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

   DiDomenico has reported on the successful use of an anterior locking compression plate through a posterior approach with compression screws as well.7 There is no study to date comparing posterior locked plate fixation with or without cross-screws to anterior constructs.

   A posterior approach to the ankle and hindfoot, as described by many authors, allows for great visualization and exposure.8 One can divide the Achilles tendon either in the coronal or sagittal plane without significant wound complications through a posterior midline incision.

   In a systematic review comparing posterior midline and posterior medial leg incision wound complication rates, authors found 7 percent and 8.3 percent complication rates with the midline incision and posterior medial incision groups respectively.9 They noted that more important than incision placement were the associated non-surgical factors, such as comorbidities and postoperative protocols. Also, the angiosomes from the peroneal vessels laterally and the posterior tibial vessels medially, as described by Taylor, meet centrally and allow for the midline incision to heal without incident.10 This approach is also appropriate in cases in which anterior soft tissues do not allow for dissection (e.g. skin flaps, grafts, wounds) and there is very little talar neck to allow for anterior plate fixation options.

In Conclusion

We have described an uncommon pathology and approach for a significant talar body cyst with salvage of the transverse tarsal joint and a successful, pain-free union.

   Here are some keys to success.

• Use minimal skin retraction during dissection to prevent any unforeseen wound complications.
• Wide Hintermann retractors are helpful in joint visualization.
• Appropriately visualize the medial neurovascular bundle and peroneal vessels.
• Resection of the large posterior malleolus allows for plate adaptation.
• Posterior plate fixation may be extraperiosteal on the posterior tibia.
• Use two compression screws with one from the posterior tibia to the talar neck and one from the posterior calcaneus to the talar body.
• It is advantageous in a non-neuropathic, sensate patient to avoid plantar neurovascular injury and scar formation.

   Dr. McAlister is a Fellow of the Orthopedic Foot and Ankle Center in Westerville, Ohio.

   Dr. Hyer is a Fellow of the American College of Foot and Ankle Surgeons, and serves on its Board of Directors. He is the Fellowship Co-Director of the Orthopedic Foot and Ankle Center in Westerville, Ohio.

References

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