ANKLE

ARTHODESIS

Dr.Mohammed AlOtaibi

Tutor: Dr.Nader AlKenani

@2012
Ankle Joint
 articulation of the talus with the tibial plafond and the distal
fibula.
 Weight bearing area
 Disturb in ligaments: instability with wt bearing
Ankle Arthritis
causes
 Posttraumatic
 Inflammatory
 Degenerative
 AVN
 malalignment (Instability ,malreduction)
 Also: position of the talus in the mortise, stability of the syndesmosis,
length of the fibula, and quality of the joint surface at the time of
reconstruction.
:Diagnosis
 Mechanical Pain
 ↓ROM
 Limitation of activity
 Limping

 P/E:
 Deformity, swelling, tenderness, ROM,
crepitation
Imaging
 Xary
 CT
 MRI
Conservative Treatment
 shoe inserts: cushioned heel and a stiff, rockerbottom sole
 ankle-foot orthosis
 walking cast for 6 weeks
 NSAID
 Wt reduction
 Activity modification
 Intra-articular injections
Surgical Treatment
 Arthroscopic ankle-joint debridement

 Ankle Arthrodesis
 Ankle Replacement
Ankle Arthrodesis
indications
 ankle arthritis and deformity did not respond to
nonoperative treatment:
Posttraumatic and primary Arthrosis  •
• Neuromuscular deformity
• Revision of Failed Ankle Arthrodesis 
• Failed Total Ankle Replacement
• AVN Talus
• Neuroarthropathy (Charcot)
• Rheumatoid Arthritis with severe deformity
• Osteoarthritis
• Pseudarthrosis
assesment
 HISTORY:
› AGE 
› MEDICAL ILLNESESS
› Signs of infection
› Previous conservative treamtment
› PREVIOUS SURGERY - ARTHRODSESIS

 EXAMINATION:
› Localize exam
› VASCULARITY
› ROM SUBTLAUR
› DEFORMITY

 Radiographic Studies:
› Ankle Wt bearing Xray
› LONG FILM LOWER LIMBS (deformity)
› Subtalar joint (Arthritis)
Methods of Fusion
 Steinmann pins
 Screws
 Plates
 External fixators, illiazrove
 Retrograde IM Nails
Selection of the surgical technique

 should be based on the underlying cause.

 As a general rule:
› external fixators and illiazrove: infections
› Arthroscopic: minimal deformity.
› Open: significant deformity
optimal postoperative position
 neutral flexion (0 degrees)
 5 to 10 degrees of external rotation
 5 degree valgus
External Fixation
 1951
 The Charnley method combined open surgical debridement of the ankle-
joint cartilage with the application of an external fixator by placing one
pin through the tibia and another through the neck of the talus, with
connecting bars
 Bone graft
 allowed to bear weight 8 weeks after surgery
 After removal – walking cast for 4 weeks
External Fixation
 Charnley Method: USE OF EX FIX ONE PLANE WITH
COMPRESSION :
› STABLE IN AP PLAN
› NOT STABLE FOR ROTATION

 Calandruccio Compression Device (Richards):

› provides three-point fixation,
stability in all planes of
 movement
illiazrove
illiazrove
 Proper in case of active infection.
illiazrove
 20 years old male
 Fracture Rt Ankel
 ORIF done
 C/o pain , with activity , even at rest
illiazrove
Jan 2012 Bone scan:
Hyperemia  with  increased  uptake
  suspicion  for  infection

Ct scan:
distal  syndesmotic  screw  loosening,
  associated  with  irregularities  at  the 
ankle  joint  with  surrounding  fluid  collection. 
illiazrove

Feb 2012
illiazrove

Removal at end of August 2012

illiazrove
illiazrove

On last visit December 2012

Arthroscopic Arthrodesis
Arthroscopic Arthrodesis
 Ports 2 or 3
› Anteromedial:
› medial to the tibialis nterior tendon, and located about 5 mm
proximal to the medial malleolus
› saphenous nerve and vein
› Anterolateral:
› lateral to peroneus tertius tendon

› lateral to the extensor digitorum longus tendon.

Arthroscopic Arthrodesis
 Distraction:
› 25 IB will give 1 to 1.5 mm of distraction
› 30 ib more than 1 hr , reversable nerve injury
 A 4.5-mm bur and curettes -remove articular surfaces
 Compression: Interanal or external
 Prevered: 2 cannulated screw
› One medial mallulus to lateral talus
› One lateral tibia to neck of talus
 NWB 5 weeks
 Progress gradual till radiological healing
Arthroscopic Arthrodesis
 Advantage:
› faster rates of union, decreased complications,
reduced postoperative pain, shorter hospital stays,
minimal loss of length of the lower limb.

 Disadvantage:
› Only for minimal deformity, because it is difficult to
correct ankle deformity arthroscopically.
Open Arthrodesis
 with severe ankle-joint deformity
 better visualization
 two-incision
› Direct over fibula
› Along anterior third of medial malluls
 maintain full-thickness flaps and protect tendons
and N,V
Open Arthrodesis
 Lateral: osteotomy 10 cm from the fibular tip,
The remaining fibular fragment can then be
excised.
 preserve the medial malleolus so as to provide an
area of solid fixation for the screw and to
preserve the medial blood supply to the talus
Open Arthrodesis
 Cut of talus 5mm paralel to tibial cut
 drilled or curetted until bleeding bone
 two guide pins for large (7.0- to 7.3-mm)
cannulated screws
 Care must be taken that the pins do not violate the
subtalar joint
 short threaded cannulated screws with washers
 bulky cast padding 2 weeks
 NWB short leg cast
 Start WTB after radiological evidence of healing
 usually occurs 8 to 12 weeks postoperatively
IM Nail
 (TTCA)
 Minimal invasive
 Better mechanical Proparties.
 Some types allow compression
 The starting point is of the most importance
IM Nail
Indication:
AVN talus
Failed Total Ankle Arthroplasty
Pseudoarthrosis
Neuropathic arthropathy

Contraindications:
 Infection
 Sever vascular disease
 Sever tibial malalignment 
 Normal subtalar joint (relative)
 Plantur pad inssuficency
 Entry point:
› 3 cm longitudinal plantur incision
› Anterior to subcalcaneak fat pad
› Lateral to mid line
 Nail length:
› Nail end should extend at least 1 ½ to 2 tibial
diameter above any potential stress risers
Post Op
 NWB for 6 weeks
 12 weeks in case of nuropathy or use of
bonegraft
IM Nail
Complications
 nonunion 
 fracture at or above the fixation construct
 Nerve and artery damage 
Complication of Arthrodesis
 Complications:*
› nonunions (41%)
› Infections (9%)
› nerve injuries (3%)
› malunions (3%)
› wound problems (3%)

Frey et al 1995
Risk Factors for Nonunion
 Risk factors associated with nonunion:
› severe fracture, an open injury, local infection,
evidence of osteonecrosis of the talus, and coexisting
major medical problems
› past history of undergoing a subtalar or triple
arthrodesis
› Smoking risk increase 16 times
…Thank You