Outcomes Following Intramedullary Nail vs Plate Fixation for Tibiotalocalcaneal Arthrodesis: A Systematic Review

Abstract

Category:Ankle Arthritis; Hindfoot; TraumaIntroduction/Purpose:Tibiotalocalcaneal arthrodesis (TTCA) is indicated to treat pain anddysfunction that may result from a variety of ankle and hindfoot pathologiesby achieving fusion of the tibiotalar and subtalar joints. Two commonfixation methods exist to achieve TTCA: retrograde intramedullary nail (IMN)fixation and plate fixation using a lateral trans-fibular or posteriorAchilles-tendon splinting approach. The purpose of this study is to reviewthe literature and compare the outcomes of TTCA using IMN fixation withthose of plate fixation using a lateral trans-fibular approach.Methods:A comprehensive search of the PubMed, Cochrane, and EMBASE databases wasperformed on 01 February 2021 for studies of all levels of evidencepertaining to TTCA using IMN and plate fixation. Reasons for exclusionincluded: no formal joint preparation, non-English language, concomitantmethods of fixation (e.g., IMN with additional plate fixation) and follow-upless than 12 months.Results:Fourteen studies (11 level III and 3 level IV) met criteria and wereincluded. A total of 386 fusions were documented in 356 patients [259 (67%)IMN and 127 (33%) plate fixation]. In the IMN group, union rates at thetibiotalar joint (TTJ) were 84% (219/259) and subtalar joint (STJ) were 90%(229/259) with an overall complication rate of 20% (53/259). Average initialAOFAS scores were 34.3+-7.9, increasing to 72.4+-9 postoperatively. In theplate fixation group, union rates at the TTJ were 82% (103/127) and STJ were86% (108/127) with an overall complication rate of 30% (39/127). Averageinitial AOFAS scores were 37.0+-6.9, increasing to 74.4+-12.5postoperatively. No statistical differences were noted between the TTCA IMNand plate cohorts when comparing rates of TTJ or STJ union (p= 0.6, andp=0.2, respectively) and postoperative AOFAS scores (p=0.59). However, theplating group had a statistically higher overall complication rate(p=0.02).Conclusion:A systematic review of the available literature suggests that there is nostatistical difference in union rates or functional outcomes between TTCAusing intramedullary nail or lateral trans-fibular plate fixation. However,the lateral trans- fibular plate has a statistically higher complicationrate when compared to intramedullary nails. Further comparative prospectivecohort studies and randomized controlled trials are needed to further elicitdifferences between these groups and confirm the findings of this systematicreview.