Orthopedics - Oleksa A.P. 2006

Joint Diseases
Degenerative and Dystrophic Joint Diseases
Static Deforming Arthrosis of the Ankle Joint

Static osteoarthritis of the ankle joint ranks second in terms of incidence. It develops gradually As a result of uneven loading of the talus within the intermalleolar mortise in pes plano-valgus, following traumatic or other axial disorders in the tibiofibular mortise or the FOOT.

If children with Flatfoot (pes plano-valgus) use orthopedic footwear and arch Supports during their growth period, the deformity gradually diminishes, and the foot can return to normal.

If a patient begins using arch supports or orthopedic footwear at an adult age, they may remain free of any ankle pain for a considerable time. However, such patients tire quickly and are unable to participate in hiking, mountain walking, and similar activities. When flat feet are subjected to frequent overload, pain emerges—initially subsiding with rest, but eventually becoming constant despite the continued use of orthopedic footwear.

Obviously, Surgical Treatment can help a patient at any stage of osteoarthritis; however, surgery performed for a flatfoot at the pre-arthritic stage prevents The Development of ankle osteoarthritis by restoring the static-dynamic function of the foot.

Technique of supramalleolar osteotomy. Under anesthesia and with a thigh tourniquet, soft Tissues are dissected down to the Fibula, which is osteotomized 2-3 cm above the level of the horizontal joint line. A second tissue incision is made in the supramalleolar region along the *planum tibiae*. The periosteum is elevated, and guided by radiographs, an oscillating saw is used to excise and remove a wedge-shaped bone fragment, the base of which is the medial cortical layer of the Tibia, and the apex corresponds to the level of the osteotomized fibula. By means of redression maneuvers, the foot is supinated and the resected surfaces of the tibia are adapted.

If the deformity can be manually corrected during surgery, the adapted tibial fragments are fixed with percutaneously inserted Kirschner wires or a metal plate, and the wounds are closed. The foot is maintained in the corrected position using a plaster cast until bony union of the fragments is achieved.

If the foot is rigid and difficult to correct manually, it is necessary to apply an Ilizarov fixator, assembled prior to surgery, to gradually correct the foot position and stabilize fragment fixation within the apparatus during the postoperative period.

The Ilizarov apparatus is also used when it is necessary to realign the tibial axis in cases of lower-third deformity, or to lengthen one of the paired bones in order to bring the foot into a normal position.

After removal of the apparatus, patients must use orthopedic footwear for a year and consistently wear arch supports in any shoes.

If a patient seeks medical attention for ankle pain that impairs their quality of life, and radiographs reveal pronounced arthritic changes, ankle arthrodesis with the foot positioned neutrally is recommended. This surgery provides significant relief by eliminating pain; however, the patient experiences some discomfort due to the loss of ankle motion, and after a few years, begins to notice Changes in the Chopart and Lisfranc joints caused by excessive compensatory movements and the onset of osteoarthritis.

Technique of arthrodesis. The surgery is performed under anesthesia and tourniquet control. A lateral Kocher incision is made, running linearly along the posterior border of the fibula and curving forward below the tip of the lateral malleolus. The peroneal tendons are mobilized and retracted, though it is preferable to transect them at different levels to ensure adequate surgical exposure. A soft-tissue flap is elevated subperiosteally and retracted anteriorly. The lateral malleolus is osteotomized at the level of the joint line and retracted laterally without cutting the ligaments. The Joint Capsule is excised, and the foot is gradually rotated to expose the articular surfaces. The articular Cartilage is removed first from the talus and subsequently from the tibia and malleoli. The foot is reduced, the resected surfaces are adapted, and if necessary, adjusted with an osteotome so that the foot is positioned in correct alignment with a slight (10°) flexion. The lateral malleolus is then adapted and fixed. Considering that postoperative casting does not provide adequate fixation of the foot, which slows bone healing, The Use of the fixation apparatus by G.A. Ilizarov or I.G. Grishin should be considered the optimal method. THE POSITION OF the foot can be further adjusted within the apparatus, and ankylosis develops within 2.5–3.5 months.

Arthrodesis can also be performed via an anterior approach to the ankle joint. An anterior linear incision of up to 10 cm exposes the tendons of the digital extensors of the foot. The tendons are retracted laterally—taking care not to damage the dorsalis pedis artery—to expose the ankle joint. The anterior wall of the joint capsule is excised, and the articular cartilage is removed with an osteotome down to the bleeding cancellous bone. It is essential not to leave the articular surfaces of the malleoli uncleaned. The resected surfaces are opposed in the correct position of the foot and fixed with a metal rod driven from the sole, through the joint, and into the tibia. Next, a notch is created in the neck of the talus, and a cortical graft is harvested from the anterior surface of the tibia, slid downward, and wedged into the notch in the talus. The wound is closed, and a plaster cast is applied.

This method of foot fixation using a bone graft ensures ankle ankylosis in the shortest possible time. The metal rod is easily removed after radiographic confirmation of bony ankylosis.

Undoubtedly, total ankle replacement would be functionally superior to arthrodesis; although many designs have been proposed, we still lack reliable endoprostheses. At the Mayo Clinic in the USA, their endoprosthesis is used, featuring a polyethylene tibial component and a metallic talar component (Fig. 340). In Ukraine, in Dnipro, O.Ye. Loskutov (1989) proposed his own design of a metal endoprosthesis and surgical technique for ankle replacement, but this Procedure has not come into widespread practice. There is hope that the required endoprostheses will eventually be manufactured.

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Fig. 340. Radiograph of the ankle joint following Mayo total replacement.

In cases of grade I–II deforming osteoarthritis of the ankle joint resulting from disruption of the physiological axis of the leg bones (congenital, post-traumatic, etc.) and uneven loading of the articular surfaces, a supramalleolar osteotomy is performed with axial correction using an Ilizarov compression-distraction apparatus. The apparatus-based technique allows not only for the realignment of the tibial axis following osteotomy but also, if necessary, for the lengthening of one of the paired bones to bring the foot into a normal, functionally advantageous position.