Tibiotalocalcaneal Arthrodesis Using a Novel Retrograde Intramedullary Nail

The Ankle Joint: Management of Significant Bone Loss with Arthrodesis

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

A modified hybrid transport technique combined with a retrograde tibiotalocalcaneal arthrodesis nail for the management of distal tibial periarticular osteomyelitis and associated defects

BACKGROUND

This paper aimed to propose a modified technique of bone transport. An annular frame combined with a retrograde tibiotalocalcaneal arthrodesis nail was used in this novel technique for treating large distal tibial periarticular osteomyelitis and associated defects.

METHODS

Our team conducted a retrospective research. Forty-three patients with large distal tibial periarticular bone loss were involved in this study. Sixteen patients were treated using the modified hybrid transport technique (MHT group) while 27 were subjected to traditional bone transport (BT group). The mean bone loss was 7.8 ± 2.4 cm in the MHT group and 7.6 ± 2.6 cm in the BT group. The external fixation index, time in transport frame, self-rating anxiety scale, bone healing results and postoperative complications were recorded.

RESULTS

The mean time in frame for the MHT group was 3.6 ± 1.5 months, while that of the BT group was 10.3 ± 2.7 months (p < 0.05). The mean external fixation index of MHT group was 0.46 ± 0.08 months/cm versus 1.38 ± 0.24 months/cm of the BT group (p < 0.05). There was no statistical difference for the bone healing results between the MHT and BT groups (p = 0.856). The self-rating anxiety scale and total complication incidence of the MHT group were significantly lower than that of BT patients (p < 0.05).

CONCLUSION

Compared to the traditional BT technique, our modified hybrid transport technique showed better clinical outcomes for treating large distal tibial periarticular bone loss, including less time in transport frame, lower external fixation index and complication incidence. Therefore, this modified technique should be further promoted and developed.

Tibiotalocalcaneal Arthrodesis: A Retrospective Comparison Between Nails and Lateral Locking Plate Complications

Background

Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications.

Methods

We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones.

Results

We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure.

Conclusion

No significant differences were found in the complication rates between the 2 implants.

Level of Evidence

Level V, Case series.

Shortening and re-lengthening versus bone transport for the treatment of distal tibial periarticular post-traumatic defects

In the present study, we presented our experience with a new modified technique of shortening and re-lengthening using a monolateral external frame combined with a calcaneal intramedullary nail and compared it with the bone transport technique for the treatment of distal tibial periarticular post-traumatic defects. Forty-one patients were retrospectively analyzed. Among them 19 were treated using our modified shortening and re-lengthening technique (MSR group) and 22 by bone transport (BT group). The difference in external fixation time (EFT), external fixation index (EFI), self-rating anxiety scale (SAS), and complications were compared between the two groups. The mean EFT was 3.4 ± 0.6 months in the MSR group and 7.5 ± 1.4 months in the BT group; the EFI was 0.57 ± 0.06 month/cm and 1.32 ± 0.23 month/cm, respectively. The EFT, EFI, and SAS scores were significantly lower in the MSR group than in the BT Group (p < 0.05). The mean number of complications per patient in the BT group was nearly 2.4 times that of the MSR group (p < 0.05). Our modified shortening and re-lengthening technique reduced the EFI and complication incidence compared to the bone transport technique. Therefore, patients with distal tibial periarticular post-traumatic defects can achieve great satisfaction with this new technique.

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

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

Femoral Head Allografts for Talar Body Defects

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, case series.

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

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