Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

486. Tibiotalocalcaneal Arthrodesis Using a Medullary Nail

George E. Quill, Jr., and Stuart D. Miller

DEFINITION

images Tibiotalocalcaneal arthrodesis is the surgical procedure to simultaneously fuse the ankle and the subtalar joints.

images In cases of posttraumatic, neuropathic, or avascular talar body bone loss, tibiocalcaneal arthrodesis may be indicated. The term pan-talar arthrodesis refers to the surgical procedure to fuse all bones that articulate with the talus: the distal tibia, calcaneus, navicular, and cuboid. In essence, this is a combined ankle and triple arthrodesis.

images In our opinion, the term medullary refers to the inner marrow cavity of a long bone and the word intramedullary is a redundant, less useful term.

images The goal of tibiotalocalcaneal arthrodesis is to create a painfree ankle and hindfoot that are biomechanically stable and fused in functional position.

images In our hands, tibiotalocalcaneal arthrodesis is a salvage operation performed for severe ankle and hindfoot deformity, bone loss, and pain.

ANATOMY

images Tibiotalocalcaneal arthrodesis aims to recreate physiologic ankle and hindfoot alignment with a plantigrade foot position (the foot is at a 90-degree angle to the long axis of the tibia) and about 5 to 7 degrees of hindfoot valgus.

images In general, rotation of the foot relative to the longitudinal axis of the tibia in the coronal plane is congruent with the anterior tibia—that is, the second ray of the foot is usually in line with the anteromedial crest of the tibia.

images Hindfoot position influences forefoot position. With longstanding ankle and hindfoot deformity, forefoot pronation, supination, adduction, and abduction may be affected. Proper positioning of a tibiotalocalcaneal arthrodesis must take forefoot position into account. Ideally, in stance phase the foot has near-equal pressure distribution under the heel and first and fifth metatarsal heads.

NATURAL HISTORY

images Severe ankle and hindfoot deformities and pathologic processes result in disabling pathomechanics and, when left untreated, often confine patients to cumbersome brace use, limited ambulation with assistive devices, or a wheelchair.

images Tibiotalocalcaneal arthrodesis is a major reconstructive process usually applied to otherwise disabling conditions.

images Gellman et al.2 noted that the dorsiflexion and plantarflexion deficits after ankle fusion compared to the nonfused contralateral ankle were 51% and 70%, respectively. Surprisingly, for tibiotalocalcaneal arthrodesis, dorsiflexion and plantarflexion deficits were 53% and 71%, respectively.

images This same study concluded, however, that inversion and eversion were 40% less after tibiotalocalcaneal fusion than after tibiotalar fusion alone.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The patient being considered for tibiotalocalcaneal arthrodesis with a medullary nail presents with a myriad of orthopaedic pathology affecting gait, weight bearing, and ability to earn a living.

images This patient may present with limited mobility, an equinus posture associated with genu recurvatum, and transverse plane deformity ranging from severe varus and instability of the hindfoot through profound valgus and ulceration over the medial structures (FIG 1).

images The neuromuscular or neuropathic patient may present with ulceration, intrinsic muscle loss, and multiple fractures in various stages of healing.

images The posttraumatic patient often has a compromised soft tissue envelope, previously placed hardware, and already medullary canal sclerosis that must be considered in preoperative planning (FIG 2). Evaluation must include gait and weight-bearing posture, assessment of the soft tissue envelope, and a thorough neuromuscular examination.

images

FIG 1  Weight-bearing clinical photograph (A) and weightbearing AP radiograph (B) of a 53-year-old laborer with persistent ankle and hindfoot varus instability after prior attempt at calcaneal osteotomy and lateral ligament reconstruction.

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FIG 2  A. Reportedly the only pair of highheeled, high-topped boots that this 42-year-old woman was comfortable wearing 2 years after sustaining bilateral talus fractures malunited in equinus. B. Clinical appearance of this woman's foot in maximal passive left ankle dorsiflexion. C. Weight-bearing lateral radiograph of same woman. Note plantarflexion talus fracture malunion and posttraumatic osteoarthritis after open reduction and internal fixation.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images We routinely obtain three weight-bearing radiographs of the ankle and foot. As many of these patients have deformity, we often obtain additional long-cassette radiographs of the ankle or even mechanical axis views of the lower leg from the hip to the foot.

images Posttraumatic and osteoarthritis

images Radiographs may reveal joint space narrowing, osteophyte formation, and subchondral sclerosis and cysts, all characteristic of osteoarthritis. Posttraumatic deformity and retained hardware may be identified and must be considered in preoperative planning (FIG 3).

images

FIG 3  Preoperative weight-bearing clinical appearance (A), AP radiograph (B), and lateral radiograph (C) of an obese 69-year-old man after valgus nonunion of attempted tibiotalar arthrodesis.

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FIG 4  Coronal (A) and lateral (B) CT images of a 48-year-old man with massive osteochondral talar insufficiency.

images Rheumatoid arthritis and other inflammatory arthritides

images Radiographs typically identify periarticular erosions and osteopenia.

images Neuropathic arthrosis or Charcot neuroarthropathy

images In our experience, this presentation is radiographically characterized by numerous fractures or microfractures in various stages of healing, hypertrophic new bone formation, and loss of normal weight-bearing architecture.

images Bone resorption may be seen, along with vascular calcification and joint subluxation or dislocation.

images Plain tomography or CT may further define deformity, arthritis, bone loss, and prior malunion or nonunion (FIG 4).

images We have not found three-dimensional CT reconstructions helpful in the routine setting.

images CT is also useful in assessing progression toward union following tibiotalocalcaneal arthrodesis.

images MRI may complement CT by evaluating for fluid in and around the joints, bone marrow edema, talar vascularity, infection, and periarticular tendon and ligament pathology (FIG 5).

images Technetium-99 bone scans may be useful in the evaluation of osteonecrosis after talus fracture, arthritic involvement of one or several joints, stress fracture, or neoplasm.

images Indium-labeled white blood cell scans can be helpful in the diagnosis of osteomyelitis or septic arthritis.

images

FIG 5  MRI demonstrating extensive bone involvement of the talus.

DIFFERENTIAL DIAGNOSIS

images Primary and secondary osteoarthrosis, including posttraumatic osteoarthritis

images Rheumatoid arthritis and other inflammatory arthritides (gout, pseudogout, pigmented villonodular synovitis, septic arthritis, psoriatic arthritis, spondyloarthropathy, Reiter syndrome)

images Neuropathic arthropathy (diabetes mellitus, spinal cord injury, hereditary sensory and motor neuropathy, syringomyelia, congenital indifference to pain, alcoholism, peripheral nerve disease, tabes dorsalis, and leprosy)

images Infectious arthritis (sepsis, open trauma, or previous surgical procedure for fixation of fractures)

images Arthritis and joint subluxation resulting from generalized ligamentous laxity, mixed connective disease, posterior tibial tendinopathy, spring ligament insufficiency

NONOPERATIVE MANAGEMENT

images Selective (diagnostic) injection of local anesthetic may help locate the exact anatomic source of the patient's pain.

images Tibiotalar arthritis may be associated with a stiff, painful subtalar joint that has a relatively normal radiographic appearance.

images The injection of 5 to 10 mL of 1% lidocaine into the subtalar joint can clarify whether the pain may not be isolated to the ankle but in fact be generated in both the ankle and subtalar joints.

images This has important implications when considering isolated tibiotalar versus tibiotalocalcaneal arthrodesis. We do not routinely incorporate the subtalar joint into the arthrodesis when performing an ankle arthrodesis. In select cases of end-stage ankle arthritis associated with severe deformity and talar bone loss, we consider including an otherwise normal asymptomatic subtalar joint in the fusion mass achieved for tibiotalocalcaneal fusion. Alternatively, an injection carefully placed in the peroneal tenosynovial sheath may prove that pain may be related to the tendons rather than the joint.

images While often challenging for the patient with deformity, we recommend bracing for the patient with prohibitive medical illness or a dysvascular extremity, particularly for the patient with a non-fixed, passively correctible deformity. A custom polypropylene ankle–foot orthosis (AFO) or a supramalleolar AFO with Velcro closures may be considered as an alternative to tibiotalocalcaneal arthrodesis in poor surgical candidates (FIG 6).

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FIG 6  Molded ankle–foot orthosis can provide stability and serve as an alternative to operative intervention.

images For the neuropathic patient in whom bracing can achieve a relatively plantigrade posture for the hindfoot and ankle, we prescribe a double-metal-upright AFO attached to an Oxford shoe that includes Plastazote liners (total contact inserts).

images In our experience, polypropylene in-shoe braces lead to ulceration in these patients with complex deformity.

images In severe deformity, a Charcot retention orthotic walker (CROW) may prove effective.

images While we favor tibiotalocalcaneal arthrodesis for patients with posttraumatic arthritis and deformity, we have had some success in relieving pain and improving function with a patellar tendon bearing brace for poor surgical candidates.

SURGICAL MANAGEMENT

Indications and Contraindications

images Indications for tibiotalocalcaneal arthrodesis

images Sequelae of degenerative, posttraumatic, or inflammatory arthritis

images Avascular necrosis of the talus

images Severe instability or paralytic ankle and hindfoot weakness

images Neuropathic arthropathy

images Failed ankle arthroplasty with subtalar intrusion

images Failed ankle arthrodesis with insufficient talar body

images Severe deformity of talipes equinovarus

images Neuromuscular disease

images Skeletal defects after tumor resection

images Pseudarthrosis

images Flail ankle

images Absolute contraindications for tibiotalocalcaneal arthrodesis with internal fixation

images Dysvascular extremity

images Active infection

images Relative contraindication to tibiotalocalcaneal arthrodesis with closed nailing techniques

images Severe, fixed deformity that precludes a colinear reduction of the tibia, talus, and calcaneus for rod placement

Preoperative Planning

images We glean essential information for preoperative planning from a thorough history and physical examination of the soft tissue envelope, vascular status, degree of deformity, and assessment of the entire limb and contralateral limb.

images We review all imaging studies, including longstanding radiographs of the lower extremity. Many of these patients have comorbidities, so we ensure that medical clearance is obtained.

images The availability of implant and instruments is ascertained and arrangements for perioperative care are confirmed.

Positioning

images The patient with severe preoperative valgus deformity is positioned supine on a radiolucent operating table with a well-padded bump under the ipsilateral buttock to rotate the involved extremity internally (FIG 7A). Another pad can be placed under the heel to facilitate cross-table fluoroscopic imaging.

images Alternatively and preferably, the patient with neutral to varus deformity is positioned in the lateral position with the affected extremity up (FIG 7B).

images We pad bony prominences and use an axillary roll in the recumbent axilla.

images The patient is usually fastened to the table with a beanbag and chest brace devices, and pneumatic tourniquet control at the level of the thigh is used.

images Parenteral, prophylactic antibiotics are administered before the tourniquet is inflated.

images

FIG 7  A. Patient is positioned on a beanbag in a modified lateral position that allows access to the medial and lateral foot. Note stack of folded sheets under foot to be operated. B. Lateral position on blankets to level the leg with the pelvis; this position still allows for external hip rotation to see the medial ankle joint.

TECHNIQUES

INCISION

images  For the patient with severe preoperative valgus, we make a longitudinally oriented incision over the medial malleolus starting just at the supramalleolar level and carried 2 to 3 cm distal to the tip of the medial malleolus.

images This allows a subperiosteal approach to the ankle and the removal of medially based closing-wedge osteotomies of diseased tibiotalar bone and cartilage to correct the preoperative valgus deformity.

images  We identify and protect the medial neurovascular structures during this approach.

images  For all patients other than those who present with severe preoperative valgus, we routinely use a lateral transfibular approach through a longitudinal incision over the distal fibula carried onto the sinus tarsi, curving slightly anteriorly as one extends beyond the distal end of the fibula.

images This approach affords wide access to both the ankle and subtalar joints and eliminates the possibility of the lateral malleolus rubbing in normal shoe wear postoperatively, and the fibula serves as a source of abundant cancellous and corticocancellous bone graft material during the case (TECH FIG 1).

images Fibular ostectomy should be especially considered at the time of hindfoot fusion if there is significant varus deformity or loss of tibial length relative to the fibula.

images Resect the distal fibula in a beveled fashion with a microsagittal saw no more than 3 cm proximal to the level of the tibiotalar joint to preserve the distal tibiofibular syndesmosis and thereby minimize postoperative discomfort caused by distal tibiofibular movement and crepitus.

images  We would like to clarify that the transfibular approach with or without fibulectomy is reserved for patients with severe deformity who are not candidates, nor will ever be candidates, for future ankle fusion takedown and conversion to total ankle arthroplasty (TAA). For patients who may be considered for future TAA, every attempt should be made to preserve anatomy, especially the fibula—that is, the arthrodesis should be performed via an anterior or posterior approach.

images

TECH FIG 1  Lateral approach to the tibiotalar and subtalar joint after distal fibulectomy.

ANKLE ARTHROTOMY

images  We use a lateral ankle arthrotomy with the incision carried over the sinus tarsi and subtalar joint to correct any deformity that may be present across the tibiotalar and subtalar joints and to prepare the joint surfaces by removing what is left of the diseased articular cartilage (TECH FIG 2).

images  Small wedges of bone may be removed to obtain the appropriate plantigrade postoperative posture for the foot and ankle.

images  These arthrotomies also leave space for insertion of bone graft as needed.

images  Often combined medial and lateral arthrotomies are needed to achieve the appropriate plantigrade posture of the foot and to remove medial malleolar prominence.

images  In the case of the ankle with preoperative valgus deformity, we use a medial approach to the tibiotalar joint in combination with a limited lateral exposure to decorticate and decancellate the subtalar joint via a separate lateral incision over the sinus tarsi.

images

TECH FIG 2  The lateral arthrotomy, with removal of fibula, allows easy access to the ankle joint as well as extending to the subtalar joint.

PLANTAR INCISION FOR GUIDEWIRE INSERTION AND REAMING

images  As is true with all other medullary fixation procedures, the starting point for insertion of the guidewire and subsequent medullary rod is critical to the success of the case.

images  The correct starting point is midway between the tips of the medial and lateral malleoli, anterior to the subcalcaneal heel pad, and about 2.5 cm posterior to the transverse tarsal joints, in line with the longitudinal axis of the tibia (TECH FIG 3A).

images Make a 2-cm, longitudinally oriented plantar incision just anterior to the weight-bearing subcalcaneal heel pad.

images After the incision is carried through dermis sharply, blunt dissection only is taken down to the plantar fascia, which is split longitudinally.

images The intrinsic muscles can be swept aside and the neurovascular bundle protected and retracted with the intrinsic flexors.

images Place a smooth Steinmann pin or a guidewire, over which is passed a cannulated drill to provide access to the talus and tibial medullary canal after calcaneal corticotomy (TECH FIG 3B).

images  Confirm optimal insertion of the cannulated drill, which passes sequentially through the inferior cortex of the calcaneus, the calcaneal body, the subtalar joint, the talar body, across the ankle, and finally into the distal tibial canal, using intraoperative fluoroscopic views in both the AP and lateral planes.

images  After removing the cannulated drill, pass a bulb-tipped guidewire through the calcaneus and talus into the distal tibial medullary canal.

images  Pass a series of progressively larger, flexible reamers over the guidewire, and use them to enlarge the tibiotalocalcaneal canal.

images  We recommend that the final reamer diameter is a full 0.5 to 1 mm larger than the anticipated implant's diameter.

images In our experience, overreaming avoids the risk of intraoperative and postoperative fracture at the proximal tip of the rod without compromising the construct's stability.

images  Overzealous reaming in osteopenic bone may result in an intraoperative tibial fracture that then warrants using a longer medullary nail for spanning the fracture. When in doubt, check the reamer position with the fluoroscope.

images  We are aware of several articles reporting fractures of the tibia at the proximal portion of the medullary nail when the nail is left at the relatively sclerotic distal tibial diametaphyseal isthmus.

images  When closing the plantar wound, use simple interrupted or horizontal mattress sutures for a flat rather than inverted skin edge closure.

images

TECH FIG 3  A. Desired starting point for the guide pin and medullary nail. With deformity, establishing this starting point's relationship to the talus and tibia may require some manipulation of the subtalar and ankle joints, but it is generally attainable. B. The guidewire should align with the tibial shaft.

NAIL SELECTION

images  In most cases a nail length of 15 to 18 cm suffices for tibiotalocalcaneal arthrodesis with the proximal extent of the nail in metaphyseal bone, distal to the diametaphyseal isthmus, where the risk of tibia fracture is greatest.

images  Nail diameter is dictated by the size of the native tibia.

images  In most cases, a 10-mm-diameter nail affords satisfactory stability to allow progression toward fusion.

images While we acknowledge that an increase in nail diameter affords greater strength to the construct, we caution that aggressive overreaming of the cortex to place a larger-diameter nail may compromise the cortex, leading to a stress fracture.

images  In profoundly neuropathic patients, we have used a long tibiotalocalcaneal nail that bypasses the distal tibial isthmus by a length equal to at least three times the diameter of the tibial canal measured at the level of the isthmus. A longer nail generally reduces the possibility of a distal tibial stress fracture, albeit by requiring more reaming of the tibia.

NAIL PLACEMENT ACROSS THE ARTHRODESIS SITE

images  We find that locking the nail to its targeting arm, with each of two drill bits inserted through the drill guides and the two proximal-most screw holes in the nail before the nail and its targeting arm are tightened, ensures optimal alignment before placement.

images  The medullary nail is attached to its alignment and targeting guide. As it is inserted in retrograde fashion at plantar foot, it is slightly internally rotated so that when the locking screws are passed from lateral to medial they will pass into the tibia without impingement upon the distal fibula (TECH FIG 4A).

images  During insertion, the distal aspect of the nail should be countersunk at least 5 mm cephalad to the plantar surface of the os calcis or at least countersunk the same distance that the surgeon anticipates achieving axial compression across the ankle and subtalar fusion sites. Be sure not to leave the nail prominent on the plantar aspect of the foot (TECH FIG 4B).

images

TECH FIG 4  A. In our experience, internally rotating the nail and the guide slightly, posterior to anterior screws placed through the guide and the nail, tend to align optimally with the calcaneus. B. Follow-up radiograph demonstrating that the nail is slightly countersunk to avoid being prominent on the plantar surface of the foot. A nail that is slightly proud rarely creates a problem since that portion of the calcaneus is not weight bearing; in fact, it may afford some further support with the end of the nail engaged in the calcaneal cortex.

SCREW PLACEMENT IN THE INTRAMEDULLARY NAIL

images  When determining the final position for the nail, we simultaneously estimate the position of locking holes in the nail relative to the distal tibia, the talar body, and the calcaneal body.

images  It is preferable but not necessary to fill all the locking holes.

images  Nail failure is likely to occur in the heavyset or neuropathic patient if locking holes are left open at the level of either the ankle or subtalar fusion site. Early reports of nail failure at the subtalar joint often noted failure to fuse the subtalar joint.

images  An advantage of modern nail design includes placement of locking screws at various angles to one another.

images  The position of the nail for the proximal screws into the tibia will dictate the final rotation; thus, the guide for the posteroanterior screw may be applied and used to check (including fluoroscopy) the later position for the posteroanterior screw in the calcaneus as well as the talar screws (TECH FIG 5A).

images  A posterior-to-anterior calcaneal locking screw increases the torsional rigidity of the nail construct by at least 40% and improves purchase of the calcaneal bone exponentially when compared to simply locking in one plane relative to the long axis of the nail (TECH FIG 5B).

images  Further manual compression and impaction can be done across the arthrodesis sites before the proximal interlocking screws are inserted. Some nails use an extramedullary compression device, while others use compression of the heel against the tibial screws.

images  Some medullary rods include an inline compression device that can provide up to 15 mm of compression across the ankle and subtalar fusion sites (TECH FIG 5C).

images

TECH FIG 5  A. The alignment guide provides a quick check of overall positioning before drilling the proximal tibial screws. The surgeon should make sure the posteroanterior screw will be hitting the posterior calcaneus at an appropriate height. B. The posteroanterior screw is predrilled and measured via the C-arm to discern the length, usually just posterior to the calcaneal cuboid joint. C. A wrench is used to tighten the bolt compressing the heel plate toward the tibial screws; this intramedullary compression force is then held with distal screws through talus and calcaneus. D. Intraoperative view of screwdriver advancing the talar screw 7 mm proximally to augment ankle compression.

images  Some nails also provide for compression of the talar screw proximally toward the tibial screws, further compressing the ankle joint 7 mm (TECH FIG 5D).

images  Do not remove this compression until the rod is locked both in the talus and the calcaneus so that the benefits of compression across both fusion sites (ankle and subtalar) can be achieved.

END CAP INSERTION

images  While some surgeons consider the end cap optional, we routinely secure it to the distal end of the nail after removal of the targeting arm. It restricts medullary bleeding, limits heterotopic calcification, and protects the threads of the nail should extraction be needed later.

images  Permanent radiographs may be obtained in the operating room, both with AP and lateral projection, to ascertain appropriate alignment, position, and fixation.

BONE GRAFTING

images  Autogenous or allograft bone grafting is done to improve healing rates.

images  Medullary reamings can be mixed with a fibular autograft and inserted at the tibiotalar and subtalar fusion sites even before placement of the nail.

images  After insertion of the nail, place bone graft anterior, lateral, and posterior to the fusion sites.

images  For large defects, such as removal of ankle prostheses, a femoral head allograft may be cut to fit the large defect, and then the nail can be placed directly through the allograft (TECH FIG 6AD).

images  Because of the bleeding, cancellous surfaces of bone achieved at surgery, and the large amounts of bone graft employed, closed suction drainage is recommended.

images  Some surgeons and investigators advocate internal or external electrical bone stimulators for improving healing rates in neuropathic, multiply operated patients or smokers.

images  We have also used bone stimulation for patients with pre-existing avascular necrosis at the arthrodesis site.

images

TECH FIG 6  A, B. Preoperative AP and lateral views of failing Agility total ankle prosthesis. C, D. Postoperative AP and lateral views after placement of femoral head allograft (soaked in concentrated bone marrow aspirate) demonstrate the excellent stability of an intramedullary device in a complicated revision situation.

WOUND CLOSURE

images  Take care to approximate the tissues in the ankle region. A layered closure is preferable.

images  Apply a sterile, nonadherent dressing with adequate padding from the tips of the toes to just below the knee.

images  This dressing includes a posterior plaster splint with the ankle and foot at neutral position and a gentle compressive wrap over padding.

EXAMPLE CASE

images  The patient is a 58-year-old man with posttraumatic talar avascular necrosis who failed brace wear.

images  Preoperative radiographs are shown in TECHNIQUE FIGURE 7AC. The patient had pain from tibiotalar arthritis due to talar dome collapse. With increasing talar collapse, the foot gradually migrated anterior to the tibia, a biomechanically unfavorable position.

images  Postoperative radiographs are shown in TECHNIQUE FIGURE 7D,E. Tibiotalocalcaneal arthrodesis with a medullary nail was performed. The anatomic relationship of the foot to the tibia has been re-established. The nail is not proud on the plantar foot. Despite the relatively large diameter of the nail, a supplemental cannulated screw can be placed adjacent to the nail from the calcaneus to the anterior tibia to provide further support to the construct. Also, a large buttress (much like the flying buttress on a French cathedral) was placed on the posterior tibia and dorsal calcaneus to increase the surface area for fusion.

images

TECH FIG 7  Preoperative weight-bearing ankle radiographs with avascular necrosis of the talar dome and some degree of anterior translation of the talus relative to the tibial axis. A. AP view. B. Mortise view. C. Lateral view. D, E. Postoperative weight-bearing ankle radiographs of the same patient after tibiotalocalcaneal arthrodesis. Fusion appears to have been successful based on the bridging trabeculation at the arthrodesis sites. In our experience, the increased surface area afforded by the bone graft to the prepared posterior tibia and dorsal calcaneus increases the chance of fusion. Note that the physiologic relationship of talus to tibial shaft axis has been re-established. Despite the nail's relatively large diameter, a supplemental cannulated screw could be passed adjacent to the nail to provide greater stability to the construct. D. AP view. E. Lateral view.

images

POSTOPERATIVE CARE

images Most patients undergoing tibiotalocalcaneal arthrodesis with medullary nail fixation can be discharged the day after surgery with oral analgesics and after having received 24 hours of parenteral antibiotics.

images The typical case will require non–weight-bearing protection in a short-leg splint or cast for 6 weeks, followed by 4 to 6 weeks of weight bearing to tolerance in a short-leg walking cast.

images At 10 to 12 weeks postoperatively the patient is fitted with a removable fracture orthosis equipped with a rocker sole to ease the transition to weight bearing in more normal shoe wear by 12 to 16 weeks postoperatively.

images Less than half of the patients fused in the appropriate plantigrade posture with otherwise normal neuromuscular function will have a noticeable limp by 6 to 12 months postoperatively.

images Those requiring shoe wear modification are often best treated with a rocker-bottom sole or a cushioned heel to make up for the rigidity of the fused joints.

images Heel lifts can be employed to equalize limb lengths to within 10 to 15 mm, the side undergoing tibiotalocalcaneal fusion desirably being the short one to allow for toe clearance during the swing phase of gait.

images The vast majority of our patients are ambulatory postoperatively in a non-custom, off-the-shelf shoe.

images Rod removal has been required in less than 1% of Dr. Quill's operative series.

COMPLICATIONS

images We have not encountered plantar wound healing problems in any patient when the procedure is done as described above.

images Damage to the medial and lateral plantar nerves can be avoided by following the technique mentioned above and by dissecting with nothing sharper than a large key elevator deep to the dermis on the plantar aspect of the foot.

images A three-quarter-inch key elevator can be used to bluntly spread the fibers of the plantar fascia and the intrinsic flexor muscles in line with the incision and to sweep soft tissues medially and laterally before inserting the guidewire through the sole of the foot.

images Complications of medullary nail fixation for ankle and hindfoot fusion include those germane to any orthopaedic procedure, such as infection, medical illness, and anesthetic perioperative complication, as well as hardware prominence.

images The complications unique to medullary nail fixation for tibiotalocalcaneal arthrodesis include delayed union, nonunion, and malunion and can be minimized by adhering to the technique described.

images The proximal dissection for screw fixation may encounter the superficial peroneal nerve and the distal dissection may expose the sural nerve; care must to be taken to avoid damage. In cases in which the medial malleolus is removed, the tibial nerve can be exposed to injury very easily.

OUTCOMES

images Medullary nail advantages over traditional fixation for arthrodesis of the ankle and hindfoot include the fact that a medullary nail is a load-sharing device that is especially indicated for the osteopenic or neuroarthropathic patient.

images Dr. Quill's personal clinical series includes a 93% union rate in an average of 12.2 weeks postoperatively (range 10 to 20 weeks).

images Delayed nonunions have occurred in neuropathic patients, but most are asymptomatic.

images Mean improvement in the AOFAS clinical scores for this series of patients has been 52 points.

images Nail-related problems include the removal of 17 of 932 locking screws removed for fracture or local irritation.

images There have been two fractured nails, both of which were in the face of severe persistent valgus and subtalar nonunion in neuropathic, obese patients.

images One tibial fracture was sustained intraoperatively in an osteopenic rheumatoid patient. It was incomplete and healed during routine casting.

images Excellent early stability and rigid early fixation are achieved and maintained, providing for less perioperative morbidity and discomfort and shorter casting.

images The medullary nail ensures position and alignment from the immediate postoperative time frame, and the patients often require less activity restriction postoperatively.

images Medullary nail fixation for tibiotalocalcaneal arthrodesis has filled a particular niche in treating patients with severe deformities, disabilities, and bone loss who otherwise would have been severely disabled or would have needed to undergo limb amputation.

REFERENCES

1.     Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 1948;30B:506–511.

2.     Gellman H, Lenahan M, Halikis N, et al. Selective tarsal arthrodesis, an in vitro analysis of the effect on foot motion. Foot Ankle 1987;8; 127–133.

3.     Hefti FL, Baumann JU, Morscher EW. Ankle joint fusion: determination of optimal position by gait analysis. Arch Orthop Trauma Surg 1980;96:187.

4.     Iwata H, Yasuhra N, Kawashima K, et al. Arthrodesis of the ankle joint with rheumatoid arthrodesis: experiences with the transfibular approach. Clin Orthop Relat Res 1980;153:189.

5.     Kile TA, Donnelly RE, Gehrke JC, et al. Tibiocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994;15:669–673.

6.     Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am 1993;75A:1056–1066.

7.     Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for posttraumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg Am 1992;74A:1042–1049.

8.     Quill GE. An approach to the management of ankle arthritis. In Myerson M, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders, 2000:1059–1084.

9.     Quill GE. Tibiotalocalcaneal and pantalar arthrodesis. Foot Ankle Clin 1991;1:199–210.

10. Quill GE. Pantalar arthritis. In: Nunnelly JA, Pfeffer GB, Sanders RW, et al., eds: Advanced Reconstruction Foot and Ankle. Rosemont, IL: American Orthopaedic Foot and Ankle Society and American Academy of Orthopaedic Surgeons, 2004:209–213.

11. Quill GE. Tibiotalocalcaneal arthrodesis. Techniques Orthop 1996; 11:269–273.

12. Stewart MJ, Morrey BF. Arthrodesis of the diabetic neuropathic ankle. Clin Orthop Relat Res 1990;253:209–211.



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