Tibiotalar Arthrodesis: Anterior Approach
Mackenzie T. Jones
Scott Ellis
Introduction
Ankle arthrodesis has been the treatment of choice for end-stage ankle arthritis. Even with the availability of total ankle arthroplasty, a fusion still has many advantages such as less need for revision,1 consistent results with regard to patient pain relief,2 low cost of initial surgery,3 and success in young active patients who would not be good candidates for arthroplasty.4
There are multiple approaches available for an ankle arthrodesis including arthroscopic, lateral, posterior, and anterior. The anterior approach provides good exposure, making it easier for the surgeon to achieve the correct position of the heel in the coronal plane.5 In addition, it is often preferred for patients with post-traumatic arthritis because the anterior approach will avoid any prior lateral incisions. Another advantage is that the anterior approach allows the fibula to be spared so that the joint can potentially be converted into arthroplasty in the future using the same incision.6
Sterile Instruments/Equipment
Tourniquet
Headlight
Esmarch bandage
Trocar for iliac crest aspiration
#15 blade
Dissecting scissors
Langenbeck retractor
Army/navy retractor
Deep Gelpi
Reciprocating saw
Curved Lambotte osteotome
Straight curette
Curved curette
Microsagittal saw
Burr
2.5-mm drill
Wire driver
0.062 Kirschner wires (K-wires)
Implants:
Anterolateral plate
Additional anteromedial plate for double-plating technique
3.5-mm locking screws
4.0-mm cortical screw
7.5-mm headless partially threaded variable pitch compression screw
0-Vicryl, 2-0 Vicryl, 3-0 Vicryl, and 3-0 nylon sutures
Positioning
The patient is placed in the supine position.
Support the ipsilateral pelvis to control external rotation of the leg. The patella should be directed upward to facilitate surgical approach and operation.
Pad all bony prominences to protect nerves.
Place a nonsterile tourniquet on the operative thigh. Prep and drape the lower extremity in a sterile manner.
Exsanguinate the lower extremity using an Esmarch bandage and inflate the tourniquet 250 to 300 mm Hg.
Iliac Crest Aspiration
Although there is no data to support the idea that an iliac crest aspiration promotes bone fusion, the procedure has low morbidity, with a chance of reducing the risk of nonunion.7
Introduce the trocar into the iliac crest, proximal to the anterior superior iliac spine.
Advance the trocar into the bone, taking care not to violate the cortex of the crest.
Remove 60 mL to be processed.
Remove the trocar and place Steri-strips over the small poke hole followed by a clean, sterile dressing.
Concentrate aspirate with one of a number of commercially available systems.
Surgical Approach
Perform an anterior approach to the ankle centered between the medial and lateral malleoli (Figure 9-1). Make an incision through the skin using a #15 blade that is long enough to insert the plate but just distal to the talonavicular joint to expose the talar neck in its entirety.
Figure 9-1. The skin incision is drawn over the anterior ankle.
Figure 9-2. The superficial peroneal nerve is identified.
Carefully dissect the subcutaneous tissue using dissecting scissors.
Identify the superficial peroneal nerve and retract it laterally (Figures 9-2 and 9-3).
Divide the extensor retinaculum longitudinally.
Retract the tibialis anterior tendon medially and the extensor hallucis longus laterally using a Langenbeck retractor (Figure 9-4).
Perform a longitudinal capsulotomy.
Figure 9-3. The medial branch of the superficial peroneal nerve is identified and must be cut.
Figure 9-4. The deep bundle anterior tibial artery and deep peroneal nerve are visible beneath the retracted tendons.
Elevate the capsule both medially and laterally to expose the joint.
Place the deep Gelpi retractor below the capsule (Figure 9-5).
Remove any osteophytes at the anterior aspect of the ankle using a reciprocating saw, first at the tibia and then at the talus (Figures 9-6 and 9-7).
Figure 9-5. Use the army/navy, Langenbeck, and deep Gelpi retractors to expose the joint under the capsule.
Figure 9-6. A reciprocating saw is used to make a cut in the tibia that is in line with the gutters to gauge the amount of anterior bone spur to remove.
Figure 9-7. A microsagittal saw is used to remove bone spur from the tibial side of the joint.
Prepare the joint from anterior to posterior. Use a smooth laminar spreader to aid in visualization of the joint (Figure 9-8), alternating between medial and lateral positions, and scrape any remaining cartilage from the tibia and talus using a combination of an osteotome, a microsagittal saw, and straight and curved curettes (Figure 9-9).Related posts:
Management of Metatarsalgia and Equinus Contracture: Gastrocnemius Recession, Percutaneous Tendoachilles Lengthening, and Diaphyseal Metatarsal Shortening Osteotomy
Management of Lesser Toe Deformity: PIP Arthroplasty and Extensor Lengthening
Medial Malleolar Stress Fractures
Talus Fractures
Fifth Metatarsal Stress Fractures
Arthroscopic Management of Osteochondral Lesions of the Talus
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