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We 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 methods
Retrospective 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.
Results
Mean 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.
Conclusion
Transfibular 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.
Ankle arthrodesis is a time tested traditional procedure for patients, having end stage ankle arthritis and involved in heavy labour specially in developing countries as it allocates painless, plantigrade, and stable foot while arthroplasty has been considered priority in patients having light or moderate activities.
Although ankle arthroplasty has gained popularity in recent years, whereas the detrimental effects of post operative complications as well as revision surgeries as a sequalae are well described in literature.
Results of total ankle arthroplasty vs tibiotalar fusion (ankle arthrodesis) in patients with ankle osteoarthritis since 2006 to 2020- A systematic review.
There are numerous methods described for ankle arthrodesis including external fixators, plate or screw arthrodesis, intramedullary nailing and strut bone graft arthrodesis, depending upon bone quality, skin condition and patient's physiological profile. We performed ankle arthrodesis using transfibular approach with sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting). The purpose of the present study is to evaluate radiological and functional outcomes of ankle arthrodesis with this technique, performed in end stage ankle arthritis.
2. Material and Methods
The present retrospective study was conducted in a tertiary care apex centre from January 2009 to December 2019 with permission of institutional review board. Total of 39 patients were recruited for the study and three patients were lost to follow up which were excluded; hence 36 patients were included for the study. Informed and written consent was obtained from all the patients before interventions and consent was obtained from all the patients for enrolment into present study. All the patients aged between 18 and 50 years, who had presented with end stage arthritis or arthritis of grade 3 or more with primary ankle arthritis or secondary arthritis due to post-traumatic, inflammatory pathology, sequalae of tuberculosis or infective pathology and failed ankle arthrodesis were included. Patients having desensate foot, Charcot's joint, failed ankle replacement and subtalar or multiple joint involvements were excluded from the study. Demographic profile of patients including age, sex, affected limb side and associated underlying diseases were documented.
Clinico-radiological evaluation was done at different follow up duration at 3, 6, 12 months and final follow-up at 2.5 years. Clinically, patients were evaluated for duration of surgery, implant used, associated bone grafting or any additional procedure, surgical complications including malunion and non-union. Serial radiographs in both antero posterior (AP) and lateral views were done for assessment of implant position, arthrodesis union, implant-bone alignment, graft incorporation and ankle alignment. Clinically, union was considered once ankle became pain free on full weight bearing and maintained up to 5° valgus alignment in coronal plane.
Radiologically, sagittal ankle alignment at final follow up was determined meticulously at final follow up. For sagittal plane alignment, in a weight bearing lateral radiograph of ankle, mid diaphyseal reference points were marked at 5 cm and 10 cm from the tibial articular surface and first line was drawned joining these two points. The second line was drawned joining inferior most point of calcaneus and medial sesamoid. The angle between the two lines were calculated. If the angle is more than 90° then ankle is in planter flexion (PF) and if less than 90° then ankle is in dorsiflexion (DF). The PF and DF angles are subsequently calculated. Coronal plane alignment was measured with a clinical photograph obtained from behind. Bony union was considered adequate once cancellous bone graft incorporated with parent bone or disappearance of any lucency between tibial and talar bone ends in both described views. Radiological union or incorporation of fibular strut graft with ankle joint were also assessed in radiographs at 3, 6, 12 months and final follow up at 2.5 years. 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 excluding ankle joint movements due to fused ankle joint. Total maximum score considered 92 instead of 100 due to fused ankle joint (8 points) while functional results considered excellent (80–92), good (70–79), fair (60–69) and poor (<60). AOFAS score was measured pre operatively and compared with scores post operatively and at final follow up.
3. Operative procedure
All the surgical interventions were performed under regional or general anaesthesia. Limb was positioned supine over operative table. Lateral exposure of ankle and lower leg was done over the fibula extending from lower end of lateral malleolus distally to 5 cm far from syndesmosis proximally (Fig. 1A, Fig. 1BA,B ). The fibula was osteotomised 2 inch above the syndesmosis and prepared by cleaning its soft tissue attachments. The fibula is osteotomised in distal third and retrieved (Fig. 2A, Fig. 2BA,B ). Cartilage of the articular surfaces of the tibia and talus were curetted to get raw subchondral bone. A midline symmetrical sagittal split is made in the osteotomised fibula by using 2 mm small drill bit, sharp ended osteotome and battery driven bone saw blade (Fig. 3A). One half of this split was morcellised and grafted in between tibio talar joint surface that was peeled off articular cartilage. Other half of the fibula is fixed laterally with screws to tibia and talus (Fig. 3B) to create a strut lateral column. Raw prepared bony surfaces were fixed and compressed by using 3 to 4, canulated cancellous (CC) screws (6.5 and 4.5 mm) and bone graft, while kept ankle in neutrally aligned or in 5° valgus with plantigrade foot (Fig. 4A, Fig. 4BA,B ). Wound closure was done meticulously to avoid any skin stress and necrosis while limb was immobilized with above knee POP slab over the compression bandage dressing for 2 weeks. Wound inspection was done on post-op day 2 and day 5 while suture removal was done at 2 weeks. Patients were evaluated clinically and radiologically at each follow-up. At final follow up, radiographs of ankle AP view (Fig. 5A) and lateral view (Fig. 5B) showing successful union of arthrodesis (Fig. 5A, Fig. 5B). Schematic line diagram of surgical technique is illustrated in Fig. 6.
Fig. 1ASurface marking of surgical incision site over the fibula extending from lower end of lateral malleolus distally to 5 cm far from syndesmosis proximally.
Patient was mobilised at 2 weeks with help of below knee walking cast and only non-weight bearing allowed up to 6 weeks followed by partial weight bearing up to 12 post-op weeks with the same cast or with functioning walking brace. Walking cast removed at 12 weeks and ankle was evaluated clinico-radiologically for union and functional outcomes. Patients were allowed full weight bearing mobilisation once radiological consolidation was achieved and ankle became pain free. Patients were encouraged and advised active physiotherapy and movements of subtalar and other foot joints.
5. Statistical analysis
All the relevant data were documented in commercially available spreadsheets application of Microsoft, Inc; excel software and analysed accordingly using program Windows IBM® SPSS® Statistics version 20. Quantitative variables were measured by the mean and standard deviation (mean ± SD) while comparative evaluation of variables at different point of times was done with chi-square test. P value < 0.05 was considered as statistically significant.
Results: Male to female ratio was around 1.5:1 with 17 males (61%) and 11 females (39%). Mean age of presentation at intervention was 40.36 ± 10.56 years (range 18–55) and right ankle was affected in 23 cases followed by 13 cases in left ankle. Patients were evaluated clinico-radiologically for mean duration of 33.32 ± 11.25 months (range 24–65) up to the final follow-up. Most of the ankles were fused over the time (91.7%) and mean duration for bony union/fusion was 5.09 ± 1.3 months (range 4–9 months). There was non-union in only three cases (8.3%). We observed mean post-operative AOFAS score at final follow up of 76.65 ± 4.87, in comparison to 45.76 ± 3.38, preoperatively, while functionally presented excellent, good, fair and poor in 15, 13, 5 and 3 patients respectively. We also noted significant improvement in pain from pre intervention to post-operative period at the final follow up (pre op VAS, 7.8 to post op VAS, 2.3). Summary of the demographic profile of patients and clinico-radiological evaluation results are tabulated in Table 1.
Table 1Demographic profile and clinico-radiological evaluation outcomes of patients managed with transfibular ankle arthrodesis.
S.N.
Total Pt 39, lost to follow-up 3, included 36 (male 21, female 15)
in 1942 and many authors have modified this approach by varying parameters including method of fixation, screw number and placement and pattern of bone grafting. Surgical success of ankle fusion depends upon adequate exposure, bone quality or surfaces, soft tissue status as well as viability and internal stability with fixation mode. Various surgical approaches (anterior, medial, lateral transfibular, combined and arthroscopic etc.) have been described for ankle fusion.
The anterior approach allows excellent visualisation of ankle joint but posterior aspect of joint is poorly visualised for preparation of articular cartilage and greater chance of superficial peroneal and anterior tibial neurovascular bundle injury.
The medial approach allows good visualisation to posterior medial and anterior medial aspect of ankle but extreme lateral joint visualisation is poor. The transfibular approach has its own merits. It allows excellent visualisation of lateral aspect of ankle and by the use of lamina spreaders, the medial joint space can also be adequately inspected and prepared without compromise soft tissues, thus allowing 360° preparation of joint surface that results in adequate fusion. Hence, adequate correction of ankle deformities is easily possible by this approach. Most of the cases (91.6%) in the present series had undergone bony union at 6 months that strengthen this fact. A few authors prefer combined medial and lateral transfibular approach
for better access to the joint but we did use lamina spreaders only to access medial side and we believe that adding a medial incision increases only surgical morbidity specially in scenario of developing countries. The lateral transfibular approach also have its advantage of having better surgical wound healing than other approaches around ankle. The well-formed musculature at lateral aspect of ankle has a better wound healing potential. The medial side of ankle due to its poor muscular envelop, frequently complicated by wound gaping leading to need of additional procedures for coverage. Transfibular approach also have excellent potential for correction of deformity as the ankle joint, subtalar joint as well as sinus tarsi are well exposed. There are also advantages of minimal shortening, and wide articular surface contact area resulting in increased stability.
The pivotal role of bone grafting in arthrodesis healing should not be underestimated as it provides stability as well as vitality to diseased bone ends at the compression site. Pioneer study by Adams et al.
documented >90% union rates after removal of lower end of fibula and used it as onlay bone graft after preparing its medial surfaces raw by removing cartilage and soft tissue. Our technique described incorporation of sagitally split osteotomised fibula as cancellous inlay morcellised bone graft in between talus and tibial surfaces so there is no need of harvesting iliac crest graft thus reduced graft site morbidity. Additionally, other half of sagittaly split fibula used as onlay strut graft after refreshing its medial surface by removing syndesmotic tissue and cartilage that reinforce the arthrodesis construct and provide additional lateral stability. This is an unique advantage of the transfibular approach.
The ideal hardware construct for ankle arthrodesis is yet to be decided. External fixators have a high complication rate.
Most commonly, cancellous screws are used for ankle arthrodesis but successful use of lateral plate, anterior plate are also described in the literature.
compared crossed screws to anterior plating plus crossed screws. They have shown better results with use of combined anterior plating and crossed screws. We used only cannulated cancellous screws that achieved successful union in a favourable biological environment of adequate joint surface preparation and fibular onlay bone grafting.
Analysing the AOFAS score at final follow up among subgroup of our patients, we concluded that patients with inflammatory arthritis have a less satisfactory outcome as they have poor bone stock and associated with deformities at other joints of hands, hips and knees. These patients also may experience diffuse somatic pain due to acute exacerbation of the systemic disease (3 cases), cannot wear fashionable shoes (2 cases) and cosmesis and thus non-union was of concern in one patient each. We experienced high superficial infection rate (3 among 4 superficially infected patients) in rheumatoid arthritis patients. Patient education regarding the post-surgical expectations is of paramount importance in this group of patients. Patients with previously operated but failed ankle arthrodesis also experienced a poorer outcome (Table 1).
There was smaller number of post-op complications with this technique including superficial infection in 4 cases only. Two patients responded well with additional oral antibiotics for five days while two patients needed intravenous antibiotics for five days according to culture sensitivity reports. There was no incidence of deep infection and no need of debridement and secondary procedure for wound care. We experienced total three cases of non-union. Out of which 1 case was failed previous arthrodesis having history of chronic smoking, one case was operated for rheumatoid arthritis and last one was operated for post traumatic arthritis having pervious history of open wound around distal third of leg. The assessment of fibula pre-operatively as well as intra-operatively has a major bearing to achieve fusion. Among three cases of non-union, two cases (except rheumatoid arthritis) had sclerotic distal fibula which was not functionally sufficient as bone graft. We also noted that AOFAS score of previously failed ankle arthrodesis was significantly low in comparison to other cases. These previously operated ankles had already compromised bone stock, poor soft tissue envelop and sclerotic fibula that was not favourable to be used as a graft. The sample size was too small in this group (previously failed ankle arthrodesis, 5 cases) to obtain a standard statistical analysis. But we personally think that using an autologous iliac crest graft may lead to better outcome in these selected cases. The non-union rate in our present study is 8.3% (3 cases) in comparison to reported mean rate of non-union of 12% in the literature (range 3–23%).
Arthroscopic ankle arthrodesis provides similarly satisfactory surgical outcomes in ankles with severe deformity compared with mild deformity in elderly patients.
We believe that meticulous articular surface preparation and meticulous bone grafting are two major determinants of fusion. Compression between articular surface is achieved by cannulated cancellous screws which we think are sufficient in a bone grafted stable biological environment. One patient among the inflammatory arthritis group had ankle malalignment for which redo surgery was performed two years after index surgery.
Limitations and strength: The study was conducted in a retrospective manner at tertiary care centre. All the surgeries were done by single senior orthopaedic experienced foot and ankle surgeon while post-operative evaluation was performed under his observation. We performed the same procedure in all the cases with satisfactory outcome that validated our technique. There were very less documented studies in literature so it may be used as reference study in future for similar profile of patients. The study has no randomization and any comparison group in study design and sample size was not estimated according to calculating power of study. The sample size is comparatively smaller but equal or larger than previous published study and have only mid-term (months) evaluation of outcomes. These limitations can be overcome with larger sample size with long term follow up or combining multicentral trials to conclude more efficiently.
Conclusion: Transfibular ankle arthrodesis with sagittaly split in lay and on lay fibula grafting seems to be an efficient and cost-effective technique for treatment of end stage ankle arthritis and comparable to other techniques. Clinico-radiological outcomes were satisfactory and there was a high rate of bony unions and adequate 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 operated for inflammatory arthritis have increased rate of dissatisfaction hence must be properly counselled before surgery.
Financial disclosure
Authors received no financial assistance to conduct the study or for publishing of the paper.
Consent
Written informed consent was taken before inclusion of the patients in the study.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
Agel J.
Coetzee J.C.
Sangeorzan B.J.
Roberts M.M.
Hansen ST Functional limitations of patients with end-stage ankle arthrosis.
Results of total ankle arthroplasty vs tibiotalar fusion (ankle arthrodesis) in patients with ankle osteoarthritis since 2006 to 2020- A systematic review.
Arthroscopic ankle arthrodesis provides similarly satisfactory surgical outcomes in ankles with severe deformity compared with mild deformity in elderly patients.
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