Complex Ankle and Hindfoot Arthrodesis Using Circular External Fixation

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  • Ankle and hindfoot fusion using circular external fixation is a useful surgical technique in patients with diabetes, Charcot, osteomyelitis, deformity, and/or bone and soft tissue compromise in order to obtain solid bony fusion, stable limb alignment, and eradication of infection in cases of complex pathology.
  • Deformity correction with osteotomies and meticulous joint preparation is required in order to obtain broad, cancellous bony surfaces for fusion with neutral alignment. Autograft from the distal fibula and/or medial malleolus can be combined with bone allograft to assist with joint fusion.
  • The ankle and hindfoot are provisionally pinned into neutral coronal and sagittal alignment through the plantar surface of the foot using large K-wires prior to placement of the lower leg in the center of a circular 3-ring compression frame. Typically, 2 to 3 points of fixation are used per ring with a combination of half-pins and smooth wires.
  • Ring attachments are built up or down to the level of the half-pins and wires in order to prevent pins and wires from bending, breaking, or causing iatrogenic deformity during tensioning. Crossing olive wires are used in the midfoot and calcaneus with dual tensioning devices to ensure an even pull on both sides of the foot.
  • Dynamic or static compression struts are used to obtain 8 to 10 mm of compression across the ankle and hindfoot, followed by addition of an anterior foot ring to increase construct rigidity. Daily pin care is started 3 to 4 days after surgery and patients are kept non-weight-bearing for approximately 2 months in the frame with a total frame period of 3 to 8 months depending on bony healing on X-ray.




Surgical reconstruction of the ankle and hindfoot in patients with diabetes, Charcot neuroarthropathy, osteomyelitis, deformity, and/or bone loss can be challenging and often results in amputation. In these patients, conventional internal fixation with plates, screws, and intramedullary nails is often not feasible because of ongoing infection or poor bone stock and soft tissue quality. The Ilizarov method of ankle and hindfoot arthrodesis is a well-established technique for limb reconstruction that uses circular external fixation to achieve solid bony fusion, optimal leg length, and eradication of infection in cases of complex pathology. This article discusses indications, contraindications, pearls, and pitfalls of performing ankle and hindfoot arthrodesis using the Ilizarov technique.

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