The patient is placed in the supine position
on a radiolucent operating table
The ipsilateral pelvis should be supported
to control external rotation of the leg,
so that the patella is directed upward to
facilitate the operation
A tourniquet is applied at the thigh
Exposure
A 10 to 12 cm anterior longitudinal incision
is performed directly lateral to the anterior
tibial tendon
Divide subcutaneous tissues to the extensor
retinaculum paying attention to the medial
branches of the superficial peroneal nerve
and the veins
Longitudinally dissect the extensor retinaculum
along the lateral border of anterior tibial
tendon
Expose the distal tibia beneath with the
anterior tibial tendon retracted medially
with a small blunt retractor, and expose
sub-periostal distal tibia using 2 small
Hohmann retractors
Arthrotomy of the ankle joint is performed
and any scarred capsule or loose bodies
are removed
Expose the neck of the talus
Position a self-retaining retractor using
caution to not apply tension to the skin
(figure 1a)
Preparation of the Joint
A Hintermann™ distractor may be used
to aid in exposure of the ankle joint.
Remaining cartilage is removed from the
talar dome, the tibial plafond and the medial
gutter using a chisel and curettes. Caution
should be used to preserve the anatomic
configuration of surfaces. (figure 1b)
After denuding the subchondral bone, a
2.5mm drill or a burr is used to break sclerotic
bone areas
Cysts are cleaned and filled with cancellous
bone graft or bone matrix
Note:
Preservation of the convexity of the talar
dome and concavity of the distal tibia may
increase residual stability after internal
fixation, particularly against rotational
forces. In any case, anterior and posterior
rims of the distal tibia should be preserved
to get high contact stress at the anterior
and posterior aspects of arthrodesis which
will increase intrinsic stability of the
arthrodesis.
The lateral gutter does not need to be
cleaned
In very sclerotic cases or talus necrosis,
opening the tourniquet during operation
may help evaluation of the vitality of the
bone
Using a sharp curved chisel allows easier
removal of the cartilage and preserves anatomic
shape of the bones
