DOI: https://doi.org/10.53350/pjmhs2115123167 ORIGINAL ARTICLE P J M H S Vol. 15, No.12, DEC 2021 3167 Efficacy of Ankle Arthodesis with Retrograde Sign Nail HAFIZ HASSAN IFTIKHAR 1 , ALI IJAZ 2 , UMAIR AHMAD 3 , M. ZAIN NASEER 4 , HIZBULLAH RIAZ ANSARI 5 , AMIR AZIZ 6 1,2,4,5 Postgraduate Residents, 3 Assistant Professor, 6 Professor & Head, Department of Orthopaedic & Spine, Ghurki Trust Teaching Hospital, Lahore Correspondence to Dr. Hafiz Hassan Iftikhar, E-mail: hassan.iftikhar1987@gmail.com Cell: 0323-6003788 ABSTRACT Aim: To evaluate the efficacy of ankle arthrodesis by using Retrograde SIGN Nail. Study Design: Retrospective study. Place and Duration of the Study: Department of Orthopaedic & Spine Surgery, Ghurki Trust Teaching Hospital, Lahore from 1 st January 2018 to 30 th June 2020. Methodology: Thirty patients were enrolled for arthrodesis by using retrograde nails. Clinical and radiological examination confirmed the severe arthritis of the subtalar joints in all cases. Surgical procedure was initiated by using lateral incision fibula segment of 1.5 cm was excised 6-8 cm proximal to the fibula tip. After adequate exposure, from proximal lateral to distal medial, approximately 5-6 cm transaction of the fibula was made obliquely. Soft tissue was the initiating point of dissection and the portion was placed on the back table for further use as an autogenous bone graft. To expose the medial gutter, approximately 2-3 cm incision was carefully made at medial to the tibialis anterior tendon without indulging saphenous nerve and vein. Results: A weak positive Pearson correlation was found between BMI and FAAM score but a significant (P=0.00001). Conclusion: Retrograde nailing techniques help to achieve the goals of the union. It also assists in the preservation of hind foot alignment. Keywords: Ankle deformity, Ankle arthrodesis, Ankle arthritis, Retrograde nailing INTRODUCTION Ankle deformity can be treated with several pain relief treatments. For end-stage arthritis, two operative methods named ankle arthrodesis and ankle arthroplasty are widely used all around the world. 1 A variety of literature draws a comparison between arthroplasty and arthrodesis. 2,3 This literature reported high functional outcomes of ankle arthroplasty than arthrodesis. Contrarily, ankle arthroplasty reported a high rate of postoperative complications. Although the high popularity of ankle arthroplasty was reported in many regions, still a variety of literature described arthrodesis as a common treatment for last-stage ankle deformity. 4,5 Several operative techniques of ankle arthrodesis are present including open or arthroscopic approaches. Both approaches have successful clinical outcomes but variation and contradiction can be seen in different studies. These variations occurred due to surgeon skill, sample size selection, and outcome measurements. 6 Researchers suggest that ankle arthrodesis should be performed for young, highly active, and severe cases of ankle deformity. 7,8 For ankle arthrodesis, intramedullary fixation was first proposed by Adams in 1948 and first inaugurated by Carrier in 1991 in severe cases of rheumatoid arthritis using Steinmann pins. For the treatment of post-traumatic arthritis, retrograde nailing was used by Kile and Moore. 9 This method was first introduced by the senior author (DP) for tibiotalocalcaneal arthrodesis in the posterior-to anterior (PA) plane to gain rotational stability and bony purchase. 10 This study was designed to evaluate the efficacy of ankle arthrodesis by using Retrograde SIGN Nail. MATERIALS AND METHODS This retrospective cohort study was conducted in Department of Orthopaedic and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore within 2 years follow-up. A total of 30 patients were enrolled for arthrodesis by using retrograde nails. Clinical and radiological examination confirmed the severe arthritis of the subtalar joints in all cases. All the cases of ankle arthrodesis which were treated by internal fixation were included. Those who filled the written consent were also included. On the other hand, all the patients with multiple ankle injuries and suffering from Charcot neuroarthropathy were excluded. A local anesthetic agent via injections was used to evaluate the subtalar joint pain. For surgical preperations, we used radiographs to excess the joint destruction. ----------------------------------------------------------------------------------------- Received on 14-06-2021 Accepted on 25-11-2021 After clinical examination of patients, the standard operative method was decided for all patients. The surgery was performed under general anaesthesia. Patient was placed in spine position on the table with a large bump under the ipsilateral hip which provide help in rotation of operative table. Surgical procedure was initiated by using lateral incision fibula segment of 1.5cm was excised 6-8 cm proximal to the fibula tip and the portion was placed on the back table for further use as an autogenous bone graft. At this stage, we easily saw the lateral aspect of the tibiotalar joint. To expose the medial gutter, approximately 2-3 cm incision was carefully made at medial to the tibialis anterior tendon without indulging saphenous nerve and vein. After the exposure of medial gutter osteotomy was made anterior to posterior extending 1-2mm beyond the subchondral plate. When performing the flat tibial cut we assured that the position of the saw blade in the left side of the medial gutter protects the medial malleolus from any damage. This procedure was further extending across the entire distal tibia. Afterward, tibial osteotomy was made from lateral to medial. We performed talar osteotomy just inferior to the subchondral plate. During the whole process, we assured that the foot was dorsiflexed to a neutral position for parallel alignment of the sagittal saw blade with tibial osteotomy. Stab incision was given on plantar surface of foot for calcaneum entry point of nail which is identified under image guidance. Entry and reaming was done thru the calcaneum, calcaneotalar joint, talus, talotibial surfaces (previously prepared) and tibia. Appropriate size nail was inserted, tibiotalar surfaces compressed and bone graft placed. In the end, proximal/distal locking screws were placed. After surgery clinical examination was conducted for two years in which we monitored the patient satisfaction and foot alignment. To access the functional limitations, we used the foot and ankle ability score (FAAM) questionnaire with a maximum of 84 points. Higher scores present better function. Statistical analysis was performed by using SPSS 23.0. For comparison student t-test was used. For analyzing categorical variables we used the student test and Pearson correlation for comparison. All P values were two-sided and the significance level was defined as P < 0.05. RESULTS The mean age of 38.33±17.4 with 18 (60%) were males and 12 (40%) were females. The average BMI was reported as 24.06±2.93. The majority of the patients had normal weight. No cases of obesity were found. Regarding the side of injury, we reported 20 (66.6%) cases of right side injury whereas 10 (33.33%)