title: Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series.
abstract: Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation is associated with a high incidence of complications. This is especially true when performed with a bulk structural allograft and poor soft tissue quality. In select high-risk limb salvage cases, we have augmented tibiotalocalcaneal arthrodesis procedures stabilized using retrograde intramedullary nail fixation with a vascularized pedicled fibular onlay bone graft. We present the data from 10 such procedures with a mean follow-up period of 10.9 ± 5.4 (range 6 to 20) months involving 10 patients (9 males and 1 female). The etiology was avascular osteonecrosis of the talus and/or distal tibia and a resultant large volume cavitary bone defect (8 ankles), severe equinocavovarus contracture (1 ankle), and failed total ankle replacement (1 ankle). A frozen femoral head bulk allograft was used twice, a whole frozen talus allograft once, and a freeze-dried calcaneal allograft once. The fibula was mobilized with intact musculoperiosteal perforating branches of the peroneal artery as a vascularized pedicle onlay bone graft fixated with a screw and washer construct. The mean fibular graft length was 10.2 ± 2.3 cm. The mean interval to radiographic fusion was 2.6 ± 0.6 months and to weightbearing was 3.1 ± 1.4 months. Two stable bulk allograft-host bone and fibular graft-host bone nonunions occurred after intramedullary nail hardware failure. Tibiotalocalcaneal arthrodesis augmented by vascularized pedicled fibular graft stabilized with retrograde compression intramedullary nail fixation offers a reliable option for complex salvage situations when few other options exist.
authors.affiliation: Orthopaedic Center, Gundersen Healthcare System, La Crosse, WI. Electronic address: tsroukis@gundersenhealth.org.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Roukis
authors.affiliation: Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI.
authors.forename: Rachel B
authors.initials: RB
authors.lastname: Kang
mesh_terms: D000369:Aged, 80 and over; D001174:Arthrodesis / Q000009:adverse effects* / Q000379:methods; D016025:Bone Transplantation / Q000379:methods*; D016208:Databases, Factual; D005360:Fibula / Q000098:blood supply / Q000637:transplantation; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000379:methods; D017102:Fracture Healing / Q000502:physiology; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000601:surgery; D006085:Graft Survival; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies; D013380:Subtalar Joint / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D013524:Surgical Flaps / Q000637:transplantation*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
keywords: complications; hindfoot fusion; intramedullary rod; limb salvage; peroneal artery