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Case report
Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases Mantu Jain a , Roop Singh b,∗ a b
Department of Orthopaedic Surgery, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India Department of Orthopaedic Surgery, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
a r t i c l e
i n f o
Article history: Received 1 August 2013 Received in revised form 2 March 2014 Accepted 4 March 2014 Keywords: Tibia Ankle Arthrodesis
a b s t r a c t Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Osteoarticular tuberculosis (TB) is an uncommon disease, and ankle TB is considered rare. It affects 5% of all osteoarticular tuberculosis [1,2]. Ankle TB often presents clinically as an insidious disease with local swelling, pain, heat, and numbness of the affected joint, but with limited systemic inflammatory manifestations which make it difficult to diagnose and many patients may receive inappropriate treatment [3]. Successful treatment depends on the extent of disease at presentation, accurate staging, duration of adequate chemotherapy, and optimal surgical intervention [4]. With modern imaging modalities, early diagnosis and proper treatment with multidrug chemotherapy gives good results in early tubercular arthritis. However, in late stage arthritis with severe destruction of joints and agonising pain, ankle arthrodesis is the traditional yet the gold standard method for treatment [5]. A variety of surgical approaches and fixation devices have been described in the literature for various indications of ankle fusion; but obtaining fusion is difficult and may be associated with complications [4,6–14]. Clinical and biomechanical trials have shown that rigid internal fixation during ankle arthrodesis leads to increased rates of union and is associated with a reduced infection rate, union time, discomfort and earlier mobilisation compared with other methods [4,8,9,15].
∗ Corresponding author at: 52/9-J, Medical Enclave PGIMS, Rohtak 124001, Haryana, India. Tel.: +91 1262 213171; fax: +91 1262 211308. E-mail address: [email protected] (R. Singh).
We describe a technique which involves internal fixation with an “anteriorly placed bridging plate reinforcing the corticocancellouus trapezoidal bone graft” obtained from ipsilateral tibia. Our aim was to assess the outcome and complications using this technique in severe tubercular ankle arthritis. 2. Operative technique Under spinal anaesthesia with patient in supine position, a highthigh pneumatic tourniquet is applied to the diseased extremity. A longitudinal skin incision placed 1 cm medial to the midline, a zigzag/spiral incision is made through the extensor retinaculum, which facilitates repair when closing the wound. The joint surfaces are removed with osteotome and a trapezoidal trough is created in the lower end of tibia and talus using the oscillating saw (Fig. 1a). The malleoli are preserved; only their inner surface and corresponding part of the talus is roughened with the same saw. A separate antero-medial incision is given in the ipsilateral tibia just below the tibial tuberosity and the medial aspect of proximal tibia exposed. With the oscillating saw a cortico-cancellous bone is removed just enough to fill the trough in the lower tibia and talus (Fig. 1b). The harvested graft is fitted in the trough with final position of the joint surfaces – the foot in neutral flexion, 0–5◦ hind foot valgus and external rotation equal to the opposite side if normal, or 5–10◦ if abnormal (Fig. 1c). A plate (L plate or a 4.5 narrow dynamic compression plate) is contoured and used in bridging fashion fixed proximally to tibia and distally to tarsal bones with the graft just under the plate to prevent it from slipping out (Fig. 1d). Usually the construct is stable but when the bones are osteoporotic like in one of our tubercular patients, we added another screw to fix the graft
http://dx.doi.org/10.1016/j.foot.2014.03.002 0958-2592/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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Fig. 1. (a) Intraoperative photograph showing anteriorly placed trapezoidal trough. (b) The harvested cortico-cancellous graft from ipsilateral tibia. (c) The graft placed in the trough and ankle positioned for fusion. (d) The plate in situ.
to the bones via the plate. The gap between the malleoli and talus is filled with bones removed from trough. If more cancellous bone is required, the same can be curetted out from the upper tibia. An intraoperative C-arm is used to check the placement and length of the screws and to ensure that the subtalar joint is spared. The wound is closed in layers. Postoperatively, the patients are given a below knee plaster slab which is converted to cast on their first visit for stitch removal. No weight bearing is allowed for initial 6–8
weeks on the operated limb (ankle fusion + ipsilateral proximal tibia donor site) and then gradual incremental loading is allowed on this limb till there is radiological evidence of fusion. No such restrictions are put on the other unoperated limb. Both illustrative case of ankle arthrodesis are presented in Figs. 1 and 2. Patients were evaluated finally at one year both clinically and radiologically. Mazur ankle scoring was done at base line and at one year follow-up [16].
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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Fig. 2. X-rays of case no. 1. (a) Pre-op X-ray shows severe post-tubercular osteoarthritis of the ankle. (b) Post-operative X-ray of graft harvested site. (c) Post-operative lateral X-ray of ankle and (d) post-operative antero-posterior X-ray view of foot. (e) Post-operative antero-posterior X-ray view of ankle.
3. Case reports 3.1. Case 1 A 52-year-old male, priest by profession with history of contact with tuberculosis presented with a 2-month history of swelling, pain and functional disability of his right ankle. On physical examination, his right ankle was tender, bulged, and had a limited painful range of motion. There was no history of trauma in the past medical history. Laboratory findings show an elevated erythrocyte sedimentation rate (ESR) of 68 mm at first hour (Wintergreen method), a positive CRP test and white blood cells at 9000 predominantly lymphocytes. The Mantoux skin test was negative. Anteroposterior (AP) and lateral radiographs of the left ankle showed an extensive irregular lytic lesion of the tibial plafond and talar bone, without the involvement of other tarsals (Fig. 2). The chest X-ray was normal. The histological examination of the biopsy sample showed granuloma and central caseating necrosis confirming tuberculosis. The patient received ATT for nine months and improved but had residual pain in the ankle. He was offered arthrodesis using our technique with anterior trapezoidal corticocancellouus bone graft and bridging L plate. One year postoperatively he was completely relieved of pain and back to pre-disease status with only mild occupational restriction. Radiologically sound ankle fusion was observed in 14th week. The pre-treatment Mazur ankle score improved from 22 to 84 and the patient was satisfied with the outcome. 3.2. Case 2 A 38-year-old manual labourer male was admitted with a 5month history of swelling, severe pain in right ankle making him unable to earn his daily living. Clinical examination showed tender ankle, with boggy swelling, and painful limitation of movement. He had history of pulmonary tuberculosis successfully treated 10 years back. Laboratory findings show an elevated ESR of 64 mm/first
hour, a positive CRP test and white blood cells at 11,000 predominantly lymphocytes. Anteroposterior (AP) and lateral radiographs of the left ankle showed severe osteoporosis, and reduced joint space. The chest X-ray was normal. A closed needle biopsy confirmed tuberculosis. The patient started on ATT and 2 months in the course of treatment had ankle arthrodesis using our technique using anterior bone graft and bridging plate. The tibialis anterior tendon was transferred to 3rd metatarsal for dynamic correction. Radiologically sound ankle fusion was observed at the 17th week. The pre-treatment Mazur ankle score improved from 16 to 78 and the patient was satisfied with the outcome (Fig. 3). 4. Discussion Arthrodesis is the most common procedure used to treat endstage osteoarthritis of the ankle, particularly in patients with difficult conditions such as poor bone quality [15]. It is a challenging procedure that must be undertaken with care in order to provide the best possible outcome [17]. While post traumatic arthrosis remains the most common indication for this surgical procedure in various reported series, tuberculosis is the leading cause in India and some other parts of the world where the disease is common. The symptoms of osteoarticular tuberculosis are nonspecific and often indolent, including pain, joint swelling, or reduced range of motion. Subsequently, there may be delays in diagnosis and therapy, with progression to bone and joint destruction and deformities [18]. Both of our patients had severe pain, bone destruction and deformities. Achieving painless sound fusion requires a thorough debridement with removal of all caseous necrotic tissue which leaves a void in the area. This needs to be filled up with an anterior bone graft and secured with rigid fixation to achieve fusion. Ansart was first to use the anterior bone graft for arthrodesis in paralytic deformity way back in 1951 and he immobilised with plaster cast, however it was associated with graft fractures [19]. Charley popularised external fixation devices to achieve compression across the fusion site, but they do not give rigid fixation [10],
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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Fig. 3. X-rays of case no. 2. (a) Pre-op X-ray shows severe post-tubercular osteoarthritis of the ankle. (b) Lateral view X-ray post fusion. (c and d) Anteroposterior and lateral X-ray views of ankle after removal of implant shows good fusion. (e) Antero-posterior X-ray view of foot post implant removal.
have their own drawbacks, and are cumbersome thus unpopular with patients. Internal fixation devices with the crossed screws have been used with reported fusion rate ranging from 40% to 97% [20–22]. In advanced osteoarticular tuberculosis the bone is osteoporotic and this method may compromise the fixation [11]. Intramedullary nails have been used for arthrodesis in tuberculosis of the ankle [11,13]. Gavaskar et al. have used intramedullary nailing in 7 of their patients with tubercular arthritis to obtain tibiotalocalcaneal fusion. They used manual pressure to obtain compression precluded use of bone graft and achieved union in all [11]. Enriquez et al. reported arthrodesis of the ankle with transcalcaneal nail. The patient did well, arthrodesis occurred at 8 weeks with proper function [13]. Yoshida et al. described arthroscopically assisted ankle fusion in two cases of tuberculosis of the ankle. They used vascularised iliac bone graft in one and osteocutaneous flap in another; and reported good satisfactory results [12]. Tang et al. reported that arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications [14]. Anterior bridge plating has been used for ankle arthrodesis to treat end-stage osteoarthritis of various etiologies. Fixation with T plate was used by Scranton et al. who used them medially and later Rowan et al. advocated anterior placement concluding that such a construct provides better fixation than the either medial/lateral plate; and bilateral plating was associated with more postoperative complications [23,24]. Cheng et al. have used an anterior T plate in one of their cases with severe bone loss and non-union [25]. More recently Mohamdean et al. in their series of 29 of their patients (none of them were tubercular) reported that ankle arthrodesis using an anteriorly placed narrow DCP was a good method to achieve ankle fusion in many types of ankle arthropathies. [8].They used iliac crest autograft in 2 of their patients of old pilon fracture with bone defect. Mears et al. have suggested that the pull of the tendo Achilles posteriorly adds to the compression across the
ankle when combined with anterior fixation [17]. Anterior bridge plating has been reported as an effective fixation technique in tibiocalcaneal arthrodesis, especially in complex hindfoot reconstructions with bone loss or deformity [26]. Plate fixation appears to be a better way to achieve fixation as it increases ankle arthrodesis construct rigidity and union rate [7,9]. Guo et al. reported that the application of an anatomically contoured plate provide many advantages, including less soft tissue disruption by using a single anterior incision, ease of deformity correction, early rehabilitation, and high rate of union [7]. Tubercular arthritis poses some unique problems. The bones are diseased and osteoporotic and hence have poor purchase for the screws. Anterior approach is commonly used to open the ankle to debride and remove the necrotic, avascular debris and open up new vascular channels to promote fusion creating a void. We have used the same incision for our fixation device and to get hold in the non affected bones using the plate in bridging fashion. The supplemented corticocancellous graft acts as a strut to give structural support, prevent collapse/shortening and enhance bony fusion. Since the graft sits properly in the created trough; thus wound healing problems are avoided. Plaass et al. reported that anterior double plating system was a reliable method to achieve solid isolated tibiotalar arthrodesis, even in ankles with difficult conditions such as loss of bone stock due to failed total ankle arthroplasty [15]. Similar to our results, they also did not encounter any complications with the procedure of anterior bridge plating [15]. Guo et al. also reported no postoperative wound problems and infections in ten ankle arthrodeses [7]. In foot and ankle surgery, there are multiple sites used for autologous bone graft, including the proximal or distal tibia, calcaneus, and iliac crest. Recently it has been reported that lowerextremity bone graft sites had the greatest risk for persistent pain at 1 year [27]. We did not encounter donor site pain problem in both of our cases. Our post operative protocol of plaster support for 6 weeks gives time for donor site (ipsilateral proximal tibia) to consolidate. Fusion was assessed both clinically and radiologically
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before starting weight bearing to avoid pathological fracture at donor site and implant/fusion failure. Long term follow up of arthrosed ankles have shown alternation in gait [28] and increased stress due to abnormal mobility in the nonfused tarsal joints leading to degenerative changes [29,30]. We have removed the implants in case no. 2 after adequate fusion, as this patient developed mild mid foot pain. Implants need not to be removed if patient does not have mid foot pain/arthritis/or hindrance with midtarsal joints movements. The surgical technique which we have described is simple and easily reproducible. It led to fusion in both of our cases. However; we believe future investigations with larger sample sizes and longer follow-up periods would be helpful in determining the high rate of fusion and to highlight any late complications. Indeed, we feel that this simple, reproducible technique with the satisfactory clinical outcome is a viable alternative to the existing open approaches to ankle arthrodesis particularly in osteoporotic bones. The technique can be extended to include fusion of the subtalar joint and other tarsal joints and necessarily modified for partial/complete talectomy. Conflict of interest None. References [1] Tuli SM. Tuberculosis of the skeletal system. 3rd ed. New Delhi: Jaypee; 2010. p. 127–34. [2] Choi WJ, Han SH, Joo JH. Diagnostic dilemma of tuberculosis in the foot and ankle. Foot Ankle Int 2008;29:711–5. [3] Chen SH, wong T, Lee CH. Tuberculous Ankle versus pyogenic septic arthritis a retrospective coparison. Jpn J Infect Dis 2011;64:139–42. [4] Chen SH, Lee CH, Wong T, Feng HS. Long-term retrospective analysis of surgical treatment for irretrievable tuberculosis of the ankle. Foot Ankle Int 2013;34(3):372–9. [5] Inoue S, Matsumoto S, Iwamatsu Y, Satomura M. Ankle tuberculosis: a report of four cases in a Japanese hospital. J Orthop Sci 2004;9(4):392–8. [6] Fattouh M, Hafez AR, Ahmed ZH. Diagnosis and treatment of ankle tuberculosis in Sohag University Hospital. J Am Sci 2012;8(6):348–52. [7] Guo C, Yan Z, Barfield WR. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int 2010;31:492–8. [8] Mohamdean A, Said HG, Sharkawi M, Adly WE, Said GZ. Technique and short term results of ankle arthrodesis using anterior plating. Int Orthop 2010;34(6):833–7.
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[9] Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 2007;28(2):219–23. [10] Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91. [11] Gavaskar AS, Chowdary N. Tibiotalocalcaneal arthrodesis using a supracondylar nail for advanced tubercular arthritis of ankle. J Orthop Surg 2009;17(3):321–4. [12] Yoshida T, Sakamoto A, Iwamoto Y. Vascularized iliac bone graft in cases of ankle tuberculosis. J Reconstr Microsurg 2009;25(2): 125–31. [13] Enriquez CJ, Lopez VA, Molina MJ, Macias CC, Echeverria BS. Osteoarticular tuberculosis of the ankle, arthrodesis with transcalcaneal nail. Case report. Acta Ortop Mex 2006;20:210–3. [14] Tang KL, Li QH, Chen GX, Guo L, Dai G, Yang L. Arthroscopically assisted ankle fusion in patients with end-stage tuberculosis. Arthroscopy 2007;23:919–22. [15] Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Foot Ankle Int 2009;30(7):631–9. [16] Mazur JM, Scwartz E, Simon SR. Ankle artodesis: long term follow up with gait analysis. J Bone Joint Surg 1979;61A:964–75. [17] Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior tension plate. Clin Orthop 1991;268:70–7. [18] Bozkurt M. Isolated medial cuneiform tuberculosis: a case report. J Foot Ankle Surg 2005;44:60–3. [19] Ansart MB. Panarthrodesis for paralytic flail foot. J Bone Joint Surg Br 1951;33B:503. [20] Dohm M, Purdy BA, Benjamin J. Primary union of ankle arthrodesis: review of a single institution/multiple surgeon experience. Foot Ankle Int 1994;15: 293–6. [21] Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg Am 1985;67-A:546–50. [22] Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using an arthroscopic method: long-term follow-up of 34 cases. Arthroscopy 1996;12:428–34. [23] Scranton Jr PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67-A:550–5. [24] Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg Br 1999;81-B(1):113–6. [25] Cheng YM, Chen SK, Chen JC, Wu WL, Huang PJ, Chiang HS, et al. Revision of ankle arthrodesis. Foot Ankle Int 2003;24(4):1–5. [26] Chodos MD, Parks BG, Schon LC, Guyton GP, Campbell JT. Blade plate compared with locking plate for tibiotalocalcaneal arthrodesis: a cadaver study. Foot Ankle Int 2008;29:219–24. [27] Baumhauer J, Pinzur MS, Donahue R, Beasley W, DiGiovanni C. Site selection and pain outcome after autologous bone graft harvest. Foot Ankle Int 2013, http://dx.doi.org/10.1177/1071100713511434 [on line first]. [28] Muir DC, Amendola A, Saltzman CL. Long-term outcome of ankle arthrodesis. Foot Ankle Clin 2002;7:703–8. [29] Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83A:219–28. [30] Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br 2003;85B:994–8.
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
ARTICLE IN PRESS
YFOOT-1310; No. of Pages 5
The Foot xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case report
Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases Mantu Jain a , Roop Singh b,∗ a b
Department of Orthopaedic Surgery, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India Department of Orthopaedic Surgery, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
a r t i c l e
i n f o
Article history: Received 1 August 2013 Received in revised form 2 March 2014 Accepted 4 March 2014 Keywords: Tibia Ankle Arthrodesis
a b s t r a c t Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Osteoarticular tuberculosis (TB) is an uncommon disease, and ankle TB is considered rare. It affects 5% of all osteoarticular tuberculosis [1,2]. Ankle TB often presents clinically as an insidious disease with local swelling, pain, heat, and numbness of the affected joint, but with limited systemic inflammatory manifestations which make it difficult to diagnose and many patients may receive inappropriate treatment [3]. Successful treatment depends on the extent of disease at presentation, accurate staging, duration of adequate chemotherapy, and optimal surgical intervention [4]. With modern imaging modalities, early diagnosis and proper treatment with multidrug chemotherapy gives good results in early tubercular arthritis. However, in late stage arthritis with severe destruction of joints and agonising pain, ankle arthrodesis is the traditional yet the gold standard method for treatment [5]. A variety of surgical approaches and fixation devices have been described in the literature for various indications of ankle fusion; but obtaining fusion is difficult and may be associated with complications [4,6–14]. Clinical and biomechanical trials have shown that rigid internal fixation during ankle arthrodesis leads to increased rates of union and is associated with a reduced infection rate, union time, discomfort and earlier mobilisation compared with other methods [4,8,9,15].
∗ Corresponding author at: 52/9-J, Medical Enclave PGIMS, Rohtak 124001, Haryana, India. Tel.: +91 1262 213171; fax: +91 1262 211308. E-mail address: [email protected] (R. Singh).
We describe a technique which involves internal fixation with an “anteriorly placed bridging plate reinforcing the corticocancellouus trapezoidal bone graft” obtained from ipsilateral tibia. Our aim was to assess the outcome and complications using this technique in severe tubercular ankle arthritis. 2. Operative technique Under spinal anaesthesia with patient in supine position, a highthigh pneumatic tourniquet is applied to the diseased extremity. A longitudinal skin incision placed 1 cm medial to the midline, a zigzag/spiral incision is made through the extensor retinaculum, which facilitates repair when closing the wound. The joint surfaces are removed with osteotome and a trapezoidal trough is created in the lower end of tibia and talus using the oscillating saw (Fig. 1a). The malleoli are preserved; only their inner surface and corresponding part of the talus is roughened with the same saw. A separate antero-medial incision is given in the ipsilateral tibia just below the tibial tuberosity and the medial aspect of proximal tibia exposed. With the oscillating saw a cortico-cancellous bone is removed just enough to fill the trough in the lower tibia and talus (Fig. 1b). The harvested graft is fitted in the trough with final position of the joint surfaces – the foot in neutral flexion, 0–5◦ hind foot valgus and external rotation equal to the opposite side if normal, or 5–10◦ if abnormal (Fig. 1c). A plate (L plate or a 4.5 narrow dynamic compression plate) is contoured and used in bridging fashion fixed proximally to tibia and distally to tarsal bones with the graft just under the plate to prevent it from slipping out (Fig. 1d). Usually the construct is stable but when the bones are osteoporotic like in one of our tubercular patients, we added another screw to fix the graft
http://dx.doi.org/10.1016/j.foot.2014.03.002 0958-2592/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
G Model YFOOT-1310; No. of Pages 5 2
ARTICLE IN PRESS M. Jain, R. Singh / The Foot xxx (2014) xxx–xxx
Fig. 1. (a) Intraoperative photograph showing anteriorly placed trapezoidal trough. (b) The harvested cortico-cancellous graft from ipsilateral tibia. (c) The graft placed in the trough and ankle positioned for fusion. (d) The plate in situ.
to the bones via the plate. The gap between the malleoli and talus is filled with bones removed from trough. If more cancellous bone is required, the same can be curetted out from the upper tibia. An intraoperative C-arm is used to check the placement and length of the screws and to ensure that the subtalar joint is spared. The wound is closed in layers. Postoperatively, the patients are given a below knee plaster slab which is converted to cast on their first visit for stitch removal. No weight bearing is allowed for initial 6–8
weeks on the operated limb (ankle fusion + ipsilateral proximal tibia donor site) and then gradual incremental loading is allowed on this limb till there is radiological evidence of fusion. No such restrictions are put on the other unoperated limb. Both illustrative case of ankle arthrodesis are presented in Figs. 1 and 2. Patients were evaluated finally at one year both clinically and radiologically. Mazur ankle scoring was done at base line and at one year follow-up [16].
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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Fig. 2. X-rays of case no. 1. (a) Pre-op X-ray shows severe post-tubercular osteoarthritis of the ankle. (b) Post-operative X-ray of graft harvested site. (c) Post-operative lateral X-ray of ankle and (d) post-operative antero-posterior X-ray view of foot. (e) Post-operative antero-posterior X-ray view of ankle.
3. Case reports 3.1. Case 1 A 52-year-old male, priest by profession with history of contact with tuberculosis presented with a 2-month history of swelling, pain and functional disability of his right ankle. On physical examination, his right ankle was tender, bulged, and had a limited painful range of motion. There was no history of trauma in the past medical history. Laboratory findings show an elevated erythrocyte sedimentation rate (ESR) of 68 mm at first hour (Wintergreen method), a positive CRP test and white blood cells at 9000 predominantly lymphocytes. The Mantoux skin test was negative. Anteroposterior (AP) and lateral radiographs of the left ankle showed an extensive irregular lytic lesion of the tibial plafond and talar bone, without the involvement of other tarsals (Fig. 2). The chest X-ray was normal. The histological examination of the biopsy sample showed granuloma and central caseating necrosis confirming tuberculosis. The patient received ATT for nine months and improved but had residual pain in the ankle. He was offered arthrodesis using our technique with anterior trapezoidal corticocancellouus bone graft and bridging L plate. One year postoperatively he was completely relieved of pain and back to pre-disease status with only mild occupational restriction. Radiologically sound ankle fusion was observed in 14th week. The pre-treatment Mazur ankle score improved from 22 to 84 and the patient was satisfied with the outcome. 3.2. Case 2 A 38-year-old manual labourer male was admitted with a 5month history of swelling, severe pain in right ankle making him unable to earn his daily living. Clinical examination showed tender ankle, with boggy swelling, and painful limitation of movement. He had history of pulmonary tuberculosis successfully treated 10 years back. Laboratory findings show an elevated ESR of 64 mm/first
hour, a positive CRP test and white blood cells at 11,000 predominantly lymphocytes. Anteroposterior (AP) and lateral radiographs of the left ankle showed severe osteoporosis, and reduced joint space. The chest X-ray was normal. A closed needle biopsy confirmed tuberculosis. The patient started on ATT and 2 months in the course of treatment had ankle arthrodesis using our technique using anterior bone graft and bridging plate. The tibialis anterior tendon was transferred to 3rd metatarsal for dynamic correction. Radiologically sound ankle fusion was observed at the 17th week. The pre-treatment Mazur ankle score improved from 16 to 78 and the patient was satisfied with the outcome (Fig. 3). 4. Discussion Arthrodesis is the most common procedure used to treat endstage osteoarthritis of the ankle, particularly in patients with difficult conditions such as poor bone quality [15]. It is a challenging procedure that must be undertaken with care in order to provide the best possible outcome [17]. While post traumatic arthrosis remains the most common indication for this surgical procedure in various reported series, tuberculosis is the leading cause in India and some other parts of the world where the disease is common. The symptoms of osteoarticular tuberculosis are nonspecific and often indolent, including pain, joint swelling, or reduced range of motion. Subsequently, there may be delays in diagnosis and therapy, with progression to bone and joint destruction and deformities [18]. Both of our patients had severe pain, bone destruction and deformities. Achieving painless sound fusion requires a thorough debridement with removal of all caseous necrotic tissue which leaves a void in the area. This needs to be filled up with an anterior bone graft and secured with rigid fixation to achieve fusion. Ansart was first to use the anterior bone graft for arthrodesis in paralytic deformity way back in 1951 and he immobilised with plaster cast, however it was associated with graft fractures [19]. Charley popularised external fixation devices to achieve compression across the fusion site, but they do not give rigid fixation [10],
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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Fig. 3. X-rays of case no. 2. (a) Pre-op X-ray shows severe post-tubercular osteoarthritis of the ankle. (b) Lateral view X-ray post fusion. (c and d) Anteroposterior and lateral X-ray views of ankle after removal of implant shows good fusion. (e) Antero-posterior X-ray view of foot post implant removal.
have their own drawbacks, and are cumbersome thus unpopular with patients. Internal fixation devices with the crossed screws have been used with reported fusion rate ranging from 40% to 97% [20–22]. In advanced osteoarticular tuberculosis the bone is osteoporotic and this method may compromise the fixation [11]. Intramedullary nails have been used for arthrodesis in tuberculosis of the ankle [11,13]. Gavaskar et al. have used intramedullary nailing in 7 of their patients with tubercular arthritis to obtain tibiotalocalcaneal fusion. They used manual pressure to obtain compression precluded use of bone graft and achieved union in all [11]. Enriquez et al. reported arthrodesis of the ankle with transcalcaneal nail. The patient did well, arthrodesis occurred at 8 weeks with proper function [13]. Yoshida et al. described arthroscopically assisted ankle fusion in two cases of tuberculosis of the ankle. They used vascularised iliac bone graft in one and osteocutaneous flap in another; and reported good satisfactory results [12]. Tang et al. reported that arthroscopically assisted debridement and ankle arthrodesis with an external fixator provided a very satisfactory rate of ankle fusion in 10 patients who had no recurrences or other complications [14]. Anterior bridge plating has been used for ankle arthrodesis to treat end-stage osteoarthritis of various etiologies. Fixation with T plate was used by Scranton et al. who used them medially and later Rowan et al. advocated anterior placement concluding that such a construct provides better fixation than the either medial/lateral plate; and bilateral plating was associated with more postoperative complications [23,24]. Cheng et al. have used an anterior T plate in one of their cases with severe bone loss and non-union [25]. More recently Mohamdean et al. in their series of 29 of their patients (none of them were tubercular) reported that ankle arthrodesis using an anteriorly placed narrow DCP was a good method to achieve ankle fusion in many types of ankle arthropathies. [8].They used iliac crest autograft in 2 of their patients of old pilon fracture with bone defect. Mears et al. have suggested that the pull of the tendo Achilles posteriorly adds to the compression across the
ankle when combined with anterior fixation [17]. Anterior bridge plating has been reported as an effective fixation technique in tibiocalcaneal arthrodesis, especially in complex hindfoot reconstructions with bone loss or deformity [26]. Plate fixation appears to be a better way to achieve fixation as it increases ankle arthrodesis construct rigidity and union rate [7,9]. Guo et al. reported that the application of an anatomically contoured plate provide many advantages, including less soft tissue disruption by using a single anterior incision, ease of deformity correction, early rehabilitation, and high rate of union [7]. Tubercular arthritis poses some unique problems. The bones are diseased and osteoporotic and hence have poor purchase for the screws. Anterior approach is commonly used to open the ankle to debride and remove the necrotic, avascular debris and open up new vascular channels to promote fusion creating a void. We have used the same incision for our fixation device and to get hold in the non affected bones using the plate in bridging fashion. The supplemented corticocancellous graft acts as a strut to give structural support, prevent collapse/shortening and enhance bony fusion. Since the graft sits properly in the created trough; thus wound healing problems are avoided. Plaass et al. reported that anterior double plating system was a reliable method to achieve solid isolated tibiotalar arthrodesis, even in ankles with difficult conditions such as loss of bone stock due to failed total ankle arthroplasty [15]. Similar to our results, they also did not encounter any complications with the procedure of anterior bridge plating [15]. Guo et al. also reported no postoperative wound problems and infections in ten ankle arthrodeses [7]. In foot and ankle surgery, there are multiple sites used for autologous bone graft, including the proximal or distal tibia, calcaneus, and iliac crest. Recently it has been reported that lowerextremity bone graft sites had the greatest risk for persistent pain at 1 year [27]. We did not encounter donor site pain problem in both of our cases. Our post operative protocol of plaster support for 6 weeks gives time for donor site (ipsilateral proximal tibia) to consolidate. Fusion was assessed both clinically and radiologically
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
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before starting weight bearing to avoid pathological fracture at donor site and implant/fusion failure. Long term follow up of arthrosed ankles have shown alternation in gait [28] and increased stress due to abnormal mobility in the nonfused tarsal joints leading to degenerative changes [29,30]. We have removed the implants in case no. 2 after adequate fusion, as this patient developed mild mid foot pain. Implants need not to be removed if patient does not have mid foot pain/arthritis/or hindrance with midtarsal joints movements. The surgical technique which we have described is simple and easily reproducible. It led to fusion in both of our cases. However; we believe future investigations with larger sample sizes and longer follow-up periods would be helpful in determining the high rate of fusion and to highlight any late complications. Indeed, we feel that this simple, reproducible technique with the satisfactory clinical outcome is a viable alternative to the existing open approaches to ankle arthrodesis particularly in osteoporotic bones. The technique can be extended to include fusion of the subtalar joint and other tarsal joints and necessarily modified for partial/complete talectomy. Conflict of interest None. References [1] Tuli SM. Tuberculosis of the skeletal system. 3rd ed. New Delhi: Jaypee; 2010. p. 127–34. [2] Choi WJ, Han SH, Joo JH. Diagnostic dilemma of tuberculosis in the foot and ankle. Foot Ankle Int 2008;29:711–5. [3] Chen SH, wong T, Lee CH. Tuberculous Ankle versus pyogenic septic arthritis a retrospective coparison. Jpn J Infect Dis 2011;64:139–42. [4] Chen SH, Lee CH, Wong T, Feng HS. Long-term retrospective analysis of surgical treatment for irretrievable tuberculosis of the ankle. Foot Ankle Int 2013;34(3):372–9. [5] Inoue S, Matsumoto S, Iwamatsu Y, Satomura M. Ankle tuberculosis: a report of four cases in a Japanese hospital. J Orthop Sci 2004;9(4):392–8. [6] Fattouh M, Hafez AR, Ahmed ZH. Diagnosis and treatment of ankle tuberculosis in Sohag University Hospital. J Am Sci 2012;8(6):348–52. [7] Guo C, Yan Z, Barfield WR. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int 2010;31:492–8. [8] Mohamdean A, Said HG, Sharkawi M, Adly WE, Said GZ. Technique and short term results of ankle arthrodesis using anterior plating. Int Orthop 2010;34(6):833–7.
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[9] Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 2007;28(2):219–23. [10] Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91. [11] Gavaskar AS, Chowdary N. Tibiotalocalcaneal arthrodesis using a supracondylar nail for advanced tubercular arthritis of ankle. J Orthop Surg 2009;17(3):321–4. [12] Yoshida T, Sakamoto A, Iwamoto Y. Vascularized iliac bone graft in cases of ankle tuberculosis. J Reconstr Microsurg 2009;25(2): 125–31. [13] Enriquez CJ, Lopez VA, Molina MJ, Macias CC, Echeverria BS. Osteoarticular tuberculosis of the ankle, arthrodesis with transcalcaneal nail. Case report. Acta Ortop Mex 2006;20:210–3. [14] Tang KL, Li QH, Chen GX, Guo L, Dai G, Yang L. Arthroscopically assisted ankle fusion in patients with end-stage tuberculosis. Arthroscopy 2007;23:919–22. [15] Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Foot Ankle Int 2009;30(7):631–9. [16] Mazur JM, Scwartz E, Simon SR. Ankle artodesis: long term follow up with gait analysis. J Bone Joint Surg 1979;61A:964–75. [17] Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior tension plate. Clin Orthop 1991;268:70–7. [18] Bozkurt M. Isolated medial cuneiform tuberculosis: a case report. J Foot Ankle Surg 2005;44:60–3. [19] Ansart MB. Panarthrodesis for paralytic flail foot. J Bone Joint Surg Br 1951;33B:503. [20] Dohm M, Purdy BA, Benjamin J. Primary union of ankle arthrodesis: review of a single institution/multiple surgeon experience. Foot Ankle Int 1994;15: 293–6. [21] Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg Am 1985;67-A:546–50. [22] Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using an arthroscopic method: long-term follow-up of 34 cases. Arthroscopy 1996;12:428–34. [23] Scranton Jr PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67-A:550–5. [24] Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg Br 1999;81-B(1):113–6. [25] Cheng YM, Chen SK, Chen JC, Wu WL, Huang PJ, Chiang HS, et al. Revision of ankle arthrodesis. Foot Ankle Int 2003;24(4):1–5. [26] Chodos MD, Parks BG, Schon LC, Guyton GP, Campbell JT. Blade plate compared with locking plate for tibiotalocalcaneal arthrodesis: a cadaver study. Foot Ankle Int 2008;29:219–24. [27] Baumhauer J, Pinzur MS, Donahue R, Beasley W, DiGiovanni C. Site selection and pain outcome after autologous bone graft harvest. Foot Ankle Int 2013, http://dx.doi.org/10.1177/1071100713511434 [on line first]. [28] Muir DC, Amendola A, Saltzman CL. Long-term outcome of ankle arthrodesis. Foot Ankle Clin 2002;7:703–8. [29] Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83A:219–28. [30] Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br 2003;85B:994–8.
Please cite this article in press as: Jain M, Singh R. Ankle arthrodesis in tubercular arthritis using anterior bridge plating: A report of 2 cases. Foot (2014), http://dx.doi.org/10.1016/j.foot.2014.03.002
