Ankle Arthrodesis



90% fusion rates


Lose 70% sagittal plane ROM


Disadvantages of Arthrodesis 


Non union rates up to 12%

Decreased gait speed

Poor mobility over uneven surfaces

Need for shoe modification

Arthritic degeneration in STJ of up to 100%




Tibiotalar arthrodesis


1.  Intra-articular


A. Open

- gold standard

- especially significant deformity / mal-alignment

- screws from tibia into talus


B. Arthroscopic

- 8 Vs 14 weeks for fusion time

- minimal deformity only


2.  Extra-articular / Frame

- children

- sepsis

- osteopenia


Tibiotalocalcaneal (TTC)  Intramedullary Nail

- commonly needed in RA


Blair Fusion

- refer to talar fracture complications




1.  5° Valgus

- excess varus causes cavovarus


2.  Neutral Dorsiflexion

- if fused in plantar flexion develop genu recurvatum to put foot on floor


3.  5-10° ER


4.  Tibia anterior on talus

- preserves heel

- decreases lever arm = less energy required for toe-off


5.  Subtalar Joint 5°Valgus

- for TTC hindfoot fusion nails 


Surgical Techniques 


1. Intraarticular Technique 

Dual incision reciprocal flat-cut technique


Ankle Fusion APAnkle Fusion Lateral



- over distal fibular, curved forward over ST joint

- inter nervous plane between sural and superficial peroneal nerves

- full thickness down to bone


Superficial dissection

- subperiosteally expose distal fibula

- protect peroneal tendons posteriorly


Fibula osteotomy / excise distal fibula

- oblique cut ending 1.5 cm proximal to joint


Fibula Osteotomy Ankle FusionFibula Osteotomy and Reflected Posteriorly


Deep dissection

- expose talar neck anteriorly

- expose tibia posteriorly

- protect anterior tendons and NV bundles with retractors

- protect posterior peroneal tendons with retractors

- open the tibio-talar joint with lamina spreaders


Distal tibial cut

- oscillating saw

- perpendicular to tibial axis

- just above subchondral bone / 2-3 mm

- care not to take off medial malleolus

- if cut is too thick, will enter medial malleolus


Make a separate antero-medial incision

- medial to T anterior, protect saphenous nerve and vein

- use osteotome to complete tibial cut and protect medial malleolus

- denude medial malleolus of articular cartilage

- also clear medial talus

- note that the deltoid ligament carries the primary blood supply to the talus, and should be preserved


Talar dome cut

- place foot in desired position

- 5o valgus and neutral DF

- make a parallel cut to distal tibia

- again only 2-3 mm

- ensure two cuts appose


Stimulate bleeding bony surfaces

- drill holes in distal tibia and talar dome / sharp osteotome

- especially if sclerotic bone


Position foot

- ER 5 – 10o depending on other foot position

- with respect to patella

- hold with wires for 6.5 mm cannulated screws




Option 1

- medial tibia down to talus

- one into dome & one into neck / parallel


Option 2

- lateral talus up to medial tibia

- region sinus tarsus / lateral process

- parallel



- medial malleolar screw

- fibular to talus screw


Check II 


Options for fibular 

- discard 

- reattach to tibia and talus as onlay graft 

- morcellize with reamer and insert 



NWB 6/52 in cast

PWB in moon boot further 6/52

Double time if diabetic


2.  External Fixation


2 circular rings distal tibia

- 4 half pins


2 wires metatarsals

- connect to half ring


2 x wires calcaneum

- foot plate

- connect to half ring


Rods between and compress


3.  Tibiotalocalcaneal (TTC) Fusion 


Pantalar Fusion APPantalar Fusion Lateral



- prepare ankle arthrodesis site as per compression arthrodesis

- approach and prepare subtalar joint between peroneus brevis and tertius

- elevate EDB

- stabilize both joints with K wires placed to not interfere with nail insertion 


Insertion site

- line from 2nd toe through centre of heel pad

- line in coronal plane / junction anterior & middle 1/3 of heel pad

- should pass through anterior part of posterior facet of calcaneum

- posterior to lateral plantar artery and nerve

- screw fixation in calcaneum and talus (lateral to medial ; possible posterior to anterior calcaneal screw)  

- compression (distally locking and tapping on inserter or company specific jig) 

- 2 x proximal screws medial to lateral 





-NV Damage 

-Metalwork Breakage 



- Immediate - Infection ; compartment syndrome 

- Medium Term - Delayed or nonunion ; painful malunion 

- Long Term - Stiffness and Gait Changes ; Arthrosis in adjacent joints 




Arthrodesis nonunionArthrodesis nonunion lateral