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Revision ankle arthrodesis with lateral cannulated angled blade plate fixation
Foot and Ankle Surgery 2001
7: 187±191
Case report
Revision ankle arthrodesis with lateral cannulated angled blade plate ®xation G. CHOI,* N. GHALAMBOR, A. NIHALà AND E.TREPMAN§ *Tufts University School of Medicine, Boston, MA, USA, The Hand Center, Orange, California, USA, àHull Royal In®rmary, Hull, East Yorkshire, UK and §Section of Orthopaedic Surgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
Summary
A 38-year-old man was treated for a severely displaced tibiotalar arthrodesis non-union. There was extensive bone loss from the anterior distal tibial plafond, anterior talar subluxation, and varus malalignment. Skin quality along the anteromedial ankle region was poor, with a history of previous wound that had required several months to heal. Using a lateral approach, the tibiotalar non-union was exposed, debrided, reduced, and ®xed with a cannulated 90-degree angled blade plate and bone graft. The cannulated feature of the blade plate enabled accurate placement of the blade, with provisional assessment of blade position prior to creating the chisel hole for the blade. The blade plate construct provided rigid internal ®xation despite extensive anterior tibial plafond bone de®ciency. The medial wound developed postoperative dehiscence that was successfully managed with cephalexin and becaplermin gel dressings. The non-union was healed 5 months after surgery. Keywords: ankle; fusion; non-union; treatment; internal ®xation
Introduction Reconstruction of a complex non-union of an ankle arthrodesis may be a dif®cult technical problem. Bone de®ciency may make it dif®cult to achieve rigid internal ®xation with screws [1, 2] or ®xation plates [3±5]; distal intramedullary nails may be contraindicated if there is a normal subtalar joint [6, 7]; and external ®xation techniques may be associated with pin track infection resulting in osteomyelitis [8]. A blade plate used from a posterior approach for tibiocalcaneal [9] or tibiotalar [10] arthrodesis, or anterior approach for tibiotalar arthrodesis [11, 12],
may provide rigid ®xation despite segmental bone loss, infected non-union and collapse of the talar body. However, in some instances, soft tissue disruption or bone loss from previous injury or surgery may preclude the posterior or anterior approach because of the increased potential for complications such as wound dehiscence, infection and loss of ®xation. These cases may potentially be salvaged from a lateral approach, as described for tibiocalcaneal and tibiotalocalcaneal arthrodesis [13±15], but review of the literature did not reveal any previous reports of lateral blade plate ®xation of a tibiotalar arthrodesis non-union.
Correspondence: Elly Trepman, M.D., Health Sciences Centre, GF307±820 Sherbrook Street, Winnipeg, MB, R3A 1R9 Canada. Ó 2001 Blackwell Science Ltd
187
1 88
G. C H O I E T A L.
Case report A 38-year-old non-diabetic male sustained a closed left ankle fracture 2 years earlier when he slipped on ice near his home. He was treated elsewhere with open reduction, complicated by loss of ®xation, and subsequent ankle arthrodesis with staples and screws, complicated by delayed wound healing, non-union and deformity (Figures 1 and 2). On presentation, the patient noted pain located in the entire left ankle area and instability, aggravated with attempted weightbearing. There was marked varus deformity, swelling and tenderness of the ankle, and pain with ankle motion (Figure 1). There was a complex, stellate, medial ankle healed scar with
brownish discolouration and sensitivity, and a healed lateral ankle longitudinal sensitive surgical scar. Radiography of the left foot and ankle showed left ankle non-union, with two retained screws and one staple (Figure 2). The distal ®bula had been excised. Extensive bone loss was noted at the anterior portion of the distal tibia and posterior portion of the talar dome, with anterior subluxation of the talus relative to the tibia and varus malalignment of the talus (Figure 2). Revision ankle arthrodesis was done with general anaesthesia, supine position, perioperative cefazolin and thigh tourniquet. The non-union was approached from the lateral ankle scar and widely exposed anteriorly and posteriorly. Medial exposure
Figure 1 Clinical appearance of the left foot and ankle on presentation. (a) Frontal view showing marked varus deformity and swelling of the ankle. (b) Lateral view showing anterior subluxation and instability of the ankle. The lateral longitudinal scar from previous surgery is noted. (c) Medial view showing complex, stellate medial ankle healed scar with brownish discolouration.
Figure 2 Radiography of the left foot and ankle on presentation demonstrating left ankle nonunion with two retained screws and one staple. The distal ®bula had been excised. (a) Anteroposterior view showing severe varus deformity at the tibiotalar nonunion. (b) Lateral view showing anterior subluxation of the talus relative to the tibia. Extensive bone loss is noted at the anterior portion of the distal tibia and posterior portion of the talar dome. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
L A TE R A L BL A D E P L A T E A N K L E A R TH R O D E S I S
was limited to 3 inches along the previous medial wound. Extensive debridement of clear ¯uid, in¯ammatory tissue and sclerotic bone was done to expose healthy bleeding cancellous bony surfaces, and the retained hardware was removed. Cultures and histological examination of debrided tissue from the non-union showed no signs of infection. Additional bone from the distal ®bula and the medial malleolus was widely excised. The capsule was released and the talus was reduced posteriorly underneath the tibia to achieve boneto-bone apposition along the posterior half of the tibiotalar joint. The non-union was ®xed with a 30-mm long, sixhole, 90-degree cannulated blade plate (90° Cannulated LC-Angle Blade Plate, Synthes, Paoli, PA, USA). With ¯uoroscopic guidance, the guide pin was placed from lateral to medial in the horizontal plane, halfway between the top of the talar dome and the inferior surface of the talar body. Then, the plate was placed backwards along the guide pin, with the blade pointing laterally and the plate against the tibia, to identify correct rotational position of the blade. The blade plate was partially inserted from the lateral to medial direction. Additional bone was removed from the lateral side of the distal tibial metaphyseal ¯are and lateral talar body to enable the plate to be advanced ¯ush with the lateral surface of the tibial shaft and talus. With the
18 9
heel held in the desired position (0±5 degrees of valgus alignment, neutral dorsi¯exion/plantar¯exion, and neutral rotation), the blade plate was impacted down and satisfactory position con®rmed with ¯uoroscopy. Rigid ®xation of the arthrodesis was accomplished with an oblique lag screw and dynamic compression. Cancellous bone graft from the proximal tibial metaphysis [16, 17] was used to densely ®ll the anterior defect. After surgery, the ankle was immobilized initially with a well-padded splint and then a short leg cast. Non-weightbearing status and electrical bone stimulation were recommended. However, he was observed to bear partial weight and continued smoking against advice. During the ®rst month after surgery, clinical follow-up was limited because of incarceration for driving under the in¯uence of alcohol. Ten weeks after surgery, he presented with a wet cast and a medial wound dehiscence, and was treated with cephalexin and dressing changes with becaplermin 0.01% gel (Regranex, Ortho-McNeil Pharmaceutical, Raritan, NJ, USA). At 5 months after surgery, the dehiscence was resolved and clinical alignment appeared stable in neutral, plantigrade position (Figure 3). Follow-up radiographs and computerized tomography 5 months after surgery showed maintenance of stable alignment and consolidation of the arthrodesis (Figure 4), and weightbearing was advanced.
Figure 3 Clinical appearance of the left foot and ankle ®ve months after surgery. (a) Frontal view showing neutral alignment, with some residual swelling noted. (b) Lateral view showing stable, neutral, plantigrade alignment of the left ankle. (c) Medial view showing stable, neutral, plantigrade alignment and resolution of the medial wound dehiscence. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
1 90
G. C H O I E T A L.
Figure 4 Radiography and computerized tomography 5 months after surgery showing maintenance of stable alignment and consolidation of the arthrodesis. (a) Anterior oblique radiograph showing ®xation with blade plate and screws. Consolidation of the arthrodesis is noted. The subtalar joint is intact. (b) Lateral radiograph showing reduction and blade plate ®xation of the talar body under the distal tibia. Plantigrade alignment is noted. (c) Coronal computerized tomography scan demonstrating the inferior end of the blade plate and part of the oblique ®xation screw. Consolidation of the arthrodesis and preservation of the subtalar joint are con®rmed.
Discussion This case demonstrated the successful application of the cannulated blade plate for complex revision tibiotalar arthrodesis from the lateral approach. This approach enabled the use of a previous well-healed incision at the lateral ankle and provided wide visualization of the tibiotalar region for debridement and reduction of the non-union. A posterior approach [9, 10] might have not allowed adequate access to the anterior ankle which was required to debride and reduce the non-union. The presence of extensive soft tissue abnormality anteromedially was a relative contraindication to wide anteromedial exposure necessary for anterior plate ®xation [11, 12]. The limited medial approach was required in this case to debride the medial malleolar non-union and remove old hardware. However, the medial wound dehiscence might have probably progressed to major wound slough and deep infection had a larger medial incision been used. The blade plate provided rigid internal ®xation that was maintained to union despite extensive bone loss and unreliable patient behaviour. The cannulated feature of the blade plate facilitated accurate placement of the plate. Fluoroscopic evaluation of guide pin location enabled accurate establishment of the planned position of the blade prior to irrevers-
ibly committing the surgeon to create the chisel hole for the blade. Accuracy in blade placement was especially important because of the small talar body from bone loss and proximity to the subtalar joint, which was preserved to advantage. Furthermore, the 90-degree angle of the plate enabled placement backwards along the guide pin, with the plate along the tibia, providing the surgeon with the correct rotational position of the blade and reducing the risk of excessive plantar¯exion or dorsi¯exion of the fusion construct. A potential disadvantage of the blade plate is the wide exposure required for insertion of the device. Ankle arthrodesis may usually be accomplished in primary cases with more limited surgical exposure and screw ®xation alone [1]. Soft tissue problems laterally may be a contraindication to the lateral approach used in the case described. Therefore, the blade plate method will probably be reserved for limited cases of complex salvage of non-union or cases with extensive bone loss or deformity.
Acknowledgements A.N. gratefully acknowledges a grant from the John Charnley Trust (U.K.) for fellowship training in the United States of America and support from the Paul W. Lapidus Fellowship in Foot and Ankle Surgery. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
L A TE R A L BL A D E P L A T E A N K L E A R TH R O D E S I S
References 1 Mann RA. Arthrodesis of the foot and ankle. In: Coughlin MJ, Mann RA, Eds. Surgery of the Foot and Ankle, Seventh Edition. St. Louis: Mosby, 1999: pp 651±699. 2 Morgan CD, Henke JA, Bailey RW et al. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg 1985; 67-A: 546±550. 3 Scranton PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg 1985; 67-A: 550±555. 4 Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg 1999; 81-B: 113±116. 5 Mears DC, Gordon RG, Kann SE et al. Ankle arthrodesis with an anterior tension plate. Clin Orthop Rel Res 1991; 268: 70±77. 6 Kile TA, Donnelly RE, Gehrke JC et al. Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994; 15: 669±673. 7 Fujimori J, Yoshino S, Koiwa M et al. Ankle arthrodesis in rheumatoid arthritis using an intramedullary nail with ®ns. Foot Ankle Int 1999; 20: 485±490. 8 Kitaoka HB, Anderson PJ, Morrey BF. Revision of ankle arthrodesis with external ®xation for non-union. J Bone Joint Surg 1992; 74-A: 1191±1200. 9 Gruen GS, Mears DC. Arthrodesis of the ankle and subtalar joints. Clin Orthop Rel Res 1991; 268: 15±20.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
19 1
10 Morgan SJ, Thordarson DB, Shepherd LE. Salvage of tibial pilon fractures using fusion of the ankle with a 90° cannulated blade-plate: a preliminary report. Foot Ankle Int 1999; 20: 375±378. 11 Weltmer JB, Choi SH, Shenoy A et al. Wolf blade plate ankle arthrodesis. Clin Orthop Rel Res 1991; 268: 107±111. 12 Sowa DT, Krackow KA. Ankle fusion: a new technique of internal ®xation using a compression blade plate. Foot Ankle 1989; 9: 232±240. 13 Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity. Foot Ankle Int 1994; 15: 354±359. 14 Mudgal CS, Wilson MG. Revision tibiotalocalcaneal arthrodesis after a failed intramedullary rod: a technique tip. Foot Ankle Int 1999; 20: 210±211. 15 Myerson MS, Alvarez RG, Lam PWC. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 2000; 21: 643±650. 16 Catone GA, Reimer BL, McNeir D et al. Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg 1992; 50: 1258±1263. 17 O'Keeffe RM, Riemer BL, Butter®eld SL. Harvesting of autogenous cancellous bone graft from the proximal tibial metaphysis. J Ortho Trauma 1991; 5: 469±474.
7: 187±191
Case report
Revision ankle arthrodesis with lateral cannulated angled blade plate ®xation G. CHOI,* N. GHALAMBOR, A. NIHALà AND E.TREPMAN§ *Tufts University School of Medicine, Boston, MA, USA, The Hand Center, Orange, California, USA, àHull Royal In®rmary, Hull, East Yorkshire, UK and §Section of Orthopaedic Surgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
Summary
A 38-year-old man was treated for a severely displaced tibiotalar arthrodesis non-union. There was extensive bone loss from the anterior distal tibial plafond, anterior talar subluxation, and varus malalignment. Skin quality along the anteromedial ankle region was poor, with a history of previous wound that had required several months to heal. Using a lateral approach, the tibiotalar non-union was exposed, debrided, reduced, and ®xed with a cannulated 90-degree angled blade plate and bone graft. The cannulated feature of the blade plate enabled accurate placement of the blade, with provisional assessment of blade position prior to creating the chisel hole for the blade. The blade plate construct provided rigid internal ®xation despite extensive anterior tibial plafond bone de®ciency. The medial wound developed postoperative dehiscence that was successfully managed with cephalexin and becaplermin gel dressings. The non-union was healed 5 months after surgery. Keywords: ankle; fusion; non-union; treatment; internal ®xation
Introduction Reconstruction of a complex non-union of an ankle arthrodesis may be a dif®cult technical problem. Bone de®ciency may make it dif®cult to achieve rigid internal ®xation with screws [1, 2] or ®xation plates [3±5]; distal intramedullary nails may be contraindicated if there is a normal subtalar joint [6, 7]; and external ®xation techniques may be associated with pin track infection resulting in osteomyelitis [8]. A blade plate used from a posterior approach for tibiocalcaneal [9] or tibiotalar [10] arthrodesis, or anterior approach for tibiotalar arthrodesis [11, 12],
may provide rigid ®xation despite segmental bone loss, infected non-union and collapse of the talar body. However, in some instances, soft tissue disruption or bone loss from previous injury or surgery may preclude the posterior or anterior approach because of the increased potential for complications such as wound dehiscence, infection and loss of ®xation. These cases may potentially be salvaged from a lateral approach, as described for tibiocalcaneal and tibiotalocalcaneal arthrodesis [13±15], but review of the literature did not reveal any previous reports of lateral blade plate ®xation of a tibiotalar arthrodesis non-union.
Correspondence: Elly Trepman, M.D., Health Sciences Centre, GF307±820 Sherbrook Street, Winnipeg, MB, R3A 1R9 Canada. Ó 2001 Blackwell Science Ltd
187
1 88
G. C H O I E T A L.
Case report A 38-year-old non-diabetic male sustained a closed left ankle fracture 2 years earlier when he slipped on ice near his home. He was treated elsewhere with open reduction, complicated by loss of ®xation, and subsequent ankle arthrodesis with staples and screws, complicated by delayed wound healing, non-union and deformity (Figures 1 and 2). On presentation, the patient noted pain located in the entire left ankle area and instability, aggravated with attempted weightbearing. There was marked varus deformity, swelling and tenderness of the ankle, and pain with ankle motion (Figure 1). There was a complex, stellate, medial ankle healed scar with
brownish discolouration and sensitivity, and a healed lateral ankle longitudinal sensitive surgical scar. Radiography of the left foot and ankle showed left ankle non-union, with two retained screws and one staple (Figure 2). The distal ®bula had been excised. Extensive bone loss was noted at the anterior portion of the distal tibia and posterior portion of the talar dome, with anterior subluxation of the talus relative to the tibia and varus malalignment of the talus (Figure 2). Revision ankle arthrodesis was done with general anaesthesia, supine position, perioperative cefazolin and thigh tourniquet. The non-union was approached from the lateral ankle scar and widely exposed anteriorly and posteriorly. Medial exposure
Figure 1 Clinical appearance of the left foot and ankle on presentation. (a) Frontal view showing marked varus deformity and swelling of the ankle. (b) Lateral view showing anterior subluxation and instability of the ankle. The lateral longitudinal scar from previous surgery is noted. (c) Medial view showing complex, stellate medial ankle healed scar with brownish discolouration.
Figure 2 Radiography of the left foot and ankle on presentation demonstrating left ankle nonunion with two retained screws and one staple. The distal ®bula had been excised. (a) Anteroposterior view showing severe varus deformity at the tibiotalar nonunion. (b) Lateral view showing anterior subluxation of the talus relative to the tibia. Extensive bone loss is noted at the anterior portion of the distal tibia and posterior portion of the talar dome. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
L A TE R A L BL A D E P L A T E A N K L E A R TH R O D E S I S
was limited to 3 inches along the previous medial wound. Extensive debridement of clear ¯uid, in¯ammatory tissue and sclerotic bone was done to expose healthy bleeding cancellous bony surfaces, and the retained hardware was removed. Cultures and histological examination of debrided tissue from the non-union showed no signs of infection. Additional bone from the distal ®bula and the medial malleolus was widely excised. The capsule was released and the talus was reduced posteriorly underneath the tibia to achieve boneto-bone apposition along the posterior half of the tibiotalar joint. The non-union was ®xed with a 30-mm long, sixhole, 90-degree cannulated blade plate (90° Cannulated LC-Angle Blade Plate, Synthes, Paoli, PA, USA). With ¯uoroscopic guidance, the guide pin was placed from lateral to medial in the horizontal plane, halfway between the top of the talar dome and the inferior surface of the talar body. Then, the plate was placed backwards along the guide pin, with the blade pointing laterally and the plate against the tibia, to identify correct rotational position of the blade. The blade plate was partially inserted from the lateral to medial direction. Additional bone was removed from the lateral side of the distal tibial metaphyseal ¯are and lateral talar body to enable the plate to be advanced ¯ush with the lateral surface of the tibial shaft and talus. With the
18 9
heel held in the desired position (0±5 degrees of valgus alignment, neutral dorsi¯exion/plantar¯exion, and neutral rotation), the blade plate was impacted down and satisfactory position con®rmed with ¯uoroscopy. Rigid ®xation of the arthrodesis was accomplished with an oblique lag screw and dynamic compression. Cancellous bone graft from the proximal tibial metaphysis [16, 17] was used to densely ®ll the anterior defect. After surgery, the ankle was immobilized initially with a well-padded splint and then a short leg cast. Non-weightbearing status and electrical bone stimulation were recommended. However, he was observed to bear partial weight and continued smoking against advice. During the ®rst month after surgery, clinical follow-up was limited because of incarceration for driving under the in¯uence of alcohol. Ten weeks after surgery, he presented with a wet cast and a medial wound dehiscence, and was treated with cephalexin and dressing changes with becaplermin 0.01% gel (Regranex, Ortho-McNeil Pharmaceutical, Raritan, NJ, USA). At 5 months after surgery, the dehiscence was resolved and clinical alignment appeared stable in neutral, plantigrade position (Figure 3). Follow-up radiographs and computerized tomography 5 months after surgery showed maintenance of stable alignment and consolidation of the arthrodesis (Figure 4), and weightbearing was advanced.
Figure 3 Clinical appearance of the left foot and ankle ®ve months after surgery. (a) Frontal view showing neutral alignment, with some residual swelling noted. (b) Lateral view showing stable, neutral, plantigrade alignment of the left ankle. (c) Medial view showing stable, neutral, plantigrade alignment and resolution of the medial wound dehiscence. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
1 90
G. C H O I E T A L.
Figure 4 Radiography and computerized tomography 5 months after surgery showing maintenance of stable alignment and consolidation of the arthrodesis. (a) Anterior oblique radiograph showing ®xation with blade plate and screws. Consolidation of the arthrodesis is noted. The subtalar joint is intact. (b) Lateral radiograph showing reduction and blade plate ®xation of the talar body under the distal tibia. Plantigrade alignment is noted. (c) Coronal computerized tomography scan demonstrating the inferior end of the blade plate and part of the oblique ®xation screw. Consolidation of the arthrodesis and preservation of the subtalar joint are con®rmed.
Discussion This case demonstrated the successful application of the cannulated blade plate for complex revision tibiotalar arthrodesis from the lateral approach. This approach enabled the use of a previous well-healed incision at the lateral ankle and provided wide visualization of the tibiotalar region for debridement and reduction of the non-union. A posterior approach [9, 10] might have not allowed adequate access to the anterior ankle which was required to debride and reduce the non-union. The presence of extensive soft tissue abnormality anteromedially was a relative contraindication to wide anteromedial exposure necessary for anterior plate ®xation [11, 12]. The limited medial approach was required in this case to debride the medial malleolar non-union and remove old hardware. However, the medial wound dehiscence might have probably progressed to major wound slough and deep infection had a larger medial incision been used. The blade plate provided rigid internal ®xation that was maintained to union despite extensive bone loss and unreliable patient behaviour. The cannulated feature of the blade plate facilitated accurate placement of the plate. Fluoroscopic evaluation of guide pin location enabled accurate establishment of the planned position of the blade prior to irrevers-
ibly committing the surgeon to create the chisel hole for the blade. Accuracy in blade placement was especially important because of the small talar body from bone loss and proximity to the subtalar joint, which was preserved to advantage. Furthermore, the 90-degree angle of the plate enabled placement backwards along the guide pin, with the plate along the tibia, providing the surgeon with the correct rotational position of the blade and reducing the risk of excessive plantar¯exion or dorsi¯exion of the fusion construct. A potential disadvantage of the blade plate is the wide exposure required for insertion of the device. Ankle arthrodesis may usually be accomplished in primary cases with more limited surgical exposure and screw ®xation alone [1]. Soft tissue problems laterally may be a contraindication to the lateral approach used in the case described. Therefore, the blade plate method will probably be reserved for limited cases of complex salvage of non-union or cases with extensive bone loss or deformity.
Acknowledgements A.N. gratefully acknowledges a grant from the John Charnley Trust (U.K.) for fellowship training in the United States of America and support from the Paul W. Lapidus Fellowship in Foot and Ankle Surgery. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
L A TE R A L BL A D E P L A T E A N K L E A R TH R O D E S I S
References 1 Mann RA. Arthrodesis of the foot and ankle. In: Coughlin MJ, Mann RA, Eds. Surgery of the Foot and Ankle, Seventh Edition. St. Louis: Mosby, 1999: pp 651±699. 2 Morgan CD, Henke JA, Bailey RW et al. Long-term results of tibiotalar arthrodesis. J Bone Joint Surg 1985; 67-A: 546±550. 3 Scranton PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg 1985; 67-A: 550±555. 4 Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. J Bone Joint Surg 1999; 81-B: 113±116. 5 Mears DC, Gordon RG, Kann SE et al. Ankle arthrodesis with an anterior tension plate. Clin Orthop Rel Res 1991; 268: 70±77. 6 Kile TA, Donnelly RE, Gehrke JC et al. Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int 1994; 15: 669±673. 7 Fujimori J, Yoshino S, Koiwa M et al. Ankle arthrodesis in rheumatoid arthritis using an intramedullary nail with ®ns. Foot Ankle Int 1999; 20: 485±490. 8 Kitaoka HB, Anderson PJ, Morrey BF. Revision of ankle arthrodesis with external ®xation for non-union. J Bone Joint Surg 1992; 74-A: 1191±1200. 9 Gruen GS, Mears DC. Arthrodesis of the ankle and subtalar joints. Clin Orthop Rel Res 1991; 268: 15±20.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 187±191
19 1
10 Morgan SJ, Thordarson DB, Shepherd LE. Salvage of tibial pilon fractures using fusion of the ankle with a 90° cannulated blade-plate: a preliminary report. Foot Ankle Int 1999; 20: 375±378. 11 Weltmer JB, Choi SH, Shenoy A et al. Wolf blade plate ankle arthrodesis. Clin Orthop Rel Res 1991; 268: 107±111. 12 Sowa DT, Krackow KA. Ankle fusion: a new technique of internal ®xation using a compression blade plate. Foot Ankle 1989; 9: 232±240. 13 Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity. Foot Ankle Int 1994; 15: 354±359. 14 Mudgal CS, Wilson MG. Revision tibiotalocalcaneal arthrodesis after a failed intramedullary rod: a technique tip. Foot Ankle Int 1999; 20: 210±211. 15 Myerson MS, Alvarez RG, Lam PWC. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 2000; 21: 643±650. 16 Catone GA, Reimer BL, McNeir D et al. Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: a preliminary report. J Oral Maxillofac Surg 1992; 50: 1258±1263. 17 O'Keeffe RM, Riemer BL, Butter®eld SL. Harvesting of autogenous cancellous bone graft from the proximal tibial metaphysis. J Ortho Trauma 1991; 5: 469±474.