Fusion Nail Research Articles

Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model.

Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct. Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions. No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure. The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.

Conversion of failed revision total knee arthroplasty in arthrodesis with modular nail maintaining the uncemented femoral stem in patient with extensor mechanism insufficiency: a case report

BackgroundThe transition from revision total knee arthroplasty (RTKA) to arthrodesis involves the replacement of cemented femoral and tibial stems with a modular nail designed for arthrodesis. This conversion process is associated with challenges such as bone loss, blood loss, and prolonged surgical durations. Effectively addressing these complexities through a less invasive surgical approach could be pivotal in enhancing patient outcomes and minimizing associated complications.Case presentationA 75-year-old white Caucasian female patient with a revision total knee arthroplasty (RTKA) performed with a modular uncemented rotating-hinge system, reporting an history of recurrent patellar dislocation, was referred to our institution after a fall resulting in periprosthetic tibial plateau fracture. The fracture was treated with open reduction and internal fixation, but afterwards the patient had been unable to walk again. Tibial stem was mobilized, and extensor mechanism was insufficient due to chronic incomplete quadriceps tendon rupture. The femoral stem was stable, so we decided to convert the rotating-hinge in a arthrodesis with an uncemented modular knee fusion nail maintaining the previous femoral stem.ConclusionsThe result was a successful arthrodesis with minimal bone and blood loss, reduced operative time, and optimal functional outcome at the one-year follow-up. This case highlights the advantage of using a modular knee revision platform system that gives the opportunity to convert a RTKA in arthrodesis.

Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population.

To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. Retrospective case series. Level I trauma center. Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. Tibiotalocalcaneal hindfoot fusion nail. Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%). Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nail Plate Constructs: A Novel Technique for Treatment of Unstable Charcot Ankle and Hindfoot Deformity

Category: Hindfoot; Diabetes Introduction/Purpose: Charcot arthropathy is a disorder known to have poor outcomes with a high risk of amputation. Life expectancy, lifetime amputation rates and five-year mortality rates approach 50%. Patients often present with multiple medical comorbidities, poor bone quality and severe deformity. They have difficulty following non-weight bearing precautions postoperatively leading to fixation failure, recurrent instability and wound problems. Recent trauma literature has shown that a nail plate construct (NPC) provides a good option for elderly patients with poor bone quality sustaining distal femur fractures. This intervention has afforded these low demand patients increased stability allowing early weightbearing while maintaining good clinical results. Implementing this concept, we report early results with a novel application of NPCs in patients with charcot arthropathy of the ankle and hindfoot. Methods: Patients with Charcot arthropathy undergoing tibiotalocalcaneal fusion via combination of intramedullary nail fixation and lateral variable angle locked plating by a single surgeon from September 2020 to August 2021 were included in our study. Age, comorbidities, Hemoglobin A1c, smoking status, ambulatory status, presence of an ulcer, history of infection, implants used, bone graft used, tourniquet time, and postoperative complications were retrospectively recorded. Results: Four patients with hindfoot charcot deformities were included in our case series. Two men and two women with an average age of 58 years (range, 45-67 years) were treated. Three patients were diabetic with an average Hemoglobin A1C of 6.9 (range 5.2-10.7). Three patients had an active or impending ulcer. All patients were treated with a tibiotalocalcaneal variable angle locked plate around a hindfoot fusion nail with fibular autograft and biologic adjunct. Follow-up ranged from 4-12 months. All patients were made non-weight bearing, but all reported weightbearing in the perioperative period. Three of the four patients have a stable, non-infected, ulcer free foot and are ambulating in commercially available footwear (75% favorable outcome). One patient suffered a deep infection which was ultimately treated with below-knee amputation. This patient was morbidly obese, failed prior ORIF of the ankle, and was on vancomycin at time of presentation. Conclusion: Charcot arthropathy is a difficult pathologic process to treat surgically with high rates of complications. This difficult patient population often is unable to follow non-weight bearing precautions putting them at increased risk for failure. NPCs, as described in new trauma literature, promote encouraging results in patients with poor bone quality permitted early weight bearing. Hindfoot nail with variable angle locked plate combination for unstable ankle and hindfoot charcot arthropathy yields a 75% favorable outcome with early results consisting of 3 patients with functional limb salvage and 1 patient with below knee amputation.

Charcot Ankle Deformity: Can the Limb be Salvaged?

Category: Diabetes; Ankle Introduction/Purpose: Diabetes mellitus (DM) may result in Charcot arthropathy (CA) in 0.1% to 2.5% of diabetic patients. Complications may arise including joint dislocation, deformities, ulcerations, and limb amputation. Surgical intervention has been shown to improve patient's walking ability and health-related quality of life compared to use of orthotics in addition to reduction of ulcer, bone infection, use of orthoses, and amputation. A retrospective review of patients with ankle charcot arthropathy was performed with hindfoot nail fixation. The aim of the study was to determine radiographic healing, complication rates of surgical intervention, and patients' ability to ambulate with therapeutic inserts or boots. The results obtained from this study serve to provide evidence for intervention via operative fixation and limb salvage in this cohort of patients. Methods: A retrospective review of patients treated with hindfoot nail with CA of the ankle was performed between 2016 to 2022. The demographic data, BMI, cause of the charcot arthropathy, the pre-operative radiographic deformity, and prior wounds and infection data was recorded. We identified 18 consecutive patients that underwent surgical intervention. The surgical technique included bimalleolar exposure, correction of the deformity, hindfoot fusion nail with or without structural femoral head graft. The follow up data collected included post-operative complications, radiographic evaluation of union, and clinical data on type of shoe wear or boots used for ambulation. Results: We identified 17 consecutive patients undergoing hindfoot deformity correction with hindfoot nail. The average follow- up for the patients was 1.7 year. The cause of neuropathy was diabetes in 15 patient and idiopathic in 2 patients. The average BMI for the cohort was 29.5. The initial 90-day complications rate for surgical intervention was 17%; with one superficial infection, one deep infection, and one death related to a cardiac event. At latest follow up 12 patients were ambulating with a CROW boot, 3 in diabetic shoes with therapeutic inserts, 1 below knee prosthesis, and 1 patient is in the initial perioperative period of healing. Radiographic union was seen in 12 patient, 3 patients had stable pseudo-union of the ankle joint with neutral alignment. Conclusion: The development of an acquired ankle deformity is associated with a poor quality of life. Traditional treatment of CA has shown to be effective when resolving infection and avoiding amputation. Our study supports the use of hindfoot nail for deformity correction/fixation and limb salvage of ankle CA patients. This patient population is highly comorbid but can have meaningful improvement in ambulator status post-surgery in a CROW boot or shoes with therapeutic insoles.

Charcot Arthropathy Limb Salvage with 3D Custom Cage and Dynamic Hindfoot Fusion Nail Combination Fixation: A Case-Series

Category: Diabetes; Ankle; Hindfoot Introduction/Purpose: Patients with Charcot arthropathy with hindfoot collapse present a difficult challenge for foot and ankle surgeons. While traditional limb salvage options include tibiotalocalcaneal (TTC) arthrodesis with accepted shortening, thin wire external fixation, or TTC arthrodesis with bulk femoral head allograft, new 3-dimensional (3D) custom patient specific implants offer a new treatment modality for limb salvage for this difficult issue. The purpose of this case-series is to offer one surgeon's experience with this new treatment technique for limb salvage. Methods: All patients undergoing limb salvage procedures for hindfoot collapse between 2018 and 2022 with a custom 3D hindfoot cage with TTC hindfoot fusion intramedullary nail were included for analysis. Along with patient demographics and length of follow up, patients were asked a series of questions on a telephone survey in order to measure patient reported outcomes including current ambulatory status and whether they would have elected to undergo the same treatment modality again. Complications were also tracked. Finally, radiographs were analyzed to evaluate the degree of deformity correction on both coronal and sagittal planes as well as degree of deformity correction maintenance at last radiographic follow up. Results: 13 patients were included in the analysis. 10 of the 13 patients had Charcot arthropathy. 2 patients had deep infections that ultimately required below knee amputation. 11 out of 13 patients had successful limb salvage as defined by the maintenance of a functional limb without need for amputation. Interestingly, both patients who failed limb salvage and required below knee amputations reported that they would prefer to have undergone the same attempt at limb salvage even with the resulting amputation. Radiographically, the average amount of coronal plane deformity correction was 25 degrees while the average amount of sagittal plane deformity correction was 6 degrees. The average amount of deformity correction maintenance seen at last radiographic follow up was high with a loss of only 0.5 degrees in coronal plane deformity correction loss throughout the time period and an average of 2 degrees of sagittal plane deformity correction loss. Conclusion: While still a challenging pathology to treat, custom patient specific 3D implants combined with TTC hindfoot fusion nail is a viable construct for patients with Charcot arthropathy undergoing limb salvage for hindfoot collapse.

Improved Pain and Function After TTC Fusion With a Custom Cage.

Three-dimensional custom cages can be used to treat complex ankle and hindfoot pathology and bone loss with potentially better patient satisfaction and higher fusion rates than tibiotalocalcaneal (TTC) fusion alone or in combination with bulk femoral head allograft. Yet there is limited literature to support this procedure. The purpose of this study is to objectively quantify the clinical and radiologic outcomes of patients undergoing patient-specific 3D-printed custom cage implantation to fill large defects around the ankle joint region as part of a limb-salvaging TTC fusion. This is a retrospective review of 21 patients (mean age 59.3 years) who underwent custom cage implantation with a TTC retrograde fusion nail by a single surgeon for massive bone loss of the ankle and hindfoot. Patient charts were reviewed for pain and functional outcomes, complications, and various demographics, including number of previous surgeries to the ipsilateral ankle. Mean follow-up was 32 months. All 21 patients had preoperative and postoperative pain and function scores available for analysis. A total of 20 (95.2%) of the 21 patients had their cage in situ at final follow-up. Overall, with the numbers available, visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, and the 12-Item Short Form Health Survey (SF-12) mental and physical health scores significantly improved from preoperative to final follow-up. However, when compared to the overall US population of age-matched 55- to 64-year-old individuals, patients still remained relatively disabled. There were 2 failures, one of which required amputation and the other was treated nonoperatively with bracing. In conclusion, in this relatively small, single-surgeon series, we found that 3D-printed custom cage technology offered a viable option for complex TTC fusion procedures performed in the presence of significant bone loss, with good fusion rates, however relatively modest improvement in functional outcomes. Level IV, retrospective case series.

Use of the Straight Retrograde Intramedullary Nail for Tibiotalocalcaneal Arthrodesis: A Single-Institution, Single-Surgeon, Single-Implant Retrospective Series.

Background:The hindfoot fusion nail has become a popular implant for tibiotalocalcaneal (TTC) arthrodeses given its rigidity, ease of insertion, and potential for less invasive surgical approaches. The purpose of this study was to evaluate fusion and complication rates following the use of a straight, retrograde intramedullary nail for TTC arthrodeses, and the influence of diabetes and smoking on these results.Methods:A review of patient cases performed by a single surgeon at a single institution was performed. Variables included age, comorbidities, smoking history, BMI, hemoglobin A1c, preoperative and postoperative visual analog scale pain scores, assessment of healing, and complications. Relative and absolute risk were assessed for smoking, diabetes, fusion, and surgical complications through risk ratios. Cox proportional hazards survival analyses were performed to assess the effects of smoking and diabetes on fusion rates and complications. Linear regressions were performed to investigate the effects of smoking and diabetes on patient-reported pain levels.Results:Of 103 patients, there were 37 cigarette smokers and 30 diabetic patients. Eighty-three patients achieved union of all involved joints and 19 patients achieved union of 1 or 2 joints. Smokers demonstrated a 1.46 (risk ratio) (95% CI 1.03-2.07) times greater risk of nonunion but were not at an increased risk of experiencing surgical complications (0.86, 95% CI 0.56-1.33). Diabetic patients did not demonstrate an increased risk of nonunion (0.86, 95% CI 0.56-1.33) or complications (1.18, 95% CI 0.76-1.83).Conclusion:Because of increased nonunion risk, patients undergoing elective tibiotalocalcaneal arthrodesis should be counseled increased nonunion risks associated with smoking. In this series, we did not find a relationship between diabetes and complications or nonunion.Level of Evidence:Level III, retrospective cohort study.

Periprosthetic Fracture After Hindfoot Fusion Nail Treated With Spanning Antegrade Tibial Nail.

Level V.

Early Failure of Paragon28 Phantom Hindfoot Fusion Nail: A Case Report

Category:Diabetes; Hindfoot; TraumaIntroduction/Purpose:Tibio-talar-calcaneal (TTC) fusion nails are commonly used to treated acute ankle fractures in patients with diabetes, Charcot arthropathy or other comorbidities. Recently, Paragon28 released the Phantom Hindfoot Fusion Nail (Phantom nail) with a unique design feature-a proximal coil.Methods:We present the case of a diabetic patient with an ankle fracture-dislocation treated with the Paragon28 nail who experienced early implant failure.Results:A 48-year-old male with HIV, end-stage renal disease requiring hemodialysis, and insulin-dependent diabetes mellitus with severe peripheral neuropathy presented a trimalleolar ankle fracture-dislocation treated with a TTC nail. At his first follow- up, he presented with early implant failure at the nail-coil interface.Conclusion:The integrity of the Phantom nail, appropriate length, and placement of the flex coil require further evaluation. Unstable pathologies such as fractures may be better stabilized with a solid nail construct.

Surgical Outcome of Hindfoot Fusion using a Retrograde Hindfoot Fusion Nail

Category:HindfootIntroduction/Purpose:TTC fusions are often performed as a salvage procedure in patient with severe hindfoot arthritis or hindfoot deformity. Comorbidities in this patient collective are frequent, leading to increased risk of postoperative complication. The purpose of this study was to evaluate the surgical outcome regarding union rate, reoperation rate and adverse events using a retrograde hindfoot fusion nail.Methods:Patient records of a single center were retrospectively reviewed in which a retrograde hindfoot fusion nail was utilized for hindfoot fusion between July 1st, 2009 and August 31st, 2018. These records included age, gender, BMI, comorbidities, indications for surgery, non-union, re-operation rates and adverse events related to the surgery. The fusions were performed by 4 fellowship trained foot and ankle surgeons at a tertiary care teaching hospital. 58 cases were identified consecutively, in 51 cases a TTC fusion was performed, in 7 cases a tibiotalar fusion with preexisting talocalcaneal fusion. 22 fusions were arthroscopic and 36 open. The average age of patients was 59 years, the average BMI 29. Main indication for the hindfoot fusion were arthritis (55%) and complex hindfoot deformity (43%).Results:An overall union rate of 89.66% was achieved, 5 non-union tibiotalar and 1 non-union tibiotalar + talocalcaneal was documented. In the group of arthroscopic fusion the non-union rate was 9.09%, in the open group 11.11% respectively. The non- union group included patient with elevated BMI (50%), Diabetes mellitus (33%) and smoking (33%). Adverse events were documented in 21%. The reoperation rate was 17%, mostly due to deep infection or wound complication requiring surgical debridement. No patient in the arthroscopic fusion group needed a reoperation due to deep infection or wound complication, whereas in open surgery this rate was 27.78%.Conclusion:A union rate of 89.66% was achieved using a retrograde hindfoot fusion nail in a high risk patient population for non- union. Arthroscopic preparation of the tibiotalar and the subtalar joint seem to prevent postoperative wound complications.

Early Results of A Nitinol Dynamic Compression Nail for Subtalar Joint Arthrodesis vs Two-Screw Fixation Construct

Category:HindfootIntroduction/Purpose:Subtalar joint arthrodesis (STJA) for deformity correction and management of arthritis is a common surgery. STJA is a reliable operation with high patient satisfaction scores. Securing the talus to the calcaneus, so as to optimize the physiologic environment for osseous healing, has been achieved with multiple fixation techniques including one, two, and three screw constructs, plates, and staples. The goal of our study is to introduce a nitinol nail system with dynamic compression as a novel fixation method for STJA and compare union rates with a standard 2 screw fixation construct. The secondary goal was to assess union rates for this subtalar fusion nail when performed below a previous ipsilateral ankle arthrodesis (AA), with comparison to results from previously published studies.Methods:From May 2019 through July 2020, 15 consecutive patients treated with a novel nitinol nail for STJA were compared to 27 patients undergoing STJA using a two-screw fixation method. The nail group was subcategorized into cases with (6 patients) or without (9 patients) ipsilateral AA. Concomitant talonavicular joint arthrodesis was also performed in patients from each group when indicated. Arthrodesis sites were augmented with autologous bone graft with or without bone graft substitute in all patients. Standard postoperative protocols were used. Primary outcomes included subtalar joint union rates determined by radiographic and clinical assessment. Perioperative complications were compared between groups. Patient specific risk factors were studied to assess any potential negative effects on STJA union rates.Results:Overall, the union rates between the nitinol nail group and screw group did not demonstrate any significant difference (87% vs 88.9%). The nail group with ipsilateral AA demonstrated a 67% union rate (4/6) whereas the nail group without previous AA achieved a 100% union rate (9/9). All patients in our study who underwent STJA with associated TNJA went on to union. Union rates were similar in both groups despite the average age of patients in the nail cohort (61.3 years) being greater than the screw cohort (55.4 years). The average age of patients in the nail group with previous AA was 71 years. No significant relationship was seen between smoking, diabetes or alcohol consumption and union rates.Conclusion:Our data supports the nitinol dynamic compression nail to have superior union rates to the two-screw fixation group when patients with previous AA were excluded (100% vs 88). Our data also indicate that the nitinol nail may provide at least equivalent or better union rates when performed under previous AA when compared to results from prior studies, despite the patients in our group having a much higher average age at the time of surgery. The early results of this nitinol nail for STJA are encouraging and appear to offer an alternative fixation construct with excellent union rates and minimal complications.

Strength and Compressive Ability of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Surgical management of midfoot Charcot arthropathy typically includes fusion through the midfoot to obtain a stable plantigrade foot. Multiple surgical strategies exist, including variable combinations of internal fixation with plates, or thin wire external fixator frames, or both. More recently, intramedullary beams and bolts have been used as an alternative means of fixation. The current understanding of midfoot fusion lacks knowledge of how much stiffness, strength and compression is provided using two different intramedullary midfoot fusion devices. The purpose of this study is to assess 3 point bending strength of midfoot fusion nails versus bolts as well as to test their compressive abilities. Additionally, we looked to assess how the addition of a subtalar fusion affects midfoot stiffness and rotational control in a cadaver model.Methods:Bone blocks and cadaver feet were used for compression and biomechanical testing, respectively. Bone blocks were pre-drilled with an undersized pilot bit and then cut in two. A washer-type load cell measured the compressive force produced by the implants. Sixteen (8 nails and 8 bolts) compressive tests were performed. Ten matched cadaver foot specimens were prepared, and medial column fusions were performed with midfoot fusion nails or bolts (10 each). Another ten matched specimens were prepared evaluating midfoot fusion nails with or without subtalar fusions. Specimens were placed on a custom platform at 20 degrees of dorsiflexion. A linear variable differential transformer (LVDT) was used to record local displacement at the midfoot (Figure 1). Each specimen underwent 3000 cycles of compressive loading (200N - 1000N) followed by displacement- controlled loading to 9mm of total axial displacement via servo-hydraulic test frame. The Wilcoxon signed rank test (paired analysis) was used for analysis.Results:The overall performance between nail vs bolt matched specimens or between nail only vs nail with subtalar fusion showed no statistical difference with regards to stiffness. The compressive force tests show the nail to be significantly stronger in all aspects of the analysis. When comparing nail vs bolt matched specimens, only the accumulated height drop at the end of cycling was significantly different (p=0.008). For the nail only VS nail with subtalar fusion, only the displacement before fatigue was significantly different (p=0.035). There was no difference among the matched pairs with regards to stiffness, displacement after fatigue or maximum force during load to failure.Conclusion:This study highlights important biomechanical and compressive data comparing midfoot fusions using nails vs bolts. The compressive force test of nails was superior to bolts. This could provide valuable insight when considering implants for arthrodesis. The overall comparison between matched pairs of nails vs bolts did not provide significant differences among those groups. Similarly, adding a subtalar fusion did not provide significant mechanical improvement based on this model. The clinical utility of these findings is limited by the difficulty in recreating a Charcot like scenario using cadavers.

Reconstructive Surgical Management of Charcot Neuropathy of the Foot and Ankle: A Retrospective Study

Category:DiabetesIntroduction/Purpose:Treatment of Charcot neuropathy (CN) of the foot and ankle remains a challenge for both patient and surgeon. Non-operative treatment with immobilization in a cast/orthosis has long been the mainstay of treatment, but more recently surgical intervention-with attention to internal fixation-has gained interest because of the poor long-term outcomes with non-operative care.Methods:To assess long-term outcomes between CN patients managed with reconstructive surgeries at a tertiary referral center; a retrospective chart review analyzed comorbidities, demographics, and complications (ulceration, infection, and below the knee amputation).Results:Over the last 16 years, 31 patients with CN were treated with internal fixation (midfoot fusion, open reduction, or hindfoot fusion nail). Average BMI was 33.5, average number of comorbidities was 2.93, and the percentage of patients with a vascular deficit was 19.3%. The rate of infection and ulceration prior to surgery was 19.4% (6/31 patients) and 45.2% (14/31 patients) respectively. After surgery, the rate of new infections was 38.7% (12/31 patients). The rate of new ulcerations was 41.9% (13/31 patients). The rates of below the knee amputation was 19.4% (6/31 patients).Conclusion:A 16-year retrospective review of operative management of Charcot neuropathy in 31 patients at a tertiary referral center found high rates of ulceration, infection, and amputation in patients treated with internal fixation. This study could prove valuable in counseling CN patients regarding reconstructive surgery.

A Study on the Design of Fusion Nail Art Based on Traditional Korean knot Patterns

Recently, nail art has rapidly grown under the influence of many creative designers. However, it has been western design patterns which have been mostly applied to nail art while it is hard to find nail art reflecting Korean traditional culture. In this study, the pattern illustration work of 8 knots with distinct form composition is bought a checkless method. After working on the Yonghae flat nail art, five knots with many symbolic stones wishing for happiness were selected and fused nails were selected. The artwork was completed. This study attempted to analyze modern nail art based on the beauty of Korean traditional knots and make pieces of works, confirming a possibility of practical nail art development with such traditional materials. Traditional knots have been commonly used in unique and typical gilsang (‘good fortune’) handicrafts which contain Korean traditional values. Therefore, this study aims to study nail art based on traditional knots and provide basic data needed for the popularization of nail art with such traditional knots by creating practical nail art patterns. It is anticipated that the study results would develop K-nail, considering the popularity of K-beauty provided that empirical studies on customer preferences and satisfaction concerning diverse traditional knot-based nail art are performed.

Geriatric Ankle Fracture: Robust Fixation Versus Hindfoot Nail.

The incidence of geriatric ankle fractures is increasing in step with the current aging population. Special considerations must be taken into account when treating geriatric patients due to increased medical comorbidities, worse soft tissue envelope, poor bone quality, and the needs for early mobilization. The orthopaedic surgeon must have a variety of surgical options to treat fractures in the elderly population based on patient-specific needs. This article uses a case-based approach to discuss relevant considerations when selecting between hindfoot fusion nail and robust open reduction and internal fixation for geriatric ankle fractures.

Fusion rate of 89% after knee arthrodesis using an intramedullary nail: a mono-centric retrospective review of 48 cases

PurposeKnee arthrodesis is an established procedure for limb salvage in cases of recurrent infection, total knee arthroplasty soft tissue defect, poor bone stock or a deficient extensor mechanism. Surgical options include compression plate, external fixator and arthrodesis nail. Different types of nail exist: long fusion nail, short modular nail and bridging nail. This study presents the results on knee arthrodesis using different types of intramedullary nails. The aim is to assess if a specific type of nail has a better fusion rate, clinical outcome and lower complication rate.MethodsA mono-centric retrospective study of 48 knees arthrodesis was performed between 2000 and 2018. 15 T2™ Arthrodesis Nail, 6 OsteoBridge® Knee Arthrodesis and 27 Wichita® fusion nail were used. The mean clinic and radiological follow-up was 9.8 ± 3.8 years (2.6–18 years).ResultsFusion rate was 89.6%. Time to fusion was 6.9 months. Mean Parker score was 6.9/9 points. Visual Analogic Scale was 1.9. The Wichita® fusion nail showed better results in terms of fusion, time to fusion and clinical outcome measured by Parker score and VAS but without statistical significance. The early revision rate was 10.4% and 20.8% presented a late complication requiring a surgery, due to nonunion or infection. 93.3% of infection was cured. Two patients live with a fistula (4.2%) and 1 was amputated (2.1%).ConclusionAlthough burdened by a big complication rate, knee arthrodesis with an intramedullary nail provides satisfactory results and is a good alternative to above-knee-amputation. The Wichita® fusion nail shows a tendency to better results compared to the two other nails.Level of evidenceCase series, level IV

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of infection, extruded talus and complex pilon fractures.

The treatment of complex pilon fractures and talus fracture-dislocations present several challenges, like avoiding infection, achieving union, management of bone loss and function preservation. Retrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0 - 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates. Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score, AOS) were the secondary measures. Eradication and prevention of deep infection was achieved in all cases. Radiological union was achieved at a mean of 9 months (range 5 - 17). Solid AA was achieved in 12 of 14 cases using the TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone transport, mean of 63mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 - 16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 - 77.5) with 69.3% of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 - 10). Minimum follow up time was 12 months (range 12 - 56). AA using TSF can be considered for complex pilon fractures and extruded talus. It has shown to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and possibly not using bone graft. Patients must be aware that while treatment of these injuries will be prolonged and carries the risk of many potential complications, it provides a good alternative to amputation.

Comparative Analysis of Knee Joint Fusion with Long Locking Nail and Ilizarov Apparatus in Patients with Deep Infection after Arthroplasty

Relevance. Deep infection after knee arthroplasty requires radical surgical treatment of the infection site, removal of endoprosthesis components, and an antimicrobial spacer placement. If revision knee arthroplasty is impossible, the «gold standard» for this kind of patients is knee joint arthrodesis. The purpose of the study was the comparative analysis of knee joint fusion by external and internal fixation. Materials and Methods. The analysis of 60 cases of knee arthrodesis was carried out. The patients were divided into two groups with 30 patients in each. In the first group, knee arthrodesis was performed with long locking nail, in the second group — with external ring fixation. We compared the groups by intraoperative and drainage blood loss, the inpatient treatment duration, the terms of fusion and complications registered. The patients quality of life was evaluated using the SF-36 questionnaire before surgery, for the periods of 3, 6, and 12 months after the surgery. Results. The comparison of two methods of knee arthrodesis showed that blood loss in the internal fixation compared with external one, was 2.03 times more, the duration of inpatient treatment was 1.4 times less, and the total number of complications was 4.4 times less. However, the complications that affected the treatment outcome in long nail group were 1.5 times more. The differences in the average time of ankylosis formation were not statistically significant (p0.05). The functional results of the treatment in 3 months after surgery in the group with internal fixation were much better. In 6 months after surgery the quality of life had no significant differences. In 12 months follow-up the indices in both groups were the same. Conclusion. The results of our study suggests us to think, knee joint arthrodesis by long fusion nail should be prefereble. If the nail insertion is technically impossible, and there is the high risk of deep infection recurrence, the external osteosynthesis should be used.

Tibiotalocalcaneal Arthrodesis Using a Novel Retrograde Intramedullary Nail.

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for complex hindfoot pathology. Overall union rates range from 50% to 86% but can be even lower in certain populations. A novel retrograde intramedullary nail has recently been developed. The purpose of this study was to report fusion rates, time to weight-bearing, and complications with the use of the A3 Fusion Nail. Methods. All patients 18 years or older who underwent TTC arthrodesis with an A3 Fusion Nail at a single institution from 2010 to 2015 with a minimum 3-month follow-up were included in this study. Rates of successful fusion, time to union, time to weight-bearing, and complications were evaluated. A total of 20 patients with an average age of 58.1 years and an average follow-up of 12.5 months met inclusion criteria. Results. Successful TTC arthrodesis was achieved in 14 of 20 patients (70%) overall. Average time to union was 8.1 months, and average time to weight-bearing was 6.8 weeks. Of 20 patients, 17 (85%) required femoral head allograft for bulk bone defects, and the union rate in this subset of patients was 76.5%. The rates of revision surgery (10%) and complications were low. Conclusion. The A3 Fusion Nail demonstrated a favorable safety profile and achieved TTC arthrodesis at a rate consistent with historical data despite being used in a patient population at high risk for nonunion. In patients with bulk bone defects at high risk for nonunion, the A3 Fusion Nail demonstrated superior rates of fusion (76.5%) to those reported in the literature (50%).Level of Evidence: Level III: Retrospective cohort study.