Tibiotalocalcaneal Fusion Research Articles

Effect of Retrograde Reaming for Tibiotalocalcaneal Arthrodesis on Subtalar Joint Destruction: A Cadaveric Study

Recent published data have suggested successful union of subtalar and tibiotalar joints without formal debridement during tibiotalocalcaneal (TTC) fusion procedures. Although previous studies have reported on the importance of the proper guidewire starting point and trajectory to obtain appropriate hindfoot alignment for successful fusion, to our knowledge, no studies have quantified the amount of articular damage to the subtalar joint with retrograde reaming. We hypothesized that reaming would destroy >50% of the posterior facet of the subtalar joint. The bilateral lower extremities of 5 cadavers were obtained and the subtalar joints exposed. Retrograde TTC nail guidewires were inserted, and a 12-mm reamer was passed through the subtalar and ankle joints. Pre- and postreaming images of the subtalar joint were obtained to compare the amount of joint destruction after reaming. We found an average of 5.89% articular destruction of the talar posterior facet and an average of 4.01% articular destruction of the posterior facet of the calcaneus. No damage to the middle facets of the subtalar joint was observed. TTC nailing is a successful procedure for ankle and subtalar joint fusion. Published studies have reported successful subtalar union using TTC nailing without formal open debridement of the subtalar joint, preserving the soft tissue envelope. TTC nail insertion using a 12-mm reamer will destroy 5.89% and 4.01% of the respective talar and calcaneal posterior facets of the subtalar joint.

Arthroscopic ankle fusion for avascular necrosis of the talus.

Avascular necrosis (AVN) of the talus is a painful condition leading to destruction of the ankle-hindfoot complex. Moderate outcomes and high complication rates are reported in small numbers of advanced disease treated with tibiotalocalcaneal fusion, which has the additional disadvantage of sacrificing both the ankle and subtalar joints. The blood supply of the talus is tenuous, and open procedures risk further talar collapse by disrupting extraosseous vessels. This article reports the outcome of arthroscopic ankle fusion for late-stage AVN of the talus. Our hypothesis was that arthroscopic ankle fusion would relieve symptoms of advanced talar AVN, prevent collapse of the talus, and preserve the subtalar joint. A cohort study was performed on 16 patients with talar AVN treated with arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included perioperative complications, ongoing pain, and further operative intervention. All radiologic investigations were reported independently by a senior radiologist. The average age of the patients was 53.5 years. The presumed causes of talar AVN were steroids, trauma, hematologic disorders, and alcoholism. The etiology was unknown in 7 patients. One patient was lost to follow-up. Clinical and radiologic fusion at the ankle joint was confirmed in 15 of 15 available patients. Thirteen patients reported resolution of pain at follow-up. Three patients had ongoing pain and underwent a subsequent successful subtalar fusion. Arthroscopic ankle fusion was a safe and reliable treatment of symptomatic advanced talar AVN. It was a minimally invasive procedure with minimal complication rate, preserving the talus and sparing the subtalar joint. Level IV, retrospective case series.

Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature.

As the number of total ankle replacements (TARs) performed has risen, so has the need for revision. The purpose of this investigation was to perform a systematic review of clinical outcomes following a salvage ankle arthrodesis from a failed TAR to identify patient- and technique-specific prognostic factors and to determine the clinical outcomes and complications following an ankle arthrodesis for a failed TAR. We searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials for studies that analyzed ankle fusion after failed TAR with a minimum follow-up of 1 year. We included 16 studies (193 patients). The majority of patients (41%) underwent the index TAR for rheumatoid arthritis. The majority of these revision surgeries were secondary to component loosening, frequently of the talar component (38%). In the cases that were revised to an ankle arthrodesis, 81% fused after their first arthrodesis procedure. The intercalary bone graft group and the blade plate group had the highest rate of fusion after the first attempt at fusion at 100%, whereas the tibiotalocalcaneal fusion with cage group had the lowest fusion rate at 50%. The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%. A salvage ankle arthrodesis for a failed TAR results in favorable clinical end points and overall satisfaction at short-term follow-up if the patients achieve fusion. The bone graft fusion and blade plate group resulted in the highest first-attempt fusion rate, with a low complication rate. Future studies should include prospective, comparative control or surgical groups and use standardized outcome measurements that will make direct comparisons easier. Level IV: Systematic Review of Level IV Studies.

Reproducibility of computed tomography to evaluate ankle and hindfoot fusions.

Although plain radiographs have been historically used to evaluate the status of arthrodesis in the foot and ankle, computed tomography (CT) has gained popularity for evaluation of fusion status. The degree of fusion identified on CT scan has been correlated with functional outcome, with an arthrodesis area of 25-50% necessary for clinical success. In the clinical setting, orthopaedic surgeons often evaluate CT scans independently. The purpose of this study was to evaluate the interrater reliability of CT scans to assess the status of hindfoot or ankle fusions among orthopaedic foot and ankle surgeons. Forty-one CT scans were identified retrospectively from the tertiary referral practices of 4 fellowship-trained orthopaedic foot and ankle surgeons. Inclusion criteria were patients with ankle, subtalar, or tibiotalocalcaneal fusions. Fusions with bulk allograft were excluded. All CT scans were completed at the investigating institution. The primary author (RAC) reviewed all CT scans to ensure the adequacy and completeness of the films. Images were blinded of any patient identifiers. All 4 surgeons individually reviewed the blinded scans and determined whether the arthrodesis site was greater than or less than 50% fused. Interrater reliability was completed via kappa analysis. Based on kappa analysis, there was high interrater reliability in the assessment of subtalar arthrodesis. This was not statistically significant for the evaluation of ankle arthrodesis. The CT scan has become instrumental in determining the adequacy of arthrodesis in the foot and ankle. The present study demonstrates the reliability of orthopaedic surgeons to ascertain the status of subtalar arthrodesis via CT scan. Level IV, case series.

Foot & Ankle

The April 2014 Foot & Ankle Roundup360 looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion.

Use of Femoral Locking Plate for Salvage of Failed Ankle Arthoplasty after Trauma

When total ankle arthroplasty fails, few good options are available for salvage. We report a case of total ankle arthroplasty displacement after trauma. The injury was initially repaired with an anterior ankle arthrodesis plate for ankle fusion. On the follow-up radiographs taken during the fourth postoperative week, internal fixation failure was noted. A second revision was undertaken, using a femoral locking plate to obtain tibiotalocalcaneal fusion. We present this case as an alternative method for developing a stable construct in revising total ankle take down.

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.

Posterior Approach Using Anterior Ankle Arthrodesis Locking Plate for Tibiotalocalcaneal Arthrodesis

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.

Radiographic Analysis of Wedge Allograft Correction of Angular Malalignment in Ankle Fusion

Patients undergoing ankle arthrodesis often have coronal or sagittal plane malalignment. Correction of this deformity can be technically challenging. This retrospective review examines the use of an augmented interposition wedge allograft for deformity correction in ankle arthrodesis. Nineteen patients underwent open ankle arthrodesis with interposition allograft at our institution since 2003. Sixteen patients had isolated ankle fusions and three patients had ankle fusions as part of a tibiotalocalcaneal fusion. A wedge of frozen tricortical iliac crest or femoral head allograft was cut to appropriate size and shape to correct angular deformity with an average maximum graft width of 9.5 mm. Fixation of the arthrodesis was with either a cannulated screw and plate construct or a lateral blade plate. Radiographs were reviewed to assess preoperative, initial postoperative and final alignment at the time of solid fusion. Fusion was assessed on plain radiographs by visualization of bridging bony trabeculae. Seventeen of 19 patients (89%) obtained fusion at an average of 14.9 wks. Eleven ankles had preoperative tibiotalar valgus deformity with an average coronal alignment of 98.8 degrees and sagittal alignment of 110.5 degrees. Final coronal alignment was 90.9 degrees and sagittal alignment was 107.7 degrees. Eight ankles had varus deformity with an average coronal alignment of 77.4 degrees and sagittal alignment of 101.9 degrees. Final coronal alignment was 89.4 degrees and sagittal alignment was 107.4 degrees. The tibiotalar joint fusion rate in this series compares favorably to historically published data for standard ankle fusion. Interposition allograft was an effective method for deformity correction in difficult ankle arthrodeses.

Tibiotalocalcaneal Arthrodesis With a Curved, Interlocking, Intramedullary Nail

Tibiotalocalcaneal fusion with a straight rod has a risk of damaging the lateral plantar neurovascular structures and may interfere with maintaining normal heel valgus position.We report the results of a prospective study of tibiotalocalcaneal (TTC) arthrodesis with a short, anatomically curved interlocking, intramedullary nail. Forty-five arthrodesis in 42 patients, performed between Jan 2003 and Oct 2008, were prospectively followed. The mean followup was 48 (range, 10 to 74) months. The main indications for the procedure were failed ankle arthrodesis with progressive subtalar arthritis, failed ankle arthroplasty and complex hindfoot deformity. The outcome was measured by a combination of pre and postoperative clinical examination, AOFAS hindfoot scores, SF-12 scores and radiological assessment. Union rate was 89% (40/45). Eighty-two percent (37/45) reported improvement in pain and 73% (33/45) had improved foot function. Satisfactory hindfoot alignment was achieved in 84% (38/45). Postoperatively there was a mean improvement in the AOFAS score of 37. Complications included a below knee amputation for persistent deep infection, five nonunions, and three delayed unions. Four nails, six proximal and six distal locking screws were removed for various causes. Other complications included two perioperative fractures, four superficial wound infections and one case of lateral plantar nerve irritation. With a short, anatomically curved intramedullary nail, we had a high rate of tibiotalocalcaneal fusion with minimal plantar neurovascular complications. We believe a short, curved intramedullary nail, with its more lateral entry point, helped maintain hindfoot alignment.

Retrograde Intramedullary Nail Arthrodesis for Avascular Necrosis of the Talus

Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

Pre- and Postoperative Gait Analysis Following Conversion of Tibiotalocalcaneal Fusion to Total Ankle Arthroplasty

Level of Evidence: V, Expert Opinion

Femoral Head Allograft for Tibiotalocalcaneal Fusion Using a Cup and Cone Reamer Technique

End-stage degenerative joint disease of the hindfoot with large structural bone deficits is a complex problem encountered by the foot and ankle surgeon. Surgical treatment of this condition often requires tibiotalocalcaneal fusion with use of structural allograft bone. In this article, we describe a technique in which an acetabular reamer is used to create a concave surface for placement of a convex femoral head allograft. This “cup-and-cone” technique provides a congruent area for placement of the allograft, thereby increasing stability of the graft during preparation and placement of an intramedullary nail, while maximizing bone-to-bone surface contact at the arthrodesis site.

Does Alignment in the Hindfoot Radiograph Influence Dynamic Foot-floor Pressures in Ankle and Tibiotalocalcaneal Fusion?

The Saltzman-el-Khoury hindfoot alignment view (HAV) is considered the gold standard for assessing the axis from hindfoot to tibia. However, it is unclear whether radiographic alignment influences dynamic load distribution during gait. We evaluated varus-valgus alignment by the HAV and its influence on dynamic load distribution in ankle and tibiotalocalcaneal (TTC) arthrodesis. We clinically assessed 98 patients (ankle, 56; TTC, 42) with SF-36 and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual hindfoot alignment, HAV angle, and dynamic pedobarography using a five-step method. For comparison, 70 normal feet were evaluated. Minimum followup was 2years (average, 4.11years; range, 2-6years). The mean HAV angle was -0.8°±7.8° for ankle and -1.2°±6.9° for TTC arthrodesis. The HAV angle correlated with pedobarographic load distribution (r=0.35-0.53). Radiographic alignment did not influence SF-36 or AOFAS scores; however, load distribution correlated to qualities of these scores. Visual alignment only predicted the corresponding HAV angle in 48%. To reproduce the dynamic load of healthy subjects, HAV angles of 5° to 10° valgus were needed. Visual positioning is inadequate to determine intraoperative positioning and resulted in a varus position with a relatively large SD. The HAV should be used to assess the hindfoot alignment correctly. HAV angles of 5° to 10° valgus are needed to reproduce a physiologic gait pattern.

Salvage arthrodesis for failed total ankle arthroplasty

Background and purpose Total ankle arthroplasty (TAA) has gained popularity in recent years. If it fails, however, salvage arthrodesis must be reliable as a rescue procedure. We therefore investigated the clinical, radiographic, and subjective outcome after salvage arthrodesis in a consecutive group of patients, and concentrated on the influence of the method of fixation on union rate and on salvage in inflammatory joint disease.Patients and methods Between 1994 and 2005, salvage arthrodesis was performed on 18 ankles (18 patients). Diagnosis was inflammatory joint disease (IJD) in 15 cases and osteoarthritis (OA) in 3. Tibio-talar fusion was performed in 7 ankles, and tibio-talocalcaneal fusion in 11. Serial radiographs were studied for time to union. Clinical outcome at latest follow-up was measured by the AOFAS score, the foot function index (FFI) and by VAS scores for pain, function, and satisfaction.Results Blade plates were used in 7 ankles (4 IJD, 3 OA); all united. Nonunion developed in 7 of the 11 rheumatic ankles stabilized by other methods. 11 patients (8 fused ankles, 3 nonunions) were available for clinical evaluation. Their mean AOFAS score was 62 and mean overall FFI was 70. VAS score for pain was 20, for function 64, and for satisfaction 74. The scores were similar in united and non-united ankles.Interpretation Blade plate fixation is successful in salvage arthrodesis for failed TAA. A high nonunion rate was found after salvage ankle arthrodesis in IJD with other methods of fixation. Clinical results were fair to good.

Femoral Head Allograft for Large Talar Defects

Large talar body defects after total or subtotal talectomy present a difficult treatment dilemma for the reconstructive foot and ankle surgeon. Treatment of these defects includes tibiocalcaneal fusion, but this leaves the patient with significant limb shortening. Tibiotalocalcaneal fusion can be done if there is a subtotal talectomy with the talar head and neck remaining. This technique is done with some form of structural or cancellous graft with internal or external fixation. These fusions are technically challenging and often involve harvesting large autografts from the iliac crest. The technique described involves a less complex reproducible 1-stage reconstruction for large talar defects using a transfibular approach with placement of a femoral head allograft in a fusion bed prepared by acetabular reamers.

Comparison of Two Intramedullary Nails for Tibiotalocalcaneal Fusion: Anatomic and Radiographic Considerations

Retrograde intramedullary nailing is an established procedure for tibiotalocalcaneal arthrodesis. This study was conducted to see whether, and if so to what extent, nail design modifications would influence the risk to anatomic structures and the bony coverage of the nail base. Six pairs of thawed fresh-frozen cadaver legs received two different intramedullary nails (N1: straight nail, lateral-medial tip locking; N2: valgus-curved nail, medial-lateral tip locking) under simulated operative conditions. The specimens were dissected; distances between the at-risk structures and the hardware were measured. The hindfoot axis and the volume of the intracalcaneal nail portion were determined with CT. At the plantar entry site, N2 was significantly farther from the flexor hallucis longus tendon (p=0.047), the medial plantar artery (p=0.026), and the lateral plantar nerve (p=0.026) than N1. The lateral-medial calcaneal locking screw of N1 damaged significantly more often the peroneus brevis tendon (p=0.03) than N2. The proximal tip-locking screw, N2, was significantly farther from the anterior tibial artery (p=0.075) and the deep (p=0.047) and superficial peroneal nerves (p=0.009) than N1; N1 was significantly farther from the great saphenous vein (p=0.075) than N2. The distal tip-locking screw, N1. damaged significantly more often the extensor digitorum longus (p=0.007), the anterior tibial artery(p = 0.04), and the deep and superficial peroneal nerves (p=0.03) than N2. CT did not show any significant changes in the hindfoot axis with either device; intracalcaneal nail volumes were similar. A curved nail can increase the distance to at-risk plantar structures. Medial-lateral nail-tip locking appears to have less risk to neurovascular structures. Safer retrograde intramedullary nailing for tibiotalocalcaneal fusion requires knowledge of the structures at risk and appropriate operative technique.

Use of the Versa nail and anterior ankle arthrotomy to achieve primary tibiotalocalcaneal arthrodesis in rheumatoid arthritis

Background Surgical treatment of rheumatoid ankle can be challenging. Tibiotalocalcaneal arthrodesis is one such treatment and has been performed using various methods and tools including different types of nails. Objective To evaluate the clinical outcome of primary tibiotalocalcaneal arthrodesis in rheumatoid arthritis using anterior ankle arthrotomy and Versa nail, an intramedullary nail designed specifically for tibiotalocalcaneal arthrodesis. Methods Review of case records, radiographs and telephonic interview of 11 rheumatoid patients who had undergone primary tibiotalocalcaneal fusion using the Versa nail between March 2004 and May 2005. Results Arthrodesis was achieved in nine cases. Complications seen in four patients included a non-union, fractured tibia, ulceration and cellulitis. All complications resolved with conservative treatment and none affected the long-term outcome. There was a highly significant improvement in the modified AOFAS score from 18 before surgery to 72 afterwards [ p < .0001]. Conclusion Tibiotalocalcaneal arthrodesis using Versa nail and anterior approach is an effective procedure in rheumatoid arthritis. Anterior approach preserves the malleoli and therefore rotational stability, making it possible to avoid the use of proximal screws. Our study suggests that, in the presence of very osteopenic bone and atrophic skin, it is safe to avoid using screws and to allow weight bearing without compromising the final outcome.

Tibiotalocalcaneal Fusion With Retrograde Locked Intramedullary Nailing

Tibiotalocalcaneal fusion with a locked intramedullary nail is an excellent option to salvage the foot and ankle for patients with severe pathologies of the tibiotalar and subtalar joints with poor bone stock and impaired soft tissue mantle. To overcome some of the pitfalls of this technique, we compiled previous publications on this subject and formulated a method for minimizing the typical problems of this procedure. The important factors to consider are the use of a minimally invasive technique for debridement of the joints, maintaining a sufficient compression and stability at the fusion site, and placing the intramedullary nail correctly.

Biomechanical Evaluation of Primary Stiffness of Tibiotalocalcaneal Fusion with Intramedullary Nails

Intramedullary implants are being used with increasing frequency for tibiotalocalcaneal fusion (TTCF). Clinically, the question arises whether intramedullary (IM) nails should have a compression mode to enhance biomechanical stiffness and fusion-site compression. This biomechanical study compared the primary stability of TTCF constructs using compressed and uncompressed retrograde IM nails and a screw technique in a bone model. For each technique, three composite bone models were used. The implants were a Biomet nail (static locking mode and compressed mode), a T2 femoral nail (compressed mode); a prototype IM nail 1 (PT1, compressed mode), a prototype IM nail 2 (PT2, dynamic locking mode and compressed mode), and a three-screw construct. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as percent of the available fusion-site area. Stiffness was tested in dorsiflexion and plantarflexion (D/P), varus and valgus (V/V), and internal rotation and external rotation (I/E) (20 load cycles per loading mode). Mean contact surfaces were 84.0 +/- 6.0% for the Biomet nail, 84.0 +/- 13.0% for the T2 nail, 70.0 +/- 7.2% for the PTI nail, and 83.5 +/- 5.5% for the compressed PT2 nail. The greatest primary stiffness in D/P was obtained with the compressed PT2, followed by the compressed Biomet nail. The dynamically locked PT2 produced the least primary stiffness. In V/V, PT1 had the (significantly) greatest primary stiffness, followed by the compressed PT2. The statically locked Biomet nail and the dynamically locked PT2 had the least primary stiffness in V/V. In I/E, the compressed PT2 had the greatest primary stiffness, followed by the PT1 and the T2 nails, which did not differ significantly from each other. The dynamically locked PT2 produced the least primary stiffness. The screw construct's contact surface and stiffness were intermediate. The IM nails with compression used for TTCF produced good contact surfaces and primary stiffness. They were significantly superior in these respects to the uncompressed nails and the screw construct. The large contact surfaces and great primary stiffness provided by the IM nails in a bone model may translate into improved union rates in patients who have TTCF.