TTC Fusion Research Articles

Efficacy and safety of carbon fiber retrograde intramedullary nailing in tibio-talar-calcaneal fusion: a single-centre retrospective study

IntroductionTibio-talar-calcaneal (TTC) fusion is a salvage procedure designated for treating various severe hindfoot pathologies. While traditional methods have been effective, the advantage of carbon fiber (CF) retrograde intramedullary nailing (RIMN) presents a potentially superior technique. This study evaluates the efficacy and safety of CF RIMN in TTC fusion, focusing on union rates, complication rates, and patient-reported outcomes. Materials and methodsConducted as a single-center, retrospective study, this research involved 21 patients who underwent TTC with CF RIMN from 2015 to 2021. Patient selection excluded those with active infections or those needing significant bone allografts. Patient follow-up was conducted at multiple intervals postoperatively, with a minimum follow-up of 24 months, assessing for union complications and using tools like the VAS, SF12, and AOFAS for patient-reported outcomes. ResultsThe study observed a 90% union rate among patients. Complication rates included a 14% incidence of iatrogenic fractures to the anterior tibial cortex and 19% postoperative complications. Significant improvement was noted in VAS scores but not in SF12 and AOFAS scores. The use of 200 mm RIMN was identified as requiring careful consideration due to associated complications. ConclusionCF RIMN in TTC fusion demonstrates a high union rate with notable complications. The significant improvement in VAS scores indicates patient satisfaction, but the lack of statistical significance in SF12 and AOFAS scores warrants attention. The findings advocate for the cautious use of 200 mm RIMN and highlight the need for further research, suggesting prospective, multicenter studies to validate these findings and explore long-term outcomes. Level of evidenceIII.

Outcomes of One-Stage Arthroscopic Ankle and Tibiotalocalcaneal Arthrodesis with External Fixation for Septic Ankle and Hindfoot Arthritis: A Case-Series Study.

The occurrence of infection in the ankle and hindfoot presents a formidable surgical challenge. Currently, there is a lack of consensus regarding its treatment strategies. The purpose of this study was to investigate the outcomes of one-stage arthroscopic ankle and tibiotalocalcaneal (TTC) arthrodesis with external fixation in the treatment of septic ankle and hindfoot arthritis. A retrospective consecutive case-series study was conducted involving six patients diagnosed with acute or chronic septic ankle or hindfoot arthritis, who underwent operative intervention entailing thorough debridement, arthroscopically assisted one-stage ankle or TTC fusion, and external fixation. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) pain score were determined preoperatively and at the final follow-up. Demographic and clinical data, inclusive of perioperative and postoperative complications, were recorded. Comparisons of AOFAS ankle-hindfoot score and VAS pain score between preoperative measures and those at the final follow-up were conducted using paired t-tests or paired Wilcoxon rank-sum tests. The study cohort comprised two males and four females, with a mean age of 48.7 years (range, 26-75) at the time of surgical intervention. At the final follow-up (mean, 26.5 months; range, 16-48), the AOFAS scores exhibited a significant improvement, ascending from an initial mean of 38.8 (range, 12-57) to 80.0 (range, 54-92) (p = 0.007). VAS scores indicated a substantial reduction in pain, decreasing from 6.5 (range, 4-9) to 0 (range, 0-5) (p = 0.046). All patients had achieved osseous consolidation, with a hindfoot infection control rate of 100%. One-stage arthroscopic ankle and TTC arthrodesis with external fixation is as an effective therapeutic choice for septic ankle or hindfoot arthritis. This approach yields favorable outcomes characterized by effective infection control, favorable osseous consolidation, and significant functional restoration of the affected limb.

Medical Malpractice Litigation Following Hindfoot Arthrodesis

Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims which can impose significant economic and psychological burden. This study investigates malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. The database was queried for all cases involving hindfoot arthrodesis using the terms “malpractice” and either “ankle fusion,” “arthrodesis,” “subtalar fusion,” “tibiotalar fusion,” “tibiotalocalcaneal fusion,” “TTC fusion,” or “tibiofibular fusion” from 1987 to 2023. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (±456,179). The most alleged category of negligence was procedural/intraoperative error (75%) followed by postsurgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Given the frequency of hindfoot arthrodesis performed, this study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality.

Single-Center, Early Experience with the First 3D-Printed Surface, Fixed Bearing, Total Ankle Arthroplasty: A Minimum of 2-Year Follow-Up

Introduction/Purpose: As the fourth generation of total ankle arthroplasty (TAA) implants evolve, treatment solutions for end- stage ankle arthritis continue to improve. Technological advancements in CT guided planning and 3-D printing offers surgeons the ability to perform TAA with patient specific instrumentation and implants. 3-D printed components are designed to act as scaffold in hopes to facilitate early in-growth, to increase implant stability, to support long-term survivorship, and ultimately to improve the quality of life our patients. We present our early experience at a single academic center with a minimum of 2-year follow up data on the first 3-D printed, fixed bearing, TAA in the United States. We hypothesize that 3-D printed technology will demonstrate improved long-term survival and increased bony in-growth on the implant-bone interface. Methods: A retrospective review was performed on patients who underwent TAA with a minimum of 2-year clinical and radiographic data in which this 3-D printed TAA was utilized at our single academic center. Patient demographic, radiographic, and functional outcome scores were collected preoperatively, at 6 months, 1 year, and 2 years. The severity of ankle arthritis and associated deformities in patients were stratified using the COFAS classification. The primary outcomes of this study were implant survivorship, comparative analysis of preoperative and postoperative Patient Reported Outcomes Measurement Information System (PROMIS) physical function scores, VAS pain scores, radiographic development of linear radiolucency >2 mm, cystic radiolucency > 5mm, subsidence, and adverse events within 2 years of surgery. Results: Thirty patients were included with a median follow-up of 26 months (range, 24-36 months). Implant survival rate was 90%. One patient was revised to a stemmed TAA secondary to tibial subsidence. One patient required a TTC fusion secondary to Charcot collapse. One patient was revised to a staged ankle fusion secondary to periprosthetic joint infection. Two patients (6.7%) experienced linear radiolucency >2mm with tibial subsidence in which one patient required a revision TAA (mentioned above) and another who was asymptomatic. No significant cystic radiolucency >5 mm were identified. Five patients required re-operation from complications unrelated to the implant. VAS scores decreased significantly from 6 (IQR, 4-8) to 1 (IQR, 2-4) (P <.001; r=0.55). PROMIS Physical scores increased significantly from 43.6 (IQR, 33-47.7) to 50.8 (44.8-57.7)(P <.001; r=0.60). Conclusion: The utilization of this new 3-D printed, fixed bearing TAA demonstrated a ninety percent overall implant survival rate in our small cohort of patients. Further data will be required to determine the long term efficacy of this new 3-D printed implant on patient outcomes. Our early experience and complications presented in our study demonstrate that this 3-D printed TAA implant is safe and effective in the treatment of end-stage ankle arthritis.

Fusion Rates in Tibiotalocalcaneal Arthrodesis with Tantalum Coated Metal Cup Augmentation

Introduction/Purpose: Tantalum coated metal spacers (TCMS) have recently been utilized to fill and provide structure to large bony defects in the hindfoot. Tantalum is an appealing material due to its biocompatibility, lack of immune response generation, and structural integrity. Compared to custom printed spacers and bulk allografts, TCMS are readily available off-the-shelf implants with significantly less cost. There is currently a paucity of literature assessing the use and outcomes of TCMS in foot and ankle surgery, specifically in tibiotalocalcaneal (TTC) arthrodesis. This study serves to assess clinical outcomes and fusion rates of patients who underwent TTC arthrodesis utilizing intramedullary nailing with TCMS augmentation for large bony defects. Methods: We retrospectively identified all patients > 18 years of age who underwent TTC arthrodesis with TCMS augmentation at our tertiary care center between 2015-2021. We also identified all patients who underwent TTC arthrodesis without augmentation within that time frame. The computed tomography (CT) scans at the six-month postoperative point were reviewed by one board-certified orthopaedic foot and ankle surgeon to determine fusion status, which was defined as having at least 50% fusion mass. Patient-reported outcomes measures (PROMs) including the modified foot function index (FFI) and PROMIS Global Mental Health Score were collected for patients in both groups. Patient demographics, clinical outcomes, and PROMs were compared between groups. A multivariate logistic regression model measured the effect of TCMS augmentation on the likelihood of achieving fusion. Results: Of the 65 patients included, 21 patients (32.3%) underwent TTC with TCMS augmentation. There were no significant differences in demographics between the two groups. Patients in the TCMS group had significantly higher modified FFI (91.1 + 47.6 vs 26.3 + 48.8, p< 0.001) and PROMIS Global Mental Health (12.2 + 4.82 vs. 5.59 + 6.76, p< 0.001) scores in the postoperative period. Overall, the fusion rate was higher for the TCMS group, however the difference was not significant between groups (90.5% vs. 80.5%, p=0.472). Multivariate logistic regression identified that TCMS augmentation was a nonsignificant predictor of increased odds of fusion at the six-month postoperative point (OR=2.87, p=0.232). Conclusion: This study is the largest to date to present 6-month postoperative CT scans demonstrating successful TTC fusion with TCMS augmentation, contributing to our understanding of its utility. Given the severity of disease and bone loss in the TCMS group, it is not surprising that post-operative patient reported outcome scores differed significantly compared to the control group. TCMS augmentation can be utilized as cost effective spacers to fill large defects in TTC arthrodesis with successful union rates. Further studies are needed to evaluate the efficacy of TCMS augmented fusions as a viable substitute to custom printed cages. Figure 1: Weight-bearing anteroposterior and lateral ankle radiographs of a patient with post-traumatic ankle arthritis and previously treated chronic osteomyelitis with valgus malalignment (A). Anteroposterior and lateral ankle radiographs status post TCMS augmented TTC arthrodesis (B). Coronal and sagittal CT scans demonstrating bony union through the TCMS augment (C).

Outcomes and Complications of Tibiotalocalcaneal Arthrodesis

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Tibio-talo-calcaneal (TTC) arthrodesis is usually a salvage procedure to address several hindfoot and ankle conditions. Non-union rate after TTC fusion is variably reported 3.4% - 48%. The aims of this study were to describe the outcomes and complications of this procedure and to determine potential risk factors associated with non-union. Methods: In this IRB-approved retrospective cohort study, we used the following codes (28705,28725 and 27870) to search the medical records for all patients who underwent TTC fusion between 2006-2022. All relevant demographic data, surgical indications, surgery details (type of the graft, type of the implant, and surgical approach, associated procedures), post-operative course (complications and union rate) and follow-up duration were extracted. Descriptive statistics were performed, and continuous variables were described using median (interquartile range) and categorical variables were described using frequency (%) and mean (standard deviation, SD). Patients and surgery characteristics were compared between united and non-united cases using Wilcoxon Rank Sum Tests for continuous variables and Chi-squared or exact tests, as appropriate, for categorical variables. Analyses were performed using SAS statistical software version 9.4 (SAS Institute Inc., Cary, NC). Results: Fifty-one patients (53 feet) were included in the study. Long hindfoot fusion nails were used in 51 cases.Ten cases were routinely dynamized 8-10 weeks after surgery. In 24 (45.3%) patients, morselized allograft was combined with infuseTM and reamer irrigation aspiration autograft (RIA). In 20 (37.7%) patients, morselized allograft was combined with infuseTM only. There were 6 non-union cases (11.3%). When comparing patients and surgery characteristics between non-union versus union group, smoking (P = 0.0150) and routine dynamization (P= 0.0297) were higher in the non-union group. No difference in union rates between different types of graft. Frequency of other complications is listed in (Figure 1). Follow up duration was 27.2 months (range 4-108 months). Conclusion: TTC fusion achieves good union rate (88.68%), however it carries a relatively high risk of complications. Routine dynamization of the TTC nail at 8-10 weeks could be a risk factor for non-union. Smoking was also associated with a high non- union rate.

Fusion Rates in Tibiotalocalcaneal Arthrodesis with Tantalum Coated Metal Cup Augmentation

Category: Ankle Arthritis; Ankle Introduction/Purpose: Tantalum coated metal spacers (TCMS) have recently been utilized to fill and provide structure to large bony defects in the hindfoot. TCMS have a porous structure and elastic modulus similar to cancellous bone, increasing resistance to collapse, as well as osteoconductive properties that allow for bony ingrowth. At this time, there is still a paucity of literature assessing the use and outcomes of TCMS in foot and ankle surgery, more specifically as bridging structures for large bony defects when performing tibiotalocalcaneal (TTC) arthrodesis. This study serves to assess clinical outcomes and fusion rates of patients who underwent TTC arthrodesis utilizing intramedullary nailing with tantalum coated metal cup augmentation for large bony defects. Methods: We retrospectively reviewed the charts of 20 patients who underwent TTC fusion with TCMS augmentation at our local tertiary care center between 2015-2021. The CT scans at the six-month post-operative window were reviewed by one orthopaedic surgeon to determine the presence of bony fusion, which was defined as having at least 50% fusion mass. From the initial cohort, we collected the following modified foot function index scores for 13 patients: PROMIS Physical Health (0-20), PROMIS Mental health (0-20), Foot Function Index (0-170), Activity Limitation Scale (0-30), Pain Scale (0-50) and Disability Scale (0-90). Results: The mean age of our cohort was 53.9 (± 12.9) with a mean CCI of 1.54 (± 1.127) and mean follow up of 451.5 days (± 353.3). Mean modified foot function index scores included: PROMIS Physical Health 12.15 (± 3.34), PROMIS Mental health 12.23 (± 4.82), Foot Function Index 91.08 (± 47.59), Activity Limitation Scale 15.00 (± 10.42), Pain Scale 25.00 (± 14.77) and Disability Scale 51.00 (± 25.06). The post-operative complication rate was 30.8% in which 3 patients required a revision surgery via nail dynamization and one patient required a below knee amputation due to an infected nonunion of the TTC arthrodesis. The overall fusion rate at the 6-month postoperative visit was 69.2%. Conclusion: Unlike prior studies, we were able to obtain 6-month post-operative CT scans to delineate successful fusions with a larger number of patients (n=13). Given the paucity of literature looking at TCMS augmented fusions in foot and ankle surgery, our data will contribute to our understanding and efficaciousness of this relatively new use of TCMS in foot and ankle surgery. Further studies are needed to evaluate the efficacy of TCMS augmented fusions as a viable surgical approach as well an alternative to standard nail dynamizations with structural grafts.

Tantalum Spacer Augmentation of Large Bony Defects in Hindfoot Arthrodesis

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a common surgical technique used in the treatment of various hindfoot pathologies. Large osseus defects are particularly challenging with a high rate of graft collapse and nonunion when using autograft or allograft. Porous tantalum has emerged as a favorable osteoconductive material to address sizeable hindfoot defects. The purpose of this study was to review the radiographic outcomes and complications associated with tantalum spacer augmentation in hindfoot arthrodesis. Methods: A retrospective review was performed of all patients who underwent a hindfoot arthrodesis augmented with a metal spacer (Trabecular MetalTM) from 2012 to 2020 at a single institution. Patients [endif]–>18 years of age who had a large, hindfoot osseus defect were included in the study. Surgeries were performed by two fellowship-trained foot and ankle orthopaedic surgeons. The primary outcomes assessed were presence of radiographic union, post-operative complications, and return to the operating room. Results: Fourteen patients were identified who underwent hindfoot arthrodesis with the use of a Trabecular MetalTM augment. Two of the 14 patients were lost to follow-up resulting in a total of 12 patients with an average age of 59 years (range, 42 - 74). The average length of follow-up was 26 months (range, 4 - 56). Four patients had plain radiographs at final follow-up compared to 7 patients who had CT scans performed. Nine patients underwent TTC fusion with a retrograde intramedullary nail (MedShape DynaNail) and three patients underwent isolated subtalar (ST) fusion. Ten of 12 fusions were augmented using reamer irrigator aspirator (RIA) autograft and two patients received autograft from either the tibia or fibula. Of the 12 patients, 10 achieved radiographic evidence of union for a union rate of 83%. There were three patients who required reoperations: one hypertrophic nonunion, one surgical site infection, and one symptomatic hardware. Conclusion: Tantalum provides a great structural option for patients undergoing TTC or ST fusion in the setting of large hindfoot bony defects. This method combined with the use of autograft and adequate biomechanical stabilization can produce reliable results. Functional outcomes are needed to capture the utility of this technique in attaining longterm clinical results.

High-risk ankle fractures in high-risk older patients: to fix or nail?

Optimal treatment of high-risk ankle fractures in older, comorbid patients is unknown. Results of open reduction internal fixation (ORIF) versus tibiotalocalcaneal (TTC) fusion nailing for the treatment of high-risk geriatric ankle fractures were investigated. Results of ORIF versus TTC fusion nailing were evaluated via retrospective case-control cohort study of 60 patients over age 50 with an open ankle fracture or one with at least 50% talar subluxation and at least 1 high-risk comorbidity: diabetes mellitus (DM), peripheral vascular disease, immunosuppression, active smoking, or a BMI > 35. The primary outcome was reoperation rate within 1-year post-surgery. Secondary outcomes include infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition, and hospital acquired complications. Mean age was 71 (ORIF) and 68 (TTC). 12/47 (25.5%) ORIF cases were open fractures versus 4/14 (28.6%) with TTC. There were no significant differences between ORIF and TTC in 1-year reoperation rates (17% vs 21.4%), infection rates (12.8% vs 14.3%), or union rates (76.% vs 85.7%), respectively. One TTC patient sustained a peri-implant fracture treated nonoperatively. There were no significant differences in medical risk factors between groups other than a higher rate of DM in the TTC group, 42.6% vs 78.6%, p = 0.02. Incomplete functional outcome data in this challenging patient cohort precluded drawing conclusions. ORIF and TTC fusion nailing result in comparable and acceptable reoperation, infection, and union rates in treating high-risk ankle fractures in patients over 50 with at least 1 major comorbidity for increased complications; further study is warranted.

Surgical Outcome of Hindfoot Fusion using a Retrograde Hindfoot Fusion Nail

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

Effect of Preoperative Ulceration on Outcomes of Tibiotalocalcaneal Arthrodesis

Category:Hindfoot; DiabetesIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. In patients with neuropathy, hindfoot deformity, and preoperative hindfoot ulceration, management options can be limited and very challenging. Previously, some authors have advocated for fine wire circular frames and avoidance of internal fixation in an effort to decrease the risk of infection in patients with preoperative ulceration, however, there is very limited data on the outcomes of TTC arthrodesis with internal fixation in this patient population. We hypothesized that internal fixation of TTC arthrodesis in patients with preoperative ulceration would lead to higher infection rates compared to patients without ulceration.Methods:A retrospective review was conducted on the TTC fusions performed from 2016-2020 by a single fellowship trained foot and ankle surgeon at an academic medical center. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients' charts. Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 3 months of follow-up. 34 patients (34 ankles) underwent TTC arthrodesis Mean age was 60.7 years and mean follow-up was 1.3 years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Nine patients had preoperative ulcers at the time of surgery.Results:Common surgical indications included Charcot neuropathy (n=17), post-traumatic (n=14), and cavovarus (n=3). All patients with preoperative ulcers underwent TTC fusion with an intermedullary rod. Of the patients without ulceration, 18 underwent intermedullary nailing, 5 underwent plating, and 1 had an external fixator placed. There was no difference in deep wound infection rates between patients with (2/9, 22.2%) and without (2/25, 8.0%; p=.386) preoperative ulceration; nor was there a difference in rate of fusion, wound healing, or radiographic alignment. One patient without preoperative ulceration underwent a below knee amputation due to infection.Conclusion:TTC arthrodesis with internal fixation appears to be a reasonable consideration in patients with a preoperative hindfoot ulcer. There was no statistical difference in infection rate in patients undergoing TTC fusion with and without preoperative ulceration. Further, the rate of infection in those with an ulcer and internal fixation was acceptable, and internal fixation can be considered in these patients.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. Level IV, case series.

Results of Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy - A retrospective analysis of 44 patients

BackgroundThe role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy. Study designA retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre. Patients and methodsIn a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction). ResultsThere were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%). ConclusionDespite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.

Bone Marrow Aspirate Concentrate as a Reliable Adjunct in Tibiotalocalcanal Fusion: A Radiographic Modified RUST Score Analysis.

Tibiotalar and subtalar arthritis requiring tibiotalocalcaneal (TTC) fusion can be technically challenging and is dependent on reliable fusion for a good clinical outcome. Initial data regarding bone marrow aspirate concentrate (BMAC) has shown promise in use as an aide in both fracture and fusion healing. The purpose of this study is to determine the outcomes in TTC fusion when utilizing BMAC as an adjunct. Twenty consecutive patients who underwent TTC fusion with BMAC adjunct between March 2013 and November 2017 were retrospectively screened for inclusion. Patients were included regardless of comorbidities or risk factors for non-union, and only excluded if they did not have a minimum of 12months of clinical and/or radiographic chart data. Follow-up was obtained at regular intervals of 6weeks, 3months, 6months and 1year. Modified RUST scores were applied to grade bony union in a blinded fashion by two orthopedic trauma fellowship-trained surgeons and agreement was assessed via intraclass correlation coefficient (ICC). Twenty patients were screened and 12 met inclusion criteria for analysis. Majority were male (66.6%) at a mean age of 55.4years and they were all treated via TTC fusion for a diagnosis of tibiotalar and subtalar arthritis. There were no postoperative complications and no reoperations in this cohort; no donor site morbidity was associated with BMAC. By the 3-month follow-up timepoint, all but one patient received a minimum modified RUST score of 10 indicating bony union (ICC 0.91); by the 6-month time point (ICC 0.94), all 12 patients were deemed united. BMAC as an adjunct in the setting of TTC fusion is a safe treatment option that can promote reliable, consistent bony fusion with minimal complications.

Outcomes of Tibiotalocalcaneal Arthrodesis using a Custom Three-Dimensional Printed Titanium Truss Implant

Category:Ankle; HindfootIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis (fusion) is considered a salvage procedure for patients with severe hindfoot and ankle pathology. Several techniques have been described for TTC fusion, including the use of an intramedullary rod, plate and screw constructs, screws only, and external fixation/frames. Recently, 3D printing technology has allowed for a new technique to treat large hindfoot and ankle osseous defects with a custom three-dimensional (3D) titanium truss implant. These implants are specifically designed based on preoperative patient computed tomography (CT) scans. Early studies have shown promising radiographic and functional results, though these have been limited largely to expert opinions and case reports. The purpose of this study is to evaluate the clinical, radiographic, and functional outcomes of TTC arthrodesis using a custom 3D titanium truss implant.Methods:A retrospective review of patients who have undergone TTC arthrodesis utilizing a custom 3D-printed titanium truss implant (4WEB Medical, Inc., Frisco, TX) with a fellowship-trained orthopaedic foot and ankle surgeon at a single institution was performed. Patients <18 years old, and those undergoing TTC arthrodesis using any other primary method of filling osseous defects (i.e. femoral head allografts, autografts) were excluded. Patient demographics including age, sex, body mass index (BMI), smoking status, laterality of surgery, co-morbidities (diabetes mellitus, rheumatoid arthritis), preoperative diagnosis, previous hindfoot or ankle surgeries, and any postoperative complications were collected. Patients at least one year removed from the procedure were contacted to complete the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale, along with the Visual Analog Scale for pain (VAS) and the Short Form-12 questionnaire (SF-12). Postoperative radiographs were reviewed to assess ankle and hindfoot alignment, implant integrity and any osseous abnormalities.Results:Eighteen patients underwent TTC fusion using custom titanium truss implants and were eligible for follow-up and analysis. Average patient age at the time of surgery was 58.7 years, and average BMI was 30.25 kg/m2. Seven patients (38.9%) were either current or former smokers, and 3 patients (16.7%) were diabetic. On average, patient FAAM ADL scores improved from 33.23 preoperatively to 59.56 (p=0.023), while VAS pain scores decreased from 59.07 to 34.22 (p<0.001). SF-12 Mental Health scores increased from 45.45 to 56.42 (p=0.031), while Physical Health scores improved mildly from 28.78 to 31.75 (p=0.110). Two patients (11.1%) had significant postoperative complications; one patient went on to require below knee amputation, and one patient demonstrated incomplete healing with implant loosening at their most recent follow-up.Conclusion:We have shown that custom titanium truss implants are viable and effective for use in TTC fusion. Use of such implants resulted in significant functional improvement among the cohort with low rates of complications and subsequent surgical interventions.

A Staged Treatment Algorithm for the Management of Severe Charcot Hindfoot Arthropathy, using Tibiotalocalcaneal Arthrodesis with Femoral Head Allograft

Category:Diabetes; Ankle; Diabetes; HindfootIntroduction/Purpose:Charcot neuroarthropathy of the hindfoot (Brodsky type 2 and 3) can involve significant talar collapse / bone loss leading to hindfoot instability, the goal of treatment to create a stable plantigrade shoeable ulcer and infection free foot. This can often be achieved with tibiotalocalcaneal (TTC) arthrodesis but a plantigrade foot can be challenging in setting of significant talar bone loss. Structural allograft has been used in association with TTC fusions in a number of settings but not explored in the treatment of charcot hindfoot. The goal of this study was to examine the outcomes of structural allografting combined with TTC arthrodesis for the treatment of charcot hindfoot.Methods:Retrospective review of all patients treated at our institution with a Brodsky type 2 or 3 was performed over a five year period from 2014 - 2019. We identified twenty-two patients, 12 males and 10 females with a mean age of 57 years. All underwent surgery by the senior author, a fellowship trained foot and ankle orthopedic surgeon. Patients with infection were treated with antibiotics and a Taylor spatial frame prior to definitive stabilization. Non-infected patients were either placed in a total contact cast (TCC) if they were in active charcot or underwent primary charcot reconstruction. If after initial treatment patients had a plantigrade foot, they were placed in stiff soled rocker bottom shoe with custom accommodative insoles. Patients who did not have a plantigrade foot underwent TTC arthrodesis to achieve this. Femoral head allograft was used if excessive talar bone loss or collapse of the hindfoot was noted.Results:At final follow up 13 patients (59%) of the cohort achieved grade 1, an infection and ulcer free plantigrade foot that was able to fit in a shoe. 7 (32%) of patients achieved grade 2, a plantigrade foot in brace, and 2 (9%) achieved level 3 a plantigrade foot. No patients in this cohort underwent amputation. Average duration of treatment until final status was 18 months (minimum 2, maximum 37), number of interventions 3.9 (minimum 1, maximum 10). Of the twelve patients who required allograft, they averaged 4.25 interventions and average time of 17.6 months until final status. Of those who did not require allograft, they averaged 3.4 interventions with follow up of 11.9 months.Conclusion:Our data suggests that patients with Brodsky type 2 and 3 charcot arthropathy of the ankle and hindfoot even with infection can be successfully treated with staged treatment. This includes external fixation and infection management, followed by tibiotalocalcaneal intramedullary nail fixation with or without femoral head allograft to allow for a plantigrade foot and weight bearing in a stiff soled rocker bottom shoe. Further study is needed to determine long term outcomes and relapse rates.

Factors Affecting the Outcomes of Tibiotalocalcaneal Fusion

Category:Hindfoot; Ankle; Ankle ArthritisIntroduction/Purpose:Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion.Methods:We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome.Results:Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019).Conclusion:We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. This helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion.

Evaluating Prospective Patient-Reported Pain and Function Outcomes after Ankle and Hindfoot Arthrodesis

Category:Hindfoot; AnkleIntroduction/Purpose:Hindfoot and ankle arthritis and deformity constitute a significant disease burden upon affected patients. Surgical hindfoot and ankle arthrodesis procedures are indicated for pain and instability in such patients and include ankle arthrodesis, tibitalocalcaneal (TTC) fusion, subtalar arthrodesis, and triple arthrodesis. Long-term patient-reported outcomes, including postoperative pain, function, and overall satisfaction, of these procedures have not yet been well-studied. The purpose of this study was to assess the outcomes and prognosis of various hindfoot fusion subtypes along with ankle fusion by using two validated patient-reported outcome measures: The Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs).Methods:The sample consisted of 68 patients presenting to a tertiary care facility for ankle and hindfoot fusion surgeries, including ankle arthrodesis (n= 16), TTC fusion (n= 9), subtalar arthrodesis (n= 25), and triple fusion (n= 18), who had completed preoperative, 12-month postoperative, and 24-month postoperative PROMIS PF and PI CATs. Differences in CAT T-scores were calculated for each patient to create a prognostic estimation of pain and physical function at one and two years postoperative. Mean absolute T-scores for each procedure were also calculated and compared to PROMIS reference population mean (SD) T- scores of 50 (10). The distribution of PROMIS PF and PI T-scores were assessed via a Shapiro-Wilk test, and then paired t-tests were used to compare mean differences in T-scores.Results:Importantly, no statistically significant difference was found between 12-month mean PI scores for patients undergoing any fusion procedure and PROMIS reference population mean. Moreover, triple fusion patients had significantly decreased pain at 12 (delta-T-score= -11.10, p= 0.02) and 24 months (delta-T-score= -12.72, p= 0.01) relative to preoperative T-scores along with increased physical function at 12 (delta-T-score= 6.67, p= 0.04) and 24 months (delta-T-score= 8.70, p= 0.04). PF differences after 12 months were not statistically significant for ankle (delta-T-score= -1.67, p= 0.73), TTC (delta-T-score= 0.04, p= 0.99), or subtalar arthrodesis (delta-T-score= 0.37, p= 0.72). PI decreased after 12 months for ankle (delta-T-score= -14.57, p= 0.16), TTC (delta-T-score =-4.08, p= 0.21), and subtalar arthrodesis (delta-T-score= -0.64, p= 0.53); however, these differences did not achieve statistical significance.Conclusion:Overall, at 12 months after an ankle or hindfoot arthrodesis, patients experienced a similar level of pain to the reference population mean. Following a triple fusion procedure, patients can be provided with an accurate prognosis that they can expect reduced pain and increased physical function that will progressively improve from 12 to 24 months postoperative. No statistically significant difference in pain or physical function at 12 or 24 months for ankle, TTC, or subtalar arthrodesis was found.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis with Autologous Bone Block is Associated with High Rates of Fusion

Category:Ankle; HindfootIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is an established salvage procedure for severe deformities of the hindfoot. Despite its prevalence, end-stage pathology, systemic comorbidities, and the physical demands of surgery often precipitate unsuccessful outcomes, with nonunion rates as high as 85% in medically complex patients. Given the considerable morbidity associated with TTC arthrodesis, there has been recent interest in maximizing the physiologic potential of fusion by means of surgical technique, osteoinductive and osteoconductive biological agents, and vascularized bone flaps. Here, we present a novel approach to TTC arthrodesis using femoral head allograft bone block, bone marrow aspirate, and demineralized bone matrix (DBM) in the absence of tourniquet. Additionally, we explore the role of the medial femoral condyle (MFC) free flap as a reconstructive adjunct to arthrodesis.Methods:The sample consisted of 14 patients presenting to a tertiary care facility for reconstructive limb salvage. TTC arthrodesis was performed without tourniquet and biologically augmented with fresh-frozen femoral head allograft, pelvic bone marrow aspirate, and DBM. Three patients with severe soft tissue defects also underwent vascularized osseous reconstruction with MFC free flap. Recovery protocol included three months of prolonged non-weightbearing mechanical stabilization followed by conversion to weightbearing AFO boot for one year. Post-operative plain radiographs and computed tomography (CT) scans were assessed for fusion at regular follow-up. After fusion, participants completed a survey on patient-reported outcomes, which included the modified Foot Function Index (FFI) and Patient-Reported Outcomes Measurement Information System (PROMIS) scales for pain and physical function.Results:Successful TTC fusion was documented on plain radiograph in 13 patients (92.9%) and confirmed via CT in 10 patients (90.9%). The mean time-to-fusion was 183.2 +- 83.2 days. One patient (7.1%) failed to achieve fusion and underwent amputation secondary to infectious wound complications. Patients who underwent vascularized bone grafting had more robust healing and significantly shorter time-to-fusion (112.3 +- 31.7 days vs. 204.4 +- 82.7 days, p = 0.05). The mean patient-reported FFI score was found to be 40.96% +- 23.08%, indicating mild-to-moderate impairment in foot function. Similarly, PROMIS data revealed that patients who underwent TTC arthrodesis had a pain T-score of 58.34 (z = 0.83) and a physical function T-score of 39.00 (z = - 1.10), corresponding to mild pain and moderate impairment, respectively.Conclusion:We sought to biologically optimize the osteoinductive and osteoconductive potential of TTC arthrodesis using femoral head allograft bone block, bone marrow aspirate, and DBM in the absence of tourniquet. This approach resulted in excellent rates of fusion with minimal pain and preserved function of the lower extremity. Osseous healing was significantly enhanced by MFC flap in patients with soft tissue defects. We, therefore, recommend biologic augmentation of TTC arthrodesis as a viable salvage option for patients facing amputation or other undesirable outcomes.

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.