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5/10/2013 1

Palo Alto Medical Foundation / UCSF Peninsula Orthopaedic Ankle Surgeons

Novel Ankle Fusion Technique Through Medial Malleolar Nonunion

Andrew Haskell, MD

Palo Alto Medical Foundation / UCSF Peninsula Orthopaedic Ankle Surgeons

Novel Ankle Fusion Technique Through Medial Malleolar Nonunion

I have no conflicts for this presentation Approved by PAMF IRB

Ankle DJD & Medial Malleolar Nonunion

Post-traumatic

Charcot Arthropathy

Surgical Goals for Ankle Surgery

• Must have a ...

– STABLE –

PAINLESS

–

PLANTIGRADE FOOT

• but we would ALSO like to...

– MAINTAIN MOTION – NORMALIZE GAIT – PROTECT SURROUNDING JOINTS

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Why Are Medial Malleolar Non-unions a Problem?

• Standard screw techniques rely on intact

medial buttress for stability

Good Bad

Why Are Medial Malleolar Non-unions a Problem?

• Retrocalcaneal nail sacrifices the subtalar joint
• Total ankle replacement needs intact medial malleolus

Why a Medial Based Approach?

• Approach via the nonunion
• Does not rely on medial

buttress

• Preserves the subtalar joint
• Can use bone for graft
• Retrospective chart review
• 42 sequential ankle/hindfoot fusion cases
• January 2006 - December 2008
• Inclusion
• intention to fuse ankle through a medial approach
• Data collection
• Demographics
• Success of fusion
• Subjective improvement & motion
• Need for further surgery

Methods

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Technique

• Medial approach
• Joint preparation
• Wire in center of talus
• wire parallel to plantigrade foot
• use plate as guide
• Impact blade into talus
• Compress if possible
• Secure plate to tibia

Results

• 4 fusions using a medial approach identified
• 4 male
• Average age 61
• Etiology
• 3 Charcot
• 1 post-traumatic

Results

• 4 (100%) of 4 fused using medial approach
• 2 ICBG
• 1 required conversion to tib-talo-calcaneal fusion after

intraoperative talus fracture Case 1: Post-traumatic nonunion

Results

• Average time to ambulation 3.3 months
• Charcot braced 6+ months
• No additional procedures required

Case 2: Charcot ankle fracture

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Results

• 4 of 4 report improvement in pain & stability
• 2 of 4 require walking aid
• Subtalar joint motion rated fair to normal

Case 3: Charcot ankle nonunion

Literature - Ankle Fusion

Study Method # Pts F/U Fusion Rate Outcome Mann 1996 Open 81 1-6 yr 88% AOFAS 41 -> 74 Myerson 1996 Mini-open 15 1 yr 100% AOFAS 43-> 82 Winson 2005 Scope 118 5 yr 92% 79% good/exc Ferkel 2005 Scope 35 6 yr 97% 74% good/exc

Literature - Medial Approach

• Medial malleolar osteotomy
• Union 12 (92%) of 13

Schuberth, J Foot Ankle Surg, 2005

Future Directions

• Locked Plates

Anterior Medial

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Future Directions

• Primary Fusion?

Palo Alto Medical Foundation / UCSF Peninsula Orthopaedic Ankle Surgeons

Thank You