Minimally invasive, no hardware subtalar arthrodesis with autogenous posterior iliac bone graft

A Novel Method of Simultaneous In Situ Decompression of Lateral Calcaneal Bulge and Subtalar Arthrodesis Via a Single Incision for Malunion After Calcaneal Fractures

OBJECTIVE

The aim of this study was to introduce a novel method of simultaneous in situ decompression of lateral calcaneal bulge and subtalar arthrodesis via a single incision for malunion after calcaneal fractures and evaluate the feasibility of this method.

METHODS

From September 2010 to October 2011, six patients (five males and one female) with malunion and delayed heel pain after conservative treatment of displaced intra-articular calcaneal fractures were included in our study. The mean age of the six patients was 32.9 years (range, 25-71 years). Patients were treated with this novel technique at our department and the functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scores during follow-up. Information of the six patients including surgical data and pre/postoperative function scores were retrospectively analyzed using SPSS 19.0 statistical software.

RESULTS

The average operation time between wire insertion and incision suture was 42.2 ± 11.5 min (range, 25-56 min). The blood loss in all patients was all less than 50 ml each. The average fluoroscopy time was 25.7 ± 11.6 s (range, 11-43 s). No wound-related and other short-term complications were recorded. Six patients who were included in our study were followed for an average period of 66.2 ± 4.7 months (range, 60-73 months). There was no patient lost to follow up. Heel pain was observed to be greatly improved preoperatively in all of the six patients. All patients restored to normal activity of life after surgery. Radiological evidence of fusion was observed in five patients. The average fusion time of these five patients was 3.5 months (range, 2-4 months). The remaining one failed to achieve fusion and the hardware removal was performed due to screw tail irritation. This patient was satisfied with the final outcomes subjectively after removal of hardware. The mean AOFAS scores at 24 months postoperative were 82.0 ± 7.0, which was greatly improved compared to preoperative (44.8 ± 10.7) (P < 0.05). The preoperative VAS pain scores were decreased from 5.8 ± 1.5 to 2.6 ± 1.4 at 24 months postoperative (P < 0.05) and slightly decreased to 2.0 ± 1.7 at 48 months postoperative (P < 0.05). No surgery-related complications were observed in any of the patients.

CONCLUSIONS

The novel technique can effectively relieve the heel pain, prompt functional recovery, decrease the incidence of complications, simplify the surgical procedure, and shorten the learning curve. Therefore, the technique is a feasible and worthwhile alternative in treating malunion after calcaneal fractures.

Systematic Review of Subtalar Distraction Arthrodesis for the Treatment of Subtalar Arthritis

BACKGROUND

Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objective of this study was to present an overview of outcomes following SDA, focusing on surgical technique as well as clinical and radiographic results.

METHODS

MEDLINE and EMBASE were queried and data abstraction was performed by 2 independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least 5 patients, and (4) reporting clinical and/or radiographic outcomes of SDA.

RESULTS

Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle-hindfoot scores with a weighted average of 33 points of improvement.

CONCLUSION

SDA provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. Higher quality studies are necessary to better assess outcomes between different operative techniques.

LEVEL OF EVIDENCE

Level III.

Minimally invasive subtalar arthrodesis for traumatic subtalar arthritis

Objective

This study was performed to introduce a new method of minimally invasive subtalar arthrodesis (MISA) and assess its clinical effects on traumatic subtalar arthritis (TSA).

Methods

Fifteen patients (8 male and 7 female; age range, 36–56 years; mean age, 48.67 years) with TSA who underwent MISA were included. All patients were treated using a series instrument. The intraoperative and postoperative indexes were recorded.

Results

Among all patients, the mean operation time was 59.67 ± 16.31 minutes and the mean intraoperative blood loss was 43.33 ± 52.87 mL. Four patients underwent iliac crest bone graft surgery, and one patient developed a complication involving fat liquefaction of the iliac crest wound. The mean bony fusion time among all patients was 3.5 months. According to the American Orthopaedic Foot and Ankle Society standard, an excellent outcome was obtained in eight patients and a good outcome was obtained in seven patients. The operation time and intraoperative blood loss were significantly different between patients who did and did not undergo iliac crest bone graft surgery.

Conclusion

MISA is a simple and effective method for the treatment of TSA.

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

INTRODUCTION

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.

MATERIALS AND METHODS

This is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.

RESULTS

Forty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53-72). Quality of life was significantly lower when compared to a reference population (p<0.001).

CONCLUSION

Satisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.

Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled Trials

The purpose of the present study was to perform an updated meta-analysis of the operative versus nonoperative treatment of displaced intra-articular calcaneal fractures in adults. We searched the Cochrane Library, MEDLINE, EMBASE, and Google Scholar for eligible studies. All published randomized controlled trials comparing operative with nonoperative treatment for displaced intra-articular calcaneal fractures were eligible. The meta-analysis was performed using RevMan, version 5.0, software. Seven studies assessing 824 patients were eligible for the meta-analysis. The pooled results indicated no significant differences between the 2 groups with regard to the functional results. The incidence of complications was 25.0% (80 of 319) in the operative group and 16.6% (55 of 330) in the nonoperative group (relative risk 1.53, 95% confidence interval 1.13 to 2.08; p = .006) with a significant difference. The rate of subtalar arthrodesis was significantly lower in the operative group than in the nonoperative group. The current evidence is still insufficient to ascertain whether operative treatment is superior to nonoperative treatment for displaced intra-articular calcaneal fractures. Operative treatment can reduce the risk of late subtalar arthrodesis but is associated with a greater risk of complications. The small sample size and the great heterogeneity of the included studies made it difficult to draw conclusions regarding some of the combined results. Furthermore, more high-quality, randomized controlled trials with long-term follow-up data on this issue are required to provide evidence for surgeons to make an informed decision.

Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

BACKGROUND

While autogenous cancellous iliac crest bone graft is the gold standard for foot and ankle surgery, it lacks Level I evidence. Although one third of all graft cases performed in the United States today rely on allograft, some surgeons believe no graft is necessary. We hypothesized that a systematic review of the foot and ankle literature would reveal that (1) autogenous bone graft during foot and ankle arthrodesis would demonstrate healing rates that were superior to the use of either using allograft or no bone graft at all, and (2) these differences would be even more dramatic in patients having risk factors that impair bone healing. To our knowledge, neither of these assessments to date has ever been performed with this body of literature. The goal of this study was to review the use and union rates of bone graft during foot and ankle arthrodesis and determine if autogenous bone graft was superior.

METHODS

A literature search was performed to include articles between 1959 and 2012 using autograft, allograft, and/or no bone graft for foot and/or ankle arthrodesis. Case reports involving fewer than four patients, investigations failing to incorporate outcome data, those involving orthobiologic augmentation, and those including vascularized graft, xenograft, or pediatric patients were excluded. Recorded search results included patient demographics, comorbidities, pre-operative diagnosis, surgical procedure, bone graft type and indication, union rate, method of fixation, patient satisfaction, all outcome scores, definition of healing/success, and any listed complications including revision. Final data were stratified based upon the type of graft material.

RESULTS

This search generated 953 related articles, of which 159 studies (5327 patients) met inclusion criteria. The majority (153/159) were retrospective case series. Systematic review demonstrated a trend toward higher union rates for cancellous autograft (OR 1.39, p=0.11), structural autograft (OR 1.52, p=0.09), and cancellous allograft (OR 1.31, p=0.52) relative to no graft material, but none reached statistical significance. Compared to no graft, structural allograft trended toward worse performance (OR 0.62, p=0.17). The overall probability of union was 93.7% for cancellous autograft, 94.2% for structural autograft, 93.3% for cancellous allograft, 91.4% for no graft, and 86.9% for structural allograft. When only comparing the 19 papers that included a no graft arm (91.9% union rate), data revealed the highest union using cancellous autograft (95.1%, OR 1.73, p=0.09) and structural autograft (96.3%, OR 2.33, p=0.06) while only 76% for structural allograft. No significant statistical association existed between union rates and other recorded variables.

CONCLUSION

Systematic analysis of bone graft use in foot and ankle fusions favors the use of autograft and cancellous allograft for optimized healing rates, although no differences were statistically significant. If we assume that graft material been chosen for more complex procedures having lower anticipated union rates, then these data lend further support to the use of autograft and cancellous allograft.

LEVEL OF EVIDENCE

Level IV.

Subtalar Joint Distraction Arthrodesis to Correct Calcaneal Valgus in Pediatric Patients with Tarsal Coalition: A Case Series

Subtalar joint middle facet coalitions commonly present in children who have a painful, rigid, pes planovalgus foot type. The middle facet coalition allows rearfoot forces to be distributed medially through the coalition, and this can result in arthritis or lateral tarsal wedging. The senior author has used a wedged bone graft distraction subtalar joint arthrodesis to correct calcaneal valgus and restore the talar height in these patients. The tight, press-fit nature of the tricortical iliac crest allograft provides stability and can negate the need for internal fixation. We retrospectively reviewed 9 pediatric subtalar joint distraction arthrodesis procedures performed on 8 patients during a 6-year period. All patients began weightbearing at 6 weeks after surgery. All patients had osseous union, and no complications developed that required a second surgery. The clinical outcomes, assessed at a mean of 25.5 (range, 6.3 to 75.8) months postoperatively, were satisfactory. The mean American Orthopaedic Foot and Ankle Society score was 90.1 (range, 79 to 94), on a 94-point scale. The wedged distraction arthrodesis technique has not been previously described for correction of pediatric patients with lateral tarsal wedging, but it is an effective option and yields successful outcomes.

Outcome After Operative Fusion of the Tarsal Joints: A Systematic Review

Arthrodesis of 1 or more joints of the hindfoot is performed to treat severe functional impairment due to pain, deformity, and/or instability. Evaluation of the results of hindfoot arthrodesis from the published data has been difficult owing to the great variety of pathologic entities and surgical techniques reported in the studies. A comprehensive search for relevant reports, reference lists, and citation tracking of the included studies was conducted using the PubMed(®), Embase(®), and CINAHL(®) databases. The studies had to have been prospective, included patients with hindfoot problems, evaluated arthrodesis of 1 or more tarsal joints, and had at least 1 of the following primary clinical outcome parameters: pain, function, or complications. Two of us independently selected the relevant studies using predefined criteria and graded the quality of evidence using a 0 to 9 star scale according to the Newcastle-Ottawa Scale. A total of 16 prospective case series were included; 5 studies scored 6 stars, 8 scored 5 stars, 2 scored 4 stars, and 1 scored 3 stars. A best evidence synthesis was performed, and improvement in function and pain was found for 3 combinations: talonavicular arthrodesis for rheumatoid arthritis, triple arthrodesis for rheumatoid arthritis, and subtalar arthrodesis for post-traumatic arthritis showed good results for pain and function, the last especially when performed arthroscopically. The best evidence syntheses revealed good results for pain and function for these disease-operative technique combinations.

Biomechanical evaluation of subtalar fusion: the influence of screw configuration and placement

Common surgical procedures for subtalar fusion include joint resection, autologous bone grafting, and osteosynthesis with screws in a parallel screw configuration. Although fusion is a routine procedure, the reported rates of nonunion have been high. The present study assessed different screw configurations in terms of their rotational and bending stability in an artificial bone model and cadaver bone. Arthrodesis was always performed with 2 screws. Three different screw configurations were tested: parallel, counter-parallel, and a delta configuration. Two different screw designs were used: a cannulated, partially threaded screw (6.5-mm and 8.0-mm diameter) and a solid screw with a different thread design. Eight experimental groups were investigated as pilot studies in artificial bones and then 3 groups in cadaver bones. The parameters were the primary stiffness and deflection of the construct for loads simulating the internal-external rotation and supination-pronation. Delta positioning of the screws resulted in the greatest biomechanical stiffness and the lowest degrees of deflection of the arthrodesis in the artificial bones and cadaver bones. Increasing the screw diameter from 6.5 to 8.0 mm resulted in no additional stability of the arthrodesis in the artificial bones. The results of the present study have indicated that the delta configuration for arthrodesis results in the greatest construct stiffness and lower relative deflection between the talus and calcaneus in the positions tested.

Minimally invasive subtalar arthrodesis with iliac crest autograft through posterior arthroscopic portals: a technical note

Level of Evidence: V, Expert Opinion