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#5 Surg > 72 - Arthrodesis of Rearfoot and Ankle > Flashcards

72 - Arthrodesis of Rearfoot and Ankle Flashcards

1
Q

Triple arthrodesis

A
  • “The essential aim of this kind of reconstructive surgery is the improvement of the function of the foot” - Ryerson 1923
  • Triple arthrodesis: STJ, talonavicular and calcaneocuboid joint fusions
  • Many procedures offered: Ryerson (first choice on boards), Hoke (second choice on boards), Lambrinudi, Brewster, Dunn, Seiffert or beak
  • Each with their own advantages and disadvantages
  • The indications have always remained the same
  • I WILL NOT TEST YOU ON MODIFICATIONS
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2
Q

Indications for arthrodesis

A
  • Pain
  • Deformity
  • Instability
  • Progression of any of the above
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3
Q

McGlamry’s list of indications for triple arthrodesis

A
  • Valgus foot deformity
  • Varus foot deformities
  • Miscellaneous
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4
Q

Valgus deformity indivations for triple arthrodesis

A

o Collapsing pes planovalgus
o Ruptured tibialis posterior tendon
o Tarsal coalition and arthritic deformities (congenital, rheumatoid, degenerative, post-traumatic)

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5
Q

Varus deformity indications for triple arthrodesis

A

o Cavus
o Cavovarus
o Talipes equinovarus

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6
Q

Miscellaneous indications for triple arthrodesis

A

o Lateral ankle instability and ankle equinus
o Neuromuscular disease (hereditary familial sensorimotor neuropathies, paralytic deformities, Charcot joint deformities, other diseases affecting spinal cord and brain)

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7
Q

McGlamry’s list of conditions requiring triple arthrodesis

A
  • Idiopathic collapsing pes planovalgus deformity
  • Peroneal spastic flatfoot
  • Tarsal coalition
  • Congenital vertical talus
  • Rheumatoid arthritis
  • Degenerative arthritis
  • Posttraumatic degenerative arthritis
  • Ruptured tibialis posterior tendon
  • Idiopathic cavus and cavovarus deformities
  • Congenital clubfoot (uncorrected)
  • Poliomyelitis
  • Spina bifida
  • Friedreich’s ataxia
  • Charcot-Marie-Tooth disease
  • Muscular dystrophy
  • Cerebral palsy
  • Myelodysplasia
  • Arthrogryposis
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8
Q

Complications of triple arthrodesis

A
  • Pseudoarthrosis/non-union (occurs 7-23% of the time)
  • Development of DJD in adjacent joints
  • AVN
  • Ankle instability (kind of related to DJD)
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9
Q

Triple arthrodesis rate of non-union

A 
o	Hoke 7%
o	Ryerson 16%
o	Brewster 20%
o	Lambrinudi 33%
o	***Usually at talonavicular joint***
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10
Q

Triple arthrodesis positioning

A

o May accommodate deformity in all three body planes by resection of bone at the joints
o Arthrodesis position of rearfoot should be 0-5 degrees of VALGUS
o Arthrodesis position of forefoot should be PARALLEL to the ground and PERPENDICULAR to the heel

NOTE: YOU CAN CORRECT DEFORMITIES IN MULTIPLE PLANES WITH A TRIPLE ARTHRODESIS PROCEDURE – THIS IS A MAJOR TAKEHOME MESSAGE
o There are images on the slides regarding all the different modifications you can make to fix deformities in different planes

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11
Q

“Thou shall not varus”

A
  • This is something you will hear again and again
  • You never want the fusion position to be in varus
  • This is the one thing that you need to make sure when you permanently fixate the subtalar joint
  • You CANNOT accommodate for this fixed position
  • Varus deformity in a foot (even if it naturally occurs as an uncompensated varus deformity), but you get ankle instability, sprains and many other pathologies occur
  • This is essentially what we will do if we fixate the STJ in a varus position
  • You will see patients who come into your clinic with a previous triple arthrodesis and they have been fixated in varus, it is an automatic need for a revision surgery
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12
Q

Lateral incision

A
  • Ollier’s incision” is a lateral approach to a triple arthrodesis from the tip of lateral malleolus to the base of the metatarsals
  • Can be modified (swing under fibula) and go down a little bit further for better exposure of the posterior facet of the STJ
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13
Q

Medial incision

A
  • Similar to lateral incision, but on medial aspect of the foot
  • Start below the medial malleolus (or slightly further back) and go down to at least the naviculocuneiform joint
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14
Q

Cartilage removal then fixation

A
  • First you always resect the cartilage from the midtarsal joint (MTJ), which includes both the calcaneocuboid joint (CC joint) and the talonavicular joint (TN joint)
  • This often “slacks up” the soft tissues and allows easier access to the subtalar joint (STJ)
  • After resecting the cartilage from the STJ, we fuse in the reverse order, meaning we then fuse the STJ first
  • When fusing the joint you will first temporarily fixate the STJ with a cannulated guidewire to assure appropriate positioning before inserting the screw for permanent fixation
  • AVOID varus when positing the STJ for fixation
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15
Q

Fixation for triple arthrodesis

A
  • Three 6.5 mm partially threaded cancellous screws (lag by design)
  • May use smaller screws or staples across midtarsal joint
  • May staple all three arthrodesis sites
  • Steinmann pins
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16
Q

Post-operative care for triple arthrodesis

A
  • Short leg cast for 12 weeks non-weightbearing

- Partial weightbearing for additional 4 weeks

17
Q

Now we are moving onto ANKLE arthrodesis

A

FYI

18
Q

Indications for ankle arthrodesis

A
  • Severe pain and/or deformity
  • DJD: S/P ankle fracture
  • RA
  • Talar collapse
  • Infection
  • Drop foot
  • Congenital deformities
  • Ankle implant revision
19
Q

Pre-operative evaluation for triple ankle arthrodesis

A
  • Evaluate adjacent joints
  • Neuropathy
  • Bone stock
  • Patient expectations (patients are fearful of losing ankle motion, but they don’t have it now and what they do have is painful – also, can’t wear high heels after procedure)
20
Q

Surgical approaches to ankle arthrodesis

A
  • Transverse anterior
  • Longitudinal anterior
  • Lateral (with fibular osteotomy)
  • Medial (with tibial osteotomy)
  • Combination
21
Q

Ankle arthrodesis procedures

A
  • Articular resection with or without bone grafting
  • Anterior arthrodesis with inlay grafting
  • Articular resection with malleolar osteotomy
  • Dowel arthrodesis
  • Compression arthrodesis
  • Arthroscopic
22
Q

Arthrodesis positioning

A
  • Right angle to leg (0° dorsiflexion***)
  • Body can tolerate 5 degrees of plantarflexion
  • External rotation of 13-15 degrees (line up tibial tuberosity with the 2nd toe to achieve this***)
23
Q

Fixation for ankle arthrodesis

A
  • Two 6.5 mm partially threaded cancellous screws

- External fixation device (can be used)

24
Q

Post-operative care for ankle arthrodesis

A
  • Short leg cast for 12 weeks non-weightbearing

- Partial weight bearing for 4 weeks

25
Q

Complications of ankle arthrodesis

A
  • Non-union (15-50%)

- Degenerative changes in adjacent joints

26
Q

STUDY: Open vs arthroscopic ankle arthrodesis: Comparison of subsequent procedures in large database

A
  • Level 3 retrospective study from 2005 to 2011 in JFS 2016
  • 7,322 open technique and 1,152 arthroscopically – Open technique is MORE popular
  • They compared two approaches, but what they are really looking at is “subsequent procedures” which really means arthritis in adjacent joints needing surgery
  • Example: you do an ankle arthrodesis and therefore put more demand on the STJ, leading to arthritis of the STJ
  • In open arthrodesis, 5.6% needed a subsequent procedure compared to arthroscopic arthrodesis in which only 2.6% of patients needed a subsequent arthrodesis
  • By doing an open approach, there are more issues with adjacent joints, but still overall a low complication rate
  • If you are going to do an ankle arthrodesis, you need to discuss this with your patients
27
Q

Other arthrodesis procedures

A
  • Pan-talar arthrodesis = ankle arthrodesis PLUS triple arthrodesis (LONG SURGERY – 4+ hours)
  • Isolated subtalar arthrodesis (if this is the only arthritic joint)
  • MTJ arthrodesis

#5 Surg (12 decks)

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