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

Tibiotalocalcaneal arthrodesis with an intramedullary nail: The functional and clinical outcome of a challenging patient group and its comparison to a below knee amputation

BACKGROUND

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to fuse the ankle and subtalar joints to treat severe ankle and hindfoot disease. Patients often have multiple operations before a TTCA. A below knee amputation (BKA) has major physical and psychological impacts. Our aim is to investigate the outcomes of these treatments in salvage situations, with a focus on objective functional measurements and patient reported outcome measures (PROMs).

METHODS

52 patients underwent TTCA with a retrograde intramedullary nail and contacted for clinical and functional assessments and compared to patients who underwent traumatic BKA. PROMS such as AOFAS score, SF-36 and foot function index (FFI), and objective functional outcome measures were used.

RESULTS

Of the 52 TTCA patients, 28 patients were recruited for follow-up. 35.7% of patients had postoperative complications. Mean postoperative AOFAS score was 63.9 ± 8.4 (range, 47-81), FFI 48.8 ± 15.8 (range, 22.2-75.2). 11 BKA patients (mean age 46.4 years) were included as control group. BKA patients scored higher than the TTCA patients on SF-36 physical functioning (p < 0.01) and SF-36 mental health (p < 0.05) subscales. The flat-surface functional tests (timed up and go test, 2-minute walk test, 10-meter walk test) showed significantly (p < 0.05) better outcomes for the BKA compared to TTCA.

CONCLUSIONS

A TTCA is a salvage procedure with high complication rates. Functional and psychometric results are reduced compared to the normal population. Patients after a BKA had significantly better scores on SF-36 functional and mental health subscales and better functional outcomes for flat ground activities compared to TTCA. Heterogeneity of the TTCA and BKA patient cohorts is a limitation of this study. With these results in mind, the outlook of a BKA is not necessarily a grim one. They may be used by surgeons to counsel patients preoperatively when managing complex ankle and hindfoot disease.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion

BACKGROUND

The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis.

METHODS

Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up.

RESULTS

TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2).

CONCLUSION

In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems.

LEVEL OF EVIDENCE

Level IV, case series.

The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects-Results of a New Technique in Tibiotalocalcaneal Arthrodesis

Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m². All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.

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.

Management of Nonunited Talar Fractures With Avascular Necrosis by Resection of Necrotic Bone, Bone Grafting, and Fusion With an Intramedullary Nail

BACKGROUND

The presence of nonunion of a talar fracture with displacement, together with complete avascular necrosis, is a challenging entity to treat.

METHODS

Twelve patients, 8 men (66.7%) and 4 women (33.3%), with nonunited talar fractures and extensive avascular necrosis of the talus were included. The average age was 27.7 years (range, 19-38 years). After exclusion of infection, the patients underwent resection of necrotic bone, bulk autograft, and fusion using an intramedullary nail. The posterior approach was used in 11 patients and the anterior approach in 1 patient. The primary outcome was solid osseous union at the ankle and subtalar level and between the talar head anteriorly and the posterior construct, as evidenced by computed tomographic examination. Functional assessment was performed with the American Orthopaedic Foot & Ankle Society score and subjective patient satisfaction Results: After a mean follow-up duration of 23 months (range, 12-60 months), solid osseous union was achieved in 8 patients (66.7%). Stable fibrous union was seen in 1 patient (8.3%). Three patients (25%) required reoperation, and osseous fusion was finally achieved. American Orthopaedic Foot & Ankle Society score improved from a mean of 39.3 (range, 12-56) preoperatively to 76.6 (range, 62-86) at last follow-up. Subjective patient satisfaction was graded good or excellent in all cases.

CONCLUSION

Resection of necrotic talar body and bulk autograft with tibiotalocalcaneal fusion by an intramedullary nail through a posterior approach was a reasonable option for the management of type IV posttraumatic talar deformity.

LEVEL OF EVIDENCE

Level IV, case series.

Tibiotalocalcaneal arthrodesis with headless compression screws

Background

Tibiotalocalcaneal arthrodesis with headless compression screws has not been previously reported. We hypothesized that these screws could be suitable for tibiotalocalcaneal arthrodesis because of their special design. This study aimed to evaluate the clinical outcomes of patients undergoing tibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint.

Methods

From 2010 to 2015, 23 patients with severe ankle and subtalar arthropathy underwent tibiotalocalcaneal arthrodesis. All surgeries were completed by a senior surgeon in the same hospital. These patients were 18~76 years (mean 54.6 years) old; the duration of their disease was 9~38 months (mean 13.2 months). The study population included 12 males and 11 females; 12 patients underwent surgery on the left and 11 on the right. Indications for surgery included avascular necrosis of the talus (n = 14), severe posttraumatic arthritis (n = 4), osteoarthritis (n = 2), terminal tuberculous arthritis (n = 1), rheumatoid arthritis (n = 1) and Charcot neuroarthropathy (n = 1). A lateral oblique incision was performed to expose the subtalar joint, and an anteromedial longitudinal incision was used to expose the ankle joint. After the articular surfaces were removed, the tibia, talus and calcaneus were carefully aligned and fixed with two headless compression screws. Patients were followed up at 6 weeks and 3, 6 and 9 months after surgery; they were evaluated by Roles and Maudsley patient satisfaction scores, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) score and radiographic evaluation.

Results

Seventeen patients were studied, with a mean follow-up time of 6.5 months (range 5–24). The mean Roles and Maudsley patient satisfaction score was 1.41 at the last follow-up; most of the patients were satisfied with the surgery results. The mean preoperative AOFAS Ankle-Hindfoot Score was 29.6 (range 18–37), while the mean last follow-up AOFAS Ankle-Hindfoot Score was 68.5 (range 61–80). The VAS score for preoperative functional pain was 6.95 (range 3–10) compared to 1.56 (range 0–3) postoperatively (P < 0.001). The mean surgical duration was 57 (range 42–125) min. The mean time to union was 3.8 months (range 3–12 months); fusion of the ankle and subtalar joint was successful in all patients. One patient experienced delayed wound healing.

Conclusions

Tibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint is an effective treatment that is minimally invasive and is associated with a short operation time, high fusion rate, low incidence of complications and good postoperative recovery.

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.

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.

Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series

Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation is associated with a high incidence of complications. This is especially true when performed with a bulk structural allograft and poor soft tissue quality. In select high-risk limb salvage cases, we have augmented tibiotalocalcaneal arthrodesis procedures stabilized using retrograde intramedullary nail fixation with a vascularized pedicled fibular onlay bone graft. We present the data from 10 such procedures with a mean follow-up period of 10.9 ± 5.4 (range 6 to 20) months involving 10 patients (9 males and 1 female). The etiology was avascular osteonecrosis of the talus and/or distal tibia and a resultant large volume cavitary bone defect (8 ankles), severe equinocavovarus contracture (1 ankle), and failed total ankle replacement (1 ankle). A frozen femoral head bulk allograft was used twice, a whole frozen talus allograft once, and a freeze-dried calcaneal allograft once. The fibula was mobilized with intact musculoperiosteal perforating branches of the peroneal artery as a vascularized pedicle onlay bone graft fixated with a screw and washer construct. The mean fibular graft length was 10.2 ± 2.3 cm. The mean interval to radiographic fusion was 2.6 ± 0.6 months and to weightbearing was 3.1 ± 1.4 months. Two stable bulk allograft-host bone and fibular graft-host bone nonunions occurred after intramedullary nail hardware failure. Tibiotalocalcaneal arthrodesis augmented by vascularized pedicled fibular graft stabilized with retrograde compression intramedullary nail fixation offers a reliable option for complex salvage situations when few other options exist.

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.

Ankle arthrodesis vs TTC arthrodesis: patient outcomes, satisfaction, and return to activity

BACKGROUND

It is believed that patients with an ankle arthrodesis (AA) have better outcomes than after a tibiotalocalcaneal (TTC) arthrodesis due to preservation of subtalar motion. However, there are no studies comparing actual functional outcomes and patient satisfaction between AA and TTC arthrodesis.

METHODS

We retrospectively analyzed patient satisfaction and functional outcomes of patients after an AA and TTC arthrodesis using a postal survey. A total of 173 patients who underwent TTC and 100 AA patients from 2002 to 2010 were identified with a minimum of 24 months follow-up. In all, 53 AA and 64 TTC arthrodesis patients were included in the study, with the remainder lost to follow-up. A return to activity questionnaire and SF-12 scores were used to compare functional outcomes. The mean follow-up time was 63 months.

RESULTS

Both groups showed good outcomes with a low visual analogue pain score (2.7 for AA and 2.8 for TTC), high satisfaction score (90.6% for AA and 87.5% for TTC), and return to work (77.4% for AA and 73.0% for TTC). In all, 84.6% of AA and 81.0% of TTC patients would have the surgery again. There were no significant differences between the 2 groups for these parameters. However, when asked if their desired activity level was met, fewer AA patients met their desired level (58.5% for AA and 66.5% for TTC, P = .02). AA patients were also more likely to feel their level was unmet due to the foot and ankle (85.6% for AA vs 25.7% for TTC, P < .001).

CONCLUSIONS

Both AA and TTC arthrodesis were associated with good functional outcomes and satisfaction. AA patients had higher postoperative activity expectations and were less likely to meet them. When they failed to meet these expectations, they were much more likely to attribute it to their operated ankle. We believe it is because of the different ways the 2 groups of patients are counseled preoperatively, which highlights the importance of managing patient expectations.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic tibiotalocalcaneal arthrodesis with locked retrograde compression nail

Tibiotalocalcaneal (TTC) arthrodesis is a demanding procedure. Several techniques have been described for successful fusion, including the use of plates, screws, intramedullary nails, and external fixators. Arthroscopic TTC fusion with intramedullary nailing has been recently described as an alternative method to traditional open procedures. The surgical technique and clinical and radiographic outcomes of 2 patients who had undergone arthroscopic TTC arthrodesis with intramedullary nailing are presented. The indication for surgery was symptomatic tibiotalar and subtalar post-traumatic arthritis in 1 patient and distal tibia and fibula nonunion in the other. In both cases, fusion was obtained at approximately 8 weeks postoperatively. At the final follow-up visit at 2 years postoperatively, their American Orthopaedic Foot and Ankle Society score had improved from 31 to 85 points and from 16 to 71 points, respectively. No intra- or postoperative complications developed. Arthroscopic TTC arthrodesis can be an alternative to traditional open procedures, especially in patients with soft tissue concerns or several previous surgeries. Experience with ankle arthroscopy procedures is mandatory to obtain satisfactory results and minimize the risk of complications.