Updated: 6/8/2021

Ankle Arthrodesis

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Cases
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  • summary
    • Ankle arthrodesis is the fusion of the tibiotalar joint most commonly performed for end-stage arthritis of the joint.
    • The procedure may be performed with an open approach or arthroscopically. 
    • The most common complications are development of subtalar arthritis and nonunion. 
  • 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
          • lateral transfibular approach allows for dual joint preparation as well as local autograft
        • 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 (22)
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(OBQ17.179) A 56 year-old male underwent a tibiotalar joint fusion six months ago. He presents for a second opinion due to chronic pain and difficulty walking. His current radiographs are shown in Figure A. The patient has a history of alcoholic induced neuropathy, type 2 diabetes, and had a previous nonunion of his left femur from an unrelated injury. His tibiotalar arthrodesis was completed for treatment of post-traumatic arthritis and his infection workup is currently negative. Which of the following places the patient at greatest risk for persistent nonunion with revision surgical fixation?

QID: 210266
FIGURES:
1

Neuropathy

34%

(611/1814)

2

Diabetes

36%

(651/1814)

3

Prior femoral nonunion

25%

(456/1814)

4

Post-traumatic arthritis

1%

(12/1814)

5

Initial fixation method

4%

(68/1814)

L 5 B

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(OBQ16.211) A 59-year-old male present with left ankle pain and drainage 3 years after surgery for a traumatic injury to the left ankle. He notes worsening pain over the past year. On examination ankle range of motion is limited to a 10-degree arc of motion with erythema and serous drainage from an anterior ankle incision. Figures A and B are his current radiographs. The patient requests a discussion of limb salvage surgery. Of the following, which is the best surgical plan for his condition?

QID: 8973
FIGURES:
1

Maintenance of prior hardware and simultaneous arthrodesis

0%

(7/2331)

2

Maintenance of prior hardware and staged arthrodesis

0%

(9/2331)

3

Removal of hardware, I&D, and simultaneous arthrodesis

5%

(124/2331)

4

Removal of hardware, I&D, and staged arthrodesis

92%

(2142/2331)

5

Removal of hardware, I&D, and simultaneous ankle arthroplasty

1%

(18/2331)

L 1 B

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(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?

QID: 4651
FIGURES:
1

Steroid injection into the ankle

1%

(28/3239)

2

Total ankle arthroplasty.

2%

(79/3239)

3

Tibiotalocalcaneal (TTC) arthrodesis with femoral head allograft

75%

(2415/3239)

4

Subtalar Fusion

5%

(164/3239)

5

Triple arthrodesis

16%

(530/3239)

L 3 B

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(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?

QID: 4708
FIGURES:
1

Arthroscopic debridement of the tibiotalar joint and corticosteroid injection

7%

(406/5455)

2

Tibiotalar arthrodesis with screws

80%

(4340/5455)

3

Total ankle arthroplasty

6%

(306/5455)

4

Tibiotalocalcaneal arthrodesis with an intramedullary device

6%

(333/5455)

5

Tibiotalocalcaneal arthrodesis with an extramedullary device

1%

(44/5455)

L 2 B

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(SBQ12FA.13) A 42-year-old female sustains the injury exhibited in Figure A. Fluoroscopic images are exhibited in Figure B following open reduction and internal fixation. Should she go on to develop tibiotalar arthritis and fail conservative management for this, which of the following treatment modalities has the highest success rate?

QID: 3820
FIGURES:
1

Isolated osteochondral allograft transplantation

1%

(24/2971)

2

Interpositional soft tissue replacement

1%

(21/2971)

3

Tibiotalar fusion

82%

(2450/2971)

4

Arthroscopic debridement and microfracture

2%

(65/2971)

5

Tibiotalocalcaneal fusion

13%

(400/2971)

L 2 C

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(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?

QID: 4540
FIGURES:
1

Brostrom anatomic reconstruction with Gould modification

9%

(379/4098)

2

Hindfoot arthroscopy with synovial debridement and Os trigonum resection

7%

(297/4098)

3

Subtalar arthrodesis

62%

(2559/4098)

4

Chrisman-Snook nonanatomic reconstruction using tendon transfer

4%

(147/4098)

5

Triple arthrodesis

16%

(662/4098)

L 3 C

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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?

QID: 2904
FIGURES:
1

Lateral plantar

80%

(1889/2357)

2

Medial plantar

1%

(18/2357)

3

Sural

14%

(329/2357)

4

Superficial Peroneal

4%

(96/2357)

5

Deep Peroneal

0%

(11/2357)

L 2 C

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

QID: 446
1

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

80%

(1851/2319)

2

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

8%

(187/2319)

3

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

8%

(178/2319)

4

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

1%

(31/2319)

5

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

3%

(58/2319)

L 2 B

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