Posterior Arthroscopic Tibio-talo-calcaneal Arthrodesis viaLocked Retrograde Intramedullary Nail in a High-risk Patient

Devin C. Simonson, DPM (PGY-II)1

Mark A. Prissel, DPM (PGY-III)1

Thomas S. Roukis, DPM, PhD, FACFAS2

1Gundersen Medical Foundation, La Crosse, WI2Gundersen Health System, La Crosse, WI

Tibio-talo-calcaneal (TTC) arthrodesis is an accepted treatment for combined degenerative joint disease (DJD) of the hindfoot/ankle. The surgical technique has evolved signi�cantly and recent advancements involve a posterior arthroscopic approach to joint preparation and insertion of a locked retrograde intramedullary nail (LRIN).1-4

PURPOSE

LITERATURE REVIEW

Limited available literature states that this approach a�ords a lower incidence of non-union, superior joint exposure and fewer incision healing complications compared to open approaches.1,2

CASE STUDY

We present a 65-year old woman who sustained a severely comminuted closed trimalleolar ankle fracture 20-years prior that ultimately required four surgeries and resulted in persistent pain with activity. She has diabetes mellitus with peripheral sensory neuropathy, peripheral vascular disease (PVD) status-post iliac stenting (ABI 0.7) and untreated osteoporosis. Plain �lm radiographs and bone scintigraphy demonstrated hindfoot/ankle DJD with distal-lateral tibial osteonecrosis (Figure 1). We proposed a TTC arthrodesis via a posterior arthroscopic approach with LRIN �xation and a mixture of synthetic bone graft, intramedullary reamings and autogenous tibial bone marrow aspirate to enhance primary union.

Osseous preparation to bleeding subchondral substrate was achieved (Figure 2) and LRIN inserted (Figure 3).5 Delayed incisional healing for �ve-months occurred; however, she healed and progressed to a stable, well-aligned arthrodesis with 13-months follow-up (Figure 4).

RESULTS

ANALYSIS and DISCUSSION

When treating high-risk patients with PVD and combined hindfoot/ankle DJD, open approaches may result in catastrophic complications. Alternatively, an arthroscopic approach allows for maximum preservation of bone mass and vascularity, and insertion of a LRIN provides sound �xation. Therefore, we believe this is a viable approach in select patients and should be considered by surgeons familiar with these techniques.

References

1. Bevernage BD, Deleu PA, Maldague P, Leemrijse T. Technique and early experience with posterior arthroscopic tibiotalocalcaneal arthrodesis. Orthop Traumatol Surg Res 96:469-75, 2010.

2. Vilà Y Rico J, Rodriguez-Martin J, Parra-Sanchez G, Marti Lopez-Amor C. Arthroscopic tibiotalocalcaneal arthrodesis with locked retrograde compression nail. J Foot Ankle Surg [Epud ahead of print], 2013.

3. Goebel M, Gerdesmeyer L, Mückley T, Schmitt-Sody M, Diehl P, Stienstra J, Bühren V. Retrograde intramedullary nailing in tibiotalcalcaneal arthrodesis: a short-term, prospective study. J Foot Ankle Surg 45:98-106, 2006.

4. 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.

5. Roukis, T. S. Determining the insertion site for retrograde intramedullary nail �xation of tibiotalocalcaneal arthrodesis: a radiographic and intraoperative anatomical landmark analysis. J Foot Ankle Surg, 45:227-234, 2006.

Figure 1: Preoperative ankle imaging. Weight-bearing radiographs, mortise (A), lateral (B) and hindfoot alignment (C), as well as, bone scintigraphy (D) demonstrating post-traumatic arthrosis with obvious distal-lateral tibial osteonecrosis.

Figure 2: Intra-operative images of ankle and subtalar joint preparation. Image intensi�cation with utilization of probe to demonstrate complete preparation of the ankle joint (A) and posterior facet of the subtalar joint (B). Arthroscopic images of ankle joint (C) and subtalar joint (D) preparation for arthrodesis, with arthroscope in posterolateral portal and patient in the prone position.

Figure 4: Postoperative weight-bearing radiographs, mortise and lateral views (A, B), demonstrating osseous union.

Figure 3: Final intraoperative images. Clinical photographs demonstrating proper alignment of hindfoot and ankle to the leg (A-C). Note the incision placement for joint preparation and insertion of intramedullary nail �xation. Image intensi�cation demonstrating �nal intramedullary nail placement on anterior- posterior and lateral views (D, E).

A B C

D E

A B

A B

C D

A B C D