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Open Posterior Approach for Tibiotalar Arthrodesis
Open Posterior A p p ro a c h f o r Tibiotalar A r t h ro d e s i s Florian Nickisch, MD*, Frank R. Avilucea, Charles Saltzman, MD
MD,
Timothy Beals,
MD,
KEYWORDS Tibiotalar Arthrodesis Posterior approach
HISTORICAL PERSPECTIVE
Traumatic injury to the ankle and hindfoot often results in tibiotalar or subtalar arthritis. The associated joint pain, stiffness, and deformity may be difficult to treat with conservative measures. For such problems, arthrodesis of the ankle or hindfoot joints is the mainstay of treatment. First described by Morgan and colleagues1 in 1879, the operative principle of approximating and securing the talus and tibial plafond surfaces of viable cancellous bone to complete a tibiotalar arthrodesis has now been described by many researchers.1–16 At present, surgeons use various techniques for the treatment of symptomatic tibiotalar arthrosis. In general, the technique used is determined by the underlying disorder, the presence and degree of deformity, the state of the soft tissue envelope, and patient factors, such as age, functional level, bone quality, previous surgeries, and medical comorbidities. Different techniques are used in patients with different characteristics; external fixators may be used for patients with septic arthritis or severe osteopenia, arthroscopic arthrodesis and percutaneous screw placement is used for those with minimal deformity, retrograde intramedullary nailing is done for those with concomitant subtalar arthritis, and open arthrodesis is often selected for patients with significant deformity. For open arthrodesis, various directional approaches have been described, including lateral transfibular approach with or without preservation of the distal fibula and anterior, anterolateral, and anteromedial (mini-open), and posterior approaches.5,17–26 In the setting of a compromised soft tissue envelope, a posterior approach, through a single incision, often offers the healthiest and deepest soft tissue bed for reconstruction. This
The authors have nothing to disclose. Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA * Corresponding author. E-mail address: [email protected] Foot Ankle Clin N Am 16 (2011) 103–114 doi:10.1016/j.fcl.2010.11.001 1083-7515/11/$ – see front matter. Published by Elsevier Inc.
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approach is particularly useful in patients with previous medial, lateral, or anterior incisions from fracture fixation, ankle arthroplasty, or arthrodesis attempts. In 1956, Staples27 endorsed the posterior approach when the anterior soft tissue envelope is scarred, and there is concomitant need for talocalcaneal arthrodesis. Gruen and Mears24 reported excellent and good results with the use of a blade plate to treat nonunion of the distal tibia, ankle, or subtalar joint through a posterior approach. Hanson and Cracchiolo28 described the use of the posterior approach to place a 95 blade plate for a tibiotalocalcaneal (TTC) arthrodesis in patients with mild to moderate hindfoot deformity, failed fusion, and anterior soft tissue scarring secondary to previous surgery; each patient had a successful arthrodesis with this approach. To further assess potential complications, Hammit and colleagues29 show that a midline posterior incision has a low primary wound complication rate. In addition, in their angiosome study assessing integument perfusion about the Achilles tendon, Yepes and colleagues30 confirm that the posteromedial and posterolateral aspects of the ankle are well vascularized, with the watershed area localized to the posterior midline as previously described by Taylor and Pan.31 From a surgical technique standpoint, with the patient prone, the posterior approach grants the surgeon access to the entire posterior hindfoot and ankle. There is substantial exposure of each joint, so a large surface area may be surgically prepared for either a tibiotalar or TTC arthrodesis. Moreover, the unscarred tissue bed is deep and provides ample tissue for coverage of implants and bone graft. The prone position allows access to the posterior iliac crest for procurement of large bone grafts, if required. A posterior approach allows for the dissection necessary to mobilize large coronal plane deformities. Finally, by flexing the knee, hindfoot alignment is easily visualized in all planes and intraoperative images may be readily obtained because minimal foot manipulation is needed to obtain anteroposterior and lateral fluoroscopic images. This article discusses the application of the posterior approach to complete, a tibiotalar and TTC arthrodeses as well as its use for converting a failed total ankle arthroplasty (TAA) to an arthrodesis. INDICATIONS AND CONTRAINDICATIONS
The authors prefer the posterior approach as a salvage procedure when the anterior, medial, or lateral soft tissue envelope is compromised by previous injury, surgical intervention, or infection. Patients who are considered for this approach are typically those who have had a previous arthrodesis, have adjacent joint fusion or TAA and have progressed to either a symptomatic nonunion or implant failure requiring surgical revision (Fig. 1). This approach should be avoided in patients with poor vascular supply to the limb or if there is a need for anterior incisions or simultaneous foot surgery. PRESURGICAL PLANNING
Revision surgery is indicated for patients with a painful nonunion or arthritis. It should be emphasized that treatment of nonunions is predicated on the reported symptoms. In evaluating the patient with previous ankle surgery, it is necessary to identify an accurate diagnosis, understand the cause of the pain, accurately identify the previous surgical interventions, and correlate that information with the mechanical findings of the physical examination and the appearance of radiographs before revision surgery is undertaken. Although a certain percentage of nonunions occur without a definite
Open Posterior Approach for Tibiotalar Arthrodesis
Fig. 1. A 50-year-old woman with a history of a revision open reduction and internal fixation of a pilon fracture after hardware failure. The 5-month postoperative radiographs demonstrate nonunion of posterior malleolus, hardware failure, and posttraumatic tibiotalar arthritis as seen on anteroposterior (A), mortise (B), and lateral (C) views.
cause, potential causes, such as infection or metabolic abnormalities, should be excluded and, if identified, treated before surgery. A thorough history and physical examination begins the process of critically assessing the patient. Medical comorbidities, such as diabetes, peripheral neuropathy, rheumatoid arthritis, history of thromboembolic disease, or long-term use of steroids, must be discussed. Patients’ skin is examined for previous traumatic and surgical scars and the quality of the soft tissue envelope is closely inspected. A complete neurovascular examination is essential to identify the quality of tissue perfusion as well as previous nerve injury. With nonpalpable pulses, the patient should be referred for a vascular consultation to establish whether arterial disease exists and, if so, whether a vascular intervention would improve tissue perfusion to promote healing and reduce the risk of infection. Previous nerve injuries must be discussed with the patient and documented so that there are no confusions about the cause of such deficits postoperatively. Sites of tenderness to palpation should be determined as well as the overall foot and ankle alignment, which should be compared with that of the contralateral limb. In cases of long-standing deformity, particular attention has to be paid to compensatory foot deformities. In a patient with a history of septic arthritis, wound healing problems, or previous postoperative infection, laboratory studies need to be reviewed to ensure resolution of any infectious process. Each patient undergoes radiographic evaluation to include 3 weight-bearing views of both the ankle and foot along with a hindfoot alignment view.32 In addition, a fine-cut (3 mm) computed tomographic (CT) scan of the ankle and hindfoot may be obtained to assess alignment, bone loss, and deformity, which may be difficult to discern on plain films. CT also allows the surgeon to inspect the integrity of adjacent joints and evaluate the available bone quality (Fig. 2) and is the gold standard for assessing the presence of union in patients with previous arthrodesis attempts.33 In discussing the risk of nonunion, it is important to ask about active tobacco use. Cigarette smoking is known to increase the risk for nonunion, and the patient should be encouraged strongly, if not convinced, to discontinue its use before and after surgical intervention, at least until the fusion is solidified.34,35 Although no evidence clearly demonstrates improved union rates with perioperative smoking cessation, there is a trend for increased union rate when cigarette use is discontinued before
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Fig. 2. Use of CT to examine bone stock quality. Coronal (A) and sagittal (B) views of a 63-year-old man’s right ankle demonstrating failed tibiotalar arthroplasty with several lucencies surrounding tibial and talar components.
and after surgery.35 In line with this notion, patients with rheumatoid disease should suspend immunosuppressant therapy 2 weeks preceding surgery.36–38 Although there are limited data examining postoperative complications related to immunomodulatory therapy, methotrexate and tumor necrosis factor blockers are associated with an increased rate of infection.36,38 Finally, diabetic patients are counseled regarding the importance of control of glucose levels throughout the perioperative period, and all patients, particularly those with several medical comorbidities, should have their nutrition optimized (albumin level <3.5 g/dL). Many fixation options may be used for tibiotalar or extended hindfoot fusion through a posterior approach. In the authors’ experience, the use of a posterior blade plate has resulted in relatively good success in many challenging situations, particularly for the indications that they describe. The authors place a 3.5-mm cannulated blade plate or fixed-angle device to provide rigid fixation of the arthrodesis. This implant is versatile in that it can be used for both tibiotalar and TTC arthrodeses. For tibiotalar fusion, a 90 blade plate is used, whereas for TTC arthrodesis the plate is usually opened to 100 to 110 . Because of the ease of contouring, the authors prefer a 3.5-mm to 4.5-mm plate. If a 4.5-mm plate is used, precontouring the plate before surgery reduces intraoperative tourniquet time. Supplementary large fragment screws are also used.
TECHNIQUE Patient Positioning and Surgical Approach
After induction of general anesthetic, prophylactic antibiotics are administered. The authors prefer to place a pneumatic tourniquet about the thigh before positioning the patient prone on an image table with gel pads. The foot should rest off the table to allow ease of positioning. Two to three folded blankets are placed beneath the operative limb to elevate it above the contralateral leg so that anteroposterior and cross-lateral fluoroscopic images may be easily obtained. The entire operative limb and ipsilateral posterosuperior iliac spine are sterilized, prepared, and draped. Anatomic landmarks are palpated and marked directly over the Achilles tendon.
Open Posterior Approach for Tibiotalar Arthrodesis
A 12- to 16-cm midline longitudinal incision exposes subcutaneous tissue, which is then sharply dissected down to the superficial fascia and paratenon overlying the Achilles tendon. These 2 layers are carefully cut longitudinally with the intent to preserve, reapproximate, and keep separated from superficial tissue at the time of closure. Careful dissection of the proximal wound is required to avoid injury to the small saphenous vein and sural nerve. To prevent compromising blood supply to the skin, the integrity between the paratenon, superficial fascia, and skin is maintained. Thus, during dissection, the surgeon should gently retract the skin, avoid excessive spreading with dissection scissors between these layers, and refrain from using self-retaining retractors. A longitudinal tenotomy of the Achilles is completed taking care to create equal medial and lateral flaps. A tenotomy of the Achilles in the coronal plane, alternatively, may be completed so that the glistening layer of the tendon abuts paratenon when the wound is closed. Each flap is retracted with respective skin edges to enable visualization of the deep compartment (Fig. 3). On dissecting deep to the Achilles, the deep posterior compartment fascia is incised from distal to proximal longitudinally exposing the deep compartment musculature. The lateral aspect of the flexor hallucis longus (FHL) is identified, and the FHL and medial soft tissues are bluntly retracted medially after elevation of the lateral aspect of the FHL off the fibular periosteum and interosseous membrane; this step protects the neurovascular bundle in this muscular envelope and provides full exposure and access to the posterior tibia, ankle joint, subtalar joint, and distal fibula (Fig. 4). During this dissection, skin retractors are used only after deeper tissues are encountered. Moreover, care is taken to maintain full-thickness flaps to optimize vascular supply to the skin edges. Meticulous surgical technique throughout the procedure and prevention of excessive traction of skin preserves angiosomal circulation and helps prevent tissue breakdown, necrosis, and infection.
Fig. 3. (A–C) Posterior midline surgical approach for hindfoot exposure. (Reprinted from Ritter M, Nicksich F, DiGiovanni CW. Posterior bladeplate for salvage of failed total ankle arthroplasty. In: Wiese SW, editior. Operative techniques in orthopaedic surgery. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2010. p. 4211; with permission.)
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Fig. 4. (A, B) Deep compartment anatomy for hindfoot exposure. Asterisk indicates the tibial nerve. PTA, posterior tibial artery; Ta, talus; TCJ, talocalcaneal joint; Ti, tibia; TTJ, tibiotalar joint. (Reprinted from Ritter M, Nicksich F, DiGiovanni CW. Posterior bladeplate for salvage of failed total ankle arthroplasty. In: Wiese SW, editior. Operative techniques in orthopaedic surgery. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2010. p. 4208–9; with permission.)
Tibiotalar Arthrodesis
With full access to the posterior hindfoot, the peroneals may be retracted subperiosteally from the distal fibula to access the lateral gutter of the tibiotalar joint. Access to this part of the joint allows incorporation of larger joint surface area in the fusion mass in addition to a greater amount of bleeding bone to promote bone healing after physical approximation of the graft and native bone. The decision of whether to include the lateral gutter in the arthrodesis is based on the amount of degenerative disease, degree of deformity, length relationship of the tibia and fibula, and lastly surgeon preference. If the fibula is to be incorporated into the fusion, the authors typically perform a fibula osteotomy approximately 4 cm proximal to the tibiotalar joint line to uncouple the proximal fibula from the ankle; this osteotomy has been shown to improve distal tibiofibular fusion rates. Although this osteotomy may be performed through the posterior approach, it is often more easily accomplished through a separate lateral incision. To prepare the tibiotalar joint for arthrodesis, a capsulotomy is initially performed. Part of the posterior malleolus is excised with an osteotome so that the posterior aspect of the tibia is flush with the posterior talus (Fig. 5), which not only improves visualization of the tibiotalar joint but also facilitates later placement of the blade plate; the excised piece of bone is morselized and saved for use as bone graft. In the setting of angular deformity, an osteotomy of distal tibia achieves angular correction (Fig. 6). Curettes, osteotomies, and rongeurs are used to remove articular cartilage from the distal tibia and talar dome. Lamina spreaders or Hintermann retractors may be used to distract the joint and improve access to the anterior aspect of the joint as well as the medial and lateral gutters. Once all cartilage is debrided and viable bone is visualized, the subchondral bone surfaces on the tibial and talar sides are perforated
Open Posterior Approach for Tibiotalar Arthrodesis
Fig. 5. Excision of posterior malleolus (A) to allow the plate to sit flush with the tibia and talus (B).
with several 2.5-mm drill holes to induce bleeding. The amount of bone required is determined, and structural or cancellous bone graft is harvested from the posterior iliac crest. The autograft is placed into the joint and firmly packed to evenly cover the entirety of the joint surface area. Structural graft may be necessary to fill large defects or correct deformities. Blade plate application begins by positioning the foot in the desired alignment with 5 of valgus, neutral dorsiflexion, and slight external rotation. Reduction position is ascertained clinically and radiographically with fluoroscopy. The tibiotalar joint
Fig. 6. A 60-year-old woman who underwent an ankle fusion resulting in hindfoot valgus and subtalar arthritis as seen on anteroposterior (A), lateral (B), and hindfoot alignment (C) plain radiographs. In performing a TTC arthrodesis through the posterior approach, the surgeon may also complete a supramalleolar osteotomy to correct such valgus deformity as shown in (D) and (E).
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reduction can be secured with the placement of 2 Steinmann pins percutaneously from the medial tibial metaphysis. Alignment is verified clinically and with anteroposterior and lateral fluoroscopic images. The ideal entry point for the blade into the talar body is identified, typically a few millimeters proximal to the posterior facet of the subtalar joint. Correct positioning of the guide wire is critical. Because proximal exposure of the tibia is limited due to the bulk of the deep posterior compartment musculature, the hinged drill guide provided in the instrument set of the cannulated blade plate systems is impractical for this application. Instead the blade plate itself can be used as a guide by turning it 180 , so that the blade faces the surgeon. The plate is then placed flush on the posterior aspect of the distal tibia, and the guide wire is advanced into the talar body. The plate may need to be prebent to achieve greater or lesser dorsiflexion. Medial deviation of the talar neck must be accounted for when advancing the guide wire to prevent lateral penetration of the blade. The authors prefer using a custom-modified drill guide. Regardless of the method of guide wire placement, this step should be performed under fluoroscopic control in the lateral projection. Once the guide wire is in a satisfactory position in this plane, an anteroposterior fluoroscopic image of the foot is obtained to verify appropriate position in the talar neck (Fig. 7). The talus being dense, predrilling a trough into the it before plate insertion is strongly recommended to avoid fracture. The proper length and angle of the plate must be assessed to avoid cutout or penetration of the talonavicular joint and ensure appropriate positioning once the plate is set in its final position. Typically a 6- or 8-hole plate with a 35- to 45-mm blade is used. Serial images with fluoroscopy help the surgeon visualize the plate position. Before locking the plate in its final position with a single proximal and distal compressive screw, the foot and ankle position is evaluated clinically and radiographically to confirm proper alignment. If additional compression is desired, a large external fixator or femoral distractor can be applied. Residual graft is packed into and around the joint. Final radiographs are taken, and repeat clinical examination is done to ensure proper alignment. The deep-posterior musculature is laid over the plate, the Achilles is reapproximated and repaired, as is the paratenon and overlying superficial fascia, with closure of the remaining soft tissues in a layered manner.
Fig. 7. Fluoroscopic control of guide wire placement in the lateral (A) and anteroposterior (B) projection is critical.
Open Posterior Approach for Tibiotalar Arthrodesis
TTC Arthrodesis
Exposure of the tibia, talus, and os calcis follows the aforementioned surgical approach. After preparation of the tibiotalar joint, the subtalar joint is prepared similarly. As with the tibiotalar arthrodesis, the foot is aligned in 5 of valgus and external rotation. A Steinmann pin is inserted percutaneously from the plantar surface of the heel to the tibia to transfix the foot in the desired position; clinical examination and radiographs confirm position. The 3.5-mm or precontoured 4.5-mm 90 fixed-angle blade plate is laid in the anticipated position, and serial fluoroscopic images are taken so the plate may be adjusted to sit centrally along the TTC axis. Because of the soft cancellous bone of the calcaneus, it is not necessary to predrill a trough to introduce the plate into the calcaneus, but doing so may prevent inadvertent tracking of the plate. The starting position and angle for insertion of the blade into the calcaneus, however, requires careful attention because this starting point will determine apposition of bone to plate once the plate is seated in its final position. The blade should be close to the hard subchondral bone of the posterior facet to achieve greatest joint compression in the final construct. Once the plate is seated into the calcaneus and buttresses, the posterior hindfoot, plate position, and foot and ankle alignment is confirmed with anteroposterior and lateral radiographs before securing with screws. Additional bone graft is packed around the plate at the tibiotalar and subtalar joints. Reconstitution of the tendo Achilles and overlying soft tissue follows the procedure previously described for wound closure. Failed TAA
TAA is commonly completed through an anterior approach. In settings in which TAA has failed and there is a need to convert to a tibiotalar arthrodesis, the posterior approach does not preclude the surgeon from removing this hardware. A femoral distractor or an external fixator with medial pins in the tibia and calcaneus facilitate joint distraction for straightforward implant removal. The remaining fibrous tissue and debris should be excised down to the bleeding trabecular bone. Alignment, bone graft requirement, and implant size needed for arthrodesis are determined. The tibiotalar or, occasionally, TTC arthrodesis procedure follows the same process as described previously. COMPLICATIONS
There are limited reports in the literature discussing clinical outcome after fusion with a posterior blade plate.24,28,29 In the authors’ experience, patients have had generally satisfactory results, and this technique could be used for the above-mentioned indications because it is versatile, addresses a difficult problem, and is relatively facile to complete. As with any major fusion procedure, there are complications of this technique, such as stress fractures above the fixation and nonunion with hardware failure. POSTOPERATIVE MANAGEMENT
Approximately 1 hour before surgical intervention, the patient administered a longacting peripheral nerve block with an indwelling catheter placed under ultrasound guidance. In the authors’ experience patients have experienced less postoperative nausea, constipation, and complications related to narcotic use and are more satisfied with pain control when regional anesthesia is administered. Postoperatively, the patient’s limb is initially placed in a very well-padded posterior U splint. If there is minimal bleeding, the splint is continued for 10 to 14 days and
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Fig. 8. A 27-year-old man who sustained a medial malleolus fracture and fracture-dislocation of his talus. After open reduction and internal fixation, the patient developed talar avascular necrosis and end-stage tibiotalar and subtalar arthritis. Patient underwent a TTC fusion. The 4-month anteroposterior (A) and lateral (B) radiographs demonstrate appropriate hardware position, and the sagittal CT images (C, D) show near-complete tibiotalar joint fusion and subtalar fusion.
thereafter changed to a below-knee cast. In all other cases, the splint is changed to a below-knee cast on postoperative day 1 to 3. The limb is elevated for the first 2 to 5 days with pillows beneath the proximal calf, knee, and thigh, so that the distal leg is not in contact with any surface. Once in a cast, the patient remains non–weightbearing for approximately 6 to 8 weeks. More precisely, weight bearing is restricted until there is radiographic evidence of trabecular bone bridging on plain radiographs or CT scan (Fig. 8). Thereafter, the patient’s foot is placed in a boot, physical therapy is commenced, and weight bearing is slowly advanced, initially beginning with 25% of total weight with a weekly increase of 25% thereafter. On average, total length of partial weight bearing is 3 to 4 months. Lastly, rocker bottom shoes help the patient transition to shoe wear. SUMMARY AND OUTLOOK
The posterior approach offers several advantages as a salvage technique. The use of a blade plate affords axial and rotational stability and the potential for compression. Compromised anterior soft tissue is avoided, and there is ample posterior soft tissue coverage of hardware and bone graft material. With the patient prone, all planes of ankle and foot alignment may be easily viewed clinically and with fluoroscopy, and access to the posterior iliac crest allows for a large volume of bone graft or bone marrow aspirate. In addition, access to the distal tibia, talus, and calcaneus is achieved with this incision, allowing for rigid fixation of the tibiotalar or TTC joints as well as enabling for removal of TAA implants. REFERENCES
1. Morgan CD, Henke JA, Bailey RW, et al. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg 1985;67:546–50. 2. Barr JS, Record EE. Arthrodesis of the ankle joint: indications, operative technic and clinical experience. N Engl J Med 1953;248:53–6. 3. Mann RA, Van Manen JW, Wapner K, et al. Ankle fusion. Clin Orthop 1991;268: 49–55. 4. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91.
Open Posterior Approach for Tibiotalar Arthrodesis
5. Ratliff AH. Compression arthrodesis of the ankle. J Bone Joint Surg Br 1959;41: 524–34. 6. Scranton PE Jr. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67:550–5. 7. Wang GJ, Shen WJ, McLaughlin RE, et al. Transfibular compression arthrodesis of the ankle joint. Clin Orthop 1993;289:223–7. 8. Holt ES, Hansen ST, Mayo KA, et al. Ankle arthrodesis using internal screw fixation. Clin Orthop 1991;268:21–8. 9. Malarkey RF, Binski JC. Ankle arthrodesis with the Calandruccio frame and bimalleolar onlay grafting. Clin Orthop 1991;268:44–8. 10. Mears DC, Gordon RG, Kann SE, et al. Ankle arthrodesis with an anterior tension plate. Clin Orthop 1991;268:70–7. 11. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop 1991;268:84–95. 12. Paremain GD, Miller SD, Myerson MS. Ankle arthrodesis: results after the miniarthrotomy technique. Foot Ankle Int 1996;17:247–52. 13. Thordarson DB, Markolf KL, Cracchiolo A III. External fixation in arthrodesis of the ankle: a biomechanical study comparing a unilateral frame with a modified transfixion frame. J Bone Joint Surg Am 1994;76:1541–4. 14. Newman A. Ankle fusion with the Hoffmann external fixation device. Foot Ankle 1980;1:102–9. 15. Kile TA, Donnelly RE, Gehrke JC, et al. Tibiocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994;15:669–73. 16. Moore TJ, Prince R, Pochatko D, et al. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 1995;16:433–6. 17. Mann RA. Arthrodesis of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL. Surgery of the foot and ankle. 8th edition. Philadelphia: Mosby Elsevier; 2007. p. 1087–125. 18. Horwitz T. The use of the transfibular approach in arthrodesis of the ankle joint. Am J Surg 1942;60:550–2. 19. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 1948;30:506–11. 20. Schuberth JM, Cheung C, Rush SM, et al. The medial malleolar approach for arthrodesis of the ankle: a report of 13 cases. J Foot Ankle Surg 2005;44:125–32. 21. Campbell CJ, Rinehart WT, Kalenak A. Arthrodesis of the ankle. J Bone Joint Surg 1974;56:63–70. 22. Chuinard EG, Peterson RE. Distraction–compression bone-graft arthrodesis of the ankle. J Bone Joint Surg 1963;45:481–90. 23. Hallock H. Arthrodesis of the ankle joint for old painful fractures. J Bone Joint Surg 1945;27:49–58. 24. Gruen GS, Mears DC. Arthrodesis of the ankle and subtalar joints. Clin Orthop 1991;268:15–20. 25. Morgan SJ, Thordarson DB, Shepherd LE. Salvage of tibial pilon fractures using fusion of the ankle with a 90 degree cannulated blade-plate: a preliminary report. Foot Ankle Int 1999;20:375–8. 26. Sward L, Hughes JS, Howell CJ, et al. Posterior internal compression arthrodesis of the ankle. J Bone Joint Surg Br 1992;74:752–6. 27. Staples OS. Posterior arthrodesis of the ankle and subtalar joints. J Bone Joint Surg 1956;38(1):50–83. 28. Hanson TW, Cracchiolo A. The use of a 95 blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle Int 2002;23:704–10.
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29. Hammit MD, Hobgood ER, Tarquinio TA. Midline posterior approach to the ankle and hindfoot. Foot Ankle Int 2006;27:711–5. 30. Yepes H, Tang M, Geddes C, et al. Digital vascular mapping of the integument about the Achilles tendon. J Bone Joint Surg 2010;92:1215–20. 31. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599–616. 32. Saltzman CL, El-Khoury GY. The hindfoot alignment view. Foot Ankle Int 1995;16: 572–6. 33. Jones CP, Coughlin MJ, Shurnas PS. Prospective CT scan of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int 2006;27:229–35. 34. Cobb TK, Gabrielsen TA, Campbell DC, et al. Cigarette smoking and nonunion after ankle arthrodesis. Foot Ankle Int 1994;15(2):64–7. 35. Ishikawa SN, Murphy GA, Richardson EG. Effect of cigarette smoking on hindfoot fusions. Foot Ankle Int 2002;23(11):996–8. 36. Busti AJ, Hooper JS, Amaya CJ, et al. Effects of perioperative anti-inflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 2005;25(11):1566–91. 37. Pieringer H, Stuby U, Biesenbach G. Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum 2007;36(5):278–86. 38. Ruyssen-Witrand A, Grossec L, Salliot C, et al. Complication rates of 127 surgical procedures performed in rheumatic patients receiving tumor necrosis factor alpha blockers. Clin Exp Rheumatol 2007;25:430–6.
MD,
Timothy Beals,
MD,
KEYWORDS Tibiotalar Arthrodesis Posterior approach
HISTORICAL PERSPECTIVE
Traumatic injury to the ankle and hindfoot often results in tibiotalar or subtalar arthritis. The associated joint pain, stiffness, and deformity may be difficult to treat with conservative measures. For such problems, arthrodesis of the ankle or hindfoot joints is the mainstay of treatment. First described by Morgan and colleagues1 in 1879, the operative principle of approximating and securing the talus and tibial plafond surfaces of viable cancellous bone to complete a tibiotalar arthrodesis has now been described by many researchers.1–16 At present, surgeons use various techniques for the treatment of symptomatic tibiotalar arthrosis. In general, the technique used is determined by the underlying disorder, the presence and degree of deformity, the state of the soft tissue envelope, and patient factors, such as age, functional level, bone quality, previous surgeries, and medical comorbidities. Different techniques are used in patients with different characteristics; external fixators may be used for patients with septic arthritis or severe osteopenia, arthroscopic arthrodesis and percutaneous screw placement is used for those with minimal deformity, retrograde intramedullary nailing is done for those with concomitant subtalar arthritis, and open arthrodesis is often selected for patients with significant deformity. For open arthrodesis, various directional approaches have been described, including lateral transfibular approach with or without preservation of the distal fibula and anterior, anterolateral, and anteromedial (mini-open), and posterior approaches.5,17–26 In the setting of a compromised soft tissue envelope, a posterior approach, through a single incision, often offers the healthiest and deepest soft tissue bed for reconstruction. This
The authors have nothing to disclose. Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA * Corresponding author. E-mail address: [email protected] Foot Ankle Clin N Am 16 (2011) 103–114 doi:10.1016/j.fcl.2010.11.001 1083-7515/11/$ – see front matter. Published by Elsevier Inc.
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approach is particularly useful in patients with previous medial, lateral, or anterior incisions from fracture fixation, ankle arthroplasty, or arthrodesis attempts. In 1956, Staples27 endorsed the posterior approach when the anterior soft tissue envelope is scarred, and there is concomitant need for talocalcaneal arthrodesis. Gruen and Mears24 reported excellent and good results with the use of a blade plate to treat nonunion of the distal tibia, ankle, or subtalar joint through a posterior approach. Hanson and Cracchiolo28 described the use of the posterior approach to place a 95 blade plate for a tibiotalocalcaneal (TTC) arthrodesis in patients with mild to moderate hindfoot deformity, failed fusion, and anterior soft tissue scarring secondary to previous surgery; each patient had a successful arthrodesis with this approach. To further assess potential complications, Hammit and colleagues29 show that a midline posterior incision has a low primary wound complication rate. In addition, in their angiosome study assessing integument perfusion about the Achilles tendon, Yepes and colleagues30 confirm that the posteromedial and posterolateral aspects of the ankle are well vascularized, with the watershed area localized to the posterior midline as previously described by Taylor and Pan.31 From a surgical technique standpoint, with the patient prone, the posterior approach grants the surgeon access to the entire posterior hindfoot and ankle. There is substantial exposure of each joint, so a large surface area may be surgically prepared for either a tibiotalar or TTC arthrodesis. Moreover, the unscarred tissue bed is deep and provides ample tissue for coverage of implants and bone graft. The prone position allows access to the posterior iliac crest for procurement of large bone grafts, if required. A posterior approach allows for the dissection necessary to mobilize large coronal plane deformities. Finally, by flexing the knee, hindfoot alignment is easily visualized in all planes and intraoperative images may be readily obtained because minimal foot manipulation is needed to obtain anteroposterior and lateral fluoroscopic images. This article discusses the application of the posterior approach to complete, a tibiotalar and TTC arthrodeses as well as its use for converting a failed total ankle arthroplasty (TAA) to an arthrodesis. INDICATIONS AND CONTRAINDICATIONS
The authors prefer the posterior approach as a salvage procedure when the anterior, medial, or lateral soft tissue envelope is compromised by previous injury, surgical intervention, or infection. Patients who are considered for this approach are typically those who have had a previous arthrodesis, have adjacent joint fusion or TAA and have progressed to either a symptomatic nonunion or implant failure requiring surgical revision (Fig. 1). This approach should be avoided in patients with poor vascular supply to the limb or if there is a need for anterior incisions or simultaneous foot surgery. PRESURGICAL PLANNING
Revision surgery is indicated for patients with a painful nonunion or arthritis. It should be emphasized that treatment of nonunions is predicated on the reported symptoms. In evaluating the patient with previous ankle surgery, it is necessary to identify an accurate diagnosis, understand the cause of the pain, accurately identify the previous surgical interventions, and correlate that information with the mechanical findings of the physical examination and the appearance of radiographs before revision surgery is undertaken. Although a certain percentage of nonunions occur without a definite
Open Posterior Approach for Tibiotalar Arthrodesis
Fig. 1. A 50-year-old woman with a history of a revision open reduction and internal fixation of a pilon fracture after hardware failure. The 5-month postoperative radiographs demonstrate nonunion of posterior malleolus, hardware failure, and posttraumatic tibiotalar arthritis as seen on anteroposterior (A), mortise (B), and lateral (C) views.
cause, potential causes, such as infection or metabolic abnormalities, should be excluded and, if identified, treated before surgery. A thorough history and physical examination begins the process of critically assessing the patient. Medical comorbidities, such as diabetes, peripheral neuropathy, rheumatoid arthritis, history of thromboembolic disease, or long-term use of steroids, must be discussed. Patients’ skin is examined for previous traumatic and surgical scars and the quality of the soft tissue envelope is closely inspected. A complete neurovascular examination is essential to identify the quality of tissue perfusion as well as previous nerve injury. With nonpalpable pulses, the patient should be referred for a vascular consultation to establish whether arterial disease exists and, if so, whether a vascular intervention would improve tissue perfusion to promote healing and reduce the risk of infection. Previous nerve injuries must be discussed with the patient and documented so that there are no confusions about the cause of such deficits postoperatively. Sites of tenderness to palpation should be determined as well as the overall foot and ankle alignment, which should be compared with that of the contralateral limb. In cases of long-standing deformity, particular attention has to be paid to compensatory foot deformities. In a patient with a history of septic arthritis, wound healing problems, or previous postoperative infection, laboratory studies need to be reviewed to ensure resolution of any infectious process. Each patient undergoes radiographic evaluation to include 3 weight-bearing views of both the ankle and foot along with a hindfoot alignment view.32 In addition, a fine-cut (3 mm) computed tomographic (CT) scan of the ankle and hindfoot may be obtained to assess alignment, bone loss, and deformity, which may be difficult to discern on plain films. CT also allows the surgeon to inspect the integrity of adjacent joints and evaluate the available bone quality (Fig. 2) and is the gold standard for assessing the presence of union in patients with previous arthrodesis attempts.33 In discussing the risk of nonunion, it is important to ask about active tobacco use. Cigarette smoking is known to increase the risk for nonunion, and the patient should be encouraged strongly, if not convinced, to discontinue its use before and after surgical intervention, at least until the fusion is solidified.34,35 Although no evidence clearly demonstrates improved union rates with perioperative smoking cessation, there is a trend for increased union rate when cigarette use is discontinued before
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Fig. 2. Use of CT to examine bone stock quality. Coronal (A) and sagittal (B) views of a 63-year-old man’s right ankle demonstrating failed tibiotalar arthroplasty with several lucencies surrounding tibial and talar components.
and after surgery.35 In line with this notion, patients with rheumatoid disease should suspend immunosuppressant therapy 2 weeks preceding surgery.36–38 Although there are limited data examining postoperative complications related to immunomodulatory therapy, methotrexate and tumor necrosis factor blockers are associated with an increased rate of infection.36,38 Finally, diabetic patients are counseled regarding the importance of control of glucose levels throughout the perioperative period, and all patients, particularly those with several medical comorbidities, should have their nutrition optimized (albumin level <3.5 g/dL). Many fixation options may be used for tibiotalar or extended hindfoot fusion through a posterior approach. In the authors’ experience, the use of a posterior blade plate has resulted in relatively good success in many challenging situations, particularly for the indications that they describe. The authors place a 3.5-mm cannulated blade plate or fixed-angle device to provide rigid fixation of the arthrodesis. This implant is versatile in that it can be used for both tibiotalar and TTC arthrodeses. For tibiotalar fusion, a 90 blade plate is used, whereas for TTC arthrodesis the plate is usually opened to 100 to 110 . Because of the ease of contouring, the authors prefer a 3.5-mm to 4.5-mm plate. If a 4.5-mm plate is used, precontouring the plate before surgery reduces intraoperative tourniquet time. Supplementary large fragment screws are also used.
TECHNIQUE Patient Positioning and Surgical Approach
After induction of general anesthetic, prophylactic antibiotics are administered. The authors prefer to place a pneumatic tourniquet about the thigh before positioning the patient prone on an image table with gel pads. The foot should rest off the table to allow ease of positioning. Two to three folded blankets are placed beneath the operative limb to elevate it above the contralateral leg so that anteroposterior and cross-lateral fluoroscopic images may be easily obtained. The entire operative limb and ipsilateral posterosuperior iliac spine are sterilized, prepared, and draped. Anatomic landmarks are palpated and marked directly over the Achilles tendon.
Open Posterior Approach for Tibiotalar Arthrodesis
A 12- to 16-cm midline longitudinal incision exposes subcutaneous tissue, which is then sharply dissected down to the superficial fascia and paratenon overlying the Achilles tendon. These 2 layers are carefully cut longitudinally with the intent to preserve, reapproximate, and keep separated from superficial tissue at the time of closure. Careful dissection of the proximal wound is required to avoid injury to the small saphenous vein and sural nerve. To prevent compromising blood supply to the skin, the integrity between the paratenon, superficial fascia, and skin is maintained. Thus, during dissection, the surgeon should gently retract the skin, avoid excessive spreading with dissection scissors between these layers, and refrain from using self-retaining retractors. A longitudinal tenotomy of the Achilles is completed taking care to create equal medial and lateral flaps. A tenotomy of the Achilles in the coronal plane, alternatively, may be completed so that the glistening layer of the tendon abuts paratenon when the wound is closed. Each flap is retracted with respective skin edges to enable visualization of the deep compartment (Fig. 3). On dissecting deep to the Achilles, the deep posterior compartment fascia is incised from distal to proximal longitudinally exposing the deep compartment musculature. The lateral aspect of the flexor hallucis longus (FHL) is identified, and the FHL and medial soft tissues are bluntly retracted medially after elevation of the lateral aspect of the FHL off the fibular periosteum and interosseous membrane; this step protects the neurovascular bundle in this muscular envelope and provides full exposure and access to the posterior tibia, ankle joint, subtalar joint, and distal fibula (Fig. 4). During this dissection, skin retractors are used only after deeper tissues are encountered. Moreover, care is taken to maintain full-thickness flaps to optimize vascular supply to the skin edges. Meticulous surgical technique throughout the procedure and prevention of excessive traction of skin preserves angiosomal circulation and helps prevent tissue breakdown, necrosis, and infection.
Fig. 3. (A–C) Posterior midline surgical approach for hindfoot exposure. (Reprinted from Ritter M, Nicksich F, DiGiovanni CW. Posterior bladeplate for salvage of failed total ankle arthroplasty. In: Wiese SW, editior. Operative techniques in orthopaedic surgery. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2010. p. 4211; with permission.)
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Fig. 4. (A, B) Deep compartment anatomy for hindfoot exposure. Asterisk indicates the tibial nerve. PTA, posterior tibial artery; Ta, talus; TCJ, talocalcaneal joint; Ti, tibia; TTJ, tibiotalar joint. (Reprinted from Ritter M, Nicksich F, DiGiovanni CW. Posterior bladeplate for salvage of failed total ankle arthroplasty. In: Wiese SW, editior. Operative techniques in orthopaedic surgery. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2010. p. 4208–9; with permission.)
Tibiotalar Arthrodesis
With full access to the posterior hindfoot, the peroneals may be retracted subperiosteally from the distal fibula to access the lateral gutter of the tibiotalar joint. Access to this part of the joint allows incorporation of larger joint surface area in the fusion mass in addition to a greater amount of bleeding bone to promote bone healing after physical approximation of the graft and native bone. The decision of whether to include the lateral gutter in the arthrodesis is based on the amount of degenerative disease, degree of deformity, length relationship of the tibia and fibula, and lastly surgeon preference. If the fibula is to be incorporated into the fusion, the authors typically perform a fibula osteotomy approximately 4 cm proximal to the tibiotalar joint line to uncouple the proximal fibula from the ankle; this osteotomy has been shown to improve distal tibiofibular fusion rates. Although this osteotomy may be performed through the posterior approach, it is often more easily accomplished through a separate lateral incision. To prepare the tibiotalar joint for arthrodesis, a capsulotomy is initially performed. Part of the posterior malleolus is excised with an osteotome so that the posterior aspect of the tibia is flush with the posterior talus (Fig. 5), which not only improves visualization of the tibiotalar joint but also facilitates later placement of the blade plate; the excised piece of bone is morselized and saved for use as bone graft. In the setting of angular deformity, an osteotomy of distal tibia achieves angular correction (Fig. 6). Curettes, osteotomies, and rongeurs are used to remove articular cartilage from the distal tibia and talar dome. Lamina spreaders or Hintermann retractors may be used to distract the joint and improve access to the anterior aspect of the joint as well as the medial and lateral gutters. Once all cartilage is debrided and viable bone is visualized, the subchondral bone surfaces on the tibial and talar sides are perforated
Open Posterior Approach for Tibiotalar Arthrodesis
Fig. 5. Excision of posterior malleolus (A) to allow the plate to sit flush with the tibia and talus (B).
with several 2.5-mm drill holes to induce bleeding. The amount of bone required is determined, and structural or cancellous bone graft is harvested from the posterior iliac crest. The autograft is placed into the joint and firmly packed to evenly cover the entirety of the joint surface area. Structural graft may be necessary to fill large defects or correct deformities. Blade plate application begins by positioning the foot in the desired alignment with 5 of valgus, neutral dorsiflexion, and slight external rotation. Reduction position is ascertained clinically and radiographically with fluoroscopy. The tibiotalar joint
Fig. 6. A 60-year-old woman who underwent an ankle fusion resulting in hindfoot valgus and subtalar arthritis as seen on anteroposterior (A), lateral (B), and hindfoot alignment (C) plain radiographs. In performing a TTC arthrodesis through the posterior approach, the surgeon may also complete a supramalleolar osteotomy to correct such valgus deformity as shown in (D) and (E).
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reduction can be secured with the placement of 2 Steinmann pins percutaneously from the medial tibial metaphysis. Alignment is verified clinically and with anteroposterior and lateral fluoroscopic images. The ideal entry point for the blade into the talar body is identified, typically a few millimeters proximal to the posterior facet of the subtalar joint. Correct positioning of the guide wire is critical. Because proximal exposure of the tibia is limited due to the bulk of the deep posterior compartment musculature, the hinged drill guide provided in the instrument set of the cannulated blade plate systems is impractical for this application. Instead the blade plate itself can be used as a guide by turning it 180 , so that the blade faces the surgeon. The plate is then placed flush on the posterior aspect of the distal tibia, and the guide wire is advanced into the talar body. The plate may need to be prebent to achieve greater or lesser dorsiflexion. Medial deviation of the talar neck must be accounted for when advancing the guide wire to prevent lateral penetration of the blade. The authors prefer using a custom-modified drill guide. Regardless of the method of guide wire placement, this step should be performed under fluoroscopic control in the lateral projection. Once the guide wire is in a satisfactory position in this plane, an anteroposterior fluoroscopic image of the foot is obtained to verify appropriate position in the talar neck (Fig. 7). The talus being dense, predrilling a trough into the it before plate insertion is strongly recommended to avoid fracture. The proper length and angle of the plate must be assessed to avoid cutout or penetration of the talonavicular joint and ensure appropriate positioning once the plate is set in its final position. Typically a 6- or 8-hole plate with a 35- to 45-mm blade is used. Serial images with fluoroscopy help the surgeon visualize the plate position. Before locking the plate in its final position with a single proximal and distal compressive screw, the foot and ankle position is evaluated clinically and radiographically to confirm proper alignment. If additional compression is desired, a large external fixator or femoral distractor can be applied. Residual graft is packed into and around the joint. Final radiographs are taken, and repeat clinical examination is done to ensure proper alignment. The deep-posterior musculature is laid over the plate, the Achilles is reapproximated and repaired, as is the paratenon and overlying superficial fascia, with closure of the remaining soft tissues in a layered manner.
Fig. 7. Fluoroscopic control of guide wire placement in the lateral (A) and anteroposterior (B) projection is critical.
Open Posterior Approach for Tibiotalar Arthrodesis
TTC Arthrodesis
Exposure of the tibia, talus, and os calcis follows the aforementioned surgical approach. After preparation of the tibiotalar joint, the subtalar joint is prepared similarly. As with the tibiotalar arthrodesis, the foot is aligned in 5 of valgus and external rotation. A Steinmann pin is inserted percutaneously from the plantar surface of the heel to the tibia to transfix the foot in the desired position; clinical examination and radiographs confirm position. The 3.5-mm or precontoured 4.5-mm 90 fixed-angle blade plate is laid in the anticipated position, and serial fluoroscopic images are taken so the plate may be adjusted to sit centrally along the TTC axis. Because of the soft cancellous bone of the calcaneus, it is not necessary to predrill a trough to introduce the plate into the calcaneus, but doing so may prevent inadvertent tracking of the plate. The starting position and angle for insertion of the blade into the calcaneus, however, requires careful attention because this starting point will determine apposition of bone to plate once the plate is seated in its final position. The blade should be close to the hard subchondral bone of the posterior facet to achieve greatest joint compression in the final construct. Once the plate is seated into the calcaneus and buttresses, the posterior hindfoot, plate position, and foot and ankle alignment is confirmed with anteroposterior and lateral radiographs before securing with screws. Additional bone graft is packed around the plate at the tibiotalar and subtalar joints. Reconstitution of the tendo Achilles and overlying soft tissue follows the procedure previously described for wound closure. Failed TAA
TAA is commonly completed through an anterior approach. In settings in which TAA has failed and there is a need to convert to a tibiotalar arthrodesis, the posterior approach does not preclude the surgeon from removing this hardware. A femoral distractor or an external fixator with medial pins in the tibia and calcaneus facilitate joint distraction for straightforward implant removal. The remaining fibrous tissue and debris should be excised down to the bleeding trabecular bone. Alignment, bone graft requirement, and implant size needed for arthrodesis are determined. The tibiotalar or, occasionally, TTC arthrodesis procedure follows the same process as described previously. COMPLICATIONS
There are limited reports in the literature discussing clinical outcome after fusion with a posterior blade plate.24,28,29 In the authors’ experience, patients have had generally satisfactory results, and this technique could be used for the above-mentioned indications because it is versatile, addresses a difficult problem, and is relatively facile to complete. As with any major fusion procedure, there are complications of this technique, such as stress fractures above the fixation and nonunion with hardware failure. POSTOPERATIVE MANAGEMENT
Approximately 1 hour before surgical intervention, the patient administered a longacting peripheral nerve block with an indwelling catheter placed under ultrasound guidance. In the authors’ experience patients have experienced less postoperative nausea, constipation, and complications related to narcotic use and are more satisfied with pain control when regional anesthesia is administered. Postoperatively, the patient’s limb is initially placed in a very well-padded posterior U splint. If there is minimal bleeding, the splint is continued for 10 to 14 days and
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Fig. 8. A 27-year-old man who sustained a medial malleolus fracture and fracture-dislocation of his talus. After open reduction and internal fixation, the patient developed talar avascular necrosis and end-stage tibiotalar and subtalar arthritis. Patient underwent a TTC fusion. The 4-month anteroposterior (A) and lateral (B) radiographs demonstrate appropriate hardware position, and the sagittal CT images (C, D) show near-complete tibiotalar joint fusion and subtalar fusion.
thereafter changed to a below-knee cast. In all other cases, the splint is changed to a below-knee cast on postoperative day 1 to 3. The limb is elevated for the first 2 to 5 days with pillows beneath the proximal calf, knee, and thigh, so that the distal leg is not in contact with any surface. Once in a cast, the patient remains non–weightbearing for approximately 6 to 8 weeks. More precisely, weight bearing is restricted until there is radiographic evidence of trabecular bone bridging on plain radiographs or CT scan (Fig. 8). Thereafter, the patient’s foot is placed in a boot, physical therapy is commenced, and weight bearing is slowly advanced, initially beginning with 25% of total weight with a weekly increase of 25% thereafter. On average, total length of partial weight bearing is 3 to 4 months. Lastly, rocker bottom shoes help the patient transition to shoe wear. SUMMARY AND OUTLOOK
The posterior approach offers several advantages as a salvage technique. The use of a blade plate affords axial and rotational stability and the potential for compression. Compromised anterior soft tissue is avoided, and there is ample posterior soft tissue coverage of hardware and bone graft material. With the patient prone, all planes of ankle and foot alignment may be easily viewed clinically and with fluoroscopy, and access to the posterior iliac crest allows for a large volume of bone graft or bone marrow aspirate. In addition, access to the distal tibia, talus, and calcaneus is achieved with this incision, allowing for rigid fixation of the tibiotalar or TTC joints as well as enabling for removal of TAA implants. REFERENCES
1. Morgan CD, Henke JA, Bailey RW, et al. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg 1985;67:546–50. 2. Barr JS, Record EE. Arthrodesis of the ankle joint: indications, operative technic and clinical experience. N Engl J Med 1953;248:53–6. 3. Mann RA, Van Manen JW, Wapner K, et al. Ankle fusion. Clin Orthop 1991;268: 49–55. 4. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91.
Open Posterior Approach for Tibiotalar Arthrodesis
5. Ratliff AH. Compression arthrodesis of the ankle. J Bone Joint Surg Br 1959;41: 524–34. 6. Scranton PE Jr. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67:550–5. 7. Wang GJ, Shen WJ, McLaughlin RE, et al. Transfibular compression arthrodesis of the ankle joint. Clin Orthop 1993;289:223–7. 8. Holt ES, Hansen ST, Mayo KA, et al. Ankle arthrodesis using internal screw fixation. Clin Orthop 1991;268:21–8. 9. Malarkey RF, Binski JC. Ankle arthrodesis with the Calandruccio frame and bimalleolar onlay grafting. Clin Orthop 1991;268:44–8. 10. Mears DC, Gordon RG, Kann SE, et al. Ankle arthrodesis with an anterior tension plate. Clin Orthop 1991;268:70–7. 11. Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop 1991;268:84–95. 12. Paremain GD, Miller SD, Myerson MS. Ankle arthrodesis: results after the miniarthrotomy technique. Foot Ankle Int 1996;17:247–52. 13. Thordarson DB, Markolf KL, Cracchiolo A III. External fixation in arthrodesis of the ankle: a biomechanical study comparing a unilateral frame with a modified transfixion frame. J Bone Joint Surg Am 1994;76:1541–4. 14. Newman A. Ankle fusion with the Hoffmann external fixation device. Foot Ankle 1980;1:102–9. 15. Kile TA, Donnelly RE, Gehrke JC, et al. Tibiocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994;15:669–73. 16. Moore TJ, Prince R, Pochatko D, et al. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int 1995;16:433–6. 17. Mann RA. Arthrodesis of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL. Surgery of the foot and ankle. 8th edition. Philadelphia: Mosby Elsevier; 2007. p. 1087–125. 18. Horwitz T. The use of the transfibular approach in arthrodesis of the ankle joint. Am J Surg 1942;60:550–2. 19. Adams JC. Arthrodesis of the ankle joint: experiences with the transfibular approach. J Bone Joint Surg Br 1948;30:506–11. 20. Schuberth JM, Cheung C, Rush SM, et al. The medial malleolar approach for arthrodesis of the ankle: a report of 13 cases. J Foot Ankle Surg 2005;44:125–32. 21. Campbell CJ, Rinehart WT, Kalenak A. Arthrodesis of the ankle. J Bone Joint Surg 1974;56:63–70. 22. Chuinard EG, Peterson RE. Distraction–compression bone-graft arthrodesis of the ankle. J Bone Joint Surg 1963;45:481–90. 23. Hallock H. Arthrodesis of the ankle joint for old painful fractures. J Bone Joint Surg 1945;27:49–58. 24. Gruen GS, Mears DC. Arthrodesis of the ankle and subtalar joints. Clin Orthop 1991;268:15–20. 25. Morgan SJ, Thordarson DB, Shepherd LE. Salvage of tibial pilon fractures using fusion of the ankle with a 90 degree cannulated blade-plate: a preliminary report. Foot Ankle Int 1999;20:375–8. 26. Sward L, Hughes JS, Howell CJ, et al. Posterior internal compression arthrodesis of the ankle. J Bone Joint Surg Br 1992;74:752–6. 27. Staples OS. Posterior arthrodesis of the ankle and subtalar joints. J Bone Joint Surg 1956;38(1):50–83. 28. Hanson TW, Cracchiolo A. The use of a 95 blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle Int 2002;23:704–10.
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29. Hammit MD, Hobgood ER, Tarquinio TA. Midline posterior approach to the ankle and hindfoot. Foot Ankle Int 2006;27:711–5. 30. Yepes H, Tang M, Geddes C, et al. Digital vascular mapping of the integument about the Achilles tendon. J Bone Joint Surg 2010;92:1215–20. 31. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599–616. 32. Saltzman CL, El-Khoury GY. The hindfoot alignment view. Foot Ankle Int 1995;16: 572–6. 33. Jones CP, Coughlin MJ, Shurnas PS. Prospective CT scan of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int 2006;27:229–35. 34. Cobb TK, Gabrielsen TA, Campbell DC, et al. Cigarette smoking and nonunion after ankle arthrodesis. Foot Ankle Int 1994;15(2):64–7. 35. Ishikawa SN, Murphy GA, Richardson EG. Effect of cigarette smoking on hindfoot fusions. Foot Ankle Int 2002;23(11):996–8. 36. Busti AJ, Hooper JS, Amaya CJ, et al. Effects of perioperative anti-inflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 2005;25(11):1566–91. 37. Pieringer H, Stuby U, Biesenbach G. Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum 2007;36(5):278–86. 38. Ruyssen-Witrand A, Grossec L, Salliot C, et al. Complication rates of 127 surgical procedures performed in rheumatic patients receiving tumor necrosis factor alpha blockers. Clin Exp Rheumatol 2007;25:430–6.