Arthroscopic tibiotalocalcaneal arthrodesis using an intramedullary locking nail

Abstract

Arthroscopic tibiotalocalcaneal arthrodesis (TTCA) aims at reconstructing apain-free, orthograde, and functional limb with reduced invasiveness and lower complication rates compared to open arthrodesis. Combined osteoarthritis of the ankle and subtalar joint or hindfoot malalignment. Osteomyelitis/deep soft tissue infections, talus necrosis, severe deformity of hindfoot or distal tibia, pronounced boney defect, indication for combined total ankle replacement and subtalar fusion. Patient in supine position; arthroscopic debridement of the cartilage and subchondral zone, perforation of the subchondral bone marrow of the ankle and subtalar joint. Foot and hindfoot positioning. Special attention has to be paid to the calcaneus and talus inclination, hindfoot alignment and rotation. Temporary fixation, insertion of the guide wire, reaming and insertion of the retrograde, curved compression arthrodesis nail. If needed, autologous bone grafting. Proximal locking of the nail, application of compression, distal locking, wound closure. Lymphatic drainage, physical therapy, and restricted bed rest until wound healing. Non-weightbearing, immobilization for 8weeks, then step-wise increase of weightbearing. Fitting of custom-made shoes. Retrospectively included were 15patients treated by arthroscopic TTCA with an intramedullary nail (average age 56 ± 10years, 93% male, all had risk factors for postoperative complications). Due to apreoperative plantar ulceration, 4patients (27%) had 3 ± 1.8conditioning operations. Sufficient hindfoot correction was achieved in all patients. Major complications occurred in 33%(non-unions). In asubgroup analysis, the presence of aplantar ulceration significantly influenced the development of amajor complication. In acase-control study, major complications occurred in 63% and wound complications in 50% of patients for the open technique compared to 33% and 0%, respectively, for the arthroscopic technique. Although the current data do not prove superiority of arthroscopic TTCA compared to open TTCA, there appears to be astrong trend towards considerably lower complication rates following arthroscopic TTCA.