Tibiotalocalcaneal arthrodesis with a compressive retrograde nail: A retrospective study of 59 nails

doi:10.1016/j.fas.2015.01.001

Foot and Ankle Surgery

Volume 21, Issue 3, September 2015, Pages 202-205

https://doi.org/10.1016/j.fas.2015.01.001 Get rights and content

Highlights

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Retrospective study of 58 patients undergoing 59 tibiotalocalcaneal arthrodesis procedures.
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93% achieved union at a mean time of 4.17 months.
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Mean VAS score preoperatively was 7.46 compared to 1.98 post-operatively (p < 0.001).
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Device and technique offers reliable fusion rates with high patient satisfaction.

Abstract

Background

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems. This study reports the elective results of combined subtalar and ankle arthrodesis using one design of retrograde intramedullary compression nail.

Methods

Retrospective review identified 58 patients undergoing 59 tibiotalocalcaneal arthrodesis procedures. Mean follow up was 9.15 (3–36) months with average age 60.7 (22–89) years. A function and subjective patient satisfaction questionnaire was achieved in 89%.

Results

53 patients (93%) achieved union at a mean time of 4.17 months. Four patients (8%) subjectively thought the procedure was of no benefit while 42 (84%) had an excellent or good result. The mean visual analogue scale (VAS) score for preoperative functional pain was 7.46 compared to 1.98 post-operatively (p < 0.001).

Conclusions

This device and technique offers an effective treatment of hindfoot pathology giving reliable compression and subsequent fusion with excellent patient satisfaction and pain relief.

Level of evidence

IV case series.

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.

Section snippets

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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Cited by (18)

Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis
2022, Journal of Foot and Ankle Surgery
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.
Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system
2020, Injury
Citation 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].
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.
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.
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.
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.
Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis
2019, Foot and Ankle Surgery
The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.
Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4 ± 1.9 years (range 1.0–6.5).
One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.
In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.
Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail
2018, Foot and Ankle Surgery
Citation 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.
Tibiotalocalcaneal (TTC) fusion using a retrograde intramedullary (IM) nail is an effective salvage option for terminal-stage hindfoot problems. However, as many patients who receive TTC fusion bear unfavorable medical comorbidities, the risk of nonunion, infection and other complications increases. This study was performed to identify the factors influencing outcomes after TTC fusion using a retrograde IM nail.
Between September 2008 and February 2012, 34 consecutive patients received TTC fusion using a retrograde IM nail for limb salvage. All patients had a minimum follow-up of two years. Throughout follow-up, standard ankle radiography was performed along with clinical outcome assessment using a visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society Ankle-Hind Foot Scale (AOFAS A/H scale) and the Foot and Ankle Outcome Score (FAOS). For the retrospective analysis, demographic factors, preoperative medical status, laboratory markers, and etiology were comprehensively reviewed using medical records. The success of the index operation was determined using clinical and radiological outcomes. Finally, the effect of each factor on failure after the operation was analyzed using univariate logistic regression.
In a mean of seven months, 82% (28/34) achieved union, as evaluated by standard radiography. All clinical outcome parameters improved significantly after the operation, including VAS, AOFAS A/H scale, and FAOS (P < 0.001). At the last follow-up, five cases of nonunion with less than AOFAS A/H scale of 80 and two cases of below knee amputation due to uncontrolled infection were determined to be failures. None of the factors (etiology, demographics, laboratory markers and medical status) significantly influenced failures. However, uncontrolled DM significantly increased the failure rate with an odds ratio of 10 (P = 0.029).
TTC fusion with a retrograde intramedullary nail is a successful treatment for complicated hindfoot problems such as traumatic osteoarthritis, Charcot arthropathy and failed TAA. However, it should be used judiciously in patients with uncontrolled DM, as the risk of failure increases.
Retrospective cohort study.
Primary Arthrodesis for Tibial Pilon Fractures
2017, Foot and Ankle Clinics
Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series
2016, Journal of Foot and Ankle Surgery
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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Tibiotalocalcaneal arthrodesis with a compressive retrograde nail: A retrospective study of 59 nails

Highlights

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Introduction

Section snippets

Patients and methods

Operative technique

Results

Discussion

Conflict of interest

Semin Arthroplast

Pain

Pain

Foot Ankle Surg

J Foot Ankle Surg

Foot

Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail

Foot Ankle Int

Tibiotalocalcaneal arthrodesis

Techn Orthop

Short-term outcome of retrograde tibiotalocalcaneal arthrodesis with a curved intramedullary nail

Foot Ankle Int