Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation.

Pseudarthrosis after failed tibiotalar arthrodesis was successfully treated surgically in nine of 11 patients between 1980 and 1987. The indication for the initial attempted arthrodesis was traumatic arthrosis in seven patients, traumatic arthrosis with osteonecrosis of the talus in two patients, degenerative arthrosis in one patient with cavovarus foot (Charcot-Marie-Tooth), and myelodysplasia with progressive valgus deformity of the foot and ankle in one. The surgical technique planned for revision arthrodesis provided firm coaptation of tibia to talus with internal fixation that maintained the foot at right angles to the tibia with the forefoot in neutral position. Seven feet in 11 patients were treated using a transfibular approach that allowed excision of fibrous tissue and sclerotic bone, decortication of the media malleolus, fixation of the tibia to the talus with cancellous screws, and onlay/inlay fibular graft. Of the remaining four patients, one was treated with medial compression plate, a second was treated using an anteromedial cortical graft, a third was treated by a combination of sliding anteromedial corticocancellous graft and tibiotalar compression screw, and a fourth was treated with tibiotalar compression screw. Clinical and roentgenographic union occurred in nine of 11 patients. One patient developed a painless, fibrous union and one patient with persistent pseudarthrosis had myelodysplasia and severe valgus deformity and required amputation. Adequate exposure was possible through the transfibular approach to provide cancellous bone opposition, to excise the pseudarthrosis membrane and sclerotic bone, and to remove necrotic segments of the talus. In addition, supplemental bone graft, internal fixation, and postoperative cast immobilization were also helpful in obtaining union.