Tibiotalocalcaneal Arthrodesis Research Articles

Comparison of 3D Printed Spherical Implants versus Femoral Head Allografts for Tibiotalocalcaneal Arthrodesis

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p = .018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p = .22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p = .016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis.

Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle?

This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5–84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.

Three-Dimensional Printed Cage in Patients With Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Early Outcomes.

Introduction. Segmental bone loss in the hindfoot hinders the chance of successful outcomes. Tibiotalocalcaneal arthrodesis is a reliable option; nevertheless, the risk of nonunion is high. Three-dimensional (3D) printed titanium implants offer a strong scaffold that can be customized and has demonstrated encouraging healing rates. In this study, we described the clinical outcomes and the radiologic union rate of a case series of patients with hindfoot arthrodesis, using a retrograde intramedullary nail associated to a 3D printed titanium cage. Methods. Seven patients undergoing hindfoot arthrodesis, using a retrograde intramedullary nail associated to a custom 3D printed titanium cage, were included. Demographic data were collected. Functional outcomes were assessed using the American Orthopedic Foot and Ankle Score and the Visual Analogue Scale for pain. Hindfoot alignment and radiographic union were evaluated using weight-bearing radiographs and computed tomography scan, respectively. Results. A total of 6 (85%) patients had more than 50% bony bridging. Only 1 patient underwent below knee amputation due to recurrence of chronic osteomyelitis. Two additional patients had minor complications. Conclusion. Tibiotalocalcaneal arthrodesis using customized titanium cages for patients with large bone defects has shown a high rate of union in those at risk of nonunion. However, further research with larger series is needed.Levels of Evidence: Level IV: Case series.

Tibiotalocalcaneal arthrodesis through retrograde nailing for the treatment of juxtaarticular distal tibia aseptic non-unions: A retrospective study at a minimum follow-up of 4 years

IntroductionThe purpose of this study is to determine the efficacy of tibiotalocalcaneal arthrodesis by reamed intramedullary nail in the management of the distal tibia non-unions, associated with end-stage osteoarthritis of ankle and subtalar joints. Materials and methods8 patients with radiographical and clinical diagnosis of non-union of the distal tibia have been treated with tibiotalocalcaneal arthrodesis by intramedullary retrograde nail and were retrospectively evaluated. Patients were radiographically and clinically evaluated preoperatively and at final follow-up regarding: satisfaction, AOFAS, VAS. Surgical technique is described. ResultsMean follow-up was 69.2 ± 23.2 months (range 48–108). In terms of subjective outcome, patients reported a highly satisfying result. All patients returned to daily activities, with an average time of 24.7 ± 8.7 weeks. 6 patients could return to their previous work activity, with an average time of 23.6 ± 6.3 weeks. ConclusionsThe procedure showed good results at final follow up. Consolidation was achieved in all the treated cases. Considering AOFAS and VAS scores at final follow-up, there was an evident improvement of the conditions of the patients.

Arthroscopic Tibiotalocalcaneal Arthrodesis

Introduction: Arthrodesis is still the gold standard for severe ankle and hindfoot osteoarthritis. The arthroscopic tibiotalocalcaneal arthrodesis technique has been described and developed in the past decade. Tibiotalocalcaneal arthrodesis (TTCA) is the election procedure for combined severe ankle and subtalar osteoarthritis after failure of conservative treatment. The arthroscopic technique is more respectful to the surrounding soft tissues and the vascular supply; hence, it provides a theoretical benefit in terms of consolidation, and it is suitable for cases in which the open surgery is not desirable. We perform the surgery with the patient in prone decubitus position, and we use conventional arthroscopic instruments. We use the posterior portals described by van Dijk to access both tibiotalar and posterior subtalar joints and perform the cartilage denudation. We aim to have a healthy, well-vascularized subchondral bone and obtain a good coaptation of the articular surfaces. The retrograde tibiotalocalcaneal nail is the implant of choice for the TTCA. We consider that the lower surgical aggression of the arthroscopic procedure compared with the open technique should allow a satisfactory union rate without bone grafting. The global consolidation rate reported is 67% to 100%. The global complication rate reported is 7% to 33%. Most are related to osteosynthesis material and superficial wound infections. Arthroscopic TTCA offers excellent results in selected patients. A protocolized surgical technique using posterior endoscopic portals is mandatory. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Tibial Stress Fracture Following Ankle Arthrodesis.

End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. Level IV, retrospective case series.

Arthroscopic tibiotalocalcaneal arthrodesis using an intramedullary locking nail

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.

Application of a Customized Total Talar Prosthesis for Revision Total Ankle Arthroplasty.

Background:The rate of revision surgery for total ankle arthroplasty (TAA) is higher than for hip and knee arthroplasties. Tibiotalocalcaneal arthrodesis is widely used; however, it requires a large allograft. Thus, the use of a customized total talar prosthesis in combination with the tibial component of TAA (combined TAA) may be an effective strategy for talar component subsidence. This study aimed to evaluate the clinical and radiographic effectiveness of the combined TAA in such revision cases.Methods:Between 2000 and 2015, 10 patients (10 women; 10 ankles) were treated using the combined TAA for revision after standard TAA or combined procedures that included the use of a talar body prosthesis. In 6 patients, the tibial component was concurrently replaced. The median follow-up period was 49 months (interquartile range [IQR], 24.5 to 90 months). The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score, a numerical rating scale (NRS) pain score, passive range of motion of the ankle, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at final postoperative follow-up.Results:The median NRS pain score improved significantly, from 7 (IQR, 6.25 to 8.75) to 2 (IQR, 1 to 3). The median JSSF ankle-hindfoot scale total score improved significantly, from 64 (IQR, 56.25 to 71.5) to 88.5 (IQR, 79.75 to 96). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20 to 27.5) to 35 (IQR, 30 to 40), and the median function score improved from 34 (IQR, 26.5 to 37) to 43.5 (IQR, 39.75 to 46). The median range of motion improved from 29° (IQR, 25.5° to 35°) to 35° (IQR, 31.25° to 43.75°). No significant difference in osteophyte formation was found. Degenerative changes in the adjacent joint were found only in the talonavicular joint.Conclusions:The combined TAA, used in revision for postoperative complications after standard TAA or combined procedures including the use of a talar body prosthesis, was associated with improved objective JSSF ankle-hindfoot scale scores, subjective pain assessment, and range of motion in the ankle.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tibiotalocalcaneal nailing in ankle arthrodesis

Aim: Our objective in this study was to present the results of the patients who had retrograde tibiotalocalcaneal implants for different etiological causes. Ankle and forefoot deformities and traumatic osteoarthritis are important problems affecting the quality of life of patients. Many implants have been tried to prevent and fix these deformities. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nail is one of these implants. While there are many studies in the literature on other systems, the low number of studies on intramedullary implants and low number of patients in this patient group encouraged us to undertake this study using the available data. Material and Methods: Twelve patients who had intramedullary tibiotalocalcaneal nail installation between January 2009 and May 2013 were retrospectively evaluated. In their etiologies, 33.33% of the patients (n=4) had firearm-related injuries, 33.33% had (n=4) trauma-related arthrosis, 16.67% had (n=2) diabetic neuropathy, and 16.67% had rheumatoid arthritis. Patients were evaluated based on pre- and post-operative American Orthopedic Foot and Ankle (AOFAS) scores.Results: Union was observed in all patients. The average union duration was found at 65.8 (45–124) days. Two of the patients who had arthrodesis due to firearm injuries had deep infections, and one had a superficial infection. No complications other than infections were observed. The average AOFAS pre- and post-operative scores were 48.7 (31–80) and 68.5 (40–96).Conclusion: As a result, ankle arthrodesis with intramedullary nail is a useful and efficient method for patients with severe underlying arthritis and can produce good results.

The "Ball in Basket" Technique for Tibiotalocalcaneal Fusion.

Tibiotalocalcaneal arthrodesis (TTCA) in severe bone deficit represents a complex challenge for expert orthopedic surgeons also. This study aims to illustrate a surgical technique, defined as “ball in basket”, that facilitates the fitting of the structural bone graft (femoral head from bone bank) and its placement, in order to fill the bone gap during instrumented arthrodesis. The proposed technique includes the preparation of the recipient bone surfaces with acetabular convex reamers and of concave reamers to shape the bone graft from bone bank. This preparation guarantees a maximum congruence of the bone surfaces and a greater stability of the bone graft during the placement of the fixation devices to optimize the bone fusion and to provide a good patient clinical outcome. The preliminary results obtained for two patients, initially presenting with severe anatomical deformity associated with severe bone gap, are described. Patients underwent clinical and radiographic follow-up evaluations (respectively at 4 and 30 months of follow-up) showing radiographic healing and good functional recovery. The results are encouraging, although long-term studies and a wider cohort of patients are necessary to consider this technique a reliable aid in case of severe bone deficit. (www.actabiomedica.it)

PO 18220 - Talocalcaneal tibio arthrodesis with percutaneous retrograde intramedullary nail

Introduction: Primary osteoarthritis, post-traumatic lesions, Charcot arthropathy and rheumatoid arthritis are some of the causes of ankle and hind foot osteoarthritis that result in pain and sometimes functional limitations in patients affected by such pathology. The therapeutic options vary from conservative treatment (painkillers, bracing and nonsteroidal anti-inflammatory drugs) and surgical treatment. The objective of this present study is to report three cases of patients with ankle osteoarthritis who had undergone minimally invasive surgery (MIS) for tibio-talocalcaneal arthrodesis with an intramedullary nail, with the use of a retrograde blocked intramedullary nail and screws as fixation. Methods: Clinical and radiographic evaluations were conducted of three cases treated using this technique at our institution in 2017, who were allowed full weight bearing postoperatively The AOFAS questionnaire and radiographic evaluation were employed in two orthogonal incidences of the ankle, evaluated after one year postoperatively. Results: We obtained AOFAS scores between 68 and 86 after one year postoperatively with this study technique, and the radiographic consolidation index was observed in 100% of cases (between 6 and 12 weeks) postoperatively. There were no complications.
 Conclusion: We obtained good results with minimally invasive surgery (MIS) for tibio-talocalcaneal arthrodesis, with satisfactory consolidation presenting no complications. However, there are an insufficient number of studies in the literature demonstrating superiority of the percutaneous tibio-talocalcaneal arthrodesis technique over the open technique. We believe that the percutaneous technique is a recent method fir study that may be added to the therapeutic arsenal.

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.

Peri-Implant Fractures Around Hindfoot Fusion Nails: A Systematic Literature Review and Classification System

Category:HindfootIntroduction/Purpose: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 hind foot 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.Methods: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 by two research assistants. The electronic database of PubMed / Medline was explored using specific search terms, Boolean operators, and field tags. The same query without field tags and under “Search All Text” was used to explore the electronic database of the Cochrane Library. 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. Manuscript language for both databases was restricted to the English literature.Results: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.Conclusion: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.

3D Printed Cage in Patients with Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Early Outcomes

Category:Diabetes, Hindfoot, Trauma, salvage procedureIntroduction/Purpose:Segmental bone loss in the hindfoot hinders the chance of successful outcomes. Tibiotalocalcaneal arthrodesis is a reliable option; however, the risk of nonunion is high. Structural graft is needed to fill the gap, but the use of bone grafts are limited by the availability, risk of collapse, and disease transmission. Three-dimensional (3D) printed titanium implants offer a strong scaffold that can be customized and present similar healing rates. The purpose of the study was to describe the clinical outcomes and the radiologic union rate of a case series of patients with hindfoot arthrodesis, using a retrograde intramedullary nail associated to a 3D printed titanium cage.Methods:After obtaining approval from our institution review board, a retrospective chart review was performed on seven patients undergoing hindfoot arthrodesis, using a retrograde intramedullary nail associated to a custom 3D printed titanium cage from March 2015 to December 2017. Demographic and clinical data were collected. Functional outcomes were assessed using The American Orthopedic Foot and Ankle Score (AOFAS) and the Visual Analog Scale (VAS) for pain. Hindfoot alignment was evaluated using preoperative and postoperative weightbearing radiographs that included anteroposterior, lateral and Saltzman views. Radiographic union was assessed using computed tomography scan at 6 and 12 months postoperatively.Results:All patients had ankle arthritis and six of them (85%) had prior surgery in the compromised hindfoot. The average age at TTC fusion was 57 (range, 29 to 71) years. The mean follow-up time was 21 (range, 12 to 32) months. Six patients had a healed fusion and one patient underwent below knee amputation due to recurrence of chronic osteomyelitis in the ankle. Two additional patients had minor complications. The average AOFAS at pre-op was 35 (range, 20 to 42) points as compared to 68 (range, 53 to 78) points at final follow-up; P=0.004. Preoperative VAS pain was 80.4 (range, 70 to 85) points as compared to 26.8 (range, 6 to 60) points; P=0.002.Conclusion:Tibiotalocalcaneal arthrodesis using customized titanium cages for patients with large bone defects has shown a high rate of union in those at high risk of nonunion. Further research is needed to monitor the development of late complications.

Outcomes and Gait Mechanics after Ankle Arthrodesis Take Down with Total Ankle Arthroplasty or Subtalar Fusion in Patients with Previous Tibiotalar Arthrodesis: A Comparative Study

Category:Ankle, Ankle Arthritis, Basic Sciences/Biologics, HindfootIntroduction/Purpose:Ankle arthrodesis has traditionally been the treatment of choice for ankle arthritis. However, loss of range of motion, chronic pain, risk of nonunion, and potential risk of adjacent arthritis are ongoing concerns after this procedure. Most of surgeons state that subtalar fusion is an alternative to treat a painful and dysfunctional ankle fusion, but successful ankle arthrodesis take down using Total Ankle Arthroplasty (TAA) has been reported in the literature. The paucity of literature comparing these two treatment methods hinders the ability to make an informed decision on the best therapy. The purpose of the study was to compare patient-reported outcomes; gait mechanics and complications in patients with ankle arthrodesis take down using TAA to those who underwent subtalar fusion in a previously fused ankle.Methods:This is a comparative study of patients who underwent tibiotalar arthrodesis take down with total ankle arthroplasty and subtalar arthrodesis in previously arthrodesed ankles. Patients who were willing to take the gait mechanics test were included. They were distributed in two groups according to the undergone procedure. Postoperative outcomes consisted of patient- reported functional measures, and complications rate. Patient-reported functional measures included the American Orthopaedic Foot & Ankle Society Score (AOFAS) hindfoot scale, Visual Analogue Scale (VAS) for pain, and the Short Form 36 Health Survey (SF-36). Three-dimensional joint mechanics and ground reaction forces were measured during level walking at least one-year post surgery. Gait mechanics included spatiotemporal parameters, and the peak plantar and dorsiflexion moment. Data were analyzed using analysis of variance (ANOVA) to determine significant differences between the two groups. (a = 0.05).Results:Ten patients were included in the ankle arthrodesis taken down (AATD) group, and seven patients were included in the subtalar fusion (STF) group. The average follow-up time in the AATD and SFT group was 70.4 and 46 months, respectively P=0.14. There were no statistically significant differences in the demographics of both groups. The peak plantar flexion was 4.6 degrees and 1.3 degrees in the AATD and STF group, respectively; P=0.04. The range of motion in the sagittal plane was 11.5 degrees and 7.8 degrees in patients with AATD and STF groups, respectively; P=0.13. The complication rate was higher in the AATD group (7 patients, 70% vs 1 patient, 14%; P=0.02). There were no statistically significant differences in the patient-reported outcomes between the two groups.Conclusion:Patients with ankle arthrodesis taken down using total ankle arthroplasty as compared with patients with tibiotalocalcaneal arthrodesis have better range of motion of the hindfoot and improved gait mechanics. The improved cadence and mobility decreased the imbalance in the midfoot and forefoot during the gait. Nevertheless, due to the complexity of the procedure the complication rate is considerably higher. Further research with a larger sample of both groups may demonstrate greater differences in patient-reported outcomes.

Comparison of Custom 3D Printed Spherical Implants vs Femoral Head Allografts for Tibiotalocalcaneal Arthrodeses

Category:Ankle Arthritis, HindfootIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis, deformity correction and salvage of failed total ankle replacement. However, union can be difficult to achieve in patients with bulk bone defects. Femoral head allograft is commonly used in the setting of TTC fusion with severe bone loss, but recent studies have reported concerns of arthrodesis rates of 50% or worse and graft collapse in these patients. Retrograde intramedullary nail placement through custom 3D spherical implants is a novel option for these patients. The purpose of this study was to compare fusion rates, graft resorption and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts.Methods:All patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant or femoral head allograft by the senior author at a single institution from 2013 to 2017 and who had at least one year of follow-up were included in this study. There were 7 patients who received a femoral head allograft and 8 patients who received a 3D printed sphere. Baseline patient and operative characteristics were collected and compared between the 3D sphere and femoral head allograft groups. The rate of successful fusion of the tibia, calcaneus and talar neck to the 3D sphere or femoral head allograft, as determined by radiographs and CT scan, as well as graft resorption and complications were compared between the groups.Results:The rates of union of the tibia (87.5% vs 71.4%), calcaneus (87.5% vs 71.4%), and talar neck (100% vs 42.9%) were higher in the 3D sphere group than in the femoral head allograft group. The rate of union of the talar neck was significantly higher to the 3D sphere implant than to the femoral head allograft (p=0.016). The number of patients achieving successful fusion of all three articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%), although not statistically significant (p=0.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p=0.016).There were no differences between the groups in terms of complications.Conclusion:These data demonstrate that the use of a custom 3D-printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail. The rate of successful fusion of all three tibial, calcaneal and talar neck articulations was higher to the 3D sphere than to the femoral head allograft, although not statistically significant. Union of the talar neck was significantly higher to the 3D sphere implants than it was to the femoral head allograft. Subsidence was significantly higher with the femoral head allograft than the 3D sphere.

Does Retention of Fibula in Transfibular Approach Leads to Complication?

Category:Ankle, Ankle Arthritis, HindfootIntroduction/Purpose:A variety of operative approaches and fixation techniques have been described for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis. In the past two decades, authors have begun to more robustly examine outcomes of the transfibular approach for TT arthrodesis and expanded its indication to include TTC fusion. The transfibular technique is broadly divided into two categories: 1) Complete excision of fibula 2) Soft tissue preservation techniques with retention of fibula. The purpose of this study was to retrospectively assess the surgery outcomes in transfibular approach and compare the fibula excision versus fibula retention techniques and examine the factors that play into the risk.Methods:Following institutional review board approval, a retrospective review was performed on all patients who underwent TT and TTC arthrodesis through a lateral transfibular approach with minimum 1 year clinical and radiologic follow up. All other operative approach and fixation combinations for arthrodesis were excluded. Primary outcomes examined were union rate, revisions, and complications related to fibula excision versus retention group. Sixteen patients underwent TT and TTC arthrodesis with fibular retention and twelve with fibular excision techniques.Results:The overall union rate was 89%, 87% (14 of 16 ankles) for the fibula retention group, and 91% (11 of 12) for fibula excision group (P = .72). Symptomatic nonunion requiring revision arthrodesis occurred in 6% (1 of 16) of the retention group versus 8% (1 of 12) in the excision group (P = .83). There were no significant differences in individual tibiotalar or subtalar union, reoperation, superficial wound problems, infection and symptomatic hardware rates. Elective hardware removal was performed in 12%(2of 16) in fibular retention group versus 25%(3 of 12) in fibula excision group (P = .39), none of the hardware removal was related to the fibula fixation. Each group had three episodes of reoperation due to non-union, osteomyelitis and painful hardware.Conclusion:Union, reoperation rates were similar in fibula resection versus retention groups. The frequency of infection and wound complication was not significantly different in both groups, despite the wide variety of patient population and preoperative indications.

Subtalar Nonunion Following Tibiotalocalcaneal Fusion Using an Intramedullary Nail: A Case Series of Errant Entry Points

Category:HindfootIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus.Methods:Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded.Results:Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment.Conclusion:Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.

Revision Arthrodesis of the Subtalar Joint

Category:HindfootIntroduction/Purpose:Subtalar arthrodesis is an invaluable tool in managing arthritis, deformity, and muscular imbalance of the hindfoot. However, failed arthrodesis is complicated by bone necrosis, sclerosis with loss of bone, less than ideal biologic settings, and the literature reports a high rate of non-union. The aim of this study was to review all subtalar arthrodeses performed within a single institution, and specifically describe the management of non-union.Methods:492 consecutive subtalar arthrodesis cases were retrospectively analyzed between October 2001 and July 2013. From the primary arthrodesis group 91 (18%) were treated for subtalar coalition (100% arthrodesis), and were excluded to better depict the arthrodesis rate; the remaining 401 patients were treated primarily for post-traumatic arthritis. Pertinent demographics, comorbidities, and clinical notes were all retrieved through the electronic medical record and radiographs were reviewed through a PACS system.Results:49 patients with a mean age of 49 years (range 23 - 80) presented with subtalar non-union (overall rate 10%, adjusted rate 18%). 41 (84%) underwent revision at a mean of 16.2 months (range 2.8 - 57.1) from the index arthrodesis. The rate of revision arthrodesis was 78%, 21/30 (70%) in situ arthrodeses, 7/7 bone block arthrodesis (p=.028), and 4/4 triple arthrodesis (p=.028). Arthrodesis was present at a mean of 3.4 months (range 1.6 - 7.6). 4/9 (44%) of the recurrent nonunions elected to abstain from surgery. Of the 5 remaining patients, 2/5 had a successful third attempt at arthrodesis, 1/5 had an additional nonunion followed by a successful fourth attempt at arthrodesis, 1/5 had a successful tibiotalocalcaneal arthrodesis, and 1/5 required a below-knee amputation.Conclusion:Risk factors identified for non-union were post-traumatic arthritis, ipsilateral ankle arthrodesis, and individual patient factors (smoking, diabetes, and infection). Different methods of screw fixation were not found to be significantly different between the fused and nonunion groups. Despite directed management to obtain rigid fixation and adequate compression, the rates of subtalar arthrodesis from primary (82%), revision (78%) and secondary revision (60%) cases were very poor with the exception of the group which underwent a bone block arthrodesis (100%, p=.028).

Prognostic risk factors for complications associated with tibiotalocalcaneal arthrodesis with a nail

BackgroundTibiotalocalcaneal (TTC) arthrodesis with a nail can be an effective salvage procedure for several foot and ankle pathologies, but has a relatively high complication rate. The purpose of this study is to investigate risk factors associated with complications after TTC arthrodesis with a nail. MethodsClinical and radiographic outcomes for 82 patients from 2012 to 2016 who underwent TTC arthrodesis with a nail were retrospectivelyevaluated to determine if patient or surgeon specific variables offered prognostic value in predicting negative outcomes. ResultsDiabetes, diabetic neuropathy, high (>2) American Society of Anesthesiologists (ASA) classification, and Charcot neuroarthropathy all were predictive of developing a nonunion in either the subtalar ortibiotalar joints (p<0.05). Diabetic neuropathy was predictive ofreoperation, and along with HbA1C >7.5 was also predictive of hardwarefailure. The odds ratio (OR) for diabetic neuropathy was 2.99 (p<0.05)for nonunion in the tibiotalar or subtalar joints, 3.46 (p<0.05) for reoperation,and 4.11 (p<0.05) for hardware failure. High ASAclassification had an odds ratio of 3.93 (p<0.05) for nonunion in the tibiotalar or subtalar joints as well. Diabetes had an odds ratio of 2.57 (p<0.05) for nonunion. ConclusionsPatients with diabetic neuropathy, Charcot neuroarthropathy, elevated HbA1C, and ASA classification >2 demonstrated a higher complication rate in patients undergoing TTC arthrodesis with a nail.