Revision arthrodesis of the ankle

The patient is placed in a prone position with a tourniquet around the upper leg. A posterior longitudinal incision is made medially to the Achilles tendon, which is exposed and divided by a Z-plasty. The posterior compartment is opened to provide access to the distal tibia and the talocrural pseudoarthrosis. When there is macroscopic instability, existing hardware is removed and 2 cannulated screws are put in from the posterior tibial cortex into the talar body and neck. Their position is checked with an image intensifier. If existing hardware cannot be removed without major exposure (e.g. when original screws are broken) or if skeletal deformity precludes the use of 2 posterior screws, an external fixator is used with 2 pins through the calcaneus and 2 pins through the tibia, connected by a bilateral rod. A 3-cm × 2-cm wide and 2-cm deep slot is cut into the talocrural area, including removal of the pseudoarthrosis. An ample amount of cancellous bone chips from the posterior iliac crest is packed into the slot (Figure 1). The postoperative regimen starts with 6 weeks without any weight bearing in cases of internal fixation in a below-knee plaster cast and in cases of external fixation without external support. Thereafter, weight bearing in a plaster cast and removal of the external fixation depends on radiographic judgment of bone healing.