1. By: William JE Adams, PGY-II
Community Health Network - Indianapolis
TTC FUSION WITH IM NAIL
2. INDICATIONS
• Arthritis – Post-trauma, Osteo & Rheumatoid
• Failed isolated fusions
• Neuropathic deformities
• Failed TAR
• Talar AVN
• Severe ankle and hindfoot deformities
3. “All methods of TTC arthrodesis strive for the
common goal of a functional, solid, pain-free
fusion.”
-Myerson, 2013
“With IM nail fixation the rigidity and
stability achieved are unsurpassed and
often result in relatively asymptomatic
bone healing complications if they
occur.”
-Yu, 2002
“Generally, I use the IM rod for
a TTC arthrodesis and a
blade plate for a TC
arthrodesis.”
-Myerson’s Reconstructive
Textbook - 2005
4. TTC VERSUS ISOLATED AJ FUSION
• Myerson 2013 FAI study showed TTC fusion pts compared to AA patients had
similar outcomes in function, satisfaction, and pain relief
• Coester/Saltzman JBJS study w/ 22 yr follow up showed 91% of ankle fusion
patients go on to develop STJ arthritis1
• Significant high level evidence supporting both techniques
• New hardware for TTC allows great compression and stable constructs that
avoid additional procedures - Myerson
5. COESTER/SALTZMAN STUDY
• 23 patients underwent isolated ankle fusions for post-traumatic arthritis & were followed up for
a mean ~ 22 years
• “The ipsilateral STJ range of motion was decreased in every patient. With no motion in nine
(39%)”1
Joint
Ipsilateral
No. of Subjects with
Moderate or Severe
Osteoarthritis
(Grade 4 or 5)
No, Doubtful, or
Minimal
Osteoarthritis
(Grade 1, 2, or 3)
STJ 21 (91%) 2
TN 13 (57%) 10
CC 5 (22%) 16
NC 7 (30%) 14
TMT 9 (39%) 13
1st
MTP 7 (30%) 14
TABLE III Grade of
Osteoarthritis According
to the System of Kellgren
and Moore
6. MYERSON STUDY
• From 2002 to 2010, 53 ankle arthrodesis (AA) pts & 64 tibiotalocalcaneal fusion pts were
included in a study comparing function & satisfaction between the procedures
• Mean follow up ~ 5.25 years
• Results: both groups overall showed good outcomes; low visual analog pain scores, high
satisfaction scores (90.6% for AA and 87.5% for TTC), & return to work (77.4% AA, & 73%
TTC).
• 84.6% of AA and 81% of TTC fusion patients say they would have surgery again.
(Statistically insignificant differences)
• However, when asked if they met their desired activity levels following the procedure 58.5%
AA pts said yes, versus 66.65 TTC pts.
• Overall, Myerson concluded that both statistically, & clinically there was no difference between
the AA group & TTC group in terms of function and satisfaction.
7. CASE REVIEW
• 62 y/o female presents as referral from ortho – Not TAR candidate due to shape of talus and
STJ involvement
• Symptoms of pain at STJ /AJ through active & passive ROM, weakness, medial knee pain, &
instability due to collapsed arch
• Pmhx: HTN, DM II, Pacemaker, HLD, COPD, obesity, and OA
• PShx: knee replacement b/l, rotator cuff repair, hysterectomy
• Allergies: Tramadol, codeine
• Neurovascular status intact
• PE: Unable to perform single or double heel rise, too many toes sign, hindfoot valgus,
abduction of forefoot on RF, equinus, severely limited ROM of AJ/STJ, decreased muscle
strength w/ inversion and plantarflexion
• Indications: AJ/STJ arthritis, End stage PTTD, Ankle joint valgus, Pes planus, Equinus, body
habitus
• Hardware: Biomet titanium phoenix IM nail - Size: 11.0X180MM
15. TECHNIQUE CONSIDERATIONS
Nail insertion point
“Step 5: Nail Entry Site and Incision Following the
preparation of the bony surfaces, a 3 cm longitudinal
plantar incision is made anterior to the subcalcaneal
fat pad slightly lateral to the midline, especially in the
patient with significant preoperative valgus deformity.
Blunt dissection is carried down to the plantar fascia,
which is split longitudinally. The intrinsic muscles are
swept medially or laterally and the neurovascular
bundle on the sole of the foot is identified”
-Biomet manufacturer recommendations (BMR)
Step 6: Entry Guide Wire Insertion The ideal position
for the plantar calcaneal entry site is well anterior to
the weight bearing surface of the calcaneal
tuberosity and approximately 2 cm posterior to the
articulation of the calcaneus with the transverse
tarsal joints.
16. “The process of defining the point of entry
of the guide pin is quite tedious and can
take as long as 1.5-20 minutes. The
importance of this step in the procedure
cannot be over-emphasized as it is this step
that will determine the final end product
with regard to placement of the nail.” – Yu,
2002
“A 3.2 mm x 320 mm Entry Guide
Wire is inserted through the
calcaneus, talus, and tibia. Confirm
the position of the wire on the C-
arm.” -BMR
25. CASE 2
• 52 y/o female presents as referral from community podiatrist that does not perform reconstructive sx
• Symptoms of pain at AJ through active & passive ROM, weakness, medial knee pain & instability due to
pain and guarding
• Pmhx: HTN, Bipolar disorder, polysubstance abuse, post-traumatic OA, tobacco abuse, depression
• PShx: Previous left ankle fracture repair
• Allergies: Ibuprofen, Ultram
• PE: Musk: Unable to balance on left ankle w/o assistance, ankle valgus deformity, equinus, severely
limited ROM of AJ w/ pain and crepitus, decreased muscle strength
Neurovasc: Intact
• Indications: Post-traumatic OA, large talar OCD, ankle valgus deformity secondary to trauma
• Hardware: Biomet titanium phoenix IM nail - Size: 11.0X180MM
26. Prior to first fall
1/26/2015
After fall, fracture, repair at Methodist, another fall, and 7/17/2015
10/17/2015
29. TIPS/PEARLS
• Thorough & honest surgical consultation addressing immediate post-op course,
expectations, recovery strategies including mobility issues, family involvement,
etc…
• VASCULAR studies
• Pre-op CT best delineates total bony integrity & structure
• Practice putting together & taking apart outrigger assembly prior to case
• Study manufacturer recommendations on implantation and technique tips
offered from the particular companies physician consultant
• Solicit a knowledgeable assist (resident or attending physician) for additional
dexterity
• Fully utilize intra-op imaging to ensure screw placement into nail – soft bone can
make purchase deceiving
30. TIPS/PEARLS CONTINUED
• Full utilization of peri-operative anesthesia to aid patient experience and
recovery, i.e. regional block, Toradol drip, etc..
• In the event the fibula is resected but not used as graft - should be saved in the
hospital's bone bank for future use if revisional surgery would become
necessary
• “It is important to monitor these patients on a 3 to 4 month basis for at least the
first year (Figures 9A, 9B). During this time loosening of the screws with or
without migration of the screws may occur necessitating the need for screw
removal or replacement. Patients should also be monitored for the development
of pathologic fractures of the tibia.” – Yu, 2002
31. REFERENCES
1. Coester, MD, L., Saltzman, MD, C., & Leupold, MD, J. (2001). Long-Term Results
Following Ankle Arthrodesis for Post-Traumatic Arthritis. The Journal of Bone and
Joint Surgery, 83A(2), 219-228. doi:February 2001
2. Myerson, MD, M., Ajis, MBChB, FRCS, A., & Tan, MBBS, FRCS, K. (2013). Ankle
Arthrodesis vs TTC Arthrodesis: Patient Outcomes, Satisfaction, and Return to
Activity. Foot and Ankle International, 34(5), 657-665. doi:10.1177/1071100713478929
3. Conti, BA, M., Ellis, MD, S., Chan, MD, J., Do, MA, H., & Deland, MD, J. (2015). Optimal
Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot
Deformity. Foot and Ankle International, (NA), 1-9. doi:10.1177/1071100715576918
4. Bennett, MD, G., Cameron, MD, B., Njus, PhD, G., Saunders, MS, PhD, M., & Kay, MD, D.
(2005). Tibiotalocalcaneal Arthrodesis: A Biomechanical Assessment of Stability. Foot
and Ankle International, 26(7), 530-536.
32. REFERENCES
5. Hernandez, MD, J., Remy, MD, S., Darcel, MD, V., Chauveaux, MD, D., & Laffentre, MD,
O. (2015). Tibiotalocalcaneal Arthrodesis Using a Straight Intramedullary Nail. Foot and
Ankle International, 36(5), 539-546. doi:10.1177/1071100714565900
6. Muckley et al. Comparison of Two Intramedullary Nails for Tibiotalocalcaneal
Fusion: Anatomic and Radiographic Considerations. Foot and Ankle International
2007. 28: 605
7. Yu, DPM, G., Gorby, DPM, P., Hudson, DPM, J., & Weinfield, DPM, G. (2002).
INTRAMEDULIARY NAIL FIXATION IN REARFOOT AND ANKLE ARTI-IRODESIS
PROCEDURES. In Podiatry Institute Chapter Update to McGlamry's (Vol. 2002, pp.
237-246). Decatur, GA: Lippincott Williams & Wilkins.
8. Myerson, Mark S. Reconstructive Foot and Ankle Surgery. 1st ed. Elsevier, 2005.
Print.
