For Orthopaedic Surgeons

1. AVN Talus Treated By
Retrograde Nail
Fusion
Dr. Apoorv Jain
D’Ortho, DNB Ortho
drapoorvjain23@gmail.com
9845669975

2. •Name: XYZ
•Age : 19 Years
•Sex : Male
•Occupation: Student

3. Chief Complaints
• C/O Pain and restriction of
movements around Right ankle
joint since last 1 year.
• C/O Difficulty in walking since last
1 year.

4. History Of Presenting Illness
• Patient was apparently normal till 1 year
back when he fell down from a moving
tractor and sustained injury to his right leg.
• Following the fall, he had severe pain
around right ankle joint and was unable to
weight bear.
• He was taken to a local hospital where
primary aid was given and he was told to
have sustained fracture around right ankle
after taking Xrays.

5. • POP slab immobilisation was done and he
was operated 8 days later.
• Non weight bearing was continued for 2
months following which implant (? K-wire)
removal was done outside.
• Partial weight bearing was started and the
patient again started having pain and
restriction of movements around the ankle
joint which was gradually progressive and
not relieved by rest or medications.

6. • Patient is able to partially weight bear
and is able to squat with support.
• H/O Prolonged intake of analgesics is
present.
• No H/O Sinus / Discharge.
• No H/O Fever/ night sweats / weight
loss/ Loss of appetite.
• Not a K/C/O DM/ HTN/ TB/ Asthma.

7. Past History:
• Nothing Significant.
Family History:
• Nothing Significant.

8. Personal History
• Diet : Veg
• Appetite : Good
• Sleep : Undisturbed
• Bowel & Bladder : Normal & Regular
• Habits : No addictions

9. General Physical Examination
• A Young male patient, moderately built and
nourished, alert, conscious and co-operative
and well oriented to time, place and person.
• Pulse : 86/min
• B.P. : 110/70 mm of Hg
• Resp. Rate : 23 cycles/min
• Temp. : 98.6°F
• No Pallor/ Icterus/ Cyanosis/ Clubbing/
Lymphadenopathy/ Oedema

10. Systemic Examination
• CVS : S1 S2 heard, No murmurs
• RS : B/L NVBS heard,
No added sounds
• PA : Soft, Non tender,
No organomegaly, BS+
• CNS : No focal neurological deficit

11. Local Examination
(Right Ankle joint)
Inspection:
- Gait: Antalgic
- Attitude: Neutral
- Diffuse swelling around ankle joint
is present.
- Skin appears tense and shiny.

12. - Healed surgical scar mark seen
over the medial aspect of distal
leg around 6 cms in size, extending
distally till medial malleolus.
- No obvious bony deformity.
- No obvious limb length
discrepancy.

13. Palpation:
- All inspectory findings are confirmed.
- Tenderness present over the neck of
talus and anterior joint line.
- No local rise of temperature.
- No Crepitus.
- No Abnormal mobility

14. - Range of movements:
>Plantar and dorsiflexion 10° and
painful.
>Inversion and eversion painful and
restricted.
- Toe movements normal.
- No Distal Neurovascular deficit.
- No lymphadenopathy.

15. X-ray (Right ankle AP and Lateral)

16. Diagnosis
• Old non united fracture Neck of
Talus.
• Avascular necrosis of the Body of
Talus.
• Arthritic changes of Tibio-talar
and Subtalar joint.

17. Routine Blood Investigations
• Hb : 14.2 gm/dl
• TC : 8,600 cells/mm³
• DC : N62L32M4E2B0
• ESR : 12 mm in 1st hour
• Urea : 22 mEq/L
• Creat: 1.1 µg/L
• Na⁺ : 138 mEq/L
• K ⁺ : 4.1 mEq/L

18. Classification Of Talus Fractures
Anatomical Classification:
•Lateral process fractures
•Posterior process fractures
•Talar head fractures
•Talar body fractures
•Talar neck fractures

19. The normal skeletal anatomy of the
foot and ankle

20. Hawkin’s Classification Of Talar Neck
Fractures
Type I: Nondisplaced
Type II: Displaced fracture/ Associated
subtalar subluxation or
dislocation
Type III: Associated subtalar and ankle
dislocation
Type IV:
(By Canale
& Kelly)
Type III with associated
talonavicular subluxation or
dislocation

21. Nondisplaced vertical fracture of the
talar neck (Hawkins type 1)

22. Displaced Hawkins Type II fracture of the
talar neck with subluxation (left) and
dislocation (right) of the subtalar joint.

23. Displaced fracture of the talar neck with
dislocation of both the subtalar and
tibiotalar joints (Hawkins Type III)

24. Type IV fracture of the talar neck with
subluxation of the subtalar joint and
dislocation of the talonavicular joint

25. Avascular Necrosis Of Talus
• The rate of osteonecrosis is related
to initial fracture displacement is:
–Hawkins I: 0% to 13%
–Hawkins II: 20% to 50%
–Hawkins III: 80% to 100%
–Hawkins IV: 100%

26. The Hawkins sign
• It is a well-described radiographic
indication of viability of the talar
body.
• The time to recognize the presence
of avascular necrosis is between the
sixth and the eighth week after the
fracture-dislocation.

27. • By this time, if the patient has been
non weight-bearing, diffuse atrophy
is evident by x-ray in the body of
Talus.
• Presence of subchondral sclerosis
suggests the diagnosis of avascular
necrosis [osteonecrosis].

29. • Other diagnostic tools used to evaluate
osteonecrosis include technetium bone scan
and magnetic resonance imaging.
• The use of bone scanning has largely been
replaced with MRI.
• MRI can be used as early as 3 weeks
postinjury, and defines not only the presence
but also the extent of osteonecrosis, as well
as the condition of the articular cartilage.

30. Treatment Options
• The prognosis and best treatment remain
a source of controversy.
• Union can occur in the presence of
osteonecrosis, provided the fixation is
stable.
• The treatment varies with individual
patient based upon clinical symptoms,
amount of fracture collapse, duration,
arthritic changes and functional demands.

32. • Selected case reports in the literature
describe successful efforts to
revascularize the necrotic talus.
• Treatment options for revascularization
of talus (in early cases only) include:
–Core decompression.
–Nonvascularized autograft.
–Nonvascularized allograft.
–Vascularized bone graft.

33. Necrotic Part of Talus excised

35. Cortico- Cancellous Iliac graft placed in
the defect

36. Vascularised Bone graft:
Proximal lateral tarsal artery with the cuboid pedicle

37. • In cases of expectant treatment for bone
union prolonged periods of nonweight-
bearing have been recommended, because
the talus is revascularized slowly via
creeping substitution of necrotic bone with
vascularized bone.
• This process may require up to 36 months.
The duration of nonweight-bearing
required is unpredictable, relatively
impractical, and difficult to adhere to for
patients.

38. • Salvage surgeries (for late cases)
include:
–Primary triple arthrodesis
–Talectomy with tibio-calcaneal fusion
–Subtalar fusion
–Pantalar fusion
–Tibiotalar fusion

39. Treatment Done
• Excision of the body of Talus and a
Tibio-Calcaneal Arthrodesis was
done with the help of a retrograde
intramedullary nail.
• Ankle and subtalar joint were fused
in neutral flexion, 5° of valgus and
10° of External rotation.

40. Post-Op X-ray

41. Evidence 1**
• Osteonecrosis is often associated with
collapse of the talar dome and the
development of symptomatic arthritis of
the ankle joint.
• For these patients, ankle arthrodesis is
indicated.
• Tibiocalcaneal arthrodesis and the Blair
fusion have both been found effective.
**(Rockwood & Green’s, 6th edition)

42. • Tibiocalcaneal arthrodesis is an option
in which fusion of the entirety of the
calcaneus to the distal tibia is done.
• Results have been noted to be superior
to talectomy or ankle fusion by Canale
and Kelly.
• The fusion of the tibia to the calcaneus
may provide more stability compared
to the Blair’s sliding graft technique.

43. Tibiotalar Arthrodesis with a Sliding
Bone Graft (Blair Technique)

44. Calandruccio II External Fixation Device
for Tibio-Talar fusion

45. Tibiocalcaneal Arthrodesis with
Intramedullary Nailing (Graves et al.)

46. • Insertion site for retrograde intramedullary fixation of tibiocalcaneal
arthrodesis. A, Line in sagittal plane from tip of second toe to center of
heel. B, Line can be drawn in coronal plane bisecting medial malleolus.
Intersection of lines indicates correct entry portal for nail.

48. As per an article by Devries JG et al
published in the journal of Foot and Ankle
International Society, November 2010
titled Retrograde intramedullary nail
arthrodesis for avascular necrosis of the
talus.
• CONCLUSION:
• Salvage of talar AVN is possible by
tibiotalocalcaneal arthrodesis with an
intramedullary nail. Physicians may offer this as
a salvage option to patients with a high
likelihood of successful fusion.

49. Another article By Shah JEHAN et al, The
Robert Jones and Agnes Hunt Orthopaedic
Hospital, Oswestry, UK. Published in the Acta
Orthopaedica Belgica, 2011 titled “The
success of tibiotalocalcaneal arthrodesis with
intramedullary nailing – A systematic review
of the literature”
• Conclusion:
• This systematic review shows that
TibioTaloCalcaneal Artrodesis with an IM nail
has relatively good fusion rates.

50. • Dynamic proximal
locking and longer nails
are a few suggestions
recommended by
authors in the studies.
• Their logic is that the
longer nails will
minimise the risk of
stress fractures, and
dynamic screws will
reduce the need for
dynamization.
Modern IM nail specially designed for tibiocalcaneal
arthrodesis (Ortho Solutions, Maldon, Essex, UK)

51. Thank You