Retrograde tibiotalocalcaneal nailing provides a novel single-stage approach to addressing hindfoot arthritis associated with tibial malunion or nonunion. The technique involves correcting tibial alignment via osteotomy and fusing the ankle and subtalar joints using a retrograde nail. In a study of 25 patients, all malunions and nonunions healed without loss of correction. Hindfoot alignment and function were restored, with 94% of patients reporting being satisfied or extremely satisfied. The technique provides an alternative to external fixation or staged procedures for treating this complex problem.

1. Addressing Hindfoot Arthritis with
Concomitant Tibial Malunion or Nonunion with
Retrograde TibioTaloCalcaneal Nailing: A Novel
Treatment Approach
Justin M. Kane et al
Rothman Institute at Thomas Jefferson University Hospital, Philadelphia,
Pennsylvania
Journal of Bone and Joint Surgery
| April 2014 | Vol. 96-A | Number 7
Level of evidence I
PRESENTER : Dr SAUMYAAGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and Dr.
Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• Tibial shaft fractures are most common
long bone fractures with incidence upto
26 / lakh people
• Malunion and nonunion most common with
tibial shaft fractures
• Prearthrotic deformity - coined by rosemeyer and
described as effect of angular deformity of tibia on
distribution of weight across adjacent joints

3. REVIEW OF LITERATURE
• Sarmiento found deformity 0f >5⁰ ---> late onset
degenerative changes in adjacent joints
• Puno et al concluded - anatomic reduction could
reduce abnormal forces at adjacent joints and
possibly delay arthritis at ankle
• Tarr et al found - more distal the deformity,
greater the impact on incongrous tibiotalar
contact area

4. • Milner et al evaluated late onset arthritis post
tibial shaft fractures and found more
osteoarthritis in knee and ankle on injured
extremity.

5. Various Treatment Options
1. Tibial osteotomy with ankle arthrodesis/
arthroplasty
2. External fixation to correct malunion or
nonunion with ankle arthrodesis
3. Tibiocalcaneal nail fixation for correction of
malunion or nonunion and arthrodesis of
ankle

6. METHODS
• A retrospective study
• Patients who underwent single stage
reconstruction for tibia malunion or nonunion
with tibiotalar arthritis were assessed
• Visual Analog Scale and American Orthopaedic
Foot and Ankle Society – Ankle Hindfoot scores
were used to assess

7. Exclusion Criteria
• Active infection
• Leg length discrepancy of >5cm
• Malunion or nonunion at ankle joint
secondary to ankle fracture
• Treatment with a staged procedure or single
stage deformity correction with arthroplasty

8. • 25 patients underwent single stage correction of
tibial malunion or nonunion with
tibiotalocalcaneal nailing
• Average age – 58 yrs
• 13 men and 12 women
• 3 patients had severe rheumatoid arthritis
• 8 patients had peripheral neuropathy

9. • 16 had healed angular malunion
• 4 had combined malunion and nonunion
• 5 had tibial nonunion

12. Varus and recurvatum deformity

13. • Overall average sagittal plane malalignment was
26⁰ and average coronal plane malalignment
was 21⁰
• Ankle joint arthritis was assessed for pain, ROM
and palpable crepitus
• AP, Mortise and lateral views were taken
• Weight bearing radiographs were taken to
assess joint space narrowing, subchondral
sclerosis and osteophyte formation

14. • Subtalar joint and transverse tarsal joints were
assessed independently
• An inflexible subtalar joint can decrease ability
to correct alignment and lead to undesirable
results
• Inclusion of subtalar joint in arthritis, aided in
correction of deformity and allowed use of
single device to treat arthritis and malunion

15. • Author hypothesized that whenever subtalar
involvement was suspected, that joint should be
included in fusion to improve the final
alignment and stability
• All patients underwent a single stage
reconstruction including deformity correction
via realignment osteotomy combined with
arthrodesis of ankle and subtalar joint

16. Surgical Technique
• Osteotomy requires preoperative radiographic
planning to establish centre of rotation axis of
deformity and to plan for triplanar cuts for
deformity correction
• Under C-arm, k-wires are drilled across tibia
• Author suggest multiple drill holes along plane of
planned cut using drill bit with continuous
irrigation

17. • Correction should be achieved in all planes i.e.,
coronal, sagittal and rotational
• Fine adjustments were made using
microsagittal saw until required alignment is
obtained, recreating mechanical axis of limb
• After correction of proximal alignment, ankle
and subtalar joints are prepared exposing
subchondral bone

18. • Definitive fixation is obtained with retrograde
intramedullary nail inserted through plantar
aspect of calcaneum into tibial shaft ending 5
cm proximal to level of deformity correction
• 15, 20 and 25cm length nail has been used
according to fracture site
• Distal part of fibula and iliac crest was used for
bone grafting

20. • 19 patients underwent tibiotalolcalcaneal
fusion , 6 underwent pantalar (talonavicular
and calcaneocuboid) fusion
• Transverse tarsal joints are approached through
standard open incisions, articular cartilage and
subchondral bone is removed and joints
derotated to neutral
• Fixation is obtained with 2 parallel retrograde
screws across talonavicular joint and staples
across calcaneocuboid joint

21. • Non weight bearing was advised for 6 weeks
for traumatic patients and 12 weeks for
patients having neuropathy
• Healing was assessed clinically and
radiographically
• 1 patient developed infection because of
additional surgery and had poor result and
was unsatisfied

22. RESULTS
• All nonunions, osteotomy sites and fusion sites
healed clinically and radiographically at an average
of 19.5 weeks
• Radiographs at final follow up showed continued
stable healing of fusion and osteotomy sites without
loss of alignment
• All deformities were corrected to neutral alignment
and all patients had a plantigrade foot and ability to
wear off the shelf shoes without bracing

24. • 21 patients were extremely satisfied
• 3 were satisfied
• 1 was not satisfied

25. DISCUSSION
• Retrograde intramedullary nailing for tibiotalo
calcaneal arthrodesis is described as a salvage
procedure for patients with
• a failed ankle fusion or
• total ankle arthroplasty with severe bone loss,
• charcot arthropathy,

26. • rheumatoid arthritis,
• posttraumatic arthritis,
• previous talectomy,
• bone loss after tumor resection,
• tuberculous arthropathy

27. • High rate of fusion and biomechanical strength
of construct successfully achieves a painless
biomechanically stable plantigrade foot
• Various studies showed high fusion rate around
90%
• Study recommends inclusion of subtalar joint
and utilization of intramedullary device to
ensure deformity correction and a stable ankle
hindfoot construct

28. PITFALLS
• Retrospective nature of study
• AOFAS scoring and patient satisfaction survey
are not validated

29. CONCLUSION
• Single stage procedure of tibial osteotomy and
retrograde intramedullary nailing for correction
of angular deformity and fusion of arthritic
hindfoot :
provides a viable alternative to
multiplanar external fixation or a staged
procedure
• Accurate correction with meticulous joint
preparation is required to achieve good results.