• Users Online: 121
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 37  |  Issue : 1  |  Page : 34-36

Bilateral ankle arthrodesis with retrograde interlocking nail in charcot arthropathy of bilateral ankle joint


1 Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India
2 Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India

Date of Submission15-Dec-2021
Date of Acceptance12-Apr-2022
Date of Web Publication13-May-2022

Correspondence Address:
Mohammad Jesan Khan
Department of Orthopaedic Surgery, Faculty of Medicine, Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_21_21

Rights and Permissions
  Abstract 

Despite technological breakthroughs in treatment techniques, definitive surgical treatment of Charcot’s arthropathy remains a difficulty. Several techniques for achieving stable ankle joint arthrodesis have been proposed. In recent research, deformity correction and arthrodesis with internal fixation have shown encouraging results. In this case report, we have described a case of severe destruction of both ankle joints treated by arthrodesis with a retrograde interlocking nail. Bilateral ankle arthrodesis in end-stage arthritis of the ankle joint is rare to find. This study addresses the proper surgical management in terms of approach and usage of appropriate implants to improve the long-term functional outcome when dealing with end-stage arthritis of the ankle joint.

Keywords: Calcaneotalotibial arthrodesis, Charcot’s arthropathy, retrograde intramedullary interlocking nail


How to cite this article:
Khan MJ, Aziz MH, Raza A, Asif S. Bilateral ankle arthrodesis with retrograde interlocking nail in charcot arthropathy of bilateral ankle joint. J Bone Joint Dis 2022;37:34-6

How to cite this URL:
Khan MJ, Aziz MH, Raza A, Asif S. Bilateral ankle arthrodesis with retrograde interlocking nail in charcot arthropathy of bilateral ankle joint. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 27];37:34-6. Available from: http://www.jbjd.in/text.asp?2022/37/1/34/345162




  Introduction Top


Charcot neuroarthropathy (CN) of the foot can result in severe ankle joint instability and deformity, contributing to major disability or even amputation.[1],[2] Charcot was the first to describe the effects of the neurological affliction of joints in 1868.[3] Currently, the most common cause of Charcot’s joint is diabetes mellitus.[4] The primary concern of treating Charcot arthropathy is establishing osseous stability, keeping the foot in a plantigrade position, and preventing ulceration.[2],[5] Despite technological breakthroughs in treatment techniques, definitive surgical treatment of Charcot’s arthropathy remains a difficulty. There has been a change in trend from amputation to limb salvage.[6],[7] Several techniques for achieving stable ankle joint arthrodesis have been proposed.[8],[9],[10] Sir John Charnley attempted ankle arthrodesis using an external fixator and compression clamps, with variable results. In recent research, deformity correction and arthrodesis with internal fixation have shown encouraging results.[11],[12] In this context, the current case report describes a Charcot joint of the bilateral ankle that was treated using a transcalcaneal retrograde intramedullary interlocking nail.


  Case Report Top


A 22-year-old man presented to JNMCH OPD with complaints of swelling in both ankle joints for 2 years, deformity in both ankles for 1.5 years, and difficulty in walking for 1 year. The patient was apparently well 2 years back when he developed swelling over both his ankles, insidious in onset, gradually progressive, and not relieved on rest and medications. The swelling and deformity gradually progressed over time and was aggravated on walking and standing. For the last 1.5 years the patient had valgus deformity at the ankle with subluxated and grossly deformed ankle joint. The patient could walk unaided but had a limp while walking. X-ray ankle anteroposterior and lateral view revealed total obliteration of joint space, tibiotalar subluxation, osteophytes, osteoarthritic changes in the ankle, and alteration of the normal anatomical axis [Figure 1]. Thus, based on the final diagnosis of the Charcot joint, debridement and arthrodesis of the ankle joint with transcalcaneal retrograde intramedullary interlocking nail was done first in the right ankle and then in the left ankle after 6 months [Figure 2]. Three doses of antibiotics were given in perioperative period.[13] The surgical wound of the right ankle healed without any complication; however, wound dehiscence took place in the left ankle which healed with secondary intention.
Figure 1: (A) Valgus deformity at ankle joint with bony prominence over both the medial malleoli. (B) X-ray Right ankle anteroposterior and lateral view shows the presence of tibiotalar dislocation, fracture at the distal end of the fibula, osteophytes, osteoarthritic changes of the ankle, and gross alteration of the normal anatomical axis. (C) X-ray left ankle anteroposterior and lateral view shows total obliteration of joint space, tibiotalar subluxation, osteophytes, osteoarthritic changes in ankle, and alteration of the normal anatomical axis

Click here to view
Figure 2: Postoperative radiograph of arthrodesis of right ankle (A) and left ankle (B) with transcalcaneal retrograde intramedullary interlocking nail in situ

Click here to view


A below-knee plaster cast was given once edema subsided, and the patient was kept non-weight-bearing for 6 weeks followed by gradual weight-bearing, and after 3 months, full weight-bearing was permitted.


  Discussion Top


Tibiotalar arthrodesis is the definitive treatment for painful terminal arthritis of the ankle. Ankle fusion results in a pain-free gait and functional improvement beyond the patient’s expectations. For this procedure, numerous approaches and procedures have been described. We feel that intramedullary nailing is an appropriate method for arthrodeses of the neuropathic joint. Küntscher[14] used an intramedullary nail passed over a guidewire through the foot to perform arthrodesis of ankle. He believed that extensive joint debridement and nailing should be done at the same time. He utilized a 12–14 mm diameter nail which he did not lock to obtain a press fit. The patients were allowed to walk in plaster after 3 weeks of bed rest. Dalla Paola et al.[15] studied 18 patients with hindfoot Charcot arthropathy associated with diabetes who had no previous history of ulcerations. All the limbs were salvaged, and a complete bony union of ankle arthrodesis occurred in 14 patients. Their study revealed that arthrodesis by retrograde nailing is an appropriate therapeutic option for ankle instability in Charcot arthropathy patients who do not have any ongoing or previous ulceration. Lee et al.[16] obtained similar results in seven patients. Oesman et al.[17] reported a single patient who underwent arthrodesis with an expert tibia nail, with good clinical and radiological outcomes and no post-operative problems. Siebachmeyer et al.[18] studied 20 patients with Charcot arthropathy and significant ankle and hindfoot deformities in which ankle arthrodesis was done with a retrograde intramedullary nail. In every patient, limb salvage was accomplished. Except for one, all of the patients could bear full weight and had 90% radiological fusion. Pinzur et al.[19] followed nine diabetics with Charcot arthropathy of the ankle in which ankle arthrodesis was done with a retrograde femoral nail of long size. Based on the findings, he agreed with the previous authors that intramedullary nailing is an effective salvage technique for CN. He further concluded that adopting longer nails and dynamic locking prevents complications such as stress fractures of the tibia at the nail’s proximal end. Millett et al.[20] studied 15 patients in which tibiotalocalcaneal nailing was done, 14 patients achieved fusion in an average of 16.5 weeks, with a satisfaction rate of 93% and low complications. Paola et al.[15] and Chraim et al.[21] studied ankle arthrodesis by a retrograde intramedullary nail in Charcot arthropathy and achieved similar results. Russotti et al.[22] published a study on 21 ankle arthrodeses with Steinmann pins and external fixation employing a posterior Achilles-splitting approach. Union was achieved in 86% of patients, with satisfactory results in 75%. In a meta-analysis of 117 CN patients, Yammine et al.[23] compared external fixation and intramedullary nailing for ankle arthrodesis. In 70 patients, intramedullary nailing was done, and external fixation in 47. In the external fixation group, there was a high rate of hardware (33.6%) and wound (23%) infection. The fusion rate was 90.7% and 74%, and the amputation rate was 2.2% and 13.1%, respectively, in the intramedullary nailing and the external fixation groups.


  Conclusion Top


The new arthrodesis technique by transcalcaneal retrograde interlocking nail has rendered amputation of the leg, which was once the basis of treatment of Charcot arthropathy, obsolete. It has yielded good outcomes while also saving the patient’s leg. Calcaneotalotibial arthrodesis appears to be a salvage operation for deformities and painful terminal arthritis in the hindfoot and ankle. Using a retrograde locking nail, the acknowledged aims of calcaneotalotibial arthrodesis, which include bony union, correction of hindfoot alignment, minimization of complications, and patient contentment, were achievable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Ethics approval and consent to participate

Approval for study was take from Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh ethical committee (institutional).

Availability of data and material

All data generated or analyzed during this study are included in this published article (and its supplementary information files, especially in tables).



 
  References Top

1.
Mittlmeier T, Klaue K, Haar P, Beck M. Should one consider primary surgical reconstruction in charcot arthropathy of the feet? Clin Orthop Relat Res 2010;468:1002-11.  Back to cited text no. 1
    
2.
Richter M, Zech S. Four-stage regimen for operative treatment of diabetic foot ulcer with deformity: A results of 300 patients. Foot Ankle Surg 2012;18:247-54.  Back to cited text no. 2
    
3.
Sur quelques arthropathies qui paraissent dépendre d’une lésion du cerveau ou de la moelle épinière | Semantic Scholar [Internet]. Available from: https://www.semanticscholar.org/paper/Sur-quelques-arthropathies-qui-paraissent-d%C3%A9pendre-Charcot/12ed8ce71eec4a21fd7cc280a66dac0e2f5fc5ce. [Last accessed on 2021 Nov 24].  Back to cited text no. 3
    
4.
Jacobs RL, Karmody A, Jacobs RL, Karmody A. Charcot foot. In: Jahss MH, editor. Disorders of Foot. Vol. 2. Philadelphia, PA: WB. Saunders; 1982. p. 1248-65.  Back to cited text no. 4
    
5.
Lowery NJ, Woods JB, Armstrong DG, Wukich DK. Surgical management of charcot neuroarthropathy of the foot and ankle: A systematic review. Foot Ankle Int 2012;33:113-21.  Back to cited text no. 5
    
6.
Richter M, Mittlmeier T, Rammelt S, Agren PH, Hahn S, Eschler A. Intramedullary fixation in severe charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction: Results from a multi-centre study. Foot Ankle Surg 2015;21:269-76.  Back to cited text no. 6
    
7.
Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82-A:939-50.  Back to cited text no. 7
    
8.
Anderson R. Concentric arthrodesis of the ankle joint: A transmalleolar approach. JBJS 1945;27:37-48.  Back to cited text no. 8
    
9.
Barr JS, Record EE. Arthrodesis of the ankle joint indications, operative technique and clinical experience. N Engl J Med 1953;248:53-6.  Back to cited text no. 9
    
10.
White AA. A precision posterior ankle fusion. Clin Orthop 1974:239-50.  Back to cited text no. 10
    
11.
Bono JV, Roger DJ, Jacobs RL. Surgical arthrodesis of the neuropathic foot. A salvage procedure. Clin Orthop 1993:14-20.  Back to cited text no. 11
    
12.
Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am 1993;75:1056-66.  Back to cited text no. 12
    
13.
Agrawal NK, Khan MJ, Sherwani MKA, Zahid M, Ahmad S, Shukla I. Short-course perioperative: Antibiotic prophylaxis to prevent surgical site infection in elective orthopedic surgery. J Orthop Traumatol Rehabil 2018;10:67.  Back to cited text no. 13
    
14.
Küntscher G. Combined Arthrodesis of the Ankle and Subtalar Joint. Practice of Intramedullary Nailing. Springfield, IL: Charles C. Thomas; 1967. p. 207-9.  Back to cited text no. 14
    
15.
Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, et al. Use of a retrograde nail for ankle arthrodesis in charcot neuroarthropathy: A limb salvage procedure. Foot Ankle Int 2007;28:967-70.  Back to cited text no. 15
    
16.
Lee BH, Fang C, Kunnasegaran R, Thevendran G. Tibiotalocalcaneal arthrodesis with the hindfoot arthrodesis nail: A prospective consecutive series from a single institution. J Foot Ankle Surg 2018;57:23-30.  Back to cited text no. 16
    
17.
Oesman I, Asdi ARB. Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series. Int J Surg Case Rep 2019;57:9-14.  Back to cited text no. 17
    
18.
Siebachmeyer M, Boddu K, Bilal A, Hester TW, Hardwick T, Fox TP, et al. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J 2015;97-B:76-82.  Back to cited text no. 18
    
19.
Pinzur MS, Noonan T. Ankle arthrodesis with a retrograde femoral nail for charcot ankle arthropathy. Foot Ankle Int 2005;26:545-9.  Back to cited text no. 19
    
20.
Millett PJ, O’Malley MJ, Tolo ET, Gallina J, Fealy S, Helfet DL. Tibiotalocalcaneal fusion with a retrograde intramedullary nail: Clinical and functional outcomes. Am J Orthop (Belle Mead Nj) 2002;31:531-6.  Back to cited text no. 20
    
21.
Chraim M, Krenn S, Alrabai HM, Trnka HJ, Bock P. Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in charcot neuroarthropathy of the hindfoot. Bone Joint J 2018;100-B:190-6.  Back to cited text no. 21
    
22.
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;70:1304-7.  Back to cited text no. 22
    
23.
Yammine K, Assi C. Intramedullary nail versus external fixator for ankle arthrodesis in charcot neuroarthropathy: A meta-analysis of comparative studies. J Orthop Surg (Hong Kong) 2019;27:2309499019836012.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed538    
    Printed98    
    Emailed0    
    PDF Downloaded39    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]