Mini-Open Ankle Arthrodesis

Christopher P. Chiodo

Eric M. Bluman

INDICATIONS

Tibiotalar arthrodesis is indicated for symptomatic ankle arthritis that sufficiently interferes with activities of daily living and has not responded to several months of non-operative therapy. Potential nonoperative interventions include anti-inflammatory medications, bracing, and cortisone injections. In older and less active individuals, arthroplasty may be considered. However, for most younger and higher-demand patients with advanced disease, arthrodesis remains the surgical treatment of choice. When considering less-invasive procedures deformity should be minimal, especially with an attempted arthroscopic procedure.

Absolute contraindications for less-invasive arthrodesis include active infection, advanced deformity that necessitates fibular osteotomy and/or flat bone cuts, as well as inability to comply with the postoperative regimen. Relative contraindications include moderate deformity, the presence of advanced cystic disease, and nicotine dependence. In some patients with a compromised soft tissue envelope a less-invasive technique may be tolerated where a traditional open procedure would not.

PATIENT POSITIONING

For the mini-arthrotomy technique, the patient is positioned supine. The ipsilateral hip is bumped if necessary such that the toes point toward the ceiling and both sides of the ankle are accessible. It is also helpful to elevate the operative leg on a foam wedge or stack of blankets (Fig. 10-1). This facilitates access to the ankle as well as facilitating intraoperative imaging. Intraoperative fluoroscopy is necessary to guide and confirm proper fixation and alignment.

Regional anesthesia, specifically a long-acting popliteal and saphenous nerve block, is advantageous and used whenever possible. This allows the majority of procedures to be performed on an outpatient basis.

SURGICAL APPROACH AND TECHNIQUES

With the arthroscopic technique, standard anteromedial and anterolateral arthroscopy portals are utilized, just adjacent to the anterior tibial and peroneus quartius tendons, respectively. One portal is used for visualization while the other is used as a working portal. An accessory posterolateral portal, located in the interval between the Achilles and peroneal tendons, can also be used if necessary. Cartilage is removed with arthroscopic instruments and then the subchondral bone is prepared with a burr.

With the mini-arthrotomy technique, two longitudinal incisions, approximately 2 to 3 cm in length, are utilized (Fig. 10-2). The locations of these anterior incisions approximate those of the standard anterolateral and anteromedial ankle arthroscopy portals. The roles of these portals alternate during the surgery. One incision is used as a distraction portal while the other is used as a working portal (Fig. 10-3).

The first incision is centered over the joint line just medial to the anterior tibial tendon. The anterior joint is exposed and anterior osteophytes are resected. A Cobb elevator is then used to release the capsule anteriorly. Any scar tissue or synovium that may impede visualization is
removed. The lateral incision is made next and is positioned just lateral to the peroneus tertius tendon. Great care should be taken to protect the superficial peroneal nerve with subcutaneous dissection. These steps are all critical to adequately visualize the joint and ensure that it is actually “exposed” and not simply “approached.”

Only gold members can continue reading. Log In or Register to continue