Foot and Ankle Surgery 20 (2014) 268–271

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Complications of tibio-talar-calcaneal fusion using intramedullary nails P. Fenton FRCS (Tr&Orth)*, N. Bali MRCS, R. Matheshwari FRCS (Tr&Orth), B. Youssef FRCS (Tr&Orth), K. Meda FRCS (Tr&Orth) Foot And Ankle Unit, Royal Orthopaedic Hospital, Birmingham, UK

A R T I C L E I N F O

A B S T R A C T

Article history: Received 13 January 2014 Received in revised form 20 May 2014 Accepted 9 July 2014

Background: Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications following the use of hindfoot nails at our institution. Methods: We identified patients from a retrospective database. All underwent hindfoot nailing under the care of the senior author. Details of complications were recorded. Results: We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18–69). Forty patients achieved ankle fusion and 36 subtalar joint fusion. Complications included prominent metalwork in 13 patients, CRPS in five and one peri-prosthetic fracture. Nine developed deep infection, and of these limb salvage was achieved in six patients by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. The remaining three patients underwent below knee amputation. Conclusion: Significant complications can occur, although limb preservation was possible in most cases of deep infection. Hindfoot nailing should be reserved as salvage procedure. ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Keywords: Hindfoot nail Complications

1. Introduction Fusions in the hindfoot can be achieved by a number of means utilising either internal or external fixation [1,2]. Often multiple joints in the hindfoot are affected necessitating fusion of multiple joints. In cases of symptomatic hindfoot arthritis secondary to neurological, traumatic, inflammatory or primary degenerative causes with associated significant deformity, combined ankle and subtalar joint fusion with deformity correction can be achieved with an intramedullary device. Tibio-talo-calcaneal nail design has evolved to allow the option of curved nails for optimum entry point placement and dynamic locking options to facilitate fusion [3]. Good results in terms of union rates, improvement in pain and functional scores have been reported with this technique, but significant complications including deep infection and symptomatic non-union can occur [4–6]. Complications can result in significant patient morbidity and necessitate further surgery or

* Corresponding author at: 87 Russell Bank Road, Sutton Coldfield B74 4RQ, UK. Tel.: +44 07779576667. E-mail address: [email protected] (P. Fenton).

even amputation. A recent systematic review reported a re-operation rate of 22% and amputation rate of 1.5% in 631 patients [6]. The purpose of this study was to describe our experience of the use of tibio-talo-calcaneal nails particularly with reference to the complications encountered and the management of them. 2. Materials and methods From patient records we retrospectively identified all patients undergoing tibio-talo-calcaneal fusion with intramedullary nail under the care of the senior author. Casenotes and radiographs were reviewed for all patients. Pre-operative indications for surgery and neurological status were recorded. Previous surgery to the hindfoot was noted as well as intra-operative details including operative time and any additional procedures. Union of fusion sites was assessed from post-operative plain film radiographs with union defined as continuous trabeculae crossing the fusion surface. From the casenotes post-operative complications were noted including those necessitating further procedures. Comparisons of union rates and complication rates between those with pre-existing neuropathy and neurologically intact

http://dx.doi.org/10.1016/j.fas.2014.07.002 1268-7731/ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

P. Fenton et al. / Foot and Ankle Surgery 20 (2014) 268–271

patients and also between patients who had undergone previous surgery and those who had not were made. Statistical analysis was made using a chi square for 2  2 contingency tables.

3. Results We identified 52 patients undergoing 55 tibiotalocalcaneal joint fusions with intramedullary nailing under the care of the senior author. The mean age at time of operation was 59.2 years (range 24–79 years). Mean follow up was for 44.8 months (range 18–69 months). Indications for hindfoot nailing are listed in Table 1. Eleven patients had a neuropathic cause of hindfoot deformity with 4 cases of Charcot-Marie Tooth disease, 5 cases of Charcot arthropathy secondary to diabetes mellitus and 2 cases of lower motor neuron injury, one following a spinal injury and one following sciatic nerve injury at the time of total hip replacement. In the remaining patients twelve developed hindfoot arthritis following fracture, seventeen had idiopathic osteoarthritis and 2 had residual deformity following congenital talipes equinovarus. Sixteen patients had undergone previous surgery including 8 with previous attempted fusion surgery and seven with previous open reduction and internal fixation of fractures. Previous operations are listed in Table 2. None of these patients was known to have active infection however all patients who had undergone previous surgery prior to hindfoot nailing underwent removal of any retained metalwork and deep tissue sampling for infection at the time of index procedure. Two of these sixteen patients, one case of prior fusion and one of prior internal fixation, had positive microbiology with both growing a coagulase negative staphylococcus. All but six of the nails used were Biomet (Biomet, Swindon, UK) hindfoot nails. Nineteen patients required additional procedures at the time of fusion, eight underwent additional fusion procedures, eight first metatarsal osteotomy and 3 removal of metalwork. Additional procedures are listed in Table 3. Of the 55 nailing procedures six patients had removal of metalwork or further procedures before it was possible to assess the fusion site union. In the remaining 50 cases radiological subtalar union was achieved in 36 and ankle union in 40 cases. In terms of post-operative hindfoot alignment the mean calcaneal pitch was 22.48 (range 13–34) and mean coronal plane alignment 5.88 valgus (range 0–15). The commonest complication was prominent metalwork with 13 patients requiring metalwork removal for symptomatic prominent locking screws. In addition five patients had ongoing pain and were diagnosed with complex regional pain syndrome. Three of these five patients had undergone previous hindfoot surgery before hindfoot nailing. The diagnosis in all cases was made by a musculoskeletal physician with an interest in pain management according to the Budapest criteria [7]. Patients were

Table 1 Indications for hindfoot nail. Neuropathy Charcot marie tooth Charcot arthropathy Lower motor neuron injury Post-traumatic arthritis Talar # Ankle # Pilon # Idiopathic osteoarthritis Idiopathic cavovarus Residual CTEV Haemophilia Other

4 5 2 3 8 1 17 4 2 2 4

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Table 2 Previous operations. Open reduction internal fixation Ankle Talus Pilon Arthrodesis Pantalar Ankle Subtalar

6 3 1 3 4 1

managed by a multidisciplinary team including musculoskeletal physicians, physiotherapists and occupational therapists. One patient sustained a periprosthetic fracture at the tip of the nail which was treated non-operatively in cast and went on to uneventful union. Nine patients developed a deep infection. In six cases the responsible organism was staphylococcus aureus, in 2 coagulase negative staphylococcus and in one enterococcus. One patient who had positive deep sampling at index operation went on to develop a deep infection, however this involved a different organism. In six patients limb salvage was achieved by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. One patient required a period of stabilisation in a monolateral external fixator, the remaining 5 needed no additional skeletal stabilisation as union had occurred. Three of the infected cases underwent below knee amputation. One patient preferred to undergo amputation rather than attempt further limb salvage. In one case the infection occurred below a total knee replacement and after discussion with the patient amputation was preferred to limb salvage. In the final patient limb salvage as described above failed to control the infection and ultimately a below knee amputation was performed. There was no statistically significant difference in the rate ankle or subtalar union or of deep infection between those patients with a neurological cause of hindfoot deformity and those with normal neurology. Similarly there was no difference in rate of union (ankle or subtalar), deep infection or development of CRPS between those who had undergone previous hindfoot surgery and those who had not. In the group of patients who underwent additional procedures at the time of hindfoot nailing there was no statistically significant difference in rate of CRPS or infection. There was a trend to increased rates of non-union in this group with 5 subtalar and 4 ankle non-unions in 12 patients compared to 8 subtalar and 5 ankle non-unions in the remaining 43 patients however this did not reach statistical significance. 4. Discussion Hindfoot nails have been used for a variety of indications with good rates of fusion and clinical outcomes. Muckley et al. reported short term results of tibio-talar-calcaneal nailing in 55 patients, 44 of whom had post-traumatic hindfoot arthritis. They reported bony union in 53 patients (93%). In 27 patients followed prospectively they found a significant improvement in the AOFAS Table 3 Additional procedures performed at the time of hindfoot nail. Additional procedures 1st metatarsal dorsiflexion osteotomy Talonavicular fusion Calcano-cuboid fusion 1st TMTJ fusion 1st MTPJ fusion Tendon transfer Removal metalwork

8 4 1 2 1 1 3

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from pre-operative (mean 30) to one year post-operative (mean 69.6, p > 0.001) [8]. Hammett et al. studied 52 hindfoot nailing procedures using a humeral nail. 12 patients had a neurological cause of hindfoot deformity and 5 post-traumatic changes. Mean post-operative AOFAS score was 63, achieving union in all but 6 patients [9]. Niinimaki et al. retrospectively reviewed 34 patients at a mean follow up of 24 months with 10 post-traumatic arthritis and one neurological deformity. Ankle fusion was achieved in 29 and subtalar fusion in 30 patients. There was a significant improvement in the post-operative visual analogue pain score both at rest and when walking compared with pre-operatively [4]. In their study Budnar et al. prospectively reviewed 45 arthrodeses with mean 48 month follow up. There were 7 post-traumatic arthroses, 12 failed ankle fusions and 8 neuropathic arthropathies. 40 (89%) patients achieved bony union. Mean post-operative AOFAS score was 69 with a mean post-operative improvement of 37 points [5]. Devries et al. reviewed a total of 154 hindfoot nailings augmented with either direct current internal bone stimulation (n = 91) or magnetic field external bone stimulation (n = 63). They reported an overall union rate of 52.7% (internal group) and 57.1% (external group) with no difference in overall success between the two groups [10]. Bussewitz et al. reported on 25 patients requiring hindfoot reconstruction with femoral head allograft and hindfoot nail. Forty-eight percent achieved union and 84% a braceable limb however 16% underwent amputation [11]. In their series of 30 patients treated with a compression hindfoot nail, Brodsky et al. reported good deformity correction and improvement in mean AOFAS hindfoot scores from 29.7 to 74.3 [12]. A multicentre study reporting a cohort of patients with severe hindfoot deformity treated with the Hindfoot Arthrodesis Nail found an overall union rate of 84% and noted the socioeconomic benefit of a high proportion of patients being able to return to work post-operatively [13]. The studies above include a wide variety of surgical indications and surgical techniques using a number of different implants. As such direct comparison of outcomes is difficult. Our group achieved ankle union in 80% of cases and subtalar union in 72% in keeping with previous studies. It is worth noting that despite what could be considered a relatively high rate of non-union when assessed on plain film radiographs none of these patients went on to require further surgery to treat a symptomatic non-union. Undoubtedly CT scanning would improve the accuracy of assessment of successful fusion however we do not routinely scan patients in the absence of symptoms. Due to the retrospective nature of our study and lack of pre-operative scoring we have not produced outcome scores for our patients. Complications are reported variably within the literature. Muckley et al. reported a 25% complication rate in their 59 patients with one periprosthetic fracture, one deep infection together with 4 recurrences of osteomyelitis, 2 delayed unions and 2 non-unions [8]. In their group of 52 patients treated with a humeral nail Hammett et al. reported 3 intra-operative fractures. 13 of their patients required removal of prominent metalwork. Six patients required treatment for an established non-union, one developed a deep infection necessitating nail removal. 2 of their group underwent amputation, one for recurrent ulceration and sepsis and one for persistent symptomatic non-union [9]. Niinima¨ki et al. [4] found complications in 15% of 32 patients with 4 cases of deep infection, 2 requiring removal of metalwork. In their study of 45 patients Budnar et al. reported one deep infection, 2 fractures, 16 cases needing removal of prominent metalwork and one amputation for infected non-union [5]. In a comparative study Devries et al. reviewed 154 patients. Reported complications include 42 patients requiring incision and drainage for infection including 22 bone infections, 47 patients undergoing removal of metalwork and 15 cases of major revision. 19 patients in their

study eventually underwent major amputation. A number of complications were encountered in our group including prominent metalwork requiring removal in 13, complex regional pain syndrome in 5, periprosthetic fracture in one patient and the development of deep infection in 9 patients with 3 eventually undergoing amputation [10]. Complications may be attributed to patient, surgeon or implant factors. Patient factors in our cohort might include a history of neuropathy or diabetes although we found no such correlation. A weakness of our study is that we were unable to accurately record data on smoking which has been demonstrated to increase bone healing complications in foot and ankle surgery [14]. Obviously in a single surgeon series it is not possible to draw any conclusions regarding surgeon related factors in complications. Any new procedure involves a learning curve during which it might be expected that the rate of complications would be increased, however there was no increase in the rate of complications earlier in our series compared with later patients. This may be due to a differing case mix as our series progressed, with more complex cases later in the series, however this is difficult to objectively measure. Implant factors may also contribute to complications and certainly nail design may be implicated in the high rate of screw removal we found. The overall complication rate in our study would appear to be consistent with previous reports. Five from 55 patients were diagnosed with CRPS after referral to a musculoskeletal physician. Rates of CRPS following foot and ankle surgery are surprisingly little reported in the literature despite it being such a devastating complication. Rewhorn et al. reported a rate of 4.36% following elective foot and ankle surgery [15]. Interestingly in a comparative study to assess the effect of vitamin C on the incidence of CRPS after foot and ankle study Besse et al. found a rate of CRPS of 9.6% in the control group (no vitamin C) but only 1.7% in the preventative vitamin C group [16]. Our somewhat higher rate of deep infection may be due to a number of factors, including case mix with a relatively high proportion of neuropathic patients in our group, although we found no increase in the rate of deep infection compared to nonneuropathic patients. In the majority of infected cases limb salvage was achieved with removal of metalwork, debridement and deep sampling followed by targeted antibiotic therapy delivered both locally with cement beads and systemically. All but one case achieved union without further instrumentation. 5. Conclusion We believe hindfoot nails can produce reliable clinical results achieving satisfactory correction of deformity and good clinical outcomes. However, complications are not uncommon and in some patients result in significant morbidity. As such we feel these procedures should be reserved for salvage cases where other methods of achieving fusion or deformity correction are not possible due to previous surgeries or soft tissue considerations. Conflict of interest statement None of the authors have any conflict of interest to declare. References [1] Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for posttraumatic osteoarthrosis of the ankle and hindfoot. J Bone Joint Surg Am 1992;74(August (7)):1042–9. [2] Onodera T, Majima T, Kasahara Y, Takahashi D, Yamazaki S, Ando R, et al. Outcome of transfibular ankle arthrodesis with Ilizarov apparatus. Foot Ankle Int 2012;33(November (11)):964–8. http://dx.doi.org/10.3113/FAI. 2012. 0964.

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Complications of tibio-talar-calcaneal fusion using intramedullary nails.

Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications fol...
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