Continuing Education
European Journal of Trauma and Emergency Surgery
The following is a reprint from Operat Orthop Traumatol 2005;17:407–25 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community.
Tibiotalar Arthrodesis with the Tibial Compression Nail Thomas Mückley1, Gunther Hofmann1, Volker Bühren2
Abstract Objective: Arthrodesis of the ankle joint in proper position (neutral position in respect to flexion/extension, 5° external rotation, 0–5° of valgus). Pain-free weight bearing of the affected limb. Indications: Painful osteoarthritis of the ankle joint resistant to conservative approaches even in the presence of poor bone quality of the distal tibia such as after pilon fractures and osteoporosis. Failure of other methods of internal fixation. Contraindications: Osteitis. Partial necrosis of the talar dome. Medullary canal of tibia not patent. Surgical Technique: Lateral approach and resection of lateral malleolus. If the joint position is normal, removal of articular cartilage of tibia and talus. If axial correction is necessary, wedge resection of articular surfaces with underlying bone. Opening of proximal tibial medullary canal, insertion of compression nail into tibia and talus. Compression osteosynthesis and cancellous bone grafting. Alternatively, the arthrodesis can be achieved with the dowel technique. Results: Between September 1993 and March 2001, 137 patients (43 women, 94 men, average age 49 years [21– 79 years]) were operated. Follow-up of 110 patients after 42 months: successful bony fusion in 99 patients (90%). In six patients (5.5%) the goal of treatment was obtained after revision with recompression of the nail and bone grafting. Nonunion in five patients (4.5%). Complications: one tibial shaft fracture, one hematoma needing evacuation, three superficial infections, and eight deep infections. Three patients developed an os1
2
teoarthritis of the subtalar joint. 70 patients (63.6%) reported an improvement, 37 (33.6%) no notable change of symptoms, and three (2.7%) a deterioration. Key Words Tibiotalar arthrodesis · Compression nail · Intramedullary fixation · Dowel technique Eur J Trauma 2007;33:202–13 DOI 10.1007/s00068-007-1151-y
Introductory Remarks The multitude of published techniques for arthrodesis of the tibiotalar joint points to the difficulties of reaching the goal of surgery, namely a bony fusion [15]. Among the various procedures the compression osteosynthesis supplemented by autogenous bone grafting stands out by its reliable primary stability, its broad contact surfaces, and the correct position of the foot [4, 6, 7, 10, 14, 15]. The internal fixation methods achieved with screws have shown to be superior to methods using an external fixator in respect to patients’ satisfaction, biomechanical stability, and low incidence of complications. Internal fixation allows an early postoperative mobilization, as well as an early partial weight bearing [2, 9, 15–17]. Already more than 40 years ago, Küntscher [8] performed a retrograde tibiocalcaneal nail arthrodesis. Experimental investigations [1] have documented the biomechanical superiority of the intramedullary procedure over the use of crossed screws for the tibiota-
Klinik für Unfall,- Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Berufsgenossenschaftliche Unfallklinik Murnau.
Reprint from: Operat Orthop Traumatol 2005;17:407–25 DOI 10.1007/s00064-005-1151-1
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Figure 1. Guide wire with chisel point.
localcaneal arthrodesis. Presently, no data are available in respect to the stiffness and stability in rotation of the nail arthrodesis of the tibiotalar joint. The development of intramedullary compression nails permitted to use the compression principle for tibiotalar arthrodesis performed in antegrade fashion [3, 5, 11, 13]. After our initial application in September 1993 we not only standardized the technique but also designed a modified intramedullary nail. Surgical Principles and Objective Compression arthrodesis of the tibiotalar joint using a special intramedullary nail after resection of the articular surfaces and apposition of autogenous cancellous bone for restoration of a pain-free weight bearing on a foot placed in a perfect functional position. Advantages • Stable internal fixation under compression. • Early postoperative mobilization and weight bearing of the limb. • No need for cast immobilization. • Successful outcome even in the presence of poor bone quality of the distal tibia such as after pilon fractures. Disadvantages • Minimal talar height of 2 cm required as measured at the talar body. • Reaming of the total medullary canal is a prerequisite. • Possibility of osteoarthritis of the neighboring joints, a complication seen in all other methods of arthrodesis of tibiotalar joint. Indications • Painful osteoarthritis of the tibiotalar joint resistant to conservative measurements including orthopedic shoes. • Osteoarthritis of the tibiotalar joint accompanied by poor bone quality of the distal tibia such as after pilon and ankle fractures and osteoporosis. • Failure of other surgical techniques.
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Figure 2. Cannulated intramedullary compression nail made from titanium alloy
Contraindications • Partial necrosis of talar dome. • Talar height < 2 cm. • Local soft-tissue inflammation as well as acute and chronic bone infections. • Posttraumatic malalignment of the tibial shaft. • Blockage of tibial medullary canal. • Open physes. Patient Information • Usual surgical risks. • Risk of fat embolism, heat necrosis of bone due to reaming of medullary canal. • Risk of damage to sural nerve, branches of superficial peroneal nerve, the infrapatellar branch of the saphenus nerve, and peroneal tendons. • Risk of damage to dorsal pedis artery, and the deep peroneal nerve during distal locking of the intramedullary nail. • Tibial fracture. • Shortening of limb. • Nonunion and loss of correction. • Arthritis of neighboring joints and persistence of symptoms. • Loosening and breakage of implant. • Shoe with rocker-bottom sole recommended. • If symptoms persist, consider orthopedic shoes. • Full weight bearing after 2–3 weeks. Preoperative Work Up • Radiographs in two planes of the lower leg including the ankle joint for assessment of axial alignment. • Radiographs in two planes of foot for determination of position of talus and calcaneus and their articular surfaces. • Possible need for CT of tibiotalar and subtalar joints. • Cleansing of foot, nail care. • Epilation of lower leg and foot with epilation cream. • Shaving of surgical field immediately before surgery. • On day of surgery: low molecular heparin such as fragmin (2,500 IU s.c. daily) for prevention of deep vein
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thrombosis. If contraindicated, use of unfractionated heparin such as Liquemin® (3 × 5,000 IU s.c. daily). • Perioperative antibiotic prophylaxis with cephalosporin i.v. Surgical Instruments and Implants • Complete set for reamed intramedullary nailing. • Guide wire with chisel point (Figure 1). • Cannulated intramedullary compression nail made of titanium alloy (Ti6Al4V, anodization type II), 10 mm diameter and length from 240 to 420 mm (Figure 2). • Locking screws and shaft screws of 5 mm diameter. • Compression screw. • The principle of compression nailing is realized by an intramedullary implant which has a loose fit in the medullary cavity; after locking it permits a movement of both bones against each other. After distal locking this movement is possible thanks to a partially threaded locking screw (shaft screw) inserted into the oblong hole in such a way that a movement between screw and nail is possible. A compression screw is inserted
into the inner threads of the proximal nail end. During tightening the compression screw exerts a thrust on the shaft screw and thus on the tibia. This movement approximates and then compresses the resection surfaces. • Radiolucent angular drive of the drill. • Oscillating saw. • Chisel, sharp curettes or hollow reamers (dowel cutter; 9 and 10 mm diameter) for resection of articular cartilage. • Image intensifier. Anesthesia and Positioning • Endotracheal or regional anesthesia. • Regional catheter for postoperative analgesia, if warranted. • Supine on operating table with radiolucent leg support. • Positioning of the lower leg on a rectangular cushion with the knee in 40° of flexion. • Free draping of limb. Tourniquet at thigh.
Surgical Technique Figures 3 to 17
N. cutaneus dors. intermed.
Abb.3
M. peroneus long. et brev.
N. suralis
Figure 3. 10–12 cm long incision over lateral aspect of distal fibula; the incision curves anteriorly around the tip of the lateral malleolus and ends at the level of the subtalar joint. Care is taken not to injure the sural and the intermediate posterior cutaneous nerve.
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Lig. tibiofibulare ant. Talus
Fibula
Lig. tibiofibulare ant. Tibia
Retinaculum mm. peron. sup.
Peroneal tendons
Talus
Fibula
Lig. tibiofibulare post.
Figure 4. Subperiosteal exposure of the lateral malleolus and the distal fibula. Having placed sharp Hohmann retractors around the fibula just proximal to the anterior and posterior tibiofibular ligaments, the fibula is divided with an oscillating saw.
Figure 5. Subperiosteal enucleation of the lateral malleolus freeing it from the ligamentous attachments. Part of the resected lateral malleolus is morcellized for later use as autogenous bone grafts around the site of arthrodesis.
Abb.6a
Fibula
Oscillating saw
Chisel
b
a Tibia
Figures 6a and 6b. The cartilaginous articular surfaces of tibia and talus are removed either with a chisel (a) or an oscillating saw (b) in such a way that the surfaces of resection form a right angle to the long axis of the tibia. The foot should be placed in 5° of external rotation, 0–5° of valgus, and at 90° to the longitudinal axis of the tibia in the sagittal plane. In women an equinus position of 5–10° may be selected. With the knee in full extension the anterior superior iliac spine, the mid part of the patella, and the first web space should lie in a straight line. Abb.7
Figure 7. In the presence of a malalignment of the ankle a wedge resection of the articular surfaces is indicated to obtain an optimal position of arthrodesis.
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85– 90°
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Patella Lig. patellae
R. infrapatellaris n. saph.
Curved awl
Tuberositas tibiae
Figure 8. Skin incision, 3–4 cm in length, medial to the patellar ligament in a distal direction starting at the level of the distal patellar pole. After blunt spreading of the subcutaneous tissues and insertion of blunt hooks the infrapatellar branch of the saphenus nerve is retracted medially.
Figure 9. The patellar ligament is retracted laterally with a Langenbeck retractor to expose the anterior aspect of the head of the tibia where the medullary canal will be opened. The entry point lies 2–2.5 cm distal to the articular surface just proximal to the tibial tuberosity. Under image intensification the medullary canal is opened with a curved awl. The tip of the awl must point to the medullary canal in both planes.
Guide wire
Figure 10. The guide with a chisel point, being 1 m long and having a diameter of 3 mm, is introduced into the medullary canal and advanced into the talus under image intensification in both planes. The guide is mounted on a Jacob’s chuck with a T-handle and directed with rotational movements. Gentle taps on the T-handle with the slotted hammer are recommended to facilitate crossing of the subchondral bone of distal tibia and talar dome.
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Flexible reamer over guide wire
Radiolucent angular drive
Figure 11. Once the guide wire is in optimal position, the medul-
Figure 12. The length of the nail is determined with the help of
lary canal of the tibia is reamed with a flexible reamer starting with an 8-mm reamer and 0.5-mm progression. During reaming the assistant holds the leg and foot in the desired position. After the first reaming the chisel-tipped guide wire is exchanged for a guide wire with an olive-shaped tip; this prevents the reamer from penetrating the subtalar joint. The position of this blunt guide wire must be checked with the image intensifier in both planes. In the proximal metaphyseal area of the tibia reaming must be done to 12 mm, in the entire shaft section to 11 mm, and in the talus to 10 mm.
the guide wire. Insertion of nail with aiming device over the guide wire. With the guide wire in place the cannulated nail is driven with a few hammer blows beyond the site of resection into its final position.
Cannulated intramedullary nail over guide wire with olive-shaped tip
Locking screw
Stab incision
Figure 13. Removal of the guide wire. Under image intensification and using the freehand technique distal locking of the nail from lateral and from anterior. We employ the radiolucent angular drive and use the already made skin incision for insertion of the lateral locking screw, and a stab incision for the anterior screw inserted after blunt separation of the soft tissues.
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Figure 14. Determination of the length of the self-cutting locking screws and their insertion from lateral and anterior.
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Figure 15. Proximal locking: with the help of the aiming device attached to the nail locking through the oblong “dynamic” hole. Stab incision over the medial aspect of the head of the tibia. Blunt spreading of the subcutaneous tissues. Insertion of drill sleeve in contact with bone. Perforation of both cortices with a 4.2-mm drill bit. Determination of screw length. Overdrilling of medial cortex with a 5-mm drill bit and introduction of a shaft screw.
Aiming device
Shaft screw
Intramedullary nail
Removal of nail holding screw
Compression screw pushing down the shaft screw thus pulling up the intramedullary nail
Insertion of compression screw
pression
Figure 16. The nail holding screw and the aiming device are removed. Insertion of the compression screw into the lumen of the nail engaging it in the inner threads of the nail.
Abb.17
Figure 17. While advancing the compression screw, the screw will exert a pressure on the shaft screw that glides in the oblong hole thus compressing the resection surfaces of the ankle. The compression is done under image intensifier control. A sufficient compression is reached when the shaft screw starts to bend. The torque of the compression screw should be identical to that of a well-seated cortical screw inserted into the diaphysis of a long bone. The resected lateral malleolus is morcellized and the chips are put around the site of the arthrodesis. Suction drain and wound closure in layers.
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Intramedullary nail being pulled up through insertion of the compression screw
Compression
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Mückley T, et al. Tibiotalar Arthrodesis with the Tibial Compression Nail
Special Considerations (Figures 18 and 19) In addition to the use of a compression nail the dowel technique can be used instead of a wide resection of the articular surfaces. After insertion of the nail two dowels are harvested from the resected lateral malleolus, dowel channels are then created in the area of arthrodesis and the dowels implanted. A prerequisite for this technique
is the absence of malalignment and the proper position of the tibiotalar arthrodesis. We proceed first with the intramedullary nailing as shown in Figures 8 to 15. Thereafter, the ankle is exposed and the lateral malleolus resected as shown in Figures 3 to 5.
Hollow reamer Abb.18
a
Cancellous bone dowel
b Figure 18. Under image intensification in the lateral plane a 10 mm thick hollow reamer is inserted into the site of arthrodesis in the frontal plane from lateral, once anterior and once posterior, to the nail. The removed dowels are discarded. Any contact between reamer and nail has to be strictly avoided.
Figures 19a and 19b. Irrigation of the resection channels. The neighboring articular cartilages are removed with a sharp curette. With a 9-mm hollow reamer two dowels are removed from the lateral malleolus in a proximodistal direction (a) and inserted and impacted into the channels between tibia and talus (b). In addition, any remaining cancellous bone grafts are apposed. If the length and width of the resected lateral malleolus are insufficient to harvest two dowels, cancellous bone chips are taken from the remaining lateral malleolus or from the site of nail introduction at the tibial head. The surfaces of resection are now compressed as shown in Figures 16 and 17.
Postoperative Management • Immediate checking of the circulatory and neurologic status of the limb. • Wound dressing and elastic bandaging from web spaces to groin. Position of the slightly elevated limb on a foam splint. First dressing change and removal of drain on day 2; at this time regular exercises of the neighboring joints of foot and toes are started. From the 3rd postoperative day the patient is allowed to walk carefully with two forearm crutches and partial weight bearing of 20 kg. • Elastic bandages remain in place till removal of stitches which is done on the 12th postoperative day.
• From the 3rd postoperative week on the patient is permitted full weight bearing. • Radiographic control of leg and foot in two planes immediately after surgery and after 3 and 12 weeks. • Prescription of support stockings to prevent edema. • Removal of implant material is optional but should not be done before 12 months postoperatively, once the arthrodesis is well consolidated. • Addition of rocker-bottom sole and elastic heel to patient’s shoes is recommended. There is no need for wearing a boot. • If the leg length discrepancy exceeds 1 cm, a shoe lift should be added.
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a
b Figures 20a to 20c. Typical course of healing of a tibiotalar arthrodesis done with a compression nail in a 54-year-old woman with posttraumatic osteoarthritis secondary to a distal intraarticular tibial fracture. a) State before arthrodesis; note the varus malposition. b) Radiographs taken 3 weeks after intramedullary nail arthrodesis, resection of articular surfaces, and correction of varus malposition. c) State after implant removal 14 months after arthrodesis.
c
Errors, Hazards, Complications • Lower leg and foot are not carefully positioned during reaming of tibia and talus and/or insertion of the nail: faulty foot position, inadequate position of nail, delayed union or nonunion of arthrodesis. Revision. • The sharp guide wire penetrates into the subtalar joint; the position of the wire has not or only unsatisfactorily been controlled: damage to the articular cartilage of the subtalar joint. Recommendation: after the initial ream-
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ing the sharp guide should be replaced by an olive-tipped guide wire acting as a stop to further reaming. • Tibial shaft fracture during nail insertion: imprecise placement of the guide wire, insufficient reaming of the medullary canal. If the bony damage is limited to a crack, mostly of the posterior cortex, no additional internal fixation is needed. In the presence of area of sclerosis in the medullary canal and/or obliterations: choose alternate technique for arthrodesis.
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b
c
a
d
e
Figures 21a to 21c. Typical course of healing of an arthrodesis achieved with the dowel technique in a 62-year-old woman. a) Preoperative state. b) Intraoperative lateral imaging done in view of reaming of the articular surface. c) Intraoperative radiograph after insertion of the dowels harvested from the lateral malleolus. d) Radiograph 12 weeks postoperatively showing beginning consolidation. e) State after implant removal 12 months postoperatively.
• Height of talar body < 2 cm: the distal locking screws cannot be properly placed into the talus, inadequate locking of the nail tip. Alternate techniques such as external fixation or crossed screws should be employed. • Nonunion: revision. • Early or late infections: treatment with well-accepted methods. Results Between September 1993 and March 2001 we operated 137 patients (94 men, 43 women, average age 49 years
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[21–79 years]). Clinical and radiological follow-up of 110 patients (80.3%) after an average of 42 months (12 months to 7.5 years). 24 patients (19.7%) could not be reached or did not report for the follow-up examination; three patients had died on account of unrelated medical conditions. A posttraumatic osteoarthritis of the ankle joint presented an indication for arthrodesis in 135 patients (98.5%): a severe joint destruction after distal intraarticular tibial fracture was seen in 35 patients (25.5%; Figure 20) and after ankle fracture-dislocations in 70 patients (51.1%). An osteoarthritis after talar fracture was
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8,0
The medullary nails were meanwhile removed in 74 patients (67.3%).
7,0 6,0 5,0 4,0 3,0 2,0 1,0
ne Oste igh oa bo rth rin rit g j is, oin ts
He m ato m a
fra ctu re ial Tib
cti on nfe pi De e
fec tio n
Su
pe
rfi ci
al in
No n
un
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Figure 22. Complications.
present in five patients (3.6%), after an ankle dislocation in four (2.9%), after leg fractures in twelve (8.7%), after posttraumatic avascular talar necrosis in three (2.2%), and after neurologic damage (severe head trauma or injury to the sciatic nerve) in six (4.4%). Osteoarthritis of the ankle joint in patients with leg fractures was mainly caused by faulty weight transmission at the ankle. In two cases primary osteoarthritis was the indication for ankle arthrodesis. The interval between accident and arthrodesis amounted to an average of 58 months (3 months to 50 years). In 17 patients (12.4%) the arthrodesis was performed inside the first 6 months after the accident. In eleven patients (8%) an arthrodesis had been attempted unsuccessfully (external fixation seven times, screw arthrodesis four times). A history of infection of the ankle joint was reported by 15 patients (10.9%). In respect to the surgical technique we performed a dowel technique in 25 patients (18.2%), and an articular cartilage resection in 78 (56.9%). A concomitant correction of ankle malalignment was done 34 times (24.8%; Figure 21). The goal of surgery was in obtained in 105 patients (95.5%), in 99 patients (90%) achieved within the first 6 months. Three patients required an additional compression procedure and eight in addition a cancellous bone grafting. These revisions took place between 5 and 7 months after the index procedure. A bony consolidation was reached in six of these eleven patients. The remaining five patients with nonunion (4.5%) did not agree to further surgery; they were provided with orthopedic shoes.
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Complications We observed 21 complications (19.1%) among the 110 followed-up patients (Figure 22). Besides the five nonunions we witnessed eleven wound infections (three superficial, eight deep), one hematoma at the site of arthrodesis, and one tibial shaft fracture during nail insertion. A history of previous infection at the site of surgery had been reported by seven of the eleven patients with wound infections. A rapidly developing, very painful osteoarthritis of the posterior facet of the subtalar joint was observed three times. An increased incidence of these complications was noticed in patients with poor talar bone stock after talus fracture or partial necrosis. As a consequence of these observations we believe that a marked malalignment of the tibia, a history of acute or chronic infection, and poor bone stock of the talus do limit the indication for the compression nail arthrodesis [13]. Outcome Analysis The analysis of our results must take the special patient population of a workers’ compensation board hospital (disability claims, request for retraining) into consideration. This applies also to the subjective assessment of results: Of 66 patients covered by the compensation board and 44 patients insured by a mandatory insurance system, 70 patients (63.6%) reported a marked improvement of their preoperative symptoms. No appreciable improvement of symptoms was reported by 37 patients (33.6%) of whom 31 were covered by the compensation board. Deterioration of symptoms was accused by three compensation board patients (2.7%), but by none of the patients insured by the mandatory health insurance. The effect of the kind of coverage on the result of treatments has also been documented by other studies of compensation board hospitals [2, 12].
References 1.
2.
3.
Berend ME, Glisson RR, Nunley JA. A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int 1997;18:639–43. Breitfuß H, Muhr G, Mönnig B. Fixateur oder Schraube bei Arthrodesen am oberen Sprunggelenk. Ein retrospektiver Vergleich bei 76 Patienten. Unfallchirurg 1989;92:245–53. Bühren V. Intramedullary compression nailing of long tubular bones. Unfallchirurg 2000;103:708–20.
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4. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91. 5. Gonschorek O, Hofmann GO, Bühren V. Interlocking compression nailing: a report on 402 applications. Arch Orthop Trauma Surg 1998;117:433–7. 6. Holz U. Die Arthrodese des oberen Sprunggelenks mit Zugschrauben. Operat Orthop Traumatol 1990;2:131–8. 7. Johnson FW, Boseker EH. Arthrodesis of the ankle. Arch Surg 1968; 97:766–73. 8. Küntscher G. Praxis der Marknagelung. Stuttgart: Schattauer, 1962. 9. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. J Bone Joint Surg Am 1979;61:964–75. 10. Midis N, Conti SF. Revision ankle arthrodesis. Foot Ankle Int 2002; 23:243–7. 11. Mückley T, Gonschorek O, Bühren V. Compression nailing of long bones. Eur J Trauma 2003;29:113–28. 12. Mückley T, Hempfling H. Neue Techniken der Arthroskopie. Ergebnisse der arthroskopischen Lavage und des Debridements beim Knorpelschaden. Chir Prax 1996;51:659–72. 13. Mückley T, Schütz T, Srivastava S, et al. Die Technik der tibiotalaren Arthrodese mit Kompressionsmarknagel. Unfallchirurg 2003;106: 732–40.
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14. Scranton PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67:550–5. 15. Scranton PE. An overview of ankle arthrodesis. Clin Orthop 1991; 268:96–101. 16. Thermann H, Hüfner T, Roehler A, et al. Schraubenarthrodese des oberen Sprunggelenks. Orthopäde 1996;25:166–76. 17. Wagner H, Pock HG. Die Verschraubungsarthrodese der Sprunggelenke. Unfallheilkunde 1982;85:280–300.
Address for Correspondence Dr. Thomas Mückley Department of Trauma, Hand, and Reconstructive Surgery University Hospital Jena Erlanger Allee 101 07747 Jena Phone (+49/3641) 9322-838, Fax -802 e-mail: [email protected]
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European Journal of Trauma and Emergency Surgery
The following is a reprint from Operat Orthop Traumatol 2005;17:407–25 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community.
Tibiotalar Arthrodesis with the Tibial Compression Nail Thomas Mückley1, Gunther Hofmann1, Volker Bühren2
Abstract Objective: Arthrodesis of the ankle joint in proper position (neutral position in respect to flexion/extension, 5° external rotation, 0–5° of valgus). Pain-free weight bearing of the affected limb. Indications: Painful osteoarthritis of the ankle joint resistant to conservative approaches even in the presence of poor bone quality of the distal tibia such as after pilon fractures and osteoporosis. Failure of other methods of internal fixation. Contraindications: Osteitis. Partial necrosis of the talar dome. Medullary canal of tibia not patent. Surgical Technique: Lateral approach and resection of lateral malleolus. If the joint position is normal, removal of articular cartilage of tibia and talus. If axial correction is necessary, wedge resection of articular surfaces with underlying bone. Opening of proximal tibial medullary canal, insertion of compression nail into tibia and talus. Compression osteosynthesis and cancellous bone grafting. Alternatively, the arthrodesis can be achieved with the dowel technique. Results: Between September 1993 and March 2001, 137 patients (43 women, 94 men, average age 49 years [21– 79 years]) were operated. Follow-up of 110 patients after 42 months: successful bony fusion in 99 patients (90%). In six patients (5.5%) the goal of treatment was obtained after revision with recompression of the nail and bone grafting. Nonunion in five patients (4.5%). Complications: one tibial shaft fracture, one hematoma needing evacuation, three superficial infections, and eight deep infections. Three patients developed an os1
2
teoarthritis of the subtalar joint. 70 patients (63.6%) reported an improvement, 37 (33.6%) no notable change of symptoms, and three (2.7%) a deterioration. Key Words Tibiotalar arthrodesis · Compression nail · Intramedullary fixation · Dowel technique Eur J Trauma 2007;33:202–13 DOI 10.1007/s00068-007-1151-y
Introductory Remarks The multitude of published techniques for arthrodesis of the tibiotalar joint points to the difficulties of reaching the goal of surgery, namely a bony fusion [15]. Among the various procedures the compression osteosynthesis supplemented by autogenous bone grafting stands out by its reliable primary stability, its broad contact surfaces, and the correct position of the foot [4, 6, 7, 10, 14, 15]. The internal fixation methods achieved with screws have shown to be superior to methods using an external fixator in respect to patients’ satisfaction, biomechanical stability, and low incidence of complications. Internal fixation allows an early postoperative mobilization, as well as an early partial weight bearing [2, 9, 15–17]. Already more than 40 years ago, Küntscher [8] performed a retrograde tibiocalcaneal nail arthrodesis. Experimental investigations [1] have documented the biomechanical superiority of the intramedullary procedure over the use of crossed screws for the tibiota-
Klinik für Unfall,- Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Berufsgenossenschaftliche Unfallklinik Murnau.
Reprint from: Operat Orthop Traumatol 2005;17:407–25 DOI 10.1007/s00064-005-1151-1
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Figure 1. Guide wire with chisel point.
localcaneal arthrodesis. Presently, no data are available in respect to the stiffness and stability in rotation of the nail arthrodesis of the tibiotalar joint. The development of intramedullary compression nails permitted to use the compression principle for tibiotalar arthrodesis performed in antegrade fashion [3, 5, 11, 13]. After our initial application in September 1993 we not only standardized the technique but also designed a modified intramedullary nail. Surgical Principles and Objective Compression arthrodesis of the tibiotalar joint using a special intramedullary nail after resection of the articular surfaces and apposition of autogenous cancellous bone for restoration of a pain-free weight bearing on a foot placed in a perfect functional position. Advantages • Stable internal fixation under compression. • Early postoperative mobilization and weight bearing of the limb. • No need for cast immobilization. • Successful outcome even in the presence of poor bone quality of the distal tibia such as after pilon fractures. Disadvantages • Minimal talar height of 2 cm required as measured at the talar body. • Reaming of the total medullary canal is a prerequisite. • Possibility of osteoarthritis of the neighboring joints, a complication seen in all other methods of arthrodesis of tibiotalar joint. Indications • Painful osteoarthritis of the tibiotalar joint resistant to conservative measurements including orthopedic shoes. • Osteoarthritis of the tibiotalar joint accompanied by poor bone quality of the distal tibia such as after pilon and ankle fractures and osteoporosis. • Failure of other surgical techniques.
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Figure 2. Cannulated intramedullary compression nail made from titanium alloy
Contraindications • Partial necrosis of talar dome. • Talar height < 2 cm. • Local soft-tissue inflammation as well as acute and chronic bone infections. • Posttraumatic malalignment of the tibial shaft. • Blockage of tibial medullary canal. • Open physes. Patient Information • Usual surgical risks. • Risk of fat embolism, heat necrosis of bone due to reaming of medullary canal. • Risk of damage to sural nerve, branches of superficial peroneal nerve, the infrapatellar branch of the saphenus nerve, and peroneal tendons. • Risk of damage to dorsal pedis artery, and the deep peroneal nerve during distal locking of the intramedullary nail. • Tibial fracture. • Shortening of limb. • Nonunion and loss of correction. • Arthritis of neighboring joints and persistence of symptoms. • Loosening and breakage of implant. • Shoe with rocker-bottom sole recommended. • If symptoms persist, consider orthopedic shoes. • Full weight bearing after 2–3 weeks. Preoperative Work Up • Radiographs in two planes of the lower leg including the ankle joint for assessment of axial alignment. • Radiographs in two planes of foot for determination of position of talus and calcaneus and their articular surfaces. • Possible need for CT of tibiotalar and subtalar joints. • Cleansing of foot, nail care. • Epilation of lower leg and foot with epilation cream. • Shaving of surgical field immediately before surgery. • On day of surgery: low molecular heparin such as fragmin (2,500 IU s.c. daily) for prevention of deep vein
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thrombosis. If contraindicated, use of unfractionated heparin such as Liquemin® (3 × 5,000 IU s.c. daily). • Perioperative antibiotic prophylaxis with cephalosporin i.v. Surgical Instruments and Implants • Complete set for reamed intramedullary nailing. • Guide wire with chisel point (Figure 1). • Cannulated intramedullary compression nail made of titanium alloy (Ti6Al4V, anodization type II), 10 mm diameter and length from 240 to 420 mm (Figure 2). • Locking screws and shaft screws of 5 mm diameter. • Compression screw. • The principle of compression nailing is realized by an intramedullary implant which has a loose fit in the medullary cavity; after locking it permits a movement of both bones against each other. After distal locking this movement is possible thanks to a partially threaded locking screw (shaft screw) inserted into the oblong hole in such a way that a movement between screw and nail is possible. A compression screw is inserted
into the inner threads of the proximal nail end. During tightening the compression screw exerts a thrust on the shaft screw and thus on the tibia. This movement approximates and then compresses the resection surfaces. • Radiolucent angular drive of the drill. • Oscillating saw. • Chisel, sharp curettes or hollow reamers (dowel cutter; 9 and 10 mm diameter) for resection of articular cartilage. • Image intensifier. Anesthesia and Positioning • Endotracheal or regional anesthesia. • Regional catheter for postoperative analgesia, if warranted. • Supine on operating table with radiolucent leg support. • Positioning of the lower leg on a rectangular cushion with the knee in 40° of flexion. • Free draping of limb. Tourniquet at thigh.
Surgical Technique Figures 3 to 17
N. cutaneus dors. intermed.
Abb.3
M. peroneus long. et brev.
N. suralis
Figure 3. 10–12 cm long incision over lateral aspect of distal fibula; the incision curves anteriorly around the tip of the lateral malleolus and ends at the level of the subtalar joint. Care is taken not to injure the sural and the intermediate posterior cutaneous nerve.
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Lig. tibiofibulare ant. Talus
Fibula
Lig. tibiofibulare ant. Tibia
Retinaculum mm. peron. sup.
Peroneal tendons
Talus
Fibula
Lig. tibiofibulare post.
Figure 4. Subperiosteal exposure of the lateral malleolus and the distal fibula. Having placed sharp Hohmann retractors around the fibula just proximal to the anterior and posterior tibiofibular ligaments, the fibula is divided with an oscillating saw.
Figure 5. Subperiosteal enucleation of the lateral malleolus freeing it from the ligamentous attachments. Part of the resected lateral malleolus is morcellized for later use as autogenous bone grafts around the site of arthrodesis.
Abb.6a
Fibula
Oscillating saw
Chisel
b
a Tibia
Figures 6a and 6b. The cartilaginous articular surfaces of tibia and talus are removed either with a chisel (a) or an oscillating saw (b) in such a way that the surfaces of resection form a right angle to the long axis of the tibia. The foot should be placed in 5° of external rotation, 0–5° of valgus, and at 90° to the longitudinal axis of the tibia in the sagittal plane. In women an equinus position of 5–10° may be selected. With the knee in full extension the anterior superior iliac spine, the mid part of the patella, and the first web space should lie in a straight line. Abb.7
Figure 7. In the presence of a malalignment of the ankle a wedge resection of the articular surfaces is indicated to obtain an optimal position of arthrodesis.
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85– 90°
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Patella Lig. patellae
R. infrapatellaris n. saph.
Curved awl
Tuberositas tibiae
Figure 8. Skin incision, 3–4 cm in length, medial to the patellar ligament in a distal direction starting at the level of the distal patellar pole. After blunt spreading of the subcutaneous tissues and insertion of blunt hooks the infrapatellar branch of the saphenus nerve is retracted medially.
Figure 9. The patellar ligament is retracted laterally with a Langenbeck retractor to expose the anterior aspect of the head of the tibia where the medullary canal will be opened. The entry point lies 2–2.5 cm distal to the articular surface just proximal to the tibial tuberosity. Under image intensification the medullary canal is opened with a curved awl. The tip of the awl must point to the medullary canal in both planes.
Guide wire
Figure 10. The guide with a chisel point, being 1 m long and having a diameter of 3 mm, is introduced into the medullary canal and advanced into the talus under image intensification in both planes. The guide is mounted on a Jacob’s chuck with a T-handle and directed with rotational movements. Gentle taps on the T-handle with the slotted hammer are recommended to facilitate crossing of the subchondral bone of distal tibia and talar dome.
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Flexible reamer over guide wire
Radiolucent angular drive
Figure 11. Once the guide wire is in optimal position, the medul-
Figure 12. The length of the nail is determined with the help of
lary canal of the tibia is reamed with a flexible reamer starting with an 8-mm reamer and 0.5-mm progression. During reaming the assistant holds the leg and foot in the desired position. After the first reaming the chisel-tipped guide wire is exchanged for a guide wire with an olive-shaped tip; this prevents the reamer from penetrating the subtalar joint. The position of this blunt guide wire must be checked with the image intensifier in both planes. In the proximal metaphyseal area of the tibia reaming must be done to 12 mm, in the entire shaft section to 11 mm, and in the talus to 10 mm.
the guide wire. Insertion of nail with aiming device over the guide wire. With the guide wire in place the cannulated nail is driven with a few hammer blows beyond the site of resection into its final position.
Cannulated intramedullary nail over guide wire with olive-shaped tip
Locking screw
Stab incision
Figure 13. Removal of the guide wire. Under image intensification and using the freehand technique distal locking of the nail from lateral and from anterior. We employ the radiolucent angular drive and use the already made skin incision for insertion of the lateral locking screw, and a stab incision for the anterior screw inserted after blunt separation of the soft tissues.
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Figure 14. Determination of the length of the self-cutting locking screws and their insertion from lateral and anterior.
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Figure 15. Proximal locking: with the help of the aiming device attached to the nail locking through the oblong “dynamic” hole. Stab incision over the medial aspect of the head of the tibia. Blunt spreading of the subcutaneous tissues. Insertion of drill sleeve in contact with bone. Perforation of both cortices with a 4.2-mm drill bit. Determination of screw length. Overdrilling of medial cortex with a 5-mm drill bit and introduction of a shaft screw.
Aiming device
Shaft screw
Intramedullary nail
Removal of nail holding screw
Compression screw pushing down the shaft screw thus pulling up the intramedullary nail
Insertion of compression screw
pression
Figure 16. The nail holding screw and the aiming device are removed. Insertion of the compression screw into the lumen of the nail engaging it in the inner threads of the nail.
Abb.17
Figure 17. While advancing the compression screw, the screw will exert a pressure on the shaft screw that glides in the oblong hole thus compressing the resection surfaces of the ankle. The compression is done under image intensifier control. A sufficient compression is reached when the shaft screw starts to bend. The torque of the compression screw should be identical to that of a well-seated cortical screw inserted into the diaphysis of a long bone. The resected lateral malleolus is morcellized and the chips are put around the site of the arthrodesis. Suction drain and wound closure in layers.
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Intramedullary nail being pulled up through insertion of the compression screw
Compression
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Special Considerations (Figures 18 and 19) In addition to the use of a compression nail the dowel technique can be used instead of a wide resection of the articular surfaces. After insertion of the nail two dowels are harvested from the resected lateral malleolus, dowel channels are then created in the area of arthrodesis and the dowels implanted. A prerequisite for this technique
is the absence of malalignment and the proper position of the tibiotalar arthrodesis. We proceed first with the intramedullary nailing as shown in Figures 8 to 15. Thereafter, the ankle is exposed and the lateral malleolus resected as shown in Figures 3 to 5.
Hollow reamer Abb.18
a
Cancellous bone dowel
b Figure 18. Under image intensification in the lateral plane a 10 mm thick hollow reamer is inserted into the site of arthrodesis in the frontal plane from lateral, once anterior and once posterior, to the nail. The removed dowels are discarded. Any contact between reamer and nail has to be strictly avoided.
Figures 19a and 19b. Irrigation of the resection channels. The neighboring articular cartilages are removed with a sharp curette. With a 9-mm hollow reamer two dowels are removed from the lateral malleolus in a proximodistal direction (a) and inserted and impacted into the channels between tibia and talus (b). In addition, any remaining cancellous bone grafts are apposed. If the length and width of the resected lateral malleolus are insufficient to harvest two dowels, cancellous bone chips are taken from the remaining lateral malleolus or from the site of nail introduction at the tibial head. The surfaces of resection are now compressed as shown in Figures 16 and 17.
Postoperative Management • Immediate checking of the circulatory and neurologic status of the limb. • Wound dressing and elastic bandaging from web spaces to groin. Position of the slightly elevated limb on a foam splint. First dressing change and removal of drain on day 2; at this time regular exercises of the neighboring joints of foot and toes are started. From the 3rd postoperative day the patient is allowed to walk carefully with two forearm crutches and partial weight bearing of 20 kg. • Elastic bandages remain in place till removal of stitches which is done on the 12th postoperative day.
• From the 3rd postoperative week on the patient is permitted full weight bearing. • Radiographic control of leg and foot in two planes immediately after surgery and after 3 and 12 weeks. • Prescription of support stockings to prevent edema. • Removal of implant material is optional but should not be done before 12 months postoperatively, once the arthrodesis is well consolidated. • Addition of rocker-bottom sole and elastic heel to patient’s shoes is recommended. There is no need for wearing a boot. • If the leg length discrepancy exceeds 1 cm, a shoe lift should be added.
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a
b Figures 20a to 20c. Typical course of healing of a tibiotalar arthrodesis done with a compression nail in a 54-year-old woman with posttraumatic osteoarthritis secondary to a distal intraarticular tibial fracture. a) State before arthrodesis; note the varus malposition. b) Radiographs taken 3 weeks after intramedullary nail arthrodesis, resection of articular surfaces, and correction of varus malposition. c) State after implant removal 14 months after arthrodesis.
c
Errors, Hazards, Complications • Lower leg and foot are not carefully positioned during reaming of tibia and talus and/or insertion of the nail: faulty foot position, inadequate position of nail, delayed union or nonunion of arthrodesis. Revision. • The sharp guide wire penetrates into the subtalar joint; the position of the wire has not or only unsatisfactorily been controlled: damage to the articular cartilage of the subtalar joint. Recommendation: after the initial ream-
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ing the sharp guide should be replaced by an olive-tipped guide wire acting as a stop to further reaming. • Tibial shaft fracture during nail insertion: imprecise placement of the guide wire, insufficient reaming of the medullary canal. If the bony damage is limited to a crack, mostly of the posterior cortex, no additional internal fixation is needed. In the presence of area of sclerosis in the medullary canal and/or obliterations: choose alternate technique for arthrodesis.
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b
c
a
d
e
Figures 21a to 21c. Typical course of healing of an arthrodesis achieved with the dowel technique in a 62-year-old woman. a) Preoperative state. b) Intraoperative lateral imaging done in view of reaming of the articular surface. c) Intraoperative radiograph after insertion of the dowels harvested from the lateral malleolus. d) Radiograph 12 weeks postoperatively showing beginning consolidation. e) State after implant removal 12 months postoperatively.
• Height of talar body < 2 cm: the distal locking screws cannot be properly placed into the talus, inadequate locking of the nail tip. Alternate techniques such as external fixation or crossed screws should be employed. • Nonunion: revision. • Early or late infections: treatment with well-accepted methods. Results Between September 1993 and March 2001 we operated 137 patients (94 men, 43 women, average age 49 years
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[21–79 years]). Clinical and radiological follow-up of 110 patients (80.3%) after an average of 42 months (12 months to 7.5 years). 24 patients (19.7%) could not be reached or did not report for the follow-up examination; three patients had died on account of unrelated medical conditions. A posttraumatic osteoarthritis of the ankle joint presented an indication for arthrodesis in 135 patients (98.5%): a severe joint destruction after distal intraarticular tibial fracture was seen in 35 patients (25.5%; Figure 20) and after ankle fracture-dislocations in 70 patients (51.1%). An osteoarthritis after talar fracture was
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8,0
The medullary nails were meanwhile removed in 74 patients (67.3%).
7,0 6,0 5,0 4,0 3,0 2,0 1,0
ne Oste igh oa bo rth rin rit g j is, oin ts
He m ato m a
fra ctu re ial Tib
cti on nfe pi De e
fec tio n
Su
pe
rfi ci
al in
No n
un
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0,0
Figure 22. Complications.
present in five patients (3.6%), after an ankle dislocation in four (2.9%), after leg fractures in twelve (8.7%), after posttraumatic avascular talar necrosis in three (2.2%), and after neurologic damage (severe head trauma or injury to the sciatic nerve) in six (4.4%). Osteoarthritis of the ankle joint in patients with leg fractures was mainly caused by faulty weight transmission at the ankle. In two cases primary osteoarthritis was the indication for ankle arthrodesis. The interval between accident and arthrodesis amounted to an average of 58 months (3 months to 50 years). In 17 patients (12.4%) the arthrodesis was performed inside the first 6 months after the accident. In eleven patients (8%) an arthrodesis had been attempted unsuccessfully (external fixation seven times, screw arthrodesis four times). A history of infection of the ankle joint was reported by 15 patients (10.9%). In respect to the surgical technique we performed a dowel technique in 25 patients (18.2%), and an articular cartilage resection in 78 (56.9%). A concomitant correction of ankle malalignment was done 34 times (24.8%; Figure 21). The goal of surgery was in obtained in 105 patients (95.5%), in 99 patients (90%) achieved within the first 6 months. Three patients required an additional compression procedure and eight in addition a cancellous bone grafting. These revisions took place between 5 and 7 months after the index procedure. A bony consolidation was reached in six of these eleven patients. The remaining five patients with nonunion (4.5%) did not agree to further surgery; they were provided with orthopedic shoes.
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Complications We observed 21 complications (19.1%) among the 110 followed-up patients (Figure 22). Besides the five nonunions we witnessed eleven wound infections (three superficial, eight deep), one hematoma at the site of arthrodesis, and one tibial shaft fracture during nail insertion. A history of previous infection at the site of surgery had been reported by seven of the eleven patients with wound infections. A rapidly developing, very painful osteoarthritis of the posterior facet of the subtalar joint was observed three times. An increased incidence of these complications was noticed in patients with poor talar bone stock after talus fracture or partial necrosis. As a consequence of these observations we believe that a marked malalignment of the tibia, a history of acute or chronic infection, and poor bone stock of the talus do limit the indication for the compression nail arthrodesis [13]. Outcome Analysis The analysis of our results must take the special patient population of a workers’ compensation board hospital (disability claims, request for retraining) into consideration. This applies also to the subjective assessment of results: Of 66 patients covered by the compensation board and 44 patients insured by a mandatory insurance system, 70 patients (63.6%) reported a marked improvement of their preoperative symptoms. No appreciable improvement of symptoms was reported by 37 patients (33.6%) of whom 31 were covered by the compensation board. Deterioration of symptoms was accused by three compensation board patients (2.7%), but by none of the patients insured by the mandatory health insurance. The effect of the kind of coverage on the result of treatments has also been documented by other studies of compensation board hospitals [2, 12].
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2.
3.
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4. Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33:180–91. 5. Gonschorek O, Hofmann GO, Bühren V. Interlocking compression nailing: a report on 402 applications. Arch Orthop Trauma Surg 1998;117:433–7. 6. Holz U. Die Arthrodese des oberen Sprunggelenks mit Zugschrauben. Operat Orthop Traumatol 1990;2:131–8. 7. Johnson FW, Boseker EH. Arthrodesis of the ankle. Arch Surg 1968; 97:766–73. 8. Küntscher G. Praxis der Marknagelung. Stuttgart: Schattauer, 1962. 9. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. J Bone Joint Surg Am 1979;61:964–75. 10. Midis N, Conti SF. Revision ankle arthrodesis. Foot Ankle Int 2002; 23:243–7. 11. Mückley T, Gonschorek O, Bühren V. Compression nailing of long bones. Eur J Trauma 2003;29:113–28. 12. Mückley T, Hempfling H. Neue Techniken der Arthroskopie. Ergebnisse der arthroskopischen Lavage und des Debridements beim Knorpelschaden. Chir Prax 1996;51:659–72. 13. Mückley T, Schütz T, Srivastava S, et al. Die Technik der tibiotalaren Arthrodese mit Kompressionsmarknagel. Unfallchirurg 2003;106: 732–40.
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14. Scranton PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am 1985;67:550–5. 15. Scranton PE. An overview of ankle arthrodesis. Clin Orthop 1991; 268:96–101. 16. Thermann H, Hüfner T, Roehler A, et al. Schraubenarthrodese des oberen Sprunggelenks. Orthopäde 1996;25:166–76. 17. Wagner H, Pock HG. Die Verschraubungsarthrodese der Sprunggelenke. Unfallheilkunde 1982;85:280–300.
Address for Correspondence Dr. Thomas Mückley Department of Trauma, Hand, and Reconstructive Surgery University Hospital Jena Erlanger Allee 101 07747 Jena Phone (+49/3641) 9322-838, Fax -802 e-mail: [email protected]
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