Tibiotalocalcaneal nail failure in a 60-year-old male: Case report and surgical technique

Abstract

Tibiotalocalcaneal (TTC) arthrodesis is a hindfoot fusion that can treat numerous conditions including osteoarthritis, Charcot arthropathy, avascular necrosis of the talus, and severe deformity. The goal of fusion is to create solid union across the joint while correcting deformity, leaving a shoeable plantigrade foot. Multiple biomechanical studies have demonstrated similar performance when comparing the properties of plate and nail constructs for TTC arthrodesis. Plate fixation and retrograde intramedullary nailing (IMN) are successful in achieving TTC fusion and favorable postoperative outcomes. Despite generally favorable outcomes, TTC arthrodesis carries the risk of complications including nonunion, infection, hardware failure, and revision surgery. We present a case of an individual who presented with a complete break of the IMN after TTC arthrodesis. We also describe the technique used for extraction of the broken nail.

1. Introduction

Tibiotalocalcaneal (TTC) arthrodesis is a hindfoot fusion procedure that can treat numerous conditions including osteoarthritis, Charcot arthropathy, avascular necrosis of the talus, and severe joint deformity.¹ The goal of fusion is to create solid union across the joint while correcting deformity, resulting in a shoeable plantigrade foot.² Multiple biomechanical studies have demonstrated similar performance when comparing the properties of plate and nail constructs for TTC arthrodesis.^{3, 4, 5}

Plate fixation and retrograde intramedullary nailing (IMN) are successful in achieving TTC fusion and favorable postoperative outcomes.^{1,6, 7, 8, 9} Despite generally favorable outcomes, TTC arthrodesis carries the risk of complications including nonunion, infection, hardware failure, and revision surgery. We present a case of an individual who presented with a complete break of the IMN after TTC arthrodesis. We also describe the technique used for extraction of the broken nail.

2. Case history

A 59-year-old non-diabetic male presented to the foot and ankle clinic for a second opinion of left Charcot foot secondary to spinal nerve root surgery eight years priorin 2011. Physical exam revealed severe valgus deformity of the left ankle with painless and limited active range of motion of the ankle/subtalar joint.

Weight bearing radiographs of the left foot and ankle in the AP, lateral, and oblique view taken at that time revealed deformity of the posterior talus, calcaneus, distal tibia and fibula with severe hindfoot degenerative change (Fig. 1). The senior author’s recommendation was left TTC arthrodesis for Charcot ankle deformity, and the patient underwent tibiotalocalcaneal fusion surgery 8 months later. The surgery was successful, and post-operative imaging revealed an intact and accurately placed TTC nail (Zimmer Biomet Phoenix TTC Nail - 11mm by 150mm) (Fig. 2). Clinical examinations were within normal limits for all postoperative follow-ups and the patient reported no concerns. All radiographs at follow-up visits showed appropriate interval healing and intact hardware (Fig. 3).

Fig. 1.

Pre-operative radiographs exhibiting deformity of the posterior talus, calcaneus, distal tibia and fibula with severe hindfoot degenerative change.

Fig. 2.

2-Week post-operative radiograph following primary TTC exhibiting accurate placement and intact nail.

Fig. 3.

6-Month post-operative radiograph exhibiting intact TTC nail and appropriate interval healing.

Approximately 10 months after the successful surgery, the patient returned to clinic with increased pain, instability, and a “squeaking” sound in his left ankle. Weight bearing 3-view radiographs revealed a complete break of the tibiotalocaneal (TTC) nail at the junction of the proximal 2/3 and distal 1/3 segment in the oblique plane at the level of the screw hole for the talar screw. There was stable pseudarthrosis across the ankle fusion site (Fig. 4). Blood work was negative for infection markers (ESR, CRP, and WBC within normal limits). RThe senior author recommended removal of the nail and revision TTC fusion was recommended by the senior author.

Fig. 4.

Foot and ankle radiograph exhibiting complete break of the tibiotalocaneal (TTC) arthrodesis nail in the oblique plane and stable pseudarthrosis across the ankle fusion site.

3. Technique for implant removal

The procedure began with localization of the interlocking screws distal to the broken piece of the nail using fluoroscopy. The posterior to anterior calcaneal screw was removed. Next, the lateral to medial talar screw head was localized but left in place to provide rotational control while extracting the distal segment. Using the previous plantar incision (Fig. 5), the distal segment was approached, and the universal threaded nail extraction device was attached under fluoroscopic guidance. Once a tight fit was ensured, the interlocking talar screw localized earlier was removed and the distal segment was easily extracted through the plantar incision. The preassembled core lock mechanism, which is embedded inside this nail system for tibiotalar compression, lies between the oblong hole and the interlocking hole distal to it. This was removed with the distal segment of the broken nail (Fig. 6).

Fig. 5.

Plantar incision site.

Fig. 6.

Removal of the distal portion of the nail and intraoperative fluoroscopy of the proximal portion being removed.

The focus was then shifted to removal of the proximal segment of the nail. The inner aspect of the nail is not threaded at this level, so it is not possible to attach a universal extraction device. Additionally, the distal end of the nail could not be directly approached given its position within the bone. A solid 5mm drill bit is available in the TTC nail set for use when additional positional screws are required. Given that the inner hollow diameter of the nail is 4.7mm, we used this drill bit to weld into the broken end of the titanium nail. The drill bit was passed over a protection sleeve through the plantar incision, inserted into the broken end of the nail under fluoroscopic guidance and welded through applied pressure. The proximal interlocking screws were not removed to prevent spinning of the nail fragment while welding. Once welded, the two proximal interlocking screws were localized fluoroscopically and removed (Fig. 7).

Fig. 7.

Removal of proximal portion of the nail and both pieces extracted.

The nonunion site was drilled across to stimulate union. A revision TTC nailing (Zimmer Biomet Phoenix TTC Nail - 12mm by 210mm) was then performed as per manufacturer guidelines and the nail diameter and length were upsized. All proximal bone reamings were collected and packed into the defect along with bone morphogenetic protein to aid in compression of the nonunion site.

4. Discussion

Intramedullary nail breakage can occur in the setting of trauma when a fracture has not fully healed or a joint has not achieved union after arthrodesis. Without the support of bony architecture, the nail is put under additional stress and can ultimately fail. Other factors affecting nail failure include: the size of the nail, type of metal, fracture pattern, weight of the patient, weight bearing status, and overall activity of the patient.¹⁰ Our patient achieved stable pseudarthrosis across the tibiocalcaneal joint, was obese with a BMI of 30.4, and lived an active lifestyle after fusion at age 59. These are all factors that could have contributed to failure of the TTC nail.

The patient returned for follow-up at 2- and 6-weeks post-arthrodesis hardware removal and revision TTC arthrodesis. At 6 weeks post-op, the physical exam was within normal limits and 3-view weight bearing radiographs showed appropriate position of the hardware and interval healing (Fig. 8). Foot Function Index and pain scores were recorded. The pain score decreased to from 36 preoperatively to 19 postoperatively. The FFI score decreased from 156 to 102 out of 170, with a higher score meaning more pain and disability.

Fig. 8.

Radiographs at 6-week follow up after nail extraction and TTC revision.

Although uncommon, hardware failure is a complication that can arise following TTC arthrodesis, with IMN failure being the most technically challenging hardware failure to correct. We present a technique for IMN removal in the setting of TTC nail failure.

CRediT authorship contribution statement

Bradley K. Alexander: Writing - original draft, Writing - review & editing. Alexandra M. Arguello: Writing - original draft, Writing - review & editing. Ashish B. Shah: Writing - original draft, Writing - review & editing, Supervision.

Declaration of competing interest

None.