Transmalleolar tibiotalocalcaneal fusion with biologic augmentation and fibular preservation for chronic Charcot ankle arthropathy: A retrospective cohort study

Figure 1 Transmalleolar approach with lateral malleolar osteotomy. A: Lateral malleolar osteotomy with preserved periosteal blood supply; B: Posterior retraction of the fibula with a Hohmann retractor providing exposure to the ankle and subtalar joints.

Figure 2 Joint surface preparation. A: Saw preparation of the inner aspect of the fibula and the lateral tibia at the syndesmosis level to create fresh, bleeding bone surfaces; B: Multiple drill holes created in the talus to enhance biological healing potential.

Figure 3 Tibiotalocalcaneal nailing procedure. A: Guide wire insertion through calcaneus across subtalar and ankle joints into tibia; B: Retrograde intramedullary nail insertion following standard technique.

Figure 4 Biologic augmentation preparation. A: Bone marrow aspirate using Jamshidi needle; B: Allograft preparation; C: Bone marrow aspirate mixed with allograft chips.

Figure 5  Biologic graft insertion and impaction.

Figure 6 Fibular reduction and fixation. A: Anteroposterior radiographic view showing fibular reduction with cannulated wires; B: Lateral radiographic view with cannulated wires; C: Anteroposterior radiographic view showing screw insertion; D: Lateral radiographic view showing screw placement; E: Final clinical image showing two screws inserted from fibula creating the “trap door” construct.