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Ankle Arthrodesis:Screw Fixation Techniques
and ConsiderationsBy,
Christopher Hood Jr.TUSPM Class of 2012
Crozer-Keystone Health System
Albert – 1879 – coined “arthrodesis”; tibio-talar arthrodesis
Lexer – 1906 – TTC Fusion with cadaver bone (boiled corpse bone pin) across AK/STJ
Charnley – 1951 – External Fixation of the Ankle for fusion compression
Schneider – 1983 – Arthroscopic Ankle Arthrodesis first described
Myerson - 1996 – “Mini-Arthrotomy”
Background
Gold Standard for Degenerative Joint Arthritis of the ankle◦ Primary DJD rare◦ Secondary/post-traumatic – Most Common
Arthritis Neuromuscular Failed Total Ankle Replacement MISC
Indications
Dotes et al. 2010
eorthopod.com
The purpose of ankle arthrodesis is to eliminate pain and deformity by solid fusion of the bones involved (talus – tibia, fibula) and to obtain a neutral plantigrade foot
How do we get solid fusion?
Theory
Complete removal of all cartilage, fibrous tissue, and any other material that may prevent contact of raw bone surfaces
Accurate and close fitting of the fusion surfaces
Optimal position of the ankle joint Maintenance of the bone apposition in an
undisturbed fashion until fusion is complete
Glissan’s Four Requirements for Successful Fusion of the Ankle
What is the Optimal Position?
Frontal Transverse Sagittal
McGlamry RF slight valgus 15° ER Right Angle (up-tp 5° PFX)
Chang Slight valgus wedging
Comparable to contra lateral limb
Right Angle
Schuberth RF slight valgus 10° ER Neutral Flexion
Myerson 5° Valgus 5° ER Neutral Flexion
Open◦ Many incision approaches
Medial / Lateral Anterior Posterior
Arthroscopic◦ Anteromedial and Anterolateral portals
Mini-Open
Surgical Methods
Open Technique
Lateral Incision Medial Incision
Chang et al.Chang et al.
Arthroscopy
http://www.orthopaedics.co.uk/boc/patients/images/ankle_arthroscopy_fig2.gif
www.thefootandankleclinic.com
www.worldortho.com
Mini-Open AM and AL incisions along talocrural gutters 1.5cm long
Raikin 2003
Screws IM Nails
◦ T2 Arthrodesis – Stryker◦ Phoenix - Biomet
Plates External Fixation
Fixation
www.thefootandankleclinic.com
Ilstraining.com - Integrawww.txsportsmed.com
www.strykerfoot.com
2 vs. 3 (vs. 4)? Direction? Order of Insertion?
Screw Placement
Zwipp et al. 2010Morgan et al. 1985
Crossing 6.5mm short-thread cancellous screws or 7.3mm cannulated screws
Crossed to cancel out any shift caused by their oblique orientation
Placement – Two Screws◦ Medial – above Medial Mallelous to AnteroMedial
aspect of talar body◦ Lateral - AnteroLateral aspect of tibia to
PosteroLatearl aspect of talar body
McGlamry – Comprehensive Textbook of Foot and Ankle Surgery
McGlamry Foot and Ankle Surgery Chapter 38
Morgan et al. JBJS 1985
101 patients underwent ankle fusion F/U 10 years 90% good to excellent results 95% fusion rate 2 screws
◦ “More than two screws were never needed.”
Long-term results of tibiotalar arthrodesis
1st – distal tibial metaphysis talar body 2nd – distal fibular metaphysis talar body Angled anteriorly at 40°
Morgan et al. 1985
Holt et al. Clinical orthopaedics and related -research 1991
23 patients - 3 screw technique◦1st – *placed posterior to anterior from posterior mallelous to talar neck/head (6.5mm)
◦2nd – medial mallelous to talar body◦3rd – lateral malleous to talar body
93% fusion rate
Ankle Arthrodesis Using Internal Screw Fixation
Holt et al. 1991
(1) Posterior Screw:• Resists flexion and extension• Pulls ankle out of equinus• Compresses joint surfaces
Holt et al. 1991
Ogilvie-Harris et al. Clin Orthop Relat Res 1994. 16 cadaver arthrodesis constructs 2 screw vs 3 screw technique compared Order of insertion compared
Arthrodesis of the ankle. A comparison of two versus three screw fixation in a crossed configuration
Ogilvie-Harris et al. 1994Ogilvie-Harris et al. 1994
2 screws < 3 screws◦ 2 screws = 1375 pixels◦ 3 screws = 3227 pixels
Order of insertion◦ Lateral >>> Anterior ≈ Medial
3 screws increased resistance to tibial torsion
Recommendations:◦ usage of 3 screws routinely ◦ lateral screw first, then medial, and 3rd screw
anterior
Results
Alonso-Vazques et al. Clinical Biomechanics 2004. 2 screws crossed medial and lateral into
talus 3rd screw either inserted:
◦ PosteroLat tibia aiming AnteroMed to talar neck (Holt et al 1991)
◦ Anterior Tibia aiming PosteroInferior talar body (Ogilvie-Harris et al 1994)
Which screw decreases micromotions greater?
Initial stability of ankle arthrodesis with three-screw fixation. A finite element analysis
Results:Anterior screw decreased peak micromotions more than posterior screw with greater torsional stability
Alonso-Vazquez 2004
Jeng et al. Foot Ankle Intl 2011 17 cadaver ankles of no deformity present Cartilage left intact 7.0 cannulated PT screws used
Results: Insertion was equal in regards to: ◦ Total contact area (0.9 – 1.1 cm²),◦ Percent contact area (10.3 – 11.9%)◦ Pressure generated (1.1-1.2 mPa)
Comparison of Initial Compression of the Medial, Lateral, and Posterior Screws in an Ankle Fusion Construct
Jeng et al. 2011
All 3 screw orientations concentrated contact area and percent contact area over the anterior half of the ankle
Jeng et al. 2011
What technique do you use?◦ 2 v 3 v 4 screws?◦ Sequence?
Additional comments? Pearls? Advice?
Your Experience?
Questions?
Alonso-Vazquez A. Initial stability of ankle arthrodesis with three-screw fixation. A finite element analysis. Clinical Biomechanics. 2004; 19: 751-759.
Chang TJ. Master Techniques in Podiatric Surgery: The Foot and Ankle. Lippincott Williams and Wilkins. First Edition. 2004.
Holt ES. Ankle Arthrodesis Using Internal Screw Fixation. Cliinical Orthopaedics and Related Research. 1991 July; 268: 21-28
Jeng et al. Comparison of Initial Compression of the Medial, Lateral, and Posterior Screws in an Ankle Fusion Construct. Foot Ankle Intl. 2011 Jan; 32(1). 71-76
McGlamry D. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Lippincott Williams and Wilkins. Third Edition. 2001.
Morgan et al. Long-term results of tibiotalar arthrodesis. JBJS. 1985 April; 67 (4): 546-550
Ogilvie-Harris DJ. Arthrodesis of the ankle. A comparison of two versus three screw fixation in a crossed configuration. Clinical Orthopaedics and Related Research. 1994; 304: 195-199.
Schuberth JM. The Tripod Fixation Technique for Ankle Arthrodesis. JFAS 2009; 48(1): 93-96.
References