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. 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. 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
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
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. Open: Lateral
• Full thickness flaps
• Periosteum of fibula stripped anteriorly and
posteriorly
• Protect peroneals
20. Open: Lateral
• Fibular osteotomy 2cm
proximal to level of joint
• Proximal-lateral
• Distal-medial
29. Open: Anterior
• Enter joint
• Prepare joint
• Position and fixation
with screws or plates
30. • Position: supine
• Extended scope portals
• Use lamina spreaders
• Debride joint
• Only do if no deformity
• Minimally invasive and
good results
Mini-Open
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. Mini-Open Results
• Early radiographic evidence on healing @ 6wks
Paremain, 1996.
• Clinical fusion = 100%
44. Ankle Arthrodeses: Open vs.
SAA
• SAA
– Less morbidity
– Decreased time to fusion
• 4 – 8 wks less
• Open
– Can address deformities
45. 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
55. • 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.
60. 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