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by The Journal
988
Copyright
Tibiotalocalcaneal
GARY
M.
RUSSOTTI,
of the
M.D.t,
the Departtnent
We
ABSTRACT:
caneal
arthrodesis
arthritis,
calcaneal
JOSEPH
of Orthopedics.
devised
to treat
R.
Mayo
a method
deformities
Clinic
and
M.D.t,
Mayo
for tibiotalocalor degenerative
approximately
75 per cent
of twenty-one
seous union was radiographically
evident
patients.
Secondary
degenerative
changes
not evident
radiographically
during
a period
that ranged
from 2.5 to seven years.
Tibiotalocalcaneal
arthrodesis
deformity
and degenerative
arthritis
is indicated
that involves
for severe
the tibio-
talar
1-A through
I-D).
and
lesion
ofthe
talocalcaneal
may
talus,
arthrodesis,
(Figs.
The
be the result of a complex
fracture-dislocation
avascular
necrosis
ofthe talus, a failed tibiotalar
a failed
arthropathy.
was devised
experience
joints
A new
by one
with
total
ankle
its use
in twenty-one
Materials
Between
1978
arthroplasty,
type of tibiotalocalcaneal
of us (K. A. J.), and
and
and
1983,
JOHNSON,
Foundation,
and
bone
tibiotalocalcaneal
arthrodesis
was performed
on twenty-one
patients
(twelve
men and nine women).
In thirteen,
the procedure
was performed
on the right side and in eight,
on the left side. At
the time of operation,
the ages of the patients
ranged
from
twenty-eight
to seventy-six
years.
The mean
duration
of
follow-up
was forty-nine
months
(range,
thirty to eightyfour months).
The operation
was done for one of several
painful
and
fixator
involvement
of both
*
No benefits
in any
form
have
been
received
or will
or both
the tibio-
the talocalfrom
a commercial
party related
directly
or indirectly
to the subject
ofthis
article.
No funds
were received
in support
of this study.
1- Mayo
Clinic,
200 First Street
SW. . Rochester.
Minnesota
55905.
1: Mayo Clinic Scottsdale.
13400
East Shea
Boulevard,
Scottsdale.
Arizona
85259.
Please
address
requests
for reprints
to Dr. Kenneth
Johnson.
1304
walking
aids
Medical,
Scottsdale
or because
they
had
lost
too
of the talus,
of the talus
at both the
joint.
The two patients
of an intra-articular
and
could
walk
unable
gait;
only
to work.
deformity.
Los
Angeles,
who
frac-
a limited
The physical
instability,
California)
eratively
and at intervals
postoperatively,
end of the follow-up
period.
or Charnley
as well
With
ipsilateral
the patient
posterior
in the prone
iliac crest
position,
are prepared
bone for grafts is first removed
standard
way and is processed
achillis,
which
in two
leg and
twenty
border
in the
of the flexor
hallucis
longus
centimeters
of the tendo
coronal
is elevated
and the interosseous
membrane
and
protect
the neurovascular
structures.
two joints
of the hind
part
THE
plane
OF
at its
transected,
level.
The
from
the fibula
is retracted
medially
to
The capsules
of the
of the foot
JOURNAL
the
Can-
from the iliac crest
in a bone
mill.
A
slightly
curved
incision,
made
along
the lateral
is split
the
and draped.
distal third.
The two halves
of the tendon
are
one at the proximal
level and one at the distal
origin
as at the
Technique
posterolateral.
long,
is then
Arthrodesis
twenty-one
be received
Scottsdale,
the talocalcaneal
and malalignment
Most of them were
included
an abnormal
(Ace
cellous
in the
had
Clinic
external
fixator (Zimmer,
Warsaw,
Indiana).
In the fourteen
patients
who were treated
most recently,
a Calandruccio
external
fixator (Richards,
Memphis,
Tennessee)
was used.
All records
were thoroughly
evaluated
by us preop-
ture at the ankle that was un-united
(two patients);
and neuropathy
that
they
Mayo
the tibiotalar
joint
from the talus.
to use
Surgical
because
and
performed
on ten of the thirteen
patients
who had either
a
failed arthrodesis
of the ankle or a failed ankle arthroplasty.
The common
presenting
symptoms
included
pain and
instability
with
weight-bearing,
and the signs
included
swelling
of the hind part of the foot. The patients
usually
disabling
conditions:
non-united
arthrodesis
of the ankle
(eight patients);
failed total ankle arthroplasty
(five patients);
osteonecrosis
of the talus (four patients);
intra-articular
frac-
patients
ARIZONA,
swelling,
and tenderness
of the hind part of the foot; and
loss of motion
of the foot and ankle.
In four of the operations,
fixation
was accomplished
with a Steinmann
pin and in three, with a Hoffmann
external
Methods
patients).
for these
SCOTTSDALE,
ture at the ankle had severe
deformity
and secondary
degenerative
changes
in the tibiotalar
and the talocalcaneal
joint.
Two or more previous
surgical
procedures
had been
had
joint (two
appropriate
M.D4,
tibiotalar
and
had non-union
distance.
findings
talar and the talocalcaneal
of only the ankle was not
Foot*
In all four patients
who had osteonecrosis
there had been extensive
resorption
and collapse
with associated
secondary
degenerative
changes
arthrodesis
we report
our
or malaligned,
involved
both
and
MINNESOTA
Rochester,
or neuropathic
patients.
unilateral
A.
Arthritis
of the
ROCHESTER,
caneal
much
patients;
osin all but three
in the adjacent
Incorporated
Part
KENNETH
CASS,
or both,
that involve
the tibiotalar
and tabjoints.
Satisfactory
results
were obtained
in
joints
were
of follow-up
Surgery.
for
Hind
ROCHESTER,
AND
From
and Joint
Arthrodesis
Deformity
BY
of Bone
are
BONE
stripped
AND
JOINT
subperiSURGERY
TIBIOTALOCALCANEAL
FIG.
1-A
of the
posterior
posterior
Distally,
aspect
of the cortex
portion
extra-articular
devices
that
necessary,
of the
calcaneus
had
of the
and
are removed
recipient
site for
had previously
been
and a trough
had
a fracture
tibial
of the ankle
component
aspects
of the tibia,
the talus,
the superior
portion
ofthe cortex
of the tibia
the bone
implanted
is cut from
the tibia
1-B
FIG.
Figs.
1-A through
l-D: Radiographs
of a man who
had been performed.
but he had increasing
pain.
Figs.
1-A and 1-B: Radiographs
showing
loosening
component
into the subtalar
joint.
osteally
from the
and the calcaneus.
1305
ARTHRODESIS
the
posterior
to provide
at the
Articular
through
bone
an
graft.
All metal
are removed
as
to the calcaneus.
5
with
resultant
arthritis.
rnethylmethacrylate-bone
cartilage
the
removed
so that
A total
and
expanse
is aligned
orientation,
and
the
ankle
subsidence
medially
a large
of the foot
of valgus
approximately
should
permit
interface
is also
trough,
is exposed.
The hind part
degrees
degenerative
arthroplasty
of the
and
laterally
of cancellous
in approximately
foot
5 degrees
of external
rotation.
the foot to be plantigrade
and
is placed
FIG.
VOL.
70-A,
treated
NO. 9. OCTOBER
with
a tibiotalocalcaneal
1988
1-C
FIG.
arthrodesis,
which
resulted
in excellent
relief
of pain.
l-D
Radiographs
made
two
years
in
This position
its rotation
to
.*
The patient
was
show the fusion.
talar
postoperatively
1306
G.
match
that
from
the
caneus
of the
other
inferior
foot.
surface
to the tibia
with
M.
RUSSOTTI,
A Steinmann
of the
the foot
heel,
pin
A.
the
position.
over
position
the
both
an intra-articular
longus
bone
graft
to its
is sutured
into
The
stirrup
splint are applied
distal to the knee.
On the second
or third postoperative
day, the drain and dressing
are removed,
and the patient
sites and on maintenance
is instructed
on the care of the pin
of the external
fixation
frame.
The
external
is removed
fixation
device
about
nine
and cast are removed
when
union
is radiographically
walk,
wearing
evident.
a compression
The
stiff
sole,
later,
able,
and
a shoe
and
with
when
weeks
post-
and it is used
Steinmann
pin
a rocker-bottom
is then permitted
to
and a shoe with a
wearing
a cushioned
heel
of the twenty-one
the result.
Five
limp.
had
Four
slight
part of the foot,
walking
were completely
satpatients
had a slight
or swelling,
or both,
on uneven
ground.
Six patients
were somewhat
dissatisfied
siderable
restrictions
in work or recreational
four
ing,
of them had moderate
or difficulty
walking
six had
in the hind
or had limitations
in work or recreational
other
patients
were
somewhat
satisfied.
had mild
pain,
a limp,
or limitations
in
four patients
had swelling
and mild restricrecreational
activities,
and they had diffi-
activities.
Four
Three
of them
walking,
but all
tions in work or
culty
pain
patients
of these
swelling
and
because
of conactivities,
and
pain, a limp, limitations
in walkon uneven
ground.
Three of the
needed
old
man
to use a walking
aid or special
were
who
of the hind
of the right
arthroplasty,
iotalar
arthrodesis
tibiotalocalcaneal
mann
external
tively,
a deep
with concurrent
the-knee
the main
had
thritis
ankle
reasons
an original
diagnosis
using
a Charnley
arthrodesis
fixator
was
was
used.
was
tibiotalar
who had loss of height
of the hind part
had the preoperative
diagnosis
of failed
arthrodesis.
We believe
on our results,
that the rigidity
of fixation
had an influence
as the five patients
who had a poor result
included
two in whom
no external
fixator
had been used,
two in whom
the Hoffmann
fixator had been used, and only
one (who had neuropathy)
in whom
the Calandruccio
apparatus
The
had
been
three
used.
patients
in whom
the
tibiotalocalcaneal
throdesis
had failed
to fuse had a poor result.
two patients
who had a poor result,
malunion
ar-
In the other
in excessive
device.
The
aureus)
months
developed,
later, a below-
of the tibiotalar
joint,
and,
finally,
by total
arthro-
tibiocalcaneal
ar-
throdesis
without
using an external
fixator.
The result was
a solid fusion,
but there was a loss of height
of the hind
part of the foot of seven
millimeters
and a dorsiflexion
of 6 degrees.
vascular
disease
development
operatively,
The patient
had a history
in the affected
extremity,
of necrosis
of the third
led to a below-the-knee
of peand the
toe, three months
amputation.
post-
Complications
No
isolated
deep
infection
of the
complication
that was directly
ternal fixation
device
occurred.
an aseptic
non-union,
and one
union.
A non-union
developed
whom the index procedure
had
use of an external
electrical
stimulation,
were
pin
tract
or other
related
to the use of the exHowever,
two patients
had
patient
had a septic
nonin one additional
patient,
in
been performed
without
the
fixation
device.
After three months
however,
solid union ensued.
of
Secondary
degenerative
changes
in the mid-talar
joints
not radiographically
evident
during
a period of follow-
up that
ranged
from
2.5
to seven
degeneration
of the subtalar
joint
talus, or both. The abnormalities
poor.
All patients
of the foot had
fixation
total
tib-
performed,
and the HoffTwo months
postopera-
for excision
of talar fragments
that were followed
ankle arthroplasty,
revision
total ankle arthroplasty,
In thirteen
result was rated
patients,
the objective
good or fair; and in five,
ar-
treated
with
and a second
performed.
would
twenty-one
in three,
rating.
of degenerative
infection
(Staphylococcus
pseudarthrosis.
Eight
shoes occasionally.
No correlation
could be established
between the original
preoperative
diagnosis
and the subjective
quality
of the result.
Twenty
of the twenty-one
patients
stated
that the operation
had been worth while.
of the
excellent;
for that
a poor result was the only
He was a sixty-four-year-
ankle.
This had been
tibiotalar
arthrodesis,
amputation
of the foot
part
One other patient
who had a poor result was a sixtyeight-year-old
man who had an initial
diagnosis
of osteochondritis
dissecans
of the talus. He had had two operations
deformity
ripheral
sole.
Results
Eleven
isfied
with
or dorsiflexion
swelling
desis
at the site of the arthrodesis
patient
stocking
angulation
CASS
One of the patients
who had
one in whom infection
developed.
tendo achillis
is reconstituted.
A drain is inserted,
the wound
is closed,
and a bulky
compression
dressing
and a plaster
operatively.
A short walking
cast is applied,
for approximately
seven
more weeks.
The
R.
with
normal
place.
J.
cal-
and an extra-
is returned
and
AND
The
external
fixator is then applied.
The morcellated
autogenous
grafts of cancellous
bone are placed
along the denuded
osseous surfaces
to create
articular
arthrodesis.
The flexor
hallucis
JOHNSON,
valgus
is inserted
transfixing
in the desired
K.
years.
Discussion
For this group
not
have
of patients,
been
routinely
assessed
grams,
and computed
resonance-imaging
malities
were
dealt
of
the
or the avascularity
of the
of the subtalar
joint were
scans.
with
the ankle
because
by bone
scans,
tomoscans,
and, on occasion,
in this
treat, and we have seen at least
in whom
there was non-union
twenty-one
often the
of only
treatment
preoperatively
tomography
by magnetic
that
arthrodesis
adequate
The
study
specific
are
abnor-
difficult
to
three (possibly
four) patients
of the arthrodesis.
For these
patients,
options
in therapy
were limited,
surgeon
could choose
only tibiotalocalcaneal
so
ar-
throdesis
or below-the-knee
amputation.
Other techniques”7’9
have been described
for achieving
a successful
tibiotalocalcaneal
fusion.
They include
singlestage and double-stage
procedures,
some done extra-articTHE JOURNAL
OF BONE
AND
JOINT
SURGERY
TIBIOTALOCALCANEAL
ularly
device.
and some intra-articularly,
with or without
a fixation
Only a few series of tibiotalocalcaneal
arthrodeses
distal aspect of the tibia or fibula with concomitant
secondary degenerative
changes
in the ankle and subtalar
joints.
The
been reported2’3’5’8’9.
Some investigators4’6
have suggested
for avascular
necrosis
of the talus,
Blair
have
yields
better
results
than
does
that, when used
(tibiotalar)
fusion
tibiotalocalcaneal
1307
ARTHRODESIS
surgical
procedure
that
we used
arthrodesis.
provided
at the site
of the
mum amount
tamed.
The
the
allows
applied
when necessary,
and
the foot could
be maintained.
for
cedure
of weight-beaming
subtalar
motion.
The leg and
stable
sential
fixation
for this
foot
on normal
are
tissue,
particularly
well
an external
fixation
procedure.
To obtain
device
optimum
and
suited
that
results
biplanar
the
is eswith
of surface
Ca]andruccio
recipient
Their contentions
have been that the Blair procedure
retains
the normal
appearance
of the foot and that normal
alignment
of the foot, relative
to the ankle, prevents
shortening,
places
thrust
offered
some
advan-
tages, in that the operative
incision
avoided
those of previous
operative
procedures
and in that optimum
exposure
was
stability
was
the
that
need
graft
so that
the
maxi-
area for the arthrodesis
was
external
fixator
provided
was
needed,
compression
obthe
could
be
the height
of the hind part of
A disadvantage
of the pro-
to harvest
autogenous
bone
from
the
posterior
iliac crest.
It must
be emphasized
that,
device
tibiotalocalcaneal
careful
of the
involved
joints,
whenever
possible.
The Calandruccio
extemnal fixator appears
to be the most appropriate
and effective
made of what the ultimate
position
of the foot, relative
to
the knee, is to be in the sagittal
plane.
The anteroposterior
position,
the transverse
rotational
position,
and the varus
device
and valgus
-
tibiotalocalcaneal
must
arthrodesis,
provide
secure
rigidity
for a patient
avascular
the
who
necrosis
of trauma
or to the
throdesis,
or a non-union
external
as well
use
fixation
as compression
has a failed
of the talus
-
total
related
ankle
arthroplasty,
to a previous
of steroids,
a failed
or malunion
episode
tibiotalar
of a fracture
arthrodesis,
orientation
of the foot
final intraoperative
positioning.
plications
with the procedure,
arof the
abnormalities
that
were
with
have
any
technique
of
has
to be
assessment
to be assessed
during
We had relatively
few comconsidering
the complicated
involved.
References
I
.
BLAIR,
C.
H.
: Comminuted
Fractures
and
Fracture
Dislocations
of the
Body
of the
Astragalus.
Operative
Treatment.
Am.
J. Surg.
,
59:
37-43,
Joint
Surg.,
1943.
2.
3.
4,
S.
CANALE,
60-A:
143-156,
COLTART,
W.
T.
and KELLY,
March
1978.
D.: “Aviator’s
,
M. D., and
5. DETENBECK,
L. C.
DENNIS,
,
6.
D.
R.
LIONBERGER,
MORRIS,
H.
8.
9.
1297, Oct. 1971.
PENNAL,
G. F. : Fractures
RECKLING,
F. W. : Early
VOL.
70-A,
B.
,
JR.:
Astragalus”.
Fractures
of the Neck
J. Bone
and
Joint
of the Talus.
Surg.
,
34-B(4):
Long-Term
Evaluation
545-566,
of Seventy-one
; BISHOP,
HAND,
NO. 9. OCTOBER
W.
Cases.
J. Bone
of the Talus.
Tibiocalcaneal
1988
and
1952.
H. S.: Blair Tibiotalar Arthrodesis for Injuries to the Talus. J. Bone and Joint Surg. 62-A: 103-107,
P. J. : Total Dislocation
of the Talus.
J. Bone and Joint Surg. . 51-A:
283-288,
March
1969.
J. 0.; and TULLOS,
H. S.: The Modified Blair Fusion. Foot and Ankle, 3: 60-62,
1982.
L.; and DUNN,
A. W.:
The
Modified
Blair
Fusion
for Fractures
of the Talus.
J. Bone and Joint Surg.
TULLOS,
and KELLY,
7,
D.;
F.
Jan.
,
Clin.
Orthop.
Fusion
in the
,
30: 53-63,
1963.
Treatment
of Severe
Injuries
of the Talus.
J. Trauma,
12:
390-396,
1972.
.
53-A:
1980.
1289-
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