lecture 37 shah ttc fusion
Post on 17-Aug-2015
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Tibiotalocalcaneal fusion:(TTC fusion)
Dr.Rajiv Shah‘Foot & ankle orthopaedics’Foot & ankle surgeonPresident, Indian Foot & Ankle Society
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Indications Post trauma
Post infection
Post degenerative arthritis -OA
AVN talus
Paralytic/flail foot & ankle
Charcot neuropathy
Loss of talar body
Failed TAR
Severe instability
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Indications Failed ankle arthrodesis
RA, Seronegative arthropathy
Skeletal defects after tumor excision
Nonunions Severe deformity
TTC fusion: Aims
Broad, congruous & bleeding articular surfaces in apposition
Well stabilized & compressed of articulating surfaces with utmost care of skin and soft tissues
Painless & stable fusion of ankle & subtalar joints in functional position
Foot at 90 degree angle to long axis of tibia with 5-7 degree of hindfoot valgus
TTC fusion: Methods
Hindfoot nail Nail + screws Blade plate External fixator Ring(Ilizarov) fixator Taylor spatial frame Combinations
TTC fusion: Lateral Approach
Valgus deformity – Supine positionVarus position – Lateral positionSevere varus – additional medial approach
Transfibular osteotomy2.5 cm above lateral malleolusFibula is cut in bevelled fashion
TTC fusion: Lateral approach
Preserve fibula in young patients for later date possibility of TAR
Preparation of ankle & subtalar joints
Fixation – nail, blade plate, ex-fix or ring fixator
Blade plate : Anterior, posterior or lateral approach
Nail: tips & tricks
Compression at both joints-15mm Two plane locking-40% increase in stability Lock all holes 10mm nail, 150-180 mm length Countersink nail up to 5mm Grafting if needed Use of end cap• Prevention of medullary bleeding• Preservation of threads for extraction• limiting the heterotopic ossification
Nail: Complications
Stress fracture at tip of nail(Controlled with longer nail)Non union(exchange nailing+ bone grafting)(ring fixator +bone grafts)
Newer generation nails
Pre-assembled, embedded distal locking mechanism in the nail
7 mm of in-board compression Ability to compress the subtalar and
ankle joints separately Screws can still be removed without
having to disengage compression and/or locking mechanisms
Blade plate – adoloscent/ humerus with blade length of 40mm with plate holes up to 5-8
Provisional fixation of joints with guide wires/k wires/ST pin/ Schanz screws before blade insertion
Blade plate fusion: tips & tricks
Blade plate fusion: tips & tricks
Guide wire:5-10mm of calcaneus bone shall remain plantar to the blade plate
Push flush to lateral cortex
Do contour to prevents valgus malunion
4.5 screw proximally & 6.5 screws distally
Guide wire in proximal screw hole to prevent rotation of blade plate while hammering it in
Cut a notch in lower end of tibia for sitting of blsde plate
Use AO tension device for giving compression
Blade plate fusion: tips & tricks
Prone position Midline longitudinal
approach -14-16cms Skin+ paratenon in one
incision Z plasty of achilles FHL with NV retracted
medially
Blade plate: Posterior approach
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