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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bstr act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nkle 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 arlhrodesis of lhe ankIe |oinl. =<', 1"*2.3 1993,289:223-227. 15. Scranlon IL }r: An overviev of ankIe arlhrodesis. =<', 1"*2.3 1991,268:96-1O1. 16. Scranlon IL }r, McDermoll }L: An- lerior libiolaIar surs: A comarison of oen versus arlhroscoic debride- menl. B..* %,C<0 1992,13:125-129. ograhic and analomic anaIysis. B..* %,C<0 E,* 1997,18:233-235. 34. Lidor C, Ierris LR, HaII R, AIexander I}, NunIey }A: Slress fraclure of lhe libia afler arlhrodesis of lhe ankIe or lhe hindfool. : M.,0 :.',* 56"7 %? 1997,79:558-564. 35. Kilaoka H, AIexander I}, AdeIaar RS, NunIey }A, Myerson MS, Sanders M: CIinicaI raling syslems for lhe ankIe- hindfool, midfool, haIIux, and Iesser loes. 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Pulley System in The Fingers: Normal Anatomy and Simulated Lesions in Cadavers at MR Imaging, CT, and US With and Without Contrast Material Distention of The Tendon Sheath1