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Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: A Case Series
Anthony Romano, DPM PGY-2
Introduction
Severe ankle and subtalar joint pain or deformity leads to limited ambulatory capacity, with limited treatment options
Non-operative measures alleviate some of the symptoms, but do little to reverse the pathology or prevent the progression
Surgical treatment is aimed at achieving a painless, plantigrade foot that allows for tolerable ambulation with/without bracing and prevention of limb loss
Tibiotalocalcaneal arthrodesis is a surgical option that offers an effective treatment for these patients
Traditionally achieved with the use of plates, screws, external fixation or a combination of fixation methods
Purpose of Study
Severe pathology of the hindfoot and ankle may indicate Tibiotalocalcaneal Arthrodesis
The primary goals: plantigrade foot and a functional limb with prevention of limb loss
Investigate the use of Intramedullary Retrograde Compression Nail for Tibiotalocalcaneal Arthrodesis with respect to fusion, alignment, and complication profile
Present this method as a viable option for patients requiring this procedure in both primary and secondary interventions.
Literature
Reports to achieve fusion of the pathological joints with varying results
parameters for the use of this procedure have not been clearly defined. The procedure has classically been described as a salvage method when other arthrodesis methods have failed
Previous reports found a 73 to 100 percent fusion rate for patients undergoing tibiotalocalcaneal arthrodesis with an ACN
Some studies showed fibrous union only; however, patients were able to ambulate with a pneumatic walker Suggesting that even without full osseous union, a functional limb can be achieved
Literature
External fixation has been described as either a method of fusion or a means to facilitate arthrodesis procedures in patients considered “high-risk” 77.3 percent fusion rate LaPorta et al. claimed that a combination of internal and external fixation was vital to the
success of the procedure Found a greater instance of nonunion when the nail was not properly aligned within the tibia Average reported fusion time was 84 to 133 days
Complications: non-union, superficial and deep wound infection, skin necrosis, sural neuroma, suture granuloma, delayed union of the ankle arthrodesis, painful hardware, CVA, myocardial infarction, fatal pulmonary embolism, and stress fracture
Indications
Charcot neuroarthropathy
Failed ankle and/or subtalar joint fusion
Severe ankle arthritis with or without angular deformity
Talar osteonecrosis
Septic subtalar or ankle joint
Osteomyelitis
The Study
A retrospective review of patients that underwent TTCA using IRCN from 2013 to 2015
Nine patients were identified that met the inclusion criteria
Patient demographics, comorbidities, indications, time to fusion, procedure details, extremity alignment, and complications were reviewed
Anterior-posterior ankle radiographs were evaluated both preoperatively and postoperatively to evaluate frontal plane alignment of the
Time to fusion was determined radiographically and correlated with absence of any clinical signs of non-union
The Procedure
All angular correction was done acutely
Both STJ and Ankle were prepared for arthrodesis
Once the subtalar and ankle joints were corrected to a more neutral or slightly valgus and plantigrade position as visualized clinically and fluoroscopically the nail was inserted
In cases of high-risk surgical candidates, an external ring fixator super construct was utilized
The Procedure
Results
2 patients with a preop valgus deformity: correction achieved between 9 -10°, to an average position < than 1° of valgus
5 patients had a preoperative varus position corrected 3 to 25° to an average position of <1° of varus deformity
All limbs were placed to a plantigrade position which allowed ambulation
The mean time to fusion was 57 days
No amputations or clinical non-unions occurred.
Pt. Pre-Op Diagnosis Pre-Op Deformity
(Degrees) Post-Op Position
(Degrees) Time to Fusion
(Days) Complications 1 Hardware Complications 10 Valgus Neutral 47 None 2 Ankle Non-union Neutral 3 Varus 39 None
3 Ankle Malunion,
Equinovarus 20 Varus 2 Valgus 46 Infection 4 Ankle & STJ Arthritis 10 Varus 1 Valgus 63 None
5 CMT, Ankle Varus, Ankle
Arthritis 29 Varus 4 Varus 46 None
6 Charcot Arthropathy of
Ankle 12 Valgus 3 Valgus 73 None
7 Post-traumatic Arthritis
of Ankle 2 Varus Neutral 50 Prominent Screw
Requiring Removal
8 Charcot Arthropathy of
Ankle 22 Varus Neutral 96 Swelling, Premature
Frame Removal 9 Ankle Arthritis Neutral 3 Valgus 56 None
Conclusions
This case series demonstrates that tibiotalocalcaneal arthrodesis can be adequately achieved with intramedullary retrograde compression nail in complex hindfoot and ankle pathology
Significant degree of angular deformity can be corrected using this procedure
Can correct severe hindfoot pathology in patients with several comorbidities or failed arthrodesis procedures
Gives surgeon the ability to provide consistent neutral alignment and a stable plantigrade foot
Complication profile displayed minimal complications (major complications can occur)
When compared to the preoperative states, patients had a plantigrade foot for ambulation
Overall, intramedullary retrograde compression nailing was found to be effective in reaching the goals of tibiotalocalcaneal arthrodesis
References
1. Mann, R. A., and L. B. Chou. 'Tibiocalcaneal Arthrodesis'. Foot & Ankle International 16.7 (1995): 401-405. Web.
2. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int. 2006;27(10):759–63.
3. Paola, Luca Dalla et al. 'Use Of A Retrograde Nail For Ankle Arthrodesis In Charcot Neuroarthropathy: A Limb Salvage Procedure'. Foot Ankle Int 28.9 (2007): 967-970. Web.
4. Niinimäki, Tuukka Timo, Tero-Matti Klemola, and Juhana Ilmari Leppilahti. 'Tibiotalocalcaneal Arthrodesis With A Compressive Retrograde Intramedullary Nail: A Report Of 34 Consecutive Patients'. Foot Ankle Int 28.4 (2007): 431-434. Web.
5. Zarutsky, Eugene, Shannon M. Rush, and John M. Schuberth. 'The Use Of Circular Wire External Fixation In The Treatment Of Salvage Ankle Arthrodesis'. The Journal of Foot and Ankle Surgery 44.1 (2005): 22-31. Web.
6. Crawford, Brooke et al. 'End-Stage Hindfoot Arthrosis: Outcomes Of Tibiocalcaneal Fusion Using Internal And Ilizarov Fixation'. The Journal of Foot and Ankle Surgery 53.5 (2014): 609-614. Web.
7. Rammelt, S. et al. 'Tibiotalocalcaneal Fusion Using The Hindfoot Arthrodesis Nail: A Multicenter Study'. Foot & Ankle International 34.9 (2013): 1245-1255. Web.
8. LaPorta, Guido A., Ellianne M. Nasser, and Jennifer L. Mulhern. 'Tibiocalcaneal Arthrodesis In The High-Risk Foot'. The Journal of Foot and Ankle Surgery 53.6 (2014): 774-786. Web.
9. Mendicino, Robert W et al. 'Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nailing'. The Journal of Foot and Ankle Surgery 43.2 (2004): 82-86. Web.
10. Thomason, K., and K. S. Eyres. 'A Technique Of Fusion For Failed Total Replacement Of The Ankle: TIBIO-ALLOGRAFT-CALCANEAL FUSION WITH A LOCKED RETROGRADE INTRAMEDULLARY NAIL'. Journal of Bone and Joint Surgery - British Volume 90-B.7 (2008): 885-888. Web.
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