lessons learned-Sequelae of open fracture talus with medial malleolus fracture

He has  pain on wt bearing with Varus hind foot and gross painful restriction of ankle movement. Varus of ankle can be partially corrected short of neutral.  Subtalar movemnts are terminally restricted but painless. Midfoot and tendons are normal.

1. Is this AVN with collapse.

2. Malunion with Sec OA

3. Investigations if any

4. what are the options

 we did an arthroscopic ankle fusion. the reasons and problems are discussed in the comments

Now after 3 months the ankle is solid fused has lateral pain from an abuting osteophyte or should one call it unionophyte. The disheartening xray is of .> 10 gegree varus which i feel i would  need correction thru a transfibular approach when symptoms arise. He is on a rocker heel slippers to simulate heel toe gait.

1.      He was referred for ankle replacement. We did a bone scan to rule out AVN and decided to do an arthroscopic ankle fusion as he was young and works as a electrician. I believe an ankle replacement at this age may not be a good idea. As his subtalar joints were relatively normal an ankle fusion was chosen. In view of his varus deformity we planned to open if the deformity was not corrected, By clearing the lateral gutter with Shaver and burr we could correct the varus and hence only the medial malleous screws were removed and percutaneous tibiotalar screws were inserted. Unfortunately one of the guide wires broke and intraop screening showed it to be intraosseous. However the postop xray showed the wire protruding into the sinus tarsi. I am hoping for an early fusion and hopefully no subtalar symptoms

Lessons learned.

1. Do not attempt arthroscopic fusion in the presence of varus deformity which is not passively correctable

2.My reason to attempt the same was due to the medial and lateral as well as anterior skin inscisions which would compromise wound healing as well as after taking out the lateral osteophyte i felt i corrcted the deformity refer xrays above which I know now was never a true AP

The Xrays below are refusion at  6 weeks postop. The fusion clinically feels solid. We have delayed wt bearing and left the foot unsupported inspite of bridging anteriorly and posteriorly as open fusions generally take 3 months to fuse.

Over all arthroscopic ankle fusions have above 95% fusion rates at 12 weeks. My personal series of 18 cases have all united execpt for 2 malunions both of which the indications were flawed due preop varus deformity as above which were only partilly corrected.