Updated: 6/10/2019

Ankle Arthrodesis

Topic
Review Topic
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Questions
17
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0
Evidence
17
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0
Videos
7
Cases
5
Techniques
1
https://upload.orthobullets.com/topic/7052/images/ankle fusion.jpg
https://upload.orthobullets.com/topic/7052/images/hindfoot nail_moved.jpg
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 
    • salvage for failed TAA   
Technique
  • Optimal Position  
    • neutral dorsiflexion
    • 5-10° of external rotation
    • 5° of hindfoot valgus
    • 5 mm of posterior talar translation
  • 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
    • staged approach
      • infection should be cleared prior to placement of definitive internal hardware for arthrodesis 
  • Tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail 
    • Load-sharing device with improved bending stiffness and rotational stability compared to plate-and-screw constructs 
    • Indications: 
      • End-stage ankle and subtalar arthritis
      • Charcot neuroarthropathy
      • Significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis)
      • Osteonecrosis of the talus
      • Severe acute trauma
    • Contraindications: 
      • Active infection
      • Profound vascular disease
      • Severe tibia malalignment
Complications
  • Nonunion
    • incidence
      • 10% non union rate
      • tobacco users have 2.7x risk 
      • neuropathy is greatest risk factor for persistent nonunion with revision of nonunion  
  • Lateral plantar nerve injury 
  • Superficial peroneal nerve
    • injury to superficial peroneal nerve during transfibular approach
  • Hindfoot arthritis
    • adjacent hindfoot arthritis commonly occurs following fusion
    • isolated hindfoot arthritis due to chronic pes planus is treated with subtalar joint arthrodesis 
 

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Questions (17)
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(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? Review Topic

QID: 2904
FIGURES:
1

Lateral plantar

81%

(1452/1783)

2

Medial plantar

1%

(15/1783)

3

Sural

13%

(228/1783)

4

Superficial Peroneal

4%

(70/1783)

5

Deep Peroneal

1%

(9/1783)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ13.16) A 45-year-old laborer sustained the injury shown in Figure A. Closed reduction is performed and post-reduction films are shown in Figure B. He elects to proceed with nonoperative treatment. Two years later he now presents with persistent ankle pain and difficulty walking long distances. On physical exam, he is found to have an antalgic gait with limited ankle motion secondary to pain. Crepitus is felt with passive range of motion of the ankle. The most recent radiographs are shown in Figure C. An MRI report indicates the presence of degenerative changes in the ankle. What would be the most appropriate option for definitive management? Review Topic

QID: 4651
FIGURES:
1

Steroid injection into the ankle

1%

(16/2625)

2

Total ankle arthroplasty.

2%

(61/2625)

3

Tibiotalocalcaneal (TTC) arthrodesis with femoral head allograft

75%

(1966/2625)

4

Subtalar Fusion

5%

(126/2625)

5

Triple arthrodesis

16%

(431/2625)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ13.73) A 36-year-old construction worker sustained an ankle fracture 4 years ago after falling off a roof. Postoperative radiographs are seen in Figure A. The hardware is removed 2 years later. He now returns with ankle pain and intermittent swelling but has no difficulty with uneven surfaces. Examination reveals 5 degrees of gastrocnemius equinus contracture, pain with passive plantar and dorsiflexion, but no pain with hindfoot inversion and eversion. Recent radiographs are seen in Figure B. CT scan shows no degenerative changes in the hindfoot. What is the best treatment option? Review Topic

QID: 4708
FIGURES:
1

Arthroscopic debridement of the tibiotalar joint and corticosteroid injection

7%

(348/4734)

2

Tibiotalar arthrodesis with screws

80%

(3804/4734)

3

Total ankle arthroplasty

5%

(241/4734)

4

Tibiotalocalcaneal arthrodesis with an intramedullary device

6%

(280/4734)

5

Tibiotalocalcaneal arthrodesis with an extramedullary device

1%

(40/4734)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 446
1

0 degrees dorsiflexion/plantarflexion, 0-5 degree hindfoot valgus, 5-10 degree external rotation

81%

(1313/1630)

2

0 degrees dorsiflexion/plantarflexion, 0-5 degrees hindfoot valgus, 0 degrees external rotation

8%

(133/1630)

3

10 degrees dorsiflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation

7%

(119/1630)

4

0 degrees dorsiflexion/plantarflexion, 20 degrees hindfoot valgus, 5-10 degrees external rotation

1%

(18/1630)

5

10 degrees plantarflexion, 0-5 degrees hindfoot valgus, 5-10 degrees external rotation

2%

(36/1630)

ML 2

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PREFERRED RESPONSE 1

(OBQ12.180) A 40-year-old male presents with long-standing right heel pain. He reports pain and swelling and points to the region of the sinus tarsi as the maximal area of pain, particularly when walking on uneven surfaces. He also reports a history of recurrent ankle sprains when he was younger. A clinical image of his foot posture is shown in Figure A. Inversion and eversion of the hindfoot reproduce pain. He has no discomfort with passive ankle dorsiflexion and plantarflexion. Coleman block testing reveals a rigid hindfoot. Sensation is fully intact throughout the extremity and he has full strength with ankle dorsiflexion, ankle plantarflexion and he can perform a single-leg heel rise without difficulty. A radiograph is shown in Figure B. What is the most appropriate step in management if conservative measures fail? Review Topic

QID: 4540
FIGURES:
1

Brostrom anatomic reconstruction with Gould modification

9%

(311/3488)

2

Hindfoot arthroscopy with synovial debridement and Os trigonum resection

7%

(244/3488)

3

Subtalar arthrodesis

63%

(2195/3488)

4

Chrisman-Snook nonanatomic reconstruction using tendon transfer

3%

(115/3488)

5

Triple arthrodesis

16%

(574/3488)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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ARTICLES (28)
VIDEOS (7)
CASES (5)
Topic COMMENTS (11)
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