Objective: This study aimed to report the short-term results of retrograde tibiotalocalcaneal (TTC) nailing in a selected series of patients with fragility ankle fractures. Methods: This study included 17 patients who underwent primary retrograde TTC nailing from January 2016 to April 2019. The Olerud-Molander ankle score (OMAS) was recorded preoperatively and at the final follow-up. Results: Mean patient age was 81.5 years (range, 67-91 years), and mean follow-up duration was 20.9 months (range, 8-50 months). No patient was lost to follow-up. Eleven patients had diabetes. Thirteen patients were able to walk with an assistive device, and 4 with help from another person. Two patients died at 8 and 9 months after treatment. Radiographic healing was observed in 100% of the fractures. No deep infection or scarring problems were recorded. Two patients were wheelchair bound after treatment, whereas 15 recovered their previous autonomy. The mean OMAS score changed from 64.1 (range, 55-75) preoperatively to 55.3 (range, 45-65) postoperatively. Conclusion: Our results suggest that primary retrograde TTC nailing is a valid option in selected patients with fragility ankle fractures, multiple comorbidities, poor soft tissue condition, and difficulty in walking before the fracture. Level of Evidence IV; Therapeutic Studies, Case Series.
Background: Deep infection after open reduction internal fixation (ORIF) of ankle fractures represents a challenge to the orthopaedic surgeon, particularly in patients in whom conventional surgical treatments have failed. The aim of this study was to assess the results of a modified technique of tibiotalocalcaneal fusion using a retrograde locked intramedullary nail covered in cement with antibiotics. Methods: Six patients treated using the authors’ technique were analyzed retrospectively. All patients had deep infection after ankle osteosynthesis and several surgical procedures (debridement, external fixation, etc) had failed. Radiographs were analyzed to confirm the healing of the bone. Outcome was measured by maintained construct stability and eradication of infection (no clinical signs of infection and normal values of laboratory markers). The average age of the series was 64.2 (range, 50-75) years, and the average follow-up period was 19.5 (range, 8-41) months. Results: Tibiotalocalcaneal stability and eradication of the infection were achieved in all patients, along with the normalization of clinical and radiologic parameters. In the patient who underwent a talectomy, one of the calcaneal locking screws broke, with no clinical repercussions. Conclusion: Tibiotalocalcaneal fusion with antibiotic cement-coated retrograde nails was useful in providing clinically acceptable results in the control of chronic infection in complex patients after the failure of previous surgeries. Level of Evidence: Level IV, therapeutic study.
Purpose The purpose of this study was to demonstrate whether application of the so-called safe incision when performing calcaneal sliding osteotomies reduces the risk of sural nerve injury. Methods Patients who underwent either medial or lateral sliding calcaneal osteotomies between 2010 and 2018 were analysed retrospectively. A thorough neurological examination was performed, and the location of the surgical wound and the type of wound closure were recorded. The European Foot and Ankle Surgery (EFAS) score and 12-item Short Form Survey (SF-12) were also documented. Results A total of 57 patients were included, of which 20 (35.1%) had a sural nerve injury. Five patients had a neurapraxia (8.8%), while 15 patients had a permanent injury (26.3%). Respecting the "safe incision" decreased sural nerve injury (p = 0.02). The type of osteotomy and closure was not significant. No significant differences were found in the functional tests between the different techniques, or between patients who presented sural nerve injury and those who did not. Conclusion Sural nerve injury after calcaneal sliding osteotomies is higher than previously reported in the scientific literature, with an incidence of 35.1% (20/57 patients). Respecting the so-called safe zone (oblique incision that runs through the point that is > 1/3 of the distance from the tip of the lateral malleolus to the posteroinferior margin of the calcaneus) clearly decreases the incidence of sural nerve injury. Finally, the majority of patients remained asymptomatic despite the neurological injury.
The incidence of peripheral neurological injuries related to calcaneal osteotomies reported in the literature is low and often described as occasional. The main objective of this study is to determine the incidence of neurological injuries after calcaneal osteotomies and identify which nerve structures are most affected. This retrospective work included 69 patients. Medical records, surgical protocols, and radiographs were analyzed. All patients were summoned to perform current functional tests (EFAS score and SF-12), and a thorough physical examination was performed systematically and bilaterally. The total incidence of neurological injuries was 43.5% (30/69). The percentage of neurapraxias (transient injuries) was 8.7%, while 34.8% of patients presented neurological sequelae (permanent injuries). The most injured nerve or branch was, in decreasing order: sural nerve, medial plantar branch, lateral plantar branch and medial calcaneal branch. Following the so-called “safe zone” clearly decreases the incidence of sural nerve injury (p = 0.035). No significant differences were found between osteotomy site, number of screws, and type of closure and increased neurological injuries. No significant differences were found in the functional tests between the different techniques, nor between patients who presented neurological injuries and those who did not. Neurological injuries after calcaneal osteotomies are underdiagnosed and the incidence is higher than previously reported (43.5%). Such injuries mostly go unnoticed and have no implications in the functional results and patients’ satisfaction.
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