Technique Tip: How to Avoid Excessive Distal Tibia Cut During Total Ankle Replacement.

Several total ankle arthroplasty systems rely on an extramedullary cutting guide that must be placed precisely to gauge the amount of distal tibia excised. While each technique guide offers granular instruction to ensure an accurate assessment of the distal tibia bone cut, it is not typically clear whether the Angel Wing should be placed medially or laterally with respect to the ankle and/or the X-ray beam. We found that placing the Angel Wing guide ipsilateral to the X-ray beam leads to added magnification of the guide with respect to the tibia. This magnification may result in a larger than intended resection of bone and subsequent placement of the implant in a more proximal position. A more proximal position of the distal tibial cutting guide leads to the implant interfacing with softer bone and an increased risk for implant subsidence. Given this risk and the possible effect of increased magnification on the extramedullary cutting guide, we strongly advise the surgeon to place the guide contralateral to the X-ray beam with respect to the tibia during total ankle arthroplasty.