JBJS | Stress Fracture of the Tibia after Arthrodesis of the Ankle or the Hindfoot*

The Journal of Bone & Joint Surgery, Volume 79, Issue 4

Articles | April 01, 1997

Stress Fracture of the Tibia after Arthrodesis of the Ankle or the Hindfoot*

COBI LIDOR, M.D., PH.D.†; LINDA R. FERRIS, M.B.B.S., F.R.A.C.S.‡; REGINALD HALL, M.D.†, DURHAM; IAN J. ALEXANDER, M.D.§, AKRON, OHIO; JAMES A. NUNLEY, M.D.†, DURHAM, NORTH CAROLINA

View Disclosures and Other Information

Investigation performed at Crystal Clinic, Akron, and Duke University Medical Center, Durham

The Journal of Bone & Joint Surgery. 1997; 79:558-64

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

text A A A

Abstract

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture.We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The goal of arthrodesis around the ankle or of triple (hindfoot) arthrodesis is a painless, plantigrade, and stable foot²⁶. These procedures are most commonly indicated for disabling pain caused by post-traumatic osteoarthrosis, degenerative osteoarthrosis, rheumatoid arthritis, or avascular necrosis of the talus that has not responded to non-operative therapy^7,15,20. Other indications include deformities due to tendon dysfunction¹⁶, poliomyelitis^2,13, cerebral palsy^10,11, Charcot-Marie-Tooth disease²³, diabetic neuropathic osteoarthropathy^3,19,25, infection, and failed total ankle arthroplasty²⁷. These arthrodeses have been reported to restore a normal or nearly normal level of activity^15,26. However, complications, such as infection, skin slough, nerve disruption or entrapment, non-union⁷, malalignment, degenerative changes in nearby joints, avascular necrosis of the talus, and limb-length discrepancy, have been reported^1,14,20,26. Some of these complications may be asymptomatic, and some can be treated or alleviated with a subsequent pantalar, tibiotalocalcaneal, or tibiocalcaneal arthrodesis²¹.

The purpose of this study was to describe what we believe to be a previously unreported, important complication: stress fracture of the tibia or the fibula after either ankle or triple arthrodesis.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710.

‡Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, California 95817.

§Crystal Clinic, 3975 Embassy Parkway, Akron, Ohio 44333.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710.

‡Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, California 95817.

§Crystal Clinic, 3975 Embassy Parkway, Akron, Ohio 44333.

View Larger

TABLE I DATA ON THE PATIENTS

					Postoperative Position (Degrees)		Stress Fracture
Case	Gender, Age	Type of Arthrodesis	Date of Arthrodesis	Diagnosis	Equinus	Valgus-Varus	Location	Date
	(Yrs.)
1	F, 41	Subtalar	7/78	Post-traumatic osteoarthritis after open reduction and internal fixation of ankle	0	5 (valgus)	Distal third, tibia	1981
		Ankle	11/79				Middle and distal thirds, tibia	9/93

2	F, 61	Triple	3/88	Rheumatoid arthritis, multiple joints	14	3 (valgus)	Distal third, tibia	8/90
		Ankle	11/89

3	M, 67	Ankle	5/88	Degenerative osteoarthrosis	10	4 (valgus)	Distal third, tibia	8/88

4	F, 58	Tibiocalcaneal	8/88	Diabetic Charcot arthropathy	0	0 (valgus)	Middle and distal thirds, tibia	8/90

5	M, 55	Pantalar	12/89	Rheumatoid arthritis	0	2 (valgus)	Distal third, tibia	8/92

6	M, 43	Tibiocalcaneal	9/90	Degenerative osteoarthrosis	0	5 (valgus)	Distal third, tibia	1/91
							Distal third, tibia	1/93

7	M, 34	Ankle	10/90	Post-traumatic osteoarthrosis after external fixation	0	3 (valgus)	Distal third, tibia	3/92
		Subtalar	6/91

8	F, 45	Ankle and triple	8/91	Degenerative osteoarthrosis	0	4 (valgus)	Distal third, tibia	10/92

9	M, 37	Tibiocalcaneal	9/91	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle, infection of ankle after failed arthrodesis	10	5 (varus)	Distal third, tibia	12/93

10	M, 63	Ankle	10/92	Degenerative osteoarthrosis	0	5 (valgus)	Middle and distal thirds, tibia	10/93

11	F, 65	Triple	9/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	26 (valgus)	Medial malleolus	4/93

12	M, 70	Triple	11/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	12 (valgus)	Distal third, fibula	10/93

13	F, 36	Ankle	12/92	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle	25	5 (varus)	Distal third, tibia	7/93

Add to My JBJS

TABLE I DATA ON THE PATIENTS

					Postoperative Position (Degrees)		Stress Fracture
Case	Gender, Age	Type of Arthrodesis	Date of Arthrodesis	Diagnosis	Equinus	Valgus-Varus	Location	Date
	(Yrs.)
1	F, 41	Subtalar	7/78	Post-traumatic osteoarthritis after open reduction and internal fixation of ankle	0	5 (valgus)	Distal third, tibia	1981
		Ankle	11/79				Middle and distal thirds, tibia	9/93

2	F, 61	Triple	3/88	Rheumatoid arthritis, multiple joints	14	3 (valgus)	Distal third, tibia	8/90
		Ankle	11/89

3	M, 67	Ankle	5/88	Degenerative osteoarthrosis	10	4 (valgus)	Distal third, tibia	8/88

4	F, 58	Tibiocalcaneal	8/88	Diabetic Charcot arthropathy	0	0 (valgus)	Middle and distal thirds, tibia	8/90

5	M, 55	Pantalar	12/89	Rheumatoid arthritis	0	2 (valgus)	Distal third, tibia	8/92

6	M, 43	Tibiocalcaneal	9/90	Degenerative osteoarthrosis	0	5 (valgus)	Distal third, tibia	1/91
							Distal third, tibia	1/93

7	M, 34	Ankle	10/90	Post-traumatic osteoarthrosis after external fixation	0	3 (valgus)	Distal third, tibia	3/92
		Subtalar	6/91

8	F, 45	Ankle and triple	8/91	Degenerative osteoarthrosis	0	4 (valgus)	Distal third, tibia	10/92

9	M, 37	Tibiocalcaneal	9/91	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle, infection of ankle after failed arthrodesis	10	5 (varus)	Distal third, tibia	12/93

10	M, 63	Ankle	10/92	Degenerative osteoarthrosis	0	5 (valgus)	Middle and distal thirds, tibia	10/93

11	F, 65	Triple	9/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	26 (valgus)	Medial malleolus	4/93

12	M, 70	Triple	11/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	12 (valgus)	Distal third, fibula	10/93

13	F, 36	Ankle	12/92	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle	25	5 (varus)	Distal third, tibia	7/93

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 1-A and 1-B: Case 1. A forty-one-year-old woman had ankle and subtalar arthrodeses performed separately. Two stress fractures occurred in the distal aspect of the tibia. Fig. 1-A: Lateral radiograph made, with the patient standing, three years after the first arthrodesis. There was anterior cortical thickening in the distal third of the tibia (arrow).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1-B: Lateral technetium-99m bone scan, made fifteen years after the first arthrodesis, showing increased uptake of the contrast medium at the junction of the distal and middle thirds of the tibia, indicating a second fracture.

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 2-A and 2-B: Case 9. A thirty-seven-year-old man had a series of procedures before tibiocalcaneal arthrodesis in 1991. Ilizarov lengthening was performed a year later because of severe shortening of the extremity. Fig. 2-A: Lateral radiograph made, with the patient standing, two years after the arthrodesis, showing a solid tibiocalcaneal fusion.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-B: Lateral radiograph made with the leg in a fiberglass cast two years and three months after the arthrodesis. The cast was applied to treat a stress fracture (arrow) that developed proximal to the site of the arthrodesis.

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 3-A and 3-B: Case 12. A seventy-year-old man with rheumatoid arthritis who had a successful triple arthrodesis. Fig. 3-A: Anteroposterior radiograph made, with the patient standing, five months postoperatively. The ankle and the foot were in a good position.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3-B: Anteroposterior radiograph of the ankle, made with the patient standing, eleven months after the arthrodesis. There is lucency in the lateral part of the talar dome, consistent with avascular necrosis, and a stress fracture of the fibula (arrowhead) with some angulation just proximal to the ankle joint.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

One hundred and five arthrodeses of the ankle (including tibiocalcaneal and pantalar arthrodeses performed concurrently or as a staged procedure) and sixty-two triple arthrodeses were performed in 165 patients by the senior ones of us (R. H., I. J. A., and J. A. N.) between July 1980 and February 1994 at Duke University Medical Center, Durham, North Carolina, and Crystal Clinic, Akron, Ohio. All patients were followed by the operating surgeon postoperatively in a routine manner, which consisted of an examination and radiographic assessment at three, six, and twelve months. Once radiographic union of the arthrodesis site was confirmed, and after a minimum of twelve months, the patients were followed on an as-needed basis.

A stress fracture was identified in thirteen patients at a mean of sixteen months (range, three to thirty-two months) after the arthrodesis (Table I). In two patients (Cases 3 and 6), the fracture was identified on routine follow-up radiographs at three and four months postoperatively. In the remaining eleven patients, the fracture was identified on the basis of symptoms—that is, pain with areas of tenderness in a previously asymptomatic extremity. A subsequent stress fracture occurred in two patients (Cases 1 and 6). Thus, fifteen stress fractures were identified in thirteen patients through a review of the charts and radiographs. There were six women and seven men who were a mean of fifty-two years old (range, thirty-four to seventy years old). The diagnosis before the arthrodesis included post-traumatic osteoarthrosis (four patients), degenerative osteoarthrosis (four patients), rheumatoid arthritis (four patients), and diabetic Charcot arthropathy (one patient) (Table I).

Operative Technique

Although there were some variations in the operative technique, all of the arthrodeses were performed with removal of the articular cartilage, bone-grafting of any defects, and rigid internal fixation. In general, the tibiotalar arthrodeses were performed through lateral and medial incisions, with two large-diameter or cannulated, partially threaded cross-screws for internal fixation⁹. The distal aspect of the fibula was used either for an overlay graft, in which case it was fixed to the tibia with a 3.5-millimeter screw, or for morselized bone graft to fill any gaps at the site of the arthrodesis. The triple arthrodeses were performed through lateral and medial longitudinal incisions with internal fixation with either a cannulated, partially threaded 7.0-millimeter screw (Synthes USA, Monument, Colorado) or an Ace 6.5-millimeter screw from the talar body into the calcaneus, an AO/ASIF 4.5-millimeter screw from the navicular to the talus, and a staple or screw from the cuboid to the calcaneus. Internal fixation for the tibiocalcaneal or pantalar arthrodesis was achieved with a combination of screws, and, when applicable, with a staple across the calcaneocuboid joint. Either autogenous bone graft from the iliac crest or morselized fibular bone graft, or both, was used in all patients.

The desired position for arthrodesis of the ankle was 0 degrees of equinus, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation. We planned subtalar arthrodeses so that the ankle would fuse in 5 degrees of valgus, although as much as 10 degrees of valgus has been reported to be well tolerated by most patients³.

A below-the-knee cast was worn for six weeks postoperatively. The patient was allowed to walk with crutches either without bearing weight or with touch-down. This was followed by six weeks of weight-bearing in a below-the-knee walking cast or a removable below-the-knee brace with a rigid ankle joint. When necessary, the protective brace was worn for more than three months postoperatively, until radiographic union was complete.

Radiographic Follow-up

All patients had anteroposterior and lateral radiographs of the ankle and the foot made at six weeks postoperatively. All subsequent radiographs, at three, six, and twelve months, were made with the patient standing. On all anteroposterior radiographs of the ankle made with the patient standing, the tibiotalar angle was measured to determine the varus or valgus alignment of the foot. Lateral radiographs of the foot, made with the patient standing, were used to measure the tibiotalar angle after ankle arthrodesis, the talocalcaneal angle after subtalar arthrodesis, and the tibiocalcaneal angle after tibiotalocalcaneal arthrodesis. These angles were used to assess the over-all dorsiflexion or plantar flexion of the foot with respect to the extremity.

Any patient who had pain and localized tenderness after radiographic evidence of osseous union at the site of the arthrodesis had radiographs made of the painful leg. If a stress fracture was identified, the patient was instructed to reduce his or her level of activity and to resume using crutches until the stress fracture was radiographically healed. If the cause of the pain and tenderness was not identified on the plain radiographs, a technetium bone scan was performed.

Results

Introduction | Materials and Methods | Results | Discussion | References

All but one of the treated joints were determined to be fused radiographically (eleven joints) or histologically (one joint) before the stress fracture occurred. The remaining joint was in a patient (Case 7) who had a hypertrophic non-union (determined radiographically and histologically) after arthrodesis of the ankle; the non-union was treated successfully after the stress fracture healed.

A stress fracture developed in the tibia of twelve patients and in the fibula of one (Table I). The stress fractures that occurred after arthrodesis of the ankle were located in the middle and distal aspects or the distal aspect of the tibia, whereas those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Two patients had a subsequent stress fracture two years (Case 6) and twelve years (Case 1) after the first one. Three of the stress fractures were diagnosed on a bone scan, and twelve were detected on plain radiographs. Seven of the twelve fractures that were detected radiographically had only a localized area of cortical thickening involving both periosteal and endosteal reaction (Figs. 1-A and 1-B), and five had visible fracture lines.

Four of the thirteen patients had had subtalar arthrodesis before the arthrodesis of the ankle and one had subtalar arthrodesis after the arthrodesis of the ankle. One patient (Case 9) had had a series of operations that resulted in a tibiocalcaneal fusion (Figs. 2-A and 2-B), but lengthening of the proximal aspect of the tibia was performed with the Ilizarov technique because of one and one-half inches (3.8 centimeters) of shortening. Eleven months after the tibial lengthening, the patient had a stress fracture of the distal end of the tibia, unrelated to the area of lengthening or to the pin sites. A painful non-union developed, leading to a below-the-knee amputation. At the time of the amputation, the tibiocalcaneal fusion was determined to be solid. Histological examination of the amputation specimen showed non-union of the stress fracture without evidence of infection, and bacteriological examination revealed negative findings.

One patient (Case 10) began a rigorous self-initiated exercise program nineteen months after the arthrodesis of the ankle. By two years postoperatively, the patient walked four miles (approximately six and one-half kilometers) a day but began to have pain in the distal aspect of the tibia. He discontinued his walking program, but the pain became worse and was present even with normal walking. There was no pain at rest so the patient did not seek medical attention, and he did not use assistive devices to walk. Four weeks after the onset of the pain, the patient had severe pain in the tibia while working in his garden. A displaced fracture of the middle and distal thirds of the tibia was diagnosed one week later and was fixed with an intramedullary locking nail (Titanium Unreamed Nailing System, Synthes USA). The fracture healed uneventfully.

A severe valgus deformity developed in one patient (Case 12), who had rheumatoid arthritis, because of osteonecrosis of the lateral side of the talar body after triple arthrodesis. As the lateral wall of the talus collapsed, the deltoid ligament elongated and the ankle joint shifted into valgus angulation (Fig. 3-A and 3-B). The osteonecrosis was confirmed histologically during a subsequent arthrodesis of the ankle, five months after the diagnosis of the stress fracture of the distal third of the fibula.

Six patients had a malposition of the site of the arthrodesis (Table I). The joint fused in excessive equinus in two patients, in undesirable valgus angulation in two, and in varus malalignment and excessive equinus in two. The remaining seven patients had what was considered to be optimum alignment of the site of the arthrodesis.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

A stress fracture results from the mechanical fatigue of bone when it is subjected to repetitive loading, such as can occur in healthy athletes²⁴ and in military recruits^12,17,18. Osteoporosis, the chronic administration of steroids^6,8,22, and changes in the mechanical axis of an extremity caused by a malaligned joint⁴ (such as may occur after arthrodesis) can also result in a stress fracture.

Factors related to ankle arthrodesis or triple arthrodesis, or both, that may contribute to stress fractures in the lower extremity include increased bending forces transmitted to the distal aspect of the tibia by the longer lever arm of a more rigid foot in association with a concomitant decrease in the mechanical strength of the bone, which occurs as a result of the operation and immobilization¹⁴; loss of the normal shock-absorption mechanism provided by the joints of the ankle and the hindfoot with each heel-strike; osteopenia related to disuse or to an underlying disease process, such as rheumatoid arthritis; magnified forces and changes in the gait pattern related to malposition of the foot⁵; and over-all diminished bone density and strength in the distal aspect of the tibia as compared with those in the talus¹⁵.

In the present series of fifteen stress fractures, only two were identified within the perioperative period, and these were detected only as radiographic changes. The remaining thirteen stress fractures were discovered because of pain in a previously asymptomatic extremity. Occasionally, the orthopaedic surgeon sees a patient who has new pain despite having had what appeared to be a successful arthrodesis. Although the more common complications after arthrodesis, such as non-union, infection, and malposition, can cause pain, such pain is usually well localized. Pain from a non-union is usually manifest at the site of the non-union and is generally associated with swelling and tenderness in this region. Pain associated with malposition is frequently along the lateral border of the foot, if the arthrodesis resulted in excessive varus, or along the medial arch of the foot, if the arthrodesis resulted in excessive valgus. Callosities may also develop on the foot in response to malposition. Pain associated with a stress fracture is in the area of the fracture, which in most of our patients was the distal aspect of the tibia at a site proximal to the arthrodesis. The physical findings of mild tenderness or swelling may be subtle, and, although a bone scan reliably identifies stress fractures, such a scan was necessary for only three of our patients. Radiographs should include an area that extends proximal to the region of the tenderness. As the stress fracture may not be identified radiographically because of the obliquity of the fracture line to the radiograph, a bone scan should be made for patients who have persistent pain.

In general, a stress fracture is treated with reduction of the amount of repetitive trauma to the bone; operative treatment is rarely necessary. If, however, patients do not reduce their level of activity, a minor stress fracture can progress to a complete, displaced fracture, as was seen in one of our patients (Case 10).

Although we have identified several causes of stress fracture, it might seem obvious that malunion at the site of an ankle or subtalar arthrodesis would lead to a stress fracture because of altered biomechanics. We do not believe that this simple hypothesis explains our data since only six of our thirteen patients had a malunion at the arthrodesis site; the remaining seven fractures were in patients who were thought to have optimum positioning after the arthrodesis. It could also be speculated that a patient who has had an arthrodesis of both the tibiotalar and the subtalar joints (pantalar arthrodesis) might also be at a higher risk for stress fracture because of a diminished shock-absorbing capacity. As only six patients in our series had either a staged or a simultaneous pantalar arthrodesis, it does not seem that incorporation of additional joints in the arthrodesis necessarily predisposes to stress fracture. Rather, it seems that diminished bone in the anterior aspect of the tibia, which occurs with aging¹⁴, and osteopenia related to disuse or to an underlying disease process such as rheumatoid arthritis, in combination with the increased forces that occur during gait after arthrodesis⁵, substantially contribute to the development of stress fractures.

The site of the stress fracture seems to be associated with malposition or rheumatoid arthritis. Severe postoperative valgus deformities developed in two patients (Cases 11 and 12), both of whom had rheumatoid arthritis, and the stress fracture occurred in the medial malleolus and the distal aspect of the fibula, respectively. These were the only patients in our series in whom the stress fracture did not occur in the distal aspect of the tibia, and we believe that malpositioning and osteopenia led to the development of these stress fractures.

Stress fractures must be considered in the differential diagnosis of pain in the leg subsequent to a successful arthrodesis of the ankle or the hindfoot. Most patients who have such pain can be managed non-operatively, with eventual healing. However, there is a potential for recurrent stress fractures years later as the underlying etiology is not fully understood.

References

Introduction | Materials and Methods | Results | Discussion | References

Aaron, A. D.: Ankle fusion: a retrospective review. Orthopedics,13: 1249-1254, 1990.131249 1990 [PubMed]

Adelaar, R. S.; Dannelly, E. A.; Meunier, P. A.; Stelling, F. H.; Goldner, J. L.; and Colvard, D. F.: A long term study of triple arthrodesis in children. Orthop. Clin. North America,7: 895-908, 1976.7895 1976

Brodsky, J. W.: Surgical treatment and reconstruction of the diabetic foot. In Operative Foot Surgery, pp. 209-224. Edited by J. S. Gould. Philadelphia, W. B. Saunders, 1994.

Cameron, H. U.: Double stress fracture of the tibia in the presence of arthritis of the knee. Canadian J. Surg.,36: 307-310, 1993.36307 1993

Carmines, D. V.; Nunley, J. A.; and McElhaney, J. H.: Effects of ankle taping on the motion and loading pattern of the foot for walking subjects. J. Orthop. Res.,6: 223-229, 1988.6223 1988 [PubMed]

Dorne, H. L., and Lander, P. H.: Spontaneous stress fractures of the femoral neck. AJR: Am. J. Roentgenol.,144: 343-347, 1985.144343 1985 [PubMed]

Frey, C.; Halikus, N. M.; Vu-Rose, T.; and Ebramzadeh, E. A.: Review of ankle arthrodesis: predisposing factors to nonunion. Foot and Ankle Internat.,15: 581-584, 1994.15581 1994

Friedl, K. E.; Nuovo, J. A.; Patience, T. H.; and Dettori, J. R.: Factors associated with stress fracture in young army women: indications for further research. Military Med.,157: 334-338, 1992.157334 1992

Friedman, R. L.; Glisson, R. R.; and Nunley, J. A., II: A biomechanical comparative analysis of two techniques for tibiotalar arthrodesis. Foot and Ankle Internat.,15: 301-305, 1994.15301 1994

Fulford, G. E.: Surgical management of ankle and foot deformities in cerebral palsy. Clin. Orthop.,253: 55-61, 1990.25355 1990 [PubMed]

Guttmann, G. G.: Subtalar arthrodesis in children with cerebral palsy: results using iliac bone plug. Foot and Ankle,10: 206-210, 1990.10206 1990 [PubMed]

Hallel, T.; Amit, S.; and Segal, D.: Fatigue fractures of tibial and femoral shaft in soldiers. Clin. Orthop.,118: 35-43, 1976.11835 1976 [PubMed]

Haritidis, J. H.; Kirkos, J. M.; Provellegios, S. M.; and Zachos, A. D.: Long-term results of triple arthrodesis: 42 cases followed for 25 years. Foot and Ankle Internat.,15: 548-551, 1994.15548 1994

Hvid, I.; Rasmussen, O.; Jensen, N. C.; and Nielsen, S.: Trabecular bone strength profiles at the ankle joint. Clin. Orthop.,199: 306-312, 1985.199306 1985 [PubMed]

Mann, R. A.: Arthrodesis of the foot and ankle. In Surgery of the Foot and Ankle, pp. 673-713. Edited by R. A. Mann and M. J. Coughlin. St. Louis, Mosby-Year Book, 1993.

Mann, R. A.: Flatfoot in adults. In Surgery of the Foot and Ankle, pp. 757-784. Edited by R. A. Mann and M. J. Coughlin. St. Louis, Mosby-Year Book, 1993.

Milgrom, C.: The Israeli elite infantry recruit: a model for understanding the biomechanics of stress fractures. J. Roy. Coll. Surg.,34 (6 Supplement): 18-S22, 1989.34 (6 Supplement)18 1989

Milgrom, C.; Giladi, M.; Stein, M.; Kashtan, H.; Margulies, J. Y.; Chisin, R.; Steinberg, R.; and Aharonson, Z.: Stress fractures in military recruits. A prospective study showing an unusually high incidence. J. Bone and Joint Surg.,67-B(5): 732-735, 1985.67-B(5)732 1985

Myerson, M.: Arthrodesis for diabetic neuroarthropathy. In Current Therapy in Foot and Ankle Surgery, pp. 116-122. Edited by M. Myerson. St. Louis, Mosby-Year Book, 1993.

Ouzounian, T. J.: Ankle arthrodesis. In Current Therapy in Foot and Ankle Surgery, pp. 105-108. Edited by M. Myerson. St. Louis, Mosby-Year Book, 1993.

Papa, J. A., and Myerson, M. S.: Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthrosis of the ankle and hindfoot. J. Bone and Joint Surg.,74-A: 1042-1049, Aug. 1992.74-A1042 1992

Pullar, T.; Parker, J.; and Capell, H. A.: Spontaneous fractured neck of femur in rheumatoid arthritis: absence of radiographic changes on initial x-ray. Scottish Med. J.,30: 178-180, 1985.30178 1985

Santavirta, S.; Turunen, V.; Ylinen, P.; Konttinen, Y. T.; and Tallroth, K.: Foot and ankle fusions in Charcot-Marie-Tooth disease. Arch. Orthop. and Trauma Surg.,112: 175-179, 1993.112175 1993

Sullivan, D.; Warren, R. F.; Pavlov, H.; and Kelman, G.: Stress fractures in 51 runners. Clin. Orthop.,187: 188-192, 1984.187188 1984 [PubMed]

Thompson, R. C., Jr., and Clohisy, D. R.: Deformity following fracture in diabetic neuropathic osteoarthropathy. Operative management of adults who have type-I diabetes. J. Bone and Joint Surg.,75-A: 1765-1773, Dec. 1993.75-A1765 1993

Vogler, H. W.: Ankle fusion: techniques and complications. J. Foot Surg.,30: 80-84, 1991.3080 1991 [PubMed]

Wynn, A. H., and Wilde, A. H.: Long-term follow-up of the conaxial (Beck-Steffee) total ankle arthroplasty. Foot and Ankle,13: 303-306, 1992.13303 1992 [PubMed]

Topics

View Large | Download Slide(.ppt)
Add to My JBJS

View Larger

TABLE I DATA ON THE PATIENTS

					Postoperative Position (Degrees)		Stress Fracture
Case	Gender, Age	Type of Arthrodesis	Date of Arthrodesis	Diagnosis	Equinus	Valgus-Varus	Location	Date
	(Yrs.)
1	F, 41	Subtalar	7/78	Post-traumatic osteoarthritis after open reduction and internal fixation of ankle	0	5 (valgus)	Distal third, tibia	1981
		Ankle	11/79				Middle and distal thirds, tibia	9/93

2	F, 61	Triple	3/88	Rheumatoid arthritis, multiple joints	14	3 (valgus)	Distal third, tibia	8/90
		Ankle	11/89

3	M, 67	Ankle	5/88	Degenerative osteoarthrosis	10	4 (valgus)	Distal third, tibia	8/88

4	F, 58	Tibiocalcaneal	8/88	Diabetic Charcot arthropathy	0	0 (valgus)	Middle and distal thirds, tibia	8/90

5	M, 55	Pantalar	12/89	Rheumatoid arthritis	0	2 (valgus)	Distal third, tibia	8/92

6	M, 43	Tibiocalcaneal	9/90	Degenerative osteoarthrosis	0	5 (valgus)	Distal third, tibia	1/91
							Distal third, tibia	1/93

7	M, 34	Ankle	10/90	Post-traumatic osteoarthrosis after external fixation	0	3 (valgus)	Distal third, tibia	3/92
		Subtalar	6/91

8	F, 45	Ankle and triple	8/91	Degenerative osteoarthrosis	0	4 (valgus)	Distal third, tibia	10/92

9	M, 37	Tibiocalcaneal	9/91	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle, infection of ankle after failed arthrodesis	10	5 (varus)	Distal third, tibia	12/93

10	M, 63	Ankle	10/92	Degenerative osteoarthrosis	0	5 (valgus)	Middle and distal thirds, tibia	10/93

11	F, 65	Triple	9/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	26 (valgus)	Medial malleolus	4/93

12	M, 70	Triple	11/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	12 (valgus)	Distal third, fibula	10/93

13	F, 36	Ankle	12/92	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle	25	5 (varus)	Distal third, tibia	7/93

Add to My JBJS

TABLE I DATA ON THE PATIENTS

					Postoperative Position (Degrees)		Stress Fracture
Case	Gender, Age	Type of Arthrodesis	Date of Arthrodesis	Diagnosis	Equinus	Valgus-Varus	Location	Date
	(Yrs.)
1	F, 41	Subtalar	7/78	Post-traumatic osteoarthritis after open reduction and internal fixation of ankle	0	5 (valgus)	Distal third, tibia	1981
		Ankle	11/79				Middle and distal thirds, tibia	9/93

2	F, 61	Triple	3/88	Rheumatoid arthritis, multiple joints	14	3 (valgus)	Distal third, tibia	8/90
		Ankle	11/89

3	M, 67	Ankle	5/88	Degenerative osteoarthrosis	10	4 (valgus)	Distal third, tibia	8/88

4	F, 58	Tibiocalcaneal	8/88	Diabetic Charcot arthropathy	0	0 (valgus)	Middle and distal thirds, tibia	8/90

5	M, 55	Pantalar	12/89	Rheumatoid arthritis	0	2 (valgus)	Distal third, tibia	8/92

6	M, 43	Tibiocalcaneal	9/90	Degenerative osteoarthrosis	0	5 (valgus)	Distal third, tibia	1/91
							Distal third, tibia	1/93

7	M, 34	Ankle	10/90	Post-traumatic osteoarthrosis after external fixation	0	3 (valgus)	Distal third, tibia	3/92
		Subtalar	6/91

8	F, 45	Ankle and triple	8/91	Degenerative osteoarthrosis	0	4 (valgus)	Distal third, tibia	10/92

9	M, 37	Tibiocalcaneal	9/91	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle, infection of ankle after failed arthrodesis	10	5 (varus)	Distal third, tibia	12/93

10	M, 63	Ankle	10/92	Degenerative osteoarthrosis	0	5 (valgus)	Middle and distal thirds, tibia	10/93

11	F, 65	Triple	9/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	26 (valgus)	Medial malleolus	4/93

12	M, 70	Triple	11/92	Rheumatoid arthritis, ruptured posterior tibial tendon	0	12 (valgus)	Distal third, fibula	10/93

13	F, 36	Ankle	12/92	Post-traumatic osteoarthrosis after open reduction and internal fixation of ankle	25	5 (varus)	Distal third, tibia	7/93