J. George DeVries

Retrograde Intramedullary Nail Arthrodesis for Avascular Necrosis of the Talus

Background: Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. Materials and Methods: A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. Results: Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. Conclusion: Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion. Level of Evidence: IV, Retrospective Case Series

Fixation of First Tarsometatarsal Arthrodesis: A Retrospective Comparative Cohort of Two Techniques

Background: Presently, indications for the Lapidus procedure include patients with many pathologies of the first metatarsocuneiform joint. Currently the standard in many areas is that of two or three crossed screws through the first tarsometatarsal region. This type of fixation requires an extended period of nonweightbearing and may be difficult for patient compliance. Materials and Methods: The present study is a retrospective comparison of crossed screw fixation to locking plate fixation without a lag screw on union rates, time to weightbearing, and complications. Results: One hundred forty-three first TMT fusions met the inclusion criteria. There were 96 fused by crossed screw construct (CS) and 47 by the locked plate with or without compression screw (LP). There was a significant difference in time to full weightbearing and union rate. Time to full weightbearing was 8.8 (range, 3 to 16) weeks and 7.8 (range, 1.5 to 34) weeks in the CS and LP groups, respectively (p < 0. 001). Union rate was 89.4% (88 of 96 joints) and 98.5% (46 of 47 joints) in the CS and LP groups, respectively (p < 0. 001). Conclusions: We found that when using a dorsal-medial locked plate with or without lag screw lead to a superior rate of union compared to standard crossed screw constructs even while allowing earlier return to full weightbearing. Level of Evidence: III, Retrospective Comparative Analysis

Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis

Background: Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. Methods: The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). Results: Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). Conclusion: This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. Level of Evidence: Level IV, case series.

Predictive Risk Assessment for Major Amputation After Tibiotalocalcaneal Arthrodesis

Background: Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. Methods: One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. Results: There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: ex/(1 + ex) where x is a factor of age, diabetes, revision, and ulceration. Conclusion: TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. Level of Evidence: Level II, prognostic.

A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator--utilization of the Retrograde Arthrodesis Intramedullary Nail database.

Brodsky type 3a Charcot destruction of the ankle is devastating to patients. The authors have surgically stabilized this deformity with the use of an intramedullary arthrodesis nail, and explore the usefulness of adjunctive application of a circular external fixator. Fifty-two patients were treated with retrograde intramedullary nail with and without circular external fixation. A comprehensive chart and radiographic review were pulled from the Retrograde Arthrodesis Intramedullary Nail database. Of these, 45 patients were treated with a nail alone (Nail group), and 7 were treated with a nail and circular external fixation augmentation (ExFix group). The primary end point was major amputation or braceable limb. The average age was 59.4 and 51.6 years in the Nail and ExFix groups, respectively (p = .0068). Chronic steroid use was statistically significantly different and was found in 3 (6.7%) and 4 (57.1%) patients in the Nail and ExFix groups, respectively (p = .0039). The rate of major amputation was 10/45 (22.2%) and 2/7 (28.6%) in the Nail and ExFix groups, respectively (p = .656), with an overall salvage rate of 40/52 limbs (75.6%). The addition of circular external fixation does not affect the overall salvage or complication rate. The authors feel that the added stability offered by external fixation may benefit patients who are at high risk for complications or require extended arthrodesis, but this was unable to be demonstrated statistically in this study. Patients with this difficult pathology can be successfully salvaged, but there is a high risk of complications.

Agility to INBONE : Anterior and Posterior Approaches to the Difficult Revision Total Ankle Replacement

Total ankle replacement is now acknowledged as a viable alternative to ankle arthrodesis for end-stage ankle arthritis. The authors present a series of 14 patients who were converted from the Agility total ankle replacement to an INBONE total ankle replacement. This report is unique in that anterior and posterior approaches are discussed and detailed. Although the authors present successful conversion of the Agility total ankle replacement to an INBONE total ankle replacement, the difficulty of this procedure is demonstrated by the high complication rate and 2 early failures.

The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database

The use of bone morphogenetic protein-2 (BMP-2) has been recommended for high-risk fusions and nonunion. Patients undergoing revisional tibiotalocalcaneal (TTC) arthrodesis via a retrograde arthrodesis nail to evaluate the influence of BMP-2 on rate of fusion in this high-risk population are presented. A retrospective chart and radiographic review were performed on 23 patients with failed prior fusion attempts at the ankle treated with retrograde intramedullary nailing. Sixteen patients were treated without BMP-2 (None group) and 7 were treated with BMP-2 (BMP group). The primary and secondary end-points were successful fusion, and time to fusion, respectively, with a variety of variables evaluated for influence. Other than the use of BMP-2, there were no statistical differences in the patient population. Overall, 11 of 16 ankles (68.8%) in the None group and 5 of 7 ankles (71.4%) in the BMP group resulted in a stable, functional limb. Rate of complication was similar between the 2 groups (p > .05). Time to radiographic ankle union was 115.2 and 184.0 days in the None and BMP groups (p > .05). The effect of BMP-2 on revisional TTC fusions with retrograde nails is reported here. The overall result as a stable, functional limb was 69.6%, which suggests that revision surgery in this high-risk population is a reasonable consideration. Even though this study was unable to demonstrate statistically significant differences, biologic augmentation with BMP-2 did not increase the complication rate and showed a slightly enhanced salvage rate for revision TTC fusions with an intramedullary nail.

Cannulated Screw Fixation of Jones Fifth Metatarsal Fractures: A Comparison of Titanium and Stainless Steel Screw Fixation

The classic Jones fracture involves the fifth metatarsal at the level of the proximal diaphyseal-metaphyseal junction. The mainstay of surgical treatment for the Jones fracture is intramedullary screw fixation. There is no consensus of the type or material of screw that should be used. The purpose of this retrospective cohort study was to test the hypothesis that there is no clinical difference in the incidence of healing, or complications, when comparing stainless steel to titanium cannulated screws used in Jones fracture open-reduction internal fixation (ORIF). Data were collected on a total of 53 patients (fractures) that were fixed with either cannulated titanium screws (Ti group) or cannulated stainless steel screws (SS group). The postoperative protocol was standardized. The mean time to radiographic union was 11.7 ± 5.1 weeks in the Ti group and 13.4 ± 5.7 weeks in the SS group (P = .333). The overall union rate for the Ti group was 36/37 (97%) and 14/16 (88%) in the SS group (P = .213). Complications were rare in both groups, and the prevalence was not statistically significantly different (P > .05). There was 1 patient with an asymptomatic radiographic nonunion in the Ti group, and this patient elected not to undergo revision. There were 2 nonunions in the SS group. One was revised and went on to heal and the other is awaiting revision. Our study has demonstrated the decision to use stainless steel or titanium can be left to patient constraints, such as allergies, or physician preference without compromising the clinical result.

Understanding Levels of Evidence for Scientific Communication

Foot & Ankle Specialist (FAS) is adding a “level of evidence” rating to all new submissions. This is important as evidence-based medicine in practice is increasingly important. The rationale for adding this rating to FAS publications is multifaceted. It will encourage researchers to design better projects and become adept at critically evaluating research. It will put research publications into appropriate context, and it will guide the profession in general to a higher level of scientific analysis. Four types of studies will be used at FAS: therapeutic, prognostic, diagnostic, and economic/decision making. Within each of these types of studies, levels of evidence between I and V can be assigned. A description of each type and explanation of how to assign evidence level is given. This may assist authors and readers as they work to design projects and critically evaluate literature.

Union Rate of Tibiotalocalcaneal Nails with Internal or External Bone Stimulation

Introduction: The use of bone growth stimulation has been reported in the application of hindfoot and ankle arthrodesis. Most studies have been retrospective case series with few patients. The authors present a comparative analysis of patients undergoing tibiotalocalcaneal (TTC) arthrodesis via a retrograde intramedullary arthrodesis nail to evaluate the influence of internal versus external bone stimulation in this population. Methods: One hundred fifty-four patients were treated with retrograde intramedullary nailing. A comprehensive chart and radiographic review was performed from a database of patients who underwent TTC fusion with or without bone stimulation. Ninety-one patients with retrograde TTC nailing were treated with direct current internal bone stimulation at the time of the index procedure (internal group) and 63 were treated with combined magnetic field external bone stimulation (external group). The primary end point was fusion with potential variables evaluated for influence on fusion rates. Results: Demographically the cohorts were similar groups in age and comorbidities. Surgical and outcome data were examined, and there were few statistically significant differences between the two groups. There was no statistically significant difference in rate of union (52.7% and 57.1%, p = .63) or rate of complications between the internal and external groups. Overall, the success rate for achieving a stable, functional limb for the groups was 81.3% (74/91 patients) and 82.5% (52/63 patients) in the internal and external groups, respectively (p = .62). Conclusion: The authors demonstrated there were no statistically significant differences between the union and complication rate when comparing these types of internal and external bone stimulation in this patient population. Consideration of these results may help guide physicians when considering bone stimulation as an adjunct to TTC fusions with a retrograde intramedullary nail. Level of Evidence: III