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Structural bone graft can be used to convert failed ankle arthroplasty to fusion
However, investigator notes that despite union, functional improvement remained modest.
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Recent research shows that incorporating large structural bone grafts can lead to high union rates in patients with failed total ankle replacements converted to ankle or extended hindfoot fusions using internal fixation.
“We have demonstrated the efficacy of structural allograft to fill even large bone defects and illustrated several successful techniques for internal fixation,” Mark J. Berkowitz, MD, said during his presentation at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS).
“Importantly, despite successful union, functional improvement remains modest, particularly in the extended hindfoot fusions. This fact emphasizes the importance of preserving the subtalar joint whenever possible, both as a means of improving function, as well as decreasing complications.”
Retrospective review
Berkowitz and his colleagues retrospectively reviewed the charts of 24 patients who had failed total ankle replacements that were converted to either an ankle-only fusion or a combined ankle and subtalar fusion. All 12 patients in the ankle only fusion group had anterior plate and screw fixation, and 10 patients received structural bone grafts.
All patients in the extended hindfoot fusion group had structural allografts with nine patients receiving femoral head allografts that were prepped using an acetabular reaming technique. Surgeons used intermedullary (IM) nails, anterior plates or a combined nail and plate construct in the hindfoot fusion group. Overall, the patients had an average follow-up of 49.5 months.
The investigators discovered one nonunion and two late soft-tissue complications in the ankle fusion group. In the extended hindfoot group, they found three subtalar nonunions and one nonunion between the femoral head allograft and the base of the talar head. However, Berkowitz noted that all of these patients eventually achieved union.
Function, union
A comparison of preoperative and postoperative AOFAS Ankle-Hindfoot and Maryland Foot Scores revealed a statistically significant improvement in the ankle fusion group, but not in the hindfoot fusion group. The investigators also found no significant differences between the groups regarding their postoperative scores.
Berkowitz said that subtalar nonunions in the extended hindfoot fusion group were of concern and cautioned that surgeons used a single anterior approach and IM nails in all of these cases.
In addition, he recommended using stronger plate fixation for ankle-only procedures and noted that the only nonunion in this group received a pelvic reconstruction plate.
For more information:
- Mark J. Berkowitz, MD, can be reached at St. Joseph’s Hospital, 13020 North Telecom Parkway, Temple Terrace, FL 33637; 813-978-9700; e-mail: mark.j.berkowitz@gmail.com. He has no direct financial interest in any product or company mentioned in the article.
Reference:
- Berkowitz MJ, Walling A, Sanders RW, et al. The salvage of failed total ankle arthroplasty with conversion to ankle or extended hindfoot fusion: Results and techniques for managing massive talar bone defects. Presented at the 25th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society. July 15-18, 2009. Vancouver, British Columbia.