Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy

Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion: a retrospective study

BACKGROUND

This retrospective study aimed to introduce a novel method for simultaneous Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion and to evaluate the feasibility of this method.

METHODS

We retrospectively analysed the clinical and imaging data of 11 patients with calcaneus malunion treated using Y-shape osteotomy and subtalar arthrodesis who were admitted to our hospital from June 2018 to October 2020. The patients included 9 males and 2 females aged from 24 to 69 years old, with an average age of 42.18 years. The clinical and radiological results were assessed with the Visual Analogue Scale (VAS) pain score and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. In addition, functional recovery and general quality of life were evaluated using the 12-Item Short-Form Survey (SF-12).

RESULTS

All radiological parameters were significantly improved at the last follow-up, with increases of 14.37°, 9.18°, and 4.51 mm in the Böhler's angle, calcaneal pitch angle, and talocalcaneal height, respectively, and decreases of 6.39 mm and 6.18° in the calcaneal width and Hindfoot alignment angle (p < 0.05). The mean AOFAS and VAS scores at the last follow-up improved compared with those preoperatively, from 34.18 ± 9.53 to 84.18 ± 11.59 and from 6.90 ± 1.22 to 1.90 ± 1.13, respectively (p < 0.05). The SF-12 physical and mental health scores were 49.65 ± 6.84 and 52.68 ± 7.88, respectively. Furthermore, the early postoperative complications included skin necrosis in one and sural neuralgia in one patient, and the late postoperative complication included ankle pain in one patient. No other complications, such as implant discomforts, malunion, nonunion and re-fracture, were presented.

CONCLUSION

These results indicate that Y-shape osteotomy combined with subtalar arthrodesis is an effective new method for the treatment of calcaneal malunion. Advantages include improvement of the anatomic shape of the calcaneus and union rates for subtalar arthrodesis.

Management of the Subtalar Joint Following Calcaneal Fracture Malunion

Subtalar joint arthrosis is common following intra-articular calcaneus fractures. The appropriate management of pain secondary to posttraumatic arthritis depends on the status of the remaining posterior facet articular cartilage, the magnitude of any residual joint displacement and distortions in the overall morphology of the calcaneus. In select circumstances, joint-preserving surgical techniques may be considered including lateral wall exostectomy, far lateral posterior facet joint debridement, and intra-articular osteotomies. When the subtalar joint is not salvageable, some form of arthrodesis procedure is pursued. Occasionally, an extra-articular osteotomy may be necessary in combination with arthrodesis to correct deformity.

Subtalar joint preparation using the Two Portal posterior arthroscopic technique versus the sinus tarsi Open approach: A cadaver study

BACKGROUND

Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. The procedure can be performed arthroscopically or through the open lateral sinus tarsi (LST) approach. The arthroscopic technique is less invasive and is associated with rapid recovery, but it is more technically challenging. One of the most important aspects of fusion is adequate preparation of the joint via denudation of articular cartilage. This study compares the efficacy of subtalar joint preparation between the lateral sinus tarsi approach and the posterior two-portal arthroscopic technique using cadaveric specimens.

MATERIALS AND METHODS

Nineteen below-knee fresh-frozen cadaver specimens were used. The subtalar joints of nine specimens were prepared through the LST approach, while ten were prepared arthroscopically. After preparation, all ankles were dissected at the subtalar joint and photographs were taken of the posterior facets of the calcaneus and talus. Total and prepared surface areas of the articular surfaces for both approaches were measured using ImageJ software and compared.

RESULTS

The LST technique resulted in significantly greater percent preparation of the posterior facet of the calcaneus, as well as of the subtalar joint as a whole. Overall, 92.3% of the subtalar joint surfaces (talus and calcaneus combined) were prepared using the LST technique, compared to 80.4% using the arthroscopic technique (p = 0.010). The posterior facet of the calcaneus was 94.0% prepared using the open technique, while only 78.6% prepared using the arthroscopic technique (p = 0.005).

CONCLUSION

The LST approach for subtalar arthrodesis provides superior articular preparation compared to the two-portal posterior arthroscopic technique. Given that joint preparation is a critical component of fusion, maximizing prepared surface area is desirable and the open approach may be more efficacious for fusion. When using the arthroscopic approach, it may be advisable to use an accessory portal if there is poor visualization or limited access to the joint space secondary to severe arthritis.

LEVEL OF EVIDENCE

V.

Do Patient Positioning and Portal Placement for Arthroscopic Subtalar Arthrodesis Matter?

Background

Arthroscopic subtalar arthrodesis was first described over 2 decades ago and originally performed in the lateral decubitus or supine position using anterolateral and posterolateral portals situated about the fibula. More recently, several authors have advocated for prone positioning utilizing posteromedial and posterolateral portals with an optional accessory lateral portal. To date, a comparison of these techniques has been limited.

Purpose

To determine the effect of patient positioning and portal placement on complication rates after arthroscopic subtalar arthrodesis.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patients were placed into 1 of 3 groups: the lateral group if they were positioned lateral or supine with lateral-based portals; the 2-portal prone group if they were positioned prone with posteromedial and posterolateral portals; or the 3-portal prone group if posteromedial, posterolateral, and accessory lateral portals were utilized in the prone position. Inverse variance-weighted fixed-effects models were used to evaluate pooled estimates.

Results

A total of 20 studies examining 484 feet in 468 patients with a mean follow-up of 36.1 months were included for analysis. Overall, 8 studies examined patients in the prone position with 2 posterior portals (n = 111; 22.9%), 7 articles evaluated lateral portals (n = 182; 37.6%), and 5 studies examined patients in the prone position with 3 portals (n = 191; 39.5%). The total complication rate was similar (P = .620) between the 2-portal prone (18.9%), 3-portal prone (17.8%), and lateral (17.6%) groups. There was no difference observed in the rate of complications secondary to portal placement (P ≥ .334), rate of painful hardware (P ≥ .497), and rate of repeat surgery (P ≥ .304). The 2-portal prone group had a significantly higher rate of nonunion than the lateral group (8.1% vs 1.1%, respectively; P = .020) but not the 3-portal prone group (5.8%; P = .198).

Conclusion

The current study demonstrated a higher rate of nonunion following arthroscopic subtalar arthrodesis with prone patient positioning using posteromedial and posterolateral portals without an accessory lateral portal.

Subtalar Fusion Preparation: What Are We Really Doing? A Cadaver Study

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study.

Managing Severely Malunited Calcaneal Fractures and Fracture-Dislocations

Severe calcaneal malunions are debilitating conditions owing to substantial hindfoot deformity with subtalar arthritis and soft tissue imbalance. Type III malunions are best treated with a subtalar distraction bone block fusion. Additional osteotomies may be required for severe varus or superior displacement of the calcaneal tuberosity. Type IV malunions result from malunited calcaneal fracture-dislocations and require a 3-dimensional corrective osteotomy. Type V malunions warrant additional ankle debridement and reconstruction of the calcaneal shape to provide support for the talus in the ankle mortise. Accompanying soft tissue procedures include Achilles tendon lengthening, peroneal tendon release, and rerouting behind the lateral malleolus.

Effect of Subtalar Fusion and Calcaneal Osteotomy on Function, Pain, and Gait Mechanics for Calcaneal Malunion

BACKGROUND

Calcaneal malunion is a common complication of nonoperative management of calcaneal fracture, which leads to a disruption of the biomechanics of the lower extremity, pain, and permanent disability. Our aim was to evaluate pain, function, and gait after combined subtalar joint fusion, calcaneal osteotomy, and lateral wall exostectomy for patients with neglected calcaneal fractures with malunion.

METHODS

Eighteen patients with malunited calcaneal fractures, varus deformity, and subtalar arthritis were operated upon and then followed up for 18 months. All cases were assessed clinically using the American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS); radiologically by measuring the talar inclination, talocalcaneal and talus-first metatarsal angles, and talocalcaneal height; and biomechanically by measuring the stride duration, step width, comfortable speed, and ground reaction forces in relation to the body weight.

RESULTS

A significant improvement in AOFAS (59.8 preoperatively to 80.2 after 18 months) and VAS (61.1 preoperatively to 29.4) was found. Also, our study revealed a significant improvement in the radiographic measurements including the valgus angle, the talocalcaneal angle, the talocalcaneal height, and the talar inclination angle. The gait analysis found that the maximum loading force in the push-off phase and comfortable speed yielded a significant improvement postoperatively. However, no significant differences between the preoperative data and the final follow-up in terms of the step width, stride duration, maximum peak force during loading phase, and minimum peak force during midstance phase were found.

CONCLUSION

The combination of valgus calcaneal osteotomy, lateral wall exostectomy, and subtalar fusion resulted in pain reduction, improved function, and better gait. However, the limited bone stock for the graft used in the subtalar fusion made use of this technique in severely reduced height unadvisable.

LEVEL OF EVIDENCE

Level IV, case series.

Distraction subtalar arthrodesis for calcaneal malunion

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Patients and Methods

We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44).

Results

The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group.

Conclusion

Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.

Arthroscopic and Endoscopic Management of Common Complications After Displaced Intra-Articular Calcaneal Fractures

The list of late complications after calcaneal fracture that can be treated through arthroscopic and/or endoscopic approach continues to expand. The late complications of calcaneal fractures can be classified into 3 groups: (1) those causing focal hindfoot or ankle pain, (2) those causing functional deficit, and (3) those present with diffuse and poorly localized pain. Many group 1 and some group 2 complications can be managed arthroscopically and/or endoscopically. There are usually multiple coexisting sources of the pain. Careful evaluation and analysis of a problem and detailed surgical planning with combination of arthroscopic/endoscopic and open procedures are key to success.

Subtalar Distraction Arthrodesis

The subtalar joint can be altered in its anatomy and biomechanical behavior. It is important to know how to assess the talar declination angle in order to assess the deformity at the subtalar joint. Consider a straight posterior approach to the subtalar joint and remain liberal in the use of z-shaped Achilles tendon lengthening. A structural bone graft should be used to elevate the talus. Positioning screws should be used to lock the construct.

Arthroscopic posterior subtalar arthrodesis for salvage of posttraumatic arthritis following calcaneal fractures

BACKGROUND

Subtalar arthrodesis is a treatment option for pain due to posttraumatic arthritis following calcaneal fractures. The goal of this study is to examine the results of arthroscopic subtalar arthrodesis for posttraumatic arthritis following calcaneal fractures.

PATIENTS AND METHODS

We performed a retrospective case series reviewing 37 consecutive patients (36 male) treated for posttraumatic arthritis following calcaneal fractures by arthroscopic subtalar arthrodesis. The fractures were due to high-energy injuries in 81% of cases, and 12 fractures (32.4%) had been previously treated with internal fixation. Average follow-up was 57.5 months.

RESULTS

Average American Orthopedic Foot and Ankle Society (AOFAS) scores significantly improved from 49.0 ± 10.9 points preoperatively to 76.0 ± 8.0 points at final follow-up. Average time to union was 12.5 weeks. Six patients (16.2%) suffered complications: superficial wound infection (2.7%), symptomatic hardware that warranted removal (5.4%) and nonunion (8.1%) presented nonunion. All three cases had prior internal fixation through an extensile lateral approach, and fused after a repeat surgery.

CONCLUSION

Arthroscopic subtalar arthrodesis offers consistent improvement in cases of posttraumatic arthritis following calcaneal fractures, with a union rate similar to published series of open arthrodesis. We observed more nonunions in patients who had been treated previously with internal fixation. In spite of this, we continue to recommend arthroscopic subtalar arthrodesis, as it preserves the soft tissue envelope better than open techniques.

Recreational Sports Activities After Calcaneal Fractures and Subsequent Subtalar Joint Arthrodesis

Subtalar joint arthrodesis is a common treatment for the management of hindfoot pathologic entities. Despite pain reduction, hindfoot stiffness is a common concern of active patients, who wish to continue or start exercising for fitness. The purpose of the present retrospective observational clinical study was to assess the rate and type of recreational sports activities in patients before and after subtalar joint arthrodesis and to correlate the clinical outcome and the level of sports activities. In 33 patients (22 males, 11 females) treated with subtalar joint arthrodesis, the pre- and postoperative participation in sports and recreational activities was evaluated. The American Orthopaedic Foot and Ankle Society hindfoot scale score, 36-item Short Form Health Survey, and a visual analog scale for pain were used as clinical outcome measures. The weekly session number, session time, and interval to activity recovery after surgery were registered. Patients with a subtalar joint arthrodesis returned to a satisfactory level of activity postoperatively. The sports participation almost reached levels similar to those preoperatively but with a shift from high- to low-impact activities.

Post-traumatic in situ fusion after calcaneal fractures: a retrospective study with 7-28 years follow-up

BACKGROUND

In situ fusion as salvage operation after calcaneal fractures has been used. In this retrospective investigation, a group of in situ fused patients is analyzed with long-term follow-up.

METHODS

Twenty-nine patients with in situ single or multiple fusions performed between 1970 and 1990 were included. In 1998 these patients were examined with plain radiographs and computerized tomography (CT) scan of the affected foot. Also, a visual analogue score (VAS) for calcaneal fractures, short form health survey (SF-36), Olerud Molander score and American Orthopaedic Foot and Ankle society (AOFAS) hindfoot score were evaluated.

RESULTS

The plain radiographs and CT scan showed severe remaining deformities in these patients. The outcome parameters were generally poor and correlated to the degree of remaining deformity.

CONCLUSIONS

Simple in situ fusion, without consideration of the deformity at hand, after a calcaneal fracture is not an adequate treatment and generally associated with poor outcome.

Modified Dwyer osteotomy with rotation and reinsertion of autograft bone wedge for residual heel deformity despite previous delayed subtalar joint arthrodesis after calcaneal fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Surgical Management of Calcaneal Malunion

Calcaneal malunion is a common complication after conservative treatment or incorrect surgical treatment of calcaneal fracture. The typical pathoanatomies of calcaneal malunion are subtalar joint incongruity, loss of calcaneal height, arch collapse, varus or valgus deformity of the calcaneus, heel widening and so on. Calcaneal malunion often needs to be treated surgically. The classification of calcaneal malunion and the detailed clinical and radiographical assessment play important roles for surgical option. The main surgical methods include in situ subtalar arthrodesis, reconstruction of calcaneal thalamus and subtalar arthrodesis, calcaneal osteotomy with subtalar arthrodesis, corrective calcaneal osteotomy without subtalar arthrodesis. Each option has its different indications, advantages and disadvantages. Thus, the surgical treatment should be individualised.

Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes

BACKGROUND

The goal of this study was to discuss the outcomes of treating calcaneal fracture malunion by restoring the subtalar joint with a reconstructive osteotomy.

METHODS

From May 2005 to November 2008, 24 patients (26 feet) with calcaneal malunions after a displaced intra-articular calcaneal fracture were treated by osteotomy and autogenous bone graft. The subtalar joint was preserved. The mean time from initial injury to reconstructive operation was 5.7 months (95% confidence interval, 4.5-8.8 months). The displaced posterior facet was restored through a reconstructive osteotomy, whereas the bone defect in the calcaneus after reduction was filled with the exostosis that had been removed; iliac bone graft was used if necessary. All patients were evaluated clinically and radiographically at a minimum of 24 months. Twenty patients (21 feet) were followed for a mean of 34.2 months (29.0-39.4 months).

RESULTS

According to American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, the average score was 85.9 points (95% confidence interval, 81.5-90.4 points), which was significantly higher than the preoperative assessment. Radiographs showed that Böhler's angle, Gissane's angle, talus declination angle, and width and height of calcaneus were improved to a great extent. Six patients had wound edge necrosis, and 2 had superficial infection. One patient required a subtalar fusion for subtalar arthritis at 2 years after surgery.

CONCLUSIONS

Restoring the subtalar joint with a reconstructive osteotomy and autogenous bone graft was an effective treatment method for selected calcaneal fracture malunions. It reconstructed calcaneal morphology and preserved the subtalar joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The subtalar distraction bone block arthrodesis following the late complications of calcaneal fractures: a systematic review

INTRODUCTION

The late complications following a displaced intra-articular calcaneal fractures includes painful arthrosis for which a subtalar fusion might be considered. In case of malalignment due to loss of height and varus deformity a reconstructive arthrodesis is necessary. The primary aim of the current review study was to assess the functional outcome of the subtalar distraction bone block arthrodesis in the management of late complications of displaced intra-articular calcaneal fractures.

METHODS

The literature was searched for studies in which a subtalar distraction bone block arthrodesis was used in the management of persistent complaints following a displaced intra-articular calcaneal fractures, after its first description in 1988 up to November 1st 2011. The methodological quality of the included studies was assessed using the Coleman Methodology Score.

RESULTS

Twenty-one studies reporting on 456 patients were identified. In 93 percent the procedure was a salvage procedures following the late complications of a calcaneal fracture (372 cases). Duration of follow-up ranged from 21 to 108 months (average 40 months). Union rates were reported with an overall average of 96% (range 83-100%). The average modified AOFAS score (maximum 94 points) was 73 points at final follow-up (range 64-83 points). Six studies reported pre- and post-reconstruction AOFAS outcome scores with an average increase of 44.2 points. Wound complications occurred in approximately 6%. With the exception of one study all were level 4 retrospective case series, with an average Coleman Methodology Score of 55 (range 41-79) points.

CONCLUSIONS

The subtalar distraction bone block arthrodesis is a technically demanding procedure which, in the right hands, provides an overall good result. This is reflected in a significant increase in outcome scores post-operatively. Although most complications are considered minor, there are several pitfalls which should be recognized and avoided.

Distraction arthrodesis of subtalar joint using a laterally placed hinged distractor

Many joint-depressive, neglected calcaneal fractures need distraction arthrodesis of the subtalar joint. Because the calcaneal tuberosity is usually malunited in the varus position, more distraction is required on the medial side to place the tuberosity in the everted position before insertion of a bone graft. Traditionally, a distractor is placed on the medial side to achieve this task. However, the medially placed distractor hinders with the positioning of the extremity and exposure of the main operative site, which is commonly on the lateral side. We introduce a technique to avoid this burden by placing a hinged distractor device on the lateral aspect of the foot while maintaining the correction of the varus deformity.

Subtalar joint arthrodesis

Isolated subtalar joint arthrodesis has gained popularity more recently. Research has shown that it preserves rearfoot motion, does not increase the risk of arthritis in adjacent joints, and is not an especially complex operative procedure. It decreases the chance of midtarsal joint nonunion and malunion postoperatively. This article takes an in-depth approach to isolated talocalcaneal fusions. Anatomy and biomechanics of the subtalar joint are reviewed. Clinical presentation and radiologic evaluation are discussed. Conservative treatment, operative technique, and postoperative management are included.

Calcaneal reconstruction for the late complication of calcaneus fracture

Calcaneal fracture is the most common fracture in the tarsal bones. Treatment is difficult because the patterns of fracture are various and complications occur frequently. The purpose of this study was to evaluate the clinical results of calcaneal reconstruction for chronic complications after calcaneal fracture. rom September 2001 to November 2004, calcaneal reconstruction was performed in 24 patients (25 feet). We reviewed 21 patients (22 feet) who could be followed up >2 years postoperatively. Patients who underwent subtalar arthrodesis and simple bone resection were excluded. Patients who underwent calcaneal sliding osteotomy were included. Nineteen men and 2 women ranged in age from 27 to 54 years (mean, 44.4 years). The mean interval between the first operation and reconstructive operation was 11.2 months (range, 3-31 months). The mean follow-up period after calcaneal reconstruction was 29.8 months (range, 24-38 months). Böhler angle, calcaneal pitch, and talocalcaneal height were checked pre- and postoperatively. The most common patient report was pain on the inferior aspect of the lateral malleolus (16 patients) and calcaneal tuberosity (3 patients). All the mean values of talocalcaneal height, calcaneal pitch, and Böhler angle improved, which was statistically significant. In the postoperative period, 10 patients were very satisfied, 9 were satisfied, and 3 were not satisfied. Although pain did not completely resolve, all patients were satisfied postoperatively.

Hindfoot arthrodesis for management of bone loss following calcaneus fractures and nonunions

Massive bone loss following calcaneal fractures is a challenging condition to treat, especially if nonunion is present. Meticulous preoperative examination and imaging are crucial for accurate preoperative planning. If performed, successful outcomes can be achieved with the strategies outlined in this article.

Management of calcaneal malunion

The potential for disabling malunion following calcaneal fracture is high, regardless whether a patient is treated nonsurgically or surgically. Fracture displacement typically results in loss of hindfoot height, varus heel position, and widening of the hindfoot, with possible subfibular impingement and irritation of the peroneal tendon and/or sural nerve. Frequently, the subtalar joint develops posttraumatic arthritis. In symptomatic patients with calcaneal malunion, systematic evaluation is required to determine the source of pain. Nonsurgical treatment, such as activity modification, bracing, orthoses, and injection, is effective in many patients. Surgical treatment may involve simple ostectomy, subtalar arthrodesis with or without distraction, or corrective calcaneal osteotomy. A high rate of successful arthrodesis and of patient satisfaction has been reported with surgical management.

Endoscopic treatment of calcaneo-fibular impingement

The calcaneo-fibular impingement syndrome is frequent after calcaneal fracture and is linked to the decreased space between the tip of the fibula and the lateral wall of the calcaneus. The reasons for the painful symptoms are mixed with both bony and soft tissue involvement. The abnormal bony contact between the lateral calcaneal cortex and the tip of the fibula depends mainly on the size and localization of the lateral exostosis of the calcaneal wall. The soft tissue impingement is due to the fibrosis and scar tissues in the lateral gutter and to the compression of the peroneal tendons in the retromalleolar groove and under the tip of the malleolus. A 2-portal endoscopic technique is described for the treatment of calcaneo-fibular impingement with bone resection, soft tissue debridement and peroneal tendons release. One of the advantages of this endoscopic technique is the possibility of an assessment and treatment of associated lesions in the same procedure. A subtalar joint fusion can be done before if needed under arthroscopic control. As this endoscopic technique is very efficient to relieve symptoms of calcaneo-fibular impingement and is focused on the most relevant symptoms, it can thus be indicated for most of cases of calcaneal malunions, whatever the type of malunion and depending of the painful symptoms.

Overview of subtalar arthrodesis techniques: options, pitfalls and solutions

BACKGROUND

Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified.

MATERIALS AND METHODS

A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation.

RESULTS

The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68-100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36-96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications.

PITFALLS

The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion.

SOLUTIONS

The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment.

CONCLUSION

The review provides practical suggestions to optimize SA-techniques.

Long-term results of in situ subtalar arthrodesis

Isolated subtalar disorders often require subtalar arthrodesis. In this retrospective study of 28 in situ subtalar arthrodeses reviewed with a median follow-up of 56 months (range, 20-115), the authors attempted to detail the outcomes of in situ subtalar fusion, the consequences on adjacent joints and to determine clinical or radiological factors of failure. Clinical evaluation was realised with the AOFAS (American Orthopaedic Foot and Ankle Society) ankle hindfoot score. Radiographic evaluation included assessment of hindfoot alignment, subtalar fusion and arthritic evolution in the adjacent joints. The median functional score was 76.5/94 (range, 36-94). All 28 arthrodeses achieved union. Mild arthritic changes occurred in 43-65% in the different adjacent joints. These changes were not symptomatic. Varus malunion and clinical nonunion seem to be the most important causes of failure.

Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter?

BACKGROUND

Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis.

METHODS

A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion.

RESULTS

All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B.

CONCLUSIONS

In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment. Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

Subtalar distraction arthrodesis through a posterior approach

BACKGROUND

Subtalar arthrodesis is a common procedure for treating subtalar arthrosis. An isolated lateral incision can be used as an approach to subtalar fusion alone. However, it can be a difficult approach for correction of varus or valgus hindfoot deformities through the subtalar joint; especially if it involves distraction to correct calcaneal alignment. Less commonly, two-incision or single-incision medial approaches also have been described, but distraction and angular correction can still be difficult. We present an alternative method, using a posterior Achilles tendon-splitting procedure, that gives excellent subtalar exposure and the ability to obtain distraction with angular correction and bone grafting.

MATERIALS AND METHODS

Six consecutive patients underwent subtalar fusion with a posterior approach. Both varus and valgus deformities secondary to trauma, tendon insufficiency, or congenital deformities were corrected. Distraction was accomplished with laminar spreaders, and fixation was obtained with two 7.3-mm partially threaded cannulated screws. All patients were followed until fusion, and clinical and radiographic results were recorded. No other concomitant procedures were performed.

RESULTS

Fusion was observed radiographically in all patients by 3 months postoperatively. No serious wound complications occurred. Correction to slightly valgus alignment (for varus deformity) or neutral alignment (for valgus deformity) was obtained without collapse of autologous bone graft. Talocalcaneal height and all angular measurements were significantly increased (all p < 0.05).

CONCLUSION

The posterior approach for distraction arthrodesis is an alternative to the standard lateral approach technique. It allows safe exposure with the ability to distract while also correcting varus or valgus deformity of the subtalar joint.

[Subtalar arthrodesis with calcaneal osteotomy]

The amount of postraumatic deformities of the calcaneus after fracture is classified in 5 types (Type I-V). The bony situation includes in the simple group A malunions, in group B the more demanding nonunions and in Group C the worst cases with additional aseptic or septic necrosis of parts of the calcaneus. For type I with posttraumatic arthritis of the subtalar joint and without malalignement, an in situ-arthrodesis is suitable. Type II, with an additional varus- or valgus hind foot deformity, but especially in type III with additional loss of height and dorsal tilting of the talus a bone block distraction arthrodesis is required. Type IV includes, additionally to the pathology of type I to type III, a lateral translation of the calcaneus. This indirectly causes a severe hind foot valgus and an abutment of the posterior facet towards the lateral malleolus. This type needs osteotomy of the calcaneus through the old fracture surfaces, performed using a bilateral approach. Type V is very rare but the most difficult one for reconstructive surgery because the talus is additionally tilted out of the ankle joint. Therefore, in addition to the bilateral approach and calcaneal osteotomy, an anteromedian approach to the ankle joint is necessary. The surgical procedure in group A (malunion) is more or less the same like in group B (nonunion). Group C (aseptic / septic osteonecrosis) needs a preliminary radical necrectomy in a two stage reconstructive procedure.

Arthroscopic subtalar arthrodesis for symptomatic osteoarthritis of the hindfoot: a prospective study of 41 cases

BACKGROUND

This prospective study evaluated the results of arthroscopic subtalar arthrodesis for painful hindfoot osteoarthritis.

METHODS

The hypotheses were that (1) the arthroscopic technique results in a reliable fusion rate, (2) the clinical outcome is better than the open procedure and (3) complication rates are lower. Forty-one arthroscopic subtalar fusions were done in 37 consecutive symptomatic patients without hindfoot deformity between December, 1997, and May, 2003. Indications for fusion were persistent pain with reduced range of motion and impaired daily activities.

RESULTS

The average modified AOFAS ankle-hindfoot score improved from 53 (range 22 to 69) points preoperatively to 84 (range 41 to 94) points at final follow-up (average 55 months, range 24 to 89 months). Union was achieved in all cases. Radiographic progression of degeneration in the adjacent joints was observed in three patients.

CONCLUSIONS

In painful hindfoot osteoarthritis the arthroscopic technique provides reliable fusion and high patient satisfaction with the advantages of a minimally invasive procedure.

Post-calcaneus fracture reconstruction

This article outlines the pathoanatomy of malunited calcaneal fractures and reviews the literature on resulting painful sequelae, diagnostic work-up, as well as reconstructive treatment options and their outcome.

[Sequelae of intra-articular calcaneal fractures: patterns and management]

PURPOSE OF THE STUDY

We reviewed retrospectively 24 feet with sequelae of transtalar process fractures of the calcaneum in order to identify the lesion pattern and determine optimal management options, both for acute and sequelar lesions.

MATERIAL AND METHODS

There were fourteen men and nine women, mean age 42 years (19-73). Twenty-three had subtalar osteoarthritis, eight had calcaneocuboid osteoarthritis, and fifteen had lateral submalleolar conflicts. There were twelve fibular tendon dislocations or fissurations, three tarsal tunnel syndromes, and two plantar splinters. Prior to treatment, all patients complained of pain. Preoperatively, walking distance was less than 500 m for thirteen patients, 2000-3000 m for four, and greater than 3000 m for five. Mean subtalar joint motion was 30% (0-100%) compared with the healthy side and mean frontal misalignment of the rear foot was 6 degrees valgus. Physical examination, podoscopy and x-rays were obtained in all patients. The Kitaoka score was noted.

RESULT

Mean follow-up was 36 months (24-72). Sequelae were treated with a single procedure or with combinations: subtalar arthrodesis (n = 23) including one in association with calcaneocuboid arthrodesis, tension on fibular tendons (n = 7), neurolysis of the posterior tibial nerve (n = 3), resection of plantar splinters (n = 2), resection of the lateral shell (n = 14), and osteotomy (n = 2) to lower the greater tubercle of the calcaneum because of pain when wearing shoes. The mean Kitaoka function score was 31.7/100 (14-79) preoperatively. After treatment, the mean score was 81.7/100 (31-94), giving a 73.2% gain. The outcome was considered good in sixteen feet, fair in six, and poor in two. Mean walking distance was greater than 3000 m for 18 patients. Mean frontal misalignment of the rear foot under loading was 4.5 degrees valgus and the podoscopy demonstrated flat foot in thirteen patients. Three subtalar arthrodesis required revision for nonhealing.

DISCUSSION

Initial treatment of a fracture, particularly an articular fracture, of the calcaneum must avoid disabling postoperative pain and shoe wearing problems. These sequelae basically concern: subtalar and calcaneocuboid arthritis, lateral submalleolar conflict, fibular tendon injury, plantar splinters, tarsal tunnel syndrome, loss of height, and misalignment of the rear foot. At the sequelar stage, the physical examination is primordial to confirm the lesion and search for any complication which could develop later postoperatively when walking distance becomes longer. For nine patients with residual pain, four resulted from lesions which were missed at the preoperative physical examination. Arthrodesis of the subtalar joint should be preferred over realignment of the rear foot and can be associated with the treatment of conflicts. This management scheme allows treating during a single operative time all sequelae, thus limiting recovery time. A scan of the ankle and foot with or without opacification of the fibular tendons is needed to confirm the physical examination which, for us, remains the key to successful surgery.

Functional evaluation of intraarticular severely comminuted fractures of the calcaneus with gait analysis

Twenty-one patients (23 feet) treated nonsurgically for severely comminuted intraarticular fractures of the calcaneus were evaluated prospectively with a clinical scoring scale and computerized gait analysis. All patients had Sanders type III and type IV fractures. The treatment protocol consisted of no closed reduction, immobilization in removable splint, physiotherapy after edema subsided, and weightbearing after 8 weeks. All patients had a minimum follow-up of 2 years (mean, 38 months). Clinical results were good in 2 patients, fair in 3 patients, and poor in 16 patients. Gait analysis showed that patients were at high risk of gastrocnemius weakness and ankle and knee instability. These results may be useful for comparison with the results of other methods, such as open reduction and internal fixation, nonsurgical closed reduction, and arthrodesis.

Fusion in posttraumatic foot and ankle reconstruction

Despite appropriate acute treatment, many foot and ankle injuries result in posttraumatic arthritis. Arthrodesis remains the mainstay of treatment of end-stage arthritis of the foot and ankle. An understanding of the biomechanics of the foot and ankle, particularly which joints are most responsible for optimal function of the foot, can help guide reconstructive efforts. A careful history and physical examination, appropriate radiographs, and, when necessary, differential selective anesthetic blocks help limit fusion to only those joints that are causing pain. Compression fixation, when possible, remains the treatment of choice. When bone defects are present, however, neutralization fixation may be necessary to prevent a secondary deformity that could result from impaction into a bone defect.

Subtalar arthrodesis

A satisfactory outcome after isolated subtalar joint arthrodesis is dependent on proper patient selection, understanding the pathology and indications, and choosing the appropriate operative technique. Performing a thorough history and physical examination will assist in this process. Ancillary tests, including radiographs and advanced imaging, should be obtained to reinforce the surgeon's suspicions and to aid in the proper surgical planning for the patient. Also, a proper postoperative protocol should be used to allow for adequate healing, and,thus, optimize functional outcome.

Displaced intra-articular fractures of the calcaneum: what is new?

The management of displaced intra-articular fractures of the calcaneum remains a contentious subject. Recent advances in the understanding of fracture anatomy have emphasized the fact that not all fractures are the same and therefore different management options should be considered for different patients. This review endeavours to highlight new developments in the assessment of the patient and his fracture and discusses new techniques for the operative management of some injuries. There is also considerable debate on how outcome should be assessed and the role of gait analysis and pedobarography is discussed. Undoubtedly some patients with a displaced intra-articular fracture of the calcaneum will benefit from a surgical procedure the skill, as always, is in deciding which fracture requires which treatment.

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus

BACKGROUND

Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures.

METHODS

The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation.

RESULTS

The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001).

CONCLUSION

On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeon's ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.

Arthrodesis as salvage for calcaneal malunions

Even with greater emphasis on anatomic reduction, outcomes after calcaneal fractures continue to be unsatisfactory in many patients. Lateral wall impingement, subtalar arthrosis with pain and stiffness, nerve compression syndromes, and hindfoot malalignment all can cause disabling symptoms. If conservative treatment fails to relieve symptoms, subtalar arthrodesis can provide a painless, stable hindfoot in most patients. For severe deformity with anterior ankle impingement and loss of the talar angle of declination, distraction bone block arthrodesis through a posterior approach is preferred.