Extensive degenerative deformations in ankle and subtalar joints caused by: traumatic injuries, failures after ankle joint replacement and avascular necrosis require surgical treatment characterized by ease of implementation, minimal invasiveness, low number of complications and a chance to restore the supportive function of the limb. Intramedullary tibiotalocalcaneal arthrodesis meets all of the above-mentioned criteria [9–11].
The analysis of the functional state of the ankle joint in the group of examined patients was based on the AOFAS classification, before and after intramedullary nail arthrodesis. Follow-up observation of patients was divided into three periods: under 2 years, 2–5 years and over 5 years after surgery. The functional state of the operated joint in examined patients during the observation period under 2 years significantly improved, expressed in the increase in the average number of points on the AOFAS scale from 24.5 to 68.0 (p < 0.05). During the observation period of 2 to 5 years after surgery, the functional condition of the operated joint deteriorated slightly, and the average number of obtained points was 56.0. However, in the late observation period over 5 years after surgery, the functional condition of the operated joint was comparable to the early observation period, and the average number of points on the AOFAS scale in this period was 63.3. Only 4 (21.1%) of the operated patients after the TTCA procedure walked with one crutch. However, almost 80% of operated patients moved without the orthopedic equipment and were able to cover a distance of over 600 meters on their own.
Lee et al., in a group of 20 patients after performing tibiotalocalcaneal arthrodesis, obtained an improvement in the functional state of the ankle joint according to the AOFAS classification from an average of 54 to 76 points in the observation period of 28 months [10]. Whereas Ozer et al. using tibiotalocalcaneal arthrodesis with the AO method (proximal humerus) in a group of 8 patients obtained the functional state of this joint at an average level of 60 points in the AOFAS classification over an average follow-up of 2.5 years [5]. The authors of this work suggest that performing arthrodesis with a proximal brachial plate may be an alternative to intramedullary arthrodesis.
Muckley et al. evaluated, according to the AOFAS classification, a group of 55 patients who had 59 tibiotalocalcaneal arthrodesis using an intramedullary nail, obtaining 66.4 points during the follow-up period of 66 months [12]. The results of the assessment of the functional state of the ankle joint obtained in our study are comparable to this report.
In turn, Brodsky et al. in the material of 30 detachable stiffeners using an intramedullary nail obtained, in the average observation period over 2 years, a statistically significant increase according to the AOFAS classification with an average of 29.7 points up to 74.3 points. Such significant clinical improvement in the examined group of patients may result from proper correction of joint deformation conducted parallel to arthrodesis [11].
TTCA in combination with arthroscopic resection of damaged articular surfaces of the ankle and subtalar joints carries a lower number of septic complications [13]. In the available literature we can find examples of papers confirming the occurrence of a lower SSI frequency when TTCA is performed under arthroscopic control [9, 13]. On the other hand, arthrodesis performed under arthroscopic control is associated with a greater likelihood of lack of bone union.
Baumbach et al., comparing the results of arthroscopic arthrodesis performed by the open method in high-risk patients (patients with diabetes, limb ischemia and RA), showed that the frequency of achieving normal bone union of 75% and 67%, respectively, did not differ statistically significantly in both groups of patients. The incidence of complications in the group of patients treated with the open method was 63%, mainly infections of the operated area (80%), while in patients treated by the arthroscopic method, the incidence of complications was almost half lower (33%) and in all cases it was the lack of bone union [13]. Hence, the choice of arthroscopic arthrodesis should be considered in cases of slight deformation, where it is enough to perform a resection of the damaged surface of articular cartilage without the need for extensive correction.
In the group of examined patients, who had tibiocalcaneal arthrodesis using an intramedullary nail, complete bone union was found in 16 (84%) patients. 18 (94.7%) procedures were performed using the open method, while using arthroscope 1 (5.3%). Shah et.al., in the mean follow-up period of 9 months, achieved full bone union in more than 80% of operated patients who had tibiotalocalcaneal arthrodesis using an intramedullary nail with additional fibular transplantation [6]. In turn, Ozer et al., performing the TTCA procedure using the AO method with the proximal humeral locking plate achieved bone union in 7 (87.5%) operated patients, 87% of the examined group were women [5]. Peterson et al., using the anatomical locking plate technique from the posterior access to obtain tibiotalocalcaneal arthrodesis, diagnosed lack of bone union in 22% of operated patients in the short term of observation [9]. However, Nikhil et al., in surgical treatment of severe stiff club foot with the use of an intramedullary nail, obtained bone union in all operated patients [14].
Wukich et al. compared the incidence of bone union in 117 patients operated with a retrograde intramedullary nail and divided them into 2 groups: patients with diagnosed diabetes and without diabetes. In the group of patients with diabetes, the authors diagnosed lack of bone union in 10 (16.39%) operated patients, while in the control group without diabetes, lack of bone union occurred in 14 (25%) operated patients [15]. Based on the results obtained in the authors' assessment, properly managed diabetes (with HbA1c levels up to 6%) does not increase the incidence of bone union in patients operated on using the TTCA method.
Pellegrini et al. showed in their work significant advantages of posterior access in the form of better visualization of the ankle and subtalar joints, high incidence of bone union (80.4%) and the presence of potentially better conditions for healing the postoperative wound due to no interference in vascularization [16].
It is currently believed that the choice of posterior access to the ankle joint may have an impact on obtaining better results in surgical treatment, taking into account the extensive scars occurring after repeated treatment with lateral and medial access [3, 9]. In the present study, performing open surgery for resection of damaged joint surfaces: anterolateral in 13 (68%) patients, antero-medial in 4 (21%) patients and posterior in 1 (5%) patient, we did not show any advantage. During the checkup of the examined group of patients, 16 (84%) operated patients had a shortened length of the operated limb, on average 1.95 mm.
Quality of life was another analyzed parameter in the examined group of patients. Health Related Quality of Life (HRQoL) research is widely used in medical practice and clinical research. Living with a chronic disease is often associated with redefining patient's physical abilities. A significant problem of patients suffering from degenerative diseases are also emotional problems and depression, which affect both the physical and mental quality of life [8, 17, 18]. Comparing the quality of life before and after the TTCA, we observed a significant improvement in the quality of life in the operated patients, both in the physical sphere PCS-12 - with an average of 25.8 points up to 39.5 points and mental sphere MCS-12 - with an average of 48.7 points up to 54.1 points. The greatest improvement in the quality of life in operated patients in the physical sphere was noted in the late observation period (over 5 years), on the PCS-12 scale − 15.9 points, while in the psychological sphere in the intermediate observation period (from 2 to 5 years), on the MCS-12 scale − 10.6 points.
Brodsky et al. in the larger group of patients (30 patients) after the surgery, using SF-36 scale to assess the quality of life, observed its improvement with an average of 85.6 points up to 98.9 points [11]. Also Lee et al., using the SF-36 scale, found a significant improvement in the individual components of this classification [10].
Escudero et al. evaluated 10 patients during a follow-up period of at least one year after retrograde intramedullary nail fixation using allogeneic grafts at the site of extensive bone defects in the ankle and subtalar joints resulting from failures after ankle arthroplasty, using the SF-12 classification to assess quality of life, and obtained higher results compared to ours, both in terms of the PCS-12 component and the MCS-12 component [19].
Comparing the intensity of pain ailments in the examined group of patients before and after the TTCA, using the VAS scale, the greatest relief was observed in the early observation period (under 2 years) - with 7.3 points up to 3.0 points. In both later observation periods, the reduction in pain intensity had lower VAS scores. It seems that the reduction in the severity of pain may have been due to a change in biomechanics of the foot.
Lee et al., in a comparable group of patients who had tibiotalocalcaneal arthrodesis using an intramedullary nail during the observation period of 13–49 months, found a significant reduction in pain intensity on the VAS scale with an average of 7.41 ± 2.12 points up to 1.77 ± 2.77 [10].
In turn, Cabrera Mendez et al., in a group of 28 men with post-traumatic degenerative changes caused by gunshot injuries of the lower leg operated on with the use of a proximal shoulder plate for tibiotalocalcaneal arthrodesis, found a significant decrease in the intensity of pain, on average from 8.0 to 2.35 points on the VAS scale, over a minimum of 6 months follow-up [20].
By contrast, Brodsky et. al., in patients operated using pantalar arthrodesis using an intramedullary nail, observed a significant reduction of pain in the VAS scale before surgery from 6.5 to 1.3 in a follow-up period of over 2 years (26 months). Significant reduction in the intensity of pain in these patients was accompanied by recovery of the operated area.
Tibiotalocalcaneal arthrodesis often restores the supporting function of the limb, however, its implementation is associated with a relatively large number of complications. In the pre-operative assessment regarding qualification for this procedure, in addition to the degree of deformation, the following should be taken into account: the state of arterial and venous vascularization of the limb, the presence of additional diseases and the degree of their control (diabetes, rheumatoid, neurological and psychiatric diseases), previous infections of the operated area, and it is important to know the patient's expectations and combine them with the skills and experience of an orthopaedic surgeon.