Tibiocalcaneal Fusion using a Peg-in-Hole Technique with Combined Ilizarov External Fixation Method
Edgardo Rodriguez, DPM Byron Hutchinson, DPM Eric Powell, DPM
www.clesf.org
Statement of Purpose
Tibocalcaneal fusion (TCF) is an end-stage procedure performed for limb salvage in the diabetic
patient due to Charcot Osteoarthropathy or osteomyelitis, for patients who have sustained
severe trauma to the talus, infection or for revision of failed total ankle arthroplasty. Often times,
poor vascular supply from trauma or disease and the metabolic imbalance of diabetes can bring
bone healing and fusion site stability into question. The authors present a new technique for
TCF via Peg-in-Hole fusion using the Ilizarov external fixation (IEF) method on 52 patients
Methodology & Hypothesis
A retrospective review of 52 patients was performed with a mean follow-up of 34 months. Age,
sex, fusion rate, time to fusion, and complication rate were all evaluated. Co-morbidities were
also identified. The hypothesis that we pose is that Peg-in-Hole TCF in the setting of a limb
salvage scenario offers better stability and fusion rate than traditional end stage salvage
procedures with the use of IEF.
Procedure
Peg-in-Hole TCF with IEF was performed on 52 patients. The distal leg is exposed via a lateral
incision. The infected bone, or in the case of Charcot the demineralized bone, is resected to
healthy, bleeding bone. The peg is made in the remaining distal tibia (figures 1 and 2) by
tapering cut. The hole is made in the residual calcaneus by matching the tapered cut made in
the distal tibia with care to preserve residual foot structure as much as possible (figure 3).
Attempt to preserve the fibula is perfomed. If unsuccessful, it is resected and discarded or used
as bone graft. The IEF is then applied via standard methods. No internal fixation is used in this
construct. The incisions are closed primarily and the External fixator is compressed to allow
good apposition of the bone ends. Standard frame and wound care maintenance is then
undertaken. Figure 4 shows the Peg-in-Hole cuts performed on a cadaver and visualized under
fluoroscan
Fig. 1: Medial view of Peg-in-Hole TCF. Fig. 2: Lateral view of Peg-in-Hole TCF.
Literature Review
TCF is well described in the literature for post-traumatic limb salvage, Charcot Osteoarthropathy
or failed total ankle arthroplasty [11, 12, 13, 15, 16] . The majority of descriptions involve the use
of internal fixation. To the contrary, there are relatively few articles that discuss TCF with the use
of IEF [1-5].
Rochman, et al retrospectively reviewed records of
patients who underwent TCF using an IEF. 11
patients were identified. The etiology was post-
traumatic in all cases with a mean age of 44 years (29-
77). TCF was performed via two methods: 8 patients
had talar body resection with fusion of the talar
head/neck to the tibia; 3 patients had complete
excision of the talus with fusion of the tibia to the
calcaneus and navicular to the tibia. The fibula was
maintained in 1 patient, 10 had the fibula excised. The
contoured surfaces were acutely shortened,
compressed and held in position with IEF. 9 TCF
Fig. 3: Anterior view of TCF. patients fused successfully. Mean follow-up of 35
months (10.5-81.5) was performed. Two nonunions
were reported. Patients were in the IEF for a mean of 7 months (5-12). AOFAS ankle-hindfoot
score mean was 65 (44-77). 7 patients at final follow-up reported no limitation in their ADLs and
had the ability to walk four to six blocks. The author’s concluded that TCF using an external fixator
is a good option for salvage procedure in the patient with severe traumatic injury with resulting loss
of the talus [1].
Hamed published results on 6 patients with a mean age of 40 years (21-60) with talar necrosis.
The cause of the necrosis was post-traumatic in 4, avascular necrosis in 1 after failed ankle fusion,
and deep infection of talus after radiotherapy following excision of intraosseous leiomyosarcoma in
1. All patients underwent at least one surgery prior, with a mean of three procedures. Mean follow-
up was 93.5 months (55-115). All fusion sites reached solid, clinical and radiographic union. Mean
time in the frame was 36 weeks (16-73). The author concluded that this method is a safe and
reliable procedure for TCF with severe talar destruction, but it is a technically demanding procedure
with close patient monitoring required [5].
Johnson, et al reported on a new technique for ankle fusion using the IEF in 6patients; 2 were
primary tibiotalar fusions and 4 were TCF due to infection. Mean age was 48 years (33-74). An
average of four previous failed surgeries occurred in the patients with infection. TCF was obtained
in 3 infected failed ankle fusion patients at a mean of 7 months (4.5-9). Mean follow-up was 26
months (19-30). The author’s concluded that the technique is difficult and requires close patient
monitoring. They do not recommend it as the initial surgical procedure for uncomplicated ankle
arthrodesis. They did feel that when used properly, it extends the ability to salvage complex ankle
deformity [2].
Weber, et al described a series of 6 patients who had what they termed a “rabbet” fashioned out of
the calcaneus, cuboid and navicular by removing the talus. The distal tibia and its anterior surfaces
were matched to the contour of the calcaneo-naviculo-cuboidal cuts. The foot was then translated
posteriorly under the tibia to allow the anterior tibial surface to contact the naviculo-cuboid surfaces.
The etiologies consisted of 2 patients with septic arthritis and 4 with malformation, deformity or
trauma. Mean follow-up time was 46 months (16-96). All fusion sites healed. The external fixator
was removed after a mean 12 months (7-16). All patients reported a satisfied outcome with the
surgery with no pain at latest follow-up. The author’s stated that the fusion technique offers distinct
adavantages over other conventional procedures, especially when the bone stock is poor [4].
Dennison, et al performed TCF on 6 patients for avascular necrosis of the talus. Trauma was the Complications encountered in our patient
reason for AVN of the talus in 5, failed ankle fusion for 1. Mean age was 45 years (27-67). Mean population were 7 patients with wound
number of prior operative procedures was 5. The frame was removed at a mean of 10.7 months, dehiscence. 2 of these healed with local
those without a proximal corticotomy had the frame removed once solid fusion was obtained at a wound care; the remaining 5 required
mean of 9months. Follow-up averaged 32 months (13-49). One excellent result occurred with pain delayed primary closure of the wound. There
free, unrestricted activity. Four cases had good results. The author’s stated that they felt this was a were 13 patients with a nonunion at the
superior method at managing patients with severe talar deformity necessitating TCF [3]. fusion site. 5 of these were infected with 1
infected prior to TCF. 3 of these resulted in
Results below knee amputation. The 2 remaining
There were 39 males, 13 females. The average age was 47 years. The overall fusion rate was 86%. infected nonunions were treated with revision
surgery. The remaining nonunions were
Mean time to fusion was 17 weeks. The overall combined complication rate was 27%. Complications
reported were 7 wound dehiscence, 13 total nonunions with 5 being septic and 3 resulting in below treated conservatively with bracing and
remain asymptomatic at the most recent Fig. 4: Peg-in-Hole TCF on a cadaver.
knee amputation. Comorbidities identified prior to surgery were diabetes mellitus, smoking, and prior
surgery. follow-up.
The complications encountered in our patient population were consistent with those described by
other author’s (1-5). However, none of our patients encountered pin tract infections in contrast to
Analysis & Discussion other author’s who reported several of their patients with pin tract infections ranging from local
We report on a new technique of creating a Peg-in-Hole type cut not previously described for TCF. A wound care to removal of the pin (2-5)
V- type osteotomy has been described in the proximal tibia to correct for tibial varum or valgum, but
the purpose was for frontal plane angular correction to alleviate medial or lateral knee compartment The authors report a new technique for TCF using a Peg-in-hole osteotomy at the fusion site with
arthrosis [6]. In our technique, the peg-in-hole osteotomy creates a higher surface area of bone IEF. We feel that this is a technically demanding procedure that has the potential for high
contact for fusion. Coupled with the superior compression that IEF allows, the entire construct is complication rate, but by using the Peg-in-Hole method, the foot and ankle surgeon is
more stable. The hole cut into the calcaneus exposes more cancellous bone for superior bone maximizing the biological and anatomical properties of each patient to allow for improved healing
healing as well. In our patient population, mean fusion time was 17 weeks with an 86% fusion rate in and better functional results. As with any reconstructive surgery and in patients with severe
52 patients. Table 1 shows fusion rate, fusion time and fusion site preparation of the compartive deformity, the risk of catastrophic surgical failure ending in below knee amputation is high.
studies.. However, given the deformity present in our patient population, we feel attempt at limb salvage
outweighs the risk of going onto a below knee amputation. Close monitoring is needed to
Fusion Rate Fusion Time (mean) Fusion site ensure proper progression and healing is occurring as well as prevention of complications, but
(fused/n) we feel that this is a superior technique to the previously described planar resection for TCF.
Rochman, et al 81% (9/11) Not reported Planar References
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