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Total ankle replacement surgeries are often complex and difficult. Don\ut leave it to trial and error. Learn from the experts: Total Ankle.
Table of contents
- Total Ankle Arthroplasty: An Imaging Overview
- Total Ankle Arthroplasty: An Imaging Overview
- Fler böcker av författarna
- Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition
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View all copies of this ISBN edition:. All goniometer measurements are performed in the weight-bearing position.. Standardized photo documentation allows for accurate clinical assessment over time: upper series, preoperatively; bottom series, at 8 year same patient as Fig 3 and Radiographic evaluation of affected ankles is performed using weight-bearing radiographs including antero-posterior views of the foot and ankle and a lateral view of the foot figure 3 A,B,D. Only weight-bearing radiographs should be used for evaluation of foot and ankle alignment and biomechanics because non-weight-bearing radiographs are often misleading.
Furthermore, standing position may help to standardize the radiograph technique allowing more reliable comparison between pre- and postoperative radiographs figure 3 and 4.
Total Ankle Arthroplasty: An Imaging Overview
Saltzman view should be used to assess the inframalleolar alignment figure 3C. The supramalleolar ankle alignment should be assessed in coronal and sagittal plane by measurement of medial distal tibial angle and anterior distal tibial angle, respectively In patients with degenerative changes of the adjacent joints single-photon-emission computed tomography SPECT-CT may help to evaluate the morphologic changes and their biological activities figure 5—7 We do not recommend the routinely use of magnetic resonance imaging in patients with ankle OA.
Preoperative evaluation for a painful end-stage OA in a year old man 12 years after a pilon tibial fracture: Standard weight-bearing X-rays. Eight-year follow-up evaluation same patient as Fig 2 : Standard weight-bearing X-rays done with the same technique under fluoroscopy allow for precise analysis. Preoperative evaluation for a painful end-stage OA in a year old woman 19 years after a severe ankle sprain.
Radiographic assessment evidences an advanced stage of ankle OA with bipolar subchondral cyst formation, a slight anterior extrusion of talus, anda peritalar instability with subsequent valgus tilt of talus with redagr to the calcaneus. Based on this, a TAR in combination with a subtalar arthrodesis was done same patient as Fig 5. A coronal plane view; B sagittal plane view.. Seven years after surgery, the patient was highly satisfied with the result. Standard X-rays show a well-balanced ankle and stable implants.
General or regional anesthesia is used for this procedure. The patient is placed in a supine position, and a pneumatic tourniquet is applied. A single preoperative dose of a second-generation cephalosporin is administered.. An anterior longitudinal incision is made to expose the extensor retinaculum, which is then dissected along the lateral border of the anterior tibial tendon. After capsulotomy and ankle joint exposure osteophytes on the tibia and on the talar neck are removed.. The tibial cutting block is placed aligned to the tibial tuberosity as the proximal anatomical landmark and to the middle of the anterior border of the tibiotalar joint as the distal anatomical landmark.
The anterior rim of the tibia serves to align the jig. Two to 3 mm of the tibial plafond is resected using an oscillating saw. Careful debridement of the posterior capsule is performed and all ossification is removed if necessary. A measuring gauge is used to determine the size of the tibial component.
Total Ankle Arthroplasty: An Imaging Overview
Tibial trial component is inserted to assess corred fit and alignment. In the case of inappropriate fit of anterior shield to anterior border of tibia, it is trimmed accordingly..
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The talar resection block is placed into the tibial cutting block, and maximal distraction is applied to the ankle in order to tension the collateral ligaments of the ankle joint complex. While to foot is held in neutral position, talar bloc is fixed to talus with two pins. After having done the horizontal resection cut of talus through the cutting slot using an oscillating saw, the resection bloc is removed.
The mm-thick spacer, accounting for the minimal thickness of the three prostheses components, is then inserted to prove whether sufficient bone resection is performed or not. Usually, the size of talar resection bloc is selected according to the measured tibial component. In the case of important undersize to the talar resection area, e. In the case of important oversize to the talar resection area, e. The selected talar resection block is positioned with its two hooks to the posterior talus and parallel to the medial border of resection area, which typically results in a correct alignment to the longitudinal axis of the foot, e.
In this position, the resection bloc is fixed to the talus with two to four pins and it serves then to perform the posterior, medial, and lateral talar resection cuts.
Fler böcker av författarna
Talar trial component is impacted. Once an appropriate fit is achieved, the anterior resection is done, and the two drill holes for the pegs are done. Tibial and talar surfaces are checked for any cysts or defects. Final prosthesis components are inserted with press-fit technique using a hammer and special impactor: first the talar component, then the tibial component, and finally the mobile bearing.
Fluoroscopy is used to check the position of implants.. If necessary, additional surgeries are added to properly balance figure 8—11 and stabilize the ankle figure 7. Then, the joint is closed over a drainage drain by continuous suture of extensor retinaculum, and interrupted sutures of the skin.. Preoperative evaluation for a painful end-stage varus OA in a year old man 35 years after a malunited pilon tibial fracture: The clinical evaluation shows a marked varus malalignment of distal tibia; whereas, the heelis only slightly in varus..
Preoperative evaluation radiographic evaluation same patient as Fig 8. Standard weight-bearing X-rays.
Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition
Intra-operative situs same patient as figura 8. In addition to the supramalleolar correction, a medial sliding osteotomy of calcaneus was done to properly align the heel..
Five years after surgery, the patient was highiysatisfied with the result. After final fluoroscopic check the wound is closed in layers. A dressing is applied, and a splint is used to keep the foot in a neutral position.. In patients with incongruent tibiotalar joint the joint contracture at the medial side can be addressed by osteophytes resection of the medial malleolus.
If medial contracture still persists a surgical release of the deltoid ligament can be performed. As an alternative, we prefer a flip osteotomy of the medial malleolus to lengthen and align it to the talus.. After the proximal varus correction is performed the hindfoot alignment should be proven clinically and using fluoroscopy. In patients with remaining varus position of the heel the deformity may be corrected by Dwyer osteotomy or z-shaped osteotomy of the calcaneus.
In patients with progressive degenerative changesof the subtalarjointthe subtalar arthrodesis may be considered.. In patients with lateral ligamental instability anatomic repair of the lateral ligament complex using suture anchors should be performed.
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In patients with insufficient ligament tissues an augmentation with a free plantaris tendon graft can be considered for reconstruction of the anterior fibulotalar and calcaneofibular ligaments. Furthermore, the peroneus longus to peroneus brevis tendon transfer may provide reliable soft tissue stabilization and reduce the inversion moment arm of the first ray.. In patients with varus malalignment of the hindfoot an equinus contractures is often observed leading to limited ankle dorsiflexion. PercutaneousAchilles tendon lengthening orgastrocnemius recession can be performed.
The surgeons should be aware to avoid the failure of triple hemisection atthe ankle mobilization, however. After the supramalleolar correction the heel position should be proven clinically and using fluoroscopy.