SLR - January 2013 - Wassell
Reference: DeVries J, Berlet G, Hyer C. Union Rate of Tibiotalocalcaneal Nails with Internal or External Bone Stimulation, Foot & Ankle International. 33: 969-978, 2012.
Scientific Literature Review
Reviewed by: Daniel Wassell, DPM
Residency Program: New Mexico Veterans Affairs Health Care System, Albuquerque NM
Podiatric Relevance:
The use of bone stimulators can be a useful supplement to podiatric arthrodesis procedures, especially in revision cases and in patients with diminished healing potential. Some patients with decreased blood flow and multiple comorbidities that are candidates for ankle arthrodesis may require the use of adjunct biologics or bone stimulation to allow for complete healing. This particular article is the largest study comparing fusion rates with retrograded intramedullary nail use in tibiotalocalcaneal (TTC) fusions. It specifically looked at the use of internal versus external bone stimulation. The foot and ankle surgeon can use the results of this study to help guide decisions on which type of bone stimulation method to use in rearfoot arthrodesis procedures.
Methods:
This study used a comprehensive chart and radiographic review of 179 patients between July 2003 and May 2009 that underwent rearfoot and ankle arthrodesis with a retrograde intramedullary nail. Overall, 91 patients were treated with internal bone stimulation and 63 patients were treated with external bone stimulation. Inclusion criteria involved any patient that received an ankle arthrodesis and had a bone stimulator used in conjunction for healing, whereas exclusion criteria included lack of adequate records and patients that did not receive a bone stimulator. In total, 154 patients met the inclusion criteria. The two study groups were similar in comparison to age and BMI (Body Mass Index), but the presence of ulceration was higher in the internal stimulation group and approached statistical significance.
Results:
The rate of radiographic fusion with the internal bone stimulation group was 52.7 percent (48/91), while the rate of fusion with the external bone stimulation group was 57.1 percent (36/63). Battery removal was required in seven patients within the internal stimulation group, but there was no significant difference between the two groups when comparing need for further surgery to remove hardware. The rate of successful outcome, which was defined as the patient having a functional stable limb, was 81.3 percent (74/91) for internal stimulation and 82.5 percent (52/63) for external stimulation.
Conclusions:
After conducting a retrospective chart review of patients that received retrograde arthrodesis intramedullary nails with either internal or external bone stimulation, no statistical significance was found in the fusion rate and overall success in the surgery between these two groups. The study also did not address the price difference between internal and external stimulation, which would help delineate which option is most cost-effective. The authors demonstrated that further studies are needed, specifically, a prospective, randomized analysis to determine the rates of fusion and examine other variables affecting the surgical outcomes.