Retrograde intramedullary smash for tibiotalocalcaneal arthrodesis is a salvage procedure reserved for severe cases of disfigurement. The aim of the present study was to compare the outcomes of this technique in patients with and without diabetes mellitus ( DM ). A sum of 61 patients with and 56 without DM undergo retrograde intramedullary smash and had a minimal follow-up time period of 12 months. The overall incidence of complicatedness was 45.2 % ; however, the overall incidence of complications between those with and without DM was not significantly unlike ( odds ratio [ OR ] 0.79, 95 % confidence interval [ CI ] 0.38 to 1.65, phosphorus = .54 ). Patients with DM had a significantly greater rate of superficial infections ( OR 8.3, 95 % CI 1.01 to 68.67, phosphorus = .03 ). however, no difference was seen in the rate of deep infection ( OR 0.90, 95 % CI 0.34 to 2.46, phosphorus = .83 ) or noninfectious complications ( OR 0.50, 95 % CI 0.23 to 1.13, phosphorus = .09 ). successful arm salvage was achieved for 96.8 % of the patients with DM and 94.7 % of those without DM ( p = .66 ). A femoral head homograft was used in 32 ( 27.4 % ) of 117 patients to substitute for an osseous invalidate. Of the 32 patients who required a femoral head homograft, 21 ( 67.7 % ) experienced a complication compared with 32 ( 37.6 % ) of 85 patients who did not require a femoral head homograft ( OR 3.16, 95 % CI 1.35 to 7.41, p = .008 ). The incidence of affected role satisfaction was 80 % for patients with DM and 72 % for those without DM ( phosphorus = .36 ). Despite a senior high school incidence of complications, limb salvage was accomplished in approximately 95 % of patients with complicate deformities. Four patients ( 6.56 % ) with DM experienced a tibia fracture ; consequently, we immediately routinely use a 300-mm-long nail for this reconstruction. austere hindfoot and ankle disfigurement can be physically and mentally debilitating for patients. versatile etiologies, such as arthritis of the subtalar and ankle joints ( whether degenerative, inflammatory, or post-traumatic ), Charcot neuroarthropathy ( CN ), DM neuropathy of other etiology, failed ankle and/or hindfoot arthrodesis, failed sum ankle arthroplasty, acquired or congenital fixed equinovarus deformities, and avascular necrosis of the anklebone, can result in deformity and deterioration that could potentially require tibiotalocalcaneal arthrodesis ( TTCA ). respective methods have been used to stabilize an ankle/hindfoot arthrodesis, including plates, screws, external fixation, and intramedullary nails. The contraindications specific to using the intramedullary nail ( IMN ) proficiency include active infection, austere angular disfigurement of the distal tibia, severe osteoporosis, and an entire subtalar articulation ( 1 ). TTCA has been used as a method acting for arm salvage to avoid major amputation, in particular, in diabetic patients with lower extremity complications ( 2 – 9 ). This technique has gained popularity over the years, in separate owing to the increased rigidity of the construct compared with that of other fixation techniques. A construct of greater rigidity allows care of proper alignment after correction. multiple studies have shown biomechanically superscript crouch and torsional properties with the IMN compared with slowdown screws ( 10 – 12 ). successful limb salvage has been reported using retrograde intramedullary nail down ; however, the procedure can be fraught with many complications, such as nonunion rates ranging from 0 % to 71 % ( 2, 3, 5, 7 – 9, 13, 14 ). A preliminary study of 40 patients from our initiation demonstrated significant improvement in the american Orthopaedic Foot and Ankle Society scores in patients with and without diabetes mellitus ( DM ), despite high complicatedness rates in both groups ( 14 ). The purpose of the present study was to expand the findings of the previous study and evaluate the success of this technique as a arm salvage operation for hard hindfoot and ankle deformity, comparing patients with and without DM. Another goal of our study was to report on the lessons learned as a solution of our ongoing feel with TTCA. descriptive statistics are summarized as frequencies and percentages for categoric data or as the mean ± standard deviation or median and interquartile range for normally or non-normally distribute continuous data, as appropriate. examination of normal distribution premise for continuous data was determined using Q–Q plots and histograms. Pearson ’ s chi-square or Fisher ’ sulfur claim examination, as allow, was used to compare the frequency distribution of the categorical variables between the groups. A 2-sample triiodothyronine test or Wilcoxon Mann-Whitney test was performed to determine the differences between groups for the normally or non-normally distribute continuous data, respectively. Univariate logistic arrested development analysis was applied to assess the persuasiveness of the association between the forecaster varying ( DM ) and the dichotomous result of pastime ( superficial infection, deep infection, infectious complication, noninfectious complication, and overall complicatedness ). The order of magnitude of associations between the potential forecaster variables and result was quantified using the odds ratio ( OR ) and corresponding 95 % confidence time interval ( CI ). All tests were 2 sided, and the meaning charge was set to p = .05. All analyses were conducted using SAS, version 9.3, statistical software ( SAS Institute, Cary, NC ). statistical analysis was performed by 2 of us ( B.L.R., N.C.S. ), both experienced in biostatistics. The analyze outcomes included infectious and noninfectious complications. superficial infections were defined as those treated with outpatient local hurt care and oral antibiotics ( 20 ). deep infections were defined as those that required hospital entrance fee for treatment, intravenous antibiotics, and/or surgical debridement ( 20 ). noninfectious complications included nonunion, the want for diagnostic hardware removal, and postoperative tibia fractures. Radiography was routinely used to assess for osseous union. If osseous union was not able to be assessed using radiography ( owing to hardware considerations ), computed imaging was performed to more accurately buttocks marriage. Patients who complained of pain at 6 months with intact hardware besides undergo computed imaging. Union was defined as ≥50 % osseous fusion of the ankle joint as seen on the radiogram or computed imaging scan. additionally, nonunion was defined as failure to achieve osseous fusion by the 12-month follow-up evaluation or catastrophic hardware failure. An infect nonunion was considered an infectious complication rather than a noninfectious complication. An overall complicatedness pace was determined by combining the infectious and noninfectious complications. Limb salvage was defined as preservation of the ankle joint, which equated to avoiding transtibial amputation.

The present study included a consecutive series of 117 patients with a minimum follow-up duration of 52 ( range 52 to 403 ) weeks. All the patients were > 18 years erstwhile. During the study period,119 patients undergo operation, but 2 did not have the needed minimum follow-up period. One patient died of a myocardial infarct 10 weeks postoperatively, and 1 affected role relocated 13 weeks after operation. At their last follow-up evaluation, no complications were observed ; however, they were excluded from the confront sketch. The demographic data, including gender, age, body mass exponent, tobacco function, presence of DM neuropathy, presence of DM, presence of CN, length of surgery, length of follow-up, ambulatory status, need for ongoing brace, postoperative infection, presence of previous ulceration, need for extra surgery, nonunion, and presence of DM arterial disease, were extracted from the electronic medical records. We besides recorded the preoperative testing ground values, including fasting glucose, creatinine, and hemoglobin. Patients with DM or DM neuropathy besides had the hemoglobin A1c measured within 1 calendar month of surgery. Peripheral neuropathy was defined as a Michigan Neuropathy Screening Index score of ≥2.5 ( 19 ). Patients with abnormal findings on a pedal pulse examen undergo measurement of the ankle brachial index. Peripheral arterial disease was considered portray if the ankle brachial exponent was < 0.9 ( 20 ). postoperatively, the patients were generally seen at 1, 3, 6, and 12 weeks and subsequently at 3-month intervals. After 1 year, the patients were either seen every 6 months or per annum depending on consequence. The postoperative protocol was standardized for patients according to the bearing or absence of neuropathy. Patients with neuropathy were placed in a short-leg non-weightbearing hurl for 12 weeks. Patients without neuropathy were placed in a short-leg non-weightbearing shed for 6 weeks, followed by a short-leg weightbearing vomit or controlled ankle motion boot for an extra 6 weeks. All patients, careless of the presence or absence of neuropathy, were finally transitioned to removable walking boots until radiographic evidence of mend was verified. Those patients with DM were subsequently placed in a brace ( molded ankle foot orthosis, double erect brace, or Charcot restraint orthotic walker ) for ≥12 months postoperatively. The american Orthopaedic Foot and Ankle Society ankle hindfoot scores were besides calculated at the final follow-up visit ( 17, 18 ). During each postoperative travel to, anteroposterior, lateral, and devious radiogram were evaluated for osseous heal or manifestation of complications. After identifying the patients from the register, data were extracted from the review of the electronic medical records and digital radiogram by one of us ( B.R.M. ). The following 3 regress intramedullary nailing systems were used : T2 Ankle Arthrodesis Nail ( Stryker, Mahwah, NJ ), Trigen Hindfoot Fusion Nail ( Smith and Nephew, Memphis, TN ), Versa Nail ( Depuy Synthes, Warsaw, IN ). The T2 Ankle Arthrodesis Nail ( Stryker ) was used entirely for the last 77 reconstructions because of our preference for a 5° valgus nail. The basal indications for surgery are listed in. The investigational inspection circuit board at our checkup center designated our study as an exempt study. We reviewed the foot and ankle surgical database of the aged writer ( D.K.W. ), searching for patients who had undergo arthrodesis of the ankle and hindfoot. A comprehensive examination foot and ankle register was created in our division in January 2005, and every surgical affected role was prospectivelyentered at surgery. Demographic data and the International Classification of Diseases, Ninth Revision ( ICD-9 ) diagnosis codes ( arthritis of the ankle and animal foot, codes 715.7 and 716.7 ; CN, code 713.5 ; and deformity of the ankle or infantry, code 736.7 ) and current Procedural Terminology codes ( codes 27870 [ ankle arthrodesis ], 28705 [ pantalar arthrodesis ], 28715 [ triple arthrodesis ], and 28725 [ subtalar arthrodesis ] ) were entered into the spreadsheet ( 15, 16 ). postoperative complications were recorded prospectively in the comprehensive foot and ankle register by flatly denoting the absence ( code 0 ) or presence ( code 1 ) of specific complications. Patients who underwent major arthrodesis were identified from the comprehensive animal foot and ankle register, and the electronic medical records and digital radiogram were reviewed. All the procedures and postoperative follow-up evaluations were performed by the aged surgeon ( D.K.W. ) from January 1, 2005 until June 30, 2013. The beggarly follow-up duration was 159.8 ± 92.9 weeks for patients with DM and 155.1 ± 89.8 weeks for patients without DM. Our 2 groups of patients were like with regard to historic period, gender, distance of surgery, body multitude index, tobacco function, previous operating room, previous foot ulcer, and rheumatoid arthritis ( ). Patients with DM had significantly greater serum glucose, creatinine, hemoglobin A1c levels and significantly lower hemoglobin levels than patients without DM. The patients with DM were besides importantly more probably to have DM neuropathy, CN, and DM artery disease. Of the 61 diabetic patients, 9 ( 14.75 % ) had previously undergo solid organ transplant versus none of our nondiabetic cohort ( ). The overall rate of complications ( infectious and noninfectious ) was not importantly different between the patients with and without DM ( OR 0.79, 95 % CI 0.38 to 1.65, phosphorus = .54 ). Patients with DM had an 8 times greater likelihood of superficial contagion than patients without DM ( OR 8.3, 95 % CI 1.01 to 68.67, p = .03 ), but no significant differences were seen in the pace of deep contagion or overall infection ( ). The incidence of noninfectious complications between the 2 groups was not significantly different ( OR 0.50, 95 % CI 0.23 to 1.13, p = .0877 ). Our 61 patients with DM experienced 15 noninfectious complications ( 24.6 % ), including 10 nonunions ( 16.39 % ), 4 tibia fractures ( 6.56 % ), and 1 hardware removal ( 1.64 % ) for a big sleep together. The see group of 56 patients without DM experienced 22 noninfectious complications ( 39.3 % ), including 14 nonunions ( 25 % ) and 8 diagnostic hardware removals ( 14.29 % ). More than 95 % of the patients in both groups were ambulatory at the most holocene follow-up examination ( phosphorus = .60 ), although a vogue was seen toward greater stimulate consumption in the patients with DM than in the see group ( p = .0569 ). The incidence of limb salvage was besides similar in the patients with ( 96.7 % ) and without ( 94.6 % ) DM ( phosphorus = .6692 ). Of the patients with DM, 80 % were satisfied with the consequence of surgery compared with 73 % of the patients without DM ( phosphorus = .3732 ). A femoral head homograft was used in 32 ( 27.4 % ) of 117 patients. Of the 32 patients who required a femoral heading homograft to replace a deficient talus, 21 ( 65.6 % ) experienced an overall complication compared with 32 ( 37.6 % ) of the 85 patients who did not require a femoral question homograft ( OR 3.16, 95 % CI 1.35 to 7.41, p = .008 ). Of the 85 patients with DM neuropathy, 37 ( 43.5 % ) experienced a complication compared with 16 ( 50.0 % ) of the 32 patients without DM neuropathy ( OR 0.77, 95 % CI 0.34 to 1.74, p = .53 ) .

Discussion

Using a retrograde ankle arthrodesis complete for TTCA, our overall rate of limb salvage in a complicated age group of patients was 95 %. The complexity of our diabetic age group is illustrated by the high prevalence of DM neuropathy ( 95 % ), CN ( 72 % ), foot ulcers ( 40 % ), and DM artery disease ( 20 % ). once a foundation ulcer develops in a diabetic patient with CN, the gamble of amputation increases by a factor of 12 ( 21 ). Of the command group of patients without DM, 50 % had DM neuropathy and 12.5 % had nondiabetic CN. Although CN engagement of the hindfoot and ankle is reported to be less common than in the midfoot, it is much more ambitious to manage owing to the adapted biomechanics associated with the disfigurement ( 8 ). nonsurgical management remains the initial and mainstay treatment of CN, although hindfoot and ankle deformities can be difficult to brace owing to prominent malleoli ( 22 ). The primary finish of nonsurgical treatment with brace and unload is to maintain an ulcer-free, static, plantigrade mammal foot for ambulation. progress of the deformity can result in severe ankle/hindfoot malalignment, resulting ininstability and an inability to brace the deformity. Prominent malleoli, secondary coil to varus, valgus, or talus collapse, can lead to ulcer, contagion, and possible amputation. For certain patients, this progress seems to be ineluctable, and surgical reconstruction become warranted.

successful outcomes have been well documented after TTCA with internal fixation in patients with CN or other hindfoot deformities, although the complications rates have been high ( 2, 3 ). A multicenter study of 38 patients from 7 participating centers across North America and Europe reported that nonunion after former ankle coalition was the most common reading for hindfoot and ankle breeze through implantation ( 23 ). Of the 38 patients,19 ( 50 % ) were retired or unemployed at operating room, and 19 were initially employed, with 13 of these patients taking sick leave as a solution of their deformity. Eventually,15 of the 19 patients were able to return to their running status after their successful operation ( 23 ). Jehan et aluminum ( 1 ) performed a systematic review of 613 patients and reported a marriage rate 87 %, complicatedness pace of 56 %, and amputation rate of 1.5 %. Our overall union pace of 79.4 % is comparable to the outcomes in that systematic revue and the published data we reviewed for the confront study ( 2 – 5, 7 – 9, 13, 23 – 37 ) ( ). The published data review presented in identify 342 diabetic patients with CN who underwent TTCA. The coupling rate was 79 %, and the overall complication rate was 40 %, findings unusually like to those from our series ( ). We used the ankle joint as the exponent articulation for union owing to the difficulty in assessing subtalar union after TTCA. We agree with Coughlin et alabama ( 38 ), who reported that radiographic evaluation of the subtalar joint was not a authentic method acting for determining union. Despite our high complication rate of 45.3 %, our limb salvage rate was 95 % and affected role satisfaction was reasonably high. One challenge that exists in comparing complication rates from discipline to study is the miss of consensus on the definition of a complication. Some studies have reported perioperative complications and postoperative complications, and others have reported only major complications that might necessitate extra operating room .

Table 4

First Author No. of Patients Union (%) Infection (%) DM/CN Patients (n) DM/CN Union (%) DM/CN Infection (%) Overall Complication (%) Limb Salvage (%)
Kile (26), 1994 30 93 6.6 1 NA NA NA 93
Moore (27), 1995 19 74 5 7 71 NA 11 100
Pinzur (8), 1997 21 90.5 28.5 21 90.5 28.5 52 95
Thordarson (28), 1999 12 100 0 1 NA NA 58 100
Stone (13), 2000 7 28.5 14 7 28.5 14 NA 86
Chou (29), 2000 37 86 11 2 NA NA 32 100
Quill (30), 2003 82 97 NA 18 NA NA NA 100
Mendicino (5), 2004 20 95 20 10 90 20 70 100
Hammett (31), 2005 52 90 3.8 2 NA NA 59 96
Pinzur (9), 2005 9 100 11 9 100 20 22 100
Caravaggi (2), 2006 14 71 29 14 71 29 29 93
Pelton (7), 2006 33 88 3 10 80 NA 18 100
Hockenbury (4), 2007 10 90 20 10 90 20 100 100
Dalla Paola (3), 2007 18 78 0 18 78 0 17 100
Niinimaki (32), 2007 34 76 12 3 NA 33 15 100
Boer (33), 2007 50 100 NA 2 100 NA NA 100
Muckley (34), 2011 55 96 9 NA NA NA 25 100
Caravaggi (35), 2012 45 87 31 45 87 31 53 87
DeVries (36), 2012 154 94 28 67 NA NA NA 88
DeVries (24), 2013 179 NA NA 78 NA NA NA 88
Rammelt (23), 2013 38 84 5 10 NA NA 24 100
Gross (37), 2014 30 86 10 7 57 NA 56 97
Brodsky (25), 2014 30 97 10 NA NA NA 33 100
Average (mean) Total 979 86 13 Total 342 79 22 40 97

Open in a separate window A recent cogitation by Bussewitz et alabama ( 39 ) concluded that in cases of complex diseased entities with austere bone loss, a femoral head homograft was a suitable substitute for reconstructing the osseous void. They reported that the function of a bulk femoral fountainhead homograft could complicate curative, although the fusion rate was 84 % ( 39 ). DeVries et alabama ( 24 ) reported that bone morphogenic protein-2 was associated with a nonsignificant enhanced limb salvage rate without an increased gamble of complications. Another retrospective, comparative survey by DeVries et aluminum ( 40 ) evaluated the outcomes of IMN arthrodesis with or without external arrested development augmentation. major amputation was required in 22 % of the IMN pinpoint group and 29 % of the IMN plus external arrested development group, for an overall arm salvage rate 76 % ( 40 ). A big series of 179 reconstructions reported a limb salvage rate of 88 %, identifying DM as the most luminary risk component associated with major amputation. other factors associated with amputation were the need for revision surgery, older age, and preoperative ulceration ( 41 ). Our limb salvage rate of 95 % is like to that reported in the published datum included in our review ( ). Of the 5 patients in our series who subsequently required below-the-knee amputation, 2 did sol because of symptomatic nonunion with hardware failure and chronic trouble and 3 because of haunting deep infection. All 5 of the patients who undergo amputation had DM neuropathy. however, the rate of complications was not significantly different when comparing patients with and without DM neuropathy. symptomatic tension reaction of the tibia is a know complication of regress IMN fixation, with rates american samoa high as 10 % in published studies ( 25 ). Noonan et aluminum ( 42 ) reported on the biomechanical analysis of complete duration and its effects on stress at the proximal tiptoe of the complete. They attributed tibial tension reactions/fractures to the difference in the modulus of elasticity between the bone implant interface and the loss of ankle and subtalar joint gesticulate ( 42 ). Four diabetic patients in our series ( 3.4 % ) experienced a tibia fracture at or above the proximal tip off of the nail ( to ). All of these fractures occurred in patients in whom we had used the shortest nail ( 150 millimeter ), and all were successfully reconstructed by revising the 150-mm pinpoint to the 300-mm nail ( to ). We now routinely use a 300-mm pinpoint for our TTCA procedures. This longer nail allows for stabilization of the breeze through in the isthmus of the tibial diaphysis, preventing valgus or varus toggle. To use the longer breeze through, free hand proximal cross-locking is necessity and surgeons must be comfortable with this technique.

Three patients in our series presented with deep infections after 6 months, and ongoing watchfulness must be used in this bad group of patients who undergo retrograde intramedullary collar. deep infections are considered surgical web site infections if they present within 1 class of surgery in patients with implants. none of the 3 patients experienced any wound problems during the perioperative run. Another lesson learned was that fixation in the anklebone is authoritative and care of acme is critical for patients undergoing TTCA ( 43 ). In patients with an avascular or deficient talus, we have used a femoral forefront homograft with effective achiever. In rare cases, the distal tibia could be compromised, and a femoral pass homograft can be used to reconstruct bone loss in the tibia ( internet explorer, after a complex tibial pilon fracture with nonunion ). approximately 25 % of the patients in the present series required a femoral head homograft for bone loss, and use of a femoral read/write head homograft was associated with a 3 times increased risk of a complication. At this point, we can not submit definitively whether this increased pace of complications resulted from the femoral head homograft or that the patients who required an homograft had more significant disfigurement. The show analyze had weaknesses that need to be acknowledged. The most obvious weakness of our study was the retrospective blueprint. even well-conducted retrospective studies will be submit to a boastfully number of biases. The excerpt of a operate group itself can introduce bias, and we attempted to minimize this by including all patients without DM as the control condition group rather than attempting to match them. retrospective studies besides rely on the accuracy of the medical records, and the data obtained for analysis will only be adenine good as the software documentation in the aesculapian criminal record. We have attempted to minimize the measurement bias between the learn and control groups by remaining reproducible in our treatment. All patients received the lapp antibiotic prophylaxis according to the Surgical Care Improvement Project protocol. Our postoperative follow-up visits generally occurred at 1, 3, 6 and 12 weeks, give or take a few days. A drift was seen toward prolong stimulate use for patients with DM, and this most probable resulted from the senior author ’ second ( D.K.W. ) concern for potential neuropathic failure in this bad group. We have attempted to minimize nonresponder bias, because we have not lost any patient to follow-up during the cogitation period, with the exception of the 2 patients previously mentioned ( and excluded ). however, our report was subjugate to this type of bias because some of the patients were followed up longer than others, and extra complications might have been detected with longer follow-up periods. Our consequence measures, the bearing or absence of a postoperative complication, was assessed and treated systematically in each patient by the lapp attend doctor. consequently, interviewer diagonal was potentially show, because the senior writer ( D.K.W. ) determined the outcomes. many unlike risk factors play a function in postoperative complications, particularly for diabetic patients ( i, old age, gender, neuropathy, and vascular disease ). We attempted to address this using the proper statistical methods. The potential for survival bias existed because of the lessons learned by the elder generator ( D.K.W. ) during the past decade. Patients with ill controlled DM have an increased risk of postoperative infection ( 20 ). consequently, we now delay elective surgery until the hemoglobin A1c level is ≤8 % and active tobacco use has stopped. Although patient gratification was relatively high in the introduce study, some patients with successful arm salvage were not satisfied with the consequence. In patients with DM, successful limb salvage was achieved in 97 % of the patients, but only 80 % were satisfy ( ). similarly, 95 % of nondiabetic patients had successful limb salvage, although the patient satisfaction rate was lone 72 % ( ). We do not have a well explanation for this disparity. The mean American Orthopaedic Foot and Ankle Society ankle hindfoot scores in both groups was < 60, implying some component of restrict function. Patients without DM neuropathy might besides experience greater rates of postreconstruction pain, possibly accounting for the lower atonement pace in this group. Despite a gamey complication rate, this single-surgeon series with a mean follow-up of > 2.5 years has demonstrated that diabetic patients with limb-threatening problems have a high likelihood of successful limb salvage with TTCA using a retrograde IMN. With the exception of an increase rate of superficial infections, patients with DM had outcomes alike to those patients without DM. The use of a femoral head homograft, although much necessary, increases the risk of complications by a agent of 3. From our have, we now routinely use retrograde nails that are 300 mm hanker .

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