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Complex Ankle and Hindfoot Arthrodesis Using Circular External Fixation

Publish date: September 25, 2018

References

1. Fragomen AT, Borst E, Schachter L, Lyman S, Rozbruch SR. Complex ankle arthrodesis using the Ilizarov method yields high rate of fusion. Clin Orthop Relat Res. 2012;470(10):2864-2873. doi:10.1007/s11999-012-2470-9.

2. Salem KH, Kinzl L, Schmelz A. Ankle arthrodesis using Ilizarov ring fixators: a review of 22 cases. Foot Ankle Int. 2006;27(10):764-770. doi:10.1177/107110070602701002.

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5. Eylon S, Porat S, Bor N, Leibner ED. Outcome of Ilizarov ankle arthrodesis. Foot Ankle Int. 2007;28(8):873-879. doi:10.3113/FAI.2007.0873.

6. Kalish S, Fleming J, Weinstein R. External fixators for elective rearfoot and ankle arthrodesis. Techniques and indications. Clin Podiatr Med Surg. 2003;20(1):65-96, vi.

7. Kollig E, Esenwein SA, Muhr G, Kutscha-Lissberg F. Fusion of the septic ankle: experience with 15 cases using hybrid external fixation. J Trauma. 2003;55(4):685-691. doi:10.1097/01.TA.0000051933.83342.E4.

8. Rochman R, Jackson Hutson J, Alade O. Tibiocalcaneal arthrodesis using the Ilizarov technique in the presence of bone loss and infection of the talus. Foot Ankle Int. 2008;29(10):1001-1008. doi:10.3113/FAI.2008.1001.

9. Saltzman CL. Salvage of diffuse ankle osteomyelitis by single-stage resection and circumferential frame compression arthrodesis. Iowa Orthop J. 2005;2547-52.

10. Fragomen AT, Rozbruch SR. The mechanics of external fixation. HSS J. 2007;3(1):13-29. doi:10.1007/s11420-006-9025-0.

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DISCUSSION

A key aspect of recovery after ankle and hindfoot fusion using the Ilizarov technique is balancing pin care, soft tissue swelling, and weight-bearing status. The average time patients will spend in the frame is approximately 25 to 28 weeks, but can range from 12 to 84 weeks.^1,2Given the considerable variability in both soft tissue healing and bony union, patients should be extensively counseled before surgery to set expectations correctly and ensure that they have the necessary help and support to care for the frame during the treatment period. Patients should be followed closely during the first 6 weeks to ensure that pins and wires do not become infected or break, as both of these issues require immediate intervention.

In a review of 11 patients who underwent tibiocalcaneal arthrodesis using an Ilizarov external fixator for infected talar nonunions or extrusions, Rochman and colleagues⁸ reported an 81% rate of successful fusion with a final mean American Orthopaedic Foot and Ankle Society score of 65 (out of a maximum 86). Similar results were reported by Saltzman⁹ in a series of 8 patients with diffuse ankle osteomyelitis treated with resection of all infected tissue and hybrid-frame compression arthrodesis. All patients received 6 weeks of intravenous antibiotics, and frames were removed at 3 months, and walking casts were applied for 1 to 2 additional months. Ankle sepsis was eradicated in all patients, and 7/8 (87.5%) ankles successfully fused at an average of 13.5 weeks (range, 10-16 weeks). One limb required below-knee amputation at 5 weeks due to non-reconstructible vascular insufficiency. At an average of 3.4-year follow-up, none of the 7 fused ankles required further surgery.

Fragomen and colleagues¹ retrospectively reviewed 101 patients who underwent complex ankle fusion using the Ilizarov technique and found that 76/91 (83.5%) patients achieved fusion at an average of 25 weeks (range, 10-65 weeks). Smoking was associated with a 54% rate of nonunion and 15/19 (79%) patients with Charcot neuroarthropathy achieved ankle fusion, but had a subsequent subtalar joint failure, thus highlighting the need for TTC arthrodesis in Charcot patients. Salem and colleagues² reviewed 21 Ilizarov ankle fusions and reported that all patients achieved fusion at an average of 28 weeks (range, 12-84 weeks). Complications occurred in 11 patients, including 2 nonunions that healed after revision frame application and 4 pin tract infections.

CONCLUSION

Overall, the Ilizarov technique using circular external fixation is a powerful tool that can be used to treat a variety of disorders including complex foot and ankle deformity and infection. While case series generally show favorable outcomes, patients must be informed that this technique is a salvage procedure for limb preservation that requires meticulous operative technique, diligent postoperative care, and tight control of medical comorbidities, such as blood sugar levels in individuals with diabetes to achieve a successful outcome.

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Complex Ankle and Hindfoot Arthrodesis Using Circular External Fixation

References

DISCUSSION

CONCLUSION

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