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The Journal of Foot & Ankle Surgery 49 (2010) 205–207

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The Journal of Foot & Ankle Surgery

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The Use of a Femoral Distractor to Aid Distal Tibial Resection During TotalAnkle Arthroplasty

Michael Whitehouse, MRCS, SpR 1, Simon Thompson, MBBS, BSc(Hons), MSc, MRCS, SpR 2,Paul Halliwell, FRCS 3, Matthew Solan, FRCS, FRCS 4

1 Specialist Registrar Trauma and Orthopaedic Surgery, Trauma and Orthopaedics, Royal Surrey County Hospital, Guildford, United Kingdom2 Specialist Registrar Trauma and Orthopaedic Surgery, Trauma and Orthopaedics, Royal Surrey County Hospital, Guildford, United Kingdom3 Consultant, Trauma and Orthopaedics, Royal Surrey County Hospital, Guildford, United Kingdom4 Consultant, Trauma and Orthopaedics, Royal Surrey County Hospital, Guildford, United Kingdom

a r t i c l e i n f o

Keywords:anklearthroplastydistal tibia

femoral distractor

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Simon Thompson, MB

Royal Surrey County Hospital, Egerton Rd, Guildford,E-mail address: s.m.thompson@ic.ac.uk (S. Thomp

1067-2516/$ – see front matter � 2010 by the Ameridoi:10.1053/j.jfas.2009.06.002

a b s t r a c t

Distal tibial resection during total ankle arthroplasty can be time consuming and presents a technical chal-lenge. We recommend the use of a femoral distractor to assist with this specific part of the operation. Wedescribe the technique below and have now adopted it as a commonplace stage in our ankle replacements.

� 2010 by the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Fig. 1. The initial application of the femoral distractor.

The total ankle replacement has been shown to be a realistic andeffective treatment alternative to arthrodesis for disabling anklearthritis (1–5). In our institution, the Mobility Total Ankle Prosthesis(DePuy, DePuy International Ltd., Leeds, UK) is currently used.

A technical issue that has come to our attention concerns theremoval of the bony fragment after resection of the distal tibia. Thecutting block for the distal tibia is applied with an external jig, and thedistal tibial cut is made with the use of an oscillating saw blade (3).The surgical technique then recommends the application of bonespreaders to distract the joint. The distal tibial cut is then completedby means of a reciprocating saw blade to release the medial edge ofthe tibial plateau by making a vertical cut in line with the medial edgeof the talus. The resected bone is then removed. The techniquemanual recommends taking care not to lever against the medialmalleolus because of the risk of fracture and does not mention or useskeletal distraction.

A laminar spreader to distract the joint is helpful, but this instru-ment restricts access and may damage the distal tibial metaphysis. Wehave also tried using the Hintermann Distractor (Newdeal, Lyon,France), which uses heavy Kirschner wires (2 mm), but found that thisis not sufficiently powerful. Removal of the fragment in one piece istherefore difficult and increases the risk of levering against the medialmalleolus as the surgeon attempts to remove the fragment intact.Because of the difficulty in obtaining sufficient distraction, the distal

BS, BSc(Hons), MSc, MRCS, SpR,United Kingdom.son).

can College of Foot and Ankle Surgeo

tibial fragment is usually removed piecemeal. This can be timeconsuming.

Operative Technique

We recommend the use of the femoral distractor to facilitateremoval of the distal tibial fragment intact, remove the need to usebone spreaders, and reduce the risk of medial malleolar fracture. Theuse of a femoral distractor allows controlled increase in distractionand is therefore also preferable to a simple monolateral externalfixator. Femoral distractors are available in most hospitals. Thispowerful distractor is applied across the ankle joint before theplacement of the jig. Two pins are used for this. The first is placed inthe talar neck, with care not to penetrate the subtalar joint and not tocompromise future talus preparation. The second pin is placed in the

ns. Published by Elsevier Inc. All rights reserved.

Fig. 3. Close-up of the distracted joint.

Fig. 2. The application of distraction. Fig. 4. The resected distal tibia in one piece.

M. Whitehouse et al. / The Journal of Foot & Ankle Surgery 49 (2010) 205–207206

M. Whitehouse et al. / The Journal of Foot & Ankle Surgery 49 (2010) 205–207 207

proximal tibia. The ankle joint is then distracted by 0.5 to 1 cm. Thisfacilitates the horizontal osteotomy of the distal tibia with the sawblade less likely to become trapped. After the horizontal cut has beenmade, the vertical cut is then made with the reciprocating saw blade(Figures 1, 2).

After completion of the horizontal and vertical cuts, the distaltibial fragment is grasped with Kocher forceps and removed intactfrom the joint space. It is usually necessary to use a curved osteotometo help free the fragment from the posterior capsule. The femoraldistractor can then be removed to facilitate the rest of the operation(Figures 3, 4).

In our experience, this technique is safe and has the advantage ofbeing quicker than the standard methoddeven when the applicationand removal of the femoral distractor are taken into account. We have

not encountered any complications particular to the use of thistechnique since adopting it.

References

1. Anderson T, Montgomery F, Carlsson A. Uncemented STAR Total Ankle Prostheses.J Bone Joint Surg Am 86:103–111, 2004.

2. Kopp FJ, Patel MM, Deland JT. O’Malley MJ. Total ankle arthroplasty with the Agilityprosthesis: clinical and radiographic evaluation. Foot Ankle Int 27(2):97–103, 2006.

3. Mobility Total Ankle System. Surgical Technique. Cat no. 8555-00-004 Version 2.DePuy International, Leeds, October 2005.

4. San Giovanni TP, Keblish DJ, Thomas WH, Wilson MG. Eight-year results ofa minimally constrained total ankle arthroplasty. Foot Ankle Int 27(6):418–426,2006.

5. Wood PLR, Deakin S. Total ankle replacement. J Bone Joint Surg Br 85(3):334–341,2003.