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1. ANKLE ARTHRODESIS
Srikanth
1st year pg
Department of orthopaedics
svsmch

2. Ankle includes
three joints
1. Ankle joint
proper or
talocrural joint
2. Subtalar joint
3. Inferior
tibiofibular
joint

3. ANKLE(TALOCRURAL) JOINT
• Ankle joint is a load
bearing joint formed by
articular surfaces of
1. Distal epiphysis of tibia
and its medial malleolus
2. Distal epiphysis of fibula
and its lateral malleolus
3. Superior , medial and
lateral aspects of TALUS
• Ankle joint is a HINGE
TYPE OF SYNOVIAL JOINT

4. • Ankle joint is a true
mortise joint
1. Tibial palfond (ceiling)
superiorly
2. Medial malleolus
medialy
3. Lateral malleolus
lateraly
forms a deep
recess(MORTISE) to
receive TALUS

7. Tibiofibular syndesmotic ligaments

8. Collateral ligaments
• Medial collateral/deltoid ligament:
1) superifical deltoid ligament : it has 3 parts
tibiotalar,tibiocalcaneal,tibionavicular
• Tibiotalar part resists abduction and eversion of foot
• Tibionavicular part prevents displacement of talar
head inwards
• Tibiocalcaneal part prevents valgus displacement
2) deep deltoid ligament: intra articular prevents lateral
displacement and external rotation of talus

9. • Lateral tibiofibular ligament: divided in to
1) Anterior tibiofibular ligament: prevents
subluxation of talus when ankle is in plantar
flexion
2) Posterior tibiofibular ligament:prevents
posterior sublaxation of talus
3) Calacaneo fibular ligament: stabilize subtalar
joint and prevents excessive inversion of foot

11. • Anterior talofibular ligament(ATFL): weakest
ligament and it is commonly injured in ankle
sprains

13. Range of movements at Ankle
Dorsiflexion:
range : 10 to 20 degrees
The joint is closely packed in full dorsi flexion. So, maximum stability of ankle is in
full dorsiflexion due to engagment of broad anterior talar trochlear surface
in the narrow posterior part of tibial surface
Plantarflexion :
Range : 20 to 40 degrees
The joint is loosely packed in plantar flexion. So, abduction and adduction is
possible in plantar flexion.
Also, the joint is insecure in plantarflexion, thus maximum chances of dislocation.
Inversion : 0 to 40 degrees
Eversion: 0 to 20 degrees

14. Biomechanics of ankle

16. Biomechanics of ankle joint

17. Talocrural joint
• The tip of medial malleoli is anterior and superior
to lateral malleloli,
• Line joining the tip of two malleoli forms an axis
oblique to both sagittal and frontal planes
• Responsible for Palantar flexion and dorsiflexion
• Axis of rotation 13-18 degrees laterally from frontal
plane and 8-10 degrees from transverse plane

19. Subtalar joint
• Talocalcaneal joint : two points of articulation
anterior talocalcaneal articulation and posterior
talocalcaneal articulation
• Subtalar joint is a sliding single axis joint that acts
like mitered hinge connecting talus and calcaneus
• Responsible for inversion and eversion
movements
• During inversion: calcaneus rolls in to inversion
and slides laterally
• During eversion :calcaneus rolls in to eversion
and slides medially

22. Mid tarsal joint
• Transverse tarsal joint or chopart’s joint: consists
of two joints
1) Talonavicular joint: formed between the anterior
talar head and the concavity on the navicular
2) Calcaneocuboid joint: formed by anterior facet
of calcaneus and posterior cuboid
3) Important function of the foot is propulsion of
weight during stance phase,this function
made possible by locking and unlocking of
midtarsal joint

23. • During heel strike foot needs to be flexible in
order to adjust to the surface so midtarsal
joint unlocks to provide flexibility
• Later in gait cycle foot needs to act as rigid
lever to propel the weight of the body forward
which is made possible by locking of mid tarsal
joints

25. • Biomechanical aspects which make ankle suitable for
arthrodesis
1) Talus sits well in between medial malleolus,tibial
plafond,lateral malleolus which provides potential
bony surfaces for healing arthrodesis
2) Ankle is hinge joint, continous change of axis of
rotation throughout range of motion at tibiotalar joint
so fixation in neutral position doesnot produce severe
biomechanical consequences
3) Normal gait require only 10 to 12 degrees of ankle
extension and 20 degress of ankle flexion so loss of
some motion is not critical as in case of knee and hip

26. Biomechanics after ankle fusion
• In a fused ankle joint there is a incresed stress in the
subtalar joint, chopart joint line and the knee joint. The
adjacent joints develop a compensatory hyper mobility
particularly in transverse tarsal articulation
• If the ankle malpositioned in excessive internal rotation
there is increased stress in the subtalar joint, mid foot,
knee and hip . there may be overuse problem of hip
and the knee because of compensatory external
rotation of hip
• In excessively externally rotated position foot rolls over
the medial side and high chances of developing hallux
valgus

27. • Plantarflexed ankle fusion leads to functional
lengthening of the limb
• Increased dorsiflexed position concentrates the
ground impact on a small area of heel which is
easily mechanically overloaded and painfull
• Fusing ankle in varus position increases stress on
lateral side of foot this locks transverse tarsal
articualtion making the transition from hind foot
to mid foot rigid,there by overloading the small
joints of the mid foot

28. • Arthrodesis :surgical fusion of joint
• Ankylosis: pathological fusion of joint

29. Ankle arthrodesis
• Albert(1879) first described ankle arthrodesis
for stabilization of paralytic foot in
poliomyelitis
• Charnley (1951) introduced the concept of
compression to ankle arthrodesis by using an
external fixator
• Arthroscopic arthrodesis described in 1983
• Mini open arthrodesis described in 1996

30. INDICATIONS OF ANKLE ARTHRODESIS
• For patients with limited motion of ankle and chronic pain in whom
conservative measures have failed
a) Post traumatic arthritis
b) Post infectious arthritis
c) Osteoarthritis
d) Arthritis from chronic instability of ankle
e) Rheumatoid or auto immune inflammatory arthritis
f) Avascular necrosis of talus
g) Failure of total ankle arthroplasty
h) Instability of ankle from neuromuscular disease
i) Charcot neuroarthropathy
j) gout

31. Contra indications
• Absolute contra indications: vascular
impairment of limb and infection of skin
through which the approach is planned
• Relative contraindications: preexisting
moderate to severe ipsilateral hind foot
arthrosis and Contralateral ankle arthrosis
• Peripheral neuropathy may be contraindicated
to arthrodesis because of increased likelihood
of non union

33. Conservative management of ankle
arthrodesis
• NSAIDS
• Glucosamine and chondrotin sulfate suppliments
• Intra articular hydrocortisone injection to relief
pain in severe arthritis
• BRACING TO LIMIT MOTION is main stay in
conservative management
• Double upright locked ankle brace with steel
shank and rocker bottom sole shoes
• Arizone type brace/ foot orthosis

36. Patient evaluation
• Carefull history for an optimum outcome
• Exact location of pain
• Examination of ipsilateral hip and knee joint
• Bone quality: osteoporosis, sclerosis, bone loss
• Subtalar arthritis: sinus tarsi tenderness in forced
passive plantar flexion
• Functional desire of patient
• Assessment of medical comorbidities
• Skin : for any previous scar

37. Radiographic evaluation
• Weight bearing ap and lateral radiographs obtained
• Assessment of deformity and palnning of correction is
necessary
• Evaluation of limb length discrepancy is important
• Hind foot alignment view can be used for assessing
deformity distal to ankle joint
• On lateral view antero posterior sublaxation of ankle
and any tilt of tibial plafond should be noted
• Ct scan for assessment of any defects in the region of
planned fusion

38. Approaches for ankle arthrodesis
• Anterior approach to ankle joint
• Antero lateral approach to ankle joint and
tarsus
• Kocher lateral approach to ankle and tarsus
• Ollier approach to the tarsus
• Posterolateral approach to the ankle
• Posterior approach to ankle
• Medial approaches to the ankle

41. Position of ankle fusion
• Ankle position is same regardless of surgical
technique
1) Neutral flexion/extension( produces relatively
normal bare foot gait pattern)
2) External rotation 5 to 10 degrees(reduces lever
arm of the foot)
3) Slight valgus of 5 degress
4) Translation of talus posteriorly to align with
posterior margin of tibia( prevents vaulting type
of gait pattern and knee pain)

42. Principles of fixation
• Creation of broad ,flat cancellous surfaces that
are placed in to opposition to allow fusion
• Site of arthrodesis should be stabilized with
rigid internal or external fixation
• Hind foot should be aligned to leg and fore
foot should be aligned to hind foot to create
plantigrade foot

43. Arthroscopic arthrodesis
• Indication: < 10 degrees varus and valgus
deformity
• Advantages:
1. maintenance of malleolar congruency
2. Decreased risk of malunion
3. Gives more bony surface and anatomical
support for fusion
4. Less post operative pain
• Disadvantages
1. Does not allow for large deformity correction

46. Alternatives to ankle arthrodesis
• Arthroscopic debridment: provides only short term relief
• Periarticular osteotomies:
1. main goal is to unload more arthritic portion of joint and
provide more anatomical axis to redistrubute joint forces
2. Ideal candidate: chondral loss primarly in the medial or
lateral gutter of ankle with minimal involvment of
superior surface of talus especially with supra malleolar
deformity
3. Open wedge osteotomy of tibia for varus deformity and
medial joint arthrosis is particularly effective as an
alternative to more invasive treatment
4. Correction planned by measuring tibial ankle surface
angle(TAS), talar tilt, tibial lateral surface angle(TLS)

47. Distraction arthroplasty
• Principle: mechanical unloading of joint and
intermittent flow of intra articular synovial fluid
encourages cartilage healing
• Ideal candidate for distraction arthroplasty:
1. Young patient with painfull congruent mobile arthritic
ankle joint
2. Symptoms not relieved by conservative management
3. Unwilling for arthrodesis
• Contraindications: active infection, advanced coronal
plane deformity and significant loss of bone stock

48. Key elements of the procedure
• Hinges should be placed along the axis of the ankle
joint to prevent uneven joint distraction
• Not more than 5 to 6 mm of acute distraction should
be applied
• A circular fixator is superior to monolateral fixation
because monolateral frame delivers uneven distraction
• Fore foot wire usage should be avoided because it is
uncomfortable and discourages weight bearing
• Range of motion should be started early to preserve
ankle mobility

49. • Preoperative planning
• weight bearing radiographs measure the
tibiotalar joint space and evaluate the degree
of arthritis
• Evaluate ankle for periarticular deformity and
determine if supramalleolar osteotomy is
indiacted at the time of distraction
arthroplasty

51. • Joint preparation
• Frame application:2 ring fixation is needed for tibia
and foot, extra proximal tibial ring needed in case of
supramalleolar osteotomy if done
• Articualting hinges placed along ankle joint axis
between rings
• 5mm distraction applied
• Post op care: at 2 weeks sutures removed distraction is
evaluated ,goal is 5mm
• At 12 weeks frame is removed , weight bearing
ambulation is encouraged

54. Mini incision technique
• Preffered when coronal plane deformity is
minimal(<10 degree valgus /varus)
• Position:with a lift under ipsilateral leg so that
leg is not externally rotated and foot is
perpendicular to floor
• Incision: two 1.5 cms incision one just medial
to tibialis anterior tendon and one lateral to
peroneus teritus tendon

57. • Sub chondral bone rescetion with high speed burr is done
along with bone grafting
• Ankle positioned approximately, fixation done with
cannulated screws
• Three screws are ideal,
• the most desirable position is the so called “home run”
screw placed from the posterolateral tibia in to the talar
neck/head area distally
• 2nd screw: proximomedial screw directed in to posterior
body of talus
• 3rd screw: proximal antero lateral to distal medial screw
from lateral process of talus directed
proximal,posterior,and medial

59. • Post op care : 6 weeks immobilisation with
rolling walker gives a better quality of life
• Knee high walking boot can be used
depending upon healing later converted to
shoe

61. ARTHRODESIS WITH EXTERNAL
FIXATION

62. CHARNLEY METHOD
• First to describe the use of external fixator (1951)
 Open debridement of ankle joint cartilage via
anterior approach + Ex-fix
 One pin through distal tibia
 One pin through neck of the talus
 Use of connecting bars
• Compression relies on intact achilles tendon

64. OPEN ARTHRODESIS WITH
INTERNAL FIXATION

65.  Transfibular (transmalleolar) arthrodesis with
fibular strut graft
 Tibiotalocalcaneal arthrodesis
 Tibiotalar arthrodesis with sliding bonegraft
(Blair’s procedure)
 Tibiotalar or Tibiotalocalcaneal fusion with
structural allograft and internal fixaton for
salvage of Total Ankle Arthroplasty

66. TRANSFIBULAR ARTHRODESIS WITH
FIBULAR STRUT GRAFT
• A vascularized fibular strut graft is used.
• Added measure of stability and vascular
supply to the fusion site
• Colman and Pomeroy reported 96%fusion rate
in 48 patients with an average time to fusion
of 82 days

67. • PROCEDURE
 Elevate the periosteum over the anterior half
of the fibula, and periosteum and capsule over
anterior aspect of tibial plafond
 Anterior marginal osteophytes removed from
the tibia and talus
 Transect the fibula proximal to the ankle
plafond and remove approximately 1cm with a
second parallel cut
 Cut in the sagittal plane to remove the medial
2/3rds of fibula preserving the lateral 1/3rd
with its periosteal attachment

68. Fibular resection

69.  Use a laminar
spreader to
remove the
residual joint
contents

70. medial
longitudinal
approach to
remove the
medial
malleolus
 Take care to
protect the
posterior tibial
tendon and the
neurovascular
bundle

71.  Construct the fusion area to obtain neutral
extension, slight ER relative to tibial tubercle
 Neutral to slight valgus depending on the
position and flexibility of the rest of the foot
 If flat cuts are made, slightly translate the
talus posteriorly under the tibia
 Obtain bleeding, healthy cancellous bone on
all fusion surfaces
 If needed add bone graft from morselized
resected fibula or from a remote location

72.  Multiple partially threaded 7.5mm or 8mm
cancellous screws inserted from:
posterolateral in the tibia into talar head and
neck
posteromedial into talar body
 Compression with the first screw inserted is ideal
 Prepare the lateral tibia and lateral talus in the same
fashion and manually appose the lateral fibula to
this area
 Occasionally a bone biter can be used to slightly
fracture this fibular strut to allow better apposition

73.  Low-profile plate with 4 to 6 screws spanning
the fusion site provides the additional stability
to the overall construct
 POSTOPERATIVE CARE
> 10 to 14 days on splint
> non weight bearing cast for 4 to 8 weeks
( cast does not become loose- would
place stress on the fusion site)
> walking boot for 4 weeks
> shoe with shank and rocker if
concomitant with hindfoot or mid foot disease

75. PREOP POSTOP

76. TIBIOTALOCALCANEAL
ARTHRODESIS
• Arthrodesis of both ankle and subtalar joints
• A lateral approach with or without fibular onlay graft is
used
• A posterior approach may be appropriate in some
situations
• After arthrodesis site is prepared, determine the position
of the foot:
patella straight up
foot in neutral
slight valgus at the heel
slight posterior displacement of calcaneus over
tibia

77. Stephenson et al

80. TIBIOTALAR ARTHRODESIS WITH A
SLIDING BONE GRAFT
• Blair’s procedure
• Body of talus is lost or osteonecrotic
• Distal tibia is fused to the talar neck using an
anterior tibial sliding graft
• Near normal appearance of the foot with little
shortening of extremity
• Permits some flexion-extension motion of the
foot

82. TIBIOTALAR OR TIBIOTALOCALCANEAL FUSION WITH
STRUCTURAL ALLOGRAFT AND INTERNAL FIXATION
FOR SALVAGE OF FAILED TOTAL ANKLE
ARTHROPLASTY

83. OPEN ARTHRODESIS
• ADVANTAGES
Improved visualization of the joint
Improved access for bony resection, large
correction, accurate screw placement
• DISADVANTAGES
Large incisions with significant soft tissue
damage

84. TRIPLE ARTHRODESIS
• Edwin Ryerson in 1923
• The most effective stabilizing procedure in the
foot, fusion of subtalar, calcaneocuboid, and
talonavicular joints
• Most common indications were to correct
lower limb deformity

85. INDICATIONS
• Post traumatic arthritis
• Degenerative arthritis
• Ctev
• Polio
• Pes cavus(high arched foot)
• Pes planovalgus
• Charcot marie tooth disease
• Cerebral palsy

86. PRINCIPLES
• Three joints are exposed and joint resection
is done followed by fixation
• Resections of mid tarsal joints are done first
as it provides increased soft tissue
relaxation and further facilitates better
exposure of the subtalar joints
• Care should be taken to leave as much bone
as possible at this joints, specially in valgus
deformity because, lateral column length is
important for correction

87. PREOP PLANNING
• Paper tracing made from lateral radio-graph of
the ankle and components of the subtalar
joints are divided into three segments:
tibiotalar
calcaneal components
component comprising all the bones of
foot distal to midtarsal joint
• These are reassembled with foot in corrected
position so that the size and shape of the
wedges to be removed can be measured
accurately

92. COMPLICATIONS
• NON-UNION
• Other complications include
o Infection
o Malunion
o Wound problems
o Lateral instability
o Avascular necrosis of talus

93. • Smoking is associated with non-union
 16 times more than that of non-smokers in
absence of other risk factors
Optimal period of smoking cessation prior
to arthrodesis is unknown, empirically
suggested as 1 week

94. Thank you