Tibio-Talo-Calcaneal (TTC/Double )fusion using Integra Advansys Plate surgical technique
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The most common reason for performing a double-fusion is in concurrent ankle and subtalar arthritis in the symptomatic patient. Consideration should also be given to the technique in cases of revision of fusion surgery to the ankle or subtalar joint, and also avascular necrosis of the talus. Arthritic change is however not a pre-requisite for this type of surgery. As a final option for an unstable ankle and hindfoot in the neurological patient it has significant merit also in the absence of degenerative change.
There are various techniques available surgically for performing a double fusion, these being to use large fragment screws in isolation, to fuse using an intra-medullary nail, an external frame or alternatively a plate designed for the purpose.
The techniques of joint preparation and correction of deformity will be broadly the same irrespective of the exact method chosen for fixation.
The INTEGRA Advansys TTC plate is designed for lateral application through a trans-fibular across the ankle & subtalar joints. As such both access and implantation are straightforward. These plates are sided and come in 4 lengths and 2 widths (of the Calcaneal limb). As such they are able to accommodate an appropriate variety of adult foot & ankle sizes. The INTEGRA TTC plate is of robust dimensions but also can be contoured if required (for example to accommodate heel valgus). The Integra screws have excellent thread purchase on bone and their innovative design (with a non-threaded head) allows them to pull the plate to the bone after which they can be locked into place with a threaded grub screw. Compression is achieved both by using an external clamp, anchored temporarily proximal to the top of the plate, as well as with a proximally placed compressive hole in the plate.
In my experience given the plate is applying compression laterally a medially placed large fragment screw across the ankle is usually required to counteract the significant medial tensile force that results.
Author: Mark Herron FRCS.
Institution: The Wellington Foot & Ankle unit, London, UK.