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Board Review Surgery

Tibio-Talo-Calcaneal (TTC) Arthrodesis with Intramedullary Fixation

Benjamin Overley, Jr, DPM

Benjamin Overley, DPM gives an in-depth look at the history and present day use of ankle arthrodesis. Dr Overley discusses the use of intramedullary fixation and proper patient selection for this procedure. He also reviews proper surgical techniques and provides pearls of wisdom for surgical success.

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Goals and Objectives
  1. Discuss the history of ankle arthrodesis
  2. List indications and preoperative considerations for Tibio-Talo-Calcaneal Arthrodesis with intramedullary fixation
  3. Describe proper surgical technique for intramedullary nail placement and surgical considerations that must addressed before placement
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  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Benjamin Overley, Jr, DPM

    Surgical Skills Committee
    Section Editor for Trauma-Journal of Foot and Ankle Surgery
    Foot and Ankle Specialist/PMSI Orthopedics
    Pottstown, PA

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  • Lecture Transcript
  • Male Speaker 1: Second installment of the trilogy I’m going to present to you today. We’re going to talk about tibiotalocalcaneal nails or tibiotalocalcaneal fusion. It goes with that saying, this is probably in terms of the size of equipment and the skill required to do these procedures it’s run not the same as total ankle replacement but the skill that sometimes required to do these types of procedures are can’t be under estimated. There is a learning curve with this as well. Not as deep as it is with anchor replacement but it’s definitely a procedure that you want to have a good understanding of because it is bailout procedure. It is something that at some point in your career, you’re going to have to do with somebody so it’s a good thing to know how to do it and you can see my disclosure. Some of them are remained to this topic, however, I will tell you that you will be seeing several different types of nails from several different types of companies and you will also get for me the sort of high points and low points of those devices as we go through. Taking a look at Albert Edward, if we go back in time and we think 1882, wow. Ulysses S. Grant was the president at that point. Ankle fusions go back that far, this is really when we started doing them and if you think about it that’s pretty amazing that with the materials that we had available and even external fixation goes back into the late 1800. The indications for doing an ankle fusion or doing a TTC or doing any kind of a really significant fusion was really predicated on the really severe patients. Remember patients were not living that one back then. Everybody checked out in their 40s and 50s was sort of consider to be elderly at that time. The majority of the populous was going away in their 40s or in their fifth decade of life. This procedure were really used for patients that was really nothing else to do for them paralytic feet, severely deformed feet, ankles, et cetera. I will not going to get crazy about this stuff but you should know ahead of time that I’m a son of history teacher, my affinity for history is clearly evident in my presentations because I absolutely love it and feel that if we don’t really take a look at what was done before, we really can’t move forward as surgical society. Really, what I want you to take a look at is Lorthioir, the first pantalar fusion, did not do the calcaneocuboid joint but this is really an exciting time here, the turn of the century, industrial revolution is sort of ending across the world and the World War I is beginning. We’re really beginning to get a lot of our medical advances as we go forward, these are battlefield advances. I mean, if you look at the DeBakey. DeBakey was an Army General Surgeon before he went on to work on the heart exclusively at Baylor. This is where we, again trying to corner medically and we’re getting out of really what we would consider to be the dark ages. But though this isn’t really a sexy thing to do, I mean using this ivory peg we see that and for those of you familiar with the right medical and in-bone implant or any of the other stem total ankle replacements, well it’s not a far lead to go from this to a lot of the implants that we have today and why? And it’s because they’re stable. They work then and to degree, they work pretty successfully then with very limited fixation and very limited knowledge in terms the way to put these things end but they still work. We’re still using them today, we’re always building on the same things medically and surgically. Taking a look at this, now we’re getting into the ‘40s and this is 1940s, Dr. Shoenhaus is going into college in his freshmen year and this is – sorry, I have more comment for you Harold but that’s not true. It was obviously not. This is where we are starting to think though about how do we do this intramedullary nails and how do we do them and where do they apply. Actually one of the great talks that I’ve had with Harold over the years and believe me, we’ve had lots of them and some of them even relatively sober, just kidding about that, but you can see here we really begin to take a look at getting these nails for this really, really complicated midshaft fractures or simplistic fractures.

    [05:04]

    Harold, one of his great statements that he ever made to me and he has made a lot over the years is he said, “You strip the extramedullary blood supply then you go in and you remount the medullary blood supply then you shove this nail in there and you go widen this thing heel.” And when you think about it without the Haroldism used and he cuts it down to the cord that’s really the basis when we got nonunions for this as we get crazy with our dissection and we stripped away everything and any possibility for healing goes out the window. Here you can see, we’re beginning taking a look at femoral nails and this gets extrapolated and all the way till today with the great devices that we have now – this is not. I’m not advancing anymore. Did I shut something off? There we go.

    Male Speaker 2: It is not green.

    Male Speaker 1: Is it supposed to be on the green? Okay. Here we go, great. Now we’re looking at ankle arthrodesis with an IM nail. Now we’re beginning to take a look at what we can do for these really severely deformed patients and really getting the foot back under the leg again. One of the great advantages of doing tibiotalocalcaneal nailing or IM nailing is that the stability of a construct. You’re basically forming a metal strut here. Now, I will make a statement on this, in terms of patients and in my patient population I really, really shy away from pantalar fusions and nonneuropathic patients. I don’t think that they tolerate them well. I think that they have a tremendous amount of difficulty and the legs simply becomes almost a prosthetic legs only it’s their leg. It’s almost ornamental on its nature. I really, really reserve these procedures for individuals with subtalar joint and ankle arthritis. Almost all the cases leave that talonavicular joint alone because I want that little bit of motion to occur. Otherwise, if I lock that up and I do a pantalar and the patient is not neuropathic they can feel things. Well, what if I really done for that individual and maybe they are better serve with an amputation and a prosthetic leg, and I can’t really argue against that, and that’s something that I picked up over the years after doing lots of these, is in patients that are none neuropath, they really, really do not tolerate them well and they don’t like them, they’re very uncomfortable if you have sensation and feeling. Indications, clearly, if the patient got RA, the things that we think about now are failed ankle replacements and what do we do with this ankle replacements and they’re big wax to begin with. Now, we take out all those metallic hardware and that polyethylene insert that you saw in my last talk. We’ve got this big gap and we’re going to throw some cadaveric bone or femoral head or patella that’s been decorticated and we’re going to try to get that in there and we’re try to get some fusion or some fusion mass to develop by running a nail up there and taking it up into the tibia. Clearly, there are limitations with these and that would be one of them. The other thing is Charcot arthropathy, these individuals who by their nature don’t play by the rules, how are they going to do with the nail? I would advocate or I would suggest to you and I don’t have it on this talk, so I’m going to just say this to you personally if you are encountering somebody with Charcot and you’re entertaining the notion of doing an intramedullary nail to fuse the subtalar and ankle joints, you really got to take that nail up high and then maybe pass your comfort zone, because if you did not take it proximal to the isthmus you leave that thing just shy or at the isthmus of the tibia that most narrowest part of the medullary canal, do not be shocked when it breaks, they don’t feel things, keep that in mind, they don’t feel it and they don’t play ball. Going back in time here to my days at Chestnut Hill [phonetic] when I started out in practice and I was starting a residency program, I had a patient that had Charcot and I admitted the patient, obviously draining wound everything, put a frame on and did all the stuff and sitting out and he knew where my office was, it’s on the court yard of the hospital, how could you not know, everybody pulls right in and my office was right there. He is sitting out there with a bag of candies, smoking cigarettes. Somehow, he’d gotten himself from the fifth floor onto an elevator by all the nursing staff, wheeled himself out of the elevator, this is like the Kennedy assassination thing, did a direct left turn then went into the gift shop, gave them money, they of course didn’t question all the metallic hardware, the draining wound and handed him a bag of candy.

    [10:02]

    He then somehow backed up because the gift shop is about that tight. How he pulled this off is beyond me. That man just wheeled himself by what? A dozen medical staff that know me and know that that's my patient and they say nothing and proceeds to park himself right outside my office window and light up a cigarette. This is why you always have a digital camera in your office. I had a whole slide show devoted to him. Unfortunately, he then went on to juvenile insulin-dependent diabetic, eventually passed away at a very young age. The point is with these Charcot individuals, these neuroarthropathic patients, they don't play ball just by the nature of who they are. Considering doing a nail for this or some a frame over nail construct, yes it is an option for you but be very, very careful with these patients because you can end up being a real issue. The things that I look and look what’s number one on my bullet points, neuropathy. Who you really considering doing this too, I talked to you earlier about the Workman’s Compensation patient and told me his next kin was the coroner. These patients, if you really want to go and go this level with, maybe this is an individual if their soft tissue envelope can afford it that you might be better serve with doing a traditional fusion or doing some sort of a TTC plating and not doing an intramedullary nail which can end up being a big issue. Of course vascular status, let's just quickly touch on that. I don't have a lot of slides in this talk, I'm going fill in the blanks with a lot of just my anecdotal things. Remember, these patients have had severe deformity whether be cavovarus, whether be an ankle valgus deformity and you're taking that foot and you're cranking it back onto the leg. What do you think happens to the blood vessels? What are the arterial circulation when you're cranking thing sand you're taking them from this paralytic look or this spastic look and you're straightening them out? What do you think takes place? I mean we know if we do external fixation on a limb segment, we roughly know about how much we can get before we get vascular spasm, right? We know this but what's the limit? What degrees and how much we can correct somebody? These are things that I like to think about before I take these things on and maybe you combine that with having a vascular surgeon see this patient. Do a CT angiography before you even do the case. Mapped out these vessels because if one goes in spasm and you don't have it documented that they had very good perfusion beforehand, you can point too and say, “Well listen I corrected you and this is what cause the spasm, it should resolved but you got two out of the three of your pipes going into your foot are still open and you will make it and things will get better, it just going to take time.” Well, that's an easy thing to say, if you have the preoperative documentation to support that. Again bone qualities, there's somebody that I want to go I mean you seen these nails. I mean they don’t go in gently, there's somebody that I want to be smashing into and I get questions all the time when I come off the stage and they say, well what happens if you put in a nail and you see a stress riser? It's easy just pull the nail out and put in a longer nail, that's what you do. It's not complicated, it's not comfortable especially if you got locked in the screws in but you need to pull out that nail, stick in your reamer, re-ream it, pass the fracture site. I mean, what are we doing with midshaft fractures? What do we do with the nail? You cross the fracture, that's all you have to do, it's not that complicated, but people don't want to take that step, “Just put him in the cast for three months.” Okay, but the better thing to do is just to take that nail out restart it then go and put your nail back in cross that fracture site then you can let them weight bear. You can dynamized these things and we'll talk about that in a little bit here. By mechanical considerations you can see there’s individual, we got recurvatum on one side and we’ve got a flexed knee on the other. Making sure that you understand and Dr. LaPorta has forgotten about more of the stuff than I'll ever know in my career with Cora [phonetic] and all these, the various different angles and the base of gait and it can be sometimes very difficult. What I try to do in my mind is match up one side to the other side. If I can match up my right and my left, relatively the same and I'm within the ball part and that goes rank replacements as well. If I got a patient that is cavovarus on the left and I put a neutral or slightly valgus anchor replacement on the right, the tendency to walk in a circle is very, very high, just seeing who is paying attention, you’re not going to walk in the circle. But the key thing there is I'm going to load my ankle replacement, add normally and that's when patients come back in and that's when they have pain and you want to know why they had pain. Well, they had pain because you didn't appreciate the other side. I think what happens in the scenarios is if they have the ability to adapt they will but if they don't, they won't. Taking a look at this, we were always been trying to get that tripod foot, we’re trying to get that foot back, posterior. Remember, we want to decrease that lever arm of the Achilles tendon because if we leave that really forward or we leave it with what I call an antegrade talus or prosthetic [phonetic] talus then the Achilles begins to pull, it wants to pull your construct the way so make sure that you get that thing back. This is an interesting thing and I've heard all kinds of things over the years about, how do you map this out? How do you make sure that you're putting in the right area, that you don't bag any neurovascular structure? There's really no rhyme or reason to it especially in these patients with a lot of deformity. Just making sure that you’re relatively close and checking these things, doing bland dissection down to the heel bone and making sure that once that's done, you can get the nail in and get in efficiently without doing to much damage, just like Miley Cyrus, don't be a wrecking ball. This is not a case or procedure where you want to go in and bag the entire plantar neurovascular structure. You see here what can happen if you think you're on and then you look at that, well that's clearly an air ball and it's not a good air ball, okay? Sometimes you're going have air balls that you can accept them, that's not one you can accept. People asked me all the time, I do press feet nails but it's all depending on the bone strength. If I have a 50-year-old guy, bone like cord with relatively healthy construction worker, big bulky, strong guy, I'm going based you a press foot nail and hand. If I have a woman with softer bone, I'm not going to do a press foot because my potential for creating a stress riser just went through the roof. If she's got soft osteopenic, osteoporotic bone and I go bashing a nail in there and I haven't rimmed appropriately to accommodate that nail. The chances are I'm going fracture it and we all know what happens if you do that, you just pull it out and you get a longer nail. Longer nails are more stable inherently, we get scared, I don't know why that is but you’ll see guys, they put these nails in and they stop them like here. Well that's really not a good nail, if you want stability, you're going take it right up to the isthmus in a none nerve path or above it in the nerve path, that's what you need to do. Making sure that you're always doing this final position checks with all of these, looking at all the different views. There's nothing wrong with taking a calca axial view in the operating room, I do it all the time from my cal slides. Make sure that everything is where it supposed to be. These can be very disorienting especially in patients with really thick soft tissue envelopes or lot of deformity. Make sure that these screws are where you want them to be. Here is the case here and I got about 10 minutes here and I’ll get done, we'll move on here. This is a very nice woman, she's actually living in a assisted facility, could not walk, you can take a look at the talus there, it obviously doesn’t look good, it's flattened, AVN is patient, obviously mentally challenged, living in assisted facility. This is someone I’m going to think about doing an ankle replacement on, absolutely not. But if you take a look at the subtalar joint, subtalar joint also looks terrible. One of the phenomenons that occurs with ankle replacement is when you do replacement often times the talus will actually spring and open up that subtalar joint and I do not do any adjacent work other than just the replacement, maybe some peripheral osteotomies but I very rarely fuse that under there. But in this case you can see, she's got a tremendous amount of arthritis and she's going to end up, if I would to do something of that, first of all she mentally was not prepared for that type of procedure. But secondly, with that subtalar joint it would be something that I would have to fuse, in that case it probably was too arthritic that it was not going to spring. Taking a look at here, you can see the large valgus ankle, this is a typical presentation. These patients have a lot arthrofibrosis, they've got a lot of heterotopic, ectopic bone and you can see how the foot is plantar flex, this is how she stands. This is not just her on the operating room table lying there in plantar flexion, this is her. This is a case where I've now got dorsiflex to a degree and people say, where do you try to hit in terms of numbers of ankle fusions? I just try to get neutral. I just try to get neutral grade, guys will say five degrees valgus, maybe a little bit of dorsiflexion or little bit plantar of flexion.

    [20:00]

    To me, I just try to hit it right that midline, just right down the middle. If I can do that, I feel like that’s a pretty good way to do it and you can see here, but this is where you get disoriented with nails, is all the soft tissue, these bumps and especially in a Charcot patient and the ankles are really thick and you’re like this is where the tibias that only – when you look at this laterally, this is the tibia right here, here and up. The tibia does not exist back here. I see guys do this and they’re back here and they’re out there but it’s really just right here. If you can get that released and in this case, this definitely going to be a case where I’ve got to do an osteotomy because I’ve already told you, she’s fixing plantar flexion. I can’t just want a nail up there and slam it home. Before I do that, I’m going to augment this with some bone marrow aspirate because I want the best chance for this fusion healing. You can see, all this is done before the tourniquet even goes up because I want to get the best amount. You can take it out of the heel, you can take it out at proximal tibia, distal tibia but you get this good bone marrow aspirate, now just quickly and again, I don’t mean to cut in anybody else’s talk but we know that typically, if you don’t spin this down, you don’t concentrate this to have effective bone marrow aspirate, you need roughly about somewhere between 14 to 1600 colony forming units or CFUs. If you don’t spin it and you just scored it on graft and it hasn’t been reduced and concentrated you’re getting about 600. Basically, this entire thing that you just did was for nothing. You might as well just scored and laminate on their ankle because it really would’ve been just as effective and probably more tasty. Understand that if you’re going to do bone marrow aspirate either the tibia or the calcaneus you must spin it down. You have to concentrate it otherwise, it does nothing for you. Now this could be combined with platelet-rich plasma and then with some of fiber substrate if you need to. But understand that it’s just not enough just to do that. You can see here what I’m using is I’m using – you can use any form of this joint spreaders, you can see the ankle joint or subtalar joint. Look how narrow that talus is. It’s very, very narrow. There’s not a lot of talus there to work with but what I’m trying to do is I’m trying to get that foot more 90 now. She’s open here so I know when the ground hits her foot, she’s going to basically come back to neutral. If I put her in neutral, once she hits the ground her foot is going to be actually be up there and dorsiflexed. There is going to be some motion pickup here and that’s what I’m looking for. You can see here and if you’re familiar with this now, great. If you’re not, it doesn’t matter. Like I said, there’s going to be several different nails in this presentation, at least a couple of different ones. You see my overworked resident falling asleep, right there she is. She’s obviously concentrating on the case so much, she had to close her eyes and lean on the bed. You can see here once this has been accomplished, now we’re getting a nail, we’re doing the final bone grafting. We got everything. I feel like I got everything in pretty good shape. In addition of little R2D2 unit in here to try to encourage the bone formation but what I found out was that screw was a complete air ball, so I had to get back in and take that out. Some of these you have to be and this which goes back to that final check thing that I talked about earlier. You got to make sure that you are where you’re supposed to be. We talked about that subtalar joint, how arthritic it was and look at it, it’s open. This was at five months and unfortunately, I did not get the new ones loaded on. She eventually went on diffuse. Now the whole theory with dynamizing nails and getting these patients to walk on and is the patient walks on the nail and the nail basically compresses your fusion site. As long you are secured down here, it will compress it. You must put your screws and dynamized it whole, which are oblong; they're not circular. If you put it on the wrong end of the hole, you didn’t dynamized anything. You basically made it static nail. That’s the two variations, static or dynamization or you can start out with static and if they don’t heal you can take them back to the OR which patients love by the way, but you can do this and take that screw out and convert it to the dynamized type of the nail that allows for that two to four or five millimeters of compression will occur with ground reaction force. You can see this gentleman work for Orkin [phonetic]. Enormous man, just really just overall big guy, a lot of upper body girth but he was a, what I call, 400, 100. If you look at him below the knees, he looked like he weighed 100 pounds and above the knees, he looked like he weighed 400.

    [25:04]

    This is an individual, obviously not going to get an anchor replacement. Somebody is going to get a nail and he actually had an attempted ankle fusion at another facility which went on to nonunion. You can see here the adaptive changes that occur over time at the TMJ and also at the subtalar joint, the spurring that occurs and this is very nice nail. Again, you notice a recurring theme here where I’m putting these internal stimulators in to augment my fusions, I do not think there’s anything wrong with that. If I’m already in there anyway, why not. I never want someone to say to me "Well, you were in there, why didn’t you put that in there? I think it’s easier just to get them in from the beginning. Here’s an interesting case. This woman is 46 years old. No distal fibula, cavovarus foot, half the fibula is whacked and was fixed at a very prestigious orthopedic institute in the Philadelphia region that I will not name but rhymes with Mothman. And for those of you who know that, she was fused actually in 35 degrees of cavovarus. She was already cavovarus and now the varus is 35 degrees at her ankle. She was essentially walking on what have been her fibula if it was there. This is a complicated case so what you can see is my three-pronged attack here. I’m nailing the subtalar joint with a rongeur. I’m only doing a posterior facet arthrodesis because I’m worried about this talar bone. Now, there has been some recent studies from Australia that say that you’re really not going to violate if you get in there and really do a full debridement that the talus isn’t going to die. I have two of them do it to me over the years so I’m very conscientious about not doing that. Posterior facet, you can see my osteotome. I’m creating a medial window and you can see what she looks like there on that as you’re looking at it on your right side and what I have to work with. You may ask and I would like you to think about that, what is that screw that I have right there. That’s what called the blocking screw. Because this woman was in so much varus that when I tried to put the nail in or even the guide pin to try to get it in, the guide pin kept deflecting. What you doing in a case like that? It’s very simple. In her case, her pin as I was putting it in was deflecting posteriorly. It kept guiding the posterior cortex, inner cortex of the tibia. I simply just grab a like metal screw to the nail so that’s a titanium screw with a titanium nail and I simply made a poke incision and drove it behind. Why would you do that? Well, I wanted to redirect my nail because as I was putting it in, I realized it was migraine posteriorly, I pulled it out and I nearly put the screw in. it’s a free screw, it’s not connected to anything which you'll see here in a second. What I achieved by doing that along with the osteotomy is I’m actually supporting the nail and I’m holding it but I also am redirecting it. In orthopedic trauma, if we got a midshaft fracture of a tibia and it’s like this and you’re trying to get it in and you’re trying to cross that fracture site, but when you’re doing it you’re deflecting, you throw an additional screw and to redirect it the way you wanted to go and then you leave it in. It does not get remove. You can see here have the screws free of the nail. Now if we look at this view here, you can really see it and you can see it there on that mortise view, you can see additional graft, you can see the FDWO down here and I had to do all these things to reconstruct her. Again, did not touch the talonavicular joint but you see I’m blocking the screw, did you see how snugly it is with that nail, that’s because it actually deflected or redirected the nail for me. That’s it on intramedullary nail. I have one minute left so I’m going to make one more comment on nails and external fixation. How many docs in the room do external fixation in Charcot patients? Because I know Marie was talking about it earlier. If you’re going to do an external fixator and loose here and it’s a trauma patient and you’re using a ring fixator, understand that if you go back and you use an intramedullary nail, the potential for infection in that nail is very high and then you end up with the medullary osteo. The reason is, is you have a tremendous amount of pin tracks that all over that bone and you’re assuming or you’re operating under the assumption that everyone of those pin tracts is clean and that’s really not a good assumption to make. If you’re going to do a frame over nail, it should be done simultaneously, going back in nailing after frame whether it would be a trauma frame, a Charcot recon frame, you’re really, really testing your luck with that. Thanks on the nails. Thank you for your attention and I don’t think we’re…