Ankle arthrodesis using a retrograde intramedullary rod with fins for highly destructive joints in elderly patients with rheumatoid arthritis: A report of two cases

Here we present two cases in older adult patients with highly destructive changes in ankle joints (Larsen Grade IV) and who underwent retrograde intramedullary nail fixation with fins. In both patients, bony union was achieved, full weight-bearing was attained 3 months after surgery and good functional outcome was acquired.

Relationship Between the Lateral Plantar Artery and the Retrograde Intramedullary Nail During Tibiotalar and Subtalar Arthrodesis: A Fresh Cadaveric Study

Background Tibiotalocalcaneal (TTC) arthrodesis with retrograde intramedullary nailing has become established. Iatrogenic injury to the vasculature (eg, lateral plantar artery [LPA] pseudoaneurysm) during insertion of the nail has been reported. The aim of this study was to identify the safe zone that avoids injury to the LPA during TTC arthrodesis. Methods The retrograde lateral curved nail entry point should be in line with the midpoint of the tibial medullary canal and the lateral column of the calcaneus. Enhanced 3-dimensional computed tomography scans of 26 fresh cadaveric feet were assessed. The closest distance between the LPA and the edge of the nail entry point was measured in the plantar view. Results The closest mean distance between the LPA and the edge of the nail entry point was 6.7 mm for all 26 feet, 12.8 mm for 3 feet (11.5%) in which the LPA did not cross the medial wall of the calcaneus, 8.1 mm for 9 (34.1%) in which the point where the LPA crossed the medial wall of the calcaneus was anterior to the center of the nail entry point, and 4.2 mm for 14 (53.8%) feet in which this point was posterior to the center of the nail entry point. Conclusions Care should be taken to avoid the LPA during reaming at the nail entry point, especially when the point where the LPA crosses the medial wall of the calcaneus is posterior to the center of the nail entry point. Levels of Evidence: IV, cadaveric study

Complications and Radiographic Outcomes After Tibiotalocalcaneal Fusion With a Retrograde Intramedullary Nail

Background Tibiotalocalcaneal (TTC) arthrodesis is a salvage reconstructive procedure for ankle and subtalar arthritis and deformity. This study aims to identify fusion rates and complications of TTC arthrodesis procedures performed at our institution using a specific retrograde intramedullary nail. Additionally, we analyzed the subpopulation that sustained an intramedullary nail break. Methods A retrospective review was conducted of 45 patients who underwent 47 TTC arthrodesis procedures with intramedullary fixation using the Phoenix nail at our institution from October 2010 to September 2017. Patient age, body mass index, sex, smoking status, diabetes diagnosis, peripheral vascular disease, thyroid disease, inflammatory arthritis, steroid use, prior ankle fractures and procedures, fusion rates, nail diameter, time to hardware failure, preoperative coronal plane deformity, and return to work were obtained. Results Successful fusion was confirmed in 79% of tibiotalar, 70% of subtalar, and 66% of combined tibiotalar and subtalar joints. Eight of 47 (17%) TTC nails suffered nail breakage postoperatively. Although statistical analysis was not performed due to the small population size, patients with nail failure had lower rates of tibiotalar (38% vs 87% of patients without nail failure) and combined tibiotalar/subtalar fusion (25% vs 74%). Ten percent of patients without nail breakage required revision surgery, compared to 75% of patient with nail breakage. Conclusion This study describes TTC arthrodesis outcomes at our institution. It demonstrates a high complication rate using a specific retrograde intramedullary nail, including nail breakage and non-union. Further analysis and improvement in technique and implant design may decrease revision rates and improve outcomes. Levels of Evidence: Therapeutic, Level IV