Arthroscopic Tibiotalocalcaneal Arthrodesis

Abstract

Introduction: Arthrodesis is still the gold standard for severe ankle and hindfoot osteoarthritis. The arthroscopic tibiotalocalcaneal arthrodesis technique has been described and developed in the past decade. Tibiotalocalcaneal arthrodesis (TTCA) is the election procedure for combined severe ankle and subtalar osteoarthritis after failure of conservative treatment. The arthroscopic technique is more respectful to the surrounding soft tissues and the vascular supply; hence, it provides a theoretical benefit in terms of consolidation, and it is suitable for cases in which the open surgery is not desirable. We perform the surgery with the patient in prone decubitus position, and we use conventional arthroscopic instruments. We use the posterior portals described by van Dijk to access both tibiotalar and posterior subtalar joints and perform the cartilage denudation. We aim to have a healthy, well-vascularized subchondral bone and obtain a good coaptation of the articular surfaces. The retrograde tibiotalocalcaneal nail is the implant of choice for the TTCA. We consider that the lower surgical aggression of the arthroscopic procedure compared with the open technique should allow a satisfactory union rate without bone grafting. The global consolidation rate reported is 67% to 100%. The global complication rate reported is 7% to 33%. Most are related to osteosynthesis material and superficial wound infections. Arthroscopic TTCA offers excellent results in selected patients. A protocolized surgical technique using posterior endoscopic portals is mandatory. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic-assisted tibiotalocalcaneal arthrodesis in an ankle fracture with a suboptimal soft tissue envelope

“…Surgical strategies wherein the extent of soft tissue disruption is minimized is preferable in these complex patient scenarios 3 , with less invasive techniques such as TTCA identified as alternatives in high risk patients when definitively treating trimalleolar ankle fractures 1 . Despite TTCA often being described as an option in the degenerative setting with compromised soft tissues 5 , it has also been proposed as a viable primary treatment strategy for management of ankle fractures in a complex diabetic population, with the utilization of percutaneous or small incisions helping to reduce the overall infection and soft tissue complication risk in patients who often present with concurrent soft tissue diabetic sequelae 4 .…”

“…While the utility of arthroscopic-assisted TTCA has been described in those with endstage osteoarthritis and susceptible overlying soft tissues 5,7 , its utility to our knowledge is seldom reported in the literature when pertaining to primary definitive management of ankle fractures in this high-risk and increasingly encountered patient group. The subsequent case thus intends to illustrate the potential role of performing an arthroscopic-assisted TTCA in primary management of an ankle fracture occurring in a comorbid individual with an underlying suboptimal surrounding soft tissue ankle envelope.…”

“…Primary arthrodesis procedures have been shown to be a valid option in those with comminuted fractures, osteoporotic bone or underlying comorbidities such as diabetes 1,4 , with the utility of retrograde tibiotalocalcaneal nail arthrodesis (TTCA) through small incisions described as of particular benefit in minimizing soft tissue risk in primary treatment of ankle fractures in a diabetic population 4 . Arthroscopic techniques have also been increasingly reported as a useful adjunct in management of acute ankle fractures as well as in planned TTCA for osteoarthritis so to reduce insult to surrounding soft tissue and vascular supply 5,6 .…”

Arthroscopic Contribution of Synthetic Graft in Tibiotalocalcaneal Arthroscopic Fusions

“…Standard arthroscopic instruments were used: 4.5mm x 30º arthroscope, 4.0mm Shaver Blade, 4.0mm burr, low-pressure infusion pump at 35 mm Hg (Stryker, Greenwood Village, CO) together with ring-handle graspers and punches, curettes, osteotomes, elevators and chondral picks (Arthrex, München Germany). We started the artroscopic procedure as published previously by van Dijk and recently by Vilá y Rico 2020 [ 7 ]. Crushing of the subtalar and tibiotalar joints was performed with motorized cutters.…”