Updated: 10/4/2016

[Blocked from Release] Hindfoot Arthrodesis Intramedullary Nail

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Pearls & Pitfalls
Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I
  • Preparation
    • check skin quality, soft tissue envelope, ankle and subtalar range of motion, degree of tibiotalar and subtalar arthritis, amount of deformity
  • Positioning
    • standard OR table with radiolucent table end
      • foot 3-4” off end of table for posterior calcaneus screws
      • c-arm from contralateral side
  • Approach
    • lateral approach to ankle
      • directly lateral to fibula with transfibular osteotomy to access joint
  • Joint Preparation
    • remove tibiotalar and subtalar cartilage
      • bony prep with kwire drill holes and osteotomes
  • Guidewire Insertion
    • start point is center of talus and distal tibia on AP and Lat xrays
  • Reaming
    • size 9mm reamer then ream 1.0-1.5mm above size of final nail
  • Nail Insertion
    • insert nail over guidewire and bury so that talar interlocking hole is in body of talus
  • Interlocking Screws
    • targeting guides to place screws in order
      • talus, proximal tibia (x2), and calcaneus (x2) screws, add endcap
  • Postoperative 
    • non-weight bearing in splint, crutches for ambulation
    • evaluate fusion mass on serial xrays, range of motion exercises and advance weight-bearing at 2-3mo post-op in CAM boot
Planning & Preparation
  • Extremity Exam
    • check soft tissue envelope, ankle and subtalar range of motion, degree of tibiotalar and subtalar arthritis, amount of deformity
    • document distal neurovascular status and associated comorbidities
  • Imaging
    • weight bearing AP/Lat/Mortise views of ankle
      • evaluate joint space narrowing, subchondral sclerosis and cysts, angular deformity of tibiotalar and subtalar joints
    • post-traumatic arthritis is most common etiology of ankle and subtalar arthritis (>2/3 cases)
      • many cases have varus/valgus deformity

Equipment & Positioning
  • Equipment 
    • hindfoot arthrodesis intramedullary nailing system (Stryker T2 Hindfoot Nail System)
    • 4.0mm cancellous screws, 2.5mm drill (Synthes Small Fragment Set)
    • 1.6mm kwires
    • osteotomes
    • ACL saw blade
    • small fragment set (4.0mm cancellous screws)
    • c-arm fluoroscopy
    • standard OR table with radiolucent end
  • Position
    • patient supine with small bump under ipsilateral thigh, tourniquet on thigh
      • stack of sterile towels under calf after draping
    • foot hanging 3-4” off end of table in order to place posterior to anterior interlocking screws
  • OR Setup and C-arm
    • standard OR table with radiolucent end
    • c-arm from contralateral side perpendicular to bed

  • Lateral Approach to Ankle
    • incision directly lateral to fibula
      • subperiosteal dissection over anterior and posterior fibula
      • curve slightly anterior over subtalar joint
      • full thickness flaps
      • identify and protect SPN
Surgical Technique
  • Approach
    • mark out medial and lateral malleoli, tibiotalar, and subtalar joints
    • incision with 15blade through skin along center of fibula
      • curved slightly anterior at tibiotalar and subtalar joints
      • only need minimal exposure of subtalar joint for preparation
      • tenotomy through subcutaneous tissue, cauterize bleeders
    • do not strip periosteum off of distal fibula
      • want to keep it as vascularized as possible for bone graft at end of case
    • subperiosteal dissection off anterior and posterior aspects of fibula
      • if lots of scar tissue use cautery to take down
      • clean out syndesmosis 3-4cm above tibiotalar joint with rongeur and curettes
  • Fibular Osteotomy
    • superolateral to inferomedial fibular osteotomy with ACL sawblade 3-4cm above tibiotalar joint
      • finish cut with osteotome
    • sharply dissect off fibula anteriorly and reflect posteriorly
      • alternatively can completely remove fibula for bone graft
      • can use hinged fibula posteriorly as vascularized graft for fusion site at end of case by fixing back into place with screws
    • clean out remaining syndesmosis and fibrous tissue to define tibiotalar joint
  • Joint Preparation
    • remove tibiotalar and subtalar cartilage using burr, ostetomes, and curettes
    • if large deformity can take large saw blade to make flat cut of distal tibia and talus (2-3mm cut) parallel to joint
      • if unequal bone loss from distal tib or talus rather than shorten bones more with more saw cuts, add in bone graft for good bony apposition
      • in cases of very large deformity (varus/valgus) add medial incision curved slightly anterior with 15blade
      • take sharply down to periosteum
      • expose anterior and posterior  and take saw through medial mal for bone graft
    • once flat cuts are made in tibiotalar joint check fluoro to line up talus in center of distal tibia so that ankle is in neutral alignment
    • while prepping tibiotalar joint extend down to subtalar joint
      • insert laminar spreaders and removed cartilage with curettes, osteotomes, drill with kwires to prep surface
    • place 1-2 kwires from calcaneus through subtalar and tibiotalar joints to pin joint in place
      • can alternatively use cross pins from proximal to distal, check on AP and Lat xrays
    • place tibiotalar joint into 0° dorsiflexion, 5° valgus, and 5-10° external rotation on mortise
  • Guidewire Insertion
    • guidepin start point is in center of talus and distal tibia on AP and Lat
      • check Harris heel view
    • use 15blade to make 3cm incision around guidewire to accommodate reamer and nail
  • Reaming
    • place soft tissue protector down to bone with entry reamer 3cm into distal tibia
    • put long ball tip guidewire though entry hole into proximal tibia
      • check proximal extent to determine nail length
    • measure nail length with measuring guide (typically use 200mm nail)
      • nail lengths are 150/200/300mm
      • length of nail should just go into diaphysis
      • for 300mm nail you need to free hand the prox tibia interlocking screws
    • start with size 9 reamer
      • ream up 0.5-1.0mm with each reamer until 1.0-1.5mm above size of nail (i.e. ream 12.5 for 11mm nail)
    • push through anterior cortex before starting reamer
      • do not ream anterior cortex as you can blow out the starting hole
      • check chatter from reamer feedback and diaphyseal fit on fluoro AP
      • ream on full speed, slowly and deliberately
      • don’t stop reamer in canal (avoids reamer head from getting stuck)
  • Nail Insertion
    • build nail on back table and make sure targeting guide lines up with holes in nail
      • check sleeves for each proximal interlock hole
    • place plastic sleeve over ball tip guidewire and exchange wire for small non-balltip guide wire
    • insert nail over guidewire and mallet in using strikeplate
      • advance to fracture site, check on fluoro AP/Lat
      • insert nail fully and check that talar interlock hole is in body of talus
      • check inferior aspect of nail on calcaneus
    • remove guidewire before placing interlocking screws
  • Interlocking Screws
    • start with lateral to medial talar interlock screw
      • use triple sleeve with 5.0mm drill
      • measure off of drill, remove inner sleeve, and insert screw
      • not always good feedback with screws so check on fluoro if needed to avoid overburying
    • use Tommy bar to end of handle to switch targeting guide to medial proximal side
    • use triple sleeve to mark appropriate length nail screw holes 150 vs 200mm
      • 15blade stab incision to skin
      • triple sleeve down to bone
      • repeat steps above to insert interlock screws
      • check feedback with screws
    • move to distal end of nail and insert tibiotalar compression screw
      • since proximal screws are locked in screw compresses across tibiotalar joint
      • check compression on AP xray
      • add black rubber sleeve close to inferior calcaneus and tighten inner turn handle to compress across subtalar joint
    • switch targeting guide back to lateral side and drill and insert calcaneus screw lateral to medial
      • check on fluoro
    • move targeting guide to posterior slot and raise leg up
      • assistant props elbow against table
      • use triple sleeve as above for posterior to anterior calcaneus screw
      • check on lateral xray to make sure screw is going through nail but not into calcaneocuboid joint
    • remove all targeting guides and kwires
      • insert endcap onto end of nail and check on fluoro
      • endcap locks calcaneus screw into place
  • Bone Graft
    • add bone graft into tibiotalar joint from lateral and/or medial mal
    • if using osteotomized fibula for vascularized bone graft can fix with 4.0mm cancellous screws
  • Confirm Nail Position and Extremity Check
    • take final fluoro AP/Lat of proximal, middle, and distal aspects of nail
    • harris heel view to check calcaneus screws
    • check limb length, rotation, and alignment
  • Irrigation & Hemostasis
    • deflate touriniquet
    • irrigate and cauterize peripheral bleeding vessels
    • place hemovac drain exiting proximal and lateral
  • Closure
    • deep layer with 0-vicryl
    • subcutaneous with 2-0 vicryl and skin closure with 3-0 nylon
      • do not forget to close all interlocking screw sites (posterior heel)
  • Dressing
    • soft incision dressings and postmold sugartong splint for immobilization
Postoperative Care
  • Immediate Post-op
    • non-weight bearing in splint, crutches for ambulation
    • discharge to home on post-op day 1 after drain removed
  • 2 Weeks
    • wound check
    • sutures removed
    • place into cast or CAM boot non-weight bearing
    • repeat xrays of ankle
  • 8-12 Weeks
    • xrays to evaluate fusion mass
    • range of motion exercises to ankle in CAM boot
    • advance weight bearing status and rehabilitation
  • Document Complications
    • wound breakdown
    • superficial/deep infection
    • symptomatic hardware
    • malunion
    • nonunion
    • neurovascular injury (lateral plantar nerve)
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