The Journal of Foot & Ankle Surgery 54 (2015) 188–191

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

A Biomechanical Comparison of Internal Fixation Techniques

for Ankle Arthrodesis
Craig Clifford, DPM, AACFAS 1, Scott Berg, DPM 2, Kevin McCann, DPM, FACFAS 3,
Byron Hutchinson, DPM, FACFAS 4
1
Franciscan Orthopedic Associates, Federal Way, WA
2
Postgraduate Year III Resident, Franciscan Health System, Federal Way, WA
3
St Cloud Orthopedics, Sartell, MN
4
Franciscan Foot and Ankle Institute, Federal Way, WA

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 5 The purpose of the present study was to compare the primary bending stiffness characteristics of 5 different
ankle arthrodesis fixation techniques: 3 compression screws, an anterior locking plate, a lateral locking plate, an
Keywords:
ankle arthrodesis anterior locking plate with a compression screw, and a lateral locking plate with a compression screw. A total of
bone model 25 full-scale anatomic models consisting of fourth-generation composite tibiae and tali were tested using an
compression screw Instron 4505 Universal Testing System. We hypothesized that the use of a compression screw with a locking
load cell plate would add considerable stiffness to the fixation construct compared with the use of a locking plate alone.
locking plate The data have shown that an anterior or lateral plate with a compression screw provides significantly greater
stiffness than both a plate and 3 compression screws used individually. No significant difference was seen be-
tween the anterior plate with a compression screw and the lateral plate with a compression screw. No significant
differences were found among the use of an anterior plate, a lateral plate, or 3 compression screws. We have
concluded that when using a locking plate in an anterior or lateral configuration, the addition of a compression
screw will considerably increase the primary bending stiffness of ankle arthrodesis.
Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

End-stage ankle arthritis is problematic for patients and surgeons
alike. When conservative care is no longer adequate, surgical inter-
vention is often considered (1,2). Arthrodesis of the ankle was first
described by Albert in 1879 for the treatment of paralytic equinus (3).
Since its initial description, the indications for the procedure have
expanded to include primary osteoarthritis, post-traumatic and
inflammatory arthritis, lower extremity deformity secondary to
neurologic dysfunction, and revision of failed total ankle arthroplasty
(4). Despite comparable outcomes using total ankle arthroplasty in
certain patient population (5,6), arthrodesis has remained the refer-
ence standard treatment of end-stage arthritis and deformity of the
ankle joint. When properly executed, ankle arthrodesis restores lower
extremity function and provides a highly robust solution to ankle pain
and dysfunction (1,2,5,7).
Financial Disclosure: The hardware used was donated by Tornier, Inc., and
research funding was provided by the International Foot & Ankle Foundation for
Education and Research.
Conflict of Interest: All of the authors are affiliated with the International Foot &
Ankle Foundation for Education and Research.
Address correspondence to: Scott Berg, DPM, Franciscan Foot and Ankle Institute,
34509 Ninth Avenue South, Suite 306, Federal Way, WA 98003.
E-mail address: scottlewisberg@gmail.com (S. Berg).
Several techniques for fixation of ankle arthrodesis have been
described, including crossing screws (1,8), external fixation, intra-
medullary nails, and plating techniques (2,7,9,10). Each could have
distinct indications, although the use of 2 or more internal fixation
screws has remained the most commonly used construct of ankle
arthrodesis fixation (7,11). It has been well documented that a suc-
cessful osseous fusion relies on bony apposition with a high contact
area, increased compression at the anticipated fusion site, and pri-
mary stiffness created by rigid immobilization (1,9,11). Successful
union rates of 94% to 100% have been reported for all forms of fixation
when these core principles have been observed (12–15).
Recent advances in locking plate technology have presented new
options for internal fixation of ankle arthrodesis. To date, few studies
comparing the various applications of locking plates to the ankle joint
have been published (16,17). More specifically, no studies have
compared the use of locking plates at the ankle joint, both with and
without the use of interfragmentary compression screws for fixation
of ankle arthrodesis.
The purpose of the present study was to compare the primary
bending stiffness characteristics of 5 different ankle arthrodesis
fixation techniques: 3 compression screws, an anterior locking plate, a
lateral locking plate, an anterior locking plate with a compression

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.06.002
 C. Clifford et al. / The Journal of Foot & Ankle Surgery 54 (2015) 188–191 189

Fig. 1. Anteroposterior and lateral radiographs of each fixation method: (A) 3 compression screws, (B) anterior plate, (C) lateral plate, (D) anterior plate with compression screw, and
(e) lateral plate with compression screw.

screw, and a lateral locking plate with a compression screw. We
hypothesized that a clinically significant difference would be identi-
fied when comparing the combined use of a compression screw and
locking plate versus the use of a locking plate alone.
Materials and Methods
Testing was performed on full-scale anatomic models consisting of fourth-
generation composite tibiae and tali (Pacific Research Laboratories, Vashon WA). The
models were prepared for arthrodesis with planar resection of the tibial and talar
articular surfaces to a maximum depth of 3 mm. The medial malleolar articular surface
was also resected to a maximum depth of 1 mm, with a planar cut at a 90
angle to the
prepared tibial surface. All specimens were placed in neutral anatomic alignment
before fixation using 1 of the 5 methods (Fig. 1):
12 cm from the center of the ankle joint (Fig. 2). The crosshead was raised 5.3 mm at a
rate of 1 mm/s to place a bending moment on the arthrodesis site to a maximum bend
of 3
. With rotation of the device, the fulcrum was varied to anterior, medial, posterior,
and lateral placement with respect to the arthrodesis site for bending evaluation in the
respective modes of dorsiflexion, inversion, plantar flexion, and eversion. Two trials of
each bending mode were performed for each specimen, with the second trial data
recorded. Force–displacement data were captured and recorded every 10 ms and
curves plotted using Bluehill software (Instron).
Bending stiffness was represented by the slope of the force–displacement curves.
The results were analyzed using 1-way analysis of variance with Tukey post hoc tests to
compare the mean values of the loading modes among each fixation method. The
overall bending stiffness was represented by the mean bending stiffness of all loading
modes within each fixation method. Statistical significance was defined at the 5%
(p ¼ .05) level. All statistical analyses were performed using IBM SPSS Statistics, version
21.0 (IBM Corp, Armonk, NY).

1. Three compression screws: Three 6.5-mm cannulated compression screws (Tor- Results
nier, Inc, Bloomington, MN) were placed from the tibia to the talus using the
technique described by Schuberth et al (8); the posterolateral screw was placed
A total of 25 fourth-generation saw bones were tested, 5 each used
first, followed by the medial and finally anterolateral screws.
2. Anterior locking plate (ALP): A contoured anterior locking plate (Tornier, Inc) was for each of the 5 different fixation constructs. With dorsiflexion loading,
placed on the anterior side of the joint in line with the talar neck. The plate was the greatest stiffness was provided by the ALP-S (60.76  12.63 N/mm),
first fixed to the talus with locking screws. Next, the arthrodesis site was com- which was significantly stiffer than all other fixation methods (p < .001),
pressed using the ratcheting compression devices supplied by the manufacturer.
Finally, the plate was fixed to the tibia with the associated nonlocking and locking
screws.
3. Lateral locking plate (LLP): A contoured lateral locking plate (Tornier, Inc) was
placed on the lateral side of the joint in the fibular groove of the tibia. First the
plate was fixed to the talus with locking screws. Next, the arthrodesis site was
compressed using the ratcheting compression devices supplied by the manufac-
turer. Finally, the plate was fixed to the tibia with the associated nonlocking and
locking screws.
4. ALP with a compression screw (ALP-S): First, a single 6.5-mm cannulated
compression screw was placed from the posterolateral tibia to the talar neck. Next,
a contoured plate was applied anteriorly, as previously described.
5. LLP with a compression screw (LLP-S): First, a single 6.5-mm cannulated
compression screw was placed from the posterolateral tibia to the talar neck. Next,
a contoured plate was applied laterally, as previously described.

Each method was used for fixation of 5 complete specimens. All proximal tibiae
were drilled and tapped for the placement of a 12-in. threaded steel rod placed at a
depth of 10 in. along the central axis of the bone for use as an attachment point to the
testing machine. All tali were potted in epoxy resin (3M, St Paul, MN) to a depth of 1 cm
distal to the arthrodesis site. The drill holes and exposed hardware were protected from
epoxy contact by covering them with plastilene modeling clay.
The 25 specimens were tested with a uniform protocol using an Instron 4505
Universal Testing System (Instron, Norwood, MA). The tibiae were affixed to the load
cell, and the potted tali were bolted to a rigid steel cantilever beam. The beam was Fig. 2. Arthrodesis specimen mounted to cantilever beam with the fulcrum 12 cm from
allowed to freely pivot on a fulcrum mounted to the crosshead of the testing machine the center of the ankle joint.
190 C. Clifford et al. / The Journal of Foot & Ankle Surgery 54 (2015) 188–191
Fig. 3. Comparative bending stiffness of each fixation method (n ¼ 5 fourth-generation saw bones for each of the 5 fixation constructs).
and provided a bending stiffness 71% greater than the anterior plate
alone (p < .001). The addition of a compression screw resulted in a
significant increase in bending stiffness (p < .001) for the anterior plate
but no significant increase in stiffness for the lateral plate (p ¼ .175).
With plantar flexion loading, the ALP-S and ALP produced
the greatest primary stiffness (65.53  12.52 N/mm and
66.07  12.83 N/mm, respectively). The difference between these
constructs was not significant (p > .05); however, these 2 constructs
had significantly greater stiffness than the remaining fixation methods
(p < .008). The addition of a compression screw provided no significant
increase in bending stiffness for the ALP or the LLP (p > .51).
With inversion loading, the LLP-S and LLP produced the greatest
primary stiffness (65.11  2.32 N/mm and 57.58  4.49 N/mm,
respectively). The difference between these constructs was not sig-
nificant (p ¼ .05). The LLP-S and LLP both provided significantly
greater stiffness than the remaining fixation methods (p < .001). The
addition of a compression screw provided no significant increase in
bending stiffness for the ALP or the LLP (p > .05).
With eversion loading, the LLP produced the least primary stiffness
(12.82  3.02 N/mm), which was significantly different compared
with all other fixation methods (p < .001). The difference between the
remaining constructs (ALP, ALP-S, LLP-S, and 3 compression screws)
was not significant (p > .05). The addition of a compression screw
resulted in no significant increase in bending stiffness (p ¼ .104) for
the ALP but a significant increase in stiffness for the LLP (p < .001).
For overall stiffness, the ALP-S and LLP-S produced the greatest
primary stiffness (51.24  16.37 N/mm and 48.82  11.79 N/mm,
respectively). The difference between these constructs was not sig-
nificant (p > .989). The addition of a compression screw resulted in no
significant increase in overall bending stiffness (p ¼ .07) for the ALP
but a significant increase in the overall bending stiffness for the LLP
(p ¼ .018). No significant difference was found among the ALP, LLP, or
3 compression screws (p > .05) (Fig. 3).
Discussion
The results of the present study highlight several important find-
ings. The initial hypothesis was supported by the data showing that a
compression screw could add considerable stiffness to a locking plate
fixation technique for ankle arthrodesis in certain cases. The addition
of a compression screw added significant stiffness to arthrodesis
constructs in which the plate was on the compression side of loading
(i.e., the anterior plate under dorsiflexion and the lateral plate under
eversion). This finding coincides with the findings from Mueckley et al
(9) and Buranosky et al (18).
The bending stiffness of each fixation method varied with the
direction of the applied force. The presented data have clearly
demonstrated the principles of plate fixation, with the greatest
resistance to bending observed when the plate was fixed on the
tension side of the applied force. It was in these situations only that
the addition of a compression screw provided no significant increase
in bending stiffness.
Our data have shown that the greatest overall bending stiffness
was with the anterior plate and compression screw method, although
this was not significantly different from that of the lateral plate with a
compression screw. Fixation with the 3 compression screws showed
comparatively low average bending stiffness; however, the stiffness
was relatively consistent across all bending modes and was not
significantly different from that with anterior or lateral plate fixation
without a compression screw.
It is important that these data not be used out of context. Although
rigid internal fixation has been shown to promote successful
arthrodesis (1,9,19–21), the optimal bending stiffness for each loading
mode of an ankle arthrodesis is not yet known. Furthermore, in a
clinical setting, it is likely unrealistic to assume equal loading in all
planes; therefore, the overall bending stiffness such as was defined in
the present study mighty not be applicable. It is reasonable to assume
that dorsiflexory loading might have a more significant role than the
other loading modes owing to the fulcrum of the foot during pro-
pulsive gait; however, this issue was outside the scope of our study.
Additionally, soft tissue structures, such as the Achilles tendon, can
impart significant forces on the arthrodesis site. The use of an anterior
plate alone could, therefore, theoretically impart dynamic compres-
sion on an ankle arthrodesis; however, this has received limited
investigation (16,22,23).
Other inherent differences exist between the test model ankle
arthrodesis methods and those encountered in vivo, including the
required incisional approach, possibility of percutaneous placement,
 C. Clifford et al. / The Journal of Foot & Ankle Surgery 54 (2015) 188–191
suitability for use with osteoporotic bone, and cost of implants (9,10).
When choosing a fixation method, the surgeon must consider many
technical and patient-specific requirements that were beyond the
scope of our report.
The main limitation of the present study was the use of biomechanical
bone models tested in a laboratory with strictly controlled motion. The
actual in situ forces will be more varied and not restricted to a single
plane of movement. However, the use of composite biomechanical
models eliminated any error caused by specimen size or bone density
(9,24,25). Additional testing could consider soft tissue attachments,
combined forces, and in vivo investigations linked to clinical outcomes.
In conclusion, ankle arthrodesis can be performed using several
different fixation methods, 5 of which were examined within the
design of our study. At the completion of the present study, we
concluded that when using a locking plate in an anterior or lateral
configuration, the addition of a compression screw will considerably
increase the bending stiffness and compensate for the tension-side
limitations of plate fixation alone. The use of 3 compression screws
provided overall stiffness similar that of provided by anterior and
lateral plates without compression screws.
Acknowledgments
We thank Tuesday Kuykendall for her assistance with the Instron
testing system and the Materials Science and Engineering Depart-
ment, University of Washington, Seattle, WA.
References
1. Kakarla G, Rajan DT. Comparative study of ankle arthrodesis using cross screws
fixation versus anterior contoured plate plus cross screw fixation. Acta Orthop Belg
72:716–721, 2006.
2. Fragomen AT, Myers KN, Davis N. A biomechanical comparison of micromotion
after ankle fusion using 2 fixation techniques: intramedullary arthrodesis nail or
Ilizarov external fixator. Foot Ankle Int 29:334–341, 2008.
3. Albert E. Zur Resektion des Kniegelenkes. Wien Med Press 20:705–708, 1879.
4. Nihal A, Gellman RE, Embil JM, Trepman E. Ankle arthrodesis. Foot Ankle Surg
14:1–10, 2008.
5. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and
long-term outcomes of total ankle arthroplasty and ankle arthrodesis: a system-
atic review of the literature. J Bone Joint Surg Am 89:1899–1905, 2007.
191
6. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger ASE. Impact of
complications in total ankle replacement and ankle arthrodesis analyzed with a
validated outcome measurement. J Bone Joint Surg Am 93:830–839, 2011.
7. Ogut T, Glisson RR, Chuckpaiwong B, Le I, Easley ME. External ring fixation vs
screw fixation for ankle arthrodesis: a biomechanical comparison. Foot Ankle Int
30:353–360, 2009.
8. Schuberth JM, Ruch JA, Hansen ST. The tripod fixation technique for ankle
arthrodesis. J Foot Ankle Surg 48:93–96, 2009.
9. Mueckley TM, Eichorn S, Oldenburg G, Speitling A, DiCicco J, Hofmann GO,
Buhren V. Biomechanical evaluation of primary stiffness of tibiotalar arthrodesis
with intramedullary compression nail and four other fixation devices. Foot Ankle
Int 27:814–820, 2006.
10. Nasson S, Shuff C, Palmer D, Owen J, Wayne J, Carr J, Adelaar R, May D. Biome-
chanical comparison of ankle arthrodesis techniques: crossed screws vs. blade
plate. Foot Ankle Int 22:575–580, 2001.
11. Dohm MP, Benjamin JB, Harrison J, Szivek JA. A biomechanical evaluation of three
forms of internal fixation used in ankle arthrodesis. Foot Ankle Int 15:297–300, 1994.
12. Braly WG. Arthrodesis of the ankle with lateral plating. Foot Ankle 15:649–653,
1994.
13. Scranton PE Jr, Fu FH, Brown TD. Ankle arthrodesis: a comparative clinical and
biomechanical evaluation. Clin Orthop Relat Res 151:234–243, 1980.
14. Sowa DT, Krackow KA. Ankle fusion: a new technique of internal fixation using a
compression blade plate. Foot Ankle 9:232–240, 1989.
15. Weitmer JB, Choi SH, Shenoy A, Schwartsman V. Wolf blade plate ankle arthrod-
esis. Clin Orthop Relat Res 268:107–111, 1991.
16. Kestner CJ, Glisson RR, DeOrio JK, Nunley JA. A biomechanical analysis of two
anterior ankle arthrodesis systems. Foot Ankle 34:1006–1011, 2013.
17. O’Neill PJ, Logel KJ, Parks BG, Schon LC. Rigidity comparison of locking plate
and intramedullary fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int
29:581–586, 2008.
18. Buranosky DJ, Taylor DT, Sage RA, Patwardhan A, Phelan M, Lam AT. First meta-
tarsophalangeal joint arthrodesis: quantitative mechanical testing of six-hole
dorsal plate versus crossed screw fixation in cadaveric specimens. J Foot Ankle
Surg 40:208–213, 2001.
19. Dennis DA, Clayton ML, Wong DA, Mack RP, Susman MH. Internal fixation
compression arthrodesis of the ankle. Clin Orthop Relat Res 253:212–220, 1990.
20. Kennedy JG, Hodgkins CW, Brodsky A, Bohne WH. Outcomes after standardized screw
fixation technique of ankle arthrodesis. Clin Orthop Relat Res 447:112–118, 2006.
21. Abdo RV, Wasilewski SA. Ankle Arthrodesis: a long term study. Foot Ankle
13:307–312, 1992.
22. Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior
tension plate. Clin Orthop Relat Res 268:70–77, 1990.
23. Tarkin IS, Mormino MA, Clare MP, Haider H, Walling AK, Sanders RW. Anterior
plate supplementation increases ankle arthrodesis construct rigidity. Foot Ankle
Int 28:219–223, 2007.
24. Cristofolini L, Viceconti M. Mechanical validations of whole bone composite tibia
models. J Biomech 33:279–288, 2000.
25. Panjabi MM, Krag M, Summers D, Videman T. Biomechanical time-tolerance of
fresh cadaveric human spine specimens. J Orthop Res 3:292–300, 1985.