Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Arthroscopic Ankle Arthrodesis


Indications

  • End-stage ankle arthritis

  • Caused by

    • Hemophilia

    • Hemochromatosis

    • Trauma

    • Osteochondral defects

    • Gout

    • Rheumatoid arthritis

    • Sepsis

    • Osteoarthritis

    • Ankle instability

Indications Pitfalls

  • Major bone loss may require a segmental allograft.

  • Infection may require a more extensive débridement than an arthroscopic fusion may achieve.

Indications Controversies

  • Avascular necrosis of the talus is increasingly indicated for arthroscopic fusion.

  • Hemophilia is an appropriate indication for arthroscopic fusion.

  • A poor soft-tissue envelope may be amenable to arthroscopic fusion when an open fusion will require a free flap.

Examination/Imaging

  • Patients are examined standing to assess the hindfoot and forefoot alignment.

  • The patient is observed walking and the phases of gait examined. The position of the foot in stance and swing phase is observed.

  • The remainder of the examination is performed with the patient sitting in a position to allow easy access of the foot to the examiner.

  • The skin is examined for scars from prior surgery or injury. The skin is inspected for other abnormalities such as hemosiderin staining and varicosities.

  • The position of the ankle and foot on the long axis of the tibia is determined. With the knee bent the alignment of the forefoot in the sagittal plane is observed to determine if it is internally or externally rotated.

  • The position of forefoot and hindfoot in varus or valgus on the longitudinal axis of the tibia is determined.

  • The ankle is examined on the longitudinal axis of the tibia to determine if there is a fixed equinus deformity, or if there is a translational deformity of the foot on the axis of the tibia in the coronal or the sagittal plane.

  • The joint lines of the ankle, subtalar, and talonavicular joints are palpated to feel for osteophytes and to determine if the joint lines are tender. The anterior and posterior margin of the ankle joint is examined.

  • Range of motion is measured with a goniometer. Range of motion is also performed in isolation of the ankle; subtalar, talonavicular, and calcaneocuboid joints are examined to determine which joints have painful motion.

  • The tibia is held and the talus moved in dorsiflexion and plantar flexion to assess the ankle for pain and motion. The talus is held at the talar neck, and the calcaneal tuberosity is moved into varus and valgus to determine if the subtalar joint moves or hurts.

  • The calcaneus is held and the cuboid moved to assess the calcaneocuboid joint. The talus is held at the talar neck and the navicular moved into internal and external rotation to determine if the talonavicular joint hurts.

  • The radiographic views (AP and lateral) show end stage ankle arthritis with varus alignment ( Fig. 53.1 and 53.2 ).

    FIG. 53.1

    FIG. 53.2

  • A magnetic resonance image is used to demonstrate ankle arthritis ( Fig. 53.3 ).

    FIG. 53.3

Treatment Options

  • Injection – steroid or hyaluronic acid

  • Activity modification

  • Bracing

  • Stabilizer brace

  • Arizona brace

  • Ankle foot orthosis brace

  • 6-week course of antiinflammatory medication

  • Physiotherapy

Surgical Anatomy

  • The ankle is the junction between the tibia, fibula, and talus. The joint has a larger tibiotalar surface that is broader anteriorly and narrower posteriorly.

  • The smaller medial joint surface comprises the articular surface between the lateral side of the medial malleolus of the tibia and the medial facet of the talar body.

  • The larger lateral joint surface consists of the medial aspect of the distal fibula and the lateral side of the body of the talus.

  • The medial gutter is the recess between the capsule, the medial malleolus, and the talar neck.

  • The lateral gutter is the recess between the capsule, the fibula, and the talar neck.

  • The posterior recess is the space between the posterior capsule, the back of the talus, and back of the tibia.

  • Anterior to the joint are the extensor tendons (medially tibialis anterior, centrally extensor hallucis longus, laterally extensor digitorum longus, and most lateral peroneus tertius). The extensor retinaculum binds these tendons in a superior and inferior portion. The deep branch of the peroneal nerve and the anterior tibial artery lie on the anterior capsule deeper than the tendons centrally over the joint. More superficial to the retinaculum and lateral to the joint lies the superficial peroneal nerve, just under the skin in either one or two branches at the level of the ankle.

  • Medial to the ankle close to the medial gutter subcutaneously lie the two branches of the saphenous nerve around the saphenous vein.

  • Posterior medially lies the tibialis posterior tendon. This lies in a tendon sheath and grove in the medial malleolus and cannot be seen from within the joint.

  • The flexor digitorum longus tendon lies posterior and lateral to this and next to the posterior joint capsule. It is held in the flexor retinaculum, a thick fibrous sheath that extends from the medial malleolus to the calcaneus, with septa penetrating deep to divide the flexor tunnel into sheaths. Behind and lateral to this lies the neurovascular bundle consisting of the tibial nerve, the posterior tibial artery, and the venae communicates. The flexor hallucis longus lies lateral and anterior to the neurovascular bundle. It can be seen within the ankle joint. The tendon passes through a fibro-osseous tunnel behind the talus, formed by the os trigonum, the posterior medial surface of the talus, and a fibrous band.

  • The peroneal tendons lie to the posterior lateral side of the joint in a grove on the posterior side of the fibula. They are bound by the superior and inferior peroneal retinaculum.

  • The ligaments around the joint include the anterior and posterior tibiofibular ligaments, which stabilize the syndesmosis. These ligaments lie quite distal and form a restraint to the talus anteriorly and posteriorly, as well as stabilize the tibia and fibula. Both ligaments can be clearly seen within the joint.

  • The posterior talofibular ligament can be seen creating part of the posterior recess and can clearly be seen within the joint.

Positioning

  • A beanbag is used to position the patient so that the foot is vertically orientated. The foot is placed at bottom edge of the operating room table.

  • The arthroscopy tower is placed to the head of the bed on the contralateral side.

  • A thigh tourniquet is used. A calf tourniquet will result in tightening of the leg muscles and loss of visualization.

  • A traction apparatus is used at surgeon preference.

  • The limb is positioned on the bed ( Fig. 53.4 ).

    FIG. 53.4

  • A leg holder is used ( Fig. 53.5 ).

    FIG. 53.5

Positioning Pearls

  • Make sure the leg is at the foot of the bed.

Positioning Pitfalls

  • External rotation of the limb will make the joint much harder to assess.

Positioning Equipment

  • Beanbag

  • Traction device

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