Early Failure of the Paragon28 Phantom Hindfoot Fusion Nail

Last week's JB&JS Case Connector Case Report “Early Failure of the Paragon28 Phantom Hindfoot Fusion Nail” by Dr. Elizabeth M. Friedmann et al., garnered a lot of buzz over various social media platforms.

The Paragon28 Phantom TTC Nail, unique in that it features a novel flexible coil proximally, is purported to reduce the risk of tibial stress risers.

The summary

The report details the use of the device for the treatment of a displaced tri-malleolar fracture in a diabetic neuropath with multiple medical comorbidities. Post-operative follow-up radiographs at four weeks depict clear failure, including breakage of the coil with proximal migration, re-displacement of the fractures and a new fracture line between the tibial interlocking screws.

The authors concluded that the 50-mm flexible coil proximally should not be considered as part of the working length of the nail, and that the junction of the coil and nail may represent a potential area for stress riser. The obvious assertion, although not directly stated in the report, is that the load-sharing capacity of the Phantom Nail may be less than traditional TTC nails in certain patient populations.

Is this really a nail issue?

Although Paragon28 has yet to release a statement, readers should consider these facts, which undoubtedly contributed to the failure: The lack of subtalar joint preparation due to wound healing concerns, and a non-compliant weightbearing patient during the immediate post-operative period. Nonetheless, the authors' concerns do warrant a closer look at the Phantom Nail.