DEPARTMENT OF ORTHOPAEDICS

KMC, MANGALORE
ANKLE ARTHRODESIS
Moderators: Presentor:
Dr. Surendra .U . Kaat!
Dr. Preet!a sa"#an Dr. $#%e& Kr. S#n'!
DEFINITION: It is a operation to produce bony ankylosis of a diseased
joint.

HISTORICAL (ACKGROUND :
Albert (1879) first described ankle arthrodesis,and it becae !uite popular for
stabili"ation of paralytic in polioyelitis.#is techni!ue lar$ely reained unchan$ed
until 19%1 &hen Charnley introduced the concept of copression to ankle
arthrodesis. 'or any years ost fre!uent indication for sur$ical arthrodesis of the
foot and ankle &as the treatent of flaccid paralysis resultin$ fro a (ariety of
neurouscular conditions, particularly polioyelitis. Internal fi)ation &as initially
perfored usin$ boiled cada(er allo$raft struts, i(ory, fibular auto$raft or sutures to
hold the bone in position lon$ enou$h to apply a cast, such techni!ues re!uired
prolon$ed periods of iobili"ation and restricted &ei$ht bearin$ in order to
inii"e the nearly ine(itable conse!uence of fibrous union.
*s techni!ues e(ol(ed and the success rates for arthrodesis increased, sur$ical
indications e)panded.
INDICATIONS
+e$enerati(e arthritis of ankle joint
,rauatic arthritis secondary to fractures of distal tibia, alleoli or
talus
-heuatoid arthritis and other serone$ati(e arthropathies of the
tibiotalar joint
.etabolic disorders such as $out that ay lead to loss of articular
cartila$e and narro&in$ of joint space.
Infectious arthritis
/eoplastic disorders resultin$ in articular daa$e
.alposition of the foot at the tibiotalar joint, includin$ (aurs, (al$us,
e!uinus, or calcaneus deforities caused by con$enital abnoralities,
neurouscular disorders, trauatic injuries, or other ac!uired
disorders.
0al(a$e of failed total ankle arthroplasty.
CONTRAINDICATIONS
1lderly debilitated patients &hose $eneral edical condition increases
the risk of $eneral anaesthesia and sur$ery.
/europathic disorders
2irculatory disorders that increase the risk of (ascular coproise or
delayed &ound healin$.
0e(ere osteoporosis
+iabetes ellitus.
*cti(e infection
,he presence of arthritis at the subtalar and3or choupart joint, &hich
ay re!uire inclusion of these joints in the for of a plantar
arthrodesis.

T)PES :
1. 1)tra articular
4. Intra articular
5. 2obined
E*TRA ARTICULAR : It is especially useful in treatin$ children, because uch
of children6s joint surfaces are cartila$e, and in treatin$ patients &ho ha(e lar$e
aounts of necrotic bone or acti(e infection as in tuberculosis.
INTRA ARTICULAR : 7erits $reater correction of defority.
Optimal position for ankle fusion : fle)ion 89 , (al$us 8 to %9 , e)ternal rotation %
to 189 , &ith sli$ht posterior displaceent of talus.
GENERAL PRINCIPLES :: Mann et al.
i) *n attept should be ade to create broad, flat, cancellous surfaces
that are placed into apposition to allo& fusion to occur.
ii) ,he arthrodesis site should be stabili"ed &ith ri$id internal fi)ation, if
possible, or &ith e)ternal fi)ation.
iii) ,he hind foot should be ali$ned to the le$ and the forefoot to the
hindfoot to create a planti$rade foot.
PREOPERATI$E COUNSELING
,he patient should be ade &ell a&are about the realistic e)pectations,
e)pected shortenin$, need for bone $raftin$, need for prolon$ed castin$ and shoe
odifications. #e or she should be fore&arned about coplications such as
infection, non:union and neuro(ascular probles.
APPROACHES :
i) Anterior ; ,hrou$h the anterior tibial tendon sheath, allo&s e)posure
of entire ankle joint, but liits access to edial and lateral alleoli.
ii) Transmalleolar (Transfibular) approach ; 0iilar to anterolateral
approach, but allo&s sli$htly better access to posterior aspect of ankle
joint.
iii) Posterior: It can be used for isolated tibiotalar fusion in patients &ith
coproised anterior skin fro pre(ious traua or sur$ery.'re!uently
used for tibiotalar calcaneal arthrodesis.
Preparation of Joint Surfaces :
0iply denudin$ the reainin$ articular cartila$e and <'ish scalin$=
the subchondral bone &ith a sall osteotoe or $au$e.
,his preser(es the noral ankle joint contour and results in inial
shortenin$ of e)treity.
,&o parallel cuts, one throu$h the distal tibia and one throu$h the talar
doe, that resects a inial aount of bone allo& e)cellent
apposition of lar$e cancellous surfaces and allo& translation of the
talus.
>(erall shortenin$ $enerally ?1c.
E*TERNAL FI*ATION
INDICATIONS
ASO!"T# : *cti(e sepsis
$#!AT%&# :
#istory of sepsis
'ailed total ankle arthroplasty
.assi(e bone loss
'ailed fusion
,ibiotalocalcaneal fusion
$#!AT%&# CO'T$A%'(%CAT%O'S : 7riary, uncoplicated arthrodesis.


Charnley ; @niplanar de(ice did not pro(ide rotatary
stability.
Charnley compression metho) ;
*nkle is opened anteriorly, and dislocated copletely by
plantar fle)ion of the foot. ,he alleoli are e)cised and half
inch of tibia is cleared of soft tissue. ,&o sall bone le(ers are
placed behind lo&er end of tibia to protect tibial ner(e and
blood (essels. ,he bone is di(ided &ith hand sa& A fro
articular surface and 989 to the lon$ a)is of tibia.
* cut is ade &ith a sa& in the body of talus parallel to cut end
of tibia, and foot is ali$ned in re!uired position. * stout
0teinann pin is passed throu$h the centre of lo&er end of tibia
%c pro)ial and parallel to cut surface. ,he cut surface are
placed in close apposition, and siilar pin is passed throu$h
body of talus parallel to the first pin. ,his pin should be placed
so as to lie just anterior to the centre of the bone copression.
2harnley claps are applied &ith butterfly scre&s do&n&ards
and copressed till there is $ood copression &ith soe
bendin$ of pins. 7ost op a belo& knee cast applied. *t % &eeks
the plaster and pins are reo(ed, and belo& knee &alkin$ cast
applied and retained until union is sound, usually 8 to 18
&eeks.
Calan)ruccio ; +e(iced a trian$ular frae to produce
copression and control otion in all three planes.
Calan)ruccio %% ; * odified desi$n, easier to apply 9
and allo&s ore latitude in pin placeent to a(oid
coproised areas of skin or boneB the eliination of
the etal cross:bar has ade it easier to se the
arthrodesis site on intraoperati(e and post operati(e
radio$raphs.
$in* or circular e+ternal fi+ators also ha(e been used
to inii"e pin tract infection, but they are
cubersoe for patient, re!uire careful pin tract care
and are e)pensi(e. 2an be used effecti(ely in patient
&ith poor bone !uality, in re(isions for non: union or in
sal(a$e situation such as failed total ankle arthoplasty or
acti(e infection.
INTERNAL FI*ATION
A),anta*e : 1ase of insertion, patient con(enience, coparable rates of delayed
union, alunion, non:union and infection, $reater resistance to shear strain.
Cancellous scre-s in (arious confi$urations are ost coonly used.
Mann et al ; recoended t&o parallel cancellous scre&s inserted fro the
lateral process of talus to en$a$e the posteroedial tibial corte).
.rie)man et al ; found ho&e(er that crossed scre&s &ere ore ri$id than
parallel scre&s, especially resistin$ torsional stress.
/olt et al0 used an <inside out= drillin$ techni!ue to place a posterolateral
tibiotalar scre& throu$h the posterolateral tibial corte) into the head of the
talus.
S-ar) et al: #e described a techni!ue of posterior internal copression usin$
t&o posterior cancellous scre&s &ith &ashers inserted obli!uely across the
tibiotalar joint and do&n into the neck of the talus.,hey added auto$enous
cancellous bone chips fro the iliac crest packed into a deep slot cut in the
joint.
O*il,ie0/arris et al: #e sho&ed in a bioechanical cada(er study that three
crossed scre&s $enerated si$nificantly ore copression and resistance to
tor!ue across the arthrodesis site than did t&o scre&s.,hey also found that
better copression &as obtained &hen lateral scre&s &as inserted first.,hey
recoended placin$ one scre& laterally, one edially and one anteriorly
fro the tibia to the talus.
Moore et al used intraedullary nails to obtain fusion.,hey recoended that
the techni!ue be reser(ed for si$nificant post:trauatic arthrosis and bone loss
after tibial plafond fracture ,concoitant subtalar arthrosis , se(ere osteopenia
(e$ in patients &ith rheuatoid arthritis) and neuropathic arthropathy.
(ONE GRAFTING:
*ddin$ bone $raft to copression has been reported to hasten fusion and
increase the fusion rate.
.
TI(IOTALAR ARTHRODESIS +ITH ILIAC CREST (ONE GRAFT
(Chuinar) an) Peterson)
I. *nterior lon$itudinal incision o(er the ankle joint, and de(elop the
approach bet&een the 1#C and 1+C tendons.
II. -etract edially the anterior tibial (essels and ner(e, and detach the
capsule of ankle joint fro the anterior ar$in of tibia.
III. *rticular cartila$e is reo(ed fro the superior surface of talus and
inferior surface of tibia. *(oid injurin$ the distal tibial physis in
children.
ID. Iliac $raft is har(ested and perforated &ith drill.
D. Eraft is inserted &ith its &ide ri facin$ anteriorly.
DI. 2heck the position of foot and adjust it to neutral.
DII. 2lose the &ound, apply an *3F cast in 1%9 knee fle)ion.
TI(IOTALAR ARTHRODESIS +ITH SCRE+ FI*ATION
(Mann et al)
I. Incision: be$in skin incision 18c pro)ial to the tip of fibula, and carry it
do&n alon$ the fibular shaft then sli$htly distally another 18c to&ards the
base of G
th
etatarsal. ,his incision passes throu$h a interner(ous bet&een the
sural ner(e posteriorly and superficial peroneal ner(e anteriorly.
II. +e(elop a skin flap to create a full:thickness flap alon$ the skeletal plane.
III. 0trip the periosteu fro fibula anteriorly and posteriorly,and carry the
incision distally to e)pose the posterior facet of the subtalar joint and the sinus
tarsi area. 2arry the dissection across the anterior aspect of tibia and ankle
joint.
ID. >steotoi"e the fibula appro)iately 4 c pro)ial to the le(el of ankle
joint.
D. -eo(e the distal portion of fibula to e)pose lateral aspect of tibia and ankle
joint and the posterior facet of the subtalar joint.
DI. 1)pose the ankle ortise.
DII. .ake the initial cut in the distal part of tibia and brin$ the cut across the ankle
joint stoppin$ just &here the cur(e of the edial alleous be$ins.
DIII. -eo(e the entire edial alleous throu$h a separate edial incision takin$
care of saphenous ner(e, posterior tibial tendon
IH. 7lace the foot in proper ali$nent, and join the t&o joint surfaces.
H. 0tabilise the talus to the tibia &ith a to&el clip,a bone clap or k:&ire.
2arefully check ali$nent.
HI. Iith a 5.% drill bit drill t&o holes across the arthrodesis site, one
be$innin$ &ith in the sinus tarsi area and other just abo(e the lateral process.
HII. *s the initial hole is drilled in the sinus tarsi, in(ert the calcaneus as uch as
possible and hold the drill bit alost parallel to floor as it passes out edially
throu$h the distal end of tibia. +isconnect this bit fro the drill, and use a
second bit to drill hole just abo(e the lateral process, alost parallel to first
drill bit. 2arefully check the ali$nent a$ain. -eo(e one drill bit and
easure the depth of the hole, tap it and insert a A.% scre&.
HIII. 7lace the scre& in the lateral process hi$h enou$h that it does6nt ipin$
a$ainst the posterior facet.
HID. If bone $raft re!uired place soe.2lose the &ound o(er a suction drain.
AD$ANTAGES ;
,he bialleolar approach allo&s for e)cellent (isuali"ation of articular
surfaces, as &ell as decopression of the typical bulbous distension of the
ankle secondary to chronic recurrent inflaation and arthritis
1)posure of the distal tibia edially and laterally allo&s for eticulous intra
operati(e e(aluation of accuracy of the cuts and the o(erall ali$nent of distal
peripheral e)treity.
Internal fi)ation a(oids pin tract infection and other probles often associated
&ith e)ternal fi)ators.
2opression scre& fi)ation allo&s e)cellent appro)iation of cut surfaces
and rapid osseous union.
Inlaid iliac bone $raft ay decrease the risk of pseudoarthrosis.
DISAD$ANTAGES
,&o incisions are re!uired
>steotoy and reo(al of edial and lateral alleolus ay result in
less surface area bein$ a(ailable for fusion.
If fi)ation is inade!uate, a third scre& (posterior or anterior) or an e)ternal
fi)ation de(ice ay be re!uired.
ARTHROSCOPIC ANKLE ARTHRODESIS
7erfored by 7atil et al, in 199G &ere articular cartila$e and joint debris is
reo(ed by po&er instruents.,echnically this does6nt allo& correction of defority
and is only su$$ested for in situ arthrodesis.
A(&A'TA1#S:
2) Juicker fusion because liited e)posure and less e)tensi(e periosteal
strippin$.
3) 7reser(ation of o(erall contour of ankle ortise and better cosetic
result.
(%SA(&A'TA1#S:
1),echnically difficult
4),ie consuin$
5)2an only be used in ankle &ith inial defority.
GAIT ALTERATION
Disual $ait analysis follo&in$ ankle fusion is noral in 435
rd
patients despite
decrease &alkin$ speed o&in$ to shortened stride len$th. .odified shoes &ith a
solid:ankle cushioned heel (0*2#) and etatarsal rocker ipro(es patient $ait.
.alposition of foot contributes to $ait abnoralities. 1)cessi(e <e!uinus=
produces a <haltin$ $ait=, in &hich the stance phase is not copleted, the foot is
kept in front of body and &alkin$ accoplished in short steps, the fused foot
bein$ pushed ahead and opposite foot brou$ht up fro rear, can result in $enu
reucur(atu.
'usion in <calcaneus= result in a stiff <pe$ like $ait= &ith lack of push:off.
<(arus= position of ankle can result in a lateral thrust at the knee. 'ailure to
translate talus posteriorly on tibia produces a <(aultin$ $ait=.
COMPLICATIONS
1. 'on union : .odern techni!ues ha(e brou$ht the rates fro 5% to G8 K
to % to 18 K. /europathic atrophy or presence of pre:operati(e infection
can si$nificantly increase the incidence of non:union.
4. Malunion : #a(e deleterious effects on the foot and adjacent joints
throu$hout the e)treity. .inor defority can be treated &ith pad
insertion and shoe odification, se(ere can be corrected &ith osteotoy.
5. %nfection : ,he routinue use of prophylactic antibiotics, care in handlin$
the soft tissues and early a$$ressi(e treatent of superficial &ound
probles ay lessen the occurrence of this coplication. 2opression
dressin$s liit s&ellin$ and inii"e haeatoa.
G. Persistent pain : 0ubtalar inflaation or arthrosis is often the cause.
0cre&s penetratin$ the subtalar joint can also be painful. .ost patients
ha(e decresed subtalar otion after aple arthrodesis.
%. (e*enerati,e chan*es: ,he chopart6s and Cisfranc6s joint ha(e been
docuented radio$raphically at lon$ ter follo& up to ha(e de$enerati(e
chan$es. .ost reain asyptoatic or can be treated &ith shoe &ear
odification.
A. Ten)on laceration:,he tibialis posterior and lon$ fle)or of the hallu) are
(ulnerable durin$ the resection of distal tibial articular surface.
CONCLUSION
'usion procedures of ankle are indicated priarily for se(ere pain, instability and
defority. -e$ardless of reason or techni!ue success is lar$ely predicted.
(I(LIOGRAPH)
2.Campbell4s operati,e orthopae)ics5 ,ol % 5 22
th
e)ition5 chapter 65p* 276 8 29:
3.Current practice in .oot an) Ankle Sur*ery. &olume 35 1lenn Pfeffer an)
Carol C. .rey . Chapter 6 pa*e ;< to :7.
6.Te+tbook of Orthopae)ics an) Trauma 3
n)
e)ition 1 S =ulkarni ,olume <
chapter 69; pa*e 699;0>?
<.Turek0te+t book of orthopae)ics