Talar necrosis and infection are serious complications that have challenged orthopedic surgeons for years. In this study, 6 patients who underwent tibiocalcaneal fusion using the Ilizarov technique, predominantly for post-traumatic talar osteitis, were reviewed after mean follow-up of 8 years. Solid fusion was obtained in all cases. In 5 patients, simultaneous lengthening was performed through a proximal tibial corticotomy. Complications were related primarily to pin insertion sites. The Ilizarov technique can be used successfully for tibiocalcaneal fusion in complex cases with talar osteitis that otherwise may ultimately require amputation.
Fractures and dislocations of the talus are notorious for their significant long-term functional problems. Because of the tenuous blood supply, the modest amount of periosteum, and the occurrence of open injuries in up to 25% of cases, such fractures have been associated with a high rate of complications.1-4 Avascular necrosis has been reported in up to 100% of Hawkins grade III fractures, with an overall incidence ranging from 21% to 58%.1-3 Infection may complicate both open and closed talar fractures. Once established, infection tends to be recalcitrant to local debridement and usually ends in sequestration of the entire talus.3
When talar collapse and destruction occur, the therapeutic alternatives become limited. Conventional tibiotalar, subtalar, or pantalar joint fusions have yielded unsatisfactory results in these situations.1,5,6 Critical analysis of the long-term results of isolated talectomy has revealed a high rate of complications such as persistent pain, limping gait, limb shortening, foot instability, recurrent deformity, and progressive tibiocalcaneal arthritis.1,2,7,8 Foot ablation may be the only treatment left in cases with chronic suppuration or repeated failed surgeries.
A successful tibiocalcaneal fusion is an ideal solution for salvaging cases with complex talar pathology.9-15 The Ilizarov technique, in addition to its reliable high fusion rate, has distinct advantages that allows problems associated with other treatment modalities to be solved ideally with few complications.6,7,16-18 This study examined the results of tibiocalcaneal arthrodesis performed with the Ilizarov frame in 6 patients.
Materials and Methods
For this study, 6 cases of Ilizarov tibiocalcaneal fusion performed between July 1995 and July 2000 at the University of Ulm were reviewed (Table). Three men (mean age, 34 years; range, 25-44 years) and 3 women (mean age, 46 years; range, 21-60 years) with unilateral talar necrosis comprised the study population.
The left side was operated on in 4 patients and the right side in 2 patients. A history of trauma was present in all but 2 patients. One patient had avascular necrosis of the talus several months after ankle fusion for a post-traumatic ankle arthrosis, and 5 patients had chronic talar osteitis. Infection developed after open fracture dislocations of the talus in 3 patients; after radiotherapy following excision of an intraosseous leiomyosarcoma, bone allograft application, and triple fusion in 1 patient; and after calcaneal spur excision in 1 patient.
All patients had undergone at least 1 previous surgical procedure (mean, 3 procedures) including open reduction and internal fixation (ORIF), ankle bridging external fixation, bone grafting, wound revisions with or without vacuum sealing, and ankle fusion. The aim of treatment was to obtain a painless solid fusion between the distal tibia and the os calcis after resection of the diseased talus and to eradicate infection if present with correction of the resulting limb-length discrepancy.
The surgical approach consisted of combined lateral and anteromedial incisions for adequate exposure of the ankle joint and the talus. The lateral malleolus was excised through a fibular osteotomy performed 1 inch proximal to the joint line. The medial malleolus also was removed, and the necrotic talus was excised.
After thorough joint irrigation and debridement, parallel cuts were made through the distal tibia and the calcaneus with an oscillating saw down to bleeding cancellous bone. The fusion site was temporary fixed using 2 crossing tibiocalcaneal pins in neutral flexion position, 5° of valgus, and 5° to 10° of external rotation.
A preassembled Ilizarov frame then was mounted on the tibia using various pin and wire combinations (hybrid technique). Two full rings were applied to the proximal tibia above the planned osteotomy site, a diaphyseal ring was added for lengthening, and 1 or 2 rings were fixed to the distal tibia. A footplate was applied at the level of the calcaneus to allow compression fusion and maintain foot alignment. Bone fixation was accomplished using multiple olive wires to the calcaneus and the metatarsals. The tibial and foot mountings were joined by at least 3 threaded rods. A percutaneous low-energy corticotomy then was performed in the proximal tibia using sharp osteotomes.
Lengthening was started after a latent period of 7 to 10 days at a rate of 1 mm per day (0.25 mm every 6 hours). Progressive compression of the fusion site was begun immediately after surgery. Early weight bearing (according to pain tolerance) was allowed in the postoperative period with patients wearing rocker bottom footwear that compensates for shortening and helps rolling. Gait and balance training were begun in the rehabilitation setting to continue later on an ambulatory basis.
Radiographs were performed every 2 to 4 weeks to assess progression of fusion as well as maturation of the distraction callus. The frame was removed after clinical and radiographic union of the arthrodesis and adequate consolidation of the lengthening site were confirmed. In cases in which solid bony fusion preceded full maturation of the regenerate, the foot frame was removed to simplify patient ambulation.
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Figure 1: AP (A) and lateral (B) radiographs showing a talar fracture complicated by infection after open reduction and internal fixation.
Mean follow-up in this series was 93.5 months (range, 55-115 months). All of the fusion sites achieved solid clinical and radiographic healing without additional intervention. Pain and function improved in all patients, and all patients were satisfied with the treatment outcome. All patients acquired an almost normal gait without assistance, although some patients noted walking on uneven ground was difficult. No case required amputation, and no neurovascular complications occurred (Figures 1-4).
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Figure 2: AP (A) and lateral (B) radiographs showing talectomy with tibiocalcaneal fusion and a proximal tibial osteotomy. Figure 3: AP (A) and lateral (B) radiographs showing progressive lengthening after solid fusion and removal of the foot frame.
Average time patients were in the Ilizarov frame was 36 weeks (range, 16-73 weeks). Tibial lengthening was performed in all cases except in the patient with leiomyosarcoma because of recurrent metastases. In half of the patients, the foot frame was removed after tibiocalcaneal fusion was achieved (15-25 weeks). In the remaining patients, the tibial lengthening frame was left in place for an additional 14 to 50 weeks until the target leg length was achieved and the regenerated bone was adequately ossified.
Planned wound revisions were performed in 4 patients to obtain a clean wound or to evacuate a local hematoma. Two patients had postoperative skin defects that were covered successfully by mesh grafts.
Complications occurred in two-thirds of the cases. The most common complication was pin tract infection requiring pin or wire removal or exchange combined with antibiotic treatment (2 patients). Complications related to lengthening included 1 case of delayed maturation of the regenerate and 1 case of fracture in the lengthening zone after frame removal. The former was treated by iliac crest bone grafting combined with low-intensity pulsed ultrasound stimulation followed by Sarmiento bracing after frame removal. In the latter case, the fractured callus united after 13 weeks of monolateral external fixation.
Chopart joint fusion was performed in 2 patients. Indications were a progressive midtarsal arthritis after fusion in 1 patient and a recurrent tarsal infection despite repeated debridement in the second patient with previous irradiation for a talar leiomyosarcoma. Fusion was performed using 2 cannulated cancellous screws in the former and an AO external fixation frame with primary bone graft application in the latter. The patient with the talar leiomyosarcoma also developed bilateral lung metastases that were treated with thoracotomy, atypical lung resection, and mediastinal lymph node dissection. A late soft tissue metastasis that also developed in this patient’s left arm recently was treated with wide resection.
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Figure 4: AP (A) and lateral (B) radiographs showing the result after full maturation of the regenerated bone and removal of the Ilizarov fixator.
Talar osteitis is usually catastrophic. In 1848, Syme19 reported 11 deaths from sepsis in 13 cases of open talar fractures. Infection also may follow closed soft tissue injuries or complicate internal fixation or hindfoot surgery. Eradication of infection is usually difficult and requires repeated debridement with removal of all necrotic and infected bone. This usually compromises the chances of obtaining a successful ankle fusion because the remaining bone stock is inadequate.6 In some cases, infection eventually may necessitate complete removal of the talus, an operation that was once popular for rigid ankle and hindfoot deformities. Unfortunately, talectomy alone does not guarantee resolution of infection and is associated with persistently poor functional results.1,2,7,8
Amputation may offer a radical solution for resistant cases of infection, with shorter hospital stay and rehabilitation time; however, amputation is not accepted by all patients.7 In addition to its psychologically morbid impact, the overall lifetime cost of amputation has been shown to be nearly 7 times more expensive than limb salvage.20 It also is associated with higher oxygen consumption and increased energy expenditure.21
Tibiocalcaneal fusion was first described by Giberson and Janes22 in the early 1950s. The technique was later refined by Reckling.15 Indications include septic or aseptic talar necrosis7,12,15,17; inflammatory arthritis12,13; severe or recurrent foot deformities in arthrogryposis, myelomeningocele, or clubfeet13,14; neuropathic arthropathy9,10,13,18; and salvage of failed ankle fusion.11,16,23
To obtain tibiocalcaneal arthrodesis, several fixation methods have been used. Internal fixation implants such as condylar blade plates and large fragment screws have been used predominantly in cases without infection in which fixation is dependent on the quality of bone present.5,9,13 Primary bone grafting usually is necessary, and the technique requires patients’ commitment to several months of nonweight-bearing ambulation.
Tibiocalcaneal fusion using antegrade or retrograde intramedullary rods is a challenging procedure, and complications such as nonunion, recurrent deformity, wound problems, and infection are common.10 Using this technique, De Smet et al23 achieved unsatisfactory results in all of their patients, forcing them to terminate their study prematurely.
Triangular external fixation with Calandruccio and Vidal-Adrey frames also has been used; however, pin-site problems and bone healing complications are common with all of the available large pin fixators.17,24 Furthermore, none of the abovementioned internal and external techniques compensate for the resulting limb shortening after excision of the talus.
Fusion concepts have changed significantly in the past 2 decades as circular external fixation has become the standard of care adopted by surgeons for complex ankle and foot problems. The Ilizarov technique and the method of transosseous osteosynthesis it harnesses offers valuable advantages over other conventional fixation techniques. A circular frame allows progressive circumferential compression with better control of foot position. The use of tensioned wires ensures optimal stabilization and allows early weight bearing, which can enhance bone healing. The technique is minimally invasive and does not cause additional soft tissue injury. It is particularly helpful in cases with infection as no metallic implants are added and radical debridement is possible without jeopardizing the chances of obtaining fusion. The frame is modular and allows simultaneous correction of deformities and limb-length discrepancies throughout treatment.4,6,7,16-18,25,26
Only a few authors have reported their experience of using the Ilizarov apparatus for tibiocalcaneal fusion. Johnson et al16 obtained successful tibiocalcaneal fusion using Ilizarov compression arthrodesis after an average of 7 months in 3 of 4 patients with failed infected ankle arthrodesis.
Uehara et al18 treated a Charcot ankle joint secondary to congenital sensory neuropathy with anhydrosis by tibiocalcaneal fusion and tibial lengthening. In another report from the same institution on 6 cases of fusions around the ankle, Sakurakichi et al17 included a second case treated with the same technique for post-traumatic arthrosis after a talar fracture dislocation.
Dennison et al7 achieved solid fusion and excellent to good functional results in all of their 6 patients with avascular necrosis of the talus using tibiocalcaneal fusion. Simultaneous lengthening was performed in all but 2 patients who were >60 years.
The results obtained in our long-term report are promising. All of our patients had solid bony fusion. Eradication of infection was achieved in all of our cases by the end of treatment, and all of our patients were satisfied with their functional outcome at latest follow-up.
Lengthening offers several advantages. Oteotomy proximal to the fusion site increases the local blood supply, which helps to resolve infection while increasing fusion potentials.17,26 Furthermore, talectomy and articular resection may lead to a 4-cm loss of limb height, and correction of shortening gives a better functional outcome.17,27 However, because lengthening prolongs the treatment period and many of the complications were related to callus distraction, the decision for lengthening should be individualized. Dennison et al7 considered 3.5 cm of shortening as the preferable option for patients >60 years to avoid a prolonged time in the frame and the associated pin-site problems. It also was not appropriate to lengthen the tibia in our patient with metastatic leiomyosarcoma.
It is well-known that tibiocalcaneal fusion can lead to degenerative changes in adjacent foot joints.12 Two patients in our study required a secondary Chopart joint fusion. Weber et al6 described a tibiocalcaneonaviculocuboidal fusion in 6 cases with complex talar and peritalar pathology. The technique combined tibiocalcaneal and midtarsal (Chopart) joint fusion with proximal metaphyseal lengthening using the same Ilizarov frame. However, such a radical approach increases the complexity of treatment and necessitates a longer period of external fixation with a subsequently higher rate of complications. Moreover, Chopart joint arthrodesis is not needed in all patients, and a secondary fusion always can be performed electively when the need arises.
A major limitation in our study was the small number of patients and the lack of a control group. However, this is a relatively new application of the Ilizarov technique, and all similar series have reported either an equal or a smaller number of cases. It also should be noted that most of our patients represented worst-case scenarios with talar collapse, persistent infection, or local irradiation in which other treatment options were contraindicated, unsuccessful, or fraught with complications; the alternative solution in these patients would have been a below-knee amputation. The method is technically demanding and requires competent surgeons and compliant patients, especially when lengthening is performed.
The Ilizarov technique is a safe and reliable procedure for obtaining solid tibiocalcaneal fusion in cases with severe talar destruction. Fusion is best combined with proximal tibial lengthening using the same circular frame. The technique addresses all aspects of pathology without major complications and offers a consistently high rate of fusion with better functional results than other conventional internal or external fusion procedures. Attention to technical details and close monitoring of patients are important prerequisites to guarantee satisfactory long-term results.
- Canale ST, Kelly FB Jr. Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978; 60(2):143-156.
- Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970; 52(5):991-1002.
- Heckman JD. Fractures and dislocations of the foot. In: Rockwood CA, Green DP, Bucholz RW, Heckman, JD, eds. Rockwood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott-Raven; 1996:2226-2405.
- Szyszkowitz R, Reschauer R, Seggl W. Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop Relat Res. 1985; (199):97-107.
- Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg Am. 1992; 74(7):1042-1049.
- Weber M, Schwer H, Zilkens KW, Siebert CH. Tibio-calcaneo-naviculo-cuboidale arthrodesis: 6 patients followed for 1-8 years. Acta Orthop Scand. 2002; 73(1):98-103.
- Dennison MG, Pool RD, Simonis RB, Singh BS. Tibiocalcaneal fusion for avascular necrosis of the talus. J Bone Joint Surg Br. 2001; 83(2):199-203.
- Legaspi J, Li YH, Chow W, Leong JC. Talectomy in patients with recurrent deformity in club foot: a long-term follow-up study. J Bone Joint Surg Br. 2001; 83(3):384-387.
- Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity. Foot Ankle Int. 1994; 15(7):354-359.
- Chi TD, McWilliam J, Gould JS. Lateral plate-washer technique for revision tibiocalcaneal fusion. Am J Orthop. 2001; 30(7):588-590.
- Edelman RD, Fisher GR. Tibiocalcaneal arthrodesis of a failed ankle fusion. J Foot Ankle Surg. 1993; 32(2):197-203.
- Mann RA, Chou LB. Tibiocalcaneal arthrodesis. Foot Ankle Int. 1995; 16(7):401-405.
- Myerson MS, Alvarez RG, Lam PW. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int. 2000; 21(8):643-650.
- Nicomedez FP, Li YH, Leong JC. Tibiocalcaneal fusion after talectomy in arthrogrypotic patients. J Pediatr Orthop. 2003; 23(5):654-657.
- Reckling FW. Early tibiocalcaneal fusion in the treatment of severe injuries of the talus. J Trauma. 1972; 12(5):390-396.
- Johnson EE, Weltmer J, Lian GJ, Cracchiolo A III. Ilizarov ankle arthrodesis. Clin Orthop Relat Res. 1992; (280):160-169.
- Sakurakichi K, Tsuchiya H, Uehara K, Kabata T, Yamashiro T, Tomita K. Ankle arthrodesis combined with tibial lengthening using the Ilizarov apparatus. J Orthop Sci. 2003; 8(1):20-25.
- Uehara K, Tsuchiya H, Kabata T, Sakurakichi K, Shimozaki E, Tomita K. Ankle arthrodesis and tibial lengthening for congenital sensory neuropathy with anhidrosis. J Orthop Sci. 2001; 6(5):430-434.
- Syme J. Contributions to the Pathology and Practice of Surgery. Edinburgh, Scotland: Sutherland and Knox; 1848.
- Williams MO. Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation. Clin Orthop Relat Res. 1994; (301):156-158.
- Huang CT, Jackson JR, Moore NB, et al. Amputation: energy cost of ambulation. Arch Phys Med Rehabil. 1979; 60(1):18-24.
- Giberson RG, Janes JM. Tibiocalcaneal fusion; a surgical technique. Surg Gynecol Obstet. 1954; 99(6):773-776.
- De Smet K, De Brauwer V, Burssens P, Van Ovost E, Verdonk R. Tibiocalcaneal Marchetti-Vicenzi nailing in revision arthrodesis for posttraumatic pseudarthrosis of the ankle. Acta Orthop Belg. 2003; 69(1):42-48.
- Rothacker GW Jr, Cabanela ME: External fixation for arthrodesis of the knee and ankle. Clin Orthop Relat Res. 1983; (180):101-108.
- Catagni MA. Biomechanics of the Ilizarov apparatus. In: Maiocchi AB, ed. Treatment of Fractures, Nonunions, and Bone Loss of the Tibia With the Ilizarov Method. Milan, Italy: Medi Surgical Video; 1998:21-24.
- Ilizarov GA. Transosseus Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. Berlin, Germany: Springer-Verlag; 1992.
- Paley D, Herzenberg JE. Application of external fixation to foot and ankle reconstruction. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia, PA: WB Saunders; 2000:1135-1188.
Dr Salem is from the Department of Orthopedic Surgery, Cairo University, Cairo, Egypt.
Dr Salem has no relevant financial relationships to disclose.
The author thanks Prof Dr Lothar Kinzl for his support and Dr Andreas Schmelz for reviewing the manuscript.
Correspondence should be addressed to: Khaled Hamed Salem, MD, Department of Orthopedic Surgery, Cairo University, Kasr El-Aini St, 11562 Cairo, Egypt.