Analysis of bone transport for ankle arthrodesis as a limb salvage procedure for the treatment of septic pilon fracture nonunion

Abstract

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients’ medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12–63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29–86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction

“…Other studies have demonstrated union rates of 80% to 100%, with larger series such as Fragomen et al 17 and Zarutsky et al 61 achieving a union rate of 84% and 80%, respectively. 4,19,21,22,28,29,38,41,48 We identified 3 risk factors for nonunion-poor soft tissue conditions, addition of subtalar fusion, and increased age, consistent with the current literature in ankle fusion. 6,44,45 Tibiotalocalcaneal fusion has been associated with lower union rates compared with isolated tibiotalar fusion.…”

“…This is consistent with results from multiple other studies reporting high complication and reoperation rates ranging from 30% to 60% in various groups of these complex procedures. 17,22,48,53,61 However, in many of the previous studies, the populations studied were not similar, the complications were not classified in a consistent manner, and outcome reporting was also variable; hence, comparisons are not easily made. Even the largest series to date, by Fragomen et al, classified complications according to a system based on general surgery complications, which may not be entirely appropriate.…”

“…2,5,8,56 Circular frames are typically reserved for complex clinical scenarios such as severe deformity, ongoing infection, poor soft tissue envelope, bone defects that are not reconstructable with conventional means, and complex revision surgery. 21,27,28,41,48,54,57 The benefits of a circular frame include early weightbearing, the ability to gradually correct severe deformity, the avoidance of internal fixation, preservation of the soft tissue envelope, and a reduction in wound complications related to large extensile surgical exposures. 17 Simultaneous limb lengthening can also be performed to correct for limb length discrepancy due to bone defects.…”

“…3,33 To date, the literature on complex ankle fusions using frames comprises a number of case series and several cohort studies. 4,[13][14][15]17,19,21,22,[26][27][28][29]38,41,47,48,[52][53][54]57,58,61 These series demonstrate a relatively high success rate of fusion. However, complications abound, and the heterogeneity of patients, relatively small sample sizes, and variability in reporting in most studies make it difficult to draw conclusions relevant to clinical practice.…”

Rate of progressive healing with a carbon‐fiber orthosis in cases of partial union and nonunion after ankle arthrodesis using the Ilizarov external fixator

“…The alternative to lower leg amputation in these cases can be the adaptation of a custom-made orthosis, provided there is no fulminant infection. The attempt to mobilize in an adapted orthosis in cases of partial union or nonunion after Ilizarov arthrodesis without any further internal osteosynthesis has only been described in very few cases, and so far, we are concerned that there are no studies on the further courses of these patients [ 1 , 2 , 4 , 9 , 10 , 13 , 19 ]. The aim of this study was therefore to determine clinical and radiological results in a difficult patient population with orthosis after fixator removal and existing nonunion or partial union.…”