Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis

Reconstruction of Bilateral Hindfoot Open Fracture Using the Femoral Head Allograft: A Three-Year Follow-Up Case Report

This case report presents a three-year follow-up of a young male with bilateral hindfoot fractures due to a high-energy road traffic accident, resulting in a comminuted open calcaneal fracture on the left and an open fracture-dislocation of the right talus. Staged reconstruction was performed, including initial debridement, temporary cement spacers, and subsequent fixation with femoral head allografts (FHAs). The right foot underwent a tibiotalocalcaneal (TTC) fusion, and the left foot received a double arthrodesis. Follow-up imaging confirmed allograft integration and complete fusion. At three years, the patient had a stable, plantigrade foot and satisfactory function for daily activities. This case demonstrates the successful use of FHAs for complex hindfoot reconstructions, preserving limb length and functionality.

Initial Safety of Total Talus Replacement Used to Treat Talar Avascular Necrosis

BACKGROUND

Total talus replacement (TTR) implants are designed to replace the diseased talar anatomy, reduce pain, maintain ankle range of motion, and restore ankle function after conservative treatments have failed. Currently TTR implants are produced by 3D printing a patient-specific implant designed from the patient's preoperative anatomy. TTR surgery using patient-specific implants is a relatively new technique that remains understudied in the literature. Therefore, the purpose of this investigation was to determine the early safety and potential benefit of the TTR implant in patients with talar avascular necrosis.

METHODS

This retrospective, multicenter, cohort study evaluates the safety and potential benefits of TTR using 3D-printed patient-specific implants across 4 US centers. The primary outcome was the occurrence of early adverse events after TTR surgery. Secondary outcomes including, pain, and physical function were assessed using the pain visual analog scale (VAS), and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), respectively.

RESULTS

The study team analyzed 15 patients with more than 1 year of follow-up. The mean duration of follow-up was 25.9 months (range: 18.3-41 months). Although 33.3% (5 of 15) of patients experienced adverse events, primarily occurring within the initial 6 months postoperatively, 93% (14 of 15) of patients reported implant survivorship. Of the 5 cases (33.3%) resulting in an adverse event, 3 (60.0%) were determined to be unrelated to the subject device, 2 (40.0%) were determined to be possibly procedure-related, and none (0%) were determined to be device-related.

CONCLUSION

Although further studies are needed to compare TTR with the standard of care, the results of this study demonstrate the relative early safety of TTR surgery using a 3D-printed implant for the treatment of challenging talar pathologies. A larger and longer clinical study is required to see if the efficacy of this approach will be statistically and clinically meaningful.

Efficacy and safety of carbon fiber retrograde intramedullary nailing in tibio-talar-calcaneal fusion: a single-centre retrospective study

INTRODUCTION

Tibio-talar-calcaneal (TTC) fusion is a salvage procedure designated for treating various severe hindfoot pathologies. While traditional methods have been effective, the advantage of carbon fiber (CF) retrograde intramedullary nailing (RIMN) presents a potentially superior technique. This study evaluates the efficacy and safety of CF RIMN in TTC fusion, focusing on union rates, complication rates, and patient-reported outcomes.

MATERIALS AND METHODS

Conducted as a single-center, retrospective study, this research involved 21 patients who underwent TTC with CF RIMN from 2015 to 2021. Patient selection excluded those with active infections or those needing significant bone allografts. Patient follow-up was conducted at multiple intervals postoperatively, with a minimum follow-up of 24 months, assessing for union complications and using tools like the VAS, SF12, and AOFAS for patient-reported outcomes.

RESULTS

The study observed a 90% union rate among patients. Complication rates included a 14% incidence of iatrogenic fractures to the anterior tibial cortex and 19% postoperative complications. Significant improvement was noted in VAS scores but not in SF12 and AOFAS scores. The use of 200 mm RIMN was identified as requiring careful consideration due to associated complications.

CONCLUSION

CF RIMN in TTC fusion demonstrates a high union rate with notable complications. The significant improvement in VAS scores indicates patient satisfaction, but the lack of statistical significance in SF12 and AOFAS scores warrants attention. The findings advocate for the cautious use of 200 mm RIMN and highlight the need for further research, suggesting prospective, multicenter studies to validate these findings and explore long-term outcomes.

LEVEL OF EVIDENCE

III.

Current Management of Acute and Posttraumatic Critical Bone Defects

SUMMARY

Limb reconstruction in patients with critical-sized bone defects remains a challenge due to the availability of various technically demanding treatment options and a lack of standardized decision algorithms. Although no consensus exists, it is apparent from the literature that the combination of patient, surgeon, and institutional collaborations is effective in providing the most efficient care pathway for these patients. Success relies on choosing a particular surgical approach that manages infection, soft tissue defects, stability, and alignment. Recent systematic reviews demonstrate high success rates with the following management options: Ilizarov bone transport, Masquelet (induced membrane) technique, cancellous bone grafting, and vascularized bone grafts.

Results of Total Ankle Arthroplasty Versus Ankle Arthrodesis

No differences have been found between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) with respect to patient-reported outcome measures (PROMs), although both interventions were shown to improve PROMs with respect to the preoperative situation. That is, both interventions (AA and TAA) were effective in improving preoperative symptoms. On the other hand, 2-year complication rates were higher after AA (27%) than after TAA (16%); however, infection rates were similar (4%). The published revision rate after AA is 16% versus 11% after TAA. In short, TAA and AA appear to offer the same PROMs, but TAA has a lower rate of complications (except for infection) and revisions.

Ten-Year Follow-Up of a Customized Total Talar Prosthesis for Revision Total Ankle Arthroplasty: A Case Report

CASE

A 74-year-old woman with rheumatoid arthritis had undergone total ankle arthroplasty (TAA) for severe ankle joint destruction at our hospital 14 years earlier. Radiographs of the ankle revealed displacement of the tibial component and subsidence of the talar component. Revision TAA was performed using a customized alumina ceramic total talar prosthesis.

CONCLUSION

The 10-year outcome of revision TAA with a total talar prosthesis was satisfactory, with no postoperative complications, such as displacement of the tibial component, dislocation of alumina ceramic artificial talus, or progression of degenerative changes in the talonavicular and subtalar joints.

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.