Tibio-Talo-Calcaneal (TTC-Double )fusion using Integra Advansys Plate

The patient is placed securely on the table in a supine position.
A thigh tourniquet has been applied and the lower limb has been prepped and towelled off so that the location of the anterior knee and patella in particular can be referenced .This allows appropriate alignment of the ankle and subtalar joints (to the anterior knee) during fusion.
The leg to be operated upon should be positioned in a neutral position as seen here(toes pointing directly upwards). This usually requires the use of a sandbag underneath the ipsilateral buttock as most legs have a tendency towards falling to external rotation.
The ankle to be operated upon should also be placed on a rolled up sterile towel which can be moved up & down the calf as required to provide appropriate access.
The approach will be using a trans-fibula approach ,extending well above the ankle (the proximal extent of this varying according to the length of plate used) and extending down across the Calcaneus and midfoot in the line of the 4th metatarsal.

The position of the fibula in the lateral plane needs to be appreciated, to centralise the skin incision over it.
In cases of osteoarthritis with varus deformity it is not uncommon to see significant fibula hypertrophy. This is seen in this case and indicated by the position of the digits which are either side of a significantly broadened distal fibula.

A lateral trans-fibular initial skin incision is made, distally extending as far as it needs which is just beyond the anterior process of the calcaneus, aiming towards the base of the 4th metatarsal.
Proximally the skin incision in this case has not been made far enough and will need to be extended during the procedure.
Once through the skin with the knife a careful dissection should be made through the fat layer , and in the line of the skin incision ,using fine scissors.

There is no necessity to dissect extensively posterior nor anterior to the line of the skin incision at this early stage.
When dissecting through the fat layer the objective is simply to clear the deeper soft tissue planes to allow exposure of the deeper soft tissue structures.
Posterior to the fibula in the fat layer lies the sural nerve(1) and anterior to the fibula in a variable position sits the superficial peroneal nerve and its various branchings.
Here a branch of the sural nerve can be seen crossing over the region of the anterior process of the calcaneus. This is to be mobilised & avoided.

Sub-periosteal dissection is commenced once on the fibula and this is extended both posterior and anterior to the fibula. Posteriorly sit the peroneal tendons which should be preserved.In this image a large round nosed periosteal elevator is shown retracting these tendons. This is a useful tool for the sub-periosteal exposure of both the Fibula and the Tibia.
Anteriorly the plane between the fibula and the distal tibia is not initially distinct.
At this stage of the exposure dissection can be progressed further distally down on to the lateral hindfoot and mid-foot. Distal to the tip of the fibula will be the extensor digitorum brevis muscle belly which can be incised longitudinally in the line of its fibres down onto bone immediately beneath to reveal the calcaneus and subtalar joint.
(In this case this step of the dissection has not been progressed at this stage as it normally would be but is done after the Fibula excision).

Anteriorly the plane between the fibula and the anterolateral tibia needs to be been identified and defined, here marked with a Lambotts osteotome.Being clear where the fibula finishes and the tibia starts ensures that the tibia is not notched during fibula resection which requires the use of a large and aggressive power saw.

Two Trethowens retractors are placed either side of the fibula at the point where the Fibula osteotomy is to be made. The Fibula can be displaced away from the Tibia and the Tibia also protected by them.
It can be difficult to get the amount of resection correct in the first instance as the proximal extent of Fibula excision will be determined by the length of the plate chosen and this may be inaccurately estimated at this early stage. There is no problem resecting more Fibula later as required.
If using a nailing technique for ankle and subtalar fusion only enough fibula needs to be resected to allow adequate access to the ankle for bone resection at the arthrodesis site.
With a lateral plating system the purpose of excision is also to provide much more extensive access so the plate can be placed appropriately along the lateral aspect of the tibia.
A large reciprocating saw blade is used to cut the fibula obliquely as seen here.

The extensor digitorum brevis (EDB) is identified distal to the fibula tip, overlying the anterior process of calcaneus and subtalar joint. It is located beneath a deep investing fascia which is longitudinally divided to access the muscle.Its overlying investing fascia can be seen at the distal end of the wound. The sural nerve is being moved out of the way (slightly unsympathetically) in this case.
The sural nerve is sensitive to mobilisation and handling and has a low threshold to produce troublesome paraesthesia in its sensory distribution post-surgery. It should be handled more gently than is shown here (though this is an insensate neurological case).

A sharp sub-periosteal dissection is performed following a longitudinal division of the EDB (in the line of its muscle fibres) to expose the anterior process of the calcaneus(A) and the lateral aspect of the talus (B) and the subtalar joint.Also seen here is the lateral aspect of the talar dome which is easily visible because there has also been a soft tissue release from the lateral aspect of the talar neck already.

The interosseous membrane should be identified between the distal fibula and the tibia and then divided. This is done with the use of a periosteal elevator and then distracting the two bones (as shown), followed by sharp dissection along its length. This is followed by sharp dissection along the line of the interosseous membrane running proximal to the distal to free it. Once this is done the fibula starts to become more mobile.

A large pair of bone holding forceps are vital at this stage of the operation to grasp the fibula and exert a fair amount of traction upon it. The soft tissue attachments around the fibula are then sequentially released. This is all much easier done with the fibula under a considerable degree of traction and distraction.The additional structures to be sectioned are the anterior talofibular ligament, the calcaneofibular ligament and the posterior tibiofibular ligament. The peroneal retinaculum will also need to be released posterior to the fibula. Care should be taken when dissecting behind the fibula. Do so under direct vision and avoid sectioning the peroneal tendons.

Here the fibula has finally lost the fight and its last few soft tissue attachments are being excised.
The fibula is usually kept as a source of either morsellised or alternatively structural bone graft at the arthrodesis sites. Often however this is not required.
The anterolateral lip of the tibia (A) is visible here because its periosteum and attachments have already been sharp dissected off this.

Dissect across the whole anterior aspect of the distal tibia, to the medial malleolus using a combination of sub-periosteal knife dissection as well as a levering of the soft tissues using the large and round nosed periosteal elevator. A Homans or Jimmies retractor to lever the soft tissue envelope off the bone whilst releasing sub-periosteally is useful.
There should be enough soft tissue laxity created anteriorly to safely elevate the entire anterior soft tissue envelope off the bone whilst the distal tibial resection is performed. and also to allow medialisation from the lateral aspect of the joint across to the medial malleolar aspect of the joint.

The posterolateral aspect of the tibia also needs to be clearly identified and visualised, using a combination of round nosed periosteal elevator and subperiosteal dissection with a knife whilst carefully placing the posterolateral soft tissues under tension using a large swab.
This will have soft tissues attached to it, ankle capsule most immediately and then posterior to this the deep flexor compartment and neuro-vascular bundle.
It is important to visualise it to ensure that the posterior aspect of the distal tibial resection cut is done under direct vision to minimse the risk to the posterior and in particular postero-medial structures.

The technique here is again using a combination of round nosed periosteal elevator and subperiosteal dissection with a knife whilst carefully placing the posterolateral soft tissues under tension using a large swab. This dissection does not need to be extensive by any means and certainly only just to allow safe identification of where the posterior aspect of the tibia sits

Make a second skin incision in the line of the medial malleolus, longitudinal and just medial to the tibialis anterior tendon at the level of the ankle joint line, then make a short vertical saw cut in the medial malleolus. The neurovascular bundle lies to the lateral aspect of the tibialis anterior tendon.
The purpose of this part of the exposure is two-fold:
To avoid cutting through the medial malleolus. During distal tibial resection a vertical cut is made usually at the junction of the plafond and malleolus. This is made with a small oscillating saw as shown .It marks both the medial extent and also the superior extent of the distal tibial cut which will be made through the lateral exposure. The cut should be progressed directly posteriorly to carefully just breach the postero-medial Tibial cortex.
To optimise reduction of the ankle. It is key in achieving a reduction at the ankle joint that the medial aspect of the joint does not impinge at any point and prevent the joint closing. In most cases I would therefore resect the tip of the fibula running from anterior to posterior using the same small oscillating saw. If this is not done there is a tendency for the tip of the medial malleolus to impinge upon the medial body of the talus which flares out. The most posterior extent of this anterior to posterior cut (not shown) is completed using a fine Lambotte osteotome, to minimise risk of damage to the tibialis posterior tendon which skirts the posterior aspect of the medial malleolus here. It may on occasion also be necessary to chamfer down the medial aspect of the talar body to allow congruent reduction of the medial aspect of the joint if this prevents the joint closing upon attempted reduction.
During this part of the procedure the foot should be dependent and mobile by means of a rolled-up towel being placed beneath the distal tibia. This also means that the posterior soft tissues will tend to sag posteriorly under the effect of gravity. This is one effective way of minimising the risk to the posterior structures when cutting towards them.

The distal tibial articular surface is cut using a large reciprocating saw blade. An assistant is required to both elevate the anterior soft tissues with a bone lever and also to visually check the medial malleolus to ensure the tip of the saw blade does not overshoot the vertical cut that has been made in the previous step.
It is important that a stout reciprocating blade is used which does not bend easily otherwise when exerting adequate force for the anterior to posterior cut there can be a tendency for the line of the cut to vary as . the blade bends.
An idea of the amount of distal tibia to be resected can be gained from the MRI or CT scans. Any angular deformity at the distal tibia should be cut straight and any cystic sub-chondral change resected as far as possible. The objective is to expose healthy subchondral bone and correct malalignment.
The transverse cut should be made to run at right angles to the longitudinal axis of the tibia. The medial extent of the cut has been marked in the previous step and the resection starts with the tip of the saw placed on this medial mark
The objective of the resection is both to cut out any deformity but also to reveal a healthy and vascular subchondral bone which will provide a good surface for fusion. Care should be taken to avoid resecting too much bone which can make congruent reduction medially difficult.
The medial incision normally is held open with a self-retaining retractor and the assistant is visualising this and feeding back to the surgeon (who is placed laterally) where the tip of the saw is sitting throughout the anterior to posterior cut.
The idea is that the tip of the blade does not overshoot either medially or superiorly the vertical cut that has been made in the previous step in the medial malleolus. Once cutting has been commenced this should continue to allow a smooth cut but the surgeon should be continually referencing his or her orientation.

As the cut approaches the posterior aspect of the tibia note how a swab is being used to hold away the posterior soft tissues so that the posterolateral aspect of the tibia can be directly visualised. The surgeon may choose to finish the cut just before he reaches this point and then to complete the posterior cut using an appropriately sized and sharp osteotome.
There can be a tendency during this step to allow the saw to wander laterally as one cuts from anterior to posterior , therefore not producing a complete cut medially. As the saw blade gets deeper it is not possible for the assistant to make a judgement on how far medially the saw blade is and the surgeon should make occasional probing manoeuvres medially with the moving blade.
Care should be taken posteriorly as the cut finishes not to overshoot the posterior border of the tibia.

Once the osteotomy has been completed posteriorly with the saw (care having been taken not to overshoot the posterior tibial cortex) the resected tibia is highly unlikely to simply fall out as it appears to do in this slide.
There is another step to be made and this is to use a combination of small hibs osteotomes and sharp Lambotte osteotomes to carefully retrace and complete the osteotomy steps. There must be no twisting action using the osteotomes in particular in the region of the medial malleolus which if this is not adhered to will risk fracturing the malleolus.
This can occur in any event and if it does should be fixed to allow a stable medial shelf of bone for the ankle to be compressed in to.

The dorsal talar surface is then resected parallel to the distal tibial cut surface, using a saw from anterior to posteriorThis step is not shown here.
To make this cut the foot is lined up in an anatomical position at right angles to long axis of the tibia and squarely beneath the tibia and the large reciprocating saw is used to cut from anterior to posterior across the talar dome. Again enough bone should be resected but not too much.
Here both the tibial and talar osteotomy cuts are being directly inspected to make sure they have been cut completely and there are no areas of irregularity which will affect a congruent reduction.
If there are such areas these can be chamfered flat using a small oscillating saw or using hibs osteotomes.

A Lambotte osteotome being used to finish off the posterior aspect of the talus to make sure it is fully flat with no prominent ridges.

With the talus reduced on to the tibia it is evident that there is a gap at the anterior aspect of the ankle and both the cut articulate surfaces should be re-inspected and small amounts of bone chamfered to ensure good bone contact results.

The subtalar joint is prepared congrously back to bleeding subchondral bone using a high speed 4.5mm burr.The Laminar spreader is seen placed at the inferior aspect of the talar neck and in the region of the sinus tarsi. This is required to gain adequate access to the subtalar joint for preparation. This starts laterally and may be with an osteotome initially to create enough space to enable controlled insertion of the burr.Any residual healthy cartilage is easier to remove by delaminating it from the underlying subchondral bone plate as an initial step before resorting to the burr.

Good clearance and preparation of the subtalar joint is now demonstrated.
There are 3 facets to the subtalar joint , the most accessible and immediately visible as seen here being the posterior (& largest )one.
In cases of subtalar deformity (or widespread arthritic change) the more medially placed anterior and middle facets may also need to be prepared to effect a reduction and appropriate union. This should be under direct vision and bearing in mind the proximity of the neurovascular bundle to the medial aspect of the joint. A surgeons preference may be to prepare all 3 facets in every case.

As a final step before fixation both the subtalar joint and the ankle are further prepared by drilling with 2.5 mm partially threaded guide-wires to further expose the subchondral bone. Small stabbing cuts into the articular surface can alternatively be made using small osteotomes to open the subchondral bone surface further.

Entirely congruent reduction of both ankle and subtalar joints is demonstrated. Compression with the implant will allow some compensation if reduction is not exact but perfection at this stage should be the aim. Time should be spent on getting this correct. Look to the cortical margins of both bones for areas of incomplete resection as well as the cancellous surfaces.

Before consideration is given to sizing and application of the plate the ankle & subtalar joints should be optimally reduced and temporarily help in position with 3 large K wires.2.5 mm diameter wires with a threaded tip are ideal but are not standard on the set.
3 wires are normally sufficient.
I will usually use two K-wires medially, both inserted in the mid-line and just above the level of the medial malleolus. One is placed purely in to the medial talus anteriorly or posteriorly angulated (to avoid the subsequent midline plate and screws).
The second will diverge from this and will cross both ankle and subtalar joints.
A further anterolateral K-wire is also required to stabilise the construct temporarily. I angle this posteriorly and across the subtalar joint as well as the ankle.
In some publications much is made of the position being a slight valgus of the heel of x degrees or so.
First off good luck with judging alignment to this degree of accuracy intra-operatively
Second off by this stage of the operation most normal Orthopeadic surgeons (if that is not too much of a contradiction in terms) would be happy having achieved congruent , well prepared and stable ankle & subtalar joints without feeling the need to start this process again by cutting in a few degrees of tilt this way or that.
The objective should be that the foot is placed squarely beneath the tibia in the coronal plane and at right angles to the long axis of the tibial in the sagittal plane.
Attention should additionally be paid to avoid translation and incorrect positioning of the foot in sagittal plane.
With alignment the two primary objectives are that both a functional position is achieved as well as that the reduction is stable with excellent bone to bone contact at the arthrodesis sites.

Here both the medial guide wires remain in the talus , though more normally one would also cross the subtalar joint.
I will usually use two K-wires medially, both inserted in the mid-line and just above the level of the medial malleolus. One is placed purely in to the talus and anteriorly or posteriorly angulated to avoid the subsequent midline plate and screws.
The second will diverge from this and will both cross talus and into the calcaneus.
A further anterolateral K-wire is also required to stabilise the construct temporarily. I angle this posteriorly and across the subtalar joint as well as the ankle. It is slightly posterior here but has provided adequate stability and so is left.

The ankle and subtalar joints have been temporarily positioned and stabilised using stout threaded end K-wires.
One of the two medial K-wires can be seen, inserted in the mid-line and just above the level of the medial malleolus. It has been placed purely in to the talus and angulated anteriorly or posteriorly (to avoid the subsequent midline plate and screws).
The second will diverge from this and will both cross talus and in to the calcaneus.
A further anterolateral K-wire is also required to stabilise the construct temporarily. I angle this posteriorly and across the subtalar joint as well as the ankle. This is shown being inserted here.
Insertion of wires is under image intensification .

The next step prior to assessing for the appropriate plate size is to ensure a relatively flat lateral bone surface onto which the plate can be applied, by burring the lateral surface of the tibia and talus.At this stage using a lateral plating system (& prior to any definitive fixation) attention should also be paid to the relative prominences and alignment of the lateral tibia, lateral talus and the lateral calcaneus.
The plates are slightly contourable but if the calcaneus and talus are very prominent laterally then consideration can also be given to medialising them by resection of some more of the medial malleolus, assuming there is adequate medial malleolus to allow this.

Once the plate has been selected fixation starts with a medial compressive screw across the ankle.This screw can alternatively be inserted after the calcaneal limb of the plate has been fixed, but always should be inserted prior to any compression using the plate.
A compressive screw generally needs to be placed across the ankle joint medially to counteract the tendency of the medial joint line to open whilst compression is being applied laterally with the plate. Aim for this screw to sit either slightly anterior or posterior to the midline laterally . If positioned in the midline laterally this medial screw will potentially prevent an appropriate length of talar screw or the most distal tibial screw being used during lateral plate fixation.
A large fragment 7-8 mm diameter short threaded screw cannulated screw is used. Here an Orthosolutions 8mm titanium short thread screw which has an excellent thread profile and can generate very good compression.

The plate templates (A) are supplied in 6 ,7 ,8 or 9 hole lengths.
The 6&8 hole lengths have 2 distal holes for calcaneal fixation and the 7 & 9 hole lengths have 3 holes for this.
They can be contoured if required and will guide the requirement for plate bending.
The locking guides for the proximal tibial holes (A) accept the 3.0mm drill (and then 4.5 mm screw) and distal holes (B) accept the 3.5mm drill (and then 6.5 mm screw).

Bending clamps are supplied to gently contour the plate if required.
The jaws must be precisely applied into a screw hole (A) and then locked into place (B) before force is applied.
Check following this that the threads have not been damaged on the plate .

The compression clamp .
Its points of fixation are onto a guide wire placed proximal to the top end of the plate(A) and the most proximal guide screwed into the plate(B). Applying compression between these two points (C) generates compression across the arthrodesis sites.

The appropriate size plate is chosen by using malleable templates. Shown is a 6 hole length by 2 hole calcaneal fix , the smallest plate.

More appropriate in this large male is a 9 hole length by 3 hole calcaneal limb.

Bear in mind that proximally the lateral aspect of the tibia is not a flat surface, rather a broad ridge (which gives excellent bone purchase for screws). The proximal plate should sit fairly flush on the ridge. Some light proximal burring may on occasion be required.
The plate can also be contoured with plate benders. but this is more relevant for the fit to the calcaneus with a constitutionally valgus hindfoot
The screw design with smooth heads allow the plate to be pulled towards the bone as they are screwed in and prior to their locking caps being applied.

The plates are supplied in 6 ,7 ,8 or 9 hole lengths.
The 6&8 hole lengths have 2 distal holes for calcaneal fixation and the 7 & 9 hole lengths have 3 holes for this.
Note that every plate has a dummy/filled hole(10) proximal to which are located the holes for tibial fixation that require a 4.5 mm screw.
Distal to this point the fixation is into the calcaneus and talus and the screws required are 6.5 mm.
Each screw diameter has a specific guide that screws into the plate and also a specific drill size (3.0 mm or 3.5 mm).
Following drilling, the guide is removed and the hole measured with the depth gauge then countersunk using the screwdriver (see next step for image of screwdriver and its integral countersink).
Following removal of any bone swarf in the screw threads on the plate the appropriate diameter screw is inserted.
One workable order of screw insertion is as follows:
1 & 2.: The calcaneal screws are drilled & inserted first. The most anterior first for ease of access.
3. The proximal guide is screwed into the most proximal hole to act as one point of attachment of the compression clamp (the other being a proximally placed guide wire). Compression can be applied at this stage using the clamp prior to any proximal screw insertion (but after a medial “freehand” joint screw across the ankle).
4.The Oblique proximal hole is specifically orientated to produce compression by its geometry. There are 2 holes into which the guide can be locked. If the more proximal one is used compression may be generated as the non-threaded head of the screw is driven home. If compression has already been applied with the clamp then maximal compression may have already been achieved. Once the screw head is seated its locking cap should be inserted. The remaining hole in the plate should have a locking cap inserted which will interference fit with the cap on the screw.
5.Before the compression clamp is removed use the proximal guide , drill then insert and lock the screw.
6, 7,8: These are next inserted , the clamp having been removed. Smaller plates do not include all holes.
9. The talar screw holes. One hole can be filled with a 6.5mm screw and then its cap screwed on. The remaining hole is filled again with a locking cap.
10:The “dummy” hole.

The green handled screwdriver(A) is for the 4.5 mm tibial screws and the Blue handled one (B) for the distal 6.5 mm Calcaneal and talar screws.
Both share the feature of having an integral countersink which is used in each respective screw hole following drilling and prior to screw insertion.

This is the dual-purpose screw driver / bone countersink , demonstrating a screw locking cap (1) mounted in this case rather than a screw.
Note that there is an integral countersink (2) to the screw-driver and this is used to countersink every hole drilled in the plate prior to screw insertion. Any bone swarf resulting then needs to be cleaned from the hole.
Once each screw has been inserted and tightened the locking cap shown here is locked down onto the screw head. This stage can be a little fiddly and the alignment needs to be precise and all bone debris removed from the plates threads.

The locking guides for the proximal tibial holes (A) and distal holes (B).

All 3 guides are here shown screwed into the plate prior to application.
In reality often only a single distal guide has space initially due to the soft tissue envelope.

The 3.0 & 3.5 mm drills with their respective guides.

The plate may need to be contoured prior to fixation. When aligning the plate distally for fixation it is important to be mindful of how it sits proximally.
The fit can also be tight distally and the more posterior holes may be easier accessed by percutaneous stab incisions (being mindful of both the location of the peroneal tendons as well as the sural nerve) after an initial anterior, distal screw has been fixed.
There are guide wires supplied that will temporarily hold plate on bone though they are not being used here.
Before drilling it is important to ensure that all of the holes are sitting appropriately. In particular there is only one aperture (admittedly with 2 holes) for talar fixation and this should be aligned so that it captures the talus for fixation .

The first hole is drilled using the 3.5mm sized drill through the most anterior calcaneal hole. This should be done in a controlled fashion and only just penetrate the medial cortex.
Also visible in this slide is the screwdriver. There are two sizes , one for the distal 6.5mm screws (Blue handled) and the other for the 4.5mm proximal screws (Green handled). The screwdriver itself has a countersink which needs to be used in every screw hole once drilled.

Once the hole is drilled this should be measured with the guide and an appropriate sized screw selected.

The drilled hole is now being chamfered with the screwdriver countersink. Care should be taken not to damage the threads on the plate during this step by making sure the countersink is appropriately seated in the drilled hole before being turned.

The hole is now clearly chamfered and is ready to accept the first screw.
The same process is repeated with every screw inserted .
Once the screw has been inserted this is followed by its locking cap.

The locking caps have now been driven home. This can be fiddly and getting the exact angle when seating each one is key.

A guide wire is now applied proximally to the plate to provide a second point for the compression clamp to work across.

The guide-wire is now appropriately proximal to the plate (around 2cm)
Ideally it should be anchored through both cortices.

The compression clamp is now applied to the proximal K wire & drill guide. Compression is gradually applied between these 2 fixed points , during which the effect upon the arthrodesis sites should be monitored.

The clamp should be well seated before compression is applied with it.
The supplied K-Wire is not especially stout and deforms readily. This does not seem to be an issue however in generating adequate compression.
This stage will start to open the medial ankle in particular , hence a compressive large fragment screw has already been placed here.

The proximal drill guide is next screwed into the top of the compressive hole .

Drilling with the proximal 3.0 mm drill.

After the length has been measured and the hole countersunk (using the screwdriver) a 4.5mm screw is inserted.

Locking caps are tightened first onto the screw and then into the neighbouring unfilled hole to interference fit with the first cap.
Here the initial locking cap is being tightened again.

Before the compression clamp is removed a more proximal 4.5mm screw and cap are inserted in standard fashion.
Here measurement following drilling is occurring . On this occasion not the most proximal hole has been used.

Insertion of the 4.5 mm screw.
The remaining holes are drilled & filled as bone quality and hole location permits (the latter having been carefully planned).

An ideal case for a plating system and in particular not using an intra-medullary nail.
A significant angular deformity of the tibial shaft that would preclude certain lengths of intra-medullary nail fixation .
A long plate has been required and has not been contoured.

A lateral view of the same case, circa 4 months post-op.
Excellent union of both ankle and subtalar joints. The talus is very slightly anteriorly translated.
Evidence of a previous calcaneal osteotomy and also a dorsiflexing osteotomy of the first metatarsal that has been performed with the TTC fusion in this neurological case .
Note the ankle is squarely aligned but there is some midfoot plantarflexion (this is flexible and positional during the X-ray)

Pre-operative coronal CT of a varus ankle osteoarthritis with associated subtalar degenerative change.

The 12 week post-operative AP X-ray.
This is a smaller patient and a shorter plate has been used. Note the obliquely placed compressive screw through the plate. The tibial screw beneath this is slightly short with no great effect. Proximally the plate has not been contoured.

The lateral view also shows union at 12 weeks on plain X-Ray.
Note that proximally there are 3 holes but only 2 have been used , due to access issues.

A stable but painful fibrous non-union after an arthroscopic ankle fusion .

One screw is also close to the subtalar joint.

On table II image showing revision using TTC plate and medial screw. The medial bone was poor quality following removal of the previous fixation. Note the washer required , this was following impaction grafting to the medial tibia and before plate application.
Good bone to bone contact on this view.

On table II image showing a posteriorly placed medial screw (dictated by location of usable medial bone after screw removal).
Talus centrally placed. Some joint lucency evident. This can be directly visualised and grafted if an actual rather than a radiographic feature.

The longest 9 hole plate has been required in this large adult male. These are 12 week images and union is progressing but not yet achieved.
The most distal tibial screws have not been placed
Constitutional hindfoot valgus has meant that the plate has been contoured to accommodate this.

A posteriorly placed medial screw across the ankle has been used here. There is some lucency associated with the screw head .This relates to an area of bone resection (then grafted) required to remove the original screws across the non-union .
The talus is well placed in the sagittal plane. These images from 3 months show some progression still required at the anterior ankle.