Evaluation of three fixation methods in tibiotalocalcaneal fusion for chronic osteomyelitis following ankle fracture

Introduction: In the scenario of chronic osteomyelitis following an ankle fracture, limb salvage and ideally infection eradication, can be an alternative to amputation.Tibiotalocalcaneal arthrodesis is perhaps the most popular procedure. When performing fusion in osteomyelitis patients, external fixation is more commonly used, although there is some experience with internal fixation. In this study, we conducted a retrospective evaluation of three groups of consecutively treated patients undergoing tibiotalocalcaneal fusion using either circular or monoplanar external fixation or an intramedullary nail coated with antibiotic-loaded cement. Our objective was to assess the success of each procedure in terms of consolidation, infection remission, and improvement in the quality of life.

Materials and methods: A multicenter, retrospective, study of 17 patients treated with tibiotalocalcaneal fusion, divided into three groups based on the treatment performed: Group A: retrograde intramedullary nail coated with Polymethylmethacrylate (PMMA) with antibiotic, Group B: monoplanar LRS (Limb Reconstruction System) external fixator, and Group C: circular external fixator; all with a minimum 12 month follow-up. Quality and percentage of consolidation were evaluated through tomography. Additionally, the SF-12 form was administered to assess the quality of life at the last follow-up visit.

Results: 17 patients were evaluated. Group A: 6 patients, average tibiotalar and subtalar consolidation rates were 66.24 % and 67.06 %. One patient did not achieve infection healing. SF-12 scores averaged 40 for physical and 48.13 for mental. Group B: 5 patients; 3 active smokers. Average tibiotalar and subtalar consolidation rates were 52.78 % and 62.3 %, respectively. All patients achieved infection remission. SF-12 scores averaged 46.7 for physical and 51.3 for mental. Group C:6 patients, 1 diabetic and 3 smokers. Average tibiotalar and subtalar consolidation rates were 65.9 % and 65.7 %. Half experienced infection recurrence. SF-12 scores averaged 36.7 for physical and 47.8 for mental.

Conclusion: Patients with coated retrograde nails exhibit higher consolidation rates; and patients with circular external fixation had a higher infection recurrence rate. Establishing generalizable treatment algorithms for these patients remains challenging, but our data suggest a favorable trend toward the use of internal intramedullary fixation coated with PMMA.