March 18, 2020

Part 1 - Introduction

Written by Dr Matija Krkovic

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I find it extremely difficult to adjust the fine wire frame in tibio-calcaneal fusion. Whilst I have gotten lucky quite a few times in the past, recently I failed twice. Dramatically. This kind of event puts me down quite badly and makes me feel rather incompetent but I cannot even imagine how patients feel. On top of the pain and discomfort, they are all faced with prolonged treatment - more time with a ****** cage on their leg.

My strategy so far was to aim and adjust the frame based on X-rays in lateral position and based on clinical examination for the AP correction (translation and valgus). Quite often I see that X-ray of an ankle joint in the AP view is not very clear and inter-/intra-observer variability must be quite significant (never tested it myself but I expect it is). The fact is, I don't know what I am aiming at in relation to an AP ankle X-ray.

I looked at the available options.

  1. CT scan - high radiation dose, not readily available in clinical settings.
  2. Tomography - due to the circular structure of the frame, artefact from the metalwork makes bone shadow almost unrecognisable.

I cannot find any other imaging options, and particularly none which would be readily available to me in the clinic.

Analysing the problem again I realised that my main problem is not being able to see the target. Possible solutions:

Cancellous screw as a target marker
It is obviously visible on any X-ray unless covered by the frame, but it needs to be surgically inserted through the sole of the foot creating a scar on the weight bearing area. Not ideal, but in the absence of any better solution I will have to accept it as even worse than a scar on the sole of a foot is another failed tibia-calcaneal fusion.

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