The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 14, 2020
RESEARCH ARTICLE

Tibiotalar Arthrodesis Using a Hybrid Technique with a New Low-profile Anatomic Plate and Two Compression Screws: First One-year Results of Twenty Patients



Christoph Eckstein1, Bernd Füchtmeier1, Franz Müller1, *
1 Clinic for Trauma, Orthopaedic and Sports Medicine, Hospital Barmherzige Brüder Prüfeninger Str. 86; Regensburg 93049, Germany

Abstract

Background:

The aim of this prospective study was to evaluate and analyse the first clinical results of a recently developed low-profile anatomic plate in combination with two headless compression screws for tibiotalar arthrodesis.

Methods:

The case series involved 20 consecutive patients who underwent ankle arthrodesis using a hybrid technique. Radiographs were obtained at 6 and 12 weeks and 1 year postoperatively. The outcome was evaluated by using AOFAS and SF 12-questionnaire. Any complications related to the arthrodesis were recorded.

Results:

The follow-up rate was 100%. Patients mean age at the time of surgery was 60.1 years (range, 40-79). Arthrodesis with full weight-bearing occurred in every patient within 12 weeks postoperatively. There were no patients with delayed union, non-union, infection or implant failure. AOFAS Score and SF-12 scores increased considerably compared to preoperatively.

Conclusion:

The hybrid technique for ankle arthrodesis is a tibiotalar compression with screws in combination with rigid anterior plate fixation. Our clinical results demonstrated no implant failure, no infection and fusion in any of the 20 patients. Further studies are necessary to support our first results.

Keywords : Tibiotalar arthrodesis, plate, screws, complications, outcome.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 232
Last Page: 238
Publisher Id: TOORTHJ-13-232
DOI: 10.2174/1874325001913010232

Article History:

Received Date: 01/09/2019
Revision Received Date: 07/12/2019
Acceptance Date: 20/12/2019
Electronic publication date: 31/12/2019
Collection year: 2019

© 2019 Eckstein et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Clinic for Trauma, Orthopaedic and Sports Medicine, Hospital Barmherzige Brüder, Prüfeninger Str. 86, Regensburg 93049, Germany; Tel: 0049-941-369-2251; Fax: 0049-941-369-2255;
E-mail: dr.med.franz.mueller@gmail.com






1. INTRODUCTION

Tibiotalar arthrodesis is the most common surgery for the treatment of end-stage ankle arthritis [1Jordan RW, Chahal GS, Chapman A. Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review. Adv Orthop 2014.986285 epub 2014 Aug 21. http://doi: 10.1155/2014/986285]. Despite an increase in total ankle replacement, patients with medical comorbidities are more likely to undergo arthrodesis [2Vakhshori V, Sabour AF, Alluri RK, Hatch GF III, Tan EW. Patient and practice trends in total ankle replacement and tibiotalar arthrodesis in the United States from 2007 to 2013. J Am Acad Orthop Surg 2019; 27(2): e77-84. http://doi: 10.5435/JAAOS-D-17-00526]. More than 40 techniques for ankle arthrodesis have been described [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
]. External fixation demonstrated inferior union rates compared with internal fixation and is recommended only for complex and severe cases [4Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop 2016; 7(11): 700-8.
[http://dx.doi.org/10.5312/wjo.v7.i11.700] [PMID: 27900266]
]. Internal fixation can be performed using compression screws, as describedby Zwipp et al. and Mann et al. [5Zwipp H, Rammelt S, Endres T, Heineck J. High union rates and function scores at midterm followup with ankle arthrodesis using a four screw technique. Clin Orthop Relat Res 2010; 468(4): 958-68.
[http://dx.doi.org/10.1007/s11999-009-1074-5]
, 6Mann RA, Van Manen JW, Wapner K, Martin J. Ankle fusion. Clin Orthop Relat Res 1991; (268): 49-55.
[PMID: 2060226]
]. Other techniques are anterior plating [7Mohamedean A, Said HG, El-Sharkawi M, El-Adly W, Said GZ. Technique and short-term results of ankle arthrodesis using anterior plating. Int Orthop 2010; 34(6): 833-7.
[http://dx.doi.org/10.1007/s00264-009-0872-4]
-10Gharehdaghi M, Rahimi H, Mousavian A. Anterior ankle arthrodesis with molded plate: technique and outcomes. Arch Bone Jt Surg 2014; 2(3): 203-9.
[PMID: 25386583]
] or screw fixation in combination with a plate (hybrid arthrodesis) [11Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
]. Biomechanical analyses have shown that the latter technique offers greater stiffness and rigidity [12Clifford C, Berg S, McCann K, Hutchison B. A biomechanical comparison of internal fixation techniques for ankle arthrodesis. J Foot Ankle Surg 2015; 54(2): 188-91.
[http://dx.doi.org/10.1053/j.jfas.2014.06.002]
, 13Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 2007; 28(2): 219-23.
[http://dx.doi.org/10.3113/FAI.2007.0219] [PMID: 17296143]
]. In clinical studies, this fusion technique showed similar complication rates as screw fixation only, but improved fusion rates [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 14Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
]. In our study, we used a recently developed low-profile anatomic plate in combination with two headless compression screws for ankle arthrodesis. The aim of this prospective case series was to evaluate and analyse our first clinical results of this hybrid technique by a prospective follow-up of 1-year postoperatively.

2. PATIENTS AND METHODS

Between 2015 and 2017, a total of 20 consecutive patients underwent open ankle arthrodesis using a hybrid technique. Within this period, no other arthrodesis techniques were performed. The fusions were performed by the senior author or under his supervision.

2.1. Surgical Technique

The same surgical technique was used for any patient. The patients were placed on a radiolucent table in a supine position, with straightened ankles at the distal end of the table. An intravenous single-shot antibiotic (Cefuroxime 1.5g) was given before incision. The leg was elevated, and a tourniquet was applied on the thigh. The surgeon was positioned in the front of the foot in standing position. All surgeries were performed using magnifying glasses with head-lights. Each surgery started with a longitudinal anterior skin incision of approximately 10 cm. Nerve- and vessel-sparing approach was used after the incision of the retinaculum. Langenbeck hooks or Hohmann retractors were used for tissue retraction. A sharp wound retractor was never used. Resection of the anterior joint capsule was performed, followed by the visualisation of the anterior joint cavity. Then, resection of the anterior tibial crest was performed with a chisel. The cartilage was completely removed from both joint surfaces, and sclerotic bone portions were resected using an arthrodesis spreader, chisels, sharp spoons, and Luers. Electronic devices (e.g. drillers) were never be used as these can produce bone necrosis through heat.

The same procedure was used for the medial and lateral ankle recesses. Both joint surfaces were reconstructed under multiple subcortical drills with a 1.8-mm K-wire. Irrigation was performed to prevent heat. The interposition of autologous cancellous bone taken from the ipsilateral iliac crest for the restoration of an orthograde joint configuration was optional but commonly performed. After manual joint positioning (90° neutral position, external rotation 5-10°), both target wires for the cannulated screws were inserted from the anterior-medial and anterior-lateral tibia into the body of the talus. A slight inward convergence was selected, but without crossing the screws within the talus. X-ray image converter verification in two standard planes (anterior and lateral) and repositioning was performed based on the requirement. It was followed by length measurements, over drilling, and insertion of the headless compression screws (HCS; Merete®). The HCS are self-drilling/self-tapping, dual pitched screws with a threaded head which can be countersunk into the bone. The diameter was always 6.5 mm in various lengths (about 44 to 55 mm). Then, the new anatomical plate (Tibiatalar fusion plate; Merete®; right or left plate design, 99° angle) was attached anteriorly (Fig. 1). The plate is made of a titanium alloy. Each plate was fixed with 2 or 3 screws of appropriate length in the distal tibia (mono- or bicortical) and talus (mono-cortical), respectively. The final step included X-ray verification for documentation, drainage without suction, closure of the retinaculum with resorbable sutures, subcutaneous sutures, skin closure with simple interrupted sutures, sterile dressing, deactivation of tourniquet, and fitting of a Vacuped-Walker® (OPED, Valley, Germany) in a neutral position.

Fig. (1)
The in-situ view demonstrates the new low-profile anatomic plate with the two headless compression screws.


2.2. Follow-up Treatment

Postoperative treatment included the immobilisation of ankle joints in a Vacuped Walker for 6 weeks, with a partial weight bearing of 20 kg using forearm crutches and accompanied by lymphatic drainage. After 6 weeks, the load was gradually increased to achieve full weight-bearing in the case of regular radiological findings. Full weight-bearing in ready-made shoes started about 12 weeks postoperatively. All patients received daily injections of low-molecular-weight heparin until full-weight bearing was achieved.

2.3. Clinical and Radiological Evaluation

All patients were investigated and evaluated with a validated translation version of the American Orthopaedic Foot and Ankle Society (AOFAS) scale [15van Bergen CJ, Sierevelt IN, Hoogervorst P, Waizy H, van Dijk CN, Becher C. Translation and validation of the German version of the foot and ankle outcome score. Arch Orthop Trauma Surg 2014; 134(7): 897-901.
[http://dx.doi.org/10.1007/s00402-014-1994-8]
] approximately one week before surgery. The pain, function and clinical alignment of the foot were evaluated using this scale. The function includes daily recreational activity, maximum walking distance, walking on different surfaces, gait abnormalities, sagittal motion, hindfoot motion and ankle-hindfoot stability. Moreover, we evaluated the physical and psychological status using the SF12-questionnaire, a self-administered general health outcome form. We used a validated translation version [16Ware J Jr, Kosinski M, Keller SDA. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.
[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042]
]. Arthritis (Fig. 2a) was graded according to the Bargon and Henkemeyer scale [17Bargon G. H. Henkemeyer H. Long-term radiological and clinical observations following surgery for tibio-fibular syndesmosis after fractures of the upper ankle joint. RoFo Fortschr Geb Rontgenstr Nuklearmed 1977; 126(6): 542-5.
[http://dx.doi.org/10.1055/s-0029-1230633] [PMID: 142716]
]. After surgery, all patients were examined with a clinical and a radiological follow-up (ankle antero-posterior and lateral) 6 weeks and 12 weeks postoperatively.

The final follow-up for this study including radiographs was done exactly one year postoperatively (Fig. 2b, 2c). At this time, the patients received examination again, and patients related outcome measurements were re-elevated. Computed tomography for the evaluation of a suspected non-union was not necessary for any patient.

Fig. (2a)
Radiograph (anterior-posterior view) of end-stage ankle arthritis at right side.


Fig. (2b)
Same patient. Radiographic (anterior-posterior ankle view) documents fusion by the hybrid technique at the final follow-up (1 year postoperatively).


Fig. (2c)
Same patient. Radiographic (lateral ankle view) documents fusion by the hybrid technique at the final follow-up (1 year postoperatively).


2.4. Statistical Analysis

Statistical analysis was performed using SPSS for Windows (version 24.0; SPSS, Inc., Chicago, IL). Metric variables and measures of dispersion are reported as mean values. All tests of significance were bilateral, and p< 0.05 was statistically significant.

The study was approved by our institutional review board and performed according to the standards of the Declaration of Helsinki. All patients gave their informed consent for this study.

3. RESULTS

The mean age of the patient at the time of surgery was 60.1 years (range, 40-79), and 10 patients were women. The mean body mass index was 31.3 kg/m2 (range, 20-59). The indications for arthrodesis were post-traumatic arthritis (n=14), degenerative arthritis (n=5) and post-septic arthritis (n=1). Moreover, 7 patients had varus deformity, and 3 patients had valgus malalignment. The mean American Society of Anesthesiology (ASA) Score [18American Society of Anesthesiology. New classification of physical status. Anesthesiology 1963; 24: 111-4.] was 2.3. Comorbidities included nicotine abuse (n=7), diabetes mellitus (n=4), 1x sarcoidosis (n=1), renal transplantation (n=1) and multiple sclerosis (n=1). Further descriptive data are shown in Table 1.

A total of 14 patients also received autologous spongiosa from the ipsilateral side of the anterior ilia wing. Application of the new plate after insertion of both compression screws was associated with no complications. The average duration for complete plating was 10 to 15 minutes. The mean duration of the surgery (incision to skin closure) was 108 min (range, 60-177), and the mean hospital stay was 7.2 days (range, 4-9).

All wounds healed primarily within 14 days, and no infection was detected until the end of this study. However, one patient required a postoperative revision for hematoma at the pelvic donor side. Fusion without suspected non-union was achieved with native radiographs in any patient between 6 and 12 weeks postoperatively.

The overall mean AOFAS Score [15van Bergen CJ, Sierevelt IN, Hoogervorst P, Waizy H, van Dijk CN, Becher C. Translation and validation of the German version of the foot and ankle outcome score. Arch Orthop Trauma Surg 2014; 134(7): 897-901.
[http://dx.doi.org/10.1007/s00402-014-1994-8]
] significantly increased from 52.2 points preoperatively to 72.4 points postoperatively (p= 0.032) (Table 2). The physical subscore of the SF 12 questionnaire [16Ware J Jr, Kosinski M, Keller SDA. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.
[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042]
] showed a significant improvement from 27.0 preoperatively to 37.8 postoperatively (p= 0.042) (Table 1). The mental subscore of the SF 12 questionnaire [16Ware J Jr, Kosinski M, Keller SDA. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.
[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042]
] was without significant difference (p= 0.824).

4. DISCUSSION

This study was conducted to summarize the results of a recently implemented anatomic low-profile plate in combination with two headless compression screws for the treatment of tibiotalar arthrodesis.

Up to date, there are only two biomechanical studies that have investigated the stability of a hybrid arthrodesis. Tarkin et al. used a human anatomical specimen and showed that an additional anterior plate increases the rigidity of arthrodesis with screws only [13Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 2007; 28(2): 219-23.
[http://dx.doi.org/10.3113/FAI.2007.0219] [PMID: 17296143]
]. Clifford et al. used an artificial bone model and compared screws, plate, and hybrid arthrodesis, with the latter showing the highest rigidity [12Clifford C, Berg S, McCann K, Hutchison B. A biomechanical comparison of internal fixation techniques for ankle arthrodesis. J Foot Ankle Surg 2015; 54(2): 188-91.
[http://dx.doi.org/10.1053/j.jfas.2014.06.002]
]. Based on these results, we conducted this clinical study to investigate the effects of this hybrid technique with a low-profile anatomic plate in situ. Therefore, we also reported any possible complications in relation to the arthrodesis.

Most clinical studies have investigated arthrodesis with screws or plates [19Kusnezov N, Dunn JC, Koehler LR, Orr JD. Anatomically contoured anterior plating for isolated tibiotalar arthrodesis: a systematic review. Foot Ankle Spec 2017; 10(4): 352-8.
[http://dx.doi.org/10.1177/1938640017700974]
]. In detail, those studies demonstrated a fusion rate of 98% for isolated anterior plate arthrodesis [19Kusnezov N, Dunn JC, Koehler LR, Orr JD. Anatomically contoured anterior plating for isolated tibiotalar arthrodesis: a systematic review. Foot Ankle Spec 2017; 10(4): 352-8.
[http://dx.doi.org/10.1177/1938640017700974]
], and 88-100% for isolated screw arthrodesis, depending on the technique and the number of screws. Only three studies have investigated the combination of both techniques (Table 2). Overall, high fusion rates in these studies were also reported from 92% to 100% [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 11Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
, 14Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
], which confirm our results with a fusion rate for any of the patients (100%).

Table 1
Data of the sample size.


Table 2
Published study results of open ankle arthrodesis using a hybrid technique.



In this study, the mean period of time until fusion was within 12 weeks. However, the exact time data is not available because no radiographs were performed between 6 weeks and 12 weeks. According to hybrid arthrodesis, no studies provide exact data when fusion occurred. Careful joint preparation using magnifying glasses and head torch as well as cancellous bone augmentation had positive effects on the fusion rate, but evidence is still lacking. Bone graft was performed supplementary in 75% of patients, which was considerably higher compared with two studies reporting 18% and 36% [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 11Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
]. However, bone graft harvesting from the iliac crest was the reason for one revision in our sample; but no patient complained about donor site discomfort at the time of follow-up.

The fusion of the arthrodesis was revealed with X-ray imaging exclusively. However, if any complication had been suspected, we would have done computer tomography at 12 weeks post-surgery or later. No case of suspected infection was observed in our sample based on laboratory values or clinical examination. Comparable studies reported infection rates of 5.2% to 8.5% with surgical revision rates of 2.1% to 2.6% [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 14Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
]. Both results (no infection and highest fusion rate) are important aspects when considering the morbidity of our sample. Accordingly, 75% of our patients suffered from comorbidities such as diabetes or had nicotine abuse. The study of Mitchell et al. [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
] included fewer patients with diabetes or nicotine abuse (21% and 13%; respectively). Other studies provided no information according to comorbidities, or patients with severe diseases were excluded [11Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
]. The mean body mass index (kg/m2) of 31.3 in our study demonstrated almost obese patients, but this was similar compared with the other studies (33.0 and 32.7; respectively) [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 14Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
]. No patient complained about device-related irritations at the final follow-up. According to those irritations, two studies with anterior plate arthrodesis revealed complication rates of 15% and 21% [3Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
, 14Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
]. We conclude, that this is the result of the overall low profile of the anatomic plate (Fig. 1). However, in combination with two compression screws, it provided enough stability, considering the fusion rate of 100% with no case of implant failure.

Mean AOFAS score showed a significant improvement from 52.2 preoperatively to 72.4 postoperatively. In comparison with the study of Karakala et al. [11Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
] our mean AOFAS score was lower. Scores between 44 and 85 were reported for the different arthrodesis procedures [4Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop 2016; 7(11): 700-8.
[http://dx.doi.org/10.5312/wjo.v7.i11.700] [PMID: 27900266]
, 5Zwipp H, Rammelt S, Endres T, Heineck J. High union rates and function scores at midterm followup with ankle arthrodesis using a four screw technique. Clin Orthop Relat Res 2010; 468(4): 958-68.
[http://dx.doi.org/10.1007/s11999-009-1074-5]
]. The morbid sample can be an explanation for the obtained lower scores.

Our study had some limitations. According to the small sample and the type of study design with no randomisation or control group, our case series is not generally valid. Furthermore, our study presents only short-term results; therefore, further complications such as late infections can still occur.

CONCLUSION

The hybrid technique is a combination of tibiotalar compression with screws and an anterior plate fixation. The technique in this study described two headless compression screws and a low-profile anatomical plate. The clinical results demonstrated no failure, no infection and fusion in any of the treated 20 patients. Further studies are necessary to support our first results. The only limitation of this low-profile anatomic plate is the higher cost compared with the standard open technique using only screws.

LIST OF ABBREVIATIONS

AOFAS  = American Orthopaedic Foot and Ankle Society Scale
HCS  = Headless Compression Screws

AUTHOR'S CONTRIBUTIONS

CE undertook significant involvement in manuscript construction and revisions, data collection and analysis.

BF provided mentorship and study design.

FM provided significant guidance with manuscript writing, manuscript revisions and study design.

All authors have read and approved the final manuscript

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical approval was obtained from the local hospital ethics committee of Hospital Barmherzige Brüder Prüfeninger Germany.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Written informed consent was obtained from all the participants.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Jordan RW, Chahal GS, Chapman A. Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review. Adv Orthop 2014.986285 epub 2014 Aug 21. http://doi: 10.1155/2014/986285
[2] Vakhshori V, Sabour AF, Alluri RK, Hatch GF III, Tan EW. Patient and practice trends in total ankle replacement and tibiotalar arthrodesis in the United States from 2007 to 2013. J Am Acad Orthop Surg 2019; 27(2): e77-84. http://doi: 10.5435/JAAOS-D-17-00526
[3] Mitchell PM, Douleh DG, Thomson AB. Comparison of ankle fusion rates with and without anterior plate augmentation. Foot Ankle Int 2017; 38(4): 419-23.
[http://dx.doi.org/10.1177/1071100716681529]
[4] Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World J Orthop 2016; 7(11): 700-8.
[http://dx.doi.org/10.5312/wjo.v7.i11.700] [PMID: 27900266]
[5] Zwipp H, Rammelt S, Endres T, Heineck J. High union rates and function scores at midterm followup with ankle arthrodesis using a four screw technique. Clin Orthop Relat Res 2010; 468(4): 958-68.
[http://dx.doi.org/10.1007/s11999-009-1074-5]
[6] Mann RA, Van Manen JW, Wapner K, Martin J. Ankle fusion. Clin Orthop Relat Res 1991; (268): 49-55.
[PMID: 2060226]
[7] Mohamedean A, Said HG, El-Sharkawi M, El-Adly W, Said GZ. Technique and short-term results of ankle arthrodesis using anterior plating. Int Orthop 2010; 34(6): 833-7.
[http://dx.doi.org/10.1007/s00264-009-0872-4]
[8] Guo C, Yan Z, Barfield WR, Hartsock LA. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int 2010; 31(6): 492-8.
[http://dx.doi.org/10.3113/FAI.2010.0492]
[9] Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg Br 1999; 81(1): 113-6.
[http://dx.doi.org/10.1302/0301-620X.81B1.0810113] [PMID: 10068017]
[10] Gharehdaghi M, Rahimi H, Mousavian A. Anterior ankle arthrodesis with molded plate: technique and outcomes. Arch Bone Jt Surg 2014; 2(3): 203-9.
[PMID: 25386583]
[11] Kakarala G, Rajan DT. Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg 2006; 72(6): 716-21.
[PMID: 17260609]
[12] Clifford C, Berg S, McCann K, Hutchison B. A biomechanical comparison of internal fixation techniques for ankle arthrodesis. J Foot Ankle Surg 2015; 54(2): 188-91.
[http://dx.doi.org/10.1053/j.jfas.2014.06.002]
[13] Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle Int 2007; 28(2): 219-23.
[http://dx.doi.org/10.3113/FAI.2007.0219] [PMID: 17296143]
[14] Prissel M, Simpson GA, Sutphen SA, Hyer CF, Berlet GC. Ankle arthrodesis: a retrospective analysis comparing single column, locked anterior plating to crossed lag screw technique. J Foot Ankle Surg 2017; 56(3): 453-6.
[http://dx.doi.org/10.1053/j.jfas.2017.01.2007.01.007]
[15] van Bergen CJ, Sierevelt IN, Hoogervorst P, Waizy H, van Dijk CN, Becher C. Translation and validation of the German version of the foot and ankle outcome score. Arch Orthop Trauma Surg 2014; 134(7): 897-901.
[http://dx.doi.org/10.1007/s00402-014-1994-8]
[16] Ware J Jr, Kosinski M, Keller SDA. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.
[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042]
[17] Bargon G. H. Henkemeyer H. Long-term radiological and clinical observations following surgery for tibio-fibular syndesmosis after fractures of the upper ankle joint. RoFo Fortschr Geb Rontgenstr Nuklearmed 1977; 126(6): 542-5.
[http://dx.doi.org/10.1055/s-0029-1230633] [PMID: 142716]
[18] American Society of Anesthesiology. New classification of physical status. Anesthesiology 1963; 24: 111-4.
[19] Kusnezov N, Dunn JC, Koehler LR, Orr JD. Anatomically contoured anterior plating for isolated tibiotalar arthrodesis: a systematic review. Foot Ankle Spec 2017; 10(4): 352-8.
[http://dx.doi.org/10.1177/1938640017700974]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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