of transfibular trabecular metal total ankle replacement − A systematic review

BackgroundIn the past decade, the transfibular approach to Total Ankle Replacement (TAR) has emerged as an alternative to anterior approach with reduced bone resection. The purpose of this systematic review is to report survival, complications, and reoperation rates of transfibular TAR. MethodsWe conducted a systematic search of studies that evaluated complications, reoperations, and survival of transfibular TAR following PRISMA guidelines across PubMed, Scopus and Web of Science. ResultsOur review included data from 12 cohorts, comprising 919 patients across 7 countries, with an average age of 62 years (59% posttraumatic). Over an average follow-up period of 3 years, adverse events occurred in 23% of cases, with 18% requiring surgical reintervention, mostly due to hardware removal. The survival rate of the transfibular TAR metal components was 97% at the final follow-up. ConclusionTransfibular TAR demonstrates a 97% survival rate at a 3-year follow-up. Level of evidenceLevel II

Ankle arthrodesis through minimally-invasive transfibular approach: a new surgical technique.

The purpose of our work was to demonstrate the surgical technique of ankle arthrodesis using the minimally-invasive transfibular (MITF) approach, which minimizes soft tissue damage and is advantageous for high-risk patients. In this prospective study, a total of 12 patients with end-stage varus ankle osteoarthritis, including high-risk individuals, underwent ankle arthrodesis using the MITF approach. The technique involves a unique osteotomy at the joint space level, minimizing soft tissue detachment from the fibula. The primary outcomes assessed included bony union, time to weight-bearing, correction of varus deformity, and functional outcomes measured by the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale. However, the study's limitations encompass a small sample size and the absence of a control group. At 6months post-operation, all patients achieved bony union, with a mean time to union of 13.7 ± 5.2weeks. The average time to initiate weight-bearing without additional support was 11.2 ± 3.8weeks. Preoperative varus deformity (17.08 ± 8.36 degrees) and talar tilt (8.75 ± 4.33 degrees) were successfully corrected, with postoperative alignment within 0-5 degrees of valgus. Functional outcomes showed a significant improvement in AOFAS scores from 37.83 ± 7.79 points preoperatively to 77.42 ± 5.63 points one year after surgery (p = 0.002). Minor complications occurred in two patients, both effectively treated with local therapy and antibiotics. The MITF approach for ankle arthrodesis demonstrates promising results in addressing end-stage varus ankle osteoarthritis, even in high-risk patients. However, the study's limitations highlight the need for a prospective comparative clinical trial with a larger sample size to ascertain the technique's effectiveness and safety definitively.

Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n=41). The mean age was 59 (range=39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range=14-46) to 80 (range=60-100) (p < .01) and VAS from 7.8 (range=6.1-9.7) to 1.3 (range=0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

Transfibular ankle arthrodesis with use of sagitally split fibula as a biological plate leads to excellent outcome: A retrospective analysis

BackgroundWe studied ankle arthrodesis with a transfibular approach using sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting) to achieve bony union. Material and methodsRetrospective clinico-radiological evaluation of 36 operated cases was done at 3, 6, 12 and 30 months follow-ups. Clinically union was considered once ankle became pain free on full weight bearing. Pain assessment was done by using VAS (visual analogue scale) score and functional evaluation was done by AOFAS (American Orthopaedic Foot & Ankle Society) hind foot score preoperatively and at different follow ups. Radiologically, sagittal plane ankle alignment and fusion status was determined at each follow up. ResultsMean age of patients was 40.36 ± 10.56 years (range 18–55), who were evaluated for mean duration of 33.32 ± 11.25 months (range 24–65). Thirty-three (91.7%) ankles were fused adequately and mean duration to achieve bony union was 5.09 ± 1.3 months (range 4–9 months). Mean post-operative AOFAS score at final follow up was 76.65 ± 4.87 in comparison to 45.76 ± 3.38, preoperatively. VAS score improved significantly from 7.8 (pre-operative) to 2.3 (final follow-up). Non-union in three patients (8.3%) and ankle malalignment in one patient was observed. ConclusionTransfibular ankle arthrodesis achieves excellent bony unions and functional outcomes in severe ankle arthritis. Biologically incompetent fibula that to be judged individually by the operating surgeon to use it as a graft. Patients having inflammatory arthritis have more dissatisfaction than other aetiologies.

TIBIOCALCANEAL ARTHRODESIS: A COMPARISON OF ANTERIOR APPROACH AND TRANSFIBULAR APPROACH.

The aim of this study was to evaluate the clinical and radiologic results and complications of patients who underwent ankle arthrodesis performed by the transfibular approach and anterior approach in end-stage ankle osteoarthritis. Between 2016 and 2022, 41 patients who satisfied the inclusion criteria for this retrospective comparative analysis were included. Of them, 19 patients are included in the anterior approach group and 22 patients are included in the transfibular approach group. The mean age of the participants is 58.9 years. Collected data included the BMI, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale, visual analogue scale (VAS) score, diabetes, smoking, time to fusion, nonunion, union rate, preoperative and postoperative coronal tibiotalar angle and complications. The mean time to bone union was 14.3 weeks (range 11-17 weeks) in the anterior approach group, and 11.3 weeks in the transfibular approach group. Statistically significant difference was found between the two groups. Nonunion occurred in one case in the transfibular approach group and three cases in the anterior approach group. There was no significant difference in the nonunion rate between the both groups (p = 0.321). VAS score, and AOFAS score of the two groups were similar and no significant differences were found (p = 0.491, p = 0.448, p = 0.146, p = 0.073, p = 0.173, p = 0.506, respectively). A stable and firm ankle arthrodesis and plantigrade foot can be achieved with both transfibular approach and anterior approach technique. Level of Evidence III, Retrospective Comparative Study.

Early Clinical Outcomes and Complications of Transfibular Total Ankle Arthroplasty: The Australian Experience

We report the short-term outcomes of a retrospective cohort of Trabecular Metal total ankle arthroplasties (TAAs) via a transfibular approach from a single, nondesigner surgeon in Australia. This was a retrospective cohort study. Demographic, clinical, and patient-reported outcome measures (PROMs) were collected. The primary outcome was the Foot and Ankle Outcome Score (FAOS), and secondary outcomes included patient satisfaction, the EuroQol-5 Dimension (EQ5D), and complications including revision rates. Between 2016 and 2019, 84 trabecular metal prostheses were implanted in 84 patients. Mean age (SD) at time of surgery was 68 (7.8) years, and 46 (55%) were male. Mean follow-up (SD) was 26.1 (13) months. There were significant (P < .001) improvements in the FAOS in the subscales of pain (47.9 to 79.1), activities of daily living (59.5 to 83.7), and quality of life (25.5 to 60.2) and EQ-5D (0.55 to 0.75) (P < .001), and overall satisfaction was 69.6%. The commonest complications were wound infection or breakdown (11.9%, n=10), fibular nonunion (3.5%), plate irritation (3.5%), and tibial nerve neuropathy (3.5%). There were no thromboembolic complications. Implant survivorship was 100%, with Trabecular Metal components retained in all patients. Two patients developed deep infection, with 1 requiring debridement and polyethylene exchange. No patients experienced implant loosening. Our results demonstrate that the trabecular metal survival rates are comparable with other total ankle implants in the Australian Orthopaedic Association National Joint Replacement Registry and as published in other international literature. Overall patient satisfaction was high, as were PROMs. However, the data highlight potential complications uniquely associated with this implant. The authors believe that these figures support TAA via a transfibular approach as a viable option in the treatment of ankle arthritis. Level IV, retrospective cohort study.

Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach

BackgroundFor posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality. MethodsClinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently. ResultsThe total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up. ConclusionTFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures. Level of evidenceLevel III

Lateral Trans-Fibular Total Ankle Replacement Capability in Correcting Ankle Osteoarthritis Deformities and Improving Clinical Outcomes

Category: Ankle; Ankle Arthritis; Hindfoot; Other Introduction/Purpose: Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion in patients with Ankle osteoarthritis (AO). Standard anterior approach TAR capability in correcting deformities is already established by several studies. However, there is a paucity of literature evaluating patient outcomes as well as the potential to correct alignment using a lateral approach TAR. Therefore, the primary objective of this study was to assess the capability of lateral trans-fibular approach TAR in correcting coronal and sagittal plane deformity and secondarily to report the ability to improve patient-reported outcomes (PROs) following lateral TAR. Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans- fibular approach TAR for end-stage AO. Average age and BMI were 63.9 years (range 43-83) and 32.7 kg/m2 (SD 7.5). All patients had received pre- and post-operative weight-bearing CT imaging on the affected foot and ankle. Foot and Ankle Offset (FAO), Talar Tilt Angle (TTA), Hindfoot Moment Arm (HMA), and Lateral Talar Station (LTS) were performed. PROs were collected pre- and post-operatively at the latest clinical follow-up including: PROMIS Global Physical Health score, the Tampa Scale of Kinesiophobia (TSK), the European Foot and Ankle Society (EFAS) score, the Pain Catastrophizing Scale (PCS) and the Foot and Ankle Ability Measure (FAAM) Daily Living Score. One-way ANOVA and Wilcoxon tests were used for comparison at each interval time period. A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results: Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months (range 11 to 24), all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA (10.93mm - 5.10mm, p=0.037), TTA (7.9o - 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROs demonstrated significant improvement postoperatively: TSK (42.7-34.5, p=0.012), PROMIS Global Physical Health (46.1- 54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7, p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of 0.98). Improvements in TSK were associated with changes in the HMA (p=0.0074), R2 of 0.66. Improvements in FAAM correlated (p=0.048) with improvements in FAO (p=0.023) and TTA (p=0.029), and an R2 of 0.78. Conclusion: In this retrospective comparative cohort study, the results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct and strong correlations between deformity correction measurements and the significantly improved PROs were found. The obtained data might help surgeons when planning treatment and may serve as the basis for future comparative prospective studies.

90-Day Reoperation and Wound Complication Rates in Lateral Approach to Total Ankle Replacement for Post-Traumatic Arthritis

Category: Ankle Arthritis; Ankle; Diabetes Introduction/Purpose: Total ankle replacement (TAR) has achieved relatively successful outcomes with respect to postoperative complications; however, mixed evidence exists regarding early complication rates, reoperation, and infection1-5. The largest study of TAR to date indicates a statistically significant risk of postoperative infection in tobacco users and diabetic patients6. Unlike currently established anterior approaches to arthroplasty, the lateral transfibular approach potentially avoids disruption of perfusion to the skin, possibly decreasing postoperative complications7. The lateral ankle allows surgeons to correct malunion of the fibula in post-traumatic arthritis deformity cases and achieve appropriate coronal and sagittal implant alignment to achieve similar physiological joint orientation8,9. The purpose of this study was to report 90-day reoperation and wound complication rates in lateral approach to total ankle replacement for post-traumatic arthritis (PTA). Methods: A retrospective chart review of lateral TAR cases from 2016-2022 was conducted at a single institution. Only patients undergoing TAR for post-traumatic arthritis were included in this review. A total of 49 patients (22 females and 27 males) underwent total ankle replacement with the Zimmer Biomet Trabecular MetalTM Total Ankle by a single surgeon. Patient demographics, operative data, complications, and adverse events requiring corrective surgery were recorded within 90 days of arthroplasty. Results: The patient sample included 6 active smokers, 11 diabetics, and 32 patients with hypertension with an average age of 60.7 and average BMI of 34.3 (Table 1). Three of the 49 (6.1%) patients required secondary surgery within 3 months of surgery (Table 2). Revision surgery indications included: 1 (2.0%) for removing painful hardware, 2 (4.1%) due to infection, and 1 (2.0%) for tarsal tunnel syndrome after surgery. There were 0 nonunions of the fibula at 90 days and through 1 year follow up. Of the patients requiring secondary surgery for infection, 1 was a smoker and 1 had a history of ankle fusion nonunion and avascular necrosis which was converted to a TAR (Table 4). Conclusion: This retrospective study demonstrates a comparable rate of secondary surgeries following TAR via lateral approach in the early postoperative period (6.1%) while having a slightly higher rate of infection than those previously reported (4.1%)7,8. Notwithstanding, we observed a 100% healing rate of fibula osteotomies; however, we failed to demonstrate a lower incidence of wound complications than previously reported. Surgeons should counsel patients of these risks in those with PTA undergoing lateral TAR, especially in smokers and diabetics.

Treatment of Posterior Malleolar Fractures in Elderly Individuals with Kirschner Wire Tension Band Fixation.

Generally, posterior malleolar fragments are fixed either with percutaneous anteroposterior screws or through a posterolateral approach using screws and/or a buttress plate. Both surgical methods have some shortcomings, and the use of anteroposterior screws to fix osteoporotic posterior malleolar fractures carries a risk of failure. Nine elderly patients (average age, 67 years) with posterior malleolar fractures were treated with transfibular Kirschner wire tension band fixation. According to the Lauge-Hansen classification, all fractures were of the supination-external rotation type. The operative duration, intraoperative blood loss, and wound healing outcome were recorded. During the follow-up period, clinical outcomes were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, and the occurrence of complications was observed. The patients were followed up for 12 to 18 months (mean, 15 months). The operative duration ranged from approximately 30 to 95 minutes, with an average of 70 minutes. Anatomical reduction was achieved in nine cases, and there were no complications, such as skin necrosis, wound infection, or skin sensory disturbance. There was one case of delayed wound healing caused by fat liquefaction, which was cured by a dressing change. The functional scores were excellent in four cases, good in four cases, fair in one case, and poor in zero cases. The rate of excellent and good results was 88.89% (eight of nine), with an average of 78.78 points. Kirschner wire tension band fixation through a transfibular approach for the treatment of posterior malleolar fractures does not require a change in patient posture. It facilitates the reduction and internal fixation of the posterior malleolar fragment; furthermore, it is easier to remove internal fixation after fracture healing, which provides a new surgical method for elderly patients with posterior malleolus fracture. Thus, this has potential as a new surgical method for elderly patients with posterior malleolar fractures.

Agreement between semiautomatic and manual measurement of selected parameters on weight-bearing computed tomography images in total ankle replacement: a retrospective study

Objective: To assess the agreement between semiautomatic 3D measurements and manual measurements derived from WBCT images in patients with end-stage ankle osteoarthritis (AO) who underwent total ankle replacement (TAR). Methods: In this retrospective, IRB-approved study (ID #201904825), we evaluated patients who underwent TAR via the lateral trans-fibular approach for end-stage ankle OA. The study included 14 ankles from 14 patients. Raw multiplanar data were analyzed using CubeVue® software. Lateral talar station (LTS) was obtained in the sagittal plane, while hindfoot moment arm (HMA) and talar tilt angle (TTA) were calculated in the coronal view. Semiautomatic 3D measurements were performed using Disior® software. Intra-rater reliabilities were analyzed using the intraclass correlation coefficient (ICC). Agreement between methods was tested with Bland-Altman plots. Each measurement was assessed using the Wilcoxon signed-rank test. Alpha risk was set to 5% (α=0.05). P-values of ≤0.05 were considered significant. Results: ICC-measured reliabilities ranged from moderate to almost perfect for manual and semiautomatic WBCT measurements in the preoperative and postoperative groups for HMA and LTS. There was high correlation between parameters calculated from manual and semiautomatic measurements, and strong agreement between the readers and software in both groups. Conclusions: Manual (M) and semiautomatic (SA) 3D measurements expressed excellent agreement for pre- and postoperative groups, indicating a high correlation between the parameters calculated and strong agreement between the readers and the software in both groups. Level of Evidence III; Therapeutic Studies; Comparative Retrospective Study.

Posterior pilon fracture treated by opening the fibula fracture gap

BackgroundPosterior pilon fracture is a relatively common clinical fracture involving the posterior articular surface of the distal tibia. Currently, this form of fracture is receiving increasing attention. The surgical approach and technique for the treatment of posterior pilon fractures are still controversial. The purpose of this retrospective study was to compare the clinical and imaging outcomes of pilon fractures after treatment with the open fibula fracture line (OFFL) surgical technique versus the traditional posterolateral approach (TPL).MethodsA retrospective analysis of patients with posterior pilon fractures treated using the open fibula fracture line technique and the traditional posterolateral approach between January 2015 and March 2020. Thirty-one cases were included in the open fibula fracture line technique group and twenty-eight cases were included in the traditional posterolateral approach group. We used the Burwell-Charnley scale to assess the effectiveness of surgical repositioning. The clinical outcomes were evaluated using American Orthopaedic Foot & Ankle Society ankle-hind foot score (AOFAS) and visual analog score (VAS).ResultsThe overall anatomic reduction rate was slightly better in the open fibula fracture line group than in the conventional posterolateral group (81% vs. 71%, p = 0.406), but there was no statistically significant difference between the two groups. There were no statistically significant differences between the two groups in terms of fracture healing time and time to full weight bearing (p > 0.05). At the final follow-up, the AOFAS functional score of the open fibula fracture line group was statistically superior to that of the conventional posterolateral group (p < 0.05). However, there was no statistical difference between the two groups in VAS pain scores at rest, during activity, and under weight bearing (p > 0.05).ConclusionThe trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome.Trial registration: Retrospective registration.

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

Transfibular Approach to Hindfoot Arthrodesis Using an Acetabular Reamer: A Technique Tip

The transfibular approach is commonly used for hindfoot arthrodesis. Fibula osteotomy with a saw blade and subsequent bone graft preparation can be time-consuming and prolong tourniquet time as well as prevent training opportunities. We describe a simple and reproducible technique to perform fibula osteotomy using an acetabular reamer. Advantages of this technique include reduction in operative time and use of the reamed bone as an autograft in the tibiotalar and talocalcaneal joints to bridge any voids and increase healing capacity.

Ankle-Hindfoot Reconstruction by Tibiotalocalcaneal (TTC) Arthrodesis Using Multiple Cannulated Screws: 32 Cases

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is a salvage procedure that can be used as an alternative to amputation for various pathologic conditions of the ankle-hindfoot. The aim of this study is to evaluate the clinical-radiological outcome of TTC arthrodesis performed using the multiple cannulated screws.Methods:From 2003 to 2018, 32 ankles (31 patients) underwent TTC arthrodesis. The mean follow-up period was mean 32.5 (12-92) months and the average patient age at surgery was 59.6 years (43-75). The etiologies of TTC arthrodesis included posttraumatic osteoarthritis (18.8%), Charcot arthropathy (18.8%), paralytic deformity (21.9%), failure of total ankle arthroplasty (9.4%), and failure of arthrodesis (9.4%). For all of 32 cases, transfibular approach was used with or without auto fibular cancellous bone graft. 7.3mm cannulated screws were used for fixation of arthodesis for all of 32 cases, and in 23 of 32 cases (71.9%), screw- fixation was used exclusively without any additional plate or Ilizarov fixator. Especially for 11 of 32 cases with large bony defect, fresh-frozen allo-femoral head structural bone graft was used. Pre- and postoperative visual analog scale (VAS) pain, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot functional score, and radiographs including CT images were assessed.Results:Overall union rate was 81.3% (26/32). Mean VAS score decreased from 6.92 preoperatively to 1.46 postoperatively and the AOFAS score improved from 27.0 to 53.7 (Max=68) at the final follow-up. Complication of TTC arthrodesis included nonunion (18.8%, 6/32), infection (12.5%, 4/32), and one case of skin necrosis. Most frequent nonunion site was tibiotalar joint (6/32). For 3 of 7 cases with nonunion, patients were painless and could ambulate without severe functional impairment. There were two cases with infective nonunion and one case with active Charcot arthropathy after artrhdesis. Union rate of two groups with/without allo-femoral head bone graft were similar to each other (81.8%, 81.0%, respectively), however, final AOFAS scores were significantly superior in 'without' femoral head bone graft group.Conclusion:This study achieved a fusion rate comparable to other previous studies and obtained favorable clinical outcomes. Realignment TTC arthrodesis using multiple cannulated screws is a valid surgical option as a salvage procedure for various deformed or arthritic conditions of ankle-hindfoot. Allo-femoral head structural bone graft can be selected as useful option for TTC arthrodesis with large bone defect.

Mid-Term Results after Lateral Transfibular Approach Total Ankle Arthroplasty

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Continued improvements in total ankle arthroplasty (TAA) implant design have led to promising clinical outcomes. The lateral transfibular approach TAA allows for excellent visualization of the center of rotation of the ankle and allows for correction of rotational and sagittal deformity by shortening or lengthening of the fibula. Furthermore, the curved implant design allows for minimal bony resection. The purpose of this study is to report the medium-term clinical and radiographic results for consecutive patients who underwent the lateral approach TAA.Methods:IRB approval was obtained for this study. Consecutive patients who underwent lateral approach TAA for tibiotalar arthritis by a single surgeon were enrolled on a prospective basis from January 2013 to June 2015. This time period represented the initial case series of TAA performed by the surgeon. Patient reported outcomes (PROs) were collected including the Ankle Osteoarthritis Scale (AOS), 12-item short-form survey (SF-12), and Visual Analogue Pain Scale (VAS). The need for subsequent procedures was recorded. Radiographs were evaluated for preoperative and postoperative alignment using the lateral distal tibial angle (LDTA), tibiotalar surface angle (TTS), anterior distal tibia angle (ADTA), and the lateral talar station (LTS). Radiographs were also evaluated for the development of peri-implant lucency and subsidence. Data was tested for normality. T-tests were used to determine differences between preoperative data and postoperative data. A p<0.05 was considered significant.Results:53 patients who underwent 59 TAA procedures were included. Average follow-up was 5.7 +/- 0.9 years. Average age was 53 +/- 7.0. Comorbidities included smoking (11/53), diabetes (6/53), and prior procedures (33/53). Sixteen ankles (27%) underwent one or more subsequent procedures including gutter debridement (7/59), debridement for periprosthetic infection (3/59), and removal of hardware (7/59). All fibular osteotomies healed. Four ankles had asymptomatic peri-implant lucency or cysts (4/59). No patients had subsidence or required revision of the tibial or talar components. Coronal and sagittal alignment were significantly improved for all measures (p<0.05). VAS scores improved from a mean of 7.5 preoperatively to 1 at final follow- up (p<0.0001). SF-12 physical component scores improved from 34 to 41.5 (p=0.0227). AOS scores improved from 54.8 to 19.1 (p<0.0001).Conclusion:At medium term follow-up, patient reported outcomes remain significantly improved in patients after lateral approach TAA. There were very few radiographic findings of lucency and cyst formation, and all of these were asymptomatic. No revision of metal implants was required. Excellent deformity correction was achieved. The rate of subsequent procedures was high, although the rate of actual component revision was 0%. Lateral approach TAA appears to have overall good outcomes at medium term follow-up.

Outcomes Following Intramedullary Nail vs Plate Fixation for Tibiotalocalcaneal Arthrodesis: A Systematic Review

Category:Ankle Arthritis; Hindfoot; TraumaIntroduction/Purpose:Tibiotalocalcaneal arthrodesis (TTCA) is indicated to treat pain and dysfunction that may result from a variety of ankle and hindfoot pathologies by achieving fusion of the tibiotalar and subtalar joints. Two common fixation methods exist to achieve TTCA: retrograde intramedullary nail (IMN) fixation and plate fixation using a lateral trans-fibular or posterior Achilles-tendon splinting approach. The purpose of this study is to review the literature and compare the outcomes of TTCA using IMN fixation with those of plate fixation using a lateral trans-fibular approach.Methods:A comprehensive search of the PubMed, Cochrane, and EMBASE databases was performed on 01 February 2021 for studies of all levels of evidence pertaining to TTCA using IMN and plate fixation. Reasons for exclusion included: no formal joint preparation, non-English language, concomitant methods of fixation (e.g., IMN with additional plate fixation) and follow-up less than 12 months.Results:Fourteen studies (11 level III and 3 level IV) met criteria and were included. A total of 386 fusions were documented in 356 patients [259 (67%) IMN and 127 (33%) plate fixation]. In the IMN group, union rates at the tibiotalar joint (TTJ) were 84% (219/259) and subtalar joint (STJ) were 90% (229/259) with an overall complication rate of 20% (53/259). Average initial AOFAS scores were 34.3+-7.9, increasing to 72.4+-9 postoperatively. In the plate fixation group, union rates at the TTJ were 82% (103/127) and STJ were 86% (108/127) with an overall complication rate of 30% (39/127). Average initial AOFAS scores were 37.0+-6.9, increasing to 74.4+-12.5 postoperatively. No statistical differences were noted between the TTCA IMN and plate cohorts when comparing rates of TTJ or STJ union (p= 0.6, and p=0.2, respectively) and postoperative AOFAS scores (p=0.59). However, the plating group had a statistically higher overall complication rate (p=0.02).Conclusion:A systematic review of the available literature suggests that there is no statistical difference in union rates or functional outcomes between TTCA using intramedullary nail or lateral trans-fibular plate fixation. However, the lateral trans- fibular plate has a statistically higher complication rate when compared to intramedullary nails. Further comparative prospective cohort studies and randomized controlled trials are needed to further elicit differences between these groups and confirm the findings of this systematic review.

Combined Transfibular and Anterior Approaches Increase Union Rate and Decrease Non-Weight-Bearing Periods in Ankle Arthrodesis: Combined Approaches in Ankle Arthrodesis.

The transfibular approach is a widely used method in ankle arthrodesis. However, it is difficult to correct coronal plane deformity. Moreover, it carries a risk of nonunion and requires long periods of non-weight-bearing because of its relatively weak stability. We hypothesized that the transfibular approach combined with the anterior approach in ankle arthrodesis wound yield a higher fusion rate and shorter non-weight-bearing period. This study was performed to evaluate the clinical and radiographic results and postoperative complications in ankle arthrodesis using combined transfibular and anterior approaches in end-stage ankle arthritis. Thirty-five patients (36 ankles) with end-stage ankle arthritis were consecutively treated using ankle arthrodesis by combined transfibular and anterior approaches. The subjects were 15 men and 20 women, with a mean age of 66.5 years (46–87). Clinical results were assessed using the visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) scores, and the ankle osteoarthritis scale (AOS) preoperatively and at the last follow-up. Radiographic results were assessed with various radiographic parameters on ankle weight-bearing radiographs and hindfoot alignment radiographs. All clinical scores significantly improved after surgery. Union was obtained in all cases without additional surgery. Talus center migration (p = 0.001), sagittal talar migration (p < 0.001), and hindfoot alignment angle (p = 0.001) significantly improved after surgery. One partial skin necrosis, two screw penetrations of the talonavicular joint, and four anterior impingements because of the bulky anterior plate occurred after surgery. In conclusion, combined transfibular and anterior approaches could be a good method to increase the union rate and decrease the non-weight-bearing periods in ankle arthrodesis.

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

IntroductionThere are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.Presentation of caseThe patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.DiscussionThe patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.ConclusionWe reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.

Three-column subdivision for isolated posterolateral tibial plateau fractures and perspective surgical approaches

BackgroundThis study aimed (1) to introduce a computed tomography (CT)-based classification of the posterolateral compartment of the tibial plateau based on the fibula and to propose the individualized surgical approaches for each zone; and (2) to determine the surgical approach based on the classification, that would achieve a safe and effective reduction and could improve postoperative clinical outcomes. MethodsEighteen cases of tibia plateau fracture involving the isolated posterolateral compartment in a single institution were retrospectively analyzed. The posterolateral compartment of the tibial plateau was segmented into three zones based on the fibular position and an individualized surgical approach was proposed for each zone. In anterior Zone I, surgical treatment was performed using an extended anterolateral approach and the patient was placed in the supine position; in middle Zone II, using the transfibular approach in the supine position; in posterior Zone III, using the posteromedial approach in the prone position. ResultsIn all cases, anatomical articular reduction (intra-articular step off in CT images <2 mm) was achieved and maintained for the follow up period. The average mechanical medial proximal tibial angle was increased from 87.6° before surgery to 88.2° in the immediate postoperative period (P = 0.060), and maintained for the follow up period (mean 89.9° at 1-year follow up). At the 1-year follow up, the knee range of motion averaged 140° and the Lysholm knee function score was 95.0 points. ConclusionAn individualized surgical approach and fixation according to three-zone subdivision for isolated posterolateral tibial plateau fractures provided an effective and safe method to treat posterolateral tibial plateau fractures.