SLR - September 2018 - Aasin Tareen
Staged Distraction Osteogenesis Followed by Arthrodesis Using Internal Fixation as a Form of Surgical Treatment for Complex Conditions of the Ankle
Reference: T-F. Lou, M. Hamushan, H. Li, C-Y. Wang, Y. Chai, P. Han Staged Distraction Osteogenesis Followed by Arthrodesis Using Internal Fixation as a Form of Surgical Treatment for Complex Conditions of the Ankle. Bone Joint J. 2018;100-B:755–60.
Scientific Literature Review
Reviewed By: Aasin Tareen, DPM
Residency Program: Cedars Sinai Medical Center, Beverly Hills, CA
Podiatric Relevance: Large bony and soft-tissue defects around the ankle joint can be caused by a high-energy trauma or an infection that has been treated with radical debridement. Limb salvage and reconstructive surgery at this level may be difficult due to insufficient soft-tissue cover, delayed healing related to poor vascularity, altered anatomy, infection, deformity and leg-length discrepancy. These factors all increase the risk of failure of arthrodesis of the ankle. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early and a reduced external fixation index (EFI) without infection or wound dehiscence.
Methods: A level IV retrospective cohort study was performed between 2008 and 2014. Distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley and by using EFI scores. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS).
Results: A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean EF) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up.
Conclusions: Destruction and bone loss of the ankle due to trauma or infection is becoming increasingly common. Possible methods of reconstruction include arthrodesis combined with either a vascularized bone graft or distraction osteogenesis. Although the combined techniques of distraction osteogenesis and arthrodesis prolong the treatment time and have their own complications, its advantages outweigh the disadvantages. First, it can be used in reconstructing defects of any length and diameter without the need for a bone bank or the risks of donor site morbidity. Second, the quality of bone obtained by distraction osteogenesis is better than that in vascularized fibular transplantation, which needs a long period of time for the fibula to hypertrophy. Third, it allows radical debridement of all infected, necrotic and poor-quality bone while correcting the resulting deformity and shortening. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early and a reduced EFI without infection or wound dehiscence.