The Journal of Foot & Ankle Surgery 53 (2014) 774–786

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Tibiocalcaneal Arthrodesis in the High-Risk Foot Guido A. LaPorta, DPM, FACFAS 1, Ellianne M. Nasser, DPM, AACFAS 2, Jennifer L. Mulhern, DPM, AACFAS 3 1 Chief, Podiatric Medicine and Surgery, and Residency Director, Geisinger Community Medical Center, Scranton, PA; and Fellowship Director, Limb Salvage and Reconstructive Surgery Fellowship Program, Northeast Regional Foot and Ankle Institute, Dunmore, PA 2 Fellow, Limb Salvage and Reconstructive Surgery Fellowship Program, Northeast Regional Foot and Ankle Institute, Dunmore, PA 3 Chief Resident, Geisinger Community Medical Center, Scranton, PA

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

The present case series outlines the history and surgical treatment of 6 patients who underwent tibiocalcaneal arthrodesis from April 2002 to May 2012, all with external fixation as the primary or secondary fixation. Surgical intervention was performed by the same surgeon at the same facility. The indication for surgery was a nonbraceable Charcot deformity in 5 (83.3%) patients and bone and soft tissue infection complicating previous intramedullary hindfoot fusion in 1 (16.7%) patient. Talectomy was performed in 2 (33.3%) patients secondary to widespread osteomyelitis of the talus and in 4 (66.7%) patients secondary to avascular necrosis and/or disintegration and fragmentation of the remaining talus. The postoperative complications have been discussed in detail and their management outlined. At the most recent follow-up visit, all patients were independently ambulating on a braceable limb with or without the use of an assistive device. In conclusion, tibiocalcaneal arthrodesis is a reasonable option for limb salvage to produce community ambulators in the high-risk population. We emphasize that although multiple fixation options are available for tibiocalcaneal arthrodesis, a combination of internal and external fixation is vital to its success. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords: Charcot external fixation joint fusion talectomy tibiocalcaneal fusion

Limb salvage using lower extremity arthrodesis in the high-risk patient population poses a challenge for the lower extremity surgeon. The high-risk limb salvage patient has had previous surgical attempts to a braceable limb fail and will have concomitant osteomyelitis or wounds. Also, the case can be complicated by comorbidities such as obesity and diabetes, patient noncompliance, and poor home support for wound care and postoperative management. Patients with Charcot arthropathy are prone to delayed wound healing, infection, and poor bone healing, with increased morbidity owing to gross instability, recurrent ulcerations, or amputation, limiting traditional methods of internal fixation (1–3). Extensive surgical planning is paramount and must be multifactorial, taking into consideration, not only the radiographic examination findings, but also patient expectations, preoperative patient quality of life, and patient comorbidities. Multiple fixation options exist for hindfoot arthrodesis, and the surgeon must choose carefully which option or combination of fixation options would most benefit the patient. Financial Disclosure: None reported. Conflict of Interest: Dr. LaPorta is a consultant for SBI, Stryker Orthopedics, and Orthofix. Address correspondence to: Ellianne M. Nasser, DPM, AACFAS, Limb Salvage and Reconstructive Surgery Fellowship Program, Northeast Regional Foot and Ankle Institute, 414 East Drinker Street, Suite 101, Dunmore, PA 18512. E-mail address: [email protected] (E.M. Nasser).

Surgical stabilization in the neuropathic patient is aimed at creating a stable, plantigrade, braceable foot to allow the limb to continue to be functional and preventing amputation (3–9). Although the published data have shown that amputation has the shortest rehabilitation time and a good functional result with modern prostheses, it is unacceptable to most patients (10). The risk of contralateral Charcot arthropathy with amputation is greatly increased in patients with a history of lower extremity amputation (5,11). Limb preservation surgery has come into greater favor, because surgeons are now avoiding primary amputation as the first-line treatment (6). Tibial-pedal arthrodesis as a limb salvage option for the unstable, unbraceable hindfoot deformity includes ankle, tibiotalocalcaneal, and tibiocalcaneal arthrodesis. In the patient with segmental bone defects, tibiotalocalcaneal and/or tibiocalcaneal arthrodesis provide a viable option. The presence or absence of soft tissue and/or bone infection will alter the sequence of fixation placement. Also, when osteomyelitis or avascular necrosis of the talus (with collapse) has complicated the neuropathic hindfoot deformity, talectomy with tibiocalcaneal arthrodesis is specifically indicated for surgical stabilization and limb salvage. In cases necessitating talectomy, the surgeon is left with the option of acute shortening of the limb, an interpositional structural graft, or concomitant lengthening. The tenants of successful fusion originally described for the Charcot knee apply and must be adhered to in tibiotalocalcaneal and

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.2014.06.027

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Table Summary of study cohort (n ¼ 6) Patient No.

DM

TC Fusion Indication

Wound Present at Surgery

Osteomyelitis of Talus

External Fixation Type

Definitive Internal Fixation

Bone Graft Used

1

No

Infected IM nail

Yes

Yes

Ilizarov

None

2

Yes

Hindfoot Charcot

Yes

Yes

IM nail

3

Yes

Hindfoot Charcot

Yes

No

First: Ilizarov Second: circular monoclonal compression Ilizarov

Demineralized bone matrix, cancellous allograft, platelet-rich plasma Autograft (resected fibula)

Tripod

4

Yes

Hindfoot Charcot

No

Delta configuration

Tripod

5

Yes

Hindfoot Charcot

First: no Second: yes

No; osteomyelitis of tibia 13 wk postoperatively treated with debridement and IV antibiotics No

First: Ilizarov Second: delta configuration

First: IM nail Second: tripod (modified)

6

Yes

Hindfoot Charcot

No

No; superficial infection just before stage 2 at pin site treated with debridement and antibiotic beads Stage 2 initially postponed.

First: triplanar (Butt construct) Second: Ilizarov

First: None Second: IM screw and staple

Autograft (resected fibula) and femoral head allograft Demineralized bone matrix and femoral head allograft

First: autograft (resected fibula and tibia), demineralized bone matrix, platelet-rich plasma Second: none First: none Second: autograft (resected fibula) and cancellous allograft

Abbreviations: DM, diabetes mellitus; IM, intramedullary; IV, intravenous; TC, tibiocalcaneal.

tibiocalcaneal arthrodesis (12). These include careful removal of all cartilage and debris; removal of sclerotic bone down to bleeding, well-vascularized bone; fashioning of congruent bone surfaces; firm fixation using an intramedullary (IM) rod or other fixation; and careful debridement of all synovial tissue and scarred capsule. The use of external fixation in the surgical treatment of Charcot arthropathy has been well documented in published studies. Internal

fixation alone carries a risk of failure secondary to osteopenic bone’s inability to support the screw threads. The postoperative course after internal fixation alone requires an extensive period of nonweightbearing. Internal fixation combined with external fixation is a viable option for arthrodesis, because the external fixator will mechanically bridge the arthrodesis site and neutralize stress within the tarsus, allowing greater stability and earlier weightbearing (7).

Fig. 1. Preoperative radiographs of patient 1 demonstrating retained intramedullary nail with diffuse osteolysis.

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Fig. 2. (A and B) Radiographs of patient 1 after resection of infected bone, insertion of an antibiotic-coated pin and beads, and application of an external fixator. (C and D) Lower leg radiographs after external fixator adjustment. A proximal ring was added with distractors after tibial corticotomy.

External fixation provides rigid stabilization and creates an optimal condition for wound healing and respect of the soft tissue envelope (3,13). In the present study, we aimed to demonstrate multiple combinations of internal and external fixation for tibiocalcaneal arthrodesis in the high-risk foot. We present a case series of 6 patients with available radiographs and clinical follow-up data who had been treated in a variety of sequences for stabilization of unstable, nonbraceable hindfoot deformity. Each case is outlined in detail, explaining the fixation choice and sequence of surgical intervention. All patients underwent talectomy with tibiocalcaneal fusion using external fixation as the primary or secondary fixation. The indication for surgery was a nonbraceable Charcot deformity in 5 patients and osteomyelitis of the talus after failed hindfoot fusion in 1 patient. We

stress that careful procedure selection is integral to successful outcomes and that a variety of surgical strategies and fixation techniques can be used.

Case Report A retrospective review of the medical records and radiographs from 6 patients who had presented from April 2002 to May 2012 with an unstable, nonbraceable hindfoot deformity and had subsequently undergone tibiocalcaneal arthrodesis as a salvage procedure is presented. The patients were not enrolled consecutively but, rather, were selected to outline the different fixation combinations for tibiocalcaneal fusion if they had the clinical, surgical, and radiographic records available. The

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Fig. 3. Radiographs of patient 1 at 8 months after external fixator removal demonstrating complete consolidation of the proximal tibial corticotomy and tibiocalcaneal arthrodesis.

included patients were not notified of their enrollment, and the institutional review board did not review the series. The outcomes were determined from the patients’ most recent clinical follow-up examination findings as documented in their medical record, with correlation of these findings to their most recent radiographic images. A summary of the patient data and their operative interventions are outlined in the Table.

Patient 1 A 56-year-old male tobacco user presented to the emergency department with left ankle pain and recurrent ulceration overlying the lateral ankle with malodor, sinus tract, purulent drainage, and exposed peroneal tendons. Historically, the patient was involved in a severe motor vehicle accident necessitating left hindfoot fusion with IM nailing for extremity salvage. The patient had a history of frequent hospitalizations for ulceration and infection during the previous 4 years that had been treated with antibiotics and local wound care. Transtibial amputation had been offered on 2 occasions but refused by the patient. On the initial radiographic evaluation, a soft tissue deficit

was visualized laterally, with diffuse osteolysis and loosening of the hindfoot nail (Fig. 1). After emergency incision and drainage with positive bone cultures, the patient underwent repeat debridement on postoperative day 2, at which point, the IM nail was removed, releasing purulent drainage from the medullary canal. A circular external fixator was applied in a standard static Ilizarov ankle construct, antibiotic beads were placed into the resultant void, and an antibiotic-coated pin was inserted into the site of the previous IM nail (Fig. 2). The antibiotic-coated pin and beads were exchanged on postoperative day 4, and the patient was subsequently discharged with intravenous antibiotics. At 16 days after this exchange, the antibiotic pin was removed, and the antibiotic beads were exchanged. During this same procedure, a second, more proximal tibial ring was secured to the existing fixator using distraction rods, and a proximal tibial corticotomy was performed between the 2 most proximal tibial rings to allow for lengthening (distraction osteogenesis) (Fig. 2). At 8 days after the proximal tibial corticotomy, the retained antibiotic beads were removed. After additional debridement, all soft tissue and bone surrounding the area of previous infection appeared healthy. The opposing bony surfaces were prepared for fusion, and a

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Fig. 4. Preoperative sagittal and coronal magnetic resonance imaging scans of patient 2 demonstrating osteomyelitis of the talus.

mixture of demineralized bone matrix, cancellous allograft, and platelet-rich plasma was placed into this region. Acute compression of 3.5 mm using the external fixator was applied across the tibiocalcaneal arthrodesis site, docking the fusion. The proximal tibial corticotomy site was distracted by 1 mm using the existing distraction rods. Postoperatively, the patient underwent additional distraction of the proximal tibial corticotomy site that was performed during his office visits. Distraction ceased once an appropriate length of the extremity had been achieved, and the patient was then held static in the frame construct. The external fixator was removed 13 months after the initial placement, revealing complete consolidation across both the proximal tibial corticotomy site and the distal tibiocalcaneal arthrodesis site. During the time in the external fixator, the patient underwent surgical debridement and application of a skin graft substitute to the lateral ankle wound. At his most recent follow-up visit, 8 months after removal of the external fixator, the patient had a stable tibiocalcaneal arthrodesis with stable regenerate bone formation at the proximal tibial corticotomy site (Fig. 3).

Patient 2 A 60-year-old diabetic male presented with left hindfoot Charcot deformity and a chronic wound under the talar head with cellulitis and purulent drainage. The talar head was prominent secondary to dislocation at the level of the talonavicular joint. No previous surgical intervention had been undertaken. At the initial radiographic and magnetic resonance imaging evaluation, osteomyelitis of the talus was confirmed (Fig. 4). The patient underwent incision and drainage with total talectomy and tibiocalcaneal fusion by application of a circular external fixator in a static Ilizarov ankle construct. An intramedullary Steinman pin was used to maintain the axial alignment of the extremity during fixator application. An autograft from the patient’s resected fibula was morselized and used as a graft to augment the fusion site (Fig. 5). The external fixator was removed at 4 months. At that point, the Steinman pin was also removed, and an IM nail was inserted, stabilizing the arthrodesis. At 2.5 years after the tibiocalcaneal arthrodesis, the patient developed an acute Charcot flare-up at the level of the previous fusion site. An external fixator for monoclonal compression of the left

Fig. 5. Ankle radiographs of patient 2 after talectomy with acute shortening and application of an external fixator.

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Fig. 6. Radiographs of patient 2 (A and B) after application of an external fixator for monoclonal compression arthrodesis of the ankle and (C and D) 9 years after external fixator removal demonstrating a stable pseudoarthrosis.

tibiocalcaneal arthrodesis site was applied and maintained for 4 months (Fig. 6). At his most recent follow-up visit, 9 years after removal of the external fixator, the patient had a stable pseudoarthrosis, was ambulating in diabetic shoes with the use of a cane, and was independently operating a motor vehicle (Fig. 6). Patient 3 A 64-year-old diabetic male presented with right hindfoot Charcot deformity and chronic ulceration to the medial and lateral malleoli with cellulitis. Historically, the patient had been treated conservatively by another physician for a 4-year period and had undergone right ankle incision and drainage 4 months before his presentation to us. He was ambulating in a lace-up ankle brace and using a walker for assistance. Pedal pulses were nonpalpable secondary to lower extremity edema; therefore, noninvasive vascular studies were ordered, with the findings within normal limits. On the initial radiographic evaluation, complete collapse and fragmentation of the talus and talonavicular joint dislocation were evident (Fig. 7). Total talectomy with tibiocalcaneal arthrodesis was performed. After joint preparation, placement of internal fixation in a “tripod” configuration, consisting of three 8.0-mm partially threaded cannulated screws, was performed. One screw was placed from the inferior-central calcaneus to the medullary canal of the tibia, one

from the posterior-inferior calcaneus (tuber) to the anterior-distal tibia, and one from the distal-lateral aspect of the cuboid to the posterior-medial tibia. A combination of a femoral head allograft and an autograft from the patient’s resected fibula were morselized and used as a graft to augment the fusion site after screw placement. After placement of internal fixation, a previously constructed circular external fixator in a static Ilizarov ankle construct was applied to the right lower extremity (Fig. 8). The external fixator was removed at 3 months, at which time the medial and lateral

Fig. 7. Preoperative radiographs of patient 3 demonstrating collapse and fragmentation of the talus.

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Fig. 8. Radiographs of patient 3 (A–C) after talectomy, tibiocalcaneal arthrodesis with “tripod” configuration of screw fixation, and application of an external fixator, and (D–F) 11 months after reconstruction showing stable pseudoarthrosis of the tibiocalcaneal arthrodesis.

malleolar ulcerations were debrided and an acellular skin substitute was applied. At his most recent follow-up visit, 11 months after removal of the external fixator, the patient was ambulating independently in a controlled ankle motion boot on the right lower extremity without assistance and had a stable pseudoarthrosis (Fig. 8). A superficial lateral ankle wound was present and was being treated conservatively. Patient 4 A 69-year-old diabetic male tobacco user presented with left hindfoot Charcot deformity without underlying ulceration. Historically, the patient reported recurrent ulceration to the left lateral ankle region that had been treated conservatively to closure. He was

ambulating in an ankle foot orthosis with custom-molded diabetic shoes. Examination revealed an obvious varus deformity of the heel and a limb length discrepancy of 2.5 cm, with the left extremity shorter than the right. The initial radiographic evaluation demonstrated dislocation of the talar neck with medial displacement of the forefoot and varus of the heel (Fig. 9). Stage 1 of surgical intervention consisted of total talectomy and tibiocalcaneal arthrodesis with application of an external fixator (delta configuration with footplate). Two intramedullary Steinman pins were used to maintain the axial alignment of the extremity during fixator application. A combination of a femoral head allograft and demineralized bone matrix were used as a graft to augment the fusion site (Fig. 10). The frame was maintained for 13 weeks. Stage 2 consisted of removal of both the Steinman pins and the external fixator, with placement of definitive internal fixation in a “tripod”

Fig. 9. Preoperative radiographs of patient 4 showing (A and B) dislocation of the talar neck medially. (C) The heel axial view revealed significant varus deformity.

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Fig. 10. Radiographs of patient 4 (A and B) immediately after talectomy with tibiocalcaneal arthrodesis and application of an external fixator and (C and D) 13 months after the initial surgical intervention.

configuration, consisting of three 8.0-mm partially threaded cannulated screws, such as were described for patient 3. Owing to postoperative noncompliance with weightbearing restrictions, the patient required 2 revision procedures, including hardware exchange and wound debridement, with application of a bilayer wound matrix to the posterior heel in conjunction with intravenous antibiotics. At the most recent follow-up visit, 13 months after the initial surgical intervention, the patient was ulceration and infection free. The patient was weightbearing on a stable pseudoarthrosis in an Arizona brace and a custom orthopedic shoe to the left lower extremity (Fig. 10).

Patient 5 A 40-year-old diabetic male with a history of bilateral lower extremity Charcot deformity presented for evaluation of an unstable right lower extremity without underlying ulceration. He was ambulating in a controlled ankle motion boot. Historically, the patient had undergone Charcot reconstruction of the left lower extremity consisting of talectomy and tibiocalcaneal arthrodesis. At his presentation to us, he had developed a stable pseudoarthrosis on the left and was ambulating without difficulty. Examination of the right lower extremity revealed significant instability of the ankle and a rockerbottom appearance of the foot. On the initial radiographic

Fig. 11. Preoperative radiographs of patient 5 revealing valgus positioning of the heel with respect to the leg and medial talar dislocation. The foot was posteriorly translated on the leg.

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Fig. 12. Radiographs of patient 5 (A and B) immediately after talectomy with an interpositional graft, intramedullary nail, and external fixator application and (C and D) immediately after external fixator removal.

evaluation, medial dislocation of the talus, posterior dislocation of the foot, and midfoot collapse and valgus deformity of the heel were evident (Fig. 11). Total talectomy with tibiocalcaneal arthrodesis by way of IM nail placement was performed. Resection of the medial and lateral malleoli was necessary to aid in deformity reduction. A combination of an autogenous graft from morselized medial and lateral malleoli, demineralized bone matrix, and platelet-rich plasma was used as a

graft to augment the fusion site after IM nail placement. The locked IM nail was then compressed, and a circular external fixator in a static Ilizarov ankle construct was applied. The external fixator was maintained for 12 weeks. On removal, the patient was placed in a weightbearing cast with an assistive device for stability (Fig. 12). At 4 weeks after frame removal, the patient presented with an infected plantar foot wound at the site of IM nail insertion, necessitating incision and drainage and removal of the IM nail. The IM nail

Fig. 13. Radiographs of patient 5 (A and B) before revision internal fixation for definitive tibiocalcaneal arthrodesis, (C and D) after insertion of modified “tripod” fixation and application of the external fixator, and (E and F) 11 months after final frame removal demonstrating a stable pseudoarthrosis.

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Fig. 14. Preoperative radiographs of patient 6 demonstrating fragmentation of the hindfoot with significant plantarflexion of the calcaneus and varus deformity noted on the heel axial view.

was replaced with an antibiotic-coated pin that was maintained for 7 weeks, and the patient was treated with intravenous antibiotics. At antibiotic rod removal, the patient was free of infection. Primary closure of the plantar foot wound was performed, and no internal fixation was placed. At 7 months after this procedure, the patient was ambulating on the right lower extremity, but reported increased pain

with motion at the previous arthrodesis site that was evident on clinical examination. Radiographic evaluation revealed nonunion, indicating a need for rigid internal fixation (Fig. 13). Placement of internal fixation in a modified “tripod” configuration, such as was described for patient 3, was used with two 8-mm, partially threaded cannulated screws and one 6.5-mm, fully threaded

Fig. 15. Radiographs of patient 6 (A–C) after deformity correction with a triplanar external fixator, (D and E) after tibiocalcaneal arthrodesis with internal and external fixation, and (F and G) 5 months after removal of the external fixator showing consolidation across the hindfoot arthrodesis.

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cannulated screw. An external fixator (delta configuration with footplate) was applied to the lower extremity for increased stabilization (Fig. 13). The external fixator was maintained for 10 weeks and subsequently removed without complications. At his most recent follow-up visit, 15 months after final frame removal, the patient was infection free and ambulating in an Arizona brace with a custom-molded accommodative shoe. Radiographs showed that the fully threaded screw within the heel had broken just proximal to the level of the fusion, but the patient had developed a stable pseudoarthrosis (Fig. 13). Patient 6 A 49-year-old diabetic male tobacco user presented with left hindfoot Charcot deformity without current ulceration. Historically, the patient had undergone multiple left foot surgeries, including incision and drainage and fifth ray resection for osteomyelitis. The patient had also undergone transmetatarsal amputation on the right lower extremity. Initial examination of the left lower extremity revealed nonpalpable pedal pulses; therefore, the patient was evaluated by a vascular surgeon who cleared the patient for operative intervention. On the initial radiographic evaluation, midfoot breakdown and talar collapse with a plantarflexed varus heel were evident (Fig. 14). Gradual correction of the forefoot to hindfoot deformity was achieved with the use of a triplanar external fixator (Butt configuration). At external fixator application, a gastrocnemius recession was also performed. After completion of the deformity corrective prescription, the patient was scheduled for definitive internal stabilization with a medial column midfoot fusion bolt (Fig. 15). However, on the day of surgery, the patient presented with a pin tract infection at the distal tibial half-pin. The frame was removed, and the wound was irrigated and debrided. Antibiotic beads were placed and subsequently removed in the office. The patient was followed up at an outpatient wound care center until closure. At 1 year after removal of the external fixator, the patient presented with recurrence of the deformity secondary to noncompliance with bracing. At that point, the patient underwent total talectomy and tibiocalcaneal fusion with application of a circular external fixator in a static Ilizarov ankle construct. An intramedullary 8-mm, partially threaded screw was used to maintain the axial alignment of the extremity during fixator application. A combination of an autograft from the patient’s resected fibula and a cancellous allograft were morselized and used as a graft to augment the fusion site. A staple was used at the anterolateral border of the fusion site to augment stabilization of the interposed graft. The external fixator was removed at 13 weeks and the patient transitioned to weightbearing (Fig. 15). At his most recent follow-up visit, 14 months after the last surgical intervention, the patient was ambulating in a controlled ankle motion boot to the left lower extremity without deformity recurrence. Discussion The results of the patients in our case series have demonstrated the use of talectomy with tibiocalcaneal fusion incorporating a variety of complimentary fixation techniques. The indication for surgery was nonbraceable hindfoot Charcot deformity in 5 patients and bone and soft tissue infection complicating previous hindfoot fusion in 1 patient. Of the 5 patients with hindfoot Charcot deformity, 1 patient had osteomyelitis of the talus. In the remaining patients, talectomy was performed secondary to avascular necrosis and/or disintegration and fragmentation of the remaining talus. All 5 patients with Charcot arthropathy had diabetes. The patient with the infected hindfoot fusion site did not. All patients required more than 1 surgical

intervention, with both minor and major complications encountered during the postoperative course. All 6 patients exhibited some form of gait disturbance both preoperatively and postoperatively. The purpose of the surgical intervention was to produce extremity stability and community ambulation; therefore, a normal gait pattern was not expected. An external fixation device was used in all 6 patients as the primary or secondary fixation. The external fixation constructs consisted of a static Ilizarov ankle construct in 5 patients, delta frame construct in 2, and a triplanar external fixator (Butt configuration) in 1 patient. Fixation for tibiocalcaneal arthrodesis consisted of external fixation alone in 1 patient, external fixation followed by IM nailing in 1 patient, external fixation followed by internal fixation using a 3-screw “tripod” technique in 2 patients, external fixation followed by additional external fixation application and an intramedullary screw and a staple in 1 patient secondary to residual instability, and external fixation with IM nailing, followed by external fixation with internal fixation using a modified 3 screw “tripod” technique in 1 patient secondary to osteomyelitis at the original fusion site. A bone graft was used in all patients in our case series. Autograft morselized bone from a resected tibia and/or fibula was used in 4 patients and platelet-rich plasma in 2 patients. A femoral head allograft was also used in 2 patients, a bioactive bone graft substitute in 3 patients, and a cancellous allograft in 2 patients. Multiple fixation options are available for talectomy with tibiocalcaneal fusion, including compression screw fixation, external fixation alone, a combination of internal and external fixation, IM nailing, and condylar blade plates. The presence of osteomyelitis necessitates a staged procedure that includes a period of external fixation alone. Stage 1 requires complete excision of all infected bone and soft tissue. External fixation devices applied at a distance from the infection allow for maintenance of the length, alignment, and rotation. After successful management of infection and soft tissue resuscitation, strategies for definitive arthrodesis include compression arthrodesis (acute shortening), compression arthrodesis with an intercalary bone graft, distraction osteogenesis, and, in some cases, bone transport. In the patient with Charcot neuroarthropathy without osteomyelitis, we recommend the concomitant use of external fixation and internal fixation to further stabilize the deformed, neuropathic, highrisk foot. The frame will neutralize stress at the arthrodesis site until the bone has consolidated. The use of external fixation will allow for biomechanical stability without compromise to local blood perfusion. In the face of infected ulceration without osteomyelitis, we have routinely used an external fixator until the ulcer has resolved and the infection has been eradicated, followed by placement of internal fixation. External fixation alone for rearfoot fusion in Charcot arthropathy has demonstrated successful results, both with and without concomitant osteomyelitis. Fabrin et al (6) reviewed 7 tibiotalar fusions and 5 tibiocalcaneal fusions using external fixation alone in the acute Charcot foot with instability and ulceration. Of the 5 patients with tibiocalcaneal fusion, 1 achieved bony union, 2 achieved stable fibrous union, 1 had an unstable fibrous nonunion, and 1 required transtibial amputation. They concluded that although bony union is unlikely at the tibiocalcaneal level with external fixation alone, the functional result with fibrous healing is satisfactory (6). Therefore, they believed the procedure would be suitable for patients with ulceration and a high risk of infection. Kolker and Wilson (14) reviewed 3 adult patients with chronic talar infections secondary to complex fracture dislocation of the talus treated with staged debridement and talectomy followed by tibiocalcaneal fusion using an autograft and external fixation. Solid union of the tibiocalcaneal fusion was achieved in all 3 patients at an average of 14 weeks.

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One of our patients underwent simultaneous tibial lengthening with tibiocalcaneal arthrodesis using a bifocal circular external fixation technique secondary to osteomyelitis of the talus at a previous hindfoot arthrodesis site. At his most recent follow-up visit, 8 months after frame removal, the patient had a stable tibiocalcaneal fusion, with full consolidation at both the arthrodesis and the lengthening sites. Our lengthening protocol for distraction osteogenesis follows that outlined by Tellisi et al (15). A latency phase of 7 to 10 days is followed by lengthening performed at a rate of 1 mm/day split into 3 intervals. The consolidation period begins when lengthening has been completed and typically requires 1.5 to 2 months/1 cm of lengthening. Frame removal is indicated when 3 of the 4 cortices have healed. Investigators have reported successful results with proximal tibial lengthening in conjunction with tibiocalcaneal fusion. Tellisi et al (15) reported an 84% fusion rate at the arthrodesis site in 12 patients undergoing simultaneous proximal tibial lengthening. All osteotomy sites in their series healed. The average external fixation period was 8.4 (range 5 to 23) months, slightly shorter than the external fixation period of 13 months for our tibial lengthening. Rochman et al (16) reported 9 successful fusions in 11 patients who had undergone tibiocalcaneal fusion using an Ilizarov external fixation method for infected talar nonunions or extrusions, with 8 patients undergoing concomitant lengthening with the fixator. They reported that an advantage to using a circular external fixation device was that the wires can be kept outside the zone of injury or infection; thus, arthrodesis can be achieved without leaving a foreign body at the arthrodesis site. IM nailing has been described successfully for tibiocalcaneal fusion. Paola et al (17) reported a 100% limb salvage rate for 18 diabetic patients who had undergone pantalar arthrodesis using IM retrograde transcalcaneal nailing, 3 of whom underwent talectomy. Screw placement for IM nailing in tibiocalcaneal arthrodesis is challenging. Many newer nails have talar screw holes, which pose difficulty in tibiocalcaneal fusion. The use of IM nailing in a talectomy patient necessitates the use of 2 screw holes in the calcaneus for adequate rigidity. Often, attempted placement of a second point of fixation in the calcaneus will be difficult, and the screw hole intended for the talus could end up in the distal tibia. Many newer ankle arthrodesis nails feature a valgus bend to provide an anatomic fit, with better purchase through the calcaneal bone. Although we have routinely used these anatomic nails for tibiotalocalcaneal arthrodesis, we believe that a straight nail should be used for tibiocalcaneal fusion. In tibiocalcaneal arthrodesis, posterior and medial displacement of the foot reduces the amount of pedal bone mass available to accept the base of the IM nail. Thus, straight ankle fusion nails or distal femoral retrograde nails might be more anatomically reliable. Pelton et al (18) used a dynamic retrograde IM nail for tibiotalocalcaneal fusion in 33 patients, specifically studying the insertion technique, length, and valgus orientation of the IM nail. They reported an 88% fusion rate (18). They noted that they attempted to maintain a more valgus heel orientation by obliquely orienting the rod in the distal tibial metaphysis, which inherently increased the nail–tibial angle. Of the 4 nonunions in the study, 3 had a nail–tibial angle of 6.8 to 8.0 of valgus positioning, emphasizing the importance of inserting the nail along the mechanical axis of the tibia. In patients with successful fusions, the average nail–tibial angle was 2.8 . No stress fractures occurred. Pinzur and Noonan (19) discussed the importance of using a longer IM nail in the neuropathic at-risk population to prevent stress fracture of the tibia at the proximal aspect of the nail. Their work was based on the findings from Noonan et al (20) in a biomechanical study showing an area of stress concentration about the proximal locking screw of a standard-length ankle fusion nail (15 to 18 cm). This stress concentration was shown to dissipate by using a nail that extended to the

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proximal tibial metaphysis. We agree with Noonan et al (20) regarding the use of a longer IM nail in compromised bone and have routinely used 300-mm ankle fusion nails or humeral or femoral nails to ensure that the nail passes the isthmus of the tibia. Successful outcomes have been reported using condylar blade plates for tibiocalcaneal arthrodesis. Myerson et al (21) retrospectively reviewed the records of 30 patients who had undergone tibiocalcaneal fusion performed with an adolescent-size condylar blade plate and allograft bone. Of the 30 patients, 2 developed a tibial stress fracture that occurred at the proximal end of the blade plate 9 and 14 months after surgery. They postulated that the etiology of these fractures was the stress concentration at the proximal screw. The investigators concluded that tibiocalcaneal arthrodesis with the use of an adolescent-size condylar blade plate and allograft bone is a viable option for the diabetic Charcot deformity and can achieve a stable plantigrade foot, with relatively few complications. The limitations of the present study included its retrospective nature and small number of cases reviewed. The patients were not enrolled consecutively. Instead, 6 cases with available radiographic and clinical follow-up data were chosen to outline the different fixation combinations for tibiocalcaneal fusion in the high-risk foot. The postoperative follow-up period was inconsistent and ranged from 8 months to 9 years. We participated in the care of the reported patients. Multiple methods of fixation are available for limb salvage tibiocalcaneal fusion in the patient with Charcot arthropathy. Although we have used multiple forms of internal fixation, including compression screw fixation and retrograde IM nailing, we believe that additional stability with external fixation is paramount for the success of neuropathic tibiocalcaneal arthrodesis. Circular multiplane fixation constructs have proved to be an effective modality for producing tibiocalcaneal arthrodesis in high-risk neuropathic patients. The fixation options must be weighed on a case-by-case basis to produce the most stable construct amenable to arthrodesis. Tibiocalcaneal arthrodesis is a reasonable and realistic method for producing community ambulators in this high-risk patient population. External fixation allows for successful early intervention, even in the presence of bone and soft tissue infection. In conclusion, we have reported successful outcomes for 6 patients who underwent tibiocalcaneal arthrodesis. All patients were capable of community ambulation on a braceable limb and were functioning independently at their most recent follow-up visit. Additional research is necessary to compare the fixation methods in tibiocalcaneal arthrodesis in the high-risk patient. A prospective cohort study comparing the internal fixation methods in conjunction with external fixation would provide insight regarding the best fixation options for difficult limb salvage reconstruction.

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15. Tellisi N, Fragomen AT, Ilizarov S, Rozbruch SR. Limb salvage reconstruction of the ankle with fusion and simultaneous tibial lengthening using the Ilizarov/Taylor spatial frame. HSS J 4:32–42, 2008. 16. Rochman R, Hutson JJ, Alade O. Tibiocalcaneal arthrodesis using the Ilizarov technique in the presence of bone loss and infection of the talus. Foot Ankle Int 29:1001–1008, 2008. 17. Paola LD, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, Merico M, De Vido D, Da Ros R, Assaloni R. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int 28:967–970, 2007. 18. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int 27:759–763, 2006. 19. Pinzur MS, Noonan T. Ankle arthrodesis with a retrograde femoral nail for Charcot ankle arthropathy. Foot Ankle Int 26:545–549, 2005. 20. Noonan T, Pinzur MS, Paxinos O, Havey R, Patwardhin A. Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a biomechanical analysis of the effect of nail length. Foot Ankle Int 26:304–330, 2005. 21. Myerson MS, Alvarez RG, Lam PWC. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 21:643–650, 2000.