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Salvage of Ankle Large Bony Defect With Spinal Cage


Indications

  • Maintenance of limb length and stability in patients requiring hindfoot arthrodesis with large bone loss

  • Hindfoot fusion after failed total ankle arthroplasty (TAA)

  • Hindfoot fusion for treatment of talar body osseous necrosis

  • Hindfoot fusion for traumatic talectomy

Indications Pitfalls

  • Nonunion

  • Meticulous attention to positioning is paramount to avoid malposition of foot

Indications Controversies

  • Benefits of spinal cage

    • Maintain limb length

    • Interference fit stabilizing the construct and reducing cantilever stress in both the sagittal and coronal planes

    • Aids in capture of graft material (femoral marrow and endosteal bone as described herein)

    • Serves as alternative to bulk allograft and the inherent problems with complete union

Examination/Imaging

  • Failed TAA; case 1: (A) anteroposterior (AP) and (B) lateral left ankle images of a 59-year-old female 12 years post-TAA for traumatic arthritis. This individual complained of pain and was unable to walk for exercise. Note: in the lateral view (B) the patient bears weight, primarily through the forefoot. She is unable to weight bear through her hindfoot due to a fixed, plantar flexed ankle position ( Fig. 61.1B ).

    FIG. 61.1

  • Osseous necrosis of the talar body; case 2: a 72-year-old female with progressively debilitating right ankle pain. Bracing improved neither pain nor function. AP and lateral weight-bearing films demonstrate sclerotic changes in the talar body and subchondral cyst formation in the tibial plafond ( Fig. 61.2A–B ). Computed tomography (CT) imaging demonstrated sclerotic changes and subchondral fracture involving the talar body ( Fig. 61.2C–D ).

    FIG. 61.2

Treatment Options

  • Fusion with interposition bulk allograft

  • Fusion tibiotalocalcaneal or tibiocalcaneal with inherent shortening

  • Bracing

Positioning

  • The patient is positioned laterally, supported by a bean bag or the surgeon’s choice of lateral positioning aid ( Fig. 61.3 ).

    FIG. 61.3

  • If femoral bone marrow is to be harvested, the operative limb preparation includes the hip ( Fig. 61.4 ).

    FIG. 61.4

Positioning Pearls

  • A stable platform as pictured in Fig. 61.3 positioning precludes the need to manipulate the limb for imaging.

  • Position the leg down to avoid moving the operative limb when obtaining a lateral view.

  • Alternatively, the patient may be positioned prone or supine. Note: supine position requires additional assistance to elevate the limb for distal locking (see Fig. 61.3A ).

Positioning Pitfalls

  • Lateral positioning requires the ability to externally rotate the operative limb for proximal nail fixation.

Portals/Exposures

  • A lateral transfibular approach is planned.

  • The fibula is outlined and the long axis of the tibia is identified using imaging and subsequently marked (see Fig. 61.4 ).

Portals/Exposures Pearls

  • The incision should be long enough to allow adequate exposure without undue tension on the skin.

  • The incision is curved anteriorly at the distal extent to facilitate débridement of the subtalar joint.

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