SLR - September 2022 - Jonathan Friedman, DPM
Reference: Reinke C., Lotzien S., Yilmaz E., Hanusrichter Y., Ull C., Baecker H., Schildhauer T., GeBmann J. Tibiocalcaneal arthrodesis using the Ilizarov fixator in compromised hosts: an analysis of 19 patients. Archives of Orthopedic and Trauma Surgery. 2021 January 23; 142(1359-1366).Level of Evidence: IV
Reviewed By: Jonathan Friedman, DPM
Residency Program: Legacy Health Podiatric Medicine and Surgery, Portland, OR
Podiatric Relevance: Arthrodesis utilizing the Ilizarov external fixator is a safe and effective procedure for compromised hosts. Patients with acute or chronic infections, co-morbidities, or severe malpositional deformities are often treated in the podiatric clinic. It is not uncommon for such patients to develop infectious or avascular osteonecrosis of the talus. In these patients, tibiocalcaneal arthrodesis is an alternative treatment option for limb salvage. Few studies have been performed evaluating the Ilizarov method for tibiocalcaneal arthrodesis. The purpose of this study was to assess the outcomes of patients who underwent tibiocalcaneal fusion utilizing the Ilizarov technique.
Methods: The study included 19 patients who underwent tibiocalcaneal fusion using the Ilizarov technique. Exclusion criteria were patients who underwent isolated or concomitant tibiotalar or subtalar arthrodesis. Patient pathologies included infectious, post-traumatic, and charcot derived necrosis of the talus. The surgical procedure involved resection of the distal tibia to viable bone, total talectomy, and removal of navicular/calcaneal cartilage. Following this most cases consisted of a single stage application of the Ilizarov fixator for tibiocalcaneal arthrodesis. The anterior edge of the tibia was also removed to achieve tibionavicular fusion. The average follow up after removal of the external fixator was 116 weeks. Bony union was confirmed clinically and radiographically. Outcomes were assessed using a modified AOFAS score with a maximum possible score of 86.
Results: The average time in frame was 22 weeks (range 14-34). All patients incurred pin site infections which were treated locally with pin care and oral antibiotics. Bony union was achieved in 14 out of 19 (74 percent) patients, with pseudoarthrosis in four patients (21 percent) and one patient (5 percent) with 40-50 percent bone consolidation. The modified AOFAS scores were collected in 7 of 19 patients with a mean score of 53/86.
Conclusion: Tibiotalar arthrodesis with Ilizarov external fixation is now a standard procedure with a plethora of established evidence-based research. However, this procedure is not viable for patients with extensive necrosis of the talus. While the complication rate in tibiocalcaneal arthrodesis was comparable to studies with tibiotalar arthrodesis, the modified AOFAS scores were lower and the average time in frame was longer. The increased comorbidity and age of the study population, as well as limb shortening without a concomitant limb lengthening procedure could have contributed to the overall poorer outcomes. Despite this, tibiocalcaneal arthrodesis with Ilizarov external fixation remains a viable alternative to amputation. This study opens the discussion about alternative limb salvage options when there are seemingly few for those suffering from complex limb threatening pathologies.