Arthroscopic Ankle Arthrodesis

Arthroscopic Ankle
Arthrodesis
Jan Veloso, MS3
Ankle Arthrodesis
Background
Indications
Contraindications
Arthroscopic
Technique
Advantages
Disadvantages
Finances
Alternatives
Background
First published in
1879
Over 40 procedures
Gold Standard
surgical treatment
for end stage
arthritis
Arthroscopic method
introduced in 1983.
Ferkel et al. "Long-Term Results of Arthroscopic Ankle Arthrodesis." Foot & Ankle International 26.4 (2005): 275-80.
Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.
Anatomy
Mortise and Tenon
type joint
Distal Tibia, Fibula,
Dome of Talus
Ahmad, J., and S. Raikin. "Ankle Arthrodesis: The Simple and the Complex." Foot and Ankle Clinics of North America
13.3 (2008): 381-400. www.amaxonaws.com
Indications
Severe Debilitating Pain with Loss of Articular
Cartilage or Instability
Primary Osteoarthritis
Post-Traumatic Arthritis
Chronic Instability
Rheumatoid Arthritis
Charcot Neurarthropathy
Failed Total Ankle Arthroplasty
Septic Arthritis
Avascular Necrosis of the Talus
Neurologic
13.3 (2008): 381-400
Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North
Contraindications
Peripheral Vascular Disease

Medical Clearance
Bil Ankle Arthritis
Active Bone Infection
Open Growth Plates
Progressive or Severe Deformities
Tobacco Use
13.3 (2008): 381-400
Positioning
Ankle at 90
5 of Rearfoot Valgus
5 to 10 External Rotation of Foot
Posterior translation of foot relative
to tibia
5mm, Long Axis of Tibia in line with Lateral
Process of Talus.
America 8.2 (2003): 347-59.
Schuberth et al. "The Medial Malleolar Approach for Arthrodesis of the Ankle: A Report of 13 Cases." JFAS 44.2
Lateral Radiograph
Ankle at 90
Long axis of Tibia
Posterior tubercle
of talus to inferior
talar neck
Normal is 106
America 8.2 (2003): 347-59.
Fixation
External Fixation
Advantageous in Osteoporotic Bone
Hx of Osteomyelitis
Internal Fixation
Parallel Screws
Cross Screws
Tripod Screws
Other Plates, IM Nail, etc
America 8.2 (2003): 347-59.
Schuberth et al. "The Tripod Fixation Technique for Ankle Arthrodesis." The Journal of Foot and Ankle Surgery 48.1
Parallel Screw Fixation

Increased
Compression
Parallel in AP and
Lat
America 8.2 (2003): 347-59.
Cross Screw Fixation
Increased rigidity
America 8.2 (2003): 347-59.
Tripod Fixation
Greatest rigidity
Decreases stress
risers on tibia
Schuberth et al. "The Tripod Fixation Technique for Ankle Arthrodesis." The Journal of Foot and Ankle Surgery 48.1
(2009): 93-96.
Arthroscopic Operative Technique
Joint Distraction
Ankle Portals
Debridement
Fixation
Collman et al. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive Patients." Foot & Ankle
International 27.12 (2006): 1079-085.
Ferkel, Richard D., and Michael Hewitt. "Long-Term Results of Arthroscopic Ankle Arthrodesis." Foot & Ankle
International 26.4 (2005): 275-80.
Joint Distraction
External distractor
Insufflate joint w/
20cc NS or
Lidocaine with
Epinephrine
International 27.12 (2006): 1079-085.
International 26.4 (2005): 275-80.
Ankle Portals
Antero-medial
Antero-lateral
Postero-medial
Postero-lateral
Postero-central
http://www.orthopaedics.co.uk/boc/patients/arthroscopy_ankle_indications.asp
Debridement
Goal: Prepare joint
for fusion
Osteophytes
Synovium
Loose Fragments
Cartilage
Subchondral Bone
International 27.12 (2006): 1079-085.
Debridement
Tibial and Talar
osteophytes
Improve exposure
Collman, David R., My H. Kaas, and John M. Schuberth. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in
39 Consecutive Patients." Foot & Ankle International 27.12 (2006): 1079-085.
Debridement
Hypertrophic
synovium
Loose fragments
Improve access to
joint surfaces
Collman, David R., My H. Kaas, and John M. Schuberth. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in
39 Consecutive Patients." Foot & Ankle International 27.12 (2006): 1079-085.
Debridement
Hyaline Cartilage
Subchondral bone
Punctate Bleeding
International 27.12 (2006): 1079-085.
Screw Fixation
6.5-mm or 7.3-mm
International 26.4 (2005): 275-80.
Post-Op Course
Ferkel et al NWB cast 2-3 wks,
walking cast 4-6 wks.
N = 35
Fusion Rate = 97%
Fusion Time = 11.8 wks
International 26.4 (2005): 275-80.
Post-Op Course
Collman et al NWB cast 6 wks,
walking cast 2 wks, walking boot 2
wks.
N = 39
Fusion Rate = 87.2%
International 27.12 (2006): 1079-085.
Post-Op Course
Gougoulias et al NWB cast 2 wks,
PWB cast 4 wks, walking boot 6 wks.
N = 78
Fusion Rate = 96.7%
Advantages of Arthroscopy
Poor skin and wound healing
potential
DM, PVD, RA, long-term steroid use,
previous skin/tissue graft
Decreased hospital stay
OBrien et al found that arthroscopy
stayed 2 days less than the open fusion
group.
O'Brien et al. "Open Versus Arthroscopic Ankle Arthrodesis: A Comparative Study." Foot & Ankle International 20.6
(1999): 368-74.
Faster fusion time
Decreased soft tissue dissection and
periosteal stripping.
Myerson et al found fusion in 8.7 wks for
arthroscopic group vs 14.5 wks for open
group. Open group had more deformity
Gougoulias et al found fusion in 11.6
wks in arthroscopic fusion with frontal
plane deformities of 16-45
Myerson et al. "Ankle Arthrodesis: A Comparison of an Arthroscopic and an Open Method of Treatment." Clinical
Orthopaedics & Related Research 268 (1991):
Decreased malunion
OBrien et al found greater variability in
post-op ankle position in open group
O'Brien et al. "Open Versus Arthroscopic Ankle Arthrodesis: A Comparative Study." Foot & Ankle International 20.6
(1999): 368-74.
Improved Ankle Osteoarthritis Scale
(AOS) score at 1yr and 2yr
Baseline
1 yr
2 yr
56
33.5
29.5
Arthroscopi 56
c
17.5
17.2
Open
Townshend et al. "Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series." The Journal
of Bone and Joint Surgery 95.2 (2013): 98-102.
Disadvantages
Traditionally, reserved for minimal
deformity.
Gougoulias et al found no difference in fusion
times and outcomes in minimal deformity
(5.6 2.9) vs severe deformity (24.7
7.5)
Technically demanding, steep learning

curve
Risk of thermal injury to the bony
surfaces from the burr
13.3 (2008): 381-400
Non-union
A Review study by Abicht et al found
an overall non-union rate of 8.6%.
N = 244
Collman et al found that Obesity

trended towards non-union.
N= 39 (20 post-traumatic)
4/5 non-unions were post-traumatic
ankle arthritis
International 27.12 (2006): 1079-085.
Abicht, Bradley P., and Thomas S. Roukis. "Incidence of Nonunion After Isolated Arthroscopic Ankle Arthrodesis."
Arthroscopy: The Journal of Arthroscopic & Related Surgery (2013): 1-6.
Finances
Outpatient
Arthroscopic
Inpatient Open
ASC/Hospital
$1,110.04 287
$8,432 2,626
Surgeon
$1,566.93 319.57
$1,107.39 277.70
Hospital Days
0
3.4
Both groups consisted of 50% medicare patients
Peterson et al. "Arthroscopic versus Open Ankle Arthrodesis: A Retrospective Cost Analysis." The Journal of Foot and
Ankle Surgery 49.3 (2010): 242-47
Alternatives to Arthroscopic
Fusion
Mini-Open Technique
Two 1.5cm incisions over traditional
portal sites.
Limited soft tissue dissection.
Removal of cartilage and subchondral
bone using curettes and chisels.
Preservation of fibula.
Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques.
Take Home Points

1. Severe deformities are relative
contraindication
2. Ankle portals: Antero-med and
Antero-lat.
3. Distractor, Scope, Abrader, Curette.
4. Fixation
5. Decreased hospital stay (2 days),
Faster time to fusion (4-5 weeks)
References
Ahmad, J., and S. Raikin. "Ankle Arthrodesis: The Simple and the
Complex." Foot and Ankle Clinics of North America 13.3 (2008): 381400.
Collman, David R., My H. Kaas, and John M. Schuberth. "Arthroscopic
Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive
Patients." Foot & Ankle International 27.12 (2006): 1079-085.
Easley, Mark, Colin Looney, Samuel Wellman, and Joseph Wilson.
"Ankle Arthrodesis Using Ring External Fixation." Techniques in Foot &
Ankle Surgery 5.3 (2006): 150-63.
Ferkel, Richard D., and Michael Hewitt. "Long-Term Results of
Arthroscopic Ankle Arthrodesis." Foot & Ankle International 26.4
(2005): 275-80.
Glick, James M., Craig D. Morgan, Mark S. Myerson, Thomas G.
Sampson, and Jeffrey A. Mann. "Ankle Arthrodesis Using an
Arthroscopic Method: Long-term Follow-up of 34 Cases." Arthroscopy:
The Journal of Arthroscopic & Related Surgery 12.4 (1996): 428-34.
References
Gougoulias, Nikolaos E., Filon G. Agathangelidis, and Stephen W.
Parsons. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International
28.6 (2007): 695-706.
Myerson, Mark S., and George Quill. "Ankle Arthrodesis: A Comparison
of an Arthroscopic and an Open Method of Treatment." Clinical
Orthopaedics & Related Research 268 (1991):
O'Brien, Timothy S., Timothy S. Hart, Michael J. Shereff, James Stone,
and Jeffrey Johnson. "Open Versus Arthroscopic Ankle Arthrodesis: A
Comparative Study." Foot & Ankle International 20.6 (1999): 368-74.
Paley, Dror. Principles of Deformity Correction. Berlin: Springer, 2003.
Peterson, Kyle S., Michael S. Lee, and Donald E. Buddecke. "Arthroscopic
versus Open Ankle Arthrodesis: A Retrospective Cost Analysis." The
Journal of Foot and Ankle Surgery 49.3 (2010): 242-47.
Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open
Techniques." Foot and Ankle Clinics of North America 8.2 (2003): 34759.
References
Schuberth, John M., John A. Ruch, and Sigvard T. Hansen.

"The Tripod Fixation Technique for Ankle Arthrodesis." The
Journal of Foot and Ankle Surgery 48.1 (2009): 93-96.
Sekiya, H., T. Horii, Y. Kariya, and Y. Hoshino. "ArthroscopicAssisted Tibiotalocalcaneal Arthrodesis Using an
Intramedullary Nail With Fins: A Case Report." The Journal
of Foot and Ankle Surgery 45.4 (2006): 266-70.
Townshend, David, Matthew D. Silvestro, and Fabian
Krause. "Arthroscopic Versus Open Ankle Arthrodesis: A
Multicenter Comparative Case Series." The Journal of Bone
and Joint Surgery 95.2 (2013): 98-102.
Winson, I. G. "Arthroscopic Ankle Arthrodesis." Journal of
Bone and Joint Surgery - British Volume 87-B.3 (2005): 34347.
Zvijac, John E., Lawrence Lemak, Matthias R. Schurhoff,
Keith S. Hechtman, and John W. Uribe. "Analysis of
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Arthroscopic Ankle Arthrodesis

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Arthroscopic Ankle

Peripheral Vascular Disease

Parallel Screw Fixation

Cross Screw Fixation

Arthroscopic Operative Technique

Technically demanding, steep learning

Collman et al found that Obesity

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques.

Take Home Points

Schuberth, John M., John A. Ruch, and Sigvard T. Hansen.

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