Ryan P. Mulligan, MD Samuel B. Adams, MD Mark E. Easley, MD James K. DeOrio, MD James A. Nunley, MD

Transcription

1 Comparison of the posterior Achilles tendonsplitting approach and intramedullary nailing versus lateral transfibular approach with fixed-angle plating for tibiotalocalcaneal arthrodesis Ryan P. Mulligan, MD Samuel B. Adams, MD Mark E. Easley, MD James K. DeOrio, MD James A. Nunley, MD Department of Orthopaedic Surgery, Duke University Medical Center Durham, NC

2 None Disclosures

3 Tibiotalocalcaneal (TTC) Arthrodesis Complex operation; salvage procedure for many indications Post-traumatic arthritis Inflammatory arthropathy Charcot neuroarthropathy Acquired or neuromuscular deformity Talus AVN Nonunion of prior arthrodesis Failed TAA

4 TTC Arthrodesis Operative Techniques Approaches Lateral, transfibular Posterior, Achilles tendon splitting Anterior + sinus tarsi Medial Posterolateral Posteromedial Primary Fixation Intramedullary nail Locking plate Anatomic Blade plate Screws External fixator

5 Purpose Many case series reporting outcomes no comparative studies Compare the results of TTC arthrodesis between the PATS and IM nailing versus the LTF approach and lateral, fixed-angle plating Union Symptomatic union with revision Complications

6 Methods Retrospective review, Minimum 1 year clinical/radiographic followup PATS/IM nail and LTF/fixed-angle plate only Union defined radiographically XR: Bridging bone in three of four cortices on orthogonal images CT (44%): Bridging trabecular bone on more than fifty percent of surface at arthrodesis site

7 Results 66 patients; 38 PATS/IM nail, 28 LTF/fixed-angle plate Overall PATS / IM nail (38) LTF / Fixed-angle plating (28) p Age (years) 58.9 (30-86) 58.8 (30-86) 59.2 (41-78) 0.89 BMI 33.6 ( ) Follow-up (months) 73.4 (12-123) 62.1 (12-72) 88.4 (12-123) 0.01 Gender 29 M / 37 L 16 M / 22 F 13 M / 15 F 0.80 Laterality 40 R / 26 L 22 R / 16 L 18 R / 10 L 0.62 Overall PATS / IM nail (38) LTF / Fixed-angle plating (28) p Diabetes mellitus 16 (24%) 5 (13%) 11 (39%) 0.02 Tobacco use 10 (15%) 6 (16%) 4 (14%) 1.00 Peripheral vascular disease 7 (11%) 4 (11%) 3 (11%) 1.00 Chronic corticosteroid use 9 (14%) 3 (8%) 6 (21%) 0.15 Presence of ulcer 4 (6%) 1 (3%) 3 (11%) 0.30 Overall PATS / IM nail (38) LTF / Fixed-angle plating (28) p Supplementary fixation (any) 46 (70%) 20 (53%) 26 (93%) <0.01 Screws 42 (64%) 16 (42%) 26 (93%) <0.01 Plates 9 (14%) 4 (11%) 5 (18%) 0.48 Supplementary graft material (any) 64 (97%) 37 (97%) 27 (96%) 1.00 Allograft 55 (83%) 34 (89%) 21 (75%) 0.18 Femoral head 20 (30%) 18 (47%) 2 (7%) <0.01 Orthobiologics 49 (74%) 28 (74%) 21 (75%) 1.00

8 Results 71 % union rate 76% PATS/IM nail, 64% LTF/fixed-angle plate (p =.41) PATS/IM nail nonunion: 7 TT, 2 TT/ST LTF/fixed-angle plate nonunion: 6 TT, 1 ST, 3 TC 12% revision rate for symptomatic nonunion 16% PATS/IM nail, 7% LTF/fixed-angle plate (p=.45) Stage 4 flatfoot 4 (6%) Prior nonunion 16 (24%) Indications Talus AVN 7 (10%) Posttraumatic 11 (17%) Endstage arthritis 11 (17%) Neuroart hropathy 8 (12%) Failed TAA 9 (14%)

9 Results PATS/IM nail 4 superficial wound complications No nerve injury 2 stress fractures (non-op) 3 elective HWR 1 amputation LTF/fixed-angle plate 4 superficial wound complications 1 sural nerve irritation 2 stress fractures (non-op) 5 elective HWR 1 amputation No significant difference with any complication

10 Conclusion Acceptable union rates and similar complication rates with either technique in a complex patient population Prior incisions, preexisting hardware or deformity may preclude techniques, but other strategies can be executed with similar success rates Future studies should evaluate coronal deformity correction, functional outcomes, and cost

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