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The Northern Ohio Foot and Ankle Journal Official Publication of the NOFA Foundation The Northern Ohio Foot & Ankle Foundation Journal, 2016 NORTHERN OHIO FOOT & ANKLE FOUNDATION Failed Tibiotalocalcaneal arthrodesis: A case report and review By Michael Wheeler, DPM 1 The Northern Ohio Foot and Ankle Journal 3 (2): 2 Abstract: This case report is a review of an instance in which a diabetic patient underwent tibiotalocalcaneal arthrodesis to correct a severe hindfoot varus deformity and salvage a patient’s limb. The deformity had progressed to a point where the extremity was no longer braceable and had led to the development of a lateral foot wound. Had no intervention been performed, it was theorized to be only a matter of time before the patient developed an acute Charcot event. The patient’s postoperative course was complicated by multiple tibial fractures which required subsequent open reduction with internal fixation and ultimately resulted in the patient having a stable extremity which allows them ambulate without a prosthetic device. Key words: Tibiotalocalcaneal Arthrodesis, TTC Fusion, TTC Plate, Tibial Fracture, Intramedullary Nail, IM nail Accepted: January, 2016 Published: February, 2016 This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Northern Ohio Foot and Ankle Foundation Journal. (www.nofafoundation.org) 2016. All rights reserved. ibiotalocalcaenal (TTC) arthrodesis is one of the most challenging endeavors in foot and ankle surgery and is often associated with poor outcomes. The goal of this surgery is to achieve a stable construct which alleviates that patient’s pain and/or corrects underlying deformity. 1 Typical indications of TTC arthrodesis include severe hindfoot deformity which is often associated with any number of neuromuscular or congenital conditions. Indications can also include end-stage arthritis of ankle and subtalar joint, failed total ankle arthroplasty, and avascular necrosis of the talus. The reported success rate of TTC arthrodesis ranges from 70-90 percent in the literature. 2 In this case report, we present a patient with severe varus hindfoot Address correspondence to: [email protected]. Department of Foot and Ankle Surgery, MercyHealth Physicians 1 Chief Resident, Healthspan/Mercy Regional Medical Center Foot and Ankle Residency Program deformity who underwent TTC arthrodesis using a locked lateral plate construct which resulted in tibial fracture followed by multiple surgical attempts at limb salvage. The Patient: A 48 year old Caucasian female was referred to our intuition from an outside provider for skin grafting of a right foot wound as well as severe right ankle deformity. The patient reported a slowly progressive deformity in her right ankle over the past 11 months despite using her Charcot Restraint Orthotic Walker (CROW) boot faithfully. She stated her CROW once fit comfortably; however, it no longer fit on her deformed right lower extremity. The patient’s past medical history was significant for type two diabetes complicated by diabetic peripheral neuropathy, hypothyroidism, hypertension, and T
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Page 1: NORTHERN OHIO FOOT& ANKLE · The!Northern!Ohio!Foot!and!Ankle!Journal! Official!Publication!of!the!NOFA!Foundation! !! The Northern Ohio Foot & Ankle Foundation Journal, 2016 NORTHERN

!The!Northern!Ohio!Foot!and!Ankle!Journal! Official!Publication!of!the!NOFA!Foundation! !!

The Northern Ohio Foot & Ankle Foundation Journal, 2016

NORTHERN OHIO FOOT & ANKLEFOUNDATION

Failed Tibiotalocalcaneal arthrodesis: A case report and review By Michael Wheeler, DPM1 The Northern Ohio Foot and Ankle Journal 3 (2): 2

Abstract: This case report is a review of an instance in which a diabetic patient underwent tibiotalocalcaneal arthrodesis to correct a severe hindfoot varus deformity and salvage a patient’s limb. The deformity had progressed to a point where the extremity was no longer braceable and had led to the development of a lateral foot wound. Had no intervention been performed, it was theorized to be only a matter of time before the patient developed an acute Charcot event. The patient’s postoperative course was complicated by multiple tibial fractures which required subsequent open reduction with internal fixation and ultimately resulted in the patient having a stable extremity which allows them ambulate without a prosthetic device. Key words: Tibiotalocalcaneal Arthrodesis, TTC Fusion, TTC Plate, Tibial Fracture, Intramedullary Nail, IM nail Accepted: January, 2016 Published: February, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Northern Ohio Foot and Ankle Foundation Journal. (www.nofafoundation.org) 2016. All rights reserved.

ibiotalocalcaenal (TTC) arthrodesis is one of the most challenging endeavors in foot and ankle surgery and is often associated with poor

outcomes. The goal of this surgery is to achieve a stable construct which alleviates that patient’s pain and/or corrects underlying deformity.1 Typical indications of TTC arthrodesis include severe hindfoot deformity which is often associated with any number of neuromuscular or congenital conditions. Indications can also include end-stage arthritis of ankle and subtalar joint, failed total ankle arthroplasty, and avascular necrosis of the talus. The reported success rate of TTC arthrodesis ranges from 70-90 percent in the literature.2 In this case report, we present a patient with severe varus hindfoot

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Address correspondence to: [email protected]. Department of Foot and Ankle Surgery, MercyHealth Physicians 1Chief Resident, Healthspan/Mercy Regional Medical Center Foot and Ankle Residency Program

deformity who underwent TTC arthrodesis using a locked lateral plate construct which resulted in tibial fracture followed by multiple surgical attempts at limb salvage. The Patient: A 48 year old Caucasian female was referred to our intuition from an outside provider for skin grafting of a right foot wound as well as severe right ankle deformity. The patient reported a slowly progressive deformity in her right ankle over the past 11 months despite using her Charcot Restraint Orthotic Walker (CROW) boot faithfully. She stated her CROW once fit comfortably; however, it no longer fit on her deformed right lower extremity. The patient’s past medical history was significant for type two diabetes complicated by diabetic peripheral neuropathy, hypothyroidism, hypertension, and

T

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Volume 3 No. 2, February 2016 The Northern Ohio Foot & Ankle Foundation Journal

The Northern Ohio Foot & Ankle Foundation Journal, 2016

hyperlipidemia. She admitted to being compliant with her home medications for management of most of her chronic medical conditions. The patient also openly admitted she was unable to afford her long-acting insulin for diabetes management as she was unemployed. She denied any previous history of foot or ankle surgery and denied the use of alcohol, tobacco, or illicit drugs. Physical examination: The patient’s vascular status was grossly intact to her right extremity. Protective sensation was absent when tested with 5.07 Semmes Weinstein monofilament. Skin temperature gradient was symmetric when compared to the contralateral extremity. There was a full-thickness ulceration noted to the lateral right foot around lateral fifth metatarsal base which measured 3.2 x 5.1 x 0.3 centimeters (fig. 1). The ulceration did not appear clinically infected with no appreciable purulent drainage, malodor, and a negative probe to bone test. The patient’s ankle had a considerable varus mal-alignment noted which as semi-reducible with manual manipulation.

Surgical Workup: Weight x-rays were obtained (fig. 2) to assess the extent of the patient’s hindfoot deformity. Routine labs were drawn and most were within normal limits with the exception of the patient’s hemoglobin A1c and vitamin D levels which were 10.8 % (4-6.4%) and 8.5 ng/mL (30.0-100.0 ng/mL) respectively. Cardiac and medical clearances were obtained and endocrinology was consulted for tighter management of patient’s blood glucose as well as vitamin D supplementation during the peri-operative period.

Attempts were made at obtaining the patient’s Dual Energy X-ray Absorptiometry Scan (DXA) from an outside medical facility; however, they were unable to be obtained prior to surgical intervention. Per the patient’s recollection, she had a conversation with her primary care physician (PCP) approximately one year prior regarding having adequate bone mineral density. Her PCP had determined that bisphosphonate therapy was not necessary at that time. Even though the patient’s pulses were felt to be adequate, noninvasive vascular testing was ordered which revealed triphasic waveforms with right sided Ankle Brachial Index (ABI) reading of 1.14 (0.9-1.3) and Toe Brachial Index (TBI) reading of 0.81 (>0.65). The patient was found to be negative for osteomyelitis by the infectious disease service due to normal erythrocyte sedimentation rate, c-reactive protein and no significant bone marrow edema around the area of open ulceration on magnetic resonance imaging (MRI). After a lengthy discussion with the patient regarding surgical intervention she agreed to undergo tibiotalocalcaneal (TTC) arthrodesis with excision and primary closure of lateral foot wound. External fixation, internal fixation, and below knee amputation were all considered as options for the patient. She was adamant that she would not consent to an amputation at this time. She did understand that her current surgery was considered high-risk and there was a very high likelihood that she may end up losing her extremity at any point in the postoperative period.

Figure 1: Clinical photograph of patient’s extremity at the time of initial presentation. The ulceration around 5th metatarsal base is depicted in the center image.

Figure 2: Initial weight bearing x-ray of patient's right lower extremity demonstrating the varus deformity and anterior displacement of the ankle joint.

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The Northern Ohio Foot & Ankle Foundation Journal, 2016!

During the conversation with the patient about external versus internal fixation, the patient desired to have only internal fixation.

Surgical Technique After obtaining a popliteal and saphenous block in the preoperative area, the patient was brought into the OR and placed on the operating room table in the lateral decubitus position and general anesthesia was induced. Initial attempts at soft tissue release were attempted with Achilles tendon lengthening, release of posterior tibial tendon, and deltoid ligaments which did not sufficiently correct the hindfoot deformity to the point of having a braceable extremity. The surgical approach was though an “L” shaped lateral incision to allow adequate visualization of the ankle and subtalar joints. Care was taken to avoid any important neurovascular structures in the region. The most distal aspect of the fibula was removed using a sagittal saw in order to gain access to the necessary articular surfaces. The distal fibula was later used as autogenous bone graft within the arthrodesis sites.

The ankle and subtalar joints were prepared via contour resection using a combination of curved osteotomes and bone curettes. The subchondral plate was prepared or “fish-scaled” per standard technique using osteotomes and a mallet. Provisional fixation of the arthrodesis sites was obtained using two 2.5 mm guide wires. A cannulated 6.5 mm short thread screw was inserted from the posterior superior tibia through the ankle joint into the anterior talus. Additional fixation was obtained using a cannulated 6.5 mm short thread screw was run from the inferior calcaneus through the subtalar and ankle joint superiorly. The entire construct was then secured using a Wright Medical Ortholoc® 3Di lateral TTC fusion plate which was filled with a combination of locking and non-locking 5.5 mm screws (fig. 4).

Figure 4: Intra-op fluoroscopy of guidewire and hindfoot alignment (top) and hardware construct (center and bottom)

Figure 3: Initial MRI of patient’s right ankle showing ankle joint effusion (top left and bottom), varus deformity (top left and right), and absence of bone marrow edema around 5th metatarsal base (bottom).

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After sound internal fixation was achieved, layered closure was performed and a closed suction drain was placed. The operative extremity was placed in a modified Jones compressive dressing with posterior splint. The closed suction drain was pulled at 48 hours. The patient was subsequently discharged to a skilled nursing facility (SNF) 72 hours postop with orders for strict non weight bearing to the operative extremity. Shortly after admission to the SNF, the patient signed herself out against medical advice as she preferred to convalesce at home.

She kept her regularly scheduled follow up appointments at weekly intervals and was placed in sequential short leg casts. Figure 5 depicts alignment of the operative extremity and condition of surgical incisions at three weeks post op when sutures were removed. She continued to follow up regularly for 3 months when for serial radiographs and sequential casting until x-rays showed signs bony bridging across the arthrodesis sites. At 3 months postop the patient was transitioned to a tall fracture walking boot and allowed to be partial weight bearing with assistance of a walker. Approximately one week after patient was permitted to begin partial weight bearing, she presented to the ED stating she felt a crack in her operative extremity after only taking 2-3 steps at home without the assistance of her boot or walker. Radiographs were taken in the ED and demonstrated a small fracture of the tibia (fig 6).

!Figure 6: AP and Lateral ED radiographs depicting fracture of medial cortex of the tibia at the most proximal screw

After being evaluated in the emergency department, the patient was placed into a short leg cast and once again instructed to maintain strict non weight bearing. Several days after discharge from the ED she returned to the ED stating that she fell.

At the time of presenting to the ED the fracture was grossly unstable and closed reduction was attempted. The patient was placed into a modified Jones compression dressing with a posterior splint. The patient was then transferred to the orthopedics service at a tertiary care hospital where she underwent partial hardware removal with open reduction and implantation of new internal fixation (fig. 8).

Figure 5: Patient's operative extremity 3 weeks postop in satisfactory rectus alignment with no wound healing issues.

Figure 7: AP and Lateral ED radiographs depicting through and through fracture of the with angular deformity.

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The patient failed to keep her regularly scheduled follow up appointments and presented to her orthopedic surgeon’s office approximately 6 weeks after her second operation ambulating unassisted in her short leg cast. Radiographs were taken and showed secondary hardware failure (fig 9). Upon removal of the cast she was found to have an open ulceration about the medial aspect of the leg with exposed hardware and bone.

The patient was brought to the operating room for a third time to remove exposed hardware and irrigation of her open anteromedial leg wound. She was subsequently placed into a total contact cast and treated for presumed osteomyelitis with a 6 week course of vancomycin and piperacillin/tazobactam IV. After treatment of the patient’s presumed osteomyelitis the wound was allowed to granulate and epithelialize by secondary intention. She was eventually transferred into a fracture walking boot and then to a solid AFO device. She now ambulates with the assistance of cane.

Despite the patient’s complex course of treatment, she now has a stable plantigrade right foot and leg which allow her to resume her normal activities of daily living. She is happy with her result and pleased

Figure 8 AP and Lateral radiographs depicting interval hardware removal and ORIF of proximal tibial fracture

Figure 9 AP and Lateral radiographs depicting failure of hardware and exuberant bone callous formation

Figure 10 Final AP and Lateral radiographs depicting exhuberant bone callous formation with remaining hardware.

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that she does not require a prosthetic limb for ambulation. Critiques & Conclusion: From a medical standpoint, the patient was not “optimized” prior to undergoing initial surgical intervention. All parties understood that this was an urgent attempt at limb salvage before the patient began an active Charcot event. The patient’s hemoglobin A1c was less than ideal, yet her wounds healed uneventfully after her initial surgery and even after her third surgery with exposed hardware. Additionally, she had a very low vitamin D level, but bone healing was never an issue for her as evidenced by the hypertrophic bone callous seen in figures 9 and 10. It may have been beneficial to obtain the patient’s DXA results prior to surgery; however, the results of the DXA scan would not have changed the patient’s postoperative course of weight bearing or the choice of fixation. While an argument can be made for fixation with an intramedullary (IM) nail, the initial surgical construct appeared well designed and robust enough for the patient’s body habitus. In a matched pair cadaveric study by O’Neill et al the authors compared the rigidity of a locked plate versus IM fixation for TTC arthrodesis. They found that a locked plate construct imparted no significant difference in initial rigidity over an IM nail and found significantly lower stiffness in the IM nail group after 250,000 cycles of loading when compared to the locked plate group. They also found that the torque to reach failure was no different between the two groups.3 In a retrospective study conducted by Thordason and Chang, seven of twelve patients experienced cortical hypertrophy and two developed stress fractures about the proximal interlocking screws when standard IM fixation was used.4 Also, in another cadaveric biomechanical study conducted by Noonan et al, the effect on tibial stress of a long versus short IM nail were compared. The authors compared the stress levels of a standard 15 cm intramedullary nail versus an IM nail which terminated in the proximal tibial metaphysis. They found that the strain on the tibia 5.3 times greater at the locked proximal end of the short IM nail than that of long locked nail. They concluded that a long IM nail which ended in proximal tibial metaphysis was ideal for patients with osteopenia.5 Finally, in a

retrospective case series by Kheir et al, the researchers analyzed 20 consecutive cases in which limited contact angled blade plate was used for TTC arthrodesis. They reported a successful fusion rate of 90 percent with no reported complications with mean follow up of 18 months.2 Perhaps the locked plate construct was too strong for the modulus of elasticity of patient’s bone in our case report. Even if an IM nail were used for this procedure the potential to fracture above the IM fixation would have remained. Based on these studies, it stands to reason that our patient’s construct allowed for too much strain in the locked proximal end of the plate and a more suitable construct would have been a longer plate or longer IM nail. Despite the complex postoperative course, the goal of the procedure to obtain a solid non-deformed limb for ambulation was achieved and the patient is able to ambulate without a prosthetic limb. References

1) Waugh, T. R., Wagner, J., & Stinchfield, F. E. (1965). An evaluation of pantalar arthrodesis. The Journal of Bone & Joint Surgery, 47(7), 1315-1322.

2) Kheir, E., Borse, V., Bryant, H., & Farndon, M. (2015). The use of the 4.5 mm 90° titanium cannulated LC-angled blade plate in tibiotalocalcaneal and complex ankle arthrodesis. Foot and Ankle Surgery

3) O'Neill, P. J., Logel, K. J., Parks, B. G., & Schon, L. C. (2008). Rigidity comparison of locking plate and intramedullary fixation for tibiotalocalcaneal arthrodesis. Foot & ankle international, 29(6), 581-586.

4) Thordarson, D. B., & Chang, D. (1999). Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail.Foot & ankle international, 20(8), 497-500.

5) Noonan, T., Pinzur, M., Paxinos, O., Havey, R., & Patwardhin, A. (2005). Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a biomechanical analysis of the effect of nail length. Foot & ankle international, 26(4), 304-308.


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