Abstract
We evaluated the results of arthrodesis that had been performed for arthrosis of the ankle and osteonecrosis of the talus in nineteen patients. Twelve patients were men, and seven were women. The mean age of the patients was thirty-four years (range, nineteen to fifty-eight years). The median interval between the injury and the index operation was twenty-one months (range, six to 408 months). The arthrodesis was performed at the level of the ankle only in three patients and in both the ankle and the subtalar joint in sixteen. External fixation was used in thirteen patients, internal fixation was used in four, and no fixation was used in two. Supplemental bone graft from the iliac crest was used in fourteen patients, and local bone graft was used in five.The mean duration of follow-up was six years (range, two to fifteen years). The clinical result was excellent in seven patients, good in six, fair in three, and poor in three. Union was achieved in sixteen ankles, but it was delayed in one of them. Complications occurred in four patients: one had a tibial stress fracture, one had an infection at the site of a non-union, and two had malalignment in plantar flexion.Overall, the arthrodesis was successful in these patients. The use of rigid fixation and bone-grafting had a rate of success approximating that reported for primary arthrodesis in patients who do not have avascular necrosis.
Several treatment options are available for a patient who has pain and disability associated with arthrosis of the ankle and osteonecrosis of the body of the talus. These options include resection of the talar body with or without tibiocalcaneal arthrodesis, conventional resection of the joint and tibiotalar arthrodesis, arthrodesis with use of an anterior sliding tibial bone graft, and posterior tibiotalocalcaneal arthrodesis1,4,7,16.
Resection of the segment of osteonecrotic bone, by either partial or complete excision of the talus, has been attempted. In a series of six patients reported on by Hawkins, excision of the talus, performed as either a primary or a secondary procedure, yielded no excellent or good results. Other investigators have reported similar findings3,6,11,15,19. Detenbeck and Kelly indicated that excision of the body of the talus may be successful if tibiocalcaneal arthrodesis also is performed; however, Reckling found that this procedure resulted in shortening of approximately one and one-quarter inches (3.18 centimeters). Other authors have thought that tibiocalcaneal arthrodesis is superior to arthrodesis of the ankle or to talectomy2,15.
The high rates of failure of conventional techniques of arthrodesis of the ankle involving resection of the joint may be due to the fact that union with the body of the talus is difficult to achieve because the bone is necrotic and the foot may remain painful because of arthrosis and incongruity of the subtalar joint2. In 1943, Blair reported on two patients who had a talar injury that was treated with resection of the body of the talus and attachment of a distal sliding tibial bone graft to the head and neck of the talus. Subsequent authors modified the technique and used it mainly in patients who had an acute fracture10,12,13.
To the best of our knowledge, a critical analysis of a series of patients who had an arthrodesis for the treatment of arthrosis of the ankle and osteonecrosis of the talar body has not been published previously. The purpose of the current study was to review our experience with arthrodesis for the treatment of these disorders.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street S.W., Rochester, Minnesota 55905. Please address requests for reprints to Dr. Kitaoka.
The records of all patients who had had a unilateral arthrodesis for the treatment of arthrosis of the ankle and osteonecrosis of the talar body at our institution between 1977 and 1990 were reviewed. Two patients who had had avascular necrosis of both the ankle and the distal aspect of the tibia were excluded, two patients had died, and three patients could not be located. Nineteen patients (nineteen ankles) were available for follow-up and formed the basis of this study (Table I).
Twelve patients were men, and seven were women. The mean age was thirty-four years (range, nineteen to fifty-eight years). The mean height was 1.74 meters (range, 1.63 to 1.90 meters), and the mean weight was 81.2 kilograms (range, sixty to 120 kilograms). The median interval from the time of the injury to the arthrodesis at our institution was twenty-one months (range, six to 408 months). A total of forty-nine previous operations had been performed in fourteen patients (mean, 3.5 procedures per patient). These procedures included débridement (twenty), open reduction (fourteen), pin removal (three), muscle-flap transposition (two), split-thickness skin-grafting (three), arthrodesis of the hindfoot (one), arthrodesis of the ankle and hindfoot (one [Figs. 1-A, 1-B, and 1-C]), arthrodesis of the ankle (one), arthroscopic débridement of osteochondral fragments (two), and wound closure (two). The remaining five patients had not had previous operative procedures. Four patients had a sensory neuropathy, two had diabetes mellitus, three had a history of a vascular disorder, six had a history of tobacco use before and after the index operation, four had a history of infection, and ten had malalignment of the ankle before the index operation.
We classified the patients into two groups according to the extent of the arthrosis and osteonecrosis. Group I consisted of three patients who had arthrosis of the ankle but not the subtalar joint and had radiographic evidence of osteonecrosis of the body of the talus. Group II comprised sixteen patients who had arthrosis of the ankle and subtalar joints and radiographic evidence of complete osteonecrosis of the body of the talus. The diagnosis of osteonecrosis was made by analysis of plain radiographs. Thirteen patients had additional studies: magnetic resonance imaging was performed in three, tomography was performed in nine, and computed tomography was done in one. All except one patient had severe trauma to the foot, and thirteen patients had a fracture-dislocation of the neck of the talus. Marked relative radiodensity of the talar body with segmental collapse and arthrosis of the ankle and the subtalar joint was seen on the plain radiographs. One patient had had extended treatment with high-dose corticosteroids, and marked relative radiodensity with segmental collapse and arthrosis was noted on plain radiographs.
The talus was divided into three zones on the lateral radiographs and into two zones on the anteroposterior radiographs in order to quantitate the extent of osteonecrotic bone. The head-and-neck zone extended anterior to a line at the junction of the talar neck and body. The talar body was divided into anterior and posterior zones by a vertical line drawn from the most superior (dorsal) point of the dome of the talar articular surface. On the anteroposterior radiographs, the talar body was divided into medial and lateral zones. The osteonecrosis consistently involved the anterior, posterior, medial, and lateral zones, but it did not involve the head-and-neck zone in any patient.
Because of the spectrum of problems in these patients, no single operative approach was applicable to all of them. A posterior incision was used in six ankles; a lateral incision, in three; a lateral and medial incision, in seven; and an anterior incision, in three. In Group I, the arthrodesis included resection of the talar and tibial joint surfaces, insertion of corticocancellous bone graft (iliac crest or local) into the defect and around the site of the arthrodesis, and use of fixation. External fixation (a Roger Anderson device) was used in one patient, internal fixation was used in one, and no fixation was used in one. In the patient who had internal fixation, a single cortical-bone screw in a tibial inlay graft was used; the screw did not span the ankle joint. This was supplemented with a single longitudinally oriented percutaneous Steinmann pin. In Group II, both joints were exposed and bone graft was placed to span both the ankle and the subtalar joint (Figs. 2-A and 2-B). In two ankles, the osteonecrotic talar body was excised. Twelve patients had external fixation (a Calandruccio device in ten and a Hoffman device in two). Three had internal fixation with staples (Figs. 3-A and 3-B), and one had no fixation. Bone graft from the iliac crest was used in fourteen patients (one in Group I and thirteen in Group II), and local bone graft was used in five.
In both groups, the external fixation device was removed at a mean (and standard deviation) of 12 ± 2 weeks (range, seven to sixteen weeks) postoperatively. A cast was worn for a mean of 20 ± 8 weeks (range, thirteen to forty-two weeks) postoperatively.
Follow-up consisted of a clinical examination for ten patients, a questionnaire or a telephone interview with a review of the radiographs for eight, and a review of the medical records for one patient who had had a revision procedure and therefore was considered to have had failure of the index operation.
Various clinical factors were graded as in previous studies8,9,14. The result was considered excellent if the patient had no pain or limitation in daily or recreational activities, did not need to wear a brace or to use walking aids, and could walk more than six blocks. The result was considered good if the patient had occasional mild pain and had limitation in recreational but not daily activities, did not need to wear a brace or to use walking aids, and could walk more than six blocks. The result was considered fair if the patient had frequent moderate pain and had limitation in recreational and daily activities, needed to wear a modified shoe or to use a cane, and could walk a maximum of four to six blocks. The result was graded poor if the patient had severe pain that was nearly always present and had severe limitation in recreational and daily activities; needed to use a brace, crutches, or a walker; and could walk less than four blocks. The result was downgraded on the basis of the worst single component; for example, the patient who had an additional operation (a revision arthrodesis) was considered to have a poor result.
The range of tibiopedal motion was measured with use of a goniometer between the axes of the tibia and the foot in positions of maximum dorsiflexion and plantar flexion. Standard anteroposterior and lateral radiographs were made at the time of the latest follow-up evaluation in order to assess union, alignment, and arthrosis of adjacent joints of the midfoot and hindfoot.
Statistical analysis was performed with use of the Spearman correlation coefficient test to evaluate the correlation between various factors and the clinical result.
The mean duration of follow-up was six years (range, two to fifteen years). At the time of the latest follow-up, ten patients had no pain, four had mild pain, two had moderate pain, and three had severe pain. Eight patients had no limitation in recreational or daily activities, one had limitation in recreational but not daily activities, four had limitation in recreational and daily activities, and six had severe limitation of nearly all activities. Fifteen patients could walk more than six blocks; none, four to six blocks; and four, less than four blocks. Seven patients could use any type of footwear, one could wear some but not all types of fashionable shoes, nine could not wear any fashionable footwear, and two had to wear modified shoes or a brace. No patient needed to use walking aids. The range of tibiopedal sagittal motion averaged 10.5 degrees (range, 2 to 20 degrees). None of the ten patients who were examined clinically had an obvious limp. Two patients had malalignment in plantar flexion of more than 5 degrees from the neutral position but were able to stand with the foot in a plantigrade position, and the remainder had satisfactory alignment. All patients had restricted motion of the subtalar joint.
In Group I, the clinical result was excellent in two patients and fair in one. In Group II, the clinical result was excellent in five patients, good in six, fair in two, and poor in three. The three poor results were due to a non-union. Another patient had a delayed union (treated with electrical stimulation) and painful degenerative arthrosis of the midfoot that had been present before the operation. These four patients were dissatisfied with the result, whereas the other fifteen patients were satisfied.
Four of the nineteen patients had a complication. One patient (who had a fair result) had a tibial stress fracture through one of the external fixation pin-holes; this was treated successfully with protected weight-bearing. Another patient (who had a poor result) had an infection at the site of a non-union that necessitated multiple revision operations. Two patients (both of whom had a poor result) had malalignment in plantar flexion.
Mild degenerative arthrosis was noted in the talonavicular joint in four patients (one of whom had had it preoperatively), and moderate arthrosis of the naviculocuneiform joint was noted in one patient (who had had it preoperatively). Severe arthrosis of the hindfoot or midfoot was not noted in any patient postoperatively. Union occurred in all three ankles in Group I, and it occurred in thirteen of the sixteen ankles in Group II but it was delayed in one of them. The three remaining ankles in Group II had a non-union. Factors that were thought to contribute to non-union were use of tobacco in one patient, diabetes mellitus in one, neuropathy in one, and a history of infection in two.
The mean age of the patients who had a successful (excellent or good) clinical result was thirty years compared with forty-four years for those who had an unsuccessful (fair or poor) result. The median interval from the injury to the index arthrodesis did not differ appreciably between the patients who had a successful result and those who had an unsuccessful result (1.3 compared with 1.8 years). Seven of the twelve men had a successful result compared with six of the seven women. Three of the five patients who had not had a previous operation had a successful result compared with ten of the fourteen patients who had had a previous operation. The mean weight of the thirteen patients who had a successful result was 76.5 ± 10.8 kilograms compared with 91.3 ± 14.5 kilograms for the six who had an unsuccessful result. Weight correlated significantly with the clinical result (Spearman correlation coefficient, r = 0.65).
There have been few reports of the results of operative treatment of arthrosis of the ankle and avascular necrosis of the talus, and most of those that have been published have involved patients who had an acute fracture1,2,4,10,12,13. Blair used a distal tibial inlay graft without fixation in two patients who had an acute fracture. At the time of follow-up (minimum, four months), both fractures had united. In 1971, Morris et al. modified the procedure by placing a screw in the tibial inlay graft and using a longitudinal Steinmann pin13. Four of their ten patients had a talar fracture with avascular necrosis, and six had an acute fracture. Seven had an excellent result and three, a good result. Morris later reported a successful result, at a minimum of two months, for four patients who had the modified Blair procedure for the treatment of a fracture and osteonecrosis12. Dennis and Tullos reported that, of seven patients who had had the Blair procedure for a talar injury, four had union and five had a good clinical result at a mean of four years. In 1982, Lionberger et al. described arthrodesis of the distal aspect of the tibia to the talar neck with use of a pediatric hip-compression screw. Of five patients who were followed for a mean of one year, one had a delayed union. Canale and Kelly reported on seventy-one fractures through the neck of the talus. Two fractures were treated with the Blair procedure, and both patients had a poor result. Russotti et al. described the results of arthrodesis in twenty-one patients who had various diagnoses, including four who had osteonecrosis. Although the results for these four patients were not specifically stated, most of the patients in the series had union.
In patients who have necrosis of a portion or all of the talar body with arthrosis of the ankle only (Group I), it is appropriate to limit the arthrodesis to the tibiotalar level and thus to preserve as much function of the hindfoot as possible. The use of external fixation is appealing because at least two fixation pins can usually be inserted transversely through the talus, whereas the talar bone defect and the poor osseous quality of the osteonecrotic talus may not provide adequate purchase for compression screws. Although we currently prefer to use internal fixation with compression screws, an external device is often necessary for adequate fixation. It was not the objective of the present study to compare types of fixation, but this could be done in the future. We did not specifically study the relationship between the amount of osteonecrotic bone and union because the necrosis involved the anterior, posterior, medial, and lateral zones of the talar body and not the head-and-neck zone in all patients.
We recommend arthrodesis with preservation of the talar body for patients who have osteonecrosis of the entire talar body with arthrosis of the ankle and the subtalar joint (Group II). There is little shortening of the lower extremity after this procedure, and the alignment, overall appearance, and gait pattern are nearly normal. Although other authors10,13 have advocated resection of the talar body when performing an operation such as the Blair tibial sliding-graft procedure, we have concerns regarding the long-term mechanical effect of overloading the remaining anterior and middle facets of the subtalar joint. Loads of three to four times body weight occur in the ankle joint during normal walking20, and the loads in the subtalar joint are similar. Sangeorzan et al., in a study of simulated, displaced fractures of the talar neck in cadavera, noted that the contact area of the posterior facet and the combined anterior and middle facets changed substantially. This suggests that resection of the entire talar body also would substantially change the contact characteristics of the remaining combined anterior and middle facets and therefore would increase the likelihood of degenerative arthrosis. Patients who have arthrosis of the ankle and the subtalar joint as well as osteonecrosis of the entire talar body, with little of the talar body remaining, can be managed with removal of the body and tibiocalcaneal arthrodesis (as were two patients in the present study).
In our study, the external fixation devices were removed when there was radiographic evidence of union, such as trabeculation across the site of the arthrodesis. The duration of fixation was generally longer than it is when arthrodesis is performed in patients who do not have osteonecrosis17.
Most of our patients had a successful clinical result, with a relatively high rate of union (sixteen of nineteen), despite the complex nature of their problems, which included numerous previous operations and associated medical conditions. The patients varied in terms of the extent of osteonecrosis and the number of joints affected by arthrosis, primarily because of the many possible variations of the osseous and soft-tissue injuries. We therefore believe that the operative technique should be chosen on an individual basis for patients who have osteonecrosis and arthrosis. The median interval between the injury and the index operation was twenty-one months, suggesting that some revascularization of the talus may have occurred.
Arthrodesis in patients who have arthrosis and talar osteonecrosis may be successfully accomplished with use of bone graft spanning the affected joints and rigid fixation. The results of this study indicate that external fixation and bone-grafting was effective for ankles that had evidence of osteonecrosis of the body of the talus. Our findings also support the use of different techniques of arthrodesis depending on whether the ankle alone or both the ankle and the subtalar joint are involved.
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