DEFINITION

Tibiotalocalcaneal arthritis is formally defined as the loss of cartilage from both the tibiotalar (ankle) and the talocalcaneal (subtalar) joints.

Tibiotalocalcaneal arthritis can cause significant disability in terms of pain and limitation of function. Nonoperative treatment options are limited, as in most instances, they only partially relieve pain and usually cannot correct deformity.

The goal of tibiotalocalcaneal arthrodesis is to produce a stable, plantigrade, and pain-free foot and ankle.1,11

Achieving stable fixation can be challenging in osteopenic bone. Blade plate fixation of the tibiotalocalcaneal joint has been shown in biomechanical studies to have higher initial and final stiffness.

 

 

ANATOMY

 

The ankle joint comprises the talus as it articulates with the tibial plafond. The body of the talus is saddle-shaped dorsally and fits congruently within the mortise created by the distal tibia and fibula. In addition, the talus and the tibial plafond are narrower posteriorly to accommodate rotation with ankle dorsiflexion and plantarflexion.

 

The subtalar joint comprises the talus and the calcaneus as they articulate through anterior, middle, and posterior facets.

 

The talus is divided into head, body, and neck. Roughly 70% of the bone is covered with cartilage and there are no muscular or tendinous attachments. The main blood supply of the talar body enters retrograde through the neck of the talus, which makes the body prone to avascular necrosis in the case of displaced talar neck fractures.

 

The lateral aspect of the foot is innervated by the superficial peroneal and sural nerves. The superficial peroneal nerve typically exits the crural fascia 10 to 12 cm proximal to the tip of the lateral malleolus. The nerve then courses anteriorly to give sensation to the dorsal aspect of the foot.

 

The sural nerve has contributions from branches of both the tibial and common peroneal nerves. It courses lateral to the Achilles tendon and is found about 1 cm distal to the tip of the fibula at the level of the ankle.

 

PATHOGENESIS

 

Arthritis of the tibiotalar and subtalar joints has multiple causes, including primary osteoarthritis, trauma, neuroarthropathy, infection, avascular necrosis, inflammatory arthritis, and failed surgery.

 

Patients typically complain of diffuse ankle pain and cannot differentiate tibiotalar from subtalar symptoms. Although it is preferable to fuse only one joint to retain an adjacent motion segment, such isolated fusion in the setting of residual arthrosis can result in persistent pain.

 

In posttraumatic cases, failure to restore articular congruency can result in increased contact stresses, with resultant cartilage wear and the development of arthritis.

 

NATURAL HISTORY

 

Hindfoot arthritis is usually a progressive disorder, although the rate of progression can vary. However, arthritis due to malalignment, trauma, and avascular necrosis of the talus can progress relatively rapidly.

 

Nonoperative treatment of hindfoot arthritis in an anklefoot orthosis (AFO) likely does not prevent or slow progression of the disease but merely decreases symptoms.3

 

Failed surgery can be quite debilitating and frequently needs expedited treatment.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Physical examination should include the following:

 

 

Gait. The surgeon should watch the patient walking both toward and away from him or her and should clinically determine whether gait is normal or antalgic on both sides. The examiner should look for any assistive devices. Patients with painful arthritis will have an antalgic gait on that side. The patient may require the use of a cane or a walker.

 

Hindfoot alignment. The hindfoot is examined from behind. The surgeon should determine whether the hindfoot is in varus or valgus. Patients can have both varus and valgus malalignment.

 

Tibiotalar range of motion. Active and passive sagittal plane motion is assessed. Normal ankle motion is about 50 degrees of plantarflexion and 10 to 20 degrees of dorsiflexion. Tibiotalar motion is usually significantly decreased compared to the unaffected side.

 

Subtalar range of motion. Active and passive coronal plane motion is assessed. Normal subtalar motion is about 10 to 20 degrees of inversion and 5 to 10 degrees of eversion. Subtalar motion is usually significantly decreased compared to the unaffected side.

 

Past medical history may be significant for antecedent ankle or hindfoot trauma, talar osteonecrosis, diabetes, neuroarthropathy, osteochondral defect, or recurrent ankle instability.

 

Past surgical history may include previous ankle or hindfoot surgery, including open reduction and internal fixation (ORIF), total ankle arthroplasty, and previous arthrodesis.

 

Patients usually complain of pain and instability with weight bearing. Selective anesthetic injections into the ankle or subtalar joints can help to determine which joints are symptomatic.

 

 

67

 

 

 

FIG 1 • Preoperative AP (A) and lateral (B) radiographs of the ankle.

 

 

Upon examination, hindfoot swelling and tenderness are usually evident. Most patients have decreased passive range of motion in both joints. Malalignment is also often present.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Weight-bearing plain radiographs including anteroposterior (AP), lateral, and mortise views of the ankle and AP, lateral, and oblique views of the foot are standard.

 

A weight-bearing lateral radiographs should be performed to assess talocalcaneal and talo-first metatarsal angles (FIG 1).

 

Computed tomography (CT) is often helpful preoperatively to assess bony anatomy, alignment, and articular integrity in greater detail.

 

DIFFERENTIAL DIAGNOSIS

Talar avascular necrosis Talar osteochondral injury Isolated ankle arthritis Isolated subtalar arthritis Ankle instability

Foreign body

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment is aimed primarily at alleviating symptoms rather than correcting deformity. The patient is placed in a robust brace such as an AFO or Arizona brace in an attempt to provide support and limit motion.

 

Bracing may not always be possible depending on the severity of the deformity. In addition, bracing typically does not prevent progression of disease.

SURGICAL MANAGEMENT

 

Surgical management is generally indicated when nonoperative modalities have failed to provide adequate relief or are impractical (eg, a nonbraceable deformity).

 

Tibiotalocalcaneal fusion is indicated in patients with arthritis in both the tibiotalar and subtalar joints. The goal of surgical intervention is to obtain a stable, plantigrade, and pain-free foot and ankle.

 

Blade plate fixation can be used primarily or in instances when the surgeon feels that intramedullary rod fixation is contraindicated. The latter may include poor bone stock or advanced osteopenia, a distal tibia deformity

greater than 10 degrees, or significant loss of calcaneal height.10

 

The main two contraindications to this procedure are (1) the presence of active infection and (2) destruction of calcaneal bone stock to the extent that purchase with the blade is compromised. In these instances, the use of a small wire ring fixator should be considered.

 

Preoperative Planning

 

A full patient assessment is made before the operation. Smokers should be counseled regarding smoking cessation because in this population, a 14-fold increase in the nonunion rate has been documented.4

 

If active infection is suspected, an appropriate workup should be performed. This may include laboratory studies, magnetic resonance imaging (MRI) with contrast, and nuclear imaging. If there is still uncertainty despite these tests, a bone biopsy or joint aspirate may be necessary.

 

Disease-modifying antirheumatic drugs (DMARDs) should be held preoperatively, typically for 2 weeks or a period determined in conjunction with a rheumatologist.

 

Patients with significant comorbidities such as diabetes, cardiovascular disease, and nephropathy should be medically optimized by their primary care doctor before surgical intervention.

 

Positioning

 

The patient is placed supine on the operating table with a bump under the ipsilateral buttock to maintain the foot in neutral or slightly rotated medially.

 

The extremity is prepared and draped, including the iliac crest if structural autograft is desired. An alternative bone graft harvest site is the proximal tibia. A thigh tourniquet is used (FIG 2).

 

Approach

 

Traditionally, an extensile lateral approach to the ankle and subtalar joints is used, although a posterior approach has also been described.8

 

 

 

FIG 2 • Preoperative positioning of the patient.

 

 

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TECHNIQUES

• Exposure

A 15- to 20-cm curvilinear incision is made through the skin centered over the fibula shaft proximally, then curving toward the base of the fourth metatarsal distally.

With deep dissection, care is taken to avoid injury to the superficial peroneal nerve, which exits the fascia about 12 cm proximal to the fibular tip. Distally, the surgeon must take care to avoid injury to the sural nerve along its course lateral to the fifth metatarsal (TECH FIG 1).

Distally, the extensor digitorum brevis is elevated to expose the subtalar joint.

In some instances, a medial (longitudinal) incision may be necessary. These include the following: (1) to remove medial bony prominences and debris and (2) to assist in resection of medial bone when advanced varus deformity precludes reduction of the foot to neutral.

 

 

 

 

TECH FIG 1 • The ankle and subtalar joints are approached through an extensile curvilinear incision.

• Osteotomy of the Fibula and Preparation of the Tibiotalar Joint

   

  Make an osteotomy of the fibula about 6 to 10 cm proximal to the tip of the lateral malleolus (TECH FIG 2A).

   

  Resect the distal section of the fibula.

   

  The distal fibula can be readily morselized into autogenous bone graft using a small acetabular reamer before resection12 (TECH FIG 2B).

   

  Retract the peroneal tendons posteriorly and protect them.

   

   

   

  TECH FIG 2 • A. An osteotomy of the fibula is performed about 6 to 10 cm proximal to the tip of the bone.

  B. The fibula can be morselized for bone graft using an acetabular reamer.

   

   

  Enter the ankle joint sharply and fully expose it by releasing the lateral ligaments and anterior and posterior capsule.

   

   

  Distract the joint using a lamina spreader. Remove any remaining cartilage with a curette.

   

  After removing the cartilage, prepare the joint surface with flexible chisels or a small, low-speed burr. If using a burr, use copious irrigation to avoid thermal necrosis. Burr holes should be just through the subchondral bone and separated by about 3 mm on all sides to avoid weakening or fracture of the cortex.

• Preparation of the Subtalar Joint

   

  Enter the subtalar joint sharply with release of the lateral ligaments, capsule, and the talocalcaneal intraosseous ligament.

   

  Maintain distraction of the joint using a lamina spreader.

   

  Curette the remaining cartilage off the joint surface and prepare the subchondral bone with flexible chisels or a burr as described earlier.

   

  If there is significant bone loss or fragmentation of the talus, the tibia may have to be fused directly to the talus. In this case, the calcaneal articular processes will need to be removed with an osteo tome to create a flat surface that will lie flush with the tibial plafond.

   

   

  Bone graft can be packed into the subtalar and ankle joints. If there is a large bony deficit with substantial loss of limb length, structural graft in the form of iliac crest autograft or femoral head allograft can be used to restore height.

   

• Insertion of the Blade Plate

  69

   

  After preparing the joint surfaces, insert a 90- or 95-degree fixed-angle blade plate for fixation. The use of both an adolescent blade plate and a humeral blade plate has been described. The length of the blade is typically 40 mm. The side plate can range from five to eight holes based on the size of the patient and the surgeon's preference.

   

  Ensure that the hindfoot is positioned in neutral to 5 degrees of valgus and the ankle is in neutral dorsiflexion and plantarflexion. External rotation should approximate that of the contralateral extremity, usually 5 to 10 degrees.

   

  The ankle and subtalar joints must be held rigidly during insertion of the blade plate. Provisional fixation can be obtained with guidewires or a Schanz pin.

   

  Use a 2.0-mm guidewire to facilitate insertion of the blade plate. The guidewire should be inserted such that 5 to 10 mm of calcaneal bone will remain plantar to the blade. Place the guidewire through the middle hole of the blade plate drill guide (TECH FIG 3A). The lateral calcaneal cortex may then be further prepared for blade insertion by predrilling with a 4.5-mm drill bit (through appropriate holes in the drill guide).

   

   

   

  TECH FIG 3 • A. A 2.0-mm guidewire is inserted through the drill guide into the calcaneus. B. The blade plate is inserted over the guidewire using the insertion handle. C. Sagittal plane malalignment can be avoided using a proximal guidewire.

   

   

  Remove the drill guide and insert the blade plate over the guidewire using the inserter-extractor handle (TECH FIG 3B). Impact the blade until it is flush with the lateral cortex of the tibia. Rotational control is best achieved by using a slotted hammer.

   

  Once the blade engages the calcaneus, the position of the plate proximally cannot be changed. To avoid sagittal plane malalignment (ie, the plate coming off the tibial anteriorly or posteriorly), consider using another guidewire through the most proximal hole of the plate as the blade plate construct is inserted (TECH FIG 3C).

   

  Contour the plate to the lateral aspect of the tibia and fill the screw holes sequentially. Use 4.5-mm cortical screws proximally and 6.5-mm cancellous screws distally.

   

  A single 6.5- or 7.3-mm cortical screw can be used to augment the blade plate fixation. Place the screw under fluoroscopic guidance from the calcaneal tuberosity into the anterior tibial cortex at roughly a 60-degree angle.

• Closure

   

  Given the large amount of bleeding cancellous bone exposed during the procedure, a meticulous layered closure should be performed. Further steps that will aid in the prevention of a postoperative hematoma include releasing the tourniquet and assessing hemostasis before closure, the use of drains, and the use of a compression dressing.

   

  70

• Case Example (Courtesy of Mark E. Easley, MD)

Background, Imaging, and Preoperative Planning

 

 

A 47-year-old 6 years after ORIF of right talar neck fracture Severe pain in right ankle and hindfoot with weight bearing

 

Failed nonoperative management, including use of a patellar tendon-bearing brace

 

 

Hindfoot alignment in slight varus Stiff ankle and hindfoot

 

 

 

Pain with stress of ankle and hindfoot Ambulates with severe limp Radiographs (TECH FIG 4)

 

Retained hardware

 

Ankle and subtalar arthritis

 

Suggestion of (at least) partial talar body avascular necrosis

 

 

Given talar body avascular necrosis, patient not a candidate for total ankle replacement Fibular preservation therefore is less important.

 

Favor tibiotalocalcaneal arthrodesis because both ankle and subtalar joint arthritis and stiffness are present.

 

 

Intramedullary nail Lateral plating

 

In this case, lateral plating is performed.

Exposure

 

Lateral longitudinal incision (TECH FIG 5A)

 

Because the implant chosen has a posterior limb to fit on the calcaneus, the approach was not curved anteriorly but instead made straight vertically to allow access to the lateral calcaneal wall.

 

Sural nerve protected

 

Distal fibula excised (TECH FIG 5B); bone morselized and used as bone graft

 

 

 

TECH FIG 4 • Weight-bearing ankle radiographs in a 47-year-old woman with right ankle and hindfoot pain and stiffness 6 years after ORIF of talar neck fracture, with some concern for talar body avascular necrosis.

A. AP and mortise views. B. Lateral view.

 

Preparation for Arthrodesis

 

 

Hardware removed Ankle and subtalar joint

 

With preoperative varus, more bone is removed laterally to promote hindfoot valgus position (TECH FIG 6A).

 

 

Drilling and chiseling to increase surface area and promote healing Posterior tibia, talus, and dorsal calcaneus

 

 

Augments arthrodesis Promotes fusion

 

Bone graft is placed within the ankle and subtalar joints (TECH FIG 6B) as well as posteriorly as a buttress.

Provisional Fixation

 

Clinically and fluoroscopically proper alignment confirmed

 

 

Sagittal plane: neutral ankle position, plantarflexion/equinus avoided Rotation: second metatarsal aligned with tibial crest

 

Coronal plane: heel valgus maintained; varus corrected/avoided

Definitive Fixation

 

Template is used to determine optimal plate position (TECH FIG 7A,B).

 

Lateral plate is positioned and provisionally secured, and position is confirmed fluoroscopically.

 

Locking plate technology: This particular plate is initially secured as a nonlocking plate so that plate has satisfactory contact with bone (TECH FIG 7C,D), then converted to locking plate with locking washers placed over screw heads, converting the plate to a fixed-angle device (TECH FIG 7E,F).

 

 

Distal fixation in calcaneus performed first Compression device used proximally (TECH FIG 7G)

 

After distal fixation

 

Prior to proximal fixation

 

Promotes compression at the arthrodesis sites

 

 

71

 

 

 

TECH FIG 5 • Lateral approach. A. Fibula excised (and used as bone graft). B. Lateral ankle and subtalar joints exposed.

 

 

 

TECH FIG 6 • Joint preparation and bone grafting. A. Chisel used to increase surface area and to remove more lateral bone to promote hindfoot valgus. B. Bone graft packed at arthrodesis sites and posterior to tibia, talus, and dorsal calcaneus.

 

 

 

TECH FIG 7 • A. Template for lateral plating being inserted. Note that this particular plate extends over lateral calcaneus posteriorly and therefore a vertical longitudinal incision was made rather than curving the distal incision anteriorly. B. Template in place with provisional fixation. C. Lateral plate in proper position based on template, clinical assessment, and intraoperative fluoroscopy. Distal screw hole being drilled with soft tissues and sural nerve protected. (continued)

 

 

72

 

 

TECH FIG 7 • (continued) D. Screw inserted. Note that this nonlocking screw allows the plate to be fully secured to bone. E. After the locking screw is fully seated and plate is secured to the calcaneus, a locking washer is placed. F. Locking washer fully seated over nonlocking screw, creating the fixed-angle construct. G. After distal fixation, proximal compression applied to the plate and proximal fixation drill hole created. H. Proximal fixation completed after compression applied. Locking washers may also be placed on proximal screws to create the fixed-angle construct.

 

 

Promotes heel valgus

 

Ideally, the provisional fixation is in neutral to slight valgus and the compression then sets optimal heel valgus.

 

If necessary, the plate may be carefully bent prior to being inserted in order to create more valgus.

 

 

Proximal screws placed after compression applied (TECH FIG 7H) Proximal locking washers convert entire construct to a fixedangle device.

Supplemental Fixation

 

Two additional cannulated screws to augment the construct

 

First screw from the posterolateral tibia into the talar neck

 

Second screw from posterolateral and inferior calcaneal tuberosity into anteromedial tibia

Postoperative Care

 

Protected weight bearing for 6 weeks in a splint, then short-leg cast

 

 

If wound stable, allow partial weight bearing for next 6 weeks; short-leg cast versus cam boot At 12 weeks, recommend CT scan to confirm adequate healing at both arthrodesis sites.

 

If healed, advance to full weight bearing.

 

If delay in healing, then continue protected weight bearing in cam boot.

 

During transition from cam boot to shoe wear, recommend stiffer-soled shoe, rocker bottom modification, and fixed ankle brace to extend to above the ankle.

 

Long-term management (TECH FIG 8)

 

Although many patients eventually function without the ankle brace, a stiffer-soled shoe and rocker bottom modification are usually recommended.

 

There is a risk of potential stress fracture at the proximal end of the plate unless some of the stresses are dissipated.

 

 

73

 

 

 

TECH FIG 8 • Six-month follow-up. A. Weight-bearing mortise view radiograph. Note that lateral plate dictates proper hindfoot alignment. B. Weight-bearing lateral radiograph. Note supplemental cannulated screw fixation and bridging trabeculation suggested. Also note posterior buttress of bone augmenting fusion.

 

 

PEARLS AND PITFALLS

 

Maintain

sagittal plane alignment.

• Use a proximal guidewire.

Bone graft

• Use the resected fibula for autogenous bone graft.

Avoid the

tendency of hindfoot to fall into valgus.

• As the plate is screwed down to the tibia, there is a tendency for the hindfoot to be

pulled into valgus, given the normal contour of the lateral tibia. To avoid this, the blade plate should be carefully contoured before insertion. Resecting a groove for the plate in the most distal portion of the tibia using a chisel or burr may also be helpful.

Avoid the

tendency of hindfoot to fall into varus.

• Failure to contour the blade plate when necessary can sometimes push the hindfoot

into varus. Incorporating a small lateral “bow” distally will avert this.

Avoid

inserting the blade plate inserted too lateral.

• If the blade plate does not lie flush with the lateral calcaneus, the blade plate may

be prominent, causing potential difficulties with wound closure and healing.

Avoid ▪ In cases of talectomy, the foot must be aligned with the leg, as alignment of the

dorsiflexion distal tibia to the posterior calcaneal facet can result in a dorsiflexion malunion. The malunion fused surfaces should be contoured accordingly.

with talectomy.

 

 

POSTOPERATIVE CARE

 

Postoperatively, patients are placed in a splint and admitted for 24 hours of intravenous antibiotics.

 

After 10 to 14 days, patients return to the office for evaluation of the wound and suture removal. At this visit, patients are placed in a non-weight-bearing short-leg cast.

 

Patients remain non-weight bearing in a short-leg cast for 6 to 12 weeks based on radiographic healing.

 

Thereafter, patients are transitioned to a short-leg walking cast or boot and progressive weight bearing is begun.

 

The fusion is protected until sufficient clinical and radiographic healing is obtained (FIG 3). A CT scan may be needed to assess the adequacy of the fusion.

OUTCOMES

A successful outcome is usually the norm for tibiotalocalcaneal fusion.

Most studies report combined results of different approaches to fusion. In studies examining the use of blade plate fixation exclusively, the reported fusion rates have ranged from 90% to 100%.2,8,10

 

 

 

 

COMPLICATIONS

Overall complication rates for tibiotalocalcaneal fusion have been as high as 50% in some series.3,5 The most common complications include nonunion, malunion, infection, and neuroma. This correlates with the reported complication profile for tibiotalar arthrodesis.6,7,9

In patients undergoing tibiotalocalcaneal fusion (regardless of fixation technique), the nonunion rate ranges from 0% to 40%. This is most common when there is avascular necrosis of the talus. In this patient

population, the nonunion rate has been as high as 89%.5 Nonunion rates are also significantly higher in smokers and patients with neuroarthropathy (33% to 75%).4,5

74

 

FIG 3 • A-C. Postoperative radiographs showing healing. In this case, the talus was “replaced” with a carefully contoured femoral head allograft.

 

Superficial and deep wound infections can be minimized through the use of appropriate perioperative antibiotics, meticulous soft tissue handling, a layered wound closure, avoidance of hematoma formation, and postoperative elevation.

Peripheral neuroma of either the sural or superficial peroneal nerves can be minimized by careful incision placement and gentle retraction and soft tissue handling. In patients with neuroarthropathy, there is usually decreased if not absent distal sensation. In these patients, peripheral nerve injury is usually clinically insignificant.

 

REFERENCES

1. Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity. Foot Ankle Int 1994; 15:354-359.

    

    

2. Chiodo CP, Acevedo JI, Sammarco VJ, et al. Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: a biomechanical investigation. J Bone Joint Surg Am 2003;85-A(12):2425-2428.

    

    

3. Chou LB, Mann RA, Yaszay B, et al. Tibiotalocalcaneal arthrodesis. Foot Ankle Int 2000;21:804-808.

    

    

4. Cobb TK, Gabrielsen TA, Campbell DC II, et al. Cigarette smoking and nonunion after ankle arthrodesis. Foot Ankle Int 1994;15:64-67.

    

    

5. Cooper PS. Complications of ankle and tibiotalocalcaneal arthrodesis. Clin Orthop Relat Res 2001;(391):33-44.

    

    

6. Crosby LA, Yee TC, Formanek TS, et al. Complications following arthroscopic ankle arthrodesis. Foot Ankle Int 1996;17:340-342.

    

    

7. Frey C, Halikus NM, Vu-Rose T, et al. A review of ankle arthrodesis: predisposing factors to nonunion. Foot Ankle Int 1994;15: 581-584.

    

    

8. Hanson TW, Cracchiolo A III. The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle Int 2002;23:704-710.

    

    

9. Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg Am 1980;62(5):777-784.

    

    

10. Myerson MS, Alvarez RG, Lam PW. Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities. Foot Ankle Int 2000;21:643-650.

     

     

11. Papa JA, Myerson MS. Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthritis of the ankle and hindfoot. J Bone Joint Surg Am 1992;74(7):1042-1049.

     

     

12. Raikin SM, Myerson MS. A technique for harvesting bone graft for arthrodeses around the ankle. Foot Ankle Int 2000;21:778-779.