Current Concepts In Pantalar Arthrodesis

Pantalar arthrodesis can be an effective limb salvage option for pathologies ranging from Charcot arthropathy to end-stage posterior tibial tendon dysfunction. Accordingly, these authors share essential pearls for the challenging procedure, explore fixation options and review the outcomes in the literature.

Pantalar arthrodesis is the fusion of the tibiotalar, subtalar, talonavicular and calcaneocuboid joints. Many consider the procedure, which severely disrupts normal hindfoot function and gait, as a salvage procedure prior to major amputation to provide brace-free gait.¹

MacKenzie and colleagues have shown that in terms of healthcare costs, limb salvage including complications will be approximately $10,000 less than the cost of amputation after two years when including the cost of prosthetics.² The lifetime healthcare costs for amputations have been approximately three times as much as for salvage.² Keeping the affected extremity, therefore, becomes ideal, not only for the patient’s desires but economically as well.³

The basic indications for pantalar arthrodesis include severe pain, deformity, instability not amenable to conservative care (bracing) and evidence of abnormal plantar pressures despite the use of orthotic devices and special shoes.^4-6 Non-surgical management is often inadequate when it comes to preventing gait abnormalities, treating chronic ulcerations, preventing skin breakdown, and fitting difficult shoe gear.⁷

Pathology leading to the basic pantalar arthrodesis indications usually includes Charcot arthropathy, post-traumatic arthritis, end-stage posterior tibial tendon dysfunction, clubfoot, failed total ankle replacement, rheumatoid arthritis and a paralytic foot like one would see in a patient with polio.^6,8-11 A commonality of each of these disease processes is involvement of multiple joints, malalignment, pain or an insensate foot, a paralytic lower extremity, and bony deficits and deformity.⁴ Patients will present with pain, a decrease in ankle and hindfoot motion, an altered gait and often with deformities of the ankle, hindfoot or both.¹²

A pantalar arthrodesis stabilizes a deformed, painful or insensate foot. In patients presenting with post-traumatic arthritis, it may allow for painless gait. For patients presenting with diabetes, pantalar arthrodesis may help realign the hindfoot and thereby decrease abnormal plantar pressures. This would allow the patient with diabetes to wear orthotics or special shoes, which may help decrease the formation of ulcers and lower the risk of complications and amputation.^13-17

Contraindications to pantalar arthrodesis include vascular insufficiency, chronic prednisone use, immunocompromised status, infection and proximal extremity contractures and malalignment.

A Guide To Pre-Operative Planning
Given the substantial nature of potential long-term sequelae and complications a pantalar arthrodesis can pose on a patient, it is critical to have an adequate understanding of the deformity and perform comprehensive preoperative planning in order to maximize the potential for a successful outcome.

Evaluation should consist of thorough imaging studies of the lower extremity, including weightbearing X-rays of the entire lower extremity. This can potentially uncover concomitant pathology presenting proximal or distal to the pantalar arthrodesis site, which then would require accommodation or correction of alignment abnormalities. Computed tomography (CT) studies and magnetic resonance imaging (MRI), as well as nuclear imaging, can provide a more thorough assessment of bone quality, a greater understanding of the extent of the deformity or pathology, and help confirm an infective process.

One should provide noninvasive vascular evaluations for patients with a known history of peripheral vascular disease or a clinical exam consistent with decreased perfusion. Patients demonstrating an ankle-brachial index (ABI) less than 0.8 or a toe pressure less than 30 mm Hg should get a referral for a vascular consultation as well as an internal medicine consultation for any medical comorbidities.⁴

Essential Surgical Insights
Pantalar arthrodesis is far from a simple surgery and we recommend that only experienced surgeons perform it. Surgeons have used and proposed a multitude of incisional approaches, fixation methods and grafts for pantalar arthrodesis. The complexity of the procedure is highlighted by the sheer number of different fusion techniques, including one-and two-incision approaches with open reduction and internal fixation, retrograde intramedullary nailing and the use of external fixation.³ One can also perform pantalar arthrodesis in one stage or two stages, depending on the complexity and extent of the deformity as well as the durability of the patient.¹ Arthroscopic fusion techniques, especially of the ankle, have become relatively common as well.³

General recommendations when approaching pantalar arthrodesis include maintaining the fibula, which may be advantageous if there is any thought for fusion takedown and insertion of total ankle joint replacement.¹⁸ Therefore, when performing cuts to reposition the foot, one should ideally attempt to resect as little bone as possible and preserve the maximum amount of bone.^3,18

Given that the pantalar arthrodesis centers on the talus, which is often the bone most affected by the previously mentioned pathologies, surgeons need to assess talus quality preoperatively and intraoperatively for proper surgical planning. Conditions such as flatfoot, Charcot arthropathy, rheumatoid arthritis and clubfoot can lead to severe accomodative changes in the structure and ultimate collapse of the talus. Depending on the extent of structural change and reducibility of the deformity, some surgeons advocate removal of the talus and reshaping for bone graft to assist with realignment and healing.8 Surgeons use additional autogenous and allogeneic bone graft at their discretion.³

Avascular necrosis of the talus poses an added challenge to successful pantalar arthrodesis as fusion between a devascularized talus and surrounding bone is difficult. Vascularized bone graft can revascularize the talus.¹⁹ Bishop and coworkers have reported on a large series of ankle arthrodesis procedures using vascularized bone transfer.²⁰ They chose a fibula transfer for patients with osseous defects larger than 4 cm and iliac crest for patients with osseous defects less than 4 cm.²¹

Thorough cartilage resection and penetration of subchondral bone are essential to maximize fusion site healing. Options include resection, curettage, drilling, fish scaling and burring. Miller and colleagues compared two methods of joint surface preparation (removal of articular cartilage only versus parallel flat saw cuts) and showed no statistical difference between the two methods when they were loaded to failure.^3,22

A Quick Primer On Alignment Goals
When aligning joints for pantalar arthrodesis, it is important to have angles and measurements from the contralateral lower extremity for comparison. It is also important to check positioning intraoperatively prior to fixation and during each subsequent step of fixation of each joint in the pantalar arthrodesis. Check anterior-posterior and lateral views of both the ankle and foot fluoroscopically along with the calcaneal axial view with simulated weightbearing.

Alignment and fixation should proceed from proximal to distal, first with the talus in relation to the tibia and then the foot in relation to the talus.²³ The tibial mid-diaphyseal line should coincide with the lateral process of the talus in the sagittal plane. The sole of the foot should be plantigrade, 90 degrees to the tibia in the sagittal plane. On the calcaneal axial view, the calcaneal bisection line should be parallel or slightly valgus (0 to 5 degrees) to the mid-diaphyseal line of the tibia and translated medial to be in line with the mid-diaphyseal line. Finally, one should ensure 10 to 15 degrees of external rotation of the foot so the second ray aligns with the tibial crest.¹⁸

Pertinent Insights On Fixation
There are numerous fixation options for pantalar arthrodesis. They range from combinations and configurations of plates and screws to intramedullary nail, external fixation and any combination of the previously mentioned modalities. Patient comorbidities, infection, skin envelope and body habitus can guide fixation choices. Anterior plating, the posterior blade plate and the proximal humeral locking plate are among the many available options for screw fixation. These include double screw fixation, tripod screw fixation and four-screw fixation.^3,24-26 Authors have also described retrograde intramedullary nailing and subsequent modification of the technique to include screw augmentation across the tibiotalocalcaneal joints to further enhance compression of the arthrodesis site and decrease the incidence of nonunion at the ankle.^27-29

Surgeons have used external fixators for hindfoot and ankle arthrodesis as well. Biomechanical studies have shown external ring fixators provide longer lasting compression across the arthrodesis site than intramedullary nailing and are equivalent to internal screw compression.^30,31 Various authors have used external fixators as the primary method of fusion, as additional fixation when addressing a delayed union and adjunctively in cases of osteomyelitis and/or substantial bone loss resulting from infection, debridement and complete talar collapse.^32-34

The indications for the Ilizarov technique include impaired healing potential due to diabetes mellitus; cigarette smoking; previous nonunion of the fusion site; a history of infection at the fusion site; and/or soft tissue deficits/infection localized to the ankle and hindfoot, as well as providing patients the ability to bear weight on the frame when they are unable to be strictly non-weightbearing.³ Paley and coworkers described the application of an Ilizarov apparatus to malunions and nonunions of the tibiotalar joint.¹⁸ They emphasized the value of prolonged compression with the circular external fixation over screws, particularly when planning a complex case.

An extensive review of the published data shows that each of these methods continues to be studied with none proving to be superior to another.³ Regardless of the fixation method, the postoperative use of CT imaging can provide a more accurate evaluation of the fusion site in comparison to standard radiographs.⁴

What The Research Says About Pantalar Arthrodesis Outcomes
The success rates of pantalar arthrodesis have been satisfactory, reaching nearly 90 percent.^35-37 Herscovici and colleagues demonstrated acceptable outcomes regardless of the implants used or whether the surgery was a single or staged procedure.⁴ For pantalar arthrodesis, they reported solid fusion in 96 percent of joints and this compares favorably to other reports of nonunions in arthrodesis of the hindfoot.^{6,8,10-12,26,38-42} Herscovici and colleagues found the average time to union for pantalar arthrodesis in a high-risk population was 44.11 weeks.⁴

The American Orthopaedic Foot and Ankle Society (AOFAS) scores of patients who had a pantalar arthrodesis approximated those of the normal population.⁴³ The Short Form-36 (SF-36) scores of patients who had a pantalar arthrodesis were approximate to those of the normal population while the scores of patients with Charcot arthropathy were approximate to patients with a primary diagnosis of diabetes.⁴ Therefore, Herscovici and coworkers concluded that when comparing the outcomes of those who had a pantalar arthrodesis to those of a normal population, the use of a pantalar arthrodesis resulted in a quality of life approximating those of a normal population.⁴

McKinley and coworkers reported on pantalar arthrodesis in patients with rheumatoid arthritis.⁴⁴ They showed the pain scores had considerable improvement in the first six months and this continued to be the case at the 12-month follow-up. The authors also showed that the SF-12 scores had continuous improvement in both components up to the 12-month follow-up. They concluded pantalar arthrodesis in the rheumatoid arthritis population leads to statistically significant improvement.⁴⁴ Provelengios and colleagues reported that pantalar arthrodesis did not negatively affect the ability of patients to walk relatively long distances (>1 km) without experiencing any discomfort in the fused foot.⁷ However, they did report patients consistently having severe difficulty when trying to climb a hill.

What You Should Know About Complications
Pantalar arthrodesis has a high rate of complications with reported complication rates as high as 28 to 41 percent.^6,45 These complications include malunion, osteoarthritis of adjacent joints, neurovascular injury and wound healing problems.⁵ Immediate postoperative complications include hematomas, skin necrosis and superficial infection. One can usually treat these complications successfully with local wound care, short courses of antibiotics and/or minor debridement. When performing pantalar arthrodesis, especially with a one-stage procedure, skin complications are not uncommon. Acosta and coworkers reported that 50 percent of patients undergoing pantalar arthrodesis developed either infections or skin ulcerations.^6,46

Patients must understand that arthrodesis of any joint leads to added stress on joints proximal and distal to the fusion site. This may lead to or exacerbate concurrent ipsilateral knee or midfoot arthritis.²⁵ Coester and colleagues assessed 23 patients at a mean follow-up of 22 years after they had an isolated ankle arthrodesis.⁴⁷ They found most patients had significantly more severe arthritis in the naviculocuneiform, tarsometatarsal and first metatarsophalangeal joints on the ipsilateral side of the arthrodesis, resulting in increased pain and activity limitation. Other studies have shown, however, that patient satisfaction does not always correlate with the development of arthritic changes. Saltzman and coworkers found that at 25 and 44 years after triple arthrodesis, all patients had eventually developed progressive arthritic changes.⁴⁸ However, 95 percent of the patients remained satisfied with the results of their operation.

The most serious complication following pantalar arthrodesis is the development of pseudarthrosis with rates ranging up to 28 percent.³² Whether one performs pantalar arthrodesis in one stage or two stages, there seems to be no difference in fusion rates with the ankle being the most common site and followed by the talonavicular joint.^1,5,33

Even with successful fusion and healing of a pantalar arthrodesis, there are restrictions, problems and disabilities that occur with activities of daily living. These include climbing a hill, an inability to participate in many athletic activities, difficulties when driving a car, difficulties when trying to ride a bicycle, the need to wear shoes of different sizes and calluses.¹

In Conclusion
Non-operative care may be ineffective for patients with ankle and hindfoot instability, or evidence of abnormal plantar pressures not amenable to a brace, accommodative orthotic devices or shoe modifications.⁴

Pantalar arthrodesis can be long-term solution to these problems. Pantalar arthrodesis is a demanding surgical procedure that can serve to stabilize and relieve dysfunction of the ankle, hindfoot and midfoot, and provide a strong, stable and painless foot that probably will function adequately for the rest of the patient’s life. Many consider pantalar arthrodesis to be a salvage procedure to avoid an amputation for the treatment of unstable and debilitating conditions as a result of severe degenerative joint disease, rheumatoid arthritis, severe posttraumatic deformities of the ankle and hindfoot joints, neuropathic joint destruction, and paralytic or flail extremity dysfunction.⁶

Pantalar arthrodesis requires careful planning, preoperative medical and vascular clearance, and appropriate patient selection. Inform patients that they should expect long periods of postoperative casting and non-weightbearing, and complications can still occur. However, Visual Analogue Scale (VAS), SF-36, short musculoskeletal function assessment (SMFA) and AOFAS scores demonstrate acceptable outcomes in patients with a pantalar arthrodesis regardless of whether the patient presented with post-traumatic arthritis or diabetes, had a staged or single approach, and regardless of whether the surgery occurred with plates and screws or an intramedullary device.⁴ Problems such as ipsilateral joint pain and limited walking ability are not uncommon and one should expect these issues, especially after the second postoperative decade.¹

Dr. Donegan is affiliated with the Section of Podiatric Surgery in the Department of Orthopedics and Rehabilitation at Yale New Haven Hospital in New Haven, Ct.

Dr. Blume is an Assistant Clinical Professor of Surgery in the Department of Surgery and an Assistant Clinical Professor of Orthopaedics and Rehabilitation in the Department of Orthopaedics, Section of Podiatric Surgery at the Yale University School of Medicine in New Haven, Ct. Dr. Blume is a Fellow of the American College of Foot and Ankle Surgeons.

References

1.     Provelengios S, Papavasiliou KA, Kyrkos MJ, Kirkos JM, Kapetanos GA. The role of pantalar arthrodesis in the treatment of paralytic foot deformities: a long-term follow-up study. J Bone Joint Surg Am. 2009; 91(3):575-83.
2.     MacKenzie EJ, Jones AS, Bosse MJ, et al. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am. 2007; 89(8):1685–1692.
3.     Crawford B, Watson JT, Jackman J, Fissel B, Karges DE. End-Stage hindfoot arthrosis: outcomes of tibiocalcaneal fusion using internal and Ilizarov fixation. J Foot Ankle Surg. 2014; 53(5):609–614.
4.     Herscovici D, Sammarco GJ, Sammarco VJ, Scaduto JM. Pantalar arthrodesis for post-traumatic arthritis and diabetic neuroarthropathy of the ankle and hindfoot. Foot Ankle Int. 2011; 32(6):581-589.
5.     Leal LO, Cangiano SA. Pantalar arthrodesis. Clin Podiatr Med Surg. 1991; 8(3):701-15.
6.     Acosta R, Ushiba J, Cracchiolo A. The results of a primary and staged pantalar arthrodesis and tibiotalocalcaneal arthrodesis in adult patients. Foot Ankle Int. 2000; 21(3):182-94.
7.     Veves A, Murray H, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992; 35(7):660–663.
8.     Barrett GR, Meyer L, Bray EW, Taylor RG. Pantalar arthrodesis: a long-term follow-up. Foot Ankle. 1981; 1(5):279–283.
9.     Miehlke W, Gschwend N, Rippstein P, Simmen BR. Compression arthrodesis of the rheumatoid ankle and hindfoot. Clin Orthop. 1997; 340:75–86.
10.     Sammarco GJ, Conti SF. Surgical treatment of neuropathic foot deformity. Foot Ankle Int. 1998; 19(2):102–109.
11.     Santavirta S, Turunen V, Ylinen P, Konttinen YT, Tallroth K. Foot and ankle fusions in Charcot-Marie-Tooth disease. Arch Orthop Trauma Surg. 1993; 112(4):175–179.
12.     Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthritis of the ankle and hindfoot. J Bone Joint Surg Am. 1992; 74(7):1042–1049.
13.     Eskelinen E, Eskelinen A, Alback A, Lepantalo M. Major amputation incidence decreases both in non-diabetic and in diabetic patients in Helsinki. Scand J Surg. 2006; 95(3):185–189.
14.     Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA. Mortality of first-time amputees in diabetics: a 10-year observation. Diabetes Research Clin Pract. 2009; 83(1):126-131.
15.     Lavery LA, Wunderlich RP, Tredwell JL. Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Research Clin Pract. 2005; 70(1):31–37.
16.     Paola L, Faglia E. Treatment of the diabetic foot ulcer: an overview strategies for clinical approach. Current Diab Rev. 2006; 2(4):431–447.
17.     Pinzur MS, Noonan T. Ankle arthrodesis with a retrograde nail for Charcot ankle arthropathy. Foot Ankle Int. 2005; 26(7):545–549.
18.     Paley D, Lamm BM, Katsenis D, Bhave A, Herzenberg JE. Treatment of malunion and nonunion at the siteof an ankle fusion with the Ilizarov apparatus surgical technique. J Bone Joint Surg. 2006; 88(Suppl 1 Part 1):119-134.
19.     Doi K, Sakai K. Vascularized periosteal bone graft from the supuracondylar region of the femur. Microsurgery. 1994; 15(5):305–315.
20.     Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the ankle with a free vascularized autogenous bone graft. J Bone Joint Surg. 1995; 77(12):1867–1875.
21.     Yajima H, Kobata Y, Tomita Y, Kawate K, Sugimoto K, Takakura Y. Ankle and pantalar arthrodeses using vascularized fibular grafts. Foot Ankle Int. 2004; 25(1):3-8.
22.     Miller RA, Firoozbakhsh K, Veitch AJ. A biomechanical evaluation of internal fixation for ankle arthrodesis comparing two methods of joint surface preparation. Orthopedics. 2000; 23(5):457–460.
23.     Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg Am. 1980; 62(5):777-84.
24.     Mohamedean A, Said HG, El-Sharkawi M, El-AdlyW, Said GZ. Technique and short term results of ankle arthrodesis using anterior plating. Int Orthop. 2010; 34(6):833–837.
25.     Hanson TW, Cracchiolo A III. The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2002; 23(8):704–710.
26.     Ahmad J, Pour AE, Raikin SM. The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2007; 28(9):977–983.
27.     Budnar VM, Hepple S, Harries WG, Livingstone JA, Winson I. Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail. Foot Ankle Int. 2010; 31(12):1085–1092.
28.     O’Neill PJ, Parks BG, Walsh R, Simmons LM, Schon LC. Biomechanical analysis of screw-augmented intramedullary fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2007; 28(7):804–809.
29.     Fu YC, Huang PJ, Tien YC, Hung SH, Cheng YM, Lin SY, Chen YC, Liu LL, Huang SH. Ankle arthrodesis: internal non-compression arthrodesis versus internal compression arthrodesis. Kaohsiung J Med Sci. 1999; 15(9):550–555.
30.     Yakacki CM, Khalil HF, Dixon SA, Gall K, Pacaccio DJ. Compression forces of internal and external ankle fixation devices with simulated bone resorption. Foot Ankle Int. 2010; 31(1):76–85.
31.     Ogut T, Glisson RR, Chuckpaiwong B, Chuckpaiwong B, Le IL, Easley ME. External ring fixation versus screw fixation for ankle arthrodesis: a biomechanical comparison. Foot Ankle Int. 2009; 30(4):353–360.
32.     Gessmann J, Ozokyay L, Fehmer T, Muhr G, Seybold D. Arthrodesis of the infected ankle joint: results with the Ilizarov external fixator. Z Orthop Unfall. 2011; 149(2):212–218.
33.     Zarutsky E, Rush SM, Schuberth JM. The use of circular wire external fixation in the treatment of salvage ankle arthrodesis. J Foot Ankle Surg. 2005; 44(1):22–31.
34.     Saltzman CL. Salvage of diffuse ankle osteomyelitis by single-stage resection and circumferential frame compression arthrodesis. Iowa Orthop J. 2005; 25:47–52.
35.     Lynch AF, Bourne RB, Rorabeck CH. The long-term results of ankle arthrodesis. J Bone Joint Surg. 1998; 70(1):113–116.
36.     Moeckel BH, Pattersonn BM, Inglis AE, Sculco TP. Ankle arthrodesis. A comparison of internal and external fixation. Clin Orthop. 1991; 268:78–83.
37.     Takakura Y, Tanaka Y, Sugimoto K, Akiyama K, Tamai S. Long-term results of arthrodesis for osteoarthritis of the ankle. Clin Orthop. 1999; 361:178–185.
38.     Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res. 2007; 463:151–156.
39.     Mendicino RW, Catanzariti AR, Saltrick KR. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg. 2004; 43(2):82–86.
40.     Niinimaki TT, Klemola TM, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a compressive retrograde intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int. 2007; 28(4):431–434.
41.     Pelton, K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int. 2006; 27(10):759–763.
42.     Russotti GM, Johnson KA, Cass JR. Tibiotalocalcaneal arthrodesis for arthritis and deformity of the hind part of the foot. J Bone Joint Surg Am. 1988; 70(9):1304–1307.
43.     American Academy of Orthopaedic Surgeons. Outcomes Instruments and Information. Available at https://www.aaos.org .
44.     McKinley JC, Shortt N, Arthur C, Gunner C, MacDonald D, Breusch SJ. Outcomes following pantalar arthrodesis in rheumatoid arthritis. Foot Ankle Int. 2011; 32(7):681-686.
45.     Anagnostopoulos F, Niakas D, Pappa E. Construct validation of the Greek SF-36 Health Survey. Qual Life Res. 2005; 14(8):1959-65.
46.     Faillace JJ, Leopold SS, Brage ME. Extended hindfoot fusions and pantalar fusions. History, biomechanics, and clinical results. Foot Ankle Clin. 2000; 5(4):777-98.
47.     Coester LM, Saltzman CL, Leupold J, PontarelliW. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001; 83-A(2):219–228.
48.     Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am. 1999; 81(10):1391–1402.

For further reading, see “A Guide To The Triple Arthrodesis For Hindfoot Deformities” in the October 2012 issue of Podiatry Today or “Pertinent Insights On The Posterior Approach To Hindfoot Arthrodesis” in the August 2013 issue.

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