Foot & Ankle

Review Article

Pilon Fracture: Preventing

Complications

Stephen A. Kottmeier, MD
Randall Drew Madison, MD
Nicholas Divaris, MD
Abstract
Fractures of the distal tibial plafond (ie, pilon) comprise a broad range
of injury mechanisms, patient demographics, and soft-tissue and
osseous lesions. Patients often present with considerably
comminuted fracture patterns and notable soft-tissue compromise.
Surgical intervention must be performed with respect for the
exceedingly vulnerable soft-tissue envelope and with a properly
executed technique. Even with proper timing, favorable host factors,
and expert surgical technique, restoration of function and avoidance of
complications are not always achievable. Recently validated
techniques further diminish the risk of soft-tissue and osseous sepsis.
These techniques include early (ie, “immediate”) fixation, upgrading,
primary arthrodesis, staged sequential posterior and anterior fixation,
acute shortening, and transsyndesmotic fibular plating. Proper
application of these recently adopted techniques may be
instrumental in achieving aseptic union of pilon fractures.

T ibial pilon fractures represent a

From the Department of Orthopedic
Trauma Service, State University of
New York Health Sciences Center,
Stony Brook, NY.
Dr. Kottmeier or an immediate family
member serves as a board member,
owner, officer, or committee member
of the Orthopaedic Trauma
Association. Neither of the following
authors nor any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Madison and Dr. Divaris.
J Am Acad Orthop Surg 2018;26:
640-651
DOI: 10.5435/JAAOS-D-17-00160
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
wide array of osteoarticular,
metaphyseal, and soft-tissue com-
promise. The mechanism of injury
is equally broad. The combinations
of articular comminution and meta-
diaphyseal osseous deficits may
prove therapeutically challenging.
Circumferential soft-tissue compro-
mise is common, and it may predis-
pose the patient to complications
such as infection and nonunion if
proper timing and surgical approach
are not carefully contemplated. Proper
management of both the osseous and
soft-tissue element of the injury is re-
quired to obtain favorable outcomes.
Restoration of function while avoiding
catastrophic complications is the pri-
mary treatment objective.
In 1969, Rüedi and Allgower,1 who
were dissatisfied with nonsurgical
management of intra-articular frac-
tures of the distal tibia, described
favorable results achieved with sur-
gical fixation. They advocated the
use of several treatment principles,
including lateral column restoration,
medial column buttressing, and au-
togenous bone grafting in combina-
tion with articular reconstitution.
Their study consisted of a cohort
of lower-energy injuries for which
wound healing complication rates
were deemed within acceptable pa-
rameters. Adopting these principles,
other investigators witnessed con-
cerning rates of infection.2,3 These
higher-energy lesions were, accord-
ingly, associated with more compli-
cated pathoanatomic characteristics.
Aseptic restoration of the articular
surface and limb alignment should be
predictive of both restored function
and the avoidance of pain. The surgi-
cal methods used to achieve articular
reduction have, however, generated
conflicting results. Variables such as
mechanism of injury, host factors, and
patient demographics may be more

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 1

Foot & Ankle
predictable determinants of out-
comes. DeCoster et al4 investigated
the influence of injury severity and
quality of reduction on the outcome.
They concluded that although the
quality of reduction offered a notable
correlation with radiographic arthro-
sis, it did not independently correlate
with the functional outcome.
High infection rates and wound-
healing complications following
traditional surgical reduction have
prompted refinement of less-invasive
methods of osteoarticular recon-
struction. Methods of minimizing the
risk of infection associated with tra-
ditional plating techniques have
evolved. Hybrid external fixation,
which is characterized by early mini-
mally invasive articular reconstruc-
tion neutralized by transarticular
external fixation, initially appeared
to be an attractive alternative to tra-
ditional plating techniques. Although
deep infection rates were diminished
with external fixation, articular
malreduction and metadiaphyseal
malalignment proved difficult to
overcome and were associated with
less desirable outcomes.5-7 Studies
seeking to compare this method of
treatment with traditional plating
techniques had considerable design
flaws. The compromised results of
these hybrid constructs nurtured
the tactic of staged treatment. This
approach emphasized soft-tissue
recovery with initial application of
a spanning external fixator. Defini-
tive fixation was completed only
after the soft tissues were receptive
(ie, resolution of swelling, regional
abrasions, and blisters). This fixation
was performed with the inclusion
of strategically positioned surgical
approaches and, where applicable,
minimally invasive methods of implant
insertion. Several studies demonstrated
efficacious management of high-
energy lesions using delayed surgi-
cal intervention in this staged fashion
and reported predictable and favor-
able outcomes.8,9 Adopted protocols
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
emphasized meticulous soft-tissue
management in combination with
delayed definitive fixation to offer
diminished additional compromise to
surrounding soft tissues. Short- and
long-term outcomes demonstrated a
reduction in surgical complications.
Despite adherence to contemporary
staged protocols, a relatively high
complication rate may still exist. The
evolution of biologically benign
methods of reduction and plate fixa-
tion has served to further diminish
complication rates. This trend is most
evident with regard to wound healing
and subsequent development of
superficial or deep infection.
Early Primary Fixation
Optimal timing for surgical manage-
ment of pilon fractures remains con-
troversial. Early transarticular external
fixation followed by delayed internal
fixation is one management option;
however, several authors have advo-
cated early primary open reduction
and internal fixation (ORIF) as a viable
strategy for managing both open and
closed pilon fractures.
White et al10 studied a cohort of
95 patients with AO Orthopaedic
Trauma Association (OTA) type 43.C
pilon fractures, most of whom had
been treated with primary ORIF within
48 hours of injury. They reported that
deep infections requiring surgery
occurred in 6% of patients. However,
patients with “local soft-tissue factors”
such as gross contamination and the
presence of hemorrhagic fracture blis-
ters were excluded from the cohort. At
a minimum 1-year follow-up, the au-
thors of the study assessed the quality
of fracture reduction and functional
outcomes. Compared with the use of
delayed strategies, these authors
observed enhanced anatomic fracture
reduction and similar functional out-
comes with ORIF. They concluded
that even high-energy pilon fractures
within their cohort could be predict-
Stephen A. Kottmeier, MD, et al
ably and effectively managed with
ORIF. However, they acknowledged
that early fixation may not yield
acceptable results in patients with
notable regional or systemic co-
morbidities (ie, alcohol abuse,
schizophrenia, diabetes, peripheral
neuropathy, hemorrhagic fracture
blisters) and discouraged surgical
intervention between 3 and 5 days
after injury. These investigators fur-
ther advised that adopting this
strategy demands the refined skills of
an orthopaedic traumatologist with
sufficient resources and access to the
operating room.10
In a retrospective comparative
study, Tang et al11 reported similar
results with early fixation of closed
pilon fractures. These authors stud-
ied two groups of 23 patients, all
with closed AO OTA type 43.C
pilon fractures. Group A was treated
with early fixation (ie, within 36
hours) using minimally invasive
techniques, and group B was treated
with delayed fixation. They excluded
all open fractures, injuries with AO
soft-tissue grades of $4, patients
with compartment syndrome, and
patients with diabetes, cancer, or
immunodeficiency. The overall in-
fection rate was 17.4%, and
there was no significant difference
between the two groups. These au-
thors, however, included superficial
wound infections that did not require
surgical intervention in their analysis.
They reported no deep infections in
the immediate fixation group and one
deep infection in the delayed fixation
group. Additionally, they reported
statistically significant reduction in
the surgical time and length of hos-
pital stay for patients treated with
early fixation (P , 0.01 for both).11
We have observed similar success
(particularly with regard to ease of
reduction) but have used this strategy
with caution. Our experience has
been limited to closed fractures, usu-
ally in patients who have sustained
isolated injuries. Typically, we
2
Foot & Ankle Stephen A. Kottmeier, MD, et al

Figure 1 and metaphyseal insufficiency in

these open lesions. They remain
fraught with complications and the
potential for quiescent or obvious
infection, either of which may be
overwhelmingly refractory. Gardner
et al13 adopted a successful protocol
to manage open pilon fractures with
results yielding favorable outcomes
and an acceptable infection rate.
The first stage focused on imme-
diate débridement of devitalized
osseous and soft-tissue elements in
addition to the application of a
temporizing ankle-spanning external
fixator (Figure 1, A). Adequate
débridement with eradication of
all devitalized tissues, both soft
A, Intraoperative photograph showing an open tibial pilon fracture in a 22-year-
and osseous, was emphasized. These
old man who presented 36 hours after initial injury from an outside hospital with a
steel wire wound closure and a Penrose drain, and without a transarticular débridement efforts were performed
external fixator. The patient was treated with a temporizing spanning external through traumatic wound extensions
fixator and serial débridement. He subsequently underwent internal fixation, or anticipated subsequent surgical
antibiotic bead placement, and definitive wound coverage. Elective autologous
incisions. After recovery of soft tis-
bone grafting and bead extraction were performed several months later. B,
Postoperative AP radiograph obtained 12 weeks after initial injury showing early sues (usually within 1 to 3 weeks)
consolidation of callus. and in the absence of obvious signs
of infection, soft-tissue coverage
was next performed with inclusion
advocate the pursuit of early defini- such as social history, regional, and of antibiotic bead placement and
tive fixation only under the direction systemic comorbidities. contemporary plate fixation. Sev-
of an orthopaedic traumatologist and LeBus and Collinge12 assessed vas- eral months later, elective bone
in cases in which patient status and cular abnormalities in high-energy grafting was performed with bead
resources permit intervention within tibial plafond fractures with CT angi- extraction (Figure 1, B). This third
12 hours. ography. Their data analysis suggested stage was performed only in the
that open fractures were far more presence of resolved edema and in
likely than closed variants to be the absence of drainage or clinical
Open Pilon Fractures associated with arterial abnormalities. signs of infection.
High-energy pilon fractures, partic- They further concluded that no other Boraiah et al14 evaluated a staged
ularly those with associated open injury characteristics offered substan- protocol to address open fractures of
lesions, often present with defi- tial correlation with arterial injury. the pilon in an effort to minimize soft-
cient osteoarticular components and They did not, however, witness nota- tissue complications and subsequent
marginally salvageable metaphyseal ble postoperative wound-healing infection. They acknowledged that
components. Failure to recognize and abnormalities despite vascular com- restoration of limb alignment, rota-
address metadiaphyseal deficits, even promise (predominantly injury to the tion, and anatomic articular reconsti-
in the absence of infection, may pre- anterior neurovascular bundle). They tution when managing these lesions
dict failure. Threatened regional soft contended that their success was may minimize the evolution of post-
tissues and a considerably heightened likely due to the use of temporizing traumatic arthrosis. They further
risk of infection pose a therapeutic external fixation and minimally cautioned that surgical goals toward
dilemma. The outcome of high- invasive techniques with delayed articular reconstitution should not be
energy pilon fractures does not solely surgical intervention. Preserved col- pursued at a cost to regional soft tis-
depend on the integrity of regional lateral blood flow was suggested to sues, owing to the potential for
soft tissues and the osseous elements. compensate for arterial deficiency. disastrous outcomes. Sanders et al15
In addition, it is very much influenced Typically, multiple surgeries are similarly observed that, in severe
by individual patient characteristics required to address both articular open pilon fractures, the required

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 3

Foot & Ankle
Figure 2
Intraoperative photographs showing the medial (A) and lateral (B) aspects of the lower leg in two different patients, with the
three angiosomes roughly delineated. Posteromedial (A) and anterolateral and posterolateral (B) approaches were
performed between the angiosomes, thereby limiting risk to the resultant skin bridge.
adequate débridement of soft and
osseous tissues may result in con-
siderable segmental bone loss and
articular deficits. The authors were
able to achieve satisfactory out-
comes in a small cohort of patients
using immediate surgical arthrod-
esis of the ankle joint. Their analysis
confirmed the feasibility of limb
reconstruction in such scenarios.
Results, however, were of ques-
tionable value. They advised that
patients be forewarned of the ex-
pected multiple surgical procedures,
lengthy hospital admissions, and
substantial imposition on voca-
tional and personal relationships.
Furthermore, they argued that pri-
mary amputation in select cases may
prove to be the “conservative”
treatment of choice.
Surgical Approach and
Infection
Numerous surgical access strategies
have been offered, each with unique
limitations, attributes, and charac-
teristics. Various combinations of
approaches have been described, as
have concerns regarding their prox-
imity to one another. Howard et al16
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
sought to ascertain the validity of a
commonly held conception that a
7-cm skin bridge must be maintained
between surgical incisions around
the ankle joint. They suggested that
adherence to this unconfirmed 7-cm
dogma was not required if proper
soft-tissue management and appro-
priate timing of surgical intervention
were maintained. They further sug-
gested that the pattern of injury, not
skin bridge dimension, should dic-
tate surgical approach selection. In
most of their retrospectively re-
viewed cases, a skin bridge of ,7 cm
was observed, and soft-tissue com-
plication and infection rates were
acceptable. The anterolateral (Böhler)
approach, in particular, has proven
resilient when combined with either
medial or posterolateral approaches.17
Despite infrequent dehiscence, super-
ficial infection, and eschar, it has
proven to be receptive to and requiring
of only local wound care and healing
by secondary intention.
Three vertically oriented angiosomes
exist, supplying the overlying soft-
tissue envelope of the lower leg and
ankle.18 Surgical incisions placed in
parallel between the angiosomes pose
no threat to the resultant skin bridge
Stephen A. Kottmeier, MD, et al
(Figure 2). The skin bridge and the
source vessels in the overlying cuta-
neous blood supply appear tolerant of
this. This is in sharp contrast to the
risks posed by transverse incisions.
The technique of deep surgical dis-
section, perhaps more than the prox-
imity of the incisions to each other, has
the greatest influence on wound
healing and evolution of infection.
Minimally Invasive Fixation
Although the combination of multi-
ple incisions and their proximity to
each other was described earlier, the
attributes of minimally invasive
techniques have been explored and
adopted by some surgeons. Sub-
muscular anterolateral (Böhler) ap-
proaches cannot be used with purely
percutaneous efforts because regional
neurovascular structures remain at
risk.19 Several studies have sought
to assess the efficacy of minimally
invasive subcutaneous instrumenta-
tion methods to address pilon fractures
and associated wound healing com-
plications.20,21 Such efforts are largely
limited to medial column restoration
using percutaneous techniques. In a
4
Foot & Ankle
Figure 3
A, Three-dimensional CT scan demonstrating proximal apical extension (arrow)
of a pilon fracture pattern in continuity with a peripheral large articular implant. B,
Intraoperative AP fluoroscopic image showing fixation of the apical portion of a
pilon fracture with an oblique extension encroaching proximally on the diaphysis
using a proximal posteromedial approach remote from anticipated subsequent
more peripheral approaches.
cadaver study, Borrelli et al22
described the extraosseous blood
supply of the tibia and the effect
various forms of plate fixation have
on it. Percutaneously introduced
plates seemed to cause less disruption
to the extraosseous blood supply,
particularly in the medial aspect of
the distal tibia. Subsequent studies
have validated these findings from a
clinical perspective.23,24 In contrast,
Lau et al25 observed a concerningly
high rate of late superficial infection,
primarily with medial subcutaneous
plates. They maintained, however,
that this had little effect on the out-
come. These infections were success-
fully managed with a brief course of
antimicrobial therapy and, on occa-
sion, implant extraction. Other
studies have demonstrated similar
findings with regard to medial wound
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
healing complications.20,26 Most of
these were easily resolved without
notable negative effects on osseous
union or functional outcome. Al-
though minimally invasive methods
of fixation demonstrated diminished
rates of infection, obstacles remained.
Among these, nonunion, malre-
duction, and angular deformities
were not uncommon.
Upgrading
When managing soft-tissue concerns
in an effort to reduce the risk of
infection, the concept of upgrading,
in which a complex fracture pattern is
converted to a simpler one, may
have a role. Dunbar et al27 identified
a subset of pilon fractures presenting
with an oblique extension that en-
croached on the diaphysis proxi-
Stephen A. Kottmeier, MD, et al
mally (Figure 3, A). They suggested
that these lesions were challenging
from the standpoint of acceptable
reduction when managed in a de-
layed fashion. The authors main-
tained that delayed management of
these lesions required excessive
stripping, greatly impaired reduction
of these fragments, and compro-
mised anatomic restoration of the
articular surface. They proposed that
this fracture pattern could be more
expeditiously managed in the acute
setting during surgical débridement
and application of a transarticular
fixator. In accordance with this
technique, small fragment plates
were applied to the diaphyseal
component of the fracture, typically
in an antiglide fashion, through
small proximal incisions (Figure 3,
B). Avoidance of tenuous peripheral
soft tissues was required, and addi-
tional osteoarticular reconstruction
was deferred until soft-tissue status
permitted. This served to reestablish
length, rotation, and alignment of
these regional fragments, which were
commonly in continuity with either
the anterolateral (Chaput) or postero-
lateral (Volkmann) articular frag-
ments. Early anatomic restoration of
these fragments (through upgrad-
ing) afforded a foundation for sub-
sequent delayed definitive fixation.
When applied to pilon fractures, the
technique of upgrading enables con-
version of an AO/OTA type C (ie,
complete articular involvement) pat-
tern to an AO/OTA type B (ie, partial
articular involvement) pattern.
Despite being performed in the acute
setting, it served to diminish subse-
quent soft-tissue compromise during
the course of definitive fixation.
This, in turn, diminished the risk of
infection and subsequent wound
compromise. The offered tech-
nique seems to be simple and safe,
and it is an adjunct to prevent
infection. It does, however, war-
rant further investigation and
cautious application.
5
Foot & Ankle Stephen A. Kottmeier, MD, et al

Sequential Fixation Figure 4

The limitations of traditional ante-
rior exposures with the patient su-
pine have proven challenging with
regard to the reduction of associ-
ated posterior malleolar patterns.
These important posterior compo-
nents, when accurately reduced, may
serve as a useful template for resto-
ration of the fracture length, angula-
tion, and articular reconstitution.
Soft-tissue detachment, in addition
to comminution and small fragment
dimensions, may make traditional
surgical exposures inadequate in
achieving required anatomic reduc-
tion (Figure 4, A). The resultant
malreduction may prohibit subse-
quent articular reconstitution. Ketz
and Sanders28 recognized potential
difficulties encountered during the
course of reduction of the posterior
malleolar fragment associated with
high-energy pilon fractures. In select
fracture patterns, the advantages of
direct posterior malleolar plating
performed with prone patient posi- A, Three-dimensional CT scan showing a posterior pilon variant with
tioning were readily apparent. These syndesmotic detachment (arrow). The syndesmotic detachment may complicate
investigators adopted a staged pro- reduction efforts when anterior approach strategies are used with the patient in
the supine position. B, Intraoperative lateral fluoroscopic image demonstrating a
tocol with initial application of an posterior antiglide plate (arrow) that was placed through a posterolateral incision
external fixator combined with a to restore an intact posterior column on which additional reduction and fixation
limited posterior open reduction may be executed. This foundation facilitates delayed, anteriorly based approach
through a posterolateral approach. and fixation.
This exposure was permitting of
concomitant fixation of the fibula. gical access (posteriorly) through dance with upgrading techniques
They acknowledged the limitations soft tissues, with subsequent fixation (despite early surgical intervention to
of articular scrutiny during the performed anteriorly. Surgical fixa- receptive soft tissues), hastened the
course of posterior fragment fixation tion through the more compromised recovery of peripheral soft tissues.
efforts, which were indirectly re- anterior soft tissues required con- This staged strategy of fixation may
duced. Caution was urged with re- siderable delay. Katz and Sanders28 reduce wound healing complication
gard to execution of fibula fixation reported improved articular re- rates and the risk of infection.
because any element of malrotation, ductions and better functional
shortening, or angular malalignment outcomes compared with previous
could prevent anatomic reduction of protocols of delayed single-stage Transsyndesmotic Fixation
the posterior fragment. After recov- definitive fixation. There were no On occasion, concerns regarding the
ery of soft tissues, a delayed second increased complications associated integrity of the soft tissues and host
staged surgical intervention was with wound healing. As described characteristics may exceed osseous
performed to reduce and fixate previously, this served to upgrade concerns. Low-energy fracture var-
the remaining anterior fragments to the lesion to a pattern of lesser iants with primarily medial com-
their now intact posterior fragment complexity with potentially more pounding wounds in patients with
counterparts (Figure 4, B). This predictable subsequent reduction considerable comorbidities are not
staged protocol permitted early sur- maneuvers. This protocol, in accor- uncommon. Sciadini et al29 reviewed

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 6

Foot & Ankle Stephen A. Kottmeier, MD, et al

Figure 5 soft-tissue coverage. Most of these

patients have preexisting medical and
regional comorbidities. In addition, we
have found that this technique is
appropriate for deliberate, acute
shortening efforts (Figure 5). When
indicated in patients in whom complex
soft-tissue coverage is not appropriate,
shortening may facilitate wound clo-
sure. It is a potentially useful strategy
in the surgeon’s armamentarium to
avoid disastrous wound healing com-
plications and subsequent infection.

Primary Ankle Arthrodesis

Although the relationship between
the quality of reduction and func-
A, Intraoperative photograph demonstrating a high-energy open pilon fracture
in a 67-year-old man. The patient presented with concerning regional and tional outcome measures may offer
systemic comorbidities. He was deemed a poor candidate for medial soft- some correlation, an exception may
tissue reconstruction efforts. Conventional fixation efforts may have further be fracture patterns with extreme
complicated recovery of soft and osseous tissues. B, AP radiograph of the comminution and metadiaphyseal
ankle showing transsyndesmotic fixation of the pilon fracture. Deliberate
shortening was performed, further facilitating wound closure and uneventful impaction. Numerous studies have
wound healing medially. Bony union was achieved without adjuvant surgical or sought to ascertain the influence of the
grafting efforts. fracture pattern and surgical treatment
selection on the quality of reduction
and functional outcome of surgically
several cases of distal tibial fractures to minimally invasive plate fixation of managed pilon fractures. Anatomic
with minimal or no articular in- the medial column. Transsyndesmotic osteoarticular reconstruction in the
volvement but with notable medial fixation is perhaps most suitable setting of severe comminution is chal-
soft-tissue injury. These authors when conventional methods of fix- lenging, with no guarantee of favorable
described a novel approach of fixed ation may pose unacceptable risks outcomes. Furthermore, reconstruc-
angle transsyndesmotic fixation, to anterior or medial soft tissues. tion may result in a severe threat to soft
which offered minimal introduction Fixation is introduced through the tissues and infection; thus, a role for
of surgical insult, particularly to com- less traumatized and more resilient primary ankle arthrodesis may exist
promised medial soft tissues. Such lateral soft tissues. (Figure 6). Arthrodesis permits cau-
constructs have been previously Technical aspects of transsyndesmotic tious delayed treatment, which allows
described to enhance fixation in pa- fixation include the use of a fibular recovery of soft tissues.
tients with diabetes and osteoporotic plate with hybrid fixation techniques. Several studies have assessed the role
ankle fractures of low complexity Transsyndesmotic locking screws are of primary arthrodesis in the setting of
and energy. The greatest utility of the placed in the distal limit of the fibular severe articular comminution that pre-
technique is in the management of plate, engaging the distal tibia in cluded anatomic reconstitution. Bea-
valgus distal tibial fractures with a quadricortical fashion. Bicortical man and Gellman30 demonstrated
associated medial traction wounds. fibular or similar quadricortical reliably good outcomes with anterior
Sciadini et al29 proposed this tech- fibular-tibial screws are introduced plate fixation supplemented by a neu-
nique as a viable method of obtain- proximally. This construct serves to tralizing external fixator with primary
ing and maintaining reduction with bridge the tibial component of the arthrodesis of the ankle. These au-
or without the sustained application fracture pattern. Preferred con- thors, encouraged by expedited patient
of a transarticular external fixator. structs use a long precontoured dis- recovery, suggested the use of primary
Their cohort included patients with tal fibular plate. We have found that ankle arthrodesis to manage complex
high-energy injuries, including falls this construct is indicated for pa- patterns that are refractory to osteo-
from a height and vehicular injuries. tients with valgus patterns who are articular reconstitution. Acceptable
Medial soft tissues were not receptive deemed poor candidates for complex healing rates were reported, with good

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 7

Foot & Ankle Stephen A. Kottmeier, MD, et al

overall functional scores. Zelle et al31 Figure 6

reported satisfactory results with the
application of a posteriorly applied
blade plate. They described it as a
reliable method of addressing a small
subset of injury patterns that are
deemed nonreconstructable. Primary
arthrodesis is indicated for manage-
ment of fracture patterns with
extensive comminution and marked
impaction of the articular cartilage
(.50% of the tibial plafond delin-
eated on preoperative CT) within the
tibial metaphysis. The authors
reported good results, even in the
setting of metadiaphyseal deficits.
Zelle et al31 advocated the use of
primary arthrodesis in select patients
and highlighted the reduced rate of
infection compared with infection
rates associated with conventional
fixation techniques. The authors did
acknowledge the preferential goal of
articular reconstitution when possible,
in an effort to limit midfoot arthrosis,
which is a complication commonly associ-
ated with otherwise successful tibiotalar
arthrodesis.

Acute Shortening
The combined presence of soft tissue
and osseous deficits complicates
management of severely comminuted
pilon fractures, particularly those with
associated metadiaphyseal comminu-
tion. Soft-tissue reconstruction op-
tions include local rotation flaps, skin
grafts, and free flaps. In patients
deemed poor candidates for such
procedures, acute shortening of the
distal fracture site facilitates closure of
the traumatic wound and may simul-
taneously address osseous deficits.
Unintended shortening upon appli-
cation of a temporary transarticular
external fixator is not uncommon
when managing open pilon fracture
variants. The wound is often perceived
as easily coapted during débridement.
For simple fracture patterns, subse-
quent anatomic restoration may result
in a readily apparent diastasis of the
A, AP radiograph of the ankle of a 67-year-old woman who sustained a pilon
fracture in a high-energy motor vehicle collision. The articular component was
deemed nonreconstructable, and the soft tissues were severely compromised. A
temporizing transarticular external fixator was applied for 4 weeks, and then
primary ankle arthrodesis was performed. B, AP radiograph of the ankle after
primary arthrodesis with a lateral blade plate.
traumatic wound, necessitating soft- described by some as less prone to
tissue coverage. We have successfully wound healing complications than
performed intentional shortening with other approaches.32,33 Others, how-
the inclusion of posterior plating ever, have not found this to be the
techniques in patients deemed poor case.34
candidates for soft-tissue transfer Alternatively, the use of ringed fix-
(Figure 7). This management option ators may be considered. Monofocal
requires segmental osseous resection methods of management involve distal
(ie, tibia and fibula), intraoperative shortening and the acceptance of lim-
vascular monitoring, and acceptance ited limb length inequality (Figure 8).
of limb shortening. The advantages of This step may be done acutely,
acute shortening include shorter hos- gradually, or as a combination of
pital stay and avoidance of compli- both if shortening of .3 cm is nec-
cated soft-tissue reconstruction, both essary. The anticipated limb length
of which reduce the cost of care. The inequality associated with acute
posterolateral approach has been peripheral shortening may be

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Foot & Ankle Stephen A. Kottmeier, MD, et al

Figure 7

A, AP radiograph of the ankle demonstrating an open pilon fracture in a 72-year-old man. Restoration of the limb length resulted
in wound diastasis. He was deemed a poor candidate for soft-tissue coverage. B, Clinical photograph of the ankle after
deliberate limb shortening was performed, resulting in approximation of robust tissue margins. C, AP radiograph of the ankle
demonstrating fixation with a posterior plate. Clinical and radiographic union was achieved with restoration of aseptic function.

Figure 8

A, Preoperative AP radiograph of the ankle demonstrating a severe open tibial pilon fracture in a 58-year-old woman who
was injured in a motor vehicle collision. Débridement of devitalized tissues resulted in considerable osseous and soft-tissue
deficits requiring resection of the distal tibial osteoarticular segment. She was a poor candidate for both soft-tissue
reconstruction and osseous regeneration reconstruction maneuvers. B, Lateral radiograph of the ankle following monofocal
methods of limb shortening with the application of a circular tensioned wire external fixator. This resolved concerns for both
soft-tissue and osseous deficits. Acute shortening followed by subsequent gradual shortening was performed to ensure limb
perfusion. The arrows to the right indicate intentional acute shortening performed at the time of surgery. The arrows to the left
indicate subsequent gradual shortening/compression through the circular frame. C, AP radiograph of the ankle obtained
6 months after injury demonstrating successful fusion. (Reproduced with permission from Kottmeier S, Madison R, Divaris N, et
al: The infected pilon: Assessment and treatment strategies. Techniques in Foot & Ankle Surgery 2016;15:188–196.)

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 9

Foot & Ankle Stephen A. Kottmeier, MD, et al

Figure 9

A, AP radiograph of the ankle showing an open distal tibial pilon fracture with devitalized metadiaphyseal implants in a 42-
year-old patient. B, AP radiograph of the ankle after application of a circular fixator. A bifocal strategy (two levels of activity)
was used with distraction osteogenesis (proximal segment) and intercalary shortening (distal segment). The arrows indicate
distraction at the proximal osteotomy site and compression at the distal intercalary defect. C, Postoperative lateral
radiograph demonstrating satisfactory proximal bone regenerate and union of the distal region of intercalary bones loss.
(Reproduced with permission from Kottmeier S, Madison R, Divaris N, et al: The infected pilon: Assessment and treatment
strategies. Techniques in Foot & Ankle Surgery 2016;15:188–196.)

addressed by distraction osteo-
genesis techniques within the proximal
metaphyseal region of the tibia.35,36
These techniques can be performed
simultaneously (ie, bifocal) or staged
at a later date. Bifocal compression/
distraction osteogenesis addresses bone
loss peripherally (through shortening)
and resolves limb length discrepancy
by proximal distraction osteogenesis
(Figure 9). Limb shortening peripher-
ally, within the region of distal meta-
physeal deficit, does not require
adjuvant bone grafting techniques or
the docking site preparation required
with bone transport techniques in
which the length of the limb is main-
tained (ie, a form of monofocal treat-
ment).37 In contrast to segmental
bone transport, acute shortening ob-
viates docking site trajectory concerns.
Additionally, adjuvant bone grafting
techniques are unlikely to be required;
these techniques are frequently re-
quired to facilitate docking site union.
Several studies have demonstrated the
efficacy of described bifocal treatment
in the acute management of distal tibial
metaphyseal pilon fractures, particu-
larly in the setting of open fractures
and metaphyseal deficits.38,39 The
ability to include primary wound clo-
sure is unique to acute shortening
protocols, thus eliminating the need for
complicated soft-tissue reconstruction
efforts. This setting is particularly
important for patients who cannot
undergo complex soft-tissue coverage.
Additional gradual shortening of
2 mm per day has been described for
defects .3 cm.39 Shortening of the
distal aspect of the tibia within the
region of comminution has been
described for defects ,3 cm. Caution
has been advised when pursuing
shortening for defects .3 cm.40
Deliberate limb length reduction is
limited by the circulatory status of
the foot, which is monitored by
means of intraoperative Doppler
ultrasonography of the posterior and
anterior tibial arteries. Atbasi et al41
assessed the arterial configuration
after acute tibial shortening with
angiographic evaluation. In a clinical
study, 16 patients were monitored
with intraoperative Doppler and
pulse oximetry. The average amount
of acute shortening was 5.5 cm
(maximum, 8 cm of shortening). Dig-
ital subtraction angiography was per-
formed 1 week after the procedure,
and CT angiography was performed

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 10

Foot & Ankle
2 years after the procedure. No
discernible change in the arterial
configuration occurred with acute
shortening ,4 cm; however, increased
tortuosity of the vessels was noted.
Arterial patency was maintained, and
the newly acquired arterial configura-
tion persisted for ,2 years with no
circulatory or limb perfusion compli-
cations. Accordingly, a threshold for
immediate acute shortening has yet to
be convincingly demonstrated.
Distally, both monofocal and bifo-
cal techniques follow a similar pro-
tocol. Devitalized bone margins are
resected with aggressive débridement
of devitalized structures. Because of
the small dimension of the distal
fragment and its proximity to the
ankle joint, inclusion of the foot
within the frame is typically re-
quired. This configuration also
serves to prevent equinus contrac-
ture and offers enhanced stability to
the ring construct. With bifocal efforts
(acute or staged), a proximal tibial
corticotomy is performed in a low-
energy fashion by means of multiple
drill holes or a Gigli saw. Proximal
distraction is initiated at a rate of
1 mm per day, with a latency period of
7 to 10 days. Both unifocal and bifocal
treatment methods facilitate closure of
the distal traumatic wound. With
either method, segmental resection
of a portion of the fibula, corre-
sponding to the anticipated measured
shortening, is required. This allows
approximation of the peripheral
proximal and distal fragments. Inten-
tional shortening of the limb may
favor primary wound healing and
make the soft tissues more resilient to
infection and osseous devitalization.
Summary
Recent advances in osteosynthesis of
the distal tibial plafond have been
promising, offering improved out-
comes and fewer complications. The
pursuit of anatomic articular recon-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
stitution cannot be at the expense of
the soft tissues. Despite adherence to
and proper execution of current fix-
ation techniques, infection of the
distal tibial pilon after surgical os-
teosynthesis remains challenging.
Patient characteristics, both regional
and systemic, must be considered.
The limitations and difficulty of these
surgical reconstructions must be rec-
ognized and accepted by both the
treating surgeon and the patient.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6,
7, 11, 28, and 40 are level III studies.
References 1-5, 8-10, 12-17, 20, 21,
23-27, 29-31, 33-35, 37-39, and 41
are level IV studies. References 18,
19, 22, 32, and 36 are level V expert
opinion.
References printed in bold type are
those published within the past 5
years.
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lower end of tibia into the ankle-joint.
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2. Dillin L, Slabaugh P: Delayed wound
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open reduction and internal fixation of
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3. McFerran MA, Smith SW, Boulas HJ,
Schwartz HS: Complications encountered
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4. DeCoster TA, Willis MC, Marsh JL, et al:
Rank order analysis of tibial plafond
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Aurori B: Hybrid external fixation in the
treatment of tibial plafond fractures. Clin
Orthop Relat Res 1996:16-22.
6. Pugh KJ, Wolinsky PR, McAndrew MP,
Johnson KD: Tibial pilon fractures: A
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KE: Pilon fractures: Treatment protocol
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Stephen A. Kottmeier, MD, et al
8. Patterson MJ, Cole JD: Two-staged delayed
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9. Sirkin M, Sanders R, DiPasquale T,
Herscovici D Jr: A staged protocol for soft
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10. White TO, Guy P, Cooke CJ, et al: The
results of early primary open reduction and
internal fixation for treatment of OTA 43.
C-type tibial pilon fractures: A cohort
study. J Orthop Trauma 2010;24:757-763.
11. Tang X, Liu L, Tu C, Li J, Li Q, Pei F:
Comparison of early and delayed open
reduction and internal fixation for treating
closed tibial pilon fractures. Foot Ankle Int
2014;35;657-664.
12. LeBus GF, Collinge C: Vascular
abnormalities as assessed with CT
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fractures. J Orthop Trauma 2008;22:
16-22.
13. Gardner MJ, Mehta S, Barei DP, Nork SE:
Treatment protocol for open AO/OTA type
C3 pilon fractures with segmental bone
loss. J Orthop Trauma 2008;22:451-457.
14. Boraiah S, Kemp TJ, Erwteman A, Lucas
PA, Asprinio DE: Outcome following open
reduction and internal fixation of open
pilon fractures. J Bone Joint Surg Am 2010;
92:346-352.
15. Sanders R, Pappas J, Mast J, Helfet D: The
salvage of open grade IIIB ankle and talus
fractures. J Orthop Trauma 1992;6:
201-208.
16. Howard JL, Agel J, Barei DP, Benirschke
SK, Nork SE: A prospective study
evaluating incision placement and wound
healing for tibial plafond fractures. J
Orthop Trauma 2008;22:299-305.
17. Mehta S, Gardner MJ, Barei DP, Benirschke
SK, Nork SE: Reduction strategies through
the anterolateral exposure for fixation of
type B and C pilon fractures. J Orthop
Trauma 2011;25:116-122.
18. Attinger CE, Evans KK, Bulan E, Blume
P, Cooper P: Angiosomes of the foot and
ankle and clinical implications for limb
salvage: Reconstruction, incisions, and
revascularization. Plast Reconstr Surg
2006;117(suppl 7):261S-293S.
19. Wolinsky P, Lee M: The distal approach for
anterolateral plate fixation of the tibia: An
anatomic study. J Orthop Trauma 2008;
22:404–407.
20. Borg T, Larsson S, Lindsjö U: Percutaneous
plating of distal tibial fractures: Preliminary
results in 21 patients. Injury 2004;35:
608-614.
21. Collinge C, Sanders R, DiPasquale T:
Treatment of complex tibial periarticular
11
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fractures using percutaneous techniques.
Clin Orthop Relat Res 2000:69-77.
22. Borrelli J Jr, Prickett W, Song E, Becker D,
Ricci W: Extraosseous blood supply of the
tibia and the effects of different plating
techniques: A human cadaveric study. J
Orthop Trauma 2002;16:691-695.
23. Ronga M, Longo UG, Maffulli N:
Minimally invasive locked plating of
distal tibia fractures is safe and effective.
Clin Orthop Relat Res 2010;468:
975-982.
24. Williams TH, Schenk W: Bridging-
minimally invasive locking plate
osteosynthesis (Bridging-MILPO):
Technique description with prospective
series of 20 tibial fractures. Injury 2008;39:
1198-1203.
25. Lau TW, Leung F, Chan CF, Chow SP:
Wound complication of minimally invasive
plate osteosynthesis in distal tibia fractures.
Int Orthop 2008;32:697-703.
26. Sitnik AA, Beletsky AV: Minimally invasive
percutaneous plate fixation of tibia
fractures: Results in 80 patients. Clin
Orthop Relat Res 2013;471:2783-2789.
27. Dunbar RP, Barei DP, Kubiak EN, Nork
SE, Henley MB: Early limited internal
fixation of diaphyseal extensions in select
pilon fractures: Upgrading AO/OTA type C
fractures to AO/OTA type B. J Orthop
Trauma 2008;22:426-429.
28. Ketz J, Sanders R: Staged posterior tibial
plating for the treatment of Orthopaedic
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Trauma Association 43C2 and 43C3 tibial
pilon fractures. J Orthop Trauma 2012;26:
341-347.
29. Sciadini MF, Manson TT, Shah SB: Trans-
syndesmotic fibular plating for fractures of
the distal tibia and fibula with medial soft
tissue injury: Report of 6 cases and
description of surgical technique. J Orthop
Trauma 2013;27:e65-e73.
30. Beaman DN, Gellman R: Fracture
reduction and primary ankle arthrodesis: A
reliable approach for severely comminuted
tibial pilon fracture. Clin Orthop Relat Res
2014;472:3823-3834.
31. Zelle BA, Gruen GS, McMillen RL, Dahl
JD: Primary arthrodesis of the tibiotalar
joint in severely comminuted high-energy
pilon fractures. J Bone Joint Surg Am 2014;
96:e91.
32. Konrath GA, Hopkins G II: Posterolateral
approach for tibial pilon fractures: A report
of two cases. J Orthop Trauma 1999;13:
586-589.
33. Sheerin DV, Turen CH, Nascone JW:
Reconstruction of distal tibia fractures
using a posterolateral approach and a blade
plate. J Orthop Trauma 2006;20:247-252.
34. Bhattacharyya T, Crichlow R, Gobezie R, Kim
E, Vrahas MS: Complications associated with
the posterolateral approach for pilon fractures.
J Orthop Trauma 2006;20:104-107.
35. El-Rosasy MA: Acute shortening and re-
lengthening in the management of bone
and soft-tissue loss in complicated
Stephen A. Kottmeier, MD, et al
fractures of the tibia. J Bone Joint Surg Br
2007;89:80-88.
36. Sales de Gauzy J, Vidal H, Cahuzac JP:
Primary shortening followed by callus
distraction for the treatment of a
posttraumatic bone defect: Case report. J
Trauma 1993;34:461-463.
37. Saleh M, Rees A: Bifocal surgery for
deformity and bone loss after lower-limb
fractures: Comparison of bone-transport
and compression-distraction methods. J
Bone Joint Surg Br 1995;77:429-434.
38. Rozbruch SR, Weitzman AM, Watson JT,
Freudigman P, Katz HV, Ilizarov S:
Simultaneous treatment of tibial bone and
soft-tissue defects with the Ilizarov method.
J Orthop Trauma 2006;20:197-205.
39. Sen C, Kocaoglu M, Eralp L, Gulsen M,
Cinar M: Bifocal compression-distraction
in the acute treatment of grade III open tibia
fractures with bone and soft-tissue loss: A
report of 24 cases. J Orthop Trauma 2004;
18:150-157.
40. Katsenis D, Triantafillis V, Chatzicristos M,
Dendrinos G: The reconstruction of tibial
metaphyseal comminution using hybrid
frames in severe tibial plafond fractures. J
Orthop Trauma 2013;27:153-157.
41. Atbasi Z, Demiralp B, Kilic E, Kose O,
Kurklu M, Basbozkurt M: Angiographic
evaluation of arterial configuration
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Orthop Surg Traumatol 2014;24:
1587-1595.
12
 Review Article

Foot and Ankle Infections:

Diagnosis and Management

Abstract
Oke A. Anakwenze, MD Infections of the foot are a common source of morbidity, disability,
Andrew H. Milby, MD and potential limb loss. A large proportion of lower extremity
infections occurs in the setting of diabetic neuropathy, with or
Itai Gans
without circulatory compromise, and are potentially preventable
John J. Stern, MD with regular surveillance. Adequate diagnosis and treatment of foot
L. Scott Levin, MD, FACS infections can be challenging. Successful treatment is dependent
Keith L. Wapner, MD on factors such as etiology; vascular, neurologic, and immune
status; and the identity of the offending organism.

F oot infections are a common

From the Department of
Orthopaedic Surgery
(Dr. Anakewnze, Dr. Milby, Dr. Levin,
and Dr. Wapner), the School of
Medicine (Mr. Gans), and the
Department of Medicine, Division of
Infectious Diseases (Dr. Stern),
University of Pennsylvania,
Philadelphia, PA.
J Am Acad Orthop Surg 2012;20:
684-693
http://dx.doi.org/10.5435/
JAAOS-20-11-684
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
source of morbidity, disability,
and potential limb loss. Trauma to
and pathology of the lower leg, an-
kle, feet, and toes are risk factors for
subsequent infection and comprised
11.8% of injuries seen in emergency
departments in 2006.1 In the setting
of systemic conditions such as diabe-
tes, infections pose an especially
challenging treatment dilemma be-
cause patients often have compro-
mised vascular status, immune sta-
tus, and wound healing capability.
Over 60% of nontraumatic lower-
limb amputations occur in patients
with diabetes.2 Because many of
these infections are preventable, their
identification has become a priority
area in healthcare quality improve-
ment.3 Despite their impact on pa-
tient health and medical costs, treat-
ment strategies for foot infections,
which may include prolonged antibi-
otic therapy with or without surgical
intervention, are poorly understood.
Diagnosis and
Classification
Evaluation of the patient with sus-
pected foot infection begins by ob-
taining a history, including questions
regarding pain; ability to bear
weight; subjective fevers or chills; re-
cent trauma; prior infections; and
changes in activity, footwear, or hy-
giene. Systemic conditions such as di-
abetes, peripheral vascular disease,
chronic liver or kidney disease, im-
munosuppressive status, and gout
also must be noted.
Examination must take into ac-
count vital signs and overall mental
status to assess for systemic infec-
tion. The affected extremity should
be compared with the unaffected ex-
tremity whenever possible, and vi-
sual inspection should note the pres-
ence of deformity or other objective
findings, including erythema, ecchy-
mosis, or swelling. The integrity of
the skin should be assessed for
calluses or blisters and drainage.
Wound odor and any associated
drainage may aid in identification of
an etiologic agent. Sites of tenderness
to palpation may be identified, and
skin warmth may be noted in the af-
fected extremity. Plantar foot sensa-
tion should be assessed, as well.
Saltzman et al4 found that the use of
a 4.5-g monofilament to test sensa-
tion at the plantar surface of the first

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 13

Foot & Ankle Oke A. Anakwenze, MD, et al

metatarsal head was highly sensitive other imaging techniques.

(up to 100%) but less specific (67%)
in predicting the risk of ulcer devel-
opment in patients with diabetic neu-
ropathy. Dorsalis pedis and posterior
tibial pulses should be graded via
palpation or Doppler ultrasound,
and perfusion of the toes should be
assessed via capillary refill time.
Particular attention should be paid
to hemoglobin and white blood cell
(WBC) count as well as to inflam-
matory markers such as erythrocyte
sedimentation rate ([ESR], normal
range, 0 to 15 mm/h) and C-reactive
protein (CRP) level (normal <1 mg/
dL). Other disease-specific markers,
such as hemoglobin A1C (normal
range, 4% to 6%), and nutritional
markers, such as serum albumin
(normal range, 3.4 to 5.4 g/dL), also
may be useful for detecting infection.
Radiographic evaluation of the
lower extremity can be tailored
based on the findings of the previ-
ously mentioned evaluation. Initial
imaging should include weight-
bearing plain radiographs to assess
for fractures or dislocations, foreign
bodies, subcutaneous emphysema,
and associated degenerative changes.
CT can be used to further evaluate
the bony architecture. Suspicion of
osteomyelitis may warrant addi-
tional evaluation with MRI. With ei-
ther of these advanced imaging tech-
niques, consideration must be given
to the patient’s renal function before
administration of contrast material.
Nuclear medicine studies, including
technetium Tc-99m– and indium-In-
111–labeled leukocyte scans, can be
used in the setting of equivocal find-
ings or relative contraindications to
Basic assessment of vascular supply
must be performed in all cases of
foot infection. In patients with sus-
pected vascular compromise, the
ankle-brachial index (ABI), including
dorsalis pedis and toe wave pressures
and wave forms, may be obtained to
assess relative large-vessel perfusion
to the extremity. Normal ABI is
>0.9, and an index of <0.45 is pre-
dictive of a poor healing response.
Toe wave pressures of 0.45 and 0.2
mm Hg are predictive of good and
poor healing responses, respectively.
Duplex ultrasonography is a nonin-
vasive method that can be used to
screen for arterial stenoses and ve-
nous outflow obstruction or insuffi-
ciency. Invasive imaging of the vas-
culature with angiography may be
required depending on the site of
suspected vascular compromise or to
assess for intraoperative changes in
perfusion; however, the use of this
method should be carefully weighed
against attendant risks of vascular
access and contrast administration.
Maintaining a working differential
diagnosis that includes noninfectious
etiologies is essential. Gout, deep
vein thrombosis, compartment syn-
drome, Charcot neuroarthropathy,
fracture, and malignancy may pre-
sent with patterns of pain, swelling,
or erythema that may arouse suspi-
cion for infection. Following diagno-
sis, infection may be subclassified
into one or more of the following
general categories: (1) skin and nail
bed disorders, (2) soft-tissue infec-
tion, (3) diabetic foot infections, (4)
deep infections, and (5) septic arthri-
tis.
Skin and Nail Bed
Disorders
Many superficial infections of the
skin and nail bed (eg, felons, parony-
chia, onychomycosis) share much
with their counterparts in the upper
extremity in terms of pathogenesis
and management. Although well-
characterized in the hand literature,
felon of the toe has not been widely
described as a distinct clinical entity.
It is an infection that occurs within
the tissue septae of the distal pulp of
the toe and is commonly the result of
direct inoculation with locally de-
structive organisms such as Staphy-
lococcus aureus. Typically, presenta-
tion consists of a severely painful,
tense, and erythematous distal toe.
Examination must assess for the ex-
tent of any local purulent collection.
Surgical drainage with concomitant
antibiotics is the treatment of choice
and may be done at the bedside or in
the operating room, depending on
patient presentation (Table 1).
Approximately 1% of patients
who present to emergency depart-
ments with upper extremity infec-
tions have paronychia.5 Presentation
and treatment of paronychia in the
upper and lower extremity is similar.
It is often caused by direct or indirect
trauma to the cuticle or nail fold and
may progress to subungual abscess if
untreated. Primary causative organ-
isms include S aureus, Streptococcus
pyogenes, Pseudomonas pyocyanea,
Proteus vulgaris, and Candida albi-
cans.6 Diagnosis may be based on a
history of minor trauma as well as
erythema, edema, and/or tenderness

Dr. Stern or an immediate family member serves as a board member, owner, officer, or committee member of the American Board of
Internal Medicine. Dr. Levin or an immediate family member has received royalties from KLS Martin. Dr. Wapner or an immediate
family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of
and serves as a paid consultant to Small Bone Innovations, Wright Medical Technology, and Stryker; and has received research or
institutional support from Small Bone Innovations. None of the following authors or any immediate family member has received
anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the
subject of this article: Dr. Anakwenze, Dr. Milby, and Mr. Gans.

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 14

Foot & Ankle
Table 1
Surgical Intervention for Foot Infections
Indications
Pedal onychomycosis
Pedal onychocryptosis
Felon, fluid collection, or abscess
Septic arthritis, infection following open
fracture
Infected neuropathic ulcers, necrotizing
infection
Infection with bony erosion and/or joint
instability, progressive deformity
Osteomyelitis, infected implant, Charcot
neuroarthropathy
Soft-tissue defect overlying exposed ten-
don or bone
Infection in the setting of vascular insuffi-
ciency, gangrene
Overwhelming infection with deep tissue
involvement, systemic toxicity, low po-
tential for rehabilitation
of proximal and lateral nail folds
found on physical examination. If no
discrete abscess has formed, warm
water compresses and soaking the af-
fected digit in Burow solution (ie,
aluminum acetate) may be effective.
Oral antibiotic therapy with appro-
priate coverage of causative organ-
isms also should be used for persis-
tent lesions.
Surgical intervention is typically re-
served for cases in which an abscess
is present.7 For refractory lesions,
deep incision under local anesthesia
(eg, digital nerve block) may be re-
quired. In our practice, we use the
Winograd procedure in cases that
fail nonsurgical management. The
nail is split and a 0.25-inch–long
edge is removed. The matrix is then
excised or curetted, with the strip of
nail fold removed to create a semiel-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Intervention
Toenail débridement
Toenail resection
Incision and drainage
Irrigation and débridement
Soft-tissue débridement
External fixation
Staged irrigation and débridement followed
by stabilization or arthrodesis
Local/regional soft-tissue transfer for wound
coverage
Minor/partial amputation
Major amputation
liptic wedge down to the bone. The
margins are then undermined, and
the wound is sutured.8
In contrast to paronychia, onycho-
mycosis typically occurs in the lower
extremity. It is present in 2% to 14%
of adults in Western populations,
and its prevalence increases with age
and factors such as nail trauma, im-
munocompromised status, peripheral
vascular insufficiency, and Down
syndrome.9 Onychomycosis is also a
risk factor for ulcers in patients with
diabetes.10 Most common patho-
gens include the dermatophytes
Trichophyton rubrum and T menta-
grophytes. Of the nondermato-
phytes, candida species are most
common, and saprophytes (molds)
comprise the remaining causal
agents.11
Presentation consists of erythema-
Oke A. Anakwenze, MD, et al
Technical Considerations
Early intervention beneficial (<6 mo symp-
tom duration)
Multiple procedural variations described
Wound must be probed to remove loculi
and is left open following packing to en-
sure continued drainage
Repeat débridements may be necessary
based on the clinical situation
Repeat débridements may be necessary
every 24 to 36 h to establish wound
margins free of infection
Ilizarov versus tubular frame fixation may
be used based on site of pathology and
remaining bone stock
Antibiotic-impregnated cement beads or
spacers may be used to increase local
drug concentrations
Must optimize vascular and nutritional
status
Site of amputation must balance the need
to eradicate disease while optimizing
potential for rehabilitation
Site of amputation must balance the need
to eradicate disease while optimizing
potential for rehabilitation
tous toes with nail scaling and scal-
ing between the toes. Diagnosis
based on clinical appearance alone is
common. Definitive diagnosis may
be made by a positive microscopic
examination of toe nail clippings or
subungual debris with potassium hy-
droxide preparation.9
In individuals with intact immu-
nity, onychomycosis is primarily a
cosmetic concern. Although a variety
of oral and topical antifungal agents
is available to manage the infection,
the benefits of treatment must be
weighed against the potential toxic-
ity of the long treatment course re-
quired to eradicate the infection.12
There is level I evidence that nail dé-
bridement with topical antifungal
lacquer may be more effective than
débridement alone for management
of onychomycosis in these patients.13
15
Foot & Ankle
Soft-tissue Infection
The foot and ankle are at particular
risk of soft-tissue infection because
of their role in weight bearing and
potential exposure to trauma. More-
over, they are frequently affected by
impaired perfusion or sensation as-
sociated with systemic conditions.
These factors must be taken into ac-
count when treating patients with
soft-tissue infections of the lower ex-
tremity as opposed to similar infec-
tions in other anatomic locations.
In a population-based, epidemio-
logic study, cellulitis of the lower ex-
tremity was found to be a common
clinical entity, with an incidence of
199 per 100,000 person-years, in-
creasing incidence with age, and an
equal sex distribution.14 Approxi-
mately 21.6% of the cases resulted in
hospitalization.14 Cellulitis is most
often the result of breaches in skin
integrity combined with risk factors
such as obesity, venous insufficiency,
or lymphatic disruption from prior
surgery.15 Physical manifestions in-
clude rapidly spreading areas of
edema, redness, and warmth, often
accompanied by lymphangitis and
regional lymphadenopathy. Systemic
toxicity is typically absent, and ex-
tensive evaluation with blood culture
or skin biopsy is only necessary in
patients with unusual risk factors or
predisposing conditions.
First-line therapy is medical, and
initial antimicrobial agents should
include coverage of streptococci and
staphylococci in the setting of
trauma. Suitable agents include di-
cloxacillin, cephalexin, or erythro-
mycin; local resistance patterns
should be taken into account when
selecting an agent. If methicillin-
resistant S aureus is suspected, then
use of clindamycin, trimethoprim-
sulfamethoxazole, vancomycin, dap-
tomycin, or linezolid may be re-
quired.15 In the absence of a discrete
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
fluctuant collection, surgical débride-
ment typically is not indicated.
Although less common than celluli-
tis, necrotizing infections of the
lower extremity can result in limb
loss or death, and a high level of
clinical suspicion must be main-
tained to facilitate prompt diagnosis
and management. Two thirds of nec-
rotizing infections present in the
lower extremity,15 and this must be
considered in the differential diagno-
sis in patients with unexplained limb
pain, especially in those with com-
promised immune systems. Diabetes
is the most common comorbidity
identified, and a heightened level of
suspicion should be maintained
when evaluating these patients.16,17
Once a patient exhibits signs of sys-
temic toxicity such as hypotension
and organ failure, mortality ap-
proaches 50% to 70%.15
Necrotizing infections may extend
from an initial skin lesion and subse-
quently spread along fascial planes
and muscle compartments, or they
may occur insidiously in the absence
of trauma. These infections are most
often polymicrobial, but causative
agents frequently include Streptococ-
cus pyogenes, S aureus, and anaero-
bic streptococci.15 Necrotizing infec-
tion must be suspected in the setting
of severe, constant pain dispropor-
tionate to examination, bullae, skin
necrosis, cutaneous anesthesia, or
subcutaneous tissues with a wooden-
hard feel. Infection may spread rap-
idly even after initiation of antibiotic
therapy. Systemic toxicity is fre-
quently observed, as manifested by
fever, leukocytosis, delirium, and re-
nal failure. Gas in the soft tissues
may be detected by crepitus, palpa-
tion, or imaging; however, this is not
pathognomonic. Early surgical dé-
bridement of skin, subcutaneous fat,
and fascia is the mainstay of treat-
ment of necrotizing fasciitis. Repeat
débridement may be required every
24 to 36 hours until there is no resid-
Oke A. Anakwenze, MD, et al
ual evidence of infection. Early surgi-
cal intervention is of paramount im-
portance; however, one study found
no difference in mortality rate in pa-
tients treated with amputation com-
pared with those treated with wide
débridement.16
Similiarly, the role of hyperbaric
oxygen (HBO) therapy, which theo-
retically increases tissue oxygen ten-
sion, has not been fully elucidated in
this patient cohort; most studies are
anectodal or retrospective and dem-
onstrate conflicting results. In a
small retrospective study, Riseman
et al18 reported decreased mortality
in a group of patients with necrotiz-
ing fasciitis treated with débride-
ment, antibiotics, and HBO therapy
compared with those treated with
débridement and antibiotics alone.
Larger prospective studies are
needed to fully define the role of
HBO therapy for management of
necrotizing fasciitis. However, we be-
lieve that this therapy should be con-
sidered as an adjunctive option and
should not be used in place of sur-
gery.
Diabetic Foot Infections
More than 18 million Americans
(6%) have diabetes, with nearly 30%
as yet undiagnosed.19 In patients
with diabetes aged >40 years, nearly
30% have impaired sensation in the
feet.2 As a result, 10% to 15% of di-
abetic patients will develop a foot in-
fection during their lifetimes.20 Foot
ulceration in the diabetic population
is the most significant risk factor for
subsequent amputation.21 Significant
risk factors for ulceration include
neuropathy, ischemia, and micro-
trauma. The neuropathic foot is
characterized by the lack of protec-
tive sensation and autonomic dysreg-
ulation, leading to dry skin. The foot
acquires the characteristic “rocker
bottom” deformity caused by degen-
16
Foot & Ankle Oke A. Anakwenze, MD, et al

Table 2
Clinical Classification of Diabetic Foot Infections
Manifestation Infection Severitya PEDIS Grade28

Wound lacking purulence or any manifestations of inflammation (ery- Uninfected 1

thema, pain, tenderness, warmth, or induration)
Presence of ≥2 manifestations of inflammation, cellulitis/erythema ex- Mild 2
tending ≤2 cm around the ulcer, with infection limited to the skin or su-
perficial subcutaneous tissues. No other local complications or sys-
temic illness.
Infection (as above) in a patient who is systemically well and metaboli- Moderate 3
cally stable but which has ≥1 of the following characteristics: cellulitis
extending 2 cm, lymphangitic streaking, spread beneath the superficial
fascia, deep-tissue abscess, gangrene, and involvement of muscle,
tendon, joint, or bone
Infection in a patient with systemic toxicity or metabolic instability (eg, Severe 4
fever, chills, tachycardia, hypotension, confusion, vomiting, leukocyto-
sis, acidosis, severe hyperglycemia, or azotemia)

PEDIS = perfusion, extent/size, depth/tissue loss, infection, and sensation

a
Foot ischemia may increase the severity of any infection, and the presence of critical ischemia often makes the infection severe.
Adapted with permission from Lipsky BA, Berendt AR, Deery HG, et al: Diagnosis and treatment of diabetic foot infections. Clin Infect Dis
2004;39(7):885-910.

eration and collapse of the normal
midfoot arch, resulting in limited
mobility. In addition, atrophy of the
intrinsic muscles of the foot allows
the stronger flexor muscles to draw
the toes up in a clawed position, cre-
ating new or increased points of
pressure at the tips of toes and meta-
tarsal heads. This atrophy, combined
with ischemia that is commonly sec-
ondary to atherosclerosis of the tibial
and peroneal arteries, is the main
causative factor that leads to ulcer
development.22,23 Once an ulcer is
present, poor nutritional status (al-
bumin level <3.5 g/dL) portends an
unfavorable prognosis for wound
healing.24
Infection is not necessarily present
or a prerequisite for development of
these ulcers. Approximately 10% to
20% of patients with diabetic foot
ulcers develop osteomyelitis.25 Estab-
lishing the presence of concomitant
infection is essential. In a meta-
analysis of studies of diabetic pa-
tients with osteomyelitis of the lower
extremity, the authors found that the
following factors aided in diagnosis
and were predictive of infection:
presence of an ulcer measuring >2
cm2; positive probe to bone test in
which a probe is used to check the
depth of an ulcer (considered posi-
tive when the ulcer is deep enough
that the probe touches bone); ESR
>70 mm/h; and abnormal findings
on radiography such as periosteal
thickening or sclerosis, osteolysis,
cortical irregularity, or abnormal tra-
becular architecture.26 In addition, a
thorough and careful vascular exam-
ination must be performed. At mini-
mum, this should include documen-
tation of dorsalis pedis and tibialis
artery pulses, with Doppler ultra-
sound and ABI assessment as needed.
Further imaging, including CT an-
giography and magnetic resonance
angiography, may be of benefit in
terms of preoperative planning and
does not have the risks inherent in
invasive angiography.
The Infectious Diseases Society of
America and the International Work-
ing Group for the Diabetic Foot have
suggested and validated a classifica-
tion and grading system whereby
such infections may be labeled mild,
moderate, or severe based on clinical
findings and the patient’s systemic
health status20,27 (Table 2). The Wag-
ner classification can aid the physi-
cian in classifying patients into dif-
ferent treatment groups; diabetic
ulcers are graded based on depth and
the presence of osteomyelitis or gan-
grene29 (Table 3).
Therapeutic management of dia-
betic foot ulcers and infections must
thoroughly address all of the relevant
causative factors. Although ulcer-
ation often precedes and coexists
with infection, the two are by no
means inextricably linked. In the ab-
sence of the clinical stigmata of in-
fection, there is no evidence to sup-
port routine antibiotic use as an
adjunct to ulcer healing.27 Whenever
possible, clean biopsy and culture
should be obtained to determine the
appropriate organism-specific ther-
apy. For ulcers with gross evidence
of infection, the initial empiric regi-
men must take into account the se-
verity of infection and likely etiologic
agents. Empiric broad-spectrum anti-
biotic therapy should be reserved for
severe infections and should be nar-
rowed based on culture results and

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 17

Foot & Ankle Oke A. Anakwenze, MD, et al

Table 3
Wagner Classification of Diabetic Ulcers and the Authors’ Preferred Treatment
Grade Description Treatment

0 Skin intact but bony deformities lead Total contact casting

to “foot at risk”
1 Localized superficial ulcer
2 Ulcer deep to tendon, bone, ligament,
or joint
3 Deep abscess or osteomyelitis
4 Gangrene of toes or forefoot
5 Gangrene of entire foot
Total contact casting ± irrigation and débridement
Irrigation, débridement, and biopsy
Correction of deforming plantar pressure-creating forces as needed (eg,
Achilles tendon lengthening, shoe modification)
Culture-specific antibiotic
Total contact casting
Irrigation, débridement, and biopsy as needed
Correction of deforming forces
Culture-specific antibiotic
Total contact casting
For significant skin defects: Free flap with plastic surgery consultation
when possible
Partial calcanectomy if heel defect is not salvageable
Amputation when all other options have failed
Low-level, safe local amputation
Amputation

antibiotic susceptibility data.
For plantar ulcerations in direct
weight-bearing areas, force patterns
must be altered sufficiently to allow
recovery of the soft-tissue envelope.
Total contact casting with continued
intermittent débridements and cast
changes every 2 to 4 weeks is an ef-
fective initial approach.30 Reusable
pneumatic orthoses may be used in
cases that require more frequent
wound checks; however, this conve-
nience must be weighed against the
increased risk of patient noncompli-
ance. Rocker-sole shoes can be used
to offload weight from the forefoot;
compared with other shoe therapeu-
tic modifications, these shoes have
been shown to significantly reduce
forefoot pressure.31
In patients with impaired vascular-
ization, restoration of arterial blood
flow is essential to promote wound
healing and relieve pain. For occlu-
sive disease distal to the knee, the
historic standard of care has been
distal tibial or pedal grafting. In ap-
propriate candidates, open revascu-
larization leads to superior long-term
patency and clinical durability.22 In
patients with extensive medical co-
morbidities or in those who lack
suitable vein graft or distal outflow
vessels, percutaneous transluminal
angioplasty with or without stenting
can be employed.32 Rates of
amputation-free survival are similar
to those of open procedures, and
length and cost of hospitalization are
both decreased in the short-term.33
However, these benefits must be
weighed against the increased risk of
restenosis and contrast nephrotoxic-
ity.
Surgical intervention is indicated
for deep sequestered purulent collec-
tions, extensive bone or joint in-
volvement, or soft-tissue necrosis.27
Correction of deformities or bony
prominences is essential to the long-
term prevention of ulcer recurrence
caused by alterations in local pres-
sure patterns.34 Achilles tendon
lengthening is an effective way to re-
lieve pressure along the metatarsal
heads, thereby preventing or effec-
tively treating ulcers in patients with
significant pressure along the fore-
foot secondary to deformity and in
those who have failed nonsurgical
therapy. In a study of 10 diabetic pa-
tients with forefoot plantar ulcer-
ation treated with percutaneous
Achilles tendon lengthening, Arm-
strong et al35 noted a significant re-
duction in forefoot dynamic pressure
along the plantar surface and signifi-
cantly increased dorsiflexion on gait
analysis.
Management of heel ulcers can be
challenging given the difficulty of at-
taining adequate soft-tissue coverage
even after eradication of infection.
Therefore, many patients with heel
ulcers undergo below-knee amputa-
tion. Sural fasciomusculocutaneous
free flaps have been used to provide
wound coverage, and promising re-
sults have been reported in a small
case series.36 However, this approach
requires an adequate hospital facility,
an experienced microvascular sur-
geon, and patency of collateral ves-
sels for flap circulation and may lead
to significant donor site morbidity.
Alternatively, a partial calcanectomy
can be used and may preclude the
need for below-knee amputation. In
a study of 12 patients with calcaneal
ulcers treated with partial calcanec-

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 18

Foot & Ankle
tomy, Smith et al37 reported that ul-
cers healed in 10 patients and that all
patients had reasonable healing po-
tential based on albumin (>3 g/dL),
ABI (>0.45), lymphocyte count
(>1,500), and transcutaneous oxygen
pressure (>28 mm Hg). Our pre-
ferred treatment for diabetic ulcers is
based on the Wagner classification
(Table 3).
Deep Infections
Osteomyelitis can occur in the pres-
ence or absence of skin ulceration.
MRI has proved to be superior to
other imaging modalities for detec-
tion of foot osteomyelitis.27 MRI
may demonstrate signal changes
within the bone and deep or superfi-
cial tissue. In addition, purulent col-
lections, soft-tissue edema, and syno-
vial enhancement can also be
appreciated by signal changes in af-
fected areas. However, in the setting
of Charcot arthropathy, MRI speci-
ficity is approximately 80%. In the
setting of equivocal MRI findings,
an In-111–labeled leukocyte scan
should be performed. A high-
intensity signal represents pooling of
leukocytes in the affected region;
normal signal intensity represents the
absence of elevated leukocyte levels
in both osteomyelitis and Charcot ar-
thropathy.38
Patients with osteomyelitis typi-
cally require a long course of tar-
geted antibiotic therapy for complete
eradication or suppression of infec-
tion. Due to the compounding of
toxicity over the course of treatment,
tailoring the antibiotic regimen to
the causative organism is essential
(Table 4). Even when extensive surgi-
cal intervention is not required, bone
biopsy may be indicated because
bone culture sensitivity is predictive
of successful nonsurgical treatment.
In a retrospective multicenter study
of diabetic patients with osteomyeli-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
tis treated nonsurgically, Senneville
et al39 found that bone culture–spe-
cific antibiotic therapy (as opposed
to soft-tissue swap culture) was the
only factor predictive of successful
treatment.
Indications for surgical interven-
tion in patients with osteomyelitis of
the lower extremity are largely de-
pendent on etiology. Early aggressive
débridement is necessary for man-
agement of penetrating traumatic in-
juries or open wounds, whereas early
débridement in the setting of chronic
disease and systemic illness is contro-
versial because acceptable results
have been reported with nonsurgical
therapy alone.25,40 In patients with
compromised bone structure or sta-
bility and progressive deformity, ex-
ternal fixation may be used to stabi-
lize the foot while allowing ongoing
treatment of infection. Débridement
with arthrodesis and external fixa-
tion following drainage of acute in-
fection may provide an alternative to
amputation. In a series of 45 patients
with Charcot arthropathy and osteo-
myelitis treated with débridement,
fusion, and external fixation, the au-
thors reported successful fusion in 39
patients at a mean follow-up of 25.7
weeks.41 In patients with large soft-
tissue defects, local or free tissue
transfer (eg, vascularized soft tissue
flaps, autogenous bone grafts, vascu-
larized bone grafts) may be used to
restore the integrity of the soft-tissue
envelope.42 When infection is associ-
ated with life-threatening systemic
symptoms or occurs in a low-
demand patient with little prospect
of rehabilitation, amputation may be
the sole remaining surgical option.
Amputation must include as much of
the diseased tissue as possible while
attempting to preserve enough resid-
ual limb for function recovery, ade-
quate wound healing, rehabilitation,
and accommodation of the prosthe-
sis.
Adequate literature is lacking to
Oke A. Anakwenze, MD, et al
guide treatment of ankle infection in
patients with ipsilateral hip or knee
prosthesis. This cohort of patients re-
quires aggressive treatment aimed at
eradicating infection before it
spreads to the implant. In these pa-
tients, we recommend treatment sim-
ilar to that for other types of remote
infection, with the knowledge that
infections of the foot and ankle may
be more challenging to clear. Thor-
ough examination of the joint with
the implant is necessary to assess for
any change in appearance (eg, swell-
ing, drainage, warmth, erythema),
range of motion, or pain with mo-
tion. The patient should be asked
about any increased discomfort
about the affected joint. If there is
suspicion for a seeded joint based on
clinical examination findings, his-
tory, and elevated ESR and CRP
level, we recommend joint aspiration
to assess cell count (normal, <1,100
cell/mL, <64% neutrophils), Gram
stain and culture, and crystal analy-
sis.43 Positive results are indicative of
a hematogenous infection, and treat-
ment is based on duration of symp-
toms. Specific management options
are beyond the scope of this review.
In patients with hematogenous
periprosthetic infections associated
with foot or ankle infections, we rec-
ommend treatment based on the
American Academy of Orthopaedic
Surgeons clinical practice guide-
lines.44
Septic Arthritis
The incidence of septic arthritis, or
infection within the joint, ranges
from approximately 2 to 10 per
100,000 persons.45 Approximately
3% to 7% of septic arthritis cases in-
volve the foot and ankle.46,47 Septic
arthritis may arise from local inocu-
lation or hematogenous spread, with
the latter being more common in
children with open epiphyses than in
19
Foot & Ankle Oke A. Anakwenze, MD, et al

Table 4
Antibiotic Therapy for Management of Foot Infections
Antibiotic Route Suggested Dose Coverage Notes

Cephalexin Oral 500 mg every 6 h Staphylococcus, Strepto- Low serum levels

coccus, Gram-negative
bacteria
Amoxicillin-clavulanate Oral 500 mg every 6 h Staphylococcus, Strepto- Broad spectrum, potential
coccus, Gram-negative for diarrhea
bacteria, anaerobes
Clindamycin Oral 300 mg every 8 h Staphylococcus, Strepto- High osseous penetra-
coccus, anaerobes tion, potential for diar-
rhea
Ciprofloxacin Oral 750 mg every 12 h Gram-negative bacteria, Not effective for Gram-
Pseudomonas positive bacteria or an-
aerobes
Levofloxacin Oral 500 mg every 12 h Streptococcus, Gram- Not effective for anaer-
negative bacteria obes
Metronidazole Oral 500 mg every 8 h Gram-negative bacteria, High osseous penetra-
anaerobes tion, metallic taste
Trimethoprim- Oral 800/160 mg every 12 h Gram-negative bacteria Potential MRSA coverage
sulfamethoxazole dependent on local re-
sistance patterns
Cefazolin Intravenous 1 g every 8 h Staphylococcus, Strepto- Not effective for MRSA,
coccus, Gram-negative many Gram-negative
bacteria bacteria now resistant
Nafcillin Intravenous 2 g every 6 h Staphylococcus, Strepto- Not effective for MRSA
coccus
Ampicillin-sulbactam Intravenous 3 g every 8 h Staphylococcus, Strepto- Not effective for MRSA
coccus, Gram-negative
bacteria, anaerobes
Piperacillin-tazobactam Intravenous 3.375 g every 8 h Streptococcus, Gram- Effective for resistant
negative bacteria, Gram-negative bacteria
Pseudomonas
Vancomycin Intravenous 1 g every 12 h Staphylococcus, Strepto- MSRA coverage; nephro-
coccus toxic—must dose by
level
Levofloxacin Intravenous 500 mg every 12 h Streptococcus, Gram- Not effective for anaer-
negative bacteria obes, questionable ef-
fectiveness for Staphy-
lococcus species
Aztreonam Intravenous 1 g every 8 h Gram-negative bacteria Appropriate for patients
with penicillin and ceph-
alosporin allergies

MRSA = methicillin-resistant Staphylococcus aureus

adults. The tibiotalar and first meta-
tarsophalangeal joints are most often
affected, presumably because of their
capacious size in comparison with
other joints of the foot and ankle. S
aureus is the most commonly iso-
lated causative organism.48
Adjacent osteomyelitis is increas-
ingly of concern in the setting of co-
morbidities such as diabetes mellitus
or intravenous drug abuse.48 Patients
commonly present with acutely swol-
len, warm, erythematous joints, in-
ability to bear weight, and severe
pain with micromotion. Plain radi-
ography is typically nonspecific but
may reveal joint effusion. Holtom
et al48 reviewed 30 patients with sep-
sis about the ankle joint and noted
that the ESR and CRP level was ele-
vated in all patients, with a mean
ESR of 82 mm/h and CRP level of
16.9 mg/dL reported. These findings
suggest that these nonspecific mark-
ers can be used to rule out ankle in-
fection. In contrast, the peripheral
WBC count was found to be neither
sensitive nor specific enough to be
relied on for diagnosis of an acute
septic joint.48 MRI was found to be

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 20

Foot & Ankle
Figure 1
Algorithm for management of foot and ankle infections.
more effective than radiography for
diagnosis of sepsis with and without
concomitant osteomyelitis. In cases
with sufficient clinical suspicion for
septic arthritis, joint aspiration is the
diagnostic tool of choice. WBC dif-
ferential counts between 50,000 and
100,000 and a neutrophil shift
>75% are commonly used as a cutoff
for infections as opposed to inflam-
matory conditions, which may pre-
sent with lower values; however, in
cases that are concerning for ankle
sepsis, one must be aware of inter-
laboratory variability in the assess-
ment of synovial fluid, whereby the
same synovial fluid may yield differ-
ent values when assayed at different
laboratories.49 Gram stain and cul-
ture can aid in narrowing the differ-
ential count, with the culture being
more sensitive (75% to 95%) and
specific (>90%) for infection.50
Surgical arthrotomy with irrigation
and débridement is the mainstay of
treatment for acute bacterial septic
arthritis to prevent articular damage
and hematogenous spread. This pro-
cedure can be performed with ar-
throscopic or open techniques based
on the clinical scenario and surgeon
preference. In the patient who is not
yet medically stable, serial aspiration
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Oke A. Anakwenze, MD, et al
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847-850.
19. Kruzikas DT, Jiang HJ, Remus D, Bar-
rett ML, Coffey RM, Andrews R: Pre-
ventable Hospitalizations: A Window
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Rockville, MD, Agency for Healthcare
Research and Quality, 2000.
20. Lavery LA, Armstrong DG, Murdoch
DP, Peters EJ, Lipsky BA: Validation of
the Infectious Diseases Society of Ameri-
ca’s diabetic foot infection classification
system. Clin Infect Dis 2007;44(4):562-
565.
21. Rosenbloom AL, Silverstein JH, Lezotte
DC, Richardson K, McCallum M: Lim-
ited joint mobility in childhood diabetes
mellitus indicates increased risk for mi-
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305(4):191-194.
22. Kalish J, Hamdan A: Management of
diabetic foot problems. J Vasc Surg
2010;51(2):476-486.
23. Duckworth T, Boulton AJ, Betts RP,
Franks CI, Ward JD: Plantar pressure
measurements and the prevention of ul-
ceration in the diabetic foot. J Bone Joint
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Surg Br 1985;67(1):79-85.
24. Pinzur M, Kaminsky M, Sage R, Cronin
R, Osterman H: Amputations at the mid-
dle level of the foot: A retrospective and
prospective review. J Bone Joint Surg Am
1986;68(7):1061-1064.
25. Game F: Management of osteomyelitis of
the foot in diabetes mellitus. Nat Rev
Endocrinol 2010;6(1):43-47.
26. Butalia S, Palda VA, Sargeant RJ, Detsky
AS, Mourad O: Does this patient with
diabetes have osteomyelitis of the lower
extremity? JAMA 2008;299(7):806-813.
27. Lipsky BA, Berendt AR, Deery HG, et al:
Diagnosis and treatment of diabetic foot
infections. Clin Infect Dis 2004;39(7):
885-910.
28. International Working Group on the
Diabetic Foot: International Consensus
on the Diabetic Foot [CD-ROM].
Brussels, Belgium, International Diabetes
Foundation, 2003.
29. Wagner FW Jr: The dysvascular foot: A
system for diagnosis and treatment. Foot
Ankle 1981;2(2):64-122.
30. Tyrrell W: Orthotic intervention in pa-
tients with diabetic foot ulceration.
J Wound Care 1999;8(10):530-532.
31. Brown D, Wertsch JJ, Harris GF, Klein J,
Janisse D: Effect of rocker soles on plan-
tar pressures. Arch Phys Med Rehabil
2004;85(1):81-86.
32. Commeau P: Endovascular procedures
for below the knee arteries in diabetics.
Ann Cardiol Angeiol (Paris) 2008;57(6):
352-358.
33. Adam DJ, Beard JD, Cleveland T, et al:
Bypass versus angioplasty in severe
ischaemia of the leg (BASIL): Multi-
centre, randomised controlled trial.
Lancet 2005;366(9501):1925-1934.
34. Mueller MJ, Hastings M, Commean PK,
et al: Forefoot structural predictors of
plantar pressures during walking in peo-
ple with diabetes and peripheral neurop-
athy. J Biomech 2003;36(7):1009-1017.
35. Armstrong DG, Stacpoole-Shea S,
Nguyen H, Harkless LB: Lengthening of
the Achilles tendon in diabetic patients
who are at high risk for ulceration of the
foot. J Bone Joint Surg Am 1999;81(4):
535-538.
36. Chen SL, Chen TM, Chou TD, Chang
SC, Wang HJ: Distally based sural fas-
ciomusculocutaneous flap for chronic
calcaneal osteomyelitis in diabetic pa-
tients. Ann Plast Surg 2005;54(1):44-48.
37. Smith DG, Stuck RM, Ketner L, Sage
RM, Pinzur MS: Partial calcanectomy
for the treatment of large ulcerations of
the heel and calcaneal osteomyelitis: An
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J Bone Joint Surg Am 1992;74(4):571-
576.
Oke A. Anakwenze, MD, et al
38. Marcus CD, Ladam-Marcus VJ, Leone J,
Malgrange D, Bonnet-Gausserand FM,
Menanteau BP: MR imaging of osteomy-
elitis and neuropathic osteoarthropathy
in the feet of diabetics. Radiographics
1996;16(6):1337-1348.
39. Senneville E, Lombart A, Beltrand E,
et al: Outcome of diabetic foot osteomy-
elitis treated nonsurgically: A retrospec-
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31(4):637-642.
40. Berendt AR, Peters EJ, Bakker K, et al:
Diabetic foot osteomyelitis: A progress
report on diagnosis and a systematic re-
view of treatment. Diabetes Metab Res
Rev 2008;24(suppl 1):S145-S161.
41. Dalla Paola L, Brocco E, Ceccacci T,
et al: Limb salvage in Charcot foot and
ankle osteomyelitis: Combined use single
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external fixation. Foot Ankle Int 2009;
30(11):1065-1070.
42. Bishop AT, Wood MB, Sheetz KK: Ar-
throdesis of the ankle with a free vascu-
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struction of segmental loss of bone
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trauma. J Bone Joint Surg Am 1995;
77(12):1867-1875.
43. Ghanem E, Parvizi J, Burnett RS, et al:
Cell count and differential of aspirated
fluid in the diagnosis of infection at the
site of total knee arthroplasty. J Bone
Joint Surg Am 2008;90(8):1637-1643.
44. Parvizi J, Della Valle CJ: AAOS Clinical
Practice Guideline: Diagnosis and treat-
ment of periprosthetic joint infections of
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Surg 2010;18(12):771-772.
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Krijnen P, Habbema JD, van de Laar
MA: Risk factors for septic arthritis in
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Gächter A: Arthroscopic management of
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50. Swan A, Amer H, Dieppe P: The value of
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22
 Review Article

Foot Compartment Syndrome:

Diagnosis and Management

Abstract
Andrew Dodd, MD Although uncommon, foot compartment syndrome (FCS) is a
Ian Le, MD, FRCSC distinct clinical entity that typically results from high-energy
fractures and crush injuries. In the literature, the reported number
of anatomic compartments in the foot has ranged from 3 to 10, and
the clinical relevance of these compartments has recently been
investigated. Diagnosis of FCS can be challenging because the
signs and symptoms are less reliable indicators than those of
compartment syndrome in other areas of the body. This may lead
to a delay in diagnosis. The role of fasciotomy in management of
FCS has been debated, but no high-level evidence exists to guide
decision making. Nevertheless, emergent fasciotomy is commonly
recommended with the goal of preventing chronic pain and
deformity. Surgical intervention may also be necessary for the
correction of secondary deformity.

F oot compartment syndrome

From the Section of Orthopaedic
Surgery, University of Calgary,
Calgary, Alberta, Canada.
Neither of the following authors nor
any immediate family member has
received anything of value from or
has stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Dodd and
Dr. Le.
J Am Acad Orthop Surg 2013;21:
657-664
http://dx.doi.org/10.5435/
JAAOS-21-11-657
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
(FCS) is relatively uncommon.1,2
Although isolated foot injuries result
in FCS in only 2% of cases,3 ortho-
paedic surgeons must remain aware
of this clinical entity because it can
result in negative sequelae. FCS ac-
counts for <5% of limb compart-
ment syndrome cases.4
Typically, FCS is the result of high-
energy injuries to the foot such as
crush injuries, Lisfranc fracture-
dislocations, midfoot and forefoot
trauma, and calcaneal fractures.2,3,5-14
FCS can also develop after a tibial
fracture secondary to the communi-
cation between the deep posterior
compartment of the leg and the cal-
caneal compartment of the foot.7
The most commonly cited etiology is
a high-energy fracture of the calca-
neus, which results in FCS in up to
10% of cases.3,10,12,15 However, data
from a study by Thakur et al3 sug-
gest that this patient population may
be undertreated because only 1% of
patients with isolated calcaneal frac-
tures and suspected FCS underwent a
fasciotomy.
Stiffness, chronic disability, defor-
mity, and pain are some of the com-
plications associated with untreated
FCS2,4-8,10-13,15,16 (Table 1). Necrosis of
the intrinsic muscles of the foot can
lead to ischemic contractures that
may result in claw toe, hammer toe,
and pes cavus. Neurovascular injury
can also cause chronic pain and an
insensate foot with secondary neuro-
pathic pathology (eg, chronic ulcer-
ation, joint destruction).2,5-8,10,12,13,15
Pathophysiology
Compartment syndrome is caused by
increasing pressure secondary to
hemorrhage or edema within an ana-
tomic compartment bound by inelas-
tic fibrous tissue. Pressures rise until
capillary perfusion pressure is ex-
ceeded, resulting in ischemia, soft-

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 23

Foot & Ankle
Table 1
Potential Complications
Associated With Untreated Foot
Compartment Syndrome
Chronic pain
Insensate foot
Foot and ankle stiffness
Claw toe deformity
Hammer toe deformity
Cavus foot deformity
Neuropathic pain
Neuropathic ulceration
tissue compromise, and subsequent
necrosis followed by fibrosis and
contracture of the compartment’s
contents.2,4
Claw toe is the most common se-
quela of FCS and develops when the
extrinsic musculature overpowers
the weak or scarred intrinsic foot
muscles, whereas cavus deformity is
the result of scarred and contracted
plantar structures.2 In the setting of
intra-articular calcaneal fracture,
claw toe develops after the fracture
hematoma in the deep central com-
partment of the foot raises pressures
and compresses the medial and lat-
eral plantar neurovascular bun-
dles.12,15 This results in ischemic in-
sult to the interosseous muscles and
quadratus plantae muscle, which de-
rive their blood supply from the me-
dial and lateral plantar arteries.
Acute compartment syndrome can
also cause ischemic neuropathy and
chronic neuropathic pain.17 Periph-
eral nerves may undergo irreversible
damage after 4 to 6 hours of isch-
emia.17 Symptoms of neuropathic
pain include numbness, spontaneous
pain, allodynia, and hyperalgesia.18
Neuropathic pain is associated with
poor general health and a decrease in
many quality of life measurements.19
Management of neuropathic pain is
difficult and the outcomes are gener-
ally poor. Multimodal drug therapy
is often necessary.20 Frink et al21 re-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Andrew Dodd, MD, and Ian Le, MD, FRCSC
ported high rates of sensory distur-
bance and pain at rest in patients
treated for lower limb compartment
syndrome. To our knowledge, no
studies have examined the prevalence
or natural history of neuropathic
pain in the setting of acute FCS.
Anatomy
Understanding of the myofascial
compartments of the foot continues
to evolve. Early reports identified
four fascial compartments: medial,
lateral, central, and interosseous.22-24
Myerson25 described methods for
surgical decompression of these com-
partments.
Manoli and Weber26 performed in-
fusion studies and reported that the
foot could be divided into nine ana-
tomic compartments, with the cen-
tral compartment divided into super-
ficial central and deep central (or
calcaneal) compartments. They also
increased the number of interosseous
compartments from one to four, add-
ing a compartment for the adductor
hallucis muscle. New decompression
techniques using multiple incisions
were recommended based on the in-
creased number of compartments.26
Guyton et al27 questioned the va-
lidity of previous gelatin infusion
studies in defining anatomic com-
partments and accurately measuring
them without image guidance. The
authors performed infusion studies
using CT guidance with simultane-
ous compartment pressure monitor-
ing, focusing on the distinction be-
tween the superficial and deep
central compartments. They demon-
strated active fluid communication
between the two compartments as
pressures rose above 10 mm Hg. In
addition, they commented on the dif-
ficulty of inserting an infusion needle
into the superficial central compart-
ment even with CT guidance.
Reach et al28 further investigated
the anatomic compartments of the
foot using high-resolution MRI. The
authors found a 10th compartment
in addition to the 9 compartments
described by Manoli and Weber.26
The 10th compartment is bounded
by the skin and contains the extensor
digitorum brevis and the extensor
hallucis brevis in a newly described
dorsal compartment.
In a cadaver study of the myofas-
cial compartments of the foot, Ling
and Kumar8 dissected 13 feet and
found three vertical fibrous septae in
the hindfoot that, along with the
plantar aponeurosis, form the com-
partments of the foot (Figure 1).
These results were substantially dif-
ferent from those of prior studies.
The septae bound compartments
identified as medial, intermediate,
and lateral. Skin and subcutaneous
tissue compose the medial border of
the medial compartment. As such,
only the intermediate and lateral
compartments are rigidly bound by
fascia on all sides. The authors found
no evidence of a thick fascial layer
between the previously described su-
perficial central and deep central
(calcaneal) compartments, finding
only a thin and often incomplete
filmy layer of tissue instead. They
concluded that the intermediate and
lateral compartments are the only
compartments that need surgical de-
compression and recommended a
single plantar-based surgical ap-
proach to do so. These findings con-
flict with those of Stotts et al29 who
reported on an isolated medial com-
partment syndrome in the foot that
required surgical decompression,
which suggests that the medial com-
partment is capable of developing
pressures sufficient to warrant de-
compression.
Ling and Kumar8 attempted to
qualify the clinical importance of the
foot compartments with regard to
surgical decompression and con-
cluded that only two rigidly bound
24
Foot & Ankle Andrew Dodd, MD, and Ian Le, MD, FRCSC

Figure 1 tense swelling. Other authors agree

that although the presence of tense
swelling is not necessarily diagnostic,
it is suggestive of FCS.11-13,31 Substan-
tial pain with passive dorsiflexion of
the toes is a common physical find-
ing, but it may be present in the ab-
sence of compartment syn-
drome.1,2,11,13,30 Passive dorsiflexion
of the toes decreases the volume of
the interosseous compartments,
which exacerbates pain.2 Sensory
changes can be nonspecific, with the
most sensitive findings being de-
creased two-point discrimination
and decreased light touch on the
plantar aspect of the foot and toes.
Decreased pin-prick sensation is a
less sensitive finding.1,2,11,13,30,31 Motor
strength and the presence or absence
of palpable pulses are poor indica-
Illustration demonstrating the anatomic structures of the foot, including the tors of a developing compartment
three vertical septae (medial, intermediate, and lateral) that form the two syndrome.2 Serial examinations are
major compartments of the foot described by Ling and Kumar.8 (Reproduced helpful to observe changes in pain
with permission from Ling ZX, Kumar VP: The myofascial compartments of patterns and sensory findings.2
the foot: A cadaver study. J Bone Joint Surg Br 2008;90[8]:1114-1118.)

compartments exist, which may sug-
gest that the clinical sequelae of FCS
are a result of injury to the medial
and lateral plantar arteries and
nerves that traverse the newly termed
intermediate compartment. More re-
search is needed to confirm or refute
these conclusions, including prospec-
tive studies comparing the new de-
compression technique described by
the authors with more aggressive re-
leases of all nine compartments of
the foot.
Diagnosis and Physical
Examination
Although diagnosis of FCS is estab-
lished clinically and follows the same
principles as those for diagnosis of
compartment syndrome in other ar-
eas of the body, the signs and symp-
toms of FCS tend to be less reli-
able.1,4 Patients who present with
high-energy fractures and severe
crush injuries to the foot are at risk
of developing FCS and should be
monitored serially.1,2 Open fractures
and wounds do not result in reliable
decompression of myofascial com-
partments and the presence or devel-
opment of compartment syndrome
cannot be ruled out in the setting of
these injuries.1
Pain associated with FCS has been
described as a severe, relentless burn-
ing that encompasses the entire
foot.12 Determining whether the pain
is out of proportion to the injury is
difficult given the severe trauma typi-
cally involved.1 Indications of a de-
veloping FCS include progressive
pain despite immobilization of the
foot and increasing analgesic re-
quirement.1,2,13
In a series of 12 cases of FCS, Fak-
houri and Manoli30 reported that the
most consistent physical finding was
Compartment Pressure
Monitoring
FCS can be difficult to diagnose
based on physical findings; therefore,
most authors agree that compart-
ment pressure monitoring is the most
reliable method for objective diagno-
sis of FCS.1,2,4,5,11-13,30,32 Myerson1 rec-
ommends liberal use of pressure
monitoring because increased pres-
sures often precede clinical signs and
symptoms. Some authors advocate
liberal pressure monitoring for any
foot trauma with significant swell-
ing.1,30 Benefits of pressure monitor-
ing include the ability to monitor the
trend of the compartment pressures
and to document adequate decom-
pression after fasciotomies.1,13
In general, absolute compartment
pressures >30 mm Hg are an indica-
tion for emergent decompres-
sion.1,2,4,12,30,32 This indication is sup-
ported by the findings of Mittlmeier

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 25

Foot & Ankle Andrew Dodd, MD, and Ian Le, MD, FRCSC

Figure 2

Photographs demonstrating the entry points for compartment pressure monitoring of the medial and calcaneal
compartments (A), superficial and deep central compartments (B), and lateral and interosseous compartments (C)
based on the specific needle placement landmarks of Reach et al.33 In panel A, for example, the needle entry point to
the calcaneal compartment is approximately 60 mm distal to the most prominent aspect of the medial malleolus.

et al16 in a study of 17 patients with
calcaneal fractures, 12 of whom had
central compartment pressures >30
mm Hg. Seven of the 12 patients
with pressures >30 mm Hg devel-
oped ischemic contractures, whereas
5 with pressures <30 mm Hg did not
develop contractures. Serial measure-
ments should be performed in pa-
tients with compartment pressures
between 20 and 30 mm Hg.5,32 Sys-
temic hypotension decreases the tol-
erance for increased compartmental
pressures, and pressures within 10 to
30 mm Hg of the diastolic blood
pressure are an indication for decom-
pression.2,12 The calcaneal compart-
ment of the foot consistently demon-
strates the highest pressures;
therefore, this compartment should
always be monitored.2,11,12 Commer-
cially available digital compartment
pressure monitors have been used in
some studies.30,32
Aside from the importance of mea-
suring the pressure of the compart-
ment containing the quadratus plan-
tae muscle, no consensus exists on
measurement of pressures in particu-
lar compartments or the number of
compartments that should be mea-
sured.2,11,12 Myerson1 suggested mea-
suring the central and interosseous
compartments; however this recom-
mendation was based on the four-
compartment model of the foot.
More recently, methods for measure-
ment of 9 or 10 compartments in the
foot have been described.2,4,33 Ling
and Kumar8 suggest that only the in-
termediate and lateral compartments
require pressure monitoring; these
are the only compartments that the
authors recommended decompress-
ing. No evidence currently exists to
substantiate a recommendation on
how many compartments’ pressures
should be measured because a firm
understanding of the number of clin-
ically important compartments in the
foot is lacking. The calcaneal (ie, in-
termediate) compartment has con-
sistently demonstrated the highest
compartment pressure readings;
therefore, it is reasonable to suggest
that an attempt should always be
made to measure this compartment’s
pressure.
Several authors have described
techniques for measuring the pres-
sure of the central compartment.
Myerson and Manoli12 describe a
method that entails entering the skin
perpendicular to the foot at a point
3.8 cm distal to the tip of the medial
malleolus. No specific depth of pene-
tration is given. In a second method,
the entry is made through the skin
just below the base of the first meta-
tarsal, passing above the abductor
hallucis to a depth of 1.5 in.1 In a
high-resolution MRI study of the
compartments of the foot, Reach
et al33 describe specific needle place-
ment landmarks (Figure 2). When
entry to the calcaneal compartment
is required, they recommend a needle
entry point approximately 60 mm
distal to the most prominent aspect
of the medial malleolus, inserted to a
depth of approximately 24 mm.33
The authors describe entry points
and depths for all 10 foot compart-
ments.

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 26

Foot & Ankle
Nonspecific findings on physical
examination contribute to the diffi-
culty in diagnosing FCS. Compart-
ment pressure monitoring should be
considered standard for establishing
a diagnosis of FCS. Increasing pain
and sensory disturbances in a tense,
swollen foot should prompt mea-
surement of compartment pressures.
Acute Management
Initial management of suspected
compartment syndrome entails the
removal of all restrictive dressings,
elevation of the extremity to the level
of the heart, and prevention of sys-
temic hypotension as well as serial
examinations and compartment
pressure monitoring.1,13 If diagnosis
of FCS is established, urgent decom-
pressive fasciotomies should be con-
sidered. Although most authors ad-
vocate the use of acute compartment
releases,1,2,4,5,12,13,25,32 we believe that
this management option remains
controversial. To date, no studies
have compared early decompression
versus delayed management of FCS,
and most recommendations in the
literature are based on level IV and V
evidence. Complication rates associ-
ated with each treatment pathway
are also poorly described in the liter-
ature, making it difficult to compare
outcomes.
Early decompression and fasciot-
omy carries the risk of wound infec-
tion and the potential need for soft-
tissue coverage. Delayed treatment
presumably results in a higher rate of
deformity and the sequelae listed in
Table 1. Chronic pain is a common
result of high-energy foot trauma
and may or may not be related to is-
chemic insult to the peripheral nerves
of the foot. Without high-quality
prospective studies, it is difficult to
determine whether one treatment
pathway is superior to another; thus,
further investigation is necessary.
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Andrew Dodd, MD, and Ian Le, MD, FRCSC
Fasciotomy
When acute FCS is diagnosed, emergent
decompressive fasciotomy should be
performed to prevent ischemic con-
tracture.1,2,4,5,12,13,25,32 In the setting of
lower limb compartment syndrome,
the best clinical results are achieved
when fasciotomy is performed early;
the potential benefits of this proce-
dure decrease the longer the decom-
pression is delayed from the time of
diagnosis.4 The high complication
rate associated with delayed fasciot-
omy has prompted the suggestion
that compartment releases should
not be done if diagnosis is delayed
>8 hours.10,34 However, it is not al-
ways possible to know when the ini-
tial signs and symptoms of compart-
ment syndrome arose.
In a study of 17 patients with
intra-articular calcaneal fractures
and 12 with calcaneal compartment
pressures documented at >30 mm
Hg, Mittlmeier et al16 reported poor
outcomes in patients with FCS
treated without fasciotomy. Seven of
the 12 patients with pressures >30
mm Hg developed symptomatic
plantar contractures, claw toe defor-
mity, or both.
Myerson32 reviewed the results of
14 cases of FCS treated with decom-
pressive fasciotomy. In nine cases,
the releases were performed through
two dorsal incisions; a single medial
incision was used in five. In three
cases, wounds were closed acutely
with split-thickness skin excision
coverage, eight required delayed
split-thickness skin grafting, and
three (all medial) were closed with
delayed primary closure. Only one
case required a free tissue transfer. At
the latest follow-up, four patients
were symptom free and six reported
only occasional discomfort in the
foot. Only one patient developed a
claw toe deformity.
In a review of 12 cases of FCS
treated with fasciotomy, Fakhouri
and Manoli30 reported good results.
Decompression was performed
through a single medial incision in
six cases, medial and double dorsal
incisions in four, and medial plus
dorsal and lateral incisions in two.
Split-thickness skin grafting was nec-
essary in four cases. At an average
follow-up of 21 months, no wound
infections or wound complications
were reported. No ischemic contrac-
tures developed; however, eight pa-
tients had some discomfort and stiff-
ness in the foot.
Currently, the three-incision ap-
proach is most commonly used for
decompressive fasciotomy in the
foot2,4,26 (Figure 3). This recommen-
dation is based on the nine-
compartment model of the foot de-
scribed by Manoli and Weber.26 A
medial incision is made starting 4 cm
anterior to the posterior aspect of the
heel and 3 cm superior to the plantar
surface of the foot. This incision is
carried distally for approximately 6
cm. Through this medial approach,
the medial, superficial and deep cen-
tral, and lateral compartments are
released (Figure 3). Two dorsal inci-
sions are used, one just medial to the
second metatarsal and one just lat-
eral to the fourth metatarsal to en-
sure an adequate skin bridge. The
interosseous and adductor compart-
ments are released through these dor-
sal incisions.2,26
An alternative to the standard
dorsal incisions was described by
Dunbar et al.35 They used a “pie-
crusting” technique in which multi-
ple stab incisions are made over the
intermetatarsal spaces followed by
blunt dissection with a hemostat.
The goal is to reduce the need for
skin grafts, which are often required
with longer incisions on the dorsum
of the foot.
Ling and Kumar8 recommend a
plantar-based, single-incision fasciot-
omy. The incision begins 5 cm distal
27
Foot & Ankle Andrew Dodd, MD, and Ian Le, MD, FRCSC

Figure 3 son32 reported dorsal skin necrosis in

one patient, and one patient required
a free gracilis tissue flap for cover-
age. The medial-based fasciotomy in-
cision places the medial calcaneal
branch of the posterior tibial nerve
at risk of injury; however, the rate of
injury has not been documented.2
For management of acute FCS, we
recommend the use of the three-
incision approach (one medial inci-
sion, two dorsal incisions), with a
full decompression of all nine com-
partments performed. Currently, the
nine-compartment model of the foot
is the most accepted model described
in the literature.26 The “pie-crusting”
technique described by Dunbar
et al35 may provide similar decom-
pression of the dorsal foot compart-
ments with a decreased need for skin
grafting. Additional studies compar-
ing this approach and other ap-
proaches, such as that described by
Ling and Kumar,8 are needed.

Illustration of the feet demonstrating incision sites for a three-incision

fasciotomy. The blue panel indicates the level of the cross-section shown in Delayed Management
the inset image. Inset, Cross-section of the medial, superficial central, deep
central, and lateral compartments. The superior blue arrow indicates the
entrance into the deep central compartment. The inferior blue arrow indicates The natural history of nonsurgically
the entrance into the medial, superficial, central, and lateral compartments managed FCS includes potential de-
(from medial to lateral). (Courtesy of Herman Johal, MD, Calgary, Alberta, velopment of ischemic contractures,
Canada.)
neuropathy, deformity, and chronic
pain.7,36,37 The goal of management is
to the posterior aspect of the heel on split-thickness skin graft coverage 5 to achieve a functional, plantigrade,
the non–weight-bearing instep and to 7 days after the fasciotomy is per- and pain-free foot.7,10 Lesser toe de-
extends 5 cm distally. The authors formed. The medial incision can of- formities, cavus foot deformity, neu-
felt that this single incision could be ten be closed primarily or with de- ropathic pain, and ulceration sec-
used to decompress the intermediate layed primary closure.2,30,32 ondary to deformity and sensory
and lateral compartments, which Complication rates associated with disturbance are common problems
they believe is sufficient to decom- fasciotomy for FCS have been re- that must be addressed.7,10,36,37
press the foot. Data are lacking to ported to be lower than those for un- Claw toe, the most common defor-
support the use of this approach in a treated FCS.5 Nevertheless, a paucity mity associated with FCS, develops
clinical setting. of data exists in the current literature due to intrinsic muscle weakness and
Stabilization or repair of forefoot with regard to complication rates of extrinsic muscle overpull. Interosse-
and midfoot fractures at the time of both acute fasciotomy and untreated ous muscle injury, denervation, and
decompression is recommended to FCS. In their study of 12 cases of ischemic contracture of the quadra-
reduce further soft-tissue trauma. FCS treated with fasciotomy, Fak- tus plantae muscle, which inserts
Definitive management of calcaneal houri and Manoli30 documented no onto the flexor digitorum longus ten-
fractures should be delayed until infections and no wound complica- don, result in hyperextension of the
soft-tissue swelling has receded.2,12,30 tions. In his series of 14 feet with metatarsophalangeal (MTP) joints
Dorsal incisions commonly require FCS treated with fasciotomy, Myer- and flexion of the interphalangeal

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 28

Foot & Ankle
joints. Less commonly, hammer toe
can develop in the setting of ischemic
contracture in the interosseous and
lumbrical muscles.36,37 Cavus defor-
mity is also common, occurring as a
result of fibrosis and contracture of
the plantar intrinsic muscles and soft
tissues.10,36,37 Additional sequelae in-
clude neuropathic changes, neuro-
pathic pain due to ischemic nerve in-
jury, nerve compression symptoms
from fibrosis and contracture, and
insensate areas of the foot with sub-
sequent ulcerations.7,36,37
Management of Sequelae
Associated With FCS
Nonsurgical
Nonsurgical management of complica-
tions associated with FCS is most likely
to be successful in patients with mild,
flexible deformities with no neuropa-
thy or static neuropathic symp-
toms.36,37 Toe deformities and cavus
foot deformity may initially be man-
aged with passive mobilization and
stretching. Shoe wear modification (eg,
deep toe box) is also recommended.
Custom orthotics may be beneficial for
management of cavus foot deformity.
In insensate areas of the foot, appropri-
ate skin care to avoid pressure ulcers is
also important.7,36,37
Surgical
In patients with more advanced de-
formity, progressive neuropathic
symptoms, or failed nonsurgical
treatment, surgical intervention may
be indicated. Soft-tissue procedures,
osteotomies, arthrodesis, and ampu-
tation are options that should be
considered depending on clinical cir-
cumstances. Correction of deformity
and maintenance of the correction
are the goals of surgical interven-
tion.36,37 Progressive neuropathic
symptoms may indicate ongoing
nerve compression in contracted fi-
brotic tissues. Nerve conduction ve-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Andrew Dodd, MD, and Ian Le, MD, FRCSC
locity studies can help distinguish be-
tween ongoing nerve compression
and static ischemic nerve injury. In
cases of nerve compression, neuroly-
sis of the tibial nerve and its distal
branches may be helpful.36,37
Management of claw toe deformity
is based on whether the deformity is
flexible or rigid. Flexible deformities
are passively correctable at the inter-
phalangeal and MTP joints, whereas
rigid deformities are not. Flexible de-
formities can often be managed with
flexor tenotomies and extensor ten-
don lengthening. Flexor-to-extensor
tendon transfer (Girdlestone-Taylor
procedure) also can be used, al-
though we infrequently perform this
procedure. In cases of rigid defor-
mity, which are far more common
than flexible deformities, arthrodesis
is recommended.7,10,36-38 We recom-
mend proximal interphalangeal ar-
throdesis with MTP arthrotomy or
even a metatarsal shortening osteot-
omy, if necessary. This is often sup-
plemented by extensor tendon
lengthening and flexor tenotomies.
Initially, cavus deformity associ-
ated with FCS should be managed
with soft-tissue procedures (eg, plan-
tar fascia release, long flexor tendon
lengthening or release, scar tissue ex-
cision) followed by osteotomies or
selective arthrodesis, if necessary. In
cases of cavus and concomitant claw
toe deformity, extensor digitorum
longus tendon transfer to the meta-
tarsal necks addresses both deformi-
ties. If the correction is inadequate, a
forefoot or midfoot dorsal closing
wedge osteotomy or arthrodesis may
be considered.36 At our institution,
we proceed with soft-tissue balanc-
ing before any bony procedures. If
soft-tissue procedures do not provide
adequate correction, we perform
dorsal closing wedge osteotomy
through the midfoot. In the setting of
degenerative changes, deformity cor-
rection with midfoot or hindfoot ar-
throdesis is most effective.
Amputation can serve as a salvage
option in cases of severe deformity,
pain, and ulceration. Poor vascular
supply may also play a role in the
choice of amputation over recon-
struction.10,36,37 We do not consider
amputation a failure of treatment.
For a functionless, insensate foot
with the sequelae of ulceration and
infection, amputation is an effective
management option.
Summary
FCS is an uncommon diagnosis, ac-
counting for <5% of limb compart-
ment syndromes.4 A high index of sus-
picion for FCS must be maintained in
the setting of a high-energy injury to
the foot (eg, severe crush injury). Phys-
ical examination findings may be un-
reliable for diagnosis; therefore, com-
partment pressure monitoring is
essential. Controversy exists regarding
acute versus delayed management of
FCS, and further research on the out-
comes of acute fasciotomy versus de-
layed management is necessary. Acute
management, if chosen, typically con-
sists of emergent decompressive fas-
ciotomies using a three-incision tech-
nique. Reconstruction options include
deformity correction, nerve decompres-
sion, and, in severe cases, amputation.
Further research is also needed to de-
termine the optimal decompression
technique to avoid chronic FCS, which
can result in deformity, dysfunction,
and chronic pain.
Acknowledgments
The authors would like to thank
Herman Johal, MD, for the artwork
he contributed to this publication.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
29
Foot & Ankle
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2. Fulkerson E, Razi A, Tejwani N: Review:
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3. Thakur NA, McDonnell M, Got CJ,
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13. Shereff MJ: Compartment syndromes of
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14. Chambers L, Hame SL, Levine B: Acute
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15. Andermahr J, Helling HJ, Tsironis K,
Rehm KE, Koebke J: Compartment
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16. Mittlmeier T, Mächler G, Lob G,
Mutschler W, Bauer G, Vogl T:
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17. Ugalde V, Rosen BS: Ischemic peripheral
neuropathy. Phys Med Rehabil Clin N
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DE: Neuropathic pain: A practical guide
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19. Smith BH, Torrance N: Epidemiology of
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20. Baron R, Binder A, Wasner G:
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21. Frink M, Klaus AK, Kuther G, et al:
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22. Grodinsky M: A study of the fascial
spaces of the foot and their bearing on
infection. Surg Gynecol Obstet 1929;49:
739-751.
23. Wood Jones F: Structure and Function as
Seen in the Foot. London, United
Kingdom, Bailliere, Tindall, and Cox,
1946.
24. Kamel R, Sakla FB: Anatomical
compartments of the sole of the human
foot. Anat Rec 1961;140:57-60.
25. Myerson MS: Experimental
decompression of the fascial
compartments of the foot: The basis for
fasciotomy in acute compartment
syndromes. Foot Ankle 1988;8(6):308-
314.
26. Manoli A II, Weber TG: Fasciotomy of
the foot: An anatomical study with
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27. Guyton GP, Shearman CM, Saltzman
CL: The compartments of the foot
revisited: Rethinking the validity of
cadaver infusion experiments. J Bone
Joint Surg Br 2001;83(2):245-249.
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et al: Anatomic compartments of the
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30
 Research Article

Patient and Practice Trends in Total

Ankle Replacement and Tibiotalar
Arthrodesis in the United States
From 2007 to 2013

Abstract
Venus Vakhshori, MD Introduction: Both total ankle replacement (TAR) and tibiotalar
Andrew F. Sabour, BS arthrodesis (TTA) are used in the surgical management of ankle
arthritis. Over the past decade, TAR instrumentation, techniques, and
Ram K. Alluri, MD
implants have improved, making the procedure more reliable and
George F. Hatch III, MD reproducible, thus making TAR more common.
Eric W. Tan, MD Methods: The Nationwide Inpatient Sample database from 2007 to
2013 was used to obtain data on patients elder than 50 years who
underwent either TAR or TTA. Differences in temporal, demographic,
and diagnosis trends between TAR and TTA were analyzed.
Results: Between 2007 and 2013, 15,060 patients underwent TAR
and 35,096 underwent TTA. Patients undergoing TTA had
significantly more comorbidities (2.17 versus 1.55; P , 0.001). The
share of TAR performed increased significantly from 2007 (14%) to
2013 (45%) (P , 0.001). From 2007 to 2013, we found a 12-fold
increase in the odds of having a TAR for patients with posttraumatic
osteoarthritis (P , 0.001), a 4.9-fold increase for those with primary
osteoarthritis, and a 3.1-fold increase for patients with rheumatoid
arthritis (P , 0.001).
Conclusions: Over the past decade, the frequency of TAR has
increased, particularly in patients with posttraumatic arthritis and
osteoarthritis. Surgeons still perform TAR in healthier patients
compared with TTA; however, because surgeons become more
experienced with the technique, patients are undergoing TAR at a
markedly higher rate.
Level of Evidence: Level III: retrospective comparative study

From the Department of Orthopaedic

Surgery, Keck School of Medicine of
the University of Southern California,
Los Angeles, CA.
Correspondence to Dr. Vakhshori:
venus.vakhshori@med.usc.edu
J Am Acad Orthop Surg 2019;27:
e77-e84
DOI: 10.5435/JAAOS-D-17-00526
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
E nd-stage arthritis of the ankle
joint results in notable pain, dis-
ability, and resultant socioeconomic
and medical costs. These patients are
often initially treated with conserva-
tive therapies including nonsteroidal
anti-inflammatory medications, joint
injections, activity modification,
bracing treatment, and physical
therapy. When these methods fail,
tibiotalar arthrodesis (TTA) has been
the historic treatment of choice.1
However, TTA has a unique set of
complications, including adjacent
joint degeneration with continued
pain, disability, activity limitation,
and persistent gait alterations.1-5
In the 1970s, total ankle replace-
ment (TAR) was introduced. Early
designs were complicated by severe
osteolysis, loosening, impingement,
infection, and soft-tissue breakdown

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 31

Foot & Ankle Venus Vakhshori, MD, et al

and therefore were not readily im-
plemented in management of ankle
arthritis.2,6 More recent implants
developed in the 1980s and 1990s
more closely replicate the ankle’s
natural anatomy and biomechanics
and thereby provide improved func-
tion with decreased wear and loos-
ening.2,6 Advances in technology,
surgical instrumentation, and implant
design, including the introduction of
mobile bearing articulations and
partially conforming surfaces, allow
decreased constraint and prosthesis-
bone interface stress, improving re-
sults and reproducibility.6
Compared with TTA, TAR has
similar clinical outcomes and compli-
cations with some reports describing
an increased risk of revision surgery
and others with lower complication
rates; however, no randomized con-
trolled trials comparing the two have
been performed and many studies
report unequal baseline character-
istics.7-11 A systematic review of
intermediate and long-term out-
comes by Haddad et al8 reported
that 68.5% of patients with TAR
have excellent or good American
Orthopaedic Foot and Ankle Society
ankle-hindfoot scores, compared
with 68.0% of patients with TTA. A
recently published meta-analysis by
Kim et al9 reports no difference in
the American Orthopaedic Foot and
Ankle Society ankle-hindfoot score,
Short Form-36 physical and mental
component scores, visual analog
scale for pain and patient satisfac-
tion; however, patients with TAR
were 81% more likely to have a
revision surgery.
Nonetheless, the use of TAR is
rapidly increasing as demonstrated
in a number of recent database stud-
ies.12-15 However, these studies have
not specifically evaluated the trends
in TAR compared with TTA with
respect to indications and patient
and hospital specific factors. The
purpose of this study was to eluci-
date these trends in the use of TAR
compared with TTA in a nationwide
database.
Methods
Data
Using the Nationwide Inpatient
Sample (NIS), Healthcare Cost and
Utilization Project, Agency for
Healthcare Research and Quality
discharge records, a retrospective
review was performed from 2007 to
2013 to identify patients who
underwent a TAR or TTA. The NIS
includes about 20% of the approxi-
mately 37 million annual discharges
in the United States and is the largest
inpatient database in the United
States.16,17 Using International
Classification of Diseases, 9th edi-
tion (ICD-9) codes, patients who
underwent a primary procedure of
TAR (81.56) or ankle arthrodesis
(81.11) were identified. Revision
procedures (81.59) and patients who
had both arthroplasty on one
extremity and TTA on the contra-
lateral extremity were excluded. All
patients included in the study had a
concomitant diagnosis of tibiotalar
arthritis. Patients who died during
their hospitalization were excluded
from our analysis. Patients younger
than 50 years were excluded to avoid
selection bias favoring TTA because
age above 50 years is a commonly
accepted relative contraindication
for TAR, because younger, more
active patients may place excessive
demand on the implants, which may
result in premature failure or need
for revision.2,6
Subjects were categorized based
on the surgical procedure. Hospital
variables including bed number, gov-
ernment (public) or private (investor-
owned or not-for-profit) ownership,
and location were identified. Bed size
categories are determined by
Healthcare Cost and Utilization Pro-
ject and vary based on region of the
country and teaching or nonteaching
status. Rural versus urban status is
based on 2000 US Census data.16
Demographic variables, comorbidities,
patient location, length of stay, median
household income, and primary pay-
ment method were assessed for each
group. Specific comorbidities such as
hypertension, depression, diabetes,
diabetes with complications (diabetes
with ketoacidosis, hyperosmolarity,
coma, renal manifestations, ophthal-
mic manifestations, neurologic mani-
festations, or peripheral circulatory
disorders), obesity (body mass index .
30), peripheral vascular disorders,
and renal failure were also identified.
The frequency of concomitant pro-
cedures as indicated by ICD-9 pro-
cedure codes was determined for
each group. These variables were
compared by surgical procedure over
the entire study period.
To determine temporal changes,
the frequency of TAR and TTA was
assessed for each year of the data-
base. The frequency of TAR was
determined for patients with post-
traumatic osteoarthritis, primary
osteoarthritis, rheumatoid arthritis,

Dr. Alluri or an immediate family member has stock or stock options held in Axogen, Medtronic, Stryker, and Zimmer Biomet and has
received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such
as paid travel) from Acumed, Arthrex, and Trimed. Dr. Hatch or an immediate family member is a member of a speakers’ bureau or has made
paid presentations on behalf of and serves as a paid consultant to Arthrex. Dr. Tan or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of Arthrex and serves as a board member, owner, officer, or committee member
of the American Academy of Orthopaedic Surgeons and the American Foot Ankle Society. Neither of the following authors nor any
immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution
related directly or indirectly to the subject of this article: Dr. Vakhshori and Mr. Sabour.

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 32

Foot & Ankle
and comorbid diabetes, hyperten-
sion, and coronary artery disease for
2007 compared with 2013. Incidence
per capita was calculated using 2010
US Census data for patients elder
than 50 years.
Statistical Analysis
Univariate analysis compared patient
demographics, preoperative co-
morbidities, inpatient variables, and
hospital variables between groups.
The Student t-test compared contin-
uous variables. The Fisher exact test
or chi-square analysis compared
categorical variables. Preoperative
comorbidities with P , 0.05 and
prevalence .0.5% were included
in a logistic regression for multivar-
iate analysis. A P value ,0.05 was
considered significant.
Results
From 2007 to 2013, an initial cohort
of 50,156 patients elder than 50 years
who underwent either TTA or TAR
was identified. TTA was performed
in 35,096 patients (69.9%), and TAR
was performed in 15,060 patients
(30.1%). From 2007 to 2013, the
yearly incidence of TAR per capita
increased 421% from 0.86/100,000
to 3.66/100,000, whereas the inci-
dence of TTA per capita de-
creased 18% from 5.37/100,000 to
4.40/100,000 (P , 0.001) (Figure 1).
As a percentage of total procedures
performed, TAR increased from
14% in 2007 to 45% in 2013
(P , 0.001). The patients in the
TAR group were older (mean age,
65.5 6 8.68 years) than those in the
TTA group (mean age, 63.7 6 8.95
years) (P , 0.001). No significant
difference was found in sex between
the two groups (48.9% female un-
derwent TTA, 50.0% female under-
went TAR; P = 0.32).
The length of stay was significantly
longer in patients with TTA (3.43 6
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Figure 1
Graph showing annual incidence of total ankle arthroplasty compared with
tibiotalar arthrodesis.
5.68 days) than in those with TAR
(2.28 6 1.41 days) (P , 0.001). In
addition, the proportion of patients
with Medicare and private insurance
receiving TAR (94.5%) was signif-
icantly higher than those receiving
TTA (87.4%), whereas the oppo-
site was true for Medicaid patients
(1.4% for TAR compared with
5.8% for TTA) (P , 0.001). Sim-
ilarly, patients with higher than
median household income were
more likely to receive TAR (P ,
0.001) (Table 1). Further demo-
graphic and hospital information
is presented in Tables 1 and 2,
respectively.
With regard to patient-specific vari-
ables, TAR was performed in healthier
patients who had an average of
1.55 comorbidities, compared with
patients who underwent TTA who
had an average of 2.17 comorbidities
(P , 0.001). Patients with alcohol
abuse, anemia, depression, diabetes
with or without chronic complica-
tions, obesity, peripheral vascular
disease, psychoses, and renal failure
were all more likely to receive TTA
compared with TAR in univariate
and multivariate analysis (P , 0.01
for each comorbidity) (Table 3).
The most common concomitant pro-
cedures performed at the time of
Venus Vakhshori, MD, et al
surgery in patients receiving TAR
were implant removal (9.8%), gas-
trocnemius recession (7.7%), and
subtalar fusion (5.8%), whereas for
those receiving TTA, the most
common concomitant procedures
were implant removal (21.7%), sub-
talar fusion (9.6%), and application
of a tibia and/or fibula external
fixation device (4.5%) (Table 4).
Analysis of primary diagnosis
demonstrated that from 2007 to
2013, we noticed a 12.1-fold increase
in the odds of having a TAR in pa-
tients with posttraumatic osteo-
arthritis (P , 0.001), a 4.9-fold
increase for those with primary
osteoarthritis (P , 0.001), and a
3.1-fold increase for patients with
rheumatoid arthritis (P , 0.001).
Furthermore, patients with combined
comorbid diagnoses of diabetes,
hypertension, and coronary artery
disease were 4.7 times more likely to
receive TAR in 2013 compared with
2007 (P , 0.001) (Table 5).
Conclusions
Ankle arthritis is a debilitating con-
dition that results in pain and
decreased function. For patients refrac-
tory to conservative management,
33
Foot & Ankle Venus Vakhshori, MD, et al

Table 1
Demographic and Patient-specific Variables in Patients Receiving TTA and TAR
Arthrodesis (TTA), Arthroplasty (TAR),
Demographics N = 35,096 (%) N = 15,060 (%) P Value

Age (mean, yr) 63.7 6 8.95 65.5 6 8.68 ,0.001

Sex (female) 17,100 (48.9) 7,520 (50.0) 0.319
Race ,0.001
White 24,000 (84.6) 11,000 (88.4) —
Black 1,800 (6.3) 373 (3.0) —
Hispanic 1,480 (5.2) 441 (3.6) —
Asian or Pacific Islander 288 (1.0) 149 (1.2) —
Native American 118 (0.4) 63 (0.5) —
Other 699 (2.5) 414 (3.3) —
Primary payment method ,0.001
Medicare 17,500 (50.0) 8,140 (54.2) —
Medicaid 2,020 (5.8) 209 (1.4) —
Private 1,310 (37.4) 6,060 (40.3) —
Self-pay 383 (1.1) 89 (0.4) —
No charge or other 2,011 (5.7) 560 (3.7) —
Median household income ,0.001
0-25th percentile 7,910 (23.0) 2,570 (17.4) —
26-50th percentile 9,460 (27.5) 3,670 (24.9) —
51-75th percentile 8,880 (25.9) 4,010 (27.3) —
70-100th percentile 8,090 (23.6) 4,480 (30.4) —

TAR = total ankle replacement, TTA = tibiotalar arthrodesis

arthrodesis has long been an option
for this condition, but leads to
noticeably altered gait mechanics
and velocity, decreased range of
motion, and resultant osteoarthritis
of the adjacent joints. 1,3 Total
ankle arthroplasty aims to address
the drawbacks of arthrodesis. After
arthroplasty, patients have im-
proved range of motion with less
load on surrounding joints and
improved gait.2,4-6 Benefits of ar-
throplasty in the perioperative pe-
riod have been reported and include
lower blood transfusion rates and
lower rates of nonhome discharge.18
However, arthroplasty is not with-
out its own limitations. Several
studies have found similar patient
satisfaction and clinical outcomes
but increased risk of major surgical
complications and revision surgery
with arthroplasty.7-9,10,11,13,19
Practice patterns have shifted in the
last decade toward favoring arthro-
plasty. From 1995 to 2004, arthro-
desis was performed nearly 10 times
more often than arthroplasty in Cal-
ifornia.10 Our study demonstrates
a relative increase in the rate of
arthroplasty compared with arthro-
desis, with arthroplasty accounting
for 14% of the procedures for ankle
arthritis in 2007, to just under 50%
by 2013. Terrell et al14 found an
increase in total ankle arthroplasty
from 0.63 per 10,000 in 2004 to
0.99 per 10,000 patients in 2009, a
nearly 40% increase. This trend is
also seen in the Medicare pop-
ulation, in which the arthroplasty
volume increased over 12-fold from
1991 to 2010, whereas arthrodesis
volume increased by only 36%, with
nearly 4 times as many US hospitals
performing arthroplasty by 2010.12
The rise in TAR is multifactorial.
Improved instrumentation and im-
plants resulting in improved clinical
outcomes and increased experience
with the procedure have contributed
to this change in practice patterns. In
the United States, the availability
of implant systems was extremely
limited until just over a decade ago.
Before 2005, the only Food and
Drug Administration-approved ankle
arthroplasty systems in the United
States were the Beuchel-Pappas TAR
(Endotec) introduced in the 1980s,
and the Agility Total Ankle System
(DePuy) prosthesis, approved in
1992.2,20 The early outcomes of these
implants, especially the first-generation
implants, were discouraging. Less
comprehensive understanding of the
ankle biomechanics, implant constraint
and bone-implant interface, and lim-
ited surgeon experience led to high

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 34

Foot & Ankle Venus Vakhshori, MD, et al

Table 2
Hospital Variables and Length of Stay in Patients Receiving TTA and TAR
Arthrodesis (TTA), Arthroplasty (TAR),
Hospital Variables N = 35,096 (%) N = 15,060 (%) P Value

Length of stay (mean, d) 3.43 6 5.68 2.28 6 1.41 ,0.001

Bed size of the hospital ,0.001
Small 4,920 (14.2) 3,060 (20.4) —
Medium 8,510 (24.5) 3,660 (24.4) —
Large 21,300 (61.3) 8,270 (55.2) —
Ownership of hospital ,0.001
Government (public) 18,580 (72.4) 5,448 (65.9) —
Private (investor-owned or not-for-profit) 7,080 (27.6) 2,822 (34.1) —
Hospital setting ,0.001
Rural 1,760 (6.8) 286 (3.5) —
Urban 23,900 (93.2) 7,980 (96.5) —

TAR = total ankle replacement, TTA = tibiotalar arthrodesis

Table 3
Univariate and Multivariate Analysis of Preoperative Comorbidities in Patients Receiving TTA and TAR
Arthrodesis Arthroplasty Univariate Multivariate
Preoperative (TTA), N = 35,096 (TAR), N = 15,060 P OR (TAR/ P OR (TAR/ P
Comorbidities (%) (%) Value TTA) Value TTA) Value

Total comorbidities 2.17 6 1.69 1.55 6 1.31 ,0.001 — — — —

Alcohol abuse 578 (1.6) 122 (0.8) 0.001 0.49 ,0.001 0.48 ,0.001
Anemia 3,950 (11.3) 778 (5.2) ,0.001 0.43 ,0.001 0.63 ,0.001
Depression 4,760 (13.6) 1,730 (11.5) 0.004 0.83 ,0.001 0.88 ,0.001
Diabetes 6,560 (18.7) 1,810 (12.0) ,0.001 0.59 ,0.001 0.57 ,0.001
(uncomplicated)
Diabetes (with chronic 3,770 (10.7) 144 (1.0) ,0.001 0.08 ,0.001 0.10 ,0.001
complications)
Hypertension 22,600 (64.4) 8,830 (58.6) ,0.001 0.78 ,0.001 1.04 0.022
Hypothyroidism 4,270 (12.2) 2,050 (13.6) 0.043 1.14 ,0.001 1.24 ,0.001
Liver disease 637 (1.8) 197 (1.3) 0.089 0.72 ,0.001 0.91 0.265
Obesity 6,680 (19.0) 1,850 (12.3) ,0.001 0.59 ,0.001 0.71 ,0.001
Peripheral vascular 1,370 (3.9) 252 (1.7) ,0.001 0.42 ,0.001 0.66 ,0.001
disorders
Psychoses 1,040 (3.0) 284 (1.9) 0.001 0.63 ,0.001 0.69 ,0.001
Renal failure 3,110 (8.9) 424 (2.8) ,0.001 0.30 ,0.001 0.59 ,0.001
Rheumatoid arthritis/ 2,070 (5.9) 881 (5.9) 0.963 0.99 ,0.001 0.97 0.471
collagen vascular
disease

OR = odds ratio, TAR = total ankle replacement, TTA = tibiotalar arthrodesis

rates of complications and limited previous implant designs and in- Technology) in 2005, the Salto
functional benefits.21,22 Since 2005, strumentation, have been intro- Talaris Anatomic Ankle (Integra
current-generation ankle replace- duced including the INBONE Total LifeSciences) in 2006, the Scandina-
ments, which have improved on Ankle System (Wright Medical vian TAR (Stryker) in 2009, and the

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 35

Foot & Ankle Venus Vakhshori, MD, et al

Table 4
Number and Frequency of Concomitant Procedures in Patients Receiving TAR and TAA
Arthrodesis (TTA), Arthroplasty (TAR),
Concomitant Procedures N = 35,096 (%) N = 15,060 (%) P Value

Removal of implanted device from bone, tibia, 7,617 (21.7) 1,474 (9.8) ,0.0001
and fibula
Removal of implanted devices from bone, tarsals, 952 (2.7) 335 (2.2) 0.001
and metatarsals
Subtalar fusion 3,370 (9.6) 880 (5.8) ,0.0001
Tarsometatarsal fusion 398 (1.1) 102 (0.7) ,0.0001
Triple arthrodesis 194 (0.6) 129 (0.9) ,0.0001
Arthrodesis of other specified joints 349 (1.0) 220 (1.5) ,0.0001
Tendon transfer or transplantation 381 (1.1) 202 (1.3) 0.016
Gastrocnemius recession 635 (1.8) 1,165 (7.7) ,0.0001
Achilles tendon lengthening 409 (1.2) 166 (1.1) 0.583
Application of external fixator device, tibia, and 1,575 (4.5) 79 (0.5) ,0.0001
fibula
Application of external fixator device, ring system 1,165 (3.3) 21 (0.1) ,0.0001

TAR = total ankle replacement, TTA = tibiotalar arthrodesis

Table 5
Change in Incidence for Patients Receiving TAR From 2007 to 2013 Based on Primary Diagnosis
Diagnosis % TAR (2007) % TAR (2013) Odds Ratio (2013/2007) P Value

Posttraumatic osteoarthritis 9.3 55.5 12.1 ,0.001

Primary osteoarthritis 25.6 62.9 4.9 ,0.001
Rheumatoid arthritis 25.5 51.4 3.1 ,0.001
Comorbid DM 1 HTN 1 CAD 12.6 40.3 4.7 ,0.001

CAD = coronary artery disease, DM = diabetes, HTN = hypertension, TAR = total ankle replacement

Zimmer Trabecular Total Ankle
(Zimmer Biomet) in 2013.20,23 The
improvements in technology, in-
creased reproducibility, and wider
range of options for arthroplasty
have likely contributed to the recent
increase in TARs.
Our data show that in this cohort
of patients (age . 50 years), arthro-
plasty is more commonly performed
in older, white patients in private
hospitals in urban settings compared
with arthrodesis. This finding is
consistent with other database studies
reporting that patients with Medicare
or private insurance are three times
more likely to undergo arthroplasty
than do those with Medicaid.24 This
phenomenon may be due to patients
with Medicaid living in rural areas
with limited access to tertiary centers
that perform arthroplasty or reim-
bursement patterns discouraging the
use of arthroplasty because of cost.24-26
Interestingly, the proportion of pa-
tients receiving arthroplasty at a
small hospital is larger than those
receiving arthrodesis at a small hos-
pital; the opposite is true for large
hospitals. This is potentially due to
patients receiving arthrodesis being
more medically complex and conse-
quently being treated at large referral
centers. Further research is needed to
elucidate the reasons behind hospital
size and treatment choice.
In our study, the increase in rate of
arthroplasty is most notable for pa-
tients with posttraumatic arthritis
who had a 12-times increase in the
odds of undergoing arthroplasty in
2013 compared with 2007. More
modest increases were seen for
arthroplasty in primary osteoarthritis
(4.9-fold increase) and rheumatoid
arthritis (3.1-fold increase). Patients
with primary osteoarthritis, post-
traumatic arthritis, and rheumatoid
arthritis have all been reported to
have good outcomes after total ankle
arthroplasty.27-29 This likely reflects
both increasing surgeon experience
and comfort with arthroplasty in
varying circumstances in addition to

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 36

Foot & Ankle
improved surgical instrumentation,
techniques, and implants.
The data from our cohort suggest
that arthroplasty was generally
limited to healthier patients. Patients
with medical comorbidities were
more likely to undergo arthrodesis
than arthroplasty, and patients who
received an arthrodesis had a higher
number of average comorbidities. In
both univariate and multivariate
analysis, patients with alcohol abuse,
anemia, depression, diabetes, obe-
sity, peripheral vascular disease,
psychoses, or renal failure were all
more likely to receive arthrodesis.
These differences likely reflect sur-
geon preference to perform arthro-
desis over arthroplasty in medically
complex patients to potentially de-
crease surgical time and risk of revi-
sion surgery.7,9 The increased length
of stay and rate of nonhome discharge
in patients with arthrodesis may be
related to medical comorbidities and
patient demographics rather than the
particular procedure being performed.
Although patients with more co-
morbidities are more likely to receive
an arthrodesis, arthroplasty volume
is expanding. Furthermore, patients
with comorbid hypertension, diabe-
tes, and coronary artery disease had
seen a 4.7-fold increase in the rate of
arthroplasty in 2013 compared with
2007. This increase is likely the result
of improvements in the implant design
and outcomes and increased surgeon
experience with arthroplasty, allow-
ing surgeons to perform arthroplasty
on a wider range of patients.
It is important to recognize the
inherent limitations of this database
study. This is a retrospective obser-
vational review of a national data-
base searched by ICD-9 codes and
is subject to inaccuracies in coding.
The NIS database includes only in-
patients, so any arthrodesis or ar-
throplasty performed in an outpatient
setting is not captured. Although
ankle arthroplasty and arthrodesis are
slowly being performed more com-
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
monly in the outpatient setting, many
patients have at least an overnight
hospital stay, with an average
reported length of stays of two to
four nights.18,30-33 The move to-
ward outpatient arthroplasty and
arthrodesis is recent, and it is possi-
ble that by not capturing outpatient
procedures, our data are most likely
understating the growth of arthro-
plasty from 2007 to 2013. In addi-
tion, outcome data are not provided
in the NIS database, and therefore,
no follow-up data exist to determine
clinical results of either intervention.
With respect to concomitant proce-
dures performed, these are listed
in the NIS by ICD-9 procedure
code, which is less descriptive than
Current Procedure Terminology
codes. Finally, this database study
allows us to draw only correlative
associations, and we cannot con-
clude the reasons behind trends
in practice patterns. However, this
study does provide valuable infor-
mation regarding national trends
regarding the use of arthroplasty
compared with arthrodesis for ankle
arthritis.
In conclusion, this study demon-
strates an increased national inci-
dence of TAR compared with TTA
from 2007 to 2013. Patients who
may have previously not been candi-
dates for arthroplasty are now more
likely to undergo the procedure. The
largest changes were seen in patients
with posttraumatic osteoarthritis,
primary osteoarthritis, and rheuma-
toid arthritis. Although arthroplasty
is typically performed in healthier
patients, its use is growing among
patients with increased medical co-
morbidities. Arthroplasty is more
common in patients who are white,
with Medicare or private insurance,
and those with higher incomes.
Future prospective studies comparing
TAR and TTA are necessary to
determine the ideal surgical proce-
dure for patients with end-stage ankle
arthritis.
Venus Vakhshori, MD, et al
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JJ, Martin CT, Cram P: Trends in the use of
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25. Patterson BM, Draeger RW, Olsson EC,
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27. Pedersen E, Pinsker E, Younger ASE, et al:
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28. van Heiningen J, Vliet Vlieland TPM, van
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JK: Total ankle arthroplasty outcome
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1046-1051.
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38
 Review Article

Ankle Distraction Arthroplasty:

Indications, Technique, and
Outcomes

Mitchell Bernstein, MD, FRCSC
Jay Reidler, MD, MPH
Austin Fragomen, MD
S. Robert Rozbruch, MD
Abstract
Ankle distraction is an alternative to ankle arthrodesis or total ankle
arthroplasty in younger patients with arthritis. Ankle distraction
involves the use of external fixation to mechanically unload the ankle
joint, which allows for stable, congruent range of motion in the setting
of decreased mechanical loading, potentially promoting cartilage
repair. Adjunct surgical procedures are frequently done to address
lower-extremity malalignment, ankle equinus contractures, and
impinging tibiotalar osteophytes. Patients can bear full weight during
the treatment course. The distraction frame frequently uses a hinge,
and patients are encouraged to do daily range-of-motion exercises.
Although the initial goal of the procedure is to delay arthrodesis, many
patients achieve lasting clinical benefits, obviating the need for total
ankle arthroplasty or fusion. Complications associated with external
fixation are common, and patients should be counseled that clinical
improvements occur slowly and often are not achieved until at least 1
year after frame removal.

A nkle osteoarthritis is generally

From the Department of Orthopaedic
Surgery, Loyola University Chicago
Stritch School of Medicine, Chicago,
IL (Dr. Bernstein), the Department of
Orthopaedics, Johns Hopkins
University, Baltimore, MD
(Dr. Reidler), and the Department of
Orthopaedic Surgery, Hospital for
Special Surgery, Cornell University,
New York, NY (Dr. Fragomen and
Dr. Rozbruch).
J Am Acad Orthop Surg 2017;25:
89-99
DOI: 10.5435/JAAOS-D-14-00077
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
a progressive condition, most
commonly the result of high-energy
tibial plafond fractures, bimalleolar
ankle fractures, recurrent ankle insta-
bility, and neuropathy.1-3 Lower-
extremity posttraumatic arthritis has
an estimated cost of $12 billion
annually in the United States.4 It is
often disabling, predominantly
affects young, active persons, and has
a negative effect on quality-of-life
measures that is comparable to that
of hip and knee arthritis.1 The
mainstay of surgical treatment of
advanced ankle arthritis has tradi-
tionally included ankle arthrodesis or
total ankle arthroplasty (TAA).
Ankle arthrodesis reliably provides
pain relief. However, loss of ankle
motion, increased stress at adjacent
joints that leads to degeneration, and
increased energy expenditure with
ambulation do occur.5 Unlike fusion,
TAA does not affect range of motion
(ROM); however, its use in young
active patients may be contra-
indicated because of wear, failure,
and subsequent revisions.6
In contrast to the aims of TAA and
ankle fusion, the aim of distraction
arthroplasty is to optimize the body’s
regenerative capacity and the func-
tion of the diseased joint.7,8 An
external fixator is used to mechan-
ically unload the ankle to relieve
pain, preserve ROM, and potentially
delay or even partially reverse the
effects of arthritis (Figure 1). The
surgeon should be aware of this
treatment option, as well as its
indications, outcomes, and potential
adverse effects for ankle arthritis.
Recent short- and intermediate-term
evidence suggests that distraction
arthroplasty may be a viable surgical

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 39

Foot & Ankle Mitchell Bernstein, MD, FRCSC, et al

Figure 1 ability to withstand up to 5.5 times with a circular fixator.18,19 The

Ankle distraction frame mounted on
an extremity model demonstrating our
current assembly method. The red
(circular) and blue (U-shaped) rings
are secured with 6-mm
hydroxyapatite-coated half pins and
1.8-mm bayonet Kirschner wires to
the tibia and foot, respectively. The
hinge (red arrow) is aligned with the
Inman axis. The acute and gradual
distraction is achieved with clockwise
rotations of the square nuts (red
arrowhead), which are attached to the
tibial ring. Range-of-motion exercises
occur with unlocking the connection
between the two rings (yellow arrow).
Gradual dorsiflexion of the ankle, in
the setting of chronic ankle equinus, is
achieved by gradually increasing the
distance between the square nut
(yellow arrow) and the proximal end of
the rod. (Copyright Mitchell Bernstein,
MD, FRCSC, Chicago, IL.)
option with the use of appropriate
patient selection criteria.9,10
Anatomy and
Biomechanics of the Ankle
Joint
The ankle is a highly constrained and
congruent weight-bearing joint. Its
body weight during ambulation
depends on a stable relationship
among the bony and ligamentous
structures of the distal tibia, fibula,
and talus.11 The tibial plafond has a
central ridge oriented in the sagittal
plane that is complementary to a
concavity on the talar dome. The
relationship between the distal fib-
ula, tibiotalar joint, and the medial
malleolus is maintained by the stout
ligaments that make up the ankle
syndesmosis.
One study demonstrated that even
a 1-mm displacement of the talus in
the ankle mortise generates a 42%
decrease in available joint contact
area.12 Consequently, the remaining
cartilage is exposed to compressive
forces over a smaller surface area,
potentially leading to degeneration
and arthritis.
The orientation of the ankle joint,
as described by a line perpendicular
to the diaphysis of the tibia, is in slight
valgus. Named the lateral distal tibial
angle, it measures on average 89°
(range, 86º to 92°). The axis of the
ankle joint is created through the
relationship between, and the geo-
metric constraints of, the talar dome,
tibial plafond, and the lateral and
medial malleoli.13 The traditionally
accepted theory, proposed in the
1950s, suggests that the ankle rotates
with one-degree of freedom about an
axis (ie, the Inman axis) that lies
between the tips of the medial and
lateral malleoli.14-16 This axis is the
basis for total ankle prosthesis
designs17 and forms the basis on
which the hinge is built when dis-
traction arthroplasty is performed
concept of the hinge is based on the
theory that the talar dome is a frus-
tum of a cone with its apex medially
directed.
Articular cartilage, or hyaline car-
tilage, lacks blood supply, nerve
innervation, and lymphatic drainage.
It receives nutrition and expels waste
via diffusion and imbibition. Its high
tensile strength and elasticity func-
tion to withstand high loads, protect
subchondral bone, and decrease
friction between the two opposing
surfaces. Hyaline cartilage is primar-
ily composed of type II collagen,
water, and chondrocytes. Chon-
drocytes, which produce enzymes,
proteins, and collagen, are responsi-
ble for the normal and pathologic
state of the articular surface.20,21
Chondrocytes are metabolically
controlled via the surrounding
mechanical environment and thus,
can upregulate the synthesis of deg-
radative cytokines, increasing cata-
bolic enzymes in the local milieu—a
concept referred to as mechanoelec-
trochemical events.22
Arthritis in the ankle is most often
secondary, usually resulting from
trauma.2,3 The energy dissipated
through the articular surface and the
ensuing inflammatory response is
thought to be critical in post-
traumatic arthritis.23,24 It has been
demonstrated that the inflammation
resulting from the energy loss causes
the production of dysfunctional
cellular elements and chondrocyte
apoptosis.25 In the subacute phase,
articular cartilage changes its com-
position, increasing its water con-
tent and decreasing its proteoglycan

Dr. Bernstein or an immediate family member serves as a paid consultant to NuVasive, Smith & Nephew, and DuPuy Synthes and serves as
a board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society. Dr. Fragomen or an immediate
family member has received royalties from Small Bone Innovations; is a member of a speakers’ bureau, or has made paid presentations on
behalf of Smith & Nephew; and serves as a paid consultant to Smith & Nephew and DePuy Synthes. Dr. Rozbruch or an immediate family
member has received royalties from Small Bone Innovations and Smith & Nephew; is a member of a speakers’ bureau, or has made paid
presentations on behalf of Smith & Nephew; serves as a paid consultant to Small Bone Innovations and Smith & Nephew; and serves as a
board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society. Neither Dr. Reidler nor any
immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution
related directly or indirectly to the subject of this article.

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 40

Foot & Ankle
concentration. Furthermore, type II
collagen is weakened by a combina-
tion of decreased production by
chondrocytes and increased concen-
tration of proinflammatory cytokines.
To restore normal homeostasis,
deeper layers containing “resting”
chondrocytes proliferate to increase
anabolic activities. The exact cellu-
lar mechanisms, signaling mole-
cules, genetic factors, and the role of
mechanical influences currently are
not fully understood.
As the catabolic processes over-
whelm resident chondrocytes, “full-
thickness” chondral involvement
ensues, exposing subchondral bone.
Healing is possible, albeit unpre-
dictably. This spontaneous healing
occurs in part because of the release
of growth factors from exposed
marrow spaces.26 The resultant local
inflammatory response recruits plu-
ripotent mesenchymal stem cells,
which, depending on the local envi-
ronment, can be manipulated to
develop fibrocartilage.27-30 This is
one potential pathway that distrac-
tion arthroplasty and adjunct pro-
cedures may use to exploit the
formation of hyaline cartilage.31
For younger patients with
posttraumatic lesions, a durable,
joint-sparing solution is desirable.
Concurrently addressing all pathol-
ogy, including equinus contracture, ti-
biotalar osteophytes, supramalleolar
or hindfoot malalignment, and insta-
bility, is central to treatment. Cartilage
regeneration is more reliable when it
occurs in the setting of a congruent,
stable limb in anatomic alignment.19,32
Distraction Arthroplasty
The success of ankle distraction
depends on proper patient selection
and appropriate management of
expectations. The ideal candidate for
ankle distraction arthroplasty is a
motivated patient who seeks an
alternative to ankle fusion or TAA
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
and has recalcitrant pain in the setting
of a congruent joint with preserved
motion of .20°.33 Relative contra-
indications include complex regional
pain syndrome, inflammatory ar-
thritides, previous infection, neuro-
pathic joint, and older age with low
functional demands. Patients with a
painful stiff ankle (ie, ,20° of
motion) are less likely to do well with
distraction because the procedure
does not reliably increase ROM, and
thus, these patients may be better
candidates for arthrodesis or TAA.10
Extra-articular deformity, located
in the hindfoot or distal tibia, is not a
contraindication if the deformity is
addressed concurrently.34 Patients
with marked intra-articular defor-
mity or a flat-top talus, however, are
felt to be poor candidates for ankle
distraction. Asymmetric arthritis of
the ankle is not a contraindication
for ankle distraction. For example,
patients with varus deformity at the
distal tibia and asymmetric joint
wear on the medial side may benefit
from a supramalleolar osteotomy,
with correction of the varus defor-
mity and ankle distraction to offload
the diseased segment. Finally, ante-
rior joint space narrowing associated
with impinging anterior osteophytes
should be identified. In these
patients, arthroscopic or open de-
compression, possibly in conjunction
with gastrocnemius recession,
should be considered.
The success of ankle distraction is
predicated on a thorough history,
physical examination, and ancillary
tests. Our evaluation includes a review
of patients’ reasons for consultation
and their perception of their disability
in addition to the basic elements of a
thorough patient history: the location
and quality of the pain, aggravating
and alleviating factors, subjective
description of instability, previous
nonsurgical and surgical treatments,
and other musculoskeletal com-
plaints. Because inflammatory arthri-
tides are relative contraindications to
Mitchell Bernstein, MD, FRCSC, et al
distraction, the etiology of ankle
arthritis is critical. A history of injury
or repetitive instability is therefore
carefully elucidated.
The physical examination begins
with an assessment to identify any
ipsilateral (or contralateral) extrem-
ity malalignment, such as tibial mal-
union, knee hyperextension, or tibia
vara. The patient is screened for limb
length inequality by comparing the
heights of the iliac crests. Dynamic
extremity instability, malalignment,
and foot progression angle are
determined by observing the patient
ambulate. A focused assessment of
the ankle and foot, including stability
and ROM testing, completes the
physical examination.
No routine laboratory tests are
required. Infectious markers, such as
white blood cell count and erythrocyte
sedimentation rate and C-reactive
protein level, are ordered when active
infection is suspected or needs to be
ruled out.
Radiographic evaluation includes
AP, lateral, and mortise weight-
bearing views of the ankle (Figure 2).
Radiographs of the tibia and/or
a standing hindfoot alignment
(Saltzman) view of the foot are ob-
tained in the case of pathology and/or
malalignment. CT scans of the ankle
are not routinely ordered. MRI is used
when osteochondral lesions need to be
delineated or in the case of nonosseous
pathology (eg, lateral ankle ligament
pathology, posterior tibial tendinosis).
The ankle radiographs are also
used to measure the weight-bearing
preoperative joint space in prepara-
tion for the required increase of 5 mm
during distraction to effectively
unload the ankle joint.10,35 The
presence of subchondral sclerosis
and subchondral cysts are noted. In
addition, the ankle joint should be
scrutinized for asymmetric wear.
This wear should be correlated to an
associated deformity. For example, if
the medial aspect of the ankle joint
demonstrates arthritis with relative
41
Foot & Ankle Mitchell Bernstein, MD, FRCSC, et al

Figure 2

Preoperative AP (A) and lateral (B) standing radiographs of the ankle joint in a 53-year-old woman with posttraumatic arthritis.
Subchondral sclerosis and cysts, as well as decreased joint space are noted. Mild flattening of the talar dome is evident
anteriorly on the lateral radiograph. AP (C) and lateral (D) standing radiographs obtained immediately postoperatively after
distraction arthroplasty and osteophyte excision. Note the 1-inch calibration ball to measure the joint space E, Photograph of
the patient wearing the frame. AP (F) and lateral (G) standing radiographs of the ankle joint demonstrating joint space and
remodeling of the joint at an 18-month follow-up visit. (Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.)

preservation of the lateral joint and
the patient has a posttraumatic varus
deformity with an apex at the distal
tibial metaphysis, joint distraction in
addition to a supramalleolar osteot-
omy may be indicated.
History of the Procedure
In 1978, seeking alternatives to
TAA for joint arthritis, Judet and
Judet36 described a technique using
external fixation to mechanically
separate opposing joint surfaces to
allow “for fibrous tissue between
the bone ends.” Their histologic
analysis of regenerated tissue in
dogs was done after the tibiotarsal
joints were devoid of articular
cartilage and distracted for 30 days
with a 4- to 8-mm gap. At 1 year,
they reported metaplastic changes
in the joint surface resembling
those of normal hyaline cartilage.36
Aldegheri et al37 reported on the
use of a hinged distractor for hip
arthritis in 80 patients. Based on
good results achieved in 46 patients
at a minimum follow-up of 5 years,
the authors concluded that radio-
graphic results do not always cor-
relate with clinical outcomes.
Patients aged .45 years with or
without inflammatory arthritis had
uniformly poor results.

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 42

Foot & Ankle
Mechanism of Action
The exact mechanism of action for
distraction arthroplasty is unknown;
however, it is based on the belief that
the biologic aspects of cartilage
regeneration are most likely to occur
in a mechanically unloaded, well-
aligned limb.38,39 The stiffness of
the circular ring fixator may allow
for sufficient stress shielding at the
ankle joint to allow subchondral
bone remodeling, which has been
shown to be of clinical benefit.40
However, this phenomenon, and its
clinical correlation to pain relief, is
still controversial.
In addition, weight bearing, sta-
bility, and motion—crucial for pro-
moting durable articular cartilage—
are possible for an extended period
in the external fixator.41-43
43
van Valburg et al measured intra-
articular hydrostatic pressure dur-
ing distraction by inserting a
pressure-sensitive catheter into the
ankle. Recordings demonstrated
intra-articular pressure fluctuations,
and the authors suggested that these
fluctuations combined with the
absence of mechanical stress were
instrumental in articular cartilage
repair.43-45 They theorized that the
intermittent fluid flow inside the
joint caused by pressure fluctuations
effectively mimics normal physio-
logic processes in the absence of
load and shear and that this pro-
motes cartilage repair. In a study of
knee arthritis (induced by anterior
cruciate ligament resection) in a
canine model, van Valburg et al31
observed that, in addition to the
intermittent fluid flow caused by
an articulated knee hinge on the
Ilizarov device, a change occurred in
the proteoglycan metabolism that
resembled the nonarthritic control
knee.
Factors that have been associated
with cartilage repair include a decrease
in joint reactive forces (shear), an
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
increase in protoeglycan synthesis,
recruitment of mesenchymal stems
cells, and optimization of the
mechanical environment.22,31,45 Fur-
thermore, an improvement is seen in
the density of the subchondral bone
with a decrease in sclerosis.40 This
subchondral change may improve the
biomechanical environment of the
arthritic joint. In addition, resorption
of subchondral cysts and improve-
ment in edema may contribute to the
clinical improvement that we have
observed.
Outcomes
In 1995, van Valburg et al44 pub-
lished a preliminary retrospective
study on the use of ankle distraction
in 11 patients with severe post-
traumatic arthritis scheduled for
ankle arthrodesis. The patient
cohort was relatively young (mean
age, 35 years). An Ilizarov distrac-
tion apparatus was used for a mean
of 15 weeks. Their technique, which
has since been slightly modified,
consisted of ensuring a post-
operative distraction gap of 5 mm
and the addition of hinges between
6 and 12 weeks postoperatively. At
a mean follow-up of 20 months
(range, 10 to 60 months), all
patients reported a decrease in pain,
and five patients (45%) reported a
complete resolution of pain.44 Six
patients (55%) had increased ROM,
and five (50%) had radiographic
evidence of increased tibiotalar joint
space. Encouraged by their results,
the authors published a prospective
study with a minimum 2-year
follow-up.46 The study included 17
patients (mean age, 39.6 years) who
underwent annual evaluations for
functional ability, mobility, and
pain scores. Ankle distraction failed
in four patients, who ultimately
proceeded with arthrodesis. Of the
remaining 13 patients, clinical out-
come scores at 2-year follow-up
Mitchell Bernstein, MD, FRCSC, et al
were better (P , 0.004) than those
obtained at 1-year follow-up.
Although poorly understood, sev-
eral studies support the process of
ankle joint remodeling after frame
removal.10,40,46,47 The restoration
of preinjury ankle architecture and
mechanics is thought to be instru-
mental for prolonged benefit. The
notion that improvements may
occur over 12 to 24 months sub-
sequent to frame removal should
be considered when counseling
patients in their recovery period.
In 2008, Paley et al48 published
their results on a modified distraction
frame that was being used in Europe.
Motion during distraction was
stressed, and an anatomically located
hinge based on the Inman axis
became the foundation of the frame.
Adjunctive procedures, such as os-
teophyte resection, gastrocnemius-
soleus complex recession, and
extremity realignment with osteot-
omy, were also done to maximize
clinical outcomes.48 Nine males and
14 females were available for ret-
rospective chart review after a mean
17 weeks with external fixation.
Preoperative and postoperative
ankle motion was 28° and 27°,
respectively. At a mean follow-up of
64 months (range, 24 to 157
months), 77% patients reported
ambulation for pleasure, and 33%
reported an ability to run. Radio-
graphic analysis revealed that the
joint space after frame removal did
not remain distracted, although this
did not affect clinical results. The
authors claimed that the purpose
of articular cartilage repair was
to “seal cartilage cracks and
defects,”48 which was supported by
an MRI study of three patients who
were treated with ankle distrac-
tion.49 Of note, 33% were not sat-
isfied with the outcome of the
procedure. Treatment failed in two
patients (11%); one patient under-
went ankle fusion and another
underwent TAA.48
43
Foot & Ankle Mitchell Bernstein, MD, FRCSC, et al

Table 1
Summary of Outcomes and Adverse Events From Studies on Distraction Arthroplasty
No. of
Study Patients Follow-upa Agea (yr) Outcomes Adverse Events

Marijnissen 111 2 yr minimum 42.7 6 9.8 Pain and disability scores 48 patients (44%) had
et al9 decreased from 67% and subsequent arthrodesis
68% to 38% and 36%,
respectively, at 2 yr
Tellisi et al10 23 30.5 mo 43 (16–73) Decrease in pain in 91% of Pin-site infection in all patients; 2
(12–60 mo) patients of 23 patients (9%) went on to
arthrodesis
Saltzman 29 2 yr Fixed: 42.4 Better pain improvement in 19 of 29 patients (66%) had
et al32 (18–53) motion group at 2 yr; both recurrent pin-site infections; 2 of
Motion: 42.7 groups better at 2 yr than 29 patients (7%) had
(27–59) baseline osteomyelitis. 8 of 29 patients
(28%) had nerve injury of medial
calcaneal branch of the tibial
nerve and deep peroneal nerve;
1 of 29 patients (3%) had deep
vein thrombosis
Intema et al40 26 2 yr 41 6 9 Decrease in AOS pain and Not reported
disability scores; correlation
with subchondral bone
remodeling and clinical
improvement
Ploegmakers 22 10 yr 37 6 11 Decrease in pain scores from 6 of 22 patients (27%) had
et al47 (7–15 yr) 78% to 30%; increase in arthrodesis; 1 of 22 patients
function scores from 20% to (5%) had complex regional pain
73% syndrome
van Valburg 11 20 wk 35 (20–70) Pain decreased in all patients Not reported
et al44 (10–60 wk) 5 patients pain free
van Valburg 17 2 yr 40 (17–55) Decrease in physical, 4 of 17 patients (24%) had
et al46 functional, and pain disability arthrodesis; 4 of 17 patients (24%)
scores at 2 yrs (P , 0.003) had broken Kirschner wires
Paley et al48 23 64 mo (24– 45 (17–62) 71% of patients ambulating for 17 of 23 patients (74%) had pin-
157 mo) pleasure; 33% can run, 22% site infection; 1 of 23 patients
using assistive devices; 11% (4%) had arthrodesis; 1 of 23
with severe limitations patients (4%) had total ankle
arthroplasty; 10 of 23 patients
(43%) returned to operating
room for unplanned procedure
Nguyen 36 8.3 yr (6.1– Fixed: 42.4 AOS score ,43; age at time of 16 of 36 patients (45%) failed
et al50 10.5 yr) (18–53) distraction, and fixed versus treatment; 8 of 16 patients (50%)
Motion: 42.7 motion ankle distraction had ankle fusion, 5 of 16 patients
(27–59) predictive of failure at 2 yr (31%) had total ankle
postoperatively arthroplasty
Marijnissen 57 2.8 yr (2.5– 44 (18–65) Decrease in pain scores by 38% 16 of 57 patients (28%) had pin-
et al51 3.1 yr) (P , 0.0001); 69% increase in site infections; 8 of 57 patients
function (P , 0.0001); increase (14%) had broken Kirschner
in clinical condition by 120% wires
(P , 0.0001)

AOS = Ankle Osteoarthritis Scale

a
The values are given as the mean with the range in parentheses.
Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.

A hinge allows for ROM during addition, while hinge distraction in ation, histologic proof of hyaline
rehabilitation, but ROM will not likely animals supports robust and dura- cartilage regeneration in humans
increase after frame removal.10,32 In ble articular-like cartilage regener- is lacking.8,31 In a prospective

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 44

Foot & Ankle
randomized controlled trial,
Saltzman et al32 compared 36
patients who underwent distraction
arthroplasty with or without a
hinge. Two years after frame
removal, clinical scores were better
in the hinge group, although ankle
motion was similar in both groups.
However, in a subsequent report on
the same cohort with longer follow-
up, the authors reported that
patients without a hinge had
improved outcomes.50 The authors
could only speculate on the reason
for the contradictory results, and
further research on the benefit of a
hinge is necessary. In a retrospec-
tive study of 23 patients with
hinged distraction arthroplasty,
Tellisi et al10 reported that all
patients in the hinge group had
severe posttraumatic arthritis and
were being considered for ankle
arthrodesis. At a mean follow-up of
30.5 months (range, 12 to 60 months),
no patient demonstrated a change in
ankle motion. At the latest follow-up,
21 of 23 patients (91%) reported
improved pain, and 17 patients (74%)
had notable improvement in Ameri-
can Foot and Ankle Society scores.
The initial enthusiasm for ankle
distraction focused on the ability to
delay arthrodesis or TAA. Propo-
nents of distraction arthroplasty
cite several advantages, including
the minimally invasive nature of
the procedure, no required internal
fixation, and no interference with
future reconstructive efforts.10 How-
ever, studies of ankle arthrodesis and
TAA after distraction arthroplasty
are lacking.
Nevertheless, clinical failures in the
form of ankle fusion or TAA do occur
following distraction.9,10,46,50 As
noted, van Valburg et al46 reported
on 17 patients with a mean age of
39.6 years who were treated with
fixed ankle joint distraction. Four
patients (24%) required ankle fusion
within 1 year postoperatively
because of the recurrence of severe
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
pain.46 Similar rates of failure were
reported by Marijnissen et al51 and
Ploegmakers et al47 (24% and 27%,
respectively), who reported that
clinical recurrence of pain 1 year
after frame removal was the reason
for ankle arthrodesis.51 Marijnissen
et al9 recently updated their clinical
results with data from a 12-year
follow-up, noting a 44% rate of
conversion to ankle arthrodesis. In
the same study, Cox regression
analysis revealed that female sex was
predictive of failure, whereas pre-
operative ankle motion permitting
distraction was protective.9 Nguyen
et al50 reported on their cohort of 36
patients who underwent ankle dis-
traction for end-stage osteoarthritis.
At a mean follow-up of 8.3 years, 29
patients (81%) were available for
follow-up. Treatment failed in 13
patients (45%), requiring either
ankle fusion or TAA. The authors
reported that age, Ankle Osteoar-
thritis Scale score, and the presence
of a hinge to allow ankle ROM were
predictors of failure at 2 years.50
Finally, it is important to note
that published results primarily
analyze patients with severe ankle
arthritis who otherwise would be
considered candidates for arthrod-
esis (Table 1). Selection of patients
with moderate arthritis could lead
to improved long-term outcomes.
Further research is necessary.
Authors’ Preferred Surgical
Technique
The patient’s history and physical
examination, as well as the results of
appropriate imaging studies will
dictate which, if any, adjunct surgi-
cal treatments are required before
the circular frame is mounted to the
leg. Ankle equinus contracture with
a positive Silfverskiöld test is treated
with a gastrocnemius Strayer or
Vulpius recession through a postero-
medial or direct posterior surgical
Mitchell Bernstein, MD, FRCSC, et al
approach, respectively. An arthrot-
omy is used to remove impinging
anterior osteophytes. A supra-
malleolar osteotomy is added to
correct concomitant coronal or sag-
ittal malalignment.19,34 This pro-
cedure requires placement of an
additional circular ring at the
proximal tibia, with the distraction
tibial ring closer to the ankle joint
(Figure 3). The supramalleolar os-
teotomy begins with the patient in a
supine position on a radiolucent
table. A bump is placed under the
ipsilateral buttock to ensure the limb
is in neutral rotation (ie, patella
facing upward).
In addition to mechanical distrac-
tion, we prefer to inject bone marrow
autograft concentrate (BMAC) from
the ipsilateral iliac crest as described
by Hernigou et al.52 An aspirate of
60 mL of marrow yields approxi-
mately 7 mL of BMAC. This aspirate
contains pluripotent stem cells,
which are injected into the ankle
joint. We inject this percutaneously
at the end of the case, after the acute
distraction has been performed. We
routinely administer this aspirate as
part of the ankle distraction pro-
cedure. Although clinical evidence is
lacking, compelling basic science and
animal studies support the use of
BMAC to augment the cartilage
regeneration.8,29,53-55
The application of the ankle dis-
traction frame begins by choosing a
tibial ring that allows for two finger-
breadths of space circumferentially
between the skin and the ring. The
medial malleolus and the anterior
and posteromedial border of the
distal tibia are marked. The prox-
imal ring is secured with two 6-mm
hydroxyapatite-coated pins.56,57 The
first pin is placed approximately 6
cm proximal to the medial malleolus
directly anterior in the tibial crest
using a 4.8-mm drill bit. The pin is
placed perpendicular to the shaft
of the tibia and secured to the
ring with a three-hole cube. Before
45
Foot & Ankle Mitchell Bernstein, MD, FRCSC, et al

Figure 3

Preoperative AP (A) and lateral (B) standing radiographs of the ankle joint in a 62-year-old woman who sustained a closed right
distal tibia fracture in a skiing accident. Note the decreased joint space, subchondral sclerosis, cysts, and anterior ankle
osteophytes. Lateral translation, recurvatum, and anterior subluxation of the talus also are evident. Supramalleolar osteotomy was
performed to correct extremity malalignment, and ankle distraction arthroplasty was done in conjunction with arthrotomy, excision
of tibiotalar osteophytes, microfracture of the talar dome and tibial plafond, and gastrocnemius-soleus complex recession. C,
Intraoperative fluoroscopic image demonstrating bone marrow aspirate injection into the ankle joint. D, Clinical photograph of the
lower extremity after frame application. Note the additional ring and struts used to correct supramalleolar malalignment. Lateral (E)
and AP (F) radiographs of the ankle joint at 6 months postoperatively. Reduction of the tibiotalar joint and restoration of coronal
and sagittal alignment have been achieved. Joint space is increased on weight-bearing radiographs. Clinical examination
demonstrated 10° of dorsiflexion and 25° of plantar flexion. (Copyright Mitchell Bernstein, MD, FRCSC, Chicago, IL.)

final tightening, intraoperative fluo- the axis of the tibial shaft. Universal of the lateral malleolus and exiting at
roscopy is used to confirm that the hinges are then applied in line with a the tip of the medial malleolus, in a
ring is positioned perpendicular to Kirschner wire, inserted from the tip posterolateral-to-anteromedial

© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 46

Foot & Ankle
direction18 (Figure 4). This approx-
imates the Inman axis. A footplate is
secured 1 inch proximal and parallel
to the plantar aspect of the foot. A
locking rod connects the footplate to
the proximal adjustable ring, which
allows for gradual dorsiflexion to
correct equinus contractures. The
ring is unlocked four times daily
for ROM exercises (15 repetitions/
session). Typically, the ankle is
acutely distracted 3 mm in the
operating room by turning the
square nuts on the proximal ring.
Acute distraction beyond that is
discouraged to avoid neurologic
traction injury; acute correction of
equinus contracture is avoided for
the same reason. Once normal post-
operative plantar sensation is con-
firmed, an additional 2 mm of
distraction is usually done on post-
operative day 1 and another 1 mm on
postoperative day 2. At the 2-week
clinic visit, another 1 to 2 mm of dis-
traction is done. Fluoroscopy is used to
confirm that a congruent distraction
gap exists on the AP and lateral views.
Postoperatively, the patient is al-
lowed full weight bearing as toler-
ated, with crutches. The neutral
position (ie, ankle dorsiflexion) is
marked on the hinge, and the physical
therapist teaches the patient how to
unlock the hinge and do active-
assisted ROM exercises with a foot
strap. Once patients are comfortable,
they are encouraged to ambulate with
the frame’s hinge unlocked. Any
residual distraction beyond what
was done in the operating room is
undertaken by the physician in the
hospital or 2 weeks later at the first
clinical visit. We typically do not
distract .3 mm acutely. Based on a
recent biomechanical study, a rela-
tive increase of 5 mm of joint space
should be obtained relative to the
preoperative standing radiograph to
ensure that the articular surfaces of
the tibial plafond and talar body do
not come in contact during weight
bearing.35 Animal models support
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
the use of the frame in distraction for
at least 8 weeks, and no added
benefit has been seen beyond 12
weeks.8,31 We prefer to use the frame
for 12 weeks.
In addition to distraction, the
senior authors (A.T.F., S.R.R.) cur-
rently inject autologous bone mar-
row aspirate into the ankle joint and
routinely affect microfracture.
Although the mechanism of action
of hyaline cartilage regeneration
remains elusive, and clinical data
are lacking, we feel that these
adjunctive procedures may opti-
mize the local healing environment.
Complications
The most common complication
associated with ankle distraction ar-
throplasty is a superficial pin-site
infection, which typically resolves
with a course of oral antibiotics. The
reported incidence ranges from 14%
to 100%.10,32,48,50,51,58 Osteomyeli-
tis that requires hospital admission
and intravenous antibiotics is less
common, with a reported incidence
of 1.2% to 5.5%.32,48,51 Pin break-
age does occur, usually in the mid-
foot because of the motion-induced
cyclic fatigue of the Kirschner wire.
Likely underreported, the estimated
incidence is 14% to 24% in two
studies of 74 patients.51,58 Typically,
this breakage occurs at the junction
of the wire connection onto the ring
and therefore is rectified by modi-
fying the connection of the wire-
fixation bolt closer to the skin.
Complications are best avoided
with stringent and consistent patient
selection, meticulous surgical tech-
nique, and close clinical follow-up.
Patients should be screened at the
initial clinical visit for the inability to
comply with postoperative regimens.
Educational level, ability to take time
off work, living situation, and the
availability of supportive family and/
or friends are determined. Patients
Mitchell Bernstein, MD, FRCSC, et al
Figure 4
AP fluoroscopic image of the ankle
demonstrating insertion of a
Kirschner wire to approximate the
Inman axis during application of an
ankle distraction frame. The wire is
inserted from the tip of the lateral
malleolus aiming toward the distal
aspect of the medial malleolus in a
posterolateral-to-anteromedial
direction. (Copyright Mitchell
Bernstein, MD, FRCSC, Chicago, IL.)
are educated preoperatively and in
the hospital before discharge regard-
ing the appropriate use of their
external fixation device. We recom-
mend daily pin-site care using a
solution of 50% normal saline and
50% hydrogen peroxide applied with
sterile cotton-tipped swabs. To pro-
tect the soft tissues, each group of
pins should be wrapped with 2-inch
cotton gauze.
A thorough knowledge of cross-
sectional anatomy in the lower
extremity is required to avoid inad-
vertent perforation or incarceration
of neurovascular structures. Specifi-
cally, when placing the tibial ring,
the tibialis anterior tendon and
anterior neurovascular bundle are at
risk of injury. The surgeon should
have access to new, sharp 4.8-mm
47
Foot & Ankle
bits to drill pilot holes for the 6-mm
half pins in each case. This pre-
caution avoids thermal damage to
bone, premature loosening, and pin-
site infection. The foot ring is applied
with care taken to avoid the medial
neurovascular structures. However,
in our experience, patients report
heel numbness, which can be attrib-
uted to medial calcaneal branch
nerve irritation from the crossed
hindfoot wires. These symptoms
should not be mistaken for plantar
numbness at the forefoot consistent
with tibial nerve injury because the
former should resolve, whereas the
latter requires urgent release of dis-
traction and possible tarsal tunnel
decompression. Posterior tibial
nerve neurapraxia often occurs with
larger, acute distraction (.5 mm) in
patients with contracted postero-
medial soft tissues.
Summary
Ankle distraction arthroplasty is a
surgical procedure whereby the
ankle joint is temporarily mechan-
ically unloaded with an external
fixator and is performed in con-
junction with osteophyte removal,
microfracture, soft-tissue release,
and deformity correction, if neces-
sary. Although robust clinical evi-
dence is lacking, studies using
animal models support the theory
that the addition of mechanical un-
loading and alignment correction
improves the inherent ability of
human cartilage repair to occur.
The goals of the procedure are to
provide pain relief, preserve
motion, and to generate hyaline
cartilage or a durable hyaline-like
cartilaginous substance. Although
clinical studies have demonstrated
good short- to intermediate-term
clinical outcomes, the mechanisms
for success and failure remain
unknown. Further clinical research
on this procedure and the histologic
© AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
composition of the resultant gener-
ated tissue is needed.
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Reference 51 and 55 are level II
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49