Lateral Transfibular Approach Research Articles

Aseptic loosening of total ankle replacement : One-stage revision ankle arthroplasty

To revise one or both loosened prosthesis components, to achieve postoperative pain relief, and preserve ankle range of motion. Aseptic loosening of the tibial and/or talar ankle prosthesis components without substantial bone defect of the tibial or talar bone stock. General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g. Charcot arthropathy), substantial nonreconstructable osseous defects with or without cysts on the tibial and/or talar side, non-compliance, patients with primary total ankle replacement (TAR) using intramedullary fixation (stem fixation), patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking, unrealistic patient expectations, patients with high activity in sports. Exposure of the ankle joint using the previous incision (anterior or lateral transfibular approach). Mobilization and removal of loosened prosthesis component. Careful debridement of bone stock at bone-prosthesis interface. Determination of prosthesis component size. Implantation of definitive prosthesis components. Wound closure in layers. Asoft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts at postoperative day1 with 15 kg partial weight bearing using astabilizing walking boot or cast for 6weeks. Following clinical and radiographic follow-up at 6weeks, full weight bearing is initiated gradually. Between January 2007 and December 2012 aone-stage revision TAR was performed in 14patients with amean age of 52.7± 12.0years (29.8-70.5years). The indication for revision surgery was aseptic loosening of one or both prosthesis components. The mean time between the initial TAR and revision surgery was 5.9± 2.9years (2.0-11.5years). In 2patients atibiotalocalcaneal arthrodesis was performed due to painful aseptic loosening of revision TAR. In all patients asignificant pain relief was observed.

Total ankle replacement through a lateral approach: surgical tips.

Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs. Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months. Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively. Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer’s surgical technique guidance for surgeons who utilize these implants.

Ankle arthrodesis from lateral transfibular approach: analysis of treatment results of 23 feet treated by the modified Mann's technique.

The aim of the study was to analyze the results of treatment by ankle arthrodesis by modified Mann's technique. The study included 23 patients, and a total of 23 feet were treated. Stabilization of arthrodesis was performed by two screws going from the sinus tarsi to the talus and tibia. Lateral part of the fibula was fixed with one or two screws to the talus and tibia. No additional medial approach to the ankle was performed. In 16 feet, arthrodesis was done due to secondary posttraumatic osteoarthritis, in five due to paralytic drop foot and in two due to osteoarthritis of unknown etiology. In 18 patients, the purpose of arthrodesis was also to correct the malalignment. The average age at operation was 46 (range 19-74) years. The average follow-up was 32 (range 12-69) months. At follow-up, the average AOFAS score was 76 points and subjective scale result 7.9 points. The correct alignment was not achieved in three feet. In one foot, fusion was not achieved and the patient needed repeated operation. The study has confirmed the effectiveness of the technique.

Anatomical Evaluation of Different Approaches for Tibiotalocalcaneal Arthrodesis

The transfibular approach is commonly used for tibiotalocalcaneal arthrodesis. However, the medial and the posterolateral approaches are available as alternatives. The present study was performed to assess the effects of the 3 approaches on the neurovascular structures encountered and to quantify the extent of cartilage in the different joint compartments that could be surgically debrided. This cadaver study was performed in 6 pairs of formalin-fixed legs (mean donor age: 80 years; 4 females, 2 males). For each approach, 4 specimens were selected. The neurovascular structures at risk and the debrided portions of the articular cartilage were compared. Arterial structures were least compromised by the transfibular approach. The posterolateral approach was particularly likely to damage the lateral malleolar branches of the peroneal artery. Venous structures were at risk mainly from the medial approach, which was also the most risk-bearing of the 3 approaches in terms of nerve damage. The proportions of cartilage-debrided joint surfaces of the tibia in the ankle joint, and of the talus and the calcaneus in the subtalar joint, did not differ notably. The proportions of debrided surfaces of the talus in the ankle joint differed notably among the 3 approaches. The medial approach could be a valid alternative to the lateral transfibular approach for tibiotalocalcaneal arthrodesis. Care should be taken, however, to prevent damage to the saphenous nerve and other neurological structures. Access morbidity and feasibility of adequate cartilage debridement are relevant to the clinical outcome of hindfoot arthrodesis.

Ankle Fusion in Patients With Hindfoot Arthritis

It is not rare for a patient to have disease of the ankle and one or more hindfoot joints. Arthritic degeneration is commonly seen as a late result of trauma, while major deformity may develop with neuromuscular disorders. When symptoms no longer respond to nonoperative measures, combined fusion of the ankle and hindfoot joints is often a good option. The goal of such surgery is to restore alignment and relieve pain. The multiply fused foot is far inferior to the normal condition, with stiffness and varying degrees of aching almost universal. Surgery is usually performed through a lateral transfibular approach. Alignment in the ankle, hindfoot, and forefoot must be precisely restored. Then rigid internal fixation with lag screws maintains the position until fusions have healed. Finally, muscle balance must be restored to prevent the development of deformity in the remaining joints. With good technique, high rates of union and patient satisfaction can be achieved. However, distal joint degeneration can be expected in long-term follow up. For this reason, we have begun performing total ankle replacement in extremities with multiple fusions.

Arthrodesis of the Ankle Joint with Rheumatoid Arthritis

There are man methods of ankle joint arthrodesis, but nearly all are used for treatment of posttraumatic talocrural joint arthritis. Relatively few case reports of ankle arthrodesis are found in the literature on rheumatoid arthritis. The transfibular approach is remarkably effective for the fusion of talocrural joints destroyed and deformed by rheumatoid arthritis. In nine cases, the overall results were excellent in six and good in three. A sliding inlay graft in one case also produced a good result. Because patients with rheumatoid arthritis have osteoporosis caused by steroid therapy or its disuse, and some vascular disease, compression arthrodesis is unsafe. Moreover, the lateral transfibular approach provides better surgical exposure as well as protecting fragile rheumatoid tendons, vessels and nerves.

Complications and long-term results of ankle arthrodeses following trauma.

A review of sixty patients who had undergone ankle fusion for post-traumatic arthritis revealed that thirty-five (58 per cent) had the procedure performed within the first year after injury. A total of forty-eight complications occurred in twenty-nine (48 per cent) of the patients. Frequent complication were infection (23 per cent), non-union (23 per cent), inadequate surgical alignment or early loss of position (15 per cent), malunion (12 per cent), and delayed union (7 per cent). The lateral transfibular approach had the highest incidence of complications, and a two-incision approach using the Charnley compression apparatus was the procedure with the fewest complications. Forty-one patients were followed for an average of 7.5 years after operation. Of these, thirty-four (83 per cent) were satisfied with the procedure. Examination of thirty of the forty-one patients at an average of 7.3 years after surgery revealed virtually no subtalar motion but motion of 13 degrees at Chopart's joint. With shoes, patients had a near-normal gait. The roentgenograms revealed a minimum amount of degenerative arthritis at Chopart's joint, which may worsen with time. Varus or valgus angulation of the hind part of the foot was associated with a greater degree of symptoms in the subtalar area as well as the middle of the foot. The neutral position in varus-valgus angulation as well as dorsiflexion-plantar flexion was the optimum position for both men and women. The results of the procedure did not deteriorate with time.

Arthrodesis of the Ankle Joint with Complete Removal of the Distal Part of the Fibula

In 20 patients the following 3 techniques have been used for ankle fusion, all with a lateral transfibular approach: (1) fibular grafting; (2) lateral removal of the distal fibula and fixation with 3 Blount staples; (3) removal of the distal fibular and fixation with Charnley compression clamps. The compression technique, through a lateral approach, was found to be superior as it avoids section of tendons. Removal of the distal portion of the fibular eliminates the risk of drainage and problems with wound healing due to the presence of a large bone graft immediately underneath the skin. Fusion is obtained more rapidly with the third than the first and second techniques. Pain seems to be related to osteoarthritis of the surrounding joints. The gait pattern depends not only on pain, but also on the position of the foot and on the posterior displacement of the talus. Less osteoarthritis as a result of shorter immoblizaition is the most favorable factor, notwithstanding the longer preoperative period in the third than in the first two methods.