Posterior Arthroscopic Tibiotalocalcaneal Fusion

Abstract

Category: Arthroscopy Introduction/Purpose: Hindfoot arthritis is treated usually with Tibiotalocalcaneal fusion when conservative treatment has failed. Indications of TCC fusion are wide, including post - traumatic arthritis, rheumatoid arthritis, acquired flat foot deformity (Myerson stage IV), failed total ankle arthroplasty. In the vast majority of these cases, there are skin problems because of systemic diseases or wound problems following prior surgery. Several methods have already been described and it seems that the use of intramedullary nail offers a load-sharing rigid internal fixation. The purpose of this presentation is to describe an alternative less invasive surgical technique of TTC fusion using an intramedullary retrograde nail via a posterior arthroscopy of the hindfoot. We present the surgical technique, the early results and quote several cases treated by this method. Methods: Under spinal or general anaesthesia, the patient is positioned prone. Using the standard posteromedial and posterolateral portals, a standard knee arthroscope is inserted via the posterolateral portal. Via the posteromedial portal, a soft tissue shaver is introduced to prepare the posterior gutter. Most of the preparation of the articular surface of the ankle joint is achieved with the arthroscope through the posterolateral portal and the instruments through the posteromedial portal. After the preparation of the ankle joint surfaces, under fluoroscopic control, a guide wire is inserted through calcaneus and talus into the tibia. Reaming is performed. Then a retrograde intramedullary nail is inserted through the calcaneal and the talus to the tibia. An anodized titanium alloy intramedullary nail is used and locked statically with one screw in the calcaneus, one in the talus and two screws in the tibial shaft. The preparation of the subtalar articular surfaces then takes place. Results: Deformity correction and hindfoot fusion were achieved in all five cases. There were no major complications, such as infection, trauma complications, nonunion, malunion or hardware failure. Fusion was achieved in about three months time (plus minus two weeks). All the patients returned back to their daily activities in four to five months time. The post-op AOFAS score was significantly improved. The mean hospitalization was 1.2 days. After the discharged, all the patients were followed at the outpatient clinic in a regular basis. Conclusion: This alternative surgical technique combines the advantages of the TTC fusion with an intramedullary nail and the advantages of the arthroscopic minimal intervention to the soft tissue envelope. This enables immediate mobilization of the patient and a small period of hospitalization. The key point is the steep learning curve. From the literature review can be found similar techniques with equally positive results.