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Lee, Kim, and Lee: Analysis about Associated Factors of Nonunion Following Tibiotalar Arthrodesis
Original Article

J Korean Foot Ankle Soc 2017;21(3):98-103.

Published online: 19 January 2017

DOI: https://doi.org/10.14193/jkfas.2017.21.3.98

Analysis about Associated Factors of Nonunion Following Tibiotalar Arthrodesis

Jun Young Lee, Bo Sun Kim, Jung Woo Lee

Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea

Corresponding Author: Jun Young Lee Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea Tel: 82-62-220-3147, Fax: 82-62-226-3379, E-mail: leejy88@chosun.ac.kr

Received 19 May 201713 July 2017       Accepted 21 July 2017

Copyright © 2017 Korean Foot and Ankle Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

The aim of this study was to analyze the factors related to nonunion in tibiotalar arthrodesis.

Materials and Methods:

Eighty cases of ankle arthritis treated with tibiotalar arthrodesis in our hospital from November 2008 to November 2015 with more than one year follow up were analyzed. Simple anteroposterior and lateral radiographs after 6 and 12 months of surgery were analyzed. Union was defined as more than 50% connection of the trabecular bone at the ankle joint surface in the anteroposterior and lateral radiographs. The nonunion group was defined as no signs of union with persistent pain 9 months after surgery. The surgical approach, type of used screw, preoperative and postoperative ankle alignment, body mass index (BMI), bone mineral density, and patients’ prior history were compared between the two groups.

Results:

There were 69 union cases and 11 nonunion cases. In the patient factors, the gender and BMI was related to nonunion (p<0.05). The mean preoperative and postoperative ankle alignment in the nonunion group was 9.93°±6.92° and 5.43°±3.35° respectively, and 9.80°±7.55° and 5.63°±3.45° in the union group, respectively; the difference was not statistically significant (p>0.05). In the technical factors, the transfibular approach showed a better relationship but the association was not significant (p<0.05). In 40 cases of the transfibu-lar approach, 12 cases used cancellous screws, and 4 cases showed nonunion due to screw breakage.

Conclusion:

Technical factors, such as the surgical approach and the type of screw used can be a risk factor in nonunion. In addition, patients’ factors, such as gender and BMI, must be considered to reduce the nonunion rate.

Keywords: Arthrodesis, Nonunion

REFERENCES

11.Gordon D., Zicker R., Cullen N., Singh D. Open ankle arthrodeses via an anterior approach1 Foot Ankle Int1. 2013. 34:386–911.
21.Maurer RC., Cimino WR., Cox CV., Satow GK. Transarticular cross-screw fixation1 A technique of ankle arthrodesis1 Clin Or-thop Relat Res1. 1991. 268:56–641.
31.Stranks GJ., Cecil T., Jeffery IT. Anterior ankle arthrodesis with cross-screw fixation1 A dowel graft method used in 20 cases1 J Bone Joint Surg Br1. 1994. 76:943–61.
41.Raikin SM. Arthrodesis of the ankle: arthroscopic, mini-open, and open techniques1 Foot Ankle Clin1. 2003. 8:347–591.
51.Akra GA., Middleton A., Adedapo AO., Port A., Finn P. Outcome of ankle arthrodesis using a transfibular approach1 J Foot Ankle Surg1. 2010. 49:508–121.
61.Holt ES., Hansen ST., Mayo KA., Sangeorzan BJ. Ankle arthrodesis using internal screw fixation1 Clin Orthop Relat Res1. 1991. 268:21–81.
71.Monroe MT., Beals TC., Manoli A 2nd. Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws1 Foot Ankle Int1. 1999. 20:227–311.
81.Kennedy JG., Hodgkins CW., Brodsky A., Bohne WH. Outcomes after standardized screw fixation technique of ankle arthrodesis1 Clin Orthop Relat Res1. 2006. 447:112–81.
91.Nielsen KK., Linde F., Jensen NC. The outcome of arthroscopic and open surgery ankle arthrodesis: a comparative retrospective.
101.Charnley J. Compression arthrodesis of the ankle and shoulder1 J Bone Joint Surg Br1. 1951. 33B:180–911.
111.Morrey BF., Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma1 J Bone Joint Surg Am1. 1980. 62:777–841.
121.Kenzora JE., Simmons SC., Burgess AR., Edwards CC. External fixation arthrodesis of the ankle joint following trauma1 Foot Ankle1. 1986. 7:49–611.
131.Frey C., Halikus NM., Vu-Rose T., Ebramzadeh E. A review of ankle arthrodesis: predisposing factors to nonunion1 Foot Ankle Int1. 1994. 15:581–41.
141.White AA 3rd. A precision posterior ankle fusion1 Clin Orthop Relat Res1. 1974. 98:239–501.
151.Scranton PE Jr. Use of internal compression in arthrodesis of the ankle1 J Bone Joint Surg Am1. 1985. 67:550–51.
161.Loughlin J. Genetic epidemiology of primary osteoarthritis1 Curr Opin Rheumatol1. 2001. 13:111–61.
171.Adams JC. Arthrodesis of the ankle joint; experiences with the transfibular approach1 J Bone Joint Surg Br1. 1948. 30B:506–111.
181.Mann RA., Rongstad KM. Arthrodesis of the ankle: a critical analysis1 Foot Ankle Int1. 1998. 19:3–91.
191.Wang GJ., Shen WJ., McLaughlin RE., Stamp WG. Transfibular compression arthrodesis of the ankle joint1 Clin Orthop Relat Res1. 1993. 289:223–71.
201.O’Brien TS., Hart TS., Shereff MJ., Stone J., Johnson J. Open versus arthroscopic ankle arthrodesis: a comparative study1 Foot Ankle Int1. 1999. 20:368–741.
211.Schutz M., Ruedi TP. Principles of internal fixation1 In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P III, editors1 Rockwood and Green’s fractures in adults1 7th ed1 Philadelphia: Lippincott Williams & Wilkins. 20101. p1162-901.
221.Kish G., Eberhart R., King T., Holzaepfel JL., Pollock T. Ankle arthrodesis placement of cannulated screws1 Foot Ankle1. 1993. 14:223–41.
231.Pak CH., Lee JY., Jeong YJ. Ankle arthrodesis outcomes in ankle osteoarthritis: comparison between anterior approach and transfibular approach1 J Korean Foot Ankle Soc1. 2014. 18:189–941.
241.Ogilvie-Harris DJ., Lieberman I., Fitsialos D. Arthroscopically assisted arthrodesis for osteoarthrotic ankles1 J Bone Joint Surg Am1. 1993. 75:1167–741.
251.Goetzmann T., Molé D., Jullion S., Roche O., Sirveaux F., Jacquot A. Influence of fixation with two vs1 three screws on union of arthroscopic tibio-talar arthrodesis: comparative radiographic study of 111 cases1 Orthop Traumatol Surg Res1. 2016. 102:651–61.

Figure 1.
Preoperative standing anteroposterior radiographs showing ankle alignment which is defined as the angle between the anatomical axis of the tibia (α) and a line drawn perpendicular to the talar dome (β).
jkfas-21-98f1.tif
Figure 2.
(A) Preoperative standing radiograph shows lateral compartment ankle osteoarthritis. (B) Ankle arthrodesis was performed with anterior approach using three cannulated screws. (C) Nonunion occurs after 12 month of first operation. (D) Revision operation with 4 cannulated screw was done.
jkfas-21-98f2.tif
Figure 3.
(A) Preoperative standing radiograph shows medial compartment ankle osteoarthritis. (B) Ankle arthrodesis was performed with transfibular approach using three cancellous screws. (C) Follow-up radiograph shows breakage of cancellous screws and valgus tibiotalar alignment. (D) Revision arthrodesis with cannulated screws was performed and bony union was evident 12 months after surgery.
jkfas-21-98f3.tif
Table 1.
VAS and AOFAS of the Nonunion and Union Groups
Variable Union (n=69) Nonunion (n=11) p-value*
VAS
Preoperative 7.19±1.01 7.00±0.63 0.404
Prerevision - 6.88±0.97
Last follow-up 4.58±1.86 3.91±0.83 0.056
p-value† <0.001 <0.001
AOFAS score Preoperative 53.30±9.33 55.45±8.20 0.473
Prerevision - 50.95±7.65
Last follow-up 70.34±7.48 73.18±3.31 0.044
p-value† <0.001 <0.001

Values are presented as mean±standard deviation. VAS: visual analogue scale, AOFAS: American Orthopaedic Foot and Ankle Society.

* By independent t-test,

† By paired t-test, Wilcoxon singed rank test.

Table 2.
Mean Difference of the Nonunion and Union Groups
Variable Union (n=69) Nonunion (n=11) p-value*
Age (yr) 59.75±11.91 65.18±9.45 0.155
Angulation (。)
Preoperative 9.80±7.55 9.93±6.92 0.957
Postoperative 5.63±3.45 5.43±3.35 0.871
No. of screws 3.00±0.00 2.91±0.37 0.057
BMI (kg/m2) 25.20±2.76 28.52±0.52 <0.001

Values are presented as mean±standard deviation. BMI: body mass index. *By independent t-test.

Table 3.
Variables of the Nonunion and Union Groups
Variable Union (n=69) Nonunion (n=11) p-value*
Sex Male 31 (44.9) 9 (81.8) 0.048
Female 38 (55.1) 2 (18.2)
Cause Primary OA 35 (50.7) 8 (72.7) 0.051
Post traumatic OA 34 (49.3) 3 (27.3)
Approach Anterior approach 38/40 (95.0) 2/40 (5.0) 0.048
Transfibular 31/40 (77.5) 9/40 (22.5)
Alignmen <10。 41 (59.4) 4 (36.4) >0.800
≥10。 28 (40.6) 7 (63.6)
BMI <25 kg/m2 30 (43.5) 0 (0) 0.005
≥25 kg/m2 39 (56.5) 11 (100)

Values are presented as number (%). OA: osteoarthritis, BMI: body mass index.

* By chi-square test (Fisher’s exact test).

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