By, Christopher Hood Jr.

TUSPM Class of 2012 Crozer-Keystone Health System

Albert 1879 coined arthrodesis; tibio-talar arthrodesis Lexer 1906 TTC Fusion with cadaver bone (boiled corpse bone pin) across AK/STJ Charnley 1951 External Fixation of the Ankle for fusion compression Schneider 1983 Arthroscopic Ankle Arthrodesis first described Myerson - 1996 Mini-Arthrotomy

Gold Standard for Degenerative Joint Arthritis of the ankle

Primary DJD rare Secondary/post-traumatic Most Common

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Arthritis Neuromuscular Failed Total Ankle Replacement MISC

Dotes et al. 2010

eorthopod.com

The purpose of ankle arthrodesis is to eliminate pain and deformity by solid fusion of the bones involved (talus tibia, fibula) and to obtain a neutral plantigrade foot How do we get solid fusion?

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Complete removal of all cartilage, fibrous tissue, and any other material that may prevent contact of raw bone surfaces Accurate and close fitting of the fusion surfaces Optimal position of the ankle joint Maintenance of the bone apposition in an undisturbed fashion until fusion is complete

Frontal McGlamry RF slight valgus

Transverse 15 ER

Sagittal Right Angle (up-tp 5 PFX) Right Angle

hang

light valgus e ging

mpara le t contra lateral lim

chu erth

RF slight valgus

10 ER

Neutral Flexion

Myerson

5 Valgus

5 ER

Neutral Flexion

Open
Many incision approaches
x Medial / Lateral x Anterior x Posterior

Arthroscopic
Anteromedial and Anterolateral portals

Mini-Open

Lateral Incision

Medial Incision

Chang et al.

Chang et al.

www.worldortho.com

http://www.orthopaedics.co.uk/boc/patients/images/ankle_arth roscopy_fig2.gif www.thefootandankleclinic.com

AM and AL incisions along talocrural gutters 1.5cm long

Raikin 2003

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Screws IM Nails
T2 Arthrodesis Stryker Phoenix - Biomet

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Plates External Fixation

www.thefootandankleclinic.com

www.txsportsmed.com

www.strykerfoot.com

Ilstraining.com - Integra

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2 vs. 3 (vs. 4)? Direction? Order of Insertion?

Morgan et al. 1985

Zwipp et al. 2010

Crossing 6.5mm short-thread cancellous screws or 7.3mm cannulated screws Crossed to cancel out any shift caused by their oblique orientation Placement Two Screws
Medial above Medial Mallelous to AnteroMedial aspect of talar body Lateral - AnteroLateral aspect of tibia to PosteroLatearl aspect of talar body

McGlamry Foot and Ankle Surgery Chapter 38

Morgan et al. JBJS 1985

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101 patients underwent ankle fusion F/U 10 years 90% good to excellent results 95% fusion rate 2 screws
More than two screws were never needed.

Morgan et al. 1985

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1st distal tibial metaphysis talar body 2nd distal fibular metaphysis talar body Angled anteriorly at 40

Holt et al. Clinical orthopaedics and related -research 1991

23 patients - 3 screw technique 1st *placed posterior to anterior from posterior mallelous to talar neck/head (6.5mm) 2nd medial mallelous to talar body 3rd lateral malleous to talar body ` 93% fusion rate
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(1) Posterior Screw: Resists flexion and extension Pulls ankle out of equinus Compresses joint surfaces

Holt et al. 1991 Holt et al. 1991

Ogilvie-Harris et al. Clin Orthop Relat Res 1994.

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16 cadaver arthrodesis constructs 2 screw vs 3 screw technique compared Order of insertion compared

Ogilvie-Harris et al. 1994 Ogilvie-Harris et al. 1994

2 screws < 3 screws

2 screws = 1375 pixels 3 screws = 3227 pixels

Order of insertion
Lateral >>> Anterior Medial

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3 screws increased resistance to tibial torsion Recommendations:

usage of 3 screws routinely lateral screw first, then medial, and 3rd screw anterior

Alonso-Vazques et al. Clinical Biomechanics 2004.

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2 screws crossed medial and lateral into talus 3rd screw either inserted:
PosteroLat tibia aiming AnteroMed to talar neck (Holt et al 1991) Anterior Tibia aiming PosteroInferior talar body (OgilvieHarris et al 1994)

Which screw decreases micromotions greater?

Results: Anterior screw decreased peak micromotions more than posterior screw with greater torsional stability
Alonso- azquez 2004

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Jeng et al. Foot Ankle Intl 2011 17 cadaver ankles of no deformity present Cartilage left intact 7.0 cannulated PT screws used
Results: Insertion was equal in regards to:
Total contact area (0.9 1.1 cm), Percent contact area (10.3 11.9%) Pressure generated (1.1-1.2 mPa)

Jeng et al. 2011

All 3 screw orientations concentrated contact area and percent contact area over the anterior half of the ankle

Jeng et al. 2011

What technique do you use?

2 v 3 v 4 screws? Sequence?

Additional comments? Pearls? Advice?

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Alonso- azquez A. Initial stability of ankle arthrodesis with three-screw fixation. A finite element analysis. Clinical Biomechanics. 2004; 19: 751759. Chang TJ. Master Techniques in Podiatric Surgery: The Foot and Ankle. Lippincott Williams and Wilkins. First Edition. 2004. Holt ES. Ankle Arthrodesis Using Internal Screw Fixation. Cliinical Orthopaedics and Related Research. 1991 July; 268: 21-28 Jeng et al. Comparison of Initial Compression of the Medial, Lateral, and Posterior Screws in an Ankle Fusion Construct. Foot Ankle Intl. 2011 Jan; 32(1). 71-76 McGlamry D. McGlamrys Comprehensive Textbook of Foot and Ankle Surgery. Lippincott Williams and Wilkins. Third Edition. 2001. Morgan et al. Long-term results of tibiotalar arthrodesis. JBJS. 1985 April; 67 (4): 546-550 Ogilvie-Harris DJ. Arthrodesis of the ankle. A comparison of two versus three screw fixation in a crossed configuration. Clinical Orthopaedics and Related Research. 1994; 304: 195-199. Schuberth JM. The Tripod Fixation Technique for Ankle Arthrodesis. JFAS 2009; 48(1): 93-96.