Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle

Abstract

Limb preservation for the severely deformed, infected, and unstable Charcot neuroarthropathic ankle is challenging. Nonoperative management may not adequately control evolving deformities, leading to nonhealing ulcerations, osteomyelitis, and amputation. Ninety percent of foot and ankle Charcot neuroarthropathy operations involve the ankle joint, 36 yet only 10% of Charcot cases occur at the ankle/ subtalar joint, 35 suggesting the difficulties with nonoperative treatment. Operative reconstruction for the neuroarthropathic ankle is appropriate for unstable, limb-threatening deformity or infection. Despite operative advancements, 43% of Charcot ankle/hindfoot fusions may have postoperative complications. 44 Intramedullary (IM) nail fixation is common for neuroarthropathic ankle reconstruction uncomplicated by wounds, infection, severe deformity, or bone loss. Coating IM nail fixation with cement-containing antibiotics may successfully treat osteomyelitis. 24,27,37,39,40,41 External fixation is an alternative method with comparable limb salvage results,

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques

“…Tomczak et al. 2019 [ 27 ] Case series 8 patients Hindfoot intramedullary nail (Tri-gen Hindfoot 10 mm × 160 mm, Smith and Nephew, Memphis, TN) with simultaneous use of external fixation Clinically osteomyelitic deformed neuropathic ankles PMMA (Simplex P with tobramycin, Stryker, Mahwah, NJ) 1 g vancomycin additionally Circumferentially Not reported Sterile silicone tube 88% (7/8) 88% (7/8) 41. Dar et al.…”

“…Furthermore, clinically beneficial constructs were also created with use of knee and ankle arthrodesis implants [ 19 , 26 ], and some authors even reported coating of inverse shoulder prosthesis and plates used for revisions of septic loosening and for fracture fixation [ 8 ], respectively. To provide more protection across the fusion site and aid in early weight-bearing, some authors reported using antibiotic-containing coated IM nails in combination with simultaneous external ring fixation in cases of unstable infected neuropathic ankles in obese patients [ 27 ].…”

“…Some studies ( n = 2) also implemented antibiotic-containing cement-coated implants as part of a three-stage revision procedure protocol [ 18 , 48 ]. Others ( n = 1) used intramedullary coated nails with simultaneous external ring fixation, the latter of which was to be removed after radiological bone healing was seen [ 27 ].…”

International recognition of the Ilizarov bone reconstruction techniques: Current practice and research (dedicated to 100thbirthday of G. A. Ilizarov)

“…The techniques may be regarded as salvage procedures in neglected adult clubfoot, challenging ulcerations, ankle joint arthrodesis for treating Charcot neuroarthropathy despite the complications[ 96 , 100 - 103 ]. Thus, a hybrid technique of circular EF and an intramedullary nail coated with antibiotic cement salvaged lower limbs in most patients and achieved a functional and clinically stable foot in infected neuropathic ankles[ 104 ]. Infected ankles were also salvaged with the Ilizarov method[ 104 - 106 ].…”

“…Thus, a hybrid technique of circular EF and an intramedullary nail coated with antibiotic cement salvaged lower limbs in most patients and achieved a functional and clinically stable foot in infected neuropathic ankles[ 104 ]. Infected ankles were also salvaged with the Ilizarov method[ 104 - 106 ]. Reconstruction of the hind foot and ankle with concurrent lengthening through a distal tibial corticotomy utilizing the Ilizarov frame was found comparable to other treatment alternatives[ 107 ].…”