Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis

The Ankle Joint: Management of Significant Bone Loss with Arthrodesis

Segmental bone loss of the distal tibia and/or talus presents a challenge to successful reconstruction for the foot and ankle surgeon. When conservative care has been exhausted, multiple surgical treatment options are available including bone transport, bulk allografts, bulk autografts, titanium cages, and external fixation techniques. The primary goals of surgical correction include restoration of limb length as well as a plantigrade, stable lower extremity.

Republication of "Total Ankle Replacement Conversion to Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft and Pseudoelastic Intramedullary Nail Providing Sustained Joint Compression"

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed to salvage a failed total ankle replacement. These salvage procedures are complicated by significant bone loss from the ankle replacement and are associated with low patient satisfaction. Here, we describe 2 cases of patients who presented with a failed total ankle replacement and underwent arthrodesis using a bulk femoral head allograft and a novel pseudoelastic intramedullary nail. The intramedullary nail contains an internal pseudoelastic element that adapts to bone resorption and settling allowing for compression to be maintained at the arthrodesis sites throughout healing. In the first case, a 65-year-old woman with a failed total ankle replacement underwent TTC arthrodesis. The second case involved an obese 53-year-old woman who had previously undergone 2 total ankle replacement procedures that resulted in unsuccessful outcomes. In both cases, union was demonstrated on computed tomographic scan by 6 months. At 2 years postsurgery, both patients were satisfied with the procedure. These cases provide preliminary evidence that tibiotalocalcaneal arthrodesis with a pseudoelastic IM nail and structural allograft is an appropriate treatment for failed total ankle replacements. Level of Evidence: Level IV, therapeutic, case series.

Reconstruction after Talar Tumor Resection: A Systematic Review

This systematic review investigated the functional outcomes and complications of reconstruction methods after talar tumor resection. A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases identified 156 studies, of which 20 (23 patients) were ultimately included. The mean Musculoskeletal Tumor Society scores in the groups reconstructed using tibiocalcaneal fusion (n = 17), frozen autograft (n = 1), and talar prosthesis (n = 5) were 77.6 (range 66-90), 70, and 90 (range 87-93), respectively. Regarding complications, sensory deficits were observed in one patient (6%) and venous thrombosis in two patients (12%) in the tibiocalcaneal fusion group, while osteoarthritis was observed in one patient (100%) in the frozen autograft group. No complications were observed in the talar prosthesis group. Reconstruction with talar prosthesis seems preferable to conventional tibiocalcaneal fusion after talar tumor resection because it offers better function and fewer complications. However, as this systematic review included only retrospective studies with a small number of patients, its results require re-evaluation in future randomized controlled trials with larger numbers of patients.

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

Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill the osseous void, preserve limb length and achieve fusion. Several authors have reported small case series on this topic, however outcomes have varied and no systematic review of this data has been published to date. The primary aim of this study is to report rates of osseous union, limb salvage and complications in patients undergoing TTC arthrodesis with a structural allograft. A total of 11 publications were identified that met the inclusion criteria. One hundred seventy-five patients were included with a weighted mean age of 60.5 (range 50-72) years and follow-up period of 29.7 (range 3-62) months. Femoral head allograft was the most commonly utilized structural graft and a retrograde intramedullary nail was the most common fixation construct. Results demonstrated an overall union rate of 67.4%, limb salvage rate of 92.5% and complication rate of 26.6%. Allograft-related complications were rare with an allograft fracture rate of 0.1% and allograft collapse rate of 1.2%. There was no significant difference in union rate when using a retrograde intramedullary nail versus a plate construct (p = .9148). TTC arthrodesis with use of a structural allograft is a viable treatment option for limb salvage when faced with complex hindfoot and ankle pathology involving large osseous defects. Despite high rates of radiographic nonunion, this approach can provide patients with a stable and functional limb while avoiding amputation.

Total Talar Replacement With Custom-Made Vitallium Prosthesis for Talar Avascular Necrosis

Background: The current study investigated the application of three-dimensional (3D) printing technology in the treatment of talar avascular necrosis (TAN). Custom-made Vitallium talar prostheses were designed and generated via 3D printing. We hypothesized that these talar prostheses would facilitate more stable positioning, better ergonomically fit the ankle joint surfaces, and promote favorable long-term prognoses. Material and Methods: Computed tomography scans of both ankle joints were acquired from three patients diagnosed with TAN. The talar on the unaffected side was used as the design blueprint. Hence, with the aid of 3D printing technology a customized talar prosthesis made from a novel Vitallium alloy could be manufactured for each individual patient. Results: In all three cases there were no signs of prosthesis loosening or substantial degenerative change in the surrounding area of the joint, but small osteophytes were observed on the tibial side and navicular side. No chronic infection or other prosthesis-related complications were observed in any of the patients. All three were able to walk without pain at the most recent follow-up. Conclusion: With the aid of 3D printing and a novel Vitallium alloy, total talar replacement achieved encouraging results in 3/3 patients. All patients were satisfied with their joint function, and were able to return to their daily activities without limitations. Although more cases and longer-term follow-up periods are required, the success rate reported herein is encouraging.

Deformity Correction of the Midfoot/Hindfoot/Ankle

The correction of the deformed arthritic foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible bony procedures and arthrodesis that maybe performed. The appropriate work up and understanding of the pathomechanics is vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection is done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct deformity of the midfoot, hindfoot, and ankle. This article will also discuss the authors' technique and pearls.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study

INTRODUCTION

Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column.

METHODS

In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed.

RESULTS

A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001).

CONCLUSION

In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results.

LEVEL OF EVIDENCE

Level II, prospective 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.

Outcome of Pantalar Fusion With Femoral Head Allograft in Avascular Necrosis of Talus

Background: Avascular necrosis (AVN) of the talus is a challenging condition that is caused primarily by trauma. The severity of the talus fracture determines the risk of AVN. Severe osteonecrosis with the loss of talar integrity can be treated with arthrodesis and structural bone graft.

Method: This study shows the experience of pantalar arthrodesis using hindfoot arthrodesis nail, screw fixation, and femoral head allograft in four patients.

Result: All patients were satisfied in terms of pain and function after an average of 4 months postsurgery. Limb length discrepancy was <1 cm and hindfoot fusion was achieved by 3 months. The mean score for SF-36 physical function and AOFAS hindfoot score at a 2-year postpantalar arthrodesis was 88 and 80.8, respectively.

Conclusion: Hindfoot ankle arthrodesis, with the usage of femoral head allograft, can be successfully used for the treatment of traumatic AVN of talus.

Three-Dimensional Printed Cage in Patients With Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Early Outcomes

Introduction. Segmental bone loss in the hindfoot hinders the chance of successful outcomes. Tibiotalocalcaneal arthrodesis is a reliable option; nevertheless, the risk of nonunion is high. Three-dimensional (3D) printed titanium implants offer a strong scaffold that can be customized and has demonstrated encouraging healing rates. In this study, we described the clinical outcomes and the radiologic union rate of a case series of patients with hindfoot arthrodesis, using a retrograde intramedullary nail associated to a 3D printed titanium cage. Methods. Seven patients undergoing hindfoot arthrodesis, using a retrograde intramedullary nail associated to a custom 3D printed titanium cage, were included. Demographic data were collected. Functional outcomes were assessed using the American Orthopedic Foot and Ankle Score and the Visual Analogue Scale for pain. Hindfoot alignment and radiographic union were evaluated using weight-bearing radiographs and computed tomography scan, respectively. Results. A total of 6 (85%) patients had more than 50% bony bridging. Only 1 patient underwent below knee amputation due to recurrence of chronic osteomyelitis. Two additional patients had minor complications. Conclusion. Tibiotalocalcaneal arthrodesis using customized titanium cages for patients with large bone defects has shown a high rate of union in those at risk of nonunion. However, further research with larger series is needed.Levels of Evidence: Level IV: Case series.

Femoral Head Allografts for Talar Body Defects

BACKGROUND

Large structural bone deficits after a failed ankle arthroplasty or avascular necrosis (AVN) of the talus present a complex reconstruction challenge. The aim of this study was to report the results of patients undergoing an ankle arthrodesis or tibiotalocalcaneal fusion using a femoral head allograft (FHA).

METHODS

All ankle and tibiotalocalcaneal fusions using FHA between February 2006 and January 2019 were included. Forty-four patients (45 ankles) with a mean follow-up of 42.8 months were studied. Males accounted for 58.1% (25/43 patients). All patients had either failure of primary or revision total ankle arthroplasty (TAA) or AVN of the talus. Pre- and postoperative Veterans RAND Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Ankle Osteoarthritis Scale (AOS) and visual analog scale (VAS) for pain scores were obtained. A patient satisfaction survey was distributed postoperatively and results were tabulated.

RESULTS

Preoperatively to postoperatively, the VR-12 Mental score remained essentially unchanged (P = .752) and the VR-12 Physical score improved (P = .007); the FAAM Activities of Daily Living (ADL) and Sport scores improved (P < .001); the AOS Pain and Disability scores improved (P < .001); and the man VAS score improved (P < .001). The overall satisfaction rate was 78.6 on a 100-point scale. At an average of 18.7 weeks, 90.7% of the ankles were substantially fused. Five patients went on to nonunions and revision surgery.

CONCLUSION

The use of FHA to treat talar defects was a viable option. In this complex patient population, the arthrodesis rate was high at 89% with very positive patient-reported outcome scores.

LEVEL OF EVIDENCE

Level IV, case series.

Comparison of 3D Printed Spherical Implants versus Femoral Head Allografts for Tibiotalocalcaneal Arthrodesis

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p = .018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p = .22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p = .016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis.

Total Ankle Total Talus Replacement Using a 3D Printed Talus Component: A Case Report

The 3D custom total talus replacement is a novel treatment for avascular necrosis of the talus. However, patients who require a total talus replacement often have concomitant degenerative changes to the tibiotalar, subtalar, or talonavicular joints. The combined 3D custom total ankle-total talus replacement (TATTR) is used for patients with an unreconstructable talus and adjacent tibial plafond involvement. The goal of performing a TATTR is to provide pain relief, retain motion at the tibiotalar joint, maintain or improve the patient's functional status, and minimize limb shortening. TATTR is made possible by 3D printing. The advent of 3D printing has allowed for the accurate recreation of the native talar anatomy with a talar dome that can be matched to a total ankle replacement polyethylene bearing. In this article, we will discuss a case of talar avascular necrosis treated with a combined TATTR and review the current literature for TATTR.

Treatment of Severe Ankle and Hindfoot Deformity: Technique Using Femoral Head Allograft for Tibiotalocalcaneal Fusion Using a Cup-and-Cone Reamer

Limb shortening due to structural bone loss in tibiotalocalcaneal arthrodesis is a concern that can negatively impact the patient's gait and weight-bearing. To aid in preventing the risk of limb shortening, the use of a femoral head allograft and intramedullary nail in tibiotalocalcaneal arthrodesis has been shown to successfully preserve limb length in patients with structural bone deficits. We present our technique using a femoral head allograft with a cup-and-cone reamer for the treatment of severe ankle and hindfoot deformity.

Avascular Necrosis of the Talus

Talar osteonecrosis results from trauma to the fragile blood supply to the talus. Many etiologies exist that can cause talar osteonecrosis, with the most common being talar neck fractures. Patients with talar osteonecrosis frequently present with progressive ankle pain and limited range of motion. Treatment strategy depends primarily on the stage of disease. Conservative care in the form of medications and bracing treatment can be beneficial for patients with low functional status and early disease stages. Surgical options also exist for early disease without talar collapse that can potentially preserve the tibiotalar joint. Once talar collapse develops, surgical treatment is move invasive and typically involves an arthrodesis or talus arthroplasty. Although some treatment guidelines exist based on the disease stage, talar osteonecrosis is a complex problem, and treatment strategy should always be determined on a case-by-case basis carefully examining all clinical aspects.

Salvage Tibiotalocalcaneal Arthrodesis Augmented With Fibular Columns and Iliac Crest Autograft: A Technical Note

Failure of ankle arthrodesis or total ankle replacement (TAR) results in a challenging clinical situation and may take the form of symptomatic nonunion following arthrodesis and aseptic or infective loosening following TAR. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required, with use of bone grafting to maintain length and reduce disability. Fibular strut grafting in the form of pillars or columns, potentially supplemented by tricortical and iliac graft, may be used in association with intramedullary TTC nailing or lateral plating and has demonstrated encouraging fusion rates. In this technical note, we review the history of this technique and report indications and surgical approach. Furthermore, of 6 cases (mean age 69.8 years) treated at our institution and followed at 13 months (range, 8 to 20 months), 5 (83%) were clinically and radiologically united, and patients were satisfied with the outcome of surgery. One patient with a background of chronic kidney disease remained dissatisfied with no union achieved, persistent pain, and awaiting a below-the-knee amputation. No other complications were observed. TTC fusion augmented with fibular columns and iliac crest autograft is an option to treat combined ankle and subtalar joint pathologies with significant talar bone loss.Levels of Evidence: Level V (technical note).

Tibiotalocalcaneal Arthrodesis Using a Novel Retrograde Intramedullary Nail

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for complex hindfoot pathology. Overall union rates range from 50% to 86% but can be even lower in certain populations. A novel retrograde intramedullary nail has recently been developed. The purpose of this study was to report fusion rates, time to weight-bearing, and complications with the use of the A3 Fusion Nail. Methods. All patients 18 years or older who underwent TTC arthrodesis with an A3 Fusion Nail at a single institution from 2010 to 2015 with a minimum 3-month follow-up were included in this study. Rates of successful fusion, time to union, time to weight-bearing, and complications were evaluated. A total of 20 patients with an average age of 58.1 years and an average follow-up of 12.5 months met inclusion criteria. Results. Successful TTC arthrodesis was achieved in 14 of 20 patients (70%) overall. Average time to union was 8.1 months, and average time to weight-bearing was 6.8 weeks. Of 20 patients, 17 (85%) required femoral head allograft for bulk bone defects, and the union rate in this subset of patients was 76.5%. The rates of revision surgery (10%) and complications were low. Conclusion. The A3 Fusion Nail demonstrated a favorable safety profile and achieved TTC arthrodesis at a rate consistent with historical data despite being used in a patient population at high risk for nonunion. In patients with bulk bone defects at high risk for nonunion, the A3 Fusion Nail demonstrated superior rates of fusion (76.5%) to those reported in the literature (50%).Level of Evidence: Level III: Retrospective cohort study.

3D Printed Total Talus Replacement for Avascular Necrosis of the Talus

BACKGROUND

Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend on disease severity and functional goals. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study was to evaluate outcomes following TTR with a custom 3D printed metal implant.

METHODS

Patients who underwent TTR were retrospectively reviewed over a 3-year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog scale (VAS) scores, Foot and Ankle Outcome Scores (FAOSs), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre- and postoperatively. Twenty-seven patients underwent TTR for talar AVN with a mean follow-up of 22.2 months.

RESULTS

Ankle range of motion remained unchanged postoperatively. VAS pain scores improved postoperatively from 7.1 to 3.9 (P < .001). FAOSs improved postoperatively with regard to pain (P < .001), symptoms (P = .001), quality of life (P < .001), and activities of daily living (P < .001). There were 3 complications requiring reoperation in this cohort.

CONCLUSION

3D printed TTRs represent a unique surgical option for patients with severe talar AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and AVN.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using an Intramedullary-Referencing Implant

BACKGROUND

Treatment of failed total ankle arthroplasty (TAA) is challenging. Limited literature is available on options and outcomes of revision arthroplasty despite failure rates ranging from 10% to 23% within 10 years after primary TAA. This study reports the clinical and radiographic outcomes of revision TAA using a fixed-bearing, intramedullary-referencing implant.

METHODS

A retrospective review was performed of 18 consecutive revision TAA cases between 2008-2015 using an intramedullary-referencing, fixed-bearing, 2-component total ankle system. Demographic and radiographic data were collected preoperatively, immediately postoperatively, and at the most recent follow-up. Functional outcome data were collected immediately postoperatively and at mean follow-up 47.5 months.

RESULTS

Eighteen patients underwent revision TAA, with 77.8% (14/18) implant survival. Index revision was performed most commonly for aseptic talar subsidence (55.6%) or implant loosening (tibia, 29.4%; talus, 58.9%). Following revision, 22.2% (4/18) patients required reoperation at a mean 57.3 (39-86) months. Osteolysis of the tibia, talus, and fibula was present preoperatively in 66.7% (12/18), 38.9% (7/18), and 38.9% (7/18) of patients, respectively, with progression of osteolysis in 27.8% (5/18), 11.1% (2/18) and 11.1% (2/18) of patients, respectively. Subsidence of the tibial and talar revision components was observed in 38.9% (7/18) and 55.6% (10/18) of patients, respectively. The median American Orthopaedic Foot & Ankle Society (AOFAS) score was 74.5 (26-100) and Foot Function Index (FFI) score 10.2 (0-50.4).

CONCLUSION

Early results of intramedullary-referencing revision TAA demonstrated good patient-reported outcomes with maintenance of radiographic parameters at mean follow-up of 47.5 months. Aseptic talar subsidence or loosening were the main postoperative causes of reoperation. Revision arthroplasty utilizing an intramedullary-referencing implant was a viable option for the failed TAA.

LEVEL OF EVIDENCE

Level IV, case series.

Midterm Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft

Background: Tibiotalocalcaneal (TTC) arthrodesis implementing adjunctive allografts is a method of limb salvage for patients with complex hindfoot osseous deficits, though outcome results are limited. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors. Methods: The authors reviewed 24 TTC arthrodesis procedures with bulk femoral head allografts performed by a single surgeon from 2004 to 2016. Radiographic union at the ankle and subtalar joints along with stability of the allograft were assessed. Patients who had clinically successful arthrodeses were contacted to score the Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) questionnaire, Visual Analog Scale (VAS) for pain, and Short Form-12 (SF-12) at a mean of 58.0 months (range, 28-102) postoperatively. Results: Complete radiographic union of involved joints was achieved in 15 patients (63%) and in 75% (36/48) of all joints; 21 ankles (88%) were assessed to be radiographically stable at final follow-up. Three patients (13%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 21 patients (88%) did not require additional surgery as of final follow-up. Patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P < .001). The mean VAS for pain significantly improved from 77.2 to 32.9 (P < .001). Male sex (P = .08) and a lateral operative approach (P = .03) both resulted in worse outcomes. Conclusion: Use of a femoral head allograft with TTC arthrodesis can offer improved functional scores and sustained radiographic outcomes.Level of Evidence: Level IV: Case series.

Revision Surgery for Failed Total Ankle Replacement

Revision surgery for failed total ankle replacement is a challenge to the revision surgeon. Deformity, presence of infection, segmental bone defects, patient comorbidities, and soft tissue compromise all are significant considerations when determining appropriate procedures. Revision total ankle replacement, explant and fusion with or without lengthening, use of a trabecular metal cage, placement of an antibiotic cement spacer, grafting, and amputation all are viable options to treat patients with failed ankle arthroplasty.

Comparison of Tibiotalocalcaneal Arthrodeses Using a Sustained Dynamic Compression Nail Versus Nondynamized Nails

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis and deformity. Loss of compression over time with statically locked nails may contribute to nonunion. A novel retrograde intramedullary nail with an internal pseudoelastic component has recently been used to provide sustained dynamic compression (SDC). The purpose of this study was to compare fusion rates and time to union between the SDC and nondynamized (ND) nails. Methods. All patients who underwent TTC arthrodesis with an intramedullary nail at a single institution from 2013 to 2017 and who had at least 1 year of follow-up were included in this study. Baseline patient and operative characteristics were collected and compared between the sustained SDC and ND nail groups. The rate of successful fusion, time to union, and complications were compared between the groups. Results. The SDC cohort had a significantly faster time to union by 3.9 months (P = .049). The SDC cohort had a higher fusion rate (78.0%) compared with the ND nail cohort (75.0%), although this was not statistically significant (P = .75). The SDC nail was used significantly (P < .05) more often in patients with known risk factors for nonunion, including female sex, smoking, revision surgery, prior trauma, and patients requiring 3D cage implants for significant bone loss. There were no differences between the groups in terms of complications. Conclusion. The SDC nail has been shown to achieve successful arthrodesis in a population at high risk for nonunion, using less hardware, and at a faster rate than ND nails. Level of Evidence: Level III: Retrospective, comparative study.

Ankle Arthrodesis With Structural Grafts Can Work for the Salvage of Failed Total Ankle Arthroplasty

Background. Treatment options after failed total ankle arthroplasty (TAA) are limited. This study reports midterm outcomes and radiographic results in a single-surgeon group of patients who have undergone ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAA. Methods. A retrospective review on patients who underwent failed TAA revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation was completed. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcome scores, and radiographs were obtained at each visit with 5-year follow-up. Results. Five patients were followed to an average of 5.2 years (range 4.7-5.6). Enrollment FFI was 34.82 (range 8.82-75.88); at midterm follow-up it was 20.42 (range 0-35.38). Enrollment AOFAS scores averaged 66.6 (range 61-77); at midterm follow-up it was 70.33 (range 54-88). Radiographs showed union in 4 of 5 patients at enrollment and 2 of 3 patients at midterm. Conclusions. Utilization of TTC fusion with femoral head allograft is a salvage technique that can produce a functional limb salvage. Our results show continued improvement in patient-reported outcomes, with preservation of limb length and reasonable union rate. Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial.

Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology

Background:

Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone.

Methods:

A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months).

Results:

The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 ( P = .017) and prior arthrodesis ( P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively ( P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 ( P < .001).

Conclusion:

The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes.

Level of Evidence:

Level IV, retrospective case series.

Tibiotalocalcaneal arthrodesis with distal tibial allograft for massive bone deficits in the ankle

BACKGROUND

The purpose of this study was to assess the outcomes of distal tibial structural allograft to obtain a stable TTC fusion.

METHODS

Retrospectively, ten patients were carried out with a minimum one year follow-up. The median age was 72 (33-81). The median BMI was 28 (24-33). Indications for TTC arthrodesis included failed total ankle arthroplasty (n=7 patients), prior nonunion (n=2 patients), and a trauma injury.

RESULTS

Union rate was 80%. The median initial height of the distal tibial allograft was 19mm (14-24mm). In seven cases the allograft did not lose height. The AOFAS score median was 69 (31-84). SF-12 median physical component was 39 (30-53), and 59 (23-62) for mental component. The VAS median was 2 (0-8).

CONCLUSIONS

TTC using distal tibial allograft shows a lower rate of collapse than other structural grafts and provides a fusion rate higher or in accordance with the literature.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Case Series: Allograft Tibiotalocalcaneal Arthrodesis Utilizing Fresh Talus

Background:

Talar body osteonecrosis can be a difficult condition to treat. Recent reports highlight a high rate of failure with the use of femoral head allograft. Additionally, higher rates of failure have been reported in diabetics and smokers. Our institution attempted a novel technique utilizing fresh allograft talus in attempt to improve on a reported 50% nonunion rate.

Methods:

Five patients who underwent tibiotalocalcaneal (TTC) fusion utilizing fresh talar allograft were clinically and radiographically reviewed to evaluate fusion rates and functional outcomes.

Results:

Our case series of 5 patients had a 100% union rate, including 2 former smokers and 2 diabetic patients. There were no infections or complications. Functional outcomes also improved in our series of patients postoperatively as noted by their FAAM and SF-36 scores.

Conclusion:

TTC fusion using fresh allograft talus has a higher union rate than reported with femoral head allograft. This case series requires further study to evaluate whether this technique can be used beyond patients with osteonecrosis of the talus.

Level of Evidence:

Level IV, case series.

Tibiotalocalcaneal Arthrodesis Utilizing a Titanium Intramedullary Nail With an Internal Pseudoelastic Nitinol Compression Element: A Retrospective Case Series of 33 Patients

Nitinol has been shown to generate durable compression under loading via pseudoelastic shape memory. The purpose of this study was to evaluate the effectiveness of a hindfoot arthrodesis nail with an internal pseudoelastic nitinol compression element. Patients who had undergone tibiotalocalcaneal arthrodesis from 2013 to 2016 were identified at 2 tertiary referral centers (12-week follow-up minimum). Patients managed with a tibiotalocalcaneal nail with an internal nitinol compression element were identified for review. Sagittal computed tomographic scan reformats were reviewed to calculate a percentage of joint surface bony union. Intraoperative and postoperative radiographs were compared to calculate postoperative screw position change generated by the nitinol element, a surrogate for postoperative unloading of compressive forces. Thirty-three patients were included in analysis and 81% of patients had successful union of both tibiotalar and subtalar joints. Overall, 90% of all arthrodesis surfaces united. The union rate of arthrodesis surfaces among patients without Charcot osteoarthropathy was 94%. A history of Charcot was identified as a risk factor for subtalar nonunion (p = .04) and was associated with less complete computed tomography-based tibiotalar union: 94% versus 71% (p < .01). The posterior-to-anterior screw translated an average of 3.9 mm proximally relative to the rigid portion of the nail from intraoperative to initial postoperative radiographs (p < .0001). High rates of computed tomography-confirmed union were demonstrated in the face of challenging clinical scenarios. Shortening of the pseudoelastic nitinol element occurs early in the postoperative period, indicating continued unloading of the nitinol compression element through the arthrodesis sites after initial implantation.

Tibiotalocalcaneal Arthrodesis for Severe Talar Avascular Necrosis

Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.

Total Ankle Replacement Conversion to Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft and Pseudoelastic Intramedullary Nail Providing Sustained Joint Compression

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed to salvage a failed total ankle replacement. These salvage procedures are complicated by significant bone loss from the ankle replacement and are associated with low patient satisfaction. Here, we describe 2 cases of patients who presented with a failed total ankle replacement and underwent arthrodesis using a bulk femoral head allograft and a novel pseudoelastic intramedullary nail. The intramedullary nail contains an internal pseudoelastic element that adapts to bone resorption and settling allowing for compression to be maintained at the arthrodesis sites throughout healing. In the first case, a 65-year-old woman with a failed total ankle replacement underwent TTC arthrodesis. The second case involved an obese 53-year-old woman who had previously undergone 2 total ankle replacement procedures that resulted in unsuccessful outcomes. In both cases, union was demonstrated on computed tomographic scan by 6 months. At 2 years postsurgery, both patients were satisfied with the procedure. These cases provide preliminary evidence that tibiotalocalcaneal arthrodesis with a pseudoelastic IM nail and structural allograft is an appropriate treatment for failed total ankle replacements.

Level of Evidence:

Level IV, therapeutic, case series.

Large Osseous Defect Reconstruction Using a Custom Three-Dimensional Printed Titanium Truss Implant

Treatment of large osseous defects remains a difficult surgical challenge. Autografts and allografts have been known to undergo late collapse, because these options are not specifically designed to withstand the high loads of the foot and ankle. The inability to achieve the correct shape for reconstruction further limits their application. Large osseous defects will result during salvage after failed Lapidus bunionectomy, explantation of failed total ankle replacements, and nonunion of Evans calcaneal osteotomy. Each of 3 patients received a 4WEB custom 3-dimensional (3D) titanium truss implant (Patient Specific Custom Implant; 4WEB Medical, Inc., Frisco, TX) for reconstruction. The mean follow-up period was 17.33 ± 3.51 months. Significant improvement was seen in pain, with a successful return to activities of daily living. The 12-month postoperative computed tomography findings demonstrated incorporation of the implant to the surrounding cortical and cancellous bone. No signs of delayed complications, such as stress shielding or implant failure, were found. This is the first case series to describe the use of a custom 3D-printed titanium truss implant to successfully contribute to reconstruction in the setting of failed elective foot and ankle surgery. This technology might play an important role in limb salvage of osseous defects that would otherwise require bone block arthrodesis with structural allograft or autograft bone.

Tibiotalocalcaneal Arthrodesis With Bulk Talar Allograft for Treatment of Talar Osteonecrosis

Talar body osteonecrosis can be a devastating, painful condition that is difficult to manage surgically when conservative treatments have failed. With early disease, nonoperative treatments can prolong the need for operative correction in the young patient. Later stage disease with extensive involvement may require a tibiotalocalcaneal (TTC) arthrodesis to retain functionality of the limb. This situation frequently requires a structural bone graft. Using the technique described in this article, the void resulting from collapse of the talar body is filled with talar allograft, which offers a more anatomic and structurally rigid construct than previously described methods using an allograft femoral head. We have found this technique to be more resilient and successful than other methods.

LEVEL OF EVIDENCE

Level V, expert opinion.

Revision of failed total ankle arthroplasty to a hindfoot fusion

Aims

The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail.

Patients and Methods

A total of 23 TAAs, in 22 patients, were revised for aseptic loosening and balloon osteolysis to a hindfoot fusion by a single surgeon (NH) between January 2012 and August 2014. The procedure was carried out without bone graft using the Phoenix, Biomet Hindfoot Arthrodesis Nail. Preoperative investigations included full blood count, CRP and ESR, and radiological investigations including plain radiographs and CT scans. Postoperative plain radiographs were assessed for fusion. When there was any doubt, CT scans were performed.

Results

The mean follow-up was 13.9 months (4.3 to 37.2). Union occurred at the tibiotalar joint in 22 ankles (95.6%) with one partial union. Union occurred at the subtalar joint in 20 ankles (87%) of cases with two nonunions. The nail broke in one patient with a subtalar nonunion and revision was undertaken. The only other noted complication was one patient who suffered a stress fracture at the proximal aspect of the nail, which was satisfactorily treated conservatively.

Conclusion

This study represents the largest group of patients reported to have undergone revision TAA to fusion of the hindfoot with good results Cite this article: Bone Joint J 2018;100-B:475–9.

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.

Management of Osteomyelitis and Bone Loss in the Diabetic Charcot Foot and Ankle

Bone loss and destruction due to diabetic Charcot neuroarthropathy (CN) and osteomyelitis of the foot and ankle is a challenging clinical condition when lower extremity preservation is considered. Resection and excision of osteomyelitis and associated nonviable soft tissue can lead into large osseous and soft tissue defects that will most likely need the utilization of bone grafting and subsequent arthrodesis for stability and anatomic alignment. In the diabetic population with peripheral neuropathy, osseous instability can lead to subsequent lower extremity deformity, ulceration, infection and/or amputation. This article reviews the surgical approach in the presence of diabetic CN and concomitant osteomyelitis.

Revision Tibiotalocalcaneal Arthrodesis With a Pseudoelastic Intramedullary Nail

Hindfoot (tibiotalocalcaneal or TTC) arthrodesis is commonly used to treat concomitant arthritis of the ankle and subtalar joints. Simultaneous fusion of both joints can be difficult to achieve especially in patients with impaired healing due to smoking, diabetes mellitus, or Charcot neuroarthropathy. Conventional intramedullary fixation devices allow for compression to be applied at the time of surgery, but this compression can be lost due to bone resorption or settling, leading to impaired healing. In contrast, the novel pseudoelastic intramedullary nail is designed to maintain compression at the arthrodesis sites throughout the healing process by the use of an internal pseudoelastic element. We present 2 cases of revision TTC arthrodesis using the pseudoelastic intramedullary nail. In the first case, an 80-year-old diabetic man with previous ankle and failed subtalar fusion with screws underwent revision TTC arthrodesis. In the second case, a 66-year-old man with Charcot neuroarthropathy and a failed TTC arthrodesis with a static intramedullary nail underwent revision tibiotalar arthrodesis. In both cases, computed tomography scan demonstrated successful union and patients were allowed full weight bearing by 3 months after surgery. These cases provide early evidence that sustained compression via an intramedullary nail can lead to rapid successful hindfoot fusion when standard approaches have failed.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nails for Tibiotalocalcaneal Arthrodesis

BACKGROUND

Tibiotalocalcaneal arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are common. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail with an internal nitinol element.

METHODS

We identified 15 patients with average age of 54.7 years (range, 28-75 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nail. Serial radiographs were used to determine the amount and rate of nitinol element migration over the first 3 postoperative months.

RESULTS

Postoperatively, there was at least 2.38 mm of nitinol element migration proximally with mean of 5.58 mm (± 1.38), (range, 2.38-8.11 mm). Average follow-up time was 195 days (± 106.3), (range, 89-490 days). On average, 86% of the total recovered distance took place within the first 39.7 days (±10.03).

CONCLUSIONS

The nitinol element recovers distance when stretched intraoperatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional intramedullary nails.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

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.

[Surgical treatment of the Charcot foot : long-term results and systematic review]

BACKGROUND

Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.

OBJECTIVES

The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.

MATERIALS AND METHODS

In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.

RESULTS

After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.

CONCLUSION

Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.

Patient-Specific 3-Dimensional Printed Titanium Truss Cage With Tibiotalocalcaneal Arthrodesis for Salvage of Persistent Distal Tibia Nonunion

Management of large structural defects of the ankle and hindfoot is challenging with modest outcomes in the literature. Tibiotalocalcaneal (TTC) arthrodesis using a retrograde intramedullary nail has been used for the treatment of talar avascular necrosis, severe tibial plafond fractures, ankle and hindfoot nonunions, Charcot arthropathy, and failed total ankle arthroplasty. External fixators and spatial frames provide robust multiplanar correction of deformity, but little is known in the literature regarding the salvage treatment of persistent nonunion refractory to frame treatment. In this report, we present the case of an open tibial plafond fracture with nonunion despite 1 year of fixator and frame management that was successfully treated using a patient-specific 3-dimensional printed titanium truss cage in combination with a retrograde TTC nail. At most recent 1-year follow-up, the patient had minimal pain, no wound complications, and was able to ambulate and work independently without an assistive device for the first time in 2 years since his original injury. The case presented here serves as a proof of principle that requires future research to determine its long-term clinical benefits, cost-effectiveness, and complications.

LEVEL OF EVIDENCE

Level V: Expert Opinion.

Tibiotalocalcaneal Arthrodesis Using a Nitinol Intramedullary Hindfoot Nail

Tibiotalocalcaneal (TTC) arthrodesis using an intramedullary hindfoot nail is a common procedure for deformity correction and the treatment of combined tibiotalar and subtalar end-stage arthritis. Nonunion at one or both fusion sites is a difficult complication that can result in reoperation, significant morbidity, and below-knee amputation. There is currently a need for sustained compression across fusion sites using a TTC hindfoot nail with good mechanical stability. The DynaNail TTC Fusion System (MedShape, Inc, Atlanta, GA) uses an internal nitinol compression element to apply sustained compression across the tibiotalar and subtalar joints after surgery. In preliminary clinical cases, we have found that the nail is safe, reliable, and has promising clinical and radiographic results in settings of hindfoot arthritis, complex deformity, Charcot arthropathy, and talar avascular necrosis.

LEVELS OF EVIDENCE

Expert opinion, Level V.

Tibiotalocalcaneal Arthrodesis Using Retrograde Intramedullary Nail Fixation: Comparison of Patients With and Without Diabetes Mellitus

Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis is a salvage procedure reserved for severe cases of deformity. The aim of the present study was to compare the outcomes of this technique in patients with and without diabetes mellitus (DM). A total of 61 patients with and 56 without DM underwent retrograde intramedullary nailing and had a minimum follow-up period of 12 months. The overall incidence of complication was 45.2%; however, the overall incidence of complications between those with and without DM was not significantly different (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.38 to 1.65, p = .54). Patients with DM had a significantly greater rate of superficial infections (OR 8.3, 95% CI 1.01 to 68.67, p = .03). However, no difference was seen in the rate of deep infection (OR 0.90, 95% CI 0.34 to 2.46, p = .83) or noninfectious complications (OR 0.50, 95% CI 0.23 to 1.13, p = .09). Successful limb salvage was achieved for 96.8% of the patients with DM and 94.7% of those without DM (p = .66). A femoral head allograft was used in 32 (27.4%) of 117 patients to substitute for an osseous void. Of the 32 patients who required a femoral head allograft, 21 (67.7%) experienced a complication compared with 32 (37.6%) of 85 patients who did not require a femoral head allograft (OR 3.16, 95% CI 1.35 to 7.41, p = .008). The incidence of patient satisfaction was 80% for patients with DM and 72% for those without DM (p = .36). Despite a high incidence of complications, limb salvage was accomplished in approximately 95% of patients with complicated deformities. Four patients (6.56%) with DM experienced a tibia fracture; therefore, we now routinely use a 300-mm-long nail for this reconstruction.

Complications of tibio-talar-calcaneal fusion using intramedullary nails

BACKGROUND

Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications following the use of hindfoot nails at our institution.

METHODS

We identified patients from a retrospective database. All underwent hindfoot nailing under the care of the senior author. Details of complications were recorded.

RESULTS

We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18-69). Forty patients achieved ankle fusion and 36 subtalar joint fusion. Complications included prominent metalwork in 13 patients, CRPS in five and one peri-prosthetic fracture. Nine developed deep infection, and of these limb salvage was achieved in six patients by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. The remaining three patients underwent below knee amputation.

CONCLUSION

Significant complications can occur, although limb preservation was possible in most cases of deep infection. Hindfoot nailing should be reserved as salvage procedure.