Tibiotalocalcaneal Fusion Research Articles

Intramedullary Nail Fixation with Posterior-to-Anterior Compared to Transverse Distal Screw Placement for Tibiotalocalcaneal Arthrodesis: A Biomechanical Investigation

Biomechanical studies on retrograde intramedullary fixation for tibiotalocalcaneal fusion have been reported, but no studies have investigated dorsiflexion stiffness, load-to-failure, fatigue endurance, and plastic deformation using different distal screw orientations. Also, no studies have examined the effect of bone density on different distal screw orientations while using a fatigue loading mode. Eight matched pairs of cadaver legs were used. In one leg from each pair an intramedullary nail was inserted with lateral-to-medial distal screws and in the other with posterior-to-anterior screws. These samples underwent dorsiflexion fatigue testing with determination of initial and final stiffness, load-to-failure, and degree of plastic deformation at failure. DEXA scanning was done of each cadaver specimen to determine bone mineral density. Statistical analysis was performed using the Student t-test and a Pearson correlation. Significance level was set at p < 0.05. The specimens with posterior-to-anterior screws had a significantly higher fatigue endurance load-to-failure (1130.0 +/- 362.0 N compared to 801.0 +/- 227 N, p = 0.01). They also had significantly higher final stiffness (203.1 +/- 23.1 N/mm compared to 146.6 +/- 46.2 N/mm, p = 0.05) and lower plastic deformation (2.4 +/- 1.5 mm compared to 3.8 +/- 2.3 mm, p = 0.04). There was a statistically significant correlation between bone mineral density and the difference in construct deformation with posterior-to-anterior and lateral-to-medial screw orientation (r = 0.76, p = 0.03). In this biomechanical investigation of tibiotalocalcaneal arthrodesis with intramedullary nail fixation, posterior-to-anterior distal screw orientation provided more stable fixation than lateral-to-medial screw orientation.

Detection of Orthopaedic Foot and Ankle Implants by Security Screening Devices

A common question asked by patients contemplating foot and ankle surgery is whether the implants used will set off security screening devices in airports and elsewhere. Detectability of specific implants may require the orthopaedic surgeon to provide attestation regarding their presence in patients undergoing implantation of these devices. Only two studies have been published since security measures became more stringent in the post-9/11 era. None of these studies specifically focused on the large numbers of orthopaedic foot and ankle implants in use today. This study establishes empiric data on the detectability by security screening devices of some currently used foot and ankle implants. A list of foot and ankle procedures was compiled, including procedures frequently used by general orthopaedists as well as those usually performed only by foot and ankle specialists. Implants tested included those used for open reduction and internal fixation, joint fusion, joint arthroplasty, osteotomies, arthroreisis, and internal bone stimulation. A test subject walked through a gate-type security device and was subsequently screened using a wand-type detection device while wearing each construct grouping. The screening was repeated with the implants placed within uncooked steak to simulate subcutaneous and submuscular implantation. None of the implants were detected by the gate-type security device. Specific implants that triggered the wand-type detection device regardless of coverage with the meat were total ankle prostheses, implantable bone stimulators, large metatarsophalangeal hemiarthroplasty, large arthroreisis plugs, medial distal tibial locking construct, supramalleolar osteotomy fixation, stainless steel bimalleolar ankle fracture fixation, calcaneal fracture plate and screw constructs, large fragment blade plate constructs, intramedullary tibiotalocalcaneal fusion constructs, and screw fixation for calcaneal osteotomies, ankle arthrodeses, triple arthrodeses, and stainless steel first metatarsophalangeal joint arthrodeses. The placement of implants in meat prevented the detectability of only the stainless steel Jones fracture implant (stainless steel 6.5-mm cannulated screw) and the stainless steel midfoot fusion construct (four stainless steel 4.0-mm cannulated screws). These data may help the orthopaedic surgeon in counseling patients as to the detectability of some orthopaedic foot and ankle implants in use today. Specific constructs for which documentation may need to be provided to the patient are identified. As security standards evolve and the environments in which they are practiced change, empiric testing of many of these devices may need to be repeated.

Tibiotalocalcaneal Arthrodesis Using a Dynamically Locked Retrograde Intramedullary Nail

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems, including Charcot arthropathy, osteonecrosis of the talus, combined arthritis of the ankle and subtalar joint, and failed total ankle arthroplasty. This study evaluated the results of a dynamic retrograde intramedullary nail for fixation with posterior to anterior distal interlocking screws placed through the calcaneus for tibiotalocalcaneal fusion. Thirty-three consecutive tibiotalocalcaneal fusions were done by a single surgeon (DBT) and were stabilized with a dynamic retrograde intramedullary nail. Time to fusion, impaction of the nail relative to the intramedullary canal, nail-tibial angle, and complications were noted. Average followup was 14 months. Twenty-nine of 33 feet (88%) fused at an average of 3.7 months after surgery. Average impaction of the nail was 2.3 (0.5 to 5.0) mm. Cortical hypertrophy at the tip of the rod or at the proximal interlocking screw was noted in 13 of 27 patients. A trend toward a higher nonunion rate was noted in patients with an increased nail-tibial angle. Dynamic retrograde intramedullary nailing for fixation of the tibiotalocalcaneal fusions is a good method of stabilizing this complex fusion construct.

Tibiotalocalcaneal Arthrodesis for Severe Calcaneovalgus Deformity in Cerebral Palsy

The authors studied the outcome of a consecutive series of nine tibiotalocalcaneal fusions for severe calcaneovalgus deformity in five adolescents with severe cerebral palsy. The indications for surgery were severe deformity, pain, brace intolerance, difficulties with shoe wear, and progressive loss of transfer, standing, or walking ability. The goals of surgery were deformity correction, reduced bracing, and ability to wear regular shoes and to maintain function. Successful correction of deformity was achieved in all patients. One patient had a stable fibrous ankylosis despite revision surgery. Functional goals were fully achieved in three patients and partially achieved in two patients. The authors conclude that tibiotalocalcaneal fusion is useful as a salvage procedure in a small group of adolescents to correct severe deformity and to maintain limited function. Isolated lengthening of the tendo Achillis had been performed in four of these patients and was a contributing factor to the development of this deformity.

Tibiotalocalcaneal fusion using retrograde intramedullary nails as a salvage procedure for failed total ankle prostheses in rheumatoid arthritis

Abstract Between 1996 and 2002, 16 patients with rheumatoid arthritis and failed total ankle prosthesis underwent tibiotalocalcaneal fusion using retrograde intramedullary nails. The functional outcome was evaluated using the AOFAS scoring system and the patients were also asked about their satisfaction. Radiographs were obtained for all 16 cases minimum 1 year after surgery. Thirteen of the 16 ankles were considered radiographically healed, 11 at the first attempt and two after repeat arthrodesis. The median AOFAS pain and total scores were 40 and 58, respectively. Two deep infections resulted in a fused ankle after antibiotic treatment. In patients with rheumatoid arthritis and a failed total ankle prosthesis, tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail resulted in primary healing in two-thirds of the cases. Only two patients with a fused ankle were dissatisfied with the final result. The procedure is recommended in selected cases as an alternative to external fixation.

Tibiotalocalcaneal arthrodesis in rheumatoid arthritis using the Supracondylar nail

Abstract Our aim was to evaluate the outcome of tibiotalocalcaneal fusion in rheumatoid arthritis patients using the locked Supracondylar nail. Methods . Twenty-four patients (27 ankles) underwent this procedure. The mean follow up was 38.4 months. Seventeen cases had ankle debridement at the time of arthrodesis. This was aimed at correcting hindfoot deformity in addition to facilitating joint fusion. The Fries scoring system was used to assess the severity of rheumatoid disease. The rheumatoid ankle score (RAS) and modified American Orthopaedic Foot & Ankle Society Score were used to analyse functional outcome. Results . Patients with ankle debridement and intramedullary nailing had mean RAS of 80.5 and bony union in 87%. However, patients with in situ nailing without ankle debridement had mean RAS of 72 and no evidence of bony union. Conclusion . We recommend that, in patients with rheumatoid hindfoot arthritis intramedullary nail fusion is always performed with ankle debridement.

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing

Nineteen patients (20 feet) with severe hindfoot and ankle deformity underwent tibiotalocalcaneal fusion with a retrograde locked intramedullary nail as a limb-salvage procedure. The purpose of this study was to compare the complication rates of this procedure in diabetic versus nondiabetic patients. There were 8 men and 11 women with preoperative diagnoses including Charcot neuroarthropathy, primary osteoarthritis, rheumatoid arthritis, equinocavovarus, posttraumatic osteoarthritis, gouty arthritis, and ankle malunion. Ten of 20 procedures were performed in patients with diabetes. The average patient age was 56 years, and the average postoperative follow-up was 19.8 months. Nineteen of 20 ankles (95%) achieved successful fusion with an average time of 4.1 months. Four patients (21%) required either a fracture brace or an ankle foot orthosis at final follow-up. Five patients (25%) had major complications and 11 patients had minor complications. Major complications included osteomyelitis (n = 2), Charcot arthropathy (n = 2), failure of fixation (n =1), soft-tissue necrosis (n = 1), cardiac arrest (n = 1), cerebral vascular accident (n = 1), and fatal pulmonary embolus (n = 1). All patients with major complications were diabetic, and 14 of 20 combined major and minor complications occurred in patients with diabetes. The complication rate was found to be high in diabetic patients with end-stage deformity undergoing a limb salvage

Report of the EFAS travelling fellows 2002

The EFAS Fellowship of 2002 comprised of visits to five different centres in three countries. The two travelling fellows were Mr Rhys Thomas from University Hospital of Wales, Cardiff and Dr Christos Alexandropolous from Health Centre of Myconos, Greece (Fig. 1). Our first visit was to Professor Sandro Giannini at the Instituto Orthopedico Rizzoli, Bologna. As we walked up the hill towards the hospital we could not fail to be impressed by this fine building that originally served as a monastery. The morning was spent observing Prof. Giannini in the operating theatre where he performed osteochondral grafting for lesions of both the tibia and talus, and also the ‘SERI’ distal osteotomy for hallux valgus. After a leisurely lunch the Professor presented a number of interesting talks including his results of reconstruction following failed ankle fracture fixation. The next morning was again spent in theatre where we were able to observe such a case. The fellows then visited the biomechanics and gait analysis laboratory and met Dr Leardini who discussed his role in the development of a new three component total ankle replacement. The afternoon was spent on a fascinating tour of the Institute’s library and the office of Professor Vittorio Putti, former Director at Rizzoli. Putti’s office has been preserved in its original state and is a trove of orthopaedic treasures containing first editions of many valuable books including Andry’s ‘L’Orthopedie ou L’Art’. The library is no less impressive. The centrepiece is a huge globe dating from the 1760s. The globe goes some way to representing an easier sporting world as it does not contain Australia! The library receives an impressive 150 journals per month. After a weekend exploring Bologna we faced a 9 h train journey to Lyon. For one of the fellows this journey was interrupted by a stay in gaol at the French/Italian border. The border police were rather concerned that a Greek male should have ‘F’ marked under ‘Sex’ on his passport! We both eventually arrived in Lyon to be met by Dr Jean-Luc Besse. The following morning we joined Dr Besse at Hospital Lyon-Sud. We spent two days in theatre with Dr Besse during our stay, assisting with a number of cases including Scarf osteotomies of both first and fifth metatarsals and tendoAchilles reconstruction. It was easy to sympathise with the trouble Dr Besse was having with bed availability for his inpatients. A scientific meeting was organised within the hospital. Dr Besse presented papers on ‘Semi-automated foot Xray assessment using the Footlog software’ and ‘Calcaneal intra-articular fracture osteosynthesis’ while Dr Alexandropolous presented ‘Evaluation of the LaugeHansen, AO and Broos-Bishop classification systems for ankle fractures’ and ‘Deep tissue infections of the diabetic foot’. Mr Thomas presented the results of ‘Functional outcome and gait analysis following isolated ankle arthrodesis’ and ‘Functional outcome following free fibula graft harvest’. Following the meeting we were taken, as guests of Professor Moyen, to watch the French football champions Olympique Lyon play, and beat, Lens. The next few days were spent exploring the many sights of Lyon. The fellows were kindly hosted by EOS medica on a visit to the beautiful medieval village of Perouges. Fortunately the train journey across the Swiss border to Geneva passed without event. We were hosted in Geneva by Dr Marino Delmi, President of the Swiss Foot and Ankle Society, at the Hopital Universitaire de Geneve. The day was spent discussing difficult cases, visiting interesting patients on the ward and in the out-patients clinic. We also met with Dr Abdi Raissi, a visiting fellow from Columbus, USA. The next day was spent assisting with a tibiotalocalcaneal fusion and a Watermann-Green osteotomy for hallux limitus. The fellows then presented at a scientific meeting and also heard papers from Dr Raissi on ‘Arthroscopic capsular shrinkage of the ankle’ and Dr Delmi on ‘Heel pain-surgical release of the first branch of the lateral plantar nerve’ and ‘Limited open repair of Achilles tendon ruptures’. Generous gifts from the Clinique d’Orthopedie and the Swiss Foot and Ankle Society were given to the participants. The fellows ate a rather

Intramedullary fibular graft for tibiotalocalcaneal arthrodesis.

The intramedullary fibular graft was used in four patients for tibiotalocalcaneal fusion. There were three men and one woman. The average age was 49.7 years (range, 35-73 years). The initial injuries were three pilon fractures and one ankle fracture. Tibiotalocalneal arthrodesis was performed as a salvage procedure for patients with significant posttraumatic arthritis of the ankle, concomitant subtalar arthritis, and severe osteopenia. The average followup was 28 months (range, 24-31 months). All the patients had successful arthrodesis and were satisfied with the outcome results. The average preoperative American Orthopaedic Foot And Ankle Society ankle-hindfoot score for the whole group was 49.5 (range, 44-54) and improved postoperatively to 78.5 (range, 71-81). Three patients had a good score and one patient had a fair score. There was no postoperative infection or fracture of the graft.

Ankle and Tibitalocalcaneal Arthrodesis using Lateral Malleolus as Bone Graft

A variety of surgical approaches and bone grafting techniques for ankle and tibiotalocalcaneal arthrodesis have been described. We used transfibular approach and lateral malleolus was used for bone graft. This permitted excellent visualization of the ankle and subtalar joint so that the fusion can readily be achieved under the direct visualization. And also we didn’t need to prepare the additional bone graft from another site. Ten ankle fusions and two tibiotalocalcaneal fusions were carried out and reviewed. The average age of the patients was 43 years(range, 27 58 years). The average follow-up was 27.8 months(range, 24 34 months). We evaluated the clinical and radiological results, and complications. All cases were satisfied and fused. But we experienced one minor complication that was posteroplantar heel pain caused by prominence of cannulated screw head. So, we suggest that this procedure has benefit for ankle or tibiotalocalcaneal fusion.

Arthrodesis for failed ankle arthroplasty

Thirty-eight ankles in 36 patients who underwent fusion for failed total ankle arthroplasty were reviewed. Twenty-two patients were women and 14 were men, and their mean age was 56.8 years. The fusion methods performed in the 38 ankles were malleolar resection in 13, intercalated bone graft in 20, and posterior tibiotalocalcaneal fusion in 5. Fixation was external in 36 ankles and internal in 2. Bone graft was used in 32 ankles. Union was achieved in 33 ankles (89%). The average duration of the follow-up period in 29 patients (31 ankles) was 8.3 years (range, 2–14.4 years). Patients had no or mild pain in 24 ankles (80%). Complications occurred in five ankles (13%). Failed total ankle arthroplasty may be successfully salvaged by arthrodesis.