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Tabarestani TQ, Anastasio AT, Lukosius EZ, Schweitzer KM. A Novel Technique for Lateral Ankle Ligament Reconstruction with Total Ankle Total Talus Replacement: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00033. [PMID: 37205776 DOI: 10.2106/jbjs.cc.22.00643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
CASE A 65-year-old man with severe left talar avascular necrosis, arthritis, and chronic lateral ankle instability underwent total ankle total talus replacement (TATTR) with lateral ligament reconstruction. Tibial component placement was performed using preoperative computed tomography navigation and patient-specific guides. A custom, total talus replacement to mate with the fixed-bearing tibial component was implanted. Last, a modified Brostrom procedure was performed to restore lateral ankle stability. The patient has performed well through 1 year with improved pain-free function. CONCLUSION This case report details a novel technique for performing a modified Brostrom procedure in conjunction with TATTR to restore lateral ankle stability.
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Affiliation(s)
| | - Albert T Anastasio
- Department of Orthopedic Surgery, Duke University Hospital, Durham, North Carolina
| | - Eric Z Lukosius
- Department of Orthopedic Surgery, Duke University Hospital, Durham, North Carolina
| | - Karl M Schweitzer
- Department of Orthopedic Surgery, Duke University Hospital, Durham, North Carolina
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2
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Sankey M, Sanchez T, Young SM, Willis CB, Harrelson A, Shah AB. Tibiotalocalcaneal Arthrodesis with Intramedullary Fibular Strut Graft and Adjuvant Hardware Fixation. JBJS Essent Surg Tech 2023; 13:e22.00004. [PMID: 38274151 PMCID: PMC10807890 DOI: 10.2106/jbjs.st.22.00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Background In patients with irreparable damage to the articular surfaces of the hindfoot, hindfoot arthrodesis is frequently chosen to provide pain relief and improve activities of daily living. Common etiologies leading to hindfoot arthrodesis procedures include osteonecrosis, failed total ankle arthroplasty, and deformities resulting from Charcot arthropathy or rheumatoid arthritis. Traditionally, this operation utilizes an intramedullary nail to obtain fusion of the tibiotalocalcaneal joint. Although 80% to 90% of patients achieve postoperative union, the remaining 10% to 20% experience nonunion1-3. Factors affecting the rate of nonunion include Charcot neuroarthropathy, use of nonsteroidal anti-inflammatory drugs or methotrexate, osteopenic bone, and smoking4. In the present video article, we describe a tibiotalocalcaneal arthrodesis performed with use of a fibular strut autograft for repeat arthrodesis following failure of primary tibiotalocalcaneal arthrodesis or as a salvage operation in end-stage pathologies of the hindfoot. Our surgical technique yields union rates of approximately 80% and provides surgeons with a viable surgical technique for patients with complex hindfoot pathologies or fusion failure. Description The patient is placed in the supine position, and a 10-cm curvilinear incision is made including the distal 6 to 8 cm of the fibula. The incision is centered directly lateral on the fibula proximally and transitions to the posterolateral aspect of the fibula distally. As the incision continues distally, it extends inferiorly and anteriorly over the sinus tarsi and toward the base of the 4th metatarsal, using an internervous plane between the superficial peroneal nerve anteriorly and the sural nerve posteriorly. Exposure of the periosteum is carried out through development of full-thickness skin flaps. The periosteum is stripped, and a sagittal saw is used to make a beveled cut on the fibula at a 45° angle, approximately 6 to 8 cm proximal to the ankle. The fibular strut is decorticated, drilled, and stripped of the cartilage on the distal end. Preparation of the tibiotalar and subtalar joints for arthrodesis are completed through the lateral incision. The foot is placed in 0° of dorsiflexion, 5° of external rotation in relation to the tibial crest, and 5° of hindfoot valgus while maintaining a plantigrade foot. This placement can be temporarily maintained with Kirschner wires if needed. Next, the plantar surface overlying the heel pad is incised, and a guidewire is passed through the center of the calcaneus and into the medullary cavity of the tibia. Correct alignment of the guidewire is then confirmed on fluoroscopy. The fibular strut autograft is prepared for insertion while the tibiotalocalcaneal canal is reamed to 1 to 2 mm larger than the graft. The graft is tapped into position, followed by placement of two 6.5-mm cancellous screws to immobilize the joint, taking care to avoid excess contact of the fibular graft with the screws. Alternatives Alternatives to this procedure include traditional arthrodesis techniques, nonoperative treatment (such as rehabilitation or bracing), or no intervention. Patients with failed primary hindfoot arthrodesis may undergo an additional traditional arthrodesis, but may face an increased risk of complications and failure1,2. Rationale A recent study1 has shown that the use of a fibular strut autograft for tibiotalocalcaneal arthrodesis produces union rates similar to those seen with the traditional intramedullary nailing technique4,5. These results are important to note, as the presently described technique, which is used as a salvage procedure, produces outcomes that are equivalent to those observed for primary tibiotalocalcaneal arthrodesis with nailing, which is used for the treatment of severe trauma, extensive bone loss, or severe hindfoot pathologies. We recommend using this technique particularly in cases of failed primary tibiotalocalcaneal arthrodesis or in patients with end-stage hindfoot pathologies. The fibular strut autograft is a viable salvage option to decrease daily pain and provide quality improvement in patient activities of daily living. Expected Outcomes Tibiotalocalcaneal arthrodesis with a fibular strut autograft has been shown to produce a union rate (81.2%) similar to that of the traditional arthrodesis technique with intramedullary nailing (74.4% to 90%). The strut graft provides an osteoinductive environment for healing and increases the post-arthrodesis load tolerance1. Mean visual analog scale pain scores improved from 6.9 preoperatively to 1.2 postoperatively with use of this procedure1. The most common complication was wound dehiscence requiring additional wound care (37.5%); its rate was higher than the rates reported in other studies of tibiotalocalcaneal arthrodesis, possibly because of the small sample size of patients undergoing such a complex procedure for a complex medical issue2,11. Although 7 patients required a reoperation, all ultimately experienced a union and recovered postoperatively. All non-retired patients were all able to return to work1. Important Tips Place your incision precisely to allow adequate exposure of both the tibiotalar and subtalar joints.Curvilinear incision should begin 6 to 8 cm proximal to, and directly lateral to, the distal end of the fibula. It should continue posterolaterally to the fibula distally and extend inferiorly and anteriorly over the sinus tarsi, toward the base of the 4th metatarsal.Prepare the tibiotalar and subtalar joints this same incision.Decorticate the fibular strut autograft; this plays a key role in obtaining fusion.Harvest the fibula 6 to 8 cm above the ankle joint line. Once the graft is harvested, smooth the edges of the fibula with a burr; this facilitates graft insertion.Finally, when immobilizing the joint, take care to avoid excessive perforation of the graft as this increases the likelihood of fracture. Acronyms and Abbreviations OR = operating roomIM = intramedullaryCT = computed tomographyTTCA = tibiotalocalcaneal arthrodesisTTC = tibiotalocalcanealK-wire - Kirschner wire.
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Affiliation(s)
- Matthew Sankey
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Thomas Sanchez
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean M. Young
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chad B. Willis
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alex Harrelson
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashish B. Shah
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, Alabama
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3
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Tsukamoto S, Mavrogenis AF, Honoki K, Kido A, Tanaka Y, Fujii H, Takakura Y, Tanaka Y, Errani C. Reconstruction after Talar Tumor Resection: A Systematic Review. Curr Oncol 2022; 29:9788-9800. [PMID: 36547183 PMCID: PMC9777178 DOI: 10.3390/curroncol29120769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
- Correspondence: ; Tel.: +81-744-22-3051
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 11527 Athens, Greece
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, Nara 634-8521, Japan
| | - Yuu Tanaka
- Department of Rehabilitation Medicine, Wakayama Professional University of Rehabilitation, Wakayama 640-8222, Japan
| | - Hiromasa Fujii
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
| | - Yoshinori Takakura
- Department of Orthopaedic Surgery, Nishi Nara Central Hospital, Nara 631-0022, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
| | - Costantino Errani
- Orthopaedic Oncology Service, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Abstract
BACKGROUND Three-dimensional custom cages can be used to treat complex ankle and hindfoot pathology and bone loss with potentially better patient satisfaction and higher fusion rates than tibiotalocalcaneal (TTC) fusion alone or in combination with bulk femoral head allograft. Yet there is limited literature to support this procedure. The purpose of this study is to objectively quantify the clinical and radiologic outcomes of patients undergoing patient-specific 3D-printed custom cage implantation to fill large defects around the ankle joint region as part of a limb-salvaging TTC fusion. METHODS This is a retrospective review of 21 patients (mean age 59.3 years) who underwent custom cage implantation with a TTC retrograde fusion nail by a single surgeon for massive bone loss of the ankle and hindfoot. Patient charts were reviewed for pain and functional outcomes, complications, and various demographics, including number of previous surgeries to the ipsilateral ankle. Mean follow-up was 32 months. All 21 patients had preoperative and postoperative pain and function scores available for analysis. RESULTS A total of 20 (95.2%) of the 21 patients had their cage in situ at final follow-up. Overall, with the numbers available, visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, and the 12-Item Short Form Health Survey (SF-12) mental and physical health scores significantly improved from preoperative to final follow-up. However, when compared to the overall US population of age-matched 55- to 64-year-old individuals, patients still remained relatively disabled. There were 2 failures, one of which required amputation and the other was treated nonoperatively with bracing. CONCLUSION In conclusion, in this relatively small, single-surgeon series, we found that 3D-printed custom cage technology offered a viable option for complex TTC fusion procedures performed in the presence of significant bone loss, with good fusion rates, however relatively modest improvement in functional outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - Jared Raikin
- Syndey Kimmel Medical College, Philadelphia, PA, USA
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5
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Kim DH, Kim W, Choi Y. Management of talar lesions with cement augmentation and autologous bone graft. J Orthop Surg (Hong Kong) 2022; 30:10225536221131159. [PMID: 36176213 DOI: 10.1177/10225536221131159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Treatment of bone lesions involved with the articular cartilage at the talus is challenging. We report the management of talus lesions, particularly tumors and avascular necrosis (AVN), at the articular surface through treatment with cement augmentation and autologous bone graft. METHODS Eight benign bone tumors and three cases of AVN were reviewed retrospectively at a mean follow-up of 56 months (range, 12-162). The mean age of all patients was 36.1 years old (range, 15-73) when assessed between February 2005 and November 2021. Curettage of tumorous and necrotic lesions resulted in significant bone defects filled with bone cement augmentation. Cartilage defects of the talar dome were supported with autologous cancellous bone graft. Tolerable weight-bearing ambulation was permitted immediately after surgery. Radiological and functional evaluations were recorded. RESULTS We observed an increase in the average The American Orthopaedic Foot and Ankle Score (AOFAS) (p = .003) and a decrease in the average Visual Analogue Scale pain score (p = .003). There was no statistically significant decrease in ROM before or after surgery (p = .114). Additionally, no talus collapse of the ankle joint occurred. Talar dome status did not aggravate before or after surgery, except for one patient. Despite no radiographic osteoarthritis exacerbation before or after surgery in six patients, five patients had osteoarthritic change. CONCLUSION Cement implantation and autologous bone graft performed simultaneously for benign bone tumors with joint cartilage damage and AVN are technically simple, have good outcomes, and may be a suitable alternative to standard treatments.
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Affiliation(s)
- Do Hun Kim
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wanlim Kim
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Youngrak Choi
- Department of Orthopaedic Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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6
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Madi NS, Fletcher AN, Pereira GF, Balu A, DeOrio JK, Parekh SG. Early Outcomes of Combined Total Ankle Total Talus Replacement Using a 3D-Printed Talus Component With Hindfoot Arthrodesis. Foot Ankle Spec 2022:19386400221120567. [PMID: 36039497 DOI: 10.1177/19386400221120567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Late-stage talar avascular necrosis (AVN) results in devascularization of the talus with osteonecrosis and subchondral collapse. A combined total ankle and total talus replacement (TATTR) with hindfoot arthrodesis may be utilized for end-stage talar AVN with tibiotalar and hindfoot joint arthritis. The purpose of this study is to evaluate the short-term outcomes of combined TATTR with hindfoot arthrodesis. Patients who underwent a combined TATTR or TTR with a hindfoot arthrodesis (subtalar with or without talonavicular arthrodesis) from 2016 to 2020 were retrospectively reviewed. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, range of motion, radiographic parameters, union rates, and complications. A total of 18 patients were reviewed. Nine patients were included with an average of 19.4 months follow-up. Significant postoperative improvements were observed in VAS scores (P < .001), ankle plantarflexion (P = .04), talocalcaneal height (P = .03), and tibiotalar alignment (P = .02). All patients achieved a successful union of their subtalar and talonavicular joints arthrodesis. There was one reoperation for a persistent varus ankle deformity. This is the first study to evaluate the clinical outcomes, radiographic outcomes, and union rate in combined TATTR with hindfoot arthrodesis. The early results demonstrated significant clinical improvement with 100% hindfoot union rate and no prosthetic failure.Level of Evidence: IV.
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Affiliation(s)
- Naji S Madi
- Foot and Ankle Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Gregory F Pereira
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - James K DeOrio
- Foot and Ankle Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Selene G Parekh
- Foot and Ankle Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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7
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Dow T, Lowe D, Morash J. Lower Limb Salvage Using Patent-Specific 3D-Printed Titanium Cage Following Severe Left Ankle Traumatic Partial Amputation: A Pediatric Case Report. Foot Ankle Spec 2022; 15:361-368. [PMID: 32907401 DOI: 10.1177/1938640020954819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with large bony defects of the ankle who wish to avoid amputation have limited surgical intervention options for limb salvage. Each of these interventions are technically complex and present significant risk for complications. The use of a patient-specific 3D-printed titanium cage in conjunction with a tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is another management option. This case adds to the scarce published literature on this technique. CASE PRESENTATION This report presents the case of a 16-year-old female who suffered a traumatic partial amputation of her left distal lower extremity following an all-terrain-vehicle accident that resulted in a 10.0 × 10.0 cm skin laceration and a 5-cm subsegmental bony loss of the distal tibia. She was successfully treated using a patient-specific 3D-printed titanium truss cage in conjunction with a TTC arthrodesis using a retrograde nail. CONCLUSIONS The decision to amputate or attempt limb salvage in a severely injured lower limb is still a topic of active debate. However, literature has shown that patients who undergo limb salvage surgery have better psychological health outcomes and equivalent functional outcomes as patients who have undergone amputation. Therefore, research on techniques that optimize and advance limb salvage surgery is needed. As the numerous potential benefits and limitations of patient-specific 3D-printed implants are assessed throughout the field of orthopedics, further research and cost-analysis will be required. Cases such as the one presented add to the limited existing literature of patient-specific 3D-printed implant for treatment of large distal lower extremity bony defects. LEVELS OF EVIDENCE Level V (Case Report).
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Affiliation(s)
- Todd Dow
- Dalhousie Medical School, Halifax, Nova Scotia, Canada (TD).,Division of Orthopedic Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada (DL, JM)
| | - Dani Lowe
- Dalhousie Medical School, Halifax, Nova Scotia, Canada (TD).,Division of Orthopedic Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada (DL, JM)
| | - Joel Morash
- Dalhousie Medical School, Halifax, Nova Scotia, Canada (TD).,Division of Orthopedic Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada (DL, JM)
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8
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Cifaldi A, Thompson M, Abicht B. Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2022; 61:900-906. [PMID: 35585002 DOI: 10.1053/j.jfas.2022.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/26/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Andrea Cifaldi
- Podiatric Medicine and Surgery Resident, Gundersen Medical Foundation, La Crosse, WI.
| | - Mitchell Thompson
- Podiatric Medicine and Surgery Resident, Gundersen Medical Foundation, La Crosse, WI
| | - Bradley Abicht
- Department Chair and Attending Staff, Podiatry Department within Orthopaedic Center, Gundersen Health System, La Crosse, WI
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9
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Brage ME, Mathews CS. Ankle and Tibiotalocalcaneal Fusion. Foot Ankle Clin 2022; 27:343-353. [PMID: 35680292 DOI: 10.1016/j.fcl.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrodesis of the ankle and/or tibiotalocalcaneal joints is a reliable treatment of arthritic conditions of the ankle and hindfoot. It may be complicated by infection, nonunion, malunion, fracture, wound complications, nerve injury, and adjacent joint degeneration. These complications may be addressed with a variety of techniques but should be done so carefully so as not to lead to more complex problems. A thorough work-up and discussion should take place prior to any surgical intervention and treatment. Several cases are presented to illustrate revision arthrodesis techniques and the management of these complications.
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Affiliation(s)
- Michael E Brage
- University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
| | - Chelsea S Mathews
- University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot #531, Little Rock, AR 72205, USA.
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10
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Zhang H, Fletcher AN, Scott DJ, Nunley J. Avascular Osteonecrosis of the Talus: Current Treatment Strategies. Foot Ankle Int 2022; 43:291-302. [PMID: 34753345 DOI: 10.1177/10711007211051013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Avascular osteonecrosis (AVN) of the talus (AVNT) is a painful and challenging clinical diagnosis. AVNT has multiple known risk factors and etiologies and presents at different stages in severity. Given these unique factors, the optimal treatment solution has yet to be determined. Both joint-preserving and joint-sacrificing procedures are available, including core decompression and arthrodeses. Recently, new salvage and replacement techniques have been described including vascularized pedicle bone grafts and total talus replacement using patient-specific prosthesis; however, evidence remains limited. This review examines the current trends AVNT treatment and the emerging data behind these novel techniques.
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Affiliation(s)
- Hanci Zhang
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel J Scott
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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11
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Rabiu AR, Mart JPS, Reichert ILH, Ahluwalia R. The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects-Results of a New Technique in Tibiotalocalcaneal Arthrodesis. J Foot Ankle Surg 2021; 60:1301-1307. [PMID: 34362653 DOI: 10.1053/j.jfas.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/13/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Abdul-Rasheed Rabiu
- Surgical Registrar, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Jean-Pierre St Mart
- Surgical Registrar, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Ines L H Reichert
- Consultant Trauma & Orthopaedic Surgeon, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom
| | - Raju Ahluwalia
- Consultant Foot and Ankle Surgeon, Department of Orthopaedics, King's College Hospital, King's College NHS Trust London, London, United Kingdom.
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12
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Ramu TK, Bajuri MY, Hayyun MF, Mazli N. Outcome of Pantalar Fusion With Femoral Head Allograft in Avascular Necrosis of Talus. Front Surg 2021; 8:658788. [PMID: 34660674 PMCID: PMC8514740 DOI: 10.3389/fsurg.2021.658788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/31/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Thiru Karthikeyan Ramu
- Department of Orthopedics and Traumatology, Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Mukhriz, Kuala Lumpur, Malaysia
| | - Mohd Yazid Bajuri
- Department of Orthopedics and Traumatology, Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Mukhriz, Kuala Lumpur, Malaysia
| | - Muhammad Fathi Hayyun
- Department of Orthopedics and Traumatology, Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Mukhriz, Kuala Lumpur, Malaysia
| | - Norliyana Mazli
- Department of Orthopedics and Traumatology, Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Mukhriz, Kuala Lumpur, Malaysia
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Coetzee JC, Den Hartog BD, Stone McGaver R, Seiffert KJ, Giveans MR. Femoral Head Allografts for Talar Body Defects. Foot Ankle Int 2021; 42:815-823. [PMID: 33541133 DOI: 10.1177/1071100720983811] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Abstract
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.
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Kadakia RJ, Akoh CC, Chen J, Sharma A, Parekh SG. 3D Printed Total Talus Replacement for Avascular Necrosis of the Talus. Foot Ankle Int 2020; 41:1529-1536. [PMID: 32806936 DOI: 10.1177/1071100720948461] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Rishin J Kadakia
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Craig C Akoh
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Akhil Sharma
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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16
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Abstract
The talus is unique in having a tenuous vascular supply and 57% of its surface covered by articular cartilage. Fractures of the head, neck, or body regions have the potential to compromise nearby joints and impair vascular inflow, necessitating surgical treatment with stable internal fixation in many cases. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Percutaneous screw fixation has also demonstrated success in certain patterns. Despite this modern technique, osteonecrosis and osteoarthritis remain common complications. A variety of new treatments for these complications have been proposed, including vascularized autograft, talar replacement, total ankle arthroplasty, and improved salvage techniques, permitting some patients to return to a higher level of function than was previously possible. Despite these advances, functional outcomes remain poor in a subset of severely injured patients, making further research imperative.
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17
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Abstract
BACKGROUND Patients with talar avascular necrosis (AVN) have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTRs) has arisen as a treatment option for these patients, possibly allowing better preservation of hindfoot motion. We hypothesized that patients undergoing TTR will demonstrate a statistically significant improvement in Foot and Ankle Outcome Score (FAOS) at 1 year after surgery. METHODS We retrospectively reviewed 15 patients who underwent a TTR over a 2-year period. Patient outcomes were reviewed, including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, radiographic alignment, FAOS and Visual Analog Scale (VAS) score, and range of motion. Data analysis was performed with Student t-tests and multivariate regression. RESULTS FAOSs and VAS scores showed statistically significant improvements postoperatively as compared with preoperative scores. There was a statistically significant decrease in VAS pain scores from 7.0 preoperatively to 3.6 (P < .001). Average follow-up was 12.8 months. With the number of patients available, there was no statistically significant change in radiographic alignment parameters postoperatively as compared with preoperatively (P values ranged from .225 to .617). CONCLUSION Our hypothesis that these patients show statistically significant improvements in FAOSs at 1 year was confirmed. TTR represents an exciting treatment option for patients with talar AVN, though longer-term follow-up is needed.Level of Evidence: Level IV: Case series.
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Affiliation(s)
- Daniel J Scott
- Duke University Department of Orthopaedic Surgery, Durham, North Carolina
| | - John Steele
- Duke University Department of Orthopaedic Surgery, Durham, North Carolina
| | | | - Selene G Parekh
- Department of Orthopaedic Surgery, North Carolina Orthopaedic Clinic/Duke Orthopaedics, Durham, North Carolina
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18
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Velasco BT, Briceño J, Miller CP, Ye MY, Savage-Elliott I, Ellington JK, Kwon JY. Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system. Injury 2020; 51:1497-1508. [PMID: 32389394 DOI: 10.1016/j.injury.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hindfoot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors. METHODS A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails. The electronic database of PubMed/Medline/Cochrane Library was explored using specific search terms. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded. RESULTS A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies. CONCLUSION Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice.
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Affiliation(s)
- Brian T Velasco
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA 18510, United States.
| | - Jorge Briceño
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile.
| | - Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, United States.
| | - Michael Y Ye
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, United States.
| | - Ian Savage-Elliott
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - J Kent Ellington
- Department of Orthopaedic Surgery, OrthoCarolina, 250 N Caswell Rd, Charlotte, NC 28207, United States.
| | - John Y Kwon
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States.
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Del Vecchio JJ, Chemes LN, Bertollotti L, Ghioldi ME, Dealbera ED, Galli Serra M, Parizzia W. Patient-specific three-dimensional printed hemi talar prostheses for the treatment of talar osteonecrosis, case report and literature review. SAGE Open Med Case Rep 2020; 8:2050313X20919223. [PMID: 32537160 PMCID: PMC7268162 DOI: 10.1177/2050313x20919223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/23/2020] [Indexed: 11/16/2022] Open
Abstract
We present the case of a 43-year-old boy who presented with progressive pain as a result of history of lateral avascular necrosis of the talus secondary to traumatic open ankle luxation 20 years ago. Conservative treatment (12-month period) prior to surgery failed. It consisted of physiokinetic treatment, insoles and analgesic medication. A diagnostic injection was used in the ankle (positive) and subtalar joint (negative) in order to recognize origin of pain. Hemilateral avascular necrosis of the talus is rare. There are no prior reported cases of the use of hemi-implants. This case highlights the potential use of a patient-specific three-dimensional printed Ti6Al4V prosthesis presented in a complex scenario.
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Affiliation(s)
- Jorge Javier Del Vecchio
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine.,Department of Kinesiology and Physiatry, Universidad Favaloro, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lucas Nicolás Chemes
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | | | - Mauricio Esteban Ghioldi
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Eric Daniel Dealbera
- Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Marcos Galli Serra
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
| | - Walter Parizzia
- Orthopaedics Oncology Section, Orthopaedics Department, Fundación Favaloro - Hospital Universitario, Ciudad Autónoma de Buenos Aires, Argentine
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20
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Steele JR, Kildow BJ, Cunningham DJ, Dekker TJ, DeOrio JK, Easley ME, Nunley JA, Parekh SG, Adams SB. Comparison of Tibiotalocalcaneal Arthrodeses Using a Sustained Dynamic Compression Nail Versus Nondynamized Nails. Foot Ankle Spec 2020; 13:193-200. [PMID: 31018671 DOI: 10.1177/1938640019843332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- John R Steele
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Beau J Kildow
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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21
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Chappell TM, Ebert CC, McCann KM, Hutchinson BL, Rodriguez-Collazo E. Distal tibial distraction osteogenesis-an alternative approach to addressing limb length discrepancy with concurrent hindfoot and ankle reconstruction. J Orthop Surg Res 2019; 14:244. [PMID: 31362774 PMCID: PMC6668173 DOI: 10.1186/s13018-019-1264-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 07/08/2019] [Indexed: 02/07/2023] Open
Abstract
Background Limb length discrepancy (LLD) in the setting of concurrent hindfoot and ankle deformity poses an added level of complexity to the reconstructive surgeon. Regardless of etiology, a clinically significant LLD poses additional challenges without a forthright and validated solution. The purpose of the current study is to determine whether reconstructive hindfoot and ankle surgery with concurrent lengthening through a distal tibial corticotomy is comparable to other treatment alternatives in the literature. Patients and methods A retrospective review of hindfoot and ankle deformity correction utilizing Ilizarov circular external fixation with concurrent distal tibial distraction osteogenesis from July 2009 to September 2014 was conducted. Results This study included 19 patients with a mean age of 47.47 ± 13.36 years with a mean follow up of 576.13 ± 341.89 days. The mean preoperative LLD was 2.70 ± 1.22 cm and the mean operatively induced LLD was 2.53 ± 0.59 cm. The mean latency period was 9.33 ± 3.47 days and distraction rate was 0.55 ± 0.16 mm/day. The mean distraction length was 2.14 ± 0.83 cm and mean duration of external fixation was 146.42 ± 58.69 days. The time to union of all hindfoot and ankle fusions was 121.00 ± 25.66 days with an overall fusion rate of 85.71%. Conclusions The successful treatment of hindfoot and ankle deformity correction in the setting of LLD using the technique of a distal tibial corticotomy and distraction osteogenesis is reported and illustrates an additional treatment technique with comparable measured outcomes to those previously described. We urge that each patient presentation be evaluated with consideration of all described approaches and associated literature to determine the current best reconstructive approach as future studies may validate or replace the accepted options at present.
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Affiliation(s)
- Todd M Chappell
- Franciscan Foot & Ankle Associates, 1608 S J St., 4th Floor, Tacoma, WA, 98405, USA.
| | - Casey C Ebert
- Department of Veterans Affairs, 2360 E Pershing Blvd, Cheyenne, WY, 82001, USA
| | - Kevin M McCann
- St. Cloud Orthopedics, 1901 Connecticut Ave South, Sartell, MN, 56377, USA
| | - Byron L Hutchinson
- Franciscan Foot & Ankle Institute, 34509 9th Ave S, Ste 306, Federal Way, WA, 98003, USA
| | - Edgardo Rodriguez-Collazo
- Department of Surgery, AMITA Health St. Joseph Hospital, Chicago Foot & Ankle Deformity Correction Center, 875 N. Dearborn St. Ste 400, Chicago, IL, 60610, USA
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22
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Vaughn J, DeFontes KW, Keyser C, Bluman EM, Smith JT. Case Series: Allograft Tibiotalocalcaneal Arthrodesis Utilizing Fresh Talus. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419834541. [PMID: 35097319 PMCID: PMC8696819 DOI: 10.1177/2473011419834541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Joshua Vaughn
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Eric M Bluman
- Brigham & Women's Faulkner Hospital, Boston, MA, USA
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23
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Abstract
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.
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24
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Abstract
Avascular necrosis (AVN) of the talus bone is a progressive and debilitating consequence of trauma or exposure to a variety of risk factors. The Ficat classification describes current understanding of the natural history of AVN, including preclinical, preradiographic, precollapse, postcollapse, and arthritic stages. The size and location of the avascular region likely determines risk of progression; however, symptoms do not correlate with stage. Patients may be minimally symptomatic despite diffuse involvement for long periods. Joint-sparing strategies have shown promise but do not universally prevent progression of the disease. When bone structure fails, joint-sacrificing strategies may be required.
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Affiliation(s)
- Andrew Haskell
- Departments of Orthopedic Surgery and Sports Medicine, Palo Alto Medical Foundation, 301 Industrial Road, San Carlos, CA 94070, USA.
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25
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Stone MA, Flato RR, Pannell W, Cohen JR, Wang JC, Marecek GS. Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample. J Foot Ankle Surg 2018; 57:737-741. [PMID: 29703458 DOI: 10.1053/j.jfas.2017.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Indexed: 02/03/2023]
Abstract
Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p = .015) and overall complications (56.8%, p < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.
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Affiliation(s)
- Michael A Stone
- Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Russell R Flato
- Medical Student, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - William Pannell
- Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeremiah R Cohen
- Medical Student, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeffrey C Wang
- Professor of Clinical Orthopaedic Surgery and Neurosurgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Geoffrey S Marecek
- Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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26
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Gross CE, Sershon RA, Frank JM, Easley ME, Holmes GB. Treatment of Osteonecrosis of the Talus. JBJS Rev 2018; 4:01874474-201607000-00002. [PMID: 27509328 DOI: 10.2106/jbjs.rvw.15.00087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis. Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis. In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Sershon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan M Frank
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - George B Holmes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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27
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Griffin MJ, Coughlin MJ. Evaluation of Midterm Results of the Panta Nail: An Active Compression Tibiotalocalcaneal Arthrodesis Device. J Foot Ankle Surg 2018; 57:74-80. [PMID: 29268906 DOI: 10.1053/j.jfas.2017.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Indexed: 02/03/2023]
Abstract
A tibiotalocalcaneal intramedullary rod is a powerful construct often reserved for difficult and salvage cases. The Panta Nail (Integra LifeSciences, Plainsboro, NJ) is a second-generation rod that offers active axial compression compared with previous rod designs. We characterized our experience with this device and identified factors associated with nonunion. We retrospectively identified 19 patients receiving the Panta Nail during a 4-year period with a mean follow-up period of 16 months. We used a consecutive series approach toward inclusion. Fusion, asymptomatic fibrous union, or nonunion was determined for each ankle and subtalar joint as the primary endpoint. Patients were grouped as follows: group A, successful outcome; group B, successful outcome after dynamization; group C, no successful outcome. Secondary data were tested for association with the probability of first-attempt fusion. The Panta Nail resulted in a first-attempt fusion rate of 65% at the ankle and subtalar joints. With implementation of dynamization (31% of cases) at an average of 28 weeks after insertion (groups A and B), the bony fusion rate was 88% and 77% at the ankle and subtalar joint, respectively. Inclusion of 3 asymptomatic fibrous unions with final visual analog scale scores <4 (1 ankle; 2 subtalar) as successful outcomes resulted in 94% and 88% success rates for the ankle and subtalar joints (groups A and B). Salvaged total ankle arthroplasties with the Panta Nail device as a subgroup had an 83% fusion rate, with a 50% dynamization rate. No predictors of nonunion were found. The Panta Nail is a second-generation tibiotalocalcaneal arthrodesis device capable of providing good success rates for fusion. Also, dynamization is an appropriate and frequent augmentation method.
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Affiliation(s)
- Matthew J Griffin
- Orthopaedic Surgeon, The Coughlin Clinic of Saint Alphonsus Hospital, Boise, ID.
| | - Michael J Coughlin
- Professor and Orthopaedic Surgeon, The Coughlin Clinic of Saint Alphonsus Hospital, Boise, ID
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So E, Mandas VH, Hlad L. Large Osseous Defect Reconstruction Using a Custom Three-Dimensional Printed Titanium Truss Implant. J Foot Ankle Surg 2018; 57:196-204. [PMID: 29103890 DOI: 10.1053/j.jfas.2017.07.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Eric So
- Chief Resident, Grant Medical Center, Columbus, OH.
| | | | - Lee Hlad
- Faculty, Grant Medical Center Foot and Ankle Residency Program, Columbus, OH; Fellowship Trained Foot & Ankle Surgeon, Columbus, OH
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Buza JA, Leucht P. Fractures of the talus: Current concepts and new developments. Foot Ankle Surg 2018; 24:282-290. [PMID: 29409210 DOI: 10.1016/j.fas.2017.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/09/2017] [Accepted: 04/14/2017] [Indexed: 02/04/2023]
Abstract
Fractures of the talus are challenging to manage, with historically poor outcomes and a high rate of complications. The rare nature of this injury limits the number of studies available to guide treatment. Fortunately, a number of advancements have been made in the last decade. There is increased recognition regarding the importance of anatomic reconstruction of the osseous injury. Advanced imaging is used to assess the subtalar joint, where even slight displacement may predispose to arthritis. Increasing use of dual anteromedial and anterolateral approaches, along with plate fixation, has improved our ability to accurately restore the anatomy of the talus. Modification of the original Hawkins classification can both guide treatment and allow us to better predict which patients will develop avascular necrosis. Lastly, improved reconstructive techniques help address the most common complications after talus fracture, including arthritis, avascular necrosis, and malunion.
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Affiliation(s)
- John A Buza
- NYU Langone Medical Center, Hospital for Joint Diseases, 301 E. 17th St., New York, NY 10003, United States
| | - Philipp Leucht
- NYU Langone Medical Center, Hospital for Joint Diseases, 301 E. 17th St., New York, NY 10003, United States.
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DeFontes KW, Vaughn J, Smith J, Bluman EM. Tibiotalocalcaneal Arthrodesis With Bulk Talar Allograft for Treatment of Talar Osteonecrosis. Foot Ankle Int 2018. [PMID: 29542351 DOI: 10.1177/1071100718761036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
| | - Joshua Vaughn
- 1 Brigham & Women's Faulkner Hospital, Boston, MA, USA
| | - Jeremy Smith
- 1 Brigham & Women's Faulkner Hospital, Boston, MA, USA
| | - Eric M Bluman
- 1 Brigham & Women's Faulkner Hospital, Boston, MA, USA
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Abstract
Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.
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Affiliation(s)
- Mandeep S Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Balvinder Rana
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Inayat Panda
- Department of Orthopaedics, Fortis Bone and Joint Institute, Fortis Hospitals, New Delhi, India
| | - Sandeep Patel
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Sandeep Patel, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail:
| | - Prasoon Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mulligan RP, Adams SB, Easley ME, DeOrio JK, Nunley JA. Comparison of Posterior Approach With Intramedullary Nailing Versus Lateral Transfibular Approach With Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis. Foot Ankle Int 2017; 38:1343-1351. [PMID: 28952355 DOI: 10.1177/1071100717731728] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Ryan P Mulligan
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
Total ankle arthroplasty is a viable surgical technique for the treatment of end-stage degenerative joint disease. With continued advancement in prosthetic design, refined surgical techniques, and improved outcomes, the indications for total ankle replacement have expanded to include cases of increasing complexity. With meticulous preoperative planning and exacting execution, many frontal plane deformities and cases of avascular necrosis can now be successfully addressed at the time of prosthesis implantation or in a staged procedure.
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Affiliation(s)
- Stephen A Brigido
- Foot and Ankle Reconstruction, Foot and Ankle Department, Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017, USA.
| | - Scott C Carrington
- Foot and Ankle Reconstruction, Foot and Ankle Department, Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017, USA
| | - Nicole M Protzman
- Clinical Integration Department, Coordinated Health, 3435 Winchester Road, Allentown, PA 18104, USA
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Abd-Ella MM, Galhoum A, Abdelrahman AF, Walther M. Management of Nonunited Talar Fractures With Avascular Necrosis by Resection of Necrotic Bone, Bone Grafting, and Fusion With an Intramedullary Nail. Foot Ankle Int 2017; 38:879-884. [PMID: 28587485 DOI: 10.1177/1071100717709574] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | - Ahmed Galhoum
- 2 Schmerzklinik Kirschgarten, Orthopedics Surgery Hirschgasslein, Basel, Switzerland
| | | | - Markus Walther
- 3 Shoen Klinic Harlaching, Orthopedic Surgery, Munich, Germany
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Watanabe K, Teramoto A, Kobayashi T, Ogon I, Sakakibara Y, Kamiya T, Suzuki T, Yamashita T. Tibiotalocalcaneal Arthrodesis Using a Soft Tissue-Preserved Fibular Graft for Treatment of Large Bone Defects in the Ankle. Foot Ankle Int 2017; 38:671-676. [PMID: 28552043 DOI: 10.1177/1071100717696252] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pathogenesis of ankle disorders with a large bone defect is varied and treatment for those problems is challenging for orthopaedic surgeons. The aims of this study were to present an operative technique of arthrodesis for the reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue-preserved fibular strut graft and to report outcomes of consecutively treated patients. METHODS Twelve feet from 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening, were treated. Bone defects were filled using iliac bone and/or resected fibula and tibiotalocalcaneal arthrodesis was performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint while preserving the lateral to posterior skin and soft tissues on the fibula. The periods of bony fusion and outcomes were radiographically and clinically evaluated. The mean follow-up period was 33.4 months. RESULTS Bony fusion was achieved within 3 months in all cases. Coronal and sagittal alignments were acceptable, and the mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded their results of treatment as "satisfied." CONCLUSION This procedure did not require special techniques and it should be applicable to complicated cases with large bone defects. High fusion rates that we believe are due to preserving blood supply to the fibular graft can be expected with preservation of the hindfoot height. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Kota Watanabe
- 1 Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Hokkaido, Japan
| | - Atsushi Teramoto
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Takuma Kobayashi
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Izaya Ogon
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Yuzuru Sakakibara
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Tomoaki Kamiya
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Tomoyuki Suzuki
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Toshihiko Yamashita
- 2 Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan
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Shah AB, Jones C, Elattar O, Naranje SM. Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation. J Foot Ankle Surg 2017; 56:692-696. [PMID: 28476401 DOI: 10.1053/j.jfas.2017.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Indexed: 02/03/2023]
Abstract
Tibiotalocalcaneal arthrodesis (TTCA) is a well-established operative procedure for different severe pathologic conditions of the ankle and hindfoot joints. We present our results with a modified technique of TTCA using an intramedullary fibular strut graft in a series of complex cases of patients treated for multiple etiologies shown to have improved union rates. The technique involves inserting the fibular strut graft intramedullary after joint preparation and the use of either a Taylor spatial frame or plate and screws for definitive fixation. We reviewed the records of 16 patients who had undergone TTCA with this technique at our hospital from September 2013 to April 2015. Sixteen patients (10 males [62.5%] and 6 females [37.5%]) were included in the present study. These patients had complex cases and multiple risk factors, including diabetes, smoking, poor bone stock, and a history of previous surgeries. The mean follow-up time was 9.1 (range 9 to 18) months. Thirteen patients (81.2%) subsequently achieved union. The mean visual analog scale scores at the final follow-up examination had improved from 6.9 to 1.2. We suggest that our technique of TTCA with intramedullary fibular strut graft with fixation is a reasonable option to salvage complex cases with risk factors for operative complications.
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Affiliation(s)
- Ashish B Shah
- Assistant Professor of Surgery, Division of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL.
| | - Caleb Jones
- Medical Student and Research Assistant, Division of Orthopedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Osama Elattar
- Research Fellow, Foot and Ankle Surgery, Division of Orthopedic Surgery, University of Alabama at Birmingham, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Sameer M Naranje
- Attending Orthopedic Surgeon, Forrest City Medical Center, Forrest City, AR
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Kodama N, Takemura Y, Shioji S, Imai S. Arthrodesis of the ankle using an anterior sliding tibial graft for osteoarthritis secondary to osteonecrosis of the talus. Bone Joint J 2016; 98-B:359-64. [DOI: 10.1302/0301-620x.98b3.36154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aims This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus. Patients and Methods We reviewed the clinical and radiological outcomes of 27 patients who underwent arthrodesis with either vascularised or non-vascularised (conventional) grafts, comparing the outcomes (clinical scores, proportion with successful union and time to union) between the two groups. The clinical outcome was assessed using the Mazur and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. The mean follow-up was 35 months (24 to 68). Results The mean outcome scores increased significantly in both groups. In the vascularised graft group, the mean Mazur score improved from 36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. In the conventional arthrodesis group, the mean Mazur score improved from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. Complete fusion was achieved in 13 patients (76%) in the vascularised group, but only four (40%) in the conventional group. The clinical outcomes and proportion achieving union were significantly better in the vascularised group compared with the conventional arthrodesis group, although time to union was similar in the two groups. Take home message: Vascularised sliding tibial grafts may be used to achieve arthrodesis in patients with OA of the ankle secondary to osteonecrosis of the talus. Cite this article: Bone Joint J 2016;98-B:359–64.
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Affiliation(s)
- N. Kodama
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Y. Takemura
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Shioji
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Imai
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
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39
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Roukis TS, Kang RB. Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series. J Foot Ankle Surg 2016; 55:857-67. [PMID: 26810126 DOI: 10.1053/j.jfas.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Thomas S Roukis
- Orthopaedic Center, Gundersen Healthcare System, La Crosse, WI.
| | - Rachel B Kang
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI
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Devalia KL, Ramaskandhan J, Muthumayandi K, Siddique M. Early results of a novel technique: Hindfoot fusion in talus osteonecrosis prior to ankle arthroplasty: A case series. Foot (Edinb) 2015; 25:200-5. [PMID: 26363580 DOI: 10.1016/j.foot.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 07/03/2015] [Accepted: 07/06/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical outcome of a two staged approach of subtalar arthrodesis followed by TAR for patients with ankle arthritis and AVN talus. METHODS Out of total 210 TARs performed at our institute; 7 patients underwent a two staged procedure between 2006 and 2010. All patients had over 3 years of follow up (except one). The clinical results were assessed using AOFAS, WOMAC, SF-36 and patient satisfaction scores. RESULTS The mean follow up was 3 years. There was significant improvement in AOFAS and WOMAC (pain and stiffness) from pre-op to 3 years post-op (P<0.05). SF 36 scores improved from pre-op to 3 years post-op for 6/8 domains. 5 patients were satisfied at 3 years for overall surgical outcomes, 4 were satisfied with pain relief. Radiological signs of talar subsidence were noted in 2 patients at year 1. This did not progress at 3 years and did not deteriorate clinical outcome. CONCLUSION We recommend our two staged approach to deal with this difficult clinical problem. We believe this approach is safe for TAR surgery where talar vascularity and bone quality is questionable leading to reduced talar subsidence, ischaemic pain and improvement in longevity of TAR. LEVEL OF EVIDENCE Evidence IV (Retrospective case series).
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Affiliation(s)
- Kailash L Devalia
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE7 7DN, United Kingdom.
| | - Jayasree Ramaskandhan
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE7 7DN, United Kingdom.
| | - Karthikeyan Muthumayandi
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE7 7DN, United Kingdom.
| | - Malik Siddique
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE7 7DN, United Kingdom.
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Hsu AR, Ellington JK. Patient-Specific 3-Dimensional Printed Titanium Truss Cage With Tibiotalocalcaneal Arthrodesis for Salvage of Persistent Distal Tibia Nonunion. Foot Ankle Spec 2015; 8:483-9. [PMID: 26169117 DOI: 10.1177/1938640015593079] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Andrew R Hsu
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina
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42
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Hsu AR, Ellington JK, Adams SB. Tibiotalocalcaneal Arthrodesis Using a Nitinol Intramedullary Hindfoot Nail. Foot Ankle Spec 2015; 8:389-96. [PMID: 26264637 DOI: 10.1177/1938640015598838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Andrew R Hsu
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
| | - J Kent Ellington
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
| | - Samuel B Adams
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
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Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Tibiotalocalcaneal Arthrodesis With an Intramedullary Hindfoot Nail and Pillar Fibula Augmentation: Technical Tip. Foot Ankle Int 2015; 36:984-7. [PMID: 25848135 DOI: 10.1177/1071100715579264] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jochen Paul
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | - Alexej Barg
- Orthopaedic Department, University Hospital Basel, Basel, Switzerland
| | | | - Mario Herrera
- Orthopaedic Department, University Hospital of Canary Island, Tenerife, Spain
| | - Heath B Henninger
- Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, Salt Lake City, USA
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