Arthroscopic Ankle ArthrodesisJan 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

Ahmad, J., and S. Raikin. "Ankle Arthrodesis: The Simple and the Complex." Foot and Ankle Clinics of North America 13.3 (2008): 381-400Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North America 8.2 (2003): 347-59.

Contraindications

• Peripheral Vascular Disease• Medical Clearance• Bil Ankle Arthritis• Active Bone Infection• Open Growth Plates• Progressive or Severe Deformities• Tobacco Use

Ahmad, J., and S. Raikin. "Ankle Arthrodesis: The Simple and the Complex." Foot and Ankle Clinics of North America 13.3 (2008): 381-400Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North America 8.2 (2003): 347-59.

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.

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North 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 (2005): 125-32Paley, Dror. Principles of Deformity Correction. Berlin: Springer, 2003.

Lateral Radiograph

• Ankle at 90°• Long axis of Tibia• Posterior tubercle of

talus to inferior talar neck

• Normal is 106°

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North 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 (2005): 125-32.

Fixation

• External Fixation– Advantageous in Osteoporotic Bone– Hx of Osteomyelitis

• Internal Fixation– Parallel Screws– Cross Screws– Tripod Screws– Other – Plates, IM Nail, etc

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North 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 (2009): 93-96.

Parallel Screw Fixation

• Increased Compression• Parallel in AP and Lat

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North America 8.2 (2003): 347-59.

Cross Screw Fixation

• Increased rigidity

Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North 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.Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.

Joint Distraction

• External distractor• Insufflate joint w/ 20cc

NS or Lidocaine with Epinephrine

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.

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

Collman et al. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive Patients." Foot & Ankle International 27.12 (2006): 1079-085.Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.

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

Collman et al. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive Patients." Foot & Ankle International 27.12 (2006): 1079-085.

Screw Fixation

• 6.5-mm or 7.3-mm

Ferkel, Richard D., and Michael Hewitt. "Long-Term Results of Arthroscopic Ankle Arthrodesis." Foot & Ankle 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

Ferkel, Richard D., and Michael Hewitt. "Long-Term Results of Arthroscopic Ankle Arthrodesis." Foot & Ankle 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%– Fusion Time = 6.7 wks

Collman et al. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive Patients." Foot & Ankle 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%– Fusion Time = 12.5 wks

Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.

Advantages of Arthroscopy

• Poor skin and wound healing potential– DM, PVD, RA, long-term steroid use, previous

skin/tissue graft

Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.

Advantages of Arthroscopy

• Decreased hospital stay– O’Brien 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.

Advantages of Arthroscopy

• 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°

Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.Myerson et al. "Ankle Arthrodesis: A Comparison of an Arthroscopic and an Open Method of Treatment." Clinical Orthopaedics & Related Research 268 (1991):

Advantages of Arthroscopy

• Decreased malunion– O’Brien 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.

Advantages of Arthroscopy

• Improved Ankle Osteoarthritis Scale (AOS) score at 1yr and 2yr

Baseline 1 yr 2 yr

Open 56 33.5 29.5

Arthroscopic 56 17.5 17.2

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

Ahmad, J., and S. Raikin. "Ankle Arthrodesis: The Simple and the Complex." Foot and Ankle Clinics of North America 13.3 (2008): 381-400Gougoulias et al. "Arthroscopic Ankle Arthrodesis." Foot & Ankle International 28.6 (2007): 695-706.Raikin, S. "Arthrodesis of the Ankle: Arthroscopic, Mini-open, and Open Techniques." Foot and Ankle Clinics of North America 8.2 (2003): 347-59.

Non-union

• A Review study by Abicht et al found an overall non-union rate of 8.6%.– N = 244– Fusion Time = 8.3 wks

• Collman et al found that Obesity trended towards non-union. – N= 39 (20 post-traumatic)– 4/5 non-unions were post-traumatic ankle arthritis

Collman et al. "Arthroscopic Ankle Arthrodesis: Factors Influencing Union in 39 Consecutive Patients." Foot & Ankle 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.

FinancesOutpatient 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): 381-400.• 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): 347-59.

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. "Arthroscopic-Assisted 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): 343-47.

• Zvijac, John E., Lawrence Lemak, Matthias R. Schurhoff, Keith S. Hechtman, and John W. Uribe. "Analysis of Arthroscopically Assisted Ankle Arthrodesis." Arthroscopy: The Journal of Arthroscopic & Related Surgery 18.1 (2002): 70-75.

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