Subtalar arthroscopy: indications, technique and results

Osteochondral Lesions of the Subtalar Joint: Clinical Outcomes in 11 Patients

OBJECTIVE

The purpose of this retrospective case series was to evaluate clinical outcomes following both conservative treatment and arthroscopic bone marrow stimulation (BMS) for the management of symptomatic subtalar osteochondral lesions (OCLs).

DESIGN

All symptomatic subtalar OCLs with a minimum of 12 months follow-up having undergone either a conservative management or arthroscopic procedure were included. Patient-reported outcomes were collected via questionnaires consisting of the Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS) of pain in rest, during walking, during stair climbing, and during running. In addition, return to sports data, return to work data, reoperations, and complications were collected and assessed. In total, 11 patients across 2 academic institutions were included (3 males, 8 females). The median age was 43 years (interquartile range [IQR]: 32-53).

RESULTS

All patients underwent conservative treatment first; in addition, 9 patients underwent subtalar arthroscopic debridement with or without BMS. The median follow-up time was 15 months (IQR: 14-100). In the surgically treated group, the median NRS scores were 2 (IQR: 1-3) during rest, 3 (IQR: 2-4) during walking, 4 (IQR: 4-5) during stair climbing, 5 (IQR: 4-5) during running and the median FAOS score at final follow-up was 74 (IQR: 65-83). In the conservatively treated patients, the median NRS scores were all 0 (IQR: 0-0) and the median FAOS scores were 90 (IQR: 85-94). In the group of surgical treated patients, 4 were able to return to the same level of sports, 2 returned to a lower level of sports. Both conservatively treated patients returned to the sport and the same level of prior participation. All patients except one in the surgical group returned to work.

CONCLUSIONS

This retrospective case series demonstrated that a high number of patients converted to surgery after initial conservative treatment. In addition, debridement and BMS show good clinical outcomes for the management of symptomatic subtalar OCLs at short-term follow-up. No complications nor secondary surgical procedures were noted in the surgically treated group. The high rate of failure of conservative treatment suggests that surgical intervention for symptomatic subtalar OCLs can be the primary treatment strategy; however, further research is warranted in light of the small number of patients.

Arthroscopy of Foot and Ankle: Subtalar Joint Arthroscopy in Intra-articular Calcaneal Fractures

The utilization of subtalar joint arthroscopy in intra-articular calcaneal fractures provides optimal visualization of articular surfaces for a more precise anatomical reduction, thus yielding better surgical outcomes. Current literature shows good functional and radiographic outcomes, fewer wound complications, and low incidence of post-traumatic arthritis with this technique than when utilizing an isolated lateral extensile incision of the calcaneus. As subtalar joint arthroscopy continues to grow in popularity and technological advancement, patients may benefit when surgeons incorporate this tool in conjunction with a minimally invasive technique for treatment of intra-articular calcaneal fractures.

Subtalar Joint Arthroscopy

Subtalar arthroscopy is being more commonly utilized by surgeons who perform foot and ankle arthroscopy. The joint can be entered from an anterior lateral or posterior approach. There is unique pathology in the joint that can be repaired through an arthroscopic approach.

Lateral Arthroscopic Subtalar Arthrodesis for Talocalcaneal Coalition: Surgical Technique

Resection of symptomatic talocalcaneal coalitions (TCCs) has been performed for patients with normal tarsal joints and <50% involvement of the subtalar joint. For those with TCCs >50% of subtalar articulation or/and subtalar arthritis, a subtalar arthrodesis is done. The purpose of this Technical Note is to describe the arthroscopic resection of TCC and talocalcaneal arthrodesis during the same procedure by using a 2 lateral portal technique. With the patient in lateral decubitus under general or locoregional anaesthesia, the foot and ankle are extended beyond the edge of the surgical table. A lateral portal is created 1 cm anterior to the tip of the lateral malleolus in which the arthroscope is introduced. The anterolateral portal is created 1 cm inferior and 2 cm anterior to the tip of the lateral malleolus. The posterior subtalar surface is prepared progressively. The TCC resection is completed. The fixation is obtained with 2 cannulated screws. The arthroscopic resection of TCC and subtalar arthrodesis during the same procedure by using 2 lateral portals can be done for correctly selected patients.

Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device

PURPOSE

To evaluate the quality of reduction and clinical outcomes by using Percutaneous Distractor and Subtalar Arthroscopy Closed Reduction followed by Internal Fixation (PDSA-CRIF) in the intra-articular calcaneal fracture.

METHODS

A consecutive case series of 453 patients with 507 displaced intra-articular calcaneal fractures was recruited in this retrospective study. We performed PDSA-CRIF to treat intra-articular calcaneal fractures. The quality of reduction was assessed by early postoperative Computed Tomography (CT) scans and measurement of serial Bohler's angles during follow-ups. Clinical outcomes were evaluated by Visual Analogue Scale (VAS) and the American Foot & Ankle Society ankle-hind foot scale (AOFAS) scoring system.

RESULTS

Fifty-nine patients (68 fractures) who had complete clinical data and follow-up of at least 12-months (mean: 14 months, range: 12-59 months) were finally included. Anatomical and near-anatomical reduction in subtalar articular surface which had less than 2 mm gap or step-off was found in 93% fractures. Unsatisfactory reduction was found in 7%.

CONCLUSION

Arthroscopic-assisted percutaneous fixation using a distraction device is effective in achieving positive short-term results in the displaced intra-articular calcaneal fractures. A multicenter, large sample, randomized control trial is needed to fully evaluate the long-term effects of PDSA-CRIF in comparison to other methods.

Arthroscopic Evaluation of the Subtalar Joint: A Review and Survey of Pathology

BACKGROUND

A survey of pathology present in the subtalar joint by means of subtalar arthroscopy with anterolateral and middle portals has not been extensively explored in the literature. The focus of this study was to identify pathology in the subtalar joint with subtalar joint arthroscopy using this approach. We also compared these arthroscopic findings with those reported in the literature.

METHODS

We performed a retrospective review of 49 consecutive patients who had undergone 53 subtalar arthroscopic procedures. Data were obtained from intraoperative arthroscopic findings that were documented in the operative note or with arthroscopic photography. Additional procedures, including ankle arthroscopy, lateral ankle stabilization, and peroneal tendon repair, were recorded. Descriptive statistics were calculated and reported.

RESULTS

Subtalar arthroscopic examination revealed that all of the patients had intra-articular synovitis or adhesions present. Twenty-two procedures (42%) demonstrated subtalar joint instability, seven (13%) revealed chondromalacia, and one (2%) had an exostosis present. These observations are consistent with other reported findings in the literature.

CONCLUSIONS

This study found that the subtalar joint was most often affected by synovitis, adhesions, and instability in patients with symptomatic pathologies requiring subtalar arthroscopy. There was a relatively low incidence of chondromalacia or exostosis formation in the survey.

Subtalar arthroscopic debridment for the treatment of sinus tarsi syndrome: case series

OBJECTIVE

The objective of this study is to report the results of arthroscopic debridement of the subtalar joint in eight patients with Sinus Tarsi Syndrome (STS) refractory to conservative treatment.

METHODS

This is a retrospective study of eight patients with STS who underwent subtalar arthroscopy for debridement of the sinus tarsi between January 2015 and January 2017 after six months of conservative treatment. All patients answered an epidemiological questionnaire and underwent functional evaluation with the Visual Analogue Pain Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in the preoperative and in the last evaluation (average of 12 months - 6-24 months).

RESULTS

All patients showed severe synovitis in the region. Seven patients had remnants of the talocalcaneal ligaments and six of the cervical ligament. AOFAS increased by 30 points on average (51.75 in the preoperative period to 82.62 in the last follow-up) and the VAS decreased on average by 5 points (7.37 preoperatively to 2.12 in the last follow-up). These results were statistically significant with p = 0.043 and p = 0.032 respectively. Six patients described the result as excellent and two as good. No complications were reported. All patients returned to sports after six months of follow-up.

CONCLUSION

The arthroscopic debridement of the subtalar joint is an effective and safe alternative in the treatment of STS refractory to conservative treatment. More studies, with a prospective methodology, are necessary to prove the results of this technique.

Role of Subtalar Arthroscopy for Displaced Intra-Articular Calcaneal Fractures

Subtalar arthroscopy has an important role in enhancing the reduction of the posterior facet in percutaneous and open approaches of displaced intra-articular calcaneal fractures. In the percutaneous approach, arthroscopically assistant percutaneous approach must be selected carefully for mild-to-moderately displaced fractures. In the open approach, there is still little evidence of the utility of subtalar arthroscopy. Therefore, intraoperative arthroscopy should always be used in conjunction with fluoroscopy to achieve reduction and assess the internal fixation placement.

Role of Subtalar Arthroscopy in Operative Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach

BACKGROUND

This study was conducted to evaluate the usefulness of subtalar arthroscopy in the operative treatment of Sanders type 2 calcaneus fractures using a sinus tarsi approach.

METHODS

Forty-six Sanders type 2 calcaneal fractures were consecutively treated using a sinus tarsi approach. Intraoperative fluoroscopy was used to evaluate fracture reduction in the first 23 patients (fluoroscopy group), and intraoperative fluoroscopy and subtalar arthroscopy were used in the latter 23 patients (arthroscopy group). Clinical evaluations were performed using a visual analog scale, the Ankle-Hindfoot Scale developed by the American Orthopaedic Foot & Ankle Society, and Short Form Health Survey. Radiographic evaluations were performed using calcaneal and lateral radiographs and computed tomography (CT) scans. Böhler's angles and calcaneal widths were compared between the groups. Reduction of the posterior facet was graded according to articular step, defect, and angulation of the posterior facet on CT.

RESULTS

At the last follow-up, clinical results as well as Böhler's angles and calcaneal widths were not different between the groups. On immediately postoperative CT, reduction of the posterior facet showed a higher-than-good grade in 17 feet (73.9%) in the fluoroscopy group and a higher-than-good grade in 22 feet (95.7%) in the arthroscopy group, and these values were significantly different between the groups ( P = .04).

CONCLUSION

A combined approach using fluoroscopy and subtalar arthroscopy showed better reduction of the posterior facet on CT than using fluoroscopy alone. Therefore, subtalar arthroscopy could be a useful method for detecting joint incongruence when using the sinus tarsi approach for Sanders type 2 calcaneal fractures.

LEVEL OF EVIDENCE

Level III, comparative series.

Recent Developments in the Treatment of Ankle and Subtalar Instability

It was nearly a centenary ago that severe ankle sprain was recognized as an injury of the ankle ligament(s). With the recent technological advances and tools in imaging and surgical procedures, the management of ankle sprains - including subtalar injuries - has drastically improved. The repair or reconstruction of ankle ligaments is getting more anatomical and less invasive than previously. More specifically, ligamentous reconstruction with tendon graft has been the gold standard in the management of severely damaged ligament, however, it does not reproduce the original ultrastructure of the ankle ligaments. The anatomical ligament structure of a ligament comprises a ligament with enthesis at both ends and the structure should also exhibit proprioceptive function. To date, it remains impossible to reconstruct a functionally intact and anatomical ligament. Cooperation of the regenerative medicine and surgical technology in expected to improve reconstructions of the ankle ligament, however, we need more time to develop a technology in reproducing the ideal ligament complex.

Arthroscopic subtalar arthrodesis

Arthroscopic subtalar arthrodesis is gaining in popularity based on evidence of bone fusion in over 90% of cases, with a shorter time to healing, a simpler postoperative course, and fewer complication compared to open surgery. Two arthroscopic techniques have been reported: one with the patient in lateral decubitus and lateral portals and the other with the patient prone and posterior portals. The objective of this technical note is to describe these two techniques, with emphasis on the specific characteristics of each.