Foot & Ankle International - June 2017 - 671

696252

FAIXXX10.1177/1071100717696252Foot & Ankle InternationalWatanabe et al

research-article2017

Article

Tibiotalocalcaneal Arthrodesis Using a
Soft Tissue-Preserved Fibular Graft for
Treatment of Large Bone Defects in the
Ankle

Foot & Ankle International®
2017, Vol. 38(6) 671-676
© The Author(s) 2017
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https://doi.org/10.1177/1071100717696252
DOI: 10.1177/1071100717696252
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Kota Watanabe, MD1, Atsushi Teramoto, MD2, Takuma Kobayashi, MD2,
Izaya Ogon, MD2, Yuzuru Sakakibara, MD2, Tomoaki Kamiya, MD2,
Tomoyuki Suzuki, MD2, and Toshihiko Yamashita, MD2

Abstract
Background: Pathogenesis of ankle disorders with a large bone defect is varied and treatment for those problems is
challenging for orthopaedic surgeons. The aims of this study were to present an operative technique of arthrodesis for the
reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue-preserved fibular strut graft and to
report outcomes of consecutively treated patients.
Methods: Twelve feet from 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening,
were treated. Bone defects were filled using iliac bone and/or resected fibula and tibiotalocalcaneal arthrodesis was
performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint
while preserving the lateral to posterior skin and soft tissues on the fibula. The periods of bony fusion and outcomes were
radiographically and clinically evaluated. The mean follow-up period was 33.4 months.
Results: Bony fusion was achieved within 3 months in all cases. Coronal and sagittal alignments were acceptable, and the
mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded
their results of treatment as "satisfied."
Conclusion: This procedure did not require special techniques and it should be applicable to complicated cases with large
bone defects. High fusion rates that we believe are due to preserving blood supply to the fibular graft can be expected with
preservation of the hindfoot height.
Level of Evidence: Level IV, case series.
Keywords: tibiotalocalcaneal arthrodesis, intramedullary nail, large bone defect, soft tissue-preserved fibular graft

Introduction
Ankle joint disorders that affect a large part of the ankle are
occasionally encountered. These disorders include talar
avascular necrosis, infection, trauma, tumor, or implant
loosening following total ankle arthroplasty (TAA). Charcot
arthropathy sometimes causes massive bone disruption in
the ankle.
Arthrodesis is one of the major options for treatment of
these disorders; however, there are several problems that
make arthrodesis technically challenging. Tibiocalcaneal
arthrodesis can stabilize a foot and reduce ongoing pain,
although leg length discrepancies may occur and an orthosis is sometimes needed following surgery. There are many
reports of attempts to restore the height of the hindfoot.
Blair fusion is a treatment option that preserves the height
after resecting the talar body because of talar avascular

necrosis. Delayed union and nonunion is a concern because
of the small contact area between the tibia and talus neck
and the difficulty in achieving rigid fixation.11 Free vascularized fibular bone grafting can fill the defect and preserve
the height using live bone.1,12 However, this procedure is
not simple, which limits the number of surgeons qualified to
perform it. Dennison et al4 applied tibiocalcaneal fusion
1

Department of Physical Therapy, Sapporo Medical University School of
Health Sciences, Hokkaido, Japan
2
Department of Orthopaedic Surgery, Sapporo Medical University
School of Medicine, Hokkaido, Japan
Corresponding Author:
Kota Watanabe, MD, Department of Physical Therapy, Sapporo Medical
University School of Health Sciences, South-1, West-17, Chuo-ku,
Sapporo, Hokkaido, 0608556, Japan.
Email: wkota@sapmed.ac.jp

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