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Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: A Case Series Anthony Romano, DPM PGY-2

Intramedullary Retrograde Compression Nail Fixation … · Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: ... Severe ankle and subtalar joint

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Page 1: Intramedullary Retrograde Compression Nail Fixation … · Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: ... Severe ankle and subtalar joint

Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: A Case Series

Anthony Romano, DPM PGY-2

Page 2: Intramedullary Retrograde Compression Nail Fixation … · Intramedullary Retrograde Compression Nail Fixation for Tibiotalocalcaneal Arthrodesis: ... Severe ankle and subtalar joint

Introduction

Severe ankle and subtalar joint pain or deformity leads to limited ambulatory capacity, with limited treatment options

Non-operative measures alleviate some of the symptoms, but do little to reverse the pathology or prevent the progression

Surgical treatment is aimed at achieving a painless, plantigrade foot that allows for tolerable ambulation with/without bracing and prevention of limb loss

Tibiotalocalcaneal arthrodesis is a surgical option that offers an effective treatment for these patients

Traditionally achieved with the use of plates, screws, external fixation or a combination of fixation methods

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Purpose of Study

Severe pathology of the hindfoot and ankle may indicate Tibiotalocalcaneal Arthrodesis

The primary goals: plantigrade foot and a functional limb with prevention of limb loss

Investigate the use of Intramedullary Retrograde Compression Nail for Tibiotalocalcaneal Arthrodesis with respect to fusion, alignment, and complication profile

Present this method as a viable option for patients requiring this procedure in both primary and secondary interventions.

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Literature

Reports to achieve fusion of the pathological joints with varying results

parameters for the use of this procedure have not been clearly defined. The procedure has classically been described as a salvage method when other arthrodesis methods have failed

Previous reports found a 73 to 100 percent fusion rate for patients undergoing tibiotalocalcaneal arthrodesis with an ACN

Some studies showed fibrous union only; however, patients were able to ambulate with a pneumatic walker Suggesting that even without full osseous union, a functional limb can be achieved

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Literature

External fixation has been described as either a method of fusion or a means to facilitate arthrodesis procedures in patients considered “high-risk” 77.3 percent fusion rate LaPorta et al. claimed that a combination of internal and external fixation was vital to the

success of the procedure Found a greater instance of nonunion when the nail was not properly aligned within the tibia Average reported fusion time was 84 to 133 days

Complications: non-union, superficial and deep wound infection, skin necrosis, sural neuroma, suture granuloma, delayed union of the ankle arthrodesis, painful hardware, CVA, myocardial infarction, fatal pulmonary embolism, and stress fracture

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Indications

Charcot neuroarthropathy

Failed ankle and/or subtalar joint fusion

Severe ankle arthritis with or without angular deformity

Talar osteonecrosis

Septic subtalar or ankle joint

Osteomyelitis

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The Study

A retrospective review of patients that underwent TTCA using IRCN from 2013 to 2015

Nine patients were identified that met the inclusion criteria

Patient demographics, comorbidities, indications, time to fusion, procedure details, extremity alignment, and complications were reviewed

Anterior-posterior ankle radiographs were evaluated both preoperatively and postoperatively to evaluate frontal plane alignment of the

Time to fusion was determined radiographically and correlated with absence of any clinical signs of non-union

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The Procedure

All angular correction was done acutely

Both STJ and Ankle were prepared for arthrodesis

Once the subtalar and ankle joints were corrected to a more neutral or slightly valgus and plantigrade position as visualized clinically and fluoroscopically the nail was inserted

In cases of high-risk surgical candidates, an external ring fixator super construct was utilized

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The Procedure

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Results

2 patients with a preop valgus deformity: correction achieved between 9 -10°, to an average position < than 1° of valgus

5 patients had a preoperative varus position corrected 3 to 25° to an average position of <1° of varus deformity

All limbs were placed to a plantigrade position which allowed ambulation

The mean time to fusion was 57 days

No amputations or clinical non-unions occurred.

Pt. Pre-Op Diagnosis Pre-Op Deformity

(Degrees) Post-Op Position

(Degrees) Time to Fusion

(Days) Complications 1 Hardware Complications 10 Valgus Neutral 47 None 2 Ankle Non-union Neutral 3 Varus 39 None

3 Ankle Malunion,

Equinovarus 20 Varus 2 Valgus 46 Infection 4 Ankle & STJ Arthritis 10 Varus 1 Valgus 63 None

5 CMT, Ankle Varus, Ankle

Arthritis 29 Varus 4 Varus 46 None

6 Charcot Arthropathy of

Ankle 12 Valgus 3 Valgus 73 None

7 Post-traumatic Arthritis

of Ankle 2 Varus Neutral 50 Prominent Screw

Requiring Removal

8 Charcot Arthropathy of

Ankle 22 Varus Neutral 96 Swelling, Premature

Frame Removal 9 Ankle Arthritis Neutral 3 Valgus 56 None

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Conclusions

This case series demonstrates that tibiotalocalcaneal arthrodesis can be adequately achieved with intramedullary retrograde compression nail in complex hindfoot and ankle pathology

Significant degree of angular deformity can be corrected using this procedure

Can correct severe hindfoot pathology in patients with several comorbidities or failed arthrodesis procedures

Gives surgeon the ability to provide consistent neutral alignment and a stable plantigrade foot

Complication profile displayed minimal complications (major complications can occur)

When compared to the preoperative states, patients had a plantigrade foot for ambulation

Overall, intramedullary retrograde compression nailing was found to be effective in reaching the goals of tibiotalocalcaneal arthrodesis

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References

1. Mann, R. A., and L. B. Chou. 'Tibiocalcaneal Arthrodesis'. Foot & Ankle International 16.7 (1995): 401-405. Web.

2. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int. 2006;27(10):759–63.

3. Paola, Luca Dalla et al. 'Use Of A Retrograde Nail For Ankle Arthrodesis In Charcot Neuroarthropathy: A Limb Salvage Procedure'. Foot Ankle Int 28.9 (2007): 967-970. Web.

4. Niinimäki, Tuukka Timo, Tero-Matti Klemola, and Juhana Ilmari Leppilahti. 'Tibiotalocalcaneal Arthrodesis With A Compressive Retrograde Intramedullary Nail: A Report Of 34 Consecutive Patients'. Foot Ankle Int 28.4 (2007): 431-434. Web.

5. Zarutsky, Eugene, Shannon M. Rush, and John M. Schuberth. 'The Use Of Circular Wire External Fixation In The Treatment Of Salvage Ankle Arthrodesis'. The Journal of Foot and Ankle Surgery 44.1 (2005): 22-31. Web.

6. Crawford, Brooke et al. 'End-Stage Hindfoot Arthrosis: Outcomes Of Tibiocalcaneal Fusion Using Internal And Ilizarov Fixation'. The Journal of Foot and Ankle Surgery 53.5 (2014): 609-614. Web.

7. Rammelt, S. et al. 'Tibiotalocalcaneal Fusion Using The Hindfoot Arthrodesis Nail: A Multicenter Study'. Foot & Ankle International 34.9 (2013): 1245-1255. Web.

8. LaPorta, Guido A., Ellianne M. Nasser, and Jennifer L. Mulhern. 'Tibiocalcaneal Arthrodesis In The High-Risk Foot'. The Journal of Foot and Ankle Surgery 53.6 (2014): 774-786. Web.

9. Mendicino, Robert W et al. 'Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nailing'. The Journal of Foot and Ankle Surgery 43.2 (2004): 82-86. Web.

10. Thomason, K., and K. S. Eyres. 'A Technique Of Fusion For Failed Total Replacement Of The Ankle: TIBIO-ALLOGRAFT-CALCANEAL FUSION WITH A LOCKED RETROGRADE INTRAMEDULLARY NAIL'. Journal of Bone and Joint Surgery - British Volume 90-B.7 (2008): 885-888. Web.