By: William JE Adams, PGY-II

Community Health Network - Indianapolis

TTC FUSION WITH IM NAIL

INDICATIONS

• Arthritis – Post-trauma, Osteo & Rheumatoid

• Failed isolated fusions

• Neuropathic deformities

• Failed TAR

• Talar AVN

• Severe ankle and hindfoot deformities

“All methods of TTC arthrodesis strive for the common goal of a functional, solid, pain-free fusion.” -Myerson, 2013

“With IM nail fixation the rigidity and stability achieved are unsurpassed and often result in relatively asymptomatic bone healing complications if they occur.” -Yu, 2002

“Generally, I use the IM rod for a TTC arthrodesis and a blade plate for a TC arthrodesis.”-Myerson’s Reconstructive Textbook - 2005

TTC VERSUS ISOLATED AJ FUSION

• Myerson 2013 FAI study showed TTC fusion pts compared to AA patients had similar outcomes in function, satisfaction, and pain relief

• Coester/Saltzman JBJS study w/ 22 yr follow up showed 91% of ankle fusion patients go on to develop STJ arthritis1

• Significant high level evidence supporting both techniques

• New hardware for TTC allows great compression and stable constructs that avoid additional procedures - Myerson

COESTER/SALTZMAN STUDY • 23 patients underwent isolated ankle fusions for post-traumatic arthritis & were followed up for

a mean ~ 22 years

• “The ipsilateral STJ range of motion was decreased in every patient. With no motion in nine (39%)”1

Joint

Ipsilateral

No. of Subjects withModerate or Severe

Osteoarthritis(Grade 4 or 5)

No, Doubtful, or Minimal

Osteoarthritis(Grade 1, 2, or 3)

STJ 21 (91%) 2TN 13 (57%) 10

CC 5 (22%) 16

NC 7 (30%) 14

TMT 9 (39%) 13

1st MTP 7 (30%) 14

TABLE III Grade of Osteoarthritis According to the System of Kellgren and Moore

MYERSON STUDY • From 2002 to 2010, 53 ankle arthrodesis (AA) pts & 64 tibiotalocalcaneal fusion pts were

included in a study comparing function & satisfaction between the procedures

• Mean follow up ~ 5.25 years

• Results: both groups overall showed good outcomes; low visual analog pain scores, high satisfaction scores (90.6% for AA and 87.5% for TTC), & return to work (77.4% AA, & 73% TTC).

• 84.6% of AA and 81% of TTC fusion patients say they would have surgery again. (Statistically insignificant differences)

• However, when asked if they met their desired activity levels following the procedure 58.5% AA pts said yes, versus 66.65 TTC pts.

• Overall, Myerson concluded that both statistically, & clinically there was no difference between the AA group & TTC group in terms of function and satisfaction.

CASE REVIEW• 62 y/o female presents as referral from ortho – Not TAR candidate due to shape of talus and

STJ involvement• Symptoms of pain at STJ /AJ through active & passive ROM, weakness, medial knee pain, &

instability due to collapsed arch• Pmhx: HTN, DM II, Pacemaker, HLD, COPD, obesity, and OA• PShx: knee replacement b/l, rotator cuff repair, hysterectomy • Allergies: Tramadol, codeine • Neurovascular status intact• PE: Unable to perform single or double heel rise, too many toes sign, hindfoot valgus,

abduction of forefoot on RF, equinus, severely limited ROM of AJ/STJ, decreased muscle strength w/ inversion and plantarflexion

• Indications: AJ/STJ arthritis, End stage PTTD, Ankle joint valgus, Pes planus, Equinus, body habitus

• Hardware: Biomet titanium phoenix IM nail - Size: 11.0X180MM

CASE

CASE

“Too many toes sign”

CASE

PRE-OP IMAGING

PRE-OP IMAGING

DOS: 8/14/15

TECHNIQUE CONSIDERATIONS

Nail insertion point

“Step 5: Nail Entry Site and Incision Following the preparation of the bony surfaces, a 3 cm longitudinal plantar incision is made anterior to the subcalcaneal fat pad slightly lateral to the midline, especially in the patient with significant preoperative valgus deformity. Blunt dissection is carried down to the plantar fascia, which is split longitudinally. The intrinsic muscles are swept medially or laterally and the neurovascular bundle on the sole of the foot is identified”

-Biomet manufacturer recommendations (BMR)

Step 6: Entry Guide Wire Insertion The ideal position for the plantar calcaneal entry site is well anterior to the weight bearing surface of the calcaneal tuberosity and approximately 2 cm posterior to the articulation of the calcaneus with the transverse tarsal joints.

“The process of defining the point of entry of the guide pin is quite tedious and can take as long as 1.5-20 minutes. The importance of this step in the procedure cannot be over-emphasized as it is this step that will determine the final end product with regard to placement of the nail.” – Yu, 2002

“A 3.2 mm x 320 mm Entry Guide Wire is inserted through the calcaneus, talus, and tibia. Confirm the position of the wire on the C-arm.” -BMR

Intra-op fluoro

Intra-op fluoro

2 weeks post-op

1 month post-op

1 month post-op

6 wks NWB min. then use radiographicevidence and symptomatology to guide when to allow WB in boot

2 months post-opPre-op

CASE 2 • 52 y/o female presents as referral from community podiatrist that does not perform reconstructive sx

• Symptoms of pain at AJ through active & passive ROM, weakness, medial knee pain & instability due to pain and guarding

• Pmhx: HTN, Bipolar disorder, polysubstance abuse, post-traumatic OA, tobacco abuse, depression

• PShx: Previous left ankle fracture repair

• Allergies: Ibuprofen, Ultram

• PE: Musk: Unable to balance on left ankle w/o assistance, ankle valgus deformity, equinus, severely limited ROM of AJ w/ pain and crepitus, decreased muscle strength

Neurovasc: Intact

• Indications: Post-traumatic OA, large talar OCD, ankle valgus deformity secondary to trauma

• Hardware: Biomet titanium phoenix IM nail - Size: 11.0X180MM

Prior to first fall 1/26/2015

After fall, fracture, repair at Methodist, another fall, and 7/17/2015

10/17/2015

PROXIMAL IMAGING is crucial

TIPS/PEARLS• Thorough & honest surgical consultation addressing immediate post-op course,

expectations, recovery strategies including mobility issues, family involvement, etc…

• VASCULAR studies

• Pre-op CT best delineates total bony integrity & structure

• Practice putting together & taking apart outrigger assembly prior to case

• Study manufacturer recommendations on implantation and technique tips offered from the particular companies physician consultant

• Solicit a knowledgeable assist (resident or attending physician) for additional dexterity

• Fully utilize intra-op imaging to ensure screw placement into nail – soft bone can make purchase deceiving

TIPS/PEARLS CONTINUED

• Full utilization of peri-operative anesthesia to aid patient experience and recovery, i.e. regional block, Toradol drip, etc..

• In the event the fibula is resected but not used as graft - should be saved in the hospital's bone bank for future use if revisional surgery would become necessary

• “It is important to monitor these patients on a 3 to 4 month basis for at least the first year (Figures 9A, 9B). During this time loosening of the screws with or without migration of the screws may occur necessitating the need for screw removal or replacement. Patients should also be monitored for the development of pathologic fractures of the tibia.” – Yu, 2002

REFERENCES1. Coester, MD, L., Saltzman, MD, C., & Leupold, MD, J. (2001). Long-Term Results

Following Ankle Arthrodesis for Post-Traumatic Arthritis. The Journal of Bone and Joint Surgery, 83A(2), 219-228. doi:February 2001

2. Myerson, MD, M., Ajis, MBChB, FRCS, A., & Tan, MBBS, FRCS, K. (2013). Ankle Arthrodesis vs TTC Arthrodesis: Patient Outcomes, Satisfaction, and Return to Activity. Foot and Ankle International, 34(5), 657-665. doi:10.1177/1071100713478929

3. Conti, BA, M., Ellis, MD, S., Chan, MD, J., Do, MA, H., & Deland, MD, J. (2015). Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity. Foot and Ankle International, (NA), 1-9. doi:10.1177/1071100715576918

4. Bennett, MD, G., Cameron, MD, B., Njus, PhD, G., Saunders, MS, PhD, M., & Kay, MD, D. (2005). Tibiotalocalcaneal Arthrodesis: A Biomechanical Assessment of Stability. Foot and Ankle International, 26(7), 530-536.

REFERENCES5. Hernandez, MD, J., Remy, MD, S., Darcel, MD, V., Chauveaux, MD, D., & Laffentre, MD,

O. (2015). Tibiotalocalcaneal Arthrodesis Using a Straight Intramedullary Nail. Foot and Ankle International, 36(5), 539-546. doi:10.1177/1071100714565900

6. Muckley et al. Comparison of Two Intramedullary Nails for Tibiotalocalcaneal Fusion: Anatomic and Radiographic Considerations. Foot and Ankle International 2007. 28: 605

7. Yu, DPM, G., Gorby, DPM, P., Hudson, DPM, J., & Weinfield, DPM, G. (2002). INTRAMEDULIARY NAIL FIXATION IN REARFOOT AND ANKLE ARTI-IRODESIS PROCEDURES. In Podiatry Institute Chapter Update to McGlamry's (Vol. 2002, pp. 237-246). Decatur, GA: Lippincott Williams & Wilkins.

8. Myerson, Mark S. Reconstructive Foot and Ankle Surgery. 1st ed. Elsevier, 2005. Print.

QUESTIONS?