Tibiotalocalcaneal arthrodesis in osteoarthritis deformation of ankle and subtalar joint – evaluation of treatment results

Background Tibiotalocalcaneal arthrodesis (TTCA) is an increasingly used method of stiffening the ankle and subtalar joints in advanced degenerative deformities. The study group consisted of 19 men who were subjected to intramedullary and intra-osseous arthrodesis using an intramedullary nail. The average age of patients was 46 years (19–68). The main indication for surgical treatment was post-traumatic arthrosis 11 (58%). In the studied group of patients, clinical condition was assessed using the AOFAS classification, quality of life using the SF-12 scale, and assessment of pain intensity using the VAS scale. The above parameters were evaluated before surgery in the early (under 2 years), intermediate (from 2–5 years) and late (over 5 years) postoperative period. Analysis of the results showed that the assessed clinical condition on the AOFAS scale improved from an average of 20.6 points before TTCA to 63.5 points after the procedure. The result was statistically significant (p < 0.0001). Analyzing the results obtained using the SF-12 quality of life scale, a statistically significant increase was found. In the physical sphere of quality of life PCS-12 increased from 26.5 points to 44.2 points (p = 0.0004) and in the mental sphere of quality of life MCS-12 from 46.1 points to 52.6 points (p = 0.030). The intensity of pain ailments, assessed in the VAS scale, decreased in all three periods of postoperative observation (in the early period p < 0.05, in the intermediate period p = 0.23, and in the late period p < 0.05), with the strongest analgesic effect (reduction of pain intensity by 4.3 points on the VAS scale) was observed in the early post-operative follow-up period.


Introduction
Tibiotalocalcaneal arthrodesis -TTCA is an increasingly used method of stiffening the ankle and subtalar joints, which dates back to the 19th century [1,2]. Correction of the deformation of the distal end of the tibia due to repeated surgery, avascular necrosis of the talus, rheumatoid arthritis (RA) and ankle arthroplasty failure remain a major challenge for the surgeon [3]. According to literature data, this problem may affect up to 25% of patients after surgery, for whom retrograde intramedullary nailing is one of the most beneficial solutions [3,4].
Pseudarthrosis resection at the distal end of the tibia using TTCA and the use of autogenous or allogenic spongy bone determines restoration of the limb support function. Obtaining bone union at the distal end of the tibia enables patients to move independently, thus allowing to dispense with the wheelchair. The most common complications of TTCA include: shortening of the operated limb, persistent infection of the surgical wound (SSI -surgical side infection), lack of bone union and further persistence of pain in the operated area [4,5]. Apart from the surgeon's skills, the independent factors of success of the applied method of surgical treatment include: reduced bone density due to osteoporosis and additional accompanying diseases such as diabetes, rheumatiod arthritis -RA, atherosclerosis and atherosclerosis obliterans (AO), causing impaired limb blood supply [6].
Properly performed tibiotalocalcaneal arthrodesis with radiologically confirmed synostosis does not always correlate with the improvement of the patient's quality of life, because the accompanying mobility disorders combined with anxiety about the further course of the disease significantly affect the quality of life of these patients in many aspects. The disease, especially chronic and progressive, affects the functioning of the sick person not only in the area of the disease and the therapeutic process, but also in terms of functioning in the patient's near and distant social environment. Therefore, in the treatment process, apart from achieving medical goals, an important role is played by improving the patient's quality of life. This is especially important in degenerative-inflammatory diseases. For a sick or disabled person, it is very often important to maintain the possibility of an active, independent life. Chronic diseases, including degenerative ones, affect the deterioration of the patient's functioning not only in the biological, but also in social, emotional, professional and spiritual aspect [7,8].

Aim Of The Study
The aim of the study was pre-and postoperative clinical evaluation in men with advanced osteoarthritis deformities of the ankle and subtalar joints treated with tibiotalocalcaneal arthrodesis using an intramedullary nail.

Material And Methods
In In the examined group TTCA procedures were performed on the right side in 11 patients and on the left side in 8 patients. ChM titanium reverse tibia nails 200, 220, 230, 240 and 260 mm long and 10-11 mm in diameter were used in all patients. Screws 30, 50, 65 and 70 mm long were used for locking the nails, placed in the proximal and distal section in the frontal and sagittal plane. In 5 (26%) patients, in addition to bones from the Tissue Bank, due to inflammation of the operated area, STIMULAN preparation containing antibiotics (vancomycin and gentamycin) was used.
The examination was conducted in accordance with the Declaration of Helsinki (1964) and its protocol was approved by the Local Bioethical Commission of the Medical University of Silesia in Katowice, Poland. All qualified patients signed a written consent for participation in this study.

Assessment Of The Clinical Condition Of Patients
In all operated patients, the functional state of the ankle joint was assessed using the AOFAS (The American Orthopedic Foot and Ankle Score), quality of life was assessed using the SF-12 scale

Statistical analysis
Statistical analysis of the obtained results was carried out using the Statistica v10 PL program.
Statistical significance of differences between values of parameters, assessed before surgery and in individual periods of observation after procedure, was assessed using the Student's T test for dependent variables, after checking the assumptions about the normality of distributions using the Kolmogorov-Smirnov test. Differences for p < 0.05 were considered statistically significant.

Results
The assessment of the functional state of the ankle joint, according to the AOFAS classification, was  Table 1). Table 1 Comparison of the quantitative assessment of the functional state of the operated ankle joint (the number of points according to the AOFAS classification) in the studied group of patients before and after the pantalar arthrodesis using an intramedullary nail, in individual groups of patients with different postoperative observation periods. In the examined group of patients, 16 (84.2%) patients before the surgery used a wheelchair or two elbow crutches. This was due to the lack of limb supporting function (Table 2). Table 2 Comparison of the qualitative assessment of the functional state of the operated ankle joint according to AOFAS classification in the examined group of patients before and after the pantalar arthrodesis procedure with intramedullary nail.  (Table 4). Table 3 Comparison of the quality of life in the physical sphere (number of points on the PCS-12 scale) assessed using the SF-12 quality of life scale in the examined group of patients before and after the tibiotalocalcaneal arthrodesis using an intramedullary nail, in individual groups of patients with different postoperative observation periods.  Table 4 Comparison of the quality of life of the psychic sphere (number of points on the MCS-12 scale) assessed using the SF-12 quality of life scale in the examined group of patients before and after tibiocalcaneal arthrodesis using an intramedullary nail. Period of follow-up < 2 years no. In the whole group of examined patients, the intensity of pain ailments on the VAS scale decreased statistically significantly from 6.7 points before surgery up to 3.6 points after TTCA (p < 0.05). The largest, statistically significant, decrease in the intensity of felt pain compared to baseline was found in the early observation period (under 2 years) after the procedure -from 7.3 points before surgery up to 3.0 points after TTCA (p < 0.05), reduction of pain intensity in the late observation period (over 5 years after surgery) was also statistically significant and amounted to 2.5 points on the VAS scale, while in the intermediate observation period (2-5 years after the procedure) the decrease in pain intensity was 2.6 points, but it did not show statistical significance (Table 5).  chronic swelling of the foot persisting for more than 6 months in 2 (10.5%) patients. In 5 (26.3%) patients it was necessary to continue the administration of analgesics, and 1 (5.3%) operated patient did not feel any improvement in pain intensity after the procedure (Table 6).  (Table 7). Table 7 Comparison of the distance that can be covered by the patients themselves, before and after tibiotalocalcaneal arthrodesis using an intramedullary nail. 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].

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The author's declare that there is no conflict of interests regarding the publication of this paper.

Funding
Not applicable.

Authors' contributions
TS -study design, data collection, data interpretation, manuscript preparation BD -study design, data collection, data interpretation, manuscript preparation JP -study design, data collection, data interpretation, manuscript preparation, literature search