FOOT & ANKLE ORTHOPAEDIC PROCEDURES

Transcription

1 FOOT & ANKLE ORTHOPAEDIC FOOT & ANKLE PROCEDURES

2 FOREFOOT PROCEDURES PIP (Proximal Interphalangeal) Joint Fusion for Hammertoe and DIP (Distal Interphalangeal) Joint Fusion for Mallet Toe Metatarsal Shortening (Weil Osteotomy) for Metatarsalgia Medial Closing Wedge Osteotomy (Akin) for Hallux Valgus (Bunion) Correction Distal Chevron Osteotomy (Austin) for Hallux Valgus (Bunion) Correction Scarf Osteotomy for Hallux Valgus (Bunion) Correction Combination of Reconstructive Forefoot s 5th Metatarsal Rotational Osteotomy for Bunionette Correction Cheilectomy (1 st MTP) for Hallux Rigidus 1 st MTP Joint (MPJ) Fusion for Hallux Rigidus (or Hallux Valgus) 1 st MTP Hemi or Total Joint Replacement for Hallux Rigidus Jones Fracture ORIF for 5 th Metatarsal Fracture MIDFOOT PROCEDURES Midfoot Fusions (TMT, NC, TN, CC) for Arthritis Lisfranc Injury for Lisfranc Joint Dislocation or Fracture Lapidus for Hallux Valgus (Bunion) Correction Cotton Osteotomy (Plantarflexing Opening Wedge of the Medial Cuneiform) for Flatfoot Correction HINDFOOT PROCEDURES Triple Arthrodesis for Arthritis or Acquired Adult Flatfoot Subtalar Fusion for Arthritis Evans Osteotomy (Lateral Column Lengthening) for Flatfoot Correction Calcaneal Osteotomy for Flatfoot or High Arch Correction ANKLE PROCEDURES Ankle Fracture and Syndesmosis Repair Ankle Fusion for Arthritis Total Ankle Arthroplasty/Replacement (TAA/TAR) for Arthritis

3 FOOT & ANKLE FOREFOOT PROCEDURES

4 PIP (Proximal Interphalangeal) Joint Fusion for Hammertoe Correction Indication The PIP is the first joint of the small toes (digits 2 5). The indication for hammertoe surgery is when the PIP joint has a fixed curved deformity, caused by a contracture of the tendons (shortening), which leads to rigidity of the joint. A deformity producing enough pain or functional limitation may warrant surgery. The deformity develops gradually and cannot be straightened because it isbentandfixedinthispositionforalongperiodof time. The procedure essentially straightens the joint and fuses the proximal and middle phalanges in a straightened position. A deformity of the PIP (proximal interphalangeal) joint is called a Hammertoe. In the DIP (distal interphalangeal) joint, it s called Mallet Toe, and deformity of both the PIP and DIP joints is called Claw Toe. There are a variety of ways that a PIP joint fusion can be performed. The joint can be approached either through a longitudinal or transverse incision on the top of the toe. Once the joint is opened up, a small segment of bone is removed from either side of the joint, which creates enough room for the joint to straighten. The joint is then fixed in the straightened position, usually with a k wire, screw, or hammertoe implant. This procedure may be done in association with other procedures, such as a tendon transfer or tendon lengthening, to help keep the toe in the newly straightened position (e.g. Girdlestone Taylor procedure or Extensor Tendon Lengthening). Additional procedures to address underlying mechanical problems such as a gastrocnemius contracture or hypermobile first ray, which may have caused the small toe deformities, may be corrected in addition to the PIP joint fusion ) K WIRE 2) ARROW LOK 3) SMART TOE 4) PRO TOE

5 Metatarsal Shortening (Weil Osteotomy) A Weil metatarsal shortening osteotomy is performed to decrease pressure on a prominent metatarsal head in the forefoot. The metatarsal head is the portion of the metatarsal bone that articulates with the base of the toe. When the metatarsal is too long or is positioned in such a way that the associated metatarsal head is taking a disproportionate amount of weight, pain can occur. This source of pain in the forefoot is called metatarsalgia. A long or prominent metatarsal bone usually affects the second and, occasionally, the third metatarsal. It is often associated with a claw toe deformity of the involved toe. As the toe claws, it pulls forward the cushioned fat pad normally present in the forefoot, uncovering the metatarsal head and further exposing it to pressure. A Weil osteotomy is performed by making an incision over the base of the second (or other involved) toe. The surgeon exposes the distal aspect of the involved metatarsal, the metatarsal head and the neck. A saw is then used to cut the bone parallel to the sole of the foot. This allows the metatarsal head to be shifted backwards towards the heel, approximately 3 5 mm, though in some cases even farther. It is also possible to remove a small section (1 3 mm) of bone to help elevate the bone so that the metatarsal head is not as prominent. The metatarsal head fragment is then stabilized in the new position with one or two small screws. For speed and convenience, and because of the predictable length of screws needed, it is common for a surgeon to use a snap off or twist off screw. This is a special type of solid screw designed with a wire like shaft attached to the screw head, which allows it to be loaded directly into a wire driver and implanted quickly and easily. The shaft loaded into the wire driver snaps off when the screw head hits the proximal cortex, hence the name. Weil osteotomies are the most common indication for snap off screws. Weil Osteotomy Fixation with Snap Off Screw Weil Second Toe Shortened Above: Snap Off Screw. The most common use for this screw is for a Weil Osteotomy.

6 Medial Closing Wedge Osteotomy (Akin) for Hallux Valgus (Bunion) Correction An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx of the great toe (hallux) to correct hallux valgus deformity. However, because the procedure only corrects the proximal phalanx, and not the metatarsal (source of the bunion), it is the least powerful procedure, and is usually performed along with a distal chevron (Austin) or a scarf osteotomy procedure. Akin (Closing Wedge) Austin (Distal Chevron) Weil (Metatarsal Shortening) The procedure involves creating an osteotomy on the medial side of the proximal phalanx. Two cuts are made to remove a wedge of bone. The toe is shifted (closing the wedge) and fixed in this position with a small screw or a staple. Top: Screw fixation for various corrective osteotomies. Right: Akin using a nitinol staple for fixation. Most common application for staples.

7 Distal Chevron Osteotomy (Austin) for Hallux Valgus (Bunion) Correction A Chevron osteotomy is indicated for correction of mild to moderate hallux valgus deformity. This allows for a small reduction of the angle between the first and second metatarsal. It is ideal for bunions that are not particularly pronounced. It is frequently performed along with a medial closing wedge osteotomy (Akin) of the proximal phalanx. The procedure involves a V shaped cut (chevron) in the distal aspect of the first metatarsal, near the metatarsal head. This allows the distal aspect of the bone to be translated in the lateral direction (towards the outside of the foot). The cut bone is then fixed in this position, usually with one or two small screw. Any excess boney prominence on the inside of the foot (medial side) is then resected.

8 Scarf Osteotomy for Hallux Valgus (Bunion) Correction A scarf osteotomy is a type of procedure for hallux valgus (bunion deformity). The term scarf describes the shape of the osteotomy that the surgeon uses. It was popularized in Europe and the term originates from an architectural and carpentry term defined as: a joint made by notching, grooving, or otherwise cutting the ends of two pieces and fastening them together so that they lap over and join firmly into one continuous piece. The scarf osteotomy is preferred by some surgeons because it allows movement of the bone in a number of different planes. The bone segments can be rotated and translated, and can therefore be very versatile. The osteotomy involves a Z shaped cut in the first metatarsal which can then be moved and fixed in a new position, usually with two small screws. The excess bone on the inside of the foot (medial side) is then removed. The procedure to correct hallux valgus may also involves a release of the tight ligaments (lateral release) and tightening of the loose ligaments (medial plication) to balance the joint. Often another osteotomy called an Akin (medial closing wedge) is made in the proximal phalanx to complete the surgical correction. Scarf Lateral View Akin Scarf Weil

9 FOOT & ANKLE Combinations of Reconstructive Forefoot s Hammertoe Weil Bunion

10 5 th Metatarsal Rotational Osteotomy for Bunionette Correction Indication Arotational5 th metatarsal osteotomy (cutting and rotating the bone) is indicated for patients with a large, painful bunionette deformity (aka Tailor s Bunion) that has failed non operative management. The deformity is associated with an enlarged angle between the 4 th and 5 th metatarsal bones. A5 th metatarsal osteotomy is performed through an incision on the outside of the foot. The dissection is carried down to the bone. The outside of the bone is identified and an incomplete oblique cut is made ¾ of the way through the bone. A drill is then placed from top to bottom through the bone and a screw is positioned, but not tightened, in this hole. The remainder of the bone cut is then made. After the cut has been made, the far end (distal part) of the 5 th metatarsal is rotated inwards towards the 4 th metatarsal, reducing the deformity and allowing for the bunionette correction. The screw is then tightened to stabilize this position, which is reviewed under x ray. Withthebonerotated, thereis nowa prominentarea ofboneontheoutside (laterally). This is cut off and smoothed. The 5 th toe is then straightened up through the capsule on the outside of the base of the 5 th toe, allowing for improved positioning of this toe.

11 Cheilectomy (1 st MTP) for Hallux Rigidus A cheilectomy removes bone spurs (osteophytes) on the top surface (dorsal aspect) of the great toe joint bones. Bone spurs develop with arthritis (hallux rigidus) of the great toe, and spurs act as a mechanical block to motion, which causes pain. The goal of a cheilectomy is to relieve pain and restore range of motion. An incision is made over the top of the first metatarsophalangeal joint. Care is taken to avoid the tendon that extends the big toe. Any bone spurs are removed. If there is inflamed joint tissue or debris, these are removed as well. The cartilage on the joint surfaces is inspected. Approximately 30 percent of the top portions of the head of the metatarsal bone and corresponding bone spurs are removed. Bone spurs on 1 st MTP joint Cheilectomy to remove bone spurs Pain eliminated, restored range of motion

12 1 st MTP Joint (MPJ) Fusion for Hallux Rigidus (or Hallux Valgus) This procedure involves fusing the great toe joint (first MTP joint) together. The goal of surgery is to make the great joint solidly aligned and immobile. This relieves much of the pain since motion through the arthritic joint is eliminated. Great toe fusion is typically performed in patients who already have significant arthritis of the 1st MTP joint (late stage or severe hallux rigidus). It can also be successfully used, however, as a salvage procedure for patients with severe bunion deformities (hallux valgus). To fuse the great toe joint, any remaining cartilage on the arthritic joint surface is removed and the underlying bone is prepared for fusion, usually by using cup and cone reamers. The joint is positioned in a manner which maximizes walking ability and maintains acceptable clinical alignment. This is traditionally done with the toe positioned so that it just gently touches the ground in a weight bearing position (i.e degrees of dorsiflexion). The fused joint is typically fixated with two cross screws or a plate with screws. MTP Fusion Plate Cross Screws One Third Tubular Plate with Lag Screw MTP Fusion Plate

13 1 st MTP Hemi or Total Joint Replacement for Hallux Rigidus A first MTP joint replacement treats arthritis of the great toe (hallux rigidus). The joint is removed and replaced with a metal, plastic, or silicone implant. Implant options include total MTP joint replacements (which replace both sides of the joint) and hemi MTP joint replacements (which replace only one side of the joint either the metatarsal head or the base of the proximal phalanx). The primary goals are to relieve pain and to retain motion (unlike a fusion which eliminates motion of the joint). An incision is made over the first MTP joint and carried down to the join. The joint surface along with a small amount of bone is removed from the arthritic joint. Bone spurs are removed. The canals of the bones are then opened with a special pre drilled or reamer, and the implants are placed. The implants may screw into the shaft of the bone, or may be press fit (e.g. Morse taper). Potential complications include silicone synovitis when a silicone implant is used, as small particles of silicone may wear off. Other complications include implant loosening or displacement, instability of the joint. Hemi (Base of Proximal Phalanx) Hemi (Metatarsal Head) Total MTP Joint Replacement

14 Jones Fracture ORIF Due to a number of mechanical and biologic factors, patients with a base of 5 th metatarsal stress fracture (Jones fractures) are at risk of inadequate healing and re fracture of the bone in the same location. Patients with this injury where it does not adequately heal, or the fracture recurs, may benefit from stabilization of the fracture with a screw placed down the intramedullary canal (shaft) of the metatarsal. Highly active and athletic patients benefit from screw fixation after the injury to accelerate healing and rehabilitation and reduce the risk of refracture. The surgical procedure involves placing an appropriate sized screw, starting at the tip of the base of the 5 th metatarsal, and placing the screw within the bone across the fracture site. This is done by making a small incisionnearthebaseofthe5 th metatarsal. The tip of the 5 th metatarsal is identified on x ray (fluoroscopy). A drill is then used to enter the canal of the 5 th metatarsal, and then placed across the fracture site. This is done under fluoroscopy to ensure the screw is correctly positioned. A screw with an appropriate diameter and length is chosen. The diameter is typically mm and the screw is then positioned across the fracture site so as to stabilizes the bone and compresses the fracture to promote healing of the fracture. Typically a solid core screw is preferred, although some systems use a cannulated approach (instrumentation) before final fixation with a solid core screw. Jones Fracture Screw Fixation

15 FOOT & ANKLE MIDFOOT PROCEDURES

16 Midfoot Fusions (TMT, NC, TN, CC) A midfoot fusion is performed to treat midfoot arthritis. The procedure involves fusion of one or more of the first three tarsometatarsal (TMT) joints. The second TMT joint is most commonly involved, but the first and third may also be affected by arthritis. Typically the 4 th and 5 th TMT joints are not fused, as these joints have more motion than the 1 st,2 nd,or3 rd TMT joints. Other common midfoot fusions include Naviculocuneiform (NC) fusions,talonavicular (TN) fusions, and Calcaneocuboid (CC) fusions, and Intercuneiform fusions. TMT Fusion Plate Fusion of any of these joints begins with removing any remaining cartilage between them. To access the joint for preparation, a special joint distractor or pin distractor, or a lamina spreader may be used. After the joint space is prepared, the bones are stabilized with screws or plates. To help aid in the fusion, bone graft may be used in some instances. These procedure essentially turns a painful, stiff, arthritic joint into a painless, fused joint. Talonavicular (TN) Fusion Naviculocuneiform (NC) Fusion

17 Lisfranc Injury FOOT & ANKLE Indication The Lisfranc joints are located in the midfoot. The main indication for this ORIF of the Lisfranc joints is a displaced or unstable Lisfranc fracture, or a dislocation. The purpose of the surgery is to reposition the bones andjointsinthemid part of the foot, allowing the associated torn ligaments (the strong tissues that hold these bones together and support the arch) to heal. The location of the incision is dictated by both the location of the fracture and the location of the joints that are disrupted. If all five of the Lisfranc joints are disrupted, then two or three incisions on the top of the foot may be needed; one on the top inside and inside border of the foot, and one on the top outside of the foot. If the first three tarsometatarsal (TMT) joints are disrupted, then only one or two incisions are made on the top and/or inside aspect of the foot. Once the disrupted tarsometatarsal joints are identified, the dissection is carried down to the involved joints and the debris is cleaned out. The disrupted joints are repositioned back to the position they were in prior to the injury. The joints are then fixed with strong screws. However, if the fragmentation is excessive, a plate may be required. One exception is a disruption of the 4 th and 5 th tarsometatarsal joints; in this case, the bone is provisionally fixed with wires. The wires are then removed after about six weeks so that some movement of these joints can be encouraged. Lisfranc surgery with TMT plates Lisfranc surgery with screws

18 Lapidus for Hallux Valgus (Bunion) Correction The Lapidus procedure is used to correct a moderate to severe hallux valgus deformity. It is also indicated for hallux valgus associated with a hypermobility of the first ray. The procedure involves an incision over the dorsomedial (top and inside) part of the midfoot. The first tarsometatarsal (TMT) joint is exposed. This joint is then prepared for fusion. In the context of fusing this joint, the angle between the first and second metatarsal is decreased. This joint is then typically fused with two screws or a plate. In addition, the bunion is corrected through a medial incision over the great toe, which allows the joint capsule to be tightened, as well as the prominent medial bone associated with the bunion to be removed. It is often necessary to perform a release of the tightened structures on the lateral (outside) part of the great toe joint. Lapidus Plate Cross Screws

19 Cotton Osteotomy (Plantarflexing Opening Wedge of the Medial Cuneiform) for Flatfoot Correction A Cotton Osteotomy is a procedure where the surgeon makes an osteotomy and an opening wedge in the dorsal aspect of the medial cuneiform. The procedure is performed to correct flatfoot deformities, usually in children and young adults. It works by plantarflexing (flexing downwards) the medial column, which are the bones along the inside of the foot). Doing this restores the arch of the foot. The procedure may be done in conjunction with other flatfoot procedures, such as an Evans Osteotomy or a Medial Displacement Calcaneal Osteotomy (also known as an MDCO or Calc Slide ). The osteotomy is made directly across (transverse) the dorsal aspect of the medial cuneiform and then spread open so that a wedge can be inserted, restore the arch of the foot. Various wedge options are available for this procedure. The surgeon may take a bone graft wedge from the patient s own body (autograft). Alternatively, an allograft bone wedge can be used, either pre shaped to perfectly fit the osteotomy, or an allograft ilium tricortical wedge where the surgeon must cut the graft to size. The surgeon may choose to use a specific Cotton plate with a built in titanium wedge. Newer wedge implants made from porous titanium or PEEK are also available. The wedge is usually between 4 7 mm in width, and may be secured with ancillary fixation to hold it in place (screws, staples, or a plate). Wedge being inserted into medial cuneiform Cotton Pre Shaped Allograft Bone Wedge Cotton Titanium Wedge

20 FOOT & ANKLE HINDFOOT PROCEDURES

21 Triple Arthrodesis for Arthritis or Acquired Adult Flatfoot Triple arthrodesis is indicated for patients who have a deformity of the hindfoot, such as acquired adult flatfoot deformity, where there is arthritis or stiffness in the involved joints. This type of procedure sometimes offers a more reliable result than other hindfoot corrective procedures. Because of the importance of preserving all the joints in the foot, this procedure is done a lot less often than it used to be. However, if there is enough arthritis or dysfunction in the involved joints where preservation is improbable, then a triple arthrodesis may be effective. TN Joint Subtalar Joint This surgical procedure involves the fusion of three joints: the talonavicular (TN) joint, the subtalar joint, and the calcaneal cuboid(cc)joint. Twoincisionsaremadeonbothsidesofthefoot;oneismadeontheinside (medial) to expose the talonavicular joint, and the other is made on the outside to expose the subtalar joint, the calcaneal cuboid joint, and the outside (lateral) aspect of the talonavicular joint. Once exposed, all of the remaining cartilage from the joints is removed and prepared for fusion. Typically, the joint is then packed with bone graft, either from other bones, such as the proximal tibia or the iliac crest, or using allograft. Once all the joints have been prepared and the bone graft has been placed, the hindfoot position is corrected to a neutral position. Once repositioned, the foot is first provisionally fixed with wires, and then definitively fixed with screws or plates in each joint. Once everything is in place, the incisions are closed up with sutures. TN Joint CC Joint CC Joint Subtalar Joint

22 Subtalar Fusion for Arthritis The main indication for a subtalar fusion is to treat painful arthritis in the subtalar joint (the large joint above the heel bone and below the ankle). Arthritis in this joint is commonly seen after heel bone fractures or joint dislocations. Another indication for a subtalar arthrodesis is for patients who need the change to position of the hindfoot in order to distribute load more evenly. For example, a patient with acquired flatfoot deformity, a condition where the heel is offset and load is unevenly distributed, might consider a subtalar fusion. On the lateral (outside front) region of the ankle, a cut is made down to the subtalar joint to expose the joint, particularly the larger posterior portion of the joint, or facet. Once exposed, the joint is ready for fusion. First, the cartilage, or what is left of the cartilage, is removed between the heel bone and the talus. Next, the bone is shaveddowntoapointthatcanfuse. Thejointisthenplacedinitsdesiredpositionandsecuredwithlarge screws. To increase the chance of the joint fusing together, bone graft is sometimes used. 6.5mm Headless / 7.0mm Headed Cannulated Screws

23 Lateral Column Lengthening (Evans Osteotomy) for Flatfoot Correction A lateral column lengthening procedure (Evans Osteotomy) is indicated for patients with acquired adult flatfoot deformity, where the front part of the foot is splayed out to the side. This procedure is often combined with a medializing calcaneal osteotomy, (often referred to as the All American procedure ), as a technique for adjusting acquired adult flatfoot deformity. The lateral column is made up of the calcaneus, the cuboid, and the fourth and fifth metatarsals. Therefore, the lateral column lengthening procedure involves lengthening this region. There are two general ways of doing a lateral column lengthening, both of which involve inserting a wedge into the lateral column. One way of performing this procedure is by cutting the bone through the front part of the calcaneus. The osteotomy is made right before the calcaneal cuboid joint, which is then spread about 7 10 mm so that a wedge can be inserted, in order to lengthen the column. Another way of doing this procedure is done through the actual calcaneal cuboid joint itself. A bone graft wedge is inserted in the joint, which serves as a joint fusion while also lengthening the lateral column. Various wedge options are available for this procedure. The surgeon may take a bone graft wedge from the patient s own body (autograft). This wedge comes from the patient s iliac crest which is at the top of the pelvis. Alternatively, an allograft bone wedge can be used, either pre shaped to perfectly fit the osteotomy, or an allograft ilium tricortical wedge where the surgeon must cut the graft to size. The surgeon may choose to use a specific Evans plate with a built in titanium wedge. Newer wedge implants made from porous titanium or PEEK are also available. The wedge is usually between 6 12mm in width, and may be secured with ancillary fixation to hold it in place (screws, staples, or a plate). A lateral column lengthening procedure is a very powerful procedure, since it can dramatically change the shape of the foot. The advantages of this procedure include the ability to take a pronounced flatfoot deformity and turn it into a near normal looking foot. However, the disadvantages include the potential of creating a stiffer foot; possibly overcorrecting the foot (which may lead to more symptoms); and a higher rate of specific complications, such as painful hardware, sural nerve irritation, and nonunion. Evans Osteotomy Wedge Plate Evans Plate with Built in Wedge Evans Pre Shaped Allograft Bone Wedge Evans Titanium Wedge

24 Calcaneal Osteotomy for Flatfoot or High Arch Correction A calcaneal osteotomy comprises cutting the heel bone and shifting it medially or laterally. A calcaneal osteotomy is indicated for patients whose hindfoot alignment is significantly offset and for whom non operative management has failed. Alignment of the heel influences how weight bearing stress is applied to the foot, ankle, knee and hip. Depending on which way the hindfoot is offset, the heel (calcaneus) may be shifted towards the midline of the body (medializing calcaneal osteotomy), or away from the midline of the body (lateralizing calcaneal osteotomy). For example, a patient with acquired adult flatfoot deformity will often have the heel offset to the outside and may benefit from a medializing calcaneal osteotomy to shift the hindfoot to the inside and change the way load is distributed through the heel. On the other hand, a patient with a high arched foot (cavus foot pattern) often has a heel that is offset to the inside. Individuals with a high arched foot may have symptoms ranging from pain along the lateral or outside half of the foot, to wearing out of the inside (medial) portion of the ankle joint. With this structural alignment, individuals are predisposed to sprain their ankle and may develop ankle instability. In severe forms of ankle instability, a lateralizing calcaneal osteotomy may be beneficial. MDCO (Calc Slide) Plate An oblique incision is made on the outside region of the heel. One precaution while exposing the bone is to avoid cutting or injuring the sural nerve which provides sensation to the outside part of the foot. Once exposed, the back part of the heel bone is cut (osteotomy) into two pieces. The back part of the bone is then either shifted medially or laterally. The bone is shifted between 5 12mm. After the bone is shifted, it is fixed in place usually with one or two large screws or a plate. Any sharp bone edges are smoothed out before closing.

25 FOOT & ANKLE ANKLE PROCEDURES

26 Ankle Fracture and Syndesmosis Repair The upper part of the ankle joint comes from the tibia and the fibula. The tibia forms the front, rear and inner part of the ankle joint. The lower fibula forms the outer part of the ankle joint. The rounded ends of these bones are called malleoli (singular is malleolus). There are two malleoli on the tibia (medial and posterior) and one on the fibula (lateral). Ankle fractures occur when the malleoli are broken. These fractures are very common. Ankle fractures can happen after falls, car accidents or twisting of the ankle. One, two or all three malleoli can be broken. In addition to ankle fractures, injury to the syndesmosis is also common. The syndesmosis is the joint just above the ankle where the tibia and fibula. Although the syndesmosis is technically a joint, there is very little motion between these bones. The main function is to provide stability to the ankle joint and allow motion of the ankle joint. The syndesmosis may become injured with a twisting or rotational injury to the ankle. It is commonly referred to as a high ankle sprain. Distal Fibula Fracture Medial Malleolus Fracture Most ankle fracture surgery involves open reduction and internal fixation (ORIF). An incision is made over the ankle to see the fractured bones. Like a jigsaw puzzle, the pieces of the broken bones are placed back together (open reduction). The broken bones are then held together (internal fixation) in this correct position with metal plates and/or screws. This internal fixation provides stability so movement can begin shortly after surgery as the ankle fracture heals. Plates and screws used to fix an ankle fracture are not removed as long as they are not causing problems. In the case of injury to the syndesmosis, the surgeon will insert one or two screws that go from the fibula into the tibia. The screws may be placed through a plate that sits on the fibula bone. Alternatively, a suture device, like the Arthrex TightRope product, may be used. Distal Fibula (Lateral) Ankle Fractures Left: Arthrex plate with TightRope Right: Synthes plate with syndesmosis screws

27 Ankle Fusion for Arthritis The goal of ankle arthrodesis (ankle fusion) is to relieve pain and maintain or improve function for a patient with ankle arthritis. Ankle arthritis is degeneration of the cartilage that covers the ends of the bones that form the ankle joint. These bones are the tibia, fibula, and talus. Pain typically is made worse with movement of the arthritic ankle. The goal of ankle arthrodesis is to take the ankle bones and fuse them into one bone. This eliminates motion and reduces pain from the arthritic joint. Ankle arthrodesis may be performed through an incision on the outside of the ankle or the front of the ankle. Sometimes a bone graft may be used to aid in fusion. This graft may be taken from the patient s own body (pelvis, heel bone or just below the knee) which is called autograft. Or, allograft DBM bone putty or bone sponge strips may be used. Ankle arthrodesis may be performed through small incisions that allow a camera and tools to be placed into the joint. This is known as arthroscopic surgery. After the joint has been accessed, instruments are used to scrape away remaining cartilage and the joint surface is prepared for fusion. Screws or plates may be used to hold the ankle in the correct position for fusion. If a patient is having his subtalar joint fused at the same time, a nail (a tubular metal implant that goes up into the canal of the bone) may be used to hold the joints in position. The choice of approach and hardware depends on a patient s specific anatomy, condition and the surgeon s preference Ankle Fusion Implant Options 1) Large cannulated screws 2) TTC (Tibiotalocalcaneal ) Nail 3) TTC (Tibiotalocalcaneal ) Anterolateral Plate

28 Total Ankle Arthroplasty/Replacement (TAA/TAR) for Arthritis Total ankle arthroplasty (TAA), also known as total ankle replacement (TAR), is a surgical procedure that treats severe ankle arthritis. Arthritic changes may be a result of normal wear and tear due to aging, or from an injury such as a broken ankle or dislocation. Arthritis eventually leads to loss of cartilage, pain and/or deformity. The goal of an ankle replacement is to improve ankle motion so the patient has less pain during activity. The ankle is approached from the front or the side depending on the type of implant being used. Bone is then cut, allowing for placement of the metal and plastic components that re create the ankle joint. Sometimes the patient will have a tight calf muscle or tight Achilles tendon that needs to be lengthened to improve range of motion of the ankle. Either before or after the ankle replacement is put in place, the surgeon will determine if the calf muscle or Achilles is tight. A tight calf muscle or Achilles tendon is addressed with a lengthening procedure. This is important to improve motion after the surgery, as well as to take stress off the ankle replacement. SALTO TALARIS TOTAL ANKLE Acquired by Integra from Tornier following Wright/Tornier Merger STAR TOTAL ANKLE Scandinavian Total Ankle Replacement. Acquired by Stryker from SBi (Small Bone Innovations) TRABECULAR METAL TOTAL ANKLE Zimmer INFINITY TOTAL ANKLE Wright Medical INBONE TOTAL ANKLE Wright Medical