Tibiotalocalcaneal arthrodesis with a compressive retrograde nail: A retrospective study of 59 nails
Introduction
Hindfoot arthrodesis is a recognised salvage procedure for patients with a number of hindfoot conditions ranging from failed arthroplasty, charcot joints, previous trauma, talar avascular necrosis and severe osteoarthritis [1]. The goal of hindfoot arthrodesis is pain relief and correction of deformity through solid fusion. For those with tibiotalar and talocalcaneal joint involvement a tibiotalocalcaneal (TTC) arthrodesis can be performed [2].
Tibiocalcaneal fusion was first introduced in 1879 by Albert but has evolved over the decades as new technologies have developed. During these early years, patients had only cast immobilisation postoperatively with no other fixation method to hold the fusion. Surprisingly good results were obtained using this technique which was primarily used for severe mal-united fractures [3]. A number of different techniques have been trialled in the following years including external fixators as well as plate and screw devices. In the 1960s, the use of intramedullary (IM) nails was developed which renewed interest in hindfoot fusions. The first IM nails used by Kuentschner in 1962 were unlocked nails, commonly femoral or humeral nails or straight ankle arthrodesis nails [4].
Their use became more widespread in 1994 when Johnson introduced locked, valgus curved IM nail fixation. This, combined with a longitudinally placed calcaneal screw from a posterior approach to the hindfoot as opposed to the originally used transverse calcaneal screw, was found to allow significantly more rotational stiffness, hence achieving better fusion rates. This has since been modified to use a lateral approach to the tibiotalar joint with excision of the distal fibular [5].
Specialised IM nails with locking systems and compression options have evolved over the past decade with third generation locking TTC nails such as the Stryker T2 ankle arthrodesis nail, which provides more rotational stiffness. This system has been used at our centre since 2005 and the authors believe this to be a safe and effective salvage procedure in appropriately selected patients. This study aims to report results of elective patients undergoing tibiotalocalcaneal arthrodesis using one design of retrograde intramedullary compression nail, the Stryker T2 ankle arthrodesis nail. The authors believe this to be one of the largest consecutive series for this device in the literature.
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Patients and methods
A retrospective study identified 58 patients (27 female and 31 male) having undergone 59 TTC nail fusions between 2005 and 2011. All were undertaken electively by two consultants with special interest in foot and ankle surgery and performed at the same centre. Two patients died from unrelated causes before initial follow up leaving 56 patients with 57 TTC nails. All patients who had elective TTC nail fusions between 2005 and 2011 using the Stryker T2 nail were included. Exclusion criteria
Operative technique
The Stryker T2 nail was used in all cases with the same surgical technique used by both surgeons. The patient is positioned supine on a radiolucent table with careful neutral alignment of the knee and ankle. The affected limb is elevated on a bolster under the calf to allow easy exposure to the C-arm for intra-operative imaging. A lateral incision is made in line with the distal lateral malleolus allowing resection of the distal portion of the fibular to gain access to the tibiotalar and
Results
53 of the 57 nails achieved union giving a union rate of 93% with a mean time to union of 4.17 months (range 3–7) and median of three months. A femoral head structural block allograft was used in 11 cases, nine of which went on to achieve union (union rate of 82%) with a mean time of 4.22 months. Union was assessed by clinical examination with asymptomatic, pain-free patients deemed clinically united and this was confirmed radiologically with plain X-ray. CT scanning was not employed routinely
Discussion
This case series supports the use of the Stryker T2 nail as a salvage procedure for complex disorders of the hind foot. The results achieved in this centre are comparative to those seen in the founding paper by Muckley et al. [4] who presented a case series of 55 patients performed between 2005 and 2008 as a pilot study for the Stryker T2 TTC device. This showed an impressively high union rate at 96% with low complication rates and high patient satisfaction scores.
It is our routine clinical
Conflict of interest
The authors report no conflict of interest to disclose.
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Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system
2020, InjuryCitation Excerpt :Given the dramatic rise of ankle arthroplasty in the United States and world-wide, TTC arthrodesis is increasingly performed as salvage for failed total ankle replacement [6–9]. While outcomes vary in the literature, TTC arthrodesis has been demonstrated to be successful at correcting hindfoot deformity and alleviating pain [3,10] with large systematic reviews demonstrating success rates over 90% [11]. While multiple fixation techniques have been described, the use of intramedullary hindfoot nails is increasing [2,3,5].
Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail
2018, Foot and Ankle SurgeryCitation Excerpt :Therefore, a study regarding prognostic factors after TTC fusion with a retrograde IM nail is important, as candidates for such surgery frequently bear unfavorable surgical factors. Nevertheless, few studies have analyzed prognostic factors after TTC fusion with a retrograde IM nail, while many studies have focused on biomechanical and clinical outcomes after the surgery [6,8,10,12–14,18–22]. To the authors’ best knowledge, there were only two studies which specifically evaluated prognostic factors for TTC fusion with a retrograde IM nail.
Primary Arthrodesis for Tibial Pilon Fractures
2017, Foot and Ankle Clinics