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Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail
Foot and Ankle Surgery 17 (2011) 228–232
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail Chettiar Krissen MRCS*, Halder Sumon MBBS, Bowman Nicholas FRCS(Orth), Cottam Howard MRCS, Armitage Andrew FRCS(Orth), Skyrme Andrew FRCS(Orth) Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex BN21 2UD, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2010 Received in revised form 31 May 2010 Accepted 3 August 2010
We present the clinical results and outcomes of 30 consecutive patients (31 ankles) who have undergone tibio-talo-calcaneal arthrodesis using an intramedullary nail to achieve bony union. This was a prospective study and surgery was performed by the senior author in a single hospital. We achieved high levels of satisfaction and outcome via the AOFAS and SF-36 scoring systems. We propose that this method of arthrodesis is reliable and easily reproducible for patients with severe arthritis and bone loss at the ankle and subtalar joints. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Locking intramedullary nail Ankle Tibio-talo-calcaneal Fusion Arthrodesis
1. Introduction Patients with significant pathology of the ankle and subtalar joint present with debilitating pain and deformity [1,2]. This is commonly due to arthritis; either non-inflammatory, inflammatory, post-traumatic and Charcot’s arthropathy. In practice the severity of these symptoms result in non-operative measures being frequently unsuccessful. In addition to this, surgical options are often limited because of previous failed procedures, poor bone stock, poor soft tissue or associated neurovascular insufficiency [3]. Arthodesis may be an only alternative to amputation. Fusion of the tibio-talo-calcaneal joints can take varying forms from external fixators, plates, screws and intramedullary nails. They have been utilised with varying degrees of success [4–9]. Our prospective study demonstrates a favourable clinical outcome with a high satisfaction level (95%) for patients undergoing arthrodesis of the ankle and subtalar joint using the Biometß compressive locked intramedullary nail. 2. Materials and methods 31 Patients (32 cases) underwent tibio-talo-calcaneal arthrodesis by the senior author in one hospital between February 2004 and March 2008. Indications included advanced osteoarthritis (3), rheumatoid arthritis (12), Charcot’s arthropathy (2), previous failed arthroplasty (1), post-traumatic arthrosis (9), osteogenesis
* Corresponding author at: 11 Rustwick, Rusthall, Tunbridge Wells, Kent TN4 8NR, United Kingdom. Tel.: +44 01892 617170. E-mail address: [email protected] (C. Krissen).
imperfecta (1), psoriatic arthropathy (1), avascular necrosis of the talus (1) and cavovarus deformity (1) (Table 1). Both ankle and subtalar fusions were performed only when both joints were affected by the disease process this included rheumatoid arthritis and post-traumatic arthritis. There were 9 males and 22 females and none were lost to follow-up. One patient died two years post-operatively of unrelated causes but she had achieved union and had been previously scored. Clinical records, functional, radiographic outcomes and complications were recorded on a database. Patients were assessed in the clinic using the AOFAS scoring system [10], SF-36 (Short-form 36), and patient satisfaction questionnaire, patients received informed consent regarding the study. Statistical analysis was carried using Students t-test showing a statistically significant difference in the scoring outcome (p < 0.01). The scores were analysed and were in normal distribution without skewing of the scores. The average age of the patients at the time of surgery was 62 (31–86), mean follow-up was 23.2 months (9–51), mean ASA (American Society of Anaesthesiologists) was 2 (2–3). Eleven out of the 31 patients had some other previous orthopaedic procedure with 8 of the eleven having multiple procedures. The surgery was carried out with the patient in a supine position with the knee and ankle in neutral and both limbs over hanging the table by 10 cm. The affected limb was draped from above the knee with a sandbag under the buttock. A transfibular approach was used; a longitudinal incision created over the posterior fibular curving distally in line with the peroneal tendons. The distal 5 cm of the fibula was resected whilst preserving the peroneal tendons. This was followed by an extension of the incision distally to the sinus tarsi for visualisation of the subtalar joint.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.08.002
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232 Table 1 Aetiology of the patients undergoing tibio-talo-calcaneal arthodesis. Aetiology
Number of patients
Rheumatoid arthritis Post-traumatic arthrosis Advanced osteoarthrtis Charcot’s arthropathy Previous failed arthroplasty Osteogensis imperfecta Psoriatic arthropathy Cavovarus deformity AVN talus
12 9 3 2 1 1 1 1 1
The articular surfaces in preparation for fusion were first denuded of all cartilage using a series of fine osteotomes. Following removal of all articular cartilage, 2.7 mm drill holes were made in all joint surfaces to increase the contact and bleeding surface area of the fusion bed to maximise the potential for successful union. The surfaces were approximated and fusion only carried out when the surfaces were congruent. The foot was placed in a plantigrade position, 58 external rotation and 58 of hindfoot valgus. To allow insertion of the Biometß ankle intramedullary nail a 3 cm longitudinal plantar incision was made. Following blunt dissection the neurovascular bundle on the sole of the foot was identified. A guide pin was inserted through the calcaneus, talus and tibia the position being checked by use of the image intensifier. The subtalar and tibiotalar articular surfaces were reamed over the guide pin. Once the tibial plafond was penetrated the guide wire was replaced by a ball-tipped guide wire. Sequential reaming was performed over the guide wire using flexible reamers to a depth of no further than the third of the distal tibia shaft, with the final ream 1 mm larger than the peripheral nail diameter. Using the nail-mounted compression device, the targeting arm was positioned for placing the medial to lateral screws. The nail was inserted and countersunk 10 mm from the plantar surface of
229
the os calcis. Using image guidance, stab incisions on the medial side were used as entry points for drill guides and two proximal locking screws. Compression was then applied at the arthrodesis site with the aid of the compression device and then locked distally with screws lateral to medial. The target arm was then rotated 908 to allow for the positioning of posterior to anterior (PA) screw. Autogenous bone grafting was used from the fibular bone. AP and lateral images are saved prior to wound closure which was done in layers and the limb was protected in a below knee backslab which was completed a few days later. Patients were non-weight bearing for 6 weeks and partial weight bearing for a further 6 weeks. 3. Results 30 Patients were available for follow-up with one dying of unrelated causes but the patient had achieved radiological union and improvements in her scores. 30 Patients (31 cases) achieved radiological union at 3 months; one patient who had a radiographic non-union was asymptomatic with the other suffering from some pain. 1 Patient sustained an intraoperative periprosthetic fracture which was treated conservatively in a below cast and was nonweight bearing. This healed uneventfully without any other complications. 7 Patients sustained wound complications, 2 were admitted for intravenous antibiotics with the wounds fully healing and 1 patient required debridement of the wound. Two patients went on to have skin grafts and also make a full recovery. 2 Patients had the intramedullary nails removed following union, due to prominence of the metal work (Table 3). The mean pre-operative AOFAS score was 22.8 (10–47) and improved to a post-operative mean of 65.8 (51–82) (p < 0.01). The mean pre-operative SF-36 score was 35.5 (14.9–65.5). Postoperatively the mean SF-36 scores improved to 57.3 (14.79– 84.7) (p < 0.01). Table 2 demonstrates the range and breakdown of
Table 2 Pre-op and most recent post-op AOFAS scoring for the patients. Patient
Pain (40)
Function (50)
Alignment (10)
Pre-op score
Pain (40)
Function (50)
Alignment (10)
Post-op score
1 2 3a 3a 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
10 20 10 10 10 20 40 10 20 10 10 10 20 10 10 10 20 10 10 10 10 20 10 10 10 10 10 10 10 10 20 10
4 2 12 11 0 0 2 0 7 15 4 25 20 7 32 2 18 9 10 0 0 9 5 6 4 0 7 0 11 9 0 7
0 5 5 0 0 0 5 5 5 5 0 5 0 0 0 0 5 0 0 10 5 5 5 0 0 0 0 5 0 0 0 0
14 27 27 21 10 20 47 15 32 30 14 40 40 17 42 12 43 19 20 20 15 34 20 16 14 10 17 15 21 19 20 17
40 30 40 30 40 20 40 30 30 20 40 40 30 40 30 30 30 30 40 30 40 20 40 20 40 40 30 30 40 40 30 30
21 31 21 25 18 8 32 35 19 18 25 32 22 26 28 12 27 31 27 23 22 12 18 21 23 22 23 31 23 23 21 28
10 10 10 10 10 10 10 10 10 5 10 10 10 5 5 10 10 10 10 10 10 5 10 10 10 10 10 10 5 10 10 10
71 71 71 65 68 38 82 75 59 43 75 82 62 71 63 52 67 71 77 63 72 37 68 51 73 72 63 71 68 73 61 68
a
Same patient.
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232
230
Fig. 1. A patient with gross post-traumatic OA treated with the IM nail.
AOFAS score. Figs. 1–3 show pre-operative and post-operative radiographs of some of the patients in the study with the different aetiologies. 29 of the patients were satisfied or highly satisfied and if required they would have the other side done. One patient was unsure and one patient was dissatisfied as they did not realise how long they would be immobilised and the post-operative pain following the procedure. These two patients when questioned would not have the other side done if required.
[4,13,14]. The objectives remain the same but with an increase in function and a decrease in complication rates. In the last decade many techniques have been described for ankle and subtalar arthrodesis with varying success [15]. These include external fixation, internal fixation using screws with or
4. Discussion Whilst ankle and subtalar arthrodesis is still not universally performed, it has been reported as far back as 1906 [4]. This was eventually popularised by Russotti et al. in 1988 [11]. A solid arthrodesis, salvage of the limb and a painless, brace-free plantigrade foot were the main objectives [1,3,9,12]. The advantages of isolated single joint arthrodesis which have been discussed extensively in the literature with including preservation of function and motion of surrounding joints and improvements in gait [30–33]. However it is not without its disadvantages and problems including pseudoarthrosis, malunion, degenerative arthrosis in surrounding joints and the need for further arthrodesis [34–38]. In our study patients presenting with pathology in both joints were listed for subtalar and tibiotalar arthrodesis using the intramedullary device. Today the combined arthrodesis with intramedullary fixation has evolved from a salvage procedure for failed ankle arthroplasty, failed primary foot fusion and complex malalignment, to a procedure that has also become the mainstay of treatment and primary approach for arthritides, residual club foot, other neuropathic arthropathies and skeletal defects after tumour resection Table 3 Lists the complications encountered during our study. Complication
Number of patients
Wound complication Admission for IV antibiotics Wound debridement Application of Vac pump Skingrafting Intraoperative fracture Removal of metal work Persistent pain
7 2 2 1 2 1 2 1
Fig. 2. (a) A 59 year old lady with a failed ankle replacement for rheumatoid arthritis. (b) Treated and fused with the IM nail.
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232
231
Fig. 3. (a) 79 year old male with avascular necrosis of the talus prior to his surgery. (b) Showing bony fusion with a plantigrade foot.
without a plate, intramedullary nailing and blade plate fixation [1,8,9,16]. Intramedullary nailing has gain popularity because of proven advantages of unrivalled stability, load sharing, maintenance of length and alignment when compared to other implants [4,15,20–29]. Common complications include stress fractures, superficial and deep infections and a high incidence of non-union (10–20%), metal ware failure and plantar foot pain [1,13,17–19]. In our opinion we were able to achieve high union rates (93%) with the use of the compressive device, drill holes and adequate preparation of the fusion beds. The high union rate has been shown with this procedure in view of the compressive nature of the implant. The main failings of the other methods of fixation for these joints are reduced fixation ability due to poor bone quality, osteoporosis or previous surgery. This intramedullary device allows for significant compression of over 15 mm along its axial length. Our case series demonstrate a wide case mix with varying pathologies attaining improvement in functional and satisfaction outcomes. We also noted that wound infections and dehiscence are significant complications. They need to be dealt with promptly and appropriately and can be further complicated by other comorbidities such as diabetes, and immunosuppressant therapy (2 and 4 patients respectively in our study).
We propose that in our hands tibio-talo-calcaneal arthrodesis can be effectively achieved using an intramedullary nail with few complications and high patient satisfaction. Using this device, the goals of stable fusion, pain alleviation and correction of deformity can be successfully achieved. Conflict of interest None declared. References [1] Chou LB, Mann RA, Yaszay B, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int 2000;21(10):804–8. [2] Buratti RA, Johnson JD, Buratti D. Concurrent ankle and subtalar joint arthrodesis. J Foot Ankle Surg 1994;33(3):278–82. [3] Anderson T, Linder L, Rydholm U, et al. Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail. Acta Orthop 2005;76(4):580–7. [4] Adams JC, et al. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg 1948;30:506–11. [5] Tavakkolizadeh A, Klinke M, Davies MS. Tibiotalocalcaneal arthrodesis in treatment of hindfoot pain and deformity. Foot Ankle Surg 2006;12: 59–64.
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[6] Alfahd U, Roth SE, Stephen D, et al. Biomechanical comparison of intramedullary nail and blade fixation for tibiotalocalcaneal arthrodesis. J Orthop Trauma 2005;19:703–8. [7] Hammet R, Hepple S, Forster B, et al. Tibio-talocalcaneal arthrodesis by retrograde intramedullary nailing using a curved locking nail. Foot Ankle Int 2005;26(10):810–5. [8] Fujimori J, Yoshino S, Koiwa M, et al. Ankle arthrodesis in rheumatoid arthritis using an intramedullary nail with fins. Foot Ankle Int 1999;20(8):485–90. [9] Fox IM, Shapero C, Kennedy A. Tibiotalocalcaneal arthrodesis with intramedullary interlocking nail fixation. Reconstr Surg Foot Ankle 2000;17(1):19–31. [10] Mendicino RW, Catanzariti AR, Saltrick KR, et al. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg 2004;43(2):82–6. [11] Noonan T, Pinzur M, Paxinos O, et al. Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a biomechanical analysis of the effect of nail length. Foot Ankle Int 2005;26(4):303–8. [12] Woodburn J, Barker S, Helliwell PS. A randomised controlled trial of foot orthoses in rheumatoid arthritis. J Rheumatol 2002;29(7):1377–83. [13] Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg (Br) 1951;33:180–91. [14] Ebraheim NA, Elgafy H, Stefancin J. Intramedullary fibular graft for tibiotalocalcaneal arthrodesis. Clin Orthop 2001;385:165–9. [15] Moore TJ, Prince R, Pochatko D, Smith JW, Fleming S. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 1995;16(7):433–6. [16] Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for posttraumatic osteoarthritis of the ankle and hindfoot. J Bone Joint Surg (Am) 1992;74(7):1042–9. [17] Levine SE, Myerson MS, Lucas P, Sahon LC. Salvage for pseudoarthritis after tibiotalar arthrodesis. Foot Ankle Int 1997;18(9):580–5. [18] Alvarez RG, Barbour TM, Perkins TD. Tibiotalocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity. Foot Ankle Int 1994;15(7):354–9. [19] Russotti GM, Johnson KA, Cass JR. Tibiotalocalcaneal arthrodesis for arthritis and deformity of the hind part of the foot. J Bone Joint Surg (Am) 1988;70(9): 1304–7. [20] Makwana NK, Morrison P, Jones CB, Kirkup J. Salvage operations after total ankle replacement. Foot 1995;5:180–4. [21] Moran CG, Pinder IM, Smith SR. Ankle arthrodesis in rheumatoid arthritis. 30 Cases followed for 5 years. Acta Orthop Scand 1991;62(6):538–43. [22] Carlsson AS, Montgomery F, Besjakov J. Arthrodesis of the ankle secondary to replacement. Foot Ankle Int 1998;19:240–5.
[23] Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone Joint Surg (Br) 2006;88:1032–8. [24] Kontis R, Pasapula C, Anwar F, Cooke P, Sharp RJ. The management of failed ankle replacement. J Bone Joint Surg (Br) 2006;88:1039–47. [25] Berend ME, Glisson RR, Nunley JA. A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int 1997;18:639–43. [26] Millett PJ, O’Malley MJ, Tolo ET, Gallina J, Fealy S, Helfet DL. Tibiotalocalcaneal fusion with a retrograde intramedullary nail: clinical and functional outcomes. Am J Orthop 2002;31(9):531–6. [27] Pinzur MS, Kelikian A. Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle Int 1997;18(11):699–704. [28] Fazal MA, Garrido E, Williams RL. Tibiotalocalcaneal arthrodesis by retrograde intramedullary nail and bone grafting. Foot Ankle Surg 2006;12(4): 185–90. [29] Greisberg J, Assal M, Flueckiger G, Hansen ST. Takedown of ankle fusion and conversion to total ankle replacement. Clin Orthop 2004;424:80–8. [30] Lance EM, Paval A, Fries I, Larsen I, Patterson Jr RL. Arthrodesis of the ankle joint. A follow-up study. Clin Orthop Relat Res 1979;142:146–58. [31] Lynch AF, Bourne RB, Rorabeck CH. The long-term results of ankle arthrodesis. J Bone Joint Surg (Br) 1988;(70):113–6. [32] Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg (Am) 1979;(61):964–75. [33] Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg (Am) 1985;(67):546–50. [34] Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg (Am) 2001;(83):219–28. [35] Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints. J Bone Joint Surg (Br) 2003;(85):994–8. [36] Katsenis D, Bhave A, Paley D, Herzenberg JE. Treatment of malunion and nonunion at the site of an ankle fusion with the ilizarov apparatus. J Bone Joint Surg (Am) 2005;(87):302–9. [37] Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg (Am) 2006;(88):526–35. [38] Said E, Hunka L, Siller TN. Where ankle fusion stands today. J Bone Joint Surg (Br) 1978;(60):211–4.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Tibio-talo-calcaneo fusion using a locked intramedullary compressive nail Chettiar Krissen MRCS*, Halder Sumon MBBS, Bowman Nicholas FRCS(Orth), Cottam Howard MRCS, Armitage Andrew FRCS(Orth), Skyrme Andrew FRCS(Orth) Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex BN21 2UD, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2010 Received in revised form 31 May 2010 Accepted 3 August 2010
We present the clinical results and outcomes of 30 consecutive patients (31 ankles) who have undergone tibio-talo-calcaneal arthrodesis using an intramedullary nail to achieve bony union. This was a prospective study and surgery was performed by the senior author in a single hospital. We achieved high levels of satisfaction and outcome via the AOFAS and SF-36 scoring systems. We propose that this method of arthrodesis is reliable and easily reproducible for patients with severe arthritis and bone loss at the ankle and subtalar joints. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Locking intramedullary nail Ankle Tibio-talo-calcaneal Fusion Arthrodesis
1. Introduction Patients with significant pathology of the ankle and subtalar joint present with debilitating pain and deformity [1,2]. This is commonly due to arthritis; either non-inflammatory, inflammatory, post-traumatic and Charcot’s arthropathy. In practice the severity of these symptoms result in non-operative measures being frequently unsuccessful. In addition to this, surgical options are often limited because of previous failed procedures, poor bone stock, poor soft tissue or associated neurovascular insufficiency [3]. Arthodesis may be an only alternative to amputation. Fusion of the tibio-talo-calcaneal joints can take varying forms from external fixators, plates, screws and intramedullary nails. They have been utilised with varying degrees of success [4–9]. Our prospective study demonstrates a favourable clinical outcome with a high satisfaction level (95%) for patients undergoing arthrodesis of the ankle and subtalar joint using the Biometß compressive locked intramedullary nail. 2. Materials and methods 31 Patients (32 cases) underwent tibio-talo-calcaneal arthrodesis by the senior author in one hospital between February 2004 and March 2008. Indications included advanced osteoarthritis (3), rheumatoid arthritis (12), Charcot’s arthropathy (2), previous failed arthroplasty (1), post-traumatic arthrosis (9), osteogenesis
* Corresponding author at: 11 Rustwick, Rusthall, Tunbridge Wells, Kent TN4 8NR, United Kingdom. Tel.: +44 01892 617170. E-mail address: [email protected] (C. Krissen).
imperfecta (1), psoriatic arthropathy (1), avascular necrosis of the talus (1) and cavovarus deformity (1) (Table 1). Both ankle and subtalar fusions were performed only when both joints were affected by the disease process this included rheumatoid arthritis and post-traumatic arthritis. There were 9 males and 22 females and none were lost to follow-up. One patient died two years post-operatively of unrelated causes but she had achieved union and had been previously scored. Clinical records, functional, radiographic outcomes and complications were recorded on a database. Patients were assessed in the clinic using the AOFAS scoring system [10], SF-36 (Short-form 36), and patient satisfaction questionnaire, patients received informed consent regarding the study. Statistical analysis was carried using Students t-test showing a statistically significant difference in the scoring outcome (p < 0.01). The scores were analysed and were in normal distribution without skewing of the scores. The average age of the patients at the time of surgery was 62 (31–86), mean follow-up was 23.2 months (9–51), mean ASA (American Society of Anaesthesiologists) was 2 (2–3). Eleven out of the 31 patients had some other previous orthopaedic procedure with 8 of the eleven having multiple procedures. The surgery was carried out with the patient in a supine position with the knee and ankle in neutral and both limbs over hanging the table by 10 cm. The affected limb was draped from above the knee with a sandbag under the buttock. A transfibular approach was used; a longitudinal incision created over the posterior fibular curving distally in line with the peroneal tendons. The distal 5 cm of the fibula was resected whilst preserving the peroneal tendons. This was followed by an extension of the incision distally to the sinus tarsi for visualisation of the subtalar joint.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.08.002
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232 Table 1 Aetiology of the patients undergoing tibio-talo-calcaneal arthodesis. Aetiology
Number of patients
Rheumatoid arthritis Post-traumatic arthrosis Advanced osteoarthrtis Charcot’s arthropathy Previous failed arthroplasty Osteogensis imperfecta Psoriatic arthropathy Cavovarus deformity AVN talus
12 9 3 2 1 1 1 1 1
The articular surfaces in preparation for fusion were first denuded of all cartilage using a series of fine osteotomes. Following removal of all articular cartilage, 2.7 mm drill holes were made in all joint surfaces to increase the contact and bleeding surface area of the fusion bed to maximise the potential for successful union. The surfaces were approximated and fusion only carried out when the surfaces were congruent. The foot was placed in a plantigrade position, 58 external rotation and 58 of hindfoot valgus. To allow insertion of the Biometß ankle intramedullary nail a 3 cm longitudinal plantar incision was made. Following blunt dissection the neurovascular bundle on the sole of the foot was identified. A guide pin was inserted through the calcaneus, talus and tibia the position being checked by use of the image intensifier. The subtalar and tibiotalar articular surfaces were reamed over the guide pin. Once the tibial plafond was penetrated the guide wire was replaced by a ball-tipped guide wire. Sequential reaming was performed over the guide wire using flexible reamers to a depth of no further than the third of the distal tibia shaft, with the final ream 1 mm larger than the peripheral nail diameter. Using the nail-mounted compression device, the targeting arm was positioned for placing the medial to lateral screws. The nail was inserted and countersunk 10 mm from the plantar surface of
229
the os calcis. Using image guidance, stab incisions on the medial side were used as entry points for drill guides and two proximal locking screws. Compression was then applied at the arthrodesis site with the aid of the compression device and then locked distally with screws lateral to medial. The target arm was then rotated 908 to allow for the positioning of posterior to anterior (PA) screw. Autogenous bone grafting was used from the fibular bone. AP and lateral images are saved prior to wound closure which was done in layers and the limb was protected in a below knee backslab which was completed a few days later. Patients were non-weight bearing for 6 weeks and partial weight bearing for a further 6 weeks. 3. Results 30 Patients were available for follow-up with one dying of unrelated causes but the patient had achieved radiological union and improvements in her scores. 30 Patients (31 cases) achieved radiological union at 3 months; one patient who had a radiographic non-union was asymptomatic with the other suffering from some pain. 1 Patient sustained an intraoperative periprosthetic fracture which was treated conservatively in a below cast and was nonweight bearing. This healed uneventfully without any other complications. 7 Patients sustained wound complications, 2 were admitted for intravenous antibiotics with the wounds fully healing and 1 patient required debridement of the wound. Two patients went on to have skin grafts and also make a full recovery. 2 Patients had the intramedullary nails removed following union, due to prominence of the metal work (Table 3). The mean pre-operative AOFAS score was 22.8 (10–47) and improved to a post-operative mean of 65.8 (51–82) (p < 0.01). The mean pre-operative SF-36 score was 35.5 (14.9–65.5). Postoperatively the mean SF-36 scores improved to 57.3 (14.79– 84.7) (p < 0.01). Table 2 demonstrates the range and breakdown of
Table 2 Pre-op and most recent post-op AOFAS scoring for the patients. Patient
Pain (40)
Function (50)
Alignment (10)
Pre-op score
Pain (40)
Function (50)
Alignment (10)
Post-op score
1 2 3a 3a 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
10 20 10 10 10 20 40 10 20 10 10 10 20 10 10 10 20 10 10 10 10 20 10 10 10 10 10 10 10 10 20 10
4 2 12 11 0 0 2 0 7 15 4 25 20 7 32 2 18 9 10 0 0 9 5 6 4 0 7 0 11 9 0 7
0 5 5 0 0 0 5 5 5 5 0 5 0 0 0 0 5 0 0 10 5 5 5 0 0 0 0 5 0 0 0 0
14 27 27 21 10 20 47 15 32 30 14 40 40 17 42 12 43 19 20 20 15 34 20 16 14 10 17 15 21 19 20 17
40 30 40 30 40 20 40 30 30 20 40 40 30 40 30 30 30 30 40 30 40 20 40 20 40 40 30 30 40 40 30 30
21 31 21 25 18 8 32 35 19 18 25 32 22 26 28 12 27 31 27 23 22 12 18 21 23 22 23 31 23 23 21 28
10 10 10 10 10 10 10 10 10 5 10 10 10 5 5 10 10 10 10 10 10 5 10 10 10 10 10 10 5 10 10 10
71 71 71 65 68 38 82 75 59 43 75 82 62 71 63 52 67 71 77 63 72 37 68 51 73 72 63 71 68 73 61 68
a
Same patient.
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232
230
Fig. 1. A patient with gross post-traumatic OA treated with the IM nail.
AOFAS score. Figs. 1–3 show pre-operative and post-operative radiographs of some of the patients in the study with the different aetiologies. 29 of the patients were satisfied or highly satisfied and if required they would have the other side done. One patient was unsure and one patient was dissatisfied as they did not realise how long they would be immobilised and the post-operative pain following the procedure. These two patients when questioned would not have the other side done if required.
[4,13,14]. The objectives remain the same but with an increase in function and a decrease in complication rates. In the last decade many techniques have been described for ankle and subtalar arthrodesis with varying success [15]. These include external fixation, internal fixation using screws with or
4. Discussion Whilst ankle and subtalar arthrodesis is still not universally performed, it has been reported as far back as 1906 [4]. This was eventually popularised by Russotti et al. in 1988 [11]. A solid arthrodesis, salvage of the limb and a painless, brace-free plantigrade foot were the main objectives [1,3,9,12]. The advantages of isolated single joint arthrodesis which have been discussed extensively in the literature with including preservation of function and motion of surrounding joints and improvements in gait [30–33]. However it is not without its disadvantages and problems including pseudoarthrosis, malunion, degenerative arthrosis in surrounding joints and the need for further arthrodesis [34–38]. In our study patients presenting with pathology in both joints were listed for subtalar and tibiotalar arthrodesis using the intramedullary device. Today the combined arthrodesis with intramedullary fixation has evolved from a salvage procedure for failed ankle arthroplasty, failed primary foot fusion and complex malalignment, to a procedure that has also become the mainstay of treatment and primary approach for arthritides, residual club foot, other neuropathic arthropathies and skeletal defects after tumour resection Table 3 Lists the complications encountered during our study. Complication
Number of patients
Wound complication Admission for IV antibiotics Wound debridement Application of Vac pump Skingrafting Intraoperative fracture Removal of metal work Persistent pain
7 2 2 1 2 1 2 1
Fig. 2. (a) A 59 year old lady with a failed ankle replacement for rheumatoid arthritis. (b) Treated and fused with the IM nail.
C. Krissen et al. / Foot and Ankle Surgery 17 (2011) 228–232
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Fig. 3. (a) 79 year old male with avascular necrosis of the talus prior to his surgery. (b) Showing bony fusion with a plantigrade foot.
without a plate, intramedullary nailing and blade plate fixation [1,8,9,16]. Intramedullary nailing has gain popularity because of proven advantages of unrivalled stability, load sharing, maintenance of length and alignment when compared to other implants [4,15,20–29]. Common complications include stress fractures, superficial and deep infections and a high incidence of non-union (10–20%), metal ware failure and plantar foot pain [1,13,17–19]. In our opinion we were able to achieve high union rates (93%) with the use of the compressive device, drill holes and adequate preparation of the fusion beds. The high union rate has been shown with this procedure in view of the compressive nature of the implant. The main failings of the other methods of fixation for these joints are reduced fixation ability due to poor bone quality, osteoporosis or previous surgery. This intramedullary device allows for significant compression of over 15 mm along its axial length. Our case series demonstrate a wide case mix with varying pathologies attaining improvement in functional and satisfaction outcomes. We also noted that wound infections and dehiscence are significant complications. They need to be dealt with promptly and appropriately and can be further complicated by other comorbidities such as diabetes, and immunosuppressant therapy (2 and 4 patients respectively in our study).
We propose that in our hands tibio-talo-calcaneal arthrodesis can be effectively achieved using an intramedullary nail with few complications and high patient satisfaction. Using this device, the goals of stable fusion, pain alleviation and correction of deformity can be successfully achieved. Conflict of interest None declared. References [1] Chou LB, Mann RA, Yaszay B, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int 2000;21(10):804–8. [2] Buratti RA, Johnson JD, Buratti D. Concurrent ankle and subtalar joint arthrodesis. J Foot Ankle Surg 1994;33(3):278–82. [3] Anderson T, Linder L, Rydholm U, et al. Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail. Acta Orthop 2005;76(4):580–7. [4] Adams JC, et al. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg 1948;30:506–11. [5] Tavakkolizadeh A, Klinke M, Davies MS. Tibiotalocalcaneal arthrodesis in treatment of hindfoot pain and deformity. Foot Ankle Surg 2006;12: 59–64.
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