Factors affecting the outcomes of tibiotalocalcaneal fusion

Abstract

Aims Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351.

Transportal Tibiotalocalcaneal Nail Ankle Arthrodesis: A Systematic Review of Initial Series

“…In another recent retrospective review of 101 patients undergoing open TTC fusion with various approaches, they found an infection rate of 37% and 29.6% for patients with nontraumatic osteoarthritis and Charcot arthropathy, respectively. 18 Additionally, 5 patients (4.9%) went on to require below-knee amputations. 18 Although there may be significant heterogeneity when comparing patients undergoing open and minimally invasive TTC fusion, transportal TTC fusion should be considered in patients with significant comorbidities, particularly those with diabetes mellitus, as it leads to low rates of surgical site infections and thereby may reduce the risk of severe complications such as amputations.…”

“… 18 Additionally, 5 patients (4.9%) went on to require below-knee amputations. 18 Although there may be significant heterogeneity when comparing patients undergoing open and minimally invasive TTC fusion, transportal TTC fusion should be considered in patients with significant comorbidities, particularly those with diabetes mellitus, as it leads to low rates of surgical site infections and thereby may reduce the risk of severe complications such as amputations.…”

“…In the recent retrospective review of 101 patients that underwent open TTC fusion, they found 29 patients (28.7%) that went on to nonunion. 18 Therefore, transportal TTC fusion may have comparable rates of full ankle fusion and time to fusion when compared to open TTC fusion; however, differences in patient populations should be examined further.…”

Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture

“…A study containing 10 patients showed that patients with CKD were 2.37 times more likely to have a nonunion from tibiotalocalcaneal fusion. 28 Of note, the comparison group used in this study was patients without CKD. One way to guide surgical decision making in patients with CKD may be to apply osteologic parameters.…”

Total Talus Replacements

“…Although there are studies that report TTC fusion as having an improvement in functional scores, 4 , 15 these procedures can be surgically challenging, with varied functional outcomes and high rates of reported nonunion and reoperation. 4 , 14 , 15 …”