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with lengthening of the leg using an Ilizarov external fixator
for 6 patients with talar avascular necrosis. Shortening was
corrected in 4 patients, and the mean period of frame application was 10.7 months. Thomason et al10 performed
arthrodesis using an allograft from the femoral head and an
intramedullary nail to restore talar height for 3 patients as a
salvage for failed total ankle arthroplasty. The patients
achieved bone fusion and were free of symptoms; however,
use of a massive non-vascularized bone graft is a concern
for infection cases.
We developed an arthrodesis procedure that uses a soft
tissue-preserved fibular autograft and tried to restore hindfoot height for patients with large bone defects, including
those of the talus. We maintained the soft tissue on the lateral and posterior aspects of the transected fibula when
exposing the ankle joint and used the fibula as a strut graft.
We also report the radiographic and clinical outcomes of
patients who underwent this arthrodesis procedure.

Methods
Twelve feet of 11 patients were treated from 2008 to 2015
at our institutions. The disorders of the ankle were aseptic
necrosis of the talus in 10 patients and aseptic loosening of
TAA (Table 1). The mean age of the patients was 68.9 years,
and the mean follow-up period was 33.4 (range, 12-85)
months. Ten patients were females and 1 was male. They
underwent tibiotalocalcaneal arthrodesis that used a soft
tissue-preserved fibular strut autograft and free bone grafting to fill the defect resulting from talar body resection. Our
institutional review board approved this study.

Operative Technique
The patient was positioned supine with a tourniquet around
the upper thigh. A J-shaped skin incision was made along
the anterior edge of the distal fibula extending to the subtalar joint. A transverse fibular osteotomy was performed 10
to 13 cm proximal to the tip of the fibula. We resected 3 to
6 cm of the length of the fibula to use as a bone graft to fill
the bone defect due to necrotic or damaged bone removal.
Ligamentous tissues connecting the tibia and fibula, and the
lateral ankle ligament were resected while preserving the
lateral to posterior skin and soft tissues on the fibula. This
was considered a modified transfibular approach. The transected fibula was not removed from the soft tissues surrounding it unlike the standard transfibular approach. A
capsulotomy was made on the lateral aspect of the ankle
and the subtalar joint. If a wider view of the joint or the talus
was needed, the fibula with soft tissues was rotated posteriorly. In cases of whole talar body necrosis, the talar body
was resected while preserving the neck and head of the
talus. Soft tissue and sclerotic bone were removed on the

Foot & Ankle International 38(6)
lateral aspect of the distal tibia and the medial aspect of the
fibula for bone fusion. Resected free fibula (nonvascularized) and/or iliac bone were grafted to fill the bone defect in
the ankle to connect the tibia and calcaneus. We previously
used only iliac bone grafts, but have subsequently used a
half thickness of the iliac crest (3 cm length) and a 3 cm
length of the free fibular graft in the later cases. Recently,
we have only used a resected free fibular graft to fill the
defect (2 grafts of 2.5-3 cm in length) after being encouraged by the high fusion rate achieved in the preceding cases.
After filling the defect with the bone graft, the ankle was
fixed temporarily with Kirschner wires in neutral flexion
and a slight valgus/external rotation position. A retrograde
intramedullary nail (Intramedullary Nail with Fin; Teijin
Nakashima Medical Co, Okayama, Japan) was used for tibiotalocalcaneal arthrodesis (Figure 1C and D). The fibula
with soft tissue was reduced and fixed using 4.0-mm cancellous screws on the lateral aspect of the tibia and calcaneus as an onlay strut graft.
A plaster splint was applied with a bulky dressing postoperatively. Skin sutures were removed within 2 weeks, and
then a below-knee cast was applied. Partial weight bearing
with the cast was started after 4 weeks of non-weight bearing. Full weight bearing was usually allowed 8 weeks after
the operation. The cast was removed when bony fusion was
confirmed radiographically.

Radiological Evaluation
Bony fusion was confirmed via 3-view x-rays or computed
tomography (CT). A CT examination was performed in
cases in which it was requested or was agreed upon with the
patient. Leg-length discrepancies were measured using lateral view radiographs of the lower leg taken in the standing
position after bony fusion was confirmed. Hindfoot coronal
alignment was assessed by measuring the hindfoot view
alignment angle (HAVA)6 and by acquiring a weight-bearing hindfoot radiograph.3 The HAVA was the angle created
by a line drawn from the most inferior point of the calcaneus to the intersection of the tibial axis with the estimated
joint line. Sagittal alignment was assessed by measuring the
sagittal calcaneal angle (SCA) on a weight-bearing lateral
foot view that included the distal shaft of the tibia. The SCA
was the angle formed by the intersection of a line drawn
along the inferior aspect of the calcaneus and the tibial axis.

Clinical Evaluation
The American Orthopaedic Foot & Ankle Score (AOFAS)
was recorded before surgery and at the final follow-up.
The use of supportive equipment when walking and level
of satisfaction at the final follow-up were assessed along
with other parameters in the clinical evaluation. The

Table of Contents for the Digital Edition of Foot & Ankle International - June 2017