Category: Trauma
Category: Trauma
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An isolated CC arthrodesis is not a common procedure. However, in certain instances like large non-united anterior process fractures, it may be the best option. Fixating the CC whether isolated or not, can be a challenge. When performed in addition to a STJ and TN fusion, the fixation is probably less important due to the inherent stability afforded with the fixation of adjacent hindfoot joints. However, in the isolated scenario, fixation is crucial as the non-union rate is much higher. We have utilized a variety of constructs; staples, screws, small plates, headless beam screws from P to A, etc….We have found firsthand the IO Fix device by Extremity Medical not only allows exceptional compression, but also addresses the ever present hardware irritation concern in thinner patients. The intramedullary IO Fix device eliminates the concern for peroneal tendon irritation, and offers superior compression. It has been a great tool for this procedure.
Case examples show good union at 8+ wks from date of surgery.
19 yo falls off rope swing
1 year later still in pain….
Advanced imaging to eval quality of lesion
….Original ER plain film shows OLT
My rules for favoring open allograft vs scope microfracture are:
-Talar shoulder lesions
-Full thickness delamination apparent on MR
-11-12mm +
-Depth is of concern
Patient also received direct ATF ligament repair with Fibertak suture anchors.
I like BioCartilage as it is half the cost of De Novo, BMAC included. You get the best of both worlds - host cells, and graft. It has been proven to have favorable MOCART scores, and robust thickness as compared to fibrocartilage, when looked at up to 19 months post-op.
71 yo PACU nurse falls at home after neck surgery. …. The most heart warming debate out there….ORIF vs Arthrodesis for Lisfranc injuries - both ligamentous, and osseous/ligamentous combined.
In my mind, patients have the last say as long as it’s reasonable.
The most important feature of the TMT complex is stability, not motion. Arthrodesis provides that, especially in patients where demand requires it. Counterintuitively active patients need this the most. Shannon Rush hammers that point. This particular patient hikes with spouse, was about to retire, and wanted the closest thing to a guarantee of 1 procedure allowing success that could be provided.
Trauma to the TMT complex inherently changes the articulation permanently, true. The advantages arthrodesis affords vs ORIF;
-1 procedure assuming union
-Superior stability
-No risk of re-injury to ligament that doesn’t exist
-Decreased risk of complications due to statistically less surgeries required
-Patients have been shown to reach pre injury activity levels up to 30% better in arthrodesis group
-Improved pain scores
Literature defines arthrodesis patients as partial vs total.
Partial = 1-3 TMT fusion
Total = 1-5 TMT fusion
Coetzee’s study is really still the best study because he compares his own patients, fusion vs ORIF, with a 3.5 yr follow up. Of course the limitation to his study is follow up time. If the ORIF group is followed for 20 yrs we would presumably see 100% post traumatic OA in the ORIF group.
Counterpoint would be prevalence of adjacent joint arthritis in arthrodesis group.
My argument to that is - does a joint that does not have exceptional motion to begin with place much burden on an adjacent joint, post fusion?
Yes - ORIF’s are quick, and easy, but do they last?
In our own patients, the arthrodesis patients are happier than the open and perc ORIF patients.
This case was fixated with Extremity Medicals IO Fix device which affords incredible compression with intramedullary fixation.
NOTE: Post-op images demonstrate union at 10th week visit.
This patient had an Achilles tendon rupture in 2015 while on vacation in the Bahamas. A mostly sensate IDDM ... 4 surgeries later, and a finally healed Achilles tendon, unfortunately however left her with chronic osteomyelitis of her calcaneus. She was referred to us in 2019. At that point she had failed 3+ yrs of wound care, immobilization, antibiotics (both oral and IV), and was living with a draining sinus tract at her medial heel. I suggested to the patient further surgery. She had multiple MRI's, and a CT scan demonstrating the chronic OM. She declined surgery however, and even cancelled after she scheduled with us twice, due to admitted PTSD from the ordeal spanning the course of 6 years. I suggested to her (not in order) we debride the bone through the sinus tract -take cultures, irrigate, excise the wound, fill the void with a non-phosphate antibiotic impregnated bone filler (Cerament), close with heavy suture, and hope for the best. After 2 years of deliberation under our care she finally agreed, and that's what we did. A culture in our office taken from active purulence in 2019 grew Enterobacter Cloacae, the repeat culture in the OR in July of 2021 also grew Enterobacter Cloacae. We used Gent/Vanc for the Cerament, although Cerament does not recommend using Gent. During surgery as soon as we started to debride the bone with a small curette, a long, purulent strand of fiberwire shot out from the intramedullary canal. This answered the question of the non-healing tract.
She is now 2 months out from surgery, and doing great. Wound free for the first time since 2015.
Note; classic chronic OM cloaca as seen on CT.
Chronic gout, and years of wear n tear from hauling the mail, on foot, in this 60 yo male!
I have not seen a lot of tophaceous gout at the TN, but this fellar had a nice collection of cottage cheese at the dorsum of the joint intra-op.. Pain at dorsal TN, and with STJ range of motion. Particularly, middle facet degeneration. ….Just a nice simple Gastroc recession, TN tidy up, and ST arthrodesis.
He was back carrying mail in 12 weeks.