Complete the 4 steps to earn your CE/CME credit:
CPME (Credits: 0.5)
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 0.5 continuing education contact hours.
Release Date: 03/16/2018 Expiration Date: 12/31/2018
Michael Troiano, DPM
Center for Foot and Ankle Disorders
University of Pennsylvania - Penn Wound Care
Adjunct Clinical Professor, TUSPM
To view Lectures online, the following specs are required:
It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.---
Michael Troiano Dr. Michael Troiano has disclosed that he has a financial relationship with HealthPoint
Male Speaker: This is probably a little bit more gory than last one probably a little bit more interesting. Intrameduallary Rod for foot and ankle fusions. Hate doing intramedullary rod and now I don’t like the idea at all. It’s pretty bad procedure when you think about it. Again if we talk about endosteal blood flow of two-thirds to three quarters of the blood flow’s endosteally, we take a rod and we kind of devitalize all of the blood flow. What we’re doing is you’re basically creating a dead bone. There are indications for intramedullary rod fixation. I think there are few and far between, it’s not my primary choice for an ankle fusion. It is more of a revision or salvage procedures as far as I’m concern. The indications that I feel are revision of the failed ankle arthrodesis, tailored deficiency conditions requiring a tibial calcaneal arthrodesis, so we were going to take the talus out. Post traumatic or primary arthrosis involving both the ankle and a subtalar joints, rheumatoid hind foot deformity with severe deformity whereby we have to make a large concession in angle of the tibia or talus, avascular necrosis of the talus, failed total ankle arthroplasty from aseptic conditions. So provided we don’t have osteomyelitis or what have you, it’s appropriate to run a nail over a failed ankle arthroplasty and total ankle implant. And of course neuro arthropic ankle deformities like Charcot. So we’re going to go through the use of what’s called the T2 nail. You’re going to position the patient supine with their foot over the table. You have two choices. You can make antero ankle joint incision or a subtalar incision and or a subtalar joint incision. Some people go laterally. I’d go for anteriorly. The reason is this it’s much easier to visualize the ankle. You can medialize the talus as necessary which makes the incision a lot easier. The down side to the anterior ankle joint incision is associated with very, very poor healing. It rises in between two angiosomes, so guarantee this incision is going to have difficulty of some sort. You’re pulling, you’re bending, you’re stretching. There’s going to be some compromised blood supply. So this is the point where for this incision, I’m going to use an incisional vac or negative pressure over the incision. Your incision should be as such that tibialis anterior and EHL or retracted medially nerve vascular bundle should be reflected to the side of this tension. You should be conscious of the DP nerve and AT artery. Subtalar joint incision is a lazy-S incision being of course cautious of the sural nerve. The EBB should be resected anteriorly. So at this point, we’re going to obliquely resected distal fibula if you choose to do so – I usually don’t because I feel like if this is a nail fails, I kind of run of oxygen if that fibula is gone. Because if the fibula is gone, that person is going to ride into a valgus position, you need to do the cartilage from the STJ and ankle joint, taking 5 millimeters from both the medial talus and medial tibial plafond. Once you do that then a second picture you can see on the right, you’re going to medialize the talus. So you almost make like a notch and key of the talus with the tibia together. Technique should be 5 degrees of hind foot valgus and external rotation, neutral in the sagittal plane with a nail typical ankle fusion. You can put a little bit of plantar flexion for a female, so she could get into a little higher heel. You can put a little dorsiflexion for increase motion very difficult to do that with a nail. Some of the nails have bend to them now which make it possible. But it’s hard to predict so usually you go with zero in the sagittal plane. You got to secure the ankle with a subtalar position with threaded Steinmann pins to hold everything into position while you run the nail. You make a plantar incision obviously this is very close to the lateral plantar artery and nerves, so you got to be cognizant with that. And then insert your guide pin and begin the reaming process. This is the striker T2 nail has a bend in it laterally such that you can use – such that there is a right side or a left side. The right side bends with bend on the medial side so the distal part there’s laterally and vice versa on the left. Definition of entry point. If you want to make sure on K-wires examination that the K-wires position on medial side of the ankle aligned with the tibial access in the frontal plane. And you want to take a Harris heel view or Salzman view whereby the K-wires positioned on the plantar plane in line with the posterior tuberosity calcaneus in the lateral thirdly anterior calcaneus. So you really want to be most importantly lateral third of the anterior calcaneus. To posteriorly, you’re going to miss the ankle at the tibia to anteriorly you’re going to fracture the anterior portion of the calcaneus.
You now going to open the patient once you visualize them and begin your reaming process. You want that reaming to be dead center on the tibia. There is a flexible reamer. What the flexible reamer does, it kind of ensures that you’re going to be in cortical bone and not necessarily fracture off of the tibia although fracture does happen. There is a compression screwing this nail such that once you get screws into the talus and into the calcaneus, you can use the compression screw to compress on the inside of the nail or internally. You don’t necessarily need an external fixator. The nail can compress the subtalar joint and the ankle joint nicely. Definition of insertion. The nail should be recessed into the calcaneus by about 5 millimeters. No more than 5 millimeters, 2 to 5. Step one, is insert the talus screw. Step two, is the proximal screws from the medial side into the tibia. Step three, is tibial talar internal compression. So once you insert the talar screw you can now compress the talus to the tibia then you’re going to go to the tibial calcaneal screw and then finally compress the tibial calcaneal screw or the calcaneus screw to the talus. So ankle gets compressed first then subtalar joint. This shows insertion of the talar screw from lateral to medial. Proximal screws, medial to lateral into the tibia, compressed with the internal screw here that you see on the left. Once you have tie compression you verify that under CRM now you’re going to go ahead and throw your calcaneal screw. Once the calcaneal screw has been inserted, you’re going to compress that and insert the end cap. So technically it’s pretty easy procedure to perform provided you have a good CRM and a little bit patience. It’s one of a bit more easy nails. Contraindication intact asymptomatic. Subtalar joint this will destroy the subtalar joints, so you don’t necessarily want to insert it if you have asymptomatic subtalar joint. If you have greater than 10 degrees of veris or valgus or sagittal coronal plane, you don’t want to use a nail. At that point, you would do your super malleolar osteotomy or what have you and correct the deformity and then run the nail up. You obviously don’t want to do this active soft tissue infection, osteomyelitis of the lower limb or significant peripheral vascular disease. So this is a 63-year-old African-American female with alcohol induced Charcot arthropathy. She been cleaned for about 10 years not smoking or drinking just significant deformity causing ulcerations. She’s a very flail foot, very neuropathic foot. Here’s a preoperative radiograph with complete disruption of the talus. The joint is prepared. The talus is removed. In this case, we’re going to do a tibial calcaneal fusion with no graft, no femoral head graft. Proper alignment of the calcaneus and tibial performed. We’re going to secure position with Steinmann pins and we’re going to start the reaming process. We reamed of the tibia. This is a bone stimulator insertion at this point and here we are with the nail in place. This is a different jig, this is the DePuy Versanail jig applied same premise though. Talar pin, proximal tibial pins and then at the distal calcaneal pin. So you could see the patient with fibular cut down finally heals after about four months. There’s our final position. And there she is 12 weeks post-op. So she now has an arthrosis continues to [Indiscernible] [09:00]. This is a uncontrolled diabetic 63-year-old with progressive Charcot deformity. Pre-operative x-rays. This is 3/2/12. You can see this is a woman that I treated and identified her Charcot here. She had kind of a red hot swollen ankle. I ordered a CRP and ESR, it was about 25. You could see that she was going into Charcot at this point. I tried to convince her to let me stabilize or put a frame on her. She refused so at this point we order a bone stimulator and we just kind of put her into a neuropathic walker. So from 3/2/12 to 7/10/12, you begin to see the talus bulldozing into the tibia. Here we are by 7/16/13 about a year later. She still refused treatment and now the talus has continued to bulldoze. Now at this point, you can see our medial malleolus starting to run under strain. So at this point, I said, “Listen, it’s either you’re going to have a below-knee amputation or we’re going to try an IM rod to stabilize this.”
You can see that her whole tibia is starting to get this kind of candle wax appearance it’s because it’s responding to the forces of the Charcot of the talus bulldozing into the tibia. Here she is 2/18/14 she finally agreed to surgical intervention. You can see the middle malleolus is destroyed and basically she’s about to go into a significant valgus position unless this is fixed. Subtalar joint was prepared using that lazy-S incision, anterior ankle joint incision is made, joint is resected. Resected a large amount of talus, a large amount of tibia. We’re going to medialize the talus onto the tibia here. Good position with Steinmann pins. We start our reaming. Final position is checked under CRM and there she is with a CRM. So we’ve been able to resect a lot of the resorbed bone from the Charcot. Now, as I was about to leave and tort for ankle a little bit too much and caused a tibial fracture which does happen. So you can see that the tibial fracture at the most proximal part of the nail, so at that point [Indiscernible] [11:26] or external fixation system and she went onto heal unremarkably but by the grace of God. Here’s her post-operative x-rays with her nail in place her tibia’s totally healed on 5/6/14. Fully healed ankle fusion, fully healed cut down. And there she is at 14 weeks. This is a woman who came to me for limb salvage. On the other side if you were in the Oasis talk yesterday, you saw a lady with horrible neuropathic ulcerations and Charcot on the right side. So she was healed for about two years and then started to develop Charcot on the left. So she’s a bilateral Charcot patient. Her foot is basically on a 9 degree angle here. She’s beginning to walk on her fibula malleolus. He refused treatment for a while. She kind of didn’t want to accept this was happening to her. These are her x-rays. There’s complete obliteration of the talus. Send to a significant varus position. Interestingly her equinus is unhurt of so I just did a full Achilles resection and put a frame on. This is a frame with struts onto it so I was able to gradually kind of push her into a rectus position. So from pre-op here to post-op and a stage procedure here. Now we have her with the frame, you can’t really appreciate it from this x-ray, so we got a CT that her talus is absolutely absent at this point. So at this point, she’s ready to undergo surgical intervention. The nail did the nail with the technique that you’re seeing and then remember in this view here, she is virtually no talar navicular articulation. So there’s not much I can do besides float the mid foot therefore I used another external fixator after I run the nail upper to control her forefoot from flapping around the whole foot gets to fibrous style. So there she is with an incisional vac, a new external fixator applied. This again is to offload the heel. It’s to maintain rotational stability of the forefoot and the IM nail is in. So there she is with her final product, frame into place. You can see I use the femoral head to incorporate. This is again the striker T2 nail in position with complete compression at the ankle joint and the subtalar joint across the femoral head. There is a lateral view. Her leg has been restored and she’s in good position with a plantar [aid] [14:10] foot. So again she gets lucky. This is kind of a meet case. I include this only because it is a form of intramedullary nailing but not necessarily with a nail but with the patient’s own fibular graft. This patient fell for my scaffold. It was a small scaffold height about six to eight feet and that’s what happened, Pilon fracture. So he went to another surgeon. Surgeon repaired the Pilon fracture. He actually did a great job. He put a delta frame on to get the Pilon fracture of the length, plated the fibula and unfortunately in 2011, patient was left with a nonunion. He took the patient back repaired again. Put a posterior plate over the Pilon fracture, at this time to realign the fracture fragments.
It is ton of work the biologics, bone marrow aspirate, inserted a internal bone stimulator and still nonunion with draining orthobiologic at this point. So what a CT scan, you can see there’s complete obliteration. All the screws are not – there are air bolts everywhere and this patient’s in significant pain. So likely scenario here’s a below-the-knee amputation. I talked to him about a procedure called the free-fibular autograph or vascularized fibular autograph whereby the fibula is taken from the converse side, from the right side and him at this point you take the fibula out. You leave it attached to the ankle. The reason why you leave it attach at the ankle is because of maintaining the mortise on the right side. So the patient doesn’t know any different, but if you think about fibula it’s really our responsible for 9 to 15% of weight bearing so they’re not going to lose a ton provided that fibula is there. They’re not going to varus or valgus, so it’s kind of worth the shot of not having a below-the-knee amputation. I talked to him about the procedure. He was okay with it. Made a posterior incision. Took out all the hardware that was inserted here and that’s what’s left. You can see it’s just scalloped bone, fragmented, minimal healing, tons of orthobiologics still in there. At this point, the fibula is mapped out on the contralateral side and the fibula is dissected out with vascular supply intact. There’s the fibula with army navy surrounding it. Fibula cut down is prepared with a saw and the fibula is harvested. Fibula is harvested again it has two blood supplies to it proximally and distally. So we’re going to sew this into the posterior tibial artery and keep this alive or anterior tibial artery as quickly as we can. Once the fibula is taken out on the contralateral side, we go back to our Pilon fracture side. We removed all the hardware at this point and we cut out the bone all the dead bone from where the suction tip is is the ankle joint. We’re cutting out that all the way up the leg and we measure the defect. So now the plastic surgeon who resected the graft or pulled the graft for me, we’re going to cut this graft down to size and there’s our defect. Pretty substantial defect. It’s about 6 to 7 centimeters. But I have 11 centimeters of graft opened at this point. So at this point, what we’re going to do is we’re going to basically use one of these reamers that we use for IM now. And we’re going to reaming out the tibia, that’s left. We’re going to make a ducting point for that tibia. Once we make our ducting point for our fibula into the tibia, then we’re going to put a screw and to stop proximal migration of that fibula graft into the tibia. Then we’re going to make a ducting point into the talus with the same reamer so that we duct the talus proximally and distally. Proximally the screws stops migration of the fibula into the tibia distally, we’re going to use compression from external fixation device to hold the fibula into the tibia and talus. So there’s our fibula, it’s kind of a cloudy picture but there’s our fibula being duct in to the tibia. You can see in the center portion of the picture, our fibula is in position. The idea here is because we have a blood supply as this fibula begins mature and the patient walks and cyclical compression occurs. What’s going to happen is the fibula is going to grow larger and larger and larger until it becomes just as large as a normal tibia would. Frame is applied after the bones are duct together. I’m concerning position here. At this point, we’re going to tighten up the struts. And plastics, we’re going to close over our graft. So this is our final result here. 90 degrees, we’ve vac the remaining open area of ulceration. And there’s our final x-rays. Okay, so you can see the tibia is duct by the fibula proximally with the screw into place, the external fixer is causing compression from the calcaneus and the talus into the fibular graft holding together. There is the AP. Interestingly what stopped compression is our fibula. Fibula is a bit long so I sacrificed the fibula and just cut it. The hope would be to go back if necessary if this doesn’t work and then table top our fibula with the resected portion of fibula to fuse that as well. So he almost has two tibia. You can see what I’m talking about here. In other words, I would take probably about an inch of fibula away and duct that end-to-end with a compression plate.
So here we are in the lateral, AP and now obviously after three to four months of this person beginning to walk. We’re going to take the frame off and you can see our fibula has grown from there to now there. It’s becoming sporadic. It’s becoming widened. It’s adapting to the forces that I’ve put upon it. You can see our fibula is alive. It has an intact blood supply to it. It’s growing and growing and continues to grow with full weight bearing now capable by this person. So another form of intramedullary rodding as well. So I appreciated we’re little early because we ended early on the last one. Any questions? All right. Thank you so much. I appreciate it.