Tibiotalar nonunion corrected by hindfoot arthrodesis

Non-Union Treatment in the Foot, Ankle, and Lower Leg: A Multicenter Retrospective Study Comparing Conventional Treatment with the Human Allogeneic Cortical Bone Screw (Shark Screw®)

Addressing non-unions involves stabilizing the affected area through osteosynthesis and improving bone biology using bone grafts. However, there is no consensus on the optimal treatment method. This study aims to compare outcomes of non-union surgery using conventional treatment methods (metal hardware ± graft) versus osteosynthesis with the human allogeneic cortical bone screw (Shark Screw®) alone or in combination with a metallic plate. Thirty-four patients underwent conventional treatment, while twenty-eight cases received one or more Shark Screws®. Patient demographics, bone healing, time to bone healing, and complications were assessed. Results revealed a healing rate of 96.4% for the Shark Screw® group, compared to 82.3% for the conventionally treated group. The Shark Screw® group exhibited a tendency for faster bone healing (9.4 ± 3.2 vs. 12.9 ± 8.5 weeks, p = 0.05061). Hardware irritations led to six metal removals in the conventional group versus two in the Shark Screw® group. The Shark Screw® emerges as a promising option for personalized non-union treatment in the foot, ankle, and select lower leg cases, facilitating effective osteosynthesis and grafting within a single construct and promoting high union rates, low complications, and a rapid healing process.

Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Tibiotalocalcaneal Arthrodesis With Bulk Talar Allograft for Treatment of Talar Osteonecrosis

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

LEVEL OF EVIDENCE

Level V, expert opinion.

[Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]

BACKGROUND

Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear.

MATERIALS AND METHODS

Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion.

RESULTS

Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation.

CONCLUSION

Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.

Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle

BACKGROUND

Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect.

METHODS

Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion.

RESULTS

Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation.

CONCLUSIONS

Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Retrograde nail for tibiotalocalcaneal arthrodesis as a limb salvage procedure for open distal tibia and talus fractures with severe bone loss

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure.