Ankle Arthrodesis

Indications

Indications
- painful arthritis following
  - infection
  - trauma (most common cause)
  - chronic instability
  - AVN of the talus
  - inflammatory arthropathy
  - primary OA
- neuropathic arthropathy
- tumor resection
- salvage for failed ORIF

Technique

Optimal Position
- neutral dorsiflexion
- 5-10° of external rotation
- 5° of hindfoot valgus
Arthroscopic arthrodesis
- only indicated if minimal deformity present
Open arthrodesis
- transfibular approach often used when deformity present
  - screw fixation
  - plate and screw construct
  - external fixation
Tibiotalocalcaneal (TTC) fusion
- performed with retrograde nail for subtalar and tibiotalar arthritis

Complications

Nonunion
- incidence
  - 10% non union rate
  - tobacco users have 2.7x risk
Lateral plantar nerve injury
Superificial peroneal nerve
- injury to superificial peroneal nerve during transfibular approach
Hindfoot arthritis
- adjacent hindfoot arthritis commonly occurs following fusion

TAG

(OBQ09.91) A patient with subtalar and tibiotalar arthritis underwent the surgery shown in Figure A. The patient now complains of numbness on the plantar/lateral aspect of his foot including the 4th and 5th toes. Which nerve was most likely injured? Topic

Review Topic

FIGURES: A

1. Lateral plantar
2. Medial plantar
3. Sural
4. Superficial Peroneal
5. Deep Peroneal

PREFERRED RESPONSE ▶

DISCUSSION: The lateral plantar nerve innervates the plantar skin covering the lateral half of the fourth toe and the entire fifth toe. This nerve also provides motor innervation to many of the deep muscles in the foot. Both references concluded that the optimal insertion site is in close proximity to many neurovascular structures. They recommend doing a careful dissection of the heel to avoid damage to any structure(s). The structure that Flock et al found to be at risk specifically was the nerve to the abductor digiti quinti, which is a branch of the lateral plantar nerve.

Illustrations: A

REFERENCES:

1. Flock TJ, Ishikawa S, Hecht PJ, Wapner KL. Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis. Foot Ankle Int. 1997 Apr;18(4):233-5. PMID:9127114 (Link to Abstract)

2. Pochatko DJ, Smith JW, Phillips RA, Prince BD, Hedrick MR. Anatomic structures at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod.Foot Ankle Int. 1995 Sep;16(9):542-7. PMID:8563921 (Link to Abstract)

Question Authors:

Khalid Yousuf MD,

Please Rate Educational Value!

3.0

Average 3.0 of 13 Ratings

TAG

(OBQ08.60) When performing an ankle fusion, the foot should be in: Topic

Review Topic

1. 0 degrees dorsiflexion/plantarflexion, 0-5 degree hindfoot valgus, 5-10 degree external rotation
2. 0 degrees dorsiflexion/plantarflexion, 0-5 degrees hindfoot valgus, 0 degrees external rotation
3. 10 degrees dorsiflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation
4. 0 degrees dorsiflexion/plantarflexion, 20 degrees hindfoot valgus, 5-10 degrees external rotation
5. 10 degrees plantarflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation

PREFERRED RESPONSE ▶

DISCUSSION: Buck et al in a retrospective analysis of 19 patients who underwent ankle fusion at 10 years follow-up found that: “The patterns of gait showed that a valgus position of the arthrodesis is more advantageous and provides more normal gait, particularly on uneven ground. To attain more normal function of the knee and improve performance on rough ground, the optimum position of arthrodesis of the ankle appears to be neutral flexion, slight (zero to 5 degrees) valgus angulation, and approximately 5 to 10 degrees of external rotation.”

Plantarflexion (#5) is never that answer as the goal is to have a plantigrade foot. Too much dorsiflexion (#3) or valgus (#4) alter the gait and place increased stress on the knee.

REFERENCES:

1. Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am. 1987 Sep;69(7):1052-62. PMID:3654697 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

Cases

	Pilon (C1502) Foot & Ankle - Treatment Consult - Ankle Arthrodesis HPI - Jumped out of second story house. Was found by police screaming and intoxicated. What would you do for initial treatment	2 weeks ago 345 responses 5
	Disaster Scenario (C1117) Foot & Ankle - - Ankle Arthrodesis HPI - s/p multiple podiatric surgeries on ankle, now with chronic pain, freely drainin... What would you do with this scenario?	12/24/2011 45 responses
	Pilon Fracture (C1191) Foot & Ankle - - Ankle Arthrodesis HPI - Rt Ankle Injury March 2011, presents now with Rt ankle pain. Neglected Injury. Management Plan?	4/16/2012 330 responses 5
	?avn of cuneiforms,navicular,base of metatarsals of left foot (C1286) Foot & Ankle - Treatment Consult - Ankle Arthrodesis HPI - patient is having pain in his left foot for 7 month aggravated by last 3 month.c... what can be the differential diagnosis and line of treatment	10/11/2012 43 responses

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Groups

ABOS II: Ankle Arthrodesis

General - Oral Boards Review

7/29/2011

0 responses

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Flock TJ, Ishikawa S, Hecht PJ, Wapner KL. Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis. Foot Ankle Int. 1997 Apr;18(4):233-5. PMID:9127114 (Link to Abstract)
Pochatko DJ, Smith JW, Phillips RA, Prince BD, Hedrick MR. Anatomic structures at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod.Foot Ankle Int. 1995 Sep;16(9):542-7. PMID:8563921 (Link to Abstract)
Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg Am. 1987 Sep;69(7):1052-62. PMID:3654697 (Link to Abstract)

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