- See:
Sub-Talar Fusion
Tibial-Talar-Calcaneal Fusion
- Discussion and Outcomes:
-
optimal position for fusion
- see
gait and
role of ankle joint in gait
- ref:
Ankle arthrodesis. Long-term follow-up with gait analysis.
- Exam:
- perform an Allen test for the foot vasculature;
- note function of
posterior tibial pulse while the
dorsalis pedis pulse is occluded and vice versa;
- check external rotation of the ipsilateral hip, since ankle fusion patients tend to hold their lower limb in external rotation inorder to progress thru
stance phase of gait;
- note amount of subtalar and transtalar mobility, since this correlates with better postoperative functional scores and satisfaction;
- ref: Arthrodesis of the Ankle: A critical analysis. RA Mann MD et al. Foot and Ankle International. Vol 19. No 1. Jan 1998. p 3.
- Radiographic Studies:
- MRI may be used to judge the
vascularity of the talus;
- it may be wise to image the
subtalar joint to ensure that there is not concomitant arthritis;
- ref: A roentgenographic technique to evaluate and document hindfoot position. Samuelson KM: Foot Ankle 1981;1:286-289.
- Non Operative Treatment Options:
- prior to ankle arthrodesis, the patient should be given the option of wearing either a below knee cast or CAM walker;
- a good candidate for ankle arthrodesis is a patient with documented ankle arthritis, who has obtained pain relief from a CAM walker,
and who does not wish to wear a CAM walker for a lifetime;
- alternatively, the patient can be provided with a double upright AFO w/ a patellar tendon bearing support which partially unload the ankle joint during gait;
- adding a rocker bottom orthosis to the shoe will improve transition throughout stance phase;
- Open Exposure for Ankle Fusion:
- alternative techniques: (
Blair fusion, compression arthrodesis)
- Arthrscopic Arthodesis:
- requires correctable deformity;
- technique:
-
ankle arthroscopy
- ankle distraction apparatus:
- remove entire articular cartilage (including medial and lateral gutters) w/ relative preservation of subchondral bone;
- drill multiple holes through the subchondral layer;
-
internal fixation w/ cannulated screws:
- screws are inserted inorder to best address direction of deformity;
- with anterior subluxation of the talus, then posterior to anterior screw (posterior malleolus to anterior talar head) is inserted first followed by
screws thru the medial malleoulus into the talar body;
- w/ minimal deformity, consider two screws inserted from medial distal tibia into talar body;
- whether fibula needs to be included into the fusion is controversial;
- references:
-
Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment.
-
Arthroscopic ankle arthrodesis.
-
Arthroscopic ankle arthrodesis in rheumatoid arthritis.
-
Arthroscopically assisted arthrodesis for osteoarthrotic ankles
-
Long-term results of arthroscopic ankle arthrodesis.
- Internal Fixation w/ Cannulated Screws:
- External Fixation:
- can be applied to medial surface of the tibia (2-3 pins) and talus (2 pins);
- references:
-
Arthrodesis of the ankle with modified distraction-compression and bone-grafting.
-
Ankle arthrodesis. A comparison of internal and external fixation.
-
Ankle arthrodesis with the Calandruccio frame and bimalleolar onlay grafting.
-
Revision of ankle arthrodesis with external fixation for non-union.
-
External fixation arthrodesis of the ankle joint following trauma.
-
Bone Grafting
- bone graft is applied to all corners of the fusion, especially between the medial malleolus and talus;
- Post operative management:
- note that even rigid fixation, 8 deg of flexion-dorsiflexion and 7 deg of torsional motion may occur;
- avg immobilization time until all casts are removed is
7-8 months;
- allow
unprotected wt-bearing only after bone trabeculation is seen across osteotomy site;
- anteromedial portion of distal tibia undergoes cyclic tension and compression during walking;
- tension in anteromedial tibia occurs after
heel strike, & compression occurs after
heel off;
- reverse of this cycle would be expected to occur in the posterolateral aspect of the tibia;
- hence, walking does not provide uniform compression across an ankle arthrodesis site, and probably
should be avoided until there is trabeculation across the frx site;
-
SACH will cushion impact of initial ground contact and help permit initiation for rocker bottom type action
during ground contact in pts who have lost ability to plantar flex from heel strike to foot flat;
- rocker sole helps tibia pass over foot w/ platar flexion from foot flat to liftoff;
- patients with greater tarsal mobility will have better postoperative foot mobility and higher satisfaction;
- Complications of Ankle Arthrodeses:
References:
General* Orthopaedics: Ankle Arthrodesis: Problems and Pitfalls.
Methods and Follow-Up Statistics on Ankle *Arthrodesis--Symposium:* An Overview of Ankle Arthrodesis.
Comparative analysis of ankle arthroplasty versus ankle arthrodesis.
Ankle arthrodesis in children.
Ankle fusion.
Salvage of nonunion following ankle arthrodesis for failed total ankle arthroplasty.
Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation.
Compression arthrodesis of the ankle. Evaluation of a cosmetic modification.
Batchelor's extra-articular subtalar arthrodesis. A report on sixty-four procedures in patients with poliomyelitic deformities.
Arthrodesis of the ankle in patients who have rheumatoid arthritis.
Transfibular compression arthrodesis of the ankle joint.
Arthrodesis of the ankle w/ free vascularized autogenous bone graft. Reconstruction of segmental loss secondary to osteomyelitis, tumor, or trauma.
Arthrodesis of the diabetic neuropathic ankle joint.
Arthrodesis of the Ankle: A critical analysis. RA Mann MD Foot and Ankle International. Vol 19. No 1. Jan 1998. p 3-9.
Outcome after single technique ankle arthrodesis in patients with rheumatoid arthritis.
Clinical outcome of tibiotalar arthrodesis utilizing the chevron technique.
