Biomechanical conditions of subtalar joint arthrodesis with calcaneal locking nail: A probabilistic numerical study

Introduction: Subtalar joint arthrodesis is primarily indicated for advanced osteoarthritis, hindfoot deformity, and/or instability. During the first 6-10 weeks after surgery, there is an intermediary structurally weaker state before complete bony fusion of the calcaneus and talus occurs. Loading of the foot can lead to mechanical stresses and relative movements in the former joint gap, which can impede the fusion process. The objective of this study was to examine the mechanical healing conditions for a subtalar arthrodesis with a calcaneal locking nail. Methods: A probabilistic finite element model of the subtalar joint with a calcaneal locking nail was created to represent the foot post-surgery that accounts for the uncertainty of the material properties. The model differentiates between cortical and cancellous bone and includes non-linear contact definitions in the subtalar joint. Multiple loading scenarios, including hindfoot inversion/eversion, were simulated to determine bone and implant stresses. Utilizing local articular coordinate systems, a displacement analysis was established to separate normal and tangential components and account for their separate effects. The loading of the locking nail was assessed through section moments. Results: Under inversion/eversion loading, the area near the locking screws and upper end of the nail experienced the highest stresses. The maximum stresses in cortical and cancellous bone were 112±8.3 MPa and 2.1±0.2 MPa, respectively. The comparison of the von Mises and maximum principal stresses for the bones showed a load case dependency with strong effect on tensile loading states. The proposed method for the analysis of relative displacement in the local articular coordinate systems showed joint regions exhibiting normal and tangential movements that changed with the considered loading states. It was found that tangential displacements of up to 0.19 mm are related to the torsional loading of the calcaneal locking nail, which is connected to the corresponding torsional stiffness of the implant and its fixation in the calcaneus and talus. Normal displacements in the joint gap of up to -0.18 mm can be shown to be governed by the bending moments acting on the calcaneal locking nail, which are linked to the nail’s bending stiffness. The ratio of tangential and normal displacement in the critical inversion configuration was determined to be -1.1. Conclusions: Inversion and eversion loads can lead to significant mechanical loading of the bones and to bending and torsional loading of the locking nail. The bending leads to normal displacements in the articular gap. Torsions can lead to significant tangential displacements that have been shown to promote non-union instead of bony fusion.