Tibiotalocalcaneal Arthrodesis Research Articles

Tibiotalocalcaneal arthrodesis with headless compression screws.

BackgroundTibiotalocalcaneal arthrodesis with headless compression screws has not been previously reported. We hypothesized that these screws could be suitable for tibiotalocalcaneal arthrodesis because of their special design. This study aimed to evaluate the clinical outcomes of patients undergoing tibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint.MethodsFrom 2010 to 2015, 23 patients with severe ankle and subtalar arthropathy underwent tibiotalocalcaneal arthrodesis. All surgeries were completed by a senior surgeon in the same hospital. These patients were 18~76 years (mean 54.6 years) old; the duration of their disease was 9~38 months (mean 13.2 months). The study population included 12 males and 11 females; 12 patients underwent surgery on the left and 11 on the right. Indications for surgery included avascular necrosis of the talus (n = 14), severe posttraumatic arthritis (n = 4), osteoarthritis (n = 2), terminal tuberculous arthritis (n = 1), rheumatoid arthritis (n = 1) and Charcot neuroarthropathy (n = 1). A lateral oblique incision was performed to expose the subtalar joint, and an anteromedial longitudinal incision was used to expose the ankle joint. After the articular surfaces were removed, the tibia, talus and calcaneus were carefully aligned and fixed with two headless compression screws. Patients were followed up at 6 weeks and 3, 6 and 9 months after surgery; they were evaluated by Roles and Maudsley patient satisfaction scores, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) score and radiographic evaluation.ResultsSeventeen patients were studied, with a mean follow-up time of 6.5 months (range 5–24). The mean Roles and Maudsley patient satisfaction score was 1.41 at the last follow-up; most of the patients were satisfied with the surgery results. The mean preoperative AOFAS Ankle-Hindfoot Score was 29.6 (range 18–37), while the mean last follow-up AOFAS Ankle-Hindfoot Score was 68.5 (range 61–80). The VAS score for preoperative functional pain was 6.95 (range 3–10) compared to 1.56 (range 0–3) postoperatively (P < 0.001). The mean surgical duration was 57 (range 42–125) min. The mean time to union was 3.8 months (range 3–12 months); fusion of the ankle and subtalar joint was successful in all patients. One patient experienced delayed wound healing.ConclusionsTibiotalocalcaneal arthrodesis with headless compression screws for the treatment of severe arthropathy of the ankle and subtalar joint is an effective treatment that is minimally invasive and is associated with a short operation time, high fusion rate, low incidence of complications and good postoperative recovery.

Minimally Invasive Surgery for Tibiotalocalcaneal Arthrodesis UsingaRetrograde Intramedullary Nail: Preliminary Results ofanInnovative Modified Technique.

The aim of the present longitudinal prospective study was to evaluate the clinical, functional, and radiologic outcomes and patient satisfaction of those who had undergone minimally invasive surgery (MIS) for tibiotalocalcaneal arthrodesis with an intramedullary nail. The 28 patients, who had consecutively undergone surgery with the MIS technique, were evaluated clinically and radiographically at 1, 2, 3, and 6months after surgery and at last follow-up examination. For the clinical evaluation, the American Orthopaedic Foot and Ankle Society scale and visual analog scale for the foot and ankle were used in the preoperative and final follow-up examinations. The patients rated their satisfaction on a scale from 0 to 10. The mean score obtained with the American Orthopaedic Foot and Ankle Society scale was 68.28±5.02 (range 58 to 74) points and with the visual analog scale for the foot and ankle was 70.76±7.72 (range 58 to 82) points, with a mean follow-up of 25.07±6.32 (range 6 to 40) months. The clinical improvement was statistically significant with both types of evaluation (p≤.05), comparing the preoperative and follow-up periods. Fusion was achieved in all patients, with a mean fusion time of 14.85±4.12 (range 8 to 56) weeks. The alignment of the ankle and foot was optimal in 27 of 28 patients (96.42%), and patient satisfaction was rated as 6.71±1.37 (range 5 to 10) points. Finally, the use of MIS for tibiotalocalcaneal arthrodesis with intramedullary nail results in fusion of the articulation with a low complication rate.

A Retrospective Study

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure for end-stage pathology of the tibiotalar and subtalar joints including primary arthritis, severe deformity, failed total ankle arthroplasty, failed ankle arthrodesis with subsequent subtalar arthritis, talus avascular necrosis and Charcot arthropathy. Although many different fixation techniques of TTCA have been proposed, there is still no consensus gold standard fixation strategy. The various options include plate and screw constructs, intramedullary nails and external fixator systems. The purpose of this study is to report our experience with rigid fixation using a commercially available 4.5 mm locking plate for TTCA. Methods: We retrospectively reviewed the clinical charts and radiographs of 17 patients who underwent TTCA during the time period of 2012-2014. We used a lateral surgical approach with fibular osteotomy and a 4.5 mm Smith and Nephew™ PERI-LOC ankle fusion plate. Two senior foot and ankle surgeons at our institution performed all surgeries. The main outcomes were postoperative fusion rate and complication rate. Results: Of the 17 patients, 9 were male and 8 were female with a mean age of 53. 29% of patients had diabetes mellitus and 69% were either current or former smokers. The average BMI was 32.9. The average follow up was 17.7 months. The nonunion rate in our patient series was 76%. Nonunion was defined as no radiographic evidence of fusion at 6 months post-surgery. This failure rate is very high in comparison to historical data of nonunion rates in TTCA, which are often reported to be 7-26%. Only four out of 17 patients had a successful arthrodesis using this locked plate construct. Complications included nonunion, hardware failure (with screws and/or plate fracture), deep infection (35% of patients), and pseudoarthrosis. Conclusion: Too rigid of fixation with thick stainless steel plates and locking screw constructs can lead to failure in tibiotalocalcaneal arthrodesis. Increased nonunion rates due to overly rigid fixation has been demonstrated in many other contexts but never in the foot and ankle literature.

Retrospective Case Study of TTC Fusion Treated with Carbon Fiber Nail

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal arthrodesis is a salvage option reserved for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. Implants have long been made from various metals most commonly stainless steel or titanium alloys. Disadvantages of metal implants include limited fatigue life, mismatch of modulus of elasticity, potential for wear debris, corrosion, and radiodensity that can preclude accurate radiographic visualization. Carbon fiber implants have been available for years. The advantageous properties of carbon fiber for use as orthopaedic implants include a similar modulus of elasticity to bone to decrease stress shielding, biocompatilibity, with minimal cellular response when studied invitro and invivo, ability to withstand prolonged fatigue straining and radiolucency on XR. Methods: A Carbofix TM carbon fiber TTC fusion nail was used in 15 patients with for Tibiotalocalcaneal /TC fusion. All patients received preop, intra op xrays, and follow up xrays at weeks 2/6/12. After 12 weeks xrays were taken every 3 months until 1 year. All xrays were read by a radiology attending to assess for consolidation and maintenance of alignment. We also performed CT scan for the nonunion [clinical &amp; Radiological] Results: We were able to find comparable results [patients operated with carbon fiber nail] to the historical data of the patients treated with different metal implants. We were also able to check the safety of using the implant [no tissue reaction or reactivity], easily able to see the fusion across the joints secondary to radioluceny and artifact free CT scan or MRI when required. There were no metal related complications noted. Conclusion: These studies have shown the usefulness of carbon fiber implants but there are no studies which explicitly review Tibiotalocalcaneal/Tibiocalcaneal fusion. We present a retrospective case series of 15 patients who were treated with carbon fiber tibiotalocalcaneal fusion nail.

Bone Reconstitution With Synthetic Bone Graft Material for Osseous Defects in Revision Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Various treatments have been suggested for the treatment of periarticular cysts in revision total ankle arthroplasty including autograft and allograft bone grafting, polymethylmethacrylate cement, and revision to ankle or tibiotalocalcaneal arthrodesis. This study investigated the rate of osseous reconstitution following treatment with a unique calcium phosphate-calcium sulfate blend. Methods: A retrospective review of all revision total ankle arthroplasty procedures over a 3 year period was performed. 37 patients were identified that had utilized the calcium phosphate-calcium sulfate blend for the treatment of osseous defects. Data on graft location, volume, infection rate, bone reconstitution rate, and further revision procedures were collected. Plain radiographs were used to determine osseous reconstitution, qualified as bony trabeculae present with no lytic area remaining. Patient's average age was 66 years old, revision performed an average of 9.5 years after primary arthroplasty, with an average of 503 (range 99-1333) days of follow up. Results: Grafting of 23 tibial, 23 talar, 7 fibular, and 5 calcaneal bone defects were undertaken. All patients had Agility implants at time of primary arthroplasty. 16 patients had retention of Agility components, with 21 being revised to Inbone 2 implants. An average of 8.25 ml of material was used. Complete bone reconstitution was noted in 24 patients (65%). Incomplete or no bony healing was noted in 9 talus, 2 tibias, and 2 fibulas. Further revision was performed or offered to 7 patients for continued symptoms(19%). No seromas or excessive wound drainage was noted. Conclusion: Grafting of osseous defects for total ankle arthroplasty with a fully synthetic calcium sulfate and calcium phosphate mixture is an effective technique. Caution should be used in its use for patients with talar subsidence, as these have higher rates of failure likely due to its diminished blood supply and smaller surrounding structural support. provide significant long-term structural support. It should not be depended to

Subtalar Arthrodesis in Patients With Avascular Necrosis of the Talus

Category: Hindfoot Introduction/Purpose: Avascular necrosis (AVN) of the talus can lead to subtalar arthritis, pain, and decreased function. Isolated subtalar arthrodesis has been attempted in these patients, potentially allowing re-vascularization of the talus from calcaneal bone ingrowth while preserving the tibiotalar joint. The purpose of this study is to determine the union rate and complications of subtalar arthrodesis in patients with AVN of the talus. Methods: After obtaining IRB approval, a retrospective review of subtalar arthrodeses performed at a single academic institution, from 2000 to 2014, was conducted. Patients were included if they had a preoperative diagnosis of avascular necrosis of the talus, underwent subtalar arthrodesis and had a minimum follow up of 12 months. Exclusion criteria include: age younger of 18 years, incomplete clinical and radiological data or those whom underwent a concomitant tibiotalar arthrodesis. Results: Twelve patients with a mean age of 46.6 ± 13.9 years were included in the study. The fusion rate was 58% with a mean time to fuse of 35 weeks (range, 14-146). Seventeen percent of the patients had diabetes or vascular disease and an additional 17% had a positive history for tobacco use. The overall complication rate was 67% (8 patients). Five patients progressed to non-union (42%) and three of them underwent revision to tibiotalocalcaneal arthrodesis. Two patients (17%) had progression of AVN, one of which necessitated a tibiotalocalcaneal arthrodesis. Two patients (17%) developed a wound dehiscence that healed uneventfully with local wound care and oral antibiotics administration. One patient (8%) underwent hardware removal. Conclusion: With a fusion rate as low as 58% and a 67% complication rate, caution should be exhibited when considering an isolated subtalar arthrodesis in the setting of AVN of the talus. In selected cases, consideration should be given to extending the arthrodesis site to include the tibiotalar or talonavicular joint or revascularization procedures such as concomitant vascularized bone grafts.

Anterior Plating with Retention of Nail for Salvage Ankle Arthrodesis After Failed Tibiotalocalcaneal Fusion

Category: Ankle Arthritis Introduction/Purpose: Tibiotalocalcaneal arthrodesis (TTCA) by retrograde intramedullary nailing (RIMN) is commonly used to treat degenerative disease affecting both the tibiotalar and subtalar joints. In the event of TTCA failure, techniques for salvage arthrodesis are not well-described. The aim of this study is to demonstrate the feasibility of anterior plating with retention of nail as a salvage option for patients who experienced failed TTCA by RIMN. Methods: Six patients with failed TTCA following RIMN underwent revision ankle arthrodesis with anterior plating and retention of nail between July 2013 and July 2015. Patient demographics, presentation details, and clinical records were reviewed for clinical and patient-reported outcome measures. Postoperative outcomes consisted of visual analog scale (VAS) pain rating, Coughlin satisfaction scale, Foot &amp; Ankle Activity Measure (FAAM) score, and complications. Results: Anterior plating was performed at a mean of 15.8 months (range, 6.3-25.7) after primary TTCA by RIMN. All patients achieved bony fusion at an average of 9.3 weeks (range, 5.4-16.1) postoperatively. Postoperative outcomes at 1 year follow-up demonstrated an average VAS score improvement from 7.8 to 5.3 (p = 0.019) and an average postoperative FAAM score of 50.9 (range, 37.5-75.0). One major complication occurred in a patient who had a posterior tibial nerve neuroma from the initial TTCA procedure. Despite achieving union following anterior plating, the patient had several subsequent procedures to manage the neuroma but eventually required amputation. There was one minor complication consisting of postoperative swelling requiring a compressive stocking. Conclusion: Anterior plating with retention of nail is a viable option for salvage arthrodesis in patients with failed TTCA after RIMN. Given the complex presentation of most patients with this problem, detailed preoperative counseling regarding the potential risks of surgery should be performed.

Use of Liposomal Bupivacaine in Major Ankle and Hindfoot Surgery

Category: Ankle Introduction/Purpose: Nearly 40% of patients undergoing ambulatory orthopedic surgery experience moderate-to-severe pain at home in spite of analgesic medication.As a result, a multimodal approach consisting of oral opioid agents and regional analgesics are recommended.Regional anesthesia is considered the primary anesthetic modality and adjunct to post-operative pain control following foot and ankle surgery, however it is not without potential complication.An ideal analgesic would provide long-term pain relief without resulting in a transiently weak or insensate limb. Extended-release liposomal bupivacaine-based analgesics as been approved by the FDA for anesthetic injection and have been shown to provide extended pain relief and decrease opioid use after bunionectomy, compared with placebo. This prospective study has been designed to evaluate the effect of surgeon applied liposomal bupivacaine on post-operative pain in patients undergoing major ankle and hindfoot surgery. Methods: 28 patients who were scheduled to undergo ankle arthrodesis, a tibiotalocalcaneal arthrodesis, hindfoot arthrodesis including, or a flatfoot procedure were enrolled prospectively. Prior to surgerypatients received a single shot popliteal block and at the conclusion of the case received 20cc of liposomal bupivacaine mixed with 10cc of normal saline injected at the surgical site. VAS pain scale at PACU admission and discharge, narcotic use, anti-emetic use, length of time in PACU and any complications were documented. A take home questionnaire documenting oral narcotic use, VAS pain scales at different intervals throughout the day, patient satisfaction with post surgical pain relief, as well as any complications for the day of surgery up to post op day 3 was completed. Patient satisfaction with post surgical pain relief and complications were also recorded at the patient’s first post- operative visit. Results: 28 total patients were enrolled ( Average age 55.6, Range 20-80). Post operatively 18/28 patients (64%) rated their satisfaction as &gt;4 (on a five-point scale). Greatest increase in VAS pain scores was seen from DOS to POD1 at 4:00 PM. Satisfaction with pain control was most strongly associated on POD3 at midday with a negative correlation (R= -0.68). Patients took the least amount of pain medications on DOS (28.83 mg) with an average total morphine equivalents consumed from DOS to POD3 of 236.68 mg. There were no complications associated with application of liposomal bupivacaine, this included postoperative wound complications, skin necrosis and persistent paresthesias. Conclusion: Extended-release liposomal bupivacaine-based analgesics when utilizedduring major ankle or hindfoot surgery did not provide complete pain relief as demonstrated by the sharp rise in pain scores seen after the resolution of the analgesic effect of the popliteal block. However it seemed that the effect of liposomal bupivacaine did contribute to lower pain scores at the conclusion of the period of efficacy, as there was no further rise in pain complaints after POD1 and lowest pain scores were seen on POD3. Application of liposomal bupivacaine appears to be safe without an increase in complications, wound problems or adverse reactions.

Technique, Complications, and Mid-Term Results of Hindfoot Arthrodesis with a Posterior Blade Plate

Category: Ankle Arthritis Introduction/Purpose: Previous hindfoot surgeries present a unique challenge in performing hindfoot arthrodesis. The use of a blade plate construct is widely accepted, however there is limited data supporting the use of a posterior approach to blade plate arthrodesis. The purpose of this study was to (1) describe demographics of patients who underwent posterior hindfoot arthrodesis using a blade plate, (2) describe our surgical technique, (3) discuss outcomes, and (4) compare patients with and without complications. Methods: Between December 2001 and July 2014, 42 patients underwent hindfoot arthrodesis using a posterior blade plate and 40 patients were included in this study. Demographic data including age, gender, body mass index, smoking status, and comorbidities were analyzed. Surgical data including indication for the surgery, previous surgical treatment, and additional surgical procedures were reviewed. Weight-bearing radiographs were used to assess the fusion rate. Clinic and surgery notes were reviewed for possible intraoperative, perioperative, and postoperative complications. Univariate analysis was performed to compare patients who experienced complications with those who did not. There were 27 male and 13 female patients with a mean age of 56.4 ± 13.4 years. Twenty-eight patients had a tibiotalocalcaneal arthrodesis in a primary (n=6), primary staged (n=10), revision (n=9), or revision staged (n=3) setting. Eleven patients had ankle arthrodesis (primary n=7, revision n=4). The latest follow-up averaged 46.5 ± 27.5 months (range, 13.7-137.2 months). Results: Patients had a median of two previous hindfoot or ankle surgeries (range, 0-9 surgeries). Thirty-three of 40 (82%) procedures fused at an average of 24.4 ± 21.2 weeks. Four patients had a delayed osseous union. Seven patients had a nonunion, including ankle (n=3), subtalar (n=3), and both (n=1) joints. Patient groups with, and without primary solid osseous unions were comparable in terms of demographic data and surgical details. Eighteen major and eight minor complications were observed. Patients with or without complications were comparable in terms of demographic data and surgical characteristics. In total six patients (15%) underwent below knee amputation due to unsatisfactory results. Conclusion: Indications for hindfoot arthrodesis using posterior blade plate fixation include a diverse patient population. These surgeries may be performed as primary, revision, primary staged, or revision staged procedures. Most of the patients in our cohort had previous ankle/hindfoot surgeries. The fusion rate is lower than in primary hindfoot arthrodesis as reported in the current literature. The complications rate is high.

Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nail in Tibiotalocalcaneal Arthrodesis

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal(TTC) arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are not uncommon. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail. Methods: We identified 15 patients (age+54.7+/-20.0 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nai. Serial radiographs were used to determine the amount and rate of Nitinol element migration over time. Results: Three months after surgery, there was at least 2.38mm of Nitinol element migration proximally with mean of 5.58mm(range: 2.38 to 8.11mm). Average follow up time was 195 days (range: 89 to 490 days). Conclusion: The Nitinol element recovers distance when stretched intra-operatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional IMN’s.

Total Ankle Replacement and Simultaneous Subtalar Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Patients with arthritis or severe malfunctions involving both the ankle and the subtalar joints can benefit tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. Actually, TTC fusion is considered as a salvage option resulting in a completely stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and surgical techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. Methods: This study includes 25 patients who underwent primary TAR and simultaneous subtalar fusion from May 2011 to November 2014. Sixteen males (64%) and 9 females (36%) were enroled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Radiographic examination included a postoperative CT scan obtained 12 months after surgery. Results: At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopedic Foot &amp; Ankle Society ankle/hindfoot score from 27.9 to 75.1. Range of motion significantly increased from 12 to 32.8 degrees. In addition, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.6 to 2.1. Conclusion: TAR and simultaneous subtalar joint fusion are reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopaedic surgeons in determining the degree of successful fusion of subtalar arthrodesis.

Tibiotalocalcaneal arthrodesis by using proximal humeral locking plate

ObjectivesThe aim of this study was to evaluate the short-term clinical and radiological results of tibiotalocalcaneal arthrodesis (TTCA) with proximal humeral locking plate. Material and methodsEight patients (7 female, 1 male; average age 53 years (range: 24–67)) who underwent TTCA with proximal humeral locking plate between 2009 and 2011, were retrospectively evaluated with AOFAS hindfoot scale and Maryland foot score system. The mean follow up was 32.6 months (range: 23–54). ResultsComplete fusion was achieved in 7 patients. Soft tissue infection was observed in 2 patients and reflex sympathetic dystrophy in 3 patients. All patients recovered with medical treatment. At the final follow-up, mean AOFAS Hindfoot score was 60 (range: 41–81) and Maryland Foot Score was 67.8 (range: 41–85). The satisfactory rates of AOFAS and MFS were found as 12.5% (1/8) and 50% (4/8), respectively. One patient had an incomplete union with 5 degrees of heel varus deformity and 5 degrees of equinus deformity was observed in another. There were no implant failure or deformation of the plate during the follow-up period. ConclusionOur study suggests that proximal humeral plate may be an alternative for fixation in tibiotalocalcaneal fusion surgery.

A modified and enhanced test setup for biomechanical investigations of the hindfoot, for example in tibiotalocalcaneal arthrodesis.

BackgroundTibiotalocalcaneal arthrodesis (TTCA) using intramedullary nails is a salvage procedure for many diseases in the ankle and subtalar joint. Despite “newly described intramedullary nails” with specific anatomical shapes there still remain major complications regarding this procedure. The following study presents a modified biomechanical test setup for investigations of the hindfoot.MethodsNine fresh-frozen specimens from below the human knee were anaysed using the Hindfoot Arthrodesis Nail (Synthes) instrument. Quasi-static biomechanical testing was performed for internal/external rotation, varus/valgus and dorsal/plantar flexion using a modified established setup (physiological load entrance point, sledge at lever arm to apply pure moments). Additionally, a 3D optical measurement system was added to allow determination of interbony movements.ResultsThe mean torsional range of motion (ROM) calculated from the actuator data of a material testing machine was 10.12° (SD 0.6) compared to 10° (SD 2.83) as measured with the Optotrak® system (between tibia and calcaneus). The Optotrak showed 40 % more rotation in the talocrural joint.Mean varus/valgus ROM from the material testing flexion machine was seen to be 5.65° (SD 1.84) in comparison to 2.82° (SD 0.46) measured with the Optotrak. The subtalar joint showed a 70 % higher movement when compared to the talocrural joint.Mean ROM in the flexion test was 5.3° (SD 1.45) for the material testing machine and 2.1° (SD 0.39) for the Optotrak. The movement in the talocrural joint was 3 times higher compared to the subtalar joint.ConclusionThe modified test setup presented here for the hindfoot allows a physiological biomechanical loading. Moreover, a detailed characterisation of the bone-implant constructs is possible.

Treatment of Osteonecrosis of the Talus.

More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis. Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis. In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.

Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nails for Tibiotalocalcaneal Arthrodesis.

Tibiotalocalcaneal arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are common. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail with an internal nitinol element. We identified 15 patients with average age of 54.7 years (range, 28-75 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nail. Serial radiographs were used to determine the amount and rate of nitinol element migration over the first 3 postoperative months. Postoperatively, there was at least 2.38 mm of nitinol element migration proximally with mean of 5.58 mm (± 1.38), (range, 2.38-8.11 mm). Average follow-up time was 195 days (± 106.3), (range, 89-490 days). On average, 86% of the total recovered distance took place within the first 39.7 days (±10.03). The nitinol element recovers distance when stretched intraoperatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional intramedullary nails. Therapeutic, Level IV: Case series.

Fibular Strut Graft for Revisional Tibiotalocalcaneal Arthrodesis.

Therapeutic, Level IV: Case report.

Internal circular arc osteosynthesis of tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis has recently become more popular as a form of reconstructive surgery. The precise anatomical orientation and the functional extrinsic musculature of the hindfoot are essential for a satisfactory result. Fixation of the arthrodesis is amechanical problem. Straight and angulated nails are not anatomically or mechanically ideal. Acircular arc nail can fix the tibia, the talus and the calcaneus in anatomical alignment. This is apure "bone nail", in contrast to the "intramedullary nail," which is driven through an existing opening in long bones. The nail is driven through a circular arc-shaped opening in the bone, which results in optimal form-fit between nail and bone. Acorresponding aiming device permits the precise shaping of the bone tunnel, which follows the orientation of the bone trabeculae. The instrumentation was applied in 11cases, with the following indications: post-traumatic conditions, congenital deformities, chronic polyarthritis and diabetic Charcot arthropathy. The desired alignment of the hindfoot is not affected while the nail is being introduced. The fixation achieves primary stability thus allowing for early functional treatment.

Hindfoot Arthrodesis with the Blade Plate: Increased Risk of Complications and Nonunion in a Complex Patient Population.

Previous hindfoot surgeries present a unique challenge to hindfoot arthrodesis, as the patients may have multiple incisions around the hindfoot. In high-risk patients with compromised soft tissues, a posterior approach can provide an alternative for a fresh soft tissue plane for the surgery. The use of a blade plate construct is widely accepted; however, there are limited data supporting the use of a posterior approach. We asked (1) what proportion of patients treated with this technique achieved osseous union; (2) what complications were observed; (3) were any patient-demographic or health-related factors associated with the likelihood that a patient would have a complication develop? Between December 2001 and July 2014, 42 patients received a posterior blade plate. During the period in question, indications for hindfoot arthrodesis using posterior blade fixation were subtalar osteoarthritis below an ankle fusion, malunion or nonunion, failed tibiotalocalcaneal arthrodesis attributable to nonunion of the tibiotalar and/or subtalar joint; or tibiotalar and subtalar osteoarthritis in patients with impaired bone or soft tissue quality (particularly if the soft tissue problem was anterior). During that period, all patients who met those indications were treated with a posterior blade plate. Forty (95%) were included in this study, and two were lost to followup before the 1-year minimum required by the study. Demographics (age, gender, BMI, smoking status, and comorbidities) and surgical data (indication, previous treatment, and additional procedures) were analyzed. Of the 40 patients included, 27 (68%) were male and 13 (33%) were female, with a median of two previous hindfoot or ankle surgeries (range, 0-9 surgeries). The mean age of the patients was 56±13 years. Followup averaged 47±28 months (range, 14-137 months). Twenty-eight of 40 (70%) patients had a tibiotalocalcaneal arthrodesis as a primary (n = 6), primary staged (n = 10), revision (n = 9), or revision staged (n = 3) procedure. Eleven of 40 patients (28%) underwent ankle arthrodesis (primary n = 7, revision n = 4). One of the 40 patients (3%) underwent tibiotalocalcaneal arthrodesis for a failed total ankle arthroplasty. Weightbearing radiographs were used to assess fusion. Osseous fusion was defined as visible trabecular bridging on the lateral and AP ankle views within 6 postoperative months. Delayed union was defined as osseous fusion occurring between 6 and 12 months. Nonunion was defined as no visible trabecular bridging at the latest followup (longer than 12 months). Clinic and surgery notes were reviewed for complications. Univariate analysis was performed to compare patient groups: patients with solid union versus nonunion, and patients with versus without complications. Twenty-nine of 40 (73%) patients had osseous fusion within 6 postoperative months. Four of 40 (10%) patients had a delayed union between 6 and 12 months, and seven of the 40 (18%) patients had nonunions, which occurred in the ankle (n = 3), subtalar (n = 3), or both (n = 1) joints. There were 26 complications observed: 18 (69%) were considered major and eight (31%) were minor. With the numbers available, we did not identify any demographic or surgical factors associated with complications, delayed union, or nonunion. The proportion of patients treated with a posterior blade plate hindfoot fusion who had delayed union or nonunion is greater than that reported for patients in other series who underwent primary hindfoot arthrodesis with other approaches, and the proportion of patients who had complications develop is high. Further studies are needed to address alternative approaches to achieve hindfoot fusion in patients with complex hindfoot problems. Level IV, therapeutic study.

Tibiotalocalcaneal arthrodesis with a retrograde triple bending nail – 2-year-followup results

Tibiotalocalcaneal arthrodesis with a retrograde triple bending nail – 2-year-followup results

Comparison of clinical outcomes between tibiotalocalcaneal arthrodesis and total ankle arthroplasty

Comparison of clinical outcomes between tibiotalocalcaneal arthrodesis and total ankle arthroplasty