Transfibular Approach Research Articles

The Modified Use of a Proximal Humeral Locking Plate for Tibiotalocalcaneal Arthrodesis

Different types of fixation have been used to achieve a tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to retrospectively examine the modified use of a 3.5-mm proximal humeral locking plate (PHILOS plate, Synthes, Paoli, PA) in obtaining a TTC fusion. Between April, 2003, and November, 2005, 17 patients had 18 TTC arthrodeses with a PHILOS plate through a transfibular approach. Preoperative diagnoses included Charcot arthropathy, neuromuscular disease, arthritis, and talar osteonecrosis. Patients were followed from 8 months to 3 years and 2 months (mean 20.6 months). Fusion was achieved in 16 of the 17 patients (94.1%) and 17 of the 18 arthrodeses (94.4%) with a mean time to fusion of 20.6 weeks. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 14.6 of 100 preoperatively to 76.7 of 86 (equivocal to 89.2 of 100) at final followup. One patient who had brittle diabetes went on to develop a nonunion. The patients in this study had a wide variety of medical conditions that left their bone osteopenic or osteoporotic. This study demonstrated that using a modified locking plate for a TTC arthrodesis results in a high rate of bony union and alignment correction stability. The locking plate provides fixation by acting as a fixed angle device, with the locking screws providing multiplanar fixation. The use of a locking plate has not been previously reported, and it may hold promise as a means of achieving a TTC fusion.

Management of the foot in rheumatoid arthritis

Rheumatoid arthritis is an autoimmune-mediated, systemic, inflammatory disease which is chronic and progressive in nature. It is the most common form of inflammatory arthritis and affects 1% of men and 3% of women. Diagnostic criteria, as defined by the American Rheumatism Association, are morning

The medial malleolar approach for arthrodesis of the ankle: A report of 13 cases

A series of thirteen patients that had primary fusion of the ankle joint through an isolated medial approach is presented. The technique involves transection of the medial malleolus for access to the articular surfaces, rather than the traditional transfibular approach. The medial malleolus was replaced in all cases, preserving the deltoid ligament. Union was achieved in 12 of 13 patients. The technique is described in detail and the advantages of this approach are discussed with respect to preservation of the blood supply to the talus and tibia.

足関節固定術の臨床成績

The clinical results of ankle arthrodesis are reviewed. From April 1990 to April 2002, we performed ankle arthrodesis on seven patients. Operations were performed on five patients with rheumatoid arthritis and two patients with osteoarthritis. All arthrodeses were performed by the transfibular approach. The mean follow-up period was 3.8 years. Clinical evaluation was assessed using the Japanese Orthopaedic Assosiation (JOA) scoring system. Both pain and gait scores after the operation markedly improved, and all patients were satisfied with the results. There was no nonunion case. Ankle arthrodesis with transfibular approach is an effective operation in patients with rheumatoid arthritis or osteoarthritis.

Transfibular Ankle Fusion Technique

Research and development of total ankle replacement is a rapidly expanding field, but ankle fusion remains the “gold standard” in the treatment of ankle arthritis. The transfibular approach is one of the most popular techniques in clinical practice. It offers the advantages of excellent exposure, the ability to minimize wound problems by developing full thickness flaps, and the availability of the distal fibula for local bone graft. Either internal or external fixation may be used, and it has been shown to have a high rate of fusion with low complication rates. With proper alignment of the fusion, the long-term results have shown 80–100% success rate. Long-term studies have raised questions about development of osteoarthritis in adjacent joints (Saltzman) and this has stimulated more research into the field of joint arthroplasty.

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.

Ankle and Tibitalocalcaneal Arthrodesis using Lateral Malleolus as Bone Graft

A variety of surgical approaches and bone grafting techniques for ankle and tibiotalocalcaneal arthrodesis have been described. We used transfibular approach and lateral malleolus was used for bone graft. This permitted excellent visualization of the ankle and subtalar joint so that the fusion can readily be achieved under the direct visualization. And also we didn’t need to prepare the additional bone graft from another site. Ten ankle fusions and two tibiotalocalcaneal fusions were carried out and reviewed. The average age of the patients was 43 years(range, 27 58 years). The average follow-up was 27.8 months(range, 24 34 months). We evaluated the clinical and radiological results, and complications. All cases were satisfied and fused. But we experienced one minor complication that was posteroplantar heel pain caused by prominence of cannulated screw head. So, we suggest that this procedure has benefit for ankle or tibiotalocalcaneal fusion.

Arthrodesis of the ankle: a critical analysis.

Arthrodeses of 81 ankles performed by a single surgeon were reviewed after a 12- to 74-month follow up. Average time to union was 13.8 weeks, and 71 (88%) of 81 ankles healed without a second surgery. Ten (12%) of the 81 ankles failed to unite. Of the 10 nonunions, two developed a dense fibrous union without screw failure, and eight underwent revisional surgery. Seven of the revisions united and one has a persistent nonunion. The transfibular approach was utilized, and specific factors related to this approach were assessed. A greater resection of the medial malleolus correlated to a longer healing time and to an increased rate of nonunion. Sixty (96%) of the 63 patients who returned for follow up had no signs or symptoms attributable to malalignment. The average postoperative score for ankle-hindfoot on the AOFAS evaluation was 74 points, and rate of the patient satisfaction was 65 (89%) of the 73 patients. There was no correlation between outcomes and patients ages. Greater tarsal mobility correlated with a higher postoperative score and to higher level of satisfaction.

EXTENSILE POSTERIOR APPROACH TO THE ANKLE

Surgical exposure of the ankle is usually obtained by an anterior approach, especially for replacement arthroplasty. The transfibular approach has been popular for arthrodesis. We describe a new posterior approach to the ankle and posterior subtalar joint based on an extra-articular vertical calcaneal osteotomy behind the subtalar joint. The posterior flap so formed is hinged medially and offers wide exposure of the back of the ankle and posterior subtalar joint. This hinge allows safe and stable reduction of the osteotomised calcaneum, and the plane of dissection follows an 'internervous plane' behind the fibula. We have had good results after using this incision in 12 patients with osteoarthritis or rheumatoid arthritis and there have been no difficulties with wound healing.

経ひ骨的足関節固定術の術後成績

The transfibular approach for ankle arthrodesis has been adopted as the standard procedure at our hospital. Clinical and x-ray evaluation was carried out in a follow-up study of 28 cases (8 males and 20 females).(1) Solid fusion was achieved in all cases, but 16 cases (57.1%) complained of mild pain in the hind part of the foot.(2) Increase of tarsal motion carrelated with improvement of A. D. L.(3) The functional clinical result was judged to be good to excellentin 89.3%.

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.

ARTHRODESIS OF THE ANKLE JOINT

The technique of the transfibular approach for arthrodesis of the ankle joint is described. The results of this operation in a series of thirty cases shows that the procedure is reliable if the technique is carried out faithfully. The two cases in which a first operation failed can both be explained by errors of technique or after-treatment.

The use of the transfibular approach in arthrodesis of the ankle joint

FIG. I. IIIustrating the use of the transfibutar approach to the ankle jomt, during panarthrodesis of the foot. The fibuIa has been osteotomized in its Iower portion and the distat fragment has been reffected IateraIIy. The subastragaIar and midtarsal joints have been exposed through the same incision. The medial haIf of the reflected fibuIar fragment has been transplanted to bridge the anterior surface of the ankIe joint, while bone chips have been introduced between the denuded articuIar surfaces. Upon cIosure, the IateraI fibuIar fragment wiI1 be restored to its original position, where it will contact the denuded IateraI surfaces of the tibia and astragahls.