Pertinent Insights On The Posterior Approach To Hindfoot Arthrodesis

Jeffrey E. McAlister, DPM, and Christopher F. Hyer, DPM, MS

   The patient remained in a non-weightbearing cast for six weeks and subsequently transitioned into a weightbearing fracture boot for eight weeks. At this point, serial radiographs revealed trabecular bridging in multiple views. He then began formal physical therapy with a lace-up ankle brace and supportive shoegear. No complications occurred during the postoperative period. At the final follow-up, he had a pain-free plantigrade foot with proper foot to leg alignment. Again, serial radiographs revealed appropriate osseous healing without hardware compromise.

   Our surgical technique has evolved in cases of tibiotalocalcaneal fusions without bulk allografts since this case. In addition to the posterior locking plate application, our institution has supplemented interfragmentary screw compression across both joints with 6.5-mm screws while avoiding a plantar incision (see Figure 18).

What The Literature Reveals

The case presented above involved a sensate, active male who presented for a second opinion with a complicated talar avascular necrosis defect. The literature is sparse when salvage of a limb with talar avascular necrosis occurs with successful results.

   Devries and colleagues retrospectively reviewed 14 patients included in the RAIN (Retrograde Intramedullary Nail Arthrodesis) database.1 The average age was 47 years old and the most common (36 percent) etiology was status-post talar fracture. Twelve of 14 patients went on to a solid union and eight patients were able to return to preoperative shoegear. The complication rate was 28.6 percent. This relatively large cohort of talar avascular necrosis cases utilizes intramedullary, load-sharing devices with good success.

   Surgeons have used multiple fixation types over the years for tibiotalocalcaneal fusions with success. Various authors have described lateral humeral locking plates, anterior locking plates and posterior blade plates.2-5 The development of locking plate technology has revolutionized fixation constructs in foot and ankle surgery, specifically hindfoot and ankle arthrodesis. Biomechanical studies have evaluated the stiffness and load to failure of screws only versus an anterior locking plate and screw construct showing that, as expected, an anterior plate and cross-screw configuration were more stiff in a cadaveric model.6 We used locking plate technology in this case due to the patient’s bone quality and large defect.

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