Long-Term

From

Results
BY the ANDREAS Department

following
BERNAU, of Orthopaedic M.D.t, Surgery.

Lambrinudi
ZURICH, Universirc SWITZERLAND of Zurich.

Arthrodesis*
Balgrist

ABSTRACT:

Long-term method

results of Lambrinudi follow-up in only

following are

triple reported

arin

throdesis

by the

fifty feet. The average Failures were encountered

was
eight

eighteen years. feet, and good

the foot in maximum plantar flexion are traced onto a transparent sheet (Fig. 1 -A, left) and an outline of the intended resection is superimposed on it. The components that are to remain are then traced onto a second sheet
-c

in

results were obtained in twenty. Most of the patients had post-poliomyelitic paralysis. This operation allowed most braced patients to be free of the orthosis. All able but three patients so had An showing the were other able severe to work, disabilities of the and those because literature contraindicaunof is
-.

_4

\
-4. I_I

to do

5)

poliomyelitis. provided, tions for

extensive review the indications

and

procedure. drop foot adults, rarely because occurs nowadays in chilis so un-

Paralytic dren and young

:,
tv

poliomyelitis

common in the developed countries. In countries where poliomyelitis occurs frequently, however, drop foot still poses a therapeutic problem. The conservative methods of
Preoperative (left) and the sketch intended

FIG. with planning postoperative

1-A of the bone foot position wedges (right). to be resected

treatment that have been prescribed include bracing type or another. While the operative treatment used to
tenodesis alone or

of one include type of

combined were

with

tendon after

transplantation, this

frequently

recurrences

noted

surgery. These operations are no longer recommended. For correction of paralytic drop foot in the absence of other deformities a posterior bone block has also been

tried,
thritis of

but resorption of the ankle also.

or fracture of the block joint led to discontinuation In 1927 Lambrinudi

and osteoarof this mode inspired by

treatment

Campbells 2 bone-block procedure, developed a procedure in which he stabilized the ankle joint by having the posterior tubercle of the talus come in contact with the posterior margin of the articular surface of the tibia, both being covered by cartilage The majority of reports on this
.

FIG.

I-B

Final

position.

procedure are more than vide long-term follow-up. perience between with 1949 this and 1964.

fifteen years Therefore, in

old, but do not prowe reviewed our expatients operated on

procedure

Methods The
cedure standardized is made

and

Materials and the operative We bone made

planning
have been procedure to determine

of the operation
well

prouse
drawing

described in which

1,3.4.611.14

the

a preoperative

the size of a lateral

and

shape

ofthe

wedge with
Foot D-7400 Corresponding
tibioplantar angle FIG.

to be removed. The
*

contours
at the

roentgenogram
of the American 5, 1976. Calwer

Read

Annual

Meeting

I-C
. The in this

Society.

New Orleans, V Orthop#{228}dische

Louisiana, February Universit#{228}tsklinik,

preoperative is 1 20 degrees

and postoperative roentgenograms because of instability of the knee

T#{252}bingen, Germany. VOL. 59-A, NO.

patient. 473

4,

474
such a way as to show the shape ofthe foot

ANDREAS

BERNAU TABLE
AGE AT OPERATION

postoperatively

I
AND

(Fig. 1 -A, 100 degrees

right). relative

The foot should to the distal part be increased of the leg.

subtend an angle of ofthe leg. This angle is instability of

FOLLOW-UP

Result No. of Cases Good

should occasionally the knee or shortening Technique A pneumatic

if there

tourniquet
the dorsal

is applied. surface

An
of the

oblique
foot from

mcithe

23 13 14 6 32 10 2

8 9 3 4 12 4 0

8 4 10 1 14 6 1

7 0 1 1 6 0 1

medial third of the talonavicular malleolus. The sinus tarsi and

joint to below the lateral the head ofthe talus are ex-

posed

important The

Avoiding damage to the capsule of the ankle joint is to prevent necrosis of the talus. planned bone wedges (Fig. 1 -A) are now resectof the talar osteotomy should be parallel to axis of the ankle joint in plantar flexion. of the hind part of the foot should be ccrcalcaneal vessels and wedge. tendons

Age at follow-up Lessthan30yrs. 30-39yrs. 40-49yrs. Morethan49yrs.

ed. The plane the transverse Any deformity rected During should the and five with

by poliomyelitis foot, and two feet were

with

in the series, spastic drop fixed

two with congenital foot. The majority (Table

club of the feet

without

deformity
was

III).

In three
indication

by resection of a corresponding the latter procedure the medial be carefully shielded by retractors. a posterolateral joint to evert

TABLE
LENGTH OF

II
FOLLOW-UP

A wedge with calcaneocuboid correct whatever millimeters deep an osteotome there surfaces, and cuboid

base is resected from the fore part of the foot

Results Follow-up (Yrs.) 13-15 16-19 20-29 No. of Cases Good Fair Failed

deformity may exist. A slot at least is then cut in the base of the navicular (Fig. 1 -B). After the osteotomies between between and navicular. have the the good contact in the joints the talus

11 16 23

6 4 10

5 9 8

0 3 5

been done osteotomy calcaneus

should be particularly

and between

The hind part of the foot should be in slight valgus, the fore part should be in slight abduction and pronation, and the head of the talus should fit medially as deeply as possible into the navicular. The axis of the talus should be aimed in the direction of the first metatarsal. Any remaining gaps in the joints being arthrodesed are filled with can-

operation. In two in the subtalarjoint in painful callosities.

of them the pain and in the third, records,

was caused deformity photographs.

by arthritis had resulted follow-up

All patients had case reports, and preoperative,

postoperative,
TABLE III

cellous bone chips. The joints being with the foot in the correct position wires (Fig. I-B).
Management

arthrodesed using three

are fixed Kirschner

RESULTS

IN RELATION AND

TO PREOPERATIVE DEFORMITIES

COMPLAINTS

Results

Postoperative

No.

of Cases

Good 11 8 1 8 6 6

Fair 19 2 1 13 1 8

Failed 1 6 1 2 4 2

Following above-the-knee with the patient the Kirschner moved. Six

subsidence of the postoperative cast is applied on the fourth anesthetized. Immediately wires which project weeks postoperatively,
six more weeks. Three

edema, to sixth following

an day this,

Instability Complaint Pain Passively drop Fixed correctable foot equinus varus, valgus, of deformity

31 16 3 23 II 16

through the cast a below-the-knee

are recast

the patient grams are below-the-knee In our

is discharged wearing made. If bone union walking clinic, 170

the cast and roentgenothen is inadequate, were

a car-

Associated or cavus

cast is reapplied. Lambrinudi arthrodeses

roentgenograms. teroposterior view

The ofthe

roentgenograms ankle joint and,

included

an

anof

between

material

in the majority

fifty only

feet (forty basis for

proximity

patients) selection the clinic.

were selected for follow-up, the being the patients geographical The mean age at operation was

cases, a view made with the foot in forced plantar flexion as recommended by other investigators In thirty-six cases the shape of the foot at follow-up could be compared with preoperative Results Follow-up was carried
THE JOURNAL

17.6 years 18.2 years were done, on the basis

(Table I). The mean length of follow-up was (Table II). In ten patients bilateral operations and in these patients the results were evaluated ofeach foot. There were forty-six feet affected

photographs.

out

by

me

personally.
AND JOINT

The
SURGERY

OF BONE

LONG-TERM

RESULTS

FOLLOWING

LAMBRINUDI

ARTHRODESIS

475

criteria of assessment were decided on prior

and the questions put to the patients to follow-up. In the summarized asresult was

of the feet than

shape with in those

of the a passively with

foot. a fixed

In our drop-foot

series,

the

results were

in the better

correctable

deformity deformity.

differentiated IV). In

from assessing

the the

functional functional at follow-up

clinical clinical were

result

(Table

result, deformity, instability, taken into consideration. This

and pain functional

at Operation

In found operation per cent sideration youngest

analyzing a failure rate

their

data,

Patterson in patients

and

associates age at rate of IS into conand our this age beage din-

of 47 per cent

whose

IV
Y ARTHODESES

FIn

Good Patients
Surgeons

Fair 27 22

Failed 3 8

Total 50 50

was less than eight years and a failure in older patients. We took this finding when selecting the cases for operation patients were eleven years old. Above

grading
grading

20 20

limit (Table I), we were unable to find tween the results and the age at operation. of the patients with the eight feet whose ical results were while the average teen with years. The failures respect

a correlation The average functional

clinical spects graded

grading therefore corresponds in all significant reto those of HallgrImsson and MacKenzie, who the results in four groups, as follows: Ideal: No pain; no instability; no limitation of activnormal gait in ordinary shoes; no

assessed as failures was fifteen years, age of those with good results was sixin our series were also evenly II). distributed

deformity

or calignores; activity; sympof all activity gait callosities arthrosis instability;

to length

of follow-up

(Table

losities;

successful

fusion

of all joints. which slight the patient limitation of very slight, fusion successful instability; high-stepping deformity; or moderate severe
required

Good. Minimum pain some subjective instability; good gait in ordinary deformity; Slight to walking or surgical or surgical tomless joints.
Fair:

shoes;

no callosities; pain; on shoes; demonstrable flat ground; moderate of one joint or severe

limited ordinary

in
FIG.

present; failure of fusion in the ankle joints. Failed:

2-A

FIG.

2-B

Moderate

pain;

of activity;

apparatus

the foot; severe fusion of more ankle

deformity; than one of IV).

callosities present; failure of joint or severe arthrosis in the results we adhered The subjective and to these objective

joints. In the
strictly

evaluation (Table

Fi;.

2-C

results correlated quite well. The cases described as failures vidual mention. Two patients (three
dissatisfied with the results. In one

are worthy of mdifeet) were completely

had

to be

arthrodesed

because

of

painful patient with

osteoarthritis. (two feet) the position was of

Fig. 2-A: A twelve-year-old boy who used long braces following bilateral poliomyelitis. Preoperative roentgenogram in maximum plantar flexion. Fig. 2-B: Postoperative roentgenogram. The medial wire which should fix the talonavicular joint is placed too far inferiorly. Fig. 2-C: Twenty-one years after operation. the patient was an architect, walked with canes, and required no brace.

The objective rating of the second graded as fair, but he was dissatisfied his

Aids All nine discard them patients who wore short Only two braces were able to

toes. He had no significant disability. Seven of the eight feet described objectively as failures of treatment had subjective results graded as fair. In assessing a result, the patients tended to emphasize the improvement from the preoperative state and objective residual disability frequently was minimized. Three feet tively as failures of treatment because
operatively was unchanged (Figs. 4-A,

postoperatively.

of the six patients

with severe residual paralysis from poliomyelitis had to continue wearing above-the-knee braces. Forty-one of the fifty feet now can wear ordinary shoes. However, eleven caused
Exereise

were graded the deformity

objecpost6-A,

patients have by a difference

had difficulties in buying in foot size (Figs. 3-A and

shoes 3-B).

and
thirty

6-B).

Four were

others incapable

were of

graded walking

similarly for

because a minimum

the of tients. could

The At walk

gait

improved

postoperatively of writing, eighteen than four hours and

in almost of the thirty-seven

all

pa-

patients

minutes. The major sources of disability and preoperative deformity as related to results (Table III) show that the majority of failures occurred subsequent to correction

the time for more

patients were

completely strenuous

fit for work, occupations.

twenty-two of them in physically In the remaining three cases the

VOL.

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4.

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1977

476

ANDREAS

BERNAU

- --

quently influence infection The nized by

than was mentioned on the final result. or osteomyelitis. two the talonavicular patients and

in the records. It had no There were no cases of deep pseudarthroses did not cause went unrecogpain. One

FIG.

3-A following several operations in a

Contracted twenty-year-old

poliomyelitic patient.

club

foot

FIG.

3-B patient was fully capable of work

Twenty and walked

years after operation, without aids.

the

patients inability eral debility, not

to work was attributable to severe to problems with the feet.

gen-

Lambrinudi emphasized that a powerful gastrocnemius muscle was a primary prerequisite for his operation. Others thought that the muscle should be active although not necessarily powerful. This requirement is not supported by our data (Table V). The functional clinical results as a whole in our Series were rather better in the extremities with a weak gastrocnemius other hand, than in those we agree with with normal strength. On the MacKenzie that the best results power in the dorsiflexors

are seen in patients and plantar flexors

with balanced of the ankle.

V
EMIUS

No. of Cases Paretic Powerful or weak 18 32

Results Good 8 12 Fair 6 16 Failed 4 4

Cotnplications
FIG.

4-C

The summarized tions

postoperative in Table occurred muscles

complications VI. Sometimes patient.

and Only two

disabilities complicaintraoperative

are

several

occurred

in the same and

complications paralyzed
fair. Delayed

transections in those feet

of tendons of the results were

wound

fection was mentioned pect, however, that

in only two this complication

case

histories. occurred

We susmore fre-

Fig. 4-A: Thirty-year-old patient with severe residual postpoliomyelitic paralysis. Sixteen years following Lambrinudi arthrodesis, the patient complained of ankle instability and stress pain under the head of the first metatarsal. On a roentgenogram of the foot made with the patient standing. the ankle joint seemed normal. Fig. 4-B: The hyperextensibility of the anterior joint capsule is only visible on a roentgenogram made in maximum plantar flexion. Note also osteoarthritis of the nay iculocune iform joint. Fig. 4-C: A lateral roentgenogram of the foot in maximum dorsal flexion shows the increased plantar flexion of the painful. overloaded first metatarsal.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

LONG-TERM

RESULTS

FOLLOWING

LAMBRINUDI

ARTHRODESIS

477

pseudarthrosis

was

accompanied

by

slight

drop

foot.
symptoms
in the ball

Five

feet

were

painful

at follow-up.

These

were localized on the underside of the foot, or in the heel and

of the big toe, were successfully

treated

by use of better footwear, insoles, and so forth. Change of occupation became necessary for only onepatient, a building-site supervisor who had to change to office work because of ankle pain. His result was graded as a failure. Ankle instability was seen in seven cases. It caused serious

disability in only two moderate relief by wearing a SO per cent disability residual paralysis.

patients. One patient high-sided boots. pension on the

obtained The other grounds of

drew severe ing

The shape of the foot was normal in twenty-one feet and improved Flat foot Residual occurred club

at the time of writin the majority of

FIG.

5-A

the others. complaints.

frequently but seldom caused foot and pes cavus, however, were most severe Markeddropfoot
I

I I

frequently led to poor results. Callosities inthiscondition and usually werepainful.

TABLE
CoMPLIcATioNs

VI

Results Total Talonavicular pseudarthrosis Pain Ankle instability Clubfoot Flatfoot

Good 0 0 1 0 5 0 2 10 6 0 0

Fair

Failed

Pes equinus Callosities Ankle arthritis Ankle arthritis-+arthrosis Ankle necrosis-arthrosis

2 5 7 2 12 3 13 28 14 1 1

2 4 4 0 7 1 9 12 6 0 1

0 1 2 2 0 2 2 6 2 1 0 FIG. 5-B

with

high-stepping

gait

occurred

in seven

feet.

Deformity

of more than 30 degrees foot besides two of the used above-the-knee teoarthritis of the but was caused carried chronic out

was only seen patients already

in one additional mentioned who

braces. ankle joint pain in only (Figs.

Roentgenographically could be seen two 6-A feet, and and 6-B).

os-

frequently arthrodesis

in them

A (iditioflal

Operations

FIG.

5-C

Frequently
Lambrinudi

the success
arthrodesis

in our cases
alone, but

was
also

not due
to

to the were were

additional

operative
carried soft-tissue out

measures.
in our operations

Many
patients,

additional the majority

procedures of which
lengthenings

Fig. 5-A: This foot was arthrodesed when the patient was nineteen years old because of equinus of poliomyelitic origin. This roentgenogram was made with the patient standing, thirteen years later. Fig. 5-B: Maximum dorsiflexion. Fig. 5-C: Maximum plantar flexion. The patient worked as a mechanic and had pain in the foot only during snowy weather.

(twenty-six

tendo
leases

achillis, of the

twenty-two plantar fascia,

tendon transfers, seventeen and twelve osteotomies).

re-

Lambrinudi Orthopaedic vestigators result groups:

himself Hospital
1,9,11,12,14

or by his pupils at the Royal National in London. In the tables of five inthe results are divided into the three fair, and failed. But only three auThe as a but researchers the their criteria of assessment. in a given case was assessed in some cent. publications, Only three

Discussion Of
Lambrinudi was that

good, published the result was

all

the

communications
the His most case

on

the

subject was

of notable

the in

arthrodesis, of MacKenzie.

comprehensive

series

thors reason failure failure

why rate

material who were

is therefore

unclear 5 to 75 per

that
VOL.

it contained
59-A, NO.
4, JUNE

many
1977

patients

operated

on by

478

ANDREAS

BERNAU

provided long-term follow-up on patients (more than ten years) and the failure rate in those series ranged from 8 to 35 per cent. Our series showed a 16 per cent failure rate.
instabilTh:

why

the incidence

of yarns

deformity

was

not

increased

in

our own series (Table VI) but, in contrast, nance of residual valgus deformity in our plained base by the difficulty through
Painful

the predomiseries is exwith a medial

stability throdesis frequency 9 per cent. of the cation cent

A patient with residual postoperative inhas to continue wearing a brace, or requires an arof the ankle joint or even of the knee joint. The of ankle
12

of resecting skin incision. MacKenzie

a wedge

a lateral

instability cent
,

in the literature and in our joint

ranged was
the fore

from 14 per
part

to 25 per instability
on

series can
with

in fifteen present.

osteoarthritis: found this sequela of his 100 cases, and in twelve of them pain was However, this complication was mentioned by

Lateral foot

of the ankle supination,

be visualized

preoperatively

a roentgenogram

held

in forced

and

is a contraindi-

only two other authors In two feet painful osteoarthritis necessitated arthrodesis joint. In three of eight feet it was responsible result. therefore our series, influence were per Severe, be painful said osteoarthritis occurred to have only

in our series, of the ankle for a failed joint can in exceptionally negative

to the operation.
Deformity.

of the ankle it had a prolonged

the difficulties nation deformity. of the foot occur

The majority of authors 912,14 mentioned encountered in attempting to correct supiPainful callosities on the lateral border frequently unless this deformity is cor-

but once it did occur on the result. The in the series in that

Pseudarthrosis:

rected. The head of the talus should be fitted as far medially as possible into the groove in the navicular in order to prevent postoperative supination deformity. This recommendation the majority was taken of our patients. into account We think by us in treating that this explains

reported cent) and

highest rates of Patterson (17

of pseudarthrosis and associates per cent).

(33

of MacKenzie

While

only one pseudarthrosis in the talocalcaneal joint was mentioned in those reports, the great majority of cases of non-union occurred in the talonavicular joint. MacKenzie found an increased frequency of pseudarthrosis in patients who were more than twenty years old at operation, in ankles operated on without Kirschner-wire fixation, and in patients weeks who used a walking cast following operation. In our in the talonavicularjoint one of the adverse factors
equinus deformity:

as early as two to six series only two pseudoccurred, and in neither apply. In his first publication, as to whether ankle
author

arthroses
did any

Increased

Lambrinudi sive tendency

posed to drop

the

question foot
was

a progreswould arise
discussed

in the
the only

joint

Tschui

who

FIG.

6-A

This patient had a poliomyelitic equinus foot and was operated on at the age of twelve years. The postoperative roentgenogram shows anterior subluxation and avascular necrosis of the retained segment of talus. One year following operation there was severe osteoarthritis, and ten years later an arthrodesis of the ankle was needed.

this question. By comparative measurement of lateral roentgenograms of the foot in maximum plantar flexion, he established that no recurrence of drop foot could be shown in two-thirds of all the feet in his series. The greatest amount of recurrence of drop foot was 10 to 20 degrees, tients
operative

and

that

was by

found

in only
in maximum

12 per cent preoperative

of the paand
flexion.

as judged

comparative the

postIn

roentgenograms

approximately greatest amount

a fifth of ofrecurrence

patients ofdrop

in our series, the foot was 35 degrees.

other tions

In analyzing our own failures authors, we have established to the

and those described a list of contraindica-

by

procedure.
joint

instability: This will be made worse by the procedure because the narrow posterior part of the articular surface of the talus will be made to articulate more loosely between the malleoli than the wider anterior seg-

ment.
FIG.

Joint
Severe

congruity
knee

is thus
instability

worsened.
such that the patient has to

6-B

Twenty-four years following the Lambrinudi arthrodesis and fourteen years after arthrodesis of the severely painful ankle joint, this housewife and office clerk was fully capable of work. She wore ordinary shoes but reported difficulty in buying shoes because ofthe three-centimeter shortening of the foot operated on.

wear

a brace
Painful Age Severe less

postoperatively.
preoperative than trophic eleven changes: osteoarthritis ears. Among the series reviewed,

of the ankle

joint.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

LONG-TERM

RESULTS

FOLLOWING

LAMBRINUDI

ARTHRODESIS

479 had an equinus foot as a result of

that of Meary nerve pareses lar interest.

(twenty-one sciatic associated with battle cases below-the-knee

and lateral peronealinjuries) is of particuamputation had to

in those

of other

authors,

In two

be carried out following a Lambrinudi arthrodesis because of the severe trophic changes caused by the sciatic denervation. In a number of other cases a similar course was expected. trophic The changes We do not muscles procedure therefore is contraindicated or active if are present. regard a paretic
4.6

poliomyelitis. the Lambnnudi flaccid equinus

However, we agree with others 4.6.10,11 that arthrodesis also is indicated in spastic and feet of all types due to hemiplegia or iso-

lated lesions of the peroneus muscle, either of the dorsiflexors of the foot or of the peroneal muscles. B#{233}nyi described his own version of the operative technique for severe cases of congenital club foot. Muller pointed out that certain brinudi throdesis. cases of pes cavus than, were for better treated the by the LamHoke triple ararthrodesis example,

gastrocnemius

peroneal Indications

as contraindications

to this procedure.

The

great

majorlty

of patlents

lfl

our

series,

as well

as

NOTE:

The author would

like to thank Dr. P. A.

Casey.

Bern.

br

assistance

n translating

this

paper.

References
I. 2. 3. 4. 5.
BENYI, PAUL: A Modified Lambrinudi Operation CAMPBELL: Cited in Lambrinudi , p. 193. DETZEL, HANS: Die operative Behandlung des FITZGERALD, HALLGRIMSSON,

for

Drop

Foot.

J. Bone

and Joint

Surg.

42-B:

333-335,

May

1960.

F. P.,

and

SN0RRI:

SEDDON, Studies Operation

paralytischen Spitzfusses. Arch. H. J.: Lambrinudis Operation for Drop-Foot. on Reconstructive and Stabilizing Operations for Drop-Foot. J. Bone and Joint Surg., J. Surg. , 15: 193-200, and Calcaneous Deformities 22:

f. orthop. Unfall-Chir., 44: 579-585, 1951. British J. Surg., 25: 283-292, 1937. on the Skeleton of the Foot. Acta Chir. 937-941, Oct. 1940. 1927. at the Sub-Astragaloid

Scandinavica,

Supplementum 6. HART. V . L.: 7. LAMBRINUDI, 8. LAMBRINUDI. 9. 10. 11 . 12. 13. 14.

78, 1943. Lambrinudi

C.:
C.:

New

on

Drop-Foot.

British

A Method

ofCorrecting

Equinus

Joint.

Proc.

Roy.

Soc.

Med.,

26:

788-

791, 1933. MACKENZIE, I. G.: Lambrinudis Arthrodesis. J. Bone and Joint Surg. , 41-B: 738-748, MEARY, M. R.: Lop#{233}ration de Lambrinudi dana Ic traitement du pied #{233}quinaralytique. p MULLER, M.: Zur Fuss-Arthrodese-Arthrorhise-Operation nach Lambrinudi. Zeitschr. PATTERSON, R. L., JR.; PARRISH, F. F.; and HATHAWAY, E. N.: Stabilizing Operations Used, PUTTI: and

Nov. 1959. Rev. chir. orthop.. 37: 66-83, 1951. f. Orthop., 85: 133-146, 1955. of the Foot. A Study of the Indications,

Techniques

End

TSCHUI,

Cited F.:

Results. J. Bone and Joint Surg. , 32-A: in M#{252}ller#{176}. Resultate der Fuss-Arthrodese-Arthrorhise-Operation

1-26,

Jan.

1950. nach Lambrinudi. Arch. f. orthop. Unfall-Chir.

54:

215-223.

1962.

VOL.

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1977