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Ankle Arthrodesis

- See:

 Sub-Talar Fusion
Tibial-Talar-Calcaneal Fusion

Ankle arthrodesis is an established treatment for painful, end-stage ankle arthritis. Over the last century, a number of operative techniques have been popularised, with modifications reflecting technological advances.  These have ranged in methods of fixation from the Charnley external clamps through to all manner of crossed/parallel screw fixation techniques implanted via open or arthroscopic means. This latter technique has gained wide popularity and has excellent results in terms of high rates of union and rapid return to function.

However, managing deformity, poor bone quality or bone loss remain difficult issues to resolve using traditional techniques.  As a result, biomechanical studies into the properties of angle-stable devices such as blade plates and anatomic locking plates have found some mechanical advantages over screws in stabilising an ankle arthrodesis, thus potentially offering a solution.

In cases with the presence of deformity, I much prefer to use open methods of arthrodesis as it is easier to gauge the intra-articular deformation and prepare the joint surfaces. In this case, a tall person with Marfan’s syndrome and isolated ankle arthritis, I elected to use an Arthrex anterior fusion plate because it provides very robust fixation , two methods of application of compression and an excellent hold that locking screws afford within the plate. The Arthrex range of plates offers a lateral ankle arthrodesis plate which requires the removal of the fibula to apply. In this instance, I wanted to preserve as much of the mortise as possible to preserve inherent ankle stability  given the degree of correction needed, and so opted for an anterior approach and plating option.

In general terms, my experience with using the Arthrex systems for either anterior or lateral ankle fusion surgery has been that the plates are very well engineered and that the trays are thoughtfully constructed with useful instruments that are easy to use. Additionally, Arthrex have recently expanded the range of plates to allow a choice of plate lengths. Previously a limiting step in using the kit was that the surgeon was confined to using one plate size per approach – for example, one anterior plate size. In large patients and in those with good soft tissue coverage, this range does offer very robust fixation for an ankle arthrodesis. However, one needs to be aware if using this plate in patients with poor soft tissue envelopes and also in smaller individuals that the dimensions of the plates are bulky and it can be difficult to close the soft tissues over them.

Readers will also find of interest the following OrthOracle techniques:

Ankle Fusion (arthrodesis): Trans-fibular approach using AnkleFix 4.0 plate (Zimmer-Biomet)

Ankle arthrodesis (fusion): Arthroscopic assisted Ankle Fusion

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- 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 ipsilateral hip, since ankle fusion patients tend to hold their lower limb in external rotation in order to
progress through 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.

- 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.


- 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;
- patients can use a double upright AFO w/ a patellar tendon bearing support which partially unload ankle joint during gait;
- adding a rocker bottom orthosis to the shoe will improve transition throughout stance phase;


Ankle arthrodesis is an established treatment for painful, end-stage ankle arthritis. Over the last century, a number of operative techniques have been popularised, with modifications reflecting technological advances.  These have ranged in methods of fixation from the Charnley external clamps through to all manner of crossed/parallel screw fixation techniques.

However, managing deformity, poor bone quality or bone loss remain difficult issues to resolve using traditional techniques.  As a result, biomechanical studies into the properties of angle-stable devices such as blade plates and non-anatomic locking plates have found some mechanical advantages over screws in stabilising an ankle arthrodesis, thus potentially offering a solution. Therefore, in Sheffield, Mr Mark Davies and Mr Chris Blundell developed a new anatomically contoured, fixed angled lateral locking ankle arthrodesis plate – the Ankle Fix 4.0. Manufactured by ZimmerBiomet, we have successfully used this device for open ankle fusion surgery especially in more challenging clinical situations. The rationale behind the plate design was formed after both authors had gained experience using an inverted PHILOS plate. It was felt that a set of divergent screws within a low-profile talar section would offer a significant pull-out strength in cancellous bone and similarly that convergent screws in the tubular, cortical bone would provide robust tibial fixation. These screws were specifically designed to be 4.0 mm in size to allow clustering of the screws which contrasts with the larger, less versatile plate designs that were on the market at the time of design in 2009.

With limited literature on the wealth of new locking ankle fusion plates, the plate designers present these results and discuss their large series in the December 2017 issue of the journal Techniques in Foot and Ankle Surgery.

Author: Mark Davies FRCS (Tr & Orth)

Institution: The Northern General Hospital ,Sheffield ,UK.

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This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

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View this procedure on OrthOracle.com

- Open Exposure for Ankle Fusion:
- alternative techniques: (Blair fusion, compression arthrodesis)


- Arthroscopic Arthrodesis:

An arthroscopic ankle fusion probably has consistently the highest union rate of any ankle fusion technique. It is often associated with lower levels of short-lived post-operative pain, when compared to open techniques. If  bone quality is good there is also the possibility of starting early limited weight-bearing in compliant patients. Union rates in excess of 90% are normal and much of the post operative period can be spent in a post-operative boot rather than cast given the inherent stability of the maintained (as opposed to flat cut) articular surfaces.

The technique is particularly useful for cases with poor soft tissue quality such as areas covered with skin graft or various plastic surgical flaps as well as in those with compromised wound healing capacity, such as diabetics.

There is disagreement about its use in the presence of significant deformity, though as long as the deformity is passively correctible there is little issue using the technique. Even a degree of fixed deformity of the arthritic ankle can be corrected by differential intra-articular resection/preparation of the adjacent joint surfaces.

In the presence of a mobile compensatory mid-foot and hind-foot a normal, or largely normal, gait pattern can be expected following arthroscopic ankle fusion. Appropriate patient selection is important and in-particular considering fusion carefully in those with pre-exisiting sub-talar or midfoot arthrosis which will deteriorate in many cases. These are the same considerations though for any ankle fusion irrespective of technique.

One should be fully conversant with the technique of ankle arthroscopy before attempting an arthroscopic ankle fusion:

Ankle arthroscopy using the Smith and Nephew Guhl non-invasive ankle distractor

Alternative techniques to fuse the ankle should always be in a surgeons skill set and examples can be read on OrthOracle at:

Ankle Fusion (arthrodesis): Trans-fibular approach using AnkleFix 4.0 plate (Zimmer-Biomet)

Ankle arthrodesis (fusion): Trans-fibular approach

Ankle Fusion: Arthrex anterior ankle fusion plate

Readers will also find the following techniques of interest:

Tibio-Talo-Calcaneal (TTC/Double )fusion using Zimmer Ankle Fix plus plate.

Tibio-Talo-Calcaneal (TTC/Double )fusion using Integra Advansys Plate

Tibio-talo-calcaneal (TTC/Double ) fusion with Wright Valor nail.

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This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

Take the Tour

View this procedure on OrthOracle.com

- requires correctable deformity;
- technique:
- ankle arthroscopy
- use standard knee arthroscopy arthroscope (4 mm) and 4.5 mm burr;
- 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;
- references:
- Safety and efficiency of posterior arthroscopic ankle arthrodesis.
- Anatomic Feasibility Study of Posterior Arthroscopic Tibiotalar Arthrodesis.
- 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 through 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.
          - Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series
- Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis.


- 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 can be applied to all corners of the fusion, especially between the medial malleolus and talus;
- one option is to insert the first long threaded cannulated screw across the joint, and to observe ankle distraction that occurs
as threads just reach the far surface;
- while the joint is distracted, inject bone graft material evenly across the interval;
- references:
- Locally generated bone slurry accelerated ankle arthrodesis.
- Use of demineralized bone matrix in ankle/hindfoot fusion
- Survey on the need for bone graft in foot and ankle fusion surgery.
- The Importance of Sufficient Graft Material in Achieving Foot or Ankle Fusion


- 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;
- walking does not provide uniform compression across an ankle arthrodesis site, and probably should be avoided until there is
trabeculation across 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;
     - Heel-to-toe Rocker Sole
             - sole is shaped with an accentuated rocker angle at both the heel and toe
- increase propulsion at toe-off, decrease pressure on heel strike, and reduce the need for ankle motion;
- this type of heel is also useful for patients with severe claw toes, and those with heel ulcers


- Complications of Ankle Arthrodeses:

 


References:

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.
Transfibular compression arthrodesis of the ankle joint.
Arthrodesis of the ankle with 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.
Outcome after single technique ankle arthrodesis in patients with rheumatoid arthritis.
Arthrodesis of the ankle in patients who have rheumatoid arthritis.
Clinical outcome of tibiotalar arthrodesis utilizing the chevron technique.
Motion Versus Fixed Distraction of the Joint in the Treatment of Ankle OsteoarthritisA Prospective Randomized Controlled Trial
Batchelor's extra-articular subtalar arthrodesis. A report on sixty-four procedures in patients with poliomyelitic deformities.