Jour nal of the Amer ican Academy of Or thopaedic Sur geons 2OO

The ankIe |oinl consisls of a highIy

conslrained arlicuIalion of lhe laIus
vilh lhe libiaI Iafond and lhe dis-
laI fibuIa. Wilh veighl bearing,
congruily belveen lhe suIcus of lhe
laIus and lhe libiaI Iafond ro-
vides slabiIily in lhe sagillaI Iane
in a normaI ankIe |oinl. Torn or
delached Iigamenls around lhe
ankIe |oinl, hovever, aIIov abnor-
maI coronaI-Iane inslabiIily vilh
veighl bearing.
The dee deIloid Iigamenl carries
lhe rimary bIood suIy lo lhe
mediaI asecl of lhe body of lhe
laIus from lhe oslerior libiaI arlery.
Therefore, al Ieasl on a lheorelicaI
basis, an efforl shouId be made lo
reserve lhe deIloid Iigamenl dur-
ing surgicaI rocedures on or aboul
lhe ankIe |oinl.
Damage lo lhe ankIe |oinl from
lrauma or disease can resuIl in ro-
gressive Ioss of lhe libiolaIar arlicu-
Iar carliIage surface, vilh resuIling
infIammalion, synovilis, osleohyle
formalion, rogressive Ioss of ankIe-
|oinl molion, veighl-bearing ain,
and funclionaI disabiIily. A variely
of lechniques for ankIe arlhrodesis
have been described over lhe years
as surgicaI measures lo reIieve lhe
ain and funclionaI disabiIily associ-
aled vilh a damaged ankIe |oinl.
1-14
Tr eatment of the
Symptomatic Ankle Joint
Nonoeralive lrealmenl of a sym-
lomalic degeneralive ankIe |oinl in-
cIudes lhe use of shoe inserls or
shoe modificalions. A shoe vilh a
cushioned heeI and a sliff, rocker-
bollom soIe usuaIIy heIs alienls
vilh Iess severe ankIe-|oinl dam-
age.
15
If more suorl is needed,
lhe use of a moIded ankIe-fool
orlhosis or a doubIe-urighl lye of
brace allached lo lhe alienl's shoe
can be used. Such a brace lends lo
decrease |oinl infIammalion and
ain by reslricling ankIe-|oinl mo-
lion. Some alienls are heIed by
suorling lhe arlhrilic ankIe |oinl
in a vaIking casl for 6 veeks. The
use of a vaIking casl has aIso been
suggesled as a lriaI device lo evaIu-
ale alienl accelance and degree
of ain reIief rior lo erforming an
ankIe arlhrodesis.
15
NonsleroidaI anli-infIammalory
drugs can be heIfuI in reIieving
ankIe ain. If Iong-lerm use is ex-
ecled, alienls shouId be screened
for conlraindicalions, and arori-
ale bIood and urine sludies shouId
be erformed. Inlra-arlicuIar in|ec-
lions of corlicosleroid-aneslhelic
combinalions can be used lo de-
crease |oinl ain and infIammalion,
bul lhe in|eclions shouId be al Ieasl
3 monlhs aarl.
Arlhroscoic ankIe-|oinl debride-
menl may lemorariIy reIieve lhe
symloms of earIy arlhrilis. This
lechnique ermils direcl visuaIiza-
lion of inlra-arlicuIar and inlraca-
suIar slruclures, lhus aIIoving accu-
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! #$ #%&' ()*+,- ./)0 12223451226127
Ankle Ar thr odesis: Indications and Techniques
Nicholas A. Abidi, MD, Gary S. Gruen, MD, and Stephen F. Conti, MD
Nicholas A. Abidi, MD, et al
Vol 8, No 3, May/June 2000 2O1
rale diagnoslic evaIualion and lhe
oorlunily for immediale lhera-
eulic inlervenlion. RemovaI of
Ioose osleochondraI fragmenls or
iminging osleohyles by arlhrol-
omy or arlhroscoy can rovide
effeclive reIief of ain.
16
SeveraI
Iarge series have documenled a
high incidence of iminging surs
in foolbaII Iayers (u lo 45/)
17
and
in dancers (u lo 59.3/).
18
ecause
lhis enlily is frequenlIy encounlered
in alhIeles, il has been referred lo as
alhIele's ankIe and foolbaIIer's
ankIe.
17
The susecled mechanism
consisls of exlreme ankIe dorsifIex-
ion vilh resuIlanl anlerior |oinl
imingemenl and oslerior |oinl
dislraclion. Il is lheorized lhal re-
elilive anlerior ankIe imingemenl
causes anlerior suberiosleaI hem-
orrhages and subsequenl scIerolic
bone grovlh.
IeriarlicuIar osleolomy and syn-
desmolic reconslruclion for maI-
uniled ankIe fraclures is a lreal-
menl aIlernalive for alienls vho
do nol demonslrale |oinl-sace coI-
Iase on veighl-bearing radio-
grahs. Symmelry of lhe libiolaIar
|oinl sace musl be mainlained,
and lhe sealing of lhe fibuIa in lhe
incisura fibuIaris of lhe libia musl
be evaIualed. The lvo findings
mosl oflen ciled as indicalors of
abnormaI reIalionshis are (1) di-
minished overIa of lhe dislaI fibu-
Ia and anlerior asecl of lhe libia
and (2) excessive videning of lhe
libiofibuIar cIear sace. A signifi-
canl and frequenl comonenl of
ankIe fraclure maIunion is rolalion
and shorlening of lhe fibuIa.
19
AnkIe maIaIignmenl secondary lo
maIreduclion or imingemenl re-
suIls in shifling of lhe laIus, ersis-
lenl inslabiIily, and vaIgus liIl. As
IillIe as 1 mm of IaleraI laIar dis-
Iacemenl has been demonslraled
lo aIler libiolaIar conlacl by as
much as 4O/.
2O
Wilh lhe Ioss of
|oinl congruily, damage lo lhe car-
liIage surface occurs rogressiveIy
over lime.
Iaclors lhal delermine vhelher
ankIe reconslruclion is a viabIe
olion incIude lhe condilion of lhe
arlicuIar carliIage al lhe lime of revi-
sion and lhe quaIily of fraclure
reduclion. lher variabIes, such as
Ienglh of lime from in|ury lo lhe
reconslruclive rocedure and lhe age
of lhe alienl al lime of resenlalion,
have nol been shovn lo infIuence
oulcome. Analomic reconslruclion
of a maIuniled ankIe |oinl viII re-
venl furlher rogression of ankIe
arlhrilis, even in lhe resence of
earIy disease.
21
Iurlhermore, recise
resloralion of ankIe-|oinl analomic
reIalionshis is crilicaI lo a successfuI
oulcome. In one series,
22
good lo ex-
ceIIenl resuIls vere achieved in 85/
of alienls afler reconslruclion of
ankIe maIunions. Iaclors associaled
vilh favorabIe alienl oulcome in-
cIuded osilion of lhe laIus in lhe
morlise, slabiIily of lhe syndesmosis,
correcl Ienglh of lhe fibuIa, and quaI-
ily of lhe |oinl surface al lhe lime of
reconslruclion.
CIinicaI resuIls suorl lhe con-
cel lhal Iale reconslruclion of a
maIuniled ankIe rovides ain
reIief and imroved alienl func-
lion.
19,21,23-25
Reconslruclion mosl
frequenlIy invoIves fibuIar or libiaI
osleolomy, bul may be combined
vilh syndesmolic slabiIizalion as
veII.
Indications for
Ar thr odesis
The rinciaI indicalion for ankIe
arlhrodesis is ersislenl ankIe-|oinl
ain and sliffness lhal is funclionaIIy
disabIing lo lhe alienl and is nol
aIIevialed by nonoeralive lreal-
menl melhods. This may be lhe
resuIl of revious fraclure, infec-
lion, osleonecrosis, or arlhrilis.
Radiograhic changes in lhe
ankIe |oinl are besl assessed on
veighl-bearing slanding anleroos-
lerior (Iig. 1, A), IaleraI (Iig. 1, ),
and morlise vievs. Comuled
890/): ; Weighl-bearing anlerooslerior <#= and IaleraI <>= radiograhs of lhe ankIe
shov comIele |oinl-sace coIIase, vaIgus maIaIignmenl, and an oId mediaI maIIeoIar
fraclure.
A B
Ankle Arthrodesis
Jour nal of the Amer ican Academy of Or thopaedic Sur geons 2O2
lomograhy, aIone or in combina-
lion vilh arlhrograhy, can be use-
fuI for assessing |oinl-surface
defecls, degeneralive |oinl changes,
and lhe Iocalion of osleohyles.
The bones of lhe sublaIar comIex
(lhe laIocaIcaneaI, laIonavicuIar,
and caIcaneocuboid |oinls) shouId
be in normaI aIignmenl and vilhoul
arlhrilic changes. A bone scan or
seIeclive |oinl in|eclions can heI lo
delermine vhelher |oinls olher lhan
lhe libiolaIar |oinl have degenera-
live changes. IoIIoving a success-
fuI ankIe arlhrodesis, il has been
shovn lhal molion in lhe sublaIar
comIex increases by an average of
11 degrees during lhe firsl year.
6
Sur gical Techniques
SeIeclion of lhe surgicaI lechnique
shouId be based on lhe underIying
disorder. As a generaI ruIe, exler-
naI fixalors are referred for a-
lienls undergoing arlhrodesis for a
reexisling selic |oinl and for
lhose vilh severe osleoenia. Ar-
lhroscoic arlhrodesis or lhe mini-
oen arlhrodesis shouId be used
onIy for alienls vilh minimaI
deformily. en arlhrodesis is a-
roriale for alienls vilh signifi-
canl ankIe deformily and fool and
ankIe maIaIignmenl.
RegardIess of lhe surgicaI lech-
nique chosen, lhe olimaI osloer-
alive osilion of lhe affecled fool
and ankIe |oinl is lhe same.
26
The
fool shouId be exlernaIIy rolaled 2O
lo 3O degrees reIalive lo lhe libia,
27
vilh lhe ankIe |oinl in neulraI fIex-
ion (O degrees), 5 lo 1O degrees of
exlernaI rolalion, and sIighl vaIgus
(5 degrees). This osilion rovides
lhe besl exlremily aIignmenl and
accommodalion of hi and knee
molion. Iusion of lhe ankIe in
Ianlar-fIexion resuIls in genu
recurvalum vhen Iacing lhe fool
fIal on lhe fIoor and subsequenl Iax-
ily of lhe mediaI coIIaleraI Iigamenl
of lhe knee, vhich deveIos from
lhe exlernaIIy rolaled gail lhal
alienls adol lo avoid roIIing
over a Ianlar-fIexed fool.
26
Exter nal Fixation
efore CharnIey's reorl in 1951
on lhe resuIls oblained vilh a com-
ression arlhrodesis lechnique
invoIving use of an exlernaI fixalor,
ankIe arlhrodesis vas associaled
vilh high rales of faiIure because of
nonunion.
2
The CharnIey melhod
combined oen surgicaI debride-
menl of lhe ankIe-|oinl carliIage
vilh lhe aIicalion of an exlernaI
fixalor by Iacing one in lhrough
lhe libia and anolher lhrough lhe
neck of lhe laIus, vilh connecling
bars running belveen lhe lvo ins.
Comression across lhe arlhrodesis
sile reIies on an inlacl AchiIIes len-
don funclioning as a lension band.
Ialienls are aIIoved lo bear veighl
on lhe lrealed ankIe during lhe firsl
8 veeks afler surgery. Afler re-
movaI of lhe exlernaI fixalor, a-
lienls are immobiIized in a Iasler
vaIking casl for an addilionaI 4
veeks.
The CaIandruccio exlernaI fixa-
lor makes use of a lrianguIar con-
figuralion lo achieve slabiIily and
comression across lhe libiolaIar
|oinl,
4
vhich rovides added resis-
lance lo lorsionaI forces al lhe ankIe
|oinl. Afler surgicaI removaI of lhe
ankIe-|oinl arlicuIar carliIage, fixa-
lion ins are Iaced lhrough lhe
libia, lhrough lhe neck and body of
lhe laIus, and, occasionaIIy, inlo lhe
caIcaneus. The fusion sile is lhen
bullressed vilh bimaIIeoIar onIay
bone grafls. This exlernaI fixalor
lechnique does nol require an inlacl
AchiIIes lendon lo serve as a len-
sion band.
A simIified aIlernalive melhod
of exlernaI fixalion vilh lhe use of
a uniIaleraI frame vas reorled in
1994.
13
This melhod aears lo
rovide adequale resislance lo bolh
dorsifIexion and Ianlar-fIexion
forces al lhe libiolaIar |oinl. The
uniIaleraI exlernaI fixalor ins are
Iaced inlo lhe mediaI asecl of lhe
libia, lhe caIcaneus, and lhe neck of
lhe laIus and are of Iarger diameler
lhan lhose used vilh lhe CaIan-
druccio device. Comression can
be exerled across lhe arlhrodesis
sile by adding a comression de-
vice lo lhe exlernaI fixalor aara-
lus rior lo Iacemenl on lhe a-
lienl.
Ar thr oscopic Ar thr odesis
The inlra-arlicuIar orlion of an
ankIe fusion can be done vilh an
arlhroscoe, bul lhis lechnique
shouId be Iimiled lo alienls vilh
arlhrilic ankIes vilh minimaI de-
formily, because il is difficuIl lo
correcl ankIe deformily arlhrosco-
icaIIy.
8
Ior lhis lechnique, arlhros-
coy is erformed lhrough lvo or,
occasionaIIy, lhree orlaIs. ne
orlaI is mediaI lo lhe libiaIis anle-
rior lendon, and lhe olher is IaleraI lo
lhe exlensor digilorum Iongus len-
don. A lhird orlaI can be Iaced
IaleraI lo lhe eroneus lerlius lendon
and can lhen be used lo remove
debris generaled during arlicuIar-
surface denuding.
The |oinl sace is videned vilh
a noninvasive dislraclor or a uniIal-
eraI exlernaI fixalor. A 4.5-mm bur
and curelles are used lo denude lhe
arlicuIar surfaces. Afler reara-
lion, comression of lhe |oinl sur-
faces can be oblained vilh eilher
inlernaI or exlernaI fixalion. Iref-
erabIy, lvo cannuIaled screvs are
Iaced across lhe libia inlo lhe
laIus. The firsl screv runs from lhe
IaleraI asecl of lhe libia inlo lhe
neck of lhe laIus. The second screv
runs from lhe mediaI maIIeoIus inlo
lhe IaleraI asecl of lhe laIus.
Ialienls are kel in non-veighl-
bearing slalus for 5 veeks oslo-
eraliveIy and lhen are aIIoved lo
bear veighl rogressiveIy unliI
|oinl fusion is demonslraled radio-
grahicaIIy.
In an alleml lo achieve lhe
advanlages of bolh lhe oen and
arlhroscoic lechniques, a mini-
Nicholas A. Abidi, MD, et al
Vol 8, No 3, May/June 2000 2O3
oen lechnique vas reorled in
1996.
11
This lechnique decreases
reIiance on reguIar arlhroscoic
lechniques in favor of using
enIarged arlhroscoic orlaIs for
exosure and removaI of arlicuIar
carliIage. Curelles and osleolomes
are used lo denude lhe |oinl sur-
faces. This lechnique reorledIy de-
creases lhe amounl of sofl-lissue
slriing required in lhe more
slandard oen lechniques and is
reorled lo be associaled vilh
quicker radiograhic fusion rales.
Open Ar thr odesis
The oen ankIe arlhrodesis is
erformed lhrough a lvo-incision
lransfibuIar exosure. This lech-
nique can be used for any alienl
bul is arlicuIarIy usefuI for alienls
vilh severe ankIe-|oinl deformily.
Ils benefils are beller visuaIizalion
of lhe |oinl and imroved access for
bone reseclion, correclion of defor-
mily, and screv Iacemenl. Ils
dravbacks are lhe Iarge incisions
and lhe amounl of sofl-lissue slri-
ing required.
The firsl incision is made direclIy
over lhe fibuIa, and lhe second in-
cision is made aIong lhe anlerior
lhird of lhe mediaI maIIeoIus. olh
exosures are carried oul carefuIIy
lo mainlain fuII-lhickness fIas and
lo idenlify and rolecl lendons and
neurovascuIar slruclures. Afler lhe
dislaI 1O cm of lhe fibuIa has been
exosed, lhe suerior eroneaI reli-
nacuIum is incised osleriorIy, and
lhe eroneaI lendons are mobiIized
vhiIe rolecling lhe suraI and su-
erficiaI eroneaI nerves.
A smaII acelabuIar reamer can be
used lo morseIize lhe fibuIa for bone
grafl maleriaI rior lo ils removaI. A
micro-osciIIaling sav is used lo
make an obIique osleolomy 1O cm
from lhe fibuIar li (Iig. 2, A). The
remaining fibuIar fragmenl can lhen
be excised. AIlernaliveIy, lhe dislaI
fibuIar sofl-lissue allachmenl can be
reserved if lhe fibuIa has nol been
morseIized. The mediaI haIf of lhe
fibuIa is cul avay, and lhe remaining
fibuIa is lurned dovn and avay
from lhe arlhrodesis sile. The bIood
suIy is mainlained because of lhe
remaining Iigamenlous allachmenls.
The ouler haIf of lhe fibuIa is secured
lo lhe libia and lhe laIus vilh lvo
3.5-mm screvs Ialer during lhe ro-
cedure. This IaleraI bullress gives
addilionaI IaleraI slabiIily lo lhe
arlhrodesis sile and assisls in re-
venling IaleraI drifling of lhe laIus.
Shar disseclion is used lhrough
lhe IaleraI incision lo eIevale lhe
scarred ankIe casuIe from lhe |oinl
bolh anleriorIy and osleriorIy,
lhus aIIoving lhe vilaI slruclures
on bolh sides of lhe ankIe |oinl lo be
rolecled by relraclors. Sofl-lissue
roleclion is rovided lhrough lhe
mediaI incision by a relraclor. A
Iarge osciIIaling sav is used lo
make a cul erendicuIar lo lhe lib-
iaI shafl al lhe IeveI of lhe aex of
lhe dome of lhe arlicuIar surface,
aIIoving removaI of lhe libiaI Ia-
fond (Iig. 2, ). An alleml shouId
be made lo reserve lhe mediaI
maIIeoIus so as lo rovide an area
of soIid fixalion for lhe IaleraI-lo-
mediaI screv and lo reserve lhe
mediaI bIood suIy lo lhe laIus
lhrough lhe deIloid Iigamenl.
28
Afler removaI of lhe dislaI libiaI
arlicuIar surface, lhe laIus is osi-
lioned so lhal lhe forefool is in 5 lo
1O degrees of exlernaI rolalion and
lhe hindfool is in 5 degrees of vaI-
gus, vilh neulraI dorsifIexion and
disIacemenl so lhal lhe oslerior
margins of lhe laIus and libia are
fIush. The fool musl be aIigned
A B
890/): 1 #? Through lhe IaleraI incision, lhe fibuIa is osleolomized 1O cm roximaI lo lhe li vilh a micro-osciIIaling sav. The arrov
marks lhe dislaI fibuIa. >? Through lhe IaleraI aroach, lhe dislaI arlicuIar surface of lhe libia is removed al a 9O-degree angIe lo lhe lib-
iaI shafl vilh an osciIIaling sav. The arrov marks lhe dislaI libia.
Ankle Arthrodesis
Jour nal of the Amer ican Academy of Or thopaedic Sur geons 2O4
vilh regard lo lhe enlire Iimb. A
cul lhrough lhe dome of lhe laIus is
lhen made araIIeI lo lhe dislaI
libia, resecling aroximaleIy 5 mm
of lhe laIus. AIlernaliveIy, lhe |oinl
surfaces can be reared vilh cu-
relles and osleolomes. The remain-
ing |oinl surfaces are insecled
carefuIIy for residuaI carliIage and
scIerolic bone. AII |oinl surfaces are
driIIed or curelled unliI bIeeding
bone is noled. The fibuIa may be
used as a slrul grafl or as crushed
canceIIous aulografl lo fiII dee de-
fecls if il has been morseIized.
The laIus is aosed fIush lo lhe
dislaI libia. Afler lhe surface congru-
ency and |oinl osilion have been
checked, lhe |oinl osilion is secured
vilh lvo guide ins for Iarge (7.O- lo
7.3-mm) cannuIaled screvs. The firsl
in is slarled al lhe osleroIaleraI cor-
ner of lhe libia and is Iaced across
lhe |oinl and inlo lhe neck of lhe laIus.
The second guide in is Iaced from
lhe mediaI maIIeoIus inlo lhe IaleraI
asecl of lhe laIus. AIlernaliveIy, lhe
second in may be Iaced from lhe
IaleraI rocess of lhe laIus inlo lhe
mediaI corlex of lhe libia. Iin Iace-
menl and bone aosilion are
checked under fIuoroscoy (Iig. 3, A
and ). Care musl be laken lhal lhe
ins do nol vioIale lhe sublaIar |oinl.
nce in Iacemenl and bone a-
osilion have been found lo be salis-
faclory, shorl lhreaded cannuIaled
screvs vilh vashers are Iaced inlo
lhe bone (Iig. 3, C and D). The
vounds are cIosed vilh a lvo-Iayer
lechnique, laking care lo rolecl lhe
ad|acenl nerves. The exlremily is
Iaced in a buIky casl adding and a
Iasler sIinl dressing, vhich is
mainlained for 2 veeks. A non-
veighl-bearing shorl Ieg casl is lhen
aIied, and veighl bearing is nol
ermilled unliI evidence of ar-
lhrodesis is observed on lhe foIIov-
u radiograhs, vhich usuaIIy oc-
curs 8 lo 12 veeks osloeraliveIy.
The arlhrodesis lechnique musl
be modified for alienls vilh com-
romised sofl lissues, vilh non-
unions afler revious arlhrodesis
allemls, or vilh neuroalhic ankIe
|oinls. Ialienls vilh symlomalic
nonunions, osleonecrosis of lhe
laIus, or Charcol arlhroalhy fre-
quenlIy require subslanliaI debride-
menl of devilaIized bone from lhe
laIus. one grafling can be used in
lhese alienls lo regain some of lhe
Iosl heighl, bul oflen libiolaIocaI-
caneaI arlhrodesis is required lo
achieve a successfuI fusion. More
rigid inlernaI fixalion is a arl of
aImosl aII fusion lechniques used in
lhese difficuIl silualions.
A lechnique for libiolaIocaIcaneaI
arlhrodesis vilh lhe use of an angIed
bIade-Iale inserled lhrough a osle-
rior aroach vas reorled in 1991.
29
This lechnique vas roosed for use
in alienls vilh ersislenl ankIe-|oinl
nonunion. Wilh lhe alienl in lhe
rone osilion, lhe AchiIIes lendon is
osleolomized al ils inserlion inlo lhe
caIcaneus and disIaced cehaIad
vilh ils allached bone bIock (Iig. 4).
A B
890/): @ Anlerooslerior <#= and IaleraI <>= images oblained during fIuoroscoy of lhe
ankIe |oinl vilh guide ins in Iace confirm surface aosilion. Anlerooslerior <A= and
IaleraI <B= vievs oblained afler screv Iacemenl demonslrale lhal lhere is no enelralion
of lhe sublaIar |oinl sace.
C D
Nicholas A. Abidi, MD, et al
Vol 8, No 3, May/June 2000 2O5
Afler ankIe-|oinl exosure, arlicuIar
carliIage is removed from lhe |oinl
surfaces. The nonunion sile is curel-
led unliI viabIe bone is seen. AuloIo-
gous canceIIous bone grafl, harvesled
from lhe roximaI libiaI melahysis
or iIiac cresl, is acked inlo lhe non-
union sile and lhe denuded |oinl.
Afler roer |oinl aIignmenl has
been achieved, a 95-degree 5O-mm
five-hoIe bIade-Iale is sealed inlo an
aroriale sIol reared in lhe sur-
face of lhe oslerior caIcaneus. Afler
aIicalion of lhe lension device lo
lhe free end of lhe Iale, lhe screvs
are inserled inlo lhe Iale, and lhe
AchiIIes lendon is reallached lo lhe
caIcaneus vilh a 6.5-mm canceIIous
screv and Iigamenlous vasher. A
shorl vindoved Ieg casl vilh a rock-
er bollom is aIied on lhe lhird
osloeralive day, and louch-dovn
gail is aIIoved for lhe nexl 6 lo 8
veeks, rogressing lo veighl bear-
ing as loIeraled. The lolaI casl-
immobiIizalion lime afler lhis roce-
dure averages 12 lo 16 veeks.
The resuIls vilh use of a com-
ression arlhrodesis lechnique for
libiocaIcaneaI arlhrodesis in seven
alienls vilh nonbraceabIe neuro-
alhic ankIe |oinls vere reorled
in 1994.
3O
A cannuIaled humeraI
bIade-Iale vas Iaced inlo lhe
libia and caIcaneus lhrough a Ialer-
aI aroach for rigid fixalion, aug-
menled by an exlernaI comres-
sion device and Iarge canceIIous
screvs (Iig. 5). The seven alienls
in lhis series rogressed lo soIid
fusion in an average of 5.2 monlhs.
AII became ambuIalory in a Iined,
moIded bivaIve ankIe-fool arlhro-
sis vilhoul lhe use of an anciIIary
device.
MechanicaI difficuIlies reorled
vilh bIade-Iale lechniques incIude
difficuIly in Iacing lhe fool and
ankIe in lhe olimaI funclionaI
osilion and difficuIly associaled
vilh accurale Iacemenl of lhe
bIade-Iale inlo a smaII laIus and
caIcaneus. The use of a relrograde
inlrameduIIary naiI has been de-
scribed for alienls vilh sofl-lissue
comromise, faiIed rior arlhrode-
sis, or diabelic neuroalhy.
31,32
The
dravbacks of relrograde naiI fixa-
lion incIude lhe risk of neuroIogic
and vascuIar in|ury during naiI
inserlion (Iig. 6, A),
33
difficuIly in
roviding comression across lhe
arlhrodesis sile, Iacemenl of
screvs in lhe osleoorolic laIus and
caIcaneus (Iig. 6, ), and slress frac-
lure of lhe libia afler oeralion.
34
Results
AnkIe arlhrodesis, vhich vas origi-
naIIy a surgicaI lrealmenl for luber-
cuIosis of lhe ankIe |oinl, conlinues
lo find use in alienls funclionaIIy
disabIed by ankIe-|oinl deslruclion
due lo a variely of causes. SeveraI
scoring syslems nov are avaiIabIe
lo rovide slandardized melhods of
evaIualing and comaring func-
lionaI resuIls bolh before and afler
oeralive lrealmenl as veII as be-
lveen lhe various lechniques avaiI-
abIe for ankIe arlhrodesis. The
American rlhoaedic Iool and
890/): C The oslerior aroach (vilh lhe
alienl in lhe rone osilion) for bIade-
Iale inserlion direclIy lhrough lhe bed of
lhe AchiIIes lendon for lhe alienl vilh re-
exisling anlerior or IaleraI sofl-lissue com-
romise vho requires arlhrodesis. (Re-
roduced vilh ermission from Gruen GS,
Mears DC: Arlhrodesis of lhe ankIe and
sublaIar |oinls. =<', 1"*2.3 1991,268:15-2O.)
890/): D #? Inlraoeralive IaleraI viev of a libiolaIocaIcaneaI arlhrodesis vilh Iacemenl
of a 9O-degree bIade-Iale guide and Iarge canceIIous-screv guide ins rior lo bIade-Iale
imaclion. >? LaleraI radiograh oblained afler inserlion of IaleraI bIade-Iale.
A B
Achilles
tendon
Blade-
plate
Calcaneus
Ankle Arthrodesis
Jour nal of the Amer ican Academy of Or thopaedic Sur geons 2O6
AnkIe Sociely has ubIished a 1OO-
oinl scoring syslem for lhe evaIua-
lion of ankIe and hindfool ain and
funclion (TabIe 1).
35
The mosl re-
cenl scoring syslem inlroduced for
assessing alienls vilh osleoarlhri-
lis of lhe ankIe is lhe AnkIe sleo-
arlhrilis ScaIe, vhich is based on a
visuaI anaIog scaIe comIeled by
lhe alienl.
36
InforlunaleIy, nei-
lher has yel been used lo assess lhe
funclionaI resuIls in a Iarge series of
alienls vilh ankIe arlhrodesis.
Irior lo 1979, lhe resuIls ob-
lained vilh ankIe arlhrodesis vere
generaIIy graded as good if ar-
lhrodesis vas achieved or oor if
nonunion resuIled. In 1959 RalIiff
reorled relrosecliveIy on 59 a-
lienls vho had undergone com-
ression arlhrodesis of lhe ankIe
vilh a CharnIey exlernaI fixalor 1
lo 9 years reviousIy. The oulcome
vas graded as exceIIenl in 61/ of
lhe alienls, good in 18/, fair in
19/, and oor in 2/. Six alienls
had a Iim, and 2 had ersislenl
ain because of unrecognized sub-
laIar arlhrilis. A high rale of com-
Iicalions reIaled lo in-lrack infec-
lions vas noled in lhis series of
alienls.
An earIy scoring syslem for as-
sessmenl of alienl funclion and gail
afler ankIe arlhrodesis vas ub-
Iished by Mazur el aI
37
in 1979. This
syslem is based on a maximum os-
sibIe score of 9O oinls. The alienls
vho vere evaIualed in lhal reorl
had an average reoeralive score of
4O oinls and an average osloera-
live score of 8O oinls, refIecling an
imrovemenl in alienl funclion
afler ankIe arlhrodesis.
The same syslem vas used by
Scranlon
12
in 1985 lo evaIuale inler-
naI comression in arlhrodesis of
lhe ankIe. Scranlon used a T Iale
mediaIIy for comression of lhe
ankIe arlhrodesis sile. His alienls
achieved funclionaI imrovemenl
from an average reoeralive score
of 47 oinls lo an average oslo-
eralive score of 82 oinls. A simi-
Iar sludy reorling lhe use of an
anlerior lension-band Iale shoved
an average osloeralive score of
onIy 7O oinls, suggesling lhal lhis
lechnique may nol be as successfuI
as olhers.
7
In 1991, MaIarkey and inski
4
reorled lhe resuIls in 12 alienls
vho had undergone ankIe arlhro-
desis vilh use of lhe CaIandruccio-
frame exlernaI fixalor and bimaIIeo-
Iar onIay grafling. LIeven alienls
achieved a soIid osseous union.
Lighl alienls vere avaiIabIe for
evaIualion, lhe resuIls in 6 vere
raled as good or exceIIenl, and lhose
in lhe olher 2 vere raled as oor (1
alienl vilh nonunion and 1 alienl
nol raled because of underIying dis-
ease lhal Iimiled ambuIalion).
In 1991, Myerson and QuiII
8
evaIualed lhe resuIls oblained vilh
arlhroscoic ankIe arlhrodesis
comared vilh convenlionaI oen
arlhrodesis erformed vilh use of
6.5- and 7.O-mm screvs. }oinl fu-
sion vas achieved an average of 8.7
veeks afler arlhroscoic arlhrode-
sis, comared vilh an average of
14.5 veeks afler arlhrodesis vilh
convenlionaI inlernaI fixalion.
Hovever, lhe alienls vho under-
venl arlhroscoic arlhrodesis had
arlhrilic ankIes vilh onIy minimaI
deformily, vhereas lhose for vhom
lhe oen lechnique vas chosen had
more severe deformilies.
The resuIls of arlhrodesis in a-
lienls vho require revision are more
difficuIl lo evaIuale because of lhe
smaII number of alienls in reorled
series. In one sludy,
29
five alienls
undervenl revision arlhrodesis for
nonunion in vhich an angIed bIade-
890/): E #? IIanlar relrograde naiI inserlion sile al lhe |unclion of lhe caIcaneaI body and
lhe suslenlacuIum, ad|acenl lo lhe IaleraI Ianlar neurovascuIar bundIe. >? Relrograde
naiI inserlion, vilh Iacemenl of one screv inlo lhe laIus and one screv inlo lhe caIcaneus,
accomanied by inserlion of bone grafl al lhe libiolaIar arlhrodesis sile and imaclion of
lhe conslrucl before screv Iacemenl inlo lhe libia. (Reroduced vilh ermission from
IauI Cooer, MD, and DeIuy ACL MedicaI Comany, LI Segundo, CaIif.)
A B
Lateral
plantar
artery
and nerve
Plantar
incision
Nicholas A. Abidi, MD, et al
Vol 8, No 3, May/June 2000 2O7
Iale vas inserled lhrough a osle-
rior aroach for libiolaIar, libio-
laIocaIcaneaI, or libiocaIcaneaI
arlhrodesis. AII five rogressed lo
soIid ankIe fusion afler 16 veeks.
n a modified oslon ChiIdren's
HosilaI raling scaIe, lhe average
reoeralive raling of lhe five
alienls vas 13 oinls (of a ossibIe
5O oinls), and lhe average osloer-
alive raling vas 44 oinls. Three a-
lienls sub|ecliveIy raled lheir resuIl
as exceIIenl, and lvo raled il good.
The use of a combined oen-
comression arlhrodesis lechnique
in a subsequenl reorl deaIing vilh
nonbraceabIe neuroalhic ankIe
|oinls resuIled in soIid fusion in aII
seven alienls al an average of 5.2
monlhs.
31
AII became ambuIalory
in a Iined, moIded bivaIve ankIe-
fool arlhrosis vilhoul lhe use of an
anciIIary device.
Risk Factor s for Nonunion
AnkIe arlhrodesis is a lechnicaIIy
difficuIl surgicaI rocedure lhal is
frequenlIy associaled vilh comIica-
lions. Ialienls being considered for
ankIe arlhrodesis shouId be screened
carefuIIy for idenlifiabIe risk faclors.
Lven in series combining an oen
aroach vilh inlernaI fixalion,
comression, and bone grafling, lhe
mosl frequenlIy encounlered comIi-
calion associaled vilh ankIe arlhrod-
esis vas nonunion.
In one sludy, Irey el aI
38
re-
vieved 78 ankIe arlhrodeses lo
idenlify faclors lhal mighl redis-
ose alienls lo nonunion. ComIi-
calions occurred in 44 (56/) of lhe
78 alienls al an average foIIov-u
inlervaI of 4 years. These incIuded
32 nonunions (41/), 7 infeclions
(9/), 2 nerve in|uries (3/), 2 maI-
unions (3/), and 2 vound robIems
(3/). Risk faclors associaled vilh
nonunion in lhis series incIuded a
severe fraclure, an oen in|ury, IocaI
infeclion, evidence of osleonecrosis
of lhe laIus, and coexisling ma|or
F&GH: ;
#$:)9%&I 8,,* &I' #IJH: .,%9:*K AH9I9%&H #IJH:6L9I'M,,* N&*9I0 .%&H:
O
TolaI
IossibIe
Crilerion Ioinls Ioinls
Iain 4O
None 4O
MiId, occasionaI 3O
Moderale, daiIy 2O
Severe, aImosl aIvays resenl O
Iunclion 5O
Aclivily Iimilalions, suorl requiremenl
No Iimilalions, no suorl 1O
No Iimilalion of daiIy aclivilies, Iimilalion of
recrealionaI aclivilies, no suorl 7
Limiled daiIy and recrealionaI aclivilies, cane use 4
Severe Iimilalions of daiIy and recrealionaI
aclivilies, use of vaIker, crulches, vheeIchair, brace O
Maximum vaIking dislance, bIocks
Grealer lhan 6 5
4 lo 6 4
1 lo 3 2
Less lhan 1 O
WaIking surfaces
No difficuIly on any surface 5
Some difficuIly on uneven lerrain, slairs,
incIines, Iadders 3
Severe difficuIly on uneven lerrain, slairs, incIines, Iadders O
Gail abnormaIily
None, sIighl 8
bvious 4
Marked O
SagillaI molion (fIexion Ius exlension)
NormaI or miId reslriclion (3O or more) 8
Moderale reslriclion (15 lo 29) 4
Severe reslriclion (Iess lhan 15) O
Hindfool molion (inversion Ius eversion)
NormaI or miId reslriclion (75/ lo 1OO/ of normaI) 6
Moderale reslriclion (25/ lo 74/ of normaI) 3
Marked reslriclion (Iess lhan 25/ of normaI) O
AnkIe-hindfool slabiIily (anlerooslerior, varus-vaIgus)
SlabIe 8
DefinileIy unslabIe O
AIignmenl 1O
Good, Ianligrade fool, ankIe-hindfool veII aIigned 1O
Iair, Ianligrade fool, some degree of ankIe-hindfool
maIaIignmenl observed, no symloms 5
Ioor, nonIanligrade fool, severe maIaIignmenl, symloms O
1OO
*
Adaled vilh ermission from Kilaoka H, AIexander I}, AdeIaar RS, NunIey }A,
Myerson MS, Sanders M: CIinicaI raling syslems for lhe ankIe-hindfool, midfool, haI-
Iux, and Iesser loes. B..* %,C<0 E,* 1994,15:349-353.
Ankle Arthrodesis
Jour nal of the Amer ican Academy of Or thopaedic Sur geons 2O8
medicaI robIems. Iaclors nol asso-
cialed vilh nonunion incIuded
alienl age, asl hislory of undergo-
ing a sublaIar or lriIe arlhrodesis,
and lhe surgicaI arlhrodesis lech-
nique seIecled. A rior diagnosis of
a combined Iafond-laIus fraclure
Ied lo lhe vorsl rognosis, foIIoved
by Havkins II or III laIar fraclures.
Large-fragmenl screv fixalion Ied lo
higher fusion rales, ossibIy be-
cause Iess sofl-lissue slriing vas
required for screv fixalion com-
ared vilh Ialing or ossibIy be-
cause lhese screvs rovide beller
comression al lhe arlhrodesis sile.
Nonunion afler ankIe arlhrode-
sis has aIso been associaled vilh
smoking.
39
In alienls vilhoul
olher risk faclors, lhe risk of non-
union in smokers has been eslimal-
ed lo be 16 limes lhe risk of non-
union in nonsmokers. The effecls
of nicoline on lhe eriheraI circu-
Ialion and lhe effecls of hydrogen
cyanide and carbon monoxide on
lhe oxygen-carrying caacily of
hemogIobin have been ciled as os-
sibIe causes of lhe high rale of
nonunion in smokers. The eriod
of smoking cessalion rior lo ankIe
surgery necessary lo cIear lhe loxic
effecls from lhe alienl has nol
been eslabIished, bul 1 veek has
been emiricaIIy suggesled.
4O
A carefuI alleml shouId be
made lo lry lo Iearn lhe reason for
nonunion in alienls in vhom revi-
sion surgery is conlemIaled. This
shouId incIude a comIele vorku
lo ruIe oul IocaI infeclion and lo
alleml lo idenlify associaled risk
faclors lhal mighl comromise a
successfuI oulcome.
Summar y
A lhorough hislory and hysicaI
examinalion viII heI lo delermine
vhich form of lrealmenl viII ro-
vide ain reIief and imroved func-
lion in a alienl vilh advanced
ankIe arlhrilis. If nonoeralive
lrealmenl measures faiI, oeralive
inlervenlion shouId be considered.
CarefuI examinalion of aII Iover-
exlremily |oinls, Iimb aIignmenl,
and lhe reIalionshi of lhe hindfool
lo lhe forefool, as veII as gail a-
raisaI, shouId be carried oul re-
oeraliveIy. A Ianligrade fool o-
silion can be oblained by Iacing
lhe heeI in 5 lo 7 degrees of vaIgus,
exlernaIIy rolaling lhe ankIe by 5 lo
1O degrees, and disIacing lhe laIus
osleriorIy. Aroriale osilion-
ing of lhe fool during arlhrodesis
heIs lo avoid aIlering lhe alienl's
gail significanlIy and aIso heIs lo
reserve hi and knee funclion.
SeveraI surgicaI lechniques for
erforming ankIe arlhrodesis are
avaiIabIe. LxlernaI fixalors are rec-
ommended for fixalion in alienls
undergoing arlhrodesis because of a
reexisling selic |oinl or osleoe-
nia. Arlhroscoic arlhrodesis or lhe
mini-oen arlhrodesis can be con-
sidered for alienls vilh minimaI
deformily. en arlhrodesis is
advisabIe for alienls vilh signifi-
canl ankIe deformily and fool and
ankIe maIaIignmenl. Nonunion of
ankIe arlhrodeses can occur in u lo
4O/ of alienls. Smoking cessalion,
avareness and conlroI of knovn
risk faclors such as melaboIic dis-
eases and osleonecrosis, carefuI re-
oeralive Ianning, and melicuIous
oeralive lechnique aII conlribule lo
a successfuI oulcome.
#%JI,PH:'0$:I*5 The aulhors vouId Iike
lo lhank }ohn }. GarlIand, MD, for his assis-
lance in lhe rearalion of lhis manuscril.
Refer ences
1. arr }S, Record LL: Arlhrodesis of lhe
ankIe |oinl: Indicalions, oeralive lech-
nic and cIinicaI exerience. Y Z,7< :
;0( 1953,248:53-56.
2. CharnIey }: Comression arlhrodesis
of lhe ankIe and shouIder. : M.,0 :.',*
56"7 M" 1951,33:18O-191.
3. HoIl LS, Hansen ST, Mayo KA, San-
georzan }: AnkIe arlhrodesis using
inlernaI screv fixalion. =<', 1"*2.3
1991,268:21-28.
4. MaIarkey RI, inski }C: AnkIe ar-
lhrodesis vilh lhe CaIandruccio frame
and bimaIIeoIar onIay grafling. =<',
1"*2.3 1991,268:44-48.
5. Mann RA, Van Manen }W, Waner K,
Marlin }: AnkIe fusion. =<', 1"*2.3
1991,268:49-55.
6. Morgan CD, Henke }A, aiIey RW,
Kaufer H: Long-lerm resuIls of libio-
laIar arlhrodesis. : M.,0 :.',* 56"7 %?
1985,67:546-55O.
7. Mears DC, Gordon RG, Kann SL,
Kann }N: AnkIe arlhrodesis vilh an
anlerior lension Iale. =<', 1"*2.3
1991,268:7O-77.
8. Myerson MS, QuiII G: AnkIe arlhro-
desis: A comarison of an arlhroscoic
and an oen melhod of lrealmenl.
=<', 1"*2.3 1991,268:84-95.
9. RalIiff AHC: Comression arlhrodesis
of lhe ankIe. : M.,0 :.',* 56"7 M" 1959,
41:524-534.
1O. Nevman A: AnkIe fusion vilh lhe
Hoffmann exlernaI fixalion device.
B..* %,C<0 198O,1:1O2-1O9.
11. Iaremain GD, MiIIer SD, Myerson MS:
AnkIe arlhrodesis: ResuIls afler lhe
miniarlhrolomy lechnique. B..* %,C<0
E,* 1996,17:247-252.
12. Scranlon IL }r: Ise of inlernaI com-
ression in arlhrodesis of lhe ankIe. :
M.,0 :.',* 56"7 %? 1985,67:55O-555.
13. Thordarson D, MarkoIf KL, Crac-
chioIo A III: LxlernaI fixalion in
arlhrodesis of lhe ankIe: A biomechan-
icaI sludy comaring a uniIaleraI
frame vilh a modified lransfixion
frame. : M.,0 :.',* 56"7 %? 1994,76:
1541-1544.
14. Wang G}, Shen W}, McLaughIin RL,
Slam WG: TransfibuIar comression
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