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Lee J, Chu AK, Brigido SA. Subtalar joint involvement with tibiotalocalcaneal intramedullary nail arthrodesis. J Foot Ankle Surg 2025; 64:224-227. [PMID: 39490608 DOI: 10.1053/j.jfas.2024.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 10/14/2024] [Accepted: 10/19/2024] [Indexed: 11/05/2024]
Abstract
Tibiotalocalcaneal (TTC) fusion with an intramedullary nail (IMN) has been utilized for a myriad of indications in hindfoot and ankle reconstruction. However, some controversies remain on the optimal position of the hindfoot. Previous studies have reported on the potential medialization of the rearfoot during insertion of the IMN, but few studies have examined the potential affect on the subtalar joint. We performed the present cadaveric study in order to assess the involvement of a 12-mm IMN with the posterior facet of the calcaneus. A 3-mm guide wire (for a standard TTC IMN) was inserted in an anterograde fashion beginning within the central aspect of the tibial canal in 10 fresh-frozen below knee cadaver specimens. The subtalar joint of each specimen was exposed and images of the posterior facet were collected. Utilizing an open source Java image processing program (ImageJ/Fiji), we calculated a mean native calcaneal posterior facet of 4.6 cm2 with a post ream surface area of 3.6 cm2, resulting in a mean of 21.4% of the posterior facet occupied by an IMN in an anterograde fashion. In conclusion, a TTC IMN placed in optimal position within the ankle and tibia is likely to occupy, on average, a fifth of the calcaneal posterior facet. Though this does leave some possibility of a medial shift of the rearfoot complex, care must be taken to not violate the lateral calcaneal or talar wall.
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Affiliation(s)
| | - Anson K Chu
- Richmond Orthopedic Institute, Richmond, VA, United States.
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Chundi G, Dawar A, Ahn DB, Chopra AA, Joshi T, Lin SS, Jones T. Use of Sustained Compression to Mitigate Nonunion in Tibiotalocalcaneal Arthrodesis: A Propensity Score-Matched Nationwide Readmissions Database Analysis. J Am Acad Orthop Surg 2025:00124635-990000000-01303. [PMID: 40249946 DOI: 10.5435/jaaos-d-25-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2025] [Accepted: 03/06/2025] [Indexed: 04/20/2025] Open
Abstract
INTRODUCTION Tibiotalocalcaneal (TTC) arthrodesis is a critical surgical intervention for advanced hindfoot and ankle pathologies, offering pain relief, stabilization, and functional alignment restoration. Intramedullary nail fixation, particularly with dynamic compression (DC) nails, has emerged as a promising solution for addressing high nonunion rates associated with standard static compression (SC) nails. This study compares union and complication rates between DC and SC nails in TTC arthrodesis using the Nationwide Readmissions Database. METHODS This retrospective cohort study used the Nationwide Readmissions Database to identify cases of TTC fusion with DC and SC nails based on ICD-10-PCS codes. Propensity score matching (1:1) controlled for confounders, including age, sex, and comorbidities. Primary outcomes included complications such as thromboembolism, wound dehiscence, cellulitis, implant-related complications, nonunion, malunion, and infections. Secondary outcomes included 30-day and 31-90-day readmission rates. Statistical significance was set at P < 0.05. RESULTS The study analyzed 311 cases (149 with DC, 162 with SC). Demographic and comorbidity distributions were balanced after matching. Nonunion rates were significantly lower in the DC group (6.0%) compared with the SC group (17.3%; P = 0.002). Overall complication rates were comparable (DC: 30.2% vs. SC: 35.2%, P = 0.350). DISCUSSION DC devices demonstrated markedly reduced nonunion rates compared with SC nails, likely because of the continuous compression provided by the nitinol-based design. This novel finding validates the biomechanical advantages of devices using DC in TTC fusion and aligns with previous research advocating for such devices. CONCLUSION DC nails offer an advancement in TTC arthrodesis by markedly reducing nonunion rates. Future studies should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization to further refine treatment protocols.
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Affiliation(s)
- Gnaneswar Chundi
- From the Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ (Chundi, Dawar, Ahn, Joshi, Lin, and Jones), and the Penn State College of Medicine, Hershey, PA (Chopra)
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Puri A. Current concepts in ankle arthrodesis. J Clin Orthop Trauma 2024; 56:102537. [PMID: 39328297 PMCID: PMC11422152 DOI: 10.1016/j.jcot.2024.102537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 08/15/2024] [Accepted: 09/06/2024] [Indexed: 09/28/2024] Open
Abstract
Ankle osteoarthritis is primarily post traumatic and affects a younger population. It, therefore, not only has a negative effect on the quality of life but also impacts the working life of these patients. A thorough history, clinical examination followed by relevant investigations, radiological and hematological, can provide the necessary information to classify the severity and associated deformity of this condition. This will provide guidance to the necessary and appropriate commencement of treatment. Options include conservative or surgical which can be joint sparing or sacrificing procedures. Ankle arthrodesis, a joint sacrificing procedure, has long been the 'gold standard' and has stood the test of time in providing a pain free plantigrade foot. However, ankle arthroplasty, with newer materials and better understanding, is increasingly being considered for ankle arthritis. In regions with financial constraints and limited accessibility to modern implants ankle arthrodesis should be the preferentially offered surgical procedure. This article will briefly cover the pathophysiology of ankle arthritis, clinical presentation, and its surgical treatment with a focus on ankle arthrodesis.
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Affiliation(s)
- Arvind Puri
- Orthopaedic Surgeon, Cairns Hospital, Australia
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Feeney KM, Murphy EP, Curran MG, Kearns SR. Outcomes following tibiotalocalcaneal arthrodesis using a solid posterior offset intramedullary nail in 44 patients with a minimum 30-month follow-up. Foot Ankle Surg 2024; 30:325-330. [PMID: 38309988 DOI: 10.1016/j.fas.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/03/2023] [Accepted: 01/27/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis is frequently performed by foot and ankle surgeons in the management of complex ankle and hindfoot pathology. In this study, the authors describe the clinical and radiological outcomes of tibiotalocalcaneal arthrodesis using a solid posterior offset hindfoot arthrodesis nail. METHODS Forty-four consecutive patients underwent tibiotalocalcaneal arthrodesis by a single surgeon operating in two centers. Clinical and radiological outcomes were assessed preoperatively and at 6-month, 12-month and final follow-up (mean 47 months). Clinical outcomes were assessed with VAS, AOFAS and MOXFQ scores. Serial radiographs were used to assess union at each follow-up visit. RESULTS Forty-four patients attended 12-month and final follow-up (mean 47 months). A total of 44 (100%) ankle joints and 44 (100%) subtalar joints were completely united at 12-month follow-up. The VAS score improved significantly from a mean of 6.5 preoperatively to a mean of 0.98 at final follow-up (P = <0.0001). AOFAS score improved significantly from a mean of 36.4 preoperatively to a mean of 73 at final follow-up (P = <0.0001). MOXFQ score improved significantly from a mean of 44.5 preoperatively to a mean of 12.7 at final follow-up (P = <0.0001). The mean change in frontal plane alignment was 5.7 degrees (P = 0.005). A total of 6 patients (13.6%) had an adverse event during the course of the study. CONCLUSIONS Tibiotalocalcaneal arthrodesis with a solid posterior offset hindfoot arthrodesis nail is a safe and effective surgical option for patients with severe ankle and hindfoot pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes.
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Affiliation(s)
- Kaylem M Feeney
- Department of Orthopaedics Bon Secours Hospital, Galway, Ireland.
| | - Evelyn P Murphy
- Department of Orthopaedics Galway University Hospitals, Galway, Ireland
| | - Michael G Curran
- Department of Orthopaedics Bon Secours Hospital, Galway, Ireland; Department of Orthopaedics Galway University Hospitals, Galway, Ireland
| | - Stephen R Kearns
- Department of Orthopaedics Bon Secours Hospital, Galway, Ireland; Department of Orthopaedics Galway University Hospitals, Galway, Ireland
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Manobianco A, Enketan O, Grass R. Tibiotalocalcaneal arthrodesis with an intramedullary nail: The functional and clinical outcome of a challenging patient group and its comparison to a below knee amputation. Foot Ankle Surg 2024; 30:268-272. [PMID: 38199925 DOI: 10.1016/j.fas.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to fuse the ankle and subtalar joints to treat severe ankle and hindfoot disease. Patients often have multiple operations before a TTCA. A below knee amputation (BKA) has major physical and psychological impacts. Our aim is to investigate the outcomes of these treatments in salvage situations, with a focus on objective functional measurements and patient reported outcome measures (PROMs). METHODS 52 patients underwent TTCA with a retrograde intramedullary nail and contacted for clinical and functional assessments and compared to patients who underwent traumatic BKA. PROMS such as AOFAS score, SF-36 and foot function index (FFI), and objective functional outcome measures were used. RESULTS Of the 52 TTCA patients, 28 patients were recruited for follow-up. 35.7% of patients had postoperative complications. Mean postoperative AOFAS score was 63.9 ± 8.4 (range, 47-81), FFI 48.8 ± 15.8 (range, 22.2-75.2). 11 BKA patients (mean age 46.4 years) were included as control group. BKA patients scored higher than the TTCA patients on SF-36 physical functioning (p < 0.01) and SF-36 mental health (p < 0.05) subscales. The flat-surface functional tests (timed up and go test, 2-minute walk test, 10-meter walk test) showed significantly (p < 0.05) better outcomes for the BKA compared to TTCA. CONCLUSIONS A TTCA is a salvage procedure with high complication rates. Functional and psychometric results are reduced compared to the normal population. Patients after a BKA had significantly better scores on SF-36 functional and mental health subscales and better functional outcomes for flat ground activities compared to TTCA. Heterogeneity of the TTCA and BKA patient cohorts is a limitation of this study. With these results in mind, the outlook of a BKA is not necessarily a grim one. They may be used by surgeons to counsel patients preoperatively when managing complex ankle and hindfoot disease. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Alexander Manobianco
- Department of Orthopaedic Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
| | - Oliver Enketan
- Department of Orthopaedic Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia; University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus Dresden, Fletscherstr. 74, 01307 Dresden, Germany.
| | - René Grass
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus Dresden, Fletscherstr. 74, 01307 Dresden, Germany
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Kyung MG, Hwang IU, Lee C, Park GY, Lee DY. Clinical outcomes following tibiotalocalcaneal arthrodesis with intramedullary nailing combined with partial fibulectomy and onlay bone graft. Arch Orthop Trauma Surg 2024; 144:567-574. [PMID: 37880455 DOI: 10.1007/s00402-023-05097-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/30/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Although intramedullary nailing is a popular method for tibiotalocalcaneal arthrodesis, nonunion is one of the most commonly reported complications. This study aimed to evaluate the fusion rate, improvement in functional outcomes, and occurrence of complications in tibiotalocalcaneal arthrodesis using retrograde intramedullary nailing with partial fibulectomy and onlay bone graft technique. MATERIALS AND METHODS Twenty-six consecutive patients using the proposed technique were retrospectively reviewed. For radiographic outcomes, the union rate, alignment, and any related complications were assessed. Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society hindfoot scale, Foot and Ankle Outcome Score, and visual analog scale, preoperatively and at the final follow-up. RESULTS The mean follow-up period was 38.2 months. The tibiotalar joint achieved complete union in 80.8% at six months postoperatively, while all the cases achieved complete union at 12 months postoperatively. However, the subtalar joint achieved complete union in 26.9% at six months postoperatively, which gradually increased to 73.1% at 12 months postoperatively, and 80.8% at the final follow-up without revision surgery. A subgroup analysis showed there was a trend of higher subtalar fusion rate when an additional screw for the subtalar joint fixation was placed (86.7% vs. 54.5%). The functional outcomes significantly improved at the final follow-up. A few minor complications occurred, including surgical site infection, irritational symptoms, and metal failure; however, they eventually resolved. CONCLUSIONS Our technique of tibiotalocalcaneal arthrodesis with partial fibulectomy and onlay bone grafting could be a good option where both the tibiotalar and subtalar joints need to be fused.
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Affiliation(s)
- Min Gyu Kyung
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Il-Ung Hwang
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Changhyon Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Gil Young Park
- Department of Orthopedic Surgery, SNU Seoul Hospital, Seoul, Republic of Korea
| | - Dong Yeon Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Trost M, Yarkin S, Knieps M, Frey S, Neiss WF, Eysel P, Gick S, Dargel J. Biomechanical comparison of different fixation methods in tibiotalocalcaneal arthrodesis: a cadaver study. J Orthop Surg Res 2023; 18:971. [PMID: 38105223 PMCID: PMC10726638 DOI: 10.1186/s13018-023-04444-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Various fixation methods are available for tibiotalocalcaneal arthrodesis: nail, plate, or screws. An intramedullary bone stabilization system within a balloon catheter has not previously been used in tibiotalocalcaneal arthrodesis. The aim of this study was to compare the stability of these techniques. METHODS Twenty-four lower legs from fresh-frozen human cadavers were used. Tibiotalocalcaneal arthrodesis was performed with a retrograde nail, a lateral locking plate, three cancellous screws, or an intramedullary bone stabilization system. The ankles were loaded cyclically in plantarflexion and dorsiflexion. RESULTS For cyclic loading at 125 N, the mean range of motion was 1.7 mm for nail, 2.2 mm for plate, 6.0 mm for screws, and 9.0 mm for the bone stabilization system (P < .01). For cyclic loading at 250 N, the mean range of motion was 4.4 mm for nail, 7.5 mm for plate, 12.1 mm for screws, and 14.6 mm for the bone stabilization system (P < .01). The mean cycle of failure was 4191 for nail, 3553 for plate, 3725 for screws, and 2132 for the bone stabilization system (P = .10). CONCLUSIONS The stability of the tibiotalocalcaneal arthrodesis differs depending on the fixation method, with nail or plate showing the greatest stability and the bone stabilization system the least. When three screws are used for tibiotalocalcaneal arthrodesis, the stability is intermediate. As the biomechanical stability of the bone stabilization system is low, it cannot be recommended for tibiotalocalcaneal arthrodesis.
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Affiliation(s)
- Matthias Trost
- Department of Orthopaedics and Traumatology, Saint Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, 44791, Bochum, Germany.
| | - Suzan Yarkin
- Department of Orthopaedics and Traumatology, Protestant Hospital Cologne Weyertal, Cologne, Germany
| | - Matthias Knieps
- Department of Orthopaedics and Traumatology, Cologne University Hospital, Cologne, Germany
| | - Sönke Frey
- Department of Orthopaedics and Traumatology, Florence Nightingale Hospital, Düsseldorf, Germany
| | | | - Peer Eysel
- Department of Orthopaedics and Traumatology, Cologne University Hospital, Cologne, Germany
- Cologne Center for Musculoskeletal Biomechanics (CCMB), University of Cologne, Cologne, Germany
| | - Sascha Gick
- Department of Traumatology, Orthopaedics and Hand Surgery, Saint Vinzenz Hospital, Cologne, Germany
| | - Jens Dargel
- Department of Orthopaedics, Saint Josefs Hospital, Wiesbaden, Germany
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Feng B, Gao QB, Dai GM, Niu KC, Jiang W, Wang ZY, Zheng HY. Comparison of different internal fixation models in ankle arthrodesis using 3D finite-element analysis. Eur J Med Res 2023; 28:574. [PMID: 38066608 PMCID: PMC10704803 DOI: 10.1186/s40001-023-01554-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The purpose of this study is to use three-dimensional finite-element analysis to better understand the biomechanical features of various internal fixators for ankle arthrodesis. METHODS We used finite-element analysis to compare four different types of internal fixations in ankle arthrodesis: Group A had three crossed screws (Ø6.5 mm); Group B had two crossed screws (Ø6.5 mm) and an anterior plate (Ø2.7 mm); Group C only had an anterior anatomical plate (Ø3.5 mm); Group D had one anterior anatomical plate (Ø3.5 mm) and one posterior-lateral screw (Ø6.5 mm). We adopted Ansys 21.0 software to analyze and compare the four types in terms of the displacement of the arthrodesis surface and the stress peak and stress distribution of these models under intorsion, extorsion, dorsiflexion torque, and neutral vertical load. RESULTS ① Displacement of the arthrodesis surface: In Group A, the maximum displacement was larger than Group D under neutral vertical load and dorsiflexion torque but less than it under intorsion and extorsion torque. In Group B, the maximum displacement against dorsiflexion, neutral vertical load, intorsion, and extorsion was less than that in the other three fixation models. In Group C, the maximum displacement against the above four loading patterns were significantly higher than that in another three fixation models. ② Stress peak and stress distribution: based on the stress distribution of the four models, the peak von Mises stress was concentrated in the central sections of the compression screws, plate joints, and bending parts of the plates. CONCLUSIONS The fixation model consisting of two crossed screws and an anterior outperformed the other three fixation models in terms of biomedical advantages; thus, this model can be deemed a safe and reliable internal fixation approach for ankle arthrodesis.
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Affiliation(s)
- Bo Feng
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China.
| | - Qing-Bo Gao
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
| | - Guang-Ming Dai
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
| | - Ke-Cheng Niu
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
| | - Wei Jiang
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
| | - Zhen-Yu Wang
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
| | - Hao-Yan Zheng
- Department of Orthopaedic Medicine, Third Affiliated Hospital of Inner Mongonia Medical University, No.20 of Shaoxian Road, Kundulun District, Baotou, 014010, China
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Zielli SO, Mazzotti A, Artioli E, Arceri A, Bonelli S, Ruffilli A, Faldini C. Retrograde intramedullary nail entry point for tibio-talo-calcaneal arthrodesis: a review of anatomical studies. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3185-3195. [PMID: 36906879 DOI: 10.1007/s00590-023-03512-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/26/2023] [Indexed: 03/13/2023]
Abstract
PURPOSE Tibio-talo-calcaneal arthrodesis (TTCA) is considered a safe and valuable option for end-stage tibiotalar and subtalar arthritis, and usually is performed with a retrograde intramedullary nail. Although the good results reported, potential complications may be related to retrograde nail entry point. Aim of this systematic review is to analyze in cadaveric studies the risk of iatrogenic injuries related to different entry points and different retrograde intramedullary nail design when performing TTCA. METHODS According to PRISMA, a systematic review of the literature was performed on PubMed, EMBASE and SCOPUS databases. A subgroup analysis comparing different entry point location (anatomical or fluoroscopic guided) and different nail design (straight vs. valgus curved nails) was performed. RESULTS Five studies were included, for a total of 40 specimens. Superiority of anatomical landmark-guided entry points was observed. Different nail designs did not seem to influence nor iatrogenic injuries neither hindfoot alignment. CONCLUSION Retrograde intramedullary nail entry point should be placed in the lateral half of the hindfoot in order to minimize the risk of iatrogenic injuries.
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Affiliation(s)
- Simone Ottavio Zielli
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Antonio Mazzotti
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Elena Artioli
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Alberto Arceri
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Simone Bonelli
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Alberto Ruffilli
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Sidney Kimmel Medical College of Thomas Jefferson University (SKMC), Philadelphia, PA, USA
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Wang R, Wu J, Akhtyamov I, Ziatdinov B, Cai J. A network meta-analysis of the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis. Injury 2023; 54:110794. [PMID: 37188587 DOI: 10.1016/j.injury.2023.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/06/2023] [Accepted: 05/05/2023] [Indexed: 05/17/2023]
Abstract
This study aimed to compare the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis. Thirty-two patients with osteoarthritis of the ankle (mean age 59.91±6.16 years) took part in the study. The patients were divided into 2 groups - Ilizarov apparatus (21 patients) and screw fixation (11 patients). Each group was also divided into subgroups based on etiology - posttraumatic and nontraumatic. The AOFAS and VAS scales were compared in the preoperative and postoperative periods. It was found that screw fixation was more effective in the treatment of late stages of osteoarthritis (OA) of the ankle during the postoperative period. Comparison of the AOFAS and VAS scales showed no significant differences between the groups in the preoperative period (p = 0.838; p = 0.937). After 6 months, the results were better in the screw fixation group (p = 0.042; p = 0.047). Complications were observed for a third of the patients (10 patients). 6 patients had pain in the operated limb (4 patients in the Ilizarov apparatus group). Three patients in the Ilizarov apparatus group developed a superficial infection, and one developed a deep infection. Different etiology did not affect the postoperative efficacy of arthrodesis. The choice of the type of should be related to a clear protocol for the presence of complications. When choosing the type of fixation for arthrodesis, a patient's condition as well as a surgeon's preferences should be taken into account.
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Affiliation(s)
- Ruoshi Wang
- Department of Traumatology, Orthopedics and Surgery of Extreme Conditions, Kazan State Medical University, 49 Butlerova, Tatarstan Respublika, Kazan 420012, Russian Federation; Trauma Department, The Central Hospital of WuHan (Affiliated to Tongji Medical College, Huazhong University of Science and Technology), 26 Shengli Street, Wuhan 430014, China
| | - Jingdong Wu
- Trauma Department, The Central Hospital of WuHan (Affiliated to Tongji Medical College, Huazhong University of Science and Technology), 26 Shengli Street, Wuhan 430014, China.
| | - Ildar Akhtyamov
- Department of Traumatology, Orthopedics and Surgery of Extreme Conditions, Kazan State Medical University, 49 Butlerova, Tatarstan Respublika, Kazan 420012, Russian Federation; Department of Traumatology №1, Orthopedics, Kazan Clinical Hospital No.7, 54 Marshala Chuykova Str., Tatarstan Respublika, Kazan 420103, Russian Federation
| | - Bulat Ziatdinov
- Department of Traumatology, Orthopedics and Surgery of Extreme Conditions, Kazan State Medical University, 49 Butlerova, Tatarstan Respublika, Kazan 420012, Russian Federation; Department of Traumatology №1, Orthopedics, Kazan Clinical Hospital No.7, 54 Marshala Chuykova Str., Tatarstan Respublika, Kazan 420103, Russian Federation
| | - Jun Cai
- Trauma Department, The Central Hospital of WuHan (Affiliated to Tongji Medical College, Huazhong University of Science and Technology), 26 Shengli Street, Wuhan 430014, China.
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Dujela MD, Berlet GC, Houng BE, Hyer CF. Comparison of Dynamic Versus Static Locked Retrograde Tibiotalocalcaneal Arthrodesis With Intramedullary Nail Fixation: Evaluation of the RAIN Database. J Foot Ankle Surg 2023:S1067-2516(23)00032-7. [PMID: 36941141 DOI: 10.1053/j.jfas.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 03/23/2023]
Abstract
Hindfoot osteoarthritis (OA) or deformity involving the ankle and subtalar joint is a disabling condition. Tibiotalocalcaneal (TTC) fusion is an effective salvage option in pathologies where total ankle replacement is contraindicated. The purpose of this study is to compare the union rate of the ankle joint in proximal static versus dynamically locked retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis. An institutional review board-approved comprehensive chart and radiographic review was performed. TTC arthrodesis performed in patients with OA, post-traumatic arthritis, or deformity corrected by retrograde nail were included. Patients with Charcot arthropathy, failed joint replacement, neuropathy, or avascular necrosis were excluded. The primary outcome was ankle joint union with secondary measure of mean time to fusion. A total of 60 patients met inclusion criteria with 30 in the static group (SG) and 30 in the dynamic group (DG). The average age of the static group (SG) and dynamic group (DG) was 56.9 and 54.1 years, respectively. Mean body mass index was 34.03 kg/m2 for SG and 33.43 kg/m2 for DG. The union rate of the ankle joint was slightly higher in the DG but not statistically significant [SG 83.3%, DG 86.6%, p > .05 (p = .83)]. Time to fusion (TTF) in SG was 111.6 days compared to 97.2 days in DG. Dynamically locked intramedullary nails allow continued compression across the arthrodesis site as fusions remodel. Time to union and union rate of the ankle joint was superior in the dynamic group but this was not statistically significant. In this cohort, union rates were excellent in both groups, and no statistically significant difference was seen in the number of nonunions.
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Affiliation(s)
- Michael D Dujela
- Fellowship-Trained Foot and Ankle Surgeon, Private Practice, Washington Orthopaedic Center, Washington, OH; Fellowship Director, Washington Orthopaedic Center Advanced Reconstructive Foot and Ankle Surgery Fellowship, Centralia, WA; Visiting Fellow, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Gregory C Berlet
- Attending Surgeon, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Brian E Houng
- Fellow, Washington Orthopaedic Center Advanced Reconstructive Foot and Ankle Surgery, Centralia, WA
| | - Christopher F Hyer
- Attending Surgeon, Orthopedic Foot and Ankle Center, Worthington, OH; Co-Fellowship Director, Orthopedic Foot and Ankle Center, Worthington, OH
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12
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Bajuri MY, Manas AM, Zamri KS. Functional outcomes of tibiotalocalcaneal arthrodesis using a hindfoot arthrodesis nail in treating Charcot's arthropathy deformity. Front Surg 2023; 9:862133. [PMID: 36743890 PMCID: PMC9895943 DOI: 10.3389/fsurg.2022.862133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023] Open
Abstract
Background Tibiotalocalcaneal arthrodesis or hindfoot fusion is a salvage surgical option used to treat symptomatic or severe deformity as a result of Charcot's arthropathy. It is an internal fixation that utilizes nails to stabilize the hindfoot after surgical correction of the deformity. This study intends to measure the change in functional outcomes of patients with Charcot's arthropathy using this technique and the time taken to achieve fusion. Method This study presents a series of 40 cases of Charcot's arthropathy where hindfoot fusion was done using a hindfoot arthrodesis nail. A retrospective analysis was done where these patients' functional scores had been evaluated preoperatively and postoperatively (serially) with the Short-Form Health Survey 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS), Foot and Ankle Outcome Score (FAOS), and Foot Function Index (FFI). Along with its complication, the length of time required for the fusion is also reported. Results This study consists of 40 patients (13 men, 27 women; mean age 60.5 years; age range 52-68 years) with a mean follow-up of 64 months (range 24-108 months). The mean time taken for fusion was 5.1 months. All patients showed improvement in functional scoring (SF-36, AOFAS, FFI, and FAOS) postoperatively. We establish that the improvements were gradual over 2 years. Approximately 37.5% of patients had a minor complication and 2.5% had a major complication. Conclusion Hindfoot fusion using a hindfoot arthrodesis nail results in improved functional outcome with an acceptable fusion time and acceptable complication rate. Level of evidence Level III.
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13
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Czerwonka N, Yi A, Miller CP. Diagnosis and Treatment of Neuropathic Ankle Fractures. JBJS Rev 2022; 10:01874474-202212000-00002. [PMID: 36732284 DOI: 10.2106/jbjs.rvw.22.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
» Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection. » Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient. » The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.
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Affiliation(s)
- Natalia Czerwonka
- Columbia University Irving Medical Center, New York-Presbyterian, New York, New York
| | - Anthony Yi
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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14
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Vesely BD, LeSavage LK, King MA, Evans JK, Scott AT. Change in Height Following Tibiotalocalcaneal Arthrodesis: Retrospective Radiographic Analysis. J Foot Ankle Surg 2022; 62:465-468. [PMID: 36504137 DOI: 10.1053/j.jfas.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022]
Abstract
Tibiotalocalcaneal arthrodesis (TTCA) with an intramedullary rod is a viable treatment option for a myriad of pathologies involving the foot and ankle. While the current literature has focused on fixation techniques, deformity correction, and clinical outcomes, we are unaware of any studies specifically examining change in height following a TTCA. In the present study, we retrospectively analyzed radiographs with novel radiographic techniques to determine the change in height from preoperative to postoperative radiographs following TTCA. Patients were divided into 3 categories: Charcot, arthritis, and pes planus as the indication for surgical intervention. We found that Charcot and arthritis had an average decrease in height on anterior and posterior measurements of the height from the distal tibia to the calcaneus, while pes planus had an increase in height. The average Charcot change in height was -12.0 ± 24.4 mm anteriorly and -7.6 ± 15.5 mm posteriorly. The average change in height for the arthritis group was -6.9 ± 6.7 mm anteriorly and -3.8 ± 5.8 mm posteriorly. The pes planus group was found to have an average increase in height 0.5 ± 8.0 mm anteriorly and 2.9 ± 5.8 mm posteriorly. Overall, we found a statistically significant difference in height change between the 3 groups in anterior measurements (p = .012) and posterior measurement (p = .006). We recommend surgeons who perform this procedure to be aware of the potential change in height to better tailor surgical and postoperative care.
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Affiliation(s)
- Bryanna D Vesely
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC.
| | - Lindsay K LeSavage
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Matthew A King
- Foot and Ankle Fellow, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Joni K Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Aaron T Scott
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
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15
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Kyung MG, Park GY, Lee DY. Removal of Broken Tibiotalocalcaneal Nail: Case Report and Technical Tip. Foot Ankle Int 2022; 43:1250-1254. [PMID: 35652752 DOI: 10.1177/10711007221093576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Min Gyu Kyung
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gil Young Park
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Yeon Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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16
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Phillips M, Bullock G, Scott A. Use of the Straight Retrograde Intramedullary Nail for Tibiotalocalcaneal Arthrodesis: A Single-Institution, Single-Surgeon, Single-Implant Retrospective Series. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221123804. [PMID: 36185348 PMCID: PMC9523874 DOI: 10.1177/24730114221123804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The hindfoot fusion nail has become a popular implant for tibiotalocalcaneal (TTC) arthrodeses given its rigidity, ease of insertion, and potential for less invasive surgical approaches. The purpose of this study was to evaluate fusion and complication rates following the use of a straight, retrograde intramedullary nail for TTC arthrodeses, and the influence of diabetes and smoking on these results. Methods: A review of patient cases performed by a single surgeon at a single institution was performed. Variables included age, comorbidities, smoking history, BMI, hemoglobin A1c, preoperative and postoperative visual analog scale pain scores, assessment of healing, and complications. Relative and absolute risk were assessed for smoking, diabetes, fusion, and surgical complications through risk ratios. Cox proportional hazards survival analyses were performed to assess the effects of smoking and diabetes on fusion rates and complications. Linear regressions were performed to investigate the effects of smoking and diabetes on patient-reported pain levels. Results: Of 103 patients, there were 37 cigarette smokers and 30 diabetic patients. Eighty-three patients achieved union of all involved joints and 19 patients achieved union of 1 or 2 joints. Smokers demonstrated a 1.46 (risk ratio) (95% CI 1.03-2.07) times greater risk of nonunion but were not at an increased risk of experiencing surgical complications (0.86, 95% CI 0.56-1.33). Diabetic patients did not demonstrate an increased risk of nonunion (0.86, 95% CI 0.56-1.33) or complications (1.18, 95% CI 0.76-1.83). Conclusion: Because of increased nonunion risk, patients undergoing elective tibiotalocalcaneal arthrodesis should be counseled increased nonunion risks associated with smoking. In this series, we did not find a relationship between diabetes and complications or nonunion. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- McLeod Phillips
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Aaron Scott
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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17
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van den Heuvel SBM, Penning D, Schepers T. Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods. J Foot Ankle Surg 2022; 61:233-238. [PMID: 34362652 DOI: 10.1053/j.jfas.2021.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/10/2021] [Indexed: 02/03/2023]
Abstract
A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.
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Affiliation(s)
- Stein B M van den Heuvel
- Medical Doctor, Trauma Unit, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Diederick Penning
- Medical Doctor, Trauma Unit, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim Schepers
- Trauma Surgeon, Trauma Unit, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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18
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Moonot P, Sharma G, Kadakia A. Functional outcome in patients with Charcot neuropathy with almost complete loss of talus treated by tibio-talo calcaneal nail: A cross-sectional study. Foot (Edinb) 2021; 49:101833. [PMID: 34687980 DOI: 10.1016/j.foot.2021.101833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 04/30/2021] [Accepted: 05/22/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Tibio-talo-calcaneal (TTC) fusion is a successful surgery for Charcot neuropathy affecting the hindfoot. A case series of Charcot neuropathy is presented with almost complete loss affecting hindfoot treated with tibio-talo-calcaneal nail. MATERIAL AND METHODS Seven patients with Charcot neuropathy of the hindfoot having varying degrees of talus loss underwent tibio-talo-calcaneal nailing between January 2014 and Feb 2016 at a tertiary care hospital by a single surgeon. All the patients were type 3a as per Brodsky classification. Patients with active infection, fractures and avascular necrosis of talus was excluded from the study. The final outcome was measured using the AOFAS and FADI scores at the end of 2 years. RESULTS The mean duration of diabetes was 8.16 ± 3.12 years. Two patients (28.6%) had total and 5 (71.4%) patients had subtotal talus loss. Anterior approach was used in four, and lateral approach was used in three cases respectively. The talus was reconstructed by using the iliac crest or the graft from the distal fibula wherever appropriate. The average surgical duration was 93.28 ± 4.84 min. One patient had deep infection, 2 years after the surgery which was treated by implant removal and antibiotics. No patients had non-union. The pre-operative AOFAS scores improved from 32.2 ± 2.58 to 73.4 ± 3.36 at 2-year follow-up (p < 0.0001). Similarly, the pre-operative FADI scores were 31.74 ± 1.98 which improved to 65.94 ± 3.68 at the end of 2 years (p < 0.0001). CONCLUSION Retrograde tibio-talo-calcaneal nail is a good option for limb salvage in patients with severe talus loss with good functional outcome. LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Pradeep Moonot
- Mumbai Knee Foot Ankle clinic & Sir HN Reliance foundation hospital, Prarthana samaj, Girgaon, Mumbai-400004, India.
| | - Gaurav Sharma
- Department of Orthopaedics, Mahatma Gandhi Mission Institute of Medical Sciences, Kamothe, Navi-Mumbai 410209, Maharashtra, India.
| | - Anish Kadakia
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
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19
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Yoshimoto K, Fukushi JI, Tsushima H, Kamura S, Miyahara HA, Mizu-Uchi H, Akasaki Y, Nakashima Y. Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle? J Foot Ankle Surg 2021; 59:984-987. [PMID: 32576440 DOI: 10.1053/j.jfas.2019.08.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/06/2019] [Accepted: 08/24/2019] [Indexed: 02/03/2023]
Abstract
This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5-84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.
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Affiliation(s)
- Kensei Yoshimoto
- Surgeon, Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Surgeon, Orthopaedic Foot and Ankle Center, Shiseikai Daini Hospital, Tokyo, Japan
| | - Jun-Ichi Fukushi
- Director, Department of Orthopedic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - Hidetoshi Tsushima
- Surgeon, Department of Orthopedic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Satoshi Kamura
- Surgeon, Department of Orthopedic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Hisa-Aki Miyahara
- Vice President, Department of Orthopedic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Hideki Mizu-Uchi
- Assistant Professor, Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukio Akasaki
- Assistant Professor, Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Professor, Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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20
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Chopra S, Crevoisier X. Bilateral gait asymmetry associated with tibiotalocalcaneal arthrodesis versus ankle arthrodesis. Foot Ankle Surg 2021; 27:332-338. [PMID: 33358603 DOI: 10.1016/j.fas.2020.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/02/2020] [Accepted: 12/11/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gait asymmetries have been reported following ankle arthrodesis. However, similar reports do not exist for tibiotalocalaneal arthrodesis (TTCA), which involves further articular fusion. This study aimed to assess the extent of gait asymmetry following TTCA when compared to ankle arthrodesis. METHOD Gait assessment was performed on 36 participants, including 12 ankle arthrodesis, 12 TTCA and 12 controls - using 3-D inertial sensors and pressure insoles. 48 gait parameters were monitored on both operated and non-operated sides. Questionnaires including AOFAS, FAAM, EQ-5D were used to assess both operative groups, comparatively. RESULTS Both operative groups reported significantly smaller stride, slower walking speed, altered stance phase with longer loading and shorter push-off compared to controls. Joint range of motion was significantly reduced on the operated side of both operative groups at hindfoot, forefoot and toe intersegments. However, the ankle arthrodesis group reported a significantly higher alteration compared to controls in maximum contact force and pressure distribution. Furthermore, bilateral comparison showed extended gait asymmetry in the ankle arthrodesis group with 29 out of 48 parameters being significantly different between the two sides, whereas only 16 out of 48 gait parameters showed bilateral difference in the TTCA group. CONCLUSION Both ankle salvage operations led to significant gait alteration and bilateral asymmetry. However, extended joint restriction in TTCA does not seem to worsen the gait outcomes. Further investigation is needed to understand the long-term impact of altered gait, on neighboring joints, following TTCA.
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Affiliation(s)
- Swati Chopra
- Centre Hospitalier Universitaire Vaudois (CHUV), Department of Orthopaedic Surgery and Traumatology, Pierre-Decker 4, CH-1011 Lausanne, Switzerland; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Xavier Crevoisier
- Centre Hospitalier Universitaire Vaudois (CHUV), Department of Orthopaedic Surgery and Traumatology, Pierre-Decker 4, CH-1011 Lausanne, Switzerland.
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21
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Kowalski C, Stauch C, Callahan R, Saloky K, Walley K, Aynardi M, Juliano P. Prognostic risk factors for complications associated with tibiotalocalcaneal arthrodesis with a nail. Foot Ankle Surg 2020; 26:708-711. [PMID: 31543311 DOI: 10.1016/j.fas.2019.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis with a nail can be an effective salvage procedure for several foot and ankle pathologies, but has a relatively high complication rate. The purpose of this study is to investigate risk factors associated with complications after TTC arthrodesis with a nail. METHODS Clinical and radiographic outcomes for 82 patients from 2012 to 2016 who underwent TTC arthrodesis with a nail were retrospectivelyevaluated to determine if patient or surgeon specific variables offered prognostic value in predicting negative outcomes. RESULTS Diabetes, diabetic neuropathy, high (>2) American Society of Anesthesiologists (ASA) classification, and Charcot neuroarthropathy all were predictive of developing a nonunion in either the subtalar ortibiotalar joints (p<0.05). Diabetic neuropathy was predictive ofreoperation, and along with HbA1C >7.5 was also predictive of hardwarefailure. The odds ratio (OR) for diabetic neuropathy was 2.99 (p<0.05)for nonunion in the tibiotalar or subtalar joints, 3.46 (p<0.05) for reoperation,and 4.11 (p<0.05) for hardware failure. High ASAclassification had an odds ratio of 3.93 (p<0.05) for nonunion in the tibiotalar or subtalar joints as well. Diabetes had an odds ratio of 2.57 (p<0.05) for nonunion. CONCLUSIONS Patients with diabetic neuropathy, Charcot neuroarthropathy, elevated HbA1C, and ASA classification >2 demonstrated a higher complication rate in patients undergoing TTC arthrodesis with a nail.
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Affiliation(s)
- Chris Kowalski
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States.
| | - Chris Stauch
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Ryan Callahan
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Kaitlin Saloky
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Kempland Walley
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Michael Aynardi
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
| | - Paul Juliano
- PGY-4, Orthopedic Surgery Resident, 30 Hope Drive, Hershey, PA, 17033, United States
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22
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Powers NS, St John JM, Burns PR. Tibia Fracture in Staged Limb Salvage Using External Ring Fixation and Intramedullary Nailing: A Report of Two Cases. J Am Podiatr Med Assoc 2020; 110:441592. [PMID: 32730606 DOI: 10.7547/19-005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Limb salvage for Charcot's neuroarthropathy has been shown to have high complication and failure rates. The aim of our report of two cases it to present a unique complication encountered with staged limb salvage for Charcot's neuroarthropathy. In two cases, patients developed delayed tibial shaft fracture associated with previous wire placement despite insertion of locked intramedullary nail fixation that spanned the delayed fracture. Both patients experienced fractures following advancement of weight after definitive fixation. In both patients, there was noted complication with the sites of the pins and revision of external fixation before fracture. In each case, the fracture was within the construct of the intramedullary fixation and successfully treated with an extended course of nonweightbearing. Complications of external fixation and intramedullary fixation are well reported within the literature; however, tibia fracture is rare. Based on these cases, it would seem prudent to recognize the risk of delayed pin-site complications and ensure adequate length of intramedullary fixation to span the potential areas of stress.
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23
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Lee M, Choi WJ, Han SH, Jang J, Lee JW. Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail. Foot Ankle Surg 2018; 24:542-548. [PMID: 29409267 DOI: 10.1016/j.fas.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/04/2017] [Accepted: 07/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) fusion using a retrograde intramedullary (IM) nail is an effective salvage option for terminal-stage hindfoot problems. However, as many patients who receive TTC fusion bear unfavorable medical comorbidities, the risk of nonunion, infection and other complications increases. This study was performed to identify the factors influencing outcomes after TTC fusion using a retrograde IM nail. METHODS Between September 2008 and February 2012, 34 consecutive patients received TTC fusion using a retrograde IM nail for limb salvage. All patients had a minimum follow-up of two years. Throughout follow-up, standard ankle radiography was performed along with clinical outcome assessment using a visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society Ankle-Hind Foot Scale (AOFAS A/H scale) and the Foot and Ankle Outcome Score (FAOS). For the retrospective analysis, demographic factors, preoperative medical status, laboratory markers, and etiology were comprehensively reviewed using medical records. The success of the index operation was determined using clinical and radiological outcomes. Finally, the effect of each factor on failure after the operation was analyzed using univariate logistic regression. RESULTS In a mean of seven months, 82% (28/34) achieved union, as evaluated by standard radiography. All clinical outcome parameters improved significantly after the operation, including VAS, AOFAS A/H scale, and FAOS (P<0.001). At the last follow-up, five cases of nonunion with less than AOFAS A/H scale of 80 and two cases of below knee amputation due to uncontrolled infection were determined to be failures. None of the factors (etiology, demographics, laboratory markers and medical status) significantly influenced failures. However, uncontrolled DM significantly increased the failure rate with an odds ratio of 10 (P=0.029). CONCLUSIONS TTC fusion with a retrograde intramedullary nail is a successful treatment for complicated hindfoot problems such as traumatic osteoarthritis, Charcot arthropathy and failed TAA. However, it should be used judiciously in patients with uncontrolled DM, as the risk of failure increases. DESIGN Retrospective cohort study.
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Affiliation(s)
- Moses Lee
- Department of Orthopaedic Surgery, Gwangmyeong Sungae Hospital, Republic of Korea
| | - Woo Jin Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Jinyoung Jang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Republic of Korea.
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Dujela M, Hyer CF, Berlet GC. Rate of Subtalar Joint Arthrodesis After Retrograde Tibiotalocalcaneal Arthrodesis With Intramedullary Nail Fixation: Evaluation of the RAIN Database. Foot Ankle Spec 2018; 11:410-415. [PMID: 29154697 DOI: 10.1177/1938640017740674] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hindfoot arthritis or significant deformity involving the ankle and subtalar joint (STJ) is a disabling condition with few salvage options. Many surgeons note a decreased STJ fusion rate compared with ankle union when a retrograde nail construct is used. The purpose of this study was to report the STJ fusion rate of tibiotalocalcaneal (TTC) arthrodesis with retrograde nail. METHODS A chart and radiographic review was performed. TTC fusions performed in patients with osteoarthritis, posttraumatic arthritis, or deformity correction with retrograde nail fixation were included. Exclusion criteria included neuropathy, Charcot arthropathy, and failed total ankle replacement. RESULTS Ultimately, 66 retrograde TTC fusions (in 63 patients) met inclusion criteria. The average age was 57.0 years. There were 29 female and 34 male patients. Radiographic fusion of the ankle and STJ was demonstrated in 68.2% of the patients. There were 11 cases (16.7%) of ankle arthrodesis with STJ nonunion, 6 cases (9.1%) of STJ fusion but ankle nonunion, and 4 cases (6.1%) of stable radiographic nonunion of both joints. The mean time to subtalar fusion was 112.1 days. One patient required revision surgery and conversion to below-knee amputation. One patient required a CROW walker for assistance with gait. CONCLUSION A 22.8% radiographic nonunion rate of the STJ was noted in retrograde TTC fusion. Despite this, patients were stable and pain free. LEVELS OF EVIDENCE Level IV: Retrospective Case series.
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Affiliation(s)
- Michael Dujela
- Washington Orthopaedic Center, Centralia, Washington (MD).,Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH, GCB)
| | - Christopher F Hyer
- Washington Orthopaedic Center, Centralia, Washington (MD).,Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH, GCB)
| | - Gregory C Berlet
- Washington Orthopaedic Center, Centralia, Washington (MD).,Orthopedic Foot and Ankle Center, Westerville, Ohio (CFH, GCB)
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Hamid KS, Glisson RR, Morash JG, Matson AP, DeOrio JK. Simultaneous Intraoperative Measurement of Cadaver Ankle and Subtalar Joint Compression During Arthrodesis With Intramedullary Nail, Screws, and Tibiotalocalcaneal Plate. Foot Ankle Int 2018; 39:1128-1132. [PMID: 29766741 DOI: 10.1177/1071100718774271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Suboptimal tibiotalocalcaneal arthrodesis (TTCA) fusion rates may result from inadequate compression that increases motion and interferes with bony bridging. The aim of this study was to evaluate compressive forces at the ankle and subtalar joints with 3 contemporary TTCA constructs. METHODS Thirty fresh-frozen cadaveric lower extremity specimens were divided into 3 groups of 10 each: 3 partially threaded cannulated screws, hindfoot nail, and lateral plate. Specimens were mounted to a testing apparatus, and compression was independently measured at the tibiotalar and talocalcaneal interfaces. Statistical analysis included paired Student t tests, analysis of variance, and Tukey post hoc tests. RESULTS Mean forces at the ankle joint for the screws, nail, and plate constructs were 331 ± 86, 479 ± 137, and 548 ± 199 N, respectively, with plates providing significantly more compression than screws ( P < .01). Similarly, subtalar compressive forces demonstrated 319 ± 105 N in the screws group, 466 ± 125 N, in the nail group, and 513 ± 181 N in the plate group, with plate compression greater than that achieved with screws ( P < .01). No differences were identified in compression between ankle and subtalar joints within specimens in any group. CONCLUSIONS Lateral TTCA plates provided increased compressive forces at the ankle and subtalar joint compared with screws-only constructs. Hindfoot nails did not demonstrate significant differences in either of these parameters compared with plates or screws in this study. CLINICAL RELEVANCE Hindfoot nail and lateral plate options should be strongly considered when aiming to maximize compression in patients undergoing TTCA.
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Failure Analysis of PHILOS Plate Construct Used for Pantalar Arthrodesis Paper II—Screws and FEM Simulations. METALS 2018. [DOI: 10.3390/met8040279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chraim M, Krenn S, Alrabai HM, Trnka HJ, Bock P. Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot. Bone Joint J 2018; 100-B:190-196. [DOI: 10.1302/0301-620x.100b2.bjj-2017-0374.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up. Patients and Methods We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). Results The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). Conclusion The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6.
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Affiliation(s)
- M. Chraim
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
| | - S. Krenn
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
| | - H. M. Alrabai
- King Saud University, P.
O. Box 7805, Riyadh 11472, Saudi
Arabia
| | - H-J. Trnka
- Fusszentrum Wien, Alserstrasse
43/8d, 1080, Vienna, Austria
| | - P. Bock
- Orthopaedic Hospital Speising, Speisingerstrasse
109, A-1130, Vienna, Austria
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de Cesar Netto C, Johannesmeyer D, Cone B, Araoye I, Hudson PW, Sahranavard B, Johnson M, Shah A. Neurovascular Structures at Risk With Curved Retrograde TTC Fusion Nails. Foot Ankle Int 2017; 38:1139-1145. [PMID: 28731802 DOI: 10.1177/1071100717715909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail. MATERIAL AND METHODS Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal). RESULTS The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve. CONCLUSION Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve. CLINICAL RELEVANCE Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.
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Affiliation(s)
- Cesar de Cesar Netto
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Johannesmeyer
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brent Cone
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ibukunoluwa Araoye
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Parke William Hudson
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bahman Sahranavard
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Johnson
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashish Shah
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Sobral L, Ângelo AC, Caetano A, Rodeia J, Rosa I. Bilateral Ankle Fusion in Leak Syndrome Induced Deformity: A Case Report. J Orthop Case Rep 2017; 7:52-56. [PMID: 28819603 PMCID: PMC5553837 DOI: 10.13107/jocr.2250-0685.748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Systemic capillary leak syndrome (SCLS) is a rare condition of unknown etiology defined by sudden episode of hypotension, high hematocrit, and low serum protein concentration due to capillary hyperpermeability. Several treatments have been published for this pathology and eventual compartment syndrome but not for the disabling consequences. This clinical case highlights the negative orthopedic consequences of a severe systemic attack and reports a subsequent deformity treatment option that resulted in the patient quality of life improvement. To our knowledge, orthopedic surgery for SCLS induced foot and ankle deformity is presented for the first time. Case Report: A 40-year-old Caucasian female patient was referred to our institution for bilateral foot and ankle deformity after compartment syndrome during SCLS attack. She presented a bilateral rigid equino-cavo-varus-adductus deformity causing walk impairment. Bilateral ankle fusion by retrograde nailing was performed in a two-staged procedure. Rigid claw toes were also surgically addressed in an additional procedure. Radiologically, apparent ankle fusion occurred at 3 months post-operative in both sides. Deformity correction allowed the patient to regain walking capacity. A right ankle tibiotalar failed arthrodesis was noticed at 24 months post-operative. Prophylactic human immunoglobulin therapy was initiated after the last surgery with no recurrent attack registered during the 38 months follow-up period. Conclusion: Bilateral ankle fusion improved this patient quality of life by restituting walking capacity and lowering the probability of lower limb deformity related ulcers and infections. Major and minor complications are also discussed. This report contributes to the global knowledge about this syndrome and elicits the importance of the induced deformities surgical correction.
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Affiliation(s)
- Luis Sobral
- Department of Traumatology and Orthopaedics, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque 1449-005, Lisboa, Portugal
| | - Ana C Ângelo
- Department of Traumatology and Orthopaedics, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque 1449-005, Lisboa, Portugal
| | - Afonso Caetano
- Department of Traumatology and Orthopaedics, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque 1449-005, Lisboa, Portugal
| | - Joaquim Rodeia
- Department of Traumatology and Orthopaedics, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque 1449-005, Lisboa, Portugal
| | - Isabel Rosa
- Department of Traumatology and Orthopaedics, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque 1449-005, Lisboa, Portugal
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Fan J, Zhang X, Luo Y, You GW, Ng WK, Yang YF. Tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS plate and medial cannulated screws with lateral approach. BMC Musculoskelet Disord 2017; 18:317. [PMID: 28738797 PMCID: PMC5525261 DOI: 10.1186/s12891-017-1666-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 07/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis is most common and effective surgical treatment for severe hindfoot pathology, but the fusion rate is often lower than the ordinary tibiotalar arthrodesis because of the more serious joint disease associated with obvious deformity and osteoporosis. Recent literature describe tibiotalocalcaneal arthrodesis with reverse PHILOS plate with good clinical outcome result, though some patients non-union, due to eccentric force of the plate may be hidden. The purpose of this study was to evaluate clinical outcome of the lateral approach for tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS Plate and medial cannulated screw. METHODS Between Jun, 2013 to April, 2015 12 patient with hindfoot pathology had TTC arthrodesis with a reverse PHILOS plate with medial cannulated screw through a lateral approach with resection of the distal fibula and bone graft. Perioperatively observe for wound and neurovascular status. Patients were follow-up from post-operative 1, 3, 6 and12 months, to observation of wound healing, ankle pain, subtalar Joint Fusion, internal fixation and ankle function. Ankle function were scored according to the American Orthopaedic Foot and Ankle Society(AOFAS) Ankle-Hindfoot Scale system. RESULTS Twelve ankle fusion all patient follow-up, with mean time to surgery 18.6 months (12-36 month). No cases infection and issue necrosis; one patient complaint of lateral foot numbness we observe and follow-up was spontaneously recovery after 3 months. After 3 months of operation, no obvious pain of ankle joint and internal fixations loose were found. Almost fusion and good axial alignment of TTC joint also were found by X-ray and CT examination. After final fellow-up of each case, no case complain of pain of ankle joint, good fusion and axial alignment of TTC joint were also all found through Terminology. The mean American Orthopaedic Foot and Ankle society (AOFAS) score average was 77.5. CONCLUSION TTC arthrodesis with reverse PHILOS Plate and medial cannulated screw have advantages of clear incision, effective bone orthopaedic and graft fully secure, stable internal fixation, high fusion rate and less complications, can effectively correct deformities, alleviate hindfoot pain and improve function, and is an effective method of treatment of after severe hindfoot disease. TRIAL REGISTRATION This trial is registered on ClinicalTrials.gov with reference number: ID: NCT02977910 . Registered 26 Nov 2016, retrospectively registered.
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Affiliation(s)
- Jian Fan
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, 200065 China
| | - X. Zhang
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, China
| | - Y. Luo
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, China
| | - GW. You
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, China
| | - WK. Ng
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, China
| | - YF Yang
- Department of Orthopedics, Tongji Hospital, Tongji University, Shanghai, 200065 China
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Abstract
Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.
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Affiliation(s)
- Patrick R Burns
- Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, 1515 Locust Street #350, Pittsburgh, PA 15219, USA.
| | - Augusta Dunse
- PGY-2, Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15217, USA
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Evers J, Schulze M, Gehweiler D, Lakemeier M, Raschke MJ, Wähnert D, Ochman S. A modified and enhanced test setup for biomechanical investigations of the hindfoot, for example in tibiotalocalcaneal arthrodesis. BMC Musculoskelet Disord 2016; 17:318. [PMID: 27472925 PMCID: PMC4966560 DOI: 10.1186/s12891-016-1177-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/28/2016] [Indexed: 11/12/2022] Open
Abstract
Background Tibiotalocalcaneal arthrodesis (TTCA) using intramedullary nails is a salvage procedure for many diseases in the ankle and subtalar joint. Despite “newly described intramedullary nails” with specific anatomical shapes there still remain major complications regarding this procedure. The following study presents a modified biomechanical test setup for investigations of the hindfoot. Methods Nine fresh-frozen specimens from below the human knee were anaysed using the Hindfoot Arthrodesis Nail (Synthes) instrument. Quasi-static biomechanical testing was performed for internal/external rotation, varus/valgus and dorsal/plantar flexion using a modified established setup (physiological load entrance point, sledge at lever arm to apply pure moments). Additionally, a 3D optical measurement system was added to allow determination of interbony movements. Results The mean torsional range of motion (ROM) calculated from the actuator data of a material testing machine was 10.12° (SD 0.6) compared to 10° (SD 2.83) as measured with the Optotrak® system (between tibia and calcaneus). The Optotrak showed 40 % more rotation in the talocrural joint. Mean varus/valgus ROM from the material testing flexion machine was seen to be 5.65° (SD 1.84) in comparison to 2.82° (SD 0.46) measured with the Optotrak. The subtalar joint showed a 70 % higher movement when compared to the talocrural joint. Mean ROM in the flexion test was 5.3° (SD 1.45) for the material testing machine and 2.1° (SD 0.39) for the Optotrak. The movement in the talocrural joint was 3 times higher compared to the subtalar joint. Conclusion The modified test setup presented here for the hindfoot allows a physiological biomechanical loading. Moreover, a detailed characterisation of the bone-implant constructs is possible.
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Affiliation(s)
- Julia Evers
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Schulze
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dominic Gehweiler
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Lakemeier
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dirk Wähnert
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Sabine Ochman
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.
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Tibiotalocalcaneal arthrodesis with a triple-bend intramedullary nail (A3)-2-year follow-up in 60 patients. Foot Ankle Surg 2016; 22:131-8. [PMID: 27301734 DOI: 10.1016/j.fas.2015.06.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/11/2015] [Accepted: 06/16/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of the study was to analyze the clinical aspects including 2-year follow-up of tibiotalocalcaneal arthrodesis (TTCA) with a triple-bend retrograde intramedullary nail (A3, Stryker, Airview Boulevard, MN, USA). METHODS All patients with TTCA with A3 between October 18, 2011 and April 29, 2013 were included. Visual Analogue Scale Foot and Anklenkle (VAS FA), indications for surgery, details of surgery, radiographic measurements, and complications were analyzed. RESULTS A total of 66 patients were included. The mean VAS FA was 29.6. Most common indications were arthrosis (n=43; 65%) and deformity (n=36; 55%). The accuracy of correction and implant position was 9.4 (maximum 10) on average. Infection rate was 3% (n=2). Sixty (91%) patients completed follow-up: VAS FA 59.9, fusion rate 100%, high accuracy of correction and implant position. CONCLUSIONS TTCA with the A3 implant system showed accurate correction and implant position. Two-year follow-up in 60 patients (91%) showed good clinical outcome scores and 100% fusion rate.
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Abstract
Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and for the management of severe planar deformities of the ankle and hindfoot. Although the procedure results in a rigid ankle and hindfoot, it is often the only means of providing patients with a stable and painless foot and ankle for ambulation. Some patients who require the procedure have substantial bone loss that can be managed with a variety of autograft and allograft options. Options for tibiotalocalcaneal fixation include both internal and external devices, the selection of which depends on the underlying pathology, amount of bone loss, and type of bone graft selected. Relatively high complication rates associated with tibiotalocalcaneal fusion have been reported, with complications ranging from superficial infection to ultimate amputation; however, proper patient selection and careful graft and fixation planning can minimize the postoperative complications of the procedure.
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Fang Z, Claaßen L, Windhagen H, Daniilidis K, Stukenborg-Colsman C, Waizy H. Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail with a valgus curve. Orthop Surg 2016; 7:125-31. [PMID: 26033993 DOI: 10.1111/os.12171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 03/01/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Many different techniques have been described for performing tibiotalocalcaneal arthrodesis (TTCA) in patients with severe hindfoot disorders such as failed ankle arthroplasty and failed ankle joint arthrodesis with subsequent subtalar arthritis. The use of straight retrograde intramedullary nails is extremely limited because they may interfere with normal heel valgus position and risk damaging the lateral plantar neurovascular structures. Curved retrograde intramedullary nails have been designed to overcome these shortcomings. The purpose of this single surgeon series was to investigate the outcomes of TTCA using a curved retrograde intramedullary nail. METHODS From June 2009 to January 2012, 22 patients underwent TTCA using intramedullary nails with a valgus curve by the same senior surgeon. All patients were available for analysis, the mean follow-up being 22.3 months (range, 6.8-38 months). The main outcome measurements included EQ-5D functional scores, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, radiologic assessment and clinical examination. RESULTS Bony union and a plantigrade foot were achieved in 100% of subjects, the mean time to union being 3.9 months (range, 2.4 to 6.2 months). Structural bone graft was used in all patients. Postoperative radiologic results showed a good hindfoot alignment in all patients. The only complication was one case of delayed wound healing without deep infection. The mean postoperative EQ-5D functional and AOFAS ankle-hindfoot scores were 69.33 (range, 20 to 90) and 69.9 (range, 45 to 85) points, respectively. No revision surgery was necessary in our cohort. CONCLUSION The results of the present study indicate that TTCA using a short, retrograde, curved intramedullary nail is an acceptable technique for obtaining solid fusion and good hindfoot alignment inpatients with severe hindfoot disorders.
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Affiliation(s)
- Zhenhua Fang
- Department of Orthopaedics, Puai Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Leif Claaßen
- Department of Orthopaedics, Hannover Medical School, Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedics, Hannover Medical School, Hannover, Germany
| | | | | | - Hazibullah Waizy
- Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany
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Shearman AD, Eleftheriou KI, Patel A, Pradhan R, Rosenfeld PF. Use of a Proximal Humeral Locking Plate for Complex Ankle and Hindfoot Fusion. J Foot Ankle Surg 2016; 55:612-8. [PMID: 26875767 DOI: 10.1053/j.jfas.2016.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Indexed: 02/03/2023]
Abstract
Arthrodesis of the ankle and hindfoot in the setting of major deformity is challenging and associated with substantial risks. Patients often have significant comorbidities that lead to unforgiving soft tissues, poor vascularity, and poor bone quality. This creates the high-risk scenario of poor wound healing and poor implant fixation. Complications can be devastating, leading to loss of the limb and sepsis. The use of locking plate technology might provide biomechanical and operative technique advantages in such patients. We retrospectively assessed the results of the modified use of the PHILOS(™) (Synthes(®), Zuchwil, Switzerland) proximal humeral locking plate in 21 patients (11 males, 10 females; mean age 56.1 years, range 25 to 74 years) who had undergone complex fusions, including tibiotalar (n = 4), tibiocalcaneal (n = 7), or tibiotalocalcaneal (n =10) fusions. The average follow-up period was 14.6 (median 10, range 6 to 49) months. Of the 21 fusions, 18 achieved union (85.7%) at an average period of 4.8 (median 4.3, range 3 to 12) months. The overall deep infection rate was 14.3%. Overall, 17 of the 21 patients (81%) were satisfied with the result (good to excellent), 1 reported the result was fair (4.8%), and 3 patients developed nonunion and were dissatisfied with the procedure (14.3%). The present study is the largest series to date of patients undergoing complex ankle and hindfoot arthrodesis with the use of a proximal humeral locking plate and confirms previous findings that the technique is reliable with union, satisfaction, and complication rates comparable to those of other techniques.
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Affiliation(s)
- Alexander D Shearman
- Specialist Registrar, St. Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | | | - Akash Patel
- Specialist Registrar, St. Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Rajib Pradhan
- Speciality Doctor, St. Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Francis Rosenfeld
- Consultant Orthopaedic Surgeon, St. Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
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Hsu AR, Ellington JK, Adams SB. Tibiotalocalcaneal Arthrodesis Using a Nitinol Intramedullary Hindfoot Nail. Foot Ankle Spec 2015; 8:389-96. [PMID: 26264637 DOI: 10.1177/1938640015598838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED Tibiotalocalcaneal (TTC) arthrodesis using an intramedullary hindfoot nail is a common procedure for deformity correction and the treatment of combined tibiotalar and subtalar end-stage arthritis. Nonunion at one or both fusion sites is a difficult complication that can result in reoperation, significant morbidity, and below-knee amputation. There is currently a need for sustained compression across fusion sites using a TTC hindfoot nail with good mechanical stability. The DynaNail TTC Fusion System (MedShape, Inc, Atlanta, GA) uses an internal nitinol compression element to apply sustained compression across the tibiotalar and subtalar joints after surgery. In preliminary clinical cases, we have found that the nail is safe, reliable, and has promising clinical and radiographic results in settings of hindfoot arthritis, complex deformity, Charcot arthropathy, and talar avascular necrosis. LEVELS OF EVIDENCE Expert opinion, Level V.
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Affiliation(s)
- Andrew R Hsu
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
| | - J Kent Ellington
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
| | - Samuel B Adams
- OrthoCarolina Foot & Ankle Institute, Charlotte, North Carolina (ARH, JKE)Department of Orthopeadic Surgery, Duke University Medical Center, Durham, North Carolina (SBA)
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Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
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Affiliation(s)
- Remy V Rabinovich
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - Amgad M Haleem
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
| | - S Robert Rozbruch
- Remy V Rabinovich, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY 10075, United States
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Rabinovich RV, Haleem AM, Rozbruch SR. Complex ankle arthrodesis: Review of the literature. World J Orthop 2015; 6:602-613. [PMID: 26396936 PMCID: PMC4573504 DOI: 10.5312/wjo.v6.i8.602] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/22/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023] Open
Abstract
Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients’ outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.
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Lucas Y Hernandez J, Abad J, Remy S, Darcel V, Chauveaux D, Laffenetre O. Tibiotalocalcaneal arthrodesis using a straight intramedullary nail. Foot Ankle Int 2015; 36:539-46. [PMID: 25561700 DOI: 10.1177/1071100714565900] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal (TTC) arthrodesis is a proven solution for severe hindfoot arthropathy that reestablishes stability for plantigrade gait and alleviates pain, while correcting deformity. Intramedullary nailing is an effective option for fixation. The aim of this study was to determine clinical outcome, analyze the fusion rate, and determine final hindfoot alignment in a consecutive series of patients using a single-design straight intramedullary nail. METHODS This study evaluated 63 patients treated between 2006 and 2010 with at least 36 months of follow-up. Ten patients were excluded because of study inclusion criteria, and 4 were lost to follow-up, leaving 49 patients available for review. The average follow-up was 70.7 ± 15.1 months. RESULTS The American Orthopaedic Foot and Ankle Society score improved from 29.7 ± 15.1 before arthrodesis to 65.8 ± 14.6 after (P < .001) with 83.7% (41/49) of patients stating they were satisfied or very satisfied with the outcome. The hindfoot angle improved from -3 ± 15 degrees (varus) before the arthrodesis to 3.5 ± 4 degrees (valgus) after; the tibiotalar angle averaged 103 ± 4.2 degrees after the arthrodesis. Fusion occurred in both joints in 86% (42/49) of patients and in 93% (91/98) of all joints. The average time to fusion was 4.5 ± 2 months. Current smokers had a significantly (P = .03) higher risk of complications. Use of an allograft, with or without bone morphogenetic protein 2, led to comparable results even in the presence of a large bone defect. CONCLUSION These results are comparable to previously published studies using intramedullary nailing to achieve tibiotalocalcaneal arthrodesis. The complication concerns typically associated with straight nails were not found. We recommend using a retrograde intramedullary nail for the fixation of TTC arthrodesis and adding an allograft in cases of significant bone loss. LEVEL OF EVIDENCE Level IV, consecutive case series.
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Affiliation(s)
| | - Julien Abad
- Bordeaux University Hospital, Centre Médico-chirurgical Universitaire du Pied, Bordeaux, France
| | | | | | - Dominique Chauveaux
- Bordeaux University Hospital, Centre Médico-chirurgical Universitaire du Pied, Bordeaux, France
| | - Olivier Laffenetre
- Bordeaux University Hospital, Centre Médico-chirurgical Universitaire du Pied, Bordeaux, France Geoffroy St Hilaire clinic, 59 rue Geoffroy St Hilaire, Paris, France
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von Recum J. [Tibiotalocalcaneal corrective arthrodesis in Charcot arthropathy of the ankle with a retrograde nail]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:114-28. [PMID: 25862127 DOI: 10.1007/s00064-014-0336-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/17/2014] [Accepted: 01/05/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Involvement of the ankle joint in Charcot osteoarthropathy is most often associated with severe instability and fracture or collapse of the talus. Caused by malalignment, ulcerations over both malleoli are associated with increased risk of major amputation. OBJECTIVE The goal of the operation is to realign the hind foot, gain a stable osteosynthesis, and prevent major amputation. INDICATIONS Charcot osteoarthropathy of the ankle joint with instability, with or without soft tissue involvement, failure of the primary arthrodesis of the ankle or subtalar joint. CONTRAINDICATIONS Acute osteitis/osteomyelitis, severe malalignment of the distal tibia, soft tissue infection close to the ankle joint. SURGICAL TECHNIQUE Realignment of the hind foot, preparation of the joint surfaces using a transfibular approach. Bone grafting of the defects, stable osteosynthesis with an anatomically shaped retrograde locking nail. POSTOPERATIVE MANAGEMENT Walker or cast for at least 12 weeks, 6 weeks no weight bearing. Partial weight bearing starting from week 7. X-ray control at 2, 6, and 12 weeks. After 12 weeks, walking in an ankle brace until fully consolidated.
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Affiliation(s)
- J von Recum
- Sektion Knie-, Fuß- und Sprunggelenkchirurgie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland,
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Wukich DK, Mallory BR, Suder NC, Rosario BL. Tibiotalocalcaneal Arthrodesis Using Retrograde Intramedullary Nail Fixation: Comparison of Patients With and Without Diabetes Mellitus. J Foot Ankle Surg 2015; 54:876-82. [PMID: 26015305 PMCID: PMC5664154 DOI: 10.1053/j.jfas.2015.02.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 02/03/2023]
Abstract
Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis is a salvage procedure reserved for severe cases of deformity. The aim of the present study was to compare the outcomes of this technique in patients with and without diabetes mellitus (DM). A total of 61 patients with and 56 without DM underwent retrograde intramedullary nailing and had a minimum follow-up period of 12 months. The overall incidence of complication was 45.2%; however, the overall incidence of complications between those with and without DM was not significantly different (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.38 to 1.65, p = .54). Patients with DM had a significantly greater rate of superficial infections (OR 8.3, 95% CI 1.01 to 68.67, p = .03). However, no difference was seen in the rate of deep infection (OR 0.90, 95% CI 0.34 to 2.46, p = .83) or noninfectious complications (OR 0.50, 95% CI 0.23 to 1.13, p = .09). Successful limb salvage was achieved for 96.8% of the patients with DM and 94.7% of those without DM (p = .66). A femoral head allograft was used in 32 (27.4%) of 117 patients to substitute for an osseous void. Of the 32 patients who required a femoral head allograft, 21 (67.7%) experienced a complication compared with 32 (37.6%) of 85 patients who did not require a femoral head allograft (OR 3.16, 95% CI 1.35 to 7.41, p = .008). The incidence of patient satisfaction was 80% for patients with DM and 72% for those without DM (p = .36). Despite a high incidence of complications, limb salvage was accomplished in approximately 95% of patients with complicated deformities. Four patients (6.56%) with DM experienced a tibia fracture; therefore, we now routinely use a 300-mm-long nail for this reconstruction.
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Affiliation(s)
- Dane K. Wukich
- Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Professor of Orthopaedic Surgery, University of Pittsburgh Medical Center Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA
| | - Brady R. Mallory
- Resident in Podiatry, University of Pittsburgh Medical Center Mercy Center for Healing and Amputation Prevention, Pittsburgh, PA
| | - Natalie C. Suder
- Graduate Student in Biostatistics and Epidemiology, Department of Epidemiology and Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Bedda L. Rosario
- Clinical Faculty in Biostatistics and Epidemiology, Department of Epidemiology and Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Pyrc J, Fuchs A, Zwipp H, Rammelt S. [Hindfoot fusion for Charcot osteoarthropathy with a curved retrograde nail]. DER ORTHOPADE 2014; 44:58-64. [PMID: 25523791 DOI: 10.1007/s00132-014-3062-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Charcot osteoarthropathy of the hindfoot with considerable dislocation and instability represents a therapeutic dilemma. The treatment goal is a plantigrade, stable foot that is free of infection and ulceration with the ability to ambulate in special footwear. MATERIALS AND METHODS Over a period of 6 years, we performed 23 hindfoot fusions in 21 patients with manifest Charcot arthropathy with the help of a curved retrograde nail (HAN). All patients suffered from insulin-dependent diabetes mellitus with polyneuropathy; 12 patients had additional peripheral vasculopathy. An average of 3.5 previous surgeries had been performed prior to hindfoot fusion. RESULTS Complete tibiotalocalcaneal fusion was obtained in 16 of 21 patients (76 %). Of these 21 patients, 18 (86 %) were followed clinically and radiologically for an average of 2 years. Overall, 16 patients (89 %) reported a substantial subjective improvement compared to the preoperative state. Hardware failure occurred in 7 cases (30 %) that could be brought to consolidation with exchange of the locking bolts or the complete nail. In 5 cases (22 %), a postoperative hematoma had to be removed and in 8 cases (35 %) wound edge necrosis was treated with local wound care. In 2 cases (9 %), a secondary or reactivated osteitis occurred that finally required below knee amputation. CONCLUSION Tibiotalocalcaneal fusion with a curved retrograde intramedullary nail (HAN) is an effective treatment option in highly unstable and deforming Charcot osteoarthropathy of the hindfoot. It is an alternative to external or other internal fixation methods and helps to avoid below knee amputation in more than 90 % of cases.
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Affiliation(s)
- J Pyrc
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstrasse 74, 01307, Dresden, Deutschland,
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Tenenbaum S, Coleman SC, Brodsky JW. Improvement in gait following combined ankle and subtalar arthrodesis. J Bone Joint Surg Am 2014; 96:1863-9. [PMID: 25410503 DOI: 10.2106/jbjs.m.01448] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study assessed the hypothesis that arthrodesis of both the ankle and the hindfoot joints produces an objective improvement of function as measured by gait analysis of patients with severe ankle and hindfoot arthritis. METHODS Twenty-one patients with severe ankle and hindfoot arthritis who underwent unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail were prospectively studied with three-dimensional (3D) gait analysis at a minimum of one year postoperatively. The mean age at the time of the operation was fifty-nine years, and the mean duration of follow-up was seventeen months (range, twelve to thirty-one months). Temporospatial measurements included cadence, step length, walking velocity, and total support time. The kinematic parameters were sagittal plane motion of the ankle, knee, and hip. The kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths on the affected and unaffected sides. RESULTS There was significant improvement in multiple parameters of postoperative gait as compared with the patients' own preoperative function. Temporospatial data showed significant increases in cadence (p = 0.03) and walking speed (p = 0.001) and decreased total support time (p = 0.02). Kinematic results showed that sagittal plane ankle motion had decreased, from 13.2° preoperatively to 10.2° postoperatively, in the operatively treated limb (p = 0.02), and increased from 22.2° to 24.1° (p = 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p = 0.007), and knee motion increased from 56° to 60° (p = 0.054). Kinetic results showed significant increases in ankle moment (p < 0.0001) of the operatively treated limb, ankle power of the contralateral limb (p = 0.009), and hip power on the affected side (p = 0.005) postoperatively. There was a significant improvement in gait symmetry (p = 0.01). CONCLUSIONS There was a small loss of sagittal plane motion in the affected limb postoperatively. There were marked increases in gait velocity, ankle moment, and hip motion and power, documenting objective improvements in ambulatory function. The data showed that preoperative ankle motion was greatly diminished. This may suggest that pain is more important than stiffness in asymmetric gait.
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Affiliation(s)
- Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel. E-mail address:
| | - Scott C Coleman
- Baylor University Medical Center, 411 North Washington Avenue, Suite 2100, Dallas, TX 75246. E-mail address for S.C. Coleman: . E-mail address for J.W. Brodsky:
| | - James W Brodsky
- Baylor University Medical Center, 411 North Washington Avenue, Suite 2100, Dallas, TX 75246. E-mail address for S.C. Coleman: . E-mail address for J.W. Brodsky:
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Ferrel JR, Davis RL, Witte ZW, Feibel JB. Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing: A Case Report. JBJS Case Connect 2014; 4:e104. [PMID: 29252772 DOI: 10.2106/jbjs.cc.m.00281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report the case of a patient who sustained injury to the anterior tibial artery during tibiotalocalcaneal retrograde nailing and developed an acutely ischemic foot. CONCLUSION Vascular injury during tibiotalocalcaneal arthrodesis with retrograde nailing is a rare but serious complication. While retrograde tibiotalocalcaneal arthrodesis nailing for end-stage ankle and subtalar arthritis has shown encouraging results, a high index of suspicion for postoperative complications is necessary in patients with risk factors for poor posterior collateral circulation.
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Affiliation(s)
- Jason R Ferrel
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
| | - Richard L Davis
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
| | - Zackary W Witte
- Department of Orthopedic Surgery, AB Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536
| | - Jonathan B Feibel
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
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Stojmenski S, Dimitrovski D, Merdzanovski I. Application of the First Expert Arthrodesis Nail to a Patient with Previous Performed Arthrodesis According to Ulrich Holz – Case Report. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM: The aim of this paper was to present application of the first expert arthrodesis nail in our clinic to a patient with previous performed arthrodesis according to Ulrich Holz.CASE REPORT: Patients A.M. on the age of 22 (1992) have a motor vehicle injury, (fall from a motor bike) with diagnosis polytrauma, shock, supra and transcondyar open fracture of the right femur III degree, open fracture of the right tibia and fibula. We perform reposition and fixation of supra and transcondyar femoral fracture with “cobra†plate. Also we perform reposition and fixation of right cruris with external fixation. After the operation we found fistula in the place of operation of the right crural regia. During the time the infection goes worse and the patient develop osteomyelittis on the right crural regia. After 5 months with therapy the situation become calm. We remove the external fixation. The patient develops severe “pes equinus†on the right leg and he cannot walk. We try to reduce this equines situation with elongation of the Achilles tendonin the first step, and because we didn’t solve the problem we continue with complete section of the Achilles tendon and after that we perform osteotomy of the right talocrural joint simultaneous to tibia plafond and talus and resection of fibula 2sm.above the syndesmosae tibiofibularis and we fixed the talocrural joint with two screws according the technique of Ulrich Holz.CONCLUSION: So we received fixed position on of the food on 110 degrees which was steel unacceptable for normal walking. At last we remove the screws, make once again osteotomy with positioning of the food in maximal dorsiflexion and perform the Experf Hindfood arthrodesis nail so with this method we achieve correction of dorsiflexion on 95 degrees, and the patient become satisfied because he can walk without support.
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Brodsky JW, Verschae G, Tenenbaum S. Surgical correction of severe deformity of the ankle and hindfoot by arthrodesis using a compressing retrograde intramedullary nail. Foot Ankle Int 2014; 35:360-7. [PMID: 24505043 DOI: 10.1177/1071100714523270] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail is a widely used surgical technique for the treatment of concomitant tibiotalar and subtalar arthritis and correction of accompanying deformity. This study was undertaken to evaluate the union rate, deformity correction, and clinical outcomes achieved using a compressing retrograde intramedullary nail. METHODS Thirty tibiotalocalcaneal arthrodeses with an osseous compressing arthrodesis nail system were studied with a mean follow-up of 26 months. Radiographic data were collected on deformity correction and union rate, and clinical outcomes were evaluated using the Visual Analogue Scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle/Hindfoot Score, and the Short Form-36 (SF-36) health survey. Records were reviewed for complications and concomitant procedures. RESULTS Thirteen of 30 operated limbs had a preoperative coronal plane deformity exceeding 15 degrees. Mean magnitude of correction was 13.2 degrees (range, 0-32 degrees, standard deviation ±9.6). In total, 76% of limbs (23/30) had postoperative coronal deformity of less than 5 degrees. Union was achieved in 96.6% of patients. There were 3 cases of tibial stress reaction, 3 cases of transient plantar nerve irritation, and 3 cases of wound infection. Clinical outcomes demonstrated a reduction in mean VAS score from 6.5 to 1.3 (P < .01), an increase in mean AOFAS Ankle/Hindfoot Scores from 29.7 to 74.3 (P < .01), and an increase in mean total SF-36 scores from 85.6 to 98.8 (P < .01). CONCLUSION A compressing retrograde intramedullary nail was effective in achieving deformity correction, a high union rate, and improvement in clinical outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Richter M, Evers J, Waehnert D, Deorio JK, Pinzur M, Schulze M, Zech S, Ochman S. Biomechanical comparison of stability of tibiotalocalcaneal arthrodesis with two different intramedullary retrograde nails. Foot Ankle Surg 2014; 20:14-9. [PMID: 24480493 DOI: 10.1016/j.fas.2013.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of the study was to compare the initial construct stability of two retrograde intramedullary nail systems for tibiotalocalcaneal arthrodesis (TTCF) (A3, Small Bone Innovations; HAN, Synthes) in a biomechanical cadaver study. METHODS Nine pairs of human cadaver bones were instrumented with two different retrograde nail systems. One tibia from each pair was randomized to either rod. The bone mineral density was determined via tomography to ensure the characteristics in each pair of tibiae were similar. All tests were performed in load-control. Displacements and forces were acquired by the sensors of the machine at a rate of 64Hz. Specimens were tested in a stepwise progression starting with six times ±125N with a frequency of 1Hz for 250cycles each step was performed (1500cycles). The maximum load was then increased to ±250N for another 14 steps or until specimen failure occurred (up to 3500cycles). RESULTS Average bone mineral density was 67.4mgHA/ccm and did not differ significantly between groups (t-test, p=.28). Under cyclic loading, the range of motion (dorsiflexion/plantarflexion) at 250N was significantly lower for the HAN-group with 7.2±2.3mm compared to the A3-group with 11.8±2.9mm (t-test, p<0.01). Failure was registered for the HAN after 4571±1134cycles and after 2344±1195cycles for the A3 (t-test, p=.031). Bone mineral density significantly correlated with the number of cycles to failure in both groups (Spearman-Rho, r>.69, p<0.01). CONCLUSIONS The high specimen age and low bone density simulates an osteoporotic bone situation. The HAN with only lateral distal bend but two calcaneal locking screws showed higher stability (higher number of cycles to failure and lower motion such as dorsiflexion/plantarflexion during cyclic loading) than the A3 with additional distal dorsal bend but only one calcaneal locking screw. Both constructs showed sufficient stability compared with earlier data from a similar test model. CLINICAL RELEVANCE The data suggest that both implants allow for sufficient primary stability for TTCF in osteoporotic and consequently also in non-osteoporotic bone. LEVEL OF EVIDENCE Not applicable, experimental basic science study.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Hospital Rummelsberg, Schwarzenbruck, Germany.
| | - Julia Evers
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Dirk Waehnert
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jim K Deorio
- Department for Orthopaedics, Duke University, Durham, NC, USA
| | - Michael Pinzur
- Department for Orthopaedics, Loyola University Chicago, IL, USA
| | - Martin Schulze
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Hospital Rummelsberg, Schwarzenbruck, Germany
| | - Sabine Ochman
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Yakacki CM, Gall K, Dirschl DR, Pacaccio DJ. Pseudoelastic intramedullary nailing for tibio–talo–calcaneal arthrodesis. Expert Rev Med Devices 2014; 8:159-66. [DOI: 10.1586/erd.10.93] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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