Any help with this staged procedure would be greatly appreciated!
6 months after the first procedure, patient returns after inflammatory markers have normalized. Patient has been able to maintain a non-weightbearing status. At the time of patient explant, talus bone appeared to be a dark brownish color and did not appear healthy. Dr did not feel bone would be amenable to holding a revision prosthesis. That as well as he had a fibular nonunion of his lateral approach osteotomy site. Patient was recommended for left tibiotalar and subtalar joint arthrodesis with custom talar cage/implant.
Postoperative Diagnosis
Left failed total ankle arthroplasty with prosthetic joint infection, status post irrigation and debridement with antibiotic spacer placement
Operation
1) Left tibiotalar arthrodesis (27870)
2) Left subtalar arthrodesis (28725)
3) Insertion of custom talus cage (?)
4) Local autograft harvest from calcaneus, fibula and tibia (20902?)
5) PDGF allograft augmentation (27899 Unlisted and compare to 20931?)
Findings
Dark brown appearing talus bone, fibular nonunion, valgus hindfoot deformity
Implants
Stryker valor hindfoot fusion nail (11.5 x 150 mm nail)
4 web custom talus cage
PDGF allograft
Technique
Lateral incision was made utilizing the previous incision. This is carried through skin and subcutaneous tissues. Hemostasis was achieved with electrocautery. Dissection was carried down anterior to the peroneal tendons, along the course of the subtalar joint. Sharp dissection was carried down to the level of the fibula. The fibula was exposed with subperiosteal dissection. Previous osteotomy site was utilized to access the medullary canal of the fibula. The existing threaded Steinmann pin was removed with a wire driver. The distal portion of the fibula was then removed and harvested as autograft. This was mixed with the PDGF on the back table.
Next, the existing cement spacer was removed with osteotomes. The distal tibial joint surface and the calcaneal joint surface were then exposed with osteotomes. Existing talus was removed. The calcaneus and the tibia were then reamed sequentially to a size 42 mm acetabular reamer. Trial implants were placed. Decision was made to use the 40 mg meter, smaller custom cage. The reamings from the tibia and calcaneus were harvested as well and placed within the structure of the custom cage.
Large K wire from the valor nail system was placed retrograde through the calcaneus and into the tibia. Positioning of this was confirmed with C-arm fluoroscopy. Opening reamer was then utilized through a distal percutaneous incision. The calcaneus and tibia that were then reamed to an 11.5 mm reamer. This was done to facilitate an 11.5 mm nail. Patient has a midshaft tibial deformity from a previous fracture. A 150 mm length nail was chosen to avoid this area.
The custom cage that had been prepared with the bone graft was then placed into the talar void. Long K wire was then re-placed through this and then the nail was placed up into the tibial shaft through the plantar aspect of the foot. Insertion jig was used to placed 2 tibial screws from medial to lateral. This was done through percutaneous incision. Excellent fixation was noted. The jig was then placed around to the lateral side. Calcaneal screw was then placed from lateral to medial. Internal compression device was then utilized and seated fully. This was noted to close down the space surrounding the custom implant.
Final calcaneal screw was placed through separate percutaneous incision. There was 1 screw hole for a anti-rotation screw through the custom implant and into the talar head. This was drilled with appropriate drill bit and a 5.0 mm screw was placed through the implant and into the talar head.
Final x-rays were taken which confirmed appropriate reduction of the joint surfaces, hardware placement, and compression surrounding the implant. Foot was noted to rest in a clinically neutral position. The bone graft that had been harvested from the fibula was packed around the implant at both the tibial and subtalar surfaces.
Wounds were then irrigated with normal saline. All deep tissues laterally were closed with 0 Vicryl suture. Subcutaneous tissues throughout the foot were closed with 3-0 Monocryl suture. Skin reapproximated with 3-0 nylon. Wounds were then dressed with Xeroform, 4 x 4, ABD, Sof-Rol, and a well padded posterior plaster splint was applied. Tourniquet was let down at approximately 135 min.
6 months after the first procedure, patient returns after inflammatory markers have normalized. Patient has been able to maintain a non-weightbearing status. At the time of patient explant, talus bone appeared to be a dark brownish color and did not appear healthy. Dr did not feel bone would be amenable to holding a revision prosthesis. That as well as he had a fibular nonunion of his lateral approach osteotomy site. Patient was recommended for left tibiotalar and subtalar joint arthrodesis with custom talar cage/implant.
Postoperative Diagnosis
Left failed total ankle arthroplasty with prosthetic joint infection, status post irrigation and debridement with antibiotic spacer placement
Operation
1) Left tibiotalar arthrodesis (27870)
2) Left subtalar arthrodesis (28725)
3) Insertion of custom talus cage (?)
4) Local autograft harvest from calcaneus, fibula and tibia (20902?)
5) PDGF allograft augmentation (27899 Unlisted and compare to 20931?)
Findings
Dark brown appearing talus bone, fibular nonunion, valgus hindfoot deformity
Implants
Stryker valor hindfoot fusion nail (11.5 x 150 mm nail)
4 web custom talus cage
PDGF allograft
Technique
Lateral incision was made utilizing the previous incision. This is carried through skin and subcutaneous tissues. Hemostasis was achieved with electrocautery. Dissection was carried down anterior to the peroneal tendons, along the course of the subtalar joint. Sharp dissection was carried down to the level of the fibula. The fibula was exposed with subperiosteal dissection. Previous osteotomy site was utilized to access the medullary canal of the fibula. The existing threaded Steinmann pin was removed with a wire driver. The distal portion of the fibula was then removed and harvested as autograft. This was mixed with the PDGF on the back table.
Next, the existing cement spacer was removed with osteotomes. The distal tibial joint surface and the calcaneal joint surface were then exposed with osteotomes. Existing talus was removed. The calcaneus and the tibia were then reamed sequentially to a size 42 mm acetabular reamer. Trial implants were placed. Decision was made to use the 40 mg meter, smaller custom cage. The reamings from the tibia and calcaneus were harvested as well and placed within the structure of the custom cage.
Large K wire from the valor nail system was placed retrograde through the calcaneus and into the tibia. Positioning of this was confirmed with C-arm fluoroscopy. Opening reamer was then utilized through a distal percutaneous incision. The calcaneus and tibia that were then reamed to an 11.5 mm reamer. This was done to facilitate an 11.5 mm nail. Patient has a midshaft tibial deformity from a previous fracture. A 150 mm length nail was chosen to avoid this area.
The custom cage that had been prepared with the bone graft was then placed into the talar void. Long K wire was then re-placed through this and then the nail was placed up into the tibial shaft through the plantar aspect of the foot. Insertion jig was used to placed 2 tibial screws from medial to lateral. This was done through percutaneous incision. Excellent fixation was noted. The jig was then placed around to the lateral side. Calcaneal screw was then placed from lateral to medial. Internal compression device was then utilized and seated fully. This was noted to close down the space surrounding the custom implant.
Final calcaneal screw was placed through separate percutaneous incision. There was 1 screw hole for a anti-rotation screw through the custom implant and into the talar head. This was drilled with appropriate drill bit and a 5.0 mm screw was placed through the implant and into the talar head.
Final x-rays were taken which confirmed appropriate reduction of the joint surfaces, hardware placement, and compression surrounding the implant. Foot was noted to rest in a clinically neutral position. The bone graft that had been harvested from the fibula was packed around the implant at both the tibial and subtalar surfaces.
Wounds were then irrigated with normal saline. All deep tissues laterally were closed with 0 Vicryl suture. Subcutaneous tissues throughout the foot were closed with 3-0 Monocryl suture. Skin reapproximated with 3-0 nylon. Wounds were then dressed with Xeroform, 4 x 4, ABD, Sof-Rol, and a well padded posterior plaster splint was applied. Tourniquet was let down at approximately 135 min.