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Retrograde Tibial Nailing for Arthrodesis of Ankle and Subtalar

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Retrograde Tibial Nailing for Arthrodesis of Ankle and Subtalar JFAS (AP) Govind Shivram Kulkarni et al 10.5005/jp-journals-10040-1031 ORIGINAL ARTICLE Retrograde Tibial Nailing for Arthrodesis of Ankle and Subtalar Joints 1Govind Shivram Kulkarni, 2Milind Govind Kulkarni, 3Sunil Govind Kulkarni 4Vidisha Sunil Kulkarni, 5Ruta Milind Kulkarni ABSTRACT INTRODUCTION Introduction: When ankle and subtalar joints are arthritic and When ankle and subtalar joints are arthritic and painful painful they both need fusion. Principles of treatment by fusion they both need fusion. This simultaneous fusion of both are removal of cartilage till bleeding of subchondral bone, keeping the joint surfaces congruous, proper positioning of the joints, so called pantalar arthrodesis (PA) is truly a sal- foot and ankle and stable fixation. vage procedure, an alternative to amputation. Previously, Materials and methods: During the last 10 years, 16 cases of PA arthrodesis was meant to fuse only ankle and subtalar retrograde nailing were done. Eight cases were post-traumatic, joints. Currently, however, PA includes talonavicular and one was tuberculosis, three for Charcot joint and three for calcaneocuboid joints besides ankle and subtalar joints. osteoarthritis of the ankle joint, and one case of rheumatoid arthritis. All patients had severe pain instability, varying deg- Historically, pantalar arthrodesis was done in two stages: rees of deformities and antalgic gain. Two cases were treated stage I—subtalar arthrodesis, stage II—ankle arthrodesis. with supracondylar femoral interlocking nail. Nine cases were Currently, it is done in one stage, as the results of either treated with antegrade tibial nail as retrograde nail. Nine cases were treated with retrograde tibial nails with posteroanterior one or two stages are the same. calcaneal screws. Two cases were treated with special nails There are several methods of doing PA. The princi- newly designed by Smith and Nephew. Initially, older the ples of treatment, however, remains the same. They are calcaneus had two latero-medial screws. Newer designs of removal of cartilage till bleeding of subchondral bone, nail have two posteroanterior screws, passing from calcaneal tuberosity through the nail—one towards cuboid and the other keeping the joint surfaces congruous, proper positioning towards talus. These two screws have increased the stability of the foot and ankle and stable fixation. Currently, inter- of the construct and improved the outcome. Mann’s technique nal fixation with screws and/or plate, retrograde nailing of ankle fusion was used. Fibular strut was used as bone graft and fixed by one screws into the tibia and the other into talus. and ring fixator are preferred methods of fixation. Indian tibia is smaller in diameter with a narrow intramedullary When both ankle and subtalar joints are involved, the canal. Indian tibia need to have a nail with a smaller diameter. preferred technique of fixation is retrograde tibial nail, Results: When supracondylar femoral and antegrade tibial which passes through calcaneus, talus and tibia. nails were used, 4 out of 5 failed. When newer design nails Tibiotalocalcaneal arthrodesis (TTCA) with intramedul- with posteroanterior calcaneal screws were used, outcome 1 improved 2 out of 11 failed. lary fixation is not a new idea. Lexer E reported in 1906 the use of boiled cadaveric bone as an intramedullary Conclusion: Newer design of retrograde tibial nails with two posteroanterior screws have greatly improved the outcome of device for tibiotalocalcaneal arthrodesis. The first case pantalar arthrodesis. of tibiotalocalcaneal arthrodesis with an intramedullary Keywords: Charcot joint, Pantalar arthrodesis, Post-traumatic (IM) nail was reported by Adams JC2 in 1948. arthritis, Retrograde tibial nail. Before the advent of retrograde intramedullary nai- How to cite this article: Kulkarni GS, Kulkarni MG, Kulkarni SG, ling, ankle and subtalar joints were fused using internal Kulkarni VS, Kulkarni RM. Retrograde Tibial Nailing for Arthro- or external fixation. However, retrograde tibial nail desis of Ankle and Subtalar Joints. J Foot Ankle Surg (Asia- Pacific) 2015;2(2):60-70. has certain advantages. The purpose of this paper is to Source of support: Nil evaluate the results of retrograde tibial nail for PA and evolution of the nail. Conflict of interest: None MATERIALS AND METHODS 1Director and Professor, 2,3Professor, 4,5Associate Professor During the last 10 years, 16 cases of retrograde nailing 1-5Department of Orthopedics, Postgraduate Institute of were done. Twelve were males and four were females, Swasthiyog Pratisthan, Miraj, Maharashtra, India age ranges from 25 to 65 (average 45). Eight cases were Corresponding Author: Govind Shivram Kulkarni, Director post-traumatic, one was tuberculosis, three for Charcot and Professor, Department of Orthopedics, Postgraduate joint and three for osteoarthritis of the ankle joint, and Institute of Swasthiyog Pratisthan, Miraj, Maharashtra, India one case of rheumatoid arthritis. All patients had severe Phone: 02332222590, e-mail: [email protected] pain instability, varying degrees of deformities and 60 JFAS (AP) Retrograde Tibial Nailing for Arthrodesis of Ankle and Subtalar Joints antalgic gain. Two cases were treated with supracondylar Recently, added oblique screw passing through posterior femoral interlocking nail. Three cases were treated with aspect of calcaneum into talus and tibia, spanning one or antegrade tibial nail as retrograde nail. Nine cases were both the joints is another important innovation. The bend treated with retrograde tibial nails with posteroanterior presents in the nail places the heel in a mild valgus posi- calcaneal screws. Two cases were treated with special tion, which is essential. The nails 10 years back had static nails newly designed by Smith and Nephew. locking screws going through the bone in the medial-to- lateral plane at all levels.4 This created a problem when Indications for Retrograde Nailing there is erosion and subsidence in some patients, such Both tibiotalar and subtalar joints may be involved in as with Charcot joints where subsidence occurs. In such inflammatory, infective, degenerative, post-traumatic a situation, the static locking bolts keep the fusion area and neuroarthopathic diseases. The joints are painful, with a gap resulting in nonunion or failure of fusion. and are usually have some deformity. Dynamic locking hole placed proximally allows closure Treatment of these joints is fusion of both ankle of the gap at the fusion site by allowing distal axial migra- and subtalar joints. Infective conditions, pyogenic or tion of the shaft tibia. There is also a distal static locking tuberculosis, also need fusion. Neuropathic deformi- hole for mediolateral fixation. There are some designs ties (Charcot joints) or fixed deformities due to other which allow compression of the fusion site by either causes may require arthrodesis. Rheumatoid arthritis is internal or external devices or both. Thomas Muckley another indication for PA. Patients who have failed total et al5 suggested intramedullary nail with a valgus curve, ankle replacement where the prosthesis has eroded into two compression options, and angle-stable locking. subtalar joint need fusion of both the joints. We have Posteroanterior screw was inserted through the cal- done tibiocalcaneal fusion when talus was removed for caneal tuberosity into retrograde nail. This was initially severely crushed talus, tumors infection of talus. perpendicular to the nail. The fixation was not optimal because of the calcaneal pitch.4 Preoperative Planning In the newer design posteroanterior screw was Careful evolution is critical for better outcomes. Bone inserted at 20º upward angle parallel to the inferior sur- quality, metabolic disease, previous injuries, and skin face of the calcaneum. This allowed better fixation and condition are carefully assessed.3 Mobility of each joint matched the calcaneal pitch angle (Fig. 1). must be tested. Standing X-rays of foot are taken. Com- Posteroanterior screw passing into the talus is impor- puted tomography is useful to access all deformities. tant to improve the construct stability. The Trigen Hind- There may be frank infection with a draining sinus or foot Fusion Nail (Smith and Nephew) allows independent may be occult infection without a sinus; so laboratory positioning of the two distal locking screws. investigations like blood count, ESR and CRP are impor- The calcaneal screw is directed from the medial part of tant to rule out infection. The patients may have bad, the calcaneal tuberosity through the nail towards cuboid scarred skin with multiple previous incisions; therefore, at a 20º inclination. The more proximal talar screw starts incision must be carefully planned. Incision either passes through or four fingers away from the previous incision. Soft tissue contractures are carefully assessed, and stiff- ness of all deformities is noted. Newer Nail Designs The retrograde nails initially used 10 years back, did not have good control over movements of the subtalar joint and calcaneum because the initial nails did not have posteroanterior locking screws. Therefore, the failure rate was very high. During the past 10 years, the retrograde tibial nail has evolved. Many companies have developed different designs. They all have similar principles. The nail passes Fig. 1: The newer nail has two posteroanterior screws inserted through the calcaneum, and allows fixation of calcaneum to the calcaneal tuberosity into the retrograde nail: (1) the cuboid talus
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