Figure 22.1
Preoperative (a) anterior-posterior, (b) mortise, and (c) lateral radiographs of the left ankle demonstrated post-traumatic degenerative changes including joint space narrowing and sclerosis along with anterior subluxation of the talus and, additionally, soft tissue calcification
Fixation: After verification of alignment and rotation using fluoroscopy, position was maintained by the placement of three guide wires (Fig. 22.2a). Two guide wires were placed through the talus, and into the distal tibia. The third guide wire was placed from the distal tibia into the talus. (Note: The sometimes recommended screw placement that we did not use for this case is directed proximal-posterior in the tibia to distal-anterior into the talar head.) Near cortices were predrilled and cannulated cancellous screws were placed. Placement of the first screw achieved compression across the arthrodesis site. The two additional screws provided additional compression, stability, and strength. Fluoroscopy was again used to confirm desired tibiotalar alignment and position of the hardware. The wounds were copiously irrigated with sterile saline and closed in a layered fashion over a drain.
Figure 22.2
(a) Intraoperative fluoroscopic AP radiograph of the left ankle showing K-wire placement for cannulated screws. (b and c) AP and lateral radiographs of the left ankle immediately postoperatively demonstrating functional alignment and fixation of the tibiotalar joint
Postoperative Plan
Sterile dressings were applied and final plain radiographic images were taken (Fig. 22.2b, c). A splint was then applied for 2 weeks for soft tissue protection. The patient’s activity status was recommended to be non-weight-bearing until wounds were healed and followed by touch-down weight-bearing until 6 weeks after surgery (with radiographic verification of maintained alignment) and finally full weight-bearing at 3 months. Protective CAM boot was utilized until pain free weight-bearing had been achieved just prior to 4 months after surgery.
Outcome
The patient’s 16-month postoperative radiographs are shown in Fig. 22.3, which demonstrated consolidated tibiotalar fusion in functional alignment without hardware complication. Functionally, he completed a course of physical therapy during which he successfully advanced to full weight-bearing activity with no residual ankle pain and no visible limp with walking at up to moderate speeds.
Figure 22.3
(a–c) 16-month postoperative AP, mortise, and lateral radiographs of the left ankle showing union of the tibiotalar joint
Salient Points/Pearls
Trauma is the most common cause of ankle arthritis (70%) with the following types of injury being the most common: rotational fractures, recurrent ankle instability, and single ligamentous sprains with continued pain [13].
Important determinants of surgical decision-making are the patient’s pain, anatomy, and functional disability.
Tibiotalar arthrodesis is indicated for post-traumatic ankle arthritis because of the procedure’s ability to improve pain while maintaining functional motion through adjacent joints, durability for active/younger patients, high success rates, and low rates of reoperation [1–12].
While tibiotalar arthrodesis is the gold standard for treatment of tibiotalar arthritis, total ankle replacement may be considered in patients with low functional demand and interest in attempted preservation of some tibiotalar motion [14].Related posts:
Trimalleolar Ankle Fracture: Screws Only for Posterior Malleolus
Trimalleolar Ankle Fracture: Posterior Plate for Posterior Malleolus Fractures
Bimalleolar Ankle Fracture: Medial Plate
Lisfranc Fracture/Dislocation Treated with Primary Arthrodesis
Calcaneus Malunion with Subtalar Fusion (Bone Block Arthrodesis)
Cuboid and Nutcracker Fractures
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