Hindfoot motion after isolated and combined arthrodeses: measurements in anatomic specimens

Passive motions at the subtalar joint, talonavicular joint and calcaneocuboid joint were measured in eight ankle specimens, using an ultrasonic motion analysis system. Arthrodeses of the three joints were performed in all feasible combinations and the resulting motion change at the unfused joints was determined. Motion at the subtalar joint was not significantly affected by fusion of the calcaneocuboid joint, reduced to one quarter by fusion of the talonavicular and calcaneocuboid joints (double arthrodesis) and almost completely eliminated with all other fusions. Motion at the talonavicular joint was not significantly affected by calcaneocuboid fusion and reduced to approximately one third with the subtalar and the double arthrodesis. Motion at the calcaneocuboid joint was not significantly reduced by subtalar fusion but almost completely eliminated in all fusions involving the talonavicular joint. It is concluded that the talonavicular joint is the key articulation for hindfoot motion. Double arthrodesis preserved significant motion at the subtalar joint. Fusion of the calcaneocuboid joint had no significant influence on remaining hindfoot motion.     

Arthrodesis for chronic lateral subtalar joint dislocation caused by posterior tibial tendon dysfunction: A case report

IntroductionAdult acquired flatfoot deformity (AAFD) caused by posterior tibial tendon dysfunction (PTTD) can lead to the development of peritalar subluxation (PTS) and much more rarely to lateral subtalar dislocation.Presentation of caseA 75-year-old woman was referred to our hospital with an approximately 15-year history of pain in her right foot without obvious trauma. The lateral shifting foot deformity had worsened in the previous 5 years. On presentation, she had tenderness over the talonavicular joint, and the skin overlying the talar head on the medial foot was taut. Imaging revealed lateral displacement of the calcaneus with simultaneous dislocation of the talonavicular and talocalcaneal joints. We diagnosed lateral subtalar dislocation including the talonavicular and talocalcaneal joints caused by PTTD, which we treated by reduction and fusion of the subtalar joint complex. The foot and ankle were immobilized with a cast for 6 weeks.DiscussionAt the 1-year follow-up visit, the patient reported no pain during daily activities, although flatfoot persisted.ConclusionWe report a rare case of chronic lateral subtalar dislocation caused by PTTD that was treated by fusion of the talonavicular and talocalcaneal joints.     

Effect of tibiotalar joint arthrodesis on adjacent tarsal joint pressure in a cadaver model

BACKGROUND: Tibiotalar arthrodesis is the most common treatment of end-stage symptomatic ankle arthritis, but concerns exist about late findings of adjacent tarsal joint osteoarthritis. The purpose of this study was to evaluate the changes of pressure in the talonavicular, subtalar, and calcaneocuboid joints before and after rigid tibiotalar joint immobilization and at different levels of tibiopedal dorsiflexion. METHODS: Twelve cadaver foot specimens were cyclically loaded on a servohydraulic test frame to 700 N. Joint contact pressure, peak pressure, and contact area in the three tarsal joints were measured before and after tibiotalar joint immobilization with three 6.5-mm screws to simulate ankle arthrodesis. Measurements were obtained at tibiopedal dorsiflexion angles of 0, 10, 20, and 30 degrees in normal ankle joints and at dorsiflexion angles of 0, 10, and 20 degrees in fixed tibiotalar joints. Paired Student's t-tests and one-way ANOVA with repeated measures were used to analyze the data. RESULTS: Joint contact pressures did not show any statistically significant difference for the talonavicular and calcaneocuboid joints in the intact ankle. Contact pressures in the talonavicular and calcaneocuboid joints showed significant differences between 0 and 10 degrees and between 0 and 20 degrees of dorsiflexion (p<0.05) in the fused ankle specimens. Comparison of the contact pressure of the talonavicular and the calcaneocuboid joints between the intact and the fused ankle specimens showed a significant difference at 10 and 20 degrees of dorsiflexion (p<0.05). Subtalar joint contact pressure in the intact ankle showed a significant difference between 0 and 30 degrees of dorsiflexion (p<0.05). CONCLUSIONS: These changes in joint pressures and contact area are consistent with findings of transverse tarsal joint arthritis seen in clinical studies. The current findings suggest that a substantial pressure increase in the talonavicular and calcaneocuboid joints at tibiopedal dorsiflexion levels simulating a late stance phase of the gait cycle may be responsible for the secondary tarsal joint degeneration occurring in late ankle arthrodesis.     

La chirurgie du couple de torsion du pied dans la polyarthrite rhumatoïde

Abductus valgus flat foot is the most common hind foot deformity in patients with rheumatic diseases. When conservative treatments (insoles and orthopaedics shoes) are not enough, surgery can be a good option. If only the talonavicular joint is affected, it can be fused. If hind foot valgus deformity is reductible, we perform a posterior tibial tendon repair associated to subtalar joint arthoereisis with an endorthesis. If hind foot deformity is severe and non-reductible, we fuse the talonavicular and subtalar joints through a double approach. We usually leave the calcaneocuboid joint not fused.     

Subtalar arthrodesis with correction of deformity after fractures of the os calcis.

We have reviewed the long-term results of 22 patients (23 fusions) with fractures of the os calcis, who had subtalar arthrodesis with correction of the deformity between 1975 and 1991. The mean follow-up was nine years (5 to 20). All patients were evaluated according to a modified foot score. A radiological assessment was used in which linear and angular variables were measured including the fibulocalcaneal abutment, the height of the heel and fat pad, the angle of the arch and the lateral talocalcaneal and the lateral talar declination angles. The technique used restores the normal relationship between the hindfoot and midfoot and corrects the height of the heel. This leads to better biomechanical balance of the neighbouring joints and gives a favourable clinical outcome. The modified foot score showed a good or excellent result in 51% of the feet. Residual complaints were mostly due to problems with the soft tissues. Subjectively, an excellent or good score was achieved in 78% of the cases. After statistical analysis, except for the height of the heel and the degenerative changes in the calcaneocuboid joint, no significant difference was found in the measured variables between the operated and the contralateral side.     

Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot

Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration.     

The influence of talonavicular versus double arthrodesis on load dependent motion of the midtarsal joint

Background

Today the most frequently used operative procedures in advanced arthritis of the hindfoot joints are isolated talonavicular arthrodesis and double arthrodesis (involving the talonavicular and calcaneocuboid joints, i.e. the Chopart joint). This in vitro study investigates whether the fusion of the talonavicular joint alone can provide the hindfoot, as well as a midfoot, with comparable biomechanical stability as the double arthrodesis does. Hence with the less-invasive intervention the same benefit in terms of pain reduction and better functionality could be achieved.

Methods

In a series of ten fresh cadaver feet without any radiological pathologies, we measured the range of motion of different tarsal bones in three planes under axial stress. Every foot was loaded without arthrodesis, after talonavicular and after double arthrodesis, by charging tibia and fibula with a force of 350 N using a calibrated Instron^® load frame. Each tarsal bone was marked with a K-wire and its motion was measured by registering the movement of the wire’s shade that was projected onto the surrounding walls of the trial box.

Results

Both operative procedures led to a considerable reduction of the motion of every marked bone to a mean of 18% of the preoperative value. In direct comparison of the two simulated arthrodeses we found for every bone and in every plane only minimal differences of the mean excursions of 1.0 mm on average. Both fusions lead to equal residual tarsal bone motion postoperatively, and provide the midtarsal joint as well as the subtalar joint with comparable biomechanical stability.

Conclusions

Isolated talonavicular arthrodesis is a useful and effective alternative to double arthrodesis. It is the less complicated, less-invasive and functionally equivalent operative option for arthritic alterations of the hindfoot and transverse tarsal joint.     

The results of a primary and staged pantalar arthrodesis and tibiotalocalcaneal arthrodesis in adult patients

Twenty-three patients (twenty-seven feet) with either a primary or staged pantalar arthrodesis or a tibiotalocalcaneal arthrodesis were evaluated to determine their clinical status. The main indication for the operation was the presence of severe pain unresponsive to non-operative treatment. Fourteen feet (twelve patients) had a pantalar arthrodesis; a fusion of the ankle, subtalar, talonavicular and calcaneocuboid joints. Half the feet in this group had either a triple arthrodesis or an ankle fusion performed at an earlier time. The remaining seven feet had all joints fused during the same operation. Thirteen feet (eleven patients) had a tibiotalocalcaneal arthrodesis. Two of these feet had an ankle arthrodesis performed four and six years previously. The other eleven had the ankle and subtalar joints fused during the same operation. All patients were followed for a mean of fifty-five months (14 to 159 months) from the time of their final arthrodesis procedure. Overall, twenty-three of the twenty-seven feet achieved a solid arthrodesis of all joints operated upon. Four feet had a failure of fusion of only a single joint and all were in the pantalar group. The mean time to radiographic fusion was twenty-three weeks and resulted in a plantigrade foot with an average tibia-floor angle of 87 degrees. Complications occurred in ten feet (37%); of which there were three deep infections; two ankles and one subtalar joint. These arthrodeses procedures resulted in marked relief of the patients' preoperative pain, the main indication for performing the surgery. Postoperatively there was no pain in eleven feet, mild occasional pain in thirteen feet, and moderate pain in only three feet. However, when all parameters of our clinical rating scale were evaluated, only five patients had an excellent clinical result, nine were rated good, three were rated fair and six patients had a poor result. These operations must be considered to be salvage procedures. They are technically difficult to perform and major complications may occur. Pain relief appears to be the main indication for performing these operations, and may account for whatever improvement occurs in the patient's function.     

距下关节融合对中后足周围关节活动度影响的生物力学实验研究

目的分析研究正常新鲜足标本在正常情况下进行距下关节融合后对跟骰、距舟关节和踝关节的三维运动度的影响程度。方法采用新鲜足标本12例，将距下关节融合后，通过加载使足产生某种形式的运动，用三维数字化坐标仪测量跟骰、距舟关节和踩关节各关节组成骨在某种运动状态下的相对三维坐标位移，通过矩阵转换和求解非线性函数方程计算其三维旋转角度，了解跟骰、距舟关节和踝关节在距下关节融合前后2种状态下的相对运动范围，确定距下关节融合后对于周围足踝关节运动的影响程度。结果距下关节融合前后跟骰、距舟关节和踝关节在背屈一跖屈、内翻一外翻、内收一外展轴的三维运动范围之间的统计学分析显示存在显著性差异（P＜0．01），各关节平均三维运动范围受限程度分别为36．14％、38．36％、21．84％。结论距下关节融合后对跟骰、距舟关节和踝关节的活动度存在一定的限制作用，降低了前足与后足的协同性，可能增加足跗关节间退行性关节炎发生，但保留了距舟、跟骰关节的大部分活动。     

Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment

BACKGROUND: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. METHOD: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. RESULTS: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. CONCLUSIONS: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.     

跗骨间骨桥临床诊断与治疗研究进展

目的总结跗骨间骨桥临床诊断与治疗研究进展。方法查阅近年关于跗骨间骨桥的诊断及治疗相关文献,进行综述分析。结果跗骨间骨桥是足部跗骨间桥接组织,常见类型为跟距骨桥和跟舟骨桥。跟舟骨桥在后足斜位X线片即可确诊,多数跟距骨桥需CT扫描确诊,MRI可用于软骨性和纤维组织性骨桥的诊断。石膏固定对于有症状患者是首选治疗方法;对于治疗失败未发生退行性变患者,切除骨桥可取得良好治疗效果。单纯距下关节融合可用于治疗跟距骨桥切除失败的患者,对于距下关节融合失败和跟舟骨桥切除失败的患者可行三关节融合术。微创治疗应严格掌控手术适应证。结论跗骨间骨桥诊断方法较为明确,应将临床表现和影像学检查结合以提高诊出率。手术治疗指征尚存在争议,仍需基于随机对照试验的长期随访报道。     

Case Reports: Symptomatic Bilateral Talonavicular Coalition

Congenital talonavicular coalition is reported less frequently than talocalcaneal or calcaneonavicular coalition and represent approximately 1% of all tarsal coalitions. Although reportedly transmitted as an autosomal-dominant disorder, tarsal coalition may be inherited as an autosomal-recessive trait. It has been associated with various orthopaedic anomalies, including symphalangism, clinodactyly, a great toe shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition, and a ball-and-socket ankle. Patients with talonavicular coalitions are usually asymptomatic and rarely undergo surgical treatment. We report the case of a 24-year-old woman with symptomatic bilateral talonavicular coalitions and previously unreported associated anomalies (nail hypoplasia and metatarsus primus elevatus) and review the relevant literature. The patient underwent surgery (calcaneocuboid joint distraction arthrodesis and a proximal plantar flexion osteotomy with a dorsal open wedge of the first metatarsal). At 1-year followup, she was pain-free with better alignment of both feet and showed radiographic consolidation of the arthrodesis. Although this condition is less likely to be clinically important than other tarsal fusions, it sometimes can be painful enough for the patient to undergo surgery. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution either has waived or does not require approval for the reporting of this case and that all investigations were conducted in conformity with ethical principles of research.     

The talonavicular and calcaneocuboid joints: anatomy, biomechanics, and clinical management of the transverse tarsal joint

The transverse tarsal plays a critical role in allowing the foot to transition from a flexible structure that dissipates impact as the foot strikes the ground and accepts the body's weight to the rigid structure that is required for efficient propulsion during toe off.Similarly, the medial longitudinal arch of the foot is controlled by the supportive structures of the talonavicular joint. A fine balance exists between muscular control and static support structures of the talonavicular joint. Failure of one support structure is often followed by fatigue of the remaining support and loss of function of the entire joint complex. This article describes the osseous and ligamentous anatomy of the talonavicular and calcaneocuboid joints and describes the biomechanical role of the transverse tarsal joint in standing and gait. Biomechanical principles are used to illustrate orthotic management of diseases that affect the transverse tarsal joint.     

Changes in Rearfoot Alignment in Chronic Plantar Heel Pain

Plantar heel pain is a common disabling condition in adults. Biomechanical factors are important in the development of plantar heel pain. Quantitative changes in rearfoot alignment in patients with plantar heel pain have not been previously investigated. From April 2016 to March 2017, 100 patients with plantar heel pain and 100 healthy individuals were recruited. The foot posture index was used for the measurement of foot alignment. The generalized joint hypermobility condition was assessed using the Beighton scale. The transverse plane talocalcaneal angle, calcaneocuboid angle, talonavicular uncovering angle, calcaneal inclination angle (CIA), talar declination angle, talar–first metatarsal angle, and sagittal talocalcaneal angle were measured on standard weightbearing anteroposterior and lateral foot radiographs. The body mass index was recorded electronically. The distribution of sex, age, weight, body mass index, side, foot posture index score, and Beighton scale were comparable between groups (p?>?.05). The mean calcaneocuboid angle (p?=?.009), talonavicular uncovering angle (p?=?.000), CIA (p?=?.000), talar declination angle (p?=?.039), and talar–first metatarsal angle (p?=?.000) were significantly higher in the plantar heel pain group. In conclusion, our study has demonstrated a relationship between chronic plantar heel pain and the CIA.     

How Do Hindfoot Fusions Affect Ankle Biomechanics: A Cadaver Model

Background

While successful subtalar joint arthrodesis provides pain relief, resultant alterations in ankle biomechanics need to be considered, as this procedure may predispose the remaining hindfoot and tibiotalar joint to accelerated degenerative changes. However, the biomechanical consequences of isolated subtalar joint arthrodesis and additive fusions of the Chopart’s joints on tibiotalar joint biomechanics remain poorly understood.

Questions/purposes

We asked: What is the effect of isolated subtalar fusion and sequential Chopart’s joint fusions of the talonavicular and calcaneocuboid joints on tibiotalar joint (1) mechanics and (2) kinematics during loading for neutral, inverted, and everted orientations of the foot?

Methods

We evaluated the total force, contact area, and the magnitude and distribution of the contact stress on the articular surface of the talar dome, while simultaneously tracking the position of the talus relative to the tibia during loading in seven fresh-frozen cadaver feet. Each foot was loaded in the unfused, intact control condition followed by three randomized simulated hindfoot arthrodesis modalities: subtalar, double (subtalar and talonavicular), and triple (subtalar, talonavicular, and calcaneocuboid) arthrodesis. The intact and arthrodesis conditions were tested in three alignments using a metallic wedge insert: neutral (flat), 10° inverted, and 10° everted.

Results

Tibiotalar mechanics (total force and contact area) and kinematics (external rotation) differed owing to hindfoot arthrodeses. After subtalar arthrodesis, there were decreases in total force (445 ± 142 N, 95% CI, 340-550 N, versus 588 ± 118 N, 95% CI, 500–676 N; p < 0.001) and contact area (282 mm², 95% CI, 222–342 mm², versus 336 ± 96 mm², 95% CI, 265–407 mm²; p < 0.026) detected during loading in the neutral position; these changes also were seen in the everted foot position. Hindfoot arthrodesis also was associated with increased external rotation of the tibiotalar joint during loading: subtalar arthrodesis in the neutral loading position (3.3° ± 1.6°; 95% CI, 2°–4.6°; p = 0.004) and everted loading position (4.8° ± 2.6°; 95% CI, 2.7°–6.8°; p = 0.043); double arthrodesis in neutral (4.4° ± 2°; 95% CI, 2.8°–6°; p = 0.003) and inverted positions (5.8° ± 2.6°; 95% CI, 3.7°–7.9°; p = 0.002), and triple arthrodesis in all loaded orientations including neutral (4.5° ± 1.8°; 95% CI, 3.1°–5.9°; p = 0.002), inverted (6.4° ± 3.5°; 95% CI, 3.6°–9.2°; p = 0.009), and everted (3.6° ± 2°; 95% CI, 2°–5.2°; p = 0.053) positions. Finally, after subtalar arthrodesis, additive fusions at Chopart’s joints did not appear to result in additional observed differences in tibiotalar contact mechanics or kinematics with the number of specimens available.

Conclusions

Using a cadaveric biomechanical model, we identified some predictable trends in ankle biomechanics during loading after hindfoot fusion. In our tested specimens, fusion of the subtalar joint appeared to exert a dominant influence over ankle loading.

Clinical Relevance

A loss or deficit in function of the subtalar joint may be sufficient to alter ankle loading. These findings warrant consideration in the treatment of the arthritic hindfoot and also toward defining biomechanical goals for ankle arthroplasty in the setting of concomitant hindfoot degeneration or arthrodesis.     

Correction of clubfoot through a peritalar release using the cincinnati approach

Surgical Principles The Cincinnati approach described by Crawford et al. [1] allows a complete medial, posterior and lateral exposure of hind- and midfoot as well as a correction of any deformity of the subtalar, talonavicular, and calcaneocuboid joints (subtalar joint complex): Correction of the rotational malposition between talus and os calcis with simultaneous reduction of the talonavicular and calcaneocuboid joints. After wound closure the corrected position is maintained by a long leg cast. In severe clubfeet an additional fixation with Kirschner wires of the talonavicular and the subtalar joints may be indicated.     

Biomechanics of the ankle joint

According to Fick, the tree-dimensional patterns of foot motion are best characterized as jawlike movement. Anatomically and biomechanically, this process represents conjoined, synchronous motion within the three mobile segments of the hindfoot: the ankle joint, the posterior subtalar joint, and the anterior subtalar joint. Foot kinematics can be described more completely if the anterior subtalar joint is defined not only as the talocalcaneal navicular joint, but as including the calcaneocuboid joint, thus representing the transverse joint of the tarsus, i.e., the Chopart joint. The axes of these three joints can be defined precisely. In some parts they represent a screwlike motion, clockwise or counter-clockwise, around the central ligamentous structures (fibulotibial ligament, talocalcaneal interosseous ligament, bifurcate ligament). The individual anatomy and structure of these ligaments provide variations in the degree and direction of foot motion. A precise knowledge of foot kinematics is important in surgical ligament and joint reconstruction and in selective foot arthrodeses.     

Arthrodese des Talonavikulargelenks

The talonavicular joint as part of the coxa pedis plays a pivotal role in the overall motion of the foot. The necessity for talonavicular fusion arises from isolated arthritis of posttraumatic, rheumatoid, degenerative, or idiopathic etiology. Posttraumatic arthritis is seen after malunited mid-tarsal (Chopart) fracture-dislocations and is frequently accompanied by malalignment due to an imbalance between the medial and lateral columns of the foot. In these cases a corrective arthrodesis becomes necessary. In cases of poor bone stock or arthritis of the calcaneocuboid joint, a double arthrodesis is preferred over isolated talonavicular fusion. Fusion with mini-plates is biomechanically superior to fusion with screws and especially staples, the latter being associated with non-union rates of up to 37%. Talonavicular fusion allows reproducible pain reduction in isolated arthritis with subjective patient satisfaction of between 86% and 100% in a literature review. The substantial reduction of movement in the triple joint complex leads to overload of the adjacent joints with development of arthritis in about 30% in the medium term.     

Reconstruction after talar fractures

Malunited and nonunited talar fractures cause significant disability. Distinction between partial and total avascular necrosis (AVN) determines the choice of treatment. Patients who have minimal or no AVN and well-preserved joint cartilage may be amenable to corrective osteotomy through the malunited fracture or removal of the pseudoarthrosis. Secondary reconstruction with joint preservation leads to considerable functional improvement in painful talar malunions and nonunions in reliable patients. If symptomatic arthritis is present, arthrodeses and correction of deformity through the fusion or with additional osteotomies provide predictable results, although they do not restore normal foot function. Fusions should be limited to the affected joint. If the subtalar joint shows severe arthritic changes, every attempt should be made to salvage the ankle and talonavicular joints.     

Bohler incision: an extensile anterolateral approach to the foot and ankle

Incisions in the foot and ankle should allow efficient surgical approaches to the anatomic structures being addressed while preventing chronic neuritic symptoms, extensive scar contractures, soft tissue ischemia or necrosis, and chronic edema. The purpose of this report is to describe the B?hler incision, an extensile approach that provides the surgeon with easy access to the anterior surface of the distal tibia, the anterior talar dome, talar neck, talonavicular, subtalar, and calcaneocuboid joints by allowing direct visualization of these areas. The incision can be extended in both directions, if needed, or it can be used at either end, produces few complications, and closes with a cosmetically acceptable scar that does not produce pressure with shoe wear.