Comparison of Two Intramedullary Nails for Tibiotalocalcaneal Fusion: Anatomic and Radiographic Considerations

Abstract

Background: Retrograde intramedullary nailing is an established procedure for tibiotalocalcaneal arthrodesis. This study was conducted to see whether, and if so to what extent, nail design modifications would influence the risk to anatomic structures and the bony coverage of the nail base. Methods: Six pairs of thawed fresh-frozen cadaver legs received two different intramedullary nails (N1: straight nail, lateral-medial tip locking; N2: valgus-curved nail, medial-lateral tip locking) under simulated operative conditions. The specimens were dissected; distances between the at-risk structures and the hardware were measured. The hindfoot axis and the volume of the intracalcaneal nail portion were determined with CT. Results: At the plantar entry site, N2 was significantly farther from the flexor hallucis longus tendon (p = 0.047), the medial plantar artery (p = 0.026), and the lateral plantar nerve (p = 0.026) than N1. The lateral-medial calcaneal locking screw of N1 damaged significantly more often the peroneus brevis tendon (p = 0.03) than N2. The proximal tip-locking screw, N2, was significantly farther from the anterior tibial artery (p = 0.075) and the deep (p = 0.047) and superficial peroneal nerves (p = 0.009) than N1; N1 was significantly farther from the great saphenous vein (p = 0.075) than N2. The distal tip-locking screw, N1. damaged significantly more often the extensor digitorum longus (p = 0.007), the anterior tibial artery(p = 0.04), and the deep and superficial peroneal nerves (p = 0.03) than N2. CT did not show any significant changes in the hindfoot axis with either device; intracalcaneal nail volumes were similar. Conclusions: A curved nail can increase the distance to at-risk plantar structures. Medial-lateral nail-tip locking appears to have less risk to neurovascular structures. Clinical Relevance: Safer retrograde intramedullary nailing for tibiotalocalcaneal fusion requires knowledge of the structures at risk and appropriate operative technique.

Keywords

Anatomic study Intramedullary Nail Structures at Risk Tibiotalocalcaneal Fusion

Get full access to this article

View all access options for this article.

References

Adkison

Bosse

Gaccione

Gabriel

: Anatomical variations in the course of the superficial peroneal nerve. J. Bone Joint Surg. 73-A:112–114, 1991.

Blair

Botte

: Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin. Orthop. 305:229–238, 1994.

Chiodo

Acevedo

Sammarco

: Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: A biomechanical investigation. J. Bone Joint Surg. 85-A:2425–2428, 2003.

Flock

Ishikawa

Hecht

Wapner

: Heel anatomy for retrograde tibiotalocalcaneal roddings: A roentgenographic and anatomic analysis. Foot Ankle Int. 18:233–235, 1997.

Goebel

Gerdesmeyer

Muckley

: Retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis: A short-term, prospective study. J. Foot Ankle Surg. 45:98–106, 2006.

Grass

: [Tibiotalocalcaneal arthrodesis using a distally introduced femur nail (DFN)]. Op. Orthop. Traumatol. 17:426–441, 2005.

Hammett

Hepple

Forster

Winson

: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures. Foot Ankle Int. 26:810–815, 2005.

Kile

Donnelly

Gehrke

Werner

Johnson

: Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int. 15:669–673, 1994.

Mann

Parks

Pak

Miller

: Tibiotalocalcaneal arthrodesis: A biomechanical analysis of the rotational stability of the Biomet Ankle Arthrodesis Nail. Foot Ankle Int. 22:731–733, 2001.

10.

McGarvey

Trevino

Baxter

Noble

Schon

: Tibiotalocalcaneal arthrodesis: Anatomic and technical considerations. Foot Ankle Int. 19:363–369, 1998.

11.

Millett

O'Malley

Tolo

: Tibiotalocalcaneal fusion with a retrograde intramedullary nail: Clinical and functional outcomes. Am. J. Orthop. 31:531–536, 2002.

12.

Moore

Prince

Pochatko

Smith

Fleming

: Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int. 16:433–436, 1995.

13.

Muckley

Eichhorn

Hoffmeier

: Biomechanical evaluation of primary stiffness of tibiotalocalcaneal fusion with intramedullary nails. 28:224–231, 2007.

14.

Noonan

Pinzur

Paxinos

Havey

Patwardhin

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: A biomechanical analysis of the effect of nail length. Foot Ankle Int. 26:304–308, 2005.

15.

Pochatko

Smith

Phillips

Prince

Hedrick

: Anatomic structures at risk: Combined subtalar and ankle arthrodesis with a retrograde intramedullary rod. Foot Ankle Int. 16:542–547, 1995.

16.

Quill

: Tibiotalocalcaneal and pantalar arthrodesis. Foot Ankle Clin. 1:199–210, 1996.

17.

Quill

: The use of a second-generation intramedullary nail in the fixation of difficult ankle and hindfoot arthrodeses. Am. J. Orthop. 1-S:23–31, 1999.

18.

Roberts

King

Wang

Seligson

Voor

: Should distal interlocking of tibial nails be performed from a medial or a lateral direction? anatomical and biomechanical considerations. J. Orthop. Trauma 13:27–32, 1999.

19.

Stephenson

Kile

Graves

: Estimating the insertion site during retrograde intramedullary tibiotalocalcaneal arthrodesis. Foot Ankle Int. 17:781–782, 1996.

20.

Urban

Jr. Tornetta

3rd : Vascular compromise after intramedullary nailing of the tibia: A case report. J. Trauma 38:804–807, 1995.