Efraim D. Leibner

Outcome of Ilizarov ankle arthrodesis.

Background: Many operative techniques have been described for ankle arthrodesis, with varying fusion rates. In revisions, the fusion rate is lower than in primary arthrodesis. Recent reports have described good results after Ilizarov ankle arthrodesis. However, descriptions were qualitative, with none using an accepted score. We describe our experience with this technique and functional outcomes in our patients. Methods: Seventeen patients (average age 48 years) had primary or revision unilateral ankle arthrodesis using the Ilizarov technique at two centers. Diagnoses included post-traumatic arthritis and Charcot arthropathy. Three patients had talar osteonecrosis. Time in the frame averaged 15 weeks and in a cast 4 weeks. Followup averaged 6 years. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Results: All ankles achieved solid fusion. The average AOFAS score was 65 out of 86 possible. Based on this, results were defined as excellent in three patients, good in eight, fair in four, and poor in two. Minor complications were common, all resolving with local treatment. No deep infection developed. One fusion malunited in 8 degrees of varus. Conclusions: The Ilizarov external fixator has numerous advantages applicable to ankle fusion, including: stable fixation, respect for soft tissues, and the possibility of postoperative alignment ‘fine-tuning’. Additionally, the ability to direct forces through or around skeletal elements allows varying of the load through the skeletal elements, allowing early weightbearing. The Ilizarov technique, with its high union rate, may be considered for any ankle arthrodesis but is especially useful in complex cases such as revisions, talar osteonecrosis, soft-tissue compromise, and infection. Early weightbearing is an added benefit.

Unloading Mechanism in the Total Contact Cast

Background: The effectiveness of total contact casts is postulated to be due to the reduction of plantar pressure. We investigated plantar loads to evaluate the mechanism by which total contact casts off-load the plantar surface of the foot to determine if it is the intimate molding of the weightbearing plantar surface or if a below-knee cast is necessary. Methods: Plantar pressures and forces in a total contact cast (TCC) were recorded in 12 healthy subjects, using the Pedar® (Novel GmbH, Munich, Germany) pedobarographic system. The measurements were repeated after removal of the ‘shank’ portion of the cast (proximal to malleoli), leaving in effect, a well-molded shoe-cast (SC). Measurements included average force and peak pressure. All parameters were measured under two different loading conditions: single-leg standing balanced on the casted limb and over-ground walking. To assess the contribution of calf geometry, the ‘calf ratio’ was calculated by dividing the largest by the smallest circumferences of the calf. All parameters were compared between TCC and SC for each subject in each of the two conditions. Paired t-tests were used to evaluate significance, which was set at a level of p < 0.006 due to the Bonferroni Correction. Results: Removal of the shank portion of the TCC significantly increased the average plantar force by 31% during walking. The force only increased 9% during standing, which was not significant. Peak pressure increased 53% after removal of the shank portion of the TCC during walking. Peak pressure was not significantly different during standing on one limb. No correlation was found between the calf ratio and the magnitude of change in the measured values. Conclusions: These results help to partially explain the widely recognized clinical observation that molded insoles and shoes, no matter how well conformed to the foot, do not reduce plantar loads as effectively as a total contact cast. The mechanism appears to be a critical unloading function of the proximal, ‘shank’ portion of the cast, presumably due to reduction in ankle motion.

Lateral malleolar reconstruction after distal fibular resection. A case report.

T umors of the distal part of the fibula necessitating resection pose a problem because of the need to reconstruct a stable ankle joint and to obtain coverage of this area. Standard textbook solutions include simple resection of the distal aspect of the fibula including the lateral malleolus, as described by Carnesale1 and later by Norman-Taylor et al.2, and resection of the distal part of the fibula with reconstruction of the lateral malleolus with use of the fibular head, as described by Carrell3, Herring et al.4, and de Gauzy et al.5. An allograft reconstruction has also been described6, as has reconstruction with an iliac crest bone graft7. Other possible techniques, albeit less desirable, are ankle arthrodesis and amputation. Although the textbook techniques are considered to be classics, not many reports have detailed their use and results2-5,8-12. These methods, at least theoretically, have a number of drawbacks. In distal fibular resection without reconstruction, the stabilizing effect of the lateral malleolus is lost. Soft-tissue reinforcement, even when it is possible, cannot fully compensate for the loss of stability13. Thus, the ankle may collapse into valgus and may be unstable in varus. Conversely, when the mortise is reconstructed with use of a proximal fibular (head) graft, the lateral collateral ligament of the knee is affected and the peroneal nerve is endangered14,15. Additionally, the fibular head is not totally congruent with the lateral articular surface of the talus and provides no stabilizing ligament attachments. Ankle arthrodesis might solve the problems of instability, but it limits the ability to walk. Amputation is reserved as a last resort for patients in whom limb-sparing is not feasible. We describe a …

Primary subtalar arthrodesis for severe talar neck fractures: a report of three cases.

Talar fractures comprise a small minority of skeletal injuries, representing about 2% of trauma cases3,19 and approximately 0.25% of all fractures.16 However, because of the pivotal role of the talus in ambulation and weightbearing, these fractures have the potential to cause considerable morbidity.9,12 Talar fractures have a propensity for posttraumatic arthritis because of frequent damage to articular surfaces from the fracture itself or from fracture malunion or nonunion that causes malalignment and incongruence. Additionally, the precarious blood supply to the talar body is jeopardized by the fracture, which may further compromise results by causing osteonecrosis.1,3,4,6,9,10–13,15,18 Primary ankle arthrodesis has been described as a treatment option for severely comminuted talar fractures.5 While this treatment can prevent posttraumatic ankle arthritis and theoretically can enhance blood supply to the talar body, loss of ankle motion has a significant effect on ambulation. Primary subtalar arthrodesis for severely comminuted talar fractures has been recommended more than half a century ago by Schrock et al.15 However, poor results in early reports1,6,8,11 seem to have discouraged the use of this technique despite obvious theoretical advantages. We found only a single case report describing this treatment in the recent English language literature.17 This, despite the prevalence of posttraumatic subtalar arthritis9 and despite the fact that many patients with displaced talar neck fractures require secondary surgical procedures, most of which involve subtalar arthrodesis.12

Tibialis Posterior Entrapment: Case Report

Level of Evidence: V, Expert Opinion

Retrograde nailing of femoral fractures distal to previous osteosynthesis.

As the proportion of elderly in the population grows, the incidence of femoral fractures distal to previous proximal osteosynthesis is increasing. When the gap between two rigid load-bearing fixations consists of osteopenic bone, the risk of further fractures increases. Herein the authors describe a load-sharing device that stabilizes the fracture and eliminates the osteopenic gap, allowing early mobilization and rapid return to the preinjury level of activity.

Partial Calcanectomy for Heel Ulcers Revisited – a Possible Solution to a Difficult Problem

Category: Diabetes Introduction/Purpose: Diabetic heel ulcers are a major problem, often leading to amputations. Partial or total calcanectomy has been described as a possible salvage procedure, by allowing soft tissue coverage after debridement of necrotic and infected tissue, and possibly allowing walking. We report on our experience with this technique which is not commonly used Methods: Fourteen patients, who presented with diabetic heel ulcers between 2010-15, and who were BKA candidates, underwent debridement and partial calcanectomy. Average age was 67.8 ±12.7 years, M:F ratio was 6:1 Extent of procedures, need for additional procedures and complications were noted. Outcome assessment included wound closure and walking status. No patients were lost to follow up. Results: Nine patients underwent partial calcanectomy as the initial procedure while others underwent prior debridement. Calcanectomies were subtotal (1), wedge (5) or partial (8). Primary closure was mostly achieved (11), the remainder requiring local skin graft (2) or myocutaneous flap (1). Ten patients underwent re-vascularization prior to calcanectomy, either angiographic (8) or bypass (2). Most calcanectomies (9/14) healed successfully, while five subsequently required amputations. Most failures were noticed within 24 days, with similar prevalence in wedge and partial calcanectomies. One patient had wound complications requiring BKA. At one year, the nine patients had full wound closure and could bear weight. Five patients regained full ambulatory status wearing specially modified shoes with custom fillers. Conclusion: Partial calcanectomy is a little-known procedure, that is a viable alternative to BKA. We present our positive experience with this procedure, which in a majority of cases not only prevented BKA, but also allowed weight bearing. Poor vascular supply is not necessarily a contraindication, as re-vascularization prior to calcanectomy is a viable option.

Technique Tip: Positioning for Hindfoot and Midfoot Surgery

Levels of Evidence: V, Expert Opinion