Complications of midfoot and hindfoot arthrodesis

Midfoot and hindfoot arthrodeses traditionally have been done to treat deformities resulting from paralytic disorders, residual clubfoot deformity, and posttraumatic arthritis. The surgical indications for midfoot and hindfoot arthrodeses more recently have been expanded to include painful arthritic deformities associated with neuroarthropathy, seropositive or seronegative arthropathies, and neurologic disorders. Regardless of the joint fused or the technique used, the goal of each remains similar: the creation of a painless, plantigrade foot capable of being fitted into, at the very least, a custom shoe. The aim of the current study is to describe the major complications associated with midfoot and hindfoot fusions in adults, and the prevention and the treatment of these complications.     

Surgical correction of midfoot arthritis with and without deformity

The goals of midfoot reconstruction are to create a painless, functional, and plantigrade foot, which are generally accomplished with arthrodesis and realignment as indicated. The latter requires not only the correction of midfoot deformity when present, but also coexisting hindfoot and forefoot deformities. Once the initial decisions have been made regarding the need for realignment and which joints to include in the arthrodesis, the surgical plan needs to account for the approach, arthrodesis preparation, order of fixation, and choice of fixation.     

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.     

Midfoot and forefoot issues cavovarus foot: assessment and treatment issues

This chapter addresses the etiology and diagnosis of forefoot and midfoot cavovarus deformities, the relevant anatomy and biomechanics, and specific procedures for correction of the forefoot and midfoot. Associated hindfoot and ankle procedures will be referenced; however, their specifics will be reserved for other chapters.     

Primary and revision total ankle replacement using custom-designed prostheses

With means for better mechanical stability and fixation, custom prostheses have improved our capabilities in salvaging failed total ankle replacements. Even in the primary total ankle replacement setting, previous contraindications due to suboptimal bony support may be adequately bypassed, and more patients may benefit from having a custom prosthesis. Accurate preoperative imaging and templating will ensure proper dimensions of the custom prosthesis. Intraoperative adjuncts such as screws, plates, and bone grafts will help address unexpected bone defects, coexisting adjacent joints arthritis, and other hindfoot and midfoot deformities. In this article, the authors discuss the history and problems of total ankle replacement failures, the surgical technique, and tips and pitfalls when using custom replacement prostheses.     

Minimally invasive surgery and percutaneous surgery of the hindfoot and midfoot

Minimally invasive surgery (MIS) and percutaneous (PC) surgery recently spread as a new technique in operative forefoot correction, and by extension in hindfoot and midfoot. Numerous procedures were described, and a race for MIS and PC has started. However, performing surgery with small incisions should not be an end in itself. Biomechanical and anatomical concerns must be taken into account and shall not be sacrificed for cosmetic reasons. For the most common hindfoot and midfoot pathologies, we discuss what we consider the surgical necessities and then describe the MIS and/or PC procedure we choose, according to these fundamentals.     

Osteotomy in the pediatric foot.

Osteotomies are the mainstays of treatment of foot deformities in patients from age 5 to skeletal maturity. A careful biomechanical assessment allows the clinician to evaluate the deformities in the frontal, sagittal, and transverse planes of the body. It also allows the clinician to relate deformities found at the ankle, hindfoot, forefoot, and midfoot to one another and to formulate a cohesive plan of treatment. Presentations with multiple deformities in different parts of the foot and ankle are common. These deformities are not always bony. A classic example is the gastrocnemius contracture in the symptomatic flatfoot. Procedures should be planned to correct all aspects of the deformity at a single sitting if possible.     

Talo-navicular arthrodesis for residual midfoot deformities of a previously corrected clubfoot

Triangular navicular, dorsal-lateral subluxation of the talo-navicular (TN) joint with a secondary forefoot cavovarus deformity, and degenerative changes of the TN joint are frequent causes of residual clubfoot deformity and pain in the midfoot after surgical correction. This study investigates the usefulness of TN arthrodesis to correct these deformities and to resolve symptoms resulting from these deformities. During the period from 1991-1996, the senior author performed 19 TN fusions (16 patients) for the above residual clubfoot deformities involving a painful TN joint. Eight of the procedures (seven patients) also required a lateral column shortening with a calcaneal wedge osteotomy to allow for a complete correction of the TN joint. The procedure was only performed in cases involving a hindfoot that was adequately aligned during a previous clubfoot correction. The average age of the patients at the time of surgery was 11 years (range: 4-20). One patient (bilateral procedures) was lost to follow-up. Fifteen patients (17 procedures) were followed-up for an average of four years (range: 2-6). All patients reported symptomatic improvement after the TN arthrodesis. Fourteen of the patients (15 procedures) were completely satisfied. The remaining patient (bilateral procedures) was only partially satisfied due to the subsequent development of navicular-cuneiform osteoarthritis in both feet. Two cases (2 patients) developed complications requiring a second procedure for satisfactory results. In addition, the procedure resulted in an improvement of the talus-first metatarsal angle on both antero-posterior and lateral radiographs. TN arthrodesis produced a correction of the residual clubfoot deformities of the midfoot and resulted in satisfactory clinical improvement in all the patients.     

Non-irradiated frozen structural allograft in reconstructive surgeries of the hindfoot and midfoot

BackgroundA few studies investigating the use of structural allograft in foot and ankle surgery are available. The purpose of this study is to analyze the clinical, functional and radiological results of patients treated with non-irradiated frozen structural bone allograft.MethodsWe analyzed 20 reconstructive surgeries of the hindfoot and midfoot performed between April 2004 and April 2010. The mean follow up period was 45.4 months. The results were evaluated according to AOFAS score, X-ray (allograft consolidation, alignment preservation, and allograft collapse or re-absorption), and complications.ResultsWe observed a 48-point mean improvement of AOFAS ankle and hindfoot score (17 cases), and a 53-point mean improvement of AOFAS midfoot score (3 cases). The mean bone consolidation time was 75 days. No graft fracture and no cases of non-union were seen.ConclusionThis treatment is a good option to treat severe defects or fill sequelae deformities.     

Evaluation of hyperpronation and pes planus in adults

Pes planus and hyperpronation of the hindfoot and midfoot are differentiated, and the numerous methods available for the clinical evaluation of both (including their norms) in the adult are presented. Pedotopography, a moiré fringe technique, is currently used in the clinical evaluation, along with "eyeball" visualization, tape measurement, ink mats, and roentgenography. Static deformities of the lower limbs and their joints are frequently responsible for manifestations of hyperpronation in the feet. Trauma and disease to bone, joints, or tendons in the region of the hindfoot or ankle can result in spastic pes planus with hyperpronation. Hyperpronation (excessive medial rotation of the talus) may exist without pes planus, but pes planus rarely is present without some degree of hyperpronation.     

The importance of the valgus hindfoot in forefoot surgery in rheumatoid arthritis

The relationship between hindfoot deformity and forefoot pressure was assessed in 28 rheumatoid patients who had undergone forefoot reconstruction four years previously. Patients with valgus hindfoot deformities tended to have high forefoot pressures whereas those with a normal hindfoot recorded normal pressures on the dynamic pedobarograph. All patients with residual forefoot pain recorded abnormal forefoot pressures. We believe that orthotic control of hindfoot deformities should be considered for those patients who require forefoot surgery as a combination of surgical and orthotic management may offer the best chance of success.     

Different faces of the triple arthrodesis

Patients with severe pes planovalgus or cavovarus foot deformities who fail conservative treatment may require a triple arthrodesis. Modifying the triple arthrodesis to include extended bone wedge resections allows for improved correction. The goal of each procedure is to obtain a less painful, plantigrade foot, and to improve function. Additional hindfoot or midfoot osteotomies may be needed in the modified triple arthrodesis. Midfoot or forefoot cavus can be addressed with either the Japas, Cole, or Jahss osteotomies, as described above. Residual hindfoot valgus can be adequately corrected with a medial displacement osteotomy of the calcaneus. Residual hindfoot varus is preferably corrected through a lateral closing wedge calcaneal osteotomy. This allows for adequate correction without the need for bone graft or an extended medial incision in the area of the tibial neurovascular bundle. Good results have been obtained with these types of complicated reconstructive procedures.     

Charcot foot and ankle reconstruction: current thinking and surgical approaches

The surgical repair of unstable diabetic neuropathic osteoarthropathy of the midfoot or the hindfoot and ankle remains a challenge with little guidance available in the medical literature. The authors present their proposed surgical intervention techniques regarding the use of external fixation with or without combined internal fixation. A step-by-step guide through the authors' preferred technique for these difficult limb salvage cases is presented in detail.     

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.     

Arthroerisis of the subtalar joint

Arthroerisis of the subtalar joint can be a valuable tool for the foot and ankle surgeon in treating flexible pes planus deformity in adults, as well as in children. Whether by itself, or in conjunction with other procedures, such as Achilles tendon lengthening (to allow dorsiflexion to at least neutral), midfoot or hindfoot osteotomies (to correct significant bony deformities), and posterior tibial tendon advancements (with associated symptomatic accessory navicular), arthroerisis can be helpful to correct deformity. When compared with procedures that involve osteotomy or arthrodesis, there is less morbidity to the patient who undergoes arthoerisis during surgery as well as postoperatively. There is no risk of nonunion, less immobilization is usually required, and arthroerisis is technically easy to perform. As with all surgical procedures, proper patient selection is extremely important.     

External fixation of the foot and ankle. Elective indications and techniques for external fixation in the midfoot

Although external fixation is widely used for treatment of fractures, limb deformities, and bone lengthening; use of external devices is still evolving. Elective cases for treatment of the midfoot and published research on external fixation specifically for surgical treatment of midfoot pain and deformity are scarce. Indications for elective external fixation in the midfoot are limited because rigid internal fixation in this area is relatively easy and successful. This article discusses podiatric conditions that can be treated advantageously by external fixation when elective surgery is done. The article also describes methods of external fixation appropriate for podiatric surgical reconstruction in patients with these conditions.     

Corrective midfoot osteotomies

Corrective midfoot osteotomies involve complete separation of the forefoot and hindfoot through the level of the midfoot, followed by uni-, bi-, or triplanar realignment and arthrodesis. This technique can be performed through various approaches; however, in the high-risk patient, percutaneous and minimum incision techniques are necessary to limit the potential of developing soft tissue injury. These master level techniques require extensive surgical experience and detailed knowledge of lower extremity biomechanics. The authors discuss preoperative clinical and radiographic evaluation, specific operative techniques used, and postoperative management for the high-risk patient undergoing corrective midfoot osteotomy.     

Management of the varus arthritic ankle

Treatment of the arthritic varus ankle presents a significant surgical challenge. The recognition of the causes and associated deformities directs the treatment of the individual patient and optimizes functional outcome. Arthrodesis and total ankle replacement often will need to be augmented by corrective hind- and midfoot procedures and by careful soft tissue balancing. Often multiple procedures are required to achieve the desired result, and patients need to be advised that surgery may need to be staged.     

Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children

Purpose  Residual midfoot and hindfoot deformities in rigidly deformed feet present a very complicated surgical dilemma. A plantigrade foot is desirous for proper lower extremity mechanics in a child with ambulatory potential. In this group of patients, soft tissue procedures are no longer an appropriate option, and well-recognized hindfoot procedures, such as talectomy, have many disadvantages. This study reviews the results obtained using multiplanar supramalleolar osteotomy as a salvage procedure to correct deformities of the complex rigid foot in children. Methods  A retrospective review was conducted of 27 multiplanar supramalleolar osteotomies in 18 children. The underlying diagnosis of the patients included seven severely rigid idiopathic clubfeet, five arthrogryposis, two myelodysplasia, one Ellis-van Creveld, one Streeter’s, one cerebral palsy, and one severe burn contracture. The average age at surgery was 5.6 years, and follow-up averaged 8 years. A successful outcome was deemed a plantigrade foot on physical exam with follow-up of at least 2 years and no subsequent tibial surgeries. All failures were included regardless of the length of follow-up. Results  A plantigrade attitude of the hindfoot was obtainable at the time of surgery in all cases. Eighteen of the 27 feet had a successful outcome. Nine of 27 (33%) feet had recurrence of the foot deformity requiring additional surgery. Time to recurrence averaged 5.7 years (9 months–13 years). Complications from the surgery included four minor wound healing problems, two delayed unions, and one screw recession, all of which healed without consequences. There was no evidence of nonunion, growth plate closure, infection, or fracture above or through screw holes. Conclusion  The multiplanar supramalleolar osteotomy appears to be a reasonable salvage procedure for severely scarred and complex rigid foot deformities and can be reinstituted for failures due to remaining growth.     

Arthrodesis technique in post-traumatic foot disorders]

Surgical arthrodesis procedures are effective in stabilizing painful joints in the foot. Joints most suitable for arthrodesis are: the hallux joints, midfoot, and hindfoot joints. The use of internal fixation is recommended whenever possible to ensure a successful fusion. However, surgical technique is most important as is the final position of the fused joints.