Pertinent Insights On The Posterior Approach To Hindfoot Arthrodesis

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Author(s): 
Jeffrey E. McAlister, DPM, and Christopher F. Hyer, DPM, MS

   The goal for this active 44-year-old male was ultimately pain relief with a functional limb. Our surgical goals were to retain as much living talus as possible without violating his transverse tarsal joint, maintain limb length and proper hindfoot-to-ankle alignment, and achieve a successful union.

A Guide To Surgical Technique

We utilized a posterior, trans-Achilles approach for adequate exposure of both joints through a single incision. After performing a 12-cm midline skin incision, we utilized a frontal plane Z-lengthening of the Achilles approximately 6 cm in length. Retraction allowed for complete visualization of the deep crural fascia and compartment.

   We dissected down in the interval between the flexor hallucis longus muscle belly and peroneal tendons, and limited retraction to the use of deep Weitlaner retractors to prevent any post-surgical wound complications. This provided excellent visualization of the posterior malleolus, posterior talus and superior calcaneus. We proceeded to retract the distal flexor hallucis longus medially and resected the posterolateral process of the talus, which aided in visualization of the subtalar joint.

   After performing a posterior capsulotomy of the ankle and subtalar joints, we placed a Hintermann retractor across the tibiotalar interface and performed subsequent joint resection via curettes and osteotomes. We performed the same for the subtalar joint. In this case, we resected the body of the cystic talus until we approached the viable talar neck. We also used femoral head allograft with bone marrow aspirate and beta-tricalcium phosphate graft (Vitoss, Stryker) to supplement limb length and healing.

   We then resected the posterior malleolus with a curved osteotome for adequate plate fixation. Using a posterior tibiotalocalcaneal compression plate (Wright Medical Technologies) with locking and non-locking screws allowed for compression and rigid internal fixation. We also placed an internal bone stimulator across the fusion site.

   We subsequently proceeded to adequate closure of the overlying flexor hallucis longus muscle belly and reapproximation of the Achilles tendon with non-absorbable sutures. Then we pursued a layered closure in typical fashion with absorbable subcutaneous sutures and non-absorbable mattress sutures. The patient wore a Jones compression posterior splint and was admitted postoperatively for pain control.

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