Tibio-talo-calcaneal (TTC/Double ) fusion with Wright Valor nail
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Tibio-talo calcaneal fusion (TTC) is an operation in the main to treat severe arthritis and deformity of the ankle and hindfoot, as well as for revision cases. It consists of fusing both the ankle and subtalar joints to create a stable column that comprises the distal tibia, the talus and the os calcis. The use of a hindfoot intra-medullary nailing system, which is inserted retrograde through the os calcis into the tibia, is very successful in maintaining position and aiding in these fusions. Various designs of Intra-medullary nails have seen use in TTC fusions over the last 2-3 decades, with varying degrees of success.
The Wright Valor hindfoot fusion nail has various advantages, one of which is having multi-planar screw trajectories, another being its straightforward and effective internal compression system which facilitates compression of the joints using the nail. The Valor nail is available in two diameters, 10mm and 11.5mm, with lengths from 150-300mm. This allows the use of the nail in most anatomical variations of the tibia. The size of the implant gives it inherent strength, which is particularly important given the bending moments that occur both across the ankle and also the subtalar joint. Moreover, the locking systems both proximally and distally allow rotational stability to be maximised in such a construct. The Valor system also comes with a calcaneal compression slot through which a screw can be inserted and then compressed by the unique internal compression system. The implant has both static and dynamic proximal options for locking which allows for later dynamization in case of delayed healing of the fusion interfaces.
The distal calcaneal compression screw, inserted medial to lateral, is well positioned in the nail and to avoids the posterior tibial neurovascular bundle. The calcaneal locking screw is inserted from posterior to anterior, allowing excellent purchase both in the tuberosity and in the anterior process of the os calcis.
Perhaps the most unique feature of the Valor nailing system is its internal compression mechanism, used following initial proximal locking, which allows the dynamic compression of both subtalar and ankle joints prior to distal locking.
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Author:Kartik Hariharan FRCS
Institution: Aneuran Bevan University Health Board, Wales, UK.