The Podiatry Institute - Seminars, Surgery Courses, Board ... · Created Date: 11/10/2011 2:44:21 PM

CHAPTER 42

INTRAMEDULIARY NAIL FIXATION IN REARFOOTAND ANKLE ARTI-IRODESIS PROCEDURES

Gerard V. Yw, DPM, FACFAS

Paul O Gorby, DPM

Jwstin R, Hudsom, DPMGlenn D. Weinfeld, DPM

Severe ankle and subtalar deformity and painsecondary to destructi\re processes continues to be adifficult dilemma for foot and ankle surgeons.Attempts at conservative bracing and off-loading ofthe severely deformed foot and ankle are the initialtreatment options. Howeveq as the problems persistand worsen, surgical intervention becomes immi-nent. This articie describes the use of the Biometointramedullary nail for the fixation of tibiocalcanealand tibiotalocalcaneal afihrodeses. The nail is usedas a saivage procedure for the patient with severepain and/or deformity of the ankle and subtalarjoints. The authors have found the intramedullarynail to be a good option for the aforementionedpatients, affording the patient the oppottunity toobtain and maintain a plantigrade foot.

The intramedullary (IM) nail has been in usefor over a century. Initially used for long bonefracture management, it has today become a moreaccepted form of fixation used in lorn er ertremitysurgery. As its popularity has increased, numerouscompanies have developed and modified their ownIM ankle arthrodesis nails. Biomet' fVarsaw, IN)has developed one version of the nail, which theauthors successfully use, secondary to its compres-sion capability and posterior-to-anterior screw)which increases stability and decreases rotationalforces. Patients undergoing tibiocalcaneal or tibio-talocalcaneal arthrodesis have severe ankle andsubtalar arthritis, instability of the rearfoot andankle, and/or severe deformity secondary toprocesses like Charcot neuroarthropathy. Many ofthem are one step from an ankle or below the kneeamputation.

The benefit of this device in a salvage-typearthrodesis procedure of the rearfoot and ankle liesin its ability to provide a stable, pain-free, andplantigracle foot. The authors realize that the finaloutcomes in these difficult cases have manv

potential complications. In these patients, the possi-bility of a plantigrade foot largely outweighs thepossible complications. Minimally, the procedurewill delay an ankle or below the knee amputation.

HISTORIC OVERVIEW

One of the earliest descriptions of the concept ofintramedullary nail fkation of bones was publishedby Nicolaysen in 1897.' Howeveq it was not until 10

years later that Lambotte'z repofied on the r-rse of IMnails for the treatment of femoral fiactures. In 1916,

Groves was the first to use IM nails on a routine basisfor the treatment of femoral. tibial and humeral frac-tures and described the insertion of the nails utilizingradiographic visualization.' Kuntscher developed a

fondness for the proceclure as a result of the per-ceived simplicity and seemingly minimal invasivenessof the sllrgery, which he felt limited periostealdestruction and prevented delayed wound healing.'

As time progressed numerous IM nails weredeveloped in varying shapes and designs; theseincluded the Kuntscher "V" shaped, Rush "diamond"shaped, Hansen and Street "so1id, triangular"shaped, Lottes "I-beam", and the Schneider "four-flanged" nail.'a Of additional interest is the fact thathistorically IM nails came in one length with varyingsize diameters. The nails were cut to length in theoperating room using a sterile bench vice andhacksaw.3 Today the nails are available in varyinglengths, and diameters.

Throughout the 1950s, the Association for theStudy of Osteosynthesis (AO) noted that nails lackedanti-rotation and compression properties.5Accordingly, the evolution of nails saw furtherchanges in design. Initially the cross sectional designchanged.''5,6 Design shapes included clover-leafs forincreased strength, fluting to oppose bending andshearing, and slotting for a more flexible nail and

238 CHAITTER,i2

easier insefiion. The rotational concerns led manysurgeons to attempt to counter the rotation bypiacing plates across the fracture site or by simplyplacing a second nail across the site. It w-as not r:ntilthe advent of the interlocking screw-s that theconcept of compression gained acceptance.(,

Ankle afthrodesis is a common surgicalprocedure that has r:sed numerous forms of fkationover the years" including multiple screws, plates,external fkators, and sometimes no flxation at all.Adams was the first to repofi on the use of an IMnail for ankle arthrodesis in 1948l He used an IMnail for a revisional ankle arlhrodesis procedure thathad previously failecl using a transfibular approach.He clescribed a three-flange nail insefiecl through thecalcaneus, talus and tibia that resulted in eventualbony effr-rsion. In an article by Watson-Jones et al in1950, brief mention of ankle fusions employing IMnails was made.' Specifically, the authors clirectedattention to the simultaneous treatment of theclamaged subtalar joint with this method of anklefr-rsion. Interestingly, a cr-ude diagram appeared inthis article illustrating the use of "two interlockingpins." It appears to have been the first description ofsuch a concept. This concept of interlocking orcompression nail techniques was furtl-ier describedby Kaessman et al. Klemrn, Shevis, and Zankowki inthe 1960s.: In7975, Huckstep produced a four-sidedcompression nail that employed a proximal screwand nut fbr fracture compression.5

Over time several adclitionai nails weredesigned with interlocking screws. Differences inthe distance from the interlocking screws to theend of the nail and the direction of the proximalinterlocking screw were seen. In 19BB Brumback etal clescribed the Russell-Taylor interlocking nail as"static interlocking fixation."10'1 Prior to the adventof interlocking screws, IM fixation nail techniqueswere considered dynamic in nature allowing foraxial loading at the site of the fracture. Many physi-cians felt that the axial loading was needed toachieve bony Lrnion."0-" Brumback describedLltilization of the nail alone or with a proximal ordistal interlocking scres,. for dynamic compressionof stable transverse fractures. In cases where amore comminuted fracture was present a proximaland distal interlocking screw was employed toobtain static interlocking fixation. A 98% fusion ratewas reported with this technique. This finding wasin contradiction to the prevailing notion of the timethat the use of static interlocking screws might

possibly impede fusion.6,rr,:Lr

During the 1970s IM nail research focused onthe disruption of the periosteal blood flowsecondary to medul1ary reaming.;l3 15 The reamingwas noted to increase pressure within the medullarycavity by pushing bone marrow into intracofiicalcanals and, in turn. blocking circulation. It wasdetermined that reduction of intramedullarypressure by the creation of several metaphysealdefects or "inventing tr-rbes" decreased the intracorti-ca1 vascular damage. Regardless of the separatemetaphyseal defects, the presence of external bonecallous was noted at 3 to 4 weeks postoperativelybridging the fracture site, allowing for revasculariza-tion of the cofiex. Franklin et al described thetreatment of broken nails in an afiicle in 1988.'n Theyreporled that IM nails without interlocking screwsbroke at the site of the fracture, non-union, orosteotomy, while nails with interlocking scrcwsappeared to fracture et the hole sites for theinsertion of the intedocking screws.

Although IM nails were originally developedfor fixation of long bone fractures, cllrrent naildesigns have found a niche in rearfoot and ankleafihrodesing procedures, especially for those with asalvage type of problem. IM nails are most com-monly employed with stabilizatiol of the tibiotalarand talocaicaneal afiiculations. Continued advancesin technology and materials, coupled with anincreased understanding of the factors governingfusions of the ankle and subtalar joint complextogether are like1y to enhance final surgicaloutcomes. IM nails are likely to continue to seeincreased utilization for stabilization afihrodesisprocedures of the ankle and subtalar jointcomplexes. They are particularly beneficial forsalvage afihrodesis of these joints. The techniquecan be combined with more distal fusions (i.e.

midtarsal joints, Lisfranc joints)

INDICATIONS FORTIBIOTALOCALCANEAL ARTHRODESIS

Tibiotalocalcaneal arthrodesis is typically used as anend-stage procedure for patients who exhibit syiltp-toms of painful afihritis with or without concomitantdeformity or instabiliry of the rearfoot and ankle. Theproceclure has been advocated for the managementof numerous severe ankle and rearfoot deformities(Table 1). In general, these deformities can bedivided into two major categories. The first category

CHAPTER,i2 239

includes patients who are diagnosed with severe,disabling arthdtis of both the subtalar and ankle jointcomplexes. The majority of patients in this categoryare diagnosed with rheumatic diseases such as

rheumatoid arthritis, osteoarthritis, post-traumaticarthritis, and avascular necrosis of the talus.

The second category of patients includesthoses who exhibit severe deformity of the rearfootand/or ankle with resultant instability upon weight-bearing. Most of the patients in this category haveadvanced neuroarthropathy. Also included in thiscategory are patients with a fixed equinovarusdeformity of the foot and ankle secondary to anunderlying neuromuscular disorder and patientswith severe peritalar dislocation and ankle valgusas a result of end-stage tibialis posterior tendondysfunction.

It should be emphasrzed that the procedure is

intended for patients with disease, deformity and/orinstability of both the ankle and subtalar jointcomplexes. Varying combinations of disease cancoexist, such as degenerative joint disease of theankle with chronic lateral subtalar joint (peritalar)dislocation. In other cases the same process canaffect both joints (ie. post-traumatic arthritis, A\N,etc.). In some patients, although one joint mightnormally be preserved, it is more prudent tostabilize both. In these cases loss of motion of a jointthat would have normally been preserued will haveminimal consequences to the patient.

Table 1

COMMON CONDITIONS TREATEDWITH TIBIOTALOCALCAI\EAL

ARTHRODESIS

. Failed Triple Arthrodesis

. AVN of Taluso Neuroarthropathy. Inflammatory Arthritis. Paraplegia \7ith Fixed Equinova ns

Deformity of the Foot. Failed Total Ankle Arthroplasty. Failed Tibiotalar Arthrodesis. Failed ORIF of Ankle Fracture \fith STJ DJD. Severe DJD of Ankle Secondary to Prior

Pilon Fracture With STJ DJD. DJD of Ankle \7ith ST Coalition

Tibiotalocalcaneal arthrodesis has beenperformed using a number of different fkationtechniques including internal fixation with pins,cancellous screws, plates and screws, intrameduliarynails, and external ftxation utilizing a variety ofdevices. Each of these fkation techniques have theirown advantages and disadvantages with respect tothe technical ease of insertion/application, ability tomaintain rearfoot alignment, fusion rates andcomplication rates. However, the selection of thetype of fixation device to be used must also take intoaccount the nature of the deformity being treatedand the quality and quantity of the bone that ispresent to accept the fixation devices.

\7hi1e simultaneous fusion of the ankle andsubtalar joints can be achieved with other forms offkation, IM nail fixation may have increasedadvantages. A11 other forms of hardware (fixation)are either removed or fail when the fusion itself fails.\fith IM nail fixation the rigidity and stabilityachieved are unsurpassed and often result inrelatively asymptomatic bone healing complicationsif they occur.

In high-risk fusion patients IM nail flration maybe indicated and is iikely to provide unsurpassedstability to the ankle and rearfoot. High-risk fusionpatients include those with chronic nicotineconsumption, known peripheral neuropathy, A\,T{

patients, and those patients with underlying poorbone stock due to a disease process such as diabetesor rheumatoid anhritis.

Patients with severe instability and deformitysecondary to neuroafihropathy often present thebiggest technical challenges when performingtibiotalocalcaneal arthrodesis. As a result of theCharcot disease process, a significant alteration inthe normal bony architecture results in malalignmentof the rearfoot and/or ankle, and leads to abnormalbony prominences and ulceration. In addition, theclinical picture may be complicated by an underly-ing infection. In these patients, tibiotalocalcanealarthrodesis is performed as an alternative to either aSyme's or below-the-knee amputation.

In patients with severe neuroarthropathy,radiographs of the affected extremity often do notclearly delineate the extent of bony destruction dueto an increase in the soft tissue density and super-imposition of the misaligned rearfoot stn-rctures. Thetalus and calcaneus are often severely fragmented,and collapse of the talar body is not uncommon. Inthese patients, a CT scan is an excellent tool for

240 CFLAPTER 42

evaluating both the quality and quantity of bone.This will give the surgeon a good idea of what typesof fixation will be acceptable for the procedure.

The authors favor the IM nail device as fixationof choice for tibiotalocalcaneal arthrodesis inpatients with unbraceable neuroafihropathy of therearfoot and ankle. -J[e have found that this deviceprovides a rigid, plantigrade foot even in theabsence of union of the subtalar andlor anklejoint(s). In cases where the talus has undergonesignificant destruction or preclucles the reduction ofthe hindfoot deformity, a talectomy is performedand the bone is morselized and used as bone graftto fill all defects. Additional allogeneic bone graft isused as needed to reestablish both the height andalignment of the 1imb.

A variety of IM nails are currently available.Although each of these devices shares commondesign features, there are subtle differences thatmay affect the overall construct of the fusion sites.

Ve favor the Biomet' nail for IM fixation oftibiotalocalcaneal and tibiocalcaneal arthrodesis.The Biomet'nail and its associated components are

constructed of titanium and the design features twoproximal locking screws and three clistal lockingscrew-s. One of the three distal locking screws can

be insefied from posterior to anterior through thebody of the calcaneus ancl into the cuboid ornavicular if desired. This may provide additionalstability of the midtarsal joint if desired or selve as

fixation for fusion of this joint. In some cases onlyone distal transverse screw can be insefied due toextensive loss of the talar body, rendering theposterior screw very effective. In a small number ofpatients, particularly those who have a concomitanttalectomy, it may be very difficult to nearlyimpossible to insefi a screw from side to side with-out a significant portion of the nail protrudingbeyond the plantar aspect of the calcaneus. Theimplication of this is obvious.

To our knowledge, only the Biomet' nail canimpart significant compression through the deviceitself at the arthrodesis site. This is particularlyadvantageous in patients with severely compro-mised bones as is seen in patients with severeCharcot neuroarthropathy or A\N of the talus. Acomparison of the features of the currently availablenails is found in Table 2. Some manufacturers con-tinue to redesign their nai1, making them moreattractive for tibiotalocalcaneal afihrodesis.

SURGICAL TECHNIQUE ANDCONSIDERATIONS

There are several approaches to insertion of IM nailsfor rearfoot and ankle arthrodesis. In patients withsignificant degenerative changes requiring jointresection, a lateral incisional approach is

recommended. The incision is placed over the distalaspect of the fibula and continues distally onto thelateral aspect of the foot. Particular care should be

taken to avoid damage to the sural nelve traversingthe lateral inferior border of the foot and ankle. Thedeep fascia, capsulaq and periosteal tissues are

incised and reflected giving excellent exposure toboth the ankle and subtalar joints. The fibula can beleft intact or, not uncommonly, is transected several

centimetem above the tibial plafond and excised intota1. The excisecl fibula may be morselized andused as auto5lenous bone graft to fill defects withinthe joint; wedges of bone can also be created. Less

commonly, the resected fibula is left whole and used

as an on-lay graft. If the fibula is removed, but notutilized as bone graft, it should be processed andsaved in the hospital's bone bank for future use inthe event revisional sllrgery becomes necessary.

The ankle and subtalar joints are resected. Theauthors frequently use an aggressive curettagetechnique although reciprocal planing of the joints is

cefiainly acceptable as wel1. If desired, an ancillarymedial incision can be made to facilitate jointresection, although this is generally not necessary. Inother cases where severe bone destruction has takenplace and the normal architectural configuration ofthe bones are severely distorled, if not a1l togetherdestroyed, resection of the joints is performed on alimitecl basis. This is commonly seen in the diabeticneuropathic foot where neuroafihropathy is present.

In these cases, complete ankle and/or subtalar jointdislocations are not uncommon and special attentionand focus is required to release the deformingtenclon and ligamentous structures in order tosuccessfully relocate the joint complexes. Extirpationof the talus may become necessary to allow forreiocation, with the removed talus becoming r:tilizedas bone graft as needed (Figure 1). In patients withCharcot neuroafihropathy, definitive afihroclesis is

desirable but neither expected nor anticipated. Thegoal of surgery in these patients is to achieve

absolute stability of the limb, thus precluding theneed for an amplltation of the foot or leg segment.

Once proper alignment and position have been

CHAPTER 42 241

Table 2

COMPARATIVE SUMMARY OF NAIL DEVICES

Nail Companies Biomet DepuyAIM' RichardsAnkle Arthrodesis NaiI Supracondylar Nail Revision*'Nail

Materials Titanium TilJnium Stainless Steel

Nail Sizes Dirmeters 10, 11, 12 mm Diameters 10 anci 12 mm Diameters 11. 12. 13 mmLength 15 and 18 cm Length 15-30 cm (5 mm increments) Lengths 15,18, and 21 cm

Numlrr of Proximal 2 2 3

Transv-erse Screw Holes

Proximal Anchor 5.0 Fully Threaded Cotical ,i,5 Fully Threaded Cortical 5.0 mm or 5.0/6.4 mm Step Screws

Screw Size and Drill 20 - 110 mm (5mm increments) 28 52 mm (,1 mm increments) 20 - 90 mm (5mm increments),1.3 Calibrated Drill and pSide i.J mm DriJl Guide 3.5, '1.0. and 8,0 mm Drills

3.8 mm Drill 3 2 mrn Guide Pin(Osteoporotic Bone)

Number of Distal Tlansverse 2 2 3

Screrv Holes

Distel Ar-rchor 5.0 Fully Threaclecl Cortical 6.i fully Threadecl Cotical i.0 mm or 5.0/6.4 mm Step Screw-s

Screrv Size and Drill 20 - 110 nrm incre:rse bv 5mm 50 - 90 mm Increase bv 5 mm 20 90 mm Increzrse bv 5mmi 3 mm Drill Guide Note: Same Drill antl iuicle as

5.3 mm Ddll Proximal Screws

Number of Distal Posterior 1 None None

Screu'Holes

Distal Posterior to (Transcalcaneal Locking Screw) Nl\ N/AAnterior Anchor Screu, Note: increases torsional rigiclity

Size and Drill 5.0 Fully Threadecl Tit'anium20 I l0 rnm inrrc.rsc b) irrulr

Drection of Insertion Meclial to Lateral OR Lateral to Lateral to Nleclial OR X{eclial Lateral to Medial OR

of Locking Scres,'s Meclial OR Combrnation to Lateral Meclial to Latetal

Drill Guicle, Reamer, and 2.4 mn'r x 91 Steinlnann f in 3.2 mm x 1,1i Guicle f in 3.2 mrn x 15" Threadecl Tip

Guicle Pin for Nail 7.0 Cannulated Drill 12 mm Entry lleamer (non-flexible) Ball Tip Guicle -ff,'ire Available

3.2 Ball Tip Guide Vire 9 mm Cannulatecl Reamer

8.0 - 2O,O mm Cannulated Reamers (Non-flerible)(Flerible and Nonflexible)

Recommendecl Reaming 18-20 cm into Tibial Canal no 0.5 - 1 nlm Greater than 0.5 mm Smaller than Nailgreater than Distal 1/3 Naii DiameterTibial Sl'raft.

0.5mm Greaier than ActualNail Diameter

Compression Options Compression Nut with 3/4" End options: None Specified'Wrench (15 n-rm Compression Unilateral Femoral DistractorPossible) Tapping Jig u,ith Mallet

End Cap Yes Yes No

242 CHAPTER 42

Figure 1. Exposure of the lateral aspect of the foot ancl ankle fbrextirpation of the talus in a patient $'ith sev-ere Charcot afthropathy. Talusis sholr,'n being excised from the foot for tibiocalcaneal afihroclesis.

achieved the process of nail insertion begins.Primary emphasis is placed on accurate placementof the guide pin. This can only be achieved by theuse of intraoperative fluoroscopy to visualize theankle joint from an anterior-posterior direction as

well as a medial-lateral direction. The goal is

determine the point of entry in the plantar aspect ofthe heel that will a1low placement of the nail withinthe center of the medullary canal of the tibia. As a

general guideline, the entry point of the guide pincan be estimated by drawing lines bisecting thefrontal plane bisection of the medial and lateralmalleoli and the longitudinal axis of the second toeto the center aspect of the plantar heel. Theintersection of these two lines can be used toestimate the entry point of the guide pin. Theprocess of defining the point of entry of the guidepin is quite tedious and can take as long as 1.5-20

minutes. The importance of this step in theprocedure cannot be over-emphasized as it is thisstep that will determine the final end product withregard to placement of the nail.

Once the point of entry has been tentativelyidentified, a traverse incision is made on the plantaraspect of the foot measuring 2-) cm in length. Theauthors do not recommend performing theprocedure through a small incision as the risk to theneurovascular structures, most notably the lateralplantar nelve, is greatly increased. Blunt dissectiontechniqr-re is used to go through the subcutaneoustissues to the leve1 of the plantar fascia. The plantarfascia is then incised and the blunt dissectioncontinues to the plantar aspect of the calcaneous. Asmuch blunt dissection as possible is used to mini-

Figr-rre 2A. Intaoperati!-e fluoroscrrpic:insefiion. A protector sleeve ovetliesnetrrovascular structures in the area.

picrure of the iniiial g:ide pinthe pin to protect the critical

Figure 28. Introduction of the ball tip guide r.ire into the medullary canal

of the tibia to gllide the cannulatecl drills and reamers, The exact locationof placen'rent has been determined uncler fluot'oscopic v-isualization

mize risk of damage the neurovascular stftlctures.Next, the skin and subcutaneous tissues are

retracted and the guide pin is insefied underfluoroscopic imaging (Figure 2A). A dril1 guide isinserted over the guide pin and the cannulated drillis then inserted and advanced from the plantaraspect of the calcaneus through the talus and intothe tlbia. At this point the guide pin is removed anda ball-tipped guide wire is inserted in its place(Figure 2B). The hole is then progressively enlargedusing a series of reamers of increasing size. Reaming

is continued until some resistance is felt as thereamer begins to intermittently contact the corticalwall of the medu1lary canal; this phenomenon is

referred to as "chatter."

CHAPTER 42 243

Figr"rre J. Insertion of the nail \\,ith the outri€lEaer assembly attachecln'hich will guide insertion of the proximal and distal locking screu-s.

Figure 5. lftilization of the u-rench to achieve compression of thefusion site, The wrenclr is sliown on the compression nlrt rvhich willapply pressure to the plantar aspect of the calcaneus.

The appropriate sized nail (both length anddiameter) is determined preoperatively by utilizing atemplate that is provided by the manufacturer ofthe nai1. The final decision, however, is made intra-operatively. The outrigger assembly is attached to theappropriate sized nail and the nail is then insetedfrom the plantar aspect of the foot underfluoroscopic visualization (Figure 3). The nail is

advanced until it has been countersunk a fewmillimeters from the plantar surface of the calcaneus.An attempt is made to place the nail in such a

position that at least one or two distal transverselocking screws can be insefied into the ca'lcaneus,talus, or both.

\X/hile the proximal anchor screws can beinserted through a medial or lateral incision our

Figure ,1. Lrtroduction of the bushing ancl guide tube lnto the outriggerassembly. Drilling of the proximal aspect of the tibia. countersinking anclinsefiion of the proxin-ral locking screns u.ill be perfonr-red tlrrough thegu'rlc tttbv and lrtrslring trnit.

Figure 6. Drilling fbr the insertion of the distal iocking scren's thror.rghthe lateral incision using the same guide tube and br.rshing Llnit show-nin figure 4. One or txio scres,-s can be inseted from lateral to medialtlrror.rgh the talus and calcaneus.

recorunendation is to do so through a medialincision overlying the medial cortex of the tibia. Thiseliminates the need for excessive dissection of thesoft tissues overlying the anterior lateral aspect ofthe leg which are encountered when using a

proximal lateral approach for the insefiion of theproximal anchor screws; the anterior tibial afiery1

nerwe and veins 1ie within this area. Depending onthe device employed, a minimum of lwo proximalanchor screws are inserted. The outrigger device willensllre the proper placement of the drill holes(Figure 4). following the insertion of the proximalscrews, compression with the Biomet@ nail is

achieved by tightening the compression nut(Figrrre 5).

The distal screws are inserted next. When

244 CHAPTER 42

possible, the authors insefi tw-o screws from a distallateral approach; one through the talus and the otherthrough the calcaneus. Again, the outriggerassembly will ensure proper placement of thesescrews (Figure 6). Typically, the distal screws are

placed into the talus and calcaneus. Unfofiunately,due to extensive bone destr-r.rction it may not bepossible to insert rwo screws distally from the lateralapproach. In these cases, the authors attempt toinsefi at least one distal screw.

Finally, a posterior to anterior screw is

inserled when additional stability is needed or we

Figure 7. Insertion of postelior locking scren' througl'r tht calcaneus.This scres, can be usecl to st:rbilize the midtarsal ioint u'tren clriven intcr

either the navicular or: rrore coumonly the ctLboicl.

Figure !A. Latelal radiogrzrph 5 months postoperativcly employing twoprorimal locking screns, tsro transverse clistal locking scres..s, ancl onep()sterior scre\\,, An excellent clinical and racliographic lusion n'zrs

achievecl.

are unable to successfully secr-rre the pin distallywith two transverse locking screws. This posteriorto anterior screw may also be used to stabilize themicltarsal joint with or without fusion (Figure 7).

The most stable construct seems to be achievedwhen two clistal screws are inserted laterally andone screw is inserted fiom a posterior approach.\(/e have been impressed with the stable constructthat can be createcl. In essence we have found thatrigid internal compression fixation is achieved.

The fusion sites are then examined andassessed. An implantable bone stimulator is insefied

Figure 8. \{orcelized alltclgenolrs corticocancellorLs chips created f1'om

the peltial resection of tl're clistal tlbular malleolus. The same techniquccan be donc s.ith an ertirpatecl talus rvhen performil-tg tibiocalcanealfr,rsion.

Figurc !B. A? radiograph of the same patient clemonstrat-

ing solid fusion of dre anklc portion of a tibiotalocalcane:rlarthroclesis. A11 four tr:rnsverce locking screns are readilyr isualizerl.

CHAPTER 42 245

in higher risk patients. Defects are filled withautogenous and/or allogeneic bone graft material(Figure 8). The wounds are irrigated aggressivelywith normal sterile saline. The periosteal, capsularand deep fascial tissues are reapproximated u.,ith

healy absorbable synthetic sutures. Thesubcutaneous tissues and skin are closed with a

suture material of choice. Staples are frequentlyused. A surgical drain is inseted if significant post-operative bleeding is anticipated.

POSTOPERATIVE MANAGEMENT

Patients are initially placecl in a Jones compressic.rn

bandage. The first major dressing change isperformed one-week postoperatively. At that tirne.patients are placed in zr short-leg Jones compressioncast that will be worn for a minimum period of B

weeks. Although many authors recommencl earlypafiial or fu1l weightbearing, we feel that weighrbearing can only be detrimental during the initial 4-6

weeks of the healing process.Serial radiographs are obtained at 4 to 5 week

interuals. \[hen radiographic consolidation is seenand correlates with the overall clinical picture, 1im-

ited weightbearing without ambulation is begun.This is generally begun around B-12 weeks post-operatively. Progressive increased weight bearingand full ambulation is permitted over the course ofthe next 4 to 5 weeks. By week 16, patients aregenerally ful1y ambulatory and the cast is removed.If necessary, they are placed in a removable castboot type of device.

It is impofiant to monitor these patients on a 3to 4 month basis for at least the first year (Figures

9A, 9B). During this time loosening of the screwswith or without migration of the screws may occlrrnecessitating the need for screw removal or replace-ment. Patients shor-rld also be monitored for thedevelopment of pathologic fractures of the tibia.

COMPLICATIONS

Although an effective method of stabilization, the useof IM nails for tibiocalcaneal and tibiotalocalcanealafihrodesis is not without its potential complications.Infection, both deep and superficial, can occul'.'r'll 1r 22

Treatment for superficial infection entails 1ocal

wound care and oral antibiotics. In the cases of deepinfection involving the medullary canal, the nail mayneed to be removecl and a below-the-knee

amputation might result.'''''r" At minimum, allinfected bone would need to be resected andintravenous antibiotics initiated. Nonunion, delayedunions, and pseudoafihroses may also occur.3re'23'21

The rate of nonunion for the IM nail athrodesis has

reached as high as 750/o in the literature.'3 In anarticle by Moore et al, the rate of pseudoafihrosisreached 250/o." It is important to note that in manycases the pseudoarthrosis is asymptomatic and is

therefore more of a radiographic finding and notnecessarily a clinical concern.

Complications directly related to the nail itselfinvolve heel pain, nail breakage, and tibial stress

risers. Heel pain may result from the prominence ofthe nail itself, or from pressure on the surroundingnerves, namely the lateral plantar ne1ve.18le25'26 Thiscan result in paresthesias or numbness along thenen'e distribution. Treatment for heel pain usuallyconsists of heel cushioning and neurolysis inrecalcitrant cases of nelve entrapment. Althor:gh nailbreakage has been mainly studied in femoral nails,recent studies have focused on the problem of tibialnail breakage.ll'16re These studies indicate that in themajority of cases, tibial nails were likely to break at

the site of the fracture or nonunion.'6'e In cases offailure, the broken tibiai nails were removed usingopen procedures unless the fracture/fusion wasalready healed, in which case the nail was left inplace. Infrequently, the interlocking screwsthemselves might break.'6" The authors haverecently had some isolated cases of "backing out" ofthe distal interlocking screws, treated with surgicalreinsefiion of the distal screws, with use of longerscrew-s in select circumstances.

Other studies have shown an increase in tibialcofiical hypertrophy postoperatively at sites of theproximai interlocking screws or the proximal extentof the nail itself. These findings are consistent withincreased stress risers al these locations.''3'" "Consistent with these findings is the development ofstress fractures at these sites, treated withimmobilization.22

Limb length discrepancy can be a potentialproblem in the tibiotalocalcaneal and tibiocalcanealafihrodesis patient secondary to cartilage resectionand possible talectomy. This is more of a concern inthe patient with a Charcot type deformity secondaryto the possibility of abnormal pressure forces on thejoints of both feet. In the Charcot patient, anyincreased or abnormal pressure distribution can resultin further breakdown of the rearfoot/ankle

246 CHAPTER 42

complexes. For this reason, bracing of both exlremi-ties postoperatively, with attempted corection of thelimb length discrepanry, is extremely important toequalize pressure gradients over both feet and ankles.

Although a remote possibility, a complicationthat deserves mention is fat embolism.5r'This occur-rence is more commonly noted with the femoralnaiiing. However, any procedure that involvesextensive medullary reaming can result in extrusionof fat into the surrounding circtrlation, as shown inanimal ancl clinical studies. Although potentialcomplications associated with the IM nail aredisastrous, the potential advantaees of the nai1,

namely a plantigrade foot type capable of weight-bearing, outweigh the potential complications.

SUMMARY

Tibiotalocalcaneal and tibiocalcaneal afihrode-sis is a major surgical procedure that is more oftenthan not a very challenging and fi-ustrating to thesurgeon dedicated to reconstructive surgery of thefoot and ankle. It is a salvage procedr-rre whose out-come is difficult to predict. IM nail fkation is onetechnique that is used in patients at higher risk forbone healing complications. Although most IM nailsprovide excellent stabiiity, the Biomet' nail offersnot only stability but compression as wel1. Thedistal posterior to anterior screw provides anadditional point of stability to the construct. Ourexperience to date has been a very positive one andwe strongly encourage its use in high-risk rearfoota.nd ankle arthrodesis cases.

REFERENCES

-Jfatson-Jones R, Adams JC, Bonnin JG, et al. Medullary Nailing offiactures after fifry- years. J BaneJaint Sarg Br L950:32$94-729.Pavlik A. A f'emoral intramedr:llary natl. J Bone Joint Surg Am795f :31):1059-75.Sage FP. The second decade of experience s,ith the Kuntschermedullary nail in the fent-t. Clin )rtbop Re/ Ru 1)68;60:77-85.Vesley DG. J0 years of erperience wiih intramedullary fixation forfractures of the femur. Clin Ortbo! Rel R* 1968;60:3-1.Aginsky J, Reis ND. The present state of medullary nailing of thefen-rur: biomechanical limitations ancl problems of bloocl supplyto the fractr-rre clue to reaming.Injury 7979;77:790-6.Inhofe PD. Bion-rechanical consicler:riions in intramedullary fixa-tion of 1os,'er-extremity fracture, )rtbop ReL 7992:945-52.Ratliff AHC. Compression arthrodesis of the ankle.,I BoneJoint SargBr L959:1L:524 34.Charnley J, Compression arthrodesis of the ankle and shoulder,,/BoneJoint Surg Br 19i7;33:780 97.Adan-rs JC. Arthrodesis of the ankle 1oint, experiences s.,ith thetransfibular approach. / BaneJoint Surg 1948;30,506-11.Brumback RJ. Reilly JP, Poka A, et al. Intramedullary nailing offemoral shaft fizrctures, part I: decision making errors with inter-locking flxation. J BoneJoint Surg Am 798870: 7147-52.Brumback RJ, lieiily JP, Poka A. et al. Intramedullary nailing offernoral shaft fractures. Part II: Fracture healing with static inter-Iocking firation. J BoxeJaint Surg AmlI 7988;70:1453-62.Ri.rsl-r LV. Dynamic intramedullary fracture-fkation of the femr-rr.reflection on the use of the rouncl rocl after J0 years. Cl)n Ortbop

Rel R* 7968:60:21-1 .

Kessler SB. Hal1feldt KK, Perren SM, et al. The effects of reamingancl intramedullary nailing on fr:rcture healing. Clix Orthap Rel Re:

7986:272:78-25.Sturmer Kr\4. Measurements of intramedullary pressure in an rnimal experiment and propositions to redllce the pressure inerca>e.Original research from Universitatsklinikum Abteilung furlinfallchirulgie: S7-S21.

Danckwardt Lilliestrom G, Lorenzi L, Olerud S. Intracortical circu-lation after intrameclullary reaming nith recluction of plessure inthe medullary cavity, a microangioglaphic study on the rabbittrbia. J BoneJoint Surg Am 1910521390-4.Franklin JL, \W'inquist RA, Benirschke SK, et al. Brokenintramednllary nat7s. J BoneJoint Surg Am 1988;70t1463-71.Fujimon .1, Yoshino S, Koiwa N,1, et al. Ankle arthroclesis inrheumatoid arthritis using an intramedullary nail with fins. Foot

Ankle lnt 1999:20:485-90.Kile TA, Donnelly RE, Gehrke JC, et al. Tibiocalcaneal afihrode-sis with an intramedullary device. Foat Arklelnt 7991;75:669-73.Moore TJ. Prince R, Pochatko D. et al. Retrogr:rcie intrat-redullarynailing for ankle arthrodesis. Foot Ankle Int 7995;16:433-6.Carlsson AS. Nlontgomery F, Beslakov J. Arthroclesis of the anklesecondary to replacement. Foot Ankle Int 1998;19:240-5.Pinzur MS, Kelikian A. Charcot ankle fusion with a retro€yadelocked intramedullary nail. Faat Ankle lnt 1991;78:699-701.Thordarson DB, Chang D. Stress fractures and tibial corticalhypertrophy after tibiocalcaneal afihroclesis u,ith anintranredullary nall. Foot Ankle lnt 799920:197-500.Berend ME, Glisson RR, Nunley JA. A biomechanical comparisonof intramedullary nail and crossed lag screw flxation for tibiocal-caneal artlrrodesis. Foot Ankle Int 7997\7&639-43.Russotti GM, Johnson 1(A., Cass Jr. Tibiocalcaneal arihrodesis for.uthdtis and deformity of the hind part of the foot. J BoneJoint Sarg

An 7988;70:7301-7.Pochatko DJ, Smith Jnf, Philips RA., et al. Anatomic stluctures atrisk: combined subtalar and ankle arthrodesis u'ith a retrogradeintramedullary rod. Foat Ankle Int 7995:76:542-7.Stephenson IiA, Kile TA, Graves SC. Estimating the insertion siteduring retrograde intramedullary tibiocalcaneal arthrodesis. Foor

Ankle lnt 7995:11: t-87-2.Wolinsky P, Teju,ani N, Richmond JH , et a1. Controversies inintramedullary nailing of femoral shaft frlct\tres.J BlneJaint Sarg Ant2001:83:7104-L4.

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