Injury 52 (2021) 1028–1037

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Injury
journal homepage: www.elsevier.com/locate/injury

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of
infection, extruded talus and complex pilon fractures
Alejandro Ordas-Bayon∗, Karl Logan, Parag Garg, Fidel Peat, Matija Krkovic
Limb Reconstruction Service, Department of Trauma and Orthopaedic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical
Campus, Hills Road, CB2 0QQ, Cambridge, Cambridgeshire, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The treatment of complex pilon fractures and talus fracture-dislocations present several
Accepted 1 February 2021 challenges, like avoiding infection, achieving union, management of bone loss and function preservation.
Methods: Retrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using
Keywords: the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four
Ankle injuries
tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases
Fractures, Open
involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0
External Fixators
Circular Fixators – 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates.
Infection Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score,
Osteomyelitis, Arthrodesis AOS) were the secondary measures.
Bone Lengthening
Results: Eradication and prevention of deep infection was achieved in all cases. Radiological union was
Limb salvage
achieved at a mean of 9 months (range 5 – 17). Solid AA was achieved in 12 of 14 cases using the
TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone
transport, mean of 63 mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 -
16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after
the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 – 77.5) with 69.3%
of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 – 10). Minimum
follow up time was 12 months (range 12 - 56).
Conclusion: AA using TSF can be considered for complex pilon fractures and extruded talus. It has shown
to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-
union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and
possibly not using bone graft. Patients must be aware that while treatment of these injuries will be pro-
longed and carries the risk of many potential complications, it provides a good alternative to amputation.
© 2021 Elsevier Ltd. All rights reserved.

Introduction sided [1]. The management of talus-fracture dislocations, especially

Tibial pilon or plafond fractures and talus fracture-dislocations
are usually the result of high-energy trauma. They are associated
with extensive soft tissue injury, bone loss and comminution, both
articular and metaphyseal. The most common method of treatment
for pilon fractures involves a staged procedure which allows the
soft tissue injury to settle. This involves applying a temporising
spanning external fixator, then performing open reduction inter-
nal fixation (ORIF) for joint reconstruction when swelling has sub-
∗
Corresponding author.
E-mail addresses: alejandro.ordas@salud.madrid.org (A. Ordas-Bayon),
k.logan1985@googlemail.com (K. Logan), paragorth@gmail.com (P. Garg),
fidelpeat@msn.com (F. Peat), Matija.krkovic@addenbrookes.nhs.uk (M. Krkovic).
in the setting of an open extruded talus is more controversial [2,3].
In both types of fractures, the short and long-term complications
of ORIF are well known. They include wound breakdown, infec-
tion, fixation failure, non-union, pain with daily activities, post-
traumatic osteoarthritis (OA) and avascular necrosis (AVN), with an
overall complication rate as high as 75% [4–6]. Particularly worry-
ing is the fact that infection after ORIF for pilon and talus fractures
has a reported incidence of 38% [3,7,8]. If infection cannot be erad-
icated, chronic osteomyelitis and infected non-union are often the
end result, and can potentially result in amputation [6,9–13].
Ankle arthrodesis (AA) remains the standard treatment for end-
stage ankle pathology [14]. This procedure is successful in relieving
pain, correcting malalignment and allows patients to regain a high
level of activity and functional independence [12]. AA can be per-

https://doi.org/10.1016/j.injury.2021.02.003
0020-1383/© 2021 Elsevier Ltd. All rights reserved.
A. Ordas-Bayon, K. Logan, P. Garg et al.
formed with a number of implants [15–19], including circular ex-
ternal fixators, which have successfully been used to treat complex
foot and ankle problems [20,21]. In the context of AA, they pro-
vide long term stable fixation without relying on implanted metal-
work, which lowers the infection risk. They also allow distraction
osteogenesis, which is a well-established method of treatment for
bone loss. Additional advantages include the possibility for later
corrections and early weight bearing (WB). Conversely, they have
well-reported complications including pain, pin site infections, pro-
longed treatment duration and docking site failure [22].
No clear evidence exists in the literature regarding the optimal
treatment for complex tibial pilon and talus fractures with asso-
ciated bone loss, soft tissue defects and comminution precluding
reconstruction.
The objective of our study is to review the outcomes of AA
using the Taylor Spatial Frame (TSF) for complex tibial pilon and
talus fractures. Our primary objective was to determine infection
and union rates. Secondary objectives were to determine function,
patient-reported outcomes (PROMs) and other postoperative com-
plications. Institutional Review Board approval was obtained prior
to the initiation of this study.
Materials and methods
A retrospective review from a UK Major Trauma Centre
database was conducted. Inclusion criteria included patients that
underwent AA through tibiotalar (TT) or tibiocalcaneal (TC) fusions
using the TSF (Smith & Nephew, Memphis, USA) from 2015 to 2019.
Patients with less than one year follow up after TSF removal were
excluded. Data collection included patients’ demographics, injury
characteristics, surgical features and outcomes.
Demographics
20 patients with AA using TSF were identified. Of those, six did
not meet the minimum follow-up time and were excluded from
the study. The remaining fourteen met inclusion criteria. 10 were
males and 4 were females. Average age was 49.4 years (range 22–
72). Mechanisms of injury were classified as 7 road traffic colli-
sions (RTC), 2 crush injuries, 4 falls from height greater than three
metres and 1 fall from standing height. Average body mass index
(BMI) at the time of admission was 30.1 (range 20–56). Comorbidi-
ties and smoking status were also collected. All patients were able
to fully weight-bear without external aids prior to injury.
Injuries
Fractures were classified according to AO/OTA classification
[23]. Five were classified as tibial pilon fractures (43C) and nine
as talus fracture-dislocations (81B/C, 82 B/C). 11 of the 14 patients
had open fractures, 7 talus and 4 pilon fractures. 9 cases with open
fractures were classified as Gustilo IIIB [24], because soft tissue
coverage surgery using local flaps (three cases) or free flaps (six
cases)was required. One case underwent isolated split skin graft-
ing (SSG). Four cases had an established infection prior to AA,
with several bacteria being identified on microbiological cultures
(E. Cloacae, E. Coli, MSSA, S. Epidermidis, Aeromonas Veronii, Cit-
robacter Braakii).
Surgical features
The mean number of operations before AA using TSF was 2.7
(range 0–8). This included all surgical procedures performed as
a result of the initial injury, such as temporary spanning exter-
nal fixators, initial open fractures debridement or infection man-
agement. Mean time from initial injury to TSF application was 6
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Injury 52 (2021) 1028–1037
weeks (range 0 – 30). In those cases that required soft tissue cov-
erage, TSF application was intentionally delayed 4–6 weeks, to al-
low flap maturation and revascularisation.
The indications for AA were varied. All five pilon fractures
and three of the talus fracture-dislocations were deemed “non-
reconstructable”. Reasons for this included massive contamination,
extensive soft tissue injury precluding acute ORIF, associated bone
loss (> 30 mm), extensive articular or metaphyseal comminution
making articular reconstruction extremely challenging and open
extruded talus. Six cases underwent AA after complications fol-
lowing talus reimplantation. These included four infections (Fig. 1),
one avascular necrosis (AVN) and one non-union. Table 1 sum-
marises cohort data.
Ankle arthrodesis using TSF - Surgical Technique
AA using TSF aimed to achieve three primary objectives. The
first was to eradicate and prevent infection. The second was to ob-
tain a stable ankle fusion. The last was to provide a pain-free func-
tional limb by providing a plantigrade foot and equal limb length.
In order to accomplish these, surgery was divided into two phases.
All cases were performed by the senior author (MK).
Debridement and joint preparation
The first part of the surgery consisted of debridement, removal
of previous metalwork (if present), microbiology specimen collec-
tion and joint surface preparation for fusion. Approaches were se-
lected according to previous surgical wounds or to accommodate
the need to excise existing sinuses. Radical debridement was per-
formed. Neither devitalised structural cortical bone fragments nor
large osteochondral fragments were retained. In the case of acute
extruded talus, no reimplantation was performed. If a sufficient
skin bridge allowed, a lateral transmalleolar approach was added
to perform fibulectomy at the level of the syndesmosis. Both the
medial and lateral malleoli were excised to minimise ankle broad-
ening and to ease shoe wearing. Articular surfaces were prepared
thoroughly with osteotomes. Oscillating saw was avoided in order
to minimise thermal damage to the bone. At least five microbiol-
ogy specimens were collected from the removed metalwork and
at the time of articular surface preparation. Once the joint was
adequately debrided and prepared, tourniquet was released, and
IV antibiotics were administered. Bone graft was added to the fu-
sion site in five cases, either from the ipsilateral femoral medullary
canal using the “Reamer-Irrigator-Aspirator” (RIA, Synthes, USA) or
from the debrided talus. Calcium sulphate pellets (Stimulan, Bio-
composites Ltd, Keele, United Kingdom) mixed with antibiotics
(Vancomycin and Gentamycin) were packed in the fusion site in
eight cases for infection prevention and treatment [25].
TSF Assembly and corticotomy
The TSF was assembled prior to debridement, for better control
of leg alignment and to minimise blood loss. The decision to pro-
ceed with TT (Fig. 2) or TC (Fig. 3) fusion was based on remaining
bone stock after debridement. Where possible TT fusion was per-
formed. This was for two reasons. Firstly, to preserve the subtalar
joint. Secondly, to retain bone stock and to minimise the need for
bone transport. The latter is particularly important given that exci-
sion of the talar body and neck creates a mean of 3 cm lower limb
discrepancy (LLD). Frames were nevertheless always assembled to
allow bone transport in the future in case it was needed (Fig. 4).
The standard TSF construct for TT fusion consisted of six to
seven rings, two for the proximal tibia, one or two distal to the
corticotomy for bone transport, one above and one below the fu-
sion site, with connecting struts in-between and a footplate dis-
tally. The frame segment proximal to the corticotomy had at least
A. Ordas-Bayon, K. Logan, P. Garg et al. Injury 52 (2021) 1028–1037

Fig. 1. 33 years-old male who sustained an infection after talus reimplantation. CT scan shows that the infection had eaten the bone away (a, b). Frame was applied and an
infection-free solid tibiocalcaneal fusion was achieved (c, d, e).

Fig. 2. Tibiotalar Fusion. Open pilon fracture (Gustilo IIIB) in a 65 years-old female (a, b) who underwent an ALT free flap and tibiotalar fusion using the TSF. CT scan shows
bone bridging across the fusion site before frame removal (c). Post-treatment radiographs and ankle inspection (d, e, f). TSF was applied for tibiocalcaneal fusion and bone
transport (d). Final radiographs after tibiocalcaneal fusion using TSF (e, f).

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 A. Ordas-Bayon, K. Logan, P. Garg et al.
Table 1
Summary Table.

Bone Follow
Initial Gustilo Previous Indication for Time to Bone Transport Rx Union TSF Time Total WB status Up
Case Sex Age BMI Comorbidities Injury Grade Surgeries Ankle Arthrodesis TSF weeks AA Type Graft mm months months Union Surgeries Post months

1 F 22 22 None Talus fracture- IIIB 1 Infected 2 TC No 40 5 6 TSF 3 FWB, 12

dislocation reimplantation unaided
2 M 55 33 None Talus fracture- IIIB 4 Infected 4 TC No 33 6 8 TSF 6 FWB, 16
dislocation reimplantation unaided
3 M 58 31 Depression Talus and Closed 0 Unreconstructable 0 TC No 0 8 11 TSF 2 FWB, 13
calcaneum unaided
fractures
4 M 37 22 None Talus fracture- IIIA 2 AVN post 3 TC No 58 8 9 TSF 5 FWB, 1 27
dislocation reimplantation crutch
5 F 22 20 Depression Talus fracture- IIIB 3 Unreconstructable 4 TC No 33 9 12 HFN 7 FWB, 24
dislocation unaided
6 F 72 30 None Pilon fracture IIIB 4 Unreconstructable 6 TC No 180 14 16 HFN 9 FWB, 2 19
1031

crutches
7 M 53 32 Depression Talus fracture- Closed 0 Unreconstructable 0 TC Yes 0 11 13 TSF 3 PWB 24
dislocation
8 M 70 27 None Talus fracture- IIIB 4 Infected 4 TC No 46 8 13 TSF 7 FWB, 26
dislocation reimplantation unaided
9 F 65 21 Alcohol- Pilon fracture IIIB 3 Unreconstructable 3 TT No 69 7 9 TSF 6 FWB, 34
induced unaided
mental
disorder
10 M 33 33 Smoker, Talus fracture- IIIB 8 Infected 30 TC No 70 8 9 TSF 10 FWB, 1 35
Psoriasis dislocation reimplantation crutch
11 M 67 32 Hypertension Talus fracture- IIIB 4 Non-union 14 TC Yes 85 9 13 TSF 7 PWB 36
dislocation
12 M 43 28 Asthma Pilon fracture IIIA 3 Unreconstructable 1 TT Yes 46 13 13 TSF 9 BKA 37
13 M 40 56 Morbid Pilon fracture Closed 1 Unreconstructable 2 TT Yes 0 13 14 TSF 4 FWB, 38
obesity unaided
14 M 55 34 None Pilon fracture IIIB 2 Unreconstructable 4 TT Yes 33 8 10 TSF 5 FWB, 56
unaided
BMI body mass index; Rx radiological; NA non-applicable; OA osteoarthritis; TC tibiocalcaneal; TT tibiotalar; TSF Taylor Spatial Frame; HFN Hindfoot Fusion Nail; AVN avascular necrosis; BKA below knee amputation.

Injury 52 (2021) 1028–1037

A. Ordas-Bayon, K. Logan, P. Garg et al.
Fig. 3. Tibiocalcaneal Fusion. 55-year-old male who sustained an open talus fracture-dislocation (a). The talus was initially reimplanted (b) but an infection developed. The
talus was excised (c) and the.
six wires, three per ring. The bone transport rings had at least
four wires and incorporated half pins from previous external fix-
ator when these were found to be stable. At least six struts were
used for compression of the fusion site. The ring distal to the struts
was positioned just above the subtalar joint with two wires. For TC
fusions, the footplate was applied in isolation and was held by six
wires (Fig. 4).
To perform the corticotomy, the corresponding bone segment
was first pretensioned by distraction between the bone transport
rings with threaded bars or clickers. A longitudinal 3-cm antero-
lateral approach was performed with sharp dissection alone, taking
care not to use diathermy to avoid damage to the periosteum. Suc-
tion was also avoided to prevent removal of fracture haematoma.
The plane between subcutaneous tissue and anterior tibial border
was then developed and the periosteum was carefully opened and
elevated. The corticotomy was initiated by drilling multiple holes
in line with a 2.5 mm drill and completed with osteotomes. Once
corticotomy was completed and confirmed using fluoroscopy, dis-
traction was released and corticotomy was compressed.
Postoperative treatment
The position of AA was tailored to each patient using the TSF
software. We did not routinely perform acute corrections of the
foot position intraoperatively. An Infectious Diseases consultation
was obtained when required. Bone transport was initiated at a rate
of 1 mm per day beginning at eight days post-op. Patients were
kept non-weightbearing while during bone transport and until ra-
diographic signs of bone healing were noted at the fusion site. We
specifically instructed patients not to weight-bear as this increases
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Injury 52 (2021) 1028–1037
the likelihood of forefoot wire breakage and pin-site irritation. To
assess LLD, a patient-led approach was used. When the patient felt
that their legs were of equal length, we asked them to sit with
their knees flexed 90° and both feet flat on the floor. When both
knees were at the same height, bone transport was stopped. For
research purposes, bone loss was assessed by measuring the length
of the bone regenerate in the final CT scan prior to TSF removal, as
determining bone loss based on surgical notes and prior radiolog-
ical imaging was found to be inaccurate. Patients were followed
regularly in outpatient clinics to monitor progress, allow physio-
therapy review and to address any other complications.
Outcome assessment
Infection was assessed clinically, radiographically and on labo-
ratory studies (white cell count, CRP, ESR). It was subdivided and
analysed in four categories: eradication of previous infection if
present (4 cases), development of new infection at the fusion site,
pin-site infections and pin site-related osteomyelitis.
Union of the AA was determined by bone healing across the fu-
sion site. When plain radiographs were highly suggestive of fusion,
a confirmation CT scan was obtained.
To assess the results of the eleven patients that underwent
bone transport, three indices were calculated. The distraction in-
dex was obtained by dividing the duration of distraction (days) by
the length of bone regeneration (cm). The consolidation or healing
index was measured by dividing the time to union by the length
of the bone transport, reflecting the time of consolidation per cen-
timetre of the distraction gap. Finally, the external fixation index
was obtained by dividing the duration of external fixation by the
A. Ordas-Bayon, K. Logan, P. Garg et al.
Fig. 4. TSF Configuration.
length of bone regeneration. Following radiological union, patients
underwent frame removal, which was performed in the operating
theatre under sedation. In the cases where a non-union was iden-
tified intraoperatively just after struts removal, no frame was reap-
plied. Instead, a below-knee back slab was applied, and patients
were scheduled for hindfoot fusion nailing. In addition to radiolog-
ical evidence, criteria for excluding non-union after TSF removal
included the absence of pain and malalignment at the fusion site
while weight-bearing. Data on final postoperative weight-bearing
status was also collected.
Functional and patient-reported outcomes were measured us-
ing two scores: a regional and disease specific score - Ankle Os-
teoarthritis Score (AOS) [27,28], and a general health outcome
measure - Short Form 36 (SF-36) [29]. The AOS is an 18-point vi-
sual analogic scale. A score of zero represents no pain or disability
and a score of 100 the worst pain and disability imaginable. SF-36
has sub-scale scores from zero to 100 where 100 indicates the best
possible levels of health. We compiled the scores and expressed
them as percentage of 100 for reproducibility. Other complications
such as LLD, residual pain and residual hindfoot deformity were
also recorded.
Results
Four TT and ten TC fusions were performed. Eradication of in-
fection was achieved in all four infected cases. No cases of fu-
sion site or pin site-related osteomyelitis were detected. Pin site
infection occurred in all 14 patients and were successfully man-
aged with short-term courses of oral antibiotics and pin site care.
Bone transport was performed in 11 patients, with a mean length
of 63 mm (range 10 - 180). Concerning the cases that under-
1033
Injury 52 (2021) 1028–1037
went bone transport, distraction, consolidation and external fixa-
tion indices are shown in Table 2. Radiological union was seen ra-
diologically at a mean of 9 months (range 5–14). TSFs were re-
moved at a mean of 11.1 months (range 6–14). Solid arthrode-
sis was achieved in 12 cases, with two cases of non-union con-
firmed, both TC fusions. The first non-union occurred in a patient
who sustained a non-reconstructable pilon fracture with a mas-
sive bone loss of 180 mm (Fig. 5). The second case of non-union
was seen in an open talus fracture-dislocation secondary to a sui-
cide attempt. Both non-unions were treated later with hindfoot fu-
sion nails (Oxbridge, Ortho Solutions Ltd, UK) and went on to suc-
cessful union. Microbiological cultures were negative in all three
cases at the time of the latter surgery. One patient underwent a
below knee amputation in the first year after TSF removal. De-
spite achieving successful union, this patient had a compartment
syndrome at the time of the initial injury which led to a painful
and non-functional foot. This case has been included for the union
and infection analysis but excluded from the functional results and
PROMs.
SF-36 and AOS data is summarised in Table 3. Mean SF-36 Gen-
eral Health Survey was 67.3 (range 40 −100). Mean AOS was 36.5
(range 6.6 – 77.5). We classified the result of the AOS score as ex-
cellent, good, fair and poor for every quartile. 69.3% of the patients
have good to excellent scores (Chart 1).
Eleven patients were able to fully weight bear (FWB) after
AA, eight unaided, two with one crutch and one requiring two
crutches. The remaining two cases mobilise partially weight bear-
ing (PWB) due to residual pain.
Other complications included a single case of refracture in a pa-
tient with a significant trauma after frame removal, who was suc-
cessfully managed conservatively. LLD discrepancy was reported in
A. Ordas-Bayon, K. Logan, P. Garg et al. Injury 52 (2021) 1028–1037

Table 2
Bone Transport Parameters.

Bone Transport Consolidation Index External Fixation Index

Case Bone Transport cm Time days Union days TSF Time days Distraction Index d/cm d/cm d/cm

1 4 65 150 180 16.2 37.5 45

2 3.3 84 180 240 25.4 54.5 72.7
4 5.8 99 240 270 17.1 41.4 46.5
5 3.3 58 270 360 17.6 81.8 109.1
6 18 180 420 480 10 23.3 26.6
8 4.6 69 240 390 15 52.2 84.8
9 6.9 99 210 270 14.3 30.4 39.1
10 7 68 240 270 9.7 34.3 38.6
11 8.5 210 270 390 24.7 31.8 45.9
12 4.6 37 390 390 8 84.8 84.8
14 3.3 30 240 300 9.1 72.7 90.9

Fig. 5. TC Non-union due to massive bone loss. 65 years-old female who sustained 180 mm distal tibia bone loss and soft tissue defect after a cycling injury (a, b). A CT
scan shows the length of the bone transport (c). Non-union / docking site failure was confirmed after frame removal (d). A hindfoot fusion nail was required to achieve solid
ankle arthrodesis. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

two of the three patients that did not undergo bone transport, both
patients requiring a heel rise permanently. Two residual hindfoot
deformities were reported, one varus and one valgus. Mean num-
ber of total operations was 5.9 (range 2–10), with the mean num-
ber of procedures for AA being 3.2. It must be remembered that
AA using TSF requires at least two procedures (frame application
and removal). Follow-up time was on average 28.3 months (range
12–56).
Discussion
Literature on AA in the setting of trauma, both acutely [1,15–
18,30] and as a salvage procedure [12,13,31–34] has focused on
union, infection and functional outcomes (Table 4). Sanders et al.
[11] presented a staged protocol for 11 acute IIIB open pilon and
talus fractures treated with TT fusion through autologous bone
grafting with dynamic compression plating. Despite infection erad-

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A. Ordas-Bayon, K. Logan, P. Garg et al. Injury 52 (2021) 1028–1037

Table 3
Functional Outcomes.

1 2 3 4 5 6 7 8 9 10 11 13 14
Short-Form 36

Physical Functioning 80 30 90 85 70 80 45 70 80 10 20 70 50
Role limitations due to physical health 100 0 100 100 75 50 25 100 25 0 75 100 100
Role limitations due to emotional problems 100 33.3 100 100 100 100 0 100 100 0 100 100 10
Energy / Fatigue 80 20 85 40 85 80 10 90 55 45 70 55 55
Emotional Well-being 84 68 100 80 88 92 12 82 96 56 96 80 88
Social Functioning 100 87.5 100 75 100 100 50 100 100 25 100 75 87.5
Pain 90 55 100 57.5 100 100 35 100 70 10 100 67.5 77.5
General Health 95 50 100 55 65 100 40 60 65 50 90 60 45
Health Change 100 0 50 75 100 100 50 50 50 50 50 75 50
AOS 10 55 23.3 20 17.7 6.6 63.3 49.4 16.8 63.8 77.5 33.3 38.3

Table 4
Literature Review on Ankle Arthrodesis as a salvage procedure.

Main Author Year N Condition AA Type Technique Deep Infection Non-Union Min FU months

Johnson1991 6 Varied TT/TC Ilizarov 0 1 19

Sanders1992 11 IIIB open pilon and talus fractures TT Dynamic compression plating 0 0 32
Mann1995 9 Varied TC Combination of IF and EF 0 0 24
Hulscher2001 19 Infected ankle ORIF TT Combination of IF and EF 1 1 42
Dennison2001 6 Talus AVN TC Ilizarov 0 0 13
Zalavras2004 6 Infected pilon ORIF TT External Fixator 0 0 24
Hamed-Salem2006 21 Ankle infection TT Ilizarov 3 2 4
Bozic2008 14 Comminuted pilon TT Fixed-angle cannulated blade plate 1 0 4.5
Rochman2008 11 Infected talar non-unions or extrusion TC Ilizarov 0 2 10.5
El-Alfy2010 12 Varied TT/TC Ilizarov 0 1 23
Thiryayi2010 [35] 10 Varied TT TSF 0 0 12
Leite2013 12 Infected talus TC Ilizarov 0 0 6
Zelle2014 17 Comminuted pilon fractures TT Blade plate 0 1 24
Beaman2014 12 Comminuted pilon fractures TT Combination of anterior plate and circular frames 0 1 6
Hasan2018 20 Varied TT Ilizarov 0 0 10
Herrera-Perez2020 6 Infected ankle ORIF TC Antibiotic cement-coated nails 0 0 8
Ordas-Bayon2020 14 Varied TT/TC TSF 0 2 12

ication and successful fusion being achieved in all cases, they
recommended delayed amputation due to significant resource re-
quirements (average of nine procedures per patient) and poor
functional results. Hulscher et al. [31] reported 29 arthrodesis at-
tempts in 19 infected osteosyntheses after ankle fractures using
various methods of internal and external fixation. At 3.5 years
follow up, one aseptic non-union and two amputations were re-
ported, one of which was secondary to an infected non-union.
In our opinion, avoiding infection should be the main prior-
ity in AA. While there are various treatment options available for
aseptic non-union (such as bone grafting, different implant usage,
etc.), amputation may be the only available solution for infected
AA. AA using external fixators and circular frames has shown to
be effective in infection eradication and prevention. Zalavras et al.
[33] published a series of six TT fusions using external fixators in
patients who were treated for infection after a fracture of the dis-
tal tibial metaphysis and plafond. At mean follow up of 5.5 years,
limb salvage and eradication of infection was accomplished in all
patients, with one patient requiring supplemental bone grafting for
delayed healing. Similarly Thiryayi et al. [35] reported 10 TT fu-
sions using TSF in 10 patients with a minimum follow-up of 12
months. Union was achieved in all cases and no deep infections
were reported.
In our study, infection rates were extremely high, with 11 out of
14 cases presenting with either pre-existing infection or infection
secondary to Gustilo III injuries. Hamed Salem et al. [12] reported
a retrospective review on 21 Ilizarov TT arthrodesis, in which the
underlying pathology was infection, with a mean follow up of 29
months. Persistent infection occurred in three cases. Two patients
developed non-union which healed after having the frame reap-
plied, one of which was an ankle septic arthritis.
Despite bone loss and infection, a solid AA was successfully
achieved in the majority of cases in our study (Table 4). We report
a 14.2% non-union rate for the index procedure (AA using TSF). We
suggest three explanations for this. Firstly, the two non-unions oc-
curred in TC fusions. TC fusion is more difficult to achieve than
TT fusion because there is less bone stock availability and less sta-
bility in the TSF construct. Distally, the footplate is used in isola-
tion, resulting in less compression at the fusion site [36,37]. We
found technically difficult to guide the tibia into the calcaneus in
the coronal plane, as the calcaneus often sits more laterally than
expected. In the sagittal plane, we also found it challenging to es-
timate whether to dock the tibia at the level of the subtalar joint
or to include the talar neck remnants as well. The second reason
for our non-union rate is that one of the three patients who had
a non-union had massive bone loss (180 mm). In our opinion, this
should be considered a docking site failure rather than a non-union
per se. Similar case reports have been published in the literature
[38–40]. Another factor that might be related to non-union is the
failure to consistently use bone graft. Bone grafting was initially
used in our protocol but it was discarded later to avoid donor site
complications (bleeding or potential femur fractures with RIA) and
to minimise infection risk even more, which ranges from 4–11%
[41]. Absence or little progression of radiological signs of healing
must also raise suspicion for nonunion.
Based on the results presented and those in the pre-existing lit-
erature, achieving solid and infection-free AA requires prolonged
treatment and significant resources.
In our series, nine patients presented with talus fracture-
dislocation as their primary injury. Smith et al. [3] reviewed 19
patients that underwent talus reimplantation following open ex-
truded talus. Two patients had documented infections and seven
had to undergo secondary procedures. No delayed amputations

1035
A. Ordas-Bayon, K. Logan, P. Garg et al.
were reported. They advocated reimplantation of the extruded
talus as a relatively safe operation with a minimal risk of infec-
tion. On the other hand, Marsh et al. [4] reviewed 18 open talar
fracture dislocations, and reported an incidence of infection of 38%
and an association between infection and extrusion of the talar
body. In line with our study, Rochman et al. [36] supported the use
of Ilizarov TC fusion after its use in 11 patients sustaining infected
talar non-unions or extrusions.
Finally, functional results, as stated in previous articles, are dif-
ficult to assess in the setting of AA. Critical factors to ensure
successful AA include alignment and length preservation. Indeed,
some patients may adapt to a stiff ankle to the extent that they re-
gain adequate function, but this requires fracture union with good
axial alignment [26]. A mild degree of equinus deformity is to be
expected when performing AA using TSF, as shown in Figs. 1-5.
However, we do not routinely add neither Achilles tendon length-
ening nor posteromedial release, as those structures are not the
primary cause for it. We think it develops when docking the trans-
ported bone. Nevertheless, usually patients do not complain of it
as the midfoot partially compensates the deformity. Zelle et al.
[16] reported similar Short Form-36 (SF-36) compared with histor-
ical ORIF cohorts in 20 patients with non-reconstructable AO/OTA
43 C2 and C3 fractures who underwent acute posterior blade plate
TT AA. We were careful to avoid using the AOFAS score for func-
tional outcome measures. Even though it is the most commonly
used score for ankle problems, it has several disadvantages [42].
Multiple studies have shown that is not a validated or reliable
score [43,44] . We have used AOS and SF36 scores instead, both
of which have been validated by multiple studies [27,45]. All nine
subscales of SF-36 scored more than 50%, with social functioning
and emotional well-being scoring over 75%. This demonstrates that
the procedure is well-tolerated by patients and that it facilitates
a return to social life. In particular, AOS score has been shown
to most accurately correlate with pain and activities of daily liv-
ing [46] in hindfoot arthrodesis. In our study, AOS scoring showed
69.3% good to excellent results. There are few studies which have
used AOS, but our results are not significantly behind large studies
for uncomplicated primary arthroscopic arthrodesis (75%) [47].
Our study has some limitations. Firstly, there are flaws inher-
ent to its retrospective design. Due to the relative rarity of these
injuries, further prospective research is required to clarify which
treatment modality should be prioritised. Secondly, the hetero-
geneity of the patient cohort. Most patients sustained high-energy
trauma, which makes difficult both to make a homogeneous study
group and to assess functional outcomes. Specifically, from our
study, some patients had ipsilateral injuries that have not been
considered while assessing both functional outcomes and PROMs.
This may represent a significant confounding factor.
Conclusion
AA using TSF can be considered as a treatment option in
complex pilon and talus fractures, especially in patients who are
high risk for infection and in those with open extruded talus. It
merges principles of limb salvage, soft tissue coverage, bone length
restoration and solid arthrodesis to achieve acceptable limb func-
tion. Although this method has been shown to be effective in in-
fection eradication, union may remain difficult to achieve in some
cases. Factors that seem to be related to AA non-union using TSF
are TC fusion, massive bone loss and potentially failure to use bone
graft. Patients should be informed that treatment will be prolonged
and counselled on realistic final functional outcomes.
Declaration of Competing Interest
None.
1036
Injury 52 (2021) 1028–1037
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