Tips and Tricks For Arthrodesis Positioning and Temporary Fixation

Surgeons learn and grow from one another’s experience, throughout training and beyond. In his portion of a session at the American College of Foot and Ankle Surgeons’ Annual Scientific Conference, Alan MacGill, DPM, FACFAS, highlighted tips and tricks from his experience on arthrodesis positioning and temporary fixation. HMP Global had the chance to touch down with Dr. MacGill on some of the highlights from his presentation.
 
What do you feel are the top things surgeons should know about universal arthrodesis positioning? How can it impact outcomes? 
 
Dr. MacGill asserted that intraoperatively assessing alignment via fluoroscopy and simulating weight-bearing are two key steps surgeons should pursue to project functional results.
 
“These two things should give the best estimate of how the anatomy will function once the patient is back on their feet,” he explained. 
 
He continued to say that inadequate alignment can results in multiple issues including abnormal biomechanics, load or pressure changes, and compensatory pain. Specifically, he notes this is of particular importance in the first metatarsophalangeal joint (MTPJ), first tarsometatarsal joint (TMTJ), talonavicular, subtalar, and tibiotalar joints.
 
What are the top pearls you propose related to using temporary fixation? When is such fixation best applied?
 
“Kirschner wires and Steinmann pins are your best friends,” said Dr. MacGill, a member of the ACFAS Board of Directors. “Two are always better than one for rotational control. A cannulated screw over the wire is an easy exchange, but if not using one, you have to be mindful to keep wire placement away from your intended final fixation.” 
 
He advocated for application of temporary fixation after curetting or resecting the joint, irrigating and placing of bone graft.
 
Overall, are there other important concepts surgeons should keep in mind?
 
Having a thoughtful, comprehensive intraoperative imaging plan is key, said Dr. MacGill, a faculty member for AO North America. Orthogonal images via fluoroscopy are a vital part of assessing hardware position and joint alignment.
 
“Be diligent to get a true talar dome lateral, axial calcaneal, and dorsoplantar (DP) with the foot in neutral, not overly supinated or pronated,” he explained. 
 
In addition, he recommends planning ahead of time for exactly what images are necessary.  
 
“(This) will help you position the patient appropriately and avoid headaches during the case,” he said. “If you're working with a new radiology tech, take time before the case starts to discuss the images you'll need so you're both on the same page.”