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Tibiotalocalcaneal arthrodesis using anterior approach
22%
536/2391
Ankle arthrodesis utilizing anterior approach
18%
422/2391
Tibiotalocalcaneal arthrodesis using lateral transfibular approach
53%
1264/2391
Total ankle arthroplasty using lateral transfibular approach
5%
121/2391
Total talectomy using lateral approach
1%
21/2391
Select Answer to see Preferred Response
This patient has broad-based avascular necrosis (AVN) of the talus with tibiotalar and subtalar arthritis. A tibiotalocalcaneal (TTC) arthrodesis is indicated. A lateral approach allows direct access to the tibiotalar and subtalar joints along with local autograft. Trauma is the most common etiology for AVN, mainly fractures of the talar body or talar neck, and comprises 75% of cases. The treatment options for talar AVN are varied and dependent to a certain extent on the osteonecrosis stage. Early cases can be treated with core decompression, nonvascularized, or vascularized bone graft. In late cases, where structural changes have occurred, treatment modalities are salvage procedures such as arthrodesis techniques. Tenenbaum reviewed 14 ankles undergoing retrograde nailing for AVN of the talus. They reported union in all cases, 4 of which required a talectomy. A lateral approach was used in 9 cases and utilized local autograft. This study showed that ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with ankle and hindfoot arthrodesis using a compressing retrograde intramedullary nail. Devries performed a case series on 14 patients undergoing retrograding intramedullary for tibiotalocalcaneal fusion secondary to AVN of the talus. 13 cases utilized the fibula as autograft via the lateral transfibular approach with an osteotomy. An adjunct medial incision was also used to debride the medial gutter and centralize the talus. 12 patients went on to union with 2 patients having a stable pseudoarthrosis (functional non-union). Figure A is an AP and lateral ankle demonstration avascular necrosis of the talus with tibiotalar and subtalar osteoarthritis. Incorrect answers: Answer 1: Using the anterior approach alone would not allow access to the subtalar joint for preparation. Answer 2: This patient has subtalar arthritis in addition to tibiotalar arthritis, a better pain-relieving option for this patient includes an arthrodesis of the subtalar joint. Answer 4: Given the broad-based avascular necrosis of the talus as well as patient's age, total ankle arthroplasty is not the best option for this patient. Answer 5: A total talectomy without an arthrodesis would result in significant functional limitation.
1.5
(8)
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