Tibiotalar Arthrodesis

Tibiotalar Arthrodesis

Aaron J. Rubinstein, MD

Siddhant K. Mehta, MD, PhD

Sheldon S. Lin, MD

Dr. Lin or an immediate family member serves as a paid consultant to or is an employee of DJ Orthopaedics and Wright Medical Technology Inc. and serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot & Ankle Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Rubinstein and Dr. Mehta.

This chapter is adapted from Mehta SK, Abidi NA, Lin SS: Tibiotalar Arthrodesis in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 509-514.


Ankle arthritis represents degenerative changes of the tibiotalar joint that often results in limited range of motion, severe pain, and difficulty in ambulation. Surgical management must be considered in patients with end-stage ankle arthritis refractory to nonsurgical treatment. Tibiotalar (ankle) arthrodesis has been the mainstay of treatment for over 50 years, providing predictable symptomatic relief in patients with severe, end-stage ankle arthritis. This chapter will discuss indications and contraindications, describe general principles and preoperative imaging, and detail the surgical technique for open ankle arthrodesis. Additionally, we will expand upon the use of bioadjuvant therapies in attaining a successful fusion, and comment on the current surgical outcomes.



Radiographic assessment is performed with conventional radiographs (ie, weight-bearing ankle series) and advanced imaging modalities (MRI, CT, nuclear imaging). Routine radiographs should include weight-bearing AP, lateral, and mortise views of the ankle (Figure 1). A
weight-bearing study is critical in providing a more accurate approximation of the presence and degree of cartilage thinning than a non-weight-bearing study.

Typical degenerative changes include joint space narrowing, osteophyte formation, subchondral bone cysts, and subchondral bone sclerosis. The presence of joint incongruency, malalignment, or dislocation should also be noted. Additionally, in inflammatory arthritis, joint subluxation, large erosions, and bone destruction may be observed. End-stage rheumatoid arthritis is noted by malalignment, displacement, and ankylosis of the joints of the foot and ankle. Furthermore, advanced imaging can allow for evaluation of the subtalar joint for concomitant arthritis (CT scan), as well as provide useful preoperative information such as evidence of osteonecrosis of the talus (MRI) or presence of infection (nuclear medicine study).


Rigid fixation, adequate compression, and a favorable biologic environment are known to be key components for osseous healing, and a successful fusion construct across the tibiotalar articulation. A stable fixation can be achieved through an external fixator device or internal fixation, performed arthroscopically or through an open approach. Selection of the surgical technique should be based on the underlying disorder. As a general rule, external fixators are preferred for patients undergoing arthrodesis for a preexisting septic joint and for patients with severe osteopenia. Arthroscopic arthrodesis or the “mini-open” arthrodesis should be used only for patients with minimal deformity. Open arthrodesis is appropriate for patients with significant ankle deformity and foot and ankle malalignment.1

Regardless of the surgical technique chosen, the optimal postoperative position of the affected foot and ankle joint is the same. The foot should be externally rotated 20° to 30° relative to the tibia, with the ankle joint in neutral flexion (zero degrees), 5° to 10° of external rotation, and slight valgus (5°).2 This position provides the optimal extremity alignment and allows for accommodation of hip and knee motion during ambulation. Fusion of the ankle in plantar flexion results in genu recurvatum when placing the foot flat on the floor. Subsequently, laxity of the medial collateral ligament of the knee develops, secondary to the externally rotated gait that patients adopt to avoid “rolling over” a plantarflexed foot.2

Although internal compression arthrodesis with two or three cannulated screws is successful and continues to be a common procedure for the management of ankle arthritis, it may not be adequate for certain patient groups.1 The arthrodesis technique must be modified for patients with compromised soft tissues, with nonunion after previous arthrodesis attempts, or with neuropathic ankle joints. Patients with symptomatic nonunion, osteonecrosis of the talus, or Charcot arthropathy frequently require substantial débridement of devitalized bone from the talus. Bone grafting with or without the use of orthobiologics can be used in these patients to regain some of the lost height, but often tibiotalocalcaneal arthrodesis is required to achieve a successful fusion. More rigid internal fixation is a part of almost all fusion techniques used in these difficult situations. Furthermore, supplemental plating at the medial, lateral, or anterior aspects of the tibiotalar joint has been shown to provide a secure fixation and thus increases fusion rates and improves stability at the fusion site.3,4,5,6

Feb 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Tibiotalar Arthrodesis

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