Fig. 8.41 (a) Lateral radiograph reveals extensive destruction of the left ankle joint with disintegration of the talus and fragmentation of bone, (b) Postoperative radiograph of the left ankle following tibiocalcaneal fusion with the intramedullary nail and interlocking screws in place, (c) Long-term follow-up. Clinical appearance of the left foot and ankle 5 years after surgery.
over the course of several months, ankle deformity and instability progressed, with disintegration of the talus (Fig. 8.41a). The patient was given the option of a salvage procedure, a tibiocalcaneal fusion vs. major amputation of the leg, and he opted for ankle fusion in the hope of saving his leg.
A standard medial incision was made over the medial malleolus, under fluoroscopic guidance, and the distal medial aspect of the tibia was exposed. The entire talus was noted to be destroyed and the foot was dislocated lateral to the leg. The distal tibia was then exposed sub-periosteally and circumferentially and the bone was cut parallel to the standing alignment. A small portion of the talus was present laterally and this was planed down flat. Detritus was removed from the ankle. A filet guide pin was placed through the centre of the heel up through the calcaneus and up through the centre of the tibia. Sequential reamers were then utilized and reamed up to 12.5 mm. An 11 mm x 15 cm intramedullary nail was then selected and placed without difficulty. Two interlocking screws were placed in the calcaneus and then the nail was impacted into the distal tibia. The rotation was set with the tibial tubercle and then distal tibial interlocking screws were placed sequentially 70 mm, 70 mm and 70 mm. A 45-mm cross-linking screw was placed proximally. All screws were checked on the radiograph and were noted to be within the nail (Fig. 8.41b). The previously resected bone from the distal tibia was then morselized and packed with bone graft posteriorly and laterally. The wounds were copiously irrigated, a Hemovac drain was placed and wounds were closed with sutures and staples. The patient recovered on the acute surgical service for 1 week, was placed in a short-leg cast and was then transferred to the physical medicine and rehabilitation inpatient service for generalized conditioning exercise and ambulation training, non-weightbearing on the left lower extremity. The patient recovered uneventfully and remains ambulatory after nearly 5 years (Fig. 8.41c).
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