Functional and radiological outcome of ankle fusion. A 33 cases report

 

Olivier JARDE, Gauthier BASSE, Joël VERNOIS, Eric HAVET, Julien DUMAS

 

 

 

INTRODUCTION

Ankle fusion is the treatment for major articular destruction of the ankle ; it relieves pain, provides stability and restores close to normal walking capability while allowing use of normal footwear. Nevertheless is this kind of lesions, many ankle prostheses are still implanted even if the failure rate reported by Jardé et al (13) about ankle prostheses is important.

Albert (1) was the first to perform surgical fusion of the ankle in 1879. Since then, numerous authors have developed a number of techniques, which is an indication that none of them is systematically effective and reliable. The techniques for ankle fusion can be subdivided in two groups: those that use internal fixation (screws, plate, and bone graft) and those that use external fixation. Authors rewied 33 patients from 52 operated in the Amiens’orthopaedic surgery service between 1987 and 1993. The minimum time since the operation was 10 years.19 patients were loose sight of but the study of they files could not find any examination mistake. The purpose of this study was to evaluate the long term functional outcome of ankle fusion and its effects on the subtalar and midtarsal joints as well as on the static of the foot. Is there still a place for arthrodesis in treatment of ankle failures.

 

MATERIAL AND METHOD

 

Patients

Thirty two patients were reviewed for this study, including one bilateral case, out of a total of 52 patients who had undergone ankle fusion. The other 20 were lost to follow-up as they declined to attend the follow-up consultation.

The series includes 12 female and 20 male patients. The average age at the time of ankle fusion was 46.8 years (range: 17 years to 86 years). The delay from injury to operation ranged from 1.5 month to 22 years with an average of 5.9 years. The shortest delay was in a patient who had sustained a fracture of tibial pilon with severe cutaneous lesions following a road traffic accident. He was treated with screwed plate but unfortunately a secondary infection had to be treated by an external fixator.

Six patients had a strenuous occupation, fourteen had a light occupation, eight were retired and four were unemployed.

The indication for ankle fusion was a post-traumatic lesion of the ankle in 28 cases, including three patients with post-traumatic palsy of the common fibular nerve; the indication was neurological in two cases (sequelae from poliomyelitis) ; one patient underwent ankle fusion to correct a long-standing club foot deformity, and three because of primary degenerative joint disease of the ankle.

Among the post-traumatic cases, the original lesion was a unimalleolar fracture in five cases, a bimalleolar fracture in six, a trimalleolar fracture in three and a tibial plafond fracture in another three. There were also one talus fracture with dislocation of the ankle, five fractures of the leg ; one patient had multiple sprains of the talo crural that induced a diastasis and so a joint destruction. Two patients had sequelae from an undiagnosed fracture of unknown origin as they did not recall any specific trauma and no radiograph had ever been made before their consultation. Two patients underwent ankle fusion owing to neurological complications following a compartment syndrome after a road traffic accident. Twelve patients presented post-traumatic degenerative changes in the subtalar joint sequellar of broken.

 

Pain was the main reason for consultation in 27 cases. Pain was moderate in seven cases, with limitation in professional activity; it was invalidating in 20 cases, preventing any activity. Walking distance was limited and did not exceed 500 meters for 30 patients. All patients limped before operation. Twenty eight patients had permanent swelling of the ankle and four had swelling with any activity. Monopodal weight bearing was impossible for 29 patients. Running and jumping were impossible for 30 patients and were very limited for two patients. Five patients used a banister to ascend stairs, twenty went up and down step by step, three reported major difficulties with stairs and four could no longer ascend stairs. Carrying heavy loads was impossible for 27 patients and was difficult for five others. Examination of the footprints showed a flat foot deformity in twelve cases, including the patient who underwent bilateral ankle fusion, and a cavus deformity in eight. The plantar arch was normal in the others cases.

Subtalar joint motion was evaluated in comparison with the contralateral side. To quantify results, we used the same scoring system as Stahl (21):

-                         4/4 if mobility is normal

-                         ¾ if it is almost normal

-                         ½ if mobility is decreased by 50%

-                         ¼ if mobility is limited by more than 50%

-                         0 if there is no mobility

For the midtarsal joint, we compared the mobility of the forefoot with the controlateral side, using a similar scoring system to quantify mobility.

Pre-operatively, the subtalar and midtarsal joints had no mobility in 17 cases, 3 had a mobility measured at 50% while 13 had normal mobility ; the mobility of the midtarsal joint was normal in 18 cases and was limited by more than 50% in 15 cases (table I).

All patients had anteroposterior radiographs of the ankle and hindfoot with a metal wire around the heel according to Meary, a lateral weight bearing view of ankle and the foot print was taken on the podoscope.

Radiological study showed in all cases grade 3 osteoarthritis of the ankle according to the SOFCOT grading system. The subtalar joint was radiologically normal in 12 cases and the midtarsal joint in 20 (table II).

Thirteen patients had static deformities of the foot: three were in varus, five in valgus, and five had malunited fractures with a recurvatum deformity. The range of dorsal flexion of the tibiotalar was between 0° and 10° (average 5°) and the range of plantar flexion was between 0° and 20° (average 18°).

Incision was always vertical anterior and extern in the hollow dip between tibia and fibula. It began at 8 cm above the tibiotalar joint’s line and ended at 3cm below this line. Tibiotalar joint is showed as usual. The inferior tibia’s cartilage and the superior’s talus cartilage were removed as less as possible.

Osteosynthesis technics : cross according to Meary screwing was used in 19 cases (fig 1), fixation plate in 8 cases (fig 2), external fixation in 3 cases, and Soulier’s technic with dorsal bone grafting without fixation in 3 cases. Fusion was achieved on average after 12 weeks (range 8 to 28 weeks).

 

Methods

 

Functional results were appreciated using Kitaoka’s score (table III).

 

Effects of ankle fusion on the subtalar and midtarsal joints

 

The radiological findings on a lateral view of the foot and ankle were compared with the preoperative findings. We used Morreys’ grading system (8) as shown in table IV :

·      Grade 0 degenerative osteoarthritis : normal joint.

·      Grade I degenerative osteoarthritis : incipient degenerative osteoarthritis. Presence of posterior marginal spurs and slight densification of subchondral bone

·      Grade II degenerative osteoarthritis : established degenerative osteoarthritis : narrowing of posterior subtalar joint line with densification and posterior spurs.

·      Grade III degenerative osteoarthritis : major degenerative osteoarthritis also involving the anterior subtalar joint.

For the midfoot, Morrey’s scoring system (8) classifies the degenerative changes as follow (table V) :

·      Grade 0 : no degenerative osteoarthritis.

·      Grade 1 : presence of isolated dorsal talonavicular spurs without reorganization.

·      Grade 2 : narrowing of joint line with densification of subchondral bone and spurs.

·      Grade 3 : severe osteoarthritis.

 

Study of the foot static

 

We assessed the position of the foot in the various planes using radiological views before and after operation. In the frontal plane, we used Meary's AP view with a wire around the heel and ankle. It was usual to respect a physiological valgus of 5° for the hindfoot, which keeps the subtalar joint to in its ordinary active position. In the sagittal plane, the position of the foot was assessed, as also done by Bresler and al (6) or Mazur and al (17), based on the value of the angle between the longitudinal axis of the tibia and the ground on the lateral weight bearing radiograph. The normal value was 90°. Radiological assessment of midfoot mobility was done on lateral views taken in maximal dorsal and plantar flexion, the reference was 15° retained as physiological motion by Bresler and al (6), Duquennoy and al (9), Dutoit (10), Stahl (21) or Ben Amor and al (2). We measured the angle between the axis of the talus and the axis of the first metatarsal bone. As regards the static of the foot, Djian-Annonier's angle i.e. the medial arch angle allowed to estimate, with regard to the healthy side, the presence of an "arched" or "flat" foot (6).

 

Complications

 

Reflex sympathetic dystrophy occurred in six cases, wound healing problems in three , pin tract infection following external fixation in one, and pulmonary embolism in one . Failure of fusion necessitating reoperation occurred in four cases: two aseptic nonunions and two septic, with fracture of a plate in one case.

 

Results

 

The minimum time since the operation was 10 years, maximum 16 years (average 12,5 years).

 

Subjective results

 

Pain was absent in eight cases: in five cases, there was occasional pain, and in nine cases, there was pain during strenuous exercises. Eight patients had mechanical pain with their normal professional activity : pain was slight in five, moderate in three and severe in another three, who were unable to work. If we compare these results with the preoperative findings, we note that complete pain relief was achieved in 14 patients. The localisation of pain was variable : it was situated around the heel in five patients, lateral in three, submalleolar (lateral and medial) in five. It was lateral and medial supramalleolar in one patient and it was anterior in four patients. Overall, 14 patients did not report any pain, 13 had pain in the subtalar joint, four in the midtarsal joint and two complained about both joints.

 

Functional results

 

They were evaluated in 32 patients including one with bilateral ankle fusion. We noted four excellent results, 13 good results, 12 fair results and four poor results.

Walking capability : the walking distance was unlimited for nine patients, over 1500 meters for three patients, lower than 1500 meters for seven patients, lower than 500 meters for eight patients and lower than 100 meters for five patients. Twenty seven patients did not use any walking support. Four patients walked with one cane outside and two patients used two canes to roam. Fourteen patients walked without any limp ; eight had a slight limp, eight had a moderate limp and two had a marked limp. Four patients could walk on irregular surfaces, six had some difficulty doing so and 22 reported major difficulty.

Monopodal weight bearing was normal in six cases ; in eleven cases it was unstable. It was difficult in thirteen cases and impossible in three cases.

Running and jumping were normal in one case, limited in three cases, difficult in one case and impossible in three cases.

Stairs climbing : three patients reported no problems with stair climbing (fig 4). Thirteen patients used a banister and eleven patients climbed step by step with the normal foot. Stairs climbing was difficult in one case; one of the patients used one cane to go upstairs. One patient was unable to ascend stairs. Five patients could go downstairs normally, fifteen used the banister to go downstairs and nine went downstairs step by step. One patient had difficulties and one used one cane. For the last one, going downstairs was impossible.

Soft tissue swelling : the foot was normal in three patients; it presented swelling during important effort in eight patients including the one who underwent bilateral fusion, vesperal swelling in 14 patients. Swelling was moderate in five patients even with important skin disorders in two patients.

Eleven patients had limitations in carrying heavy loads, thirteen could do it normally and eight were totally unable to carry loads.

Results of subtalar and midfoot joints’ motion : if we summarized all results found in the same table, we could so define existence of stiffness following the fusion (Tab 4).

Social result : following the operation, one patient quite his job for early retirement, three did not work any more, one was in long-term illness, one had been dismissed, five were disabled. Overall, eleven were able to resume a professional activity.

 

Radiological results

 

In the frontal plane, 14 ankles were fixed in neutral position; three were in valgus with an angle ranging from 6° to 10° (average 7°). We noted that the final score tended to decrease proportionally to the importance of the valgus angulation. Sixteen feet were in a varus position, with angles ranging from 2° to 10° (average 5.7°). In the sagittal plane, we found an average angle of 91.8° in our series. Two feet were in flexum, eleven feet in recurvatum (range 2° to 12°, average 6.6°) and 20 feet were in neutral position. A recurvatum deformity was especially found in women for whom the ankle had deliberately been fused in this position to allow wearing high-heel shoes. We noted that recurvatum over 10° was associated with pain, limitation of activity and decreased functional score and also with development of degenerative changes in the midtarsal joint. We also studied the static of the operated foot by measuring Djian-Annonier's angle and comparing it with the healthy side (Bresler and al) (6). The foot was considered “arched” if the angle had a smaller value than on the contralateral side. If it was more opened, the foot would be then defined as “flat”. In our series, the average angle found was 111° versus 120° for the opposite side. In five cases, the operated side was “flat” with regard to the healthy side; in ten cases, the static was unchanged, in 13 cases the foot was “arched”. In four cases, postoperative radiographs were made for different reasons.

The arched feet were distributed in two categories:

·      Posterior arched feet (2 cases) in cases with the foot fixed in flexum

·      Anterior arched feet (11 cases) in cases with the foot fixed in recurvatum

As regards midfoot mobility, plantar flexion ranged from 0° to 35° with an average of 18° and dorsal flexion ranged from 0° to 15° with an average of 6°. The overall range of motion was 24° with a maximum value of 46°. Eighteen cases had an overall range of motion equal or superior to 10°. Results of radiogical evolution of subtalar and midfoot joints before and after fusion are in tables Va and Vb. We noted that decreased range of motion as measured on radiographs correlated with decline of work score, particularly as regards use of stairs. Nine patients used a banister; five went up or down step by step and one patient could not use stairs at all. These 15 patients also presented a radiological range of motion lower than 15°.

 

Failures and reoperations

 

We had two non-unions out of 33 operations. In the first case, ankle fusion was performed for post-traumatic avascular necrosis of the talus, using Meary’s technique; one year later, non-union led to reoperation using Soulier’s technique. The second was in a fracture with valgus malunion treated at first with Meary’s technique. There was failure of consolidation due to infection. The reoperation was performed with an external fixator.

 

Discussion

 

Several authors have studied the outcome of ankle fusion (table VI). Broquin et al (7) in 1979, reported on 133 ankle fusions performed in the course of 14 years. Their series included 91 cases with isolated ankle fusion and 43 with simultaneous fusion of the posterior subtalar joint. The rate of fusion failure was 10 % for the subtalar joint. In 80 % of cases, there was stiffness of the subtalar joint consecutive to the operation and not related with pre-existing pathology. In one-third of cases, the hindfoot was stiff and painful, we found the same results in our study (tables Va and Vb). For these authors, poor outcomes are related to fusion in a recurvatum position, because it limits function and hampers barefoot walking, and with disorders of the posterior subtalar joint. In their series, only one patient out of five kept a useful subtalar joint; in those cases, results were good and did not seem to deteriorate over time. Stahl (9), in 1985, reviewed 52 patients with a follow-up of seven years and two months. He found 67 % very good and good results and 9 % poor results. Osteoarthritis of the subtalar joint was a frequent finding. Functional results were inferior in those patients with marked degenerative osteoarthritis. Moderate osteoarthritis was not associated with pain in all cases. In cases with pre-existing osteoarthritis of the subtalar joint, the latter tended to get worse postoperatively, especially if there was malalignment. However, stiffness and moderate degenerative osteoarthritis were not synonymous with poor results as in our report. For the author, poor results like in our series are due to established degenerative osteoarthritis of the subtalar joint or more rarely to associated degenerative changes in the midfoot. Residual soft-tissue disorders seem to be another cause of failures. However, he believes that they are more related with the injury than with the ankle fusion. We think as Stahl (9) that performing subtalar fusion in all patients presenting stiffness of this joint is not satisfactory. The purpose is to keep, to restore, and even to enhance mobility in the underlying joints. We noted like Bertrand et al (3), a constant degradation of the subtalar joint. All our cases evolved towards degenerative osteoarthritis and pain during movement with poor adaptation of the foot on irregular grounds. Dutoit in 1987 (10), reviewed 20 patients with a follow-up of nine years and six months. He found 55 % very good and good results and 45 % fair results. No patient had a score lower than 30 in Duqennoy and al score (9). He noticed that fusion in a recurvatum position results in marked degradation of the subtalar joint. If the recurvatum is over 5°, the subtalar joint deteriorates more quickly and more importantly than in cases fused in neutral position. In his series, recurvatum also seems to provoke faster degradation of the midtarsal joint, although this joint generally appears to suffer less from ankle fusion. We suggests like him to discontinuing ankle fusion in equinus position, even in female patients, because it results in degenerative changes in the underlying joints, the outcome of which remains problematic. So in this case, we suggest the 90° position. Bresler and al (6) in 1993, also incriminate fixation in an equinus position in subsequent degradation of the subtalar joint. Wearing adapted insoles brings little improvement and degrades functional long-term results. They also advise to fuse the ankle in a physiological valgus position. They advise like Hefti (12), slight external rotation to allow better progress of the foot during walking. Rougereau et al (18) reported a series of 51 ankle fusions performed in 50 patients, between 1985 and 1993 and reviewed with an average follow-up of 4.5 years. There was no case of reoperation. They found nine very good results, 19 good results, 20 fair results and three poor results. The average range of motion was 15° in dorsal flexion and 5° in plantar flexion at the difference of our serie. At the different for them there is no influence of the position of the ankle on time to fusion or on function. Ben Amor and al (2), in 1999, reviewed 36 patients with follow-up over three years. They found 58.4 % very good and good results. They also noted stiffness of the subtalar joint in 70 % of cases and pain in one-third of cases especially for patients with recurvatum larger than 5°. They think that it is better to perform combined tibiotalar and subtalar fusion if there is preoperatively, degenerative radiological and symptomatic posterior subtalar osteoarthritis. They share Buck's opinion (8) about the necessity to fix the ankle in neutral position, although a slight recurvatum lower than 5° may be tolerated for women who wear high heels. They also advise external rotation from 10 to 15° to facilitate progress of step. In our series, we find young male predominance. And, there is no, as described Stahl (9) predominance of right side over left side. If we compare the pain scores in preoperative and post-operative in our patients, we note that 27 patients had permanent pain before operation, resulting in marked reduction in activity. Pain was invalidating in 20 of them versus only eleven post-operatively. Ankle fusion has brought real improvement. We can also note that for patients who still have marked pain postoperatively, the global score is lower than 60. The pain score appears to properly reflect the overall result. As regards stairs climbing, results give evidence of adaptation difficulty for the operated foot. We found 51.5% good or very good results and 12.5 % poor results. Our findings are fairly similar to those reported by Bresler and al (6) : subtalar joint mobility has been reduced after ankle fusion. Because after ankle fusion, it is the first joint sought-after. As Stahl (9), our opinion is that responsible factors of stiffness are : the post-traumatic origin of the preoperative condition, the treatment and the delay from injury to fusion, the subtalar joint involvement during injury and possible subtalar joint compression by osteosynthesis or screws across the subtalar joint. The duration of post-operative immobilisation also seems to play a role as well as insufficient physiotherapy. In accordance with Broquin and al (7), we never observed improvement in the subtalar joint mobility when it was stiff or arthrotic preoperatively. For those authors it conservation does not provide then anything, and it can be source of pains, that’s why we don’t agree with this idea. Like Bertrand et al (3), we also noted systematic degenerative changes on the radiographs of the subtalar joint, to varying degrees. There is deterioration with regard to the preoperative condition in 73 % of cases. The subtalar joint is painful in 49% of cases. We found like Stahl (9) or Bresler et al (16) no correlation between advanced degenerative subtalar osteoarthritis and pain. Pain is associated with poor functional outcome in the long-term. This frequent degradation of the subtalar joint brought certain authors such as Broquin et al (7) to combine ankle fusion with subtalar fusion in cases of established degenerative osteoarthritis.

The midtarsal joint is also affected by osteoarthritis but to a lesser extent. It is painful in 12.5 % of cases. We also noted it is hyper mobile: 60.6 % of patients have midtarsal mobility superior or equal to 10°. Bresler et al (6), Said et al (19) and many others authors consider it as a criteria for good results after ankle fusion. In conclusion with our study and the rewiew of literature we can affirm that this hyper motion allows more harmonious progress of step. As regards the ideal position of the foot, it seems to be 90° in the sagittal plane, a few degrees of valgus in the frontal plane and around 10° of external rotation in the horizontal plane (12, 8, and 16). Indeed, we observed for valgus in frontal plane over 5°, final functional score is fair. Recurvatum over 10° is responsible for pain with limitation of activity and a lower global functional score. As regards complications of fusions, non-unions are dreaded and it risk factors were studied in the literature. Kirkpatrick and al (14) identified several causes: sepsis, premature micro-movements in the fusion owing to inadequate immobilisation, inadequate position of fixation. In our series, we found four cases of non-union including two cases with deep sepsis. The use of an athroscopic technique for fusion appears to reduce morbidity. In our experience, there was only one case of fusion made by arthroscopy. In their series, Bresler and al (6) find 100% of good results for seven patients after 14 months of follow-up but they underline the necessity of centered degenerative osteoarthritis with little frontal deformation as well as little or no bone destruction. Bonnin and Carret (4) find, with precise selection, nine good results out of on ten.

 

Conclusion

 

For this study, it seems determining elements for patients still position of immobilization of the foot and effect on underlying joints that are subtalar and midfoot. The optimal position of the foot according to most recent studies seems to be 90° in the sagittal plane a few degrees of valgus in the frontal plane and external rotation of 10° to 15° to facilitate progress of stepstiffness of subtalar joint consequently at the surgical operation was present in about 80% of our patients. We don’t suggest systematic arthrodesis. The amyotrophy is the consequence of initially failure. Pseudarthrosis are less frequent with fixed osteosynthesis, we suggest the use of an anterior screwed plate. It also seems that ankle fusion remains the treatment of choice in sequellae from septic arthritis, post-traumatic secondary exentric osteoarthritis, malunion of intra-articular fractures, poliomyelitis and neurological conditions which are not ankle prosthesis indications

REFERENCES

 

1.                      Albert E. Zur Resektion des Kniegelenkes. Wien Med Press 1879; 20: 705-708.

 

2.                      Ben Amor H, Kallel S, Karray S et al. Etude du retentissement de l’arthrodèse tibio-talienne sur le pied. A propos de 36 cas revus avec un recul moyen de 8 ans et demi. Acta Orthop Belg 1999; 65: 48-56.

 

3.                      Bertrand M, Charissoux JL, Mabit C, Arnaud JP. Etude de la tolérance à long terme de l’arthrodèse talo-crurale. Rev Chir Orthop 2001; 87: 677-684.

 

4.                      Bonin M, Carret JP L’arthrodèse de la cheville sous arthroscopie. A propos de 10 cas revus à plus de 1 an. Rev Chir Orthop 1995; 81: 128-135.

 

5.                      Boobbyer GN The long term result of ankle arthrodesis. Acta Orthop Scand 1981; 52: 107-110.

 

6.                      Bresler F, Mole D, Blum A, Rio B, Schmitt D Arthrodèse tibio-astragalienne: retentissement de la position de fixation sur le pied. A propos d’une série de 50 cas revus à plus de 9 ans de recul moyen. Rev Chir Orthop 1993; 79: 643-649

 

7.                      Broquin J, Emani A, Maurer P, Tomeno B Arthrodèse tibio-tarsienne. Etude des complications et de la tolérance. Rev Chir Orthop 1979; 65: 393-401

 

8.                      Buck P, Morrey BF, Chao EYS The optimum position of arthrodesis of the ankle. J Bone Joint Surg 1987; 69-A: 1052-1062.

 

9.                      Duquennoy A, MESTDAGH H, TILLIE B, STAHL P Résultats fonctionnels de l’arthrodèse tibio-tarsienne. A propos de 52 cas revus. Rev Chir Orthop 1985; 71: 251-261.

 

10.                   DUTOIT M. Évolution à long terme des arthrodèses tibio-astragaliennes. Rev Chir Orthop 1987; 73: 189-196.

 

11.                   FAVRE E, ROSSET PH, LAULAN J Résultats à long terme des arthrodèses tibio-astragaliennes. Etude rétrospective de 20 cas avec un recul moyen de 19 ans et un minimum de 12 ans. Rev Chir Orthop 1996; 82: 195 dernière page

 

12.                   HEFTI F Die Stellung des Fusses bei Arthrodesen der oberen Sprunggelenks. Ferdinand Enke Verlag 1981; Stuttgart

 

13.                   JARDE O, GABRION A, MEIRE P, TRINQUIER-LAUTARD JL, VIVES P Complications et échecs des prothèses totales de cheville. A propos de 21 observations. Rev Chir Orthop 1997; 83: 654-651

 

14.                   KIRKPATRICK JS, GOLDNER JL, GOLDNER RD Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation. Clin Orthop 1991; 268

 

15.                   Kitaoka HB, LEE MD, MORREY BF, Repair and delayed reconstruction for lateral ankle instability: twenty years follow-up study. J Orthop Traum 1997; 11: 530-535

 

16.                   MANN RA, VAN MANEN JW, WAPNER K, MARTIN J Ankle fusion. Clin Orthop 1991; 268: 49-55

 

17.                   MAZUR JM, SCHWARTZ E , SHELDON RS Ankle Arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg 1979; 61-A: 964-975

 

18.                   ROUGEREAU G, DENORMANDIE P, FERON JM, SIGNORET F,PATEL A. Les arthrodèses tibio-tarsiennes dans les séquelles post-traumatiques. A propos d’une série de 50 patients. Rev Chir Orthop 1996; 82: 195 dernière page

 

19.                   SAID E, HUNKA L, SILLER TN Where ankle fusion stands today. J Bone Joint Surg 1978; 60-B: 211-214

 

20.                   SOULIER A, DUQUENNOY A Arthrodèse tibio-tarsienne par greffons cylindriques. Acta Orthop Belg 1969 ; 35 : 377-391.

 

21.                   VAN EYGEN. Ankle arthrodesis. J Bone Joint Surg 1996; 120-127.

 

Table I : Pre-operative range of motion of subtalar and midtarsal joints.

Table II: Preoperative subtalar and midtarsal joints degenerative arthritis grades according to Morrey.

 

Table III: Kitaoka’s score.

 

Table IV: Midfoot and subtalar joints’ motion before and after ankle fusion.

 

Table V a: Radiological findings before and after fusion. a:, with respect to the subtalar joint; b: with respect to the midtarsal joint.

 

Table VI:Functional results of ankle fusion in the literature.

 

 

 

 

 

Fig 1: Fusion technique according to Meary.

 

Fig 2: Fusion technique according to Soulier.

 

Fig 3: Fusion with plate and screws fixation.

 

Fig 4: Stair climbing after ankle fusion.

 

 

 

Table I

 

            Subtalar                   Midtarsal     

0         7 patients                 0 patient       

¼        2 patients                 2 patients     

½        6 patients                 8 patients     

¾        4 patients                 4 patients     

4/4 113 patients             18 patients  

 

Table II

 

            Subtalar                   Midtarsal      

AR 0   12 patients               20 patients                                                 

AR 1   11 patients               10 patients  

AR 2   9 patients                 2 patients

AR 3   0 patient                   0 patient

           

Table III

 

Pain (40 points)

None                                                                                     40

Mild occasional                                                                     30

Moderate daily                                                                      20

Severe almost always present                                            0

Function (50 points)  

            Activity limitations support requirement       

                       No limitation no support                                            10

                       No limitation of daily activities limitation

                       of recreational activities no support                                 7

                       Limited daily and recreational activities

cane                                                                        4

Severe limitation of daily and recreational

activities walker crutches wheelchair

brace                                                                                0

Maximum walking distance blocks

            Greater than 6                                                          5

            4-6                                                                            4

            1-3                                                                            2

            Less than 1                                                               0

Walking surfaces

            No difficulty on any surface                                     5

            Some difficulty on uneven terrain stairs      

            inclines ladders                                                       3

            Severe difficulty on uneven terrain stairs

            inclines ladders                                                        0

Gait abnormality

            None slight                                                                8

            Obvious                                                                    4

            Marked                                                                     0

Sagittal motion (flexion plus extension)

            Normal or mild restriction (30° or more)                   8

            Moderate restriction (15° - 29°)                                4

            Severe restriction (less than 15°)                            0

Hindfoot motion (inversion plus eversion)

            Normal or mild restriction (75% – 100% normal) 6

            Moderate restriction (25% - 74% normal)              3

            Marked restriction (less than 25% normal)             0

Ankle-hindfoot stability (anteroposterior varus-valgus)

            Stable                                                                       8

            Definitely unstable                                                    0

Alignment (10 points)

            Good plantigrade foot ankle-hindfoot well aligned               10

            Fair plantigrade foot some degree of ankle-hindfoot          

                       malalignment observed no symptoms                   5

            Poor nonplantigrade foot severe malalignment

                       Symptoms                                                              0                  

Tableau IV

 

          Subtalar before      Subtalar after         Midfoot before        Midfoot after          

0         7 patients                 12 patients               0 patient                   5 patients     

1/4      2 patients                 8 patients                 2 patients                 1 patient       

1/2      6 patients                 4 patients                 8 patients                 4 patients     

3/4      4 patients                 1 patient                   4 patients                 2 patients     

1         13 patients               7 patients                 18 patients               20 patients  

 

Table V a

 

            Before operation   After operation     

AR 0 12 patients               0 patient       

AR 1  11 patients               3 patients     

AR 2  9 patients      18 patients      

AR 3  0 patient        11 patients      

 

T able 5V b

 

            Before operation   After operation     

AR 0 20 patients               2 patients  

AR 1  10 patients               18 patients  

AR 2  2 patients               8 patients   

AR 3  0 patient                 4 patients   

 

 

 

Table VI.

 

Authors and Years	Cases	Follow-up in years	Very good and good %	Fair /poor %	% of nonunion	Fusion in weeks	Midfoot motion
SAID et al 1978 (19)	24	7.5	81.9	4.5 /13.6	21.7	17.5	5-10° FD 20°-35°FP
STAHL (9) 1983	52	7.2	67	24  / 9			Hyper mo-tion 44 % 24°moyen
DUTOIT 1987 (10)	20	9.6	55	45	5		15.7°
BRESLER 1993 ( 6 )	50	9	6 / 40	40 / 14	12		12.7°
BONNIN AND CARRET 1995 ( 4 )	10	10	90	10	1		14.5
FAVRE (1996) (11)	20	19	70	25 / 5	10		Hyper mo- tion 55 %
BEN AMOR et al (2) On 1999	36	3	58.4	30.6 / 11	0		15.2
BERTRAND et al 2001 (3)	33	12.8	66	30 / 4	12	12	13.1
BOOBYER 1981 (5)	37	8	65	30 / 5	21.6
VAN EYGEN et al 1999 (21)	41	6.6	58.5	36.6/4.9	16	4.4 months	5-20° FP
Our series	33	6.5	51.5	36.4   12.1	9	12	24°

 

 

 

Summary

Our study concerned 33 fusions. It was about 12 women and 20 men. The average of age was 46.8 years. Postoperative follow-up was 6.5 years. In 85% of cases, origin of hurts was traumatic, neurological in 6 % of cases and primary degenerative in 9 % of cases.

Patients underwent preoperative and postoperative clinical and radiological examination. We make functional study of ankle that finds 51.5% of good and very good results. We studied position of the foot in various plans. We also studied effects of ankle fusion on subtalar and midfoot joints by means of radiological views. These joints were seat of degenerative arthritis with aggravation in 73 % of cases for subtalar joint with regard to preoperative state. This would entail poor functional result for gravest cases. According to this study and after 10 years of minimum follow-up, it appears that ideal position of fusion is 90° or slight flexum in sagittal plan, some degrees of valgus in frontal plan and external rotation of 10° to 15° to facilitate progress of step.

 

Keywords : fusion, ankle, consolidation.

 

L’ARTHRODESE TALO-CRURALE :

ETUDE A LONG TERME DES RESULTATS FONCTIONNELS ET RADIOLOGIQUES.

ETUDE DE LA TOLERANCE. A PROPOS DE 33 CAS.

 

O. JARDE, G. BASSE, J. BASSE, E. HAVET, B. OLORY

 

Notre étude a porté sur 33 arthrodèses. Il s’agissait de 12 femmes et de 20 hommes. La moyenne d’âge était de 46,8 ans. Le recul post-opératoire était de 6,5 ans. Dans 85% des cas, l’origine des lésions était traumatique, neurologique dans 6% des cas et arthrosique primaire dans 9% des cas.

Les patients ont bénéficié d’un examen clinique et radiologique pré-opératoire et post-opératoire. Nous avons ainsi pu faire une étude fonctionnelle de la cheville qui retrouve 51,5% de bons et très bons résultats. Nous avons également étudié la position du pied dans les différents plans de l’espace. Nous avons ainsi retrouvé une mobilité médio-tarsienne à 24. Nous avons aussi étudié le retentissement de l’arthrodèse talo-crurale sur la sous-talienne et la médio-tarsienne à l’aide des clichés radiologiques.

Ces deux articulations étaient ainsi sujettes à une dégénérescence arthrosique avec une aggravation dans 73% des cas et la sous-talienne par rapport à l’état pré-opératoire. Ceci entraînerait un mauvais résultat fonctionnel pour les cas les plus graves.

Au terme de cette étude et à 10 ans de recul minimum, il apparaissait donc la position idéale de la cheville arthrodésée était à 90° ou avec un léger talus dans le plan sagittal, quelques degrés de valgus dans le plan frontal et une rotation de 10° à 15° afin de faciliter le déroulement du pas.

 

Mots clés : arthrodèse, talo-crurale, consolidation.