SLR - April 2017 - Hima Patel

Tibiotalocalcaneal Arthrodesis with Headless Compression Screws

Gong JC, Zhou BH, Tao X, Yuan CS, Tang KL. Tibiotalocalcaneal Arthrodesis with Headless Compression Screws J Orthop Surg Res. 2016 Aug 19; 11(1): 91.

Reviewed By: Hima Patel, DPM
Residency Program: Hoboken University Medical Center, Hoboken, NJ

Podiatric Relevance: The primary indications for tibiotalocalcaneal arthrodesis include osteoarthritis of the ankle and subtalar joints, talar ischemia and necrosis, and failure of ankle replacement. Throughout the years, technological advancements have led to the utilization of various types of fixation, including screws, external fixators, plates and intramedullary nails for tibiotalocalcaneal arthrodesis; however, each fixation method presents its own set of complications. Screws, for example, cannot provide enough stability, leading to loosening and breakage. External fixation devices can be difficult to care for and are associated with a high incidence of infection and nonunion. Plate fixation can also increase the risk of nonunion and involve wide incisions and extensive soft-tissue dissection. While the intramedullary nail provides excellent structural stability and axial compression, there is a high degree of technical difficulty in inserting the nail, and it also has been reported to cause many postoperative complications, including soft-tissue irritation, deep infection and bone fracture surrounding the nail in the distal tibia. While there is abundant literature regarding the aforementioned fixation methods, a simple fixation method with a high union rate and a low complication rate has not yet been reported. Thus, the aim of this study is to evaluate the clinical outcome of tibiotalocalcaneal arthrodesis with headless compression screws for treating advanced ankle and subtalar arthritis.

Methods: Between 2010 and 2015, 23 patients underwent tibiotalocalcaneal arthrodesis due to severe ankle and subtalar joint arthritis. Of these, five patients were excluded from the study due to the use of cannulated-head compression screws, and one patient was excluded after undergoing an amputation secondary to discovery of a foot metastasis of malignant tumor one month after tibiotalocalcaneal arthrodesis. Thus, 17 patients were included in this study. In all patients, a 6 cm anteromedial incision was used to expose the ankle joint, and a 4 cm lateral oblique incision was used to expose the subtalar joint. Upon preparation of the articular surfaces, the tibia, talus and calcaneus were carefully aligned and fixed with two 120 mm Acutrak headless compression screws. Post-operatively, the patients were evaluated based on the Roles and Maudsley patient satisfaction scores, the AOFAS and VAS scores. The patients also underwent radiographic evaluation for assessment of hindfoot alignment and osseous union.

Results: The average follow-up duration was six and a half months for the 17 patients. Based on the average Roles and Maudsley patient satisfaction score of 1.41, most patients had satisfactory function improvement postoperatively. The VAS pain scores decreased from 6.95 preoperatively to 1.56 postoperatively. The AOFAS score at the last visit was 68.5, which was significantly higher than the preoperative AOFAS score of 29.6. All patients achieved bony fusion at a mean union time of 3.8 months. The mean operation time was 57 minutes. Only one patient experienced poor wound healing, which was resolved after debridement and suturing. No other patients required additional surgery. No other complications, such as poor blood supply, loss of sensation due to nerve damage or hardware failure, were encountered.

Conclusions: While there are many fixation options for tibiotalocalcaneal arthrodesis, the development of second-generation headless compression screws has allowed surgeons to achieve fusion due to their special design. In this study, the Acutrak headless compression screws were used; these screws were designed to improve the load to failure by providing excellent compression across the joint surface. In light of their findings, the authors have concluded that tibiotalocalcaneal arthrodesis with headless compression screws is not only effective, but it also has many advantages. These advantages include minimal invasiveness, short operation time, high union rate, low complication rate and a good postoperative recovery. Despite the promising clinical and radiographic outcomes in this study, the average follow-up time was low. It would be interesting to see if this procedure could predispose patients to early deterioration of the neighboring joints in the future. Furthermore, additional biomechanical research is necessary to evaluate the stability of the various fixation constructs. 

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