Effect of Preoperative Ulceration on Outcomes of Tibiotalocalcaneal Arthrodesis

CATEGORY: Hindfoot; Diabetes INTRODUCTION/PURPOSE: Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. In patients with neuropathy, hindfoot deformity, and preoperative hindfoot ulceration, management options can be limited and very challenging. Previously, some authors have advocated for fine wire circular frames and avoidance of internal fixation in an effort to decrease the risk of infection in patients with preoperative ulceration, however, there is very limited data on the outcomes of TTC arthrodesis with internal fixation in this patient population. We hypothesized that internal fixation of TTC arthrodesis in patients with preoperative ulceration would lead to higher infection rates compared to patients without ulceration. METHODS: A retrospective review was conducted on the TTC fusions performed from 2016-2020 by a single fellowship trained foot and ankle surgeon at an academic medical center. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients' charts. Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 3 months of follow-up. 34 patients (34 ankles) underwent TTC arthrodesis Mean age was 60.7 years and mean follow-up was 1.3 years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Nine patients had preoperative ulcers at the time of surgery. RESULTS: Common surgical indications included Charcot neuropathy (n=17), post-traumatic (n=14), and cavovarus (n=3). All patients with preoperative ulcers underwent TTC fusion with an intermedullary rod. Of the patients without ulceration, 18 underwent intermedullary nailing, 5 underwent plating, and 1 had an external fixator placed. There was no difference in deep wound infection rates between patients with (2/9, 22.2%) and without (2/25, 8.0%; p=.386) preoperative ulceration; nor was there a difference in rate of fusion, wound healing, or radiographic alignment. One patient without preoperative ulceration underwent a below knee amputation due to infection. CONCLUSION: TTC arthrodesis with internal fixation appears to be a reasonable consideration in patients with a preoperative hindfoot ulcer. There was no statistical difference in infection rate in patients undergoing TTC fusion with and without preoperative ulceration. Further, the rate of infection in those with an ulcer and internal fixation was acceptable, and internal fixation can be considered in these patients.