The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Revision Subtalar Joint Fusion with a Porous Metal Spacer and an Intramedullary Nail: A Case Report Martin Wiewiorski, MD 1, Alexej Barg, MD 1, Monika Horisberger, MD 1, Mario Herrera, MD 2, Jochen Paul, MD 1, Victor Valderrabano, MD, PhD 1 1 2
Orthopaedic Department, University Hospital Basel, Basel, Switzerland Department of Orthopaedic Surgery, University Hospital of Santa Cruz, Tenerife, Spain
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Nonunion of hindfoot arthrodesis can be difficult to successfully treat and will often require bone graft techniques. Large amounts of autogenous bone graft can be difficult to procure and will be associated with donor site morbidity. The use of porous metal implants has been shown to satisfactorily bridge segmental bone defects and to work in conjunction with allogeneic bone graft material, without the risks associated with autogenous bone graft donor site morbidity. The purpose of the present report is to describe the use of a perforated, porous metal implant combined with an intramedullary nail for revision surgery of failed subtalar joint fusion in an adult female patient. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle hindfoot nail nonunion talocalcaneal arthrodesis tibiotalar fusion tantalum implant
Subsequent osteoarthritis of the adjacent foot joints is a known long-term complication of ankle joint fusion (1). Subtalar osteoarthritis can be found in up to 43% of patients after ankle joint fusion (2). In such cases, subtalar fusion will commonly be performed. However, nonunion after subtalar fusion has been a common complication (3). Revision surgery will typically consist of screw fixation with a bone graft. In the present case report, we report a new method for revision arthrodesis of the subtalar joint in the presence of ankle joint fusion. A porous metal spacer was interposed in the subtalar joint and fixated with an intramedullary nail. Case Report A 43-year-old female patient seen in our outpatient clinic complained of recurrent load-dependent pain in her right hindfoot. She had undergone ankle joint fusion 13 years previously and subsequent subtalar fusion for post-traumatic osteoarthritis 2 years previously. Hardware removal had been performed just 1 year before her presentation to our clinic. Her clinical examination showed discreet swelling localized to the hindfoot and pain with palpation of her right sinus tarsi. No gross movement of the ankle and subtalar joints was possible. She was also an active cigarette smoker. Her subjective Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Victor Valderrabano, MD, PhD, Orthopaedic Department, University Hospital of Basel, Spitalstrasse 21, Basel 4031 Switzerland. E-mail address: [email protected] (V. Valderrabano).
hindfoot pain, measured on a 10-cm visual analog scale (VAS) (4), with 0 representing no pain and 10 representing maximal pain during normal walking, was 8. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (5) includes pain, function, and alignment domains, with 0 the minimum score and 100 the maximum score. Her score was considered poor at 55 points. The initial conventional radiographs of her right hindfoot and ankle showed a fully fused ankle joint and hypertrophic nonunion of the right subtalar joint (STJ; Fig. 1). Single photon emission computed tomography– computed tomography (6) scanning revealed elevated technetium99m diphosphonate uptake localized to the right subtalar joint, showing pathologic remodeling indicative of nonunion and consistent with her source of pain (Fig. 1). After discussion of the diagnosis and treatment options, operative treatment was chosen, in agreement with the patient’s consent and expectations. Subsequently, the patient was taken to the operating room and positioned prone to allow a posterolateral approach to her right subtalar joint. A curvilinear skin incision positioned anterior and lateral to the lateral margin of the Achilles tendon was used (Fig. 2). The deep flexor tendons and peroneal tendons were exposed and protected, and a large posterior osteophyte was removed from the area where the ankle fusion and subtalar nonunion had merged. One 2.5-mm Kirschner wire (K-wire) was placed superior and parallel to the joint line, and another was positioned inferior to the subtalar joint. The orientation of the wires was inspected using image intensification fluoroscopy. The joint surfaces were then resected using an oscillating saw along the plane of the STJ established by the K-wires (Fig. 2), after which the fusion site was prepared for insertion of an
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.019
2
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. Preoperative imaging. (A) Conventional lateral radiographs showing a fused tibiotalar joint and nonunion of the subtalar joint (arrows). (B) The diagnosis was confirmed by a single photon emission computed tomography–computed tomography scan showing elevated uptake in the nonunion site.
intramedullary arthrodesis nail (Hindfoot Arthrodesis Nail, Synthes, Solothurn, Switzerland; Fig. 2). Specifically, a K-wire was inserted through the calcaneus, the STJ, and the ankle fusion site and propagated into the distal tibia. The K-wire was then overdrilled, and a 10mm intramedullary nail was provisionally inserted and checked for the correct position using fluoroscopy. The nail was then removed, and a perforated, porous metal spacer (Trabecular Metal Ankle Fusion
Spacer, base size L, 7.5-mm, Zimmer, Warsaw, IN) was placed into the subtalar interface between the talus and calcaneus. The nail was then inserted into the predrilled hole in the calcaneus, with the tip placed just inferior the STJ line (Fig. 2). The porous metal spacer was manipulated such that the tip of the nail could pass through the perforation in the spacer. Next, the nail was inserted into the distal tibia and locked statically through the calcaneus and dynamically
Fig. 2. Operative course. (A) An incision lateral to the Achilles tendon (X) was used to expose the nonunion site (arrow). (B) Two Kirschner wires were inserted parallel to the subtalar joint line to guide the saw blade. The defective joint surfaces were resected, leaving a substantial osseous defect. (C) The implants before implantation, with a hindfoot arthrodesis nail (cross) that fit through the perforation of a porous metal spacer (asterisk). (D) The spacer was impacted into the bony defect. The hindfoot arthrodesis nail was inserted through the calcaneus, passing through the perforation of the spacer and into the distal tibia (see Fig. 3 for radiographs).
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 3. Postoperative imaging. Postoperative weightbearing radiographs of the ankle joint in the (A) anteroposterior and (B) lateral views showing correct position and integration of the porous metal disc (asterisk) and correct position of the hindfoot arthrodesis nail (cross).
through the tibia. The remaining gap of the STJ was then backfilled with cancellous allograft bone (Musculoskeletal Transplant Foundation, Edison, NJ). After the surgery, the patient’s initial postoperative care consisted of immobilization using a functional orthosis (VACOpedÒ, OPED, Cham, Switzerland), and it was not until 6 weeks postoperatively that she resumed full weightbearing. The patient returned for scheduled follow-up visits at 6 and 12 weeks and 6 months postoperatively. After 6 weeks, she had a VAS score of 0; however, at 12 weeks, she complained of subjective hindfoot pain, and her VAS score was 4. Her pain at that point was considered the normal postoperative pain associated with the resumption of full weightbearing and physical therapy after immobilization. At 6 months postoperatively, she was free of pain (VAS score 0) during her daily activities, and her American Orthopaedic Foot and Ankle Society hindfoot score had increased to 76 points. Conventional radiographs at 6 months postoperatively showed satisfactory osseous integration of the porous metal disk and the unchanged position of the implant and fusion alignment (Fig. 3). She had continued to increase her activities at her discretion, and additional follow-up examinations were scheduled. Discussion The aspect of nonunion has been well researched for primary and revision subtalar fusion in the presence of an intact ankle joint. The nonunion rate has been 4% to 23% for primary fusion (3,7) and 29% to 32% in cases of revision arthrodesis (3,8). Smoking has been found to be the primary risk factor for failure of primary and revision subtalar fusion (4,5). The treatment of nonunion after failed STJ fusion in the presence of ankle joint fusion will be even more challenging. Large bony defects after debridement can prolong the healing period and decrease the union rate. Screw fixation and bone plasty can be performed; however, these have a high risk of nonunion recurrence. Porous metal coated implants or augments have recently been introduced and have been successfully used in primary and revision
surgery for total hip (9) and knee (10) replacement. The theoretical advantage of porous metal is its high porosity, and its elastic moduli approach that of cancellous bone (11). The increased coefficients of friction reduce the prospect of micromotion to facilitate osseous ingrowth (12). The use of porous metal augments has been previously described for use in foot and ankle surgery. Frigg et al (13) described the use of a porous metal spacer combined with a retrograde nail in their case series of 9 ankle and STJ fusions. A technical description was not provided. At 2 years of follow-up, all 9 arthrodeses were fused. In a case series of 13 patients with failed total ankle replacement, Henricson and Rydholm (14) performed ankle joint fusion using an intramedullary nail through a porous metal spacer. Successful union was achieved in all cases after a mean follow-up period of 1.4 years. We have seen the following 4 advantages in the use of porous metal spacers for hindfoot arthrodesis: (1) no risk of transmitted disease in association with an allograft, (2) several shapes and sizes available “off the shelf,” (3) no donor site morbidity at the iliac crest, and (4) no allograft shrinkage or breakage, resulting in shortage. In conclusion, the combination of a porous metal spacer with an intramedullary hindfoot fusion nail is a feasible and safe procedure for revision STJ fusion in the presence of ankle joint fusion. References 1. Leicht P, Kofoed H. Subtalar arthrosis following ankle arthrodesis. Foot 2:89–92, 1992. 2. Buchner M, Sabo D. Ankle fusion attributable to posttraumatic arthrosis: a long-term followup of 48 patients. Clin Orthop Relat Res 406:155–164, 2003. 3. Chahal J, Stephen DJ, Bulmer B, Daniels T, Kreder HJ. Factors associated with outcome after subtalar arthrodesis. J Orthop Trauma 20:555–561, 2006. 4. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17:45–56, 1983. 5. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353, 1994.
4
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
6. Kretzschmar M, Wiewiorski M, Rasch H, Jacob AL, Bilecen D, Walter MA, Valderrabano V. 99mTc-DPD-SPECT/CT predicts the outcome of imaging-guided diagnostic anaesthetic injections: a prospective cohort study. Eur J Radiol 80:e410–e415, 2011. 7. Flemister AS Jr, Infante AF, Sanders RW, Walling AK. Subtalar arthrodesis for complications of intra-articular calcaneal fractures. Foot Ankle Int 21:392–399, 2000. 8. Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am 82:613–624, 2000. 9. Skytta ET, Eskelinen A, Paavolainen PO, Remes VM. Early results of 827 trabecular metal revision shells in acetabular revision. J Arthroplasty 26:342– 345, 2011.
10. Pagenstert G. CORR insights: trabecular metal in total knee arthroplasty associated with higher knee scores: a randomized controlled trial. Clin Orthop Relat Res 471:3554–3555, 2013. 11. Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J Bone Joint Surg Br 81:907–914, 1999. 12. Bobyn JD, Toh KK, Hacking SA, Tanzer M, Krygier JJ. Tissue response to porous tantalum acetabular cups: a canine model. J Arthroplasty 14:347–354, 1999. 13. Frigg A, Dougall H, Boyd S, Nigg B. Can porous tantalum be used to achieve ankle and subtalar arthrodesis? A pilot study. Clin Orthop Relat Res 468:209–216, 2010. 14. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop 81:745–747, 2010.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Revision Subtalar Joint Fusion with a Porous Metal Spacer and an Intramedullary Nail: A Case Report Martin Wiewiorski, MD 1, Alexej Barg, MD 1, Monika Horisberger, MD 1, Mario Herrera, MD 2, Jochen Paul, MD 1, Victor Valderrabano, MD, PhD 1 1 2
Orthopaedic Department, University Hospital Basel, Basel, Switzerland Department of Orthopaedic Surgery, University Hospital of Santa Cruz, Tenerife, Spain
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Nonunion of hindfoot arthrodesis can be difficult to successfully treat and will often require bone graft techniques. Large amounts of autogenous bone graft can be difficult to procure and will be associated with donor site morbidity. The use of porous metal implants has been shown to satisfactorily bridge segmental bone defects and to work in conjunction with allogeneic bone graft material, without the risks associated with autogenous bone graft donor site morbidity. The purpose of the present report is to describe the use of a perforated, porous metal implant combined with an intramedullary nail for revision surgery of failed subtalar joint fusion in an adult female patient. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle hindfoot nail nonunion talocalcaneal arthrodesis tibiotalar fusion tantalum implant
Subsequent osteoarthritis of the adjacent foot joints is a known long-term complication of ankle joint fusion (1). Subtalar osteoarthritis can be found in up to 43% of patients after ankle joint fusion (2). In such cases, subtalar fusion will commonly be performed. However, nonunion after subtalar fusion has been a common complication (3). Revision surgery will typically consist of screw fixation with a bone graft. In the present case report, we report a new method for revision arthrodesis of the subtalar joint in the presence of ankle joint fusion. A porous metal spacer was interposed in the subtalar joint and fixated with an intramedullary nail. Case Report A 43-year-old female patient seen in our outpatient clinic complained of recurrent load-dependent pain in her right hindfoot. She had undergone ankle joint fusion 13 years previously and subsequent subtalar fusion for post-traumatic osteoarthritis 2 years previously. Hardware removal had been performed just 1 year before her presentation to our clinic. Her clinical examination showed discreet swelling localized to the hindfoot and pain with palpation of her right sinus tarsi. No gross movement of the ankle and subtalar joints was possible. She was also an active cigarette smoker. Her subjective Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Victor Valderrabano, MD, PhD, Orthopaedic Department, University Hospital of Basel, Spitalstrasse 21, Basel 4031 Switzerland. E-mail address: [email protected] (V. Valderrabano).
hindfoot pain, measured on a 10-cm visual analog scale (VAS) (4), with 0 representing no pain and 10 representing maximal pain during normal walking, was 8. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (5) includes pain, function, and alignment domains, with 0 the minimum score and 100 the maximum score. Her score was considered poor at 55 points. The initial conventional radiographs of her right hindfoot and ankle showed a fully fused ankle joint and hypertrophic nonunion of the right subtalar joint (STJ; Fig. 1). Single photon emission computed tomography– computed tomography (6) scanning revealed elevated technetium99m diphosphonate uptake localized to the right subtalar joint, showing pathologic remodeling indicative of nonunion and consistent with her source of pain (Fig. 1). After discussion of the diagnosis and treatment options, operative treatment was chosen, in agreement with the patient’s consent and expectations. Subsequently, the patient was taken to the operating room and positioned prone to allow a posterolateral approach to her right subtalar joint. A curvilinear skin incision positioned anterior and lateral to the lateral margin of the Achilles tendon was used (Fig. 2). The deep flexor tendons and peroneal tendons were exposed and protected, and a large posterior osteophyte was removed from the area where the ankle fusion and subtalar nonunion had merged. One 2.5-mm Kirschner wire (K-wire) was placed superior and parallel to the joint line, and another was positioned inferior to the subtalar joint. The orientation of the wires was inspected using image intensification fluoroscopy. The joint surfaces were then resected using an oscillating saw along the plane of the STJ established by the K-wires (Fig. 2), after which the fusion site was prepared for insertion of an
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.019
2
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. Preoperative imaging. (A) Conventional lateral radiographs showing a fused tibiotalar joint and nonunion of the subtalar joint (arrows). (B) The diagnosis was confirmed by a single photon emission computed tomography–computed tomography scan showing elevated uptake in the nonunion site.
intramedullary arthrodesis nail (Hindfoot Arthrodesis Nail, Synthes, Solothurn, Switzerland; Fig. 2). Specifically, a K-wire was inserted through the calcaneus, the STJ, and the ankle fusion site and propagated into the distal tibia. The K-wire was then overdrilled, and a 10mm intramedullary nail was provisionally inserted and checked for the correct position using fluoroscopy. The nail was then removed, and a perforated, porous metal spacer (Trabecular Metal Ankle Fusion
Spacer, base size L, 7.5-mm, Zimmer, Warsaw, IN) was placed into the subtalar interface between the talus and calcaneus. The nail was then inserted into the predrilled hole in the calcaneus, with the tip placed just inferior the STJ line (Fig. 2). The porous metal spacer was manipulated such that the tip of the nail could pass through the perforation in the spacer. Next, the nail was inserted into the distal tibia and locked statically through the calcaneus and dynamically
Fig. 2. Operative course. (A) An incision lateral to the Achilles tendon (X) was used to expose the nonunion site (arrow). (B) Two Kirschner wires were inserted parallel to the subtalar joint line to guide the saw blade. The defective joint surfaces were resected, leaving a substantial osseous defect. (C) The implants before implantation, with a hindfoot arthrodesis nail (cross) that fit through the perforation of a porous metal spacer (asterisk). (D) The spacer was impacted into the bony defect. The hindfoot arthrodesis nail was inserted through the calcaneus, passing through the perforation of the spacer and into the distal tibia (see Fig. 3 for radiographs).
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 3. Postoperative imaging. Postoperative weightbearing radiographs of the ankle joint in the (A) anteroposterior and (B) lateral views showing correct position and integration of the porous metal disc (asterisk) and correct position of the hindfoot arthrodesis nail (cross).
through the tibia. The remaining gap of the STJ was then backfilled with cancellous allograft bone (Musculoskeletal Transplant Foundation, Edison, NJ). After the surgery, the patient’s initial postoperative care consisted of immobilization using a functional orthosis (VACOpedÒ, OPED, Cham, Switzerland), and it was not until 6 weeks postoperatively that she resumed full weightbearing. The patient returned for scheduled follow-up visits at 6 and 12 weeks and 6 months postoperatively. After 6 weeks, she had a VAS score of 0; however, at 12 weeks, she complained of subjective hindfoot pain, and her VAS score was 4. Her pain at that point was considered the normal postoperative pain associated with the resumption of full weightbearing and physical therapy after immobilization. At 6 months postoperatively, she was free of pain (VAS score 0) during her daily activities, and her American Orthopaedic Foot and Ankle Society hindfoot score had increased to 76 points. Conventional radiographs at 6 months postoperatively showed satisfactory osseous integration of the porous metal disk and the unchanged position of the implant and fusion alignment (Fig. 3). She had continued to increase her activities at her discretion, and additional follow-up examinations were scheduled. Discussion The aspect of nonunion has been well researched for primary and revision subtalar fusion in the presence of an intact ankle joint. The nonunion rate has been 4% to 23% for primary fusion (3,7) and 29% to 32% in cases of revision arthrodesis (3,8). Smoking has been found to be the primary risk factor for failure of primary and revision subtalar fusion (4,5). The treatment of nonunion after failed STJ fusion in the presence of ankle joint fusion will be even more challenging. Large bony defects after debridement can prolong the healing period and decrease the union rate. Screw fixation and bone plasty can be performed; however, these have a high risk of nonunion recurrence. Porous metal coated implants or augments have recently been introduced and have been successfully used in primary and revision
surgery for total hip (9) and knee (10) replacement. The theoretical advantage of porous metal is its high porosity, and its elastic moduli approach that of cancellous bone (11). The increased coefficients of friction reduce the prospect of micromotion to facilitate osseous ingrowth (12). The use of porous metal augments has been previously described for use in foot and ankle surgery. Frigg et al (13) described the use of a porous metal spacer combined with a retrograde nail in their case series of 9 ankle and STJ fusions. A technical description was not provided. At 2 years of follow-up, all 9 arthrodeses were fused. In a case series of 13 patients with failed total ankle replacement, Henricson and Rydholm (14) performed ankle joint fusion using an intramedullary nail through a porous metal spacer. Successful union was achieved in all cases after a mean follow-up period of 1.4 years. We have seen the following 4 advantages in the use of porous metal spacers for hindfoot arthrodesis: (1) no risk of transmitted disease in association with an allograft, (2) several shapes and sizes available “off the shelf,” (3) no donor site morbidity at the iliac crest, and (4) no allograft shrinkage or breakage, resulting in shortage. In conclusion, the combination of a porous metal spacer with an intramedullary hindfoot fusion nail is a feasible and safe procedure for revision STJ fusion in the presence of ankle joint fusion. References 1. Leicht P, Kofoed H. Subtalar arthrosis following ankle arthrodesis. Foot 2:89–92, 1992. 2. Buchner M, Sabo D. Ankle fusion attributable to posttraumatic arthrosis: a long-term followup of 48 patients. Clin Orthop Relat Res 406:155–164, 2003. 3. Chahal J, Stephen DJ, Bulmer B, Daniels T, Kreder HJ. Factors associated with outcome after subtalar arthrodesis. J Orthop Trauma 20:555–561, 2006. 4. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17:45–56, 1983. 5. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353, 1994.
4
M. Wiewiorski et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
6. Kretzschmar M, Wiewiorski M, Rasch H, Jacob AL, Bilecen D, Walter MA, Valderrabano V. 99mTc-DPD-SPECT/CT predicts the outcome of imaging-guided diagnostic anaesthetic injections: a prospective cohort study. Eur J Radiol 80:e410–e415, 2011. 7. Flemister AS Jr, Infante AF, Sanders RW, Walling AK. Subtalar arthrodesis for complications of intra-articular calcaneal fractures. Foot Ankle Int 21:392–399, 2000. 8. Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am 82:613–624, 2000. 9. Skytta ET, Eskelinen A, Paavolainen PO, Remes VM. Early results of 827 trabecular metal revision shells in acetabular revision. J Arthroplasty 26:342– 345, 2011.
10. Pagenstert G. CORR insights: trabecular metal in total knee arthroplasty associated with higher knee scores: a randomized controlled trial. Clin Orthop Relat Res 471:3554–3555, 2013. 11. Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J Bone Joint Surg Br 81:907–914, 1999. 12. Bobyn JD, Toh KK, Hacking SA, Tanzer M, Krygier JJ. Tissue response to porous tantalum acetabular cups: a canine model. J Arthroplasty 14:347–354, 1999. 13. Frigg A, Dougall H, Boyd S, Nigg B. Can porous tantalum be used to achieve ankle and subtalar arthrodesis? A pilot study. Clin Orthop Relat Res 468:209–216, 2010. 14. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop 81:745–747, 2010.
![[Distal tibia peri-implant fracture with an intramedullary nail: a case report].](/assets/img/hold.png)
