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Journal of Peking University (Health Sciences) ›› 2024, Vol. 56 ›› Issue (2): 299-306. doi: 10.19723/j.issn.1671-167X.2024.02.015

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Tibiotalocalcaneal arthrodesis for end-stage ankle and hindfoot arthropathy: Short- and mid-term clinical outcomes

Wenjing LI,Baozhou ZHANG,Heng LI,Liangpeng LAI,Hui DU,Ning SUN,Xiaofeng GONG,Ying LI*(),Yan WANG,Yong WU   

  1. Department of Foot and Ankle Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China
  • Received:2023-01-06 Online:2024-04-18 Published:2024-04-10
  • Contact: Ying LI E-mail:ly9323@126.com
  • Supported by:
    the Wu Jieping Medical Foundation(320.6750.2021-7-15)

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Abstract:

Objective: To analyze the clinical data of patients with end-stage ankle and hindfoot arthropathy who underwent tibiotalocalcaneal (TTC) arthrodesis by the same surgeon, explore the short- and mid-term clinical results, complications and functional improvement, and discuss the clinical prognosis and precautions of TTC arthrodesis. Methods: Retrospective analysis was made on the clinical data of 40 patients who underwent TTC arthrodesis by the same surgeon from March 2011 to December 2020. In this study, 23 males and 17 females were included, with an average age of (49.1±16.0) years. All the patients underwent unilateral surgery. The clinical characteristics, imaging manifestations, main diagnosis and specific surgical techniques of the patients were recorded. The clinical outcomes were evaluated by comparison of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) between pre-operation and at the last follow-up. The fusion healing time, symptom improvement (significant improvement, certain improvement, no improvement or deterioration) and postoperative complications were also recorded. Results: The median follow-up time was 38.0 (26.3, 58.8) months. The preoperative VAS score was 6.0 (4.0, 7.0), and the AOFAS score was 33.0 (25.3, 47.3). At the last follow-up, the median VAS score was 0 (0, 3.0), and the AOFAS score was 80.0 (59.0, 84.0). All the significantly improved compared with their preoperative corresponding values (P < 0.05). There was no wound necrosis or infection in the patients. One patient suffered from subtalar joint nonunion, which was syphilitic Charcot arthropathy. The median bony healing time of other patients was 15.0 (12.0, 20.0) weeks. Among the included patients, there were 25 cases with significant improvement in symptom compared with that preoperative, 8 cases with certain improvement, 4 cases with no improvement, and 3 cases with worse symptoms than that before operation. Conclusion: TTC arthrodesis is a reliable method for the treatment of the end-stage ankle and hindfoot arthropathy. The function of most patients was improved postoperatively, with little impact on daily life. The causes of poor prognosis included toe stiffness, stress concentration in adjacent knee joints, nonunion and pain of unknown causes.

Key words: Ankle joint, Foot, Tibiotalocalcaneal, Arthrodesis, Treatment outcome

CLC Number: 

  • R687.4

Figure 1

Optimal fusion position of the TTC arthrodesis A, (anterior view) the talus and calcaneus were located directly below the tibia; B, (lateral view) the ankle was 0° dorsiflexion; C, (hindfoot alignment view) the heel was 5°-10° valgus. TTC, tibiotalocalcaneal."

Figure 2

A 55-year-old male with diabetic Charcot ankle arthropathy on the left side underwent TTC arthrodesis with intramedullary nail A, (anterior view) appearance of the bilateral ankles before surgery; B, plantar flexion of the left ankle before surgery; C, dorsal flexion of the left ankle before surgery; D, hindfoot alignment of the bilateral ankles before surgery; E and F, preoperative anteroposterior and lateral X-ray of the left ankle; G and H, postoperative anterior and lateral appearance of the left ankle; I, postoperative hindfoot alignment of the bilateral ankles; J-L, postoperative anteroposterior, lateral and hindfoot alignment views of the left ankle. TTC, tibiotalocalcaneal."

Figure 3

A 24-year-old male with bilateral flail ankle joints and tethered cord syndrome underwent TTC arthrodesis on the left side with intramedullary nail fixation A, (anterior view) appearance of the bilateral ankles before surgery; B, hindfoot alignment of the bilateral ankles before surgery; C-E, preoperative anteroposterior, lateral and hindfoot alignment X-ray of the left ankle; F, postoperative anterior appearance of the bilateral ankles; G, postoperative hindfoot alignment of the bilateral ankles; H-J, postoperative anteroposterior, lateral and hindfoot alignment X-ray views of the left ankle; K and L, ipsilateral tibial plateau fracture occurred postoperatively. TTC, tibiotalocalcaneal."

Figure 4

A 37-year-old male with septic ankle arthritis on the right side had a course of 2 months, underwent ankle debridement and TTC arthrodesis with external circular fixator A and B, anteroposterior and lateral X-rays of the right ankle before surgery; C and D, the skin and soft tissue condition before surgery; E, debridement of the lateral malleolus and removal of the dead bone of the fibular; F and G, postoperative appearance of the ankle; H and I, anteroposterior and lateral X-rays after surgery; J and K, lateral appearance and hindfoot alignment at the final follow-up; L-N, anteroposterior, lateral and hindfoot alignment X-ray views at the final follow-up. TTC, tibiotalocalcaneal."

Table 1

General clinical data of patients"

Items Data (n=40) P value
Age/years 49.1±16.0
Duration/months 33.0 (21.3, 106.0)
Union time/weeks 15.0 (12.0, 20.0)
Follow-up/months 38.0 (26.3, 58.8)
AOFAS <0.001*
  Preoperative 33.0 (25.3, 47.3)
  Postoperative 80.0 (59.0, 84.0)
VAS <0.001*
  Preoperative 6.0 (4.0, 7.0)
  Postoperative 0 (0, 3.0)
Maximal walking distance/m 3 000 (1 000, 3 000)
Maximal walking time/min 60 (30, 60)

Table 2

Comparison of the data of patients with functional improvement (Group A and B) and with no improvement (Group C and D) at the last follow-up"

Items Group A + Group B (n=33) Group C + Group D (n=7) P value
Age/years 47.8±16.1 55.0±15.3 0.290*
Duration/months 30.0 (17.5, 104.0) 48.0 (24.0, 120.0) 0.669#
Union time/weeks 14.0 (12.0, 17.5) 20.0 (15.0, 36.0) 0.049#
Follow up/months 39.0 (31.5, 66.0) 25.0 (17.0, 55.0) 0.170#
AOFAS
  Preoperative 37.0 (27.0, 49.0) 30.0 (20.0, 40.0) 0.262#
  Postoperative 81.0 (73.0, 84.0) 33.0 (27.0, 42.0) <0.001#
VAS
  Preoperative 6.0 (4.0, 7.0) 6.0 (4.0, 9.0) 0.626#
  Postoperative 0 (0, 2.0) 5.0 (5.0, 8.0) <0.001#
Maximal walking distance/m 3 000 (1 000, 4 500) 30 (30, 100) <0.001#
Maximal walking time/min 60 (30, 60) 10 (5, 20) <0.001#
1 Brage ME , Mathews CS . Ankle and tibiotalocalcaneal fusion[J]. Foot Ankle Clin, 2022, 27 (2): 343- 353.
doi: 10.1016/j.fcl.2021.11.020
2 Stołtny T , Dugiełło B , Pasek J , et al. Tibiotalocalcaneal arthrodesis in osteoarthritis deformation of ankle and subtalar joint: Evaluation of treatment results[J]. J Foot Ankle Surg, 2022, 61 (1): 205- 211.
doi: 10.1053/j.jfas.2021.09.005
3 Yao Y , Mo Z , Wu G , et al. A personalized 3D-printed plate for tibiotalocalcaneal arthrodesis: Design, fabrication, biomechanical evaluation and postoperative assessment[J]. Comput Biol Med, 2021, 133, 104368.
doi: 10.1016/j.compbiomed.2021.104368
4 Perez-Aznar A , Gonzalez-Navarro B , Bello-Tejeda LL , et al. Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: A prospective cohort study at a minimum five year follow-up[J]. Int Orthop, 2021, 45 (9): 2299- 2305.
doi: 10.1007/s00264-020-04904-3
5 Pitts C , Alexander B , Washington J , et al. Factors affecting the outcomes of tibiotalocalcaneal fusion[J]. Bone Joint J, 2020, 102-B (3): 345- 351.
doi: 10.1302/0301-620X.102B3.BJJ-2019-1325.R1
6 Kitaoka HB , Alexander IJ , Adelaar RS , et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes[J]. Foot Ankle Int, 1994, 15 (7): 349- 353.
doi: 10.1177/107110079401500701
7 Reed MD , van Nostran W . Assessing pain intensity with the visual analog scale: A plea for uniformity[J]. J Clin Pharmacol, 2014, 54 (3): 241- 244.
doi: 10.1002/jcph.250
8 Martínez-de-Albornoz P , Monteagudo M . Tibiotalocalcaneal arthrodesis in severe hindfoot deformities[J]. Foot Ankle Clin, 2022, 27 (4): 847- 866.
doi: 10.1016/j.fcl.2022.08.008
9 Burns PR , Dunse A . Tibiotalocalcaneal arthrodesis for foot and ankle deformities[J]. Clin Podiatr Med Surg, 2017, 34 (3): 357- 380.
doi: 10.1016/j.cpm.2017.02.007
10 Monteagudo M , Martínez-de-Albornoz P . Deciding between ankle and tibiotalocalcaneal arthrodesis for isolated ankle arthritis[J]. Foot Ankle Clin, 2022, 27 (1): 217- 231.
doi: 10.1016/j.fcl.2021.11.012
11 Rana B , Patel S . Results of ankle and hind foot arthrodesis in diabetic Charcot neuroarthropathy: A retrospective analysis of 44 patients[J]. J Clin Orthop Trauma, 2021, 23, 101637.
doi: 10.1016/j.jcot.2021.101637
12 Chraim M , Krenn S , Alrabai HM , et al. Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot[J]. Bone Joint J, 2018, 100-B (2): 190- 196.
doi: 10.1302/0301-620X.100B2.BJJ-2017-0374.R2
13 Kollig E , Esenwein SA , Muhr G , et al. Fusion of the septic ankle: Experience with 15 cases using hybrid external fixation[J]. J Trauma, 2003, 55 (4): 685- 691.
doi: 10.1097/01.TA.0000051933.83342.E4
14 Hartmann R , Grubhofer F , Waibel FWA , et al. Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis[J]. J Orthop Res, 2021, 39 (10): 2151- 2158.
doi: 10.1002/jor.24938
15 Baumbach SF , Massen FK , Hörterer S , et al. Comparison of arthroscopic to open tibiotalocalcaneal arthrodesis in high-risk patients[J]. Foot Ankle Surg, 2019, 25 (6): 804- 811.
doi: 10.1016/j.fas.2018.10.006
16 Rausch S , Loracher C , Fröber R , et al. Anatomical evaluation of different approaches for tibiotalocalcaneal arthrodesis[J]. Foot Ankle Int, 2014, 35 (2): 163- 167.
doi: 10.1177/1071100713517095
17 Wu M , Scott D , Abar B , et al. Does a fibula-sparing approach improve outcomes in tibiotalocalcaneal arthrodesis?[J]. Foot Ankle Surg, 2023, 29 (1): 90- 96.
doi: 10.1016/j.fas.2022.11.001
18 Carranza-Bencano A , Tejero S , Del CG , et al. Minimal incision surgery for tibiotalocalcaneal arthrodesis[J]. Foot Ankle Int, 2014, 35 (3): 272- 284.
doi: 10.1177/1071100713515447
19 Pellegrini MJ , Schiff AP , Adams SJ , et al. Outcomes of tibiotalocalcaneal arthrodesis through a posterior Achilles tendon-splitting approach[J]. Foot Ankle Int, 2016, 37 (3): 312- 319.
doi: 10.1177/1071100715615398
20 Eckholt S , Garcia-Elvira R , Fontecilla N , et al. Role of extra-articular tibiotalocalcaneal arthrodesis and posterior approach in highly complex cases[J]. Foot Ankle Int, 2018, 39 (2): 219- 225.
doi: 10.1177/1071100717737973
21 Gong J , Zhou B , Tao X , et al. Tibiotalocalcaneal arthrodesis with headless compression screws[J]. J Orthop Surg Res, 2016, 11 (1): 91.
doi: 10.1186/s13018-016-0425-7
22 Gutteck N , Schilde S , Reichel M , et al. Posterolateral plate fixation with Pantalarlock® is more stable than nail fixation in tibiotalocalcaneal arthrodesis in a biomechanical cadaver study[J]. Foot Ankle Surg, 2020, 26 (3): 328- 333.
doi: 10.1016/j.fas.2019.04.006
23 Richman J , Cota A , Weinfeld S . Intramedullary nailing and external ring fixation for tibiotalocalcaneal arthrodesis in Charcot arthropathy[J]. Foot Ankle Int, 2017, 38 (2): 149- 152.
doi: 10.1177/1071100716671884
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