Department of Orthopaedics & Spine Surgery

Tibiotalocalcaneal Arthrodesis with Retrograde intramedullary SIGN Nail

Prof. Dr. Naeem Ahmed Department of Orthopedic And Spine

Lahore Medical & Dental College / Ghurki Teaching Hospital, Lahore. Pakistan


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SIGN Nail


Introduction

Tibiotalocalcaneal arthrodesis is a salvage procedure for hindfoot problems that affect both the ankle and subtalar joints Arthritis Severe acute trauma Osteonecrosis of the talus Severe mal-alignment deformities Significant hindfoot bone loss.


Aim of Surgery

“The primary goal of any surgery on the foot or ankle is to establish a

painless, plantigrade foot that fits in a shoe”


History • Albert first described arthrodesis of the ankle in

1879 • Lexer, 1906 used boiled cadaveric bones as an

intramedullary device for tibiotalocalcanealarthrodesis.

• Albee 1915, used fibula to perform an ankle and sub talarfusion .

• Adams 1948, first case of tibiotalocalcaneal arthrodesis with intramedullary nail.

• Kile 1994, used retrograde nail as a sole mean of fixation.

Surgical Options

• Allograft resurfacing

• Arthroscopic debridement and osteophyte resection

Surgical Options

• Joint distraction arthroplasty

• Total ankle replacement

• Tibio-talo-calcaneal Arthrodesis

• Steinmann pins

• Screws

• Plates

Available Options

Available Options

• Illizarov • Retrograde

Intramedullary nailing


Retrograde Intramedullary Nailing

Provides a load-sharing fixation device with superior biomechanical properties and is an

excellent choice for use in tibio-talo-calcaneal arthrodesis


Contraindications

• Infection

• Severe vascular disease

• Severe mal-alignment of the tibia.

SIGN NAIL----FEATURES • Solid,stainlesssteel nail with

no cannulation

• The proximal and distal ends of the nail have a 9 and 1.5 degree apex posterior bend, respectively.

• Can be used in both antegrade and retrograde fashion

• Special jigs for interlocking screws.

POSITION FOR ARTHRODESIS • 5 degrees of valgus • Neutral

dorsiflexion/plantarflexion • Rotation equal to

contralateral side, or slightly more externally rotated (5-10 degrees)

• Talus aligned under tibial plafond or slightly posterior; use the anterior aspect of tibial dome and anterior aspect of tibia as reference points.

Surgical Technique • The patient is positioned supine on a

radiolucent operating table

• An anterolateral ankle arthrotomy

with an incision carried over the sinus

tarsi.

• Prepare the joint surfaces by

removing what is left of the diseased

articular cartilage.

• A longitudinally oriented plantar

incision is placed just anterior to the

weight bearing subcalcaneal heel

pad.

Surgical Technique • A series of progressively larger

flexible reamers are then passed over

the guide wire.

• The SIGN nail is placed in a

retrograde fashion passing through

the calcaneus, talus and through the

distal tibia in to the medullary cavity.

• Proximal and distal locking is done

after compression at the arthrodesis

site

Post Operative Care • The short-leg cast is changed

at 2 to 3 weeks

• Weight bearing is not allowed

for 6 weeks

• Patient was followed at 02

weeks, 06 weeks, 03 months

and 06 months, after surgery.


OBJECTIVE

“To determine the outcome of Tibio-talo-calcaneal arthrodesis with Retrograde

Intramedullary SIGN Nail in patients with tibiotalar and subtalar joint pathologies”


Study Design

Descriptive case series.


SETTING

• The study is being conducted in Department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital/Lahore Medical and Dental College, Lahore.


Duration Of Study

• Its an on going study. • Started from September 2012. • Cases done till August 2015 are being included

in this study


SAMPLE SIZE

39 cases has been done so far

(It’s a study of 50 cases)

SAMPLING TECHNIQUE

Non Probability Purposive sampling


Outcome Variable

• Radiological Bone Union

INCLUSION CRITERIA – All patients with combined

ankle and subtalar arthritis – Adults of age > 18 years

– Both genders

– Ankle and subtalar joint

instability/ arthritis

– Osteonecrosis of the talus

– Neglected club foot

– Neglected ankle dislocation

EXCLUSION CRITERIA

– Patients with active

infection – Peripheral vascular

disease – Severely deformed distal

tibia – Failed arthrodesis – Useless/ insensate limb

Results


Male: Female

Sex Frequency Percentage

Male 33

85%

Female 06

15%


Male: Female

MALE, 85%

FEMALE, 15%


Frequency distribution of Radiological Bone Union

(n = 39)

33

3 2 0

5

10

15

20

25

30

35

3 MONTH 5MONTH 6 MONTH


FOLLOW UP FREQUENCY PERCENTAGE

03 MONTHS 33 85%

05 MONTHS 3 92.6%

06 MONTHS 2 97.7%

1 PATIENT LOST TO FOLLOW UP

Frequency distribution of Radiological Bone Union

(n = 39)

Case 1


• H/O trauma – Fall from height

• Treated else whereby bone settler

• Developed pain Rt. Ankle

• Difficult walking


Immediate Post op


3 Months Follow Up

CASE 2


• H/O RTA, pedestrian hit by bike

• Treated elsewhere by bone settler

• C/O – pain Rt. Ankle – Difficult walking


Post Op


3 months follow up

CASE 3

• H/O trauma – Fall from height

• Treated elsewhereby bone settler

• Developed pain Rt. Ankle

• Difficult walking


Post Op

Case 4

• 50 years old male • History of RTA 8 months

back • S/P left side BKA and

fracture right distal tibia manage in Ex-fix

• Now with nonunion left distal tibia


3 months follow up


CASE 5

• 40 years old male • History of RTA 3

months back • Fracture Talus, treated

by local bone setter • c/o pain and unable to

bear weight of right ankle

Follow up

Immediate post op picture 3 months follow up

Case 6

• 19yr/M

• C/O pain Lt. Ankle after RTA few weeks ago.

• AVN Talus


Immediate Post-Op Radiographs


06 months Follow up


CASE 7

• 60 year/F

• S/P ORIF distal Tibia 09 months back

• C/O Pain Left Ankle

• Non Union Distal Tibia/fibula


Immediate Post Op Radiograph


06 months Follow up

CASE 8

• 45year/F • H/O fall from roof 3

months back • C/O pain & inability to

bear weight on Left leg • Fracture dislocation Lt.

Ankle – Arthrits ankle and subtalar joint


06 months Follow up

CASE 9

• H/O Trauma • Treated with across

ankle Ex. Fix • C/O Pain and instability


CASE 10


CASE 11

CASE 12


CASE 13


CASE 14

03 Months Follow up

18 months Follow up


Complications

• Infection – 2.5% ( 1 case) • Ankle pain – 2.5%( 1case)

• Palpable Implant- 0%

• Loose implant-0%

• Broken implant-0%


CONCLUSION

• Arthritis and deformity involving both the ankle and subtalar joints continues to present a clinical challenge.

• Tibiotalocalcaneal arthrodesis with retrograde intramedullary SIGN nail provides an excellent load sharing with a solid fusion in a considerable short time and less soft tissue compromise with early weight bearing in patients with end stage ankle and subtalar arthritis and other foot deformities

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