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Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation
The Journal of Foot & Ankle Surgery xxx (2016) 1–6
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The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation Jennifer L. Mulhern, DPM, AACFAS 1, Nicole M. Protzman, MS 2, Maxwell J. Levene, DPM, AACFAS 3, Scott M. Martin, DPM 4, Justin J. Fleming, DPM, FACFAS 5, J. Randolph Clements, DPM, FACFAS 6, 7, Stephen A. Brigido, DPM, FACFAS 8, 9 1
Associate Physician, Martin Foot and Ankle, York, PA Research Associate, Coordinated Health, Allentown, PA Fellow, Foot & Ankle Reconstruction, Aria 3B Orthopaedic Specialists Philadelphia, PA 4 Resident, Carilion Clinic, Roanoke, VA 5 Fellowship Director, Foot & Ankle Reconstruction, Aria 3B Orthopaedic Specialists, Philadelphia, PA 6 Assistant Professor, Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 7 Co-Section Chief, Foot and Ankle, Virginia Tech Carilion School of Medicine, Carillion Clinic, Roanoke, VA 8 Fellowship Director, Foot & Ankle Reconstruction, and Department Chair, Foot and Ankle Department, Coordinated Health, Bethlehem, PA 9 Clinical Professor of Surgery, Clinical Sciences Department, The Commonwealth Medical College, Scranton, PA 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) ¼ –6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: arthrodesis end-stage osteoarthritis intramedullary nail pantalar subtalar joint
Ankle arthrodesis is a powerful procedure that can provide stability to previously unstable or painful joints. The indications for arthrodesis include end-stage ankle joint arthritis, either posttraumatic or resulting from systemic arthritic processes, such as
Financial Disclosure: None reported. Conflict of Interest: Stephen A. Brigido serves as a consultant for Alliqua, Stryker Orthopedics, Zimmer, and Wright Medical. J. Randolf Clements is a paid consultant for Tornier and Smith & Nephew. Justin J. Fleming is a paid consultant for Arthrex and Stryker Orthopedics. None of these companies had any knowledge or influence in the study design, protocol, or data collection. For the remaining authors, no potential conflicts of interest exist. Address correspondence to: Stephen A. Brigido, DPM, FACFAS, Foot & Ankle Reconstruction, Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017. E-mail address: [email protected] (S.A. Brigido).
Charcot joint disease with talar collapse or talar avascular necrosis, and failed ankle arthrodesis or ankle arthroplasty (1–3). The primary operative objective is to create a stable, plantigrade extremity to promote ambulation (4). Multiple fixation constructs can be used to perform ankle arthrodesis with or without subtalar joint fusion. In 1948, Adams (5) was the first to describe intramedullary nailing as a form of fixation for ankle arthrodesis. Intramedullary nailing has since become advantageous, because it can be performed through small incisions, is a load-sharing device, offers axial stability, and allows for dynamic compression (1,2). Tibiotalocalcaneal (TTC) arthrodesis is performed with formal cartilage resection of both the ankle joint and the subtalar joint before intramedullary nail placement (1,4,6–8). This technique has been
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.11.007
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shown to reduce pain and improve function (3). The incidence of nonunion has reportedly ranged from 12% to 34%, with a mean operative time of 117 minutes (1,4,6–8). With this traditional approach, the subtalar joint is sacrificed. In cases of severe deformity, neuropathic arthropathy and severe post-traumatic osteoarthritis, stabilization of the subtalar joint aids in deformity reduction and increases stability and, therefore, is often preferred (2). In young, otherwise healthy patients with singular ankle joint pathology, sacrifice of the subtalar joint might not be ideal. Despite documented success, we have questioned the need for formal subtalar joint cartilage resection. To the best of our knowledge, only 2 reports have described TTC fusion with formal preparation of the ankle joint but not the subtalar joint, with good outcomes (8,9). From the available evidence and personal experience, we hypothesized that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing TTC arthrodesis with retrograde intramedullary nail fixation. The primary aim of the present multicenter retrospective study was to evaluate the clinical and radiographic outcomes of patients who had undergone TTC arthrodesis with intramedullary nail fixation, without formal subtalar joint cartilage resection. Patients and Methods A multicenter retrospective case series was conducted to evaluate the clinical and radiographic outcomes and the operative duration and complications associated with TTC arthrodesis without subtalar joint cartilage resection. Three sites participated in the present investigation. Consecutive patients who underwent TTC arthrodesis with intramedullary nail fixation from March 2009 to December 2014 were identified. The electronic health records were reviewed to determine which patients met the inclusion and exclusion criteria. Patients who were 18 years old and had undergone TTC arthrodesis with intramedullary nailing performed by 1 of 3 preidentified senior surgeons were considered for inclusion. The patients who had undergone TTC arthrodesis with intramedullary nailing for acute traumatic distal tibial fracture or for salvage after total ankle replacement or had experienced trauma to either the tibiotalar or the subtalar joints after TTC arthrodesis were excluded from the present study. Once a patient was determined to have met the inclusion and exclusion criteria, the contributory patient demographics and comorbidity data were recorded. These consisted of patient age (years), body mass index (kg/m2), gender (male versus female), operative side (left versus right), smoking status, and the presence or absence of diabetes mellitus, neuropathy, and obesity. The data were recorded into a password-protected, secure database, and the confidentiality and privacy of the patients were ensured and maintained. According to the institutional review board, this research project met the conditions for exemption. Thus, the institutional reviewed board approved the protocol and waived the requirement for informed consent.
Table 1 Concomitant procedures Variable
All Ankles (N ¼ 40)
Ankle arthroscopy Bone stimulator implantation Bone tumor excision Harvest of graft Lisfranc ORIF Removal of hardware Revision of talonavicular fusion Tendo-Achilles lengthening External fixator modifications from previous pilon repair Vacuum assisted wound closure No additional procedures performed
1 1 1 8 1 8 1 7 1 1 17
(2.5) (2.5) (2.5) (20.0) (2.5) (20.0) (2.5) (17.5) (2.5) (2.5) (42.5)
Abbreviation: ORIF, open reduction internal fixation. Data presented as n (%). fellowship-trained surgeons (J.L.M., M.J.L) and a resident (S.M.M.) reviewed all the radiographs to determine the time to bony union at the tibiotalar joint and to evaluate deterioration of the subtalar joint. These assessors were not unaware of the patient data. The immediate postoperative radiograph and the most recent follow-up radiograph were evaluated to determine the extent of deterioration of the subtalar joint using a modified version of the grading system developed by Takakura et al (10) (Table 3). The 3 patients who required hardware removal were excluded from these analyses. The intraoperative and postoperative complications and operative time were also recorded from the patients’ electronic medical records. The most recent radiograph was examined to determine whether any patients demonstrated failure of the talar and/or calcaneal locking screw. The statistical analyses were performed by the research associate at our institution. Statistical Analysis All analyses were conducted using IBMÒ SPSSÒ Statistics, version 20 (IBM Corp., Armonk, NY). The significance level for all statistical tests was set at p ¼ .05. Data are reported as the mean standard deviation within the text and tables and the mean standard error elsewhere. Because the data were collected retrospectively, complete data sets were not available for all patients. Therefore, the sample size for each calculation is provided. A 2-factor analysis of variance (time neuropathic status) with repeated measures for time was conducted to compare the pain across time and between patients with and without neuropathy. Independent t tests were used to compare the operative duration and time to bony union between patients with and without neuropathy. An independent t test was also used to compare the time to bony union between patients who had required additional hardware and those who had not. A paired samples t test was used to compare the extent of subtalar joint deterioration across time (immediately postoperative to the most recent follow-up visit). Using G*Power, version 3.1.9.2, a post hoc calculation was completed. Given an a of 0.05, a sample size of 40, and an effect size of 1.68, the study was found to be adequately powered.
Results Intervention All patients received prophylactic intravenous antibiotics before induction and underwent TTC arthrodesis with retrograde intramedullary nail fixation and formal preparation of the ankle joint, without formal preparation of the subtalar joint. Concomitant procedures and supplementation of internal fixation were performed as necessary (Table 1). Surgeon preference dictated the incisional approach (Table 2). Autograft and/or allograft placement and the use of a straight versus a valgus-bend nail varied by case (Table 2). Postoperatively, all patients were placed in a splint and compressive dressing and kept non-weightbearing. The sutures and staples were removed as dictated by skin coaptation. All patients maintained non-weightbearing status for a minimum of 8 weeks. Progressive weightbearing was advanced in accordance with evidence of radiographic healing. Endpoints A multicenter medical record review was performed to collect the operative, clinical, and radiographic data. The operative duration was defined as the time from tourniquet inflation to tourniquet deflation. The study endpoint for the clinical data (pain) was the most recent follow-up appointment after TTC arthrodesis. The amount of preoperative and postoperative pain was recorded from the patients’ electronic medical records. Pain was assessed using a visual analog scale from 0 to 10, with 0 representing no pain and 10 representing excruciating pain. The study endpoint for the radiographic data at the tibiotalar joint was evidence of bony union after arthrodesis. Bony union was defined as bony trabeculation across the fusion site in all 3 radiographic views. Two
Forty consecutive patients (aged 61.9 12.9 years; 17 men) met the inclusion and exclusion criteria (Table 4). The indications for Table 2 Operative summary Variable Approach Anterior Anterolateral Lateral Medial Medial and lateral Graft type Allograft Allograft and autograft combination Autograft Synthetic substitute None Nail type Straight Valgus Data presented as n (%).
All Ankles (N ¼ 40) 3 5 22 6 4
(7.5) (12.5) (55.0) (15.0) (10.0)
15 3 7 2 13
(37.5) (7.5) (17.5) (5.0) (32.5)
27 (67.5) 13 (32.5)
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Table 3 Modified joint deterioration grading system
Table 5 Outcomes
Grade
Description
Variable
Patients (n)
Mean SD
1 2 3 4
No joint space narrowing, but early sclerosis and osteophyte formation Narrowing of the joint space Obliteration of a portion of the joint with subchondral bone contact Obliteration of the whole joint space with complete bone contact
Operative duration (min) Time to bony union at tibiotalar joint (mo) Clinical follow-up duration (mo) Preoperative pain (VAS) Postoperative pain (VAS)
39 34 33 33 33
111.1 3.8 11.1 6.4 1.2
surgery included combined ankle and hindfoot arthritis and isolated ankle arthritis associated with neuropathy. In our patient population, end-stage joint arthritis had developed secondary to osteoarthritis in 23 patients (57.5%), a Charcot joint in 11 (27.5%), post-traumatic arthritis in 5 (12.5%), and rheumatoid arthritis in 1 patient (2.5%). In terms of comorbid conditions, 19 patients (47.5%) were diagnosed with diabetes mellitus and 15 patients with neuropathy (37.5%). Eight patients (20.0%) required augmentation with additional hardware at surgery. Plates or screws, or a combination of both, were used in most patients. As indicated in Table 1, 1 patient required external fixation modification from a previous pilon repair, and 1 patient had a bone stimulator implanted. The mean operative duration was 111.1 33.3 minutes, and the mean clinical follow-up duration was 11.1 months (Table 5). One tourniquet was deflated before closure for hemostasis. No patient required tourniquet reinflation. The 2-factor analysis of variance (time neuropathic status) for pain revealed a main effect of time (p < .001), indicating that pain had significantly declined after surgery (Table 5; Fig. 1). No main effect of neuropathy (p ¼ .692) was found, and the time by neuropathy interaction (p ¼ .822) was insignificant. The mean time to bony union at the tibiotalar joint was 3.8 1.5 months. Of the 34 patients with radiographic data available, 31 (91.2%) achieved bony union at the tibiotalar joint within the 6 months after operative intervention. The 3 remaining patients subsequently achieved bony union at 7.1, 7.8, and 8.2 months, respectively. The patient who required 8.2 months to achieve union had neuropathy. The mean time to bony union was significantly shorter for patients who had received augmentation with additional hardware (3.1 0.3 months) than for patients who were not [4.0 1.6 months, t(30.774) ¼ 2.529, p ¼ .017]. To determine whether neuropathy influenced the operative duration or the time to bony union, the results were stratified and compared using independent t tests. Comparing the patients with and without neuropathy, no significant difference was found in operative duration [t(37) ¼ 0.184, p ¼ .855] or the time to bony union [t(32) ¼ –0.977, p ¼ .336).
Abbreviations: SD, standard deviation; VAS, visual analog scale. * p .05, comparing preoperative and postoperative pain scores.
The complications are summarized in Table 6. A total of 4 major complications (10.0%) had a negative effect on patient outcome. Of the 4 major complications, 2 occurred in neuropathic patients. In 3 patients, 2 of whom were neuropathic, the hardware was removed secondary to infection. The fourth patient required hardware removal because of persistent pain at the subtalar joint. Despite hardware removal, the pain did not resolve, and the patient underwent subtalar joint arthrodesis because of residual pain involving this joint. In addition, 10 complications (25.0%) had no negative effect on patient outcomes. In the case of delayed union, successful union was achieved with bone stimulation. Both periprosthetic fractures healed successfully after internal fixation. At the most recent follow-up evaluation, 1 patient experienced failure of the calcaneal locking screw and 1 patient experienced failure of the intramedullary rod at the location of the talar locking screw; neither screw failure required intervention. The 2 superficial wounds and 1 full-thickness wound were treated with local wound care until closure was obtained. Wound closure was achieved in the other full-thickness wound after application of a splitthickness skin graft. The posterior tibial pseudoaneurysm required a return trip to the operating room. The vascular surgeon successfully treated the pseudoaneurysm with no residual sequelae. The mean radiographic follow-up duration was 11.6 9.1 months. A statistically significant increase in deterioration occurred at the subtalar joint from the immediate postoperative evaluation (2.0 0.9) to the most recent follow-up evaluation [2.9 1.0; t(36) ¼ –6.200, p < .001; Table 7 and Fig. 2).
Discussion Intramedullary nailing for TTC arthrodesis with formal subtalar joint preparation was first documented in the 1940s (5). Although the intramedullary nail crosses the subtalar joint, we do not believe the subtalar joint requires formal preparation before TTC arthrodesis. Therefore, we hypothesized that the stability imparted by the intramedullary nail with fusion of the ankle joint would provide sufficient
Table 4 Patient demographics and comorbidities Variable Demographic data Age (yr) BMI (kg/m2) Gender Male Female Operative side Left Right Comorbidity Diabetic Neuropathic Obese (BMI 30 kg/m2) Smoker (current and former) Abbreviation: BMI, body mass index. Data presented as mean standard deviation or n (%).
All Ankles (N ¼ 40) 61.9 12.9 32.4 8.2 17 (42.5) 23 (57.5) 13 (32.5) 27 (67.5) 19 15 24 19
33.3 1.5 10.2 2.7 1.8*
(47.5) (37.5) (60.0) (47.5) Fig. 1. Pain experienced across time. Data plotted as mean standard error.
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Table 6 Intraoperative and postoperative complications Complications
All Ankles (N ¼ 40)
Intraoperative Edema preventing wound closure Postoperative Delayed union Pain at subtalar joint Periprosthetic fracture Hardware failure Superficial wound Full-thickness wound Infection Posterior tibial pseudoaneurysm
Patients With Neuropathy Yes (n ¼ 15)
No (n ¼ 25)
1 (2.5)
1 (4.0)
1 1 2 2 1 2 3 1
1 1 2 1
(2.5) (2.5) (5.0) (5.0) (2.5) (5.0) (7.5) (2.5)
1 (6.7) 1 (6.7)
(4.0) (4.0) (8.0) (4.0)
2 (8.0) 1 (4.0)
2 (13.3) 1 (6.7)
Data presented as n (%).
stabilization to yield satisfactory patient outcomes. To evaluate this hypothesis, patients who had undergone TTC joint arthrodesis without subtalar joint cartilage resection were identified, and a retrospective medical record review was conducted. Proper placement of the intramedullary nail at the junction of the sustentaculum tali and the body of the calcaneus is vital to achieve successful TTC arthrodesis and extremity alignment (7,11). Although we believe that stability of the nail and arthrodesis of the tibiotalar joint without formal preparation of the subtalar joint leads to successful outcomes, we recognize, just as did Boer et al (12), that when proper placement is achieved, the subtalar joint will be violated during reaming. Depending on the size of the nail used, an 11-mm or 12-mm portion of the posterior facet will be damaged during this process, informally destroying cartilage at that region. This could lead to partial union of the subtalar joint and add stability to the extremity postoperatively. The findings of the present retrospective evaluation confirmed clinically significant improvements in pain with a high rate of union. Given the large percentage of patients with neuropathy included in the present report, TTC arthrodesis without formal subtalar joint resection appears to be an excellent procedure for both insensate and sensate patients. The advantage of this technique is that a stable extremity can be achieved through mini-arthrotomy incisions with minimal trauma to the soft tissues, reducing large deformities with advanced arthritic changes. This is in contrast to the use of large incisions for placement of blade plate or locking plate fixation. Additionally, limiting dissection around the talus with this technique reduces the likelihood of damaging the talar blood supply. This is advantageous, because maintaining this blood supply is vital to successful arthrodesis. In reviewing the published data, only 2 published reports have described TTC arthrodesis with cartilage resection of the ankle joint and not the subtalar joint (1,4). In 1995, Moore et al (4) did not prepare the subtalar joint in 6 of 19 ankles. No clinical motion was observed at the subtalar joint postoperatively (4). In their study population, only 2 complications resulted: 1 deep infection and 1
Table 7 Evaluation of subtalar joint deterioration Grade
Immediate Postoperative Radiograph (n ¼ 37)
Most Recent Follow-Up Radiograph (n ¼ 37)
1 2 3 4
12 13 11 1
5 5 15 12
(32.4) (35.1) (29.7) (2.7)
(13.5) (13.5) (40.5) (32.4)
Data presented as n (%). The mean radiographic follow-up duration was 11.6 9.1 months.
broken intramedullary rod (4). More recently, in 2014, Gross et al (1) reported performing ankle arthrodesis without subtalar joint cartilage resection in 30 patients. They reported a 27% major complication rate that included nonunion of the subtalar joint and/or ankle joint, reoperation, deep infection, and below-the-knee amputation (1). With radiographic assessment, the fusion rate was reportedly 86% for the tibiotalar joint and 74% for the subtalar joint (1). These data are difficult to interpret, because complete union should not have been anticipated at the subtalar joint in the absence of formal cartilage resection. In the present report, a 10% major complication rate was appreciated. Three patients required hardware removal secondary to infection and one required hardware removal because of persistent pain. Two of the patients who had developed an infection underwent initial TTC arthrodesis because of Charcot arthropathy; the third patient had undergone initial TTC arthrodesis for post-traumatic osteoarthritis after a high-energy open fracture with a poor soft tissue envelope. All 3 patients underwent hardware removal, the joint was stabilized with internal or external fixation, and the infection was appropriately treated. Stable TTC arthrodesis was achieved in all 3 patients. In the patient who required hardware removal because of persistent pain, the pain did not resolve, and the patient underwent subtalar joint arthrodesis. The disparity between the 2 reports in terms of the major complication rate (27% versus 10%) is difficult to reconcile given the similar surgical approach (1), although some variation could be attributable to differences in defining the criteria and expectations. Although few reports have described TTC arthrodesis without formal preparation of the subtalar joint, numerous reports have described the outcomes after formal preparation of both joints. A study conducted in 2006 reported the findings for 33 patients who had undergone TTC arthrodesis with intramedullary nailing by 1 surgeon (13). Formal cartilage resection of both the ankle joint and the subtalar joint was completed before intramedullary nail placement. The investigators reported successful union in 29 of the 33 patients (88%) (13). Of the 4 patients with nonunion, 3 reported functioning with mild pain with the use of ankle-foot orthoses (13). Similar results were reported by Niinimaki et al (6), with a 76% fusion rate (26 of 34 patients) after formal preparation of the involved joints and an overall complication rate of 14%. Hammett et al (2) reported a nonunion rate of 13% (6 of 45 patients), with 2 nonunions occurring at the ankle joint and 4 at the subtalar joint. Rammelt et al (8), in 2013, reported the outcomes from a multicenter study of 38 patients who had undergone TTC arthrodesis with intramedullary nailing. All patients had undergone formal preparation of the subtalar and ankle joints, with resection of all interposed cartilage. They reported a 16% (6 of 38 patients) nonunion rate and an overall complication rate of 24% (9 of 38 patients) at the final follow-up visit (8). In the present report, a 91.2% fusion rate was achieved at the ankle joint 6 months after surgery in the 34 patients with radiographic follow-up data available. The 3 patients who had not achieved union at 6 months had achieved bony union at 7.1, 7.8, and 8.2 months, respectively. One patient (2.6%) experienced delayed union that was successfully treated with bone stimulation. Compared with the published results when both the subtalar joint and the ankle joint were formally prepared, these results suggest that union at the tibiotalar joint will be more predictable without formal preparation of the subtalar joint. Therefore, we recommend performing TTC arthrodesis without formal subtalar joint preparation. To further evaluate this surgical approach, the condition of the subtalar joint was evaluated on the immediate postoperative radiographs and the radiographs obtained at the most recent followup visit. This evaluation confirmed that the condition of the subtalar joint deteriorated over time. Presumably, 1 of 2 events occurred,
J.L. Mulhern et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–6
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Fig. 2. Deterioration of the subtalar joint. Radiographs demonstrate deterioration of the subtalar joint across time. The radiographs were obtained after tibiotalocalcaneal arthrodesis without cartilage resection of the subtalar joint at 2 weeks (A) and 1 year (B) postoperatively. Using the modified joint deterioration grading system, cartilage deterioration was noted to progress from a score of 1 to 3.
either progression of osteoarthritis due to motion at the subtalar joint or partial union/stable pseudoarthrosis. Only 1 patient reported pain at the subtalar joint postoperatively and was treated with revision with formal preparation. Two patients developed hardware failure: one at the calcaneal locking screw and one at the intramedullary rod at the level of the talar locking screw; neither required removal or intervention. In the absence of pain and/ or hardware failure, all patients subsequently developed partial union or stable pseudoarthrosis, which was deemed a successful outcome. We recognize that if the intramedullary nail at the tibiotalar joint is compressed intraoperatively, this could lead to distraction of the subtalar joint and predispose patients to subtalar joint complications. However, this was not observed in our patient population, obviating our ability to comment on the clinical significance and influence on the outcomes. In 2005, Hammett et al (2) reported a mean operative time of 117 minutes when the subtalar joint and ankle joint were both formally prepared before intramedullary nailing. In the present report, the mean operative time was 111 minutes, demonstrating that operative time slightly decreases when preparation of the subtalar joint is not performed, without compromising clinical outcomes. We expected a larger difference in operative time between the historical control and the study group, because opening the joint and resecting the cartilage likely requires >6 minutes. Given the large number of patients who underwent concomitant procedures in the present report, however, similar procedures were not compared and the presumed difference in operative time was not appreciated. The benefits of a decreased operative time are many, but of particular
importance is the potential to reduce costs. This is especially relevant because the current healthcare reform is promoting a bundled system of payment. When adopted by the foot and ankle community, shorter operative times will translate into decreased costs to both the facility and the patient, permitting more affordable treatment. Rammelt et al (8) reported an average postoperative pain score of 2.2 (range 0 to 9), with only 1 patient reporting a pain score of 9. In the patient population examined in the present study, the mean postoperative pain score was 1.2 (range 0 to 6). These results and the results of previous reports appear comparable, indicating that although the subtalar joint was not fused, the fusion at the tibiotalar joint and the stability imparted from the intramedullary nail is as effective in reducing pain postoperatively. Although additional prospective comparative trials are needed to reach definitive conclusions, we recommend performing TTC arthrodesis without formal subtalar joint preparation. These provisional results indicate that this technique obtains a similar reduction in pain and time to bony union, with a shorter operative duration, compared with TTC arthrodesis with formal subtalar joint preparation. The present study had a number of limitations, which could have influenced the validity of our conclusions. The most substantial methodological shortcoming of the present investigation was its retrospective design. As such, we were responsible for reviewing and collecting the data from the patients’ medical records and radiology reports, increasing the potential for bias. Additionally, because of the retrospective nature of the present study, not all patients had complete data sets. Finally, owing to the multicenter nature of the study, no predetermined intervals were established for radiographic
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evaluation, which could have potentially skewed the results for the time to bony union. In conclusion, despite these limitations, we believe that the results of the present investigation can be used in the development of future prospective studies to determine whether eliminating cartilage resection at the subtalar joint has any negative effects on patient outcomes. References 1. Gross JB, Belleville R, Nespola A, Poircuitte JM, Coudane H, Mainard D, Galois L. Influencing factors of functional result and bone union in tibiotalocalcaneal arthrodesis with intramedullary locking nail: a retrospective series of 30 cases. Eur J Orthop Surg Traumatol 24:627–633, 2014. 2. Hammett R, Hepple S, Forster B, Winson I. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: the results of 52 procedures. Foot Ankle Int 26:810–815, 2005. 3. Mendicino RW, Catanzariti AR, Saltrick KR, Dombek MF, Tullis BL, Statler TK, Johnson BM. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg 43:82–86, 2004. 4. Moore TJ, Prince R, Pochatko D, Smith JW, Fleming S. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 16:433–436, 1995.
5. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 30B:506–511, 1948. €ki TT, Klemol T, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a 6. Niinima compressive retrograde intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int 28:431–434, 2007. 7. Pochatko DJ, Smith JW, Phillips RA, Prince BD, Hedrick MR. Anatomic structures at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod. Foot Ankle Int 16:542–547, 1995. 8. Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier P, Friscia DA, Hansen ST, Schaser K, Ljungqvist J, Sands AK. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int 34:1245–1255, 2013. 9. Thomas RL, Sathe V, Habib SI. The use of intramedullary nails in tibiotalocalcaneal arthrodesis. Am Acad Orthop Surg 20:1–7, 2012. 10. Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle: results of a new operation in 18 patients. J Bone Joint Surg Br 77:50–54, 1995. 11. Belczyk R, Sung W, Wukich DK. Technical tip: a simple method for proper placement of an intramedullary nail entry point for tibiotalocalcaneal or tibiocalcaneal arthrodesis. Foot Ankle J 1:4, 2008. 12. Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res 463:151–156, 2007. 13. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int 27:759–763, 2006.
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Original Research
Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation Jennifer L. Mulhern, DPM, AACFAS 1, Nicole M. Protzman, MS 2, Maxwell J. Levene, DPM, AACFAS 3, Scott M. Martin, DPM 4, Justin J. Fleming, DPM, FACFAS 5, J. Randolph Clements, DPM, FACFAS 6, 7, Stephen A. Brigido, DPM, FACFAS 8, 9 1
Associate Physician, Martin Foot and Ankle, York, PA Research Associate, Coordinated Health, Allentown, PA Fellow, Foot & Ankle Reconstruction, Aria 3B Orthopaedic Specialists Philadelphia, PA 4 Resident, Carilion Clinic, Roanoke, VA 5 Fellowship Director, Foot & Ankle Reconstruction, Aria 3B Orthopaedic Specialists, Philadelphia, PA 6 Assistant Professor, Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 7 Co-Section Chief, Foot and Ankle, Virginia Tech Carilion School of Medicine, Carillion Clinic, Roanoke, VA 8 Fellowship Director, Foot & Ankle Reconstruction, and Department Chair, Foot and Ankle Department, Coordinated Health, Bethlehem, PA 9 Clinical Professor of Surgery, Clinical Sciences Department, The Commonwealth Medical College, Scranton, PA 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) ¼ –6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: arthrodesis end-stage osteoarthritis intramedullary nail pantalar subtalar joint
Ankle arthrodesis is a powerful procedure that can provide stability to previously unstable or painful joints. The indications for arthrodesis include end-stage ankle joint arthritis, either posttraumatic or resulting from systemic arthritic processes, such as
Financial Disclosure: None reported. Conflict of Interest: Stephen A. Brigido serves as a consultant for Alliqua, Stryker Orthopedics, Zimmer, and Wright Medical. J. Randolf Clements is a paid consultant for Tornier and Smith & Nephew. Justin J. Fleming is a paid consultant for Arthrex and Stryker Orthopedics. None of these companies had any knowledge or influence in the study design, protocol, or data collection. For the remaining authors, no potential conflicts of interest exist. Address correspondence to: Stephen A. Brigido, DPM, FACFAS, Foot & Ankle Reconstruction, Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017. E-mail address: [email protected] (S.A. Brigido).
Charcot joint disease with talar collapse or talar avascular necrosis, and failed ankle arthrodesis or ankle arthroplasty (1–3). The primary operative objective is to create a stable, plantigrade extremity to promote ambulation (4). Multiple fixation constructs can be used to perform ankle arthrodesis with or without subtalar joint fusion. In 1948, Adams (5) was the first to describe intramedullary nailing as a form of fixation for ankle arthrodesis. Intramedullary nailing has since become advantageous, because it can be performed through small incisions, is a load-sharing device, offers axial stability, and allows for dynamic compression (1,2). Tibiotalocalcaneal (TTC) arthrodesis is performed with formal cartilage resection of both the ankle joint and the subtalar joint before intramedullary nail placement (1,4,6–8). This technique has been
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.11.007
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shown to reduce pain and improve function (3). The incidence of nonunion has reportedly ranged from 12% to 34%, with a mean operative time of 117 minutes (1,4,6–8). With this traditional approach, the subtalar joint is sacrificed. In cases of severe deformity, neuropathic arthropathy and severe post-traumatic osteoarthritis, stabilization of the subtalar joint aids in deformity reduction and increases stability and, therefore, is often preferred (2). In young, otherwise healthy patients with singular ankle joint pathology, sacrifice of the subtalar joint might not be ideal. Despite documented success, we have questioned the need for formal subtalar joint cartilage resection. To the best of our knowledge, only 2 reports have described TTC fusion with formal preparation of the ankle joint but not the subtalar joint, with good outcomes (8,9). From the available evidence and personal experience, we hypothesized that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing TTC arthrodesis with retrograde intramedullary nail fixation. The primary aim of the present multicenter retrospective study was to evaluate the clinical and radiographic outcomes of patients who had undergone TTC arthrodesis with intramedullary nail fixation, without formal subtalar joint cartilage resection. Patients and Methods A multicenter retrospective case series was conducted to evaluate the clinical and radiographic outcomes and the operative duration and complications associated with TTC arthrodesis without subtalar joint cartilage resection. Three sites participated in the present investigation. Consecutive patients who underwent TTC arthrodesis with intramedullary nail fixation from March 2009 to December 2014 were identified. The electronic health records were reviewed to determine which patients met the inclusion and exclusion criteria. Patients who were 18 years old and had undergone TTC arthrodesis with intramedullary nailing performed by 1 of 3 preidentified senior surgeons were considered for inclusion. The patients who had undergone TTC arthrodesis with intramedullary nailing for acute traumatic distal tibial fracture or for salvage after total ankle replacement or had experienced trauma to either the tibiotalar or the subtalar joints after TTC arthrodesis were excluded from the present study. Once a patient was determined to have met the inclusion and exclusion criteria, the contributory patient demographics and comorbidity data were recorded. These consisted of patient age (years), body mass index (kg/m2), gender (male versus female), operative side (left versus right), smoking status, and the presence or absence of diabetes mellitus, neuropathy, and obesity. The data were recorded into a password-protected, secure database, and the confidentiality and privacy of the patients were ensured and maintained. According to the institutional review board, this research project met the conditions for exemption. Thus, the institutional reviewed board approved the protocol and waived the requirement for informed consent.
Table 1 Concomitant procedures Variable
All Ankles (N ¼ 40)
Ankle arthroscopy Bone stimulator implantation Bone tumor excision Harvest of graft Lisfranc ORIF Removal of hardware Revision of talonavicular fusion Tendo-Achilles lengthening External fixator modifications from previous pilon repair Vacuum assisted wound closure No additional procedures performed
1 1 1 8 1 8 1 7 1 1 17
(2.5) (2.5) (2.5) (20.0) (2.5) (20.0) (2.5) (17.5) (2.5) (2.5) (42.5)
Abbreviation: ORIF, open reduction internal fixation. Data presented as n (%). fellowship-trained surgeons (J.L.M., M.J.L) and a resident (S.M.M.) reviewed all the radiographs to determine the time to bony union at the tibiotalar joint and to evaluate deterioration of the subtalar joint. These assessors were not unaware of the patient data. The immediate postoperative radiograph and the most recent follow-up radiograph were evaluated to determine the extent of deterioration of the subtalar joint using a modified version of the grading system developed by Takakura et al (10) (Table 3). The 3 patients who required hardware removal were excluded from these analyses. The intraoperative and postoperative complications and operative time were also recorded from the patients’ electronic medical records. The most recent radiograph was examined to determine whether any patients demonstrated failure of the talar and/or calcaneal locking screw. The statistical analyses were performed by the research associate at our institution. Statistical Analysis All analyses were conducted using IBMÒ SPSSÒ Statistics, version 20 (IBM Corp., Armonk, NY). The significance level for all statistical tests was set at p ¼ .05. Data are reported as the mean standard deviation within the text and tables and the mean standard error elsewhere. Because the data were collected retrospectively, complete data sets were not available for all patients. Therefore, the sample size for each calculation is provided. A 2-factor analysis of variance (time neuropathic status) with repeated measures for time was conducted to compare the pain across time and between patients with and without neuropathy. Independent t tests were used to compare the operative duration and time to bony union between patients with and without neuropathy. An independent t test was also used to compare the time to bony union between patients who had required additional hardware and those who had not. A paired samples t test was used to compare the extent of subtalar joint deterioration across time (immediately postoperative to the most recent follow-up visit). Using G*Power, version 3.1.9.2, a post hoc calculation was completed. Given an a of 0.05, a sample size of 40, and an effect size of 1.68, the study was found to be adequately powered.
Results Intervention All patients received prophylactic intravenous antibiotics before induction and underwent TTC arthrodesis with retrograde intramedullary nail fixation and formal preparation of the ankle joint, without formal preparation of the subtalar joint. Concomitant procedures and supplementation of internal fixation were performed as necessary (Table 1). Surgeon preference dictated the incisional approach (Table 2). Autograft and/or allograft placement and the use of a straight versus a valgus-bend nail varied by case (Table 2). Postoperatively, all patients were placed in a splint and compressive dressing and kept non-weightbearing. The sutures and staples were removed as dictated by skin coaptation. All patients maintained non-weightbearing status for a minimum of 8 weeks. Progressive weightbearing was advanced in accordance with evidence of radiographic healing. Endpoints A multicenter medical record review was performed to collect the operative, clinical, and radiographic data. The operative duration was defined as the time from tourniquet inflation to tourniquet deflation. The study endpoint for the clinical data (pain) was the most recent follow-up appointment after TTC arthrodesis. The amount of preoperative and postoperative pain was recorded from the patients’ electronic medical records. Pain was assessed using a visual analog scale from 0 to 10, with 0 representing no pain and 10 representing excruciating pain. The study endpoint for the radiographic data at the tibiotalar joint was evidence of bony union after arthrodesis. Bony union was defined as bony trabeculation across the fusion site in all 3 radiographic views. Two
Forty consecutive patients (aged 61.9 12.9 years; 17 men) met the inclusion and exclusion criteria (Table 4). The indications for Table 2 Operative summary Variable Approach Anterior Anterolateral Lateral Medial Medial and lateral Graft type Allograft Allograft and autograft combination Autograft Synthetic substitute None Nail type Straight Valgus Data presented as n (%).
All Ankles (N ¼ 40) 3 5 22 6 4
(7.5) (12.5) (55.0) (15.0) (10.0)
15 3 7 2 13
(37.5) (7.5) (17.5) (5.0) (32.5)
27 (67.5) 13 (32.5)
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Table 3 Modified joint deterioration grading system
Table 5 Outcomes
Grade
Description
Variable
Patients (n)
Mean SD
1 2 3 4
No joint space narrowing, but early sclerosis and osteophyte formation Narrowing of the joint space Obliteration of a portion of the joint with subchondral bone contact Obliteration of the whole joint space with complete bone contact
Operative duration (min) Time to bony union at tibiotalar joint (mo) Clinical follow-up duration (mo) Preoperative pain (VAS) Postoperative pain (VAS)
39 34 33 33 33
111.1 3.8 11.1 6.4 1.2
surgery included combined ankle and hindfoot arthritis and isolated ankle arthritis associated with neuropathy. In our patient population, end-stage joint arthritis had developed secondary to osteoarthritis in 23 patients (57.5%), a Charcot joint in 11 (27.5%), post-traumatic arthritis in 5 (12.5%), and rheumatoid arthritis in 1 patient (2.5%). In terms of comorbid conditions, 19 patients (47.5%) were diagnosed with diabetes mellitus and 15 patients with neuropathy (37.5%). Eight patients (20.0%) required augmentation with additional hardware at surgery. Plates or screws, or a combination of both, were used in most patients. As indicated in Table 1, 1 patient required external fixation modification from a previous pilon repair, and 1 patient had a bone stimulator implanted. The mean operative duration was 111.1 33.3 minutes, and the mean clinical follow-up duration was 11.1 months (Table 5). One tourniquet was deflated before closure for hemostasis. No patient required tourniquet reinflation. The 2-factor analysis of variance (time neuropathic status) for pain revealed a main effect of time (p < .001), indicating that pain had significantly declined after surgery (Table 5; Fig. 1). No main effect of neuropathy (p ¼ .692) was found, and the time by neuropathy interaction (p ¼ .822) was insignificant. The mean time to bony union at the tibiotalar joint was 3.8 1.5 months. Of the 34 patients with radiographic data available, 31 (91.2%) achieved bony union at the tibiotalar joint within the 6 months after operative intervention. The 3 remaining patients subsequently achieved bony union at 7.1, 7.8, and 8.2 months, respectively. The patient who required 8.2 months to achieve union had neuropathy. The mean time to bony union was significantly shorter for patients who had received augmentation with additional hardware (3.1 0.3 months) than for patients who were not [4.0 1.6 months, t(30.774) ¼ 2.529, p ¼ .017]. To determine whether neuropathy influenced the operative duration or the time to bony union, the results were stratified and compared using independent t tests. Comparing the patients with and without neuropathy, no significant difference was found in operative duration [t(37) ¼ 0.184, p ¼ .855] or the time to bony union [t(32) ¼ –0.977, p ¼ .336).
Abbreviations: SD, standard deviation; VAS, visual analog scale. * p .05, comparing preoperative and postoperative pain scores.
The complications are summarized in Table 6. A total of 4 major complications (10.0%) had a negative effect on patient outcome. Of the 4 major complications, 2 occurred in neuropathic patients. In 3 patients, 2 of whom were neuropathic, the hardware was removed secondary to infection. The fourth patient required hardware removal because of persistent pain at the subtalar joint. Despite hardware removal, the pain did not resolve, and the patient underwent subtalar joint arthrodesis because of residual pain involving this joint. In addition, 10 complications (25.0%) had no negative effect on patient outcomes. In the case of delayed union, successful union was achieved with bone stimulation. Both periprosthetic fractures healed successfully after internal fixation. At the most recent follow-up evaluation, 1 patient experienced failure of the calcaneal locking screw and 1 patient experienced failure of the intramedullary rod at the location of the talar locking screw; neither screw failure required intervention. The 2 superficial wounds and 1 full-thickness wound were treated with local wound care until closure was obtained. Wound closure was achieved in the other full-thickness wound after application of a splitthickness skin graft. The posterior tibial pseudoaneurysm required a return trip to the operating room. The vascular surgeon successfully treated the pseudoaneurysm with no residual sequelae. The mean radiographic follow-up duration was 11.6 9.1 months. A statistically significant increase in deterioration occurred at the subtalar joint from the immediate postoperative evaluation (2.0 0.9) to the most recent follow-up evaluation [2.9 1.0; t(36) ¼ –6.200, p < .001; Table 7 and Fig. 2).
Discussion Intramedullary nailing for TTC arthrodesis with formal subtalar joint preparation was first documented in the 1940s (5). Although the intramedullary nail crosses the subtalar joint, we do not believe the subtalar joint requires formal preparation before TTC arthrodesis. Therefore, we hypothesized that the stability imparted by the intramedullary nail with fusion of the ankle joint would provide sufficient
Table 4 Patient demographics and comorbidities Variable Demographic data Age (yr) BMI (kg/m2) Gender Male Female Operative side Left Right Comorbidity Diabetic Neuropathic Obese (BMI 30 kg/m2) Smoker (current and former) Abbreviation: BMI, body mass index. Data presented as mean standard deviation or n (%).
All Ankles (N ¼ 40) 61.9 12.9 32.4 8.2 17 (42.5) 23 (57.5) 13 (32.5) 27 (67.5) 19 15 24 19
33.3 1.5 10.2 2.7 1.8*
(47.5) (37.5) (60.0) (47.5) Fig. 1. Pain experienced across time. Data plotted as mean standard error.
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Table 6 Intraoperative and postoperative complications Complications
All Ankles (N ¼ 40)
Intraoperative Edema preventing wound closure Postoperative Delayed union Pain at subtalar joint Periprosthetic fracture Hardware failure Superficial wound Full-thickness wound Infection Posterior tibial pseudoaneurysm
Patients With Neuropathy Yes (n ¼ 15)
No (n ¼ 25)
1 (2.5)
1 (4.0)
1 1 2 2 1 2 3 1
1 1 2 1
(2.5) (2.5) (5.0) (5.0) (2.5) (5.0) (7.5) (2.5)
1 (6.7) 1 (6.7)
(4.0) (4.0) (8.0) (4.0)
2 (8.0) 1 (4.0)
2 (13.3) 1 (6.7)
Data presented as n (%).
stabilization to yield satisfactory patient outcomes. To evaluate this hypothesis, patients who had undergone TTC joint arthrodesis without subtalar joint cartilage resection were identified, and a retrospective medical record review was conducted. Proper placement of the intramedullary nail at the junction of the sustentaculum tali and the body of the calcaneus is vital to achieve successful TTC arthrodesis and extremity alignment (7,11). Although we believe that stability of the nail and arthrodesis of the tibiotalar joint without formal preparation of the subtalar joint leads to successful outcomes, we recognize, just as did Boer et al (12), that when proper placement is achieved, the subtalar joint will be violated during reaming. Depending on the size of the nail used, an 11-mm or 12-mm portion of the posterior facet will be damaged during this process, informally destroying cartilage at that region. This could lead to partial union of the subtalar joint and add stability to the extremity postoperatively. The findings of the present retrospective evaluation confirmed clinically significant improvements in pain with a high rate of union. Given the large percentage of patients with neuropathy included in the present report, TTC arthrodesis without formal subtalar joint resection appears to be an excellent procedure for both insensate and sensate patients. The advantage of this technique is that a stable extremity can be achieved through mini-arthrotomy incisions with minimal trauma to the soft tissues, reducing large deformities with advanced arthritic changes. This is in contrast to the use of large incisions for placement of blade plate or locking plate fixation. Additionally, limiting dissection around the talus with this technique reduces the likelihood of damaging the talar blood supply. This is advantageous, because maintaining this blood supply is vital to successful arthrodesis. In reviewing the published data, only 2 published reports have described TTC arthrodesis with cartilage resection of the ankle joint and not the subtalar joint (1,4). In 1995, Moore et al (4) did not prepare the subtalar joint in 6 of 19 ankles. No clinical motion was observed at the subtalar joint postoperatively (4). In their study population, only 2 complications resulted: 1 deep infection and 1
Table 7 Evaluation of subtalar joint deterioration Grade
Immediate Postoperative Radiograph (n ¼ 37)
Most Recent Follow-Up Radiograph (n ¼ 37)
1 2 3 4
12 13 11 1
5 5 15 12
(32.4) (35.1) (29.7) (2.7)
(13.5) (13.5) (40.5) (32.4)
Data presented as n (%). The mean radiographic follow-up duration was 11.6 9.1 months.
broken intramedullary rod (4). More recently, in 2014, Gross et al (1) reported performing ankle arthrodesis without subtalar joint cartilage resection in 30 patients. They reported a 27% major complication rate that included nonunion of the subtalar joint and/or ankle joint, reoperation, deep infection, and below-the-knee amputation (1). With radiographic assessment, the fusion rate was reportedly 86% for the tibiotalar joint and 74% for the subtalar joint (1). These data are difficult to interpret, because complete union should not have been anticipated at the subtalar joint in the absence of formal cartilage resection. In the present report, a 10% major complication rate was appreciated. Three patients required hardware removal secondary to infection and one required hardware removal because of persistent pain. Two of the patients who had developed an infection underwent initial TTC arthrodesis because of Charcot arthropathy; the third patient had undergone initial TTC arthrodesis for post-traumatic osteoarthritis after a high-energy open fracture with a poor soft tissue envelope. All 3 patients underwent hardware removal, the joint was stabilized with internal or external fixation, and the infection was appropriately treated. Stable TTC arthrodesis was achieved in all 3 patients. In the patient who required hardware removal because of persistent pain, the pain did not resolve, and the patient underwent subtalar joint arthrodesis. The disparity between the 2 reports in terms of the major complication rate (27% versus 10%) is difficult to reconcile given the similar surgical approach (1), although some variation could be attributable to differences in defining the criteria and expectations. Although few reports have described TTC arthrodesis without formal preparation of the subtalar joint, numerous reports have described the outcomes after formal preparation of both joints. A study conducted in 2006 reported the findings for 33 patients who had undergone TTC arthrodesis with intramedullary nailing by 1 surgeon (13). Formal cartilage resection of both the ankle joint and the subtalar joint was completed before intramedullary nail placement. The investigators reported successful union in 29 of the 33 patients (88%) (13). Of the 4 patients with nonunion, 3 reported functioning with mild pain with the use of ankle-foot orthoses (13). Similar results were reported by Niinimaki et al (6), with a 76% fusion rate (26 of 34 patients) after formal preparation of the involved joints and an overall complication rate of 14%. Hammett et al (2) reported a nonunion rate of 13% (6 of 45 patients), with 2 nonunions occurring at the ankle joint and 4 at the subtalar joint. Rammelt et al (8), in 2013, reported the outcomes from a multicenter study of 38 patients who had undergone TTC arthrodesis with intramedullary nailing. All patients had undergone formal preparation of the subtalar and ankle joints, with resection of all interposed cartilage. They reported a 16% (6 of 38 patients) nonunion rate and an overall complication rate of 24% (9 of 38 patients) at the final follow-up visit (8). In the present report, a 91.2% fusion rate was achieved at the ankle joint 6 months after surgery in the 34 patients with radiographic follow-up data available. The 3 patients who had not achieved union at 6 months had achieved bony union at 7.1, 7.8, and 8.2 months, respectively. One patient (2.6%) experienced delayed union that was successfully treated with bone stimulation. Compared with the published results when both the subtalar joint and the ankle joint were formally prepared, these results suggest that union at the tibiotalar joint will be more predictable without formal preparation of the subtalar joint. Therefore, we recommend performing TTC arthrodesis without formal subtalar joint preparation. To further evaluate this surgical approach, the condition of the subtalar joint was evaluated on the immediate postoperative radiographs and the radiographs obtained at the most recent followup visit. This evaluation confirmed that the condition of the subtalar joint deteriorated over time. Presumably, 1 of 2 events occurred,
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Fig. 2. Deterioration of the subtalar joint. Radiographs demonstrate deterioration of the subtalar joint across time. The radiographs were obtained after tibiotalocalcaneal arthrodesis without cartilage resection of the subtalar joint at 2 weeks (A) and 1 year (B) postoperatively. Using the modified joint deterioration grading system, cartilage deterioration was noted to progress from a score of 1 to 3.
either progression of osteoarthritis due to motion at the subtalar joint or partial union/stable pseudoarthrosis. Only 1 patient reported pain at the subtalar joint postoperatively and was treated with revision with formal preparation. Two patients developed hardware failure: one at the calcaneal locking screw and one at the intramedullary rod at the level of the talar locking screw; neither required removal or intervention. In the absence of pain and/ or hardware failure, all patients subsequently developed partial union or stable pseudoarthrosis, which was deemed a successful outcome. We recognize that if the intramedullary nail at the tibiotalar joint is compressed intraoperatively, this could lead to distraction of the subtalar joint and predispose patients to subtalar joint complications. However, this was not observed in our patient population, obviating our ability to comment on the clinical significance and influence on the outcomes. In 2005, Hammett et al (2) reported a mean operative time of 117 minutes when the subtalar joint and ankle joint were both formally prepared before intramedullary nailing. In the present report, the mean operative time was 111 minutes, demonstrating that operative time slightly decreases when preparation of the subtalar joint is not performed, without compromising clinical outcomes. We expected a larger difference in operative time between the historical control and the study group, because opening the joint and resecting the cartilage likely requires >6 minutes. Given the large number of patients who underwent concomitant procedures in the present report, however, similar procedures were not compared and the presumed difference in operative time was not appreciated. The benefits of a decreased operative time are many, but of particular
importance is the potential to reduce costs. This is especially relevant because the current healthcare reform is promoting a bundled system of payment. When adopted by the foot and ankle community, shorter operative times will translate into decreased costs to both the facility and the patient, permitting more affordable treatment. Rammelt et al (8) reported an average postoperative pain score of 2.2 (range 0 to 9), with only 1 patient reporting a pain score of 9. In the patient population examined in the present study, the mean postoperative pain score was 1.2 (range 0 to 6). These results and the results of previous reports appear comparable, indicating that although the subtalar joint was not fused, the fusion at the tibiotalar joint and the stability imparted from the intramedullary nail is as effective in reducing pain postoperatively. Although additional prospective comparative trials are needed to reach definitive conclusions, we recommend performing TTC arthrodesis without formal subtalar joint preparation. These provisional results indicate that this technique obtains a similar reduction in pain and time to bony union, with a shorter operative duration, compared with TTC arthrodesis with formal subtalar joint preparation. The present study had a number of limitations, which could have influenced the validity of our conclusions. The most substantial methodological shortcoming of the present investigation was its retrospective design. As such, we were responsible for reviewing and collecting the data from the patients’ medical records and radiology reports, increasing the potential for bias. Additionally, because of the retrospective nature of the present study, not all patients had complete data sets. Finally, owing to the multicenter nature of the study, no predetermined intervals were established for radiographic
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evaluation, which could have potentially skewed the results for the time to bony union. In conclusion, despite these limitations, we believe that the results of the present investigation can be used in the development of future prospective studies to determine whether eliminating cartilage resection at the subtalar joint has any negative effects on patient outcomes. References 1. Gross JB, Belleville R, Nespola A, Poircuitte JM, Coudane H, Mainard D, Galois L. Influencing factors of functional result and bone union in tibiotalocalcaneal arthrodesis with intramedullary locking nail: a retrospective series of 30 cases. Eur J Orthop Surg Traumatol 24:627–633, 2014. 2. Hammett R, Hepple S, Forster B, Winson I. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: the results of 52 procedures. Foot Ankle Int 26:810–815, 2005. 3. Mendicino RW, Catanzariti AR, Saltrick KR, Dombek MF, Tullis BL, Statler TK, Johnson BM. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg 43:82–86, 2004. 4. Moore TJ, Prince R, Pochatko D, Smith JW, Fleming S. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 16:433–436, 1995.
5. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 30B:506–511, 1948. €ki TT, Klemol T, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a 6. Niinima compressive retrograde intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int 28:431–434, 2007. 7. Pochatko DJ, Smith JW, Phillips RA, Prince BD, Hedrick MR. Anatomic structures at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod. Foot Ankle Int 16:542–547, 1995. 8. Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier P, Friscia DA, Hansen ST, Schaser K, Ljungqvist J, Sands AK. Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int 34:1245–1255, 2013. 9. Thomas RL, Sathe V, Habib SI. The use of intramedullary nails in tibiotalocalcaneal arthrodesis. Am Acad Orthop Surg 20:1–7, 2012. 10. Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle: results of a new operation in 18 patients. J Bone Joint Surg Br 77:50–54, 1995. 11. Belczyk R, Sung W, Wukich DK. Technical tip: a simple method for proper placement of an intramedullary nail entry point for tibiotalocalcaneal or tibiocalcaneal arthrodesis. Foot Ankle J 1:4, 2008. 12. Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res 463:151–156, 2007. 13. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int 27:759–763, 2006.