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Ankle arthritis - Derek Park
Ankle arthritis - Derek Park
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Lecture 33 34 parekh ankle arthritis

  1. 1. Ankle Arthritis & Fusion: Open, Mini, Arthroscopic Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
  2. 2. Ankle Arthritis • Ankle is more commonly injured than any other joint in the body • Subject to more WB force per cm2 than any other joint • Prevalence of ankle arthritis is 9 x’s lower than at the hip or knee • Trauma is the most common cause • Ankle sprains, ankle fx, pilon fx …
  3. 3. Indications • Arthrosis • Pain • Deformity • Failed TAR • Charcot ankle • Degenerative Arthritis • Rheumatoid Arthritis • Post Traumatic/ Acquired Deformity • Instability from Paralytic Disorders • Neuropathic Joint • Failed Total Ankle Replacement
  4. 4. Goals • To create a painless, stable, plantigrade foot
  5. 5. Surgical Considerations • Minimal periosteal stripping • Rigid internal fixation • Screws • Plates • External fixation • Attention to alignment and position • Plantigrade foot • 5-7 deg valgus • Neutral to 5 degrees DF • Rotation equal to other side • Posterior displacement: anterior-anterior
  6. 6. Preoperative Planning • R/O subtalar DJD • May require CT scan • May need combined fusion of both joints
  7. 7. Preoperative Planning • R/O AVN talus • May require MRI • May require bone graft • May require tibio-calcaneal fusion
  8. 8. Preoperative Planning • R/O fixed equinus • Achilles contracture • TAL • Gastroc recession • Anterior osteophytes • Excision of osteophytes • +/- tendoachilles lengthening
  9. 9. Preoperative Planning • Varus or Valgus deformity • Plafond fracture • Talar collapse • Bone grafting • Osteotomy
  10. 10. Problems • Nonunion rate – 0 – 40% • Initial pain relief can be elusive • Functional limitations • Uneven surfaces>stairs>objects from floor=driving • Shoe modifications • SACH heel/rocker-bottom sole • Adjacent joint degeneration • 50% arthroses within 7 yrs
  11. 11. Concepts • Technical considerations – In-situ fusion • Usually no deformity – Deformity-correcting fusion
  12. 12. Concepts • Soft tissue considerations – Avoid placing tension on skin edges – Utilize full-thickness flaps – Cognizant of cutaneous nerves
  13. 13. Surgical Principles • Create broad, congruent cancellous surfaces • Remove all cartilage • Feather and penetrate into subchondral bone • Use bone graft or substitutes to fill defects • Stabilize w/ rigid fixation • Appropriate alignment to create a plantigrade foot
  14. 14. Complications • Infections – Careful soft tissue handling, removal of devitalized tissue, prevention of hematoma • Nerve disruption/entrapment • Nonunion – Prepare joint, adequate fixation • Malalignment
  15. 15. Ankle Arthrodeses • Open • Mini-open • Arthroscopic- assisted
  16. 16. Ankle Fusions - Open • Advantages • Easier visualization • Ability to address deformity • Better opposition of joint surfaces • Disadvantages • More soft tissue dissection
  17. 17. Open • Lateral/Transfibular approach • Never a TAR candidate • Posterior • Poor anterior or lateral skin • Anterior • All others
  18. 18. Open: Lateral • Position: supine • Incision • 10cm prox to tip of fibula  base of 4th MT • Structure at risk • Anterior branch sural n. • Peroneals
  19. 19. Open: Lateral • Full thickness flaps • Periosteum of fibula stripped anteriorly and posteriorly • Protect peroneals
  20. 20. Open: Lateral • Fibular osteotomy 2cm proximal to level of joint • Proximal-lateral • Distal-medial
  21. 21. Open: Lateral • Morcellize for bone graft • Use for lateral onlay graft
  22. 22. Open: Lateral • Remove osteophytes • Remove cartilage and subchondral bone • Feather cancellous surfaces
  23. 23. Open: Posterior • Position: prone • Incision • 10-12cm from glabourous skin • Structure at risk • Sural n. • Tibial n. • Achilles • FHL tendon
  24. 24. Open: Posterior • Split Achilles • Maintain full thickness flaps
  25. 25. Open: Posterior • Open deep posterior compartment • Find FHL muscle belly • Retract medially
  26. 26. Open: Posterior • Enter joint • Prepare joint • Position and fixation with screws
  27. 27. Open: Anterior • Position: supine • Incision • 1 fingerbreadth lateral to ant tibial spine • 10cm (2/3 prox, 1/3 distal) • Structure at risk • Medial branch SPN • EHL, TA
  28. 28. Open: Anterior • Find EHL distally and remove from sheath
  29. 29. Open: Anterior • Enter joint • Prepare joint • Position and fixation with screws or plates
  30. 30. • Position: supine • Extended scope portals • Use lamina spreaders • Debride joint • Only do if no deformity • Minimally invasive and good results Mini-Open
  31. 31. Mini-Open
  32. 32. Mini-Open • Place laminar spreader in one wound and prepare from the other • Posterior 1/3 ankle difficult to visualize • Prepare joint • Position and fixation with screws
  33. 33. Mini-Open Results • Early radiographic evidence on healing @ 6wks Paremain, 1996. • Clinical fusion = 100%
  34. 34. Ankle Fusions - Arthroscopic • Advantages • Minimal dissection • Decreased wound healing • Minimal interference with surrounding tissue • Disadvantages • Technically challenging • Less optimal fusion surface • Inability to correct deformity
  35. 35. Ankle Arthrodeses: SAA • Indications – Similar to open – Minimal deformity of ankle • Limited ability to correct varus/valgus tilt
  36. 36. Ankle Arthrodeses: SAA • Prepare room for ankle arthroscopy • Distract • Non/invasive • Aggressive shaver for anterior synovectomy
  37. 37. Surgical Armamentarium • Small joint arthroscope 2.7 30 degree • Currette small joint (need long narrow shaft and curved if available) • Large joint shaver • 4.0 round burr • 5.5 shaver aggressive • Yankauer suction tip • Noninvasive ankle distractor
  38. 38. Ankle Arthrodeses: SAA • Residual cartilage removed • Shaver/currettes • Burr used to make pockmarks • Fluid on/off
  39. 39. Ankle Arthrodeses: SAA • Average 2.5 hours Ogilvie-Harris ,1993 • Complication rate 9.8% Ferkel, 1993 • 50% nerve injury • Union rate of 100% Myerson, 1989 • 34/35 overall fusion rate Ferkel, 2005 • 31/35 solid fusion arthroscopically Jerosch ,2005
  40. 40. Ankle Arthrodeses: Open vs. SAA • SAA – Less morbidity – Decreased time to fusion • 4 – 8 wks less • Open – Can address deformities
  41. 41. Ankle Arthrodeses: Open • Alignment & fixation • Ant aspect of talus aligns ant cortex of tibia • Screws • W/in sinus tarsi, above lat process • Aim screws medially & as proximal as possible • Ensure all threads are in proximal piece
  42. 42. Fixation Options • Screws • Size • Large: 6.5, 7.0, 7.3 • Cannulated vs solid • Orientation
  43. 43. Ankle Fusions - Internal Fixation Options • 2 Parallel Screws - optimal compression • 2 Crossed Screws - optimal stability • 2 Parallel and one Cross Screw • 2 Parallel and one P-A screw
  44. 44. Ankle Arthrodeses: Open
  45. 45. Open: Lateral
  46. 46. Fixation Options • Plates • Anterior
  47. 47. • Solid arthrodesis 12 weeks (no BG), 14 wks (BG) • AOFAS from 37 to 68. • 93% were satisfied. No complications . • CONCLUSION: The anterior double plating system: Reliable method to achieve solid tibiotalar arthrodesis, even with loss of bone , e.g. failed TAA Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Plaass C, Knupp M, Barg A, Hintermann B. Foot Ankle Int. 2009 Jul;30(7):631-9.
  48. 48. Fixation Options • Plates • Anterior
  49. 49. Fixation Options • Plates • Anterior
  50. 50. Fixation Options • Plates • Lateral
  51. 51. External Fixation • Advantages • Avoid metal in infected bone • Better control in poor quality bone • May lengthen and fuse at some time - Ilizarov • Disadvantage • Pin tract infections • Patient acceptance of fixator • Pin breakage
  52. 52. Ankle Arthrodeses: Open • Post-op – Dressings for 10-12d – SL-NWB cast – WB CAM boot
  53. 53. RE ECT the ankle the foot

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