Biomechanical Evaluation of Primary Stiffness of Tibiotalocalcaneal Fusion with Intramedullary Nails

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Intramedullary implants are being used with increasing frequency for tibiotalocalcaneal fusion (TTCF). Clinically, the question arises whether intramedullary (IM) nails should have a compression mode to enhance biomechanical stiffness and fusion-site compression. This biomechanical study compared the primary stability of TTCF constructs using compressed and uncompressed retrograde IM nails and a screw technique in a bone model. For each technique, three composite bone models were used. The implants were a Biomet nail (static locking mode and compressed mode), a T2 femoral nail (compressed mode); a prototype IM nail 1 (PT1, compressed mode), a prototype IM nail 2 (PT2, dynamic locking mode and compressed mode), and a three-screw construct. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as percent of the available fusion-site area. Stiffness was tested in dorsiflexion and plantarflexion (D/P), varus and valgus (V/V), and internal rotation and external rotation (I/E) (20 load cycles per loading mode). Mean contact surfaces were 84.0 +/- 6.0% for the Biomet nail, 84.0 +/- 13.0% for the T2 nail, 70.0 +/- 7.2% for the PTI nail, and 83.5 +/- 5.5% for the compressed PT2 nail. The greatest primary stiffness in D/P was obtained with the compressed PT2, followed by the compressed Biomet nail. The dynamically locked PT2 produced the least primary stiffness. In V/V, PT1 had the (significantly) greatest primary stiffness, followed by the compressed PT2. The statically locked Biomet nail and the dynamically locked PT2 had the least primary stiffness in V/V. In I/E, the compressed PT2 had the greatest primary stiffness, followed by the PT1 and the T2 nails, which did not differ significantly from each other. The dynamically locked PT2 produced the least primary stiffness. The screw construct's contact surface and stiffness were intermediate. The IM nails with compression used for TTCF produced good contact surfaces and primary stiffness. They were significantly superior in these respects to the uncompressed nails and the screw construct. The large contact surfaces and great primary stiffness provided by the IM nails in a bone model may translate into improved union rates in patients who have TTCF.