Ankle distraction arthroplasty has historically been used as an alternative to ankle arthrodesis and total ankle arthroplasty in treating patients with end-stage ankle arthritis. The external frame allows immediate weight bearing after the procedure, provides unloading of the joint to relieve pain, and preserves range of motion (ROM). Successful short-term to midterm outcomes have been reported for distraction arthroplasty for ankle arthritis; however, there are no reports describing its role in acute treatment for ankle fracture.
A 73-year-old woman presented to the emergency department with a grade I open left ankle fracture dislocation after falling in her bathroom 2 days earlier. She did not report other injuries or loss of consciousness. She continued to ambulate on the ankle after the initial injury and had developed an open wound over the medial aspect of it, which prompted her presentation to the emergency department. Her past medical history was significant for end-stage renal disease on hemodialysis, type II diabetes (hemoglobin A1C of 13) with significant neuropathy, peripheral vascular disease, coronary artery disease status post myocardial infarction with 3 prior stents, diastolic heart failure (ejection fraction of 60%), and invasive ductal carcinoma of the breast status post partial left mastectomy and radiation therapy.
On physical examination, an obvious valgus deformity was seen in her left ankle with a 1-cm poke hole opening over the medial malleolus. Sensory examination was limited because she had significant diabetic neuropathy at baseline. Motor examination was intact and she was able to fire the tibialis anterior, gastrocsoleus, and extensor hallucis longus. Weak dorsalis pedis and posterior tibial pulses were palpated. Radiographs obtained in the emergency department demonstrated a left bimalleolar ankle fracture dislocation (Figure 1). She immediately underwent closed reduction in the emergency department with placement in a posterior-U splint to maintain reduction. Results of the neurovascular examination were unchanged after reduction.
Lateral (A), anteroposterior (B), and oblique (C) radiographs of the ankle and foot on admission to the emergency department. These radiographs demonstrate an open (grade I) left ankle fracture dislocation.
Given the patient's extremely complex medical comorbidities and significant injury, the decision was made to use distraction arthroplasty as a definitive surgical treatment to minimize surgical risks while allowing immediate full weight bearing.
The patient was initially managed by the trauma team overnight with external fixation. She was placed in the supine position under regional anesthesia. The external fixator was placed first to achieve closed reduction. Two tibial 6-mm hydroxyapatite-coated half pins were placed proximally. Distally, a transfixion pin was drilled across the calcaneus and two 4.8-mm half pins were placed in the first and fifth metatarsals, respectively. A delta frame was then assembled with bars, clamps, and outriggers. Traction was applied and satisfactory fracture reduction and pin placement was confirmed on fluoroscopy. The ankle was then dorsiflexed to neutral position with metatarsal half pins, and the frame was tightened in this position. Fracture reduction and placement of the external fixator were confirmed on fluoroscopy. Thorough irrigation and debridement was performed as well.
On postoperative day 4, the patient returned to the operating room for definitive distraction arthroplasty. She was again placed in the supine position under regional anesthesia. Prior delta frames were removed. A 155-mm–diameter full ring was first placed around the mid tibia, at the level of one 6-mm half pin. Next, another 6-mm hydroxyapatite-coated half pin was predrilled in the tibia and then secured to the ring. A second full ring was then placed around the ankle, secured to the tibia using two 0.62-inch Ilizarov wires tensioned to 130 kg at approximately 1.5 cm proximal to the ankle joint. One of these wires was inserted from the fibula to the tibia to stabilize the syndesmosis. Next, a 145-mm–long foot ring was placed around the foot. Two olive wires were inserted from medial to lateral (and vice versa) across the calcaneus. They were tensioned to 130 kg and secured to the foot ring. A 0.62-inch Ilizarov wire was then inserted across the midfoot, tensioned to 110 kg, and secured to the foot ring. The proximal and middle rings were connected with four threaded rods, while the middle and distal rings were connected with another four threaded rods. The distal two rings were distracted to gain approximately 3 mm of ankle distraction. Reduction and placement of hardware were confirmed with fluoroscopy (Figure 2).
Lateral (A), anteroposterior (B), and oblique (C) radiographs of the ankle and foot 3 months after surgery.
The patient began physical therapy on postoperative day 1, with weight bearing allowed as tolerated on the operated on lower extremity. She felt comfortable walking without assistance by the second postoperative week. Her fracture appeared to be healed by 5.5 months, and the external fixator was removed at 6 months postoperatively (Figure 3). At her final follow-up visit 1 year postoperatively, the patient had a visual analog scale score of 0, 30° of ankle plantarflexion, 5° of dorsiflexion, and no signs of instability.
Lateral (A), anteroposterior (B), and oblique (C) radiographs of the ankle and foot 6 months after surgery.
The authors have presented a case of using distraction arthroplasty as an acute treatment for a grade I open bimalleolar ankle fracture in a patient with significant medical comorbidities. The patient tolerated the procedures well. She had no complications, good ankle function, and no ankle pain at the 1-year postoperative visit.
Initially described by Judet and Judet1 as alternative management for hip arthritis, the concept of distraction arthroplasty was first applied to ankle arthritis by van Valburg et al2 in 1995.3 The procedure involves temporary mechanical unloading of the ankle joint with a central external fixator. While the underlying mechanism of this procedure is not completely understood, cartilage regeneration due to decreased mechanical load and proper joint alignment, diminished postoperative subchondral sclerosis, and intermittent flow of intra-articular synovial fluid are all thought to play important, beneficial roles.4–6
Several independent studies have found distraction arthroplasty to be a viable solution for severe ankle arthritis. In their initial retrospective study of 11 patients, van Valburg et al2 reported significant pain relief in all patients at 20 months postoperatively, with 5 reporting complete resolution of pain. In a study of 25 patients with a mean age of 43 years (range, 16–95 years), Tellisi et al7 reported that 91% had improvement in pain at a mean follow-up of 30.5 months. Significant improvement of the American Orthopaedic Foot & Ankle Society score was demonstrated in 74% of the patients (preoperative score, 15; range, 0–20; and postoperative score, 74; range, 47–96). A modest improvement in all of the Short Form-36 components was found. An improvement of 10° of the arch of movement was seen in patients with a mild equinus contracture preoperatively.7 Xu et al8 also reported a modest clinical improvement in a study of 16 patients with a mean age of 30.3 years (range, 14–60 years) and a mean follow-up of 40.9 months. A significant improvement was observed in all outcome scores: American Orthopaedic Foot & Ankle Society score from 41.9 to 68.1; Short Form-36 score from 43.1 to 62.7; and visual analog scale score from 5.9 to 3.7.8
However, two studies showed that patients undergoing ankle distraction may be susceptible to high failure rates and that they had to be revised to ankle arthrodesis or total ankle arthroplasty. In 2014, a survival analysis conducted by Marijnissen et al9 showed that 17% of patients required re-operation within 2 years and another 37% failed within 5 years of joint distraction, with females being at higher risk of failure. The risk of failure was 30% within 3 years in the female population. This percentage was not reached in the male population after 11 years of follow-up.9
In an analysis of 29 patients with at least 5 years of follow-up, Nguyen et al10 reported secondary ankle arthrodesis or total arthroplasty in 45% of patients. Older age was a positive predictor of failure in this study, and the authors concluded that careful patient selection could be key to preventing and reducing the risk of failures of distraction arthroplasty.
Ultimately, while ankle distraction arthroplasty has been proven to provide moderate to complete relief of pain for patients with ankle arthritis, risk factors for reoperation are not completely understood and must be more thoroughly investigated to reduce the incidence of failed operations. Furthermore, to the current authors' knowledge, there are no reports of the role of distraction arthroplasty in acute settings.
In this case, the rationale for using distraction arthroplasty as an acute treatment was based on the combination of the patient's health, the status of the surrounding soft tissue, and the immediate weight bearing status to be functional. The authors believe that the concept of allowing cartilage to repair and heal in traditional osteoarthritis cases applies in the acute fracture setting as well. This patient maintained ankle joint space without ankle pain at 1 year postoperatively. This case demonstrates that distraction arthroplasty is a viable treatment option for acute ankle fractures in high-risk patients, allowing immediate weight bearing.
- Judet R, Judet T. Arthrolyse et arthroplastie sous distracteur articulaire. Rev Chir Orthop Repar Appar Mot. 1978;64(5):353–365.
- van Valburg AA, van Roermund PM, Lammens J, et al. Can Ilizarov joint distraction delay the need for an arthrodesis of the ankle? A preliminary report. J Bone Joint Surg Br. 1995;77(5):720–725. doi:10.1302/0301-620X.77B5.7559696 [CrossRef]. PMID:7559696
- van Valburg AA, van Roermund PM, Marijnissen AC, et al. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage. 1999;7(5):474–479. doi:10.1053/joca.1998.0242 [CrossRef]. PMID:10489320
- Bernstein M, Reidler J, Fragomen A, Rozbruch SR. Ankle distraction arthroplasty: indications, technique, and outcomes. J Am Acad Orthop Surg. 2017;25(2):89–99. doi:10.5435/JAAOSD-14-00077 [CrossRef]. PMID:28030511
- Marijnissen AC, van Roermund PM, van Melkebeek J, Lafeber FP. Clinical benefit of joint distraction in the treatment of ankle osteoarthritis. Foot Ankle Clin. 2003;8(2): 335–346. doi:10.1016/S1083-7515(03)00044-5 [CrossRef]. PMID:12911245
- van Roermund PM, Marijnissen AC, Lafeber FP. Joint distraction as an alternative for the treatment of osteoarthritis. Foot Ankle Clin. 2002;7(3):515–527. doi:10.1016/S1083-7515(02)00027-X [CrossRef]. PMID:12512407
- Tellisi N, Fragomen AT, Kleinman D, O'Malley MJ, Rozbruch SR. Joint preservation of the osteoarthritic ankle using distraction arthroplasty. Foot Ankle Int. 2009;30(4):318–325. doi:10.3113/FAI.2009.0318 [CrossRef]. PMID:19356356
- Xu Y, Zhu Y, Xu XY. Ankle joint distraction arthroplasty for severe ankle arthritis. BMC Musculoskelet Disord. 2017;18(1):96. doi:10.1186/s12891-017-1457-9 [CrossRef]. PMID:28245830
- Marijnissen AC, Hoekstra MC, Pré BC, et al. Patient characteristics as predictors of clinical outcome of distraction in treatment of severe ankle osteoarthritis. J Orthop Res. 2014;32(1):96–101. doi:10.1002/jor.22475 [CrossRef]. PMID:23983196
- Nguyen MP, Pedersen DR, Gao Y, Saltzman CL, Amendola A. Intermediate-term follow-up after ankle distraction for treatment of end-stage osteo-arthritis. J Bone Joint Surg Am. 2015;97(7):590–596. doi:10.2106/JBJS.N.00901 [CrossRef]. PMID:25834084