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Foot & Ankle
The Use of Accell Connexus® in a Subtalar Arthrodesis
of the Left Foot
Louis Keppler, M.D.
Brook Park, Ohio 44142
 Introduction
The use of a new potentially osteoinductive bioimplant, Accell Connexus®
(IsoTis OrthoBiologics, Inc., Irvine, CA), is described in
a patient undergoing a subtalar arthrodesis of the left foot
two years after a crushing injury.
Of the 1.78 million hospitalized fractures in 2005, ankle
fractures comprised 7.2% of the total or about 128,160 hospitalized
fractures. 0.6% of the fractures reported occurred in the
industrial/work area.1 This patient’s fracture occurred
in the work setting.
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Patient Profile
A 28-year-old male presented with an approximate two-year history
of problems associated with a crushing injury of the left ankle.
The injury forcibly supinated the foot so that the sole of the foot
faced dorsally. At that same time, amputation of the fifth toe was
required. Initially the fracture was treated by casting.
The patient developed metatarsalgia, heel pad pain and lateral ankle
pain. There was numbness over the medial aspect of the foot. He
was unable to plantar flex his remaining toes and had weakness with
active ankle dorsiflexion.
Subtalar arthritis was present in the left foot and a subtalar arthrodesis
was planned. The patient was a smoker, but no other significant
relevant medical conditions were present.
Surgical Method
After satisfactory spinal anesthesia was obtained, the hip and foot
were prepped and draped in the usual sterile fashion with a pneumatic
tourniquet about the upper leg. A lateral incision was made, just
distal to the tip of the fibula and carried distally along the subtalar
joint.
The peroneal tendon sheath was incised and tendons retracted posteriorly.
Dissection proceeded sharply down into the subtalar joint, taking
very thick flaps of tissue, so as not to compromise the overlying
skin. A complete debridement was done of any remaining articular
cartilage in the subtalar joint, using rongeurs, curved osteotomes
and curettes. A sharp curette, osteotome and burr were used to decorticate
the subtalar joint.
Allograft demineralized bone putty (5 cc of Accell Connexus®)
was used as an addition to allograft tricortical iliac crest to
the bone graft site. This allograft composite graft was augmented
with bone marrow aspirated from the left iliac crest. Apposition
of the bone segments and preparation of the joint surfaces were
satisfactory. With the aid of a C-arm, a guidewire was placed up
into the talus. Biplanar images showed satisfactory placement. Titanium
6.5 cancellous screws were placed, fixation tested, and found to
be rigid. Soft tissue flaps were closed and the skin closed with
simple sutures. The plan was to have the patient in a cast for six
weeks post-operatively.
Outcome
Within six weeks a hard walking cast was applied. At three months,
there was some foot pain and night sweats. There was a suggestion
of radiolucency about the screw. The patient was advised that smoking
might be inhibiting healing. By six months, it was concluded that
the internal fixation could be removed.
Six weeks after removal of the internal fixation pin and nine months
after the initial surgery, the patient felt his pain had decreased
and radiographs showed satisfactory results.
Reference
1. Orthopedic Network News.
www.OrthopedicNetworkNews.com, Volume 16: Number 2, April 2005,
p.2.
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