Effects of five hindfoot arthrodeses on foot and ankle motion: Measurements in cadaver specimens

Three-Plane Calcaneal Osteotomy With Joint Preservation vs Subtalar Arthrodesis to Treat Painful Calcaneal Fracture Malunions

BACKGROUND

Calcaneal fracture malunion (CFM) commonly occurs with multiple pathologic changes and progressive pain and difficulty walking. The purpose of this study was to propose a modified 3-plane joint-preserving osteotomy for the treatment of CFM with subtalar joint incongruence, and to compare its efficacy to subtalar arthrodesis.

METHODS

A retrospective comparative analysis of the data of 56 patients with CFM admitted from January 2017 to December 2022 was performed. Twenty-six patients were in the osteotomy group and 30 in the arthrodesis group. Computed tomographic (CT) scans were used for measurement of the intraarticular steps. Radiologic parameters, visual analog scale (VAS) score for pain, 12-Item Short Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores were compared between the 2 groups of patients to assess the outcome preoperatively and at last follow-up, which averaged 22.6 ± 3.6 months and 27.6 ± 3.6 months for the osteotomy and arthrodesis groups, respectively.

RESULTS

Improvements in pain, function, and overall quality of life were obtained in both groups compared with the preoperative values at last follow-up. The VAS and SF-12 scores were similar between the groups at the last follow-up. In the osteotomy group, the average CT scan-measured intraarticular step-offs were significantly reduced from 3.7 ± 1.2 mm to 0.9 ± 0.3 mm. The osteotomy group showed improvement in pronation and supination range of motion (ROM) of the feet (P < .01). The correction of the ankle height and Meary angle were slightly better in the osteotomy group.

CONCLUSION

In this short-term follow-up study, good results were achieved in both joint-preserving osteotomy and subtalar arthrodesis groups for the treatment of CFM with subtalar joint incongruence. The osteotomy group preserved the subtalar joint and achieved improvements in pronation and supination ROM.

A CT-Validated Comparative Analysis of Fixation Constructs for Hindfoot Arthrodesis: Fusion and Complication Rates

Background

Hindfoot arthrodesis is a procedure commonly performed to address degenerative changes and/or malalignment of the hindfoot, yet robust literature comparing traditional and modern constructs is sparse. The purpose of this study is to evaluate the efficacy of nitinol staples in hindfoot arthrodesis as compared to isolated screws and combined staple and screw constructs.

Methods

A 10-year retrospective review of all patients undergoing hindfoot arthrodesis at our institution was performed. Hindfoot arthrodesis was defined as either a triple (subtalar, talonavicular, and calcaneocuboid), double (subtalar + talonavicular), or isolated arthrodesis. Outcomes included fusion success rate and reoperation rate. A postoperative CT confirming the presence or absence of osseous bridging was required for inclusion in the fusion outcome analysis.

Results

We assessed 113 patients who underwent arthrodesis procedures across 128 joints in the hindfoot. There was no significant difference in functional outcomes between screws, staples, or the combination screw and staple constructs used in hindfoot arthrodesis. However, screws alone were associated with a significantly higher complication rate than staple-only fixation (P = .028).

Conclusion

Nitinol staples are effective in hindfoot arthrodesis with respect to fusion success rate and may be associated with decreased revision rates compared with traditional screws only or staple plus screw constructs. Larger studies will be necessary to validate these findings and contribute to an assessment of the usage of these nascent constructs in hindfoot arthrodesis.

Level of Evidence

Level III, retrospective cohort study.

May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

BACKGROUND

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture.

METHODS

We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection.

RESULTS

Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001).

CONCLUSION

For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement.

LEVEL OF EVIDENCE

IV, Case series.

Influence of Isolated Talonavicular and Subtalar Joint Arthrodesis on Hindfoot Kinematics and Range of Motion During Cadaveric Gait Simulation

BACKGROUND

Isolated subtalar and talonavicular joint arthrodeses have been associated with adjacent joint arthritis and altered hindfoot kinematics during simplified loading scenarios. However, the effect on kinematics during dynamic activity is unknown. This study assessed changes in subtalar and talonavicular kinematics after isolated talonavicular (TNiso) and subtalar (STiso) arthrodesis, respectively, during stance simulations.

METHODS

Fourteen midtibia specimens received either a TNiso or STiso arthrodesis, with 7 randomized to each group. A 6-degree-of-freedom robot sequentially simulated the stance phase for the intact and arthrodesis conditions. Bootstrapped bias-corrected 95% CIs of the talonavicular and subtalar joint kinematics were calculated and compared between conditions.

RESULTS

The TNiso decreased subtalar inversion, adduction, and plantarflexion in late stance (P < .05). The subtalar range of motion in the sagittal and coronal planes decreased by 40% (P = .009) and 46% (P = .002), respectively. No significant changes in talonavicular joint kinematics were observed after isolated subtalar arthrodesis; however, the range of motion was reduced by 61% (P = .007) and 50% (P = .003) in the coronal and axial planes, respectively.

CONCLUSION

In this model for arthrodesis, changes in subtalar kinematics and motion restriction were observed after isolated talonavicular arthrodesis, and motion restriction was observed after isolated subtalar arthrodesis. Surprisingly, talonavicular kinematics did not appear to change after isolated subtalar arthrodesis.

CLINICAL RELEVANCE

Both joint fusions substantially decrease the motion of the reciprocal adjacent joint. Surgeons should be aware that the collateral costs with talonavicular fusion appear higher, and it has a significant effect on subtalar kinematics during the toe-off phase of gait.

Hindfoot Arthrodeses and the Order of Joint Fixation Influence Tibiotalar Kinematics During Simulated Stance

BACKGROUND

Although hindfoot arthrodeses relieve pain and correct deformity, they have been associated with progressive tibiotalar degeneration. The objective was to quantify changes in tibiotalar kinematics after hindfoot arthrodeses, both isolated subtalar and talonavicular, as well as double arthrodesis, and to determine if the order of joint fixation affects tibiotalar kinematics.

METHODS

Hindfoot arthrodeses were performed in 14 cadaveric mid-tibia specimens. Specimens randomly received isolated fixation of the subtalar or talonavicular joint first, followed by fixation of the remaining joint for the double arthrodesis. A 6-degree-of-freedom robot sequentially simulated the stance phase of level walking for intact, isolated, and double arthrodesis conditions. Tibiotalar kinematic changes were compared for the intact and arthrodesis conditions. A subsequent analysis assessed the effect of the joint fixation order on tibiotalar kinematics.

RESULTS

Isolated and double hindfoot arthrodeses increased tibiotalar plantarflexion, inversion, and internal rotation during late stance. Tibiotalar kinematics changes occurring after isolated arthrodesis remained consistent after the double arthrodesis for both the subtalar- and talonavicular-first conditions. The order of joint fixation influenced tibiotalar kinematics through some portions of stance, where the talonavicular-first double arthrodesis increased tibiotalar plantarflexion, eversion, and internal rotation compared to the subtalar-first double.

CONCLUSION

Tibiotalar kinematics were modestly altered for all conditions, both isolated and double hindfoot arthrodeses. Changes in tibiotalar kinematics were consistent from the isolated to the double arthrodesis conditions and varied depending on which isolated hindfoot arthrodesis was performed first. Further research is needed to assess the clinical implications of the observed changes in tibiotalar kinematics, particularly as it pertains to the development of adjacent joint arthritis.

CLINICAL RELEVANCE

These findings may correlate with clinical research that has cited hindfoot arthrodesis as a risk factor for adjacent tibiotalar arthritis. Once either the subtalar or talonavicular joint is fused, avoiding the arthrodesis of the second joint may not necessarily protect the tibiotalar joint.

Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series

BACKGROUND

The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture.

MATERIAL AND METHODS

We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively.

RESULTS

There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use.

CONCLUSION

Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Foot and Ankle Motion after Tibiotalocalcaneal Arthrodesis: Comparison with Tibiotalar Arthrodesis Using a Multi-Segment Foot Model

BACKGROUND

Tibiotalocalcaneal arthrodesis is an established surgical procedure for treating patients with end-stage ankle joint arthritis and subtalar joint arthritis. Although it greatly relives pain, a major drawback is loss of range of motion. Although it is known to restrict an additional subtalar joint compared to tibiotalar arthrodesis, there is a lack of gait analysis studies comparing the two methods. This study aimed to evaluate the differences in kinematics of the foot and ankle joints between tibiotalar and tibiotalocalcaneal arthrodesis. We also compared preoperative and postoperative statuses for each surgical method.

METHODS

The study included 12 and 9 patients who underwent tibiotalar and tibiotalocalcaneal arthrodesis, respectively, and 40 healthy participants were included in the control group. The DuPont foot model was used to analyze intersegmental foot and ankle kinematics during gait.

RESULTS

Compared to controls, both tibiotalar and tibiotalocalcaneal arthrodesis resulted in slow gait speed with reduced stride length, increased step width, and decreased range of sagittal plane motion. Both fusion methods showed similar range of motion in all segments and planes following surgery. Coronal positions showed more supination of the forefoot and pronation of the hindfoot segment after each operation, particularly tibiotalocalcaneal arthrodesis. Gait after tibiotalocalcaneal arthrodesis did not significantly differ from that after tibiotalar arthrodesis, but there was a tendency of more pronation in the hindfoot segment.

CONCLUSIONS

Both fusion methods limited foot and ankle motion in similar ways. Comparing tibiotalar and tibiotalocalcaneal arthrodesis suggests that additionally fusing the subtalar joint does not cause greater movement restriction in patients. Objectively comparing tibiotalar and tibiotalocalcaneal arthrodesis will facilitate further understanding of the effect of tibiotalocalcaneal arthrodesis on movement and the value of subtalar joint motion for improved preoperative counselling.

Extended Tourniquet Times and the Impact on Wound Healing in Foot Surgery

OBJECTIVE

The aim of this study was to compare the effect of tourniquet time less than or in excess of 120 minutes on foot surgery wound healing.

NULL HYPOTHESIS

A tourniquet time of over 120 minutes will not affect wound healing in foot surgery.

DESIGN, SETTING, PARTICIPANTS AND METHOD

A retrospective comparative cohort analysis was performed on 96 patients undergoing complex hindfoot surgery in a large central teaching hospital. Fifty-five patients receiving tourniquet pressure for >120 minutes and 41 receiving <120 minutes of tourniquet pressure were identified from electronic case records. The primary outcome was surgical wound healing. Secondary outcomes were discharge date and complication rate.

RESULTS

There was no significant difference in reported time for wounds to heal in the <120-minute or >120-minute cohort. There were no other significant differences in secondary clinical outcomes and no significant variations in patient demographics.

CONCLUSION

This study suggests that tourniquet times from 2 to 3 hours in foot and ankle surgery with pressures up to 300 mmHg are not associated with a significant effect on wound healing.

Cadaveric Gait Simulation of the Effect of Subtalar Arthrodesis on Total Ankle Replacement Kinematics

BACKGROUND

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR.

METHODS

Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-ST_fuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-ST_fuse.

RESULTS

There were significant differences in kinematics and range of motion between TAR and TAR-ST_fuse groups. At the ankle joint, TAR-ST_fuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003).

CONCLUSION

In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint.

CLINICAL RELEVANCE

These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

Isolated Talonavicular Arthrodesis for Traumatic Talonavicular Arthritis: Report of 2 Cases With Gait Analyses

Isolated talonavicular arthrodesis is one of the surgical procedures for patients with talonavicular arthritis. However, the 3-dimensional kinematic behavior of the hip, knee, and foot/ankle complex during walking after the arthrodesis remains unclear. The clinical outcomes and gait analyses of 2 cases who underwent isolated arthrodesis for talonavicular osteoarthritis with chronic dislocated navicular fracture are presented. Gait analysis was carried out in both cases 1 year after surgery to clarify the side-to-side differences in the ranges of motion of the hip, knee, and foot/ankle complex during walking. Both cases showed good clinical results and radiographic bone union. The kinematic data of the gait analyses showed considerable restriction in the range of motion of the ankle in all 3-dimensional planes for the fused foot compared with the contralateral side. Additionally, hyperextension of the knee in the late stance of gait on the operated side was observed in both cases. When talonavicular arthrodesis was performed for talonavicular osteoarthritis with chronic dislocated navicular fracture, postoperative generalized stiffness of the ankle and future disorder of the knee should be considered.Levels of Evidence: Level V: Case report.

Talonavicular Joint-Sparing 3D Printed Navicular Replacement for Osteonecrosis of the Navicular

Pathology of the navicular can be a difficult entity to treat, particularly when the injury has progressed to osteonecrosis. While various nonoperative and operative modalities have been described, the emerging field of additive manufacturing has become a potential solution to this difficult problem in certain scenarios. While these implants have largely been used for fusion in the past, the concept of joint sparing with 3D printed implants is also emerging, and this case highlights a patient treated with a talonavicular joint-sparing, patient-specific 3D printed total navicular replacement.

Diagnosis and Treatment of Peritalar Injuries in the Acute Trauma Setting: A Review of the Literature

The bony and ligamentous structure of the foot is a complex kinematic interaction, designed to transmit force and motion in an energy-efficient and stable manner. Visible deformity of the foot or atypical patterns of swelling should raise significant concern for foot trauma. In some instances, disruption of either bony structure or supporting ligaments is identified years after injury due to chronic pain in the hindfoot or midfoot. This article will focus on injuries relating to the peritalar complex, the bony articulation between the tibia, talus, calcaneus, and navicular bones, supplemented with multiple ligamentous structures. Attention will be given to the five most common peritalar injuries to illustrate the nature of each and briefly describe methods for achieving the correct diagnosis in the context of acute trauma. This includes subtalar dislocations, chopart joint injuries, talar fractures, navicular fractures, and occult calcaneal fractures.

Ankle Arthrodesis using Ilizarov Ring Fixator: A Primary or Salvage Procedure? An Analysis of Twenty Cases

Introduction: Ankle arthrodesis using the Ilizarov technique provides high union rate with the added benefits of early weight-bearing, and the unique advantage of its ability to promote regeneration of soft tissue around the bone, including skin, muscle and neuro-vascular structures, and its versatility to allow correction of the position of the foot by adjusting the frame post-operatively as needed. We describe our experience with this technique and the functional outcomes in our patients.

Materials and Methods: This retrospective study was conducted in 20 ankle fusion cases using the Ilizarov method between the years 2007 and 2017. We defined success in treatment by loss of preoperative symptoms and radiological union on plain radiographs of the ankle.

Results: Fusion was achieved in all patients (100%). Immediate post-operative ambulation was with full weight bearing (FWB) in 16 (83%) of the participants and non-weight bearing (NWB) in 3 patients (17%). Post-procedure 11 patients (67%) of the participants who were full weight bearing required some form of support for walking for 2-3 weeks. Post-operatively three patients had pin tract infection requiring intravenous antibiotics. Radiological union took range of 6-12 weeks, mean union time was 8 weeks. Only one patient required bone grafting due to bone loss. Average follow-up period was 10-45 months.

Conclusion: The Ilizarov technique has a high union rate and leads to general favourable clinical outcome and may be considered for any ankle arthrodesis but is especially useful in complex cases such as for revisions, soft-tissue compromise, infection and in patients with risk for non-union. Early weight bearing is an extra benefit.

Ilizarov external fixation versus plate internal fixation in the treatment of end-stage ankle arthritis: decision analysis of clinical parameters

The purpose of this study was to evaluate the effect of Ilizarov external fixation (IEF) and plate internal fixation (PIF) in the treatment of end-stage ankle arthritis on pain relieving and function improvement. The study cohort consisted of 59 patients with end-stage ankle arthritis underwent ankle arthrodesis with IEF or PIF between June 2011 and June 2015. Standard radiographs and computed tomography (CT) scans were obtained before surgery and during the follow-up. Functional assessments were performed using Foot and Ankle pain score of American Orthopedics Foot and Ankle Society (AOFAS) and Visual Analogue Scale (VAS). The average AOFAS scores in both IEF group and PIF groups increased significantly after operation, from 45.5 ± 6.3 to 84.8 ± 4.9 and from 45.9 ± 6.6 to 86.6 ± 5.4, respectively. The average VAS scores in both groups decreased significantly after operation, from 8.4 ± 1.9 to 2.5 ± 0.6 and from 8.2 ± 1.5 to 2.3 ± 0.7, respectively. Nevertheless, there was no significant difference for preoperative or postoperative AOFAS and VAS scores between the two groups. The IEF would result in comparable postoperative functional recovery and pain relieving to PIF and may be an effective substitute to PIF in the treatment of end-stage ankle arthritis.