From the Guidelines
The procedure for treating an old tibial fracture by implant removal and tibiotalar arthrodesis with cannulated compression (CC) screws involves several key steps, prioritizing the patient's morbidity, mortality, and quality of life as the primary outcome.
Preoperative Planning
The procedure begins with preoperative planning, which includes imaging studies such as CT scans to determine the extent, displacement, comminution, intra-articular extension, associated injuries, and potential classification of fractures 1. This is particularly important in subtalar, calcaneal, and talar fractures due to the complex anatomy.
Surgical Procedure
The patient is positioned supine on the operating table under appropriate anesthesia with a tourniquet applied to the affected limb. After surgical site preparation and draping, an incision is made over the previous surgical site to expose the old implant. The implant is carefully removed by identifying all screws and plates, then extracting them using appropriate instrumentation while preserving surrounding tissues.
- The tibiotalar joint surfaces are prepared by removing all cartilage down to bleeding subchondral bone using osteotomes, curettes, and burrs.
- The joint surfaces are then shaped to achieve optimal contact between the tibia and talus.
- Bone grafting may be performed using autograft (typically from the iliac crest) or allograft to fill any defects and promote fusion.
- The ankle is positioned in neutral dorsiflexion with slight external rotation and 5-10 degrees of valgus alignment.
- Provisional fixation is achieved with Kirschner wires, followed by placement of two or three cannulated compression screws.
- These screws are typically inserted from the distal tibia into the talus in a parallel or slightly convergent orientation.
- Fluoroscopic guidance ensures proper screw placement and compression across the fusion site.
Postoperative Care
After confirming satisfactory position and fixation, the wound is irrigated, hemostasis achieved, and closure performed in layers. A well-padded splint or cast is applied with the ankle in the fusion position. Postoperatively, the patient remains non-weight bearing for 8-12 weeks until radiographic evidence of fusion appears, followed by gradual weight bearing as tolerated. It is crucial to manage potential complications, such as fracture-related infection, by following established treatment principles, including surgical debridement, fracture consolidation, and soft tissue management, as outlined in recent studies 1.
From the Research
Procedure Overview
The procedure for old tibial fracture by implant removal and arthrodesis tibio-talar done by cc screw involves several steps:
- Implant removal: This step involves the removal of the existing implant from the tibial fracture site 2.
- Preparation of the fracture site: The fracture site is prepared for arthrodesis by removing any debris or damaged tissue 3.
- Arthrodesis: The tibio-talar joint is fused using a cc screw to stabilize the joint and promote healing 4.
- Wound closure: The wound is closed and dressed to promote healing and prevent infection 5.
Indications for Implant Removal
The indications for implant removal after fracture healing are not well defined and guidelines hardly exist 6. However, some common indications include:
- Pain or discomfort at the implant site 6
- Prominent material or implant failure 6
- Infection or intra-articular material 6
- Patient request for removal 2
Complications and Outcomes
The complications and outcomes of implant removal and arthrodesis tibio-talar done by cc screw include:
- Surgical site infection 4
- Implant failure 4
- Unplanned return to operating room 4
- Improvement in clinical outcomes and patient satisfaction 5
- Improvement in functional outcomes and reduction in pain 5
Classification and Treatment
Peri-implant fractures around hindfoot fusion nails can be classified and treated based on the location and severity of the fracture 3. A classification system can be helpful to guide clinical practice and treatment decisions.
Patient Selection and Counseling
Patients who are unhappy with their clinical result should be counseled that removal of the implant may improve function, but may not improve pain 5. Patients should be properly informed and consented before undergoing implant removal and arthrodesis tibio-talar done by cc screw.