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FAI December 2024 Podcast: One-Stage Tibiotalocalcaneal Arthrodesis for Severe Septic Destruction of the Ankle Joint Using a Retrograde Intramedullary Nail: A Retrospective Cross-sectional Study
00:26:53
Severe septic destruction of the ankle joint poses a therapeutic challenge but lacks a consensus optimal treatment. Tibiotalocalcaneal arthrodesis (TTCA) is considered a valuable salvage procedure, but the literature remains scarce. Conventional...
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- [00:05]
A
This is Mark Easley, Foot and Ankle International's podcast editor, and I have the distinct honor of talking with Dr. Geoffrey Buchlis, who is the lead author of December's lead paper in Foot and Ankle International. The paper is titled One stage tibiotalocalcaneal arthrodesis for Severe Septic destruction of the Ankle joint using a Retrograde Intramedullary Nail. A retrospective cross sectional study with regard to Dr. Geoffrey Buckley, he is at the Amboise Paris Hopital in Boulogne Pilancourt in France and hopefully I said that close to properly. I'll do my best when I have to speak a little French. So welcome to the program. Dr. Buckley, would you please provide the listeners with a brief summary of your paper and its major findings?
- [01:01]
B
Our paper is about one stage tibio telocalcaneal arthrodesis using a retrograde intramedullary nail in severe septic destruction at the ankle. A majority of authors in septic context prefers two stage surgery in order to eradicate infection before any fusion. External fixation by a classic external fixator or hybrid Elizarov external fixator is classically privileged because it is admitted that internal implants might pose a risk for persistence or recurrent infection. We hypothesized that one stage arthrodesis by intramedullary nail with with radical debridement of infected tissue and postoperative adapt antibiotic therapy could be an effective procedure to treat severe septic ankle destruction in a similar way to one stage septic total knee arthroplasty or total hip arthroplasty revision. We found a recurrent infection rate of 24% and a fusion rate of of 83% at two years. Follow up with only two case of below the knee amputations of 25 patients.
- [02:23]
A
Thank you, that's a great summary. As you and your co authors suggested, traditional orthopedic teaching favors a two stage management protocol for septic joint arthritis and are there examples or precedents in orthopedics that have had successful one stage procedures and if so, do you think that these may be readily extrapolated to manage similar problems in the foot and ankle?
- [02:56]
B
We routinely treat infected total knee arthroplasty or total hip arthroplasty with one stage procedure in our referral center for Bone and joint infection? Dr. Puget, one of the authors of this paper have published a series of 154 infected prosthetic knees successfully treat by one stage exchange total knee arthroplasty. Few studies describing one stage procedure in ankle arthrodesis are available in the literature. Richter and Al have published the results of a series of 45 patients with ankle infection treated by one stage arthrolysis using either two compression screws or an external fixator, either anterior plate compression screws and external fixtures. Colleague and AL in 2003 and later Cibura and AL in 2022 demonstrated successful results in their service of 15 and 13 patients treated by respectively one stage tibia tal arthrodesis and one stage tibiatalocal canal arthrodesis in septic context using elisaravibrid fixator. We fully believe that one stage surgery could be used in infection problem in the foot and the ankle.
- [04:26]
A
Perfect. So there is good experience outside of the foot and ankle. So that leads to my next question. Our readers in the United States and some other international readers and surgeons would consider a one stage debridement and arthrodesis with a metal intramedullary implant plus using allograft bone a risky procedure. In your manuscripts discussion you mentioned that you and your co authors could not find any previously published studies of one stage management of septic ankle arthritis. You did mention that there are some other techniques, but not using this metal implant plus allograft. So what aside from having a faster, a more rapid recovery, what prompted you to take this risk of this one stage procedure? It sounds like it may be some experience with your other authors and other parts of orthopedics, but what prompted you to take this one stage procedure risk?
- [05:36]
B
We think that faster recovery and faster weight bearing is very important because it prevents muscle atrophy and can accelerate fusion but stimulate bone metabolism as described in elder population with any kind of ankle fracture. One stage procedure also limits peroperative morbidity by reducing the number of surgical intervention and anesthesia the patient go by. And finally, it lows socioeconomic costs by reducing the numbers of hospital stay, the numbers of surgery and a quick recovery of autonomy in daily activities.
- [06:16]
A
That's terrific. Yes, that's that's a what we all would like to achieve. So I really commend you on pushing forward a technique that could be a great benefit to patients and also to hospital systems. Would you please describe in detail how you you clear the infection? So in your technique you mentioned debridement and then repetitive intramedullary reaming to remove potential infected tissue from the inner medullary canal. I'm familiar with that from some of my trauma experience or managing infections in long bones. That can work. Do you have any other technique tips to help the readers use your technique to best eradicate infection in a single stage?
- [07:15]
B
The key to eradicate the infection, I think, is a good exposure of the ankle. Crawford Adams approach allow us to show all the articulation. So the infected tissues removal is quite radical. Almost like in oncological surgery. Every necrotic or infected tissue is aggressively debride. And then we perform aggressive manual debridement of every bone surface with a chloric solution. And finally we wash the ankle with at least six liters of water.
- [07:59]
A
Understood? Okay, good. So those are good extra ways or having good advice to make sure the infection has the best chance to clear. Thank you. Do you believe that routine use of a suction drain with the wound closure in these patients is important or do you tell the readers they do not need to use a suction drain?
- [08:23]
B
This surgery can be quite hemorrhagic and inflammatory given the debridement, the bone cuts and the rimming. We also use a lot of water. These are the reasons we think that post operative draining is important to evacuate as much fluid as possible at an early stage.
- [08:43]
A
Good. So you routinely use a drain. Okay, good. Your technique also includes obtaining multiple tissue specimens for culture. Do you have some technique tips for the readers and the surgeons that want to use your technique to optimize obtaining the most meaningful cultures to direct the postoperative antibiotic regimen following the immediate empiric post operative IV antibiotic regimen?
- [09:14]
B
There is not any tips to obtain the most meaningful cultures. We just take deep samples with clean instruments during the surgery to obtain accurate bacteriological analysis. The postoperative antibiotic protocol is always the same with daptomycin, axepim and metronidazole initially in the absence of anaerobic. Anaerobic germs. After 48 hours of culture, metronidazole is stopped, axepim is stopped in the absence of gram negative bacteria after 72 hours of culture and intravenous daptomycin is continued at least five days. It's always the same protocol.
- [09:59]
A
Always the same. So you can standardize the protocol. That's great. Okay, thank you. That's very helpful. You and your co authors described a relatively standardized six week oral antibiotic regimen. You just described a very standardized way of obtaining the cultures and the management around the surgery, the perioperative time. Is your regimen for the oral antibiotics always six weeks or are there culture results that demand longer IV antibiotic therapy beyond the immediate empiric antibiotic regimen? In other words, are there situations where greater than six weeks of oral antibiotics are needed?
- [10:48]
B
The duration of antibiotic therapy is systematically six weeks. After six weeks, we stop all antibiotics. In every case, if the samples come back negative at seven days post operative daptomycin is relayed by intravenous Dalbavancin each 15 days. If the samples come back positive to Pseudomonas aeruginosa or some rare positive gram cocci, intravenous B antibiotic therapy is extended for two weeks. In all the other cases, an oral regiment is initiated after five days.
- [11:33]
A
Understood. So you're able to standardize this. That's very helpful. And that's obviously, it's obviously better for a protocol that could be then adopted by other surgeons. So thank you. Yes, that's very helpful to know that this, this regimen can be standardized. Next question. You described a validated team approach and I love this. I think this is very important. And thank you for including this in your article and thank you for including this in your technique to share with other surgeons because we're always curious of how we can build a team to best treat these patients, patients with a difficult problem. So you talked about a team approach to identify appropriate patients indicated for your TTCA procedure with a committee that comprises an orthopedic surgeon, an infectologist and a microbiologist. I would assume that this same team participates throughout the management of these patients with complex septic arthritis. Would you please share with the readers how they may best assemble and use a similar team throughout the management so that they may be able to validate the post operative antibiotic regimen and reproduce your results?
- [13:00]
B
First, there is an amphitheologist reference in our surgical department who ensures daily communication between microbiologists and orthopedic surgeons. Second, there is a multidisciplinary medical committee including at least one orthopedic surgeon, one microbiologist and one infectiologist which meets systematically once a week to discuss all the infectiology cases.
- [13:35]
A
Wonderful. One extra question there. Who leads that team? Does the orthopedic surgeon lead the team or do you find that the infectologist leads the team?
- [13:49]
B
There is no, no real leader. Orthopedic surgeons do the surgery for everything which concern bacteria. It's the enthusiologists who take the decision.
- [14:08]
A
Right. So that's good. So it's truly a team approach. That's wonderful. Yeah, we. Yes, we. We really we, or at least at my institution, we try to do the same thing. But it sounds that yours is your, your approach is Very standardized. And you have a team that really, truly works together on all of these complex patients that have infections. So thank you for sharing that. Very important. So you and your co authors describe complex cases with many revision procedures and patients with poor soft tissues, even some of those patients having fistulas. Is there a role? You described a team already, and it's a team that works well together. And there's an orthopedic surgeon. Is there also a role for a plastic surgeon to be part of the committee for complex soft tissue management management, and perhaps even in select cases using free tissue transfer? Or do you find that's not necessary to have a plastic surgeon on the team?
- [15:14]
B
The majority of our patients had fistulas. It could be a role for plastic surgeon. Indeed. But in our department, we are doing by ourselves basic flaps like sural or supramalleolar flaps. And moreover, as described in the surgical procedure, if closure without tension is not possible during the surgery, the distal fibula is excised and allows to gain a lot of space. And so we, most of the time we don't need any flap to close the scar.
- [15:59]
A
Right. That's very helpful. So you do have some experience with local wound flaps. That's important to know. Yeah. And for me as an orthopedic surgeon, I can follow your technique, but I'd probably have to engage a plastic surgeon to do those rotational flaps. So you have great experience. That's good to know. Thank you for sharing that. Another question. In your post operative protocol, you and your co authors describe a bivalved resin boot followed by a circular resin boot. Could you just explain what a. What is a resin boot? What is that exactly?
- [16:40]
B
Resin boot is just a cast made of resin. Circular. It's like a cast.
- [16:49]
A
So is it plaster, like what we call plaster of Paris, or is resin different than plaster of paris?
- [16:57]
B
Resin is different. It's like plaster, but a little bit lighter.
- [17:08]
A
A little bit lighter. Okay, good. That's helpful. Thank you. And then would you please also clarify your post operative weight bearing protocol as to some readers it may seem accelerated. You mentioned early that you want, or mentioned earlier that you would like to have the patient's weight bearing early. You think that's very important for patient recovery, and I agree. But to some of the readers, including myself, your protocol seems very accelerated. You say at six weeks you allow the patients to be fully weight bearing, provided there's no hardware secondary displacement. So unless there's a problem with the fixation, at six weeks, you routinely allow all patients to be fully weight bearing. Without a protective device or are they still in a boot beyond six weeks?
- [18:03]
B
Yes. 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 on their own, depending on the pain, without putting too much pressure on the ankle. They usually use two crutch, then one and after a while none. It's the usual procedure.
- [18:31]
A
Perfect. So again, standardized. So I like that. That's good. So you feel with the intramedullary device allograft, proper soft tissue management, they can weight bear early. That's good to know.
- [18:42]
B
Yes, yes. But without going too hard on the ankle, if the patients start to walk full weight bearing and start feeling pain, we encourage him to go slowly and put less pressure on the ankle. It's very gradual procedure.
- [19:06]
A
Right. So it's weight. We would call that weight bearing is tolerated? I think so. Good. So I understand that protocol. Could you clarify one more time? Are they in a protective boot past six weeks or so? You let them go without the protective boot early. After six weeks they don't have a protective boot. Okay, good. All right, thank you. With respect to outcomes, you state that you determine healing by clinical exam and then two orthopedists, or at least in your study, a two orthopedist review the radiographs to look for bridging trabeculation at the arthrodesis sites. You mentioned or acknowledged that follow up CT scan could have an advantage over radiographs. With your union rate of 83%, which is terrific for these complex cases. Do you recommend to the readership to obtain follow up CT scans to confirm fusion?
- [20:11]
B
Given the bony remodeling and the presence of significant artwork in the ankle, it can be indeed difficult to differentiate between union and asymptomatic tight, non union only CT scan can confirm fusion without depth. In practice, we don't think it's necessary to confirm fusion with CT scan if the patient is able to walk without pain. Any fusion seems to be acquired on X rays. We do not recommend surgery for asymptotic nonunion, asymptomatic nonunion, especially in this frayed patient with a multi operated ankle.
- [20:57]
A
So routine CT scan not necessary with the standardized protocol. But, but, but if it's available, maybe would help allow you to see it better. But you base it on clinical findings and the appearance of the radiograph. So that's very helpful. Of the 17 patients with non union in your study, were those all patients with persistent and and recurrent infection? Or were some of those 17% of patients, was there nonunion because of other reasons than recurrent infection?
- [21:36]
B
Among the patients with nonunion, only one was concerned by recurrent infection. Other factors that are described in the literature can be attributed to nonunion as active smoking or kidney disease, for example. However, our court was too small to statistically determine risk factors for non union.
- [22:01]
A
Understood? Yes. Let me ask that. You mentioned smoking. Do you have a team member somewhere that helps the patients limit their smoking while they're trying to heal, or do you just have to accept that some patients will smoke?
- [22:20]
B
Both of the answer yes, we try to make them quit smoking, but with with some addictologists, but sometimes the patient just refuse. We just let them smoke.
- [22:41]
A
Understood. So. So I'm glad to hear that we share some of the same challenges. Good. Yeah, we live. I live in an area that is where there are many tobacco farms, so there's a long history of cigarette smoking and so it's difficult to sometimes control the habits of our patients. But I understand that we have some of the same challenges. A few more questions. To monitor infection, you routinely evaluate cultures, the C reactive protein and white blood cells. After studying your patients, do you recommend to the readership or the listeners to this podcast to consider any other labs or tests to monitor the clearing or the persistence of infection?
- [23:35]
B
We don't use any other test during the follow up, so no.
- [23:41]
A
Good. So this is standardized as well. That's helpful. There are other tests available. I was just curious if you need to depend on those in any situations, but it sounds like you can really standardize with cultures, C reactive protein and white blood cells, so that's very helpful. Thank you. With 24% persistence or recurrence of infection, do you and your co authors have any other thoughts for future management of complex patients with septic ankle arthritis? You have standardized this technique, which is very helpful for our readership. But do you believe that if available, could you put implants in that may have antibiotics in them, such as antibiotic laden implants? Do you think they may be beneficial? And what's your opinion regarding placing antibiotic or just vancomycin powder in the surgical wound prior to closure? Is there a benefit to that?
- [24:43]
B
Antibiotic laden implants could be an option to reduce this rate of persistent infection, but we don't have any experience of using it. Some of our colleagues usually use vancomycin powder in shoulder surgery, but we don't have any experience of using it in the ankle. There is no consensus in the literature about it, but we think studies exploring this could be very Interesting. Yes.
- [25:20]
A
Good. Okay. Thank you. Yeah. Just some other thoughts. I have the same experience, meaning that I don't have any evidence to support it, but I have colleagues that have used these techniques, so we'll see what the future holds. But it seems your standardized technique is pretty effective, so maybe not too much change needed. So we'll conclude the podcast with one last question. And I want to mention that this has been a particularly meaningful podcast to me and I'm sure to the readership as well. And we really appreciate you sharing your experience in treating these complex patients. To finish, is there anything else you would like to add for the readers and the listeners of this podcast?
- [26:11]
B
I encourage them to try the technique and to see if it fits to them.
- [26:21]
A
This is great. Well, thank you. Yes, this is very progressive for many of our readers to try to do this in one stage. So we really appreciate you and your co authors and co investigators to push this forward to best help the patients, to have them mobilize early, and to have the best chance to treat and cure a very difficult problem. It.