Subtalar fusion for isolated subtalar disorders. Preliminary report

Retrospective observations on subtalar fusions performed for isolated subtalar disorders in 11 feet were performed to determine whether a satisfactory result could be obtained without significant changes to the talonavicular and calcaneocuboid joints. Preoperative diagnoses included five feet with degenerative arthritis secondary to a calcaneal fracture, four feet with a talocalcaneal bar, one foot with a degenerative subtalar arthropathy of unknown cause, and one foot with an unstable subtalar joint secondary to a peroneal tendon rupture. The average follow-up period was 41.5 months (range, 23-103 months). The hindfoot was fused in a average of 6 degrees of valgus. The feet maintained approximately 50% of their transverse tarsal motion, compared with the contralateral side. No foot developed hypermobility of any tarsal joint. Three feet fused for degenerative joint disease developed very mild talar beaking, and two feet fused for a tarsal coalition developed a mild progression or increase in talar beaking. Three feet demonstrated very minimal osteophyte formation at the calcaneocuboid joint. Functional and pain ratings for patients who had fusions for talocalcaneal bars or degenerative joint disease were good to excellent. Minimal radiographic changes at the talonavicular and calcaneocuboid joints secondary to increased stress brought about by the fusion did not seem to be clinically significant. Isolated subtalar fusion for lesions limited to the subtalar joint, which includes talocalcaneal bars, is a satisfactory method of treatment.     

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.     

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.     

Foot lengthening using the Ilizarov device: the transverse tarsal joint resection versus osteotomy

The aim of the study was the evaluation of both the foot correction and foot lengthening obtained using the distraction method with osteotomies versus distraction after the transverse tarsal joint resection. Ten patients (10 feet) aged from 5 years to 24 years (average, 10.5 years) were analyzed. Seven of them were treated for severe equinovarus deformity: six of congenital and one of post-traumatic etiology. In three patients, the indication for treatment was foot shortening due to hypoplasia with tibial shortening, combined with foot deformity. Preoperative shortening of the foot ranged from 1.5 cm to 10 cm (average, 4.5 cm). In four patients, osteotomy between the tarsometatarsal and transverse tarsal joints was carried out. In two cases, 'V-shaped' osteotomy through the hindfoot and midfoot was performed. In the remaining four patients, wedge resection of the transverse tarsal joint was performed. The follow-up was a mean of 32 months (range, 12-55 months). It was observed that foot lengthening after transverse osteotomy of the midfoot is difficult and unpredictable, because of distraction at the adjacent joints level instead of osteotomy site. The greatest lengthening of the foot (mean, 4 cm) was observed in the patients with the transverse tarsal joint resection. It was concluded that the transverse tarsal joint resection following callus distraction in the place of the resected joint is the effective method for foot lengthening, which can be combined with deformity correction.     

Bilateral coexistent calcaneonavicular and talocalcaneal tarsal coalition: a case report.

Tarsal coalition refers to a union of two or more tarsal bones. The union may be fibrous, cartilaginous, or bony. The most common sites of tarsal coalition reported in the literature are the calcaneonavicular, the talocalcaneal, and, less commonly, the talonavicular areas. Bilateral coexistent multiple tarsal coalitions are a rare occurrence. The authors present a case report of a 17-year-old boy with bilateral coexistent calcaneonavicular and talonavicular bars. The diagnosis was established by radiographs and CT scanning. The patient was treated conservatively with immobilization of the foot in a below-knee walking plaster cast followed by the use of an orthosis with a lateral iron and a medial T strap. The patient was pain-free at 2-year follow-up.     

A rare case of an osteochondral lesion of the tarsal navicular with a subacute stress fracture in a high level athlete

In this report, an osteochondral lesion of the tarsal navicular associated with a subacute stress fracture in a professional basketball player surgical treatment is presented. The surgical technique involved extra-articular curettage, bone grafting and plate stabilisation. Postoperative CT scan confirmed that both the osteochondral lesion and the stress fracture healed. The talonavicular joint showed no signs of arthritis on imaging. Clinical foot scores showed marked improvement after surgery. At 6 months patient managed to return to competitive play without pain in the foot and ankle. The outcome of this case indicates that the combination of curettage, bone grating and plate stabilisation works well for this rare and potentially career ending dual lesions.     

Nonoperative treatment of posterior tibial tendon dysfunction

One of the most common causes of acquired flatfoot deformity in adults is dysfunction of the posterior tibial tendon. The main function of the posterior tibial tendon is to invert the midfoot and lock the transverse tarsal joints (talonavicular and calcaneocuboid joints). When the tendon fails to function properly, a progressive flatfoot deformity develops. Because the disease process is a continuum, a staging system has been devised to offer guidelines for nonoperative and operative treatment of this problem. The rationale for nonoperative treatment of this disorder is to support the longitudinal arch and to decrease the valgus angulation of the calcaneus for flexible flatfoot deformity, and to immobilize and support the hindfoot and midfoot for rigid flatfoot deformities. The success of nonoperative treatment first requires the assessment of the flexibility of the flatfoot deformity. For a flexible deformity, the custom orthosis should be fitted with the foot and ankle in a corrected position as close to the neutral position as possible. Whereas, for a rigid deformity, it is imperative for the custom orthosis to be fitted with the affected foot and ankle in an in situ position.     

Bilateral arthrodesis of the medial foot joints in a patient with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) often have foot problems. The subtalar and particularly talonavicular joints are affected most frequently. The posterior tibial tendon has an important role in mid-foot stability. In RA patients, chronic inflammation of this tendon or talonavicular joint arthritis can results in posterior tibial tendon rupture. This leads to a collapsed talonavicular joint and forefoot instability, first with talonavicular and later Chopart's joint involvement. This shows as a planovalgus foot, with the forefoot in pronation and the heel in valgus deviation. In a 61-year-old RA patient, ruptures of the posterior tibial tendon due to rheumatoid inflammation occurred bilaterally, with subsequent deviation and instability of the forefoot. Arthrodesis with a medial column screw-Midfoot Fusion Bolt was carried out on the left foot and 4 months later on the right foot. At 7 months after the left and 4 months after the right foot surgery, the patient was free from pain, both feet were stable under loading and the forefoot was firm. The planovalgus deformity was corrected, as well as a valgus deviation of the great toe. Radiography showed a good position of the screws and complete healing of the medial foot joints.     

A Complete Dislocation of the Calcaneus: A Case Report

Isolated dislocation of calcaneus from cuboid and talus is extremely rare. This is a report of a 40-year-old man who sustained an open dislocation of calcaneus from cuboid and talus with subluxation of the talonavicular joint. Immediate reduction and stabilization with Kirschner wires and an external fixator was performed. At 2-year follow-up, there was no evidence of infection or avascular necrosis of tarsal bones. However, osteoarthrosis of the calcaneocuboid joint was evident. The functional result after 2 years was satisfactory. This case illustrates that the diagnosis of concomitant injuries in the adjacent column of the foot and compliance with principles of management of multiple injuries in the midfoot are paramount in reducing morbidity, which is common in such injuries.     

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。     

跟骰关节融合对距舟关节三维运动度影响的实验研究

目的探讨跟骰关节融合对距舟关节三维运动度的影响及其临床意义。方法10只新鲜尸体足标本，通过建立非负重位尸体足模型，结合力偶矩、弯矩及平衡加载方法，应用三维坐标仪测量分析跟骰关节融合前、后距舟关节在大体足背屈、跖屈、内收、外展、内翻及外翻运动中的三维运动度变化。结果跟骰关节融合后，距舟关节三维运动度较融合前明显减小（P〈0．01）；其运动范围在矢状面减少31．21％±6．08％，冠状面减少51．46％±7．91％，水平面减少36．98％±4．12％，平均减少41．25％±6．02％。结论跟骰关节融合对距舟关节三维运动度有较大的限制作用，临床应用时不可忽视此负面效应。     

Fluoroscopic and Gait Analyses for the Functional Performance of a Custom-Made Total Talonavicular Replacement

The present study evaluated the restoration of joint function in a special clinical case: a professional rock climber who underwent an original total talonavicular replacement with a custom-made prosthesis after a complex articular fracture. Full body gait analysis and 3-dimensional joint kinematics using single-plane fluoroscopy were performed on the same day at the 30-month follow-up examination. Gait analysis was performed using stereophotogrammetric, dynamometric, electromyographic, and baropodometric systems. Gait analysis showed good restoration of rotation, as well as moment patterns in the main lower limb and foot joints in the operated leg. At the artificial tibiotalar joint, videofluoroscopic analysis revealed a flexion capability of about 20°, together with a few degrees of motion in the frontal and transverse planes. The neighboring joints of the foot did not present with severe kinematic abnormalities. A full talonavicular replacement can be a viable and effective solution for complex ankle injury sequelae, even in patients with highly demanding functionality.     

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.     

Bilateral Triple Talocalcaneal,Calcaneonavicular, and Talonavicular Tarsal Coalition: A Case Report

We report a rare case of a female, aged 42 years, with symptomatic bilateral triple tarsal coalition, that is, talocalcaneal, calcaneonavicular, and talonavicular tarsal coalition. The patient was treated conservatively by adjusting her activities. At the 12-month follow-up, the patient was asymptomatic. Bilateral triple tarsal coalition is a rare disorder, especially in nonsyndromic patients. The purpose of this case report was to highlight this rare type of multiple bilateral tarsal coalitions and to discuss the relevant existing literature.     

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.     

Congenital paralytic vertical talus. An anatomical study.

Dissections of the feet of a three-month-old infant with paralytic congenital vertical talus secondary to lumbar myelomeningocele were compared with a dissection of a normal foot. The major differences appeared to be absence of the plantar intrinsic muscles and dorsal dislocation of the talonavicular joint. It is postulated that the pathological process begins as a failure of the intrinsic muscles to oppose the unbalanced, active dorsiflexion forces of the anterior crural muscles. This imbalance then allows disruption of the talonavicular joint, mechanically the least stable joint in the mid-part of the foot. All dorsiflexion forces acting on the ankle then become ineffective and plantar flexion forces serve only to pull the calcaneus and talus into equinus, causing a "vertical" talus. Treatment must be directed at reducing the talonavicular dislocation, correcting the equinus deformity of the hind part of the foot, and substituting for the undeveloped plantar intrinsic muscles.     

Partielle Verdoppelung eines Fußes

The Problem Complex deformity with partial duplication of the left foot in an 8-month-old girl with numerous other congenital deformities. Marked broadening of the foot due to three additional toe rays and tarsal bones. The Solution Resection of the three intermediate supernumerary toe rays and narrowing of the foot by wedge resection of the corresponding tarsal bones. Fibular transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament around the two metatarsals adjacent to the cleft. Surgical Technique Elliptic dorsal and plantar incision around the three supernumerary toes and their excision. Through partial excision of the tarsal bones, the width of the foot is reduced. Lateral transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament using one extensor tendon of a supernumerary toe to hold both parts of the foot in close approximation. The extensor tendon of the second remaining toe counted from fibular that runs in an abnormal direction is attached to the proximal tendinomuscular stumps of the excised toes. The skin tag at the fibular side of the foot is resected. Result Eleven years later, the girl is able to wear normal shoes and has minimal complaints after prolonged walking. The scars are barely visible and not sensitive to pressure. The mobility of the fibular toes is slightly reduced; also the range of motion of the subtalar joint is limited by 50%. The radiologic aspect of some tarsal bones is unusual, but with smooth articular surfaces.     

The effect of frontal plane position on first ray motion: forefoot locking mechanism

BACKGROUND: Several joints in the foot have a locking mechanism that allows the foot to function as a rigid lever. The transverse tarsal joint (talonavicular and calcaneocuboid joints) has a locking mechanism that is well understood. The purpose of the study is to determine if the first ray also has such a locking mechanism. METHOD: Five cadaver limbs were loaded onto a custom frame. The first metatarsal was attached to a jig that placed a force of 50 N in plantarflexion and dorsiflexion. The motion of the jig was measured with the first ray in three positions: maximally everted, neutral, and maximally inverted. No tendons were loaded to ensure that any change in motion was solely due to osseous position. RESULTS: The average motion of the first ray for the three testing position was as follows: 7 mm in the everted position, 14 mm in the neutral position, and 18 mm in the inverted position. There was a statistically significant increase in range of motion from an everted position to a neutral position (p=0.003). This increase in range of motion continued when the first ray was inverted compared to neutral, but not statistically significance (p=0.07). CONCLUSION: This study demonstrates that the frontal plane position of the first ray affects the sagittal plane motion. An everted position has the least mobility, and we hypothesize that this represents a closed-packed or locked position.     

Anatomic Reconstruction of Malunited Chopart Joint Injuries

Fractures and dislocations at the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted at first presentation. Inadequate joint reduction and stabilization almost invariably lead to painful malunions or nonunions, residual instability, and deformity. Because of the central position and the essential function of the mid-tarsal joint, malunions lead to a considerable impairment of global foot function and the rapid development of posttraumatic arthritis. While secondary anatomical reconstruction with joint preservation would be desirable in order to restore normal foot function, it is amenable only if no symptomatic arthritis or avascular necrosis is present. Over a course of 6 years, eight patients have been treated with secondary correction, joint realignment, and internal fixation. In four of these cases, nonunions of the tarsal navicular were debrided and bone-grafted; in the remaining cases, a corrective osteotomy at the navicular or cuboid was carried out. At 2 years followup, all but one patient were satisfied with the result. One patient underwent fusion of the talonavicular joint for avascular necrosis and collapse of the navicular. The mean American Orthopaedic Foot and Ankle Score (AOFAS) improved significantly from 38.8 preoperatively to 80.8 at follow-up. However, the majority of malunited mid-tarsal fracture-dislocations will require corrective fusion of the affected joint(s) with axial realignment because of manifest posttraumatic arthritis at the time of patient presentation.     

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.