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http://dx.doi.org/10.14517/aosm13010 Review Article pISSN 2289-005X·eISSN 2289-0068

Arthroscopically assisted ankle fusion

Yoon-Chung Kim1, Jae Hoon Ahn2

1Department of Orthopaedic , St. Vincent’s Hospital, The Catholic University of Korea College of Medicine, Suwon; 2Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea

Ankle has been performed for the treatment of symptomatic ankle with reported complications such as , malunion and nerve injury. Arthroscopic ankle fusion has the advantages of minimal soft tissue damage, short fusion period, high union rate, and early rehabilitation. The authors describe the surgical technique and the advantages and disadvantages of arthroscopically assisted ankle arthrodesis.

Keywords: Ankle arthritis; Ankle fusion;

INTRODUCTION OVERVIEW

In spite of being one of the main weight-bearing Indications of the body, the ankle is relatively resistant to the The indications for arthroscopic ankle arthrodesis are similar development of primary . The majority of to those for conventional open arthrodesis [3]. The primary ankle arthritis is secondary to trauma, such as a fracture, indication is end-stage degenerative arthritis of the ankle ligament injury, and damage. Inflammatory that does not respond to conservative therapy, including arthropathies including rheumatoid arthritis and avascular medication, bracing, and orthotics. Other indications necrosis of the talus also can lead to the development include septic arthritis, rheumatoid (inflammatory) arthritis, of arthritis in the ankle. Ankle arthrodesis has been avascular necrosis with less than 30% of involvement of the considered as one of the standard surgical treatment talus, failed total , deformity resulting options for severely painful ankle arthritis refractory from neuromuscular disease, and severe instability to conservative management [1]. It produces relatively [4,5]. The arthroscopic procedure can be useful when open satisfactory results, and thus has been widely performed. arthrodesis is not feasible due to poor soft tissue condition More than 40 different surgical techniques are available and scarring. for ankle fusion, including conventional open arthrodesis, mini-open arthrodesis, and arthroscopically assisted Contraindications arthrodesis. Of these, arthroscopically assisted arthrodesis, Arthroscopic arthrodesis has not been recommended for first introduced by Schneider [2] in 1983, has been more ankles with a severe varus/valgus deformity due to the frequently performed due to improved arthroscopic difficulty of joint surface preparation and the necessity of surgical techniques and instrumentation. extensive resection to achieve neutral ankle position [4]. Although it can be considered as an option in the

Received August 1, 2013; Revised September 26, 2013; Accepted October 8, 2013 Correspondence to: Jae Hoon Ahn, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea. Tel: +82-2-2258-2837, Fax: +82-2-535-9834, E-mail: jahn@ catholic.ac.kr

Copyright © 2014 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ AOSM by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Arthrosc Orthop Sports Med 2014;1(1):1-5 1 Yoon-Chung Kim, Jae Hoon Ahn. Arthroscopically assisted ankle fusion

presence of less than 10o-15o of varus/valgus deformity, it achieved due to the presence of joint instability, a 4.0 is imperative for the surgeon to be highly experienced in mm diameter arthroscope can be used as well. The larger the conventional open arthrodesis to successfully carry diameter arthroscope may facilitate the arthrodesis, out the arthroscopic procedure. In the planning stage of because it provides wider and clearer view. Other the operation, the determination of a surgical technique instruments needed to address the articular surfaces should be based on the assessment of the alignment of include shavers, burrs, curettes, and osteotomes. the ankle using weight-bearing anteroposterior and lateral radiographs and the surgeon’s experience (Fig. 1A, B). Portal establishment and operative technique Avascular necrosis involving more than 30% of the After palpating the soft spot located medial to the tibialis talus is a relative contraindication for arthroscopic ankle anterior tendon, 10-15 mL of sterile saline is injected to arthrodesis. It can be better addressed with Blair tibiotalar distend the joint cavity. Then, arthroscopic portals are or tibiotalocalcaneal arthrodesis, because poor bone created. We prefer to use three portals (anteromedial, quality due to extensive avascular necrosis increases the anterolateral, and posterolateral portals) for ankle risk of nonunion [6]. Therefore, it is important to verify arthrodesis. Care should be taken to avoid damaging of the extent of avascular necrosis in the talus with imaging nerve branches, such as the superficial peroneal nerve, by modalities such as plain radiography, magnetic resonance delicately incising the skin only without penetrating the imaging, and bone scan prior to surgery. subcutaneous tissues during portal placement. This ‘nick Extensive bone loss, poor bone density, neuropathic and spread’ technique during portal placement can be arthropathy (Charcot arthropathy), and the presence of helpful for preventing nerve damage. The anteromedial acute infection are also known as contraindications for portal is established first, just medial to the tibialis anterior ankle arthrodesis [7]. tendon, because it is relatively easy to make and no major neurovascular structures exist. The anterolateral portal is Advantages created lateral to the peroneus tertius tendon, taking care Arthroscopic arthrodesis makes minimal soft-tissue to avoid the branches of the superficial peroneal nerve. damage around the ankle, and thus decreases the It is easy and safe to ensure the location by palpating incidence of complications, such as nonunion, post­ the skin and observing the anterolateral aspect at the operative infection, and neurovascular damage. The same time with an arthroscope introduced through the arthro­scopic procedure is advantageous over the open anteromedial portal. The posterolateral portal is placed procedure in terms of decreased time to fusion, post­ 1-1.5 cm proximal to the tip of the lateral malleolus of the operative pain reduction, rapid rehabilitation, short fibula and just lateral to the Achilles tendon, avoiding the hospital stay, and reduced treatment cost [1,5,6,8-11]. In course of the sural nerve. It usually serves as an inflow addition, it allows for future total ankle replacement by portal that allows optimal visualization. The anteromedial minimizing the damage to the periarticular structures. and anterolateral portals can be used alternately for either arthroscopic viewing or for resection of the synovial OPERATIVE TECHNIQUE tissue, osteophytes, articular cartilage, and subchondral bone with a shaver or a curette. Meticulous debridement Instrumentation and setup and resection of articular cartilage and subchondral For successful arthroscopy, sufficient distraction should bone of the talar dome and distal tibia are performed. To be applied to the ankle joint to expand the joint space. determine the adequacy of debridement and resection, Currently, noninvasive distraction devices with use of the the sufficient punctate bleeding should be confirmed straps around the midfoot and hindfoot are commonly on the bony surfaces after the infusion pump turned off used. Noninvasive distraction can be applied with the momentarily (Fig. 1C). Then a guide pin for a 6.5 mm patient in the supine position by taking (1) the extension cannulated screw is inserted into the medial aspect of of the knee, (2) the flexion of the hip and the knee using the distal tibia and lateral aspect of the distal fibula under a thigh holder, or (3) the flexion of the knee far down on arthroscopic view using a drill guide such as Microvector the operating table. In general, a short arthroscope with (Smith Nephew Endoscopy, Andover, MA, USA). After a diameter of 2.7 mm and an obliquity of 30o is used for removing the arthroscope and the distraction device, the arthroscopic procedure. If sufficient distraction can be surgeon ensures the contact of opposing joint surfaces by

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applying appropriate pressure with the ankle placed in The rehabilitation protocol consists of 6-8 weeks of non- neutral position in the sagittal plane, 0o-5o of valgus in the weight bearing short leg cast immobilization followed coronal plane, and 5o of external rotation in the transverse by weight bearing immobilization for another 2-4 weeks plane. Subsequently, the two guide pins are advanced until fusion is evident on radiographs. In most cases, into the talus for preliminary fixation. After ascertaining radiographic evidence of fusion is observed 8-12 weeks the position of ankle joint and the location of the guide after surgery, and thereafter, patients are permitted to pins with C-arm fluoroscopy, the cannulated screws are resume normal walking (Fig. 1F). inserted for permanent fixation. It is recommended to place the two cannulated screws in the opposite direction. OUTCOMES AND COMPLICATIONS In some instances, the two screws are placed in parallel with each other from the medial aspect of distal tibia to With recent development in arthroscopic surgical the neck of talus. Two screws are usually used for joint techniques and instrumentation, arthroscopic ankle fixation, however an additional screw can be inserted arthrodesis has yielded much encouraging results and the to provide stability in some cases. After screw fixation, it indications for the procedure have been broadened. In an should be verified that there has been no penetration into 8-year long-term follow-up study of 34 ankle arthrodesis, the subtalar joint on the anteroposterior and lateral views Glick et al. [12] reported that the fusion rate was 97% and using an image intensifier or with radiography (Fig. 1D, E). the time to fusion was 9 weeks. Myerson and Quill [5]

Fig. 1. The standing anteroposterior (A) and lateral (B) radiographs of the right ankle of a 68-year-old man shows severe osteoarthritic changes in the joint with a varus deformity. (C) The arthroscopic view shows the joint after preparation of the joint surface. Bleeding areas are well seen on the exposed bony surface. Visualization is performed through the anteromedial portal. Immediate postoperative antero­posterior (D) and lateral (E) radiographs of the right ankle show the joint is fixed with two screws. The varus deformity has been well corrected, and the screws are kept away from the subtalar joint. (F) The anteroposterior radiograph of the right ankle at postoperative 12 weeks shows complete union of the joint.

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compared the arthroscopic arthrodesis group (n = 17) and surgeon’s proficiency is a prerequisite for the success of an open arthrodesis group (n = 16) and found that fusion was arthroscopic ankle arthrodesis. Considering the relatively obtained earlier in the former group (the mean time to steep learning curve for the procedure, it is advised fusion, 8.7 weeks vs. 14.5 weeks) and the fusion rate was that the surgeons should be experienced in the open similar between the groups. Many studies have shown procedure to improve understanding on the anatomy of that the arthroscopic procedure produces superior results the ankle and arthrodesis techniques before proceeding than the open procedure in terms of the time to fusion (8- to the arthroscopic fusion [19]. 12 weeks vs. 8-24 weeks) and nonunion rate (5%-10% vs. Possible complications of arthroscopic ankle fusion 5%-41%) [1,4,5,8,13-15]. Based on our experience of more include nonunion, malunion, subtalar joint violation by than 30 arthroscopic procedures with nonunion in only screws, and screw prominence, in addition to infections 2 diabetic patients, we believe that arthroscopic ankle and wound healing problems. Complications particularly arthrodesis is an advantageous procedure with respect to associated with the arthroscopic technique include an the fusion rate. injury to the neurovascular structures and tendons in the In the past, arthroscopic arthrodesis was considered proximity of the portals, skin damage due to distraction, to be technically difficult to perform for ankle arthritis nerve compression, and instrument breakage within the combined with severe angular deformity. Hence, the joint. procedure has been recommended for osteoarthritis of In conclusion, arthroscopic ankle arthrodesis is a the ankle with no or mild angular deformity [6,11,16]. safe and effective procedure for the treatment of ankle However, Winson et al. [1] reported that 10o-15o of defor­ osteoarthritis. The arthroscopic procedure is advan­ mity could be corrected with arthroscopic arthrodesis tageous in terms of low complication rate, reduced and fusion could be obtained even in patients with severe operating time, short hospital stay, and high fusion rate deformities of 25o. Other recent studies also suggest that compared to the open arthrodesis. high fusion rates can be achieved with arthroscopic arthrodesis regardless of the severity of deformity [17,18]. CONFLICT OF INTEREST We have performed the arthroscopic procedure on patients with up to 20o of deformities without noticing No potential conflict of interest relevant to this article was any increase in the complication rate. Above all, the reported.

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