Tibiotalocalcaneal arthrodesis: anatomic and technical considerations

Area of Science:

• Orthopedic surgery
• Biomechanics
• Anatomy

Background:

• Antegrade tibial nailing is a common procedure for tibial fractures.
• The standard antegrade approach carries risks to vital plantar and medial foot structures.
• Cadaveric studies are essential for anatomical risk assessment in surgical procedures.

Purpose of the Study:

• To evaluate the anatomical risks associated with standard antegrade tibial nailing.
• To investigate an alternative surgical technique to mitigate these risks.
• To assess the biomechanical stability of the modified approach.

Main Methods:

• Part 1: Antegrade tibial nailing in eight cadaver specimens, followed by dissection to identify structures at risk.
• Part 2: Modified antegrade nailing with medial malleolar resection and talar displacement in eight cadaver specimens, followed by dissection and radiographic analysis.
• Assessment of distances to neurovascular structures and bone-to-implant interface.

Main Results:

• Standard antegrade nailing placed the lateral plantar artery and nerve at risk (0 mm), damaging surrounding tissues and tendons.
• The exit point was consistently the sustentaculum tali, compromising stability and locking.
• The modified technique (malleolar resection, talar displacement) increased the distance to the neurovascular bundle to an average of 18.4 mm, preventing damage and ensuring robust bony contact.

Conclusions:

• Standard antegrade tibial nailing poses significant risks to plantar neurovascular structures and offers suboptimal fixation.
• Medial malleolar resection and medial talar displacement represent a safer and more stable alternative for antegrade tibial nailing.
• This modified approach enhances fixation rigidity and reduces the risk of iatrogenic injury.