Subtalar distraction arthrodesis using interpositional frozen structural allograft

BACKGROUND: Subtalar bone-block distraction arthrodesis using structural autograft carries the risk of donor site morbidity. Recent reports suggest that structural allograft may be an attractive alternative to structural autograft in subtalar arthrodesis. This prospective study analyzes subtalar distraction arthrodesis using interpositional structural allograft. MATERIALS AND METHODS: Between 2000 and 2006, 22 patients (24 feet; mean age, 45.6 years) underwent subtalar arthrodesis with interpositional fresh-frozen femoral head structural allograft. Indications included subtalar arthrosis, loss of heel height, and anterior ankle impingement. Clinical outcome was assessed using the AOFAS ankle-hindfoot scoring system. Time to union was determined by previously reported clinical findings and radiographic evidence for bridging trabeculation between host bone and structural allograft. RESULTS: Mean followup was 35.8 months for 20 patients (21 feet) available for followup evaluation. Union was achieved in 19 of 21 patients (90%) at a mean of 15.5 (range, 11 to 19) weeks. Mean AOFAS hindfoot score improved from 21 to 71 points (p < 0.05). Radiographic analysis suggested significant (p < 0.05) improvement in all measurements. Complications included nonunion (2), varus malalignment (1), persistent subfibular impingement (1), sural neuralgia (1), and prominent hardware (2). Both patients with nonunions had avascular bone at the arthrodesis site and used tobacco products. CONCLUSION: This study supports recent publications that subtalar arthrodesis using interpositional structural allograft can have a favorable outcome. Our clinical and radiographic results suggest that restoration of hindfoot function and dimensions with structural allograft are comparable to results reported for the same procedure using structural autograft. LEVEL OF EVIDENCE: Level IV, prospective case series.     

Distraction Arthrodesis of the Subtalar Joint Using Allogeneic Bone Graft: A Review of 15 Cases

Distraction arthrodesis of the subtalar joint is often used for the correction of neglected calcaneal fractures. Although different techniques have been advocated, there remains some debate as to the optimal type of bone graft for this purpose. This study retrospectively reviewed one surgeon's results for distraction arthrodesis of the talocalcaneal joint for 15 consecutive feet in 15 patients using 12 frozen femoral head and 3 freeze-dried iliac crest allografts. Indications for distraction arthrodesis in this series included neglected calcaneal fracture (n = 10), failed open reduction with internal fixation (n = 3), malunion after ankle fusion (n = 1), and subtalar joint arthritis with deformity (n = 1). The mean patient age was 47.5 (range 29 to 66) years, and the mean duration of follow-up was 20.6 (range 13 to 31) months. Complete union was achieved in 14 (93.33%) feet. Orthobiological agents were used in every case, including 7 (46.67%) platelet-rich plasma, 5 (33.33%) demineralized bone matrix combined with platelet-rich plasma, 2 (13.33%) platelet-rich plasma combined with an implantable electrical bone growth stimulator, and 1 (6.67%) demineralized bone matrix only. One (6.67%) patient developed a nonunion with collapse of the allogeneic graft, requiring revision with autogenous iliac crest bone graft. There were 8 (53.33%) minor complications, including 4 (26.66%) cases with inferior heel irritation, 2 (13.33%) with sural nerve paresthesia, and 2 (13.33%) with wound dehiscence. In conclusion, the use of allograft for subtalar joint distraction arthrodesis results in similar union rates as autogenous iliac crest grafting previously reported in the literature.     

Subtalar distraction bone block arthrodesis

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5 degrees and 4.9 degrees before operation, 25.9 degrees and 8.3 degrees immediately after, and 24.6 degrees and 7.7 degrees at the final follow-up, respectively. The mean talar declination angle improved from 6.5 degrees (-10 to 22) before operation to 24.8 degrees (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up.     

Outcomes of Hindfoot Arthrodesis Supplemented With Bioactive Glass and Bone Marrow Aspirate: A Retrospective Radiographic Study

Foot and ankle surgeons continue to explore bone graft alternatives that will be comparable to the reference standard of autologous bone. The purpose of the present study was to consider the outcomes of hindfoot arthrodesis supplemented with bioactive glass in patients at risk of delayed union and nonunion. We performed a retrospective radiographic review of 29 consecutive patients (48 joints) who had undergone arthrodesis of ≥1 joint of the hindfoot (ankle, subtalar, talonavicular, calcaneocuboid). All patients included in the present study had a minimum of 1 documented risk factor for osseous nonunion (history of previous nonunion, trauma, smoking, diabetes, Charcot arthropathy, obesity, age >65 years at surgery). The patients were followed up for a minimum of 24 weeks or until radiographic healing had been achieved. We found 12 (25.0%) nonunions across all 48 joints supplemented with bioactive glass. We found 4 (16.7%) nonunions in the subtalar joint, 1 (11.1%) in the calcaneocuboid joint, and 1 (11.1%) in the talonavicular joint. We found that hindfoot arthrodesis procedures supplemented with bioactive glass resulted in an incidence of union comparable to that with autograft and other bone graft substitutes.     

Posterior Arthroscopic Subtalar Arthrodesis: Clinical and Radiologic Review of 19 Cases

Arthroscopic subtalar arthrodesis has recently gained popularity in the treatment of primary subtalar or post-traumatic arthritis, coalition, or inflammatory diseases with subtalar arthritis. The present study reports the clinical and radiologic results of 19 patients (19 feet) who underwent posterior arthroscopic subtalar arthrodesis using 2 posterior portals. A total of 19 posterior arthroscopic subtalar arthrodeses (minimum follow-up of 24 months) performed without a bone graft and with 2 parallel screws were prospectively evaluated. The fusion rate was 94% (mean time to fusion 9.8 weeks). Modified American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score (maximum 94 points) improved significantly from 43 to 80 points and the visual analog scale for pain score improved from 7.6 to 1.2. The 12-item short-form physical and mental scores at the last follow-up point were 52.5 and 56.4, respectively. One (5.3%) patient underwent open repeat fusion for nonunion, 2 (10.5%) patients required a second procedure for implant removal, and 1 (5.3%) experienced reversible neuropraxia. In conclusion, posterior arthroscopic subtalar arthrodesis is a safe technique with a good union rate and a small number of complications in patients with no or very little hindfoot deformity.     

Further experience with Grice subtalar arthrodesis

Between 1952 and 1973, 302 Grice-type subtalar arthrodeses were performed with a minimum follow-up evaluation of two years and a maximum follow-up evaluation of 22 years. Seventy-three feet were followed more than ten years. Seventy-three percent of the 244 operations done for poliomyelitis residuals were considered satisfactory. The number of cases in other diagnostic groups ranged from six to 18 and showed unpredictable results. The major reasons for an unsatisfactory result were fusion in unacceptable position (usually varus) and nonunion of the arthrodesis. Correct positioning of the subtalar joint at surgery is essential for a satisfactory result, and recommendations are made as to how to obtain such a position. Minimal degenerative arthritis of adjacent joints occurred in feet fused in acceptable positions.     

Comparative Nonunion Rates in Triple Arthrodesis

The contemporary literature is unclear regarding the joint that is most “at risk” to yield a nonunion in the performance of triple arthrodesis of the foot. There is also a debate regarding the best methods of joint preparation. A retrospective radiographic review was conducted of all primary triple arthrodeses performed within in a Northern California health maintenance organization between January 2007 and June 2013. Data documenting joint preparation techniques were collected, and postoperative imaging was reviewed to measure time to osseous union. Patient demographics were also collected. One hundred fifty-two patients (157 procedures) met the inclusion criteria. The overall nonunion rate for triple arthrodesis in this series was 29.9% (47/157). The nonunion rate of the talonavicular joint was 20.4% (32/157); the nonunion rate of the calcaneocuboid joint was 17.2% (27/157); and the nonunion rate of the subtalar joint was 8.9% (14/157). In conclusion, we found the most likely joint to obtain nonunion during triple arthrodesis was the talonavicular joint. Furthermore, the most efficacious joint preparation technique was a combination joint resection or curettage with fish scaling.     

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.     

Symptomatic nonunion after fracture of the calcaneum. Demographics and treatment

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.     

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.     

Fusion rate of first tarsometatarsal arthrodesis in the modified Lapidus procedure and flatfoot reconstruction

BACKGROUND: The purpose of this study was to determine the overall first tarsometatarsal joint (TMTJ) union rate in patients after they had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction. METHODS: We retrospectively reviewed the charts of 182 patients (201 feet) who had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction between May, 1997, and May, 2001; all had at least a 6-month followup. The data collected included age, gender, tobacco use, diabetic status, complications, and radiographic evidence of union. There were 167 women and 15 men. The right foot was operated on in 106 patients and the left foot in 95. The average age was 53 (range 11 to 87) years. RESULTS: First TMTJ arthrodesis healed uneventfully in 193 (96%), and eight (4%) had nonunions. Of those eight patients with nonunions, five had previous bunion surgeries, two were smokers, and one had diabetes. There were 25 (12%) patients with previous bunion surgeries and five of these (20%) had nonunions. Four patients (2%) had symptomatic nonunions resulting in revision. Of the 21 patients undergoing flatfoot reconstruction, none had a nonunion. CONCLUSION: One criticism of the modified Lapidus procedure is the unacceptable nonunion rate (10 to 12%). Out of the 201 feet, we had a 4% nonunion rate and a 2% revision rate, which is well below the reported nonunion rates. We also have found that patients with previous bunion surgery and recurrent deformity were at a higher risk for a nonunion. CLINICAL RELEVANCE: We believe that the modified Lapidus procedure and first TMTJ arthrodesis can achieve acceptable union rates and be successful for correcting hallux valgus with a hypermobile first ray and can also be applied to certain patients undergoing flatfoot reconstruction.     

Does Preparation of the Subtalar Joint for Primary Union Affect Clinical Outcome in Patients Undergoing Intramedullary Nail for Rheumatoid Arthritis of the Hindfoot and Ankle?

This study aimed to evaluate whether preparation of the subtalar joint affects the clinical outcomes after tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid ankle/hindfoot deformity. Fifty-three joints in 51 patients who underwent tibiotalocalcaneal arthrodesis using an intramedullary nail with fins for rheumatoid arthritis at 2 institutions were included. Ten patients were male and 41 were female, with a mean age at surgery and follow-up period of 61.3 years and 71.6 months, respectively. Radiographic bone union was evaluated at the most recent visit. Univariate and multivariable analyses were performed to determine the risk factors associated with nonunion. The mean postoperative Japanese Society for Surgery of the Foot ankle/hindfoot scale was 65.3 (range, 5–84). The tibiotalar nonunion rate was 0%, whereas the subtalar nonunion rate was 43.3% (23 joints). Revision surgery was performed in 5, all of which were due to painful subtalar nonunion. Absence of subtalar curettage and earlier postoperative weightbearing were significantly associated with subtalar nonunion (p = .0451 and p = .0438, respectively). Subtalar nonunion after tibiotalocalcaneal arthrodesis for rheumatoid hindfoot is associated with higher revision rate. To decrease the risk of subtalar nonunion after tibiotalocalcaneal arthrodesis with an intramedullary nail in rheumatoid patients, curettage for the subtalar joint should be performed, and full weightbearing should be delayed until at least 26 days postoperatively.     

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.     

Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis

Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill the osseous void, preserve limb length and achieve fusion. Several authors have reported small case series on this topic, however outcomes have varied and no systematic review of this data has been published to date. The primary aim of this study is to report rates of osseous union, limb salvage and complications in patients undergoing TTC arthrodesis with a structural allograft. A total of 11 publications were identified that met the inclusion criteria. One hundred seventy-five patients were included with a weighted mean age of 60.5 (range 50-72) years and follow-up period of 29.7 (range 3-62) months. Femoral head allograft was the most commonly utilized structural graft and a retrograde intramedullary nail was the most common fixation construct. Results demonstrated an overall union rate of 67.4%, limb salvage rate of 92.5% and complication rate of 26.6%. Allograft-related complications were rare with an allograft fracture rate of 0.1% and allograft collapse rate of 1.2%. There was no significant difference in union rate when using a retrograde intramedullary nail versus a plate construct (p = .9148). TTC arthrodesis with use of a structural allograft is a viable treatment option for limb salvage when faced with complex hindfoot and ankle pathology involving large osseous defects. Despite high rates of radiographic nonunion, this approach can provide patients with a stable and functional limb while avoiding amputation.     

Incidence of Nonunion of First Metatarsal–Phalangeal Joint Arthrodesis with Autogenous Iliac Crest Bone Graft after Failed Keller–Brandes Arthroplasty: A Systematic Review

The Keller–Brandes arthroplasty has well-documented outcomes, including many complications that culminate in arthrodesis of the first metatarsal–phalangeal joint. In the setting of a large osseous defect, the autogenous iliac crest is the most commonly referenced source for the autogenous bone graft. We undertook a systematic review of electronic databases and other relevant sources regarding the incidence of nonunion after arthrodesis of the first metatarsal–phalangeal joint using autogenous iliac crest bone graft for failed Keller–Brandes arthroplasty. Six studies involving 42 arthrodeses met our inclusion criteria. The incidence of nonunion was 4.8% (2 of 42). It has been inherently accepted that revisional surgery can increase the incidence of nonunion. Our systematic review of the available data revealed that the use of an autogenous iliac crest bone graft results in a high incidence of primary union (95.2%) for salvage arthrodesis. However, additional appropriately weighted prospective studies and comparative analyses are needed regarding this topic.     

Technique and early experience with posterior arthroscopic subtalar arthrodesis

BACKGROUND: Subtalar arthrodesis is a reliable procedure for pain relief and improved function in patients with isolated subtalar arthritis. Arthroscopic subtalar arthrodesis (ASTA) was designed to improve upon traditional methods by using a minimally invasive technique. However, posterior arthroscopic subtalar arthrodesis (PASTA) has not been described. The purpose of the present study was to investigate the early results of PASTA. METHODS: A retrospective review of 11 feet in 10 patients (one bilateral) that had PASTA was conducted. Inclusion criteria were isolated subtalar arthritis with no or minimal deformity and no significant bone loss. Exclusion criteria included patients requiring adjunctive open procedures or who had significant deformity. The technique involved prone positioning, two posterolateral portals and one posteromedial portal, posterior talocalcaneal facet debridement, percutaneous cancellous allografting and internal screw fixation. Outcome measures included patient satisfaction, the modified American Orthopaedic Foot and Ankle Society (AOFAS) score, union rate, time to union, and postoperative complications. RESULTS: All patients were discharged the day of surgery or stayed one night in the hospital. Eight patients were very satisfied, one satisfied, and one patient not satisfied with the results of their surgery. The average modified AOFAS score (maximum 94 points) improved from 36 points preoperatively to 86 points postoperatively. Ten joints fused by 10 weeks postoperatively, and one patient developed a nonunion. No other postoperative complications occurred. CONCLUSIONS: For surgeons familiar with posterior ankle or subtalar arthroscopy, PASTA offers superior exposure of the posterior talocalcaneal facet, high patient satisfaction, an excellent fusion rate, and less postoperative morbidity for patients with subtalar arthritis.     

Results of calcaneocuboid distraction arthrodesis

BackgroundOne powerful method of reconstructing an adult acquired flatfoot deformity is a calcaneocuboid distraction arthrodesis. We performed a retrospective review of a small series of patients who underwent a calcaneocuboid distraction arthrodesis with a femoral head allograft.Materials and methodsSixteen feet (14 patients) were identified with an average follow up of 23 months (8–39 months) and an average age of 43 years (16–60 years). A calcaneocuboid distraction arthrodesis was performed with a femoral head allograft, secured with a 3 hole 1/3 tubular plate with 7 of the grafts being supplemented with platelet rich plasma (PRP). Patients were kept non-weight bearing for 6 weeks with an additional 6 weeks in a walking cast or boot. Plain radiographs and if necessary a CT or MRI were used to evaluate for union.ResultsSeven of the 16 feet developed a nonunion. Five of 9 patients without PRP developed a nonunion vs 2 of 7 patients where PRP was used.ConclusionDue to the unacceptably high complication rate with this procedure, the authors have abandoned this procedure. If an allograft is to be used for a calcaneocuboid arthrodesis, the authors strongly recommend using rigid locking fixation with a longer period of protected immobilization.     

Triple arthrodesis: is bone grafting necessary? The results in 100 consecutive cases

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site. The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion. Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.     

Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures

BACKGROUND: The purpose of this study was to report the results of 52 combined subtalar and ankle arthrodesis using an intramedullary nail. METHODS: Retrospective review identified 49 patients who had 52 combined ankle and subtalar arthrodeses with an ACE retrograde locked intramedullary humeral nail (DePuy-Ace), Warsaw, IN). Most procedures included bone grafts from the fibula, proximal tibia, or iliac crest or femoral head allograft. Intraoperative complications included one fractured tibia and one fractured medial malleolus. The procedure was done mainly for the treatment of combined ankle and subtalar arthritis (31) or complex hindfoot deformities (12). Outcome was assessed by a combination of chart review, clinical examination, and telephone questionnaire. Followup averaged 34 (8 to 73) months. RESULTS: At followup 82% of patients were satisfied with the results of surgery, 82% reported improvements in pain levels, and 67% reported improved foot function. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 63. Postoperative complications included deep infection, amputation, stress fracture, nonunion, and prominent hardware. CONCLUSION: Hindfoot arthrodesis with intramedullary nailing is an effective technique for treating complex foot deformities and often is the only alternative to amputation. Patient satisfaction is high, but the procedure is demanding and complications are frequent.     

The results of Grice Green subtalar arthrodesis of valgus foot in spina bifida

Background:

Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft.

Materials and Methods:

Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50–108 months).

Results:

The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction. Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5° and 31.9°, respectively, which decreased to 38.5° and 29.1°, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements (P<0.05).

Conclusion:

Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients.