Watkin's Manual of Foot and Ankle Surgery: Triple Arthrodesis, Arthroereisis, Ankle Arthroscopy
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Terms in this set (22)
∙Fusion of three joints in the foot.
Triple Arthrodesis: Fixation
∙Is often with 6.5 or 7.0mm cannulated screws for the STJ.
∙Two staples at 90° for the CC and TN joints.
∙Hindfoot should be positioned in
slight valgus position, about 5°.
→Body can compensate for valgus.
Varus foot should be avoided at all cost
→These patients end up with pain and callus formation under the lateral midfoot and forefoot.
∙TN fusion requires the longest time for revascularization.
∙As a result of a triple arthrodesis, there is extra stress on the ankle joint.
→The ankle joint should be free of DJD pre-op.
∙Sliding the calcaneus posteriorly on the talus will raise the arch, and sliding the calcaneus anteriorly on the talus will lower the arch.
Triple Arthrodesis: Indications
∙Collapsing pes valgo planus
∙Ruptured posterior tibial tendon
Triple Arthrodesis: Incisions
Lateral incision (Ollier incision)
: Extends from the tip of the lateral malleolus to the base of the 4th metatarsal,
providing access to STJ and CC joint.
: Extends from medial gutter of the ankle joint to the 1st metatarsal base,
providing access to TN joint and TC fixation.
Triple Arthrodesis: Order of Joint Resection and Fixation
1. Resect MTJ (CC then TN)
→this allows access to the STJ.
2. Resect STJ.
3. Temporarily fixate STJ.
4. Temporarily fixate MTJ (TN then CC).
5. Fixate STJ.
6. Fixate MTJ.
Triple Arthrodesis: Post-Operative Course
∙Apply Jones compression dressing immediately post-op for 2 to 3 days.
→casting is generally avoided because of swell.
∙Change dressing at 48 hours.
∙At 2 to 3 days, pull drain and apply a BK NWB cast.
∙At 3 weeks, D/C cast and remove sutures.
∙Apply removable BK NWB cast for an additional 4 weeks.
∙Progressive WB and PT for an additional 3 months.
∙Return to work 6 months.
Triple Arthrodesis: Complications
∙adjacent joint degeneration
Subtalar Arthroeresis Implants:
∙Implants designed to
limit subtalar joint pronation
blocking anterior-inferior displacement of the talus.
∙Although commonly referred to as subtalar joint implants, they are
not inserted into the joint
Inserted into the sinus tarsi between the posterior and middle facets of the STJ.
∙Goal of STJ arthroereisis implants is to limit pronation and reduce heel valgus by
blocking contact of the lateral talar process against the calcaneal sinus tarsi floor
→sometimes described as an "implantable orthotic."
∙All subtalar implants are considered both "direct impact" and "axis-altering" implants.
→considered direct impact implants because the implants physically block the motion of the talus.
→decreased motion alters spatial orientation of the STJ axis during gait, making them "axis-altering" too.
Subtalar Arthroeresis Implants: Classifications
→have stem that is fit into a hole drilled into the floor of the sinus tarsi
→requires some bone resection.
→these are falling out of favor and slowly being discontinued.
→simply screwed into the sinus tarsi
→no bone resection required.
→further divided into type I and type II.
I*: inserted into the sinus portion of the sinus tarsi.
I*: have a narrower distal (medial) portion to the implant, allowing them to fit into both the sinus and the deeper canalis portion of the sinus tarsi.
Subtalar Arthroeresis Implants: Indications
∙Flexible pes planus
Subtalar Arthroeresis Implants: Complications
∙Device migration (backing out).
∙Lateral foot and ankle soft tissue strain.
∙Sinus tarsi pain.
∙Talar neck fracture.
Subtalar Arthroeresis Implants: Contraindications
∙Angular deformity of knee
∙Torsional leg deformities
Subtalar Arthroeresis Intraosseous Type Implants: LSI Implant (Lundeen Subtalar Implant)
Subtalar Arthroeresis Intraosseous Type Implants: STA-Peg Subtalar Implant
Subtalar Arthroeresis Intraosseous Type Implants: Future ASI (Angled Subtalar Implant)
∙Angled intraosseous subtalar implant
Ankle Arthroscopy: Instruments
a*: Rigid hollow tube used to establish and maintain portal for both the scope and instruments.
r*: Sharp pyramidal tipped solid rod placed in the cannula
→used to pierce soft tissue and capsule. →portal has been established, trochar is removed, leaving cannula in place.
r*: Same as a trochar but with a blunt tip.
→Less destructive when bone contact is made.
→Used to penetrate the joint when placing the cannula in an already-established portal.
e*: With ankle arthroscopy usually a 4.0-mm scope is used with a 30° viewing radius.
Ankle Arthroscopy: Terminology
g*: Side-to-side and up-and-down movement of the scope to view anatomical areas.
g*: Moving the scope in for magnification and moving the scope out for better orientation.
n*: bringing the scope and another instrument together, through two different portals at a specific site in the joint.
Ankle Arthroscopy: Common Portals
anterior tibialis tendon
lateral to saphenous vein and saphenous nerve.
→Care should be taken to avoid the superficial peroneal nerve branches (medial and intermediate dorsal cutaneous nerves).
→Transillumination can assist with the placement of this portal.
→The posterior-lateral portal is created
1.0 to 1.5 cm lateral to the Achilles tendon
n* at the level of the distal tip of the lateral malleolus.
→The sural nerve, lesser saphenous vein, and peroneal tendons should all be lateral to the portal.
What is Transillumination?
A technique where the arthroscope is inserted through the
medial portal and directed laterally
to transilluminate the soft tissues. This technique is
useful for proper portal placement and avoiding critical structures
Ankle Arthroscopy: Irrigation
∙Normal saline or Ringer solution may be used.
Ringer's is preferred because it is less damaging to chondrocyte
s*: where the irrigation fluid enters the joint.
s*: where the irrigation leaves the joint.
Ankle Arthroscopy: Less Common Portals
lateral to the EHL tendon
medial to the EDL tendon
→Avoid the anterior tibial artery, the deep peroneal nerve.
Medial to the Achilles
s*, lateral to the tarsal canal.
→High-risk portal due to the proximity to the neurovascular structures.
→Also called the trans-Achilles, portal is created directly through the posterior aspect of the Achilles tendon at the level of the ankle. →While this portal involves splitting the Achilles tendon, it is farther from any local nerves as compared with the other portals.
Ankle Arthroscopy: Gutters
→space between the medial articular surface of the talus and the tibia.
→space between the lateral articular surface of the talus and the fibula.
→most anterior portion of the ankle joint.
→most posterior portion of the ankle joint.