Arthrodesis (closure) of the ankle joint: indications and methods of implementation

Arthrodesis of the ankle joint is a surgical intervention for artificial fusion of the articulating articular surfaces of the ankle in a position that is physiologically advantageous for the functioning of the leg. The main goal of surgical treatment is to provide support to the problem area by completely blocking its mobility (creating ankylosis). Immobilization is achieved by rigidly connecting the adjacent ends of the joint bones to each other with special metal fixators (knitting needles, screws, pins, etc.). This allows the articular surfaces to firmly fuse with each other at the desired angle, that is, to bring the joint into a completely motionless state, which will help the patient get rid of severe pain and instability of the foot.

Example of fusion.

The arthrodesis technique dates back to the very beginnings of the development of orthopedics, and therefore is an outdated tactic for ankle surgery. The discovery of the “joint closure” method dates back to 1887, first proposed by the Viennese surgeon Albert. Operational technical concepts have changed little since that time.

The effectiveness of ankle arthrodesis has a long-standing evidence base, but due to the radical approach and the high incidence of postoperative complications, retro-style intervention is used in the most extreme cases.

Ankle injuries

The main purpose of the ankle joint, formed by the tibia, fibula and talus bones, is to be a reliable support for the musculoskeletal system. This section of the leg must consistently support almost 90% of the total body weight when a person stands or performs any kind of physical activity in an upright position. In addition to supporting functions, the joint provides shock absorption of the limb, various movements of the foot in a normal amplitude:

flexion;
extension;
abduction;
casting;
rotation.

The stable functioning of the bone joint is guaranteed by the healthy condition of the ligaments, bones, cartilage, and muscles that form it. If at least one unit of a joint fails, not only its performance is impaired, but also an imbalance in the functions of the entire musculoskeletal system occurs. Diseases of the ankle joint have a detrimental effect on the ability to move, lead to deterioration of gait, and often lead to disability. Often, serious pathologies that may require arthrodesis begin with trivial injuries localized in this area:

bruises;
dislocations and subluxations;
ankle fractures;
violation of the integrity of the heel bone;
ligamentous distortion (sprains, tears of ligaments, etc.).

Lesions of a traumatic nature often occur as a result of direct exposure to mechanical force, which is provoked by local impacts, falls from a height, unsuccessful jumps, and sharp rotational turns. After all, sometimes it is enough for a person to simply slip on a slippery surface or trip for damage to the constituent structures of the ankle.

Any traumatic lesions require timely diagnosis and immediate treatment. After a certain period, the injury, if proper medical care was not provided in due time, makes itself felt with serious consequences. Pathologies resulting from an old injury, against the background of imaginary well-being, are manifested by the sudden onset of pain and increasing limitation of the locomotor and support potential. People don’t understand what happened, where the discomfort came from, and the cause turns out to be a past injury.

Remember! Complex degenerative-dystrophic processes, often irreversible, predominantly do not develop on their own, but are diagnosed as a post-traumatic complication. The most common pathologies of post-traumatic origin with a serious progressive course are arthritis and osteoarthritis.

Arthrosis, in turn, is a consequence of arthritis. This is the chain mechanism for the development of a complex clinical situation. It is not difficult to go from injury to deforming osteoarthritis (DOA) in a couple of years. But if the injury is not difficult to treat conservatively, then with arthrosis of the ankle joint everything is different - it is an incurable disease that critically depresses the quality of life and negatively affects the statics and dynamics of the entire limb.

In what cases is endoprosthetics indicated?

The upper ankle joint, formed from the ankle joint itself, the tibia and fibula, is susceptible to arthrosis. In advanced stages, patients suffer from chronic pain and are unable to move normally. If conservative therapy fails, they are recommended to undergo upper ankle joint replacement. After operation:

the pain subsides;
gait normalizes, although it is impossible to completely restore mobility;
the patient can perform daily tasks again.

About 90% of patients are satisfied with the results of ankle replacement

Indications for surgery

Blocking the motor functions of the ankle segment by bone fusion is prescribed when such pathological conditions are identified as:

secondary (post-traumatic) and primary arthrosis, grade 3-4;
severe chronic arthritis, including rheumatoid type;
constant pain in the ankle and/or radiating to the knee joint, which intensifies even with minor loads;
severe lameness due to joint deformation;
persistent impairment of the support ability of the foot, expressed by the inability to fully stand on the leg due to weakness of the ankle system, laxity;
severe flexion-extension contracture of the joint;
paresis and paralysis of the leg muscles, which developed against the background of polio in the past;
improperly healed fracture, pseudarthrosis.

Arthrosis of the left joint. The joint space is very small.

Department of Traumatology and Orthopedics

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ON THE. Gear1, A.M. Matsakyan2, V.G. Protsko3

1Federal State Autonomous Educational Institution of Higher Education First Moscow State Medical University named after. THEM. Sechenov (Sechenov University) Ministry of Health of the Russian Federation, Moscow 2GKB named after. A.K. Eramishantsev DZM, Moscow 3GKB named after. S.S. Yudina DZM, Moscow

Summary: Currently, varus deformity of the feet is considered one of the most common diseases of the foot and ankle joint. With this type of deformity, the foot has a characteristic hemilateral curvature, which is accompanied by inward deviation of the forefoot and the development of clubfoot.

The purpose of this study is to improve the results of surgical treatment, analyze the system of surgical treatment techniques and develop an algorithm for selecting the most optimal surgical treatment options for the 3rd stage of development of polovarus foot deformity.

We have summarized the clinical experience of surgical treatment of 145 patients with grade 3 polovarus foot deformity, who underwent 177 surgical interventions.

Analysis of the long-term results of surgical treatment showed that an individual approach to such severe deformities, depending on the involvement of the foot, a combination of operations on both bones and soft tissues, ensured a favorable course of the postoperative period and an earlier start of rehabilitation.

Key words: polovarus deformity, osteotomy, arthrodesis, foot.

SURGICAL METHODS OF CORRECTION VARUS DEFORMITY OF THE FOOT 3 DEGREES

Shesternya NA1, Matsakyan AM2, Protsko VG3

1I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia 2Municipal Clinical Hospital named after AK Eramishancev, Moskow 3Municipal Clinical Hospital named after SS Yudin

Summary: Currently, varus deformity of the foot is one of the most common in the structure of diseases of the foot and ankle. With this type of foot deformities has a characteristic curvature that is accompanied by deviation of the forefoot inside and to the development of clubfoot. e purpose of this study is to improve the results of surgical treatment, the analysis of methods of surgical treatment and testing of the algorithm for choosing the best options in the surgical treatment of 3rd stage of development proviruses of deformity. We summarized the clinical experience of surgical treatment of 145 patients with a varus feet deformity of 3 degrees, which made 177 surgical interventions. Analysis of remote results of surgical treatment showed that an individual approach in such severe deformities, depending on the involvement of the foot, the combination of operations on the bones and so tissues, provided a favorable postoperative period and an earlier start of rehabilitation.

Key words: varus deformity, osteotomy, arthrodesis, foot.

Introduction

Currently, varus deformity of the feet is considered one of the most common diseases of the foot and ankle joint [1, 4, 10]. With this type of deformity, the foot has a characteristic planovarus curvature, which is accompanied by inward deviation of the forefoot and the development of clubfoot. In addition, this type of deformity is characterized by an O-shaped shape of the legs, in which the legs have an external convexity, and in the most severe cases, an outward displacement of the thigh develops [3, 5, 7, 9].

Varus deformity of the feet can be either congenital or acquired. The main causes of varus deformity of the feet are various metabolic disorders, as well as various diseases of the skeletal system, as a result of which the strength of bone tissue is impaired [2, 6, 8].

The complex anatomical and functional features of the foot and the high incidence of polovarus deformity in the population determine the relevance of the development of surgical methods for treating this type of pathology. This paper presents our experience in the surgical treatment of grade 3 polovarus foot deformity.

Characteristics of patients and surgical interventions performed

We have summarized the clinical experience of surgical treatment of 145 patients with grade 3 polovarus foot deformity, who underwent 177 surgical interventions. The characteristics of the operated patients by gender and age are shown in Table 1.

All patients underwent comprehensive diagnostic measures, which included a clinical examination and radiography. A number of patients underwent electroneuromyography as part of an additional examination. In addition, the study of neurological status, MRI results, myelography, arteriography, and genetic research helped substantiate the diagnosis for most patients.

When choosing a method of surgical treatment, the criteria given in Table 2 were used.

Depending on the location and nature of the polovarus deformity, different types of surgical interventions were performed (Table 3).

Metatarsal V-shaped osteotomy

The hollow foot in the middle section at the level of the talonavicular and calcaneal-cuboid joints or at the level of the navicular-cuneiform joint (depending on the degree of rigidity of the deformity) was subjected to surgical intervention: plantar fasciotomy in combination with calcaneal osteotomy or metatarsal osteotomy. This procedure made it possible to restore optimal support to the foot.

An anterior wedge osteotomy of the tarsal region was also performed. The technique of this operation was described by Japas. It is important that the tip of the sharp wedge is at the level of the highest point of the arch of the foot deformity. This usually occurs on the scaphoid bone. In this case, the side of the wedge on the medial side passes through the first sphenoid bone, and on the lateral side - through the third sphenoid and cuboid, respectively. Bone tissue is not excised. The proximal edge of the distal foot was sunk plantar while the metatarsal heads were elevated dorsally, correcting the deformity and lengthening the plantar surface. Hindfoot deformity has been corrected in some cases by Dwyer osteotomy or triple arthrodesis.

The operation in some cases is supplemented by resection arthrodesis of the calcaneocuboid joint and plastic surgery of the posterior tibial tendon. Below is a variant of a V-shaped metatarsal osteotomy in combination with a calcaneal osteotomy.

Patient Shch., born in 1971. Case history No. 9852. Diagnosis: Polovarus deformity of the left foot. Arthrosis of the subtalar joint.

The operation was performed on June 4, 2013. Anesthesia was spinal. The operation was performed under a pneumatic tourniquet. Access to the calcaneus is from the outer side, 6 cm long. An oblique osteotomy of the calcaneus was performed using an oscillatory saw. Then the calcaneal tuberosity was lateralized by 1 cm. The calcaneal bone fragment was fixed with Ikos screws.

In the projection of the scaphoid bone, a longitudinal soft tissue incision 4 cm long was made. The talonavicular and scaphoid-sphenoid joints were isolated. A V-shaped osteotomy was performed and fixed with shape memory clamps. The wounds are sutured layer by layer (Fig. 1-5).

Resection arthrodesis of the calcaneocuboid joint

Resection arthrodesis of the calcaneocuboid joint is the operation of choice for severe varus deformity of the feet. Due to resection, a bone tissue defect appears, the forefoot shifts outward, as a result of which the longitudinal arch of the foot drops.

A longitudinal incision is made in the area of the calcaneocuboid joint, and the bones are exposed using a blunt or sharp method. Next, a wedge-shaped osteotomy is performed using an oscillatory saw. Options for fixation after resection can be different: screws, shape memory clamps (Fig. 6, 7).

Resection of the calcaneocuboid joint, removal of the scaphoid, triple arthrodesis

The third option for osteotomy of bones in the metatarsal part of the foot is a combination of resection of the calcaneocuboid with removal of the navicular bone and triple arthrodesis. All this makes it possible to form a normal arch of the foot and rigid fixation in the osteotomy areas (Fig. 8, 9).

Metatarsal osteotomies in combination with soft tissue operations

In stage 3 foot deformity, metatarsal osteotomies often have to be supplemented with soft tissue operations. The big problem at this stage is the tibialis posterior tendon. Usually it is highly developed, thickened in diameter, and strongly stretched. We lengthened this tendon, both openly and endoscopically, and transplanted the tendon to a more advantageous position to correct the deformity. We have received a patent for endoscopic operations on this tendon. With endoscopy, it is possible to perform tendon lengthening, debridement to eliminate tendovaginitis, minimally invasive tendon release, etc.

A) open lengthening of the tibialis posterior tendon

The stages of open lengthening of the tibialis posterior tendon are illustrated in Figures 10 and 11.

B) Endoscopic lengthening of the tibialis posterior tendon

We have developed a technology for endoscopic lengthening of the tibialis posterior tendon (Fig. 12-16). The advantages of this operation technique include reducing the risk of complications due to the low invasiveness of the operation and the small size of the wounds (in known techniques, an incision of 7-10 cm is made, which increases the risk of soft tissue trauma). In the developed technique, the incision does not exceed 3 cm, which significantly improves the conditions for wound healing and rehabilitation; reducing rehabilitation time due to stable static stabilization. Since with transposition of the tendon and fixation in the bone according to the developed method, the stability of fixation of the talonavicular joint is much higher, the load on the leg in the postoperative period began after 2-3 weeks, while when performing the operation using traditional methods, the load is possible only after 4-5 weeks.

Operation technique

1. A minimal incision (3-4 cm) is made in the area of attachment of the posterior tibial tendon to the scaphoid bone, the tendon is visualized, and then an endoscope is inserted.

2. Under endoscopic control, the tendon is visualized over a length of about 5 cm.

3. The tendon is bifurcated along its entire length using a puncture needle (divided in half), after which one part of the tendon in the proximal section is cut off with a scalpel.

4. Using an arthroscopic hook, the severed half of the tendon is brought out into the wound.

After this, the tendon is sutured with a Z-shaped seam, and its lengthening by 3-4 cm is achieved.

B) Minimally invasive tendon transfer of the tibialis posterior muscle to the dorsum of the foot

In this case, the SZBBM is endoscopically isolated for 5-6 cm, after which the tendon is brought out to the anterior surface of the leg.

Next, the attachment site is formed on the dorsum of the foot, after which the tendon is subcutaneously brought to a new attachment site in the area of the wedge-shaped bones and fixed with an anchor or biodegradable screw. This operation can be performed in combination with various metatarsal osteotomies.

For paresis of the peroneal muscles, the transfer of the tendon of the tibialis posterior muscle to the dorsum of the foot was combined with the transfer and suturing of the tendon of the peroneus longus muscle to it (Bridle operation) (Fig. 19).

results

Treatment results were assessed 12 months or more after surgery (Table 4).

Clinical evaluation criteria: range of motion of the foot, limb function, pain and patient satisfaction. The dependence of the treatment result for grade 3 polovarus foot deformity was noted. on the severity of the midfoot deformity, heel supination, on the degree of damage to the tendon complex, as well as the gender and occupation of the patients. The surgical technique and the adequacy of its application were important.

It is important to note that it is initially impossible to obtain ideal foot function with grade 3 deformity. Our goal was to restore the support ability of the foot, relieve pain, and make it easier to select shoes.

Note that in most cases (70%) the results of surgical treatment were assessed as excellent or good. 2.3% of unsatisfactory results were associated with the initial severity of foot deformity and technical difficulties during operations, as well as patient violation of the postoperative treatment regimen.

Conclusion

Analysis of long-term results of surgical treatment showed that an individual approach to such severe deformities, depending on the involvement of the foot, a combination of operations on both bones and soft tissues, ensured a favorable course of the postoperative period and an earlier start of rehabilitation.

Thus, a differential approach to the choice of surgical intervention technique for polovarus foot deformity is accompanied, in general, by good and excellent results of surgical treatment.

For citation

Matsakyan A.M., Shesternya N.A., Protsko V.G. Surgical methods for correcting grade 3 polovarus deformity of the foot // Department of Traumatology and Orthopedics. No4(30). 2021. p.-48.

Matsakyan AM, Shesternya NA, Protsko VG Surgical methods of correction of varus deformity of the foot 3 degrees // e Department of Traumatology and Orthopedics. No4(30). 2021. p.-48.

List of references/References

1. Zyryanov S.Ya. Result of replacement of bone and soft tissue defects of the hindfoot in post-traumatic flatfoot / Zyryanov S.Ya., Soldatov Yu.P., Zyryanov S.S. // Genius of orthopedics. 2011.-No4. - With. 126-127. .

2. Kozhevnikov O.V. Comparative assessment of the results of complex and conservative treatment of planovalgus foot deformity in children / Kozhevnikov O.V., Kosov I.S., Ivanov A.V., Gribova I.V., Bolotov A.V. // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2015.-No2. - With. 22-24. .

3. Koryshkov N.A. Surgical correction of the pathological position of the foot and ankle joint / Koryshkov N.A., Levin A.N., Khodzhiev A.S., Sobolev K.A. // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2013.-No.1. - With. 74-75. .

4. Privalov A.M. Surgical correction of severe secondary deformity of the forefoot / Privalov A.M. // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2014.-No.1. - With. 84-85. .

5. Reutov A.I. Features of orthograde standing in patients with post-traumatic osteoarthritis of the ankle and talocalcaneal joints / Reutov A.I., Davydov O.D., Ustyuzhaninova E.V. // Genius of orthopedics. 2013.-No4. - With. 48-52. [Reutov AI Peculiar properties of orthograde standing in patients with posttraumatic osteoarthrosis of the ankle and talocalcaneal joints. / Reutov AI, Davydov OD, Ustyuzhaninova EV // Genii ortopedii. 2013.-No4. – s. 48-52. RUS].

6. Reutov A.I. Classification of the functional state of the musculoskeletal system in patients with shortening and deformities of the lower extremities / Reutov A.I. // Vestn. traumatology and orthopedics of the Urals. 2012.-No3-4. - With. 65-69. . Usoltsev I.V. Surgical treatment of severe forefoot deformity / Usoltsev I.V., Leonova S.N., Kosareva M.A. // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2015. -No3. - With. 84. [Usol'tsev IV Operativnoe lechenie tyazheloi deformatsii perednego otdela stopy / Usol'tsev IV, Leonova SN, Kosareva MA // Vestnik travmatologii i ortopedii im. NN Priorova. 2015.-No3. – s. 84. RUS].

7. Shchurov V.A. Functional state of patients with varus deformity of the lower extremities of various etiologies / Shchurov V.A., Novikov K.I., Dolganova T.I. // Genius of orthopedics. 2012. - No.3. - With. 122-125. .

9. Patrick N. E ects of Medial Displacement Calcaneal Osteotomy and Calcaneal Z Osteotomy on Subtalar Joint Pressures: A Cadaveric Flat-foot Model / Patrick N, Lewis GS, Roush EP, Kunselman AR, Cain JD // J Foot Ankle Surg. 2021.-No6. - R. 1175-1179. PMID: 27545512.

10. Wiewiorski M. Computed Tomographic Evaluation of Joint Geometry in Patients With End-Stage AnkleOsteoarthritis / Wiewiorski M, Hoechel S, Anderson AE, Nowakowski AM, DeOrio JK, Easley ME, Nunley JA, Valderrabano V, Barg A // Foot Ankle Int. 2021. - No6. - R. 644-651. doi: 10.1177/1071100716629777 PMID: 26843547.

11. Koryshkov N.A., Levin A.N., Kuzmin V.I. Tactics for the treatment of equine excavatus deformity of the feet in adults // Department of Traumatology and Orthopedics. 2021.No4(20). pp. 37-43 [.., Levin AN, Kuzmin VI // e Department of Traumatology and Orthopedics. 2021. No4(20). p.37-43 RUS].

Author information

Shesternya Nikolay Andreevich – Doctor of Medical Sciences, Professor of the Department of Traumatology and Orthopedics of the Institute of Postgraduate Education. Email: [email protected]

Matsakyan Artak Matsakovich – City Clinical Hospital named after. A.K. Eramishantseva DZM, Moscow. E-mail, Moscow, 115612, st. Brateevskaya, 23-1-55, Tel. +7 (915)141 11 44.

Protsko Viktor Gennadievich – State Clinical Hospital named after. S.S. Yudina DZM, Moscow. Email

Information about authors

Shesternya Nikolaj Andreevich – PhD, prof. of the Department of Trauma and Otrhopedics of Sechenov University, IM Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia,

Matsakyan Artak Macakovich – Municipal Clinical Hospital named a er AK Eramishancev, st. Brateevskaya, 23-1-55, Moskow, Russia, 115612, Phone +7 (915) 141 11 44,

Protsko Viktor Gennadievich – Municipal Clinical Hospital named a er SS Yudina, Moscow

Contraindications to ankle arthrodesis

Arthrodesis is not recommended for use in the musculoskeletal segment of the ankle if:

the patient is at an age when the musculoskeletal system continues to actively grow (surgery is strictly contraindicated before the age of 12);
fistulas of non-tuberculous origin were found in the joint;
active infectious and inflammatory processes in the area of proposed intervention or any common infectious diseases in the acute phase have been identified;
the patient suffers from severe forms of pulmonary, renal or heart failure;
there is a chronic disease in the stage of decompensation (diabetes mellitus, etc.);
intolerance to anesthetic drugs was revealed.

Method of three-joint arthrodesis of the foot

The invention relates to the field of medicine, namely to traumatology and orthopedics. An external fixation device is applied. Eliminate foot deformities. Distraction is performed in three joints: talocalcaneal, talonavicular, calcaneal-cuboid. Surgical access is performed by puncturing the skin in the projection of the tarsal sinus. Articular cartilage is removed from the talocalcaneal, talonavicular and calcaneal-cuboid joints through a puncture of the skin using arthroscopic instruments until “blood dew” appears on the articular surfaces. Eliminate residual foot deformities. Compression is applied in the three indicated joints until their articular surfaces come into complete contact. The foot is stabilized. The method ensures complete reconstruction of the foot, reduces the trauma of surgical intervention, and reduces the period of formation of ankylosis in the joints. 2 salary f-ly, 1 ave.

The invention relates to the field of medicine, namely to traumatology and orthopedics, and can be used to treat patients with instability and deformities of the feet.

In recent years, there has been a clear increase in congenital and acquired pathologies of the musculoskeletal system and, in particular, the development of instability and various types of foot deformities. More than 40 arthrodesis methods have been proposed to correct foot deformities and stabilize joints.

The literature describes Dan's method of triple arthrodesis, in which the head of the talus, the entire scaphoid bone, and the articular cartilage of the 1st sphenoid bone are resected. The calcaneocuboid and talocalcaneal joints are resected with a chisel.

However, when performing resection with a chisel, significant trauma is caused to the surrounding tissues. Due to the dissection of the ligaments connecting the talus, calcaneus, navicular and cuboid bones, it is difficult to keep them in the correct position after surgery, and therefore delayed formation of ankylosis is possible.

P.G. Kornev proposed to perform resection of the ankle, Chopart and Lisfranc joints, followed by placing an extra-articular graft on the front surface of the foot. In 1933, S. Lambrinudi improved the three-joint arthrodesis technique: after removing the articular cartilage of the subtalar joint, a bone spike was formed from the head of the talus, which was inserted into a previously made groove in the lower part of the scaphoid. In this case, the talus should be in the position of maximum flexion, and the anterior section in the position of extension. Additionally, resection of the calcaneocuboid joint was performed [RU patent for invention No. 2197193].

However, these methods require long-term immobilization due to the long-term reconstruction of grafts, which can lead to contracture of the foot joints, especially the ankle.

There is also a known method of three-joint arthrodesis using the Lortioir method [Chaklin V.D. "Operative orthopedics". M.: Medgiz, 1951. P.266-268, 415-420]. A lateral Kocher incision is made, which begins from above behind the fibula, bending around the lateral malleolus, and directed medially, ending distal to the attachment of the tuberosity of the fifth metatarsal bone. The talus is exposed and the ligaments between it and adjacent bones are cut. The talus is removed, wrapped in a warm compress, and then the cartilage is removed with a knife from all articular surfaces in contact with the talus. The bed is packed and the soft tissue over it is temporarily covered. The cartilaginous cover of the talus is also completely removed with a bone knife, but in such a way that the normal shape and size of the bone is preserved. Apply a blind suture to soft tissues and skin. A plaster cast is applied for 6 weeks. Subsequently, the bandage is changed, the position is corrected and a new plaster cast is applied.

However, this method of treatment, like all of the above analogues, is traumatic.

The closest analogue to the claimed invention is the method of three-joint arthrodesis of the foot [SU author's certificate for the invention No. 1063396]. Surgical access is made by making a skin incision along the inner surface of the foot below the inner malleolus. The soft tissues are separated and held with hooks. Using needles, the location of the talocalcaneal and talonavicular joints is indicated. The destruction of articular cartilage from the talocalcaneal, talonavicular and calcaneal-cuboid joints is carried out by drilling holes. Pieces of destroyed cartilage and bones are washed with a solution of novocaine. The holes are tightly filled with bone autografts. Apply catgut sutures to soft tissues and skin, an alcohol bandage and a plaster boot for 3 months.

However, the use of this method does not provide complete reconstruction of the foot. The method is applicable mainly for arthrodesis of the ankle joint in case of deforming arthrosis and can be used, for example, for multiplanar foot deformity affecting the Chopart joint.

The objective of the claimed invention is to provide complete reconstruction of the foot while reducing the trauma of the surgical intervention and reducing the time for the formation of ankylosis in the talocalcaneal, talonavicular and calcaneal-cuboid joints.

The essence of the claimed invention lies in the fact that in the method of three-joint arthrodesis of the foot, including surgical access, removal of articular cartilage from the talocalcaneal, talonavicular and calcaneal-cuboid joints, elimination of foot deformities, performing compression in three joints - talocalcaneal, talonavicular, calcaneal-cuboid until their articular surfaces are in full contact, stabilization of the foot is carried out, before surgical access, an external fixation device is applied, then, through the latter, deformities of the foot are eliminated and distraction is carried out in these three joints, surgical access is performed by puncturing the skin in projections of the tarsal sinus, removal of articular cartilage is carried out through a puncture of the skin using arthroscopic instruments until “blood dew” appears on the articular surfaces, after which residual deformities of the foot are eliminated.

A method of three-joint arthrodesis of the foot with the above-described symptoms is also claimed, in which, when applying an external fixation apparatus, two intersecting spokes are passed through the lower third of the leg, the talus and calcaneus, one wire with a thrust platform is passed through the scaphoid and cuboid bones, and they are fixed in rings and semi-rings , which are connected to each other using rods and brackets with shanks.

In addition, a method of three-joint arthrodesis of the foot with the above-described symptoms is also claimed, in which distraction in the joints is performed by 4-6 mm.

The technical result of the claimed invention consists in solving the previously posed problem. Using arthroscopic instruments, removing the articular cartilages of the talus, calcaneus, navicular and cuboid bones until “blood dew” appears on the articular surfaces and performing rigid fixation of the foot using an external fixation device helps to: ensure complete ankylosis in the talocalcaneal, talonavicular and calcaneal cuboid joints in a shorter time; restoration of lost biomechanics and support ability of the foot with the possibility of performing its complete reconstruction; preventing recurrence of foot deformities. Carrying out all manipulations performed during surgical intervention through one skin puncture made in the projection of the tarsal sinus makes it possible to reduce the trauma of surgical treatment, preserving the capsular-ligamentous apparatus of the foot as much as possible, which in turn helps to shorten the rehabilitation period and reduce the risk of postoperative complications.

The method of three-joint arthrodesis of the foot is carried out as follows.

The patient is placed on the operating table on his back with bolsters under the knee joint and lower third of the leg. The surgical field is processed. An external fixation device is applied to the lower leg and foot. To do this, two intersecting knitting needles are passed through the lower third of the tibia and the talus, pulled tight and fixed in rings. The latter are connected to each other using rods. Two intersecting knitting needles are passed through the heel bone, which are pulled and fixed in a semi-ring. This half-ring is connected by rods to rings installed in the projection of the lower third of the tibia and talus. A pin with a thrust pad is passed through the scaphoid and cuboid bones, pulled tight and fixed in a half-ring, which is connected with three rods to the ring and half-ring installed in the projection of the calcaneus and talus bones.

Using an external fixation device, foot deformities are eliminated and distraction is carried out in three joints - talocalcaneal, talonavicular and calcaneal-cuboid by 4-6 mm. Surgical access is performed by puncturing the skin in the projection of the tarsal sinus. Articular cartilage is removed from the talocalcaneal, talonavicular and calcaneal-cuboid joints using arthroscopic instrumentation. To do this, an arthroscopic tube is inserted through a puncture of the skin, through which olive-shaped and round arthroscopic burs are alternately passed, connected to a shaver unit. Using burs, the articular cartilage on the surfaces of the talus, calcaneus, navicular and cuboid bones is processed until “blood dew” appears on the articular surfaces. The interarticular space is washed with 0.9% saline solution, ensuring the removal of cartilage and bone chips. The arthroscopic instrumentation is removed. A suture is placed on the wound. Then residual deformities of the foot are eliminated, for example: supination in the talocalcaneal joint, and adduction and varus deformity of the foot in the talonavicular joint. Next, compression is carried out under X-ray control using an external fixation device alternately in three joints: talocalcaneal, talonavicular and calcaneal-cuboid until their articular surfaces are completely in contact. Stabilize the foot.

Example

Patient L., 20 years old, was admitted to the department of traumatology and reconstructive surgery with the diagnosis: “Relapse of congenital clubfoot on the right. Condition after surgery according to Zatsepin. Recurrence of all elements of clubfoot. Arthrosis of the talonavicular and talocalcaneal joints. Pain syndrome".

After preoperative preparation, the patient underwent surgical intervention under spinal anesthesia according to the method described in this application. In the postoperative period, maintenance compression was performed at 1 mm per day for 5 days. 3 months after surgery, a control radiograph showed the formation of a bone block in all arthrodesed joints. The external fixation device was dismantled. The patient began to work.

1. A method of three-joint arthrodesis of the foot, including surgical access, removal of articular cartilage from the talocalcaneal, talonavicular and calcaneocuboid joints, elimination of foot deformities, compression in three joints - talocalcaneal, talonavicular, calcaneal-cuboid until their articular surfaces are in complete contact and the foot is stabilized, characterized in that before surgical access, an external fixation device is applied, then, through the latter, deformities of the foot are eliminated and distraction is carried out in these three joints, surgical access is performed by puncturing the skin in the projection of the tarsal sinus, Articular cartilage is removed through a puncture of the skin using arthroscopic instruments until “blood dew” appears on the articular surfaces, after which residual deformities of the foot are eliminated.

2. The method of three-joint arthrodesis of the foot according to claim 1, characterized in that when applying an external fixation device, two intersecting needles are passed through the lower third of the leg, the talus and calcaneus, one wire with a thrust platform is passed through the scaphoid and cuboid bones, and they are fixed in rings and half-rings, which are connected to each other using rods and brackets with shanks.

3. The method of three-joint arthrodesis of the foot according to claim 1, characterized in that distraction in the joints is performed by 4-6 mm.

Types of surgery

When the wear and deformation of the joint is too severe, this can become an obstacle to replacing the joint block with an endoprosthesis. Therefore, even with every desire, replacing a diseased segment with an artificial analogue is not always feasible. In this and all the situations described above, there is only one way out - to use arthrodesis surgery. It will stabilize the ankle and reduce pain symptoms to a minimum, thereby significantly improving the patient’s quality of life. There are several methods of surgical intervention.

Intra-articular. During surgery, the joint capsule is opened, followed by removal of damaged hyaline cartilage from the surfaces of the bone elements. After repositioning the bones in an advantageous position, they are fixed with metal devices.
Extra-articular. Fixation of the bones of the articulation only by placing a bone graft, while the cartilaginous covers are not subject to resection.
Combined. This technique involves the combination of two methods in one surgical process: intra-articular and extra-articular. Thus, the cartilaginous structures from the joint are completely removed, an autograft is introduced, which is fixed with special metal plates.
Compression. The operation consists of squeezing the articulating surfaces with a compression or compression-distraction type apparatus for their further fusion. Widely used designs are Ilizarov, Grishin, Volkov-Oganesyan apparatuses. Removal of cartilage is not excluded. Implantation of a bone graft is not required for the compression method.

Technique No. 1.

Types of ankle arthrosis

Arthrosis of the ankle occurs not only due to age-related changes in the joints. It can be triggered by cartilage injury, sprained ligaments, valgus flatfoot, and rheumatism. Osteoarthritis is also caused by a crooked position of the leg axis, metabolic disorders, rheumatism and other pathologies.

There are several types of arthrosis of the ankle joint. Depending on its type, the patient is selected a suitable method of surgical intervention.

With concentric arthrosis, the talus bone is located in the center.
When eccentric, it is displaced.
There is also rear and front centering.
Valgus and varus arthrosis.

If the disease is accompanied by bone necrosis and has reached an advanced stage, endoprosthetics is pointless. Based on the diagnostic results, the doctor makes a decision, assesses the condition of the ligaments, the position of the hindquarters and arch of the foot: surgery is not always indicated and does not help everyone.

You need to seriously prepare for ankle replacement surgery.

Preparing the patient for ankle arthrodesis

When planning this type of surgical treatment, it is extremely important to evaluate all joints adjacent to the problem area. This is necessary to understand how capable neighboring segments are of taking on a larger load complex. Since the movement potential of the ankle joint is blocked after surgery, the adjacent movable joints will naturally be subject to more stress. It is especially important to reliably assess the condition of the talonavicular joint, because it is precisely this central segment of the foot that will bear the maximum share of the load. A positive effect from arthrodesis can be counted on only in the absence of degenerative pathogenesis in it.

The go-ahead to operate on a patient is given only after a comprehensive examination confirming the clear need for this medical care in the absence of contraindications. The patient is prescribed a series of diagnostic measures:

detailed blood and urine tests, including biochemistry;
X-ray, MRI or CT scan of the joint in several planes;
testing for HIV, syphilis, hepatitis;
fluorography and electrocardiography;
examination by highly specialized doctors (cardiologist, pulmonologist, etc.);
consultation with an anesthesiologist.

In addition, the specialist must additionally make sure that the effect of arthrodesis is most likely to “work” and the patient’s well-being will noticeably improve. To do this, a kind of test is first carried out, which consists of applying a plaster cast to the joint. So, a person walks with his ankle fixed in a cast for about 7 days, and after a week, the orthopedic traumatologist finally determines the feasibility of the operation. If the test immobilization helped to create support for the limb and significantly reduce pain, the operation is performed. If discomfort persists, pain appears or pain increases, or gait worsens, arthrodesis is cancelled.

Technique No. 2.

A week before the expected date of the intervention, the use of drugs with anti-inflammatory effects (NSAIDs) and agents that have blood-thinning properties should be stopped. On the eve of surgery, the diet should be light, stop eating 6-8 hours before.

Attention! Make sure your living space is prepared in advance when you arrive home from the hospital. You should remove carpets, runners and cords from floors that could cause your foot to get caught and fall. Place essential items and things in easily accessible places. In the bathroom it is necessary to lay non-slip mats made of rubber or silicone materials with Velcro, etc.

Ankle pain

Conservative treatment

A patient with arthrosis of the ankle joint, especially in the initial stages, requires conservative or non-surgical treatment. Conservative treatment includes the prescription of anti-inflammatory and painkillers. The patient also needs to change his daily physical activity. Axial load on the joint, especially associated with running and jumping, should be limited. This will help reduce pain in the joint area. It is also important to choose comfortable orthopedic shoes for the patient, make individual insoles and fix the ankle joint with a special orthotic bandage.

All these simple procedures will relieve stress on the ankle joint when walking and reduce the manifestations of arthrosis. The use of intra-articular injections of hyaluronic acid preparations and the introduction of platelet-rich plasma (PRP) into the joint cavity, especially in the initial stages of arthrosis, can alleviate the symptoms of damage to the ankle joint.

In case of severe inflammation, glucocorticoids can be injected into the joint cavity. Glucocorticoids can significantly reduce inflammation and pain in the ankle joint.

Surgery

If there is no effect from conservative treatment, as well as if there are signs of total destruction of the ankle joint, surgery may be indicated.

At certain stages of arthrosis, minimally invasive surgical interventions can be performed on the ankle joint using the arthroscopy method.

As mentioned earlier, with arthrosis of the ankle joint, bone spines or osteophytes form along the edges of the bones. Large osteophytes can collide with each other during movements in the foot and ankle and cause pain in the patient. Such osteophytes usually form along the anterior surface of the joint.

Modern equipment allows us to insert a small video camera into the ankle cavity through a skin puncture and examine the joint from the inside. When identifying bone growths and osteophytes, doctors can remove excess bone tissue using a special bone micro-bur and through skin punctures.

During the operation, loose cartilage and bone bodies are removed from the joint cavity, which form in the ankle joint during arthrosis and cause pain and periodic blockages during movement.

Carrying out sanitation arthroscopy of the ankle joint in combination with the subsequent introduction of hyaluronic acid preparations into its cavity can alleviate the condition of a patient with arthrosis for up to 3-5 years. The operation is very well tolerated by the patient and practically does not require the patient to stay in the hospital.

In case of total damage to the cartilage of the ankle joint (arthrosis of the fourth stage), often accompanied by severe deformation of the joint, it is necessary to resort to surgery for arthrodesis of the joint.

The advantage of arthrodesis of the ankle joint is the possibility of significantly reducing the severity of pain due to arthrosis with the patient returning to normal everyday life.

The disadvantage of arthrodesis of the ankle joint is the loss of mobility in it. The function of the ankle joint after arthrodesis is transferred to other joints of the foot.

In general, even though the ankle joint is locked as a result of the operation, the long-term results of such surgical intervention, according to modern research, are more than good.

Previously, surgery for arthrodesis of the ankle joint was performed openly, using wide skin incisions, sometimes even several, and was accompanied by severe pain and swelling in the postoperative period. The evolution of surgical technologies has naturally led to the fact that today ankle joint arthrodesis surgery can be performed minimally invasively, or arthroscopically, through small punctures of the skin.

The benefits of arthroscopic ankle arthrodesis are clear. This includes less severe pain after surgery, more acceptable incisions from a cosmetic point of view, and relatively less trauma to healthy soft tissues during surgery.

However, arthroscopic arthrodesis compared to open surgery is a much more complex intervention from a technical point of view and requires a highly qualified surgeon.

After the operation, the patient is recommended to elevate the limb and fix the foot and lower third of the leg in a special bandage. The load on the limb is eliminated for 8-10 weeks.

More information about the treatment of ankle arthrosis.

Carrying out the operation

Arthrodesis of the ankle joint according to the traditional method is performed under general anesthesia in an open manner. Surgical procedures under arthroscope control can be performed under spinal anesthesia. The session requires an average of 2-3 hours of intraoperative time. Let's consider the principle of classical tactics.

A pneumatic tourniquet is applied to the lower third of the thigh. Next, access is created by making a linear skin incision along the joint with a scalpel. The incision is approximately 10 cm.
At the next stage, an opening and reliable supination of the joint is performed, which will facilitate the work with the next manipulations.
The surfaces of the tibia and talus are then prepared. Preparation includes resection of cartilage tissue with a surgical chisel and removal of ossification.
Then the foot is removed from the vicious position. The tibial element and the talus component are tightly juxtaposed with each other in a position that is convenient from a physiological point of view. The achieved position is secured by a metal structure of the required type.
The surgical tracts used are closed at the final stage using layer-by-layer suturing of soft tissues, leaving drainage.

In cases of severe deformity, fibular osteotomy may be used. Extensive bone losses are compensated by grafts - fragments of similar biological material taken from the patient from the iliac crest.

If external fixation systems were used, for example, the Ilizarov apparatus, plaster is not used. When installing internal metal implants, a cast is placed on the operated limb. Until ankylosis occurs, the patient is in a plaster cast. The rate of bone fusion in each individual patient may differ due to the physiological characteristics of the body. The joint is completely fused and immobilized 3-6 months after surgery.

Features of the modern approach to ankle replacement

During endoprosthetics, a small part of the talus is removed, and the cancellous bone tissue fuses with the surface of the endoprosthesis. The denser the bone, the more stable the prosthesis will be.

In recent years, the possibilities of endoprosthetics have expanded, and surgical methods for treating osteoarthritis have become more progressive. Orthopedic surgeons resort to accompanying measures for improved fixation of the prosthesis. These include correction of the support, plastic surgery of the tibial collateral and external ligaments, refixation and tightening of ligaments, and other operations that improve stability in a standing position, with maximum load on the prosthesis. Similar events are carried out several months before endoprosthetics.

In order for the prosthesis to last as long as possible, at the preparatory stage, surgeons eliminate deformations resulting from accidents and injuries. The more deviations of the axis from the norm, the faster the wear of the prosthesis will occur. Therefore, doctors strive to correctly align the hindfoot and get rid of deformities.

Ankle rehabilitation

After arthrodesis performed in the ankle area, physical therapy classes begin from the first day. They will prevent the development of muscle atrophy, prevent blood clots and prevent congestion in the lungs. With sufficiently long-term immobilization of the limb and a low level of patient activity without adequate physical training, very disastrous results can be achieved.

Surgical sutures.

Exercise therapy in the early period includes breathing exercises, isometric exercises to maintain and strengthen the calf and thigh muscles. The exercises are performed under the supervision of a physical postoperative rehabilitation methodologist. Gymnastics involves gradually increasing the load and introducing new exercises in accordance with the patient’s well-being and recovery time.

Medication treatment is mandatory for rehabilitation, including:

highly effective therapy against the formation of infectious pathogenesis;
use of symptomatic drugs;
use of medications for thromboembolic complications.

From the second day they try to verticalize the patient. Walking is allowed only with the support of crutches, avoiding any load on the operated limb. Not earlier than after the first signs of ankylosis appear, and this is after about 6 weeks, it is allowed to partially include a gentle axial load on the sore leg. The patient will be able to try to walk normally no earlier than after 4-6 months. Removal of metal structures is usually prescribed after 6-12 months. Internal fixators do not always need to be removed.

What are the treatment options?

For ankle arthrosis, the following types of joint replacement are practiced:

Installation of a titanium prosthesis with a movable polyethylene core. This option is suitable even if the cartilage is completely worn out. The technology of ankle replacement has greatly improved over the past 10 years and has gradually begun to replace the “gold standard” (arthrodesis).
Arthrodesis is therapeutic immobilization to relieve pain when putting weight on a joint. After surgery, gait is disrupted and the load on the hip and adjacent ankle joints increases. The rehabilitation period is at least 4 months. Arthrodesis comes to the rescue if endoprosthesis replacement is contraindicated.
Osteotomy is a modification of the talus and calcaneus so as to move healthy cartilage to the area of the main load and preserve the joint.

Which is better – ankle replacement or arthrodesis? The expert’s reasoning is in the video:

Complications of ankle arthrodesis

The incidence of complications after a standard operation with a wide opening of the joint, as clinical experience shows, is an order of magnitude higher than after arthroscopic interventions. Here is some comparative data on negative reactions for two types of procedures (without the use of external fixators) detected during the first 3 weeks:

phlebothrombosis is detected in 22% of cases after open ankle arthrodesis, in 1.8% after minimally invasive intervention;
wound infection develops in approximately 12% of patients, while the risks after arthroscopy are practically absent (<0.1%)
necrosis of surrounding tissues, respectively, in 17% and 0.2%;
wound hematomas and seromas: 22% and 0.9%.

Persistent swelling.

Intraoperative blood loss after standard arthrodesis is 250 ml, after arthroscopic arthrodesis - about 120 ml. Failure of ankylosis after 6 months is determined in 5%-6% of people who underwent the procedure according to the traditional scenario, and in 0.5%-0.9% of patients who underwent arthroscopy with intramedullary fixation. Skipping the topic of comparison, we note that after any type of artificial ankylosis there are increased risks associated with the formation of arthrosis in other joints of the limb and shortening the leg length to 3 cm.

“I have a deformity of the left ankle joint. I suffer from constant pain. Due to joint instability, I often fall. I do gymnastics, wear special insoles, take non-steroidal anti-inflammatory drugs, chondroprotectors, but the condition of the joint does not improve. What can be done in this case?

This is a fairly common complaint seen by traumatologists. For such patients, the solution to the problem may be an operation that will restore the foot and relieve pain - arthrodesis of the ankle joint. Oleg Kezlya , head of the Department of Traumatology and Orthopedics of BelMAPO, Doctor of Medicine, spoke about it in detail sciences, professor.

Oleg Kezlya, Head of the Department of Traumatology and Orthopedics of BelMAPO, Doctor of Medical Sciences. sciences, professor

The essence of the operation

Arthrodesis of the ankle joint is an operation for artificial fusion of the articulating articular surfaces of the ankle in a position that is physiologically advantageous for the functioning of the leg. The goal is to provide support to the problem area, completely blocking its mobility (creating ankylosis).

Immobilization is achieved by rigidly connecting the adjacent ends of the joint bones to each other with special metal clamps: knitting needles, screws, pins. This allows the articular surfaces to grow together at the desired angle, that is, to bring the joint into a completely motionless state, which relieves pain.

When may arthrodesis be needed?

Common injuries in the ankle joint area can lead to serious pathologies that may require arthrodesis:

dislocations and subluxations,
bruises,
ankle fractures,
violation of the integrity of the calcaneus and talus,
ligamentous distortion.

Falls from a height or on a slippery surface, sharp rotational turns, unsuccessful jumps are typical situations that can lead to damage to the structures of the ankle.

Therefore, any traumatic lesions require timely diagnosis and treatment. Old, untreated injuries can result in pain and increasing limitations of locomotor and support potential after a while.

The most common pathology of post-traumatic origin with a progressive course is osteoarthritis. The injury can be treated conservatively, but arthrosis of the ankle joint is an incurable pathology that significantly worsens a person’s quality of life.

Endoprosthesis replacement of a joint block is not always possible. This can be prevented, for example, by severe wear and deformation of the joint. There is only one option left - arthrodesis surgery.

Types of surgery

There are several methods of surgical intervention.

1. Intra-articular. Opening the joint capsule with subsequent removal of damaged hyaline cartilage from the surfaces of bone elements. After repositioning the bones in an advantageous position, they are fixed with metal devices.

2. Extra-articular. Fixation of the bones of the articulation only by placing a bone graft, while the cartilaginous covers are not subject to resection.

3. Combined. A combination of intra-articular and extra-articular methods in one surgical process. The cartilaginous structures from the joint are completely removed, an autograft is introduced, which is fixed with special metal plates.

4. Compression. Compression of articulating surfaces with a compression or compression-distraction type apparatus for their further fusion. Ilizarov, Grishin, Volkov-Oganesyan apparatuses are used. Removal of cartilage is not excluded. Implantation of a bone graft is not required for the compression method.

Indications

secondary (post-traumatic) and primary arthrosis of the 3rd–4th stage;
severe chronic arthritis, including rheumatoid type;
constant pain in the ankle and/or radiating to the knee joint, which intensifies even with minor loads;
severe lameness due to joint deformation;
persistent impairment of the support ability of the foot, expressed by the inability to fully stand on the leg due to weakness of the ankle system, laxity;
severe flexion-extension contracture of the joint;
paresis and paralysis of the leg muscles, which developed against the background of polio in the past;
improperly healed fracture, pseudarthrosis.

Contraindications

age when the musculoskeletal system continues to actively grow (up to 12 years of age, surgery is strictly contraindicated);
fistulas of non-tuberculous origin in the joint;
active infectious and inflammatory processes in the area of the proposed intervention or any common infectious diseases in the acute phase;
severe forms of pulmonary, renal or heart failure;
chronic disease in the stage of decompensation (diabetes mellitus, etc.).

Patient preparation

When planning this type of surgical treatment, it is important to consider several points.

Assess all joints adjacent to the problem area in order to understand how capable the neighboring segments are of absorbing the increased load complex. It is especially necessary to reliably assess the condition of the talonavicular joint: this central segment of the foot will bear the maximum share of the load. The positive effect of arthrodesis is possible only in the absence of degenerative-dystrophic changes in it.

Prescribe the patient a comprehensive examination confirming the need for this operation in the absence of contraindications.

Main instructions for the patient:

detailed blood and urine tests, including biochemistry;
X-ray, MRI or CT scan of the joint in several planes;
testing for HIV, syphilis, hepatitis;
fluorography and electrocardiography;
examination by highly specialized doctors (cardiologist, pulmonologist, etc.);
consultation with an anesthesiologist.

A week before the proposed operation, the patient must stop using NSAIDs and agents with blood-thinning properties.

If external fixation systems were used, for example, the Ilizarov apparatus, plaster is not used. When installing internal metal implants on the operated limb, plaster immobilization is used in the postoperative period. Until ankylosis occurs, the patient is in a plaster cast. The joint is completely fused and immobilized 3–6 months after surgery. The rate of bone fusion may differ due to the physiological characteristics of the individual patient.

Rehabilitation

Exercise therapy. After arthrodesis of the ankle joint, physical therapy should be carried out from the first day to prevent the development of muscle atrophy, thrombus formation and congestion in the lungs. These are breathing exercises, isometric exercises to maintain and strengthen the muscles of the lower leg and thigh. Gymnastics involves a gradual increase in load.

Drug treatment. It includes highly effective therapy against the formation of infectious pathogenesis; use of symptomatic drugs; use of medications for thromboembolic complications.

From the second day the patient can get up. Walking is allowed only with the support of crutches, avoiding any load on the operated limb. After the first signs of ankylosis appear (after about 6 weeks), it is allowed to partially apply a gentle axial load on the sore leg. The patient will be able to try to walk normally no earlier than after 4–6 months. Removal of metal structures is usually after 10–12 months. Internal fixators do not always need to be removed.

Complications

The incidence of complications after standard surgery with a wide joint opening is higher than after arthroscopic interventions. Here are some comparative data on adverse reactions for 2 types of procedures (without the use of external fixators) found during the first 3 weeks:

phlebothrombosis is detected in 22% of cases after open ankle arthrodesis, in 1.8% after minimally invasive intervention;
wound infection develops in approximately 12% of patients, while the risks after arthroscopy are practically absent (<0.1%);
necrosis of surrounding tissues, respectively, in 17% and 0.2%;
wound hematomas and seromas: 22% and 0.9%.

Intraoperative blood loss after standard arthrodesis is 150–200 ml, after arthroscopic arthrodesis - about 120 ml. Failure of ankylosis after 6 months is determined in 5-6% of people who underwent the procedure according to the traditional scenario, and in 0.5-0.9% of patients who underwent arthroscopy with intramedullary fixation. After any type of artificial ankylosis, there are increased risks associated with the formation of arthrosis in other joints of the limb and shortening the leg length by up to 3 cm.

REFERENCE

The ankle is the support of the entire skeleton and muscular system. The ankle joint should normally support almost 90% of the total body weight when a person stands or engages in physical activity in an upright position. The joint also provides shock absorption for the limb and various movements of the foot in a normal amplitude. Violation of its performance can lead to deterioration of gait, limiting a person’s movement even to the point of disability.

Arthrodesis of the knee joint

Today, patients with joint diseases are increasingly turning to doctors, so orthopedics is developing at a rapid pace. In modern medicine, a wide variety of techniques are used to preserve the function of the musculoskeletal system. In the initial stages of the disease, this is conservative therapy (physical therapy, physiotherapy, medications), in advanced conditions - surgery. Endoprosthetics shows excellent results, but its indications are limited. When the soft and bony tissues are in poor condition and the extensor apparatus of the knee is damaged, arthrodesis is an appropriate treatment option—with high success rates.

What is arthrodesis?

Arthrodesis is an operation to artificially immobilize a pathological joint, allowing the leg to function as a support. This intervention usually leads to disability, but relieves the person of excruciating pain. The joint is fixed in the optimal position for a person, that is, the patient can move, rest, work with it, but it will be necessary to use adaptive means, since mobility in the joint will be completely lost.

When do doctors stop with this technique?

If treatment of the joint with this technology proceeds normally without complications, stability of the knee joint and the possibility of full weight-bearing can be achieved, allowing patients to have a satisfactory overall quality of life. In addition, recent research shows that this method can combat mixed infections or infections caused by highly virulent microorganisms when other surgical techniques fail.

Arthrodesis works well in patients with multiple risk factors for reinfection of the prosthesis and, at the same time, with lower functional demands on the knee joint. This is the only effective help when you can save the joint at least as a support for the body.

Indications for arthrodesis

Indications for this technique are almost all diseases of the joint, when its surface is destroyed and any movement causes pain.

Severe deforming arthritis
Pathological changes in bones due to degenerative arthrosis.
Changes in the joint due to poliomyelitis
Severe joint contractures
Hypermobility of the joint and its looseness due to atrophy of the ligamentous and muscular apparatus.
The patient cannot move
Joint damage due to tuberculosis
Pseudoarthrosis that occurs after a fracture

Contraindications to arthrodesis

This technology has certain contraindications and limitations.

Age restrictions. It is not recommended for children under 12 years of age and adults over 60. In the first case, due to increased bone growth and an unformed skeleton, in the second, with a high risk of postoperative complications.
Fistulas due to purulent processes occurring in the joint.
General serious condition of the patient
Exhaustion
Diseases of the heart and blood vessels in the stage of decompensation.

Advantages of arthrodesis

The advantage of arthrodesis is that it can be used in cases of poor implant support (poor bone condition), poor soft tissue condition and defective extensor apparatus. A stable axis of the lower limb can be achieved which, in most cases, can be fully weight-bearing. With an uncomplicated course of treatment, a large proportion of patients (85%) after arthrodesis are satisfied with their condition. Often with replacement of the prosthesis and repeated debridement (removal of dead/necrotic tissue), an intractable mixed infection can also be brought under control using this method.

Studies have noted that patients with stable and painless arthrodesis have functional results no worse than those shown in patients who have a total knee replacement (link to article_110918_Knee endoprosthesis). In turn, according to other studies, although somewhat poorer, but still quite satisfactory functional results were revealed after arthrodesis, but at the same time, a higher level of pain was observed than after implantation of a revision prosthesis. In addition to good clinical and functional results, arthrodesis offers the opportunity to maintain the lower limb in a weight-bearing state for a longer period of time.

Disadvantages of arthrodesis

The patient should be informed preoperatively that reconversion of an arthrodesis to a total endoprosthesis is associated with high complication rates and, in many cases, is not possible at all. After surgery, most patients require walking aids. The number of such patients according to clinical studies is 76.2%. Some of them had lameness due to a shortened limb, while others had difficulty climbing stairs and higher energy costs while walking. If the leg on which arthrodesis was performed is shorter (by approximately 2-2.5 cm), doctors recommend increasing the sole of the shoe.

Questioning and examining the patient before the intervention

Before performing arthrodesis, the following questions are clarified:

date of implantation;
the period between the last event (either infection or revision prosthesis) and the performance of arthrodesis;
physical endurance/performance (full weight-bearing, partial weight-bearing, heel-to-toe weight-bearing, no weight-bearing);
mobility during prosthetics (neutral-zero method);
type of mobility assistance (wheelchair, wheeled walker, crutches with elbow support, none);
number of crutches with elbow support (one or two);
duration of use of mobility aids (permanently or temporarily);
wearing an orthosis.

After a thorough examination of the patient and collection of anamnesis, taking into account the patient’s age, his motivation, the purpose of the operation, possible risks, the type of arthrodesis is selected (hybrid fixator, plate osteosynthesis, external fixator with/without screws, using an arthrodesis nail or associated modular rods).

Coalitions of the bones of the foot

Please see the relevant section of our website for information regarding what you may encounter after surgery.

You must understand that the following is only an approximate rehabilitation plan, while each patient’s recovery process is different. This information is intended to help you understand the essence of your condition, treatment and rehabilitation options. The time frames we have given are only a minimum, and when deciding in favor of surgical treatment, you should keep in mind that in your case the healing and rehabilitation process may take longer.

Early postoperative period

All operations for osteoarthritis of the subtalar joint are performed under general anesthesia.

After resection of the tarsal coalition

After surgery, the foot and ankle joint will be fixed with a posterior plaster splint while the surgical wounds heal.

Postoperative immobilization

Do not remove the splint until the next dressing change, which will take place 2-3 weeks after surgery.

You should not put any weight on your limb for approximately 2-3 weeks after surgery. Before you are discharged home, you will be advised by a physiotherapist, who will include: will tell you how to use crutches correctly.

In the first 2 weeks after surgery, try to elevate your foot and keep it in that position 95% of the time.

Elevated foot position

Most people certainly don't have a functional bed at home like the one in this photo. However, the same effect can be achieved on a regular bed or sofa by placing a pillow under your foot. You should not put your feet in an elevated position when you are sitting on a chair. And once again we advise you to stay at home for the first two weeks.

To minimize the risk of infection, keep your feet dry and cool. Avoid excess humidity and heat. When showering, wear a sealed bag over your foot.

In order to prevent venous thrombosis, regularly perform movements in the foot and ankle joint. Drink enough fluids. If you have risk factors for thrombosis, be sure to tell your doctor about this; if necessary, he can prescribe you anticoagulants.

Subtalar/triarticular arthrodesis addendum

You will spend the first night after surgery in the clinic, and the next day we will repeat antibiotic prophylaxis. Your foot and ankle will be immobilized in a rigid splint for 6 weeks after surgery, and you will not be able to put any weight on your limb for at least this period.

Two weeks after surgery

You will be examined by your doctor and your dressing will be changed. You will be allowed to drive for a short time, but only if your left leg has been operated on and your car has an automatic transmission. If the right leg has been operated on, we recommend driving no earlier than 6-8 weeks after the operation.

After resection of the tarsal coalition

If the healing process is going well, by this time your swelling and bleeding will have largely disappeared, but some swelling may persist for up to 3-4 months after surgery. If the wounds have completely healed, then we will tell you how to properly massage the tissues in the intervention area. Measures aimed at reducing the sensitivity of the scar begin only after the wound has completely healed. For this purpose, you can use a massage cream (for example, E45), which should be rubbed into the scar area and around it. You can expose the surgical area to moisture and take a shower only after the wounds have completely healed.

You will be advised to wear special orthopedic shoes for approximately 4 weeks.

At this stage we may refer you to the rehabilitation department. And this is the earliest time you can return to your job.

Subtalar/triarticular arthrodesis addendum

At this stage, if post-operative swelling has largely subsided, we will allow you to lower your foot down more often, but we recommend that you still keep it flat most of the time if possible. The ankle joint will be immobilized with a rigid bandage for another 4-6 weeks. Loading during this period is still prohibited. You can take short walks outside as long as your pain and swelling allow.

Six weeks after surgery

After resection of the tarsal coalition

Significant reduction in the severity of swelling and pain. You will be able to start wearing normal shoes (as swelling will allow), but we recommend wearing hard-soled shoes during this time. Over the next 3-6 months, you will undergo physical therapy classes, which will allow you to achieve the most optimal result of the surgical intervention.

Subtalar/triarticular arthrodesis addendum

If the healing process is going well, by this time your swelling and bleeding will have largely disappeared, but some swelling may persist for up to 4-6 months after surgery.

Depending on the results of the x-ray control, you will be advised to use an orthopedic boot that allows the possibility of weight bearing on the operated foot, or immobilization will continue and weight bearing will continue to be excluded.

If the results of X-ray control are satisfactory and postoperative wounds have completely healed, massage of the soft tissues in the surgical area and desensitization of the scar will be recommended.

Measures aimed at reducing the sensitivity of the scar begin only after the wound has completely healed. For this purpose, you can use a massage cream (for example, E45), which should be rubbed into the scar area and around it. You can expose the surgical area to moisture and take a shower only after the wounds have completely healed.

Three months after surgery

After resection of the tarsal coalition

If you are satisfied with the result, then this is your last visit to the doctor.

After subtalar/triarticular arthrodesis

Control radiography, which should show signs of consolidation. You will be able to start wearing normal shoes (as swelling will allow), but we recommend wearing hard-soled shoes during this time. Over the next 3-6 months, you will undergo physical therapy classes, which will allow you to achieve the most optimal result of the surgical intervention.

How is the operation performed?

The operation is performed under epidural anesthesia. An injection is made in the spine, which “turns off” the sensitivity of the body below the belt for the duration of the operation.

Having cut the soft tissue, the surgeon carefully moves aside the nerves, vessels and ligaments, without crossing them, but providing access to the joint.
Next, the doctor removes the joint capsule, scar tissue and very sparingly excises the deformed areas of the tibia and talus bones that form the ankle joint.
Then all the components of the artificial joint are installed in the prepared bed, including a polymer liner that serves as a gasket between the metal parts.
The endoprosthesis is installed using the press-fit method (tight fit into the bone). The implant has a special coating that facilitates its ingrowth into bone tissue. This allows the endoprosthesis to be firmly fixed in the bone.
The surgeon then sutures the soft tissue.

After the operation, an x-ray is taken to verify the correct installation of the prosthesis.

At the end of the operation, the joint is fixed with an orthosis. The patient is transferred to the hospital inpatient unit.