SLR - April 2015 - Jill F. Ashcraft

Tibiotalocalcaneal Arthrodesis Using an Intramedullary Nail: A Systematic Review

Reference: Franceschi F, Franceschetti E, Torre G, Papalia R, Samuelsson K, Karlsson J, Denaro V. Tibiotalocalcaneal Arthrodesis Using an Intramedullary Nail: A Systematic Review. Knee Surg Sports Traumatol Arthrosc. 2015 Feb 26.

Scientific Literature Review

Reviewed By: Jill F. Ashcraft, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA

Podiatric Relevance: Tibiotalocalcaneal arthrodesis (TTCA) is a procedure that has a multiple indications. In foot and ankle surgery, tibiotalocalcaneal arthrodesis is used as a primary procedure in cases of severe osteoarthritis, Charcot neuroarthropathy, diabetic reconstructions, neuromuscular disease, trauma, severe clubfoot, avascular necrosis of the talus, and more. It is also utilized as a secondary procedure for revision of complications in cases of ankle fusions and total ankle arthroplasties. This procedure allows for correction of severe degeneration and alleviation of pain, all the while preventing loss of bone tissue and joint collapse. The purpose of this article was to do to a complete systematic review to evaluate the clinical outcomes following a tibiotalocalcaneal arthrodesis using intramedullary nail fixation, in either open or arthroscopically assisted procedures. This primary aim of this study was to review the success rate of the procedure, with specific analysis of union rate, complications, and clinical outcomes. The secondary aim of this study was a comparison between the open and arthroscopic techniques.The authors believed that intramedullary nailing would a safe and successful procedure when performed with arthroscopic assistance.

Methods: This systematic review was conducted in accordance with the PRISMA guidelines.Inclusion criteria consisted of studies in English, Italian, French, Spanish and German. The articles must have been peer-reviewed randomized controlled trials, comparative studies, or case series. Patient selection included adult patients only, and a treatment requirement of ankle arthrodesis using an intramedullary nail, with either open or arthroscopic technique. Exclusion criteria consisted of in-vitro and animal model studies, and case reports that had data with four or less patients generating low scientific impact. The systematic review included an electronic systematic search of CINAHL, EMBASE, PubMed and the Cochrane Central Registry of Controlled Trials, until February 2014. Two un-blinded authors evaluated each article in full text. All included studies were analyzed and data related to the type of surgery, clinical features, outcomes, complications, and all clinical scores were put into tables.

Results: A total of 93 studies were found through the electronic searching engines and manual search. A total of 32 studies were included in this systematic review. Of the included studies, twenty one were prospective case series, ten were retrospective case series and one was a randomized control trial. A total of 865 patients undergoing TTCA with intramedullary nail were described. The selected articles were broken down into categories of type of surgery, complications, and outcomes. Types of surgery included open technique, which analyzed subcategories of TTCA using classic hardware, TTCA with special hardware, use of bone stimulation in TTCA, TTCA in patients with rheumatoid arthritis, and TTCA in diabetic patients with Charcot arthropathy. The category types of surgery also included arthroscopic articles, which only revealed one study and evaluated TTCA using classic hardware. Unfortunately, the studies were found not comparable in terms of cohort size, surgical details and specific outcome measures. With that being said, the main reported clinical outcome score was the American Orthopaedic Foot and Ankle Society scale. Other clinical scoring systems were reviewed and included foot and ankle outcome score questionnaire and the visual analogue scale for evaluation of pain. This study found that in almost every article included in the review there had been an increase in clinical and functional outcome scores. The overall bony fusion rate was also evaluated and ranged between 52 percent and 96.6 percent, evaluated clinically or by radiological assessment. Fusion was generally described as boney trabeculation across the arthrodesis site. In this review, successful arthrodesis was always higher than 50 percent, however in reviewing complications, several cases of non-unions or delayed unions were observed. The authors of this systematic review found that some studies reported separate tibiotalar and subtalar union rates, because of different consolidation times and the higher rate of ST non-union. This systematic review did not identify any unsuccessful case series, and also found that the reported limb salvage rate reported by the studies was 90 percent. Therefore, the authors determined that the procedure could be considered a valid option, which usually provides satisfying results. Complications found included infection, hardware pain and removal, mal-union, and stress fractures.

Conclusions: In this current systematic review, union rates were reported for open tibiotalocalcaneal arthrodesis and were found to be, in the majority, above 80 percent for open and arthroscopic procedure. Clinical features and clinical outcome scores were also found in these studies to have increased after surgery.  The fusion rate combined with the improved clinical outcomes allowed the authors to conclude that the benefit of this surgery can be considered as high. The low complication rate reported also supported this. The second goal of this review of the literature was to compare outcomes of arthroscopic and open TTCA. Unfortunately, this was not successful due to a lack of literature regarding arthroscopically assisted intramedullary nailing. Limitations to the study included a large diversity of outcome measures and no high level studies being included. Overall, this systematic review explores that a tibiotalocalcaneal arthrodesis is a viable primary and secondary procedure for an array of foot and ankle pathologies. 

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