579264
research-article2015
FAIXXX10.1177/1071100715579264Foot & Ankle InternationalPaul et al
Technique Tip
Tibiotalocalcaneal Arthrodesis With an Intramedullary Hindfoot Nail and Pillar Fibula Augmentation: Technical Tip
Foot & Ankle International® 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715579264 fai.sagepub.com
Jochen Paul, MD1, Alexej Barg, MD1, Monika Horisberger, MD1, Mario Herrera, MD2, Heath B. Henninger, PhD3, and Victor Valderrabano, MD1
Level of Evidence: Level V, expert opinion. Keywords: tibiotalocalcaneal arthrodesis, intramedullary hindfoot nail, autologous augmentation, fibular autograft
Introduction Tibiotalocalcaneal (TTC) arthrodesis can provide ankle stability and shows promising results as a salvage procedure even in cases with severe bone loss at the ankle.1,11 Correct hindfoot and ankle alignment seems important in these cases to achieve adequate hindfoot stability and adequate pain relief. Especially in failed total ankle replacement, failed ankle arthrodesis, or cases of severe bone loss (eg, talectomy), revision surgery is challenging.3,6,12,13,16 In this technical tip we describe a new method using an autologous fibula augmentation in combination with an intramedullary hindfoot nail. The equal-sized pieces of the distal fibula are inserted in a circular array into the defect area, providing biomechanical stability and filling of the bony defect. The equal-sized fibula fragments are harvested from the ipsilateral fibula and placed in a vertical pillar technique around the hindfoot nail (Figure 1).
Description of Technique General or spinal anesthesia was used for surgery. Patients were placed in a supine position to operatively assess hindfoot alignment. A tourniquet was used at thigh level. Starting 20 cm above the tip of the lateral malleolus, a longitudinal incision was made down to the level of the sinus tarsi. Soft tissue preparation was performed to dissect the lateral ankle ligaments and syndesmosis, followed by a fibular osteotomy above the level of the syndesmosis. The distal fragment of the fibula was then osteotomized in a sagittal direction along its length, removing the medial half of the fibula and leaving the lateral half attached to its dorsal soft tissues, preserving the blood supply. The lateral half was also used for final stabilization on the lateral ankle after insertion of the hindfoot nail (lateral autologous fibula bridge
plating). The ankle joint was prepared for fusion depending on the index surgery by first removing any total ankle replacement (TAR) components, remaining cartilage, necrotic bone, or fibrotic tissue resulted from an ankle nonunion. Scar tissue, cysts, and/or osteophytes were resected and debrided. After preparation of the ankle joint, subtalar cartilage was removed to ensure solid subtalar fusion. A laminar spreader was used to distract the ankle joint, and the bone defect was measured (Figure 2A). Afterward, 4 ipsilateral autograft fibula fragments of the appropriate size were obtained via serial fibular osteotomies from distal to proximal (fibula fragments). The foot was then placed in a plantigrade position with approximately 0 to 5 degrees of hindfoot valgus and 10 degrees of external rotation. A guide wire was inserted at the plantar insertion point under fluoroscopic control and used for drilling and reaming to the desired nail diameter. After insertion of the curved hindfoot nail (Expert Hindfoot Arthrodesis Nail, Depuy-Synthes, West Chester, PA) under fluoroscopic guidance, distal nail fixation was performed with either 2 locking screws or a spiral blade, depending on bone quality of the calcaneus. The autograft fragments were placed in a circular pillar arrangement for bridging the defect at the ankle (Figure 2B). A press-fit insertion of the autograft fragments was the goal for maximal initial stability. Proximal fixation of the hindfoot nail was performed with 2 medial 1
Orthopaedic Department, University Hospital Basel, Basel, Switzerland Orthopaedic Department, University Hospital of Canary Island, Tenerife, Spain 3 Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, Salt Lake City, USA 2
Corresponding Author: Alexej Barg, MD, University Hospital, University of Basel, Spitalstrasse 21, 4031 Basel, Switzerland. Email: [email protected]
Downloaded from fai.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 10, 2015
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Foot & Ankle International
Figure 1. Schematic drawing of autologous circular pillar fibular augmentation with an intramedullary hindfoot nail from lateral view. The distal part of the fibula is resected and cut into 4 equal pieces. These pieces are assembled in a circular array to fill the bony defect around the hindfoot nail. At the end of the procedure, the lateral part of the distal fibula is fixed on the lateral side. HAN, Expert Hindfoot Arthrodesis Nail (Depuy-Synthes, West Chester, PA).
locking screws. A ventral angular stable locking plate was applied for additional sagittal stability. This implant bridged from the navicular and/or talus and the distal tibia. The remainder of the distal intact lateral fibula fragment was then approximated to the lateral side of the fusion, bridging the tibia to the calcaneus, and fixed with two 3.5 AO cortical screws for additional stabilization. The resected medial half of the fibula was used for additional bone graft. Demineralized bone matrix (DBM) was added in cases with gapping arthrodesis: for example, straight hindfoot positioning of a former valgus malalignment and gapping of the subtalar joint on the lateral side. Figure 3 illustrates a case of a male patient after talectomy on his left foot.
Figure 2. (A) Intraoperative documentation (lateral view of a left lower leg) of the bony defect at the ankle. A laminar spreader is used to distract the ankle joint. The intramedullary nail is in place. (B) The fibular parts are assembled in a circular fashion around the nail filling the bony defect.
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Figure 3. (A) Preoperative radiographs of an 38-year-old patient after talectomy on his right foot in Africa in 2007. He presented with shortening of the leg and persistent pain during weight bearing. (B) Postoperative radiographs after 6 weeks of tibiotalocalcaneal (TTC) arthrodesis with an anterior plate for additional sagittal stabilization (AP view of the ankle, lateral and AP view of the foot). (C) Computed tomography scan in 3 planes illustrating solid TTC fusion and good positioning of the circular augmentation with the fibula pieces. *Fibula pillar pieces around the nail in the axial view. (D) Radiographs of stable TTC arthrodesis with an additional anterior plate (AP and lateral views) after 2 years providing a good clinical result. AP view shows the height of the fibula resection.
Postoperative Rehabilitation The foot was placed in a plantigrade splint. After satisfactory wound healing and decreased swelling, the patient was mobilized with a stable walker (Aircast Walker, DonJoy Global, Vista, CA). Partial weight bearing (15 kg) was maintained during the first 8 weeks after surgery. The walker was removed after 8 weeks, and weight bearing was increased to full body weight.
Results Six patients were treated with TTC arthrodesis from January 2010 to December 2012 using the above described technique. There were 3 female and 3 male patients with a mean age of 55 ± 13.9 years (range, 38-73 years) at surgery. One patient had a posttraumatic talectomy with persistent pain, and 5 patients had failed TAR. The mean follow-up was 26 ± 10 months (range, 12-34 months). In this patient group, the preoperative mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was 29 ± 11.1 points (range, 12-40 points), and the mean visual analog scale (VAS) for pain was 7.5 ± 0.55 (range, 7-8). At follow-up, the mean AOFAS score was
significantly higher, 65 ± 8.7 points (range, 49-73 points) (P = .028) (with a maximum of 86 points for fused ankle and subtalar joints). The mean postoperative VAS for pain was significantly lower, 2 ± 1.1 (range, 1-4) (P = .026). The postoperative computed tomography (CT) scans showed good bony consolidation of the fibula augmentation pillars in all patients.
Discussion The circular fibula augmentation in combination with an intramedullary hindfoot nail is a treatment option in cases of ankle salvage surgery for stabilization of the hindfoot and restoration of leg length. More studies with a larger number of patients and a longer follow-up are needed to confirm the efficacy of the procedure. However, it is difficult to recruit a large number of patients in revision cases. TTC arthrodesis using an intramedullary nail is well studied in the literature and shows promising results.2,14 In cases with bone loss at the ankle, allografts and autogenous bone grafts (autografts) can compensate for the bone loss and restore leg length. Even if allografts are available from a bone bank, failure of integration, disease transmittance, and collapse of transplants are still unsolved problems.10 The
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Foot & Ankle International
World Health Organization Project NOTIFY documented transmission of different infectious diseases, such as human T-lymphotropic virus (HTLV) (1 case), hepatitis C virus (HCV) (10 cases), and even human immunodeficiency virus (HIV) (12 cases) after allograft implantation.10 In contrast, autografts have limited availability and potential donor-site morbidity: for example, when the graft is taken from the iliac crest.5,7,15 However, when the graft is taken from the distal fibula, donor site morbidity is low, as described in the literature.4 Another alternative to compensate for bone loss is to use an artificial product, such as trabecular metal (tantalum). Tantalum spacers have been used in revision cases to restore the bone loss and compensate for defect size.5,8 This might be an option for isolated arthrodesis of the ankle or the subtalar joint, but it is quite expensive. In addition, it is not compatible with the retrograde hindfoot nail and is an off-label use in this combination.5,8 Other treatment options are amputation or shortening arthrodesis. However, amputations are generally avoided whenever possible, and shortening arthrodesis can produce significant complications and limitations in everyday living.9 The described relevant complications for the lower extremity are a change of the pelvic tilt and functional changes in gait patterns.9
Conclusion The surgical technique presented here using an autologous ipsilateral circular pillar fibula augmentation in combination with an intramedullary hindfoot nail is a useful salvage surgery. The technique with equal-sized fibula pieces provided biomechanical stability, restored leg length and ankle stability, and corrected hindfoot alignment without the use of allograft. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Bennett GL, Cameron B, Njus G, Saunders M, Kay DB. Tibiotalocalcaneal arthrodesis: a biomechanical assessment of stability. Foot Ankle Int. 2005;26(7):530-536.
2. Budnar VM, Hepple S, Harries WG, Livingstone JA, Winson I. Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail. Foot Ankle Int. 2010;31(12):1085-1092. 3. DeVries JG, Nguyen M, Berlet GC, Hyer CF. The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg. 2012;51(4):426-432. 4. Farhadi J, Valderrabano V, Kunz C, Kern R, Hinterman B, Pierer G. Free fibula donor-site morbidity: clinical and biomechanical analysis. Ann Plast Surg. 2007;58(4):405-410. 5. 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. 2010;468(1):209-216. 6. Gursu S, Bahar H, Camurcu Y, et al. Talectomy and tibiocalcaneal arthrodesis with intramedullary nail fixation for treatment of equinus deformity in adults. Foot Ankle Int. 2015;35(1):46-50. 7. Heary RF, Schlenk RP, Sacchieri TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery. 2002;50(3):510-516; discussion 516-517. 8. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop. 2010;81(6):745-747. 9. Herscovici D Jr, Scaduto JM. Assessing leg length after fixation of comminuted femur fractures. Clin Orthop Relat Res. 2014;472(9):2745-2750. 10. Hinsenkamp M, Muylle L, Eastlund T, Fehily D, Noel L, Strong DM. Adverse reactions and events related to musculoskeletal allografts: reviewed by the World Health Organisation Project NOTIFY. Int Orthop. 2012;36(3):633-641. 11. Huang PJ, Fu YC, Lu CC, Wu WL, Cheng YM. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci. 2007;23(3):120-127. 12. Labek G, Klaus H, Schlichtherle R, Williams A, Agreiter M. Revision rates after total ankle arthroplasty in samplebased clinical studies and national registries. Foot Ankle Int. 2011;32(8):740-745. 13. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR. Circular external fixator-assisted ankle arthrodesis following failed total ankle arthroplasty. Foot Ankle Int. 2012;33(11):947-955. 14. Shah KS, Younger AS. Primary tibiotalocalcaneal arthrodesis. Foot Ankle Clin. 2011;16(1):115-136. 15. Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2003;28(2):134-139. 16. Tenenbaum S, Stockton KG, Bariteau JT, Brodsky JW. Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft. Foot Ankle Int. 2015;36(3):282-287.
Downloaded from fai.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 10, 2015
research-article2015
FAIXXX10.1177/1071100715579264Foot & Ankle InternationalPaul et al
Technique Tip
Tibiotalocalcaneal Arthrodesis With an Intramedullary Hindfoot Nail and Pillar Fibula Augmentation: Technical Tip
Foot & Ankle International® 1–4 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715579264 fai.sagepub.com
Jochen Paul, MD1, Alexej Barg, MD1, Monika Horisberger, MD1, Mario Herrera, MD2, Heath B. Henninger, PhD3, and Victor Valderrabano, MD1
Level of Evidence: Level V, expert opinion. Keywords: tibiotalocalcaneal arthrodesis, intramedullary hindfoot nail, autologous augmentation, fibular autograft
Introduction Tibiotalocalcaneal (TTC) arthrodesis can provide ankle stability and shows promising results as a salvage procedure even in cases with severe bone loss at the ankle.1,11 Correct hindfoot and ankle alignment seems important in these cases to achieve adequate hindfoot stability and adequate pain relief. Especially in failed total ankle replacement, failed ankle arthrodesis, or cases of severe bone loss (eg, talectomy), revision surgery is challenging.3,6,12,13,16 In this technical tip we describe a new method using an autologous fibula augmentation in combination with an intramedullary hindfoot nail. The equal-sized pieces of the distal fibula are inserted in a circular array into the defect area, providing biomechanical stability and filling of the bony defect. The equal-sized fibula fragments are harvested from the ipsilateral fibula and placed in a vertical pillar technique around the hindfoot nail (Figure 1).
Description of Technique General or spinal anesthesia was used for surgery. Patients were placed in a supine position to operatively assess hindfoot alignment. A tourniquet was used at thigh level. Starting 20 cm above the tip of the lateral malleolus, a longitudinal incision was made down to the level of the sinus tarsi. Soft tissue preparation was performed to dissect the lateral ankle ligaments and syndesmosis, followed by a fibular osteotomy above the level of the syndesmosis. The distal fragment of the fibula was then osteotomized in a sagittal direction along its length, removing the medial half of the fibula and leaving the lateral half attached to its dorsal soft tissues, preserving the blood supply. The lateral half was also used for final stabilization on the lateral ankle after insertion of the hindfoot nail (lateral autologous fibula bridge
plating). The ankle joint was prepared for fusion depending on the index surgery by first removing any total ankle replacement (TAR) components, remaining cartilage, necrotic bone, or fibrotic tissue resulted from an ankle nonunion. Scar tissue, cysts, and/or osteophytes were resected and debrided. After preparation of the ankle joint, subtalar cartilage was removed to ensure solid subtalar fusion. A laminar spreader was used to distract the ankle joint, and the bone defect was measured (Figure 2A). Afterward, 4 ipsilateral autograft fibula fragments of the appropriate size were obtained via serial fibular osteotomies from distal to proximal (fibula fragments). The foot was then placed in a plantigrade position with approximately 0 to 5 degrees of hindfoot valgus and 10 degrees of external rotation. A guide wire was inserted at the plantar insertion point under fluoroscopic control and used for drilling and reaming to the desired nail diameter. After insertion of the curved hindfoot nail (Expert Hindfoot Arthrodesis Nail, Depuy-Synthes, West Chester, PA) under fluoroscopic guidance, distal nail fixation was performed with either 2 locking screws or a spiral blade, depending on bone quality of the calcaneus. The autograft fragments were placed in a circular pillar arrangement for bridging the defect at the ankle (Figure 2B). A press-fit insertion of the autograft fragments was the goal for maximal initial stability. Proximal fixation of the hindfoot nail was performed with 2 medial 1
Orthopaedic Department, University Hospital Basel, Basel, Switzerland Orthopaedic Department, University Hospital of Canary Island, Tenerife, Spain 3 Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, Salt Lake City, USA 2
Corresponding Author: Alexej Barg, MD, University Hospital, University of Basel, Spitalstrasse 21, 4031 Basel, Switzerland. Email: [email protected]
Downloaded from fai.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 10, 2015
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Foot & Ankle International
Figure 1. Schematic drawing of autologous circular pillar fibular augmentation with an intramedullary hindfoot nail from lateral view. The distal part of the fibula is resected and cut into 4 equal pieces. These pieces are assembled in a circular array to fill the bony defect around the hindfoot nail. At the end of the procedure, the lateral part of the distal fibula is fixed on the lateral side. HAN, Expert Hindfoot Arthrodesis Nail (Depuy-Synthes, West Chester, PA).
locking screws. A ventral angular stable locking plate was applied for additional sagittal stability. This implant bridged from the navicular and/or talus and the distal tibia. The remainder of the distal intact lateral fibula fragment was then approximated to the lateral side of the fusion, bridging the tibia to the calcaneus, and fixed with two 3.5 AO cortical screws for additional stabilization. The resected medial half of the fibula was used for additional bone graft. Demineralized bone matrix (DBM) was added in cases with gapping arthrodesis: for example, straight hindfoot positioning of a former valgus malalignment and gapping of the subtalar joint on the lateral side. Figure 3 illustrates a case of a male patient after talectomy on his left foot.
Figure 2. (A) Intraoperative documentation (lateral view of a left lower leg) of the bony defect at the ankle. A laminar spreader is used to distract the ankle joint. The intramedullary nail is in place. (B) The fibular parts are assembled in a circular fashion around the nail filling the bony defect.
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Paul et al
Figure 3. (A) Preoperative radiographs of an 38-year-old patient after talectomy on his right foot in Africa in 2007. He presented with shortening of the leg and persistent pain during weight bearing. (B) Postoperative radiographs after 6 weeks of tibiotalocalcaneal (TTC) arthrodesis with an anterior plate for additional sagittal stabilization (AP view of the ankle, lateral and AP view of the foot). (C) Computed tomography scan in 3 planes illustrating solid TTC fusion and good positioning of the circular augmentation with the fibula pieces. *Fibula pillar pieces around the nail in the axial view. (D) Radiographs of stable TTC arthrodesis with an additional anterior plate (AP and lateral views) after 2 years providing a good clinical result. AP view shows the height of the fibula resection.
Postoperative Rehabilitation The foot was placed in a plantigrade splint. After satisfactory wound healing and decreased swelling, the patient was mobilized with a stable walker (Aircast Walker, DonJoy Global, Vista, CA). Partial weight bearing (15 kg) was maintained during the first 8 weeks after surgery. The walker was removed after 8 weeks, and weight bearing was increased to full body weight.
Results Six patients were treated with TTC arthrodesis from January 2010 to December 2012 using the above described technique. There were 3 female and 3 male patients with a mean age of 55 ± 13.9 years (range, 38-73 years) at surgery. One patient had a posttraumatic talectomy with persistent pain, and 5 patients had failed TAR. The mean follow-up was 26 ± 10 months (range, 12-34 months). In this patient group, the preoperative mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was 29 ± 11.1 points (range, 12-40 points), and the mean visual analog scale (VAS) for pain was 7.5 ± 0.55 (range, 7-8). At follow-up, the mean AOFAS score was
significantly higher, 65 ± 8.7 points (range, 49-73 points) (P = .028) (with a maximum of 86 points for fused ankle and subtalar joints). The mean postoperative VAS for pain was significantly lower, 2 ± 1.1 (range, 1-4) (P = .026). The postoperative computed tomography (CT) scans showed good bony consolidation of the fibula augmentation pillars in all patients.
Discussion The circular fibula augmentation in combination with an intramedullary hindfoot nail is a treatment option in cases of ankle salvage surgery for stabilization of the hindfoot and restoration of leg length. More studies with a larger number of patients and a longer follow-up are needed to confirm the efficacy of the procedure. However, it is difficult to recruit a large number of patients in revision cases. TTC arthrodesis using an intramedullary nail is well studied in the literature and shows promising results.2,14 In cases with bone loss at the ankle, allografts and autogenous bone grafts (autografts) can compensate for the bone loss and restore leg length. Even if allografts are available from a bone bank, failure of integration, disease transmittance, and collapse of transplants are still unsolved problems.10 The
Downloaded from fai.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 10, 2015
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Foot & Ankle International
World Health Organization Project NOTIFY documented transmission of different infectious diseases, such as human T-lymphotropic virus (HTLV) (1 case), hepatitis C virus (HCV) (10 cases), and even human immunodeficiency virus (HIV) (12 cases) after allograft implantation.10 In contrast, autografts have limited availability and potential donor-site morbidity: for example, when the graft is taken from the iliac crest.5,7,15 However, when the graft is taken from the distal fibula, donor site morbidity is low, as described in the literature.4 Another alternative to compensate for bone loss is to use an artificial product, such as trabecular metal (tantalum). Tantalum spacers have been used in revision cases to restore the bone loss and compensate for defect size.5,8 This might be an option for isolated arthrodesis of the ankle or the subtalar joint, but it is quite expensive. In addition, it is not compatible with the retrograde hindfoot nail and is an off-label use in this combination.5,8 Other treatment options are amputation or shortening arthrodesis. However, amputations are generally avoided whenever possible, and shortening arthrodesis can produce significant complications and limitations in everyday living.9 The described relevant complications for the lower extremity are a change of the pelvic tilt and functional changes in gait patterns.9
Conclusion The surgical technique presented here using an autologous ipsilateral circular pillar fibula augmentation in combination with an intramedullary hindfoot nail is a useful salvage surgery. The technique with equal-sized fibula pieces provided biomechanical stability, restored leg length and ankle stability, and corrected hindfoot alignment without the use of allograft. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Bennett GL, Cameron B, Njus G, Saunders M, Kay DB. Tibiotalocalcaneal arthrodesis: a biomechanical assessment of stability. Foot Ankle Int. 2005;26(7):530-536.
2. Budnar VM, Hepple S, Harries WG, Livingstone JA, Winson I. Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail. Foot Ankle Int. 2010;31(12):1085-1092. 3. DeVries JG, Nguyen M, Berlet GC, Hyer CF. The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg. 2012;51(4):426-432. 4. Farhadi J, Valderrabano V, Kunz C, Kern R, Hinterman B, Pierer G. Free fibula donor-site morbidity: clinical and biomechanical analysis. Ann Plast Surg. 2007;58(4):405-410. 5. 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. 2010;468(1):209-216. 6. Gursu S, Bahar H, Camurcu Y, et al. Talectomy and tibiocalcaneal arthrodesis with intramedullary nail fixation for treatment of equinus deformity in adults. Foot Ankle Int. 2015;35(1):46-50. 7. Heary RF, Schlenk RP, Sacchieri TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery. 2002;50(3):510-516; discussion 516-517. 8. Henricson A, Rydholm U. Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement. Acta Orthop. 2010;81(6):745-747. 9. Herscovici D Jr, Scaduto JM. Assessing leg length after fixation of comminuted femur fractures. Clin Orthop Relat Res. 2014;472(9):2745-2750. 10. Hinsenkamp M, Muylle L, Eastlund T, Fehily D, Noel L, Strong DM. Adverse reactions and events related to musculoskeletal allografts: reviewed by the World Health Organisation Project NOTIFY. Int Orthop. 2012;36(3):633-641. 11. Huang PJ, Fu YC, Lu CC, Wu WL, Cheng YM. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci. 2007;23(3):120-127. 12. Labek G, Klaus H, Schlichtherle R, Williams A, Agreiter M. Revision rates after total ankle arthroplasty in samplebased clinical studies and national registries. Foot Ankle Int. 2011;32(8):740-745. 13. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR. Circular external fixator-assisted ankle arthrodesis following failed total ankle arthroplasty. Foot Ankle Int. 2012;33(11):947-955. 14. Shah KS, Younger AS. Primary tibiotalocalcaneal arthrodesis. Foot Ankle Clin. 2011;16(1):115-136. 15. Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2003;28(2):134-139. 16. Tenenbaum S, Stockton KG, Bariteau JT, Brodsky JW. Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft. Foot Ankle Int. 2015;36(3):282-287.
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