Outcome of Pantalar Fusion With Femoral Head Allograft in Avascular Necrosis of Talus

Background: Avascular necrosis (AVN) of the talus is a challenging condition that is caused primarily by trauma. The severity of the talus fracture determines the risk of AVN. Severe osteonecrosis with the loss of talar integrity can be treated with arthrodesis and structural bone graft.Method: This study shows the experience of pantalar arthrodesis using hindfoot arthrodesis nail, screw fixation, and femoral head allograft in four patients.Result: All patients were satisfied in terms of pain and function after an average of 4 months postsurgery. Limb length discrepancy was <1 cm and hindfoot fusion was achieved by 3 months. The mean score for SF-36 physical function and AOFAS hindfoot score at a 2-year postpantalar arthrodesis was 88 and 80.8, respectively.Conclusion: Hindfoot ankle arthrodesis, with the usage of femoral head allograft, can be successfully used for the treatment of traumatic AVN of talus.

Early Failure of Total Ankle Arthroplasty in a Patient with Ipsilateral Varus Knee Deformity

Multiple risk factors such as age, body mass index (BMI), preoperative diagnosis, smoking, diabetes mellitus, malalignment of an implant, and presence of ipsilateral hindfoot fusion have been shown to contribute to failure of total ankle arthroplasty (TAA). However, the exact causes of TAA failure remain uncertain, and various causes can lead to a need for revision surgery. We report a case of early aseptic loosening of the implant following TAA in a patient with severe varus deformity of the ipsilateral knee.

The use of low intensity pulsed ultrasound in the foot and ankle

Low intensity pulsed ultrasound (LIPUS) therapy has demonstrated clinical effectiveness in achieving union in a variety of fracture situations. Few studies have investigated the effectiveness of LIPUS therapy in foot and ankle surgery. The overall rate of union in all published studies relating to the use of LIPUS in a variety of foot and ankle fracture and fusion situations is 95%. Some studies suggest lower healing rates (~ 67%) when LIPUS therapy is used to treat hindfoot fusion nonunion. A well-powered, high-quality, randomized controlled trial is needed to demonstrate the clinical and cost effectiveness of LIPUS therapy in foot and ankle surgery. Cite this article: EFORT Open Rev 2021;6:217-224. DOI: 10.1302/2058-5241.6.200045

Risk Factors for Early Failure of 4th Generation Total Ankle Arthroplasty Prostheses

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: A number of two-component, 4th generation total ankle arthroplasty (TAA) prostheses have been introduced to the market in the past few years, as the popularity and indications for TAA have continued to expand. The purpose of the present study was to identify independent risk factors for the early failure of 4th generation TAA prostheses. Methods: A total of 97 ankles underwent TAA with a 4th generation prostheses (INFINITY, CADENCE) between August 2015 and June 2018 at a single institution and were at least 6 months postoperative (mean 18.3 months, range 6-43). The primary outcome assessed was the need for revision surgery, defined as removal of 1 or both metal components for any reason, excluding infection. Baseline patient demographics, characteristics, radiographic alignment parameters, and distal tibia cortical bone thickness (CBT) were assessed. Revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook et el., respectively. Univariate and multivariate analyses were performed. Results: Three ankles (3.1%) underwent revision surgery for aseptic loosening at a mean of 24.3 (range, 16-31) months; all had a CBT <4mm. Independent predictors for reoperation were a CBT < 4mm, the presence of diabetes, and ipsilateral hindfoot fusion (p=0.04). No associations were identified for purported risk factors (age, BMI, and coronal deformity). Conclusion: The present study is the first to suggest a potential relationship between CBT of the distal tibia and TAA failure. Additional studies are warranted to better understand the role of bone density in TAA survivorship.

Masquelet Technique for Hindfoot Fusion of Gustilo IIIA Open Ankle Dislocation with Complete Talar Extrusion and Loss

Category: Hindfoot, Trauma, Ankle Introduction/Purpose: Complete talar extrusion is a rare injury resulting from high-energy trauma, with dissociation of the talus from surrounding bony and soft-tissue structures. Complications after complete talar extrusion include infection, osteonecrosis, posttraumatic osteoarthritis, and leg-length discrepancy. There is a lack of consensus on the optimal treatment algorithm for complete talar extrusion, due in part to high complication rates associated with injury and treatment. Thus, we report a staged treatment method utilizing the Masquelet Technique with temporary cement spacer, followed by bone grafting with use of femoral shaft autograft and bulk cancellous allograft. Methods: 44-year-old male status post high-speed motorcycle collision presented with left ankle Gustilo IIIC open fracture dislocation with complete talar extrusion and loss, concomitant ipsilateral tibial plateau fracture and metatarsal shaft fractures. Twelve weeks post-injury, after multiple staged debridements, external fixation and extensive wound vac treatments, removal of the left leg multi-planar external fixator was performed with left distal tibial, fibular, navicular and calcaneal articular and subchondral bone debridement in preparation for Masquelet procedure and pantalar fusion. Open reduction and realignment of left ankle and foot with intramedullary fixation with hindfoot fusion nail was performed, with placement of antibiotic cement spacer for development of secondary reactive periosteal membrane. After nine weeks, intramedullary bone reaming aspiration tool was utilized for removal of left femur intramedullary bone marrow for autograft. Hindfoot pantalar fusion was performed using ipsilateral femoral shaft autograft and bulk cancellous allograft in place of antibiotic spacer. Results: Patient went on successfully to fusion and had one transfixation screw removed during the course of his recovery. Patient was also treated using a long leg ankle foot orthosis brace as a stress shielding device during heavy labor. Patient returned back to work and heavy labor as a landscaper and has had no residual pain. At 24 months postoperative, patient achieved an AOFAS ankle-hindfoot score of 83/100 (good). Conclusion: To our knowledge, this is the first case of complete talar extrusion treated with a Masquelet procedure with ipsilateral femoral shaft autograft and bulk cancellous allograft. While chronic pain is reported in as many as 75% of patients post- complete talar extrusion, and infection rates as high as 88%, our patient reports no residual pain and did not experience a postoperative infection. This technique represents a reasonable approach and warrants consideration for the treatment of this rare, complex injury.

Peri-Implant Fractures Around Hindfoot Fusion Nails: A Systematic Literature Review and Classification System

Category: Hindfoot Introduction/Purpose: Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hind foot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors. Methods: A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails by two research assistants. The electronic database of PubMed / Medline was explored using specific search terms, Boolean operators, and field tags. The same query without field tags and under “Search All Text” was used to explore the electronic database of the Cochrane Library. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded. Manuscript language for both databases was restricted to the English literature. Results: A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies. Conclusion: Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice.