Blade plate compared with locking plate for tibiotalocalcaneal arthrodesis: a cadaver study

Tibiotalocalcaneal Arthrodesis: A Retrospective Comparison Between Nails and Lateral Locking Plate Complications

Background

Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications.

Methods

We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones.

Results

We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure.

Conclusion

No significant differences were found in the complication rates between the 2 implants.

Level of Evidence

Level V, Case series.

Tibiotalocalcaneal Arthrodesis in Severe Hindfoot Deformities

Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies--weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.

Plate Fixation in Midfoot and Ankle Charcot Neuroarthropathy

Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity.

Percutaneous Plate Arthrodesis

Arthrodesis is an elective surgical procedure that aims at eliminating pain and dysfunction by promoting deliberate osseous fusion of the involved joint(s). Percutaneous plating can be used to perform carpal and tarsal arthrodeses in dogs and cats. After cartilage debridement is performed, the plate is introduced through separate plate insertion incisions made remote to the arthrodesis site and advanced along an epiperiosteal tunnel, and screws are inserted through the 3 existing skin incisions. The primary advantage of this technique is a decreased risk of soft-tissue complications, including postoperative swelling, ischemia, and wound dehiscence. Preliminary clinical results have been promising.

Outcomes of Locking-Plate Fixation for Hindfoot Fusion Procedures in 15 Patients

Tibiotalocalcaneal arthrodesis is a salvage procedure for various end-stage foot and ankle pathologic entities. Several factors are known to influence the union rate after these procedures, including construct rigidity. The data on locked plates as a fixation technique have been inconclusive, with variable union rates reported. One recent study suggested that locking plates can lead to high nonunion rates owing to excessive rigidity. The purpose of the present study was to retrospectively examine the outcomes of locking plate fixation. We retrospectively reviewed the cases of 15 patients (7 [46.7%] male, 8 [53.3%] female) who underwent tibiotalocalcaneal, tibiocalcaneal, or tibiotalar arthrodesis fixed with a locking plate from January 2013 to January 2014. The average age was 52.19 ± 5.8 years. The mean follow-up period was 17 ± 5.3 months. We examined the overall union rates and the effects of smoking, diabetes, and rheumatologic status on the union rate. Of the 15 cases, 11 (73.3%) did not achieve union. The mean time to failure was 10 ± 5.3 months. Age, gender, smoking, diabetes, use of augmentation screws outside the plate, and operating surgeon did not have an effect on the failure rate (p > .50). In addition, gender, smoking, and diabetes did not predict for nonunion. The high failure rate of rigid locking plate fixation reported might be attributable to the high incidence of smoking and diabetic comorbidities in our study. However, excessive construct rigidity might play an important role. Larger studies are needed to establish more reliable union rates with the use of locking plates in foot and ankle fusion.

Comparison of Posterior Approach With Intramedullary Nailing Versus Lateral Transfibular Approach With Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis

BACKGROUND

A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. The intramedullary (IM) nail and lateral, fixed-angle plating are commonly used because of ease of use and favorable biomechanical properties. A lateral, transfibular (LTF) approach allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PATS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either a PATS approach with IM nailing or LTF approach with fixed-angle plating.

METHODS

A retrospective review was performed on all patients who underwent simultaneous TTC arthrodesis with minimum 1 year clinical and radiographic follow up. Patients were excluded if they underwent TTC arthrodesis through an approach other than PATS or LTF, and received fixation without an IM nail or fixed-angle plate. Primary outcomes examined were union rate, revisions, and complications. Thirty-eight patients underwent TTC arthrodesis with a PATS approach and IM nailing, and 28 with a LTF approach and lateral plating.

RESULTS

The overall union rate was 71%; 76% (29 of 38 patients) for the PATS/IM nail group, and 64% (18 of 28) for LTF/plating group ( P = .41). Symptomatic nonunion requiring revision arthrodesis occurred in 16% (6 of 38) of the PATS/IM nail group versus 7% (2 of 28) in the LTF/lateral plating group ( P = .45). There were no significant differences in individual tibiotalar or subtalar union rates, superficial wound problems, infection, symptomatic hardware, stress fractures, or nerve irritations.

CONCLUSION

Union, revision, and complication rates were similar for TTC arthrodesis performed with a PATS approach and IM nail compared with an LTF approach and fixed-angle plate in a complex patient population. Both techniques were adequate, especially when prior incisions, preexisting hardware, or deformity preclude options.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Tibiotalocalcaneal arthrodesis by using proximal humeral locking plate

Objectives

The aim of this study was to evaluate the short-term clinical and radiological results of tibiotalocalcaneal arthrodesis (TTCA) with proximal humeral locking plate.

Material and methods

Eight patients (7 female, 1 male; average age 53 years (range: 24–67)) who underwent TTCA with proximal humeral locking plate between 2009 and 2011, were retrospectively evaluated with AOFAS hindfoot scale and Maryland foot score system. The mean follow up was 32.6 months (range: 23–54).

Results

Complete fusion was achieved in 7 patients. Soft tissue infection was observed in 2 patients and reflex sympathetic dystrophy in 3 patients. All patients recovered with medical treatment. At the final follow-up, mean AOFAS Hindfoot score was 60 (range: 41–81) and Maryland Foot Score was 67.8 (range: 41–85). The satisfactory rates of AOFAS and MFS were found as 12.5% (1/8) and 50% (4/8), respectively. One patient had an incomplete union with 5 degrees of heel varus deformity and 5 degrees of equinus deformity was observed in another. There were no implant failure or deformation of the plate during the follow-up period.

Conclusion

Our study suggests that proximal humeral plate may be an alternative for fixation in tibiotalocalcaneal fusion surgery.

Short-Term Radiographic Results and Technique of Tibiotalocalcaneal Arthrodesis With a Posterior Anatomic Locking Plate

Tibiotalocalcaneal arthrodesis is a salvage procedure for severe hindfoot/ankle deformities, arthritis, avascular necrosis of the talus, failed total ankle replacement, and Charcot neuroarthropathy. The methods for fixation include anterior and lateral plates, screws, retrograde intramedullary nails, and external fixation. The purpose of the present report was to describe the short-term radiographic outcomes and technique using a posterior approach with an anatomic-specific locking plate for tibiotalocalcaneal arthrodesis. Nine patients underwent tibiotalocalcaneal arthrodesis using a posterior locking plate. The medical records and radiographs were retrospectively reviewed for patient demographics, fusion rate, complications, and patient satisfaction. The mean patient age was 57.89 ± 10.8 years, and the follow-up period was 11.11 ± 4.74 months for the patients undergoing posterior tibiotalocalcaneal arthrodesis. The mean time to weightbearing in a shoe with a brace was 16.68 weeks. The ankle and subtalar joints had healed within a mean duration of 13.61 ± 2.96 weeks. Two patients (22%) developed nonunion, 1 at both the ankle and subtalar joint and 1 at the ankle only. The present report demonstrates an alternative posterior approach to joint preparation and fixation. Direct visualization of both joints and soft tissue coverage provide a viable option for posterior fusion in patients with compromised anterior and/or lateral skin envelopes.

Use of a Proximal Humeral Locking Plate for Complex Ankle and Hindfoot Fusion

Arthrodesis of the ankle and hindfoot in the setting of major deformity is challenging and associated with substantial risks. Patients often have significant comorbidities that lead to unforgiving soft tissues, poor vascularity, and poor bone quality. This creates the high-risk scenario of poor wound healing and poor implant fixation. Complications can be devastating, leading to loss of the limb and sepsis. The use of locking plate technology might provide biomechanical and operative technique advantages in such patients. We retrospectively assessed the results of the modified use of the PHILOS(™) (Synthes(®), Zuchwil, Switzerland) proximal humeral locking plate in 21 patients (11 males, 10 females; mean age 56.1 years, range 25 to 74 years) who had undergone complex fusions, including tibiotalar (n = 4), tibiocalcaneal (n = 7), or tibiotalocalcaneal (n =10) fusions. The average follow-up period was 14.6 (median 10, range 6 to 49) months. Of the 21 fusions, 18 achieved union (85.7%) at an average period of 4.8 (median 4.3, range 3 to 12) months. The overall deep infection rate was 14.3%. Overall, 17 of the 21 patients (81%) were satisfied with the result (good to excellent), 1 reported the result was fair (4.8%), and 3 patients developed nonunion and were dissatisfied with the procedure (14.3%). The present study is the largest series to date of patients undergoing complex ankle and hindfoot arthrodesis with the use of a proximal humeral locking plate and confirms previous findings that the technique is reliable with union, satisfaction, and complication rates comparable to those of other techniques.

[Tibiotalocalcaneal arthrodesis using a humeral locking plate]

OBJECTIVE

To describe the results of tibiotalocalcáneal arthrodesis (TTC) using a humeral locking plate.

METHODS AND MATERIALS

A retrospective, observational study was conducted between January 2007 and December 2013 in the Hospital Militar Central de Bogotá. The study included patients with symptomatic osteoarthritis diagnosed clinically and radiologically, and who underwent TTC arthrodesis using a humeral locking plate with a minimum follow up of 6 months.

RESULTS

The total number patients was 35, of whom 7 (20%) were women and 28 (80%) men, with a mean age 36.3 years (19.77).

AETIOLOGY

74% with post-traumatic arthritis, most of them secondary to gunshot wounds and fragmentation weapons, and neuropathic in 20%. An autogenous graft was used in 13 cases, and 14 cases using both, with a mean consolidation time of 4.37 months. Complications include, delayed union in 3 cases, and surgical site infection in 4. The postoperative functionality (AOFAS) mean was 66.7/100 points, with a score of 2.35 on a visual analogue pain scale.

CONCLUSION

TTC arthrodesis using a humeral locking plate is a suitable option for fixing this type of arthrodesis, with a low rate of complications, and postoperative results that revealed satisfactory improvement in pain and consolidation.

The use of the 4.5 mm 90° titanium cannulated LC-angled blade plate in tibiotalocalcaneal and complex ankle arthrodesis

BACKGROUND

Tibiotalocalcaneal arthrodesis is used to manage end stage arthritis, often associated with severe bone loss. The goal is to relieve pain through a stable, well-aligned hindfoot and ankle. We describe our initial results and outcome of ankle and tibiotalocalcaneal arthrodesis using a 90° blade plate.

METHODS

We retrospectively reviewed the records of patients managed at our institution between 2010 and 2014. Twenty cases were identified who had either talocrural (n = 9) or TTC fusion (n = 11) with 1 patient having both ankle and then TTC fusion in separate sittings.

RESULTS

Fusion occurred in 18 of the 20 cases (90%) with correction of angular deformity and restoration of hindfoot alignment. None of the 18 patients developed complications and all discharged to follow-up when independently mobile and satisfied with the outcome.

CONCLUSIONS

This study demonstrated that using a 90° blade plate for ankle or TTC arthrodesis in a diverse group of complex primary and revision indications associated with severe deformity and bone loss resulted in a high rate of bony union and stable deformity correction.

Ankle arthrodesis in tubercular arthritis using anterior bridge plating: a report of 2 cases

Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results.

Ankle salvage surgery with autologous circular pillar fibula augmentation and intramedullary hindfoot nail

Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.

Topical review: locking plate technology in foot and ankle surgery

The use of locking plate technology in foot and ankle surgery has increased over the last decade. Reported applications include fracture repair, deformity correction, and arthrodesis. There is limited evidence, however, to guide clinicians with regard to the appropriate and optimal use of this technology. This work aims to examine the current biomechanical and clinical evidence comparing locking construct technology to other forms of fixation in the field of foot and ankle surgery.

TIBIOTALOCALCANEAL ARTHRODESIS WITH LATERAL COMPRESSION PLATE: ARTRODESE TIBIO-TALO-CALCANEANA COM PLACA DE COMPRESSÁO LATERAL

OBJECTIVE

The objective of this study was to evaluate the short-term clinical and radiographic results from a TTC fusion procedure using a lateral locking plate specifically designed for this purpose.

METHODS

All the fourteen patients were evaluated using a variety of methods, including a visual analogue scale (VAS), the AOFAS hindfoot score and a subjective satisfaction scale. The average follow-up was 10 months.

RESULTS

The average AOFAS score improved from 41 points preoperatively to 63 points postoperatively. The VAS pain score decreased from 7 to 3 points. Four patients reported excellent results, eight good, one fair and one poor.

CONCLUSION

Our study provides support for using a specially designed plate for TTC fusion in hindfoot salvage surgery.

RESUMO

Objetivo: O propósito deste estudo é avaliar os resultados clínicos e radiológicos a curto prazo do procedimento de fusão tíbio-talo-calcaneana (TTC) com o uso de uma placa lateral bloqueada específicamente concebida para este fim. Métodos: Todos os 14 pacientes foram avaliados usando uma variedade de métodos, incluindo a escala analógico visual da dor (EAV), escore da AOFAS para o retropé e escala subjetiva de satisfação. O acompanhamento médio foi de 10 meses. Resultados: O escore AOFAS médio melhorou de 41 pontos no período pré-operatório para 63 pontos no período pós-operatório. O escore da dor (EAV) caiu de 7 para 3 pontos. Quatro pacientesforam classificados como excelentes resultados, oito bons, um moderado e um ruim. Conclusão: Nosso estudo dá suporte ao uso da placa especialmente desenhada para a fusão tibio-talo-calcaneana (TTC) nas cirurgias de salvamento do retropé.

Tibiotalocalcaneal arthrodesis using a femoral locking plate

The goal of a tibiotalocalcaneal arthrodesis is to create a pain-free, stable hindfoot and ankle. Although a reserved procedure, it is useful when simultaneous ankle and subtalar joint pathology exists. Numerous complications have been reported after tibiotalocalcaneal arthrodesis, most importantly nonunion. Locking plates have proved to be a more stable construct than alternative forms of arthrodesis. In the inverted positions, the hybrid plating of the femoral locking plate structurally aligns with the anatomy of the hindfoot. This provides an anatomically sound construct, while allowing for both locking and lag screw insertion. We describe a new technique using a 4.5-mm condylar plate for tibiotalocalcaneal arthrodesis.

Locking plate technology and its use in foot and ankle surgery

This article discusses the history of conventional plating, plate biomechanics, and screw function to provide better understanding of osseous physiology and biology using locking plates. The peer-reviewed and non-peer-reviewed literature have been researched to decipher and share the most pertinent information on this topic.

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.

Technique and early experience with posterior arthroscopic tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis is indicated for pain relief in patients with combined arthritis of the ankle and subtalar joint. An arthroscopic posterior approach was designed to improve upon traditional methods by using a minimally invasive technique. The technique involves prone positioning of the patient, one anterolateral and two posterolateral portals, and arthroscopic debridement of both the tibiotalar and posterior talocalcaneal joint. Stabilisation is obtained with a retrograde intramedullary nail, with static interlocking. This article presents illustrative cases and discusses some of the technical advantages and disadvantages over conventional open surgery. For surgeons familiar with posterior ankle or subtalar arthroscopy, this minimally invasive debridement and nailing appears to offer superior exposure, high patient satisfaction and lower postoperative morbidity than traditional methods; fusion is encouraged by preserving the medullary reaming material at the site of the fusion.

Surgery on the rheumatoid ankle joint: efficacy versus effectiveness

This article examines synovectomy and ankle arthrodesis for the rheumatoid ankle joint. Reviews of osteoimmunology and gait analyses specific to rheumatoid arthritis are included. Comparison studies including ankle arthrodesis and total ankle arthroplasty are reviewed.

Treatment of nonunion and malunion of trauma of the foot and ankle using external fixation

Salvage of nonunion and malunion of trauma of the foot and ankle is often challenging surgery. Internal fixation provides the mainstay of most orthopedic surgeons' treatment of these conditions. Patient systemic factors, local factors, and the complex nature of these often multiplanar deformities may make external fixation a more viable option. This article provides an overview of the principles and results of the use of external fixation.

Tibiotalocalcaneal arthrodesis with the use of a humeral locking plate

Combined arthrosis or deformity of the subtalar and ankle joints presents a challenge to the foot and ankle specialist. Tibiotalocalcaneal arthrodesis is a well-described surgical technique used for resolution of deformity and end-stage arthrosis of the ankle and subtalar joints and is currently the standard of care for this condition. This article highlights the technique of insertion of the humeral locking plate for the stabilization of tibiotalocalcaneal arthrodesis. A case study is provided to serve as an example of the technique.

Tibiotalocalcaneal arthrodesis for salvage of severe ankle degeneration

Tibiotalocalcaneal arthrodesis is a successful and proven surgical procedure for patients who have significant arthritic changes, deformity, and failed previous operations. Surgical technique varies depending on the type of fixation. Basic surgical principles should not be violated. Correction of the deformity with appropriate joint preparation and stable fixation is important for a good outcome. Other adjunctive materials, such as bone growth stimulators and orthobiologics, should be used appropriately to ensure adequate primary arthrodesis.