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Ankle Arthrodesis Using Ring/Multiplanar External Fixation

Indications Ankle arthrodesis Symptomatic end-stage ankle arthritis (posttraumatic, inflammatory, primary) Failed nonoperative management External fixation History of sepsis/osteomyelitis at the arthrodesis site ( Fig. 55.1A–B ) Compromised soft tissue envelope Inadequate bone stock to support internal fixation at the arthrodesis site Failed prior ankle arthrodesis using internal fixation ( Fig. 55.1C ) Failed total ankle arthroplasty ( Fig. 55.1D ) Anticipated noncompliance with non–weight-bearing status The…

Rigid Fixation for Ankle Arthrodesis Using Double Plating

Indications Posttraumatic or idiopathic ankle osteoarthritis with severe bony deformity Inflammatory ankle arthropathy (i.e., rheumatoid arthritis) Unmanageable ankle joint instability or neurologic disorders Distinct osseous defects (i.e., posttraumatic, postinfectious, after failed total ankle replacement) Indications Pitfalls Acute or chronic osteomyelitis has to be treated before ankle arthrodesis is performed. Smoking may lead to nonunion and wound healing problems postoperatively. Indications Controversies Peripheral artery disease is a…

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…

Osteotomies for the Correction of Varus Ankle

Indications Malaligned ankles with medial osteoarthritis Malunions after distal tibial fractures or malleolar fractures Realignment prior to total ankle replacement (TAR) or ankle fusion Corrections after malpositioned TAR or ankle fusion Medial osteochondritis dissecans of the talus Indications Pitfalls Loss of >50% of tibiotalar joint surface (plain radiographs, magnetic resonance imaging, arthroscopy) may be treated with TAR or ankle fusion. Lack of compliance with the postoperative…

Realignment Surgery for Valgus Ankle Osteoarthritis

Indications Physically active patients with lateral ankle joint degeneration associated with valgus malalignment (e.g., posttraumatic malalignment, ankle joint instability) Lateral osteochondritis dissecans of the talus associated with valgus malalignment Realignment prior to total ankle replacement (TAR) or ankle fusion Indications Pitfalls Loss of >50% of tibiotalar joint surface (anteroposterior radiographs, magnetic resonance imaging, arthroscopy) may be treated with TAR or ankle fusion. Lack of compliance with…

Anterior Ankle Impingement

Indications Painful ankle dorsiflexion due to impingement of bone and/or soft tissue in the anterior ankle joint Loss of ankle dorsiflexion due to anterior tibiotalar spurs Indications Pitfalls Severe anterior ankle arthritis with loss of anterior joint space, or anterior subluxation of the talus, will do poorly with decompression. Not recognizing subtle cavus and associated instability. Neglected calcaneal fractures with talar angle declination causing anterior impingement…

Vascularized Bone Graft for Extended Osteochondral Lesion of Talus

Indications Large osteochondral lesions (OCLs) that are bigger than one third of the articular surface in at least one plane (sagittal and/or coronal) A history of persistent pain for >1 year after conservative treatment or previous surgical treatment Indications Pitfalls Ankle osteoarthritis grade II and III (Takakura) Presence of a tibial osteochondritis dissecans (OCD) opposite to the talar OCD (kissing lesion) Indications Controversies Patients <16 years…

Osteochondral Lesion of the Ankle: OATS Procedure

Osteochondral autograft transfer system (OATS) procedure consists of transplanting one or various osteochondral cylinders from a donor site to a osteochondral defect to supply the smoothness and support of the articular surface that has been lost. Indications Stage III–IV osteochondral lesions of the talus Diameter of <10 mm Previous failure of microfracturing or retrograde grafting Indications Pitfalls Panarticular arthritis conditions Smokers Patients >50 years old Donor…

Ankle Arthroscopy From a Posterior Approach

Indications Isolated posterior ankle pathology such as flexor hallucis longus (FHL) tendonitis, posterior impingement from a Stieda process, an os trigonum, or soft tissue Posterior osteochondral defects Ankle fusion, or combined ankle and subtalar fusion Typically posterior ankle arthroscopy is performed in the prone position, although a full lateral position can be used on occasion, or two posterior portals in the supine position using a leg…

The Valgus Malaligned Triple With Subtalar and Transverse Tarsal Deformity

Indications Residual lateral subfibular impingement, medial ankle, or medial arch pain Radiographic valgus tilt of the talus in the ankle mortise Secondary lateral knee pain, gait changes, or imbalance related to foot deformity Symptoms interfering with normal daily activity Indications Pitfalls Skin breakdown or ulceration in the medial arch Diabetic or nondiabetic peripheral neuropathy Peripheral vascular disease Other medical comorbidities precluding surgery Indications Controversies The most…

Single Medial Approach for Triple Arthrodesis

Indications Symptomatic adult rigid flatfoot deformity due to dysfunction of the posterior tibial tendon (stage III according to the classification of Johnson and Storm), which is not responding to conservative treatment Tarsal coalitions Inflammatory or posttraumatic arthritis of the hindfoot Indications Pitfalls Any kind of infection of the foot is an absolute contraindication for a hindfoot fusion. Posterior tibial tendon-dysfunction stage IV with tilt in the…

Triple Arthrodesis

Indications Fixed hindfoot deformities Symptomatic hindfoot arthritis Salvage procedure of the foot Treatment Options Nonoperative treatments include hindfoot and ankle bracing Physical therapy and nonsteroidal antiinflammatory drugs may help alleviate pain Examination/Imaging Weight-bearing physical examination reveals hindfoot range of motion, if any, and alignment. Weight-bearing radiographs are obtained in anteroposterior (AP; Fig. 44.1A ) and lateral ( Fig. 44.1B ) views to evaluate for degenerative changes…

Distraction Subtalar Fusion

Indications Symptomatic osteoarthritis of the subtalar joint After calcaneal fracture In peritalar instability Symptomatic anterior ankle impingement/ankle osteoarthritis due to horizontalized talus Symptomatic valgus instability of the ankle in peritalar instability Painful tarsal coalition Indications Pitfalls Avascular necrosis of the talar body Fusion of the subtalar joint in a nonanatomic position of the talus Indications Controversies Crucial for success, for example, obtaining a plantigrade and stable…

Arthroscopy of the Subtalar Joint

Indications Posterior subtalar impingement syndrome due to symptomatic os trigonum Flexor hallucis longus tenosynovitis Arthrofibrosis Subtalar arthrosis Calcaneal/talar fracture reduction control Osteochondral lesions Indications Pitfalls Active infections Severe subtalar malalignment Indications Controversies Talocalcaneal coalitions Triple arthrodesis Examination/Imaging Range of motion of the subtalar joint must be addressed and compared with the opposite side, and pain must be evaluated either on physical examination or after anesthetic injection…

Arthroscopic Talus Fracture Fixation

Indications Talar neck fractures that can be reduced without making an incision using traction or manipulation only Lateral talar process fractures Medial talar fractures Posterior body fractures Minimally comminuted talar body fractures Indications Pitfalls Talar neck fractures with lateral comminution Talar body fractures not reducible closed Talar neck fractures with talar body dislocations that cannot be reduced via traction Indications Controversies No outcome data to date…

Percutaneous Fixation of Talus Fracture

Indications Acute talar neck fractures (Hawkins type I–III) Nonunited talar neck fractures (<9 months after injury) Indications Pitfalls Closed reduction is not feasible (e.g., interposed fragment that cannot be removed arthroscopically). Extended defect on the anterior talar neck (comminuted area) that requires open visualization for reduction and grafting. Indications Controversies Open fractures Comminuted fracture at the subtalar joint side Examination/Imaging Check for neurovascular deficits and skin…

Sinus Tarsi Approach for Calcaneal Fractures

Indications Displaced tongue-type fractures Large extraarticular fractures (>1 cm) with detachment of Achilles tendon and/or >2 mm displacement Urgent if skin is compromised Sanders type II and III Posterior facet displacement >2–3 mm, flattening of Böhler angle, or varus malalignment of the tuberosity Anterior process fracture with >25% involvement of the calcaneocuboid joint Indications Pitfalls Heavy smokers Vasculopathies Indications Controversies Initial Böhler angle <0° Primary subtalar…

Nonextensile Techniques for Treatment of Calcaneus Fractures

Indications Displaced intraarticular calcaneus fractures Simpler patterns Early fixation Patients at high risk for wound healing complications with extensile approaches including smokers, diabetics, and those with medical comorbidities Indications Pitfalls Inexperience with calcaneus fracture reduction techniques Fractures treated beyond 2–3 weeks Indications Controversies Which fractures are best suited for this treatment? Can this technique be used for all fracture types? Examination/Imaging Computed tomography scan images demonstrate…

Intraarticular Calcaneus Fractures

Indications Nonoperative management is indicated for nondisplaced calcaneal fractures or extraarticular calcaneal fractures with near-physiologic hindfoot alignment (computed tomography [CT] confirmation is recommended). Operative treatment of calcaneus fractures is indicated for displaced intraarticular and open calcaneal fractures. Indications Pitfalls When the soft tissues allow, operative treatment should be performed within 2–3 weeks from injury, before the fracture heals in a malunited position. Operative treatment should be…

Calcaneus Fractures: Treatment Using Extensile Lateral Approach and Open Reduction Internal Fixation

Indications Intraarticular calcaneal fractures with ≥2 mm step off of the posterior facet, and intraarticular calcaneal fractures with Böhler angle <15° on lateral radiographs of the foot or ankle Contraindications: vascular insufficiency, poorly controlled diabetes, smokers, and noncompliant patients Relative contraindications may include various medical comorbidities Surgical intervention with extended lateral incision may be performed urgently before swelling occurs, or within 1–3 weeks with the resolution…