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The Journal of Foot & Ankle Surgery 54 (2015) 1172–1177

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The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Tibiocalcaneal Arthrodesis With a Porous Tantalum Spacer andLocked Intramedullary Nail for Post-Traumatic Global AvascularNecrosis of the Talus

Michael M. Cohen, DPM, FACFAS 1, Marat Kazak, DPM2

1Chief, Department of Podiatry Surgery, Miami Veterans Affairs Medical Center, Miami, FL2 Third Year Podiatry Surgical Resident, Miami Veterans Affairs Medical Center, Miami, FL

a r t i c l e i n f o

Level of Clinical Evidence: 4

Keywords:ankle arthrodesisavascular necrosis talusbone grafttantalumtotal ankle replacement

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Michael M. Cohen

Podiatry Surgery, Miami Veterans Affairs Medical CenMiami, FL 33125.

E-mail address: michael.cohen@med.va.gov (M.M.

1067-2516/$ - see front matter � 2015 by the Americhttp://dx.doi.org/10.1053/j.jfas.2015.01.009

a b s t r a c t

Global avascular necrosis of the talus is a devastating complication that usually occurs as a result of a post-traumatic or metabolic etiology. When conservative options fail, tibiocalcaneal arthrodesis is generally indi-cated in conjunction with massive bone grafting to maintain the functional length of the extremity. Severalbone grafting options are available, including the use of a freeze-dried or fresh-frozen femoral head allograft orautograft obtained from the iliac crest or fibula, all of which pose their own inherent risks. The noted com-plications with massive bone grafting techniques have included graft collapse, infection, immune response,donor site morbidity, and nonunion. In an effort to avoid many of these complications, we present a casereport involving post-traumatic talar avascular necrosis in a 59-year-old male who was successfully treatedwith the use of a porous tantalum spacer, an autogenic morselized fibular bone graft, and 30 mL of bonemarrow aspirate in conjunction with a retrograde tibiocalcaneal nail. Porous tantalum is an attractive sub-stitute for bone grafting because of its structural integrity, biocompatibility, avoidance of donor site compli-cations, and lack of an immune response. The successful use of porous tantalum has been well-documented inhip and knee surgery. We present a practical surgical approach to tibiotalocalcaneal arthrodesis with a largesegmental deficit. To our knowledge, this is the first published report describing an alternative surgicaltechnique to address global avascular necrosis of the talus that could have additional applications in salvagingthe ankle with a large bone deficiency.

� 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Global avascular necrosis (AVN) of the talus is a devastatingcomplication that usually occurs as a result of a post-traumatic ormetabolic etiology. Over time, the condition will commonly result insignificant disability. Surgical correction requires tibiocalcanealarthrodesis, generally in conjunction with massive bone grafting tomaintain the functional length of the extremity. Several graftingoptions are available, including the use of a massive freeze-dried andfresh-frozen allograft or autograft obtained from the fibula or iliaccrest, all of which pose their own inherent risks. These risks includegraft collapse (Fig. 1) with hardware failure, infection, immuneresponse, donor site morbidity, and nonunion (1). The rate of donorsite morbidity with grafts obtained from the anterior iliac crest hasbeen reported to be as high as 43% (2). The most common compli-cations have included nerve injury, hematoma, and chronic pain (3,4).

, DPM, FACFAS, Department ofter, 1201 Northwest 16th Street,

Cohen).

an College of Foot and Ankle Surgeon

In an effort to avoid many of these complications, we present acase report involving post-traumatic talar AVN in a 59-year-old malewho was successfully treated with the use of a porous tantalumspacer, an autogenic morselized fibular bone graft, and 30 mL of bonemarrow aspirate in conjunction with a retrograde tibiocalcaneal nail.Porous tantalum is an attractive substitute for bone grafting becauseof its structural integrity, biocompatibility, and lack of immuneresponse, all of which have been well-documented in knee and hipsurgery. Its use with ankle arthrodesis with a large segmental defect,such as AVN of the talus and failed total ankle replacement, appears tobe a practical and attractive approach to massive bone grafting. This isparticularly significant at a time when ankle replacement systems arebecoming increasingly more popular in the United States. To ourknowledge, we present the first published report describing thistechnique to address global AVN of talus in the United States.

Case Report

A 59-year-old male presented to the Podiatry Service at the MiamiVeterans Affairs Medical Center with chronic right ankle pain. The

s. All rights reserved.

Fig. 1. (A) Tibiocalcaneal arthrodesis with a large interpositional femoral head allograft in another patient with insulin-dependent diabetes and a Charcot ankle. (B) Catastrophic collapseof the graft with hardware failure at 13 months after surgery.

M.M. Cohen, M. Kazak / The Journal of Foot & Ankle Surgery 54 (2015) 1172–1177 1173

patient had a history of a high-energy right ankle fracture in theearly 1990s that subsequently resulted in AVN of the talus. At thattime, salvage was attempted with triple arthrodesis. He did well withthe procedure for several years until he developed severe post-staticpain and progressive discomfort that ultimately became disabling.He was unable to tolerate nonsteroidal anti-inflammatory medicationbecause of gastroesophageal reflux disorder and an exhaustive trialof bracing, shoe modifications, and assistive devices had failed.He consequently requested definitive treatment with surgicalintervention.

His medical history was otherwise significant for a 20 pack-yearhistory of tobacco use, hypertension, and dyslipidemia. The ortho-pedic examination revealed mild crepitation with very limited andpainful ankle motion, diffuse tibiotalar joint line tenderness, andeffusion. The ankle was essentially fixed in 5� of neutral plantarflexion without varus or valgus malalignment.

Fig. 2. Preoperative lateral (A) and anteroposterior (B) radiographs demonstrating severe talanecrosis of the talus.

The imaging studies, consisting of radiographs, computed to-mography, and magnetic resonance imaging indicated ankle jointcollapse with significant sclerotic and cystic lesions within the entirebody of the talus and subchondral cysts along the tibial plafond. T2-weighted magnetic resonance imaging indicated multiple bony cystswith minimal reactive bone marrow edema in the talus, consistentwith AVN (Figs. 2 to 4). Evidence was seen of the previous triplearthrodesis with successful fusion at the talonavicular and subtalarjoints.

The patient was offered tibiocalcaneal arthrodesis, provided thathe discontinued tobacco use during the perioperative period. Heagreed to participate in an in-house smoking cessation program, andcompliance was ensured with sporadic unannounced serum nicotinelevels during a 3-month period preoperatively. The patient attendedthe classes faithfully, and the serum nicotine levels were normalthroughout the preoperative course. It was clear that he was

r collapse and cystic bone changes with sclerosis of the body consistent with avascular

Fig. 3. (A to C) Preoperative computed tomography scan demonstrating talar dome collapse with tibiotalar arthritis. Extensive cystic changes with sclerosis can be readily appreciatedthroughout the body of the talus.

M.M. Cohen, M. Kazak / The Journal of Foot & Ankle Surgery 54 (2015) 1172–11771174

motivated to undergo his procedure and reduce his risk of compli-cations. Therefore, his surgery was scheduled accordingly.

Operative Technique

A transfibular approach, ensuring the creation of full-thicknessskin flaps, was used to access the body of the talus. The fibulawas osteotomized just above the ankle joint, saved, and morsel-ized. The tourniquet was deflated, and all bleeding vessels weretied or cauterized. After a thorough intraoperative inspection,debridement of the avascular tissue in the talus was performeddown to bleeding bone, ultimately requiring that most of the talarbody be removed, leaving the talonavicular joint intact. The

Fig. 4. (A and B) Preoperative T2-weighted magnetic resonance images showing global talar bodto the talus and avascular necrosis.

remaining defect was modified to create a broad flat surfaceusing a saw. The tibial plafond was resected, with a sagittal sawparalleling the flat surface of the talus while the foot was held inneutral beneath the tibia, ensuring the medial malleolus was notviolated. A series of curettes were used to denude the cartilage inthe medial gutter. This created a large osseous rectangular deficitmeasuring approximately 3.75 � 2.7 cm2. A hollow poroustantalum proximal tibial cone spacer (Fig. 5) (Zimmer, Warsaw, IN)was trimmed to size using a high-speed saw on the operating table,as described by Claridge et al (5). Specific care was taken to notweld the porous chambers shut by continuous cooling of theimplant and instrumentation with chilled irrigation fluid. Afterappropriate sizing, 30 mL of bone marrow aspirate was tapped

y sclerosis with minimal reactive bone marrow edema, consistent with a lack of blood flow

Fig. 5. Tantalum tibial cone. Note the aperture located in the center for placement of theknee implant stem. The conduit was used to pass a retrograde intramedullary nail,allowing for a more stable arthrodesis construct. (Image courtesy of Zimmer, Warsaw, IN.)

M.M. Cohen, M. Kazak / The Journal of Foot & Ankle Surgery 54 (2015) 1172–1177 1175

from the tibial diaphysis, of which 15 mL was used to coat all sidesof the tantalum spacer.

Fresh morselized bone harvested from the fibular malleolus wasmixed with the remaining 15 mL of bone marrow aspirate and packedinto the hollow void of the tantalum spacer. The tourniquet wasreinflated, and the spacer was placed into the void, making sure tocentralize the circular canal with the tibial diaphysis. This ensured aclear passage of the titanium nail. Under fluoroscopic guidance, theankle was nailed and locked in neutral flexion/extension, with slightexternal rotation, while compressing the spacer within the void.Excellent construct stability was noted. Additional morselized fibularbone graft material was packed into the medial, lateral, anterior, andposterior recesses. The tourniquet was again deflated, and the woundwas closed in layers over a Jackson-Pratt drain.

The extremity was placed in a posterior splint, and the patient wasadmitted for 23 hours of observation and pain control. He was dis-charged home with instructions to remain non-weightbearing withthe aid of crutches. After discharge, the patient returned to thepodiatry outpatient clinic every 2 to 4 weeks for evaluation, castchanges, and baseline radiographs. Our subjective and clinical ex-amination findings were the primary indicator for transitioning thepatient through the recovery stages. At 8 weeks postoperatively, thepatient was instructed to remain non-weightbearing in a removablecontrolled ankle motion walker. Partial weightbearing began at 12weeks postoperatively. At 16 weeks postoperatively, he was transi-tioned to full, unassisted weightbearing in a controlled ankle motionwalker. Use of the walker was discontinued at 19 weeks, at whichpoint, he was switched to a light-weight, molded polypropylene anklefoot orthosis and a rocker depth inlay shoe for 1 year. During theentire postoperative period, the clinical and radiographic anklealignment was maintained without hardware loosening. At21 months after surgery, he was ambulating asymptomatically andwithout the use of assistive aids (Fig. 6).

Discussion

Arthrodesis remains the reference standard for salvaging thepainful end-stage arthritic or unstable ankle. Contraindications tothe procedure include significant peripheral arterial disease, poorlycontrolled diabetes, poor nutritional status, and tobacco abuse (6). Aretrospective study by Frey et al (7) discovered a 41% ankle nonunionrate, with most patients undergoing fusion to address post-traumatic arthritis. Perlman and Thordarson (8) studied 67 anklefusions performed to address post-traumatic arthritis and reported a28% nonunion rate, with trend toward significance in those who

smoked, abused alcohol, abused illicit drugs, those with diabetes,and those with psychiatric disorders. Zarutsky et al (9) conducted astudy on the use of circular wire external fixation in the treatment ofsalvage ankle arthrodesis and reported a 51.2% major complicationrate, with 17.7% of the patients developing unstable nonunion and9.8% stable pseudoarthrosis after initial salvage surgery. In addition,Cobb et al (10) reported that although the actual risk of nonunionafter ankle fusion could not be established in their study, the relativerisk was approximately 4 times greater for the patients who weresmokers at surgery. We had attempted to preempt the postoperativecomplications related to tobacco use in our patient by addressingthis issue proactively. The patient remained tobacco free throughoutthe perioperative period and had continued to do so at the lastfollow-up visit.

The goals of any ankle arthrodesis include alleviating pain byobtaining a solid union, realigning the ankle, and achieving a planti-grade foot while restoring the limb length and function. Multipleapproaches have been described to achieve fusion, including internaland external fixation, each with its own risks and benefits. Althoughearly attempts at ankle fusion were marked by high nonunion rates,especially those with large intercalary bone grafts, improvements intechnique and materials have led to better outcomes (5,11).

In 2013, Jeng et al (12) performed a retrospective review ofallograft bone block tibiotalocalcaneal arthrodesis using internalfixation to determine the predictive factors for successful fusion. Inthe present study, a bulk femoral head allograft was used for salvageof the large defects in the ankle secondary to degenerative arthritis,failed total ankle replacement, talar AVN, ankle fusion nonunion,Charcot arthropathy, and pilon fracture nonunion. They included 32allograft bone block tibiotalocalcaneal arthrodesis proceduresduring a 7-year period, with a minimum follow-up duration of16 months (12). Various surgical techniques were used according tosurgeon preference and patient factors. Either a freeze-dried orfresh-frozen bulk femoral head allograft was used to fill the bonydefect. All but 2 patients underwent supplemental electrical and/orbiologic stimulation. In 78% of the patients, an intramedullary rodwas used for fixation. Six patients received a proximal humerallocking plate or pediatric blade plate. One patient with a history oftobacco abuse and diabetes developed infected ankle nonunion thatwas treated with irrigation, debridement, and insertion of an anti-biotic cement spacer in conjunction with 6 weeks of intravenousantibiotics. The patient was stabilized with an external fixator. Plainfilm radiographs were used to track trabeculation and fusion. Jenget al (12) judged the fusion to be successful when �50% bonyapposition at the fusion site was observed. They reported a radio-graphic fusion rate of 50% and clinical success rate of 72% in theirstudied population. The investigators noted that diabetes was theonly noteworthy risk factor for nonunion (12). Of the 9 diabeticpatients enrolled in their study (5 with non–insulin-dependent and4 with insulin-dependent diabetes), all developed nonunion. Thepresence of insulin-dependent diabetes, in contrast to non–insulin-dependent diabetes, did not correlate with a greater incidence ofpostoperative complications or amputations. Nevertheless, 19% ofthe total patient population subsequently required a below-the-knee amputation (12). A study by Myerson et al (13) of fresh-frozen structural allografts in the foot and ankle reported theresults of 6 tibiocalcaneal arthrodesis and 6 ankle arthrodesisprocedures. Of the 12 procedures, 7 were required for neuro-arthropathy, 4 because of trauma, and 1 for rheumatoid arthritis. Nononunions developed, but 6 and 4 delayed unions in the tibio-calcaneal arthrodesis and ankle arthrodesis groups occurred,respectively (13).

When confronted with this unique situation, the implication ofusing porous tantalum instead of alternative techniques merits

Fig. 6. (A) Anteroposterior and (B) lateral radiographs at 21 months postoperatively showing stable alignment, without hardware loosening.

M.M. Cohen, M. Kazak / The Journal of Foot & Ankle Surgery 54 (2015) 1172–11771176

discussion. As previously discussed, from our clinical and radio-graphic findings, the treatment options for our patient includedtibiocalcaneal arthrodesis, with talectomy, interpositional bonegrafting, or a spacer. However, total ankle replacement was not aviable option, because it is contraindicated in patients with globalAVN of the talus.

Tibiotalocalcaneal arthrodesis with talectomy provides a func-tional plantigrade foot and effectively eliminates joint pain; however,it has the disadvantage of shortening the limb significantly (Fig. 6) ifthe deficit is large. In the present case, the patient would have beenrelegated to lifelong prosthetic shoemanagement and a greater risk ofdeveloping subsequent pathologic features in the surrounding joints.

In contrast, tibiocalcaneal arthrodesis with an allograft or auto-graft can address the problem of the limb length discrepancy byreestablishing the limb length with new bone. The approach, how-ever, has often been complicated by nonunion and graft collapse(14). Furthermore, despite the benefit of a better take, the autografthas been associated with donor site morbidity in �48% of cases (14).The noted complications have included, but not limited to, chronicpain, fracture, hematoma, hypoesthesia, and wound dehiscence.Patients have reported more pain, in the short term, at the donor sitethan at the surgical site. Other shortcomings have included thepotential for graft collapse and a limited quantity of iliac crestautograft available (14).

Massive allografts avoid donor site complications but often yieldless predictable results and have a lower potential to integrate thanautografts. Additional risks include the transmission of infectious dis-ease when using fresh-frozen allografts, although the risk is small (1).

Using a porous tantalum spacer will allow the surgeon to achievesuccessful arthrodesis without such complications. Some of thebenefits of the porous tantalum include a healing rate similar to thatof an autograft without the problems associated with donor sitemorbidity or graft collapse. The implant is structurally stable and itsmicroarchitecture closely resembles that of bone. Furthermore, itscompressive strength and elastic modulus are also similar to those ofnormal bone. Tantalum is osteoconductive and biocompatible and hasbeen successfully used in hip, knee, and spinal surgery (14,15). Wefound the trapezoidal tibial spacer was anatomically appropriate forthe shape of the deficit. Moreover, the central canal, designed toaccommodate the tibial stem during total knee replacement surgery,will easily accommodate a tibiocalcaneal nail.

A disadvantage of tantalum includes difficulty in visualizingradiographic fusion and bone integration on plain film or magneticresonance imaging. The use of micro-computed tomography has beenreported to be helpful in addressing this problem (14). Otherwise, onemust rely on objective clinical and indirect radiographic findings, suchas pain and hardware loosening, for a relatively valid assessment ofstability. Nevertheless, it is the senior author’s opinion (M.M.C.) thatthe bone-to-implant surface integration at 12 weeks will often bestable enough to allow weightbearing, in particular, when accompa-nied by stable fixation such as an intramedullary nail. Care, however,should be taken when trimming the implant using a high-poweredsaw. The heat generated could weld the porous surfaces shut, pre-cluding proper osteoconduction. To avoid this, we suggest careful andslow rhythmic use of the saw, with frequent cooling using chilledirrigation fluid. Claridge (5) reflected some concerns associated with

M.M. Cohen, M. Kazak / The Journal of Foot & Ankle Surgery 54 (2015) 1172–1177 1177

tantalum, including nonunion, which he believed could be reducedwith liberal use of bone grafting. To that end, morselized fibularautograft mixed with tibial bone marrow aspirate and coating thesurfaces of the tantalum implant withmarrow aspirate seemed to be arational adjunct to enhance the chances of fusion.

The current indications for tantalum continue to expand andcorrelate with its versatility. In their 2012 retrospective case series,Sagherian and Claridge (1) listed multiple applications for tantalum,including midfoot fusion, large defect filling after giant cell tumorresection from the tibia, subtalar fusion, and multiple cases of anklefusion after failed total ankle replacement. The implications of usingtantalum to salvage failed ankle implant arthroplasty will be signifi-cant as the procedure becomes increasingly more popular in theUnited States. Undoubtedly, reliable salvage techniques will need tobe established because all current ankle replacement systems willultimately fail with time.

References

1. Sagherian B, Claridge R. Porous tantalum as a structural graft in foot and anklesurgery. Foot Ankle Int 33:179–189, 2012.

2. Hahne J, Chiodo CP, Wilson MG. Autogenous bone grafts in foot and ankle surgery.Orthop J Harvard Med Sch 9:113–116, 2007.

3. Ahlmann E, Patzakis M, Roidis N, Shepard L, Holtom P. Comparison of anterior andposterior iliac crest bone grafts in terms of harvest site morbidity and functionaloutcomes. J Bone Joint Surg Am 84:716–720, 2002.

4. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications ofiliac crest bone harvesting. Clin Orthop Relat Res 329:300–309, 1996.

5. Claridge R. Management of failed ankle arthroplasty. Techn Foot Ankle Surg9:134–141, 2010.

6. DeHeer PA, Catoire SM, Taulman J, Borer B. Ankle arthrodesis: a literature review.Clin Podiatr Med Surg 29:509–527, 2012.

7. Frey C, Halikus NM, Vu-Rose T, Ebramzadeh E. A review of ankle arthrodesis:predisposing factors to nonunion. Foot Ankle Int 15:581–584, 1994.

8. Perlman MH, Thordarson DB. Ankle fusion in a high risk population: an assess-ment of nonunion risk factors. Foot Ankle Int 20:491–496, 1999.

9. Zarutsky E, Rush SM, Schuberth JM. The use of circular wire external fixation in thetreatment of salvage ankle arthrodesis. J Foot Ankle Surg 44:22–31, 2005.

10. Cobb TK, Gabrielsen TA, Campbell DC II, Wallrichs SL, Ilstrup DM. Cigarettesmoking and nonunion after ankle arthrodesis. Foot Ankle Int 15:64–67,1994.

11. Bowers C, Catanzariti A, Mendicino R. Traditional ankle arthrodesis for the treat-ment of ankle arthritis. Clin Podiatr Med Surg 26:259–271, 2009.

12. Jeng CL, Campbell JT, Tang EY, Cerrato RA, Myerson MS. Tibiotalocalcanealarthrodesis with bulk femoral head allograft for salvage of large defects in theankle. Foot Ankle Int 34:1256–1266, 2013.

13. Myerson MS, Neufeld SK, Uribe J. Fresh-frozen structural allografts in the foot andankle. J Bone Joint Surg Am 87:113–120, 2005.

14. Frigg A, Dougall H, Boyd S, Nigg B. Can porous tantulum be used to achieve ankleand subtalar arthrodesis? Clin Orthop Relat Res 468:209–216, 2010.

15. Bouchard M, Barker LG, Claridge RJ. Technique tip: tantalum: a structural bonegraft option for foot and ankle surgery. Foot Ankle Int 25:39–42, 2004.

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