When An Ankle Fusion Fails

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Author(s): 
Bradly Bussewitz, DPM

What The Revision Surgical Approach Entailed

This revision surgery again consisted of an anterior approach. After removing the visible hardware, the three broken screws remained within the tibia. I debrided the non-viable tissue down to bleeding cancellous bone. I again utilized demineralized bone matrix with bone marrow aspirate to fill any voids remaining post-debridement. Employing a more robust 7.0 headless cannulated screw helped set the position and gain compression. I also used a more robust titanium anterior locking plate with 5.5-mm locking screws and added bone morphogenetic protein to the anterior fusion site prior to performing standard closure.

   After his revision surgery, the patient continued to utilize the bone stimulator. He discontinued tobacco use. He was non-weightbearing for 10 weeks prior to protected weightbearing. The patient’s most recent radiographs at five months show interval healing and he has no pain to date. He has transitioned to a brace and has been deer hunting with no problems.

In Conclusion

Ankle fusion in an obese patient with diabetes who smokes can be difficult. Ultimately, tobacco cessation, the use of bone marrow aspirate, demineralized bone matrix, bone morphogenetic protein and increasing plate strength allowed a solid union to date. Assessing and maximizing the use of orthobiologics in at-risk patients may offer a greater chance at successful outcomes, particularly in difficult cases. As anterior locking plate options continue to evolve, choosing a robust plate and screw can offer improved stability in patients who are particularly at risk for an elongated healing period.

   Dr. Bussewitz is a fellowship-trained foot and ankle surgeon who is currently in private practice in Iowa City, Iowa.

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