Once I decided to have the surgery, I was sent to the hospital to their Pre-Admission Clinic.
I had to bring along all medications that I was taking, including herbal (the glucosamine).
At the appointment, they sent me for x-rays, and an ECG, and I had to blow into a balloon device to measure lung capacity.
They explained the operation, and the healing process, and care after the surgery, and gave me some handouts to take home.
I received paperwork for lab work.
I was told to stop taking all medications 5 days prior to the surgery date.
I was at the hospital early on the morning of the surgery.
I was taken to the pre-operation room by an orderly and assigned a bed. From there, I was wheeled to another room, where a popliteal block was inserted into my right calf. (The area was frozen before the block was put in). They used ultrasound to locate where to do the insertion.
I was wheeled into the operating room and general anesthetic was given.
"A standard lateral extensile incision was made over the fibula and carried out towards the 4th metatarsal. Dissection was carried through subcutaneous tissue. All tendons were identified and protected plantarly. I identified the fibula and using the microsagittal saw to create an osteotomy in the fibula. I cut in an angle in a way to prevent prominence of the residual fibula at the side of the lateral wound. The fibula was then removed with a half inch osteotome. We then removed osteophytes in the syndesmosis as well as around the anterior aspect of the ankle. The ankle was distracted with a laminar spreader. There were two large cavernous defects in the more medial and central aspects of both the tibia and the talus. They were debrided back to stable bleeding bone. Some residual cartilage laterally was also removed from the distal tibia, as well as the talus itself. We took intraoperative specimens and sent them to pathology for analysis to show that there were no signs of acute inflammation or infection. There were no signs of significant white cells when examined intraoperatively by the pathologist. We thus proceeded with stabilization of the ankle.
We also did take intraoperative cultures and sent them to the lab. We then prepared the bony surfaces in the usual manner with combination of curette, burr and 2.5 drill bit. We removed some bone on the lateral tibial plafond and the lateral talus to allow for good opposition of the bony surfaces without any further varus tilt in the ankle.
We then exposed the subtalar joint and distracted it with a Hinterman distractor. Cartilage was again removed in the usual manner. Bony surfaces were prepared in the usual manner with a burr curette and 2.5 drill bit. Bone graft was then inserted both into this place was well as the ankle joint. The bone graft was a combination of morselized bone graft from the distal fibula as well as from femoral head allograft. Bone was packed into place. We then temporarily placed the ankle in neutral dorsiflexion, appropriate valgus for alignment and external rotation. We pinned this in place with temporary 1.6 k-wires along the periphery of the joint.
Fluoroscopic images were used to confirm position of the fusion. We then made a 2 cm incision on the plantar aspect of the foot. The skin only was incised. We bluntly dissected down to the calcaneus. We then inserted a guide wire into the calcaneus and advanced it to the centre of the talus. Reaming was then carried out over top of this. We then inserted a guide wire into the tibia and reamed to a size of 12.5. There was some cortical chatter at this point. We also elected to use a 12 mm x 300 mm length Stryker T2 retrograde arthrodesis nail.
The nail was prepared on the side table including a compression screw. The nail was inserted. There was some difficulty in rotation, we removed the nail and reinserted it again. Once it was reinserted there was good position of the arthrodesis site. We placed a lateral locking screw into the lateral talus. Then we placed two locking screws into the proximal tibia using the radiolucent drill through 2 stab incisions under fluoroscopy. Compression was then applied. We then compressed the subtalar joint separately. We then placed an additional lateral to medial blocking screw and a posterior to anterior locking screw in the calcaneus. Then we took final fluorscopic images and removed the nail insertion device.
We had sagittal position of the foot. There was 0 degrees of dorsiflexion, 3 degrees of high foot valgus and appropriate external rotation. The bony surfaces were well apposed. No residual defects required bone grafting.
We then irrigated the wound with copious saline. Closure of the lateral wound was carried out with 0 Vicryl deep in subcutaneous tissue and 2-0 Vicryl to subcutaneous tissue. Skin was closed with 3-0 Nylon. The plantar incision was closed in a similar manner. Proximally the incisions were closed with staples. The posterior heal incision was closed with Nylon suture.
The wound was clean and dry. Jelonet gauze was affixed to the limb and the limb was wrapped in a well molded posterior splint.
Total tourniquet time was 110 minutes.
Postoperatively the patient will be mobilized non-weight bearing to the affected side for 6 to 8 weeks. He received routine post-operative antibiotics and DVT prophylaxis.
The surgery took nearly two hours.
I had been given a nerve block prior, so it helped a great deal with the pain immediately afterwards.