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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Benjamin Overley, Jr, DPM
Surgical Skills Committee
Section Editor for Trauma-Journal of Foot and Ankle Surgery
Foot and Ankle Specialist/PMSI Orthopedics
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Ben Overley: Okay guys I am going to get started here on arthrodesis techniques. When I got this topic sent to me I thought you know could give me a broader topic here to deal with arthrodesis of what? You know we are talking toes here, ankles, so I am going to try to get through this real quick, try to kind of get us back on track then I am going to come right back with the calcaneal fractures, which is actually scheduled to follow Dr. [Sharon House] [00:00:28] [Phonetic] lecture he will be following me. So I am going to try to tie together Dr. Rowe and Dr. Josephs talk a little bit here because there are some cases to share you here and maybe you will get something out and maybe you won't, hopefully none of your aid so we will be ready to get going here again on this disclosures � and so when we talk about arthrodesis really the key things here and again this is you know I have got you know fourteen minutes to cover, well it could be like a two hour lecture here it's really just the understanding you know how do we get these things defuse you, you heard you know Dr. Ralph here talking about Lapidus and great toe fusions and you know I am in a complete agreement with what he had to say about everything and you know fixation constructs and what parts do they play and then in addition you know Dr. Sharon is also going to be talking about orthobiologics or osteobiologics, augmentation, how do we deal with these difficult fusion sites so and then how do you know that it's effused.
So, I mean that�s really kind of the question, so when we took, when I think about fusion or arthrodesis sites what I am trying to do is I am trying to think about these dos and don�ts and I try to just kind of keep these in my head as I am working through this and really the key take home message with this is you know really don�t skeletonize the tissue, you don�t want to strip these things down, remove the blood supply and then scratch your head three months later and say why didn�t this fusion take, it doesn�t make sense that it would. You are going to make sure that you have got a good solid foundation for fixation, that you have got good compression across the fusion site, but in addition you need to make sure that you have good stability of your fusion side because really you know whether you are dealing with people that are going to be walking prematurely on these areas, I mean these are all things that you need to consider when you are you know doing arthrodesis on any joint.
So, you know just commonsense things, there is a lot that had been added in the foot and ankle but it certainly is not like doing an anterior cervical diffusion in the neck. No one is going to become a horse after, I don�t know one gets so much feedback here, but you can see you know when we have this much anatomy to deal with here, you know you hate to have a good fusion and have the patient come back with a lot neuritis afterwards so a lot of anatomy just keep that in mind when you are, you know making your approach to these sites.
So again going back to what I you know spoke about earlier, you know making sure that you don�t skeletonize the tissue, you can see you know appropriate decortications, you are going to make sure that you are removing cartilage that your fenestrating that bone, you want to puncture that subchondral plate allow for that good bleeding to occur so you can get your fusion site to heal and then probably number one source of online unions when you think about it is you didn�t do adequate dissection, you really didn�t remove everything, you didn�t puncture that plate and then you wonder why it's not healed down the road well that�s probably going to be your most likely suspect of then premature motion at diffusion site.
So you can see there the, you know the tissue is left intact down here and on doing it's basically just decorticating that talar head and the way I always explain it to the people that I have trained in the past is when you think about a fusion site, fusion site basically two sides of an English muffin, okay. So you have got an area that�s got raised areas and you have got you know little you know holes or crevices so if you take an English muffin apart that�s basically fusion sites, so here areas are going to undergo primary bone healing with the cutting cone because they are touching and pushing together. You have other areas where you are going to have a valley lining up with the valley where you are going to have to get that second type of primary bone healing to occur where you need that clot formation to form up so you have a good cell fusion. Okay so we are all on the same page with that and the understanding is, here is when you use hyper compression or you are really, really over compressed fusion site what are you doing to your high points to your mountains and you are smashing them and understand that there is going to be two millimeters at that fusion site that needs to basically be regenerated because you are basically tamponading just like pressing your finger tip and keeping the blood out of it, you are basically doing that with your fusion now so what's too much fusion, what's too much compression well I mean that�s a topic for another time but you know when you take a look at it you know hear two finger tightness, well I mean I have hands like ET so what's you know two finger tightness in my hands, what's two finger tightness in the little you know dainty five foot one you know woman you know so I mean all these stuff is relative because it all comes down to making sure that your fusion is solid and that we have good side to side or bone to bone contact.
The other thing is making sure that you in every case possible that you keep your anatomic contour, where do we get into trouble with fusions is when we start messing with anatomic architecture. We start cutting things out, moving them, shifting them, wedging them, throwing in things here and throwing in things there and that�s when you end up with trouble. So I will just run you through some quick cases here, we will move on to the next talk here, but this is you know like when is enough fixation, is enough fixation that�s probably not fixation I probably could have plantar flexed here a little bit better, but the take on point is that I have got good fixation purchasing across these joint sites so I am able to control them a lot better.
Now this is maybe a little, you know this gets back to my old days in practice probably my first one in two years out and you can see there that�s a lot of metal. We, you know didn�t have all these nice plates and screws that we have today from all these different companies as you know Dr. Rowe was saying you know in my practice I think every day I am visited by a rep, it's sort of like that goes to Christmas pastor or whatever so everyday so you can see here you know you can achieve good fusions and this is you know want a metal but we did get a good result you know but this is you know no joke here I mean that that you can really over metal some of these people so that was just kidding it and almost out from every metallosis, but the, so you don�t want to over metal things because remember every millimeter that you take up in a fusion sight you are actually taking away and bone to bone contact which is inevitably what you want at the end right, I mean that�s what I am looking for, so if you can get these two fixation points for all your joint surfaces that you are trying to fuse you probably are going to have a very stable fusion and one that�s probably going to heal and like here is the case, which to me this was actually the one I reviewed and you can see this probably needs some more metal, but you know you look at them, you say well that should have been enough but really you are not controlling all those plains emotion because you are not controlling those plains emotion you are more like to get a non-union which is what happened in this case.
So angular deformities and why do we do, you know I said, you are aware of angular deformities, but most of these people are fusing, whether it's a triple, whether it's a great toe, they have got angular deformity that�s where we are fusing them okay so how can I say beware of these and then we move on to fusing them, well understand that if you have got some patient that�s had thirty five years of ankle valgus and you try to fuse them it's going to want to go back, okay, it's you know it's coming like the you know the ankle that keep showing up you know what I mean, you know it's, these people are going to want to drift back into theirs, drift back into valgus and you are really going to have to fight them tooth and nail to make sure that they say where they are so if I have got a valgus patient I will tend to fix some adductive and in slight wears because I know when they begin to walk, they don�t walk externally rotated like they always have with their valgus foot and I know they are going to try to drift that fusion site and think about it, we have got screws fixed in soft cancellous bone in most of these cases this is not a rigid cortical bone, it has the ability to move, it can shift, those screws can dial in and they can change position just by a shear, you know gate and gate pattern so we have to take that into account when we are doing these things and make sure that we are able to stabilize them and fight them.
[Off the mic comments]
So you take a look here I mean this is your typical valgus, you know patient you can see here you know we have got this foot it doesn�t look that bad when you look at it from this view but when I flip it and you see what she looks like you know you can see that�s the patient that�s going to you know be walking externally rotated, she is going to have a lot of hindfoot valgus and you can see her she actually had a callus from where her talar head has actually been driving through in the underside of the skin. So you can see what I like to do here with these is just basically, I removed everything, I take the posterior tibia down I cut that spring ligament, I want to expose that talar head and I get everything exposed and if I decide I am going to do triple arthrodesis I can do it all through this incision , I can access a subtalar joint, posterior facet, the back half of the middle facet and I can actually use these joint expanders to isolate the CC joint do it all from the medial approach and I never go laterally with it and you can see here with that callus formation again and one of the things that happens with these patients that have long term valgus is that that spring ligament is a bag, it's basically so beat up and torn and so attenuated that you really even with an imbrications you are not going to hold that talar head back in place and I don�t care how tight you make it or if you put surgical steel in it it's still not going to hold. So what I do is I actually use just a simple little cut up mesh plate and I grab that talar head on the underside after I have got my inner fragment area or my interfusion compression and I am using that basically just to stabilize so this is my new spring ligament only it's metallic and then I can come back later and I can silver over top of that with the you know the former spring ligament which is baggy and I will often time tighten that up and I do that in an effort to control that abnormal motion because it wasn�t to go back, understand it, it always wants to drift back to that position that it was in.
So here you know you can end and again this is just the expanding on you know with Dr. Rowe said you know you are placing this interfusion compression, but instead of plate I am using these two screws but what are they doing, they are splinting my fusion site just like a plate would, only there are very big screws and you can see there are cannulated screws here and they are basically just holding my fusion together and controlling these emotions in these various plains allowing for the fusion to take place. And here is old school again you know when you know this was like probably my first or second year out but you can see this is before we had all the neat little low profile plates which you get the point you know a large, you know metatarsal ferrous angle, we see pre-dislocation location here at the second MTP and you can correct that out with a plate and again I am using that plate over top after I have got my compression, so I get my compression and then I am going to solidify that fusion site with that screw. And you know here is, this was a case that was actually from North PA that came down to me, you can see it didn�t work out well, she got a varus, she has got an extensus and what you do with somebody like that because you know they are going to want to go back to that sort of cocked up position, so what you do with them is the same thing and you are basically just going to plate them actually just set a flexor release on her, plate at the great toe joint got that healed and you can see the result as you know that�s definitely adequate and a lot better than what she had, she can wear any shoes so and you can see those are post-op views they are looking from a lateral.
So again you know the concept is really just to make sure that you are getting that compression and then plating over top of it, so here we can see for subtalar joint arthroereisis tips I only fuse the posterior facet, I do not, I don�t do any denuding or stripping of this region, I don�t want to get into this area because I am worried about that blood supply, I have had talar heads disappear on me and you know four or five months after what I felt was a solid fusion I began that to see that talar dome beginning to get flatter and flatter, when you take an AP of the ankle and you see your ankle, you taluses now expand immediately and laterally. Now what's happening there, well I will tell you what's happening, you got a little crazy in there with your burr and your rongeur and you cleaned out every bit of blood supply to this talar body and then you wonder why you end up with this disappearing talus and it begins to flatten out, then what you do you do because now really you got to, it's behold and you did cut that out and come back and re-graft it.
So again just you know here is an ankle replacement, isolated posterior fusion or a posterior facet fusion and you can see here I mean this is a you know failed agility probably it shouldn�t have been put into this patient, this is a cavovarus ankle, these are very difficult, this would require a malleolar type osteotomy on the heal, a stemmed implant to control motion, dorsiflexion, first metatarsal osteotomy to even get that sort of tripod flip formation and look at that, I mean look at the callus formation here on the toes, so you know that this thing is going to subside you can see it and where is it going to go unlike a flat foot which was subsided posteriorly, a callus foot is always going to subside anteriorly so when the replacement fails that�s where it's going to fail is on the anterior threshold or anterior manifold. So you can just go in and this is just again you know intramedullary nailing so to my other cases it's just a simplistic striker nail going in and making incisions and making your incision getting that you know implant out and just coming back and writing and putting in the slide valgus, I am sorry about the clarity of the photographs there but it's the best I could do, this is the case that I was referred to me and actually from Mahwah, New Jersey and you can see this was a tri-malleolar ankle fracture that went bad, did not heal, so then there was an attempt made by the local surgeon to do an arthrodesis that also did not work out too well as you can see. Kind of the wrong screws and this is how, actually how she presented the emergency room, this was the position she was fixed in, not to mention there was a little open wound here on the side. So what do you do with that, I basically just kind of ignored everything, went in and got with the ankle, applied lateral plating and got her plantar great food and I did not, I did a very minimal takedown here and just threw my screws across again as Dr. Rowe said using a lot of plating and her ankle joint was compressed that�s her first post-op view and she is doing well at this point, I can always go back and fix the callus forefoot if I need to.
This was a case that was actually from Philadelphia where an � he came to me for a second opinion and the orthopedists in Philadelphia said he could have an ankle replacement, this is a three hundred fifty pound diabetic male, I know who the orthopod was and I am really shocked that he even offered that to this patient, but this is not somebody that�s going to do well with an ankle replacement down the line. So you can go in and again use a lot of plating to again stabilize these fusion sites basically giving him pantalar, I am always concerned with diabetics that if you start locking up joints what's going to happen to be adjacent joint especially with somebody that�s three hundred and fifty pounds and we can get them all straight that way instead. So from my last case we are down to about five second here so I will get through this quick.
This is a woman I did, you can see hindfoot ankle valgus, OA in the ankle joint and you can see she has got all sort of cystic degeneration, ankle arthritis, hindfoot valgus. So what I did with her was I did a triple with an INBONE stemmed modular implant here and you can see I have done a triple with naviculocalcaneal screw, this is just a three screw configuration with an isolative posterior facet fusion, everything is moving along assumingly except for I have got a wound. So you can see that and you can begin to see what's going on with that, she swelled up pretty badly and I am at this point beginning to get a little nervous so whenever I get nervous I would like to load the bone and I get plastic involved so � and the plastic surgeon decides he is going to attempt to rotate a flap, so she does that and there is the flap rotation and you can see now this was doing well but now it's beginning to break back open up again this is at the point where the infectious disease specially says to me this ankle implant is interrupted that�s why her wound won't heal and this needs to come out and by the way I am documenting that and I have also called the plastic surgeon and I told him to document that the ankle implant is infected. So my one gun went from, I went from one to two guns and this was in a pretty span of an hour so now what do I do, it's in paper now, I have got to get it out of there so excise the wound, open it up, do my explantation, culture everything in the world, take biopsies from everything around the implant itself you can see on putting some injectable antibiotic and bone grafting material and cement up there. Again here you know there is my implant that it's out, there is my block sizes, I am planning to do with this and there is me preparing it and you can see I have got my antibiotics spacer in there and now I am going to do a local wound care. So what's the moral of the story? So this goes back to Dr. Joseph, so six weeks of antibiotics, twenty cultures and biopsies taken all hardware removed, what did it show me? But the only thing that was infected was that stupid little scab that was on the top of her ankle.
Yeah I know it's not a collected gas, yeah I did, if you think you feel bad for me you can only imagine how bad I feel for me after that, so MSSA really like you give me MRSA. Give me VRE; give me something worthwhile so what's the next move folks, well as we just go to the augmentary graft and Dr. [Sharon House] [00:17:31] [Phonetic] is showing how this is going to go into that I don�t want to step too much in his lecture, so what am I going to do to just look up this wound upfront so what do I do with this patient, I mean this is a problem here because I got to figure out a way to address it, well let's see if the front door is closed it's going in the back. So I am going to make a Z line thing , I am going to go in through that posterior manifold, I am going to gain access to that posterior ankle joint, I am going to get my, I am going to use my heinemanns [phonetic] [00:17:54] which get a severe workout every week and you can see I am going to remove that cement block, you can see me beginning to wedge and lift that out and I have got my acetabular reamers, I have got my femoral head and I am going to basically shape that to allow for bony in growth and it's going to be a real flow to get aside a little posterior lock plating and there we go. So that�s it for the arthrodesis techniques and I am only three twenty four over, I will pick it up in the calc lecture I promise.