CASE STUDYIntegra™ Use of Integra™ Panta® Nail for Failed Total Ankle Arthroplasty

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Pre-Operative Procedure

The patient was given the choice of fusing the right ankle or having a right ankle replacement. Given the existing problem on the left ankle and his desire to keep movement in the right ankle, the patient and his wife decided that the risks of ankle replacement were worthwhile. Although the patient had obvious lack of range of motion in the right subtalar joint, no subtalar arthrodesis was planned because it was not felt this was a source of pain. AP and Lateral Ankle X-rays of the right ankle [Figures 1-3].

Patient Profile

The patient is a 73-year-old male with a history of right ankle pain for four years. He indicates he fractured this right ankle in the past and has suffered many sprains of both ankles. He has a similar problem on the left but not as severe. On physical examination, he walks with an obvious limp on the right leg, has severe hindfoot valgus, right > left, and has pain in the right ankle with range of motion which is relatively normal with 15 degrees of dorsiflexion and 30 degrees of plantarflexion. He has no motion in the right subtalar joint but no tenderness to palpation in the right sinus tarsi. The posterior tibial and dorsalis pedis pulses are palpable. Neurologic status is intact.

Panta® Nail Tibiotalocalcaneal Arthrodesis for Failed Ankle Replacement

James K. DeOrio, M.D.Associate ProfessorDuke OrthopedicsDurham, NC

Figure 1. Anterior weight bearing Figure 2. Full stance Figure 3. Lateral

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At 9 months postoperatively the patient had a little right ankle discomfort, had resumed all activities and was quite pleased with his ankle. However the x-rays showed some early subsidence of the talar component. [Figures 7-9] The patient was instructed to contact his surgeon should the pain increase. He returned at 1 year 9 months post operatively complaining of increased pain in his right ankle. His x-rays showed complete collapse of the right talus with the prosthesis resting on the calcaneus. With so little talar bone available, there was really no hope of revision ankle replacement. Thus, the patient was offered a tibiotalocalcaneal fusion with an Integra Panta Nail.

The patient underwent surgery to include a right uneventful ankle replacement. His x-rays at 3 months looked excellent and he had 90% of his pain relieved. [Figures 4-6]

Figure 4. Anterior weight bearing Figure 5. Anterior weight bearing Figure 6.Lateral

Figure 7. Anterior weight bearing Figure 8. Subsidence Figure 9. Talar collapse

Primary Surgical Procedure

Primary Implant Failure

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A guide pin was inserted into the calcaneus and up into the tibia [Figure 4]. After reaming over the guide pin for the Panta Nail insertion, a femoral head is contoured to fill the defect, inserted to fill the space and the femoral head reamed to accommodate the Panta Nail placement. After the Panta Nail is inserted, the insertion of the posterior to anterior calcaneal screws is made quite easy by having the patient in the prone position [Figure 5]. Two medial to lateral tibial screws are then added as well. Together with additional frozen allograft cancellous bone mixed with a small amount of Vancomycin placed into any remaining defects, the surgery is uneventful. Compression is applied at the time of surgery.

The patient was placed prone on the operating room table and a posterior achilles tendon splitting approach was used with preservation of the fibula. The following photograph from this approach shows initial exposure of the replacement [Figure 1], exposure of tibial stem after removal of a small cortical window in the posterior tibia [Figure 2] and the defect which remains after removal of the prosthesis [Figure 3].

Figures 1-3 Progressive exposure of the surgical site.

Figures 4-5 showing insertion of the guide pin into the heel and after Panta Nail insertion, locking the Panta Nail in place with two posterior to anterior screws.

Revision Surgical Procedure

Figure 1. Full stance weight bearing Figure 2. Lateral weight bearing Figure 3. Anterior weight bearing - Note femoral head

After 6 weeks of casting and 2 weeks non-weight bearing in a removable boot, the patient is full weight bearing in his boot for 2 weeks and then advances to shoes. He returns 19 months after the rod placement with no pain in his right ankle. X-rays show full incorporation of the bone into the fusion site and a solid arthrodesis with the Panta Nail. [Figures 4-6]

Figure 4. Anterior weight bearing - Note bony incorporation of the femoral head

Figure 5. Figure 6.

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Post-Operative

X-rays taken 6 weeks after the surgery are simulated weight-bearing. Note the gap between the femoral head and the remaining talus in [Figures 1- 3].

Why Panta?

The Panta Nail from Integra was chosen for this case because of its ease of use. The system offers a wide range of compression across the ankle and subtalar joint, has an easy to insert end-cap and offers the strongest fixation by providing 2 posterior to anterior screws in the calcaneus. Additionally, it has a wide variety of diameters and lengths of nail which become particularly important in diabetics, patients with previously failed ankle fusions and total ankle replacement extractions like this one which require bulk allograft to fill the defect left when the ankle prosthesis is removed.

X-Rays at 6 Weeks Post-op

X-Rays at 19 Months Post-op

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Panta Surgical Technique Highlights (See Panta Nail Surgical Technique for additional information)

Step 1 • K-Wire Alignment and Reaming

Step 4 • Compression

Posterior Views

Step 2 • Nail Insertion/Support Device

Step 3 • Calcaneal Screw Fixation

No Compression Maximum Compression

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Step 5 • Tibial Fixation Step 6 • Optional Talar Fixation

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Panta® Nail

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