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 risk factor for nonunion or wound healing problems. If peripheral pulses are not palpable, noninvasive vascular studies should be performed before any surgical treatment.
Chronic skin ulcers should be treated before ankle arthrodesis is performed.

Proper clinical assessment of the complete lower extremity is essential. In particular, the hindfoot should be assessed regarding alignment, functional impairment, and instability.
The adjacent joints, in particular the subtalar and talonavicular joints, should be examined for degenerative wear pattern or dysfunction. In order to achieve a plantigrade and stable foot postoperatively, additional procedures may be necessary if osteoarthritis or dysfunction are present.
Assessment of the vascular and neurologic status is essential to prevent malunion or wound healing problems postoperatively. Noninvasive vascular studies may be necessary preoperatively.
The skin incision may include preexisting scars. If necessary, a plastic surgeon should be counseled.
Plane weight-bearing radiographs (anteroposterior or mortise view, lateral view) should be done in a standardized setting. A Saltzman view can be added in case of a severe hindfoot malalignment ( Fig. 54.1 ).
In case of a severe osseous defect or severe malalignment, a computed tomography (CT) scan is helpful for preoperative planning. Single-positron electron CT can be added for assessment of adjacent joint dysfunction.

Treatment Options

Conservative treatment (i.e., pain medication, shoe modification, orthoses) should always be considered before surgery is done.
Supramalleolar osteotomy can be considered in young and healthy patients with early- to mid-stage asymmetric ankle osteoarthritis without distinct bony deformity.
Total ankle replacement is a feasible alternative for end-stage ankle osteoarthritis.
Arthroscopic ankle fusion can be considered for patients with minor ankle deformity but contraindication for total ankle replacement.
Retrograde nailing can be considered if adjacent joints, in particular the subtalar joint, also have to be fused.

The anterior aspect of the ankle is covered by the superior extensor retinaculum, a thickening of the deep fascia. From medially to laterally, it includes the tendons of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus ( Fig. 54.2 ).
The neurovascular bundle can be found between the extensor hallucis longus and the extensor digitorum longus tendon (halfway between the malleoli; Fig. 54.3 ).
The safe zone while approaching the anterior ankle joint lies beneath the anterior tibial tendon.
Branches of the superficial peroneal nerve cross from lateral to medial and ensure the sensory skin supply of the dorsum of the foot.

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

If you are a member. Log in here