Stiffening the joint (arthrodesis) is a surgical procedure that permanently abolishes the mobility of the joint. Arthrodesis involves the removal of articular surfaces and resection of bone tissue, and then a stable fusion of the bones so that they become permanent fusing. Movement in the place of the operated joint is impossible, which is the intended effect - thanks to the stiffening of the joint, pain relief, correction of the incorrect position of the joint and restoration of the limb support function are achieved. Ankle arthrodesis is the "gold standard" in the treatment of advanced degenerative disease and post-traumatic conditions with irreversible damage to the articular cartilage. The surgeon can additionally stiffen the joints within the foot, which is used in selected corrective procedures of fixed flatfoot and clubfoot in adults
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Indications for arthrodesis
The method of treatment consisting in stiffening the joints of the foot and ankle is successfully used in post-traumatic conditions and in the correction of painful deformities which are a complication of various foot diseases.
Correction of severe forms of the flat valgus foot
Stiffening of the ankle joint (arthrodesis) is a method of treating the painful fixed flat valgus foot when conservative treatment is ineffective and other surgical procedures would be insufficient to achieve correction and relieve pain. The foot deformity should be completely corrected to minimize the effect of valgus force and restore normal mechanical axis of the lower limb. Thanks to this, pain in the foot or knee can be effectively relieved.
Foot deformities in the course of rheumatoid arthritis
Arthrodesis of the ankle joint is a good solution when anti-inflammatory and analgesic drugs and orthopedic equipment do not eliminate the pain sufficiently, and the progressive deformation leads to serious destruction of the joints and soft tissues of the foot. Surgical treatment usually includes the correction of valgus of the hindfoot and additional procedures in the area of the forefoot.
Post-traumatic conditions
When the ankle joint is completely damaged, arthrodesis is the treatment of choice. The most common indications for joint stiffening are multi-fracture unstable fractures involving the articular surfaces of the tibia and talus.
Clubfoot correction in adults
Clubfoot is characterized by a varus position of the heel, adduction of the forefoot and permanent plantar flexion in the ankle joint. The patient puts a strain on the outer edge of the foot, and in advanced states he is unable to walk without the orthosis on, because the lateral ankle escapes excessively to the side. There are many sub-types of clubfoot, and the type of surgery treatment is tailored to each individual case. Arthrodesis is performed mainly in severe permanent forms of clubfoot in adults. If the neuromuscular imbalance was still present while the bones are growing, their shape is permanently changed. During the correction procedure, the Achilles tendon is lengthened, and then procedures are undertaken to restore the correct axis of the ankle joint, techniques to shorten the lateral column of the foot and lengthen the medial column of the foot. In some cases, it is necessary to excise the bone wedges and apply grafts to restore the desired shape of the foot.
Charcot's foot a complication of diabetes
Charcot's arthropathy is associated with loss of sensation and impaired blood supply to the foot in the course of poorly treated diabetes. The result is an increased bone resorption, leading to massive fractures under the influence of limb loading. The patient does not feel the pain of the fracture. Often there is a collapse of the longitudinal arch of the foot and deformation of the "rocking chair" when the elevations of the broken bone fragments are located on the bottom of the foot. Surgery of the foot and ankle allows the reconstruction of the shape of the foot in order to avoid the formation of ulcerations on its plantar side. Surgical treatment and recovery after surgery are very difficult due to impaired healing processes, limited ability of the body to fight local infection and difficulty in obtaining full bone union.
What is the arthrodesis procedure?
The ankle brace procedure includes the following stages:
Create a bone bed from a spongy bone to aid healing The surgeon removes the joint cartilage and part of the bone with an osteotome or a bone spoon. To increase the healing potential, he can make small bone drilling.
Proper positioning of the ankle joint The joint is positioned in a neutral position in the sagittal plane, with 5 degrees of valgus and 5 degrees of external rotation.
Stable immobilization with an internal fixation with adequate compression between the bones. The fixation is made with two or three titanium screws, inserting them through the tibia and talus bone. The screws are placed crosswise to each other - the first from the medial side, the second from the lateral side and the third from the back descending forward. This allows you to get the best compression ratio.
The arthrodesis procedure is most often performed openly, although in the case of limited deformities, the procedure can be arthroscopic or mini-invasive.
Classic arthrodesis of the ankle - open-ended
Open access gives a good exposure of the articular surfaces and allows for precise possible correction of deformation. The most common method is lateral access, where the surgeon cuts the fibula slightly above the ankle joint. After resection of the osteochondral tissue and fusion of the fragments, the fibula is put back in place in most cases. Before that, its medial cortical surface is removed to facilitate consolidation with the substrate. Any defects are filled with bone grafts - this is sometimes necessary during procedures correcting large deformities. The graft may be a fragmented fragment of the fibula or a removed portion of the iliac crest. Much less frequent arthrodesis is performed from the anterior approach between the tendon of the anterior tibial muscle and the long extensor of the toe. This access is technically difficult and requires more experience from the surgeon.
Arthroscopic arthrodesis of the ankle joint
The operator makes two or three small incisions (up to 4 mm) through which he introduces the surgical instruments into the joint. The incisions are located within the anteromedial and anterolateral ports of classic ankle arthroscopy. The operator removes cartilage from the end of the tibia and talus, and then grinds a specific layer of bone. During the procedure, a distractor is used to move the articular surfaces away from each other and make it easier for the surgeon to perform the necessary procedures. The arthroscopic procedure is characterized by less traumatization of soft tissues, which reduces the risk of complications (e.g. skin necrosis) in people with impaired blood supply in the lower extremities. Due to the limited access to bone tissue, the arthroscopic arthrodesis procedure is reserved mainly for single stiffeners and without the planned large correction of the joint axis.
Subtalar arthrodesis
When it is necessary to stiffen the subtalar joint (ankle joint), the surgeon, under X-ray control, introduces the so-called calcaneus from the bottom of the calcaneus. detachment nail reaching the talus. The nail can stiffen only the subtalar joint, or it can stiffen the upper and subtalar joint at the same time - this is the so-called tibio-calcaneus stiffening.
The "triple arthrodesis" takes into account the stiffening of three joints: the subtalar joint, the ankle joint and the calcane-cubic joint. The triple arthrodesis procedure is often performed in patients with rheumatoid arthritis.
Procedure after surgery
The operated limb is placed in a plaster splint until the wounds heal and the sutures are removed. Then, a shin cast or a special ankle orthosis is put on. Full loading is possible after confirming the radiological signs of union. This time may be longer than for the healing of an ordinary fracture - a major arthrodesis involving several joints may involve a time of 3-4 months for complete bone union. Before that, it is possible to partially load the limb under the strict supervision of a doctor and a physical therapist.
Rehabilitation
The basis of early rehabilitation after the wounds have healed and the sutures removed is manual therapy of soft tissues, including work on the scars to make them more flexible. The adjacent healthy joints are also mobilized to improve the compensatory abilities of the musculoskeletal system. Do not forget about exercises to strengthen the muscles of the thigh, hip girdle and trunk stabilization training. An important task of physiotherapy is learning symmetrical loading of the lower limbs and functional use of the operated limb while walking. In the case of delayed bone union, stimulation of bone consolidation can be achieved through physical therapy procedures, e.g. magnetic field exposure.
Complications after arthrodesis surgery
Lack of bone union may be manifested by persistent pain in the operated area. X-ray images may show thinning of the bone tissue at the border of the fragments. A symptom of undesirable mobility is local osteolysis in the area of the anastomosis. The factors that increase the risk of nonunion include: blood circulation disorders, previous fractures (especially "pilon fracture" of the tibia or talus fractures) and infections. Smokers should permanently quit smoking as soon as possible before surgery.
Fusion in improper positioning may result from improper bone positioning during surgery, poor bone tissue condition, and disturbances in the axis of adjacent joints. The aggravation of the deformity (e.g. joint varus) may be an indication for revision arthrodesis.
Possible disturbances in the healing of soft tissues occur due to impaired vascularization in this area. In people at risk (diabetics, smokers), arthroscopic or smaller incision arthrodesis may be considered to reduce the degree of tissue traumatization.
Important information
| Duration of the procedure (depending on the method) | 60-120 minutes |
| Tests required for surgery | basic - preparation for surgery tab |
| Anesthesia | standard subarachnoid, periosteal block |
| Hospital stay | minimum 6 - 8 hours after surgery |
| A period of significant dysfunction | 3-4 weeks |
| A period of limited dysfunction | 6-10 weeks |
| Removal of stitches - first visit | 12-18 days |
| Change of dressings | every 3- 4 days |
| Contraindications to the procedure | obesity, blood clotting disorders, anesthetic contraindications |
Frequently asked questions about the ankle arthrodesis procedure:
Arthrodesis is a surgical procedure to stiffen the ankle joint. For this purpose, the articular surfaces are removed and the tibia is joined with the talus bone so that they become permanent fusing. Movement in the place of the operated joint is impossible, which is the intended effect - thanks to the stiffening of the ankle joint, pain relief, correction of incorrect positioning and restoration of the limb support function are achieved.
The arthrodesis procedure is most often performed in patients who suffer from pain associated with advanced degenerative changes of the ankle joint. The condition for qualification is the lack of effects of conservative treatment or the lack of purposefulness of undertaking other methods of surgical treatment. Stiffening of the ankle joint is also performed in extensive post-traumatic conditions involving the ankle joint. In addition, arthrodesis can be used as a method of correcting foot deformities, such as fixed flatfoot or clubfoot in adults.
Most patients are given epidural anesthesia to eliminate feeling from the waist down or the nerves supplying the operated limb are blocked. The ankle brace procedure is most often performed by the open method - the surgeon makes an incision of several centimeters on the side or in front of the ankle joint. Thanks to this, it has maximum access to the pond and can precisely correct its incorrect position. Arthrodesis can also be performed using the arthroscopic method, which leaves minimal scars (up to 4mm), but this method is reserved for smaller degrees of deformation.
During the operation, the surgeon removes the debris of the damaged cartilage, and then prepares the end of the tibia and the talus to allow them to heal later in the corrected position. The connection is stabilized with special screws or plates. The wounds are closed and a plaster splint is placed over the foot and ankle.
