SLR - July 2021 - Assal Nour

Closed Arthrodesis in Infected Neuropathic Ankles Using Ilizarov Ring Fixation 

Reference: Alammar Y, Sudnitsyn A, Neretin A, Leonchuk S, Kliushin NM. Closed Arthrodesis in Infected Neuropathic Ankles Using Ilizarov Ring Fixation . Bone Joint J. 2020 Apr;102-B(4):470-477

Level of Evidence: Level 3

Scientific Literature Review 

Reviewed By: Assal Nour, DPM 
Residency Program: Geisinger Community Medical Center – Scranton, PA

Podiatric Relevance: Ankle joint arthrodesis is indicated for end-stage conditions of the ankle and as a salvage procedure for failed trauma reduction and failed total ankle replacement. Fusion can be achieved by various methods; however, all pose potential complications. One technique used for tibiotalar fusion which has shown added benefits with satisfactory outcomes is the application of Ilizarov Ring Fixator (IRF). An important step in any fusion procedure has been joint preparation. To date, no study has described the results of ankle joint fusion with closed IRF technique, in the absence of joint preparation. The aim of this study was to evaluate closed ankle arthrodesis technique by application of IRF in patients with underlying neuropathic arthropathy and superimposed osteomyelitis without joint preparation. 

Methods: In this retrospective study, authors reviewed the Ilizarov Scientific Centre database for all neuropathic patients with superimposed osteomyelitis of the tibia and/or talus that underwent isolated tibiotalar arthrodesis by closed IRF without joint preparation and open IRF with joint preparation over a 5 year period (2013 to 2018). Clinical and radiographic evaluation with a minimum of one-year follow-up after frame removal was required. A total of 60 patients met the inclusion criteria. The closed and open groups were further divided into 3 subgroups: Charcot arthropathy, Charcot-Marie-Tooth (CMT), and post-traumatic arthritis. Nonunion was diagnosed if a visible cleft was present radiographically at the fusion site or if movement at the ankle joint was assessed clinically. Outcomes were measured by American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score pre- and postoperatively. 

Results: In the closed IRF group 81 percent achieved fusion and 19 percent developed a nonunion with recurrent infection. Of those that developed a nonunion, solid fusion was achieved with open revision in 100 percent. In the open ankle arthrodesis group 84.6 percent achieved fusion and 15.5 percent developed a nonunion. Fusion rate was not statistically significant between the two groups. The average time in IRF was 71.5 days for closed group and 69 days in open group. However, patients with Charcot arthropathy and CMT achieved fusion two weeks earlier by closed ankle arthrodesis method in comparison to the open group. In contrast, patients with post-traumatic arthropathy achieved fusion two weeks earlier than the same subset in the closed group. Limb shortening was greater in open group by 0.83 centimeters. Postoperative hospital stay was one-week shorter in closed ankle arthrodesis group. Mean operative time was doubled in open group compared to closed group (40 min and 80 min). AOFAS hindfoot score outcomes were not statistically significantly different.

Conclusions: This study demonstrates that application of IRF by closed technique, in the absence of joint preparation, is an effective treatment option to achieve ankle joint arthrodesis in neuropathic patients with superimposed osteomyelitis of the talus and/or tibia. This is particularly true in patients with Charcot arthropathy and CMT. However, the outcomes were no more statistically significantly better when compared with open IRF with joint fixation. A closed IRF technique can, however, reduce operative time, length of hospital stay, time in fixation and limb shortening.   

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