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Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Retrograde nailing, trabecular metal implant and use of bone marrow

aspirate concentrate after failed ankle joint replacement
Mads Sundeta,* , Elena Johnsenb , Kari Helene Eikvarc, Marianne Lund Eriksena
a
Consultant Foot and Ankle Surgeon, Diakonhjemmet Hospital, Oslo, Norway
b
Consultant Radiologist, Diakonhjemmet Hospital, Oslo, Norway
c
Department of Professional Affairs,The Norwegian Medical Association, Oslo, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Background: Ankle fusion after removal of alloplasty is known to be a procedure with a high potential for
Received 10 October 2019 non-unions and poor function, especially tibio-talo-calcaneal fusion. We wanted to review our results
Received in revised form 4 March 2020 after using a novel method for the procedure, combining retrograde nailing with a trabecular metal
Accepted 6 March 2020
implant and bone marrow aspirate concentration applied in an ostoconductive pad in addition to
Available online xxx
autologous bone grafting.
Materials and methods: Retrospective review of a patient series, with some prospectively registered data.
Keywords:
31 ankles in 30 patients were operated from January 2016 to February 2019.
Ankle alloplasty
Ankle arthrodesis
Results: There were two non-unions (6.5%), and one delayed union, none of these were reoperated. The
Revision alloplasty mean postoperative Manchester-Oxford Foot and Ankle Questionnaire score (MOxFQ) was 33.6 points. 9
Retrograde nailing patients scored an average MOxFQ at 72.9 immediately before surgery, while at follow-up this had
Bone marrow aspiration concentrate decreased to 36.2, an improvement of 36.7 points (95% CI 18.3–54.9). There were 1 minor infection and 5
possible nerve injuries. One patient had the leg amputated 1 year after the surgery due to a non-related
necrotizing fasciitis.
Conclusion: We present reasonably good short to medium term patient satisfaction and fusion rates with
this novel combination of techniques.
© 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Ankle fusion is a salvage procedure after failed ankle joint
replacement, the other alternatives being revision arthroplasty or
in rare cases amputation. It has a fairly high complication rate with
a primary union rate reported at 83% in a metaanalysis [1]. With
bone loss or poor bone stock in the talus, it is often necessary to do
a tibio-talo-calcaneal fusion, and this has an even lower primary
union rate according to the same metaanalysis, at 65% [1]. A recent
Dutch retrospective study had a primary fusion rate of 57%, in this
study they were utilizing different methods of fixation [2].
The use of trabecular metal implants with the tibio-talo-
calcaneal fusion has been reported in 13 patients by Henricson and
Rydholm [3], with no obvious non-unions and fairly satisfied
patients, while Aubret and co-workers found less favorable results
in 10 patients, where only 5 patients healed in both joints [4]. Apart
* Corresponding author.
E-mail addresses: mads.sundet@icloud.com (M. Sundet),
elenajohnsen@gmail.com (E. Johnsen), Kari.Eikvar@legeforeningen.no
(K.H. Eikvar), Marianne.Eriksen@diakonsyk.no (M.L. Eriksen).
from these two studies, there are only few case reports with less
than 3 patients published [5–7].
In this study we have utilized a method similar to that described
by Henricson and Rydholm with retrograde nailing and trabecular
metal, but we also augmented it with a modern biological
treatment modality involving bone marrow concentrate and an
osteoconductive pad.
Trabecular metal (Zimmer/Biomet, Warsaw, USA) has been
used widely in orthopedic surgery the last decade, mostly in knee
and hip revision surgery, but also in foot and ankle surgery [8]. It is
made of the metal tantalum and has a pore structure similar to
cancellous bone, and the porosity and elasticity of the implant
provides a good potential for ingrowth of bony tissues.
Bone marrow aspirate concentrate contains different cell types,
such as stem cells and other progenitor cells. It also contains bone
morphogenetic proteins and growth factors that are vital for bone
healing, and both animal and human studies have shown
promising results for achieving bony healing [9,10].
Our department is the main ankle alloplasty center for Norway,
and we treat patients from all over the country. We also treat failed
ankle alloplasties from the other hospitals in Norway that until
recently has been doing alloplasties. This has led to a quite high

https://doi.org/10.1016/j.fas.2020.03.003
1268-7731/© 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: M. Sundet, et al., Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate
after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
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2 M. Sundet et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx

volume of revisions. In the years 2012–2016 we managed most of
these by doing revision alloplasty, with quite satisfying results. In
2016, however, our revision alloplasty was taken off the market
and we had to look for other alternatives. We then started doing
retrograde nailing with autogenous bone graft with or without a
tantalum cage for most of the patients, and anterior plating with
allogenous or autogenous bone graft when it was possible to keep
the subtalar joint. We then experienced several non-unions, and
decided to try to improve the method by adding autogenous bone
marrow aspirate concentrate. This study is a retrospective review
of the patients operated with this latter procedure.
2. Materials and methods
2.1. Study design
This was a retrospective study. Because some of the patients
were enrolled in a prospective study of our own ankle alloplasties,
we also had some prospectively recorded data on 9 patients.
Patients were identified by going through the operation logbook.
Permission was obtained from our internal scientific review board
and from our data protection officer. Due to the retrospective,
quality control nature of the study, a formal application to the
regional ethics committee was not necessary according to
Norwegian health research regulations. All patients provided a
signed consent to participate in the study. Patient files and
available radiology were reviewed, and all patients were inter-
viewed by phone by one of the authors, and they received and
returned PROM questionnaires by mail. Patients with less
favorable results were called back to the outpatient department
for a new clinical and radiological review. Most of the patients lived
far away, and were not called in for a clinical examination if they
were fairly satisfied. All patients who had bothersome symptoms
were offered an appointment for a clinical examination. We had
the ethical permission only to do a quality control study, and
radiological investigations were only done on clinical indications.

Fig. 1. Preoperative and 6 months post-operative X-rays of healed fusion. A TTC fusion was chosen because a preoperative CT showed cysts and osteoarthritis of the subtalar
joint.

Please cite this article in press as: M. Sundet, et al., Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate
after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
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M. Sundet et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx 3

All X-rays were reviewed by an experienced radiologist (ES) and
by two experienced surgeons (MS, MLE). Trabecular bone
formation across the arthrodesis was defined as satisfactory
radiological union. In 7 patients, plain X-rays were inconclusive or
the patients had unexplainable symptoms, and a CT scan was
performed.
Analysis was done using STATA SE 15.0 (College station, TX).
2.2. Outcome measures
All patients had a Norwegian translation of the Manchester-
Oxford Foot and Ankle Questionnaire (MOxFQ) sent by mail. This is a
16-question inventory, with a 5-point Likert score on each question.
It was originally intended to be divided into 3 subdomains, walking/
standing, pain, and social interaction, but the developers have also
validated the use of a single summary score for all 16 items [11],
where 100 is the worst possible score, and 0 is the best possible. We
also used the self-administered patient satisfaction scale (SAPS) to
assess the satisfaction of the patients [12].
2.3. Patients
31 ankles in 30 patients were operated with this method by
three experienced foot- and ankle surgeons (KE, MLE, MS) between
January 2016 and February 2019 at our institution. The indication
for surgery was failed ankle alloplasty, where an isolated tibiotalar
fusion was seen as no alternative by the surgeon, due to inadequate
bone stock in the talus or osteoarthritis or other pathology in the
subtalar joint. 21 of the patients had their primary alloplasty done
at our institution, while 9 patients had primary alloplasties from
other hospitals.
In the same time period we did no revision alloplasties, due to
unavailability of our previously used implant. Several isolated
tibiotalar fusions with anterior plates were done when we found
adequate bone stock in the talus and preserved subtalar motion,
these are not included in the study.
The patients were informed that this was a salvage procedure
that would lead to a stiff foot with gait abnormalities, and that pain
relief was the main objective. Most patients were also informed

Fig. 2. Preoperative and 12 months post-operative X-rays of patient with non-union, confirmed by CT.

Please cite this article in press as: M. Sundet, et al., Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate
after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
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that below-knee amputation was a possible alternative to this
procedure.
None were lost to follow-up, but one patient did not return the
MOxFQ questionnaire. There were 11 men and 19 women, mean
age was 56.1 years. Mean time from initial ankle replacement was
77.5 months (SD 61), and the initial indications for alloplasty were
post-traumatic arthritis in 19 patients, inflammatory arthritis in 11
patients and primary osteoarthritis in 1 patient. The removed
alloplasties were 17 STAR, 3 Mobility, 1 Rebalance, 1 STAR revision
alloplasty and 8 Salto Talaris, 1 of them with a Salto XT tibia
revision component. Including arthroscopies and fracture surgery,
the patients had a median of 3 previous operations on their ankle
(range 1–6, means 3.3).
The causes of revisions were aseptic loosening in 16 cases, pain
in 7 cases, cysts in 7 cases and 1 case was a second stage revision of
an hematogenously infected implant.
2.4. Surgical technique and follow-up
The one infected alloplasty was treated with a two-stage
procedure with cement spacer after alloplasty removal, the others
were one-stage procedures. The prosthesis was removed through
the original surgical approach, which was the standard anterior
approach in all cases. Bone marrow was aspirated from the iliac
crest using the Biocue system (Zimmer Biomet, Warsaw, IN, USA).
After that, autologous bone was harvested from the inside of the
iliac crest with curved chisels. Approximately 55 ml of bone
marrow aspirate was then centrifuged for 15 min, the plasma and
red blood cells were removed and 6 ml of concentrated cells was
applied to a Collapat II pad, which is a haemostatic bone substitute
biomaterial (Symatese, Chaponost, France). Joint surfaces of the
subtalar joint were removed through a separate sinus tarsi
incision, and the bony surfaces of the cavity after alloplasty
removal were debrided and drilled down to bleeding, subchondral
bone tissue. After this, a tantalum cage trial implant (Zimmer-
Biomet, Warsaw, IN, USA) was fitted into the cavity, and the
guidewire for a retrograde ankle fusion nail (T2 ankle arthrodesis
nail, Stryker, Kalamazoo, MI, USA) was placed under fluoroscopic
guidance, aiming to obtain a plantigrade foot with a slight valgus
and outward rotation. The Collapat II pads were soaked in bone
marrow concentrate, and then placed on the inner and outer
surface of the tantalum cage, together with autogenous bone. This
Fig. 3. Manchester-Oxford score (MOxFQ) of individual patients, ordered by increasing values. Preoperative values are indicated for 9 patients.
Please cite this article in press as: M. Sundet, et al., Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate
after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
was then placed in the cavity after alloplasty removal. In the early
phase we had different heights of the implant to choose from
depending on the present gap. In the later part of the study, we had
only 15 mm implants available, due to changes in the product line
of the producer. After introduction of the nail, the distal locking
screws of the nail were inserted, but the screw designated for the
talus was mostly not possible to utilize because of the cage, which
also prevented us to use the internal compression mode of the nail.
X-rays from a typical case are shown in Fig. 1.
All patients had a postoperative slab for 3 days, then a circular
cast for 6 weeks and a Walker boot for the next 6 weeks. They were
allowed 10–15 kg of weight bearing the first 6 weeks, then a
gradual increase until 12 weeks.
3. Results
Mean follow-up time from surgery to the telephone interview
was 23 months (range 6–46). The mean time from surgery to the
latest available radiological examination was 10.9 months (range
3–34 months, median 11 months).
In two patients (6.5%) there were clear signs of non-union, one
of them involving the subtalar joint and the other one both
interphases of the tantalum cage (Fig. 2). To date, they have not
been reoperated, despite a poor clinical outcome (patients are
identified with yellow bars in Fig. 3). Another patient had delayed
subtalar union, with clinical and radiological signs of a subtalar
non-union after 6 months, but it healed spontaneously before 1
year. The mean postoperative Manchester-Oxford Foot and Ankle
Questionnaire score (MOxFQ) was 33.6 points. There were no
significant differences in MOxFQ between men and women, or
between inflammatory or post-traumatic arthritis. 9 patients
scored an average MOxFQ at 72.9 immediately before surgery,
while at follow-up this had decreased to 36.2, an improvement of
36.7 points (95% confidence interval 18.3–54.9). Fig. 3 shows the
MOxFQ scores of individual patients, including the preoperative
scores for 9 patients, the scores for the two non-unions are shown
with yellow bars. Table 1 shows the results from the self-
administered patient satisfaction scale for the patients.
There was one superficial infection treated only with antibiotics
and one stress fracture above the nail that was treated
conservatively. 1 patient had a complex regional pain syndrome
that resolved within one year, 2 patients had most likely an injury
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Table 1
Self-administered patient satisfaction scale.
How satisfied are you with the results of your surgery?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with the results of your surgery for improving your pain?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with the results of surgery for improving your ability to do home or yard work?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
How satisfied are you with the results of surgery for improving your ability to do recreational activities?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
to the medial plantar nerve or the tibial nerve, and 2 patients
reported worsening of nerve symptoms that most likely were
present before the surgery.
After this study was completed, but before submission of the
paper, we were informed that one of the patients had her operated
leg amputated because of necrotizing fasciitis one year after
surgery. This was triggered by a minor paronychia after cutting her
toenail, and according to the surgeon who treated her at another
hospital, the infection and amputation was unrelated to the
previous fusion surgery. Because this complication happened after
the data collection was completed, her results before amputation
are still included in the analysis. 2 patients needed removal of the
proximal locking screws.
4. Discussion
Fusion after removal of ankle alloplasty is difficult and the
outcome is rather poor for many patients, and the procedure
should be prevented whenever possible. The median number of
surgeries before this procedure in our patients was 3, and this truly
is a salvage procedure.
We have however achieved reasonably good short to medium
term fusion rates, complication rates and patient-reported
outcome with this method of tibio-talo-calcaneal fusion after
removal of ankle alloplasty. These results play into the larger
debate of how to manage the failed ankle arthroplasty. Revision
arthroplasty is a standard technique, but there are not many
results published about the outcome of this procedure, except
for Dr. Hintermann's good results in 113 cases published in 2013
[13]. The Swedish ankle registry has presented poor results after
revision ankle alloplasty, with a 5-year survival rate of 76% and a
10-year survival of 55% [14]. The patient satisfaction and
functional outcomes in that study were comparable to the
outcomes after salvage arthrodesis in the same registry [15].
They concluded that until further evidence of the benefit of
revision alloplasty over fusion was available, they would favor
salvage fusion over revision alloplasty. This study adds support
to this conclusion, demonstrating the feasibility of salvage
fusion even in the most difficult patients demanding a tibio-
talo-calcaneal fusion.
Please cite this article in press as: M. Sundet, et al., Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate
after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
5
%
17 54.8
13 41.9
1 3.2
0 0
%
19 61.3
11 35.5
1 3.2
0 0
%
23 74.2
7 22.6
1 3.2
0 0
%
18 58.1
12 38.7
1 3.2
0 0
The previously published reports of using hindfoot nailing in
combination with a trabecular metal cage have shown very
different results, with our results being quite similar to the results
of the patient series of 13 patients published by Henricson in 2010
[3]. Aubret and co-workers had less favorable results in 9 patients,
and they found 4 subtalar non-unions and 2 doubtful tibiotalar
fusions in the 9 patients, and rather low patient satisfaction with
an average AOFAS score of 56. The radiological criteria for healing
were more strict in that study, with CT-scanning on all patients,
which might explain some of the difference in outcome.
What makes our operative technique different from the studies
above is the use of bone marrow concentrate added to an
osteoinductive pad. This is an expensive addition to the procedure,
and it is not well proven in clinical trials. Our 93.5% union rate in
this study might indicate that this extra cost is justified, but it is not
possible to prove this by this study design.
It is a bit surprising that subtalar non-union seems to be as big a
problem as tibiotalar non-union, both in our and in Aubret's study.
In other clinical settings, non-union surgery in the subtalar joint is
not very problematic, but in these patients it would be necessary to
remove the nail to do a re-fusion, something that both patients and
surgeons are very reluctant to do, reflected in the fact that none of
the 2 non-unions has been reoperated, despite poor clinical
outcome in those patients. The remedy for this problem might be
an increased attention to the subtalar joint while doing the surgery.
Bone grafting should be done also in the subtalar joint if necessary,
and perhaps a bone marrow aspirate/osteoconductive pad is just as
helpful in the subtalar joint as in the tibiotalar joint.
The most frequent complication was nerve injuries, which was
reported by 5 patients. As the follow-up was mainly by telephone,
we were not able to characterize these injuries further, and 2 of
these injuries were most likely pre-existing, as those patients had
multiple surgeries from before. Nerve injuries are a serious
concern for this patient group, and these patients are at high risk
because of long tourniquet times and changed anatomy due to
multiple previous surgery. As a result we now try to keep
tourniquet time below 1 h, doing a large part of the procedure
without tourniquet.
The weakness of the study is it's retrospective nature, and it's
relatively short follow-up. Due to practical and logistical issues, we
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did not clinically examine all the patients at the time of data
collection, and information about deformities after surgery, pain
distribution, nerve function, and patient gait is lacking. We have
not performed CT scans of all patients, and some non-unions might
be undetected. It is also possible that with time, new complications
will occur, and functional scores might deteriorate.
5. Conclusion
We observe reasonably good fusion rates and patient satisfac-
tion after a novel combination of methods for achieving salvage
fusion after failed ankle arthroplasty. The study indicates that
tibio-talo-calcaneal fusion might be a feasible alternative to
revision alloplasty, but more research is needed to determine
the proper handling of the failed ankle alloplasty.
Conflict of interest
We hereby declare that none of the authors has received
funding, grants, or in-kind support in support of the research or the
preparation of the manuscript.
None of the authors have associations or financial involvement
(i.e. consultancies/advisory board, stock ownerships/options,
equity interest, patents received or pending, royalties/honorary)
with any organizations or commercial entities having a financial
interest in or financial conflict with the subject matter or research
presented in the manuscript.
Acknowledgements
No funding has been received for this study. We would like to
thank Victoria Puchkova Kleive for invaluable technical support
during the project.
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after failed ankle joint replacement, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.03.003
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