Residence Jnane Pasteur, Boulevard Abdelmoumen, Casablanca, Morocco.
*Bensaka Mohammed, Residence Jnane Pasteur, Boulevard Abdelmoumen, Casablanca, Morocco.
Introduction
The ankle joint is a trochlear joint whose main characteristic is to be a load joint and therefore sensitive to the slightest anatomical anomaly. At a time when progress in orthopedics is due to prosthetic surgery in many joints (hip, knee, shoulder, etc.), the ankle continues to benefit from the classic arthrodesis technique, known since ALBERT in 1879 Thus, ankle arthrodesis is an operation intended to produce ankylosis of the talocrural joint, which remains a rescue intervention in joint destruction of the hindfoot, to be proposed only after having exhausted conservative options. Its goal is to restore perfect indolence with good stability and plantigrade locomotion. There are two intervention groups depending on the type of stabilization chosen; internal (screwing, plate, retro-rigged nail, staple or others) or external using an external fixator. Tibiotalo-calcaneal arthrodesis using a retrograde transplant nail is one of the ankle arthrodesis techniques introduced in 1967 by Kuntscher, difficult and considered a challenge for orthopedic surgeons, its implementation must be gentle and careful after a good evaluation clinical and radiological of the ankle in order to provide the best possible result.
Materials and methods
This is a retrospective study of 21 patients who were treated by ankle arthrodesis, including 7 patients treated by tibiotalo-calcaneal arthrodesis using a retrograde transplant nail and 14 patients by other means of fixation, collected at the Traumatology Orthopedics B4 department of CHU HASSAN II in Fez, over a period of 2 years from October 2019 to November 2021. -The objective of our study is to evaluate the results and functional impact of surgical treatment by arthrodesis Tibio-Talo-Calcaneal by retrograde transplant nail. As well as comparing the results obtained by this technique to the results of other techniques by referring to the patients of the department and the literature. The data from our study were analyzed based on an operating sheet, the statistical study was carried out on Microsoft Excel.
Results
The average age of patients who underwent arthrodesis by retrograde transplant nail is 41 years with a sex ratio of 0.75, while that of patients who benefited from an arthrodesis by another means of fixation is 46 years with a sex ratio of 1. Figure 01
Table 1:
Figure 5:
For patients who benefited from an arthrodesis using a retrograde transplant nail, the right ankle was operated on in 6 patients or 85%, compared to 1 patient for the left ankle, while for patients who benefited from arthrodesis by another technique, the right ankle was operated on in 12 patients or 85%, compared to 2 patients for the left ankle. Figure 02
The etiologies were dominated for patients who underwent ankle arthrodesis using a retrograde transplant nail due to post-traumatic osteoarthritis. 5 cases including (1 case of post-traumatic talus non-union, 2 cases of talus fracture. , 1 case of subtalar dislocation, 1 case of subtalar and Talonavicular dislocation). We also indicated the indication for this technique in 1 patient for acquired equinovarus foot malformation, 1 patient for secondary rheumatic osteoarthritis such as ankylosing spondylitis. For patients who underwent ankle arthrodesis using another technique, we established the indication in 5 patients for post-traumatic osteoarthritis (2 cases of bimalleolar fracture, 2 cases of fracture of the tibial pilon, 1 case of fracture of the astragalus), the use of other techniques was also designed in 1 patient for primary osteoarthritis, 1 patient for secondary post-rheumatic osteoarthritis such as ankylosing spondylitis, 1 patient for acquired neurological cavus foot malformation, 3 patients for acquired equinus foot malformation, 2 patients for congenital bilateral equinovarus clubfoot malformation and 1 patient for bilateral congenital flatfoot valgusmalformation. Figure 03
Pain was the major symptom, present in 100% of patients who underwent ankle arthrodesis using a retrograde transplant nail and in 83% of patients who underwent ankle arthrodesis using another fixation technique, DUQUENNOY rating was used to evaluate the condition of the ankle after intervention. The treatment consisted of an arthrodesis of the ankle using a retrograde transplant nail in 7 patients, 3 patients benefited from an arthrodesis using cancellous screwing, 5 patients benefited from an arthrodesis using the MEARY technique and cancellous screwing, 3 patients benefited of amixed arthrodesis using staples and cancellous screw fixation, 3 patients underwent arthrodesis using Blount staples. In terms of complications, for patients who underwent ankle arthrodesis using a retrograde transplant nail, we noted 1 case of skin disunion, 1 case of thromboembolic complications, 1 case of pseudarthrosis, 3 cases of residual pain, 4 cases of trophic disorders. For patients who underwent ankle arthrodesis by another means of fixation, there were 2 cases of superficial infection, 2 cases of skin disunity, 1 case of thromboembolic complications, 1 case of pseudarthrosis, 4 cases of residual pain, 1 cases of shortening of the lower limb, 5 cases of trophic disorders, 2 cases of malunion. Furthermore, the functional results according to the postoperative Duquennoy score for patients who benefited from an ankle arthrodesis using a retrograde transplant nail were very good to good in 85%, average in 14% and poor in 0%, with a rate of 86% merger. For patients who underwent ankle arthrodesis by another means of fixation, the postoperative functional results were very good to good in 57%, average in 29% and poor in 14%, with a fusion rate of 93%. %. The average follow-up was 2.5 years.
Discussion
Post-traumatic osteoarthritis represents the most common indication for talocrural arthrodesis. Our data are almost identical to those reported in different publications and literature. In our series, for the patients who benefited from a tibiotalo-calcaneal arthrodesis using a retrograde transplant nail, we have 5 cases of post-traumatic osteoarthritis, i.e. 71% of the etiologies. For the patients who benefited from an arthrodesis of ankle by other technique we have 5 cases of post-traumatic arthrosis i.e. 36%, 1 case of primary osteoarthritis i.e. 7%, 1 case of paralytic foot i.e. 7%, 2 cases of congenital club foot i.e. 14%, no case of sequelae No arthritis of the ankle was found in our series. There are many surgical techniques for ankle arthrodesis. In El.Idrissi M's series, the MEARY technique was performed in all patients, i.e. 100%, compared to 25.5% in our series. The Boumaaz series reports the completion of an ankle arthrodesis by intramedullary nailing in 47%, compared to 30% in our series. According to the literature, the choice of technique turns out to be dependent on the etiology, bone stock and surgical experience.
Our overall functional results are close to those reported in the literature. In all talocrural arthrodesis techniques, the fusion rates reported in the literature vary between 65 and 100%. The fusion time of our arthrodesis was on average 4 months with extremes of 3 and 6 months. For patients who underwent ankle arthrodesis using a retrograde transplant nail, 6 were fused first, i.e. 86%. For patients who underwent ankle arthrodesis using other techniques, 13 were fused as first intention, i.e. 93%. This is an excellent result, if we refer to certain publications which put forward failure figures of up to 35%. Classically, ankle arthrodesis is known to give good results.
However, analysis of the literature highlights a certain number of complications. Their frequency varies depending on the series, ranging from 5% (MORGANE) to 60% in certain series such as (BESSE). The incidence of infectious complications varies from 14% for AHLBERG to 23% for MORREY. In our series, we noted no cases of superficial infection in patients who underwent ankle arthrodesis using a retrograde transplant nail, while we reported 2 cases of superficial infections in patients who underwent d an ankle arthrodesis using another technique, i.e. 13%, which remains close to the other series. Some authors report less than 10% pseudarthrodesis (DENNIS, JARDE, Fath K).
The series by Ben Hadou and others report between 10 and 20% non-union. MITTELMEIR AND SCRANTON report no nonunion over 13 and 25 years respectively. In our series we noted 1 case of pseudarthrodesis, i.e. 14% in patients who benefited from an ankle arthrodesis using a retrograde transplant nail and 1 case of pseudarthrodesis, i.e. 7% in patients who benefited from an ankle arthrodesis using a retrograde transplant nail. another technique, these pseudarthrodeses were taken up later. For nervous complications, BROQUIN reports in his series, 5 cases of nerve lesions out of 134 cases or 3.7%. A single case of hypoesthesia of the dorsum of the foot in the series of Ben Hadou N., and no case in the series of Fath K. In our series we noted no cases of nervous complications.Figure 05
Conclusion
Ankle arthrodesis remains the “gold standard” intervention in the panel of therapeutic solutions for significant joint destruction in the ankle. The difficulties of talocrural arthrodesis are based on two pitfalls: on the one hand the fusion of the arthrodesis which must be obtained within a reasonable time, and on the other hand the correct orientation of the hindfoot. Post-traumatic osteoarthritis represents the most frequent etiology in most series. Finally, performing an ankle arthrodesis using a retrograde transplant nail seems to be able to improve pain and function, however it is a difficult intervention because the result, in particular bone fusion, depends on the quality of its achievement and the patient's terrain.
