Posttraumatic severe infection of the ankle joint - long term results of the treatment with resection arthrodesis in 133 cases
© I. Holzapfel Publishers 2010
Received: 4 July 2009
Accepted: 5 August 2009
Published: 26 February 2010
Although there is a clear trend toward internal fixation for ankle arthrodesis, there is general consensus that external fixation is required for cases of posttraumatic infection. We retrospectively evaluated the technique and clinical long term results of external fixation in a triangular frame for cases of posttraumatic infection of the ankle. From 1993 to 2006 a consecutive series of 155 patients with an infection of the ankle was included in our study. 133 cases of the advanced "Gächter" stage III and IV were treated with arthrodesis. We treated the patients with a two step treatment plan. After radical debridement and sequestrectomy the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted in the tibia and in the calcaneus and the gap was temporary filled with gentamicin beads as the first step. In the second step we performed an autologous bone graft after a period of four weeks. The case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues. Mean age at the index procedure was 49.7 years (18-82), 104 patients were male (67,1%). Follow up examination after mean 4.5 years included a standardised questionnaire and a clinical examination including the criteria of the AO-FAS-Score and radiographs. 92,7% of the cases lead to a stable arthrodesis. In 5 patients the arthrodesis was found partly-stable. In six patients (4,5%) the infection was not controllable during the treatment process. These patients had to be treated with a below knee amputation. The mean AOFAS score at follow up was 63,7 (53-92). Overall there is a high degree of remaining disability. The complication rate and the reduced patient comfort reserve this method mainly for infection. Joint salvage is possible in the majority of cases with an earlier stage I and II infection.
KeywordsInfection ankle joint posttraumatic resection arthrodesis tibial pilon
Severe infection is still an important concern in the treatment of ankle and especially tibial plafond fractures . Predisposing factors for joint infection are in particular open fractures, penetrating injuries, necrosis of the skin, soft tissue infection and comorbidity like diabetes, rheumatism and vascular disease [1, 2]. Goal of the treatment must primarily be control of the infection. Secondly absence of pain, mobility, joint function and the ability to return to work. The methods for ankle arthrodesis differ significantly, probably a sign that no method is clearly superior to others. In the last ten years there is a clear favour toward internal fixation by screws with or without resection of the joint surfaces for cases of posttraumatic arthritis [3–7]. Surprisingly, there are only very few publications concerning arthrodesis for cases of posttraumatic joint infection, which makes comparison of the results of post-traumatic arthritis and septic cases difficult [8, 9]. Methods using internal fixation seem to provide better comfort and compliance of the patients and some authors quote a higher rate of non-union for the use of external fixators [10–15]. On the other hand results of internal fixation are often compared with historical studies or techniques using the Charnley-type external fixation. Compared to modern fixators, the Charnley type is a highly unstable frame fixator construction [10, 16, 17]. Studies directly comparing the techniques were unable to find a significant difference in non union rates [18–20]. In particular for cases of joint infection there is consensus, that external fixation is first choice treatment [9, 13, 21–26].
Gächter Joint-infection classification
Hyperaemia of synovia, effusion
Hypertrophia of synovia/pus
Beginning cartilage damage, no radiological destruction
Radiological visible changes to bony structures, synovia grows over the cartillage
Stage adapted treatment algorithm
We did not see any stage I infection in our study population. 22 patients (14%) had a stage II Infection treated with bilateral arthrotomy, synovialectomy, debridement and application of antibiotic beads as the first step. Open wound treatment with daily irrigation in the bath for one week followed. Wound closure was performed as the second step. Systemic antibiotic therapy was applied for at least five days in accordance to the swab results. In 19 of the 22 cases (86%) with a stage II infection the joint could be salvaged. 3 cases showed re-infection. 2 of them were treated with arthrodesis and one below knee amputation was necessary.
Stage adapted treatment of ankle joint infection
Gächter stage Number of Patients
I = 0 II = 22 (14%)
Bilateral arthrotomy, open wound treatment for one week before closure.
III-IV = 133 (86%)
Distance arthrodesis and temporary filling with gentamicin beads. Autologous bone graft after 4 weeks.
Operative technique of resection arthrodesis
An AO fixator was applied with 4 Steinmann nails. Two Steinmann-nails were inserted with approximately 8 cm distance in the tibia, and two in the calcaneus. We recommend installing the external fixator before resection of joint surfaces and malleoli to prevent malrotation. Therefore draping should leave the knee blank. Predetermined approaches were used if possible. Metalwork implanted during previous operations was completely removed. After radical debridement and sequestrectomy of the infected areas malleoli and joint surfaces were resected. We aim for a neutral position of the arthrodesis with a maximum of 5° valgus und slight dorsalisation of the talus.
The AOFAS score gives scores from 0 to 100. A score of 90-100 is judged as an excellent result, 75-89 as good, 60-74 as fair and below 60 as poor. Follow-up examination included all 133 patients treated with resection arthrodesis.
Results intraoperative Swab
No pos. swab
Although two staged treatment protocols for the treatment of fractures of the tibial plafond have been established, posttraumatic infection is still an important concern when dealing with these injuries [2, 28]. The external compression arthrodesis as described by Charnley (1951) was the standard method for aseptic arthrodesis of the ankle joint for a long while. High rates of non union [10, 14, 15, 29] led to biomechanical [5, 30–33] and clinical comparison with internal fixation methods . Biomechanical studies showed the Charnley type external fixator to have inferior stability especially regarding rotational forces [34, 35]. Hagen (1986) and Berman (1989) achieved a significant improvement in stability via a three point fixation using 2 more Steinmann-nails and thereby improved union rates. There are only few publications concerning arthrodesis for cases of posttraumatic joint infection, what makes comparison of the results of posttraumatic arthritis and septic cases difficult [8, 9] but for cases of joint infection there is consensus, that external fixation is the first choice treatment [9, 13, 21–26]. With this technique we saw a non-union and failure rate of 8.5% in our series. The pinsite infection rate of 19% is in accordance with other studies. In series treated with internal fixation there are complication rates of up to 10% reported due to the osteosynthesis material [5, 16, 36], the rate of necessary further procedures including the removal of metalwork is reported between 11 to 22% . The loss of alignment was a known problem of the Charnley type external fixation [15, 17], with our frame setup of the fixator, no secondary loss of correction occurred in our study. The surgical techniques for ankle arthrodesis differ. In the case of infection it is required to radically remove all the infected parts of cartilage and bone. Some authors recommend to salvage the medial malleolus [16, 38] others always perform arthrodesis under usage of the osteomised distal fibula [15, 38–40]. Again our results suggest that this is not necessary, the correction of a deformity might actually be hindered by remaining malleoli [31, 41]. The perfusion of the talus is sometimes quoted as a rationale for salvage of the medial malleolus [16, 38]. We saw no cases of osteonecrosis of the talus in our series. For the AOFAS-Score after internal osteosynthesis results between 67 to 76 points are reported [16, 37, 42], which is compared to the slightly worse 63,7 points we found in our series treating only septic cases of the advanced Gächter stage III and IV.
Clinical outcome of ankle arthrodesis with a frame-pattern external fixator due to advanced infection showed slightly worse results compared to arthrodesis following posttraumatic arthritis. In advanced cases the two staged treatment with arthrodesis gives satisfactory healing rates, pain control and mobility. Overall there is a high degree of remaining disability. The complication rate and the reduced patient comfort reserves this method mainly for cases of infection and for complicated soft tissue situations. Joint salvage is possible in the majority of cases with an earlier stage I and II infection. Because infection of the ankle joint is often diagnosed in an advanced stage, when arthrodesis cannot be avoided and after several pervious operations, suspicious cases should be referred to a specialised center as early as possible.
Conflict of interests statement
The authors declare that they have no competing interests.
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