Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

Abstrak
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. Headnote Stress Fractureof the Tibiaafter Arthrodesis of the Ankle or the Hindfoot* Headnote ABSTRACT: We studied twelve patients who had a stress fractureof the tibiaand one patient who had a stress fractureof the fibula after arthrodesis of the ankle or the foot. A second stress fracturesubsequently developed in two patients. All but two patients were managed non-operatively, and the fractureshealed 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 fractureoccurred. All of the stress fracturesthat 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 fracturemust be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis. 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 therapy7,15,20 Other indications include deformities due to tendon dysfunction"6, poliomyelitis2", cerebral palsy'", Charcot-Marie-Tooth disease23, diabetic neuropathic osteoarthropathy3,19,25, infection, and failed total ankle arthroplasty27. These arthrodeses

have been reported to restore a normal or nearly normal level of activity15,26 . However, complications, such as infection, skin slough, nerve disruption or entrapment, non-union', malalignment, degenerative changes in nearby joints, avascular necrosis of the talus, and limb-length discrepancy, have been reported1,14,20,26. 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 fractureof the tibiaor the fibula after either ankle or triple arthrodesis. Materials and Methods 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 asneeded basis. A stress fracturewas 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 fracturewas identified on routine follow-up radiographs at three and four months postoperatively. In the remaining eleven patients, the fracturewas identified on the basis of symptoms - that is, pain with areas of tenderness in a previously asymptomatic extremity. A subsequent stress fractureoccurred in two patients (Cases 1 and 6). Thus, fifteen stress fractureswere 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, thirtyfour 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 tibiawith 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 6.5millimeter 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 touchdown. This was followed by six weeks of weight-bearing in a below-the-knee walking cast or a removable belowthe-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 fracturewas identified, the patient was instructed to reduce his or her level of activity and to resume using crutches until the stress fracturewas radiographically healed. If the cause of the pain and tenderness was not identified on the plain radiographs, a technetium bone scan was performed. Results All but one of the treated joints were determined to be fused radiographically (eleven joints) or histologically (one joint) before the stress fractureoccurred. 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 fracturehealed. A stress fracturedeveloped in the tibiaof twelve patients and in the fibula of one (Table I). The stress fracturesthat 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 fracturetwo years (Case 6) and twelve years (Case 1) after the first one. Three of the stress fractureswere diagnosed on a bone scan, and twelve were detected on plain radiographs. Seven of the twelve fracturesthat 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 fracturelines.

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 tibiawas 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 fractureof 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 belowtheknee 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 fracturewithout 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 tibiawhile working in his garden. A displaced fractureof the middle and distal thirds of the tibiawas diagnosed one week later and was fixed with an intramedullary locking nail (Titanium Unreamed Nailing System, Synthes USA). The fracturehealed 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 (Figs. 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 fractureof 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

A stress fractureresults 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 steroids6,8,22, and changes in the mechanical axis of an extremity caused by a malaligned joint" (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 fracturesin the lower extremity include increased bending forces transmitted to the distal aspect of the tibiaby 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 immobilization"4; 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 overall diminished bone density and strength in the distal aspect of the tibiaas 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 fractureswere 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 fractureis in the area of the fracture, which in most of our patients was the distal aspect of the tibiaat 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 fracturemay not be identified radiographically because of the obliquity of the fractureline to the radiograph, a bone scan should be made for patients who have persistent pain.

In general, a stress fractureis 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 fracturecan 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 fracturebecause 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 fractureswere 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 fracturebecause 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 aging", 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 fractureseems 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 fractureoccurred in the medial malleolus and the distal aspect of the fibula, respectively. These were the only patients in our series in whom the stress fracturedid 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 fracturesmust 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 nonoperatively, with eventual healing. However, there is a potential for recurrent stress fracturesyears later as the underlying etiology is not fully understood. Footnote *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. References References References 1. Aaron, A. D.: Ankle fusion: a retrospective review. Orthopedics, 13: 1249-1254,1990. 2. 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. 3. 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. 4. Cameron, H. U.: Double stress fractureof the tibiain the presence of arthritis of the knee. Canadian J Surg., 36: 307-310,1993. 5. 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. 6. Dorne, H. L., and Lander, P. H.: Spontaneous stress fracturesof the femoral neck. AJR: Am. J. Roentgenol., 144: 343-347,1985. 7. 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. 8. Friedl, K. E.; Nuovo, J. A.; Patience, T. H.; and Dettori, J. R.: Factors associated with stress fracturein young army women: indications for further research. Military Med., 157: 334-338,1992. 9. 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: 301305,1994. 10. Fulford, G. E.: Surgical management of ankle and foot deformities in cerebral palsy. Clin. Orthop., 253: 55-61,1990. 11. Guttmann, G. G.: Subtalar arthrodesis in children with cerebral palsy: results using iliac bone plug. Foot and Ankle, 10: 206-210,1990. 12. Hallel, T.; Amit, S.; and Segal, D.: Fatigue fracturesof tibial and femoral shaft in soldiers. Clin. Orthop., 118: 35-43, 1976.

13. Haritidis, J. H.; Kirkos, J. M.; Provellegios, S. M.; and Zachos, A. D.: Long-term results of triple arthrodesis: 42 cases followed for 25 References years. Foot and Ankle Internat., 15: 548-551, 1994. 14. Hvid, I.; Rasmussen, O.; Jensen, N. C.; and Nielsen, S.: Trabecular bone strength profiles at the ankle joint. Clin. Orthop., 199: 306312, 1985. 15. 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. 16. 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. 17. Milgrom, C.: The Israeli elite infantry recruit: a model for understanding the biomechanics of stress fractures. J. Roy. Coll. Surg., 34 (6 Supplement): S18-S22,1989. 18. Milgrom, C.; Giladi, M.; Stein, M.; Kashtan, H.; Margulies, J. Y.; Chisin, R.; Steinberg, R.; and Aharonson, Z.: Stress fracturesin military recruits. A prospective study showing an unusually high incidence. J. Bone and Joint Surg., 67-B(5): 732-735, 1985. 19. 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. 20. 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. References 21. Papa, J. A., and Myerson, M. S.: Pantalar and tibiotalocalcaneal arthrodesis for posttraumatic osteoarthrosis of the ankle and hindfoot. J Bone and Joint Surg., 74-A: 1042-1049, Aug.1992. 22. 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. 23. 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: 175179,1993. 24. Sullivan, D4 Warren, R. F; Pavlov, H.; and Kelman, G.: Stress fracturesin 51 runners. Clin. Orthop., 187: 188-192,1984. 25. Thompson, R. C., Jr., and Clohisy, D. R.: Deformity following fracturein diabetic neuropathic osteoarthropathy. Operative management of adults who have type-I diabetes. J Bone and Joint Surg., 75-A: 1765-1773, Dec.1993.

26. Vogler, H. W.: Ankle fusion: techniques and complications. J. Foot Surg., 30: 8084,1991. 27. Wynn, A. H., and Wilde, A. H.: Long-term follow-up of the conaxial (Beck-Steffee) total ankle arthroplasty. Foot and Ankle, 13: 303306, 1992. AuthorAffiliation BY COBI LODOR. MD. PH.D. ^, LINDA R. FERRIS, M.B.B.S., F.R.A.C.S.^^ REGINALD HALL., HALL M.D.^ DURHAM, IAN J. A;EXANDER. M.D.sec AKRON, OHIO AND JAMES A. NUNLEY, M.D. ^ DURHAM, NORTH CAROLINA

Pengindeksan (detail)
Kutip MeSH Fibula -- injuries, Humans, Ankle Joint -- surgery, Aged, Tibial Fractures --surgery, Arthrodesis -- adverse effects, Fractures, Stress -- radiography, Tibial Fractures -- radiography, Fractures -- surgery, Adult, Fractures, Stress -- etiology, Fractures -radiography, Middle Aged, Female, Male Judul Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot Pengarang Lidor, Cobi; Ferris, Linda; Hall, Reginald; Ian J Alexander: James A Nunley Judul publikasi Journal of Bone and Joint Surgery Volume 79 Edisi 4 Halaman 558-64 Jumlah halaman 7 Tahun publikasi 1997 Tanggal publikasi Apr 1997 Tahun 1997 Penerbit Journal of Bone and Joint Surgery, Inc. Tempat publikasi Boston Negara publikasi United States Subjek jurnal Medical Sciences--Surgery, Medical Sciences--Orthopedics And Traumatology ISSN 00219355 CODEN JBJSA3 Jenis sumber Scholarly Journals Bahasa publikasi English Jenis dokumen Journal Article Nomor aksesi 97265464 ID dokumen ProQuest 205144389 URL Dokumen http://search.proquest.com/docview/205144389?accountid=48290 Hak cipta Copyright Journal of Bone and Joint Surgery, Inc. Apr 1997 Terakhir diperbarui 2010-06-07 Basis data ProQuest Nursing & Allied Health Source
Kami mempelajari dua belas pasien yang mengalami patah tulang stres dari tibia dan satu pasien yang mengalami patah tulang fibula stres setelah arthrodesis dari pergelangan kaki atau kaki. Sebuah fraktur stres kedua kemudian dikembangkan dalam dua pasien. Semua kecuali dua pasien

dikelola non-bedah, dan patah tulang sembuh tenang. Satu pasien yang berhasil dioperasi memiliki amputasi bawah-the-lutut untuk mengobati menyakitkan non-serikat dari fraktur tibia, dan yang lain saling memaku intramedulla untuk patah tulang pengungsi. Semua kecuali satu dari situs arthrodesis telah menyatu sebelum terjadi fraktur stres. Semua fraktur stres yang terjadi setelah pergelangan kaki arthrodesis berada di tengah dan distal aspek atau aspek distal tibia, sementara mereka yang terjadi setelah tiga arthrodesis berada di aspek distal fibula atau maleolus medial. Meskipun enam dari tiga belas pasien masih tidak dikoreksi keselarasan dan deformitas setelah arthrodesis, keselarasan yang optimal setelah arthrodesis tidak menghalangi terjadinya fraktur stres. Kami menyimpulkan bahwa fraktur stres harus dipertimbangkan dalam diagnosis diferensial dari bulan sakit atau bahkan tahun setelah fusi padat di lokasi dari pergelangan kaki atau arthrodesis tiga. Kata pembuka singkat Stres Fractureof yang arthrodesis Tibiaafter pergelangan kaki atau * hindfoot

Kata pembuka singkat Abstraksi: Kami mempelajari dua belas pasien yang mengalami stres fractureof yang tibiaand satu pasien yang memiliki fractureof stres fibula setelah arthrodesis dari pergelangan kaki atau kaki. Sebuah stres kedua fracturesubsequently dikembangkan dalam dua pasien. Semua kecuali dua pasien dikelola non-bedah, dan fractureshealed tenang. Satu pasien yang berhasil dioperasi memiliki amputasi bawah-the-lutut untuk mengobati menyakitkan non-serikat dari fraktur tibia, dan yang lain saling memaku intramedulla untuk patah tulang pengungsi. Semua kecuali satu dari situs arthrodesis telah menyatu sebelum stres fractureoccurred. Semua fracturesthat stres terjadi setelah arthrodesis dari pergelangan kaki berada di tengah dan distal aspek atau aspek distal tibia, sementara mereka yang terjadi setelah tiga arthrodesis berada di aspek distal fibula atau maleolus medial. Meskipun enam dari tiga belas pasien masih tidak dikoreksi keselarasan dan deformitas setelah arthrodesis, keselarasan yang optimal setelah arthrodesis tidak menghalangi terjadinya fraktur stres. Kami menyimpulkan bahwa stres fracturemust dipertimbangkan dalam diagnosis diferensial dari bulan sakit atau bahkan tahun setelah fusi padat di lokasi dari pergelangan kaki atau arthrodesis tiga. Tujuan dari arthrodesis sekitar pergelangan kaki atau triple (hindfoot) arthrodesis adalah foot26 menyakitkan, plantigrade, dan stabil. Prosedur-prosedur ini paling sering diindikasikan untuk menonaktifkan nyeri yang disebabkan oleh pasca-trauma osteoarthrosis, osteoarthrosis degeneratif, rheumatoid arthritis, atau nekrosis avaskular dari talus yang belum menanggapi therapy7 nonoperatif, 15,20 indikasi lainnya termasuk cacat karena disfungsi tendon " 6, poliomyelitis2 ", serebral palsy '", Charcot-Marie-Tooth disease23, osteoarthropathy3 neuropatik diabetik, 19,25, infeksi, dan gagal total halaman arthroplasty27 pergelangan kaki. arthrodeses ini telah dilaporkan untuk mengembalikan tingkat normal atau hampir normal activity15, 26 Namun,. komplikasi, seperti infeksi, kulit rawa, saraf gangguan atau jebakan, non-serikat ', malalignment, perubahan degeneratif pada sendi terdekat, nekrosis avaskular dari talus, dan anggota tubuh-panjang ketidaksesuaian, telah reported1, 14,20, 26. Beberapa komplikasi ini bisa asimtomatik, dan beberapa dapat diobati atau dikurangi dengan pantalar berikutnya, tibiotalocalcaneal, atau arthrodesis21 tibiocalcaneal. Tujuan dari penelitian ini adalah untuk menggambarkan apa yang kita yakini menjadi komplikasi, yang sebelumnya dilaporkan penting: fractureof stres tibiaor fibula setelah pergelangan kaki atau arthrodesis baik tiga. Bahan dan Metode

Seratus lima arthrodeses dari pergelangan kaki (termasuk arthrodeses tibiocalcaneal dan pantalar dilakukan secara bersamaan atau sebagai prosedur dipentaskan) dan arthrodeses enam puluh dua tiga dilakukan pada 165 pasien dengan yang lebih senior dari kita (RH, IJA, dan JAN) antara Juli 1980 dan Februari 1994 di Duke University Medical Center, Durham, North Carolina, dan Crystal Klinik, Akron, Ohio. Semua pasien yang diikuti oleh ahli bedah operasi pasca operasi dengan cara rutin, yang terdiri dari pemeriksaan dan penilaian radiografi pada tiga, enam, dan dua belas bulan. Setelah serikat radiografi dari situs arthrodesis telah dikonfirmasi, dan setelah minimal dua belas bulan, pasien diikuti pada dasar yang dibutuhkan. Sebuah fracturewas stres diidentifikasi pada pasien tiga belas pada rata-rata enam belas bulan (kisaran, 3-32 bulan) setelah arthrodesis (Tabel I). Dalam dua pasien (Kasus 3 dan 6), fracturewas diidentifikasi pada radiografi rutin tindak lanjut pada tiga dan empat bulan pasca operasi. Dalam sebelas pasien yang tersisa, fracturewas diidentifikasi berdasarkan gejala - yaitu, nyeri dengan daerah kelembutan dalam ekstremitas yang sebelumnya tanpa gejala. Sebuah stres berikutnya fractureoccurred dalam dua pasien (Kasus 1 dan 6). Jadi, lima belas fractureswere stres diidentifikasi pada pasien tiga belas melalui review grafik dan radiografi. Ada enam perempuan dan tujuh laki-laki yang rata-rata lima puluh dua tahun (rentang, 34-70 tahun). Diagnosis sebelum arthrodesis termasuk pasca-trauma osteoarthrosis (empat pasien), osteoarthrosis degeneratif (empat pasien), rheumatoid arthritis (empat pasien), dan diabetes arthropathy Charcot (satu pasien) (Tabel I).

Satu pasien (Kasus 10) memulai program yang diprakarsai sendiri latihan yang ketat sembilan belas bulan setelah arthrodesis pergelangan kaki. Dengan dua tahun pasca operasi, pasien berjalan empat mil (sekitar enam dan satu setengah kilometer) sehari tetapi mulai memiliki rasa sakit pada aspek distal tibia. Dia dihentikan programnya berjalan, tetapi rasa sakit menjadi lebih buruk dan bahkan hadir dengan berjalan normal. Ada tidak ada rasa sakit saat istirahat sehingga pasien tidak mencari perhatian medis, dan dia tidak menggunakan alat bantu untuk berjalan. Empat minggu setelah onset nyeri, pasien mengalami nyeri parah di tibiawhile bekerja di kebunnya. Sebuah fractureof pengungsi tersebut pertiga tengah dan distal tibiawas didiagnosis satu minggu kemudian dan tetap dengan penguncian kuku intramedulla (Titanium Unreamed Sistem Memaku, Synthes AS). Para fracturehealed tenang. Sebuah deformitas valgus parah dikembangkan pada satu pasien (Kasus 12), yang telah rheumatoid arthritis, karena osteonekrosis dari sisi lateral tubuh talar setelah tiga arthrodesis. Sebagai dinding lateral lereng runtuh, ligamentum deltoid memanjang dan sendi pergelangan kaki bergeser ke angulasi valgus (Gambar 3-A dan 3-B). Osteonekrosis itu dikonfirmasi secara histologis selama arthrodesis berikutnya dari pergelangan kaki, lima bulan setelah diagnosis fractureof stres ketiga distal fibula. Enam pasien memiliki malposisi dari situs arthrodesis (Tabel I). Bersama menyatu dalam equinus berlebihan dalam dua pasien, dalam angulasi valgus tidak diinginkan dalam dua, dan di malalignment varus dan equinus berlebihan dalam dua. Tersisa tujuh pasien memiliki apa yang dianggap optimal keselarasan tempat arthrodesis tersebut. diskusi
Sebuah stres fractureresults dari kelelahan mekanis tulang bila terkena pembebanan berulang, seperti dapat terjadi pada athletes24 sehat dan dalam merekrut militer, 12,17,18 Osteoporosis, administrasi kronis steroids6, 8,22, dan perubahan dalam sumbu mekanik dari ekstremitas disebabkan oleh gabungan malaligned "(seperti mungkin terjadi setelah arthrodesis) juga dapat mengakibatkan fraktur stres.

Faktor yang berhubungan dengan arthrodesis pergelangan kaki atau arthrodesis tiga, atau keduanya, yang dapat berkontribusi terhadap stres fracturesin ekstremitas bawah termasuk kekuatan lentur meningkat ditransmisikan ke aspek distal tibiaby itu, lengan tuas yang lebih panjang dari kaki lebih kaku dalam hubungannya dengan penurunan bersamaan di kekuatan mekanik tulang, yang terjadi sebagai akibat dari operasi dan imobilisasi "4; hilangnya mekanisme penyerapan shock yang normal disediakan oleh sendi pergelangan kaki dan hindfoot dengan setiap pemogokan tumit-; osteopenia berkaitan dengan tidak digunakannya atau ke penyakit yang mendasari proses, seperti rheumatoid arthritis, pasukan diperbesar dan perubahan dalam pola gaya berjalan yang berhubungan dengan malposisi dari foot5, dan keseluruhan berkurang kepadatan tulang dan kekuatan pada aspek distal tibiaas dibandingkan dengan mereka di talus15. Dalam seri ini lima belas patah tulang stres, hanya dua yang diidentifikasi dalam periode perioperatif, dan ini terdeteksi hanya sebagai perubahan radiografi. Para fractureswere stres tersisa tiga belas ditemukan karena nyeri di ekstremitas yang sebelumnya tanpa gejala. Kadang-kadang, ahli bedah ortopedi melihat seorang pasien yang memiliki rasa sakit baru meskipun telah memiliki apa yang tampaknya menjadi arthrodesis sukses. Meskipun komplikasi yang lebih umum setelah arthrodesis, seperti non-serikat, infeksi, dan malposisi, dapat menyebabkan rasa sakit, nyeri tersebut biasanya juga lokal. Sakit dari non-serikat biasanya bermanifestasi di lokasi non-serikat dan umumnya berhubungan dengan pembengkakan dan nyeri di daerah ini. Nyeri berhubungan dengan malposisi sering sepanjang batas lateral kaki, jika arthrodesis mengakibatkan varus yang berlebihan, atau di sepanjang lengkungan medial kaki, jika arthrodesis mengakibatkan valgus berlebihan. Callosities juga dapat mengembangkan pada kaki dalam menanggapi malposisi. Rasa sakit yang terkait dengan stres fractureis di daerah fraktur, yang dalam sebagian besar pasien kami adalah aspek distal tibiaat situs proksimal arthrodesis tersebut. Temuan fisik kelembutan ringan atau pembengkakan mungkin halus, dan, meskipun scan tulang terpercaya mengidentifikasi fraktur stres, seperti scan diperlukan hanya tiga dari pasien kami. Radiografi harus mencakup area yang memanjang proksimal ke daerah kelembutan. Sebagai stres fracturemay tidak diidentifikasi radiografi karena arah miring dari fractureline untuk radiografi, scan tulang harus dibuat untuk pasien yang mengalami nyeri persisten. Secara umum, stres fractureis diobati dengan pengurangan jumlah trauma berulang ke tulang, pengobatan jarang diperlukan operasi. Namun, jika pasien tidak mengurangi tingkat aktivitas, sebuah fracturecan kemajuan stres kecil untuk patah tulang, lengkap pengungsi, seperti yang terlihat di salah satu pasien kami (Kasus 10). Meskipun kami telah mengidentifikasi beberapa penyebab fraktur stres, mungkin tampak jelas bahwa malunion di lokasi dari pergelangan kaki atau arthrodesis subtalar akan mengakibatkan stres biomekanik fracturebecause diubah. Kami tidak percaya bahwa hipotesis sederhana menjelaskan data kami karena hanya enam dari tiga belas pasien kami memiliki malunion di situs arthrodesis, sedangkan tujuh yang tersisa fractureswere pada pasien yang dianggap memiliki posisi yang optimal setelah arthrodesis tersebut. Hal ini juga dapat berspekulasi bahwa seorang pasien yang telah memiliki arthrodesis dari kedua tibiotalar dan sendi subtalar (pantalar arthrodesis) juga mungkin berada pada risiko tinggi untuk fracturebecause stres dengan kapasitas menyerap goncangan berkurang. Karena hanya enam pasien dalam seri kami memiliki baik dipentaskan atau arthrodesis pantalar simultan, tidak tampak bahwa penggabungan sendi tambahan di arthrodesis serta merta predisposes untuk fraktur stres. Sebaliknya, tampaknya bahwa tulang berkurang dalam aspek anterior tibia, yang terjadi dengan penuaan ", dan osteopenia terkait dengan tidak digunakan atau proses penyakit yang mendasari seperti rheumatoid arthritis, dalam kombinasi dengan kekuatan yang meningkat yang terjadi selama kiprah setelah arthrodesis5, substansial berkontribusi pada pengembangan patah tulang stres.

Situs stres fractureseems berhubungan dengan malposisi atau rheumatoid arthritis. Parah cacat valgus pasca operasi dikembangkan dalam dua pasien (Kasus 11 dan 12), keduanya memiliki rheumatoid arthritis, dan stres fractureoccurred di maleolus medial dan aspek distal fibula, masingmasing. Ini adalah pasien hanya dalam seri kami di antaranya stres fracturedid tidak terjadi pada aspek distal tibia, dan kami percaya bahwa malpositioning dan osteopenia menyebabkan perkembangan patah tulang ini stres. Stres fracturesmust dipertimbangkan dalam diagnosis diferensial nyeri pada kaki berikutnya ke arthrodesis sukses dari pergelangan kaki atau hindfoot tersebut. Kebanyakan pasien yang mengalami sakit tersebut dapat dikelola nonoperatively, dengan penyembuhan akhirnya. Namun, ada potensi untuk stres berulang fracturesyears kemudian sebagai etiologi yang mendasari tidak sepenuhnya dipahami. Catatan kaki * Tidak ada manfaat dalam bentuk apapun telah diterima atau akan diterima dari pihak komersial yang berkaitan langsung atau tidak langsung dengan topik artikel ini. Tidak ada dana diterima dalam mendukung penelitian ini. ^ Divisi Bedah Ortopedi, Departemen Bedah, Duke University Medical Center, Durham, North Carolina 27710.