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.     

Reconstruction After Malunited Lisfranc Injuries

Symptomatic secondary osteoarthritis of the Lisfranc joints due to malunion following Lisfranc joint fracture dislocations or ligamentous lesions at the Lisfranc and innominate joint level generally lead to a painful functional loss and a substantial disturbance of the walking performance. Initially missed or inadequately addressed primary lesions still represent the major source of Lisfranc joint malunions. Neuro-osteoarthropathic disorders may also become manifest in the Lisfranc joint region and may be mistaken for truly posttraumatic consequences. Secondary osteoarthritis may be combined with typical multiplanar deformities. The concept of a corrective arthrodesis includes restoration of stable physiologic axes and length proportions of the foot columns. A standardized approach to analyze the clinical picture and corresponding pathomorphology and the transfer into a comprehensive surgical concept which respects the realignment of any component of deformity is a prerequisite for a good functional outcome and a high degree of patient satisfaction. A fusion limited to the medial three rays combined with a soft tissue release may be sufficient for a favorable outcome in the majority of cases and preserve the mobility of the two lateral rays.     

Malunited juvenile upper and lower leg fractures. Spontaneous correction, complications, indication for corrective intervention]

If malunion occurs after shaft fractures of the femur or tibia, it often corrects itself spontaneously. If the remaining growth period is +/- 2 years, side to side dislocations, shortening and varus deformities (up to 15 degrees) are equalized. Valgus, recurvation and antecurvation equalize much more slowly and rotation deformities only at the femur. The indication to perform a corrective osteotomy before the end of growth is therefore rare, and the remaining axis deviations have a good long-term prognosis as far as arthritic changes are concerned. Exceptions of this rule are rotation deformities in the lower leg and progressive valgus after high tibial fractures. Contractures instabilities and overuse of neighbouring joints represent another indication for early correction osteotomies. Risk of damage to the growth plate limits the possibilities for performing corrective osteotomies in young children. On the other hand, stable fixation is of less importance. At the end of growth, the procedures are the same as for adults.     

Osteotomy of the hind-foot in children and adolescents

The position of the talus and the os calcaneum has consequences for the architecture of the forefoot. Medial tilting of the talus with vertical position provokes flattening of the medial arch and abduction of the forefoot. Varus position of the calcis and lateral direction of the talus (as in residual clubfoot), however, causes supination and adduction of the forefoot. Repair of deformities in the hindfoot therefore also influences the forefoot. A large number of various osteotomies have been proposed at both bones. The most popular ones are Dwyer's osteotomy at the corpus of the calcis and its modification described by Mitchell at the same location for correction of the cavus foot and the residual clubfoot, and the lengthening osteotomy at the neck of the calcaneum according to Evans. Indication and operative technique of these three procedures are described in detail. The closing wedge osteotomy according to Dwyer is indicated in cases of cavus feet. In clubfeet the os calcis is usually too short and the medial opening wedge osteotomy provokes skin problems. In these cases an osteotomy according to Mitchell with lateral displacement of the tuber calcanei is more suitable. In flat- and skew-feet a lengthening osteotomy at the neck of the calcaneum according to Evans can be indicated, especially when the load of the foot is bigger medially under the talus rather than at the lateral margin of the foot. If these procedures are carried out carefully, they have low complications rates.     

Arthrodese (mit/ohne Korrektur) des oberen und unteren Sprunggelenks

Objective

Restoration of a stable and plantigrade foot in deformities of the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joints.

Indications

Deformities at the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joint. Failed (corrective) arthrodesis of the ankle and subtalar joints. Fused ankle and degeneration of the subtalar joint. Failed total ankle replacement with insufficient substance of talar body and/or degeneration of subtalar joint. Massive hindfoot instability.

Contraindications

Active local infection or relevant vascular insufficiency, possible preservation of the ankle or subtalar joint (relative contraindication).

Surgical technique

Prone position and posterolateral approach to ankle and subtalar joints (alternative supine position/anterior approach; lateral position/lateral approach). Exposition of ankle and subtalar joints and removal of remaining cartilage. Optional corrective osteotomies and/or bone grafting. Correction and optional fixation of the corrected position with 2.0 mm K-wires. Mechanically navigated insertion of a retrograde guide wire in projection of the tibial axis and insertion of a second guide wire through the entry point of the nail lateral and dorsal to the tibial axis. Reaming and insertion of the A3 nail with a distal double bend; one posterior and one lateral, and a proximal bend corresponding to a slight recurvatum. Insertion of locking screws into the calcaneus, talus and tibia (twice with optional static or dynamic locking). Optional compression between calcaneus and talus, and between tibia and talus. Insertion of a drainage and layer-wise closure.

Postoperative management

For the first 6 weeks 15 kg partial weight bearing in an orthosis, followed by full weight bearing in a stable standard shoe.

Results

In October 2010 (n?=?2) and from 15 October 2011 to 13 April 2012 (n?=?26) 28 arthrodeses (with/without correction) with A3 fixation were performed. In all cases, exact nail placement was achieved. Thirteen cases completed follow-up (3–11 months) and showed timely fusion and full mobilization.     

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.     

Schwere Fußdeformitäten im Jugend- und Erwachsenenalter — Techniken nach Imhäuser, Lelièvre und Lambrinudi

Severe contraction deformities of the foot, e.g. after trauma or spasticity, often lead to an inability to walk and can, in part, only be rectified by corrective bone osteotomy of the hind and middle foot. In this article, we discuss hind and middle foot osteotomies in cases of severe foot deformities in adolescents and adults. The surgical techniques of Lambrinudi, Imhäuser and Lelièvre will be considered. The surgical technique of Lambrinudi uses a triple arthrodesis between the talus, calcaneus and navicular bones, and the cuboid bone, in addition to the removal of a bone wedge from the talus for correction of the talipes equinus deformity. Severe contraction talipes calvus can be straightened and capable of loading using Imhäuser’s technique with wedge osteotomy and arthrodesis in Chopart’s joint. The planigrade position is achieved by the removal of a dorsolaterally based wedge from Chopart’s joint. Using Lelièvre technique, severe contraction club foot with hind foot varus can be treated with a wedge from Chopart’s joint and the talocalcaneal joint with arthrodesis. For stabilization, a compression clamp system is used. The advantages of the system used by us is that, in comparison with other systems, it can also be used for sclerotic bones as the shank is not hammered in but is introduced after boring. Using the compression clamp system, good stability and a high rate of osseous blood circulation can be achieved using osteotomies and arthrodeses. The aim of surgery is, in all cases, the correction of the deformity, functional improvement and the elimination of pressure points and pain.     

Single stage osteotomy and total knee arthroplasty for tibio-femoral malunion with osteoarthritis of the knee

Extraarticular tibiofemoral malunion causing malalignment and osteoarthritis of the knee can be managed by an extraarticular osteotomy, or by compensatory distal femoral or proximal tibial wedge resection along with total knee replacement, to achieve limb alignment and improve knee function. We operated on 6 knees with tibiofemoral malunion with osteoarthritis of the knee. All knees had an extraarticular osteotomy either at the site of malunion (3 knees) or away from the malunion site (3 knees). There were 4 femoral deformities and 2 tibial malunions. In one patient a femoral osteotomy was done as a part of revision knee replacement for loosening with supracondylar malunion. 5 of these patients had a press fit stemmed superstabiliser total knee replacement. In the remaining patient with tibial malunion, a conventional total condylar total knee replacement was done along with a high tibial osteotomy. At a mean follow-up of 45 months (range 24 to 84), one osteotomy had not healed inspite of bone grafting and one patient had an above knee amputation for infection. The HSS (Hospital for Special Surgery) scores revealed a good result in 4 knees, fair in 1 and poor in 1 patient. None of the surviving knee replacement has required a revision to date for clinical or radiological loosening. All patients had a good mechanical alignment of the lower limb, with no ligamentous imbalance following surgery. Single stage osteotomy and total knee arthroplasty is a technically demanding surgery associated with complications and should be reserved for large deformities. Minor deformities should be corrected by intraarticular distal femoral or proximal tibial wedge resection taking due care that ligament balance is not compromised and a satisfactory alignment is restored.      

Soft-tissue operations in neuromuscular foot deformities

The management of neuromuscular foot deformities in children and adolescents must be individualized because of differences in etiology and pathomechanics. If conservative treatment fails or reaches a plateau early soft tissue procedures are recommended. Treatment should focus not only at correction of the deformity but also at reestablishment of muscular balance. Early postoperative mobilisation is usually possible provided adequate orthotic control is maintained. Regular clinical follow-ups help to minimize postoperative problems. The general aim should be an optimization of functions and only rarely to achieve a normal foot. The basic principles of management can be described as correction of deformity, stabilization of unstable joints and balance of muscle power.     

Talus verticalis

Congenital vertical talus is a rare condition which presents as an isolated deformity or in association with neuromuscular and/or genetic disorders. Pathoanatomically the deformity shows a dislocated talonavicular and subtalar joint. The etiology and pathogenesis are still not finally determined although in some cases a genetic basis has been identified. The clinical picture is that of a flat, convex longitudinal arch with abduction and dorsiflexion of the forefoot and an elevated heel. Clinical diagnosis is confirmed by plain radiographic imaging. Congenital vertical talus should not be confused with other deformities of the foot, such as congenital oblique talus, flexible flat feet or pes calcaneus. The object of treatment of congenital vertical talus is to restore a normal anatomical relationship between the talus, navicular and calcaneus to obtain a pain-free foot. Major reconstructive surgery has been reported to be effective but is associated with substantial complications. Good early results of a modified non-operative treatment using serial manipulation, cast treatment and minimally invasive surgery may change therapeutic concepts.     

Treatment of malunion in ankle fractures

Malunions are fractured bones that have healed in pathological positions. This leads to nonphysiological load transfer. Clinical symptoms at the ankle may include swelling, pain and impaired function. Lateral, posterolateral or posteromedial subluxation of the talus will be visible on the radiographs. Surgical correction may be indicated if the malunion is symptomatic. Different osteotomies have been described, but the goal of surgery will always be the reduction and retention of the subluxed talus in an effort to recreate stable conditions. Eighty percent of patients show good results with significant pain reduction in mid-term follow-up studies. Ankle arthrodesis after corrective osteotomy is rarely necessary.     

Results of Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy - A retrospective analysis of 44 patients

BackgroundThe role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy.Study designA retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre.Patients and methodsIn a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction).ResultsThere were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%).ConclusionDespite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.     

Malunions of the finger metacarpals and phalanges

Many malunions of the finger metacarpals are mild and do not require or justify operative intervention. Early recreation of the fracture or osteotomy is more likely to be rewarded with favorable results than late operation. Rotational malunions of the metacarpals or proximal phalanges may be treated by transverse extra-articular transverse or step-cut osteotomies at or proximal to the malunion site. Rotational malunions of the proximal phalanges as great as 200 in the index, middle, and ring fingers and 300 in the small finger may be managed by transverse extra-articular osteotomy at the adjoining metacarpal base. Angular and combined angular and rotational deformities of the metacarpal can be corrected by closing wedge osteotomy at the malunion site, with adjustment for malrotation when necessary. Angular and combined angular and rotational deformities of the proximal phalanx may be corrected by dorsal opening or lateral opening or closing wedge osteotomy, with derotation when needed. Articular malunions may be treated by osteotomy at the fracture site, a sliding osteotomy of the fracture and its proximal supporting cortex, or extra-articular osteotomy. Each approach for articular malunions has its potential risks and benefits. The true risks of articular malunion correction may not be fully known, because of the small number of cases in each presented series and the short follow-ups. Finger motion may be improved by correction of deformity alone, and may be further enhanced by tenolysis of adjacent adhesions. Capsulolysis may be helpful in instances of adjacent joint contracture. Despite improvement of finger motion in a majority of cases, some degree of remaining stiffness is common. Stiffness is almost always a residual of the original injury rather than a complication of corrective surgery, and serves to reinforce the fact that primary fracture reduction, stabilization, and rehabilitation are usually the best deterrents to malunion and consequent impairment. Much of the best available information has been gained from retrospective cohort or case study reports that may have inherent flaws in study design that limit their statistical validity and ability to detect trends. Flaws may include heterogeneity; investigator enthusiasm; and a lack of enrollment, prospective controlled randomization, blinding, confidence interval determinations, and follow-up. The statistical ability to determine trends in past reports may be compromised. Past reports provide important information and advances, but should be interpreted with some discretion. The pen may be mightier than the scalpel. In spite of encouraging reported results, phalangeal and articular osteotomies, in particular, remain daunting procedures for most hand surgeons. Prospective, controlled randomized studies maybe difficult to achieve in the clinical setting because of the time that would be necessary to secure adequate enrollments for statistical validity andthe occurrence of "dropouts" before completion of adequate follow-up. Meta-analysis is difficult because of variations in discriminators for patient selection and clinical outcomes. Although multicenter studies have their own inherent flaws, they may represent the best future option to add a higher level of study design and validity as compared with past studies. The incorporation of subjective patient outcome instruments into future studies might also provide valuable information. Investigators should review previous reports with a goal of improving study designs and scientific methodology, confirming or contradicting past results, or adding new information.     

One-session surgery for correction of lower extremity deformities in children with cerebral palsy

Traditional thinking regarding surgery for the spastic child has favored correction of joint deformities one at a time. This often necessitates several operations. In addition, deformities of unoperated joints may jeopardize operative results. Since 1975, we have surgically treated all the lower extremity deformities of each cerebral palsied child in one session. We have carried out single measure operations as well as multiple operative procedures in which bilateral corrective operations are performed on several joints. Of 114 children treated, 40 had multiple and 74 had single operative procedures. Treatment was successful, without need for further surgery, in 80% of the former group and in 61% of the latter. The advantages of one-session surgery are a reduction in the number of operations and, possibly, a reduced chance of reoperation and complications.     

Triple arthrodesis.

Arthrodesis, the surgical fusion of a joint or joints when motion is undesirable, is one of the most exacting surgical procedures performed on the foot. In this article, the authors discuss arthrodesing techniques from the earliest attempts in 1878 to the more sophisticated and more successful corrective procedures of the present day. Their preference of the two surgical techniques used for triple arthrodesis is the method which involves two incisions--a 12-cm. incision on the medial aspect of the foot and an 8-cm. incision on the lateral aspect of the foot.     

Talar neck osteotomy for flatfoot reconstruction: a 27-year follow-up study

The talar neck osteotomy is done at the junction of the head and neck of the talus, frequently in conjunction with desmoplasty and posterior tibial tendon advancement. This is done effectively to correct severe deformities involving the talus. The correction produces a structural realignment of the talar head. Adjunctive procedures are also done when these are deformities involving the posterior column, lateral column, and/or medial column. A 27-year follow-up study is presented containing data from 215 procedures on 117 patients with a minimum of one year follow-up.     

Alignment and technique in total ankle arthroplasty

Total ankle arthroplasty has emerged as a promising alternative to ankle arthrodesis, especially in cases where multiple hindfoot joints are arthritic. Proper alignment of the limb must be restored to be most successful over the long term. Misalignment above the ankle typically involves a malunion of a previous tibia fracture and can be treated by corrective osteotomy. Deformity in the joint itself can arise from congenital malformation or from bony erosion, usually as a late result of joint trauma. Mild amounts of bone loss can be corrected through bone cuts during ankle replacement, but more severe deformity may require distal tibial osteotomy. Misalignment below the ankle (in the foot) is probably the most common deformity. Secondary procedures in the foot and leg, including muscle balancing, osteotomies, or fusions are often a part of the surgical plan and are performed either before or simultaneously with ankle replacement. The goal is to restore an ankle with neutral static and dynamic balance during stance and gait. Achieving that goal will give the best chance for pain free ankle motion over the long term.     

Talus fractures: evaluation and treatment

Fractures of the talus are uncommon. The relative infrequency of these injuries in part accounts for the lack of useful and objective data to guide treatment. The integrity of the talus is critical to normal function of the ankle, subtalar, and transverse tarsal joints. Injuries to the head, neck, or body of the talus can interfere with normal coupled motion of these joints and result in permanent pain, loss of motion, and deformity. Outcomes vary widely and are related to the degree of initial fracture displacement. Nondisplaced fractures have a favorable outcome in most cases. Failure to recognize fracture displacement (even when minimal) can lead to undertreatment and poor outcomes. The accuracy of closed reduction of displaced talar neck fractures can be very difficult to assess. Operative treatment should, therefore, be considered for all displaced fractures. Osteonecrosis and malunion are common complications, and prompt and accurate reduction minimizes their incidence and severity. The use of titanium screws for fixation permits magnetic resonance imaging, which may allow earlier assessment of osteonecrosis; however, further investigation is necessary to determine the clinical utility of this information. Unrecognized medial talar neck comminution can lead to varus malunion and a supination deformity with decreased range of motion of the subtalar joint. Combined anteromedial and anterolateral exposure of talar neck fractures can help ensure anatomic reduction. Posttraumatic hindfoot arthrosis has been reported to occur in more than 90% of patients with displaced talus fractures. Salvage can be difficult and often necessitates extended arthrodesis procedures.     

Minimal-invasive Therapieverfahren angeborener Fußdeformitäten im Säuglingsalter

In the last decade treatment of foot deformities has changed from extensive surgery to casting and minimally invasive surgery. The Ponseti method has become the most preferred treatment for clubfoot deformities and early evaluations showed promising results. Mid-term results for idiopathic clubfoot revealed the need for additional surgery by anterior tibial tendon transfer in 11–32?% of cases depending on the duration of bracing. Anterior tibial tendon transfer is the most important surgical procedure for relapses in the Ponseti concept. Casting, recasting in cases of relapses, bracing and anterior tibial tendon transfer altogether represent the Ponseti method and cannot be considered as single entities. The Dobbs method is a new concept for the treatment of vertical talus. Treatment of vertical talus should start with the Dobbs method but in comparison to clubfoot treatment there has not been a complete change to minimally invasive treatment. Especially in non-idiopathic vertical talus cases open reduction of the talonavicular and calcaneocuboid joint are often necessary.     

Deformity correction planning for hindfoot, ankle, and lower limb

Many patients with foot and ankle deformities have concurrent deformities (osseous and soft tissue), with or without limb length discrepancies. Lower extremity deformities and limb length discrepancies typically result from trauma, congenital abnormality, avascular necrosis, previous surgery, nonunion, and malunion. Limb deformity correction requires extensive surgical experience because many considerations and factors apply to realignment. The considerations and factors regarding realignment are highlighted throughout this article.