SLR - June 2017 - Priya Samant

An Analysis of Two Fusion Methods for the Treatment of Osteomyelitis Following Fractures About the Ankle

Reference: Moore J, Berberian WS, Lee M. An analysis of 2 Fusion Methods for the Treatment of Osteomyelitis Following Fractures About the Ankle. Foot Ankle Int. 2015 May;36(5):547–55.

Scientific Literature Review

Reviewed By: Priya Samant, DPM
Residency Program: St. John Providence-Providence Park Hospital

Podiatric Relevance: Chronic osteomyelitis is a common sequela after open ankle fractures and long-term ankle ulcerations. Many surgeons prefer the use of external fixation over internal fixation in patients with chronic osteomyelitis. External fixation decreases the risk of recurrent infection and premature hardware failure due to poor bone stock. This study hypothesizes that there is no difference in risk factors for ankle fusion with either internal fixation or external fixation for patients with resolution of active infection with intravenous antibiotics and multiple debridements.

Methods: This is a level III retrospective comparative study on 32 arthrodesis with previously septic ankle following traumatic injury. Nineteen patients underwent internal fixation arthrodesis, and 13 patients underwent external fixation for salvage fusion. Each patient underwent multiple irrigation and debridements with local and intravenous antibiotics until negative bone biopsy was confirmed. The outcomes were based on salvage, functional status, nonunion and infection recurrence.

Results: The salvage rate was similar between the internal fixation and external fixation groups. Ninety percent of internal fixation underwent limb salvage fusion compared to 92 percent of the external fixation group. The internal fixation group required two amputations whereas the external fixation required one. Twenty-one percent recurrent infection rate and five developed nonunion for the internal fixation group. In the external fixation group, 15 percent experienced recurrent infection and four went onto nonunion. Seventy-nine percent of internal fixation group was walking with a rocker bottom shoe while 77 percent in external fixation were walking with an orthotic. The average time to union was 8.5 months compared to 8.1 months with internal and external fixation respectively.

Conclusion: There were no statistically significant differences found in the outcome measures, including salvage, functional status, nonunion and infection recurrence. There are limitations to the study, such as a small sample size, lack of consistent follow-up times, short follow-up and retrospective in nature. Both fusion methods are sufficient limb salvage options for patients, especially when considering patient compliance, but higher level of evidence studies will need to be performed to determine true efficacy. 

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