Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail: a retrospective study of 26 patients with rheumatoid arthritis

Retrograde intramedullary nail entry point for tibio-talo-calcaneal arthrodesis: a review of anatomical studies

PURPOSE

Tibio-talo-calcaneal arthrodesis (TTCA) is considered a safe and valuable option for end-stage tibiotalar and subtalar arthritis, and usually is performed with a retrograde intramedullary nail. Although the good results reported, potential complications may be related to retrograde nail entry point. Aim of this systematic review is to analyze in cadaveric studies the risk of iatrogenic injuries related to different entry points and different retrograde intramedullary nail design when performing TTCA.

METHODS

According to PRISMA, a systematic review of the literature was performed on PubMed, EMBASE and SCOPUS databases. A subgroup analysis comparing different entry point location (anatomical or fluoroscopic guided) and different nail design (straight vs. valgus curved nails) was performed.

RESULTS

Five studies were included, for a total of 40 specimens. Superiority of anatomical landmark-guided entry points was observed. Different nail designs did not seem to influence nor iatrogenic injuries neither hindfoot alignment.

CONCLUSION

Retrograde intramedullary nail entry point should be placed in the lateral half of the hindfoot in order to minimize the risk of iatrogenic injuries.

Reconstruction of the Articular Surface in the Subtalar Joint by Osteochondral Autologous Transplantation After Failure of Tibiotalocalcaneal Fusion With a Retrograde Nail: A Case Report

Tibiotalocalcaneal arthrodesis (TTCA) using the intramedullary nail has been conducted for severe deformity of both ankle and subtalar joints. While good clinical outcomes have been reported for TTCA, its nonunion rate is relatively high. We report a case of a 65-year-old male with nonunion of the tibiotalar joint and destruction of the subtalar joint after TTCA using a retrograde intramedullary nail. For this patient, we conducted a salvage procedure for the subtalar joint along with revision surgery for the tibiotalar joint to achieve bone union. The intramedullary nail was removed and the tibiotalar joint was debrided. Two osteochondral plugs were harvested from the lateral aspect of the talus and transplanted to the subtalar joint. The tibiotalar joint was fixed using screws and staples, with bone grafting. Magnetic resonance imaging (MRI) at six months after surgery showed that the articular surface of the subtalar joint was flushed and the osteochondral plugs were united with the surrounding bone. At one year and three months after surgery, the pain in the tibiotalar and subtalar joints had completely disappeared. Plain radiographs revealed that bone union of the tibiotalar joint and joint space of the subtalar joint was maintained. Japanese Society for Surgery of the Foot (JSSF) hindfoot scale improved from 53 points to 84 points at the final follow-up. Reconstruction of the subtalar joint using osteochondral autologous transplantation is a useful technique for failure cases with nonunion of the tibiotalar and subtalar joints after TTCA.

Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review

INTRODUCTION AND AIM

The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS).

MATERIALS AND METHODS

A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal.

RESULTS

A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions.

CONCLUSION

Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

Relationship Between the Lateral Plantar Artery and the Retrograde Intramedullary Nail During Tibiotalar and Subtalar Arthrodesis: A Fresh Cadaveric Study

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis with retrograde intramedullary nailing has become established. Iatrogenic injury to the vasculature (eg, lateral plantar artery [LPA] pseudoaneurysm) during insertion of the nail has been reported. The aim of this study was to identify the safe zone that avoids injury to the LPA during TTC arthrodesis.

METHODS

The retrograde lateral curved nail entry point should be in line with the midpoint of the tibial medullary canal and the lateral column of the calcaneus. Enhanced 3-dimensional computed tomography scans of 26 fresh cadaveric feet were assessed. The closest distance between the LPA and the edge of the nail entry point was measured in the plantar view.

RESULTS

The closest mean distance between the LPA and the edge of the nail entry point was 6.7 mm for all 26 feet, 12.8 mm for 3 feet (11.5%) in which the LPA did not cross the medial wall of the calcaneus, 8.1 mm for 9 (34.1%) in which the point where the LPA crossed the medial wall of the calcaneus was anterior to the center of the nail entry point, and 4.2 mm for 14 (53.8%) feet in which this point was posterior to the center of the nail entry point.

CONCLUSIONS

Care should be taken to avoid the LPA during reaming at the nail entry point, especially when the point where the LPA crosses the medial wall of the calcaneus is posterior to the center of the nail entry point.

LEVELS OF EVIDENCE

IV, cadaveric study.

Nonunion After an Open Trimalleolar Ankle Fracture: An Extended Clinical Course and a Novel Approach to Tibio-Talo-Calcaneal Arthrodesis

Nonunion in the setting of chronic osteomyelitis after severe open ankle fractures is a feared outcome with severe loss in patient quality of life. Tibio-talo-calcaneal arthrodesis is a good salvage treatment option in this difficult patient cohort. We report a case of chronic osteomyelitis with severe destruction of the ankle joint after failed fracture fixation of an open trimalleolar ankle fracture. Fusion was ultimately achieved 5 years later using a novel-staged Masquelet technique with external ring fixator stabilization and bone graft reconstruction including femoral harvested autograft using reamer-irrigator-aspirator. This case shows that infection free arthrodesis of the ankle can be achieved even years after failed treatment. This procedure restored significant quality of life through pain relief and much improved mobility and may be a helpful technique in complex tibio-talo-calcaneal arthrodesis in the setting of chronic osteomyelitis and significant joint destruction.

Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle?

This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5-84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.

Bilateral gait asymmetry associated with tibiotalocalcaneal arthrodesis versus ankle arthrodesis

BACKGROUND

Gait asymmetries have been reported following ankle arthrodesis. However, similar reports do not exist for tibiotalocalaneal arthrodesis (TTCA), which involves further articular fusion. This study aimed to assess the extent of gait asymmetry following TTCA when compared to ankle arthrodesis.

METHOD

Gait assessment was performed on 36 participants, including 12 ankle arthrodesis, 12 TTCA and 12 controls - using 3-D inertial sensors and pressure insoles. 48 gait parameters were monitored on both operated and non-operated sides. Questionnaires including AOFAS, FAAM, EQ-5D were used to assess both operative groups, comparatively.

RESULTS

Both operative groups reported significantly smaller stride, slower walking speed, altered stance phase with longer loading and shorter push-off compared to controls. Joint range of motion was significantly reduced on the operated side of both operative groups at hindfoot, forefoot and toe intersegments. However, the ankle arthrodesis group reported a significantly higher alteration compared to controls in maximum contact force and pressure distribution. Furthermore, bilateral comparison showed extended gait asymmetry in the ankle arthrodesis group with 29 out of 48 parameters being significantly different between the two sides, whereas only 16 out of 48 gait parameters showed bilateral difference in the TTCA group.

CONCLUSION

Both ankle salvage operations led to significant gait alteration and bilateral asymmetry. However, extended joint restriction in TTCA does not seem to worsen the gait outcomes. Further investigation is needed to understand the long-term impact of altered gait, on neighboring joints, following TTCA.

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up

PURPOSE

To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of five years.

METHODS

Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed.

RESULTS

The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection.

CONCLUSIONS

The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.

Outcomes of Tibiocalcaneal Arthrodesis in High-Risk Patients: An Institutional Cohort of 18 Patients

INTRODUCTION

Tibiocalcaneal (TC) arthrodesis is commonly performed in patients with severe hindfoot disease. These include severe Charcot deformities, ankle malformations, chronic osteomyelitis (COM), and avascular necrosis (AVN). The talar vascular becomes disrupted to the point that the bone can no longer be salvaged. The procedure involves performing a talectomy and fusing the tibia to the calcaneus. This helps in preserving the remaining hindfoot anatomy, while allowing the patient to regain function and mobility. Our study highlights certain risk factors that influence the rate of postoperative complication after tibiocalcaneal surgery.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 18 patients from a single institution who underwent tibiocalcaneal between the years of 2011 and 2019. Preoperative diagnoses, comorbidities, and post-operative outcomes were noted among all patients. Then, the rates of non-union, below-knee amputations, revision surgeries, postoperative infections, and hardware failure were recorded. These data were then analyzed to determine which preoperative and perioperative factors affected postoperative outcomes for patients after tibiocalcaneal arthrodesis surgery.

RESULTS

Nonunion was the most commonly reported complication in this series. Eight of the eighteen patients were documented to have nonunion including three patients with stable pseudarthrosis. Diabetic patients had a slightly higher incidence of nonunion (4 of 7 patients) compared to those without diabetes (4 of 11 patients). Of the nine patients diagnosed with Charcot arthropathy, five had nonunion. Three of the five individuals with a BMI ranging from 25 to 30, and four of the six individuals with a BMI of greater than 30 had a nonunion. Infection was a post-operative complication for four of the eighteen patients. Two of the four patients had multiple comorbidities in addition to chronic infections in the joint which were recurrent after surgery.

CONCLUSION

In conclusion, TC arthrodesis provides a viable option for high-risk patients with complicated ankle pathology who have not had successful outcomes from previous treatment. It is not without complications considering the comorbidities the patients present with before requiring this procedure. Further studies are necessary to validate the trends of outcomes and comorbidities of patients with TC arthrodesis.

Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases

INTRODUCTION

Total ankle arthroplasty (TAA) has the objective to maintain the range of motion of the tibiotarsal joint and to preserve the nearby joints. However, the complication rate and failures remain quite high after TAA. The main objective of the study was to evaluate the improvement in the functional scores of the tibiotarsal arthrodesis after TAA failure. The secondary objective was to assess the specific complications.

MATERIALS AND METHODS

This monocentric retrospective series includes 12 patients (nine men, three women, average age 52.5 years) operated between 2003 and 2018. An iliac graft was used in all cases. The arthrodesis was stabilized either by screws or by retrograde nailing.

RESULTS

The reoperation was due to painful malleolar conflicts or loosening. The AOFAS score increased from 38/100 to 67/100 (51-86) post-operatively. The fusion was acquired at 3.7 months (3-6) except in two cases.

DISCUSSION AND CONCLUSION

The 83% primary fusion rate is in the low average of the literature and 92% fusion rate in the high average after reoperation. All patients were improved even in two non-unions. The results of this study confirm that the arthrodesis after TAA failure is a reliable alternative to the TAA replacement. However, they are lower than those after a first-line arthrodesis.

Re-arthrodesis after primary ankle fusion: 134/1,716 cases from the Swedish Ankle Registry

Background and purpose - Arthrodesis is the most common treatment of severe ankle arthritis. Large studies on the occurrence of re-arthrodesis are few, especially with information in terms of risk. We used the National Swedish Ankle Registry to assess incidence and risk factors for re-arthrodesis. Patients and methods - In the Registry, we examined the occurrence of re-arthrodesis in 1,716 patients with a primary ankle arthrodesis. We also analyzed associations between the re-arthrodesis risk and sex, diagnosis, and surgical method. Results - The risk of first re-arthrodesis at 2.5 years was 7.4% and the rate at 9 years 7.8%. The risk following arthroscopic surgery with fixation by screws was 15%, which is statistically significantly higher than the 8% following the gold standard technique with open screw fixation, the 5% following fixation by intramedullary nailing, and the 3% following fixation by plate and screws. Patients with either idiopathic osteoarthritis or posttraumatic arthritis had a higher risk of re-arthrodesis than patients with rheumatoid arthritis. We could not find that the risk of re-arthrodesis was associated with sex. Interpretation - In Sweden, the re-arthrodesis risk varied by primary technique and was especially high after arthroscopic surgery. Reasons are unknown but poor surgical technique and/or surgeon inexperience may contribute, as may patient selection.

Evaluation of Midterm Results of the Panta Nail: An Active Compression Tibiotalocalcaneal Arthrodesis Device

A tibiotalocalcaneal intramedullary rod is a powerful construct often reserved for difficult and salvage cases. The Panta Nail (Integra LifeSciences, Plainsboro, NJ) is a second-generation rod that offers active axial compression compared with previous rod designs. We characterized our experience with this device and identified factors associated with nonunion. We retrospectively identified 19 patients receiving the Panta Nail during a 4-year period with a mean follow-up period of 16 months. We used a consecutive series approach toward inclusion. Fusion, asymptomatic fibrous union, or nonunion was determined for each ankle and subtalar joint as the primary endpoint. Patients were grouped as follows: group A, successful outcome; group B, successful outcome after dynamization; group C, no successful outcome. Secondary data were tested for association with the probability of first-attempt fusion. The Panta Nail resulted in a first-attempt fusion rate of 65% at the ankle and subtalar joints. With implementation of dynamization (31% of cases) at an average of 28 weeks after insertion (groups A and B), the bony fusion rate was 88% and 77% at the ankle and subtalar joint, respectively. Inclusion of 3 asymptomatic fibrous unions with final visual analog scale scores <4 (1 ankle; 2 subtalar) as successful outcomes resulted in 94% and 88% success rates for the ankle and subtalar joints (groups A and B). Salvaged total ankle arthroplasties with the Panta Nail device as a subgroup had an 83% fusion rate, with a 50% dynamization rate. No predictors of nonunion were found. The Panta Nail is a second-generation tibiotalocalcaneal arthrodesis device capable of providing good success rates for fusion. Also, dynamization is an appropriate and frequent augmentation method.

Reconstruction of bone defect with allograft and retrograde intramedullary nail for distal tibia osteosarcoma

BACKGROUND

To investigate the effectiveness of tibiotalocalcaneal arthrodesis with a retrograde nail and allograft in limb salvage surgery for patients with distal tibia osteosarcoma.

METHODS

5 patients diagnosed as distal tibia osteosarcoma underwent ankle arthrodesis with a retrograde nail in our hospital. During the follow-up, radiographic views of the ankle joint were taken in two planes to assess bone healing and axis alignment. Other measurements of outcomes included procedure-related complications, local recurrence, and metastasis. Functional outcomes were evaluated with the Musculoskeletal Tumor Society (MSTS) scoring system.

RESULTS

Postoperative complications occurred in 4 patients, including 4 cases of mild subcutaneous fluid and 1 case of screw breakage. All patients showed stable ankle and could stand or walk with the assistance of crutch before the complete union between allograft and host bone. One patient died due to multiple bone and pulmonary metastasis at 1 year after surgery. As for the other 4 patients, they were followed-up regularly for a mean period of 42 months. No local recurrence or distant metastasis occurred in any of these four patients. All the 4 patients expressed satisfaction with the outcome. According to MSTS scale, the mean postoperative functional score was 74.3%±4.4% (range, 70%-81%).

CONCLUSIONS

Intramedullary retrograde nail for distal tibia osteosarcoma could produce a satisfactory outcome in terms of functional results and complications. Excellent stabilization of the ankle joint can be achieved through this technique, as it allows patients to perform much earlier postoperative weight-bearing exercise.

Clinical assessment of 115 cases of hindfoot fusion with two different types of graft: Allograft+DBM+bone marrow aspirate versus autograft+DBM

INTRODUCTION

Nonunion is a common complication (15%) of hindfoot and ankle arthrodesis. Autograft can improve the fusion rate because of its osteoconductive, osteoinductive and osteogenic properties. However, autograft harvesting is a source of morbidity. One alternative is to combine allograft with demineralized bone matrix (DBM) and iliac bone marrow aspirate (BMA). This combination graft has similar biological properties to healthy bone. When used alone, allograft has osteoconductive and sometimes structural properties. DBM provides osteoinduction and improves the osteconductivity. BMA adds cells and thereby osteogenic potential.

HYPOTHESIS

Given its intrinsic properties, allograft-DBM-BMA is as effective as autograft-DBM treatment while simplifying the clinical practice.

MATERIAL AND METHODS

One hundred and fifteen cases of ankle and hindfoot arthrodesis were studied in 82 patients divided in two groups: autograft-DBM vs allograft-DBM-BMA. Treatment effectiveness was assessed using clinical (time to fusion, fusion rate) and radiological (trabecular bone bridge, disappearance of joint space) criteria. A CT scan was done in 60% of cases when fusion could not be confirmed using the clinical and radiological criteria.

RESULTS

There was no significant difference between the two groups in terms of fusion rate, time to fusion, number of heterotopic ossifications, revision rate and quantity of DBM used. The nonunion rate was 18% in the autograft group and 13% in the allograft group. The infection rate was 11% in the autograft and 4% in the allograft group.

DISCUSSION

Allograft-DBM-BMA is an alternative to autograft-DBM that provides similar effectiveness without increasing the number of nonunion or complications. Osteonecrosis and surgical revision are risk factors.

LEVEL OF EVIDENCE

III retrospective study.

Operative Fixation Options for Elective and Diabetic Ankle Arthrodesis

Ankle arthrodesis remains one of the most definitive treatment options for end-stage arthritis, paralysis, posttraumatic and postinfectious conditions, failed total ankle arthroplasty, and severe deformities. The general aims of ankle arthrodesis are to decrease pain and instability, correct the accompanying deformity, and create a stable plantigrade foot. Several surgical approaches have been reported for ankle arthrodesis with internal fixation options. External fixation has also evolved for ankle arthrodesis in certain clinical scenarios. This article provides a comprehensive analysis of midterm to long-term outcomes for ankle arthrodesis using internal and/or external fixation each for elective and diabetic conditions.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Tibiotalocalcaneal arthrodesis using an intramedullary nail: a systematic review

PURPOSE

Tibiotalocalcaneal arthrodesis is aimed to block the ankle joint motion in cases of severe osteoarthritis, avascular necrosis of the talus and/or failure of arthroplasty operations. This systematic review was carried out to evaluate the clinical outcome after tibiotalocalcaneal arthrodesis using intramedullary nail either open and arthroscopically assisted. Focus was on the success rate of the procedure in terms of union and complications and on the comparison between the techniques.

METHODS

The databases PubMed (Medline), EMBASE and Cochrane Library were searched in order to retrieve relevant studies. All therapeutic level 1-4 studies involving humans with intramedullary nail fixation technique were included. Only studies written in English, Italian, French, Spanish and German were included. Data related to the type of surgery, complications and clinical outcomes were extracted and analysed.

RESULTS

A total of 83 studies were identified, of which 32 studies were eligible for inclusion; 31 case series and one randomized controlled trial. The main reported outcome score was the American Orthopaedic Foot and Ankle Society scale. Almost, all the included studies reported higher than 50% union rates and a significant improvement in terms of the clinical and mechanical ankle function after treatment.

CONCLUSIONS

Results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal arthrodesis using intramedullary nailing. Low complication rates contribute to make this a safe procedure. No comparison can be done between arthroscopic and open technique, due to the lack of scientific works on the first one.

LEVEL OF EVIDENCE

IV.

Tibiocalcaneal arthrodesis as a limb salvage procedure for complex hindfoot deformities

INTRODUCTION

Tibiocalcaneal (TC) arthrodesis is a limb salvage method for patients with severe deformities combined with necrosis and/or luxation of the talus. The aim of this study was to examine the clinical and radiological outcome of TC arthrodesis.

MATERIALS AND METHODS

This retrospective study identified 12 patients with luxation and/or necrosis of the talus, due to charcot neuroarthropathy (83.3 %) or traumatic injuries (16.7 %). All patients underwent TC arthrodesis by an external fixator or nail arthrodesis. The mean follow up was 18 (6-36) months with a mean age of 51.3 (30-66) years. The data were collected using the AOFAS score as well as clinical and radiological examination during regular follow up.

RESULTS

Seven (58.3 %) patients were treated with an external fixator, four (33.3 %) with nail arthrodesis and one (8.3 %) patient rejected both fixation methods. Four (100 %) patients achieved radiological and clinical bone union after nail arthrodesis and four (57.1 %) patients after external fixation. Three (42.9 %) patients treated by an external fixator showed a radiological moderate bone fusion, but a stable, asymptomatic non-union. One (8.3 %) case ended up in transfemoral amputation. Eleven patients (91.7 %) regained independent mobilization. The mean AOFAS score improved from 24.3 preoperatively to 66.7 postoperatively (p < 0.05). The postoperative satisfaction rate was good to excellent in 83.3 %.

CONCLUSION

TC arthrodesis is a promising and effective method for the treatment of severe ankle deformities with talus luxation. It allows patient's return to mobility with good to excellent patient satisfaction.

Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail with a valgus curve

OBJECTIVE

Many different techniques have been described for performing tibiotalocalcaneal arthrodesis (TTCA) in patients with severe hindfoot disorders such as failed ankle arthroplasty and failed ankle joint arthrodesis with subsequent subtalar arthritis. The use of straight retrograde intramedullary nails is extremely limited because they may interfere with normal heel valgus position and risk damaging the lateral plantar neurovascular structures. Curved retrograde intramedullary nails have been designed to overcome these shortcomings. The purpose of this single surgeon series was to investigate the outcomes of TTCA using a curved retrograde intramedullary nail.

METHODS

From June 2009 to January 2012, 22 patients underwent TTCA using intramedullary nails with a valgus curve by the same senior surgeon. All patients were available for analysis, the mean follow-up being 22.3 months (range, 6.8-38 months). The main outcome measurements included EQ-5D functional scores, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, radiologic assessment and clinical examination.

RESULTS

Bony union and a plantigrade foot were achieved in 100% of subjects, the mean time to union being 3.9 months (range, 2.4 to 6.2 months). Structural bone graft was used in all patients. Postoperative radiologic results showed a good hindfoot alignment in all patients. The only complication was one case of delayed wound healing without deep infection. The mean postoperative EQ-5D functional and AOFAS ankle-hindfoot scores were 69.33 (range, 20 to 90) and 69.9 (range, 45 to 85) points, respectively. No revision surgery was necessary in our cohort.

CONCLUSION

The results of the present study indicate that TTCA using a short, retrograde, curved intramedullary nail is an acceptable technique for obtaining solid fusion and good hindfoot alignment inpatients with severe hindfoot disorders.

Tibiotalocalcaneal arthrodesis with a compressive retrograde nail: A retrospective study of 59 nails

BACKGROUND

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems. This study reports the elective results of combined subtalar and ankle arthrodesis using one design of retrograde intramedullary compression nail.

METHODS

Retrospective review identified 58 patients undergoing 59 tibiotalocalcaneal arthrodesis procedures. Mean follow up was 9.15 (3-36) months with average age 60.7 (22-89) years. A function and subjective patient satisfaction questionnaire was achieved in 89%.

RESULTS

53 patients (93%) achieved union at a mean time of 4.17 months. Four patients (8%) subjectively thought the procedure was of no benefit while 42 (84%) had an excellent or good result. The mean visual analogue scale (VAS) score for preoperative functional pain was 7.46 compared to 1.98 post-operatively (p<0.001).

CONCLUSIONS

This device and technique offers an effective treatment of hindfoot pathology giving reliable compression and subsequent fusion with excellent patient satisfaction and pain relief.

LEVEL OF EVIDENCE

IV case series.

Tibiotalocalcaneal arthrodesis using a straight intramedullary nail

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is a proven solution for severe hindfoot arthropathy that reestablishes stability for plantigrade gait and alleviates pain, while correcting deformity. Intramedullary nailing is an effective option for fixation. The aim of this study was to determine clinical outcome, analyze the fusion rate, and determine final hindfoot alignment in a consecutive series of patients using a single-design straight intramedullary nail.

METHODS

This study evaluated 63 patients treated between 2006 and 2010 with at least 36 months of follow-up. Ten patients were excluded because of study inclusion criteria, and 4 were lost to follow-up, leaving 49 patients available for review. The average follow-up was 70.7 ± 15.1 months.

RESULTS

The American Orthopaedic Foot and Ankle Society score improved from 29.7 ± 15.1 before arthrodesis to 65.8 ± 14.6 after (P < .001) with 83.7% (41/49) of patients stating they were satisfied or very satisfied with the outcome. The hindfoot angle improved from -3 ± 15 degrees (varus) before the arthrodesis to 3.5 ± 4 degrees (valgus) after; the tibiotalar angle averaged 103 ± 4.2 degrees after the arthrodesis. Fusion occurred in both joints in 86% (42/49) of patients and in 93% (91/98) of all joints. The average time to fusion was 4.5 ± 2 months. Current smokers had a significantly (P = .03) higher risk of complications. Use of an allograft, with or without bone morphogenetic protein 2, led to comparable results even in the presence of a large bone defect.

CONCLUSION

These results are comparable to previously published studies using intramedullary nailing to achieve tibiotalocalcaneal arthrodesis. The complication concerns typically associated with straight nails were not found. We recommend using a retrograde intramedullary nail for the fixation of TTC arthrodesis and adding an allograft in cases of significant bone loss.

LEVEL OF EVIDENCE

Level IV, consecutive case series.

Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft

BACKGROUND

Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis.

METHODS

Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire.

RESULTS

Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection.

CONCLUSION

Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.

Improvement in gait following combined ankle and subtalar arthrodesis

BACKGROUND

This study assessed the hypothesis that arthrodesis of both the ankle and the hindfoot joints produces an objective improvement of function as measured by gait analysis of patients with severe ankle and hindfoot arthritis.

METHODS

Twenty-one patients with severe ankle and hindfoot arthritis who underwent unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail were prospectively studied with three-dimensional (3D) gait analysis at a minimum of one year postoperatively. The mean age at the time of the operation was fifty-nine years, and the mean duration of follow-up was seventeen months (range, twelve to thirty-one months). Temporospatial measurements included cadence, step length, walking velocity, and total support time. The kinematic parameters were sagittal plane motion of the ankle, knee, and hip. The kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths on the affected and unaffected sides.

RESULTS

There was significant improvement in multiple parameters of postoperative gait as compared with the patients' own preoperative function. Temporospatial data showed significant increases in cadence (p = 0.03) and walking speed (p = 0.001) and decreased total support time (p = 0.02). Kinematic results showed that sagittal plane ankle motion had decreased, from 13.2° preoperatively to 10.2° postoperatively, in the operatively treated limb (p = 0.02), and increased from 22.2° to 24.1° (p = 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p = 0.007), and knee motion increased from 56° to 60° (p = 0.054). Kinetic results showed significant increases in ankle moment (p < 0.0001) of the operatively treated limb, ankle power of the contralateral limb (p = 0.009), and hip power on the affected side (p = 0.005) postoperatively. There was a significant improvement in gait symmetry (p = 0.01).

CONCLUSIONS

There was a small loss of sagittal plane motion in the affected limb postoperatively. There were marked increases in gait velocity, ankle moment, and hip motion and power, documenting objective improvements in ambulatory function. The data showed that preoperative ankle motion was greatly diminished. This may suggest that pain is more important than stiffness in asymmetric gait.

Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing: A Case Report

CASE

We report the case of a patient who sustained injury to the anterior tibial artery during tibiotalocalcaneal retrograde nailing and developed an acutely ischemic foot.

CONCLUSION

Vascular injury during tibiotalocalcaneal arthrodesis with retrograde nailing is a rare but serious complication. While retrograde tibiotalocalcaneal arthrodesis nailing for end-stage ankle and subtalar arthritis has shown encouraging results, a high index of suspicion for postoperative complications is necessary in patients with risk factors for poor posterior collateral circulation.

Radiologic patterning of joint damage to the foot in rheumatoid arthritis

OBJECTIVE

Foot and ankle deformities greatly affect the quality of life of rheumatoid arthritis (RA) patients. The aim of this study was to elucidate the pattern of destruction of the RA foot and its impact on patients.

METHODS

We cross-sectionally investigated RA patients (274 patients and 542 feet) using radiographs. The grade of joint destruction was assigned using Larsen's grading system for 12 joints in the foot and ankle. Cluster analysis was performed using the K-means method to classify the pattern of joint destruction. Of the 274 patients evaluated radiographically, 212 were assessed for functional disability using questionnaires.

RESULTS

Cluster analysis revealed that 542 feet were divided into 5 clusters, named according to the characteristic distribution of joint destruction: cluster I (normal type), cluster II (forefoot type), cluster III (midfoot type), cluster IV (mid-hindfoot type), and cluster V (combined type). Radiographic measurements revealed the characteristic deformities of each cluster: splay foot for cluster II, flat foot for cluster III, hindfoot malalignment for cluster IV, and mixtures of these characteristics for cluster V. A distribution map of each cluster based on disease duration revealed that cluster III peaked in cases of 5-10-year disease duration and subsequently decreased, followed by a gradual increase of cluster IV and cluster V. Cluster IV and cluster V showed significant changes in functional disability compared to cluster III.

CONCLUSION

This report is the first to reveal the pattern of RA foot deformities and their impact on patients using statistical measures in a large series.

Surgical correction of severe deformity of the ankle and hindfoot by arthrodesis using a compressing retrograde intramedullary nail

BACKGROUND

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail is a widely used surgical technique for the treatment of concomitant tibiotalar and subtalar arthritis and correction of accompanying deformity. This study was undertaken to evaluate the union rate, deformity correction, and clinical outcomes achieved using a compressing retrograde intramedullary nail.

METHODS

Thirty tibiotalocalcaneal arthrodeses with an osseous compressing arthrodesis nail system were studied with a mean follow-up of 26 months. Radiographic data were collected on deformity correction and union rate, and clinical outcomes were evaluated using the Visual Analogue Scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle/Hindfoot Score, and the Short Form-36 (SF-36) health survey. Records were reviewed for complications and concomitant procedures.

RESULTS

Thirteen of 30 operated limbs had a preoperative coronal plane deformity exceeding 15 degrees. Mean magnitude of correction was 13.2 degrees (range, 0-32 degrees, standard deviation ±9.6). In total, 76% of limbs (23/30) had postoperative coronal deformity of less than 5 degrees. Union was achieved in 96.6% of patients. There were 3 cases of tibial stress reaction, 3 cases of transient plantar nerve irritation, and 3 cases of wound infection. Clinical outcomes demonstrated a reduction in mean VAS score from 6.5 to 1.3 (P < .01), an increase in mean AOFAS Ankle/Hindfoot Scores from 29.7 to 74.3 (P < .01), and an increase in mean total SF-36 scores from 85.6 to 98.8 (P < .01).

CONCLUSION

A compressing retrograde intramedullary nail was effective in achieving deformity correction, a high union rate, and improvement in clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimal incision surgery for tibiotalocalcaneal arthrodesis

BACKGROUND

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure for severe diseases involving ankle and subtalar joints. However, this procedure is often associated with postoperative complications related to preoperative comorbidities. The purpose of this study was to present the clinical and functional outcomes of a consecutive series of TTCA using an original operative approach based on minimal incision surgery (MIS).

METHODS

Forty patients were followed prospectively for a mean (SD) of 31 (12.5) months. Clinical data, which included x-rays, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, SF-36 scores, and a patient satisfaction survey, were collected. A further 25 patients were examined retrospectively.

RESULTS

In the prospective group (n = 40), the mean AOFAS score improved by 44.8 points 1 year after the intervention (95% confidence interval [CI], 40.6-48.9), and the SF-36 improved by a mean of 17.5 points (95% CI, 1.4-20.9) in the mental component summary (MCS) score and 11.5 points (95% CI, 8.3-14.7) in the physical component summary (PCS) score. In the prospective group, postsurgical pain correlated with MCS score (r = 0.47, P < .001). In the entire group, bony union (defined as radiographic consolidation and absence of clinical symptoms) was observed in 86% of cases. Two deep infections, 2 nonunions in patients with preoperative persistent ulcers, and 7 delayed unions were the major complications observed in the entire group. One patient required amputation. No cases of superficial infection, wound dehiscence, or deep venous thrombosis were recorded.

CONCLUSION

To our knowledge, the present series represents the largest study on TTCA using MIS. The data obtained in the present study showed clinical and functional improvement after surgery and similar bony union rates as previously reported in the literature but with fewer complications related to the surgical wounds.

LEVEL OF EVIDENCE

Level IV, case series.

Tibiotalocalcaneal arthrodesis in a Singaporean hospital

PURPOSE

To report 18 patients who underwent tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail or cannulated screws.

METHODS

10 men and 8 women (19 ankles) aged 36 to 70 (mean, 52) years underwent tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail (n=13) or cannulated screws (n=6). Indications for arthrodesis were severe cavovarus deformity secondary to polio or charcot-marie-tooth disease (n=7), severe osteoarthritis in the ankle and subtalar joints (n=6), Charcot joint deformity (n=3), failed fusion procedures (n=2), and foot drop secondary to T12 tumour surgery (n=1). The visual analogue score (VAS) for pain was assessed, as were the American Orthopaedic Foot and Ankle Society (AOFAS) scores (for subjective and objective pain, function, and stability of the ankle), short form 36 (SF-36), and patient expectation and satisfaction scores.

RESULTS

The mean follow-up period was 35.6 (range, 11-144) months. 13 of 18 patients returned for assessment of scores. 18 of the 19 ankles achieved fusion after a mean period of 5.9 (range, 3-11) months. The mean VAS scores for pain, AOFAS scores, and SF-36 scores all improved. 11 patients had good-to-excellent satisfaction and expectation scores. Two patients had severe wound infections and underwent implant removal (after bone union), debridement, and intravenous antibiotic therapy. Two other patients had superficial wound infections. One patient with retrograde intramedullary nailing had a pseudoarthrosis and underwent implant removal, redebridement, re-autografting, and cannulated screw fixation. Fusion was achieved subsequently.

CONCLUSION

Tibiotalocalcaneal arthrodesis improved the pain score and quality of life, despite a high risk of complications.

Fusion following failed total ankle replacement

Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement. The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.

[Hindfoot arthrodesis for post-infectious ankle destruction using an intramedullary retrograde hindfoot nail]

BACKGROUND

Limb salvage after operations with deep infections of the ankle is often successful using arthrodesis of the hindfoot. The aim of this study was to evaluate the results of arthrodesis using a retrograde intramedullary nail following post-infectious ankle destruction.

PATIENTS AND METHODS

Between 2007 and 2010 a total of 44 patients were treated with tibiotalocalcaneal (TTC) arthrodesis and 14 patients with tibiocalcaneal (TC) arthrodesis using a retrograde hindfoot nail after quieting of infection. Evaluation included the American Orthopaedic Foot and Ankle Society (AOFAS) and the short-form 12-item (SF-12) scores.

RESULTS

Of the 58 patients 49 (35 male and 14 female) could be followed-up. The average time of follow-up was 18 months and the mean age was 58 years. In 85.7 % bony union could be achieved and 10.2 % suffered from reinfections. The mean results achieved in the different scores were AOFAS 56 and SF-12 39.1 (physical health summary scale) and 46.1 (mental health summary scale). Statistical analysis showed a significantly higher rate of bony fusion for TTC arthrodesis. Bony non-union showed a significant correlation to patients with reinfection and to diabetic patients.

CONCLUSIONS

Hindfoot arthrodesis for treatment of septic arthritis after infections is possible by using an intramedullary nail. The results show a high rate of fusion with an acceptable reinfection rate and good patient acceptance.

Retrograde nail for tibiotalocalcaneal arthrodesis as a limb salvage procedure for open distal tibia and talus fractures with severe bone loss

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure.

Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail

We present the clinical results and outcomes of 30 consecutive patients (31 ankles) who have undergone tibio-talo-calcaneal arthrodesis using an intramedullary nail to achieve bony union. This was a prospective study and surgery was performed by the senior author in a single hospital. We achieved high levels of satisfaction and outcome via the AOFAS and SF-36 scoring systems. We propose that this method of arthrodesis is reliable and easily reproducible for patients with severe arthritis and bone loss at the ankle and subtalar joints.

Primary tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal (TTC) arthrodesis is a salvage operation to treat a difficult problem; normal function is not expected with arthrodesis of these 2 major joints. However, in properly selected patients, TTC arthrodesis using intramedullary nailing is an effective technique to reduce pain and improve function. It allows load sharing, provides anatomic alignment, and has the advantage of being able to simultaneously arthrodese both the joints with 1 device. Its use is not without risks, and care must be taken when choosing the insertion site to reduce the risk of neurovascular insult.

Short-term outcome of retrograde tibiotalocalcaneal arthrodesis with a curved intramedullary nail

BACKGROUND

The aim of this study was to investigate the potential clinical benefit of tibiotalocalcaneal arthrodesis (TTCA) with an intramedullary nail with a valgus curve, two compression options, and angle-stable locking.

MATERIAL AND METHODS

Patients who had undergone TTCA at two tertiary hospitals were eligible. Patients who had undergone TTCA before the beginning of the study were evaluated retrospectively, then all following patients were examined prospectively. There were 59 TTCAs; 55 patients were available for analysis. Twenty-eight were evaluated retrospectively, 27 prospectively. Main Outcome Measures were an SF-36, Mazur-, and AOFAS ankle-hindfoot rating scores and radiographic examination.

RESULTS

Bony union was obtained in 53 patients. Fifty-one patients were satisfied with the outcome. Fifty-one patients had marked subjective improvement in mobility. The mean AOFAS score of the 55 patients at the latest followup was 66.8 (range, 38 to 86). The mean Mazzur score was 68.0 (range, 30 to 83). In the prospective group, the scores were significantly improved: AOFAS score by an average of 39.6 points (p<0.001); Mazur score by an average of 43 points (p<0.001); SF-36 physical component summary score (p<0.001) and mental component summary score also improved (p<0.048). Radiology showed good hindfoot alignment. The complication rate was 25%.

CONCLUSION

Compared with the literature, the data obtained in this study show a good outcome and a high rate of bony union, with comparable complication rates. Patient satisfaction was good. However, the patients still had limitations. The clinical benefit of the nail used was confirmed.

Development of a technique for cement augmentation of nailed tibiotalocalcaneal arthrodesis constructs

BACKGROUND

Tibiotalocalcaneal arthrodesis with a retrograde nail is an established procedure. Many patients considered for this arthrodesis have poor bone stock, which may make it difficult to obtain construct stability. This study was undertaken to determine whether stability could be enhanced by the cement augmentation of the calcaneal locking screws.

METHODS

A cannulated and perforated screw, and a technique for cement augmentation via this screw, were developed. Eight pairs of human cadaver bones were instrumented with a retrograde intramedullary device (Expert Hindfoot Arthrodesis Nail, Synthes AG, Solothurn, Switzerland). Within each pair, one specimen was randomized to have the nail interlocked in the calcaneus with two conventional screws; while the other specimen was similarly instrumented with the use of two cement-augmented screws. The bone mineral density was determined. In quasi-static tests, the neutral zone and the range of motion of the constructs were determined. Subsequently the specimens were tested in dorsiflexion/plantar flexion until failure occurred. The neutral zone and the range of motion of the constructs were determined every 200 cycles.

FINDINGS

Augmentation resulted in significantly greater stiffness and a significantly smaller range of motion in the quasi-static dorsiflexion/plantar flexion test, and in a significantly smaller neutral zone in all quasi-static tests. With cyclic loading, the number of cycles to failure was significantly larger in the augmented group. In both groups, bone mineral density was significantly correlated with the number of cycles to failure. Two augmented screws broke.

INTERPRETATION

Cement augmentation confers significant mechanical benefit in hindfoot arthrodesis and therefore can be used as a salvage procedure. Further development should be performed to validate the concept.

The complications encountered with the rheumatoid surgical foot and ankle

Rheumatoid arthritis (RA) is a chronic, degenerative, systemic disease that leads to the destruction of articular cartilage of the joints. Complications, including infection, delays in wound healing, malunion, nonunion, implant failure, and degeneration of adjacent joints soon after primary fusion, have been described in the literature and are generally accepted as commonplace in reconstructive surgeries of the foot and ankle. The combined efforts of the surgeon and supporting physicians to maintain optimal health for the patient, along with the principles discussed in this article, can lead to superior outcomes with fewer complications in the postoperative course.

Perioperative management of the patient with rheumatoid arthritis

Familiarity with the systemic manifestations of rheumatoid arthritis as well as familiarity with drug therapy used for the management of rheumatoid arthritis may be helpful in the avoidance of some postoperative complications. Drug effects on soft tissues and bone may complicate reduction, stabilization, and fixation of deformities. Evaluation of the patient with rheumatoid arthritis for extraarticular disease may also explain symptomatology, and reduce the incidence of complications by unrecognized contributions of soft tissue pathology of osseous and articular disorders.

Salvage arthrodesis for failed total ankle arthroplasty

BACKGROUND AND PURPOSE

Total ankle arthroplasty (TAA) has gained popularity in recent years. If it fails, however, salvage arthrodesis must be reliable as a rescue procedure. We therefore investigated the clinical, radiographic, and subjective outcome after salvage arthrodesis in a consecutive group of patients, and concentrated on the influence of the method of fixation on union rate and on salvage in inflammatory joint disease.

PATIENTS AND METHODS

Between 1994 and 2005, salvage arthrodesis was performed on 18 ankles (18 patients). Diagnosis was inflammatory joint disease (IJD) in 15 cases and osteoarthritis (OA) in 3. Tibio-talar fusion was performed in 7 ankles, and tibio-talocalcaneal fusion in 11. Serial radiographs were studied for time to union. Clinical outcome at latest follow-up was measured by the AOFAS score, the foot function index (FFI) and by VAS scores for pain, function, and satisfaction.

RESULTS

Blade plates were used in 7 ankles (4 IJD, 3 OA); all united. Nonunion developed in 7 of the 11 rheumatic ankles stabilized by other methods. 11 patients (8 fused ankles, 3 nonunions) were available for clinical evaluation. Their mean AOFAS score was 62 and mean overall FFI was 70. VAS score for pain was 20, for function 64, and for satisfaction 74. The scores were similar in united and non-united ankles.

INTERPRETATION

Blade plate fixation is successful in salvage arthrodesis for failed TAA. A high nonunion rate was found after salvage ankle arthrodesis in IJD with other methods of fixation. Clinical results were fair to good.

Compression forces of internal and external ankle fixation devices with simulated bone resorption

BACKGROUND

Internal and external fixation techniques have been developed to provide rigidity and stability to a fusion site such as in tibiotalocalcaneal (TTC) arthrodesis. Compression of the fusion site plays an integral role in primary bone healing, though little work has been done to quantify the compressive force values of ankle fixation devices.

MATERIALS AND METHODS

Using synthetic and cadaveric bone models, a Newdeal/Integra PantaNail and DePuy VersaNail were tested as compressive intramedullary (IM) nails while an Encore True/Lok and an Ace-Fischer frame were tested as external fixators.

RESULTS

The PantaNail experienced maximum compressive loads of 1898 and 1255 N in synthetic and cadaveric constructs, respectively. The VersaNail experienced max compressive loads 388 N during installation. All IM nails tested experienced decreased compressive loads after removal of the external guide and instrumentation. The external fixators were loaded to approximately 1200 N in both synthetic and cadaveric constructs. The decrease in compressive load was recorded as a function of simulated fusion site bone resorption for all devices. The IM nails experienced a 90% reduction in load with less than 1 mm of resorption, while the external fixators held 50% load for over 4 mm of resorption. These data were verified using a simple constitutive model of IM nails and external fixators.

CONCLUSION

Intramedullary nails are capable of generating compression, however, are unable to provide sustained compression for any considerable amount of resorption. External fixators are inherently capable of applying and sustaining greater amounts of compression.

CLINICAL RELEVANCE

Surgeons who perform TTC arthrodesis procedures should be aware of a device's ability to generate and sustain compression with respect to bone resorption.

Intraoperative mechanical bone strength determination in tibiotalocalcaneal fusion: a biomechanical investigation

BACKGROUND

Bone strength is currently measured with indirect techniques. We investigated the use of an intraoperative mechanical measurement for local bone strength determination and prediction of intramedullary-nail fusion failure. We investigated whether intraoperative local bone strength determination may be useful to the surgeon in predicting intramedullary nail hindfoot fusion performance.

MATERIALS AND METHODS

In seven human specimens, bone mineral density (BMD) was determined with qCT. A device (DensiProbe) specially devised for nailed tibiotalocalcaneal arthrodesis (TTCA) was inserted at the intended calcaneal screw sites of an intramedullary nail, and the cancellous break-away torque was measured. The constructs were then cyclically loaded to failure in dorsiflexion-plantarfexion.

RESULTS

The BMD range was wide (42.8 to 185.9 mg HA/cm(3)). The proximal-screw site peak torque was 0.47 to 1.61 Nm; distal-screw site peak torque was 0.24 to 1.06 Nm. The number of cycles to failure correlated with peak torque both proximally (p = 0.021; r(2) = 0.69) and distally (p = 0.001; r(2) = 0.92). Proximally, peak torque did not correlate with BMD (p = 0.060; r(2) = 0.54); distally, it correlated significantly (p = 0.003; r(2) = 0.86).

CONCLUSION

DensiProbe measurements can be used in the hindfoot to assess bone strength. In this study, specimens that failed early could be identified. However, in clinical practice fusion failure is multifactorial in origin, and failure prediction cannot be based upon peak torque measurements alone.

CLINICAL RELEVANCE

The technique described here may be of use to give an intraoperative decision aid to predict intramedullary nail hindfoot fusion performance.

Revisional hindfoot arthrodesis

Salvage of a failed hindfoot arthrodesis is an extensive undertaking for the surgeon and patient. With increased morbidity and postoperative convalescence and complications, patients must understand the risk involved in this type of revisional surgery. This article provides a systematic approach to revisional hindfoot arthrodeses, focusing on patient evaluation, surgical technique, and postoperative treatment.

A technique of fusion for failed total replacement of the ankle

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).

Ankle arthrodesis in rheumatoid arthritis: techniques, results, and complications

This article defines specific risks associated with rheumatoid arthritis, including an increased incidence of medical comorbidities, the use of steroids and other immunosuppressive agents, osteoporosis, vascular disease, and the common occurrence of severe deformity. This article suggests approaches for management and techniques that may improve specific surgical issues in this challenging patient population.

Wound healing complications and infection following surgery for rheumatoid arthritis

The goal of the foot and ankle surgeon is to achieve balanced correction of deformity in patients who have rheumatoid arthritis (RA) while minimizing the risk for complications. To achieve these goals, a large number of procedures may be required at a single or in a staged operative setting. In this article, the evaluation of the patient to assess operative risks and the management of perioperative complications in the RA foot and ankle patient are presented.