orthopaedics

1. 2012
@

2.  articulation of the talus with the tibial plafond and the
distal fibula.
 Weight bearing area
 Disturb in ligaments: instability with wt bearing

4.  Posttraumatic
 Inflammatory
 Degenerative
 AVN
 malalignment (Instability ,malreduction)
 Also: position of the talus in the mortise, stability of the
syndesmosis, length of the fibula, and quality of the joint surface at
the time of reconstruction.

5.  Mechanical Pain
 ↓ROM
 Limitation of activity
 Limping
 P/E:
 Deformity, swelling, tenderness, ROM,
crepitation

6.  Xary
 CT
 MRI

7.  shoe inserts: cushioned heel and a stiff, rockerbottom sole
 ankle-foot orthosis
 walking cast for 6 weeks
 NSAID
 Wt reduction
 Activity modification
 Intra-articular injections

8.  Arthroscopic ankle-joint debridement
Ankle Arthrodesis
 Ankle Replacement

10.  ankle arthritis and deformity did not respond
to nonoperative treatment:
• Posttraumatic and primary Arthrosis
• Neuromuscular deformity
• Revision of Failed Ankle Arthrodesis
• Failed Total Ankle Replacement
• AVN Talus
• Neuroarthropathy (Charcot)
• Rheumatoid Arthritis with severe deformity
• Osteoarthritis
• Pseudarthrosis

11.  HISTORY:
› AGE
› MEDICAL ILLNESESS
› Signs of infection
› Previous conservative treamtment
› PREVIOUS SURGERY - ARTHRODSESIS
 EXAMINATION:
› Localize exam
› VASCULARITY
› ROM SUBTLAUR
› DEFORMITY
 Radiographic Studies:
› Ankle Wt bearing Xray
› LONG FILM LOWER LIMBS (deformity)
› Subtalar joint (Arthritis)

12.  Steinmann pins
 Screws
 Plates
 External fixators, illiazrove
 Retrograde IM Nails

13.  should be based on the underlying cause.
 As a general rule:
› external fixators and illiazrove: infections
› Arthroscopic: minimal deformity.
› Open: significant deformity

14.  neutral flexion (0 degrees)
 5 to 10 degrees of external rotation
 5 degree valgus

15.  1951
 The Charnley method combined open surgical debridement of the
ankle-joint cartilage with the application of an external fixator by
placing one pin through the tibia and another through the neck of
the talus, with connecting bars
 Bone graft
 allowed to bear weight 8 weeks after surgery
 After removal – walking cast for 4 weeks

16.  Charnley Method: USE OF EX FIX ONE PLANE WITH
COMPRESSION :
› STABLE IN AP PLAN
› NOT STABLE FOR ROTATION
 Calandruccio Compression Device (Richards):
› provides three-point fixation,
stability in all planes of
movement

18.  Proper in case of active infection.

19.  20 years old male
 Fracture Rt Ankel
 ORIF done
 C/o pain , with activity , even at rest

20. Jan 2012 Bone scan:
Hyperemia with increased uptake
suspicion for infection
Ct scan:
distal syndesmotic screw loosening,
associated with irregularities at the
ankle joint with surrounding fluid collection.

21. Feb 2012

22. Removal at end of August 2012

24. On last visit December 2012

26.  Ports 2 or 3
› Anteromedial:
› medial to the tibialis nterior tendon, and located about 5 mm
proximal to the medial malleolus
› saphenous nerve and vein
› Anterolateral:
› lateral to peroneus tertius tendon
› lateral to the extensor digitorum longus tendon.

27.  Distraction:
› 25 IB will give 1 to 1.5 mm of distraction
› 30 ib more than 1 hr , reversable nerve injury
 A 4.5-mm bur and curettes -remove articular surfaces
 Compression: Interanal or external
 Prevered: 2 cannulated screw
› One medial mallulus to lateral talus
› One lateral tibia to neck of talus
 NWB 5 weeks
 Progress gradual till radiological healing

29.  Advantage:
› faster rates of union, decreased complications,
reduced postoperative pain, shorter hospital
stays, minimal loss of length of the lower limb.
 Disadvantage:
› Only for minimal deformity, because it is difficult to
correct ankle deformity arthroscopically.

30.  with severe ankle-joint deformity
 better visualization
 two-incision
› Direct over fibula
› Along anterior third of medial malluls
 maintain full-thickness flaps and protect
tendons and N,V

31.  Lateral: osteotomy 10 cm from the fibular tip,
The remaining fibular fragment can then be
excised.
 preserve the medial malleolus so as to
provide an area of solid fixation for the screw
and to preserve the medial blood supply to
the talus

32.  Cut of talus 5mm paralel to tibial cut
 drilled or curetted until bleeding bone

34.  two guide pins for large (7.0- to 7.3-mm)
cannulated screws
 Care must be taken that the pins do not violate
the subtalar joint
 short threaded cannulated screws with washers
 bulky cast padding 2 weeks
 NWB short leg cast
 Start WTB after radiological evidence of healing
 usually occurs 8 to 12 weeks postoperatively

35.  (TTCA)
 Minimal invasive
 Better mechanical Proparties.
 Some types allow compression
 The starting point is of the most importance

37. Indication:
AVN talus
Failed Total Ankle Arthroplasty
Pseudoarthrosis
Neuropathic arthropathy
Contraindications:
 Infection
 Sever vascular disease
 Sever tibial malalignment
 Normal subtalar joint (relative)
 Plantur pad inssuficency

38.  Entry point:
› 3 cm longitudinal plantur incision
› Anterior to subcalcaneak fat pad
› Lateral to mid line

39.  Nail length:
› Nail end should extend at least 1 ½ to 2 tibial
diameter above any potential stress risers

40.  NWB for 6 weeks
 12 weeks in case of nuropathy or use of
bonegraft

41. Complications
 nonunion
 fracture at or above the fixation construct
 Nerve and artery damage

42.  Complications:*
› nonunions (41%)
› Infections (9%)
› nerve injuries (3%)
› malunions (3%)
› wound problems (3%)
Frey et al 1995

43.  Risk factors associated with nonunion:
› severe fracture, an open injury, local infection,
evidence of osteonecrosis of the talus, and
coexisting major medical problems
› past history of undergoing a subtalar or triple
arthrodesis
› Smoking risk increase 16 times