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Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary Nail


Indications

  • Posttraumatic/degenerative/primary/secondary arthritis of tibiotalar and subtalar joints

  • Rheumatoid arthritis of tibiotalar and subtalar joints

  • Significant osteonecrosis of the talus

  • Diabetic patients with unstable Charcot neuroarthropathy or peripheral neuropathy

  • Failed ankle arthrodesis

  • Failed total ankle replacement

  • Skeletal defects after tumor resection or trauma

  • Severe malalignment or deformities associated with neuromuscular disease or clubfoot

Indications Pitfalls

  • Contraindications for this procedure

    • Acute or chronic infections with/without osteitis/osteomyelitis

    • Severely compromised critical and poor skin and soft tissue conditions

    • Severe malalignment of the tibia (mostly as a result of previous trauma) with blocked and/or deformed medullary canal of the tibia

    • Severe vascular disease

    • Reflex sympathetic dystrophy of leg

Indications Controversies

  • Presence of a normal subtalar joint is a relative contraindication for this procedure.

  • In diabetic patients with Charcot arthropathy of the tibiotalar joint, the subtalar joint can be sacrificed to provide good initial stability using tibiotalocalcaneal arthrodesis.

Examination/Imaging

  • Clinical examination, particularly to exclude all contraindications

  • Careful evaluation of medical history, particularly with regard to previous injuries and surgeries, all comorbidities (including metabolic and vascular problems), as well as acute and chronic infection

  • Detailed assessment of pain, limitations in daily activities, sports/recreation activities, as well as current and previous treatments

  • Careful inspection of periarticular soft tissue conditions including possible wounds and scars

  • Determination of the neurovascular status of the affected leg and, if necessary, consultation with neurology and/or internal medicine

  • Routine physical examination starting with careful inspection of the foot and ankle while walking and standing; all obvious deformities are documented

  • Manual assessment of hindfoot stability with the patient sitting

  • Assessment of hindfoot alignment with the patient standing

  • Clinical measurement of tibiotalar and subtalar joint range of motion using a goniometer

  • Conventional weight-bearing radiographs for assessment of malalignment, deformity, osteoarthritic changes, and instability

  • Weight-bearing anteroposterior and lateral views of the foot and anteroposterior (mortise) view of the ankle ( Fig. 56.1 A 60-year-old male patient with end-stage posttraumatic ligamentous tibiotalar and subtalar osteoarthritis: weight-bearing mortise view of the ankle, weight-bearing anteroposterior and lateral views of the foot)

    FIG. 56.1

  • Weight-bearing hindfoot alignment view for assessment of the hindfoot axis in relation to the tibial axis, including inframalleolar deformities ( Fig. 56.2 Weight-bearing hindfoot alignment view; the same patient from Fig. 56.1 )

    FIG. 56.2

  • Computed tomography scan for exact assessment of degenerative changes; a weight-bearing computed tomography scan can additionally help assess the hindfoot alignment and concomitant deformities ( Fig. 56.3 Weight-bearing computed tomography of the hindfoot: axial, coronal, and sagittal planes; the same patient from Fig. 56.1 )

    FIG. 56.3

  • Single-photon emission computed tomography for assessment of the extent of degenerative changes in foot and hindfoot joints, and proper evaluation of their biologic activity

  • Magnetic resonance imaging for assessment of bone vitality and status of periarticular soft tissues

Treatment Options

  • Conservative treatment including medication, shoe modification, and/or orthoses.

  • Hindfoot arthrodesis using alternative fixation methods: ankle arthrodesis using two ventral plates fixation, tibiotalocalcaneal arthrodesis using blade-plate fixation.

Surgical Anatomy

  • Plantar approach to the calcaneus ( Fig. 56.4 Plantar anatomy of the calcaneus including fat pad, plantar fascia, and neurovascular structures)

    FIG. 56.4

  • Calcaneal fat pad

  • Plantar fascia

  • Neurovascular structures (run medial to the insertion area; Fig. 56.5 Plantar approach to the calcaneus. (A) Plantar calcaneal fat pad was removed, (B) plantar soft tissues were removed)

    FIG. 56.5

  • Fig. 56.5 shows insertion area of the nail (crosshairs) with plantar calcaneal fat pad removed ( Fig. 56.5A ) and with plantar soft tissue removed ( Fig. 56.5B )

  • Anterior approach to the ankle ( Fig. 56.6 : Anterior approach to the ankle)

    FIG. 56.6

  • Superficial peroneal nerve

  • Extensor retinaculum

  • Anterior tibial tendon, extensor hallucis longus tendon, extensor digitorum longus tendon

  • Anterior neurovascular bundle includes anterior tibial artery and the deep peroneal nerve. It can be found mostly between the extensor hallucis longus and extensor digitorum longus tendons

  • Lateral approach to the subtalar joint ( Fig. 56.7 )

    FIG. 56.7

  • Peroneal tendons

  • Sinus tarsi

  • Sural nerve

  • Lateral transfibular approach to the tibiotalar and subtalar joints

  • Peroneal tendons

  • Fibula

  • Anterior talofibular ligament, posterior talofibular ligament, calcaneofibular ligament

Positioning

  • Supine position with the feet on the edge of the table

  • The ipsilateral back of the patient is lifted until a strictly upward position of the whole lower extremity is obtained

  • Pneumatic tourniquet on the ipsilateral thigh

  • Mini C-arm (at the same side) or regular C-arm (from the opposite side) is placed

  • Free draping of the whole limb

Positioning Pearls

  • Positioning of the heel at the edge of the operating table will facilitate surgery.

  • We recommend using a regular C-arm for easy and more reliable fluoroscopic control during the surgery.

  • An adjustable lower leg holder helps to facilitate the plantar approach to the calcaneus.

Positioning Pitfalls

  • In the supine position the leg is usually externally rotated. If the strictly upward position of the lower extremity is not obtained as described above, the lateral approach to the ankle and/or sinus tarsi is hindered.

Positioning Equipment

  • Radiolucent surgery table

  • Sand bag or unsterile towels to lift the ipsilateral back

  • Adjustable lower leg holder

Positioning Controversies

  • Some intramedullary nail suppliers recommend the prone position with a lateral transfibular approach for this procedure.

  • If the posterior approach is chosen for this procedure, the patient is positioned prone.

Portals/Exposures

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