avn talus treated by retrograde nail fusion: a case report

AVN Talus Treated By Retrograde Nail

Fusion

Dr. Apoorv JainD’Ortho, DNB Ortho

drapoorvjain23@gmail.com9845669975

•Name: XYZ•Age : 19 Years•Sex : Male•Occupation: Student

Chief Complaints• C/O Pain and restriction of

movements around Right ankle joint since last 1 year.

• C/O Difficulty in walking since last 1 year.

History Of Presenting Illness • Patient was apparently normal till 1 year

back when he fell down from a moving tractor and sustained injury to his right leg.

• Following the fall, he had severe pain around right ankle joint and was unable to weight bear.

• He was taken to a local hospital where primary aid was given and he was told to have sustained fracture around right ankle after taking Xrays.

• POP slab immobilisation was done and he was operated 8 days later.

• Non weight bearing was continued for 2 months following which implant (? K-wire) removal was done outside.

• Partial weight bearing was started and the patient again started having pain and restriction of movements around the ankle joint which was gradually progressive and not relieved by rest or medications.

• Patient is able to partially weight bear and is able to squat with support.

• H/O Prolonged intake of analgesics is present.

• No H/O Sinus / Discharge.• No H/O Fever/ night sweats / weight

loss/ Loss of appetite.• Not a K/C/O DM/ HTN/ TB/ Asthma.

Past History:• Nothing Significant.

Family History:• Nothing Significant.

Personal History• Diet : Veg• Appetite : Good• Sleep : Undisturbed• Bowel & Bladder : Normal & Regular• Habits : No addictions

General Physical Examination• A Young male patient, moderately built and

nourished, alert, conscious and co-operative and well oriented to time, place and person.

• Pulse : 86/min• B.P. : 110/70 mm of Hg• Resp. Rate : 23 cycles/min• Temp. : 98.6°F• No Pallor/ Icterus/ Cyanosis/ Clubbing/

Lymphadenopathy/ Oedema

Systemic Examination• CVS : S1 S2 heard, No murmurs• RS : B/L NVBS heard,

No added sounds• PA : Soft, Non tender, No organomegaly, BS+• CNS : No focal neurological deficit

Local Examination(Right Ankle joint)

Inspection:- Gait: Antalgic- Attitude: Neutral- Diffuse swelling around ankle joint

is present.- Skin appears tense and shiny.

- Healed surgical scar mark seen over the medial aspect of distal leg around 6 cms in size, extending distally till medial malleolus.- No obvious bony deformity.- No obvious limb length discrepancy.

Palpation:

- All inspectory findings are confirmed.- Tenderness present over the neck of

talus and anterior joint line.- No local rise of temperature.- No Crepitus.- No Abnormal mobility

- Range of movements:>Plantar and dorsiflexion 10° and

painful.>Inversion and eversion painful and

restricted.- Toe movements normal.- No Distal Neurovascular deficit.- No lymphadenopathy.

X-ray (Right ankle AP and Lateral)

Diagnosis• Old non united fracture Neck of

Talus.• Avascular necrosis of the Body of

Talus.• Arthritic changes of Tibio-talar

and Subtalar joint.

Routine Blood Investigations• Hb : 14.2 gm/dl• TC : 8,600 cells/mm³• DC : N62L32M4E2B0

• ESR : 12 mm in 1st hour• Urea : 22 mEq/L• Creat: 1.1 µg/L• Na⁺ : 138 mEq/L• K ⁺ : 4.1 mEq/L

Classification Of Talus FracturesAnatomical Classification:

•Lateral process fractures•Posterior process fractures•Talar head fractures•Talar body fractures•Talar neck fractures

The normal skeletal anatomy of the foot and ankle

Hawkin’s Classification Of Talar Neck Fractures

Type I: Nondisplaced

Type II: Displaced fracture/ Associated subtalar subluxation or dislocation

Type III: Associated subtalar and ankle dislocation

Type IV:(By Canale& Kelly)

Type III with associated talonavicular subluxation or dislocation

Nondisplaced vertical fracture of the talar neck (Hawkins type 1)

Displaced Hawkins Type II fracture of the talar neck with subluxation (left) and dislocation (right)

of the subtalar joint.

Displaced fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints (Hawkins Type III)

Type IV fracture of the talar neck with subluxation of the subtalar joint and dislocation of the

talonavicular joint

Avascular Necrosis Of Talus• The rate of osteonecrosis is related

to initial fracture displacement is:–Hawkins I: 0% to 13% –Hawkins II: 20% to 50% –Hawkins III: 80% to 100% –Hawkins IV: 100%

The Hawkins sign• It is a well-described radiographic

indication of viability of the talar body.

• The time to recognize the presence of avascular necrosis is between the sixth and the eighth week after the fracture-dislocation.

• By this time, if the patient has been non weight-bearing, diffuse atrophy is evident by x-ray in the body of Talus.

• Presence of subchondral sclerosis suggests the diagnosis of avascular necrosis [osteonecrosis].

• Other diagnostic tools used to evaluate osteonecrosis include technetium bone scan and magnetic resonance imaging.

• The use of bone scanning has largely been replaced with MRI.

• MRI can be used as early as 3 weeks postinjury, and defines not only the presence but also the extent of osteonecrosis, as well as the condition of the articular cartilage.

Treatment Options• The prognosis and best treatment remain

a source of controversy.• Union can occur in the presence of

osteonecrosis, provided the fixation is stable.

• The treatment varies with individual patient based upon clinical symptoms, amount of fracture collapse, duration, arthritic changes and functional demands.

• Selected case reports in the literature describe successful efforts to revascularize the necrotic talus.

• Treatment options for revascularization of talus (in early cases only) include:–Core decompression.–Nonvascularized autograft.–Nonvascularized allograft.–Vascularized bone graft.

Necrotic Part of Talus excised

Cortico- Cancellous Iliac graft placed in the defect

Vascularised Bone graft:Proximal lateral tarsal artery with the cuboid pedicle

• In cases of expectant treatment for bone union prolonged periods of nonweight-bearing have been recommended, because the talus is revascularized slowly via creeping substitution of necrotic bone with vascularized bone.

• This process may require up to 36 months. The duration of nonweight-bearing required is unpredictable, relatively impractical, and difficult to adhere to for patients.

• Salvage surgeries (for late cases) include:–Primary triple arthrodesis–Talectomy with tibio-calcaneal fusion–Subtalar fusion–Pantalar fusion–Tibiotalar fusion

Treatment Done• Excision of the body of Talus and a

Tibio-Calcaneal Arthrodesis was done with the help of a retrograde intramedullary nail.

• Ankle and subtalar joint were fused in neutral flexion, 5° of valgus and 10° of External rotation.

Post-Op X-ray

Evidence 1**

• Osteonecrosis is often associated with collapse of the talar dome and the development of symptomatic arthritis of the ankle joint.

• For these patients, ankle arthrodesis is indicated.

• Tibiocalcaneal arthrodesis and the Blair fusion have both been found effective.

**(Rockwood & Green’s, 6th edition)

• Tibiocalcaneal arthrodesis is an option in which fusion of the entirety of the calcaneus to the distal tibia is done.

• Results have been noted to be superior to talectomy or ankle fusion by Canale and Kelly.

• The fusion of the tibia to the calcaneus may provide more stability compared to the Blair’s sliding graft technique.

Tibiotalar Arthrodesis with a Sliding Bone Graft (Blair Technique)

Calandruccio II External Fixation Device for Tibio-Talar fusion

Tibiocalcaneal Arthrodesis with Intramedullary Nailing (Graves et al.)

• Insertion site for retrograde intramedullary fixation of tibiocalcaneal arthrodesis. A, Line in sagittal plane from tip of second toe to center of heel. B, Line can be drawn in coronal plane bisecting medial malleolus. Intersection of lines indicates correct entry portal for nail.

As per an article by Devries JG et al published in the journal of Foot and Ankle International Society, November 2010 titled Retrograde intramedullary nail arthrodesis for avascular necrosis of the talus.

• CONCLUSION: • Salvage of talar AVN is possible by

tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

Another article By Shah JEHAN et al, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK. Published in the Acta Orthopaedica Belgica, 2011 titled “The success of tibiotalocalcaneal arthrodesis with intramedullary nailing – A systematic review of the literature”

• Conclusion:• This systematic review shows that

TibioTaloCalcaneal Artrodesis with an IM nail has relatively good fusion rates.

• Dynamic proximal locking and longer nails are a few suggestions recommended by authors in the studies.

• Their logic is that the longer nails will minimise the risk of stress fractures, and dynamic screws will reduce the need for dynamization.

Modern IM nail specially designed for tibiocalcaneal arthrodesis (Ortho Solutions, Maldon, Essex, UK)

Thank You