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Surgical Technique for Total Ankle Arthroplasty in Ankles with Preoperative Coronal Plane Varus Deformity of 10° or Greater
Timothy R. Daniels, MD, FRCS(C)1
1 Division of Orthopaedic Surgery, St. Michael’s Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address: danielst@smh.ca
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Based on an original article: J Bone Joint Surg Am. 2013 Aug 7;95(15):1382-8.



Disclosure: The author received payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of an aspect of this work. In addition, the author, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2013 Nov 27;3(4):e22 1-10. doi: 10.2106/JBJS.ST.M.00043
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Extract

Overview
Introduction

Total ankle replacement for end-stage ankle arthritis with talar varus malalignment of ≥10° can achieve satisfactory outcomes in the ankle joint, and ≥10° of talar varus malalignment should not be considered a contraindication for surgery.

Step 1: Preoperative Assessment and Planning

Conduct a thorough clinical and radiographic evaluation of the entire lower extremity.

Step 2: Surgical Assessment

In the operating room, conduct a physical examination prior to and following ankle exposure to determine the ancillary procedures required.

Step 3: Medial Soft-Tissue Release (Pes Cavus Correction)

Proceed with tendon and soft-tissue release as needed to correct pes cavus deformity and improve range of motion.

Step 4: Correction of Varus Talar Deformity

Correct varus talar deformity via a standard resection of the ankle joint osteophytes, starting laterally and finishing medially.

Step 5: Posterior Tibial Tendon Transfer to the Peroneus Brevis

Consider transfer of the posterior tibial tendon to the peroneus brevis to help maintain correction of the varus deformity.

Step 6: Ankle Replacement

Once you determine that the talar varus is correctable and you have prepared the posterior tibial tendon for transfer, perform the total ankle replacement.

Step 7: Foot Evaluation and Ancillary Procedures

Evaluate the rest of the foot and perform any required ancillary procedures; most often a dorsiflexion osteotomy of the first metatarsal is necessary to correct forefoot valgus, which is commonly seen in forefoot-driven cavovarus deformities.

Results

Patients with preoperative coronal plane varus tibiotalar deformities of ≥10° who underwent total ankle replacement have shown significant improvement in clinical outcome scores at the time of mid-term follow-up.

Indications

Contraindications

Pitfalls & Challenges

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    Video 1 Preoperative foot position. This video demonstrates the physical examination of the ankle in the operating room, after the patient has been fully anesthetized.

    Running Time: 0:32

    Video 2 Plantar fascia release. This video demonstrates the incision made in line with the posterior border of the medial malleolus and blunt dissection down to the fascia of the abductor hallucis and of the plantar fat pad away from the plantar fascia. Note the collapse of the medial arch following the plantar fascia release.

    Running Time: 1:53

    Video 3 Talonavicular (TN) capsule release. The posterior tibial tendon has been released and has been prepared for transfer to the peroneus brevis. A laminar spreader is used, and a Cobb elevator is inserted to gently lever the navicular away from the talus.

    Running Time: 4:04

    Video 4 Debridement of lateral osteophytes. A lateral incision is made, starting proximally at the fibula and extending distally into the sinus tarsi, to open the peroneal sheath. The fibula and lateral aspect of the talus are exposed by carefully dissecting the anterior talofibular ligament and the ankle capsule off of the fibula. Osteophytes are carefully resected off the anterior aspect of the fibula and talar body.

    Running Time: 3:47

    Video 5 Debridement of the medial aspect of the ankle joint. The ankle joint is exposed through a standard anterior approach. Osteophytes located on the anterolateral plafond, medial aspect of the tibia, medial malleolus, talar neck, anteromedial surface of the talus, and inferomedial aspect of the talar neck are debrided. The ability to reduce and correct talar alignment in the coronal and transverse planes is evaluated and is demonstrated on fluoroscopic stress views.

    Running Time: 3:23

    Video 6 Cementing technique. In a staged total ankle replacement, the gap between the corrected talus and the medial malleolus is visible. Antibiotic cement is inserted into the medial gutter and is allowed to cure before removal of the Kirschner wires that hold the corrected talus in position.

    Running Time: 1:31

    Video 7 Transfer of the posterior tibial tendon to the peroneus brevis. A proximal release of the posterior tibial tendon sheath is performed to facilitate delivery of the posterior tibial tendon proximally. A posteromedial incision is made at the junction of the middle and distal parts of the leg to expose the proximal aspect of the posterior tibial tendon. The flexor digitorum longus is retracted to expose the posterior tibial tendon at its musculotendinous junction, and the posterior tibial tendon is carefully transferred from the medial to the lateral side. Observe the diseased peroneus longus and the ruptured peroneus brevis tendon. The posterior tibial tendon is transferred to the peroneus brevis.

    Running Time: 3:01

    Video 8 Medial malleolar osteotomy. A gap between the talar component and the medial malleolus is observed, and the talus falls into this gap on internal rotation of the foot and ankle. A transverse rotational medial malleolar osteotomy decreases the anteromedial volume of the ankle mortise. The medial malleolus is then rotated at the anterior aspect in a lateral direction. A towel clip is used to bring the anterior aspect of the medial malleolus in a lateral direction, and care is taken to not damage the total ankle replacement components. A fully threaded 4.0-mm cancellous screw is used to stabilize the rotated medial malleolar fragment.

    Running Time: 2:53

    Video 9 Removal of cement. In a two-stage total ankle replacement, the cement is removed without difficulty during the second operation. The surgeon then proceeds with a standard ankle replacement.

    Running Time: 1:21

    Video 10 Calcaneal osteotomy. The lateral fibular incision is well healed, and the lateral tissues are receptive to a second incision. A lateral based closing wedge calcaneal osteotomy is performed. The calcaneal osteotomy is stabilized with two 4.5-mm fully threaded cannulated screws.

    Running Time: 4:41

    Video 11 First metatarsal osteotomy. A dorsiflexion osteotomy of the first metatarsal is performed to correct forefoot valgus. Usually, <5 mm of bone is removed to appropriately position the plantar flexed first metatarsal. The osteotomy site is stabilized with bone staples.

    Running Time: 0:49

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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