Arthrodesis Surgery
Which joints are placed used rigid fixation in TMT arthrodesis? Which are placed in flexible fixation?
- 1st/2nd/3rd TMT joint using 4/3.5/2.7 solid screws - 4th/5th TMT joints using K-wires
Intermediate Column
- 2nd, 3rd, TMT joints and NC joints - Rigid (no motion for propulsion)
Lateral Column
- 4th and 5th TMT joints - Mobile - Essential (shock absorber and accomodates to uneven surfaces)
Is the triple arthrodesis a dinosaur?
- According to the literature, a double arthrodesis leaving the CCJ intact had equivalent deformity reduction. Maintains length at lateral column and shortens OR time - There are other articles that state that the triple is better since it has been proven, can be reproducible, time tested, and CCJ fusion leads to stability and better alignment of the entire foot.
Fleck Sign
- Avulsion of the Lisfranc's ligament - Loss of alignment of the 2nd met with the 2nd cuneiform and loss of the mortise keystone configuration - Look at cuboid and always order a CT
What consists of the Pantalar Arthrodesis? When should it be used? Goals? Fixation? Complications?
- CCJ, TNJ, STJ, and TTJ - Polio, destructive arthritis (charcot), post trauma, N/M disease. Basically a last resort before BKA - Pain, malalignment and function - Screws and/or plates and/or IM nail - Post op NWB is long and ankle highest non-union rate.
Strain ranges for the following? Bone formation Fibrocartilage formation? Granulation tissue formation (non union)
- Change in L/L is <2% - <10% and >2% - <100% and >10%
Indications for a Tibiotalocalcaneal fusion?
- Charcot, talar avn, failed ankle arthroplasty and OA - High risk (high rate of complications)
Where does the main motion of the lateral column come from? What type of foot can this possibly be used for?
- Comes from the 4-5 m/cuboid articulation not the CCJ - Perform diagnostic injections and can possibly be used for flat foot
Glissan's Principles of Arthrodesis
- Complete removal - Accurate fit - Optimal positioning - Undisturbed
Medical comorbidities increasing NWB time frame Patient non-compliance including smoking Malalignment and positioning of the foot (do not place in varus!) Non union
- Complications of Arthrodesis
What are the indications for a STJ arthrodesis? How can you determine if it's actually the STJ causing the problem? How do you position?
- DJD from old talus or calcaneal fractures, recurrent TEV, coalitions, RF varus/valgus, or TPTD - You can do a diagnostic injection at the sinus tarsi (2cc of lidocaine) - Do not position as varus
Why does an avascular non-union originate?
- Due to the devascularization of the bone fragments adjacent to the fracture site due to injury and/or surgery
Hypertrophic rich in callus Mildly hypertrophic, less in callus Not hypertrophic, minimal callus
- Elephant foot - Horse foot - Oligotrophic
Hypervascular non-unions? Avascular non unions? What is the nonsugical management?
- Elephant foot, horse hoof and oligotrophic - Torsion wedge, defect/void, and atrophic - NWB with prolonged immobilization (cast) and/or bone stim
Medial Column
- First TMT and NC joints - Limited mobility at first TMT (lever for propulsion) - Mobile segment is the talonavicular joint
What makes up a Triple Arthrodesis?
- Fusion of the STJ, TNJ, and CCJ
In regards to being backed in literature, do you fix or fuse a Lisfranc's injury?
- Fusion/ primary arthrodesis is a better choice for treating Lisfranc's injury
Big classification system for Lisfranc's (TMT Arthrodesis) What can a delay in treatment cause?
- Hardcastle - Since it is frequently misdiagnosed (20% initially missed), a delay in treatment frequently leads to the ultimate reason for arthrodesis
Pseudoarthrosis with biological reaction capacity? Without biological reaction capacity?
- Hypervascular or hypertrophic - Avascular or atrophic
TMT arthrodesis surgical techniques
- Incision placement (1 vs 2 dorsal incisional approach) - Remove cartilage - K-wires - Screws (3.5 or 4) - Plates (locking) - External fixation - Bone graft - Muscle tendon rebalancing needed
Fleck Sign and gap sign What should you always look at? Always order a?
- Lisfranc's which can lead to TMT arthrodesis - Cuboid - CT
Reasons to fuse?
- Medial and middle columns rigid anyways - Restores functional anatomy - Fusion after ORIF more difficult - Major ligament disruption - Multidirectional instability - One surgery - Pain
Imaging finding on 30 degree oblique for Lisfranc's?
- Medial base 3rd MT in line with medial aspect of lateral cuneiform - Medial base 4th MT in line with medial aspect of cuboid
Microfracture technique
- Microfracture holes are placed in bare subchondral bone to allow access to marrow elements. - Allows atraumatic perforation of the plate minimizing the chance of ectopic bone formation - Placed 2 to 3 mm apart - Goal is to gain access to the bone marrow elements without causing excessive injury to subchondral bone
Reasons to fix?
- ORIF has improved - Preserve joints - Difficult to make a fusion heal w/multiple fx's - Screws or plates
Main source of nutrition and articular cartilage
- Originates from vascularity in the synovium - Factors, vitamins, minerals, carbs, metabolites rapidly diffuse through the synovial fluid while diffusion through the cartilage matrix is significantly slower
Since you can't fuse 4 and 5, what can you use instead?
- Orthospheres
Techniques for cartilage removal and joint preparation?
- Osteotome and fishscaling - Contoured resection with currettage or power Burr/Shaver - Planal resection (leaves a large gap and you could end up abducting the foot) - Fenestration (helps get capillary beds into the fusion site!!)
How are screws placed for arthrodesis?
- Placed in lag mode which generate compression to assist with fusion
How does the foot present if a lisfranc's injury occurred?
- Plantar ecchymosis
How is an ankle fusion positioned?
- Position the foot 90 degrees to the leg (er same as contralateral limb), neutral to some valgus (5 degrees) hindfoot - Posterior translation of talus on tibia (5 mm) - Er on the side of equinus positioning of the foot
What does a TNJ arthrodesis do to the STJ? How do you remove cartilage? How can you fixate? What is a complication?
- Reduces STJ motion by 2/3rds (most powerful arthrodesis) - Chisel, osteotome or burr not a sagittal saw - Screws, staples, plates or a combination - Non union complication as high as 35%
What are the indications for a CCJ arthrodesis? How does this technique begin and how can you fixate?
- Relapsed TEV, DJD, correct midfoot adductus, cuboid syndrome. idiopathic lateral column pain, or a s/p aggressive plantar fasciotomy - Incision from the malleolus to the 4th metbase. Fixation includes staples, screws and a locking H-plate
In terms of anatomy what do the transverse intermetatarsal ligaments do? What is Lisfranc's ligament? Which are stronger plantar or dorsal ligaments?
- Secure M2-M5 and there is no intermetatarsal ligament between M1-M2 - Interosseous C1-M2 ligament - Plantar
What test can you use to see if there is biologic activity?
- TC-99 scan
What is the classic two-incision approach for a Triple Arthrodesis? What is the Paprika sign?
- The lateral is from the malleolus to the 4th metbase. The medial begins at the superior aspect of the malleolus to the inferior margin of the navicular/cuneiform joint. - Pinpoint bleeding after you resect cartilage
What do Ray, Myerson, and Yu view the subchondral bone plate conservation
- They all believe preserving the subchondral bone plate helps healing. Ray believes that retention not only enhances the stability of the arthrodesis by resisting migration of the screw shaft but also stabilizes the fixation site. - Rest also were in favor of preserving the sbp
How are screws placed for open reduction and internal fixation?
- They are in positional mode so they are maintaining alignment and provide no compression
Judet-Weber classification on hypervascular or hypertrophic non-union? Classification on avascular or atrophic non-union?
- They do not heal because of instability - Do not heal because of biological deficit
What were Schuberth and Carro's views on the SBP?
- They said that preserving it actually hinders fusion.
Imaging findings on AP for Lisfranc's?
- Up to 3mm normal between 1st and 2nd met bases - Lateral base 1st MT inline with lateral aspect of medial cuneiform - Medial base 2nd MT in line with medial aspect of middle cuneiform
Can you perform parts of the triple arthrodesis as stand alone procedures?
- Yes
Progressive stages in joint path
1) Early degenerative changes with surface fraying of articular cartilages 2) Further erosions of cartilages, pitting and cleft formation. Hypertrophic changes of bone at joint margins 3) Cartilages almost completely destroyed and joint space is narrowed. Subchondral bone is irregular and eburnated. Spur formation at margins and fibrosis at joint capsule
Indications for arthrodesis?
1) Pain 2) Deformity correction 3) Plantigrade foot 4) Replace bracing 5) Return patient to their normal ADL