18 yr old girl with ankle pain for 15 years. open biopsy done 10 years ago was reported as nonspecific. She had rest pain. Xrays showed consider narrowing of the joint space as well as osteophytes. The plan was arthroscopic ankle fusion. I have performed 14 of these and all united within 6 weeks except one where in resulted in a nonunion (gross deformity was the reason). Due to severe fibrous ankylosis of the joint one could not enter the notch of Harty or ankle. One had to identify the anterior joint with great difficulty. I was on the anterior tibia and walked down under IMI control as there was no joint space to enter. Using osteotomes the joint was entered, scar removed with small curreted and arthrodesed with 2 converging tibitalar 6.5 mm cannulated cancelous Screws.
The biopsy was done 15 years ago and reported as nonspecific synovitis. Xrays- 6 degrees plantar flexion,neutral varus/valgus.
We unfortunately did not biopsy this time. As far as Sunjays comment goes. You are spot on. One cannot correct deformity with arthroscopic ankle fusion and the only failure I had with a arthroscopic ankle fusion is a deformed ankle(1/ 14). As far getting into the ankle is concerned, it is best done with ankle in dorsiflexion, no traction, direct trocar medial to lateral after entering into the capsule at the AM portal (Notch of Harty) in the coronal plane and look posteriorly to identify the joint. The clea8vage even in fibrous ankylosis is visible, if not the under x ray control using a quarter inch osteotome one could identify the same and work posteriorly with osteotome, currettes and vapr etc before fusing it. Long term secondary OA is expected when in further fusion may be needed. TER at this age is not advisable.
Bimal, 1.
The morbidity is less. The patient is home the next day comfortable. The oedema and pain post op in open lasts for a long time.
2. The union rates after scopic fusion is much higher above 95% and even the duration to fusion is less.
the xrays are uploaded for comments
could you come up with a diagnosis sir for her early OA?
ReplyDelete1. ascopic fusion not advisable for deformed ankle. Only you can do it. I would have converted to an open fusion, when i found that finding the space was difficult, not that i do ascopy.
ReplyDelete2. 18 yrs old female?? long term followup studies have shown, significant, midfoot and subtalar OA changes with symptoms, following ankle fusion. what will you do when she comes back? It will be interesting to know your 5 years, independantly reviewd radiographic and clinical results at 5 years. Are you scoring them? just a thought.
Sunjay, yes the 10 yr results show midfoot- subtalar oa with minimal symptoms. The results of replacement are at best 70 percent at 10 yrs with designer surgeons. Even they have changed or rather improved their designs hopefully. The joint space being narrow does not make access difficult as we enter trnsverserly in a mediolateral direction with the foot dorsiflexed and no traction
Deletesir, what do we gain by doing this procdure (ankle fusion)athroscopically in comparison to open ankle fusion.. or in other words what were ur reasons for deciding on an arthroscopic apporach (not only in this case..but the previous cases too)
ReplyDelete