ortho journal club 11 by dr saumya agarwal
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Addressing Hindfoot Arthritis with Concomitant Tibial Malunion or Nonunion
with Retrograde TibioTaloCalcaneal Nailing: A Novel Treatment Approach
Justin M. Kane et alRothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Journal of Bone and Joint Surgery| April 2014 | Vol. 96-A | Number 7
Level of evidence I
PRESENTER : Dr SAUMYA AGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum
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INTRODUCTION• Tibial shaft fractures are most common long bone fractures with incidence upto 26 / lakh people
• Malunion and nonunion most common with tibial shaft fractures
• Prearthrotic deformity - coined by rosemeyer and described as effect of angular deformity of tibia on distribution of weight across adjacent joints
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REVIEW OF LITERATURE
• Sarmiento found deformity 0f >5⁰ ---> late onset degenerative changes in adjacent joints
• Puno et al concluded - anatomic reduction could reduce abnormal forces at adjacent joints and possibly delay arthritis at ankle
• Tarr et al found - more distal the deformity, greater the impact on incongrous tibiotalar contact area
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• Milner et al evaluated late onset arthritis post tibial shaft fractures and found more osteoarthritis in knee and ankle on injured extremity.
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Various Treatment Options
1. Tibial osteotomy with ankle arthrodesis/ arthroplasty
2. External fixation to correct malunion or nonunion with ankle arthrodesis
3. Tibiocalcaneal nail fixation for correction of malunion or nonunion and arthrodesis of ankle
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METHODS
• A retrospective study
• Patients who underwent single stage reconstruction for tibia malunion or nonunion with tibiotalar arthritis were assessed
• Visual Analog Scale and American Orthopaedic Foot and Ankle Society – Ankle Hindfoot scores were used to assess
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Exclusion Criteria
• Active infection
• Leg length discrepancy of >5cm
• Malunion or nonunion at ankle joint secondary to ankle fracture
• Treatment with a staged procedure or single stage deformity correction with arthroplasty
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• 25 patients underwent single stage correction of tibial malunion or nonunion with tibiotalocalcaneal nailing
• Average age – 58 yrs
• 13 men and 12 women
• 3 patients had severe rheumatoid arthritis
• 8 patients had peripheral neuropathy
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• 16 had healed angular malunion
• 4 had combined malunion and nonunion
• 5 had tibial nonunion
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Varus and recurvatum deformity
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• Overall average sagittal plane malalignment was 26⁰ and average coronal plane malalignment was 21⁰
• Ankle joint arthritis was assessed for pain, ROM and palpable crepitus
• AP, Mortise and lateral views were taken
• Weight bearing radiographs were taken to assess joint space narrowing, subchondral sclerosis and osteophyte formation
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• Subtalar joint and transverse tarsal joints were assessed independently
• An inflexible subtalar joint can decrease ability to correct alignment and lead to undesirable results
• Inclusion of subtalar joint in arthritis, aided in correction of deformity and allowed use of single device to treat arthritis and malunion
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• Author hypothesized that whenever subtalar involvement was suspected, that joint should be included in fusion to improve the final alignment and stability
• All patients underwent a single stage reconstruction including deformity correction via realignment osteotomy combined with arthrodesis of ankle and subtalar joint
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Surgical Technique
• Osteotomy requires preoperative radiographic planning to establish centre of rotation axis of deformity and to plan for triplanar cuts for deformity correction
• Under C-arm, k-wires are drilled across tibia
• Author suggest multiple drill holes along plane of planned cut using drill bit with continuous irrigation
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• Correction should be achieved in all planes i.e., coronal, sagittal and rotational
• Fine adjustments were made using microsagittal saw until required alignment is obtained, recreating mechanical axis of limb
• After correction of proximal alignment, ankle and subtalar joints are prepared exposing subchondral bone
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• Definitive fixation is obtained with retrograde intramedullary nail inserted through plantar aspect of calcaneum into tibial shaft ending 5 cm proximal to level of deformity correction
• 15, 20 and 25cm length nail has been used according to fracture site
• Distal part of fibula and iliac crest was used for bone grafting
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• 19 patients underwent tibiotalolcalcaneal fusion , 6 underwent pantalar (talonavicular and calcaneocuboid) fusion
• Transverse tarsal joints are approached through standard open incisions, articular cartilage and subchondral bone is removed and joints derotated to neutral
• Fixation is obtained with 2 parallel retrograde screws across talonavicular joint and staples across calcaneocuboid joint
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• Non weight bearing was advised for 6 weeks for traumatic patients and 12 weeks for patients having neuropathy
• Healing was assessed clinically and radiographically
• 1 patient developed infection because of additional surgery and had poor result and was unsatisfied
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RESULTS• All nonunions, osteotomy sites and fusion sites
healed clinically and radiographically at an average of 19.5 weeks
• Radiographs at final follow up showed continued stable healing of fusion and osteotomy sites without loss of alignment
• All deformities were corrected to neutral alignment and all patients had a plantigrade foot and ability to wear off the shelf shoes without bracing
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• 21 patients were extremely satisfied
• 3 were satisfied
• 1 was not satisfied
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DISCUSSION
• Retrograde intramedullary nailing for tibiotalo calcaneal arthrodesis is described as a salvage procedure for patients with
• a failed ankle fusion or
• total ankle arthroplasty with severe bone loss,
• charcot arthropathy,
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• rheumatoid arthritis,
• posttraumatic arthritis,
• previous talectomy,
• bone loss after tumor resection,
• tuberculous arthropathy
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• High rate of fusion and biomechanical strength of construct successfully achieves a painless biomechanically stable plantigrade foot
• Various studies showed high fusion rate around 90%
• Study recommends inclusion of subtalar joint and utilization of intramedullary device to ensure deformity correction and a stable ankle hindfoot construct
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PITFALLS
• Retrospective nature of study
• AOFAS scoring and patient satisfaction survey are not validated
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CONCLUSION• Single stage procedure of tibial osteotomy and
retrograde intramedullary nailing for correction of angular deformity and fusion of arthritic hindfoot :
provides a viable alternative to multiplanar external fixation or a staged procedure
• Accurate correction with meticulous joint preparation is required to achieve good results.
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