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