Paper of the Week: Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis

Paper of the Week: Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis

ICM Philly December 29, 2020

Rebecca Hartmann, Florian Grubhofer, Felix W. A. Waibel, Tobias Götschi, Arnd F. Viehöfer, Stephan H. Wirth

J Orthop Res. 2020; 1– 8.

Summary by Paul D. Minetos, MD, MBA

Infection of the ankle or hindfoot after plate and screw osteosynthesis, total ankle arthroplasty, or hindfoot arthrodesis can lead to loss of limb and other serious consequences.1,2 Currently there is no consensus regarding optimal surgical management of bacterial infection of the ankle and/or hindfoot.2-5 This study aims to compare infection control rates as well as clinical and radiographic outcomes between two methods of arthrodesis in the treatment of hindfoot and ankle infection: a one-stage approach with Ilizarov external fixation versus a two-stage approach with cement spacer placement followed by secondary arthrodesis.

In this retrospective study, the authors analyzed the medical records of 18 patients treated with ankle arthrodesis (11 one-stage and 7 two-stage interventions) for hindfoot or ankle infection and associated osteomyelitis between January 1, 2005 and December 31, 2015. The one-stage procedure involved hardware removal and irrigation and debridement, followed immediately by installation of an external Ilizarov ring fixator. The two-stage intervention incorporated hardware removal and irrigation and debridement as well as placement of an antibiotic-impregnated cement spacer in the first stage, with a period of postoperative antibiotic therapy followed by second-stage ankle arthrodesis. Absence of the Musculoskeletal Infection Society criteria was used to indicate infection control, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to measure functional outcome and visibility of bony bridges of at least 50% of the joint surface on postoperative CT or weight-bearing dorsoplantar and lateral foot radiographs was used as evidence of radiographic fusion.

Infection control was achieved in 82% (9/11) of patients in the one-stage cohort and 86% (6/7) of patients in the two-stage cohort (p>0.99). Mean postoperative AOFAS hindfoot scores were 71.7 in the one-stage cohort vs. 74.8 in the two-stage cohort (p=0.7) at mean 5.1 years follow-up. Two patients (18%) in the one-stage cohort and one patient (14%) in the two-stage cohort required below-knee amputation. The fusion rate was 73% (8/11 patients) in the one-stage cohort vs. 71% (5/7 patients) in the two-stage cohort (p>0.99).

Infection control, functional outcome, and radiographic fusion were comparable between one-stage Ilizarov external fixation and two-stage cement spacer placement with secondary arthrodesis. This study corroborates previously demonstrated utility of the Ilizarov technique in complex cases of ankle arthrodesis, including revision procedures and for patients with soft-tissue compromise.6-8 Limitations of this study include a small sample size of non-consecutive patients, no preoperative functional outcome scores, and a retrospective design.


  1. Krissian S, Samargandi R, Druon J, Rosset P, Le Nail LR. Poor prognosis for infectious complications of surgery for ankle and hindfoot fracture and dislocation. A 34-case series. Orthop Traumatol Surg Res. 2019;105(6):1119-1124. doi:10.1016/j.otsr.2019.06.006
  2. Ellington K, Hirose CB, Bemenderfer TB. What Is the Treatment “Algorithm” for Infection After Ankle or Hindfoot Arthrodesis? Foot & Ankle International. 2019;40(1_suppl):64S-70S. doi:10.1177/1071100719861643
  3. Short A, Penrose C, Adams S. A Novel Technique for Creating an Articulating Cement Spacer for Ankle Prosthetic Joint Infections. J Foot Ankle Surg. 2020;59(1):216-219. doi:10.1053/j.jfas.2019.07.021.
  4. Elmarsafi T, Oliver NG, Steinberg JS, Evans KK, Attinger CE, Kim PJ. Long-Term Outcomes of Permanent Cement Spacers in the Infected Foot. J Foot Ankle Surg. 2017;56(2):287-290. doi:10.1053/j.jfas.2016.10.022
  5. Hulscher JB, te Velde EA, Schuurman AH, Hoogendoorn JM, Kon M, van der Werken C. Arthrodesis after osteosynthesis and infection of the ankle joint. Injury. 2001;32(2):145-152. doi:10.1016/s0020-1383(00)00156-x
  6. Hasan O, Fahad S, Sattar S, Umer M, Rashid H. Ankle Arthrodesis using Ilizarov Ring Fixator: A Primary or Salvage Procedure? An Analysis of Twenty Cases. Malays Orthop J. 2018;12(3):24-30. doi:10.5704/MOJ.1811.006
  7. Alammar Y, Sudnitsyn A, Neretin A, Leonchuk S, Kliushin NM. Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation. Bone Joint J. 2020;102-B(4):470-477. doi:10.1302/0301-620X.102B4.BJJ-2019-1158.R1
  8. Johnson EE, Weltmer J, Lian GJ, Cracchiolo A 3rd. Ilizarov ankle arthrodesis. Clin Orthop Relat Res. 1992;(280):160-169.
%d bloggers like this: