Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.ResultsThe mean postoperative [TCH] [70.3 ± 1.9 mm] was statistically better than the preoperative value [64.7 ± 2.2 mm] [p < 0.001]. There was a statistically significant decrease in [HVA] [p < 0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p < 0.001].ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.     

Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results.     

保留距下关节的跟骨V形截骨矫形术治疗陈旧性跟骨骨折

目的：探讨保留距下关节的跟骨V形截骨矫形术治疗陈旧性跟骨骨折的临床疗效。方法：回顾性分析2014年3月至2017年11月采用跟骨V形截骨术治疗的陈旧性跟骨骨折18例（18足）,其中男13例（ 13足）,女5例（ 5足）;年龄23～48（34.3±4.5）岁;病程2～9（4.5±4.1）个月。Sanders分型：Ⅱ型14例,Ⅲ型4例。观察手术并发症,比较术前及术后12个月跟骨Böhler角、Gissane角、跟距高度、距骨倾斜角的变化情况;并采用Maryland足部评分评估其临床疗效。结果：14例（14足）患者获得随访,时间13～35（21.2±4.1）个月,4例患者失访。骨折愈合时间10～15（12.4±2.1）周。术后1例患者切口皮肤坏死,未发生骨折不愈合及内固定松动或断裂等并发症。术后12个月距骨倾斜角、Böhler角、Gissane角及跟距高度［（11.4±5.1）°、（24.7±4.3）°、（124±3.1）°、（46.1±2. 8）mm］较术前［（9.1±2.9）°、（6.8±3.1）°、（93.4±11.7）°、（34.5±5. 3）mm］明显改善。Maryland评分由术前的59.21±7.21提高至术后12个月的86.34±4.14（t=43.1,P<0.05）;其中优8例,良4例,可1例,差1例。结论：保留距下关节的跟骨V形截骨矫形术是治疗陈旧性跟骨骨折的有效方法之一,具有保留距下关节,纠正跟骨畸形,改善足部外观,缓解患足疼痛,提高足部功能等优点。     

AO-wrist arthrodesis: with and without arthrodesis of the third carpometacarpal joint

The incorporation of the third carpometacarpal joint (CMCJ-3) during wrist arthrodesis is controversial. This retrospective study of 146 consecutive wrist arthrodeses with AO plate fixation specifically addresses this question. In 79 wrist arthrodeses the CMCJ-3 was also arthrodesed, and in 67 the CMCJ-3 was simply bridged. Problems relating specifically to the CMCJ-3 could not be analyzed clearly with the plate in situ. Therefore after plate removal only 81 wrists were evaluated with respect to the CMCJ-3. Of 47 wrists that had CMCJ-3 arthrodesis and plate removal, 20 developed a nonunion. Eleven of these were painful and further surgical treatment was required. In contrast, of 34 wrists with the CMCJ-3 bridged all but one remained free of symptoms after the plate had been removed. We conclude that the CMCJ-3 must not be included in the arthrodesis when performing an AO-wrist arthrodesis.     

关节镜下手术松解治疗跟骨骨折后距下关节僵硬

目的 探讨关节镜下手术松解治疗跟骨骨折后距下关节僵硬的临床效果.方法 2004年9月至2006年12月共治疗跟骨骨折后距下关节僵硬患者10例,其中男性8例,女性2例.年龄18～48岁,平均36岁.除2例为双足受累外,其余均为单足病变.根据AOFAS后足活动度分级标准,手术前10足为Ⅲ级,2足为Ⅱ级;AOFAS后足功能评分术前为71.4分.术中患者取侧卧位,分别建立外侧、前外侧、后外侧3种入路,逐步松解前方关节囊、距下关节外侧间隙、跟腓韧带、后方及后内侧关节囊.最后进行手法松解.结果 所有患者均获随访,随访时间12～36个月,平均24.5个月.末次随访时, AOFAS后足活动度分级标准9足后足活动度提高到Ⅰ级,3足提高到Ⅱ级,未见Ⅲ级病例.AOFAS后足功能评分术后为90.6分,与术前比较差异具有统计学意义(P<0.01).所有患者均在术后1～3个月(平均1.8个月)恢复原工作. 结论 关节镜下手术松解治疗跟骨骨折后距下关节僵硬具有微创、操作简单、疗效确切的优点.     

Subtalar versus triple arthrodesis after intra-articular calcaneal fractures

Depending upon initial treatment, between 2 and 30% of patients with a displaced intra-articular calcaneal fracture require a secondary arthrodesis. The aim of this study was to investigate the effect of subtalar versus triple arthrodesis on functional outcome. A total of 33 patients with 37 secondary arthrodeses (17 subtalar and 20 triple) with a median follow-up of 116 months were asked to complete questionnaires regarding disease-specific functional outcome (Maryland Foot Score, MFS), quality of life (SF-36) and overall satisfaction with the treatment (Visual Analogue Scale, VAS). Patient groups were comparable considering median age at fracture, initial treatment (conservative or operative), time to arthrodesis, median follow-up, and post-arthrodesis radiographic angles. The MFS score was similar after subtalar versus triple arthrodesis (59 vs. 56 points; P = 0.79). No statistically significant difference was found for the SF-36 (84 vs. 83 points; P = 0.67) and the VAS (5 vs. 6; P = 0.21). Smoking was statistically significantly associated with a non-union (χ² = 6.60, P = 0.017). The current study suggests that there is no significant difference in functional outcome between an in situ subtalar or triple arthrodesis as a salvage technique for symptomatic arthrosis after an intra-articular calcaneal fracture. Smoking is a risk factor for non-union.     

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

IntroductionSubtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.Materials and methodsThis is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.ResultsForty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53–72). Quality of life was significantly lower when compared to a reference population (p < 0.001).ConclusionSatisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.     

A comparison of outcomes of posterior arthroscopic subtalar arthrodesis with or without bone graft for treatment of subtalar arthritis

BackgroundIt remains unclear whether to perform a bone graft is necessary during posterior arthroscopic subtalar arthrodesis. The present research aimed to comparatively analyze the outcomes of arthroscopic subtalar arthrodesis through a 3-portal posterior approach with or without bone graft.MethodsA total of 93 patients with subtalar arthritis who underwent posterior arthroscopic subtalar arthrodesis were retrospectively examined. The patients were divided into two groups according to whether they received bone graft or not. The clinical outcomes were compared for analysis.ResultsAmong the 93 patients included, 53 received bone graft and 40 did not. The union rate and time to osseous fusion suggested no significant difference between the two groups. The improvement of clinical outcomes were comparable between the two groups at the final follow-up.ConclusionsIn the present study, bone graft could not effectively reduce the risk of nonunion and improve the outcome.     

Percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures: Systematic review and surgical technique

BackgroundThe aim of this study was to systematically evaluate the available literature on technique and outcomes of percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures.MethodsA systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane Library database was performed, including studies from January 1985 to august 2018. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The surgical technique and perioperative management, clinical outcomes scores, radiographic outcomes and complication rate were evaluated.ResultsOf 66 reviewed articles, 8 studies met the inclusion criteria. The included studies reported on the results of 152 patients. At last follow up the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot was ranging from 72.1 to 94.1. The complication rate was low, including only one superficial infection.ConclusionsThe studies included were of too little level of evidence to allow for data pooling or meta-analysis. However, the percutaneous arthroscopic calcaneal osteosynthesis seems to be a good option for displaced intra-articular calcaneal fractures with a low complication rate. Appropriately powered randomized controlled trials with long-term follow up are needed to confirm the efficacy of this technique.Level of evidenceLevel III, systematic review of Level III studies.     

Factors associated with outcome after subtalar arthrodesis

OBJECTIVES: To evaluate radiographic and functional outcomes after subtalar arthrodesis and to identify patient factors associated with poor outcome. DESIGN: Retrospective study. SETTING: Two academic hospitals. PATIENTS: Eighty-eight patients with primary or secondary osteoarthritis treated between 1995 and 2002. INTERVENTION: Primary subtalar arthrodesis. MAIN OUTCOME MEASUREMENTS: Radiographic outcome was assessed by determining union rates. Functional outcome was assessed through self-administered questionnaires (Short Form-36, Short Musculoskeletal Function Assessment, and the AAOS Foot and Ankle Instrument). RESULTS: After adjusting for age and sex smokers were 3.8 times more likely to go on to nonunion than nonsmokers (P < 0.05). As patients aged, there was a higher likelihood of nonunion if they also smoked (P < 0.05). Of patients undergoing subtalar bone block distraction arthrodesis 95% went on to union compared with 65% of patients treated with an in situ subtalar arthrodesis without bone graft (P < 0.05). There was a trend for higher rates of union if a bone graft was used among patients treated with an in situ subtalar arthrodesis. Diabetic patients were 18.7 times more likely to have a malunion (P < 0.05). As a group, patients who have undergone subtalar arthrodesis can expect significantly worse functional outcomes compared with the Canadian and American normative populations. The poorest functional outcomes were observed among patients with diabetes. A trend for poorer outcome in bodily pain and general health (Short Form-36) was seen in workers' compensation patients. CONCLUSIONS: Certain patient variables are associated with poorer outcomes after subtalar fusion. The results of this study will enable surgeons to provide better information to patients in preoperative discussions with respect to patient expectations, outcomes, and the success of surgery.     

Primary subtalar joint arthrodesis with internal and external fixation for the repair of a diabetic comminuted calcaneal fracture

Comminuted, intra-articular calcaneal fractures can cause severe lower extremity impairment and have devastating effects on a patient's well being. Diabetes is a multisystem process that may cause neuropathy and loss of protective sensation further complicating the prognosis. Not all calcaneal fractures are created equal and when considering the patient's overall presentation and extent of injury, the combined approach of internal and external fixation for fracture reduction may be beneficial for restoration of anatomic alignment and function.     

距下关节融合钢板内固定治疗Sanders IV型跟骨骨折

目的总结距下关节融合钢板内固定术对SandersIV型跟骨骨折的手术经验。方法对16例(17侧)SandersIV型跟骨骨折在行切开复位的同时根据粉碎程度行距下关节融合跟骨钢板内固定,疗效采用AOFANS评分标准。结果16例获得6~47个月随访(平均19.7个月),AOFANS评分平均为84.6分。结论对于SandersIV型跟骨骨折根据其粉碎程度可行距下关节融合跟骨钢板内固定术。     

后关节面移位的跟骨骨折的手术治疗

目的探讨后关节面移位的跟骨骨折手术治疗的相关问题。方法2003年1月～2006年1月，26例33足后关节面移位的跟骨骨折，经可延长的外侧“L”形入路行切开复位异形钢板内固定治疗。Essex—Lopresti分类：舌形骨折18足，关节压缩骨折15足；Sanders分类：Ⅱ型骨折21足，Ⅲ型骨折12足。13例合并身体其他部位骨折。骨折后平均8．3d（4～15d）接受手术。结果所有患者获得8～44个月（平均24．3个月）随访，切口均愈合良好，无皮瓣坏死及局部感染，骨折复位满意。按Maryland足部评分标准评价手术效果：优18足，良10足，中4足，差1足，优良率84．8％。结论经跟骨外侧“L”形入路的切开复位内固定技术是一种值得信赖的治疗移位跟骨骨折的方法。     

Timax钛合金跟骨钢板治疗移位的关节内跟骨骨折

目的 探讨切开复位、Timax钛合金跟骨钢板内固定治疗移位的关节内跟骨骨折的疗效.方法 对37例(45足)波及距下关节面的移位性跟骨骨折进行切开复位、Timax钛合金跟骨钢板内固定治疗.结果 37例获12～29(15.4±4.11)个月随访,术后3个月骨折均完全愈合,未发生伤口感染、钢板外露等并发症,3足出现表皮坏死.按照Maryland足部评分标准:优23足,良16足,中4足,差2足,优良率达86.7%.结论 波及距下关节的移位性跟骨骨折采用Timax钛合金跟骨钢板治疗,可有效恢复跟骨解剖位,显著减少手术并发症的发生率,降低病残率.     

距下关节创伤性关节炎原位植骨融合术后疗效与步态分析的临床研究

目的评价距下关节原位植骨融合术后疗效与足底压力变化特征的关系,为临床疗效评价提供依据。方法 2004年3月-2008年12月,将26例单侧距下关节原位植骨融合患者纳入试验组,观察术后双侧影像学变化和距下融合对邻近关节的影响,应用美国足踝外科协会(AOFAS)踝与后足评分标准对手术前后足部功能进行评价。同时纳入26例健康成人作为对照组。应用Footscan足底压力分析系统对两组受试者进行测试,对足底峰值压力和重心动态位移曲线进行比较。两组受试者的性别、年龄、身高、体重等一般资料比较差异均无统计学意义(P>0.05),具有可比性。结果试验组患者术后均获随访,随访时间14～71个月,平均18.2个月。所有患者距下关节于术后4个月15 d～11个月,平均5.6个月达骨性融合。术后12个月AOFAS踝与后足评分为(76.36±6.90)分,较术前(35.18±8.16)分显著增加(t=13.910,P=0.000)。9例(34.6%)患者手术效果评定为满意,13例(50.0%)为基本满意。术后距跟高度、距跟角、距骨倾斜角和跟骨补偿角分别为健侧的87.04%±6.17%、76.73%±5.13%、65.86%±7.01%和70.19%±8.33%。7例患者同侧邻近关节出现退变性关节炎表现。与对照组比较,试验组患侧第3～5跖骨区域峰值压力上升(P<0.05),第1、2跖骨区域峰值压力下降(P<0.05)。试验组患侧与健侧比较,足底各区域峰值压力差异无统计学意义(P>0.05)。9例临床疗效满意者足底峰值压力分布较为均匀,但较健侧仍有一定差距。6例中足峰值压力较高患者,有临床不易观察的轻度足跟内翻。足底重心动态位移曲线试验组健侧与对照组基本一致,前足触地时曲线内移;患侧足底重心位移不规则并较对照组外移,前足触地曲线无内移。结论原位植骨融合术治疗距下关节创伤性关节炎效果满意。步态分析可对手术疗效进行评价,并指导制定手术方案。融合后健侧步态会发生适应性变化,进行步态分析时应采用正常人群作为对照。     

距下关节融合术后中足功能评价

 目的 探讨单纯距下关节融合术后中足关节的活动度改变和退变情况。方法 回顾性分析1996年1月至2011年8月行距下关节融合并获得完整随访的37例患者资料,男27例,女10例;年龄13~74岁,平均42.6岁。采用健康调查简易量表（the MOS item short form health survey,SF-36）评分和美国足踝外科学会（American Orthopaedic Foot and Ankle Society, AOFAS）中足评分评价疗效。摄双足负重位X线片,观察中足关节是否有退变。双足在踝关节最大跖屈和最大背伸时摄侧位X线片,从矢状面测量Meary角,比较患侧与健侧跖跗关节活动度。患者站立于内翻30°和外翻30°斜面并摄踝关节正位X线片,从冠状面测量胫骨长轴与足前跖面所夹锐角（tibio-plantar angle, TPA）,比较中足的活动度改变。行足踝部SPECT/CT检查,评估中足关节退变情况。结果 37例患者随访2~17年,平均9.2年。术前SF-36总分评分为（34.26±11.02）分,末次随访时为（77.59±12.57）分,两者比较有统计学差异;术前AOFAS中足评分为（86.14±16.79）分,末次随访时为（86.43±16.70）分,两者比较差异无统计学意义。矢状面,内侧跖跗关节活动度患侧约受限20%。冠状面,内翻时健侧与患侧TPA分别平均为61.32°和64.91°,患侧减小12.5%;外翻时双侧TPA分别平均为76.54°和82.28°,患侧减小约42.6%。SPECT/CT发现13例患者（35.1%,13/37）的距舟关节、21例（56.8%,21/37）的跟骰关节、10例（27.0%,10/37）的跖骰关节、5例（13.5%,5/37）的舟楔关节发生退变,但关节无明显疼痛。结论 距下关节融合可导致中足的矢状面活动受限,冠状面活动代偿性增加,特别是外侧跗中和跖跗关节活动度增加,这使跗中关节更易出现轻度退变。     

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

Sixteen patients underwent minimally invasive subtalar arthrodesis through a mini-invasive approach with posterior iliac graft between 2004 and 2006. No hardware was used to transfix the arthrodesis and partial weight bearing was allowed immediately. The primary indication for surgery was the squeal of fracture os calcis in terms of subtalar joint arthritis, loss of heel height, malalignment of the hindfoot, and pain with weight bearing. There were 12 male and 4 female patients with a mean age of 30 (range 17–52). Patients were followed up for a period of 40.8 months (range 36–48 months). The mean interval from injury to fusion was 2 (+0.6) years ranging from 6 months to 6 years post fracture. The average clinical rating scale based on the American Orthopaedic Foot and Ankle Society (AOFAS) improved from 36 preoperatively to 78 at the latest follow-up (P < 0.05). Union rate was 94%. Radiographic evaluation revealed a mean increase in calcaneal inclination of 6.25 + 8.3° (P < 0.07) and a mean increase in the lateral talocalcaneal angle of 7.42 + 10.2° (P < 0.08). Complications were graft nonunion in 1 patient and transient tendoachilles tendinitis in another. This technique can be used to decrease the morbidity associated with the late complications of os calcis fractures by aligning the hindfoot, restoring the heel height and correcting calcaneal and talar inclination. It offers the advantage of early weight bearing while avoiding hardware complications.     

Triple arthrodesis of the foot after calcaneal fractures. Twelve patients treated using K wires stabilization

The most frequent problem following intra-articular calcaneal fracture is pain from the subtalar joint. Subtalar arthrodesis is not considered to be an optimal solution because it can lead to degenerative changes in the ankle joint. The aim of this study was to evaluate patients with such fractures treated by triple arthrodesis. The treated group consisted of 12 patients (5 female, 7 male) with no bilateral fractures. The mean age at injury was 36 years (22–54). The patients had surgery 2 years on average after injury. In all cases the arthrodesis was stabilized with Kirschner wires.The follow-up ranged from 1 to 5 years (average 2.9 ± 1.4). In 2 feet the calcaneal fracture was associated with a fracture of the talus. At clinical evaluation the Ankle–Hindfoot Scale (AOFAS) was applied. From the 100 point scale the question concerning movement in the subtalar joint was removed which made the scale range from 0 to 94 points. Postoperative scoring ranged from 19 to 92 points (mean 57.3 ± 25.1). The patients also evaluated the result of treatment on a visual analogue scale from 0 to 10 points which gave a mean score of 7.7 ± 2.2. Early results of the treatment of calcaneal fractures by triple arthrodesis show that this is valuable method for the prevention of significant foot pain.     

Outcomes of management of displaced intra-articular calcaneal fractures

Despite the advances in operative management, displaced intra-articular calcaneal fractures (DIAFCs) are often associated with long term sequelae, permanent disability, a considerable reduction in quality of life, and a high socio-economic cost. Randomized controlled trials have shown that patient reported outcomes of surgery are no better than those of nonoperative management. Methodological flaws and selection bias may have influenced the results, however, and subgroup analysis showed that some patients could benefit from surgery, whilst patients’ preference can be the decisive factor in choosing a management modality. Fractures with significant lateral wall displacement predisposing to impingements often require surgery, and management has to be individualized and tailored to the patient. Surgery does not usually achieve excellent results, though it exposes the patient to potential risks and complications. Wound healing problems and infections affect around 20% of patients when the extensile lateral approach has been used. Sinus tarsi approach and minimally invasive surgery may be viable alternatives, offering similar results with fewer wound complications, but most of the available studies are of low to moderate quality. Late subtalar joint arthrodesis is often required: however, such procedure would be less technically difficult and could result in better foot function should the shape of the calcaneus have been anatomically restored with surgery in the acute phase.