Ankle Arthrodesis: Indications and Techniques

Journal of the Amer ican Academy of Or thopaedic Surgeons200

The ankle joint consists of a highlyconstrained articulation of the taluswith the tibial plafond and the dis-tal fibula. With weight bearing,congruity between the sulcus of thetalus and the tibial plafond pro-vides stability in the sagittal planein a normal ankle joint. Torn ordetached ligaments around theankle joint, however, allow abnor-mal coronal-plane instability withweight bearing.

The deep deltoid ligament carriesthe primary blood supply to themedial aspect of the body of thetalus from the posterior tibial artery.Therefore, at least on a theoreticalbasis, an effort should be made topreserve the deltoid ligament dur-ing surgical procedures on or aboutthe ankle joint.

Damage to the ankle joint fromtrauma or disease can result in pro-gressive loss of the tibiotalar articu-lar cartilage surface, with resultinginflammation, synovitis, osteophyteformation, progressive loss of ankle-joint motion, weight-bearing pain,

and functional disability. A varietyof techniques for ankle arthrodesishave been described over the yearsas surgical measures to relieve thepain and functional disability associ-ated with a damaged ankle joint.1-14

Tr eatment of theSymptomatic Ankle Joint

Nonoperative treatment of a symp-tomatic degenerative ankle joint in-cludes the use of shoe inserts orshoe modifications. A shoe with acushioned heel and a stiff, rocker-bottom sole usually helps patientswith less severe ankle-joint dam-age.15 If more support is needed,the use of a molded ankle-footorthosis or a double-upright type ofbrace attached to the patient’s shoecan be used. Such a brace tends todecrease joint inflammation andpain by restricting ankle-joint mo-tion. Some patients are helped bysupporting the arthritic ankle jointin a walking cast for 6 weeks. The

use of a walking cast has also beensuggested as a trial device to evalu-ate patient acceptance and degreeof pain relief prior to performing anankle arthrodesis.15

Nonsteroidal anti-inflammatorydrugs can be helpful in relievingankle pain. If long-term use is ex-pected, patients should be screenedfor contraindications, and appropri-ate blood and urine studies shouldbe performed. Intra-articular injec-tions of corticosteroid-anestheticcombinations can be used to de-crease joint pain and inflammation,but the injections should be at least3 months apart.

Arthroscopic ankle-joint debride-ment may temporarily relieve thesymptoms of early arthritis. Thistechnique permits direct visualiza-tion of intra-articular and intracap-sular structures, thus allowing accu-

Dr. Abidi is Assistant Professor of OrthopaedicSurgery, Jefferson Medical College, ThomasJefferson University, and Chief, Division ofOrthopaedic Foot and Ankle Surgery, RothmanInstitute, Philadelphia. Dr. Gruen is AssociateProfessor and Chief, Division of OrthopaedicTrauma Surgery, University of PittsburghMedical Center, Pittsburgh. Dr. Conti is Asso-ciate Professor and Chief, Division of Foot andAnkle Surgery, University of Pittsburgh Medi-cal Center.

Reprint requests: Dr. Gruen, Department ofOrthopaedic Surgery, University of PittsburghMedical Center, Suite 911 Kaufmann Building,3471 Fifth Avenue, Pittsburgh, PA 15213.

Copyright 2000 by the American Academy ofOrthopaedic Surgeons.

Abstract

Patients with ankle arthritis and deformity can experience severe pain and func-tional disability. Those patients who do not respond to nonoperative treatmentmodalities are candidates for ankle arthrodesis, provided pathologic changes inthe subtalar region can be ruled out. Several techniques are available for per-forming the procedure; the most successful combine an open approach withcompression and internal fixation. The foot must be positioned with regard tooverall limb alignment and in the optimal position for function. A nonunionrate as high as 40% has been reported. Osteonecrosis of the talus and smokingare known risk factors for nonunion. When good surgical technique is used incarefully selected patients, ankle arthrodesis can be a reliable procedure for therelief of functionally disabling ankle arthritis, deformity, and pain.

J Am Acad Orthop Surg 2000;8:200-209

Ankle Ar thr odesis: Indications and Techniques

Nicholas A. Abidi, MD, Gary S. Gruen, MD, and Stephen F. Conti, MD

Nicholas A. Abidi, MD, et al

Vol 8, No 3, May/June 2000 201

rate diagnostic evaluation and theopportunity for immediate thera-peutic intervention. Removal ofloose osteochondral fragments orimpinging osteophytes by arthrot-omy or arthroscopy can provideeffective relief of pain.16 Severallarge series have documented ahigh incidence of impinging spursin football players (up to 45%)17 andin dancers (up to 59.3%).18 Becausethis entity is frequently encounteredin athletes, it has been referred to as“athlete’s ankle” and “footballer’sankle.”17 The suspected mechanismconsists of extreme ankle dorsiflex-ion with resultant anterior jointimpingement and posterior jointdistraction. It is theorized that re-petitive anterior ankle impingementcauses anterior subperiosteal hem-orrhages and subsequent scleroticbone growth.

Periarticular osteotomy and syn-desmotic reconstruction for mal-united ankle fractures is a treat-ment alternative for patients whodo not demonstrate joint-space col-lapse on weight-bearing radio-graphs. Symmetry of the tibiotalarjoint space must be maintained,and the seating of the fibula in theincisura fibularis of the tibia mustbe evaluated. The two findingsmost often cited as indicators ofabnormal relationships are (1) di-minished overlap of the distal fibu-la and anterior aspect of the tibiaand (2) excessive widening of thetibiofibular clear space. A signifi-cant and frequent component ofankle fracture malunion is rotationand shortening of the fibula.19

Ankle malalignment secondary tomalreduction or impingement re-sults in shifting of the talus, persis-tent instability, and valgus tilt. Aslittle as 1 mm of lateral talar dis-placement has been demonstratedto alter tibiotalar contact by asmuch as 40%.20 With the loss ofjoint congruity, damage to the car-tilage surface occurs progressivelyover time.

Factors that determine whetherankle reconstruction is a viableoption include the condition of thearticular cartilage at the time of revi-sion and the quality of fracturereduction. Other variables, such aslength of time from injury to thereconstructive procedure and the ageof the patient at time of presentation,have not been shown to influenceoutcome. Anatomic reconstructionof a malunited ankle joint will pre-vent further progression of anklearthritis, even in the presence ofearly disease.21 Furthermore, preciserestoration of ankle-joint anatomicrelationships is critical to a successfuloutcome. In one series,22 good to ex-cellent results were achieved in 85%of patients after reconstruction ofankle malunions. Factors associatedwith favorable patient outcome in-cluded position of the talus in themortise, stability of the syndesmosis,correct length of the fibula, and qual-ity of the joint surface at the time ofreconstruction.

Clinical results support the con-cept that late reconstruction of amalunited ankle provides painrelief and improved patient func-tion.19,21,23-25 Reconstruction mostfrequently involves fibular or tibialosteotomy, but may be combinedwith syndesmotic stabilization aswell.

Indications forAr thr odesis

The principal indication for anklearthrodesis is persistent ankle-jointpain and stiffness that is functionallydisabling to the patient and is notalleviated by nonoperative treat-ment methods. This may be theresult of previous fracture, infec-tion, osteonecrosis, or arthritis.

Radiographic changes in theankle joint are best assessed onweight-bearing standing anteropos-terior (Fig. 1, A), lateral (Fig. 1, B),and mortise views. Computed

Figure 1 Weight-bearing anteroposterior (A) and lateral (B) radiographs of the ankleshow complete joint-space collapse, valgus malalignment, and an old medial malleolarfracture.

A B

Ankle Arthrodesis


tomography, alone or in combina-tion with arthrography, can be use-ful for assessing joint-surfacedefects, degenerative joint changes,and the location of osteophytes.The bones of the subtalar complex(the talocalcaneal, talonavicular,and calcaneocuboid joints) shouldbe in normal alignment and withoutarthritic changes. A bone scan orselective joint injections can help todetermine whether joints other thanthe tibiotalar joint have degenera-tive changes. Following a success-ful ankle arthrodesis, it has beenshown that motion in the subtalarcomplex increases by an average of11 degrees during the first year.6

Sur gical Techniques

Selection of the surgical techniqueshould be based on the underlyingdisorder. As a general rule, exter-nal fixators are preferred for pa-tients undergoing arthrodesis for apreexisting septic joint and forthose with severe osteopenia. Ar-throscopic arthrodesis or the “mini-open” arthrodesis should be usedonly for patients with minimaldeformity. Open arthrodesis is ap-propriate for patients with signifi-cant ankle deformity and foot andankle malalignment.

Regardless of the surgical tech-nique chosen, the optimal postoper-ative position of the affected footand ankle joint is the same.26 Thefoot should be externally rotated 20to 30 degrees relative to the tibia,27

with the ankle joint in neutral flex-ion (0 degrees), 5 to 10 degrees ofexternal rotation, and slight valgus(5 degrees). This position providesthe best extremity alignment andaccommodation of hip and kneemotion. Fusion of the ankle inplantar-flexion results in genurecurvatum when placing the footflat on the floor and subsequent lax-ity of the medial collateral ligamentof the knee, which develops from

the externally rotated gait thatpatients adopt to avoid “rollingover” a plantar-flexed foot.26

External FixationBefore Charnley’s report in 1951

on the results obtained with a com-pression arthrodesis techniqueinvolving use of an external fixator,ankle arthrodesis was associatedwith high rates of failure because ofnonunion.2 The Charnley methodcombined open surgical debride-ment of the ankle-joint cartilagewith the application of an externalfixator by placing one pin throughthe tibia and another through theneck of the talus, with connectingbars running between the two pins.Compression across the arthrodesissite relies on an intact Achilles ten-don functioning as a tension band.Patients are allowed to bear weighton the treated ankle during the first8 weeks after surgery. After re-moval of the external fixator, pa-tients are immobilized in a plasterwalking cast for an additional 4weeks.

The Calandruccio external fixa-tor makes use of a triangular con-figuration to achieve stability andcompression across the tibiotalarjoint,4 which provides added resis-tance to torsional forces at the anklejoint. After surgical removal of theankle-joint articular cartilage, fixa-tion pins are placed through thetibia, through the neck and body ofthe talus, and, occasionally, into thecalcaneus. The fusion site is thenbuttressed with bimalleolar onlaybone grafts. This external fixatortechnique does not require an intactAchilles tendon to serve as a ten-sion band.

A simplified alternative methodof external fixation with the use ofa unilateral frame was reported in1994.13 This method appears toprovide adequate resistance to bothdorsiflexion and plantar-flexionforces at the tibiotalar joint. Theunilateral external fixator pins are

placed into the medial aspect of thetibia, the calcaneus, and the neck ofthe talus and are of larger diameterthan those used with the Calan-druccio device. Compression canbe exerted across the arthrodesissite by adding a compression de-vice to the external fixator appara-tus prior to placement on the pa-tient.

Arthroscopic Ar throdesisThe intra-articular portion of an

ankle fusion can be done with anarthroscope, but this techniqueshould be limited to patients witharthritic ankles with minimal de-formity, because it is difficult tocorrect ankle deformity arthroscop-ically.8 For this technique, arthros-copy is performed through two or,occasionally, three portals. Oneportal is medial to the tibialis ante-rior tendon, and the other is lateral tothe extensor digitorum longus ten-don. A third portal can be placedlateral to the peroneus tertius tendonand can then be used to removedebris generated during articular-surface denuding.

The joint space is widened witha noninvasive distractor or a unilat-eral external fixator. A 4.5-mm burand curettes are used to denude thearticular surfaces. After prepara-tion, compression of the joint sur-faces can be obtained with eitherinternal or external fixation. Pref-erably, two cannulated screws areplaced across the tibia into thetalus. The first screw runs from thelateral aspect of the tibia into theneck of the talus. The second screwruns from the medial malleolus intothe lateral aspect of the talus.Patients are kept in non-weight-bearing status for 5 weeks postop-eratively and then are allowed tobear weight progressively untiljoint fusion is demonstrated radio-graphically.

In an attempt to achieve theadvantages of both the open andarthroscopic techniques, a “mini-



open” technique was reported in1996.11 This technique decreasesreliance on regular arthroscopictechniques in favor of usingenlarged arthroscopic portals forexposure and removal of articularcartilage. Curettes and osteotomesare used to denude the joint sur-faces. This technique reportedly de-creases the amount of soft-tissuestripping required in the morestandard open techniques and isreported to be associated withquicker radiographic fusion rates.

Open Ar throdesisThe open ankle arthrodesis is

performed through a two-incisiontransfibular exposure. This tech-nique can be used for any patientbut is particularly useful for patientswith severe ankle-joint deformity.Its benefits are better visualizationof the joint and improved access forbone resection, correction of defor-mity, and screw placement. Itsdrawbacks are the large incisionsand the amount of soft-tissue strip-ping required.

The first incision is made directlyover the fibula, and the second in-cision is made along the anterior

third of the medial malleolus. Bothexposures are carried out carefullyto maintain full-thickness flaps andto identify and protect tendons andneurovascular structures. After thedistal 10 cm of the fibula has beenexposed, the superior peroneal reti-naculum is incised posteriorly, andthe peroneal tendons are mobilizedwhile protecting the sural and su-perficial peroneal nerves.

A small acetabular reamer can beused to morselize the fibula for bonegraft material prior to its removal. Amicro-oscillating saw is used tomake an oblique osteotomy 10 cmfrom the fibular tip (Fig. 2, A). Theremaining fibular fragment can thenbe excised. Alternatively, the distalfibular soft-tissue attachment can bepreserved if the fibula has not beenmorselized. The medial half of thefibula is cut away, and the remainingfibula is turned down and awayfrom the arthrodesis site. The bloodsupply is maintained because of theremaining ligamentous attachments.The outer half of the fibula is securedto the tibia and the talus with two3.5-mm screws later during the pro-cedure. This lateral buttress givesadditional lateral stability to the

arthrodesis site and assists in pre-venting lateral drifting of the talus.

Sharp dissection is used throughthe lateral incision to elevate thescarred ankle capsule from the jointboth anteriorly and posteriorly,thus allowing the vital structureson both sides of the ankle joint to beprotected by retractors. Soft-tissueprotection is provided through themedial incision by a retractor. Alarge oscillating saw is used tomake a cut perpendicular to the tib-ial shaft at the level of the apex ofthe dome of the articular surface,allowing removal of the tibial pla-fond (Fig. 2, B). An attempt shouldbe made to preserve the medialmalleolus so as to provide an areaof solid fixation for the lateral-to-medial screw and to preserve themedial blood supply to the talusthrough the deltoid ligament.28

After removal of the distal tibialarticular surface, the talus is posi-tioned so that the forefoot is in 5 to10 degrees of external rotation andthe hindfoot is in 5 degrees of val-gus, with neutral dorsiflexion anddisplacement so that the posteriormargins of the talus and tibia areflush. The foot must be aligned

A B

Figure 2 A, Through the lateral incision, the fibula is osteotomized 10 cm proximal to the tip with a micro-oscillating saw. The arrowmarks the distal fibula. B, Through the lateral approach, the distal articular surface of the tibia is removed at a 90-degree angle to the tib-ial shaft with an oscillating saw. The arrow marks the distal tibia.

Ankle Arthrodesis


with regard to the entire limb. Acut through the dome of the talus isthen made parallel to the distaltibia, resecting approximately 5 mmof the talus. Alternatively, the jointsurfaces can be prepared with cu-rettes and osteotomes. The remain-ing joint surfaces are inspectedcarefully for residual cartilage andsclerotic bone. All joint surfaces aredrilled or curetted until bleedingbone is noted. The fibula may beused as a strut graft or as crushedcancellous autograft to fill deep de-fects if it has been morselized.

The talus is apposed flush to thedistal tibia. After the surface congru-ency and joint position have beenchecked, the joint position is securedwith two guide pins for large (7.0- to7.3-mm) cannulated screws. The firstpin is started at the posterolateral cor-ner of the tibia and is placed acrossthe joint and into the neck of the talus.The second guide pin is placed fromthe medial malleolus into the lateralaspect of the talus. Alternatively, thesecond pin may be placed from thelateral process of the talus into themedial cortex of the tibia. Pin place-ment and bone apposition arechecked under fluoroscopy (Fig. 3, Aand B). Care must be taken that thepins do not violate the subtalar joint.

Once pin placement and bone ap-position have been found to be satis-factory, short threaded cannulatedscrews with washers are placed intothe bone (Fig. 3, C and D). Thewounds are closed with a two-layertechnique, taking care to protect theadjacent nerves. The extremity isplaced in a bulky cast padding and aplaster splint dressing, which ismaintained for 2 weeks. A non-weight-bearing short leg cast is thenapplied, and weight bearing is notpermitted until evidence of ar-throdesis is observed on the follow-up radiographs, which usually oc-curs 8 to 12 weeks postoperatively.

The arthrodesis technique mustbe modified for patients with com-promised soft tissues, with non-

unions after previous arthrodesisattempts, or with neuropathic anklejoints. Patients with symptomaticnonunions, osteonecrosis of thetalus, or Charcot arthropathy fre-quently require substantial debride-ment of devitalized bone from thetalus. Bone grafting can be used inthese patients to regain some of thelost height, but often tibiotalocal-caneal arthrodesis is required toachieve a successful fusion. Morerigid internal fixation is a part of

almost all fusion techniques used inthese difficult situations.

A technique for tibiotalocalcanealarthrodesis with the use of an angledblade-plate inserted through a poste-rior approach was reported in 1991.29

This technique was proposed for usein patients with persistent ankle-jointnonunion. With the patient in theprone position, the Achilles tendon isosteotomized at its insertion into thecalcaneus and displaced cephaladwith its attached bone block (Fig. 4).

A B

Figure 3 Anteroposterior (A) and lateral (B) images obtained during fluoroscopy of theankle joint with guide pins in place confirm surface apposition. Anteroposterior (C) andlateral (D) views obtained after screw placement demonstrate that there is no penetrationof the subtalar joint space.

C D



After ankle-joint exposure, articularcartilage is removed from the jointsurfaces. The nonunion site is curet-ted until viable bone is seen. Autolo-gous cancellous bone graft, harvestedfrom the proximal tibial metaphysisor iliac crest, is packed into the non-union site and the denuded joint.After proper joint alignment hasbeen achieved, a 95-degree 50-mmfive-hole blade-plate is seated into anappropriate slot prepared in the sur-face of the posterior calcaneus. Afterapplication of the tension device tothe free end of the plate, the screwsare inserted into the plate, and theAchilles tendon is reattached to thecalcaneus with a 6.5-mm cancellousscrew and ligamentous washer. Ashort windowed leg cast with a rock-er bottom is applied on the thirdpostoperative day, and touch-downgait is allowed for the next 6 to 8weeks, progressing to weight bear-ing as tolerated. The total cast-immobilization time after this proce-dure averages 12 to 16 weeks.

The results with use of a com-pression arthrodesis technique fortibiocalcaneal arthrodesis in seven

patients with nonbraceable neuro-pathic ankle joints were reportedin 1994.30 A cannulated humeralblade-plate was placed into thetibia and calcaneus through a later-al approach for rigid fixation, aug-mented by an external compres-sion device and large cancellousscrews (Fig. 5). The seven patientsin this series progressed to solidfusion in an average of 5.2 months.All became ambulatory in a lined,molded bivalve ankle-foot arthro-sis without the use of an ancillarydevice.

Mechanical difficulties reportedwith blade-plate techniques includedifficulty in placing the foot andankle in the optimal functionalposition and difficulty associatedwith accurate placement of theblade-plate into a small talus andcalcaneus. The use of a retrogradeintramedullary nail has been de-scribed for patients with soft-tissuecompromise, failed prior arthrode-sis, or diabetic neuropathy.31,32 The

drawbacks of retrograde nail fixa-tion include the risk of neurologicand vascular injury during nailinsertion (Fig. 6, A),33 difficulty inproviding compression across thearthrodesis site, placement ofscrews in the osteoporotic talus andcalcaneus (Fig. 6, B), and stress frac-ture of the tibia after operation.34

Results

Ankle arthrodesis, which was origi-nally a surgical treatment for tuber-culosis of the ankle joint, continuesto find use in patients functionallydisabled by ankle-joint destructiondue to a variety of causes. Severalscoring systems now are availableto provide standardized methods ofevaluating and comparing func-tional results both before and afteroperative treatment as well as be-tween the various techniques avail-able for ankle arthrodesis. TheAmerican Orthopaedic Foot and

Figure 4 The posterior approach (with thepatient in the prone position) for blade-plate insertion directly through the bed ofthe Achilles tendon for the patient with pre-existing anterior or lateral soft-tissue com-promise who requires arthrodesis. (Re-produced with permission from Gruen GS,Mears DC: Arthrodesis of the ankle andsubtalar joints. Clin Orthop 1991;268:15-20.)

Figure 5 A, Intraoperative lateral view of a tibiotalocalcaneal arthrodesis with placementof a 90-degree blade-plate guide and large cancellous-screw guide pins prior to blade-plateimpaction. B, Lateral radiograph obtained after insertion of lateral blade-plate.

A B

Achillestendon

Blade- plate

Calcaneus

Ankle Arthrodesis


Ankle Society has published a 100-point scoring system for the evalua-tion of ankle and hindfoot pain andfunction (Table 1).35 The most re-cent scoring system introduced forassessing patients with osteoarthri-tis of the ankle is the “Ankle Osteo-arthritis Scale,” which is based on avisual analog scale completed bythe patient.36 Unfortunately, nei-ther has yet been used to assess thefunctional results in a large series ofpatients with ankle arthrodesis.

Prior to 1979, the results ob-tained with ankle arthrodesis weregenerally graded as good if ar-throdesis was achieved or poor ifnonunion resulted. In 1959 Ratliffreported retrospectively on 59 pa-tients who had undergone com-pression arthrodesis of the anklewith a Charnley external fixator 1

to 9 years previously. The outcomewas graded as excellent in 61% ofthe patients, good in 18%, fair in19%, and poor in 2%. Six patientshad a limp, and 2 had persistentpain because of unrecognized sub-talar arthritis. A high rate of com-plications related to pin-track infec-tions was noted in this series ofpatients.

An early scoring system for as-sessment of patient function and gaitafter ankle arthrodesis was pub-lished by Mazur et al37 in 1979. Thissystem is based on a maximum pos-sible score of 90 points. The patientswho were evaluated in that reporthad an average preoperative score of40 points and an average postopera-tive score of 80 points, reflecting animprovement in patient functionafter ankle arthrodesis.

The same system was used byScranton12 in 1985 to evaluate inter-nal compression in arthrodesis ofthe ankle. Scranton used a T platemedially for compression of theankle arthrodesis site. His patientsachieved functional improvementfrom an average preoperative scoreof 47 points to an average postop-erative score of 82 points. A simi-lar study reporting the use of ananterior tension-band plate showedan average postoperative score ofonly 70 points, suggesting that thistechnique may not be as successfulas others.7

In 1991, Malarkey and Binski4

reported the results in 12 patientswho had undergone ankle arthro-desis with use of the Calandruccio-frame external fixator and bimalleo-lar onlay grafting. Eleven patientsachieved a solid osseous union.Eight patients were available forevaluation; the results in 6 wererated as good or excellent, and thosein the other 2 were rated as poor (1patient with nonunion and 1 patientnot rated because of underlying dis-ease that limited ambulation).

In 1991, Myerson and Quill8

evaluated the results obtained witharthroscopic ankle arthrodesiscompared with conventional openarthrodesis performed with use of6.5- and 7.0-mm screws. Joint fu-sion was achieved an average of 8.7weeks after arthroscopic arthrode-sis, compared with an average of14.5 weeks after arthrodesis withconventional internal fixation.However, the patients who under-went arthroscopic arthrodesis hadarthritic ankles with only minimaldeformity, whereas those for whomthe open technique was chosen hadmore severe deformities.

The results of arthrodesis in pa-tients who require revision are moredifficult to evaluate because of thesmall number of patients in reportedseries. In one study,29 five patientsunderwent revision arthrodesis fornonunion in which an angled blade-

Figure 6 A, Plantar retrograde nail insertion site at the junction of the calcaneal body andthe sustentaculum, adjacent to the lateral plantar neurovascular bundle. B, Retrogradenail insertion, with placement of one screw into the talus and one screw into the calcaneus,accompanied by insertion of bone graft at the tibiotalar arthrodesis site and impaction ofthe construct before screw placement into the tibia. (Reproduced with permission fromPaul Cooper, MD, and DePuy ACE Medical Company, El Segundo, Calif.)

A B

Lateral plantarartery and nerve

Plantar incision



plate was inserted through a poste-rior approach for tibiotalar, tibio-talocalcaneal, or tibiocalcanealarthrodesis. All five progressed tosolid ankle fusion after 16 weeks.On a modified Boston Children’sHospital rating scale, the averagepreoperative rating of the fivepatients was 13 points (of a possible50 points), and the average postoper-ative rating was 44 points. Three pa-tients subjectively rated their resultas excellent, and two rated it good.

The use of a combined open-compression arthrodesis techniquein a subsequent report dealing withnonbraceable neuropathic anklejoints resulted in solid fusion in allseven patients at an average of 5.2months.31 All became ambulatoryin a lined, molded bivalve ankle-foot arthrosis without the use of anancillary device.

Risk Factors for Nonunion

Ankle arthrodesis is a technically difficult surgical procedure that isfrequently associated with complica-tions. Patients being considered forankle arthrodesis should be screenedcarefully for identifiable risk factors.Even in series combining an openapproach with internal fixation, compression, and bone grafting, themost frequently encountered compli-cation associated with ankle arthrod-esis was nonunion.

In one study, Frey et al38 re-viewed 78 ankle arthrodeses toidentify factors that might predis-pose patients to nonunion. Compli-cations occurred in 44 (56%) of the78 patients at an average follow-upinterval of 4 years. These included32 nonunions (41%), 7 infections(9%), 2 nerve injuries (3%), 2 mal-unions (3%), and 2 wound problems(3%). Risk factors associated withnonunion in this series included asevere fracture, an open injury, localinfection, evidence of osteonecrosisof the talus, and coexisting major

Table 1American Foot and Ankle Society Clinical Ankle-Hindfoot Rating Scale*

TotalPossible

Criterion Points Points

Pain 40None 40Mild, occasional 30Moderate, daily 20Severe, almost always present 0

Function 50Activity limitations, support requirement

No limitations, no support 10No limitation of daily activities, limitation of

recreational activities, no support 7Limited daily and recreational activities, cane use 4Severe limitations of daily and recreational

activities; use of walker, crutches, wheelchair, brace 0Maximum walking distance, blocks

Greater than 6 54 to 6 41 to 3 2Less than 1 0

Walking surfacesNo difficulty on any surface 5Some difficulty on uneven terrain, stairs,

inclines, ladders 3Severe difficulty on uneven terrain, stairs, inclines, ladders 0

Gait abnormalityNone, slight 8Obvious 4Marked 0

Sagittal motion (flexion plus extension)Normal or mild restriction (30° or more) 8Moderate restriction (15° to 29°) 4Severe restriction (less than 15°) 0

Hindfoot motion (inversion plus eversion)Normal or mild restriction (75% to 100% of normal) 6Moderate restriction (25% to 74% of normal) 3Marked restriction (less than 25% of normal) 0

Ankle-hindfoot stability (anteroposterior, varus-valgus)Stable 8Definitely unstable 0

Alignment 10Good, plantigrade foot, ankle-hindfoot well aligned 10Fair, plantigrade foot, some degree of ankle-hindfoot

malalignment observed, no symptoms 5Poor, nonplantigrade foot, severe malalignment, symptoms 0

100

* Adapted with permission from Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA,Myerson MS, Sanders M: Clinical rating systems for the ankle-hindfoot, midfoot, hal-lux, and lesser toes. Foot Ankle Int 1994;15:349-353.

Ankle Arthrodesis


medical problems. Factors not asso-ciated with nonunion includedpatient age, past history of undergo-ing a subtalar or triple arthrodesis,and the surgical arthrodesis tech-nique selected. A prior diagnosis ofa combined plafond-talus fractureled to the worst prognosis, followedby Hawkins II or III talar fractures.Large-fragment screw fixation led tohigher fusion rates, possibly be-cause less soft-tissue stripping wasrequired for screw fixation com-pared with plating or possibly be-cause these screws provide bettercompression at the arthrodesis site.

Nonunion after ankle arthrode-sis has also been associated withsmoking.39 In patients withoutother risk factors, the risk of non-union in smokers has been estimat-ed to be 16 times the risk of non-union in nonsmokers. The effectsof nicotine on the peripheral circu-lation and the effects of hydrogencyanide and carbon monoxide onthe oxygen-carrying capacity ofhemoglobin have been cited as pos-sible causes of the high rate ofnonunion in smokers. The periodof smoking cessation prior to anklesurgery necessary to clear the toxic

effects from the patient has notbeen established, but 1 week hasbeen empirically suggested.40

A careful attempt should bemade to try to learn the reason fornonunion in patients in whom revi-sion surgery is contemplated. Thisshould include a complete workupto rule out local infection and toattempt to identify associated riskfactors that might compromise asuccessful outcome.

Summary

A thorough history and physicalexamination will help to determinewhich form of treatment will pro-vide pain relief and improved func-tion in a patient with advancedankle arthritis. If nonoperativetreatment measures fail, operativeintervention should be considered.Careful examination of all lower-extremity joints, limb alignment,and the relationship of the hindfootto the forefoot, as well as gait ap-praisal, should be carried out pre-operatively. A plantigrade foot po-sition can be obtained by placingthe heel in 5 to 7 degrees of valgus,

externally rotating the ankle by 5 to10 degrees, and displacing the talusposteriorly. Appropriate position-ing of the foot during arthrodesishelps to avoid altering the patient’sgait significantly and also helps topreserve hip and knee function.

Several surgical techniques forperforming ankle arthrodesis areavailable. External fixators are rec-ommended for fixation in patientsundergoing arthrodesis because of apreexisting septic joint or osteope-nia. Arthroscopic arthrodesis or the“mini-open” arthrodesis can be con-sidered for patients with minimaldeformity. Open arthrodesis isadvisable for patients with signifi-cant ankle deformity and foot andankle malalignment. Nonunion ofankle arthrodeses can occur in up to40% of patients. Smoking cessation,awareness and control of knownrisk factors such as metabolic dis-eases and osteonecrosis, careful pre-operative planning, and meticulousoperative technique all contribute toa successful outcome.

Acknowledgment: The authors would liketo thank John J. Gartland, MD, for his assis-tance in the preparation of this manuscript.

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Ankle Arthrodesis: Indications and Techniques