ARTHRODESIS Experiences

J.

with

CRAWFORD

Assistant Formerly

The

as

Hospital

has

been

employed

thus

be

of its

value.*

for

An

incision,

tip

of

the

inches

end

by

splitting

tissues

clearly and

talus osteotome. equinus.

lateral half

erased

down

to

Trimming

of

the

is closed

Small A bed

and

astragalus

the

joint

the

astragalus

spaces

(Fig. The

4). and

by weeks

radiographic

tests

Thirty an

are

shown

[* Tile to

in

and

calcaneus)

That

service to

effective surgeon of Oxford,

orthopaedic 506

this

have

period

technique tibia and

the

that

cases

average

was day

Figs.

5 to

In

six

developed

by us

Neither

knows

does

a particular operation. James Armstrong of

in

an

the

graft

are

of

a plaster

operation.

side

After

grip

a gouge

a few

the

degrees

cancellous

the

is tibia

when

bone

of the

graft-bed,

applied.

as

joint

with

aspect

to the

which is

with

lateral

use

both

that with

four

stripping

ankle

manner

filled

is applied

for

of

position the

two

the

the

to

After

lateral

to

three

prepared!

tibia

a

distal

divided

tibia

bridging

tibia

and

one

\Veight-bearing

twelve

weeks,

the

in plaster

is

THE

RESULTS there series

was of

successful

primary

radiographs

in

fusion

typical

cases

8.

characterised

specialists

years. form

subcutaneous

cartilage

such

ends

screws,

Illustrative

was

of

from

twenty-eight

weeks.

of the ankle joint case of tibio-calcaneal

none

of the

freshening

and

OF

studied.

thirteen

four

of fusion.

of arthrodesis talus (or in the

operation. to

been of

been London

to

inch

length.

articular in

bone

of the

of

last

the

an

and

plantigrade

by

three

ANALYSIS

in

the

is closed

years the

and

of

and

end

out

optimal

aspect

the

half

its

The working

graft

recent At

third

a point

is removed

carried

between fibular

a few

lower to

lower

bone, in the

wound

within

clinical

rests

is secured The

operation

the

wound. is

cancelious

graft

(Fig.

for

The

during

throughout

of the

bones

the

fusion

fragment

the

Hospital

in

of the

subperiosteally

cortex

aspect

has

ankle

over

distal

of

joint

centres.

downwards

inner

remaining

ankle

London

ARTHRODESIS

made

vascular

foot for

3).

is encouraged

removed

the

is prepared

space.

plaster

The

the

orthopaedic

technique

is exposed

the

the

gap

chips.

2). off

lower

is then

intervening

(Fig.

from in

is

fibula

the

exposed

or of

lower

graft

ligamentous

The

the

TRANSFIBULAR

length,

Hospital

Department,

of

the

It is prolonged

malleolus.

its

onlay

1).

Mary’s

requiring

record

OF in

(Fig.

case

to

ENGLAND

St

of

JOINT Approach

Accident

a number

in every

inches

fibula

lateral

from

an

five

of the

Surgeon, and

at

opportune

ANKLE

LONDON,

arthrodesis

TECHNIQUE

surface

Transfibular

ADAMS,

procedure

may

it

time

estimate

standard

the

Orthopaedic

approach

the

THE

Orthopaedic

Assistant,

transfibular

adopted The

Chief

OF

the

Royal

or

eight

years

a magnificent with

any

certainty

one

But London,

Air

by

of us if credit and

Force

the transfibular fusion, with

approach, with grafting of the fibuia grafting of the fibula to the tibia, talus, in the orthopaedic service of the Royal Air Force. spirit in which exchange of ideas was so constant, first conceived the brilliant idea of this simple and that it is important to attach the name of a single be attached it should be shared by James C. Scott

ago

team who believe must John

Crawford

Orthopaedic

Adams

of

London,

all

of

whom

served

Service-EDIToR.] THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

as

ARTHRODESIS

of

over

the lower is divided

cancellous

freshened

(Fig.

cancelious

VOL.

30B,

NO.

3,

AUGUST

arthrodesis

third in its

of the lower

of

fibula shaft,

tile

ankle

joint.

(Fig. 1 ). Tile and removed

3

cartilage

with

307

JOINT

FIG.

transfibular

JIG. Articular

ANKLE

THE

1

FIG.

Technique is made

OF

surface,

1948

A five-inch

fibuia (Fig.

removed

from

the

joint.

chips, and the lateral surfaces 3). The fibular fragment, after is screwed in close contact with

incision

is exposed. 2).

11G. is

2

It

4

bone spaces are packed of tile tibia and talus are being split to expose its the tibia and talus (Fig. 4).

The

J. C. ADAMS

508

Ra(liograpil

of

old

unreduced

backward

disiocati)n

of tile

ankle

joint.

I

I 6

‘rue

joint

has

been

arthrodesed by the third of the fibula

transfibular as an onlay

THE

approach, graft.

JOURNAL

using

OF

BONE

the

lower

AND

JOINT

SURGERY

ARTHRODESIS

OF

THE

example

of

incongruity

509

JOINT

7

FIG.

Another

ANKLE

f tile fracture-(iisiocatin.

ankle

surfaces

joint

due

to

)1(i

I

A

I. FIG. Arthrodesis

has being

\.oI.

. 30 B,

NO.

3,

AUGUST

been secured

1948

performed in

by tiliS

case

tile by

8 trans-fibuiar two,

instea(l

approach. of three

the screws.

llhular

graft

510

J. C. ADAMS

116.

l)isorganisation joint had alrea(ly

9

1K;.

of an ankle joint been performed

after a gunshot wound. (Fig. 9). Attempted

Of fibular

grafting

failed

Arthrodesis fusion of the (Fig.

10).

was secured by The nail was renlove(l as Sound fusion (Fig.

means after

10

of the subastragaloid ankle joint by means

j

I JiG.

At a sec)nd peratin across the joint from

I I rigid below

12

FIG.

immobilisation (Fig. 11). there

THE

of

a three-flanged

fourteen

nail

weeks,

by

driven

which

time

JOINT

SURGERY

12).

JOURNAL.

OF

BONE

AND

ARTHRODESIS

two

In two

cases

there

failures

are

instructive

Case

report-A

resulting

man,

from

been

performed

the

ankle

the

bone

joint nail

This

of

was

were in

the

shearing

at

These

cases

Case

post-operative not

by

been

performed joint

There

bone

is little

inadequate suggests

and

into

also any

the

the

small

to

the

and

in

this

bones

of

that

may

surfaces

and

talus,

an(l

no

evidence

canceilous

case

the

failure

This

be

an

to

forward

und!em

of operation. week.

‘as

packed

obvious between

contact

chips

firmly

due

was

importance

is close

and

immobilisation.

fusion

the

in the operation

firmly

of plaster

primary

but fibula

A secondary

were

bone

of painful performed

transplanted

gap

months

secure

the

The

fusion.

five

there

treatment was

appreciable

emphasises

that

between

which

prevent

fourteenth

for

poor.

bone chips

cancellous

left

in to

time

Arthrodesis

after

failure

a manner

series,

at the

admitted was

of bone

obtained

packing

was

bone

then

surfaces.

in such

pounds)

was

the

consequent

taken

well

plaster

malunion.

was

this

tile

rigidity

of technique.

with of

tibia

fusion

bone

(224

that permitted

was

from

previously

was

extending weeks

of the

error

fracture

there

advisability spaces

stones

freshened

that

of the

an

apposition

operation were

to

old

the

plaster twelve

After

arthrodesis

with

in

care

three-

11).

have

joint,

cases

particular

a long

(Fig.

walking,

subsequent out,

on removal

due

an

apposition

doubt

in shaping

It

three

and

ankle

of

operation

after

mid-tarsal during

arthrodesis

shaft

joints

of the

the

ankle

moulded

sixteen

that

the

carried

fusion

from

of

joint,

joint

previously

a secondary

immobilisation mid-tarsal

fusion

until

was

Satisfactory

apposition

technique

bone

ends

surfaces.

In

the

fusion.

ankle

had

after

At tibial

bone

or

to

months

10). the

into

These

disorganised

joint

around

calcis

rigid

stiffness

series

after

sound

associated

been

Four

(Fig.

packed

os

providing

a closely

showed

were the

of primary

weighing

in close

; the

the

of

arthrodesis.

resulting

months

was

weight-bearing

patient

applied Six

around

of

this

ankle

there

movements

satisfactory

the

of

and

subastragaloid

fusion

subastragaloid

previously

in

chips

of failure

applying

radiographs

radiographs.

and

deferring

female of

cause

site

failure

report-A

whose

had

showed

other

osteoarthritis

importance

by

and

The

was

the

movements

forefoot,

the patients

forefoot

fusion

bone surface

bone

required.

considerations.

a painful

the

movement.

of

weeks

of

of

mid-tarsal

were

practical

treatment

evidence lower

fourteen

joint,

strain

of

operations

important

Arthrodesis

511

JOINT

secondary

for

9).

canceiious

for

ANKLE

and

admitted

(Fig.

the

THE

illustrate

impairment

from

slight

subastragaloid

was

radiographic

probable

of

shearing

had

up

subastragaloid

transmission

tile

was

in

The

they

freshened,

joint

fused.

of fusion

wound

illustrates

ankle

failure in that years,

no

plaster

case

the

been

there

driven

immobilisation

of

and

was

36

gunshot

there

surfaces

flanged

aged

old

an

was

OF

to

of careful

over

a wide

area.

the

joint

around

bones.

DISCUSSION With be

careful

relied

upon.

articular

It

surfaces

a scaffolding the

and

the

transfibulam

a method

which

obtained.

formation

astragalus

has The

for

merit

of

fibular

graft

onlaid

of a stout

is essential,

approach the

bone

and

the

bridge

packing

amthrodesis

of the

simplicity.

across

gives the

sound

Close

bone

joint

exposure

stability

joint.

of cancellous

ankle

Clear

chips

can of

and

contact

the

affords between

around

the

bones

advantage. When

arthrodesis

is performed

are

is

the

is readily

for

tibia

is an

OI

technique

not

the

transmitted

should

extend

until

of the

at

ten

fixation

twelve

the

forward

particular forefoot.

beneath

weeks

after

is the

use

of a long

into

the

shaft

calcaneus

subastmagaloid-mid-tamsal time,

from well

or

same

This the

three-flanged

is necessary demands

forefoot,

operation.

of the

joint care

An nail

has to

rigid

previously ensure

performed,

shearing

immobilisation.

and

weight-bearing

alternative

procedure

driven

been that

upwards

The should

which

from

the

be gives

lower

strains plaster deferred adequate

surface

of the

tibia. SUMMARY

The The if the

technique

results

of the

of this

technique

both

be

VOL.

30B,

operation

is carried

explained NO.

transfibular

by 3,

AUGUST

in out

errors 1948

a series

faithfully. of technique

approach

for

of thirty The or

two

arthrodesis cases cases

after-treatment.

of the

shows in which

that

ankle

joint

is described.

the

procedure

is reliable

a first

operation

failed

can