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Failed Intramedullary Screw Fixation of a Proximal Fifth Metatarsal Fracture (Jones Fracture) in a Division I Athlete: A case report

Posted on June 1, 2009 | Comments Off on Failed Intramedullary Screw Fixation of a Proximal Fifth Metatarsal Fracture (Jones Fracture) in a Division I Athlete: A case report

by Dane K. Wukich, MD1 , Bora Rhim, DPM2, Dekarlos M. Dial, DPM3

The Foot and Ankle Online Journal 2 (6): 1

Intramedullary screw fixation of a Jones fracture is described in a basketball player (division I athlete). Early mobilization is the cornerstone to using intramedullary screw fixation in athletes. This case report describes the use of a smaller diameter screw to fixate a Jones fracture that failed. The authors have found that using a screw diameter similar to the diameter of the medullary canal may help to prevent screw failure.

Keywords: Intramedullary screw fixation, Jones fracture, screw failure.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0001

Jones fracture of the fifth metatarsal has been defined as an acute fracture occurring in the proximal portion of the fifth metatarsal base at the metaphyseal and diaphyseal junction in which the fracture can involve the 4th and 5th intermetatarsal joints. [1] Currently, there is no clear consensus on optimal treatment of acute Jones fractures in the athletic or the non-athletic population. There has been much debate in the treatment of proximal 5th metatarsal fractures since described by Sir Robert Jones in 1902. [2] The treatment of Jones fractures continues to remain controversial and challenging. [3]

Optimal screw selection for operative treatment in competitive athletes with 5th metatarsal Jones fracture has not been determined. Cannulated screw fixation has been a popular method of fixation and has gained wide acceptance. Due to increased failure rates in elite athletes from refracture, delayed union, and non union, Wright, et al., recommended using a larger solid screw in competitive athletes to counter the higher amount of torsional stress placed on the fracture site. [4] We present in this case report a Division I competitive basketball player who sustained a proximal 5th metatarsal fracture. His initial treatment involved open reduction and internal fixation (ORIF) with a small diameter intramedullary screw. The patient developed a nonunion and required autogenous bone grafting with larger diameter screw fixation. Selection of screw type and diameter deserves thorough consideration. The authors utilize large diameter solid screws that are compatible with the 5th metatarsal intramedullary canal diameter.

Case Report

A 21-year-old male collegiate basketball player presents with right foot pain. His symptoms began after jumping and landing awkwardly. He developed severe pain on the lateral border of his right foot. The pain is exacerbated with weightbearing and walking. The patient also reports a similar injury involving the right foot that resulted in a 5th metatarsal fracture 9 months prior.

The initial injury was treated operatively with intramedullary screw (4.0 mm cannulated) fixation. He is 6.9ft tall, weighs 113kg and in good health. The patient is not taking medications and denies any drug allergies. After the initial ORIF, he played in the 2004 – 2005 season. He reported intermittent pain of his right foot at the time.

The patient was evaluated after sustaining the second injury. He walked with an antalgic gait and had no deformity or atrophy.

The foot was tender to palpation at the base of the 5th metatarsal. Neurovascular status was intact with normal range of motion of his right foot and ankle.

Plain radiographs of the right foot revealed a nonunion of the proximal 5th metatarsal right foot. There was a 4.0 mm intramedullary cannulated screw within the 5th metatarsal. The screw was bent on both the anteroposterior and oblique radiographs. (Figs. 1A and B)

 

Figures 1A and 1B Anteroposterior and oblique radiographic views of the right foot demonstrating a bent 4.0 mm cannulated intramedullary screw. (A)  The oblique radiograph demonstrates the nonunion of left proximal 5th metatarsal fracture. (B)

The lateral preoperative views also show bending forces within the screw. (Fig. 2)

Figure 2  Pre-operative lateral radiograph right foot demonstrating nonunion of left 5th metatarsal Jones fracture and bending of the screw fixation.

A computed tomography (CT) scan was ordered and revealed a 50% incomplete union of a fifth metatarsal fracture consistent with nonunion. (Figs. 3A and B)

 

Figures 3A and 3B  CT scan of the right foot demonstrating non-union of right proximal 5th metatarsal (arrow).(A) Reformatted CT scan right foot demonstrating plantar lucency involving 50% of the proximal plantar cortex. (B)

The patient was then scheduled for hardware removal, bone grafting and screw exchange with a larger diameter intramedullary fixation screw. Before surgery, the patient was placed in a CAM walker with weight bearing to tolerance. In surgery, the 4.0mm cannulated intramedullary screw was identified and removed. The nonunion site was identified and curettaged. Autogenous bone graft was harvested from the ipsilateral calcaneus. A larger diameter 6.5 mm screw was placed in the intramedullary canal to achieve appropriate stabilization. He was placed in a compressive dressing immediately postoperatively and transferred into a below-the-knee fiberglass cast on the fifth post-operative day. Clinical union was achieved at 6-weeks and the patient was then asymptomatic. He was advanced to protected weight bearing in a CAM walker. (Figs. 4A and B)

 

Figure 4A and 4B  Post-operative anteroposterior radiograph left foot demonstrating radiographic union after revisional surgery with a 6.5 mm solid screw. (A)  Post-operative lateral radiograph demonstrating complete radiographic union using a 6.5mm solid screw along the plantar cortex with good alignment. (B)

At this time, stationary biking exercises were permitted. At 3-month follow-up, complete radiographic consolidation was noted at the fracture site. A CT scan was ordered and demonstrated complete radiographic healing of the fracture at 5 months. (Figs. 5A and B) The patient was permitted to return to competitive sports at 6 month follow-up.

 

Figure 5A and 5B  Post operative CT scan demonstrating stable 6.5 mm solid screw fixation with complete fracture union right 5th proximal metatarsal. (A)  Post operative reformatted sagittal CT scan. Note the stable fixation and complete fracture union. (B)

Discussion

The type of screw fixation in the treatment of Jones fractures is controversial. Many surgeons support intramedullary screw fixation for Jones Fractures. [1,5,6,7,8,9] Kelly, et al., found that a 6.5 mm screw was superior to a 5.0 mm screw with respect to both pullout strength (in medullary canals greater than 5mm) and cantilever bending forces. [6] Excessive repetitive cantilever forces applied to a suboptimal smaller diameter screw may result in bending and ultimately screw failure resulting delayed or nonunion. For this reason, utilizing a large diameter screw in the larger athletic patient population has been advocated. [4,9,10] Vertullo, et al., encouraged utilizing an internal fixation device with the capability to resist torsion as well as bending. [11]

Refractures following initial intramedullary screw fixation of Jones fractures has been documented in athletes. Wright, et al., reported six refractures after complete radiographic and clinical union utilizing cannulated screw fixation of Jones fractures in athletes. [4]

The refractures were attributed to insufficient screw diameter in athletes with a larger body mass and failure to incorporate functional bracing during first season of play. Glasgow, et al., concluded that insufficient screw selection and vigorous return to activity appeared to correlate with failure and strongly discouraged intramedullary fixation with any device other than a 4.5 malleolar screw. [9]

Conversely, Porter, et al., reported on 23 consecutive athletes treated surgically with a 4.5 cannulated stainless steel screw for Jones fractures. [12] The authors reported 100% clinical healing, mean radiographic healing rate of 98.9% and a zero incidence of refracture in this series. Larson et al reported a 40% (6 of 15) failure rate of patients treated with initial intramedullary screw fixation. [10] There were a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%). None of the screws fractured in the failure group, but it was noted intraopratively that three were bent. There were no significant differences in age, sex, and screw diameter, use of bone graft or age of fracture between patients with failures and those without complications. In the current case report, suboptimal screw diameter was implicated as the precursor to refracture and failure.

Operative and non-operative treatment for Jones fractures has been described in the literature; however, in competitive athletic patients, operative treatment appears to be more favorable. [13,14] Due to vascularity, muscle insertions, and motion related to the fifth metatarsal, O’Shea, et al., recommend that most Jones fractures be internally fixated for a more rapid return to function. [15] Early operative treatments of acute Jones fractures results in quicker times to union and return to sports compared with cast treatment. [5,13,15,16] Konkel, et al., recommended nonoperative treatment of fifth metatarsal fractures for patients in whom the time to full activities is not critical. [17]

The fifth metatarsal shaft bowing and intramedullary canal width deserve special attention. If unrecognized, variations in 5th metatarsal diaphyseal anatomy could lead to intraoperative morbidity. Ebraheim, et al., demonstrated that the intramedullary canal is bowed and the dorsoplantar diameter is more than 1mm narrower than the mediolateral diameter. [18]

Pre-operative lateral and oblique radiographs allow assessment of severe lateral bowing of the shaft. [3] We concur with Ebraheim, et al., in that the intramedullary canal assessment allows for precise and accurate screw placement.

When utilizing intramedullary screw fixation for Jones fractures, we interpose the screw over the metatarsal under fluoroscopy. This facilitates accurate intramedullary screw selection and avoids potential intraoperative fracture.

Zelko, et al., reported that athletes in sports such as football or soccer are often able to participate in sports while the fracture is healing and basketball players are most disabled and require surgical treatment. [19] Kavanaugh, et al., noted a predilection for failure of varsity basketball players treated non-operatively. [13] In theory, the repetitive jumping and running of basketball increases cantilever bending at the fracture site compromising union.

Pietropaoli, et el., conducted a biomechanical study demonstrating no biomechanical difference between a 4.5mm malleolar screw and a 4.5mm partially threaded cancellous cannulated screw. [20] The physiologic loading of bone may be greater in the high performance athlete with a larger body mass; making smaller screws vulnerable to bending. In the study by Wright, et al., all patients were athletes and returned to full-speed activity an average of 8.5 weeks post-fixation. [4] Speculation on the cause of re-fracture included early return to activity, insufficient screw diameter, use of cannulated screws, and large patient body mass as possible sources. This case report is consistent with Wright’s study and we believe larger diameter screws are required in patients with a larger body mass.

In conclusion, intramedullary screw fixation provides excellent stabilization in proximal 5th metatarsal fractures. The 5th metatarsal diaphyseal anatomy and patient body mass deserve thorough consideration in selecting a screw that affords adequate endosteal purchase and stability.

References

1. Nunley JA. Jones fracture technique. Techniques in Foot and Ankle Surgery 2: 131 – 137, 2002.
2. Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg 35: 697 – 700, 1902.
3. Horst F, Gilbert BJ, Glisson RR, James A: Torque resistance after fixation of Jones fractures with intramedullary screws. Foot & Ankle Int 25 (12): 914 – 919, 2004.
4. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW: Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 28 (5): 732 – 736, 2000.
5. DeLee JC, Evans JP, Julian J: Stress fractures of the fifth metatarsal. Am J Sports Med 11(5): 349 – 353, 1983.
6. Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA: Intramedullary screw fixation of Jones fractures. Foot Ankle Int 22 (7): 585 – 589, 2001.
7. Nunley JA. Fractures of the base of the fifth metatarsal: The Jones Fracture. Ortho Clin North Am 32: 171 – 180, 2001.
8. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB: Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int 22 (7): 581 – 584, 2001.
9. Glasgow, MT, Naranja, RJ, Glasgow SG, Torg JS: Analysis of failed surgical management of fractures of base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 17 (8): 449 – 457, 1996.
10. Larson C, Almekinders L, Taft T, Garrett, W: Intramedullary Screw Fixation of Jones Fractures: Analysis of Failure. Am J Sports Med 30: 55 – 60, 2002.
11. Vertullo C, Glisson R, Nunley J: Torsional Strains in the Proximal Fifth Metatarsal: Implication for Jones and Stress Fracture Management. Foot Ankle Int 25(9): 650 – 656, 2004.
12. Porter D, Duncan M, Meyer S: Fifth metatarsal Jones fracture fixation with a 4.5mm cannulated stainless steel screw in the competitive and recreational athlete: A clinical and radiographic evaluation. Am J Sports Med 33(5): 726 – 733, 2005.
13. Dameron TB Jr: Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg 3: 110 – 114, 1995.
14. Kavanaugh JN, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg 60A: 776 – 782, 1978.
15. O’Shea MK, Spak W, Sant’Anna S, Johnson C: Clinical perspective of the treatment of 5th metatarsal fractures. JAPMA 85 (9) :473 – 480, 1995.
16. Mologne T, Lundeen J, Clapper M, O’Brien T: Early Screw Fixation Versus Casting in Acute Jones Fractures. Am J Sports Med 33 (7): 970 – 975, 2005.
17. Konkel K, Menger A, Retxlaff S. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic surburban private multispecialty practice. Foot Ankle Int 26(9): 704 – 707, 2001.
18. Ebraheim NA, Haman SP, Lu J, Padanilam TG, Yeasting RA. Anatomical and radiological considerations of the 5th metatarsal bone. 21(3): Foot Ankle Int, 212 – 215, 2000.
19. Zelko RR, Torg JS, Rachum A: Proximal diaphyseal fractures of the fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 28: 732 – 736, 2000.
20. Pietropaoli MP, Wnorowski DC, Wener FW, et al. Intramedullary screw fixation of Jones fractures: A biomechanical study. Foot Ankle Int 20 (9): 560 – 563, 1999.

Address correspondence to: Dekarlos M. Dial, DPM, Cornerstone Foot and Ankle Specialists, 1814 West Chester Drive, Suite 300, High Point, North Carolina 27262

1  Chief, Foot and Ankle Division, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
2  3rd year resident, Department of Graduate Medical Education; University of Pittsburgh Medical Center Surgery, Pittsburgh, Pennsylvania.
3  Foot and Ankle Fellow, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

© The Foot and Ankle Online Journal, 2009

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Technical Tip: A Simple Method for Proper Placement of an Intramedullary Nail Entry Point for Tibiotalocalcaneal or Tibiocalcaneal Arthrodesis

Posted on September 1, 2008 | Comments Off on Technical Tip: A Simple Method for Proper Placement of an Intramedullary Nail Entry Point for Tibiotalocalcaneal or Tibiocalcaneal Arthrodesis

by Ronald Belczyk, DPM 1 , Wenjay Sung, DPM 2, Dane K. Wukich, MD 3

The Foot & Ankle Journal 1 (9): 4

The purpose of this article is to report on a technical tip when performing tibiotalocalcaneal or tibiocalcaneal arthrodesis. Technical faults of this arthrodesis may include malpositioning of the IM nail that can potentiate complications such as nonunion, delayed union, malunion, screw fracture, painful hardware, fracture of the intramedullary nail, tibial fracture, wound healing complications, and nerve damage. This article will present important information to aid the surgeon in preventing malpositioning of an IM nail and will provide a simple clinical pearl for perioperative incisional planning using image intensification.

Key words: Tibiotalocalcaneal fusion, tibiocalcaneal fusion, IM nail, intramedullary rod, complications

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: July 2008
Published: September 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0109.0004

Several authors have reported the use of intramedullary (IM) nails in ankle and hindfoot arthrodesis with varying rates of success and complications. [1, 5, 7, 12] Since intramedullary nailing involves arthrodeses of the ankle and hindfoot, accurate entry point placement is a critical step with this procedure. Although many technical pearls of initial guide-wire placement have been described in the literature, we have nonetheless seen complications arising from malpositioning. [1-3]

This manuscript reviews potential complications associated with intramedullary nailing, in particular to malpositioning of the retrograde nail. We present two cases that presented with continued pain upon ambulation after attempted tibiotalocalcaneal fusions. Their nonunion and failure of fixation was related in part due to malpositioning of the intramedullary nail. This article further reviews several authors’ recommendations for determining the ideal entry point for the insertion of an intramedullary nail for tibiotalocalcaneal fusion. Many of these studies recommend a guide wire entry point based on anatomical landmarks and preoperative radiographic findings.

Lastly, this article will describe a simple method of perioperative incisional planning by using image intensification.

Potential complications

Potential complications associated with this type of procedure include: nonunion, delayed union, malunion, screw fracture, painful hardware, fracture of the intramedullary nail, tibial fracture, wound healing complications, and nerve damage. [4-10]  Table 1 summarizes complications encountered by several foot and ankle surgeons.

Table 1  Reported complications of IM nailing. 

In addition to those complications listed in table 1, we present two cases with improperly placed intramedullary nails. Figures 2 and 3b are calcaneal axial radiographs which reveal malpositioning of an intramedullary nail.

Case 1

A 56 year old female with hypothyroidism, diabetes, peripheral neuropathy and a significant history of tobacco use presented to our service with severe pain in the medial aspect of her foot. She had sustained an ankle fracture five years prior and underwent open reduction internal fixation, subsequently developing a valgus deformity of her ankle and Charcot neuroarthropathy. Her ankle and hindfoot deformity was treated with a tibiotalocaneal fusion using a retrograde intramedullary nail. At the time of IM nail removal, movement was seen through the subtalar joint. (Figs.1ab, Fig.2)

 

Figure 1a  Case 1:  Anteroposterior (AP) ankle radiographs showing an intramedullary nail for a tibiotalocalcaneal arthrodesis.

Figure 1b  Case 1:  Lateral ankle radiographs showing placement of  intramedullary nail for the tibiotalocalcaneal arthrodesis.

Figure 2  Case 1:  Calcaneal Axial radiograph demonstrating malpositioning of the IM nail through the hindfoot with the insertion site too medial.

Case 2

A 66 year old male with rheumatoid arthritis, diabetes and peripheral neuropathy presented with significant pain upon ambulation. He related a history of a talus fracture that went on to Charcot neuroarthropathy of the ankle and hindfoot. He underwent a tibiotalocalcaneal fusion with intramedullary nail two years prior to our initial consultation. Figures 3abc demonstrate the patient’s initial presenting radiographs. The radiographs reveal distal migration of the IM nail. A computerized tomography (CT) scan showed a nonunion of the tibiocalcaneal joint. Laboratory data revealed no clinical signs of infection. Revisional arthrodesis was performed using circular ring fixation and external bone stimulation.

  

Figure 3abc  Case 2:  AP (a), axial (b) and Lateral (c)  radiographs of the ankle demonstrate an attempted tibiocalcaneal fusion with an intramedullary nail with broken calcaneal screw and distal migration of the nail.

Recommendations for determining guide wire entry point

Accurate guide wire placement is critical prior to reaming and inserting a retrograde intramedullary nail for tibiotalocalcaneal or tibiocalcaneal fusion. The guide wire is typically placed into the central medial aspect of the calcaneus and centered in the medullary canal of the tibia. Because the longitudinal bisection of the calcaneus is lateral relative to the alignment of the tibia in a normal anatomic structure, it is usually necessary to medially translate the talus and calcaneus.

This will allow insertion of a straight nail from the calcaneus into the central portion of the tibia. [11]

The foot placement should be 90 degrees with respect to the lower leg, maintaining the heel in neutral position with 10-15 degrees of external rotation. Blunt dissection is carried down to the bone to avoid any neurovascular structures. [13]

A number of authors have described the anatomical placement of the IM nail. Table 2 summarizes several author recommendations for determining the proper entry point. The surgical approach to placement of the IM nail is described in terms of measurement from specific landmarks and anatomical structures.

Table 2  Several recommendations for determining proper IM nail entry points.

Our technique uses perioperative imaging to determine the placement of the IM nail. Using intraoperative C-arm visualization, the long axis of the tibia on lateral view is used to determine the tibial location along the plantar entry point of the foot. The IM nail is simply placed along the lateral leg just above the border of the fibula. A marking pen is then used to draw a horizontally placed line along the plantar aspect of the foot. This corresponds to the central tibial component for IM nail placement.

The IM nail should visually appear to go directly through the lateral process of the talus on lateral view.

The second vertical or longitudinal bisecting line is made with the calcaneal axial view perioperatively. The IM nail is placed directly against the plantar heel on axial view. The line corresponds to the valgus or varus rotation of the calcaneus. The marking pen is then used to draw a longitudinal bisecting line. The center of the bisecting line represents the ideal entry point for the IM nail. Here, no measurements are required, and the landmarks to determine the ideal entry point correspond to radiographic anatomical structures. Figures 4-7 show a stepwise approach for perioperative incisional planning. The entry point is based on lateral ankle and calcaneal axial views utilizing C-arm visualization.

  

Figure 4abc  Preoperatively, a line is made on the ankle which is consistent with a line that bisects the tibia and goes through the lateral talar process.

Figure 5  The mark on the lateral aspect of the ankle is then continued transversely on the plantar surface of the foot.  A guide-wire or metallic marker, in this case a threaded rod, is then placed against the plantar aspect of the foot along the center of the heel. 

Figure 6   Using image intensification, a calcaneal axial view is taken and a line bisecting the calcaneus is then marked on the plantar skin.

Figure 7   The center of the two intersecting lines is the ideal entry point.

Summary

In summary, ideal incisional placement permits accurate insertion, good screw purchase, and avoids neurovascular damage. (Fig. 8ab)

 

Figure 8 ab Lateral ankle (a), calcaneal axial (b) radiographs demonstrate a tibiotalocalcaneal fusion with a properly placed intramedullary nail.

Although fixed angled devices are being popularized as being able to purchase a greater amount of calcaneus and not having to medially translate the talus to align the tibia and calcaneus, clearly intraoperative errors can lead to postoperative complications as presented in this article. A simple, accurate, and reproducible method of determining the proper entry point as described in this article is invaluable to the foot and ankle surgeon performing tibiotalocalcaneal or tibiocalcaneal fusion with intramedullary devices. Currently there are retrograde devices approved for use that have a valgus orientation built into the nail.

The valgus nail such as the T2 Ankle arthrodesis nail (Stryker, Kalamazoo, MI) or the Hindfoot Arthrodesis Nail-EX (Synthes, West Chester, PA) can facilitate proper entry site placement, however, we recommend the above technique to guide proper placement. Proper placement of the device in the calcaneus improves fixation with the distal interlocking screws whether they be transverse or axial in nature.

References

1. Paley D, Herzenberg J, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and saggittal plane corrective osteotomies. Orthop Clin N Am 25(3):425-465, 1994.
2. Roukis T. Determining the Insertion Site for Retrograde Intramedullary Nail Fixation of Tibiotalocalcaneal Arthrodesis: A Radiographic and Intraoperative Landmark Analysis. J Foot and Ankle Surgery 45(4):227-234, 2006.
3. Lamm B, Paley D. Deformity correction planning for hindfoot, ankle, and lower limb. Clin Podiatr Med Surg 21(3):305-326, 2004.
4. Buratti R, Johnson J, Buratti D. Concurrent ankle and subtalar arthrodesis. J Foot and Ankle Surgery 33(3):278-282, 1994.
5. DiDomenico L, Adams H. Intramedullary nailing for Charcot arthroplasty of the hindfoot and ankle. Philadelphia: Lippincott Williams and Wilkins Co., 2005.
6. Harvey E, Agel J, Selznick H, Chapman J, Henley M. Deleterious effect of smoking on open tibia-shaft fractures. Am J Orthop 31(9):518-521, 2002.
7. Kile T, Donnelly R, Gehrke J, Werner J, Johnson K. Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 15(12):669-673, 1994.
8. Perlman M, Thordarson D. Ankle fusion in a high risk population: an assessment of nonunion risk factors. Foot Ankle Int 20(8):491-496, 1999.
9. Quill G. Tibiotalocalcaneal Arthrodesis with Medullary Rod Fixation. Techniques in Foot and Ankle Surgery 2(2):135-143, 2003.
10. Thordarson D, Chang D. Stress fractures andtibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 20(8):497-500, 1999.
11. McGarvey WC, Trevino SG, Baxter DE, Noble PC, Schon LC. Tibiotalocalcaneal arthrodesis: anatomic and technical considerations. Foot Ankle Int 19(6):363-9, 1998.
12. Singh PJ, Perera NS, Dega R. Measurement of the dose of radiation to the surgeon during surgery to the foot and ankle. J Bone Joint Surg Br 89(8):1060-3, 2007.
13. Flock TJ, Ishikawa S, Hecht PJ, Wapner KL. Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis. Foot Ankle Int 18(4):233-5, 1997.

Address correspondence to: Dane Wukich, MD. UPMC Comprehensive Foot and Ankle Center. Roesch-Taylor Bldg Ste 7300. 2100 Jane St. Pittsburgh, PA 15203. Phone: 412-586-1546 Fax: 412-586-1544
Email: wukichdk@upmc.edu

1  PGY-4, Fellow, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
2  Resident, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
3  Chief, Foot and Ankle Division, University of Pittsburgh Medical Center Department of Orthopedic Surgery and Assistant Professor, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 15203.

© The Foot & Ankle Journal, 2008

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