OBJECTIVES: DISCLOSURES: NONE NEW APPROACHES TO ANKLE ARTHRODESIS: CURRENT INDICATIONS FOR ANKLE ARTHRODESIS. Surgical Technicalities

Transcription

1 NEW APPROACHES TO ANKLE ARTHRODESIS: CURRENT INDICATIONS FOR ANKLE ARTHRODESIS Christopher W. Hodgkins, M.D. Miami Orthopaedics and Sports Medicine VUMEDI MARCH 22 ND The best place to be your best. DISCLOSURES: NONE 2 The best place to be your best. OBJECTIVES: Indications for ankle arthrodesis Surgical Approaches Fixation Techniques Surgical Technicalities 3 The best place to be your best. 1

2 INDICATIONS 4 The best place to be your best. INDICATIONS: Failed non surgical management of ankle arthritis: Post traumatic Inflammatory Primary osteoarthritis Chronic ankle instability AVN of the talus Post infection Neuropathic Salvage for failed ORIF or Ankle Arthroplasty Correction of deformity 5 The best place to be your best. CONTRAINDICATIONS: Limited Soft tissue/vascular issues Active infection Adjacent arthrodesis (arthroplasty) 6 The best place to be your best. 2

3 NON SURGICAL MANAGEMENT: Weight loss Activity modification Bracing/immobilization NSAID s Physical Therapy Intra articular corticosteroid injections 7 The best place to be your best. SURGICAL OPTIONS 8 The best place to be your best. SURGICAL OPTIONS: Supra-malleolar osteotmies Distraction arthroplasty Ankle arthrodesis Ankle arthroplasty 9 The best place to be your best. 3

4 SURGICAL APPROACHES 10 The best place to be your best. SURGICAL APPROACHES: Anterior Lateral transfibular/fib sparing Posterior Mini Arthrotomy Arthroscopic 11 The best place to be your best. ANTERIOR APPROACH: Interval between TA and EHL Easy positioning Fibula sparing Good access to both medial and lateral gutters Allows anterior plate augmentation Utilitarian incision, allows for later conversion to TAA 12 The best place to be your best. 4

5 LATERAL APPROACH: Frequently uses prior incisions (often location of pathology) Better access to entire joint (anterior to posterior) Easier for deformity correction (+/-) Fibula can be utilized as graft Sacrifices fibula -decreases surface area for fusion -can allow valgus drift in delayed union -makes conversion to TAA more difficult Complicates conversion to TAA 13 The best place to be your best. POSTERIOR APPROACH: Less common Can be useful in revisions, particularly if poor soft tissue anteriorly/laterally Visualization less optimaland deformity correction more difficult Orientation takes getting used to, not a big fan of doing anything upside down 14 The best place to be your best. MINI ARTHROTOMY: 2 small incisions Useful when soft tissue is compromised Visualization somewhat more limited Deformity correction can be more difficult 15 The best place to be your best. 5

6 ARTHRSCOPIC: Can be very useful when soft tissue envelope/vascular status precludes open approach More technically demanding Deformity correction can be more difficult 16 The best place to be your best. FIXATION TECHNIQUES 17 The best place to be your best. FIXATION TECHNIQUES: CROSS SCREWS +/- PLATE AUGMENTATION LATERAL PLATE POSTERIOR PLATE INTRAMEDUALLRY NAIL EXTERNAL FIXATORS 18 The best place to be your best. 6

7 SCREWS: Large Cannulated screws Many configurations Positioning requires attention to avoid each other Alone: less stable construct Anterior plate: Increases stability Contour a simple recon plate Anatomic contoured plates on the market 19 The best place to be your best. INTRAMEDUALLRY NAILS: Load sharing device with improved bending stiffness and rotational stability compared to plate and screw constructs Addresses both ankle and subtalar joint pathology 20 The best place to be your best. EXTERNAL FIXATORS: Useful in cases with history of infection Poor soft tissue Non compliance Complex revision/salvage cases 21 The best place to be your best. 7

8 TECHNICALITIES 22 The best place to be your best. SURGICAL PEARLS: POSITION: NEUTRAL DORSIFLEXION 5-10 DEGREES EXTERNAL ROTATION 5 DEGRESS HINDFOOT VALGUS METICULOUS JOINT PREPARATION RIGID INTERNAL FIXATION WITH JOINT COMPRESSION 23 The best place to be your best. THANK YOU 24 The best place to be your best. 8

9 Arthroscopic ankle fusion Dr. Alastair Younger, Vancouver, Canada. Professor, Department of Orthopaedics, University of British Columbia, Conflict of interest Consultant: Acumed, Wright medical, Cartiva, Zimmer Institutional support: BioMimetic; Wright Medical Technology, Inc.; Synthes; Integra Foundation; Carticept; Smith and Nephew; Bioset; Zimmer, Amniox, Acumed Medical associations: AOFAS, COA Reviewer: JBJS A and B, FAI, CJS, CORR Summary Less pain Less swelling Less wound complications Shorter stay or daycare Less cost Less clinic visits after surgery Better outcomes at 2 and 4.5 years 1

10 Complications to avoid Wounds Arthroscopic ankle arthrodesis You can do this.. Fixation Large fragment screws Cannulated Solid Retrograde nail 2

11 Prospective Comparison of Open and Arthroscopic Ankle Arthrodesis using Validated Outcomes M Di Silvestro, MD FRCSC, F Krause MD, A Younger MD FRCSC, M Glazebrook MD PhD FRCSC, D. Townshend, MD, M Penner MD FRCSC, K Wing MD FRCSC University of British Columbia Vancouver, Canada Dalhousie University, Halifax, Canada 3

12 AOS Baseline 12mon Change Comparison of outcome in isolated non-deformed endstage ankle arthritis between ankle replacement, arthroscopic ankle fusion, and open ankle fusion Andrea Nicole Veljkovic, BcComm, MD, FRCSC Timothy R Daniels, MD, FRCSC Mark Anthony Glazebrook, MSc., PhD, MD, FRCSC Peter Dryden, MSc,MD,FRCSC Murray J Penner, B.Sc., MD, FRCSC Kevin J Wing, B.Sc, MD, FRCSC Alastair S Younger, MB ChB Introduction The purpose of this study is to compare the outcomes of TAR, AAA, and OAA with the AOS in isolated, non-deformed ankle arthritis. 4

13 Methods, 88 TAR (Hintegra), 50 AAA, and 100 OAA ankles followed for an average of 3.57 yrs (+/-SD 1.60) Methods primary outcome measure was significant reoperation and AOS total change score Results 5

14 Results Conclusion TAR and AAA had significantly higher outcomes than OAA Remove all cartilage Penetrate subchondral bone Reduce ankle joint Transfix with hardware Surgical Goals 6

15 Remove instruments Hold ankle in neutral position Obtain provisional fixation Wire from cannulated screw set Drill bit (solid screws) Check position Insert hardware Vumedi.com has saw bones screw positions 7

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17 5 portal technique Get rid of all cartilage Access gutters Anterior medial Anterior lateral medial Acevedo portal Tip of medial mal Tip of lateral mal Case Paratrooper 1980 s Basic training fractured ankle Ongoing ankle pain Arthroscopy x 2 Signficiant cartilage damage X rays relatively normal Ongoing resriction to mobility 9

18 Plan Arthroscopic ankle fusion positioning 10

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21 Final appearence 13

22 Why is arthro better? Open Arthroscopic AOS scores 14

23 Swelling affects outcome Why is arthro better? Open Arthroscopic Swelling scores AVN talus 41 year old RN 15

24 Arthroscopic debridement Combined ankle and subtalar fusion Removal of dead bone fragments Graft Reamings from the tibia (joint contained) PDGF /TCP / Collagen graft 16

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26 78 year old pt Diabetes Subtalar debridement 18

27 Surgery arthroscopic ankle and subtalar fusion Graft Reamings PDGF Summary Less pain Less swelling Less wound complications Shorter stay or daycare Less cost Less clinic visits after surgery Better outcomes at 2 and 4.5 years 19

28 Thank You Cases 22 year old Motor cycle accident Fracture talus with AVN 20

29 Risk factors Prior surgery Open fracture AVN 21

30 Lateral incision through old compound wound Chevron fusion to preserve bone stock Back fill with local bone and PDGF injectable Retrograde rod 22

31 14 year old Fell on log Compound pilon fracture with extensive soil contamination Ex fix Free flap ORIF 23

32 Ongoing drainage and infection after 6 months All hardware removed Posterior approach Debridement PDGF and calcium sulphate with Tobramycin Removal of sequestrum 24

33 Mass on ankle 56 year old businessman Studying theology Enjoys cycling 25

34 Plan Radical excision Ankle fusion Femoral head graft Extensor tendon repair Free flap (delayed by a week with VAC dressing) 26

35 76 year old with diabetes Medial ulcer Admitted to medicine floor Treated with antibiotics 27

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37 Successful fusion Eradication of infection PDGF and calcium sulphate with Tobramycin Pt with R A and diabetes 29

38 Lateral wound failed to heal Debrided by Colleague (bad idea) Recurrent infection Extended to nail Nail exchange 30

39 Infection eradicated.. But ongoing pain With PGDF and screw fixation Revision fusion 31

40 24 year old Club foot Short limb 5 cm No ankle motion Pain 32

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42 Regenerate! Cross lock nail and remove ex fix 34

43 30 year old Independent Not working Female Prader Willi Syndrome Equinus deformity Uncontrolled gout Diabetes 59 yo male Diabetes Type 1 Works as architect HBA1c is 7 Ankle fracture 3 months ago Trip 2 weeks ago Developed swelling behind heel 35

44 Achilles exam No active plantar flexion Thompson test shows deficient tendon Excessive dorsiflexion with knee extended Slow healing wounds after fracture Part of fibular nail study CT 36

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46 Good news! Kept his leg Is back at work! 38

47 3/22/2016 ANKLE ARTHRODESIS NAIL COMBINED ANKLE-HINDFOOT FUSIONS MIAMI ANKLE FOOT THOMAS INTERNATIONAL P. SAN GIOVANNI ALLIANCE MD MIAMI ORTHOPEDICS & SPORTS MEDICINE INSTITUTE DISCLOSURES Consultant/Design - Arthrosurface, Medshape, Paragon28 Royalties Arthrosurface, Paragon 28, OrthoHelix/Wright Medical Stock/Stock Options Cytonics Corp, Medshape, Paragon 28 ANKLE ARTHRODESIS NAIL TECHNIQUE AND CASE EXAMPLES 1

48 3/22/2016 RETROGRADE IM NAIL COMBINED ANKLE-HINDFOOT ARTHRODESIS Ankle Fusion Nails not typically or routinely used for isolated ankle fusions TTC Arthrodesis Nails - TibioTaloCalcaneal Tibiotalar (ankle joint) + Talocalcaneal (subtalar joint) My preference for the ankle-hindfoot region is to spare one level from fusion to keep a mobile segment -subtalar or triple hindfoot arthrodesis below and total ankle above -not always possible Combined ankle and subtalar joint involvement and both have significant % pain contribution to patient symptoms not just radiographic examine pt. Clinical scenarios more complex ANKLE ARTHRODESIS NAILS COMMON INDICATIONS FOR USE AVN Talus Posttraumatic sequelae talar neck fx Systemic process rheum/endocrine/hematologic Medication-induced Posttraumatic Arthritis Ankle and Subtalar Joint Significant loss of talar bone stock Severe angular deformity Failed Ankle Arthrodesis Nonunion/Malunion Failed Total Ankle Arthroplasty Charcot Neuroarthropathy Ankle Hindfoot New Designs New biomaterials and metals Various shapes/sizes/angulation Interlocking screws mechanisms Different methods of achieving compression through the nail 2

49 3/22/2016 Not-So-New Concept? since late 1940 s description of case with use of IM Nail from calcaneus through talus tibia Started to catch on early to mid 1990 s with Dr Kenny Johnson (1993) description of a case series later followed through by Dr Todd Kile (1994) Dr George Quill (1996) series 40 pts with supracondylar nail : 90% union rate time to union of 14 wks How Do I Use It-Technique & Decision Making Each case individualized Deformity/Skin Issues Approach (Lateral, Anterior, Posterior) Is talus viable, how much to work with, can it be used or discarded? Graft Choices (Autogenous ICBG, Bulk Structural Allograft, Biologics) Do I have the equipment I need? BackUp plan/plan B TECHNIQUE 3

50 3/22/2016 Positioning & Approach Straight longitudinal incision centered over fibula lateral transfibular approach Preserve peroneals for soft tissue coverage or excise if tight Bone graft reamings using small acetabular reamer against distal fibula (36mm) *perform prior to excising distal end of fibula Distal Fibula Resection excise the distal 8-10cm with chamfer cut after bone graft reaming performed *improves exposure to both ankle and subtalar joints for joint preparation 4

51 3/22/2016 AVASCULAR NECROSIS TALAR BODY COMPLETE EXCISION entire talar body excised at junction of body-neck level avascular necrosis with complete involvement of talar body TALUS EXCISED POOR BONE STOCK FOLLOWING FAILED TOTAL ANKLE PREPARATION OF JOINT SURFACES ACETABULAR REAMERS FOR TTC WITH BULK FEMORAL HEAD 5

52 3/22/2016 Joint preparation with acetabular reamers to match diameter of bulk femoral head allograft (38mm-46mm range) inferior aspect of tibia superior aspect calcaneus posterior facet region leg length to replace what was removed, may ream more or less depending on size of graft Graft Prep Video Graft Prep Video 6

53 3/22/2016 Per surgeon s discretion May consider preloading bone graft reamings and femoral head allograft with PRP or bone marrow aspirate dense packing of defect with autogenous graft from distal fibula Placement of Graft Assess Alignment /Rotation Video Bulk femoral head allograft placed to restore height and fill defect created by talar body excision (*freeze dried allograft femoral head easiest to work with and more porous) Saw flush with tibia and calcaneus 7

54 3/22/2016 Bulk femoral head allograft placed to restore height and fill defect created by talar body excision (*freeze dried allograft femoral head easiest to work with and more porous) Saw flush with tibia and calcaneus SETTING FUSION POSITION ASSESS ALL PLANES VARUS/VALGUS, DF/PF, ROTATION 8

55 3/22/2016 femoral head allograft filling of talar defect establish excellent surface area contact at fusion levels leave no gaps PLACEMENT OF NAIL GUIDE PIN INFERIOR ASPECT OF CALCANEUS CANNULATED STARTER DRILL SEQUENTIAL REAMING TO 1-1.5MM > FINAL NAIL DIAMETER (MOST NAILS 10-12MM RANGE) NAIL ASSEMBLY Setting proper alignment of fusion position Placement of TTC Arthrodesis Nail 9

56 3/22/2016 DISTAL INTERLOCKING SCREWS IN CALCANEUS COMPRESSION MECHANISM SET Setting of compression mechanism INTRAOPERATIVE FLUORO VIEWS PROXIMAL INTERLOCKING SCREWS PLACED MOST NAILS HAVE 2 MEDIAL TO LATERAL PROXIMAL INTERLOCKING TIBIAL SCREWS OFTEN ONE SET IN STATIC AND THE OTHER IN DYNAMIC MODE SO CAN BE USED IF NECESSARY END CAP IF DESIRED DISTALLY 10

57 3/22/2016 Post Op Protocols NWB splint until 2 weeks CT TO CONFIRM UNION At 2 wks postop place in a cast and kept NWB until 8-10 wks - depending on whether own viable talus (6-8wks) or bulk allograft (10wks). Begin PWB at 6-10 wks depending on individual case in boot for 2 wks progressing to WBAT in boot Extremely compliant patient can put in Boot at 2 wks but keeping NWB At 8-10 wks postop obtained CT scan to assess fusion sites. Further progression of weightbearing based on adequacy of bone consolidation. Sneaker with stirrup brace 6 WEEKS POSTOP 11

58 3/22/ weeks postop CT Scan 10 wks postop Ankle Fusion Nail System CASE PRESENTATIONS 12

59 3/22/ y/o male involved in motor vehicle accident with a closed Hawkins Type 3 talar neck fx s/p ORIF talus. He is 3 years postop and presents c/o severe ankle pain Complete talar body AVN and collapse Combined ankle and subtalar joint involvement Case #1 JL HPI: 53 yom presented to the office with persistent right ankle pain following an MVA 8 months prior. He was seen initially at a local trauma center were they surgically treated him for an ankle dislocation and comminuted talus fx. PE: Skin: medial malleolar wound that intermittently drains with purulent fluid, anterior ankle incision 15cm, medial malleolar incision 4cm, skin graft anterolateral ankle to sinus tarsus area Foot/Ankle: Ankle swelling, right slight genu valgum, left moderate genu valgum.unable to bear weight to right foot, with slight equinus, adduction, and external rotation Neuro: Hypersensitivity to superficial peroneal nerve distribution on dorsal foot, decreased sensation to superficial and deep peroneal nerves X-Ray: avascular nonunited talar neck/body fx, degenerative changes within the tibiotalar, subtalar and talonavicular joints. 13

60 3/22/2016 Case #2 GC HPI: 69 yom presents to the clinic c/o severe chronic B/L ankle pain. He claims the left ankle has become worse the last year. He has a Hx of arthritis w/o injury or accident. PE: Severe deformity noted, severe hindfoot varus, severe midfoot cavus CT Scan: Left ankle had severe varus deformity with severe arthritis. The left subtalar joint had extensive arthritis of the anterior and middle facets 14

61 3/22/2016 Case #3 HV HPI: 43yom presents to the clinic c/o right foot and ankle pain. In 2010 the pt was in an MVA in Mexico where he was surgically treated for a foot fracture. He continues to have sharp pain and swelling with walking and occasionally uses a brace for support. PE: Right ankle has a mild effusion and is the primary location of tenderness. The pt has no ankle dorsiflexion or plantarflexion and has limited foot inversion and eversion at 5 degrees each. The foot has no ability to adduct or abduct X-Ray: Talus fracture with avascular necrosis and arthritis 15

62 3/22/2016 Case #4 OD HPI: The patient is a 24-year-old gentleman who resides in Dominican Republic and was involved in a motor vehicle accident approximately five months ago. he had an open fracture of the talus, which underwent debridement, irrigation, and placement of an external fixator. The external fixator has subsequently been removed and he is presently in a brace. He presents with continued pain along the medial aspect of his ankle. PE: diffuse swelling and erythema of the foot and ankle. Purulent drainage from a previous external fixator tract along the medial malleolus. The ankle is in a fixed 20 degree plantarflexion with no motion. Decreased sensation along the plantar aspect of the foot X-ray: deformity of the talus and previous talar neck fracture. There appears to be increased bone radiodensity of the talar body suggestive of avascular necrosis. Previous pin tract holes for the external fixator are noted in the tibia, talus, and calcaneus. 16

63 3/22/2016 CONCLUSIONS PROCEDURE TO HAVE IN YOUR ARMAMENTARIUM FOR COMPLEX COMBINED ANKLE-HINDFOOT CASES NAILS HAVE A ROLE AND PLACE, OFFER GOOD BIOMECHANICAL ADVANTAGES TO OTHER TECHNIQUES WHEN USED IN THE RIGHT SETTING NOT MATTER HOW GOOD OR BIOMECHANICAL STRONG THE DEVICE IS, SUCCESS STILL BOILS DONE TO ADHERENCE TO THE PRINCIPLES OF OBTAINING BRIDGING BONE MOST IMPORTANTLY JOINT PREPARATION AND ADEQUATE SURFACE AREA OF CONTACT TO BLEEDING BONE EDGES 17