Addressing Hindfoot Arthritis with Concomitant Tibial Malunion or Nonunion

with Retrograde TibioTaloCalcaneal Nailing: A Novel Treatment Approach

Justin M. Kane et alRothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

Journal of Bone and Joint Surgery| April 2014 | Vol. 96-A | Number 7

Level of evidence I

PRESENTER : Dr SAUMYA AGARWAL

Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum

INTRODUCTION• Tibial shaft fractures are most common long bone fractures with incidence upto 26 / lakh people

• Malunion and nonunion most common with tibial shaft fractures

• Prearthrotic deformity - coined by rosemeyer and described as effect of angular deformity of tibia on distribution of weight across adjacent joints

REVIEW OF LITERATURE

• Sarmiento found deformity 0f >5⁰ ---> late onset degenerative changes in adjacent joints

• Puno et al concluded - anatomic reduction could reduce abnormal forces at adjacent joints and possibly delay arthritis at ankle

• Tarr et al found - more distal the deformity, greater the impact on incongrous tibiotalar contact area

• Milner et al evaluated late onset arthritis post tibial shaft fractures and found more osteoarthritis in knee and ankle on injured extremity.

Various Treatment Options

1. Tibial osteotomy with ankle arthrodesis/ arthroplasty

2. External fixation to correct malunion or nonunion with ankle arthrodesis

3. Tibiocalcaneal nail fixation for correction of malunion or nonunion and arthrodesis of ankle

METHODS

• A retrospective study

• Patients who underwent single stage reconstruction for tibia malunion or nonunion with tibiotalar arthritis were assessed

• Visual Analog Scale and American Orthopaedic Foot and Ankle Society – Ankle Hindfoot scores were used to assess

Exclusion Criteria

• Active infection

• Leg length discrepancy of >5cm

• Malunion or nonunion at ankle joint secondary to ankle fracture

• Treatment with a staged procedure or single stage deformity correction with arthroplasty

• 25 patients underwent single stage correction of tibial malunion or nonunion with tibiotalocalcaneal nailing

• Average age – 58 yrs

• 13 men and 12 women

• 3 patients had severe rheumatoid arthritis

• 8 patients had peripheral neuropathy

• 16 had healed angular malunion

• 4 had combined malunion and nonunion

• 5 had tibial nonunion

Varus and recurvatum deformity

• Overall average sagittal plane malalignment was 26⁰ and average coronal plane malalignment was 21⁰

• Ankle joint arthritis was assessed for pain, ROM and palpable crepitus

• AP, Mortise and lateral views were taken

• Weight bearing radiographs were taken to assess joint space narrowing, subchondral sclerosis and osteophyte formation

• Subtalar joint and transverse tarsal joints were assessed independently

• An inflexible subtalar joint can decrease ability to correct alignment and lead to undesirable results

• Inclusion of subtalar joint in arthritis, aided in correction of deformity and allowed use of single device to treat arthritis and malunion

• Author hypothesized that whenever subtalar involvement was suspected, that joint should be included in fusion to improve the final alignment and stability

• All patients underwent a single stage reconstruction including deformity correction via realignment osteotomy combined with arthrodesis of ankle and subtalar joint

Surgical Technique

• Osteotomy requires preoperative radiographic planning to establish centre of rotation axis of deformity and to plan for triplanar cuts for deformity correction

• Under C-arm, k-wires are drilled across tibia

• Author suggest multiple drill holes along plane of planned cut using drill bit with continuous irrigation

• Correction should be achieved in all planes i.e., coronal, sagittal and rotational

• Fine adjustments were made using microsagittal saw until required alignment is obtained, recreating mechanical axis of limb

• After correction of proximal alignment, ankle and subtalar joints are prepared exposing subchondral bone

• Definitive fixation is obtained with retrograde intramedullary nail inserted through plantar aspect of calcaneum into tibial shaft ending 5 cm proximal to level of deformity correction

• 15, 20 and 25cm length nail has been used according to fracture site

• Distal part of fibula and iliac crest was used for bone grafting

• 19 patients underwent tibiotalolcalcaneal fusion , 6 underwent pantalar (talonavicular and calcaneocuboid) fusion

• Transverse tarsal joints are approached through standard open incisions, articular cartilage and subchondral bone is removed and joints derotated to neutral

• Fixation is obtained with 2 parallel retrograde screws across talonavicular joint and staples across calcaneocuboid joint

• Non weight bearing was advised for 6 weeks for traumatic patients and 12 weeks for patients having neuropathy

• Healing was assessed clinically and radiographically

• 1 patient developed infection because of additional surgery and had poor result and was unsatisfied

RESULTS• All nonunions, osteotomy sites and fusion sites

healed clinically and radiographically at an average of 19.5 weeks

• Radiographs at final follow up showed continued stable healing of fusion and osteotomy sites without loss of alignment

• All deformities were corrected to neutral alignment and all patients had a plantigrade foot and ability to wear off the shelf shoes without bracing

• 21 patients were extremely satisfied

• 3 were satisfied

• 1 was not satisfied

DISCUSSION

• Retrograde intramedullary nailing for tibiotalo calcaneal arthrodesis is described as a salvage procedure for patients with

• a failed ankle fusion or

• total ankle arthroplasty with severe bone loss,

• charcot arthropathy,

• rheumatoid arthritis,

• posttraumatic arthritis,

• previous talectomy,

• bone loss after tumor resection,

• tuberculous arthropathy

• High rate of fusion and biomechanical strength of construct successfully achieves a painless biomechanically stable plantigrade foot

• Various studies showed high fusion rate around 90%

• Study recommends inclusion of subtalar joint and utilization of intramedullary device to ensure deformity correction and a stable ankle hindfoot construct

PITFALLS

• Retrospective nature of study

• AOFAS scoring and patient satisfaction survey are not validated

CONCLUSION• Single stage procedure of tibial osteotomy and

retrograde intramedullary nailing for correction of angular deformity and fusion of arthritic hindfoot :

provides a viable alternative to multiplanar external fixation or a staged procedure

• Accurate correction with meticulous joint preparation is required to achieve good results.