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Tibiotalar Arthrodesis

Planning

B

Preoperative Plan

1

Radiographic templating

  • Use radiographs and CT scan to map out placement of implants

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • microsagittal saw
  • osteotomes
  • curets
  • 7.3 mm cannulated screws
  • 4.0 or 4.5 mm cannulated screws
  • plating systems (optional)

2

Room setup and equipment

  • standard OR table

3

Patient positioning

  • supine with foot at the edge of the table
  • place sandbag under the ipsilateral hip to internally rotate the foot

Technique

D

Superficial Dissection

1

Mark out the anatomy and the incision

  • start incision 10 proximal to the tip of the fibula
  • extend incision distally down the shaft of the fibula to the base of the fourth metatarsal
  • internervous plane is between the peroneal muscles and the extensors

2

Incise retinaculum

  • incise the superior peroneal retinaculum posteriorly
  • mobilize the peroneal tendons
  • protect the sural and SPN
  • make sure to maintain full thickness skin flaps

3

Remove periosteum

  • use osteotomes to strip the periosteum of the fiibula anteriorly
E

Deep Dissection

1

Extend the incision medially

  • expose the distal tibia, tibiotalar articulation posterior facet of the subtalar joint and the sinus tarsi

2

Strip the periosteum off the fibula

  • use an osteotome to strip the anterior fibula and strip the posterior fibula slightly
F

Joint Preparation

1

Expose the anterior joint

  • use a periosteal elevator to strip the soft tissue from the distal end of the tibia and the talar neck to the medial malleolus

2

Perform fibular osteotomy

  • use an oscillating saw to create a fibular osteotomy approximately 4 to 6 cm proximal to the tip of the lateral malleolus
  • debride the syndesmosis cartilage soft tissue and cortical bone

3

Harvest fibular bone graft

  • make a sagittal cut of the fibula to resect the medial fibular fragment
  • morselize and use for autologous bone graft

4

Remove ankle capsule

  • use sharp dissection through the lateral incision to elevate the scarred ankle capsule and strip soft tissue attachments from the joint both anteriorly and posteriorly
  • place retractors to expose the ankle mortise and protect soft tissues while the bone cuts are made
  • manually denude the tibiotalar joint of cartilage and subchondral bone with curettes and or osteotomes
G

Arthrodesis Preparation

1

Place foot in proper alignment for arthrodesis

  • place talus in position so that the forefoot is in 5 to 10 degrees of external rotation
  • place hindfoot into 5 degrees of valgus and 0 degrees of dorsiflexion
  • make a cut through the dome of the talus that is parallel to the distal tibia cut
  • resect 3 to 5 mm of bone
  • bring the joint together and check the alignment

2

Expose the medial malleolus

  • make a 6 cm longitudinal incision along the anterior third of the medial malleolus
  • dissect through the subcutaneous tissue
  • make sure to maintain full thickness flaps
  • remove the ankle capsule and periosteum
  • remove any residual cartilage and sclerotic bone

3

Create vascular channels

  • drill joint surface until bleeding bone is obtained
  • obtain the desired alignment
H

Fixation

1

Place guidepins

  • secure joint by placing to guidepins for large partially threaded cannulated screws
  • start at the base of the talar neck and direct guidepin proximally in the posteromedial direction and lateral to the anterior process
  • start the second guidepin just above the posterior facet and anterior to the lateral process in the postermedial direction parallel to the first guidepin
  • make sure not to violate the subtalar joint with the guidepins

2

Check alignment

  • use fluouroscopy to check the alignment and placement of the guidepins

3

Place cannulated screws

  • remove guidepins

4

Use fluoroscopy to check reduction and screw placement

I

Treat Intraoperative and Immediate Postoperative Complications

1

Step 1 of treating intraoperative complications

2

Step 2 of treating intraoperative complications

J

Wound Closure

1

Irrigation and hemostasis

  • ensure hemostasis using cautery

2

Superficial closure

  • use 3-0 nylon horizontal mattress sutures for skin

3

Deep closure

  • use 2-0 vicryl for the subcutaneous layer

4

Dressing and immediate mobilization

  • place in well padded non-weightbearing short leg plaster cast
  • split in postop to allow for swelling

Patient Care

K

Preoperative H & P

1

Obtain history and perform basic physical exam

  • complete neurovascular exam of extremity.
  • identify medical co-morbidities that might impact surgical treatment
  • diabetes, smoking and previous surgery all effect wound healing

2

Order basic imaging studies

  • order weight-bearing triplanar films of the ankle

3

Perform operative consent

  • describe complications of surgery including
  • infection
  • nonunion
  • neurovascular injury
  • wound healing problems
L

Peroperative Inpatient Management

1

Write comprehensive admission orders

  • pain meds
  • IV fluids
  • DVT prophylaxis
  • advance diet as tolerated
  • check appropriate labs
  • foley out when ambulating
  • wound care
  • physical therapy
  • non-weightbearing
  • strict elevation
  • check postoperative films

2

Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • check neurovascular status

2

Appropriately orders and interprets advanced imaging studies/lab studies

  • radiographs
  • weigthbearing ankle series
  • AP
  • mortise
  • lateral
  • CT scan
  • determines the degree of arthritis in the subtalar joint and anatomy of the ankle
  • MRI
  • used to check for osteonecrosis of the talus

3

Prescribes and manages non-operative treatment

  • activity modification
  • guides trial of medical managment
  • NSAIDS
  • intraarticular steroid injections
  • UCBL brace

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove cast
  • remove sutures
  • place in weightbearing short fiberglass cast
  • diagnose and management of early complications
  • wound healing
  • infection
  • DVT
  • postop: 4-6 week postoperative visit
  • obtain radiographs
  • remove cast
  • place in walking orthosis
  • diagnosis and management of late complications
  • postop:12 week postoperative Visit
  • obtain radiographs to check for union
  • start range of motion exercises
N

Advanced Evaluation and Management

1

Provides patient specific non-operative treatment

  • diagnostic injections

2

Modifies and adjusts post-operative treatment plan as needed

O

Complex Patient Care

1

Treat complex complications

 

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