TIBIOTALOCALCANEAL ARTHRODESIS BY INTRAMEDULLARY NAIL IN PATIENTS WITH RHEUMATOID ARTHRITIS

Abstract

Tibiotalocalcaneal (TTC) fusion is indicated in rheumatoid patients with combined ankle and subtalar disease, particularly when severe deformity is present. In theory, if bone stock is good, a staged subtalar/triple arthrodesis followed by total ankle replacement (TAR) can be used. This is so rarely the case that the author has no experience of this. TTC fusion is also useful in rheumatoid patients with previous joint sepsis, to salvage a failed TAR and to salvage a non-united ankle fusion. It allows early weight bearing, which is valuable in those patients who have multiple joint, particularly upper limb, involvement.

In our study, 18 patients underwent 21 TTC fusions from August 1988 to September 2002. The average age was 48 years (range 23–90). Nine patients had undergone previous hindfoot procedures, five were smokers, one was diabetic and one had chronic renal failure. Surgery was performed under GA with tourniquet. Patients were reviewed using a modified American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and with regard to their personal satisfaction. Follow up was 18–57 months.

Post-operatively, the oldest patient died due to fulminant sepsis. Seven patients had superficial wound infections but none required re-operation. Fusion was achieved in 18 limbs. Average time to radiological union was 36 weeks (range 9–68), two patients required nail dynamisation. In six cases it was necessary to remove irritating locking screws, either the posterior screw for heel rubbing, or the medial tibial screws for stress riser symptoms. One patient required complete nail removal. There were no amputations.

Fourteen patients were very satisfied, two reasonably so and one not. The average AOFAS pain score (max 40) improved from 11 to 32, and the average AOFAS functional score (max 28) from 4 to 21.

We feel that despite the relatively high complication rate, this technically challenging procedure is a very useful salvage option in these very disabled patients.