Implantable electrical stimulation in high-risk hindfoot fusions

The risk of nonunion in both the ankle and subtalar joints has been reported as high as 41% and 16%, respectively. Several factors have been reported to significantly increase the incidence of nonunion: smoking, previous nonunion, osteonecrosis, history of infection, fracture type, and major medical problems. A single surgeon's experience is retrospectively reviewed. Thirteen patients who were identified as high risk for non-union had an implantable electrical stimulator placed at the time of their ankle or hindfoot fusion along with bone grafting. Three ankle, two subtalar, six tibiotalocalcaneal, and two tibiocalcaneal fusions were performed. All 13 patients had a minimum of two major risk factors for non-union. Of the 13 patients, 11 were active smokers and five of 13 had three or more major risk factors. At a minimum of one year follow-up (average, 24.6 months), successful fusion was achieved in 12 of 13 (92%) patients. Pain scores improved from a mean of 8.5 points preoperatively (range, 7 to 10) to a mean of 1.9 points postoperatively (range, 1 to 6), while the preoperative mean modified AOFAS score of 31.2 points (range, 15 to 55) improved to 85.4 points (range, 45 to 100) postoperatively. The improvement was statistically significant at p<0.01. Eleven of 13 patients (85%) ranked their pain as a 1 or 2 out of 10, and achieved a modified AOFAS score of 80 or better. No additional procedures were done to achieve fusion. Four patients developed superficial wound infections requiring local wound care. The subcutaneous battery pack was bothersome to eight of 13 patients, painful to one, and removed in four patients. The results suggest that electrical implantable stimulation may be a useful adjunct to rigid internal fixation and bone grafting for ankle and hindfoot fusions in high-risk patients.