Arthrodesis of the ankle and subtalar joints

The late reconstruction of a complex nonunion of the distal tibial metaphysis, the ankle, or the subtalar joint was undertaken in five patients through a posterior surgical approach and the application of a blade plate into the os calcis. This technique was preferred as a salvage operation when the surrounding soft tissue envelope was compromised by the initial injury, previous surgical procedures, or infection. Each of the cases was notable for a segmental bone loss, an infected nonunion, or a collapse of the talar body. In the presence of a major soft tissue defect, the internal fixation was accompanied by the application of a microvascular free flap. The postoperative assessment of the posterior arthrodesis with the blade plate fixation was at an average of 33 months. Using a modification of the Boston Children's Hospital ankle scoring system, a preoperative and postoperative assessment was made. The criteria included an objective rating system based on the intensity of pain, the cessation of drainage, the degree of independent ambulation, and the roentgenographic documentation of union. The average preoperative score was 13 (range, 8-16). After arthrodesis, the average score was 44 (range, 40-48), with three patients rated excellent and two rated good.     

Arthrodesis of the subtalar and talonavicular joints through a medial surgical approach: a series of 15 cases

Introduction  

We report a series of 15 double-hindfoot (subtalar and talonavicular joint) arthrodeses through a single medial approach on 14 patients. Mean age at surgery was 59.3 years. The chosen surgical technique was always identical using a medial approach and performed by a single surgeon. The average follow-up was 20.6 months.     

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.     

Arthrorisis by means of a subtalar polyethylene peg implant for correction of hindfoot pronation in children

A modified subtalar arthrorisis is obtained by implantation of an endoprosthesis manufactured from ultrahigh molecular weight polyethylene. It is fashioned into the shape of a peg and implanted into the dorsal surface of the calcaneus just anterior to the posterior facet of the subtalar joint and fixed with polymethylmethacrylate. The purpose of the implant is to eliminate abnormal pronation, correct heel valgus, and produce an increase of the medial longitudinal arch in the growing child.     

Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1-4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.     

Arthrodesis of the hindfoot for valgus deformity. An entirely medial approach

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8 degrees (45 degrees to 66 degrees) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6 degrees (7 degrees to 23 degrees). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.     

Arthrodesis of the talonavicular joint using angle-stable mini-plates: a prospective study

Purpose

The talonavicular joint is a central connection of the human foot. Symptomatic talonavicular arthritis can be adequately addressed by isolated talonavicular fusion. However, non-union remains a relevant clinical challenge to the orthopaedic surgeon. The aim of this study was to analyse the clinicoradiological outcome of talonavicular fusion using angle-stable mini-plates.

Methods

We performed 30 talonavicular fusions in 30 patients (12 male, 18 female) with a mean age of 58.8 years (range, 22–74) between 2005 and 2007. Osseous joint fusion was achieved using mono- and multidirectional angle-stable mini-plates. The patients followed a standardised immobilisation and weight bearing protocol. The mean postoperative follow up was 15.8 months (6.1–23.8).

Results

The American Orthopedic Foot and Ankle Society AOFAS score increased significantly from 31.7 (19–42) to 82.3 points (55–97) (p < 0.001). Neither age at operation nor gender influenced the score results significantly, while the aetiology of talonavicular degeneration showed a significant effect. Mean visual analogue scale (VAS) pain intensity (0–10) reduced from 8.6 to 1.7 (p < 0.001). Good or excellent results were achieved in 26 patients, while two patients reported fair and another two poor results. Complete osseous fusion was observed at a mean of 10.9 weeks (8–13) postoperatively.

Conclusions

For the treatment of talonavicular arthritis, the application of mono- and multidirectional angle-stable mini-plates provided a strong fixation that led to high union rates and good to excellent overall outcome.     

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.     

Ligamentous injuries about the ankle and subtalar joints

Ligamentous injuries at the ankle and subtalar joint range from simple sprains to severe talar dislocations. While lateral ankle sprains are among the most frequently encountered injuries and do not pose a greater diagnostic problem, the surgeon must be suspicious not to overlook associated ligamentous injuries at the subtalar and midtarsal level that may result in chronic painful conditions. Syndesmotic instabilities with or without ankle fractures must be assessed carefully and treated properly, since these are prearthrotic conditions. In the treatment of chronic ankle or subtalar instability tenodeses provide mechanical stability while reducing subtalar mobility. Anatomic reconstruction methods therefore should be considered for both conditions.     

Surgical correction of miserable malalignment syndrome

Anterior knee pain is one of the more frustrating problems that orthopaedic surgeons treat. This study investigates the results of surgical correction of miserable malalignment syndrome associated with significant patellofemoral pain. The authors identified and retrospectively reviewed 14 consecutive patients with 27 limbs associated with excessive femoral anteversion, excessive tibial outward rotation, and patellofemoral pain. All of the patients were initially reviewed by the senior author and subsequently treated by ipsilateral outward femoral osteotomy and inward tibial osteotomy. All of the patients had failed nonoperative treatment. No persistent complications were seen. Subjectively and clinically, all of the patients were reviewed at an average of 5.2 (range 2.0-12) years after surgery. All of the patients reported full satisfaction with their surgery and outcomes. Most of the current literature discusses alignment in association with patellofemoral pain in the form of the extensor mechanism alignment. When evaluating patients with patellofemoral pain, it is imperative to assess the rotational profiles of the femur and tibia. The authors recommend that rotational osteotomies be performed in patients with patellofemoral pain and associated excessive femoral and tibial torsion, otherwise known as miserable malalignment syndrome.     

The effects on subtalar contact and pressure following talonavicular and midtarsal joint arthrodesis.

Many clinical studies have demonstrated the effectiveness of both isolated talonavicular and complete midtarsal joint arthrodesis as an alternative to triple arthrodesis. However, in many cases, controversy exists as to which procedure to utilize. Evidence of degenerative radiographic changes and stiffness of the subtalar joint have been reported postoperatively. A cadaveric study at two different loading values, utilizing low-range pressure film transducers and digital scanning, was performed to quantify articular contact effects on the subtalar joint following isolated talonavicular joint arthrodesis and complete midtarsal joint arthrodesis as compared to the intact specimen. Statistically significant differences were found at p < .05 in this study regarding maximum contact pressure and in location of the applied pressures. Results of this study suggest complete midtarsal joint arthrodesis may be favored over isolated talonavicular joint arthrodesis, especially in the setting of a flatfoot deformity.     

Arthrodesis for degenerative disease of the hallux metatarsophalangeal and interphalangeal joints

Arthrodesis of the hallux metatarsophalangeal (MTP) or interphalangeal (IP) joint is a sound surgical solution to degenerative disease of these joints. Where conservative measures have failed, MTP or IP arthrodesis can alleviate pain and normalize gait. Preoperative planning should include evaluation of the skin, bone quality, and range of motion of the involved and adjacent joints. The technique of joint preparation described allows for easily individualized fusion position and maintenance of length. In patients with adequate bone stock, the fixation techniques described provide for compression and obviate the need for removal for most patients. Where bone stock is questionable, plate fixation can provide stability, improving results. With careful patient selection, preoperative planning, and conservative postoperative care, predictable results can be obtained with these techniques.     

距下关节植入物手术在平足症的争议

平足可分为柔性平足和僵硬性平足。而当平足患者出现症状则称为平足症,保守治疗效果不佳则需要手术治疗。距下关节植入物手术（subtalar arthroereisis,SA）是一种微创手术,尽管应用于柔性平足症多年且取得良好疗效,但仍有诸多争议之处。争议点集中于其适应证与禁忌证、年龄、单独使用与否、可吸收材料植入物的疗效与安全性以及植入物去除。本文对其争议总结如下：SA最佳适应证是儿童及青少年柔性平足症,10～12岁是最佳治疗年龄;跗骨联合伴平足及成人平足是相对适应证。僵硬性平足、韧带过度松弛、距下关节炎是距下关节植入物手术的绝对禁忌;肥胖、神经源性柔性平足是相对禁忌证。SA的矫形能力有限,可根据实际情况联合其他手术。可吸收材料植入物的安全性和有效性已得到研究证实。没有必要常规去除植入物,去除主要原因是跗骨窦区疼痛。     

Epidemiologic investigation of 1394 feet: Coincidence of hindfoot malalignment and Achilles tendon disorders

BackgroundThe aim of this epidemiologic study was to evaluate the incidence of the Achilles tendinopathy in non athletes and the coincidence with varus alignment of the hindfoot.MethodsSix hundred ninety-seven patients (1394 feet) have been analysed. The tibiocalcaneal axis was goniometrically measured. The presence of a non insertional and insertional Achilles tendinopathy was clinically determined.ResultsAchilles tendinopathy was found in 5.6% of the patients (4% insertional, 3.6% non insertional, 1.9% both forms). The average tibiocalcaneal angle was calculated with ?0.76° for the tendinopathy group and ?0.96° for the insertional tendinopathy whereas the control group showed an average angle of 1.77°. For the total group the average tibiocalcaneal axis was calculated with 1.62°. Out of 1394 feet 38.3% showed a varus axis of the hindfoot and 61.7% a valgus alignment.ConclusionsThe coincidence of varus alignment and Achilles tendinopathy could be validated.