Podcast Summary: Foot & Ankle International – December 2024

"One-Stage Tibiotalocalcaneal Arthrodesis for Severe Septic Destruction of the Ankle Joint Using a Retrograde Intramedullary Nail"

Date: December 11, 2024
Host: Dr. Mark Easley
Guest: Dr. Geoffrey Buchlis (Lead author, Amboise Paris Hopital, France)

Overview

In this episode, Dr. Mark Easley interviews Dr. Geoffrey Buchlis about his team's recent study on a novel, one-stage surgical approach for managing severe septic destruction of the ankle joint. The approach involves tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail and focuses on challenging cases typically handled using multi-stage procedures. The discussion covers the rationale, detailed surgical techniques, standardized protocols, outcomes, and future directions for one-stage management of complex septic ankle arthritis.

Key Discussion Points & Insights

1. Study Summary & Major Findings

• Traditional Approach: Two-stage surgery with preference for external fixation is the norm, given the risk of persistent/recurrent infection with internal implants.
• Study Hypothesis: A one-stage approach with radical debridement, retrograde intramedullary nailing, and postoperative antibiotics may effectively treat severe septic ankle destruction.
• Results:
  • Recurrent infection rate: 24%
  • Fusion rate: 83% at two years
  • Only two amputations among 25 patients
• Quote (01:01, Dr. Buchlis):

  “We hypothesized that one stage arthrodesis... could be an effective procedure... We found a recurrent infection rate of 24% and a fusion rate of 83% at two years.”

2. Precedents for One-Stage Procedures

• Orthopedic Context:
  • Many infected knee or hip replacements are now treated with a one-stage protocol in their center.
  • Previous studies in the literature support one-stage arthrodesis using external fixators but not with internal metal implants.
• Extrapolation to Foot & Ankle:
  • Authors believe the one-stage principle is transferable, despite few prior reports employing intramedullary devices.
• Quote (02:56, Dr. Buchlis):

  “We routinely treat infected total knee arthroplasty or hip arthroplasty with one stage procedure... We fully believe that one stage surgery could be used in infection problem in the foot and the ankle.”

3. Rationale & Risk Assessment

• Motivations for One-Stage Procedure:
  • Faster recovery and early weight-bearing, preserving muscle and promoting bone metabolism.
  • Single surgery decreases operative morbidity, anesthesia risk, hospitalization, and overall cost.
• Quote (05:36, Dr. Buchlis):

  “Faster recovery and faster weight bearing is very important... One stage procedure also limits peroperative morbidity... and lowers socioeconomic costs…”

4. Detailed Surgical Technique & Tips

• Eradicating Infection:

  • Radical exposure and debridement (“almost like in oncological surgery”)
  • Manual debridement with chloric solution
  • Lavage with at least six liters of water

• Quote (07:14, Dr. Buchlis):

  “The key... is a good exposure... almost like in oncological surgery. Every necrotic or infected tissue is aggressively debrided... washed... with at least six liters of water.”

• Postoperative Drains:

  • Routinely used due to expected hemorrhage and inflammation.
  • Drains help evacuate fluid early postoperatively.

5. Antibiotic Protocols & Culture Techniques

• Standardized Regimen:
  • Deep tissue samples with clean instruments.
  • Initial empirical therapy: daptomycin, cefepime, and metronidazole.
  • Adjust based on culture results at 48–72 hours.
  • Routine oral antibiotics for six weeks; regimen only extended for specific pathogens.
• Quote (10:47, Dr. Buchlis):

  “The duration of antibiotic therapy is systematically six weeks. After six weeks, we stop all antibiotics.”

6. Multidisciplinary Team Approach

• Committee Structure:
  • Includes orthopedic surgeon, microbiologist, and infectologist.
  • Weekly meetings to discuss each complex case.
• No Single Leader:
  • Surgical and infectious decisions divided by specialty.
• Quote (13:00, Dr. Buchlis):

  “There is a multidisciplinary medical committee... meets systematically once a week to discuss all the infectiology cases.”

7. Soft Tissue & Wound Management

• Plastic Surgical Involvement:
  • Most basic flaps (e.g., sural, supramalleolar) are handled by the ortho team.
  • Plastic surgeon rarely required due to routine excision of the distal fibula for wound closure.
• Quote (15:14, Dr. Buchlis):

  “The majority... had fistulas. It could be a role for plastic surgeon. Indeed. But in our department, we are doing by ourselves basic flaps...”

8. Postoperative Immobilization & Weight-Bearing

• Immobilization:
  • A "resin boot" (cast made of resin, lighter than plaster of Paris) used postoperatively.
• Accelerated Protocol:
  • Full weight-bearing encouraged at six weeks, progressing as tolerated even without protective boot.
• Quote (18:03, Dr. Buchlis):

  “All the patients were allowed to be full weight bearing after six weeks and encouraged to do it. In practice, patients gradually resume full weight bearing... depending on the pain...”

9. Assessing Fusion & Outcomes

• Clinical and Radiographic Evaluation:
  • Fusion assessed via both clinical signs and review by two orthopedists.
  • Routine CT scanning not necessary if patient is asymptomatic.
  • Of nonunions, most were unrelated to infection; other factors (e.g., smoking, kidney disease) implicated.
• Quote (20:11, Dr. Buchlis):

  “In practice, we don't think it's necessary to confirm fusion with CT scan if the patient is able to walk without pain.”

10. Smoking & Comorbidities

• Protocols to Limit Smoking:
  • Efforts made to encourage cessation, but patient autonomy respected.
• Quote (22:19, Dr. Buchlis):

  “We try to make them quit smoking... but sometimes the patient just refuse. We just let them smoke.”

11. Monitoring for Infection

• Follow-Up Tests:
  • Only cultures, CRP (C-reactive protein), and WBC (white blood cell count) used in follow-up.
  • No additional routine testing.
• Quote (23:34, Dr. Buchlis):

  “We don't use any other test during the follow up...”

12. Future Considerations & Adjuncts

• Potential for Antibiotic-Laden Implants:
  • No experience with these in the current cohort, but future studies warranted.
  • Vancomycin powder sometimes used in other joints, but no direct evidence for the ankle yet.
• Quote (24:43, Dr. Buchlis):

  “Antibiotic laden implants could be an option... but we don't have any experience of using it... studies exploring this could be very interesting.”

Notable Quotes & Memorable Moments

• On clinical innovation:

  "We hypothesized that one stage arthrodesis... could be an effective procedure... We found a recurrent infection rate of 24% and a fusion rate of 83% at two years."
  — Dr. Geoffrey Buchlis (01:01)

• On standardized protocols and accelerated care:

  “All the patients were allowed to be full weight bearing after six weeks and encouraged to do it...”
  — Dr. Geoffrey Buchlis (18:03)

• On key aspects of one-stage infection eradication:

  “Almost like in oncological surgery. Every necrotic or infected tissue is aggressively debrided... washed... with at least six liters of water.”
  — Dr. Geoffrey Buchlis (07:14)

• On teamwork:

  “There is a multidisciplinary medical committee... meets systematically once a week to discuss all the infectiology cases.”
  — Dr. Geoffrey Buchlis (13:00)

Important Timestamps

• [01:01] – Study summary and findings
• [02:56] – Precedents in one-stage procedures
• [05:36] – Rationale for taking a one-stage approach
• [07:14] – Detailed infection eradication technique
• [08:23] – Use of postoperative drains
• [09:14] – Tissue culture and antibiotic protocol
• [10:47] – Oral antibiotic regimen and duration
• [13:00] – Multidisciplinary team structure
• [15:14] – Role of plastic surgery and flap management
• [16:40] – Explanation of "resin boot"
• [18:03] – Postoperative weight-bearing protocol
• [20:11] – Assessing fusion, imaging considerations
• [22:19] – Smoking cessation challenges
• [23:34] – Monitoring for infection postoperatively
• [24:43] – Future directions, including antibiotic-laden implants

Final Thoughts

• Dr. Buchlis encourages other surgeons to try this standardized one-stage technique and see if it fits their practice.
• The episode highlights a progressive, multidisciplinary, and patient-centered approach to managing a complex and traditionally high-risk orthopedic problem.

Quote (26:10, Dr. Buchlis):

“I encourage them to try the technique and to see if it fits to them.”

This episode provides a thorough, well-structured look into the rationale, execution, outcomes, and future possibilities of one-stage intramedullary nail arthrodesis in severe septic ankle destruction—delivering actionable insights for both seasoned and aspiring foot and ankle surgeons.