Salvage Tibiotalocalcaneal Arthrodesis Augmented with Fibular Columns and Iliac Crest Autograft: A Technical Note

Abstract

Category: Ankle; Ankle Arthritis Introduction/Purpose: End-stage ankle arthritis may be managed with ankle arthrodesis or total ankle replacement (TAR). Failure of these procedures results in a challenging clinical situation. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required. Bone grafting may be necessary to maintain length and reduce disability, and fibular strut grafting in form of ‘pillars’ or ‘columns’ may be used in association with intramedullary TTC nailing. In our experience, fibular column autograft may be supplemented with tricortical and cancellous iliac crest graft and stabilised with cannulated screws and either an intramedullary nail or a lateral plate. In this technical note, we review the history of this technique and report indications, surgical approach, results and complications. Methods: A distal J-shaped lateral approach is performed over the posterior edge of the distal fibula. An oblique fibular cut is made with a saw at 8- 12 cm from the fibular tip. Careful removal of the implant, previous cement spacer or metalwork is performed then articular surfaces are prepared. After assessment of the articular gap, the autograft is prepared by removing the tip of the fibula from the fibular block, then sectioning it in to either three or four columns which are positioned into the gap and stabilised either in a press-fit fashion or using 1.6mm K-wires. Six patients (4M, 2F; mean age: 69.8 years (range, 51 to 83)) were treated between December 2018 and March 2019 (5 failed TAR and 1 was symptomatic tibiotalar non-union) at our institution. Fixation was achieved in 5 cases with a locked intramedullary nail and in 1 case with a lateral locking plate. Results: At a mean follow up of 10 months (range, 6 to 11 months), 4 patients had clinically and radiologically united and were satisfied with the outcome of surgery. Two patients remained dissatisfied having not united: one patient with a background of chronic kidney disease had raised inflammatory blood markers at 10 months and is undergoing investigation to exclude infection whilst one other patient with no obvious risk factors for non-union has started low intensity pulsed ultrasound treatment at 6 months. No other complications were observed. Conclusion: Tibiotalocalcaneal fusion augmented with fibular columns and iliac crest autograft is an option to treat combined ankle and the subtalar joint pathologies with significant talar bone loss. However larger studies with longer follow-up are required to define the rates of success and failure with future research directed to better understand which factors may predict the outcome.