The Foot 16 (2006) 33–37

Management of complications of tibiotalocalcanealarthrodesis in patients with co-morbidity

D.K. Sharma∗, I. Yunas, James RamosFoot and Ankle Disorder Unit, Department of Orthopaedics, Birmingham Heartlands & Solihull Hospitals,

Birmingham, United Kingdom

Abstract

Tibiotalocalcaneal arthrodesis is a viable alternative to amputation in severely deformed hindfoot deformity. We report the results ofretrospective analysis of single centre, single surgeon operated consecutive 15 cases of tibiotalocalcaneal arthrodesis at our institution. Thediagnosis was rheumatoid arthritis in one case, traumatic arthritis in six, degenerative osteoarthritis in five and neuropathic ankle in threecases. Co-morbidity was seen in 13 cases of which six patients were suffering from diabetes. Bony union was observed in 87% of cases, 85%patients were satisfied at the end result achieved. The aim of this study was to determine improvement in pain, function and to determinepatients satisfaction achieved. Considering improvement in pain, function, AOFAS score and patient’s satisfaction achieved post-operatively,w of failure.©

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e feel this is good technique with satisfactory outcome. It provides good biomechanical stability thereby minimising the chances2005 Elsevier Ltd. All rights reserved.

eywords: Deformed; Hindfoot; Tibiotalocalcaneal arthrodesis; Surgical results

. Introduction

Disease involvement of both the ankle and subtalar jointsan lead to patients having symptoms of pain, deformitynd limited ambulatory capacity of the affected limb. Tibio-

alocalcaneal arthrodesis has become an accepted treatmentor these severely deformed arthritic hind feet. Reports havehown that patients with pain or deformity of the hind footespond well to arthrodesis of the affected tibiotalar and sub-alar joints[1–3]. Thus far the procedure has been advocatedor the treatment of talus problems; avascular necrosis, arthri-is and complex fracture dislocations, and also for failed totalnkle arthroplasty and neuropathic arthropathies affecting theind foot.

The main aim of this treatment is to obtain a painless,race-free, plantigrade foot. At the same time achieve a goodnion which maintains hind foot alignment. Tibiotalocal-aneal arthrodesis is a salvage operation performed as an endtage operation for multiple conditions of ankle and subtalar

∗

joint. It is only performed when both (ankle and subtajoints are involved.

We hereby report the results of 15 cases treated ainstitution by means of retrograde nail and the complicatwe had and how these were overcome.

2. Methodology

From 2000 to 2004 we treated 15 patients with this oation. All patients were treated by means of retrogradeinserted through the calcaneus. All had plaster for the fiweeks followed by full weight bearing in a Cam boot (Ttype of boot is a functional splint which holds the foot ineutral position while healing takes place after a surgerya further 6 weeks. The average age of this cohort wasyears which varies from 52 to 87 years. The mean followduration was 30.5 months and varied from 12 months tmonths. There were seven females and eight males incohort. One patient had a bilateral operation. The diagnwas rheumatoid arthritis in one case, traumatic arthritis i(Fig. 1), degenerative osteoarthritis in five and neuropa

Correspondence to: 169, Kineton Green Road, Solihull, West Midlands

92 7EQ, United Kingdom. Tel.: +44 7980 858038; fax: +44 121 7068783.E-mail address: dksharma@doctors.org.uk (D.K. Sharma).

foot (Fig. 2) in three cases. Co-morbidity was seen in 13 casesof which six patients were suffering from diabetes. Four of

958-2592/$ – see front matter © 2005 Elsevier Ltd. All rights reserved.

oi:10.1016/j.foot.2005.11.002

34 D.K. Sharma et al. / The Foot 16 (2006) 33–37

Fig. 1. Post-traumatic OA following open fracture.

these patients were on insulin and the rest on oral hypogly-caemic agents. Three patients had problem in maintainingtheir blood sugar level.

The majority were complaining of pain, decrease mobil-ity and deformity of ankle. All these patients were regularlyassessed in the clinic.

Operative technique: All cases were operated throughan anterolateral approach. Eleven patients required fibular

osteotomy to correct the deformity and all had open debri-ment of the joint.

The patients were assessed clinically for pain, improve-ment in walking ability post-operatively, any complicationsand alignment of the hind foot. Serial radiographs were takento assess progression of arthrodesis and fusion rates. TheAmerican Orthopaedics Foot and Ankle Score (AOFAS) wascalculated for each patient.

sult afte

Fig. 2. Re r 9 months.

D.K. Sharma et al. / The Foot 16 (2006) 33–37 35

Fig. 3. Severely deformed neuropathic joint.

3. Results

Eighty-five percent patients were satisfied at the end resultachieved. Bony union (Figs. 3–4) as demonstrated by radio-graphs was observed in 87% of cases observed in mean timeof 4.5 months which varied from 3 months to 7 months.The American Orthopaedics Foot and Ankle Score (AOFAS)improved from 34 pre-operatively to 63.

4. Complications

Infection by Staphylococcus aureus was seen in four caseswhich lead to removal of one nail and in another case involve-ment of plastic surgeon for skin grafting. This was a patientwith a neuropathic foot and superficial infection by mixedcoliform organisms lead to skin loss after nearly 2 months ofoperation and hence the requirement for a skin grafting. The

sult afte

Fig. 4. Re r 6 months.

36 D.K. Sharma et al. / The Foot 16 (2006) 33–37

other two settled down with a prolonged antibiotic course.Two cases had fibrous non-union leading to bone graftingand exchange nail with bigger diameter. One case had astress fracture of the tibia at the point of proximal insertionof screw leading to revision with longer nail bypassing thefracture site. One case developed sacral sore; one case hadremoval of distal protruding screw as it was too long. Healpain was seen in one case who also had a valgus position of thehindfoot.

5. Discussion

The aims of this operation are to achieve bony union,maintain hind foot correction and alignment whilst limitingcomplications. This extended arthrodesis is the only viablealternative to amputation in disorders involving both the ankleand subtalar joints.

Various methods of fixation have been documented in theliterature; tibiotalocalcaneal arthrodesis including pins[2]screws[3], bone grafting[4], anterior plating[5] externalfixators[2] and intramedullary nails[1,6].

The use of pins and screws alone could lead to loss of align-ment and resulting mal-union or non-union. External fixatorshave many disadvantages and are therefore no longer recom-mended. The disadvantages include pin site infection, poorp andd ryn tiona taina -i vedw osss era-t t tom n isn d5 relyd ol-l cal-c aruso hi rom7 eri il orr t. Ifd amiseb twoc . Tom bes n wee n duet nail.T r thet tibia[

Maintaining desired multiplane alignment during healingis critical to the success of tibiotalocalcaneal arthrodesis. Thecontraindications to this include single joint pathology, loss ofcalcaneal body mass, tibial deformity, vascular compromiseand active infection[14]. We would like to point out the highco-morbidity seen in our series. Eighty-seven percent of ourpatients had medical problems, 40% (n = 6) of which haddiabetes. This may have contributed to the high infection rateobserved in our study. Our finding are similar to Mendicinoet al. [15] who has demonstrated higher complication ratein diabetes cases compared to non diabetes group for thisoperation.

We feel medical problem should be adequately addressedbefore embarking on this operation. Patient should be opti-mised and diabetes is well controlled for some time to reducethe incidence of infection. We found exchange nail, a goodtechnique to achieve bony union in fibrous union.

6. Conclusions

Tibiotalar calcaneal arthrodesis is an end stage operationthat gives good symptomatic results. It is a last ditch operationfor a severely disabling ankle condition. Infection remains asource of concern. Adequate precaution should be taken totry to reduce its incidence.

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atient compliance, technically demanding procedureifficulty in achieving multiplane stability. Intramedullaailing has become the favourite because of rigid fixand increase fusion rate as well as its ability to mainlignment during bony fusion[1,6]. Biomechanical stud

es [7,8] have shown better strength of implant achieith the use of intramedullary nail in comparison to crcrew technique. The most important aspect of this opion is to achieve appropriate alignment of the hind fooaintain a plantigrade foot. The recommended positioeutral ankle flexion extension, 5◦ of hind foot valgus an–15◦ of external rotation. The reconstruction of a seveeformed arthritic hind foot is complex and it tends to c

apse into a shortened and malaligned position. If theaneus is not placed centrally under the tibia, then vr valgus deformities may result[9]. Previous studies wit

ntramedullary nail reported a union rate which varies f4 to 93%[1,10–12]. If this occurs it is managed by eith

ntramedullary reaming and exchanging for a larger naevision with plate and screws along with a bone grafelayed union is encountered, then it is necessary to dyny means of removing proximal screws as we did inases or by exchange nailing as we did in another twoinimise the chances of plantar pain the nail should

eated flush with the calcaneus. The other complicationcountered was a stress fracture; this could have bee

o a proximal stress riser as the result of a malalignedhis can be avoided by aligning the calcaneus unde

ibia and using a longer nail to bypass the isthmus of13].

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[13] Thordarson DB, Chang D. Stress fractures and tibial cortical hyper-trophy after tibiotalocalcaneal arthrodesis with an intramedullarynail. Foot Ankle Int 1999;20:497–500.

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