Open vs Arthroscopic Fusion of the Ankle or Subtalar Joint: A Comparison and Analysis of Long-term Results.

Category: Ankle Arthritis Introduction/Purpose: It has been shown that total ankle replacement (TAR) is effective in reducing pain and maintaining function in posttraumatic ankle osteoarthritis (OA). Compared to ankle fusion, TAR restores hindfoot kinematics more physiological. However, the assumption that the maintenance of ankle motion has a protective effect on the subtalar joint is still a matter of debate. Only a scarce number of long-term studies exist to support this statement.The purpose of this study was (1) to evaluate to which extent the integrity of the subtalar joint can be preserved by treating patients with a TAR, (2) to determine the rate of subtalar fusion following TAR, and (3) to determine whether the need of subsequent subtalar fusion was predictable at time of TAR. Methods: A consecutive series of 1140 primary TAR (508 female, 632 male, median age 63.5 years), performed between May 2000 and December 2015, were prospectively documented. The indication for TAR was posttraumatic OA in 78%, primary and systemic OA in 10% each, and other secondary OA in 3% of the cases. 199 subtalar joints were either fused before (n=73) or during TAR surgery (n=126), leaving 941 subtalar joints available for analysis. Radiographs before implantation and at latest follow-up were classified using the Kellgren and Lawrence Grading Score (KLS). In case of a subtalar fusion, the radiograph prior to the fusion was classified. Results: After a median radiographic follow-up of 6.1 years, the KLS remained unchanged in 66% of all cases. While it was increased by one stage in 30%, it was increased by two stages in 3%; whereas, signs of OA decreased by one stage in 1%. Cases with an increase of two stages on the KLS had a longer follow-up compared to cases without increase (p=0.047).37 cases (3.9%) underwent a subtalar joint fusion, of which the indication was progressive OA in 19 cases (51%), instability in 10 cases (27%) and others in 8 cases (22%). Subtalar joints that required a fusion after TAR did not show higher preoperative KLS than the group which did not need a subtalar joint fusion. Conclusion: Apparently, TAR protects the subtalar joint from secondary degeneration, as found in 67% with no increase in KLS. Although 33% showed an increase in the KLS, only 2% required a subtalar fusion due to progressive OA. Overall, the rate of subtalar joint fusion after TAR was low and comparable to the rates reported in the literature. Subtalar joints requiring fusion after TAR did not show higher preoperative rates of OA. Therefore, the KLS classification of subtalar OA on conventional radiographs provides only limited information about the need for postoperative subtalar fusion, and thus need to be interpreted with caution.

Category: Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Patients with arthritis or severe dysfunction involving both the ankle and the subtalar joints can benefit tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. With the evolution of prosthetic design and surgical techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint and talonavicular joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. Methods: This study includes 11 patients who underwent primary TAR and simultaneous subtalar and talonavicular fusion from May 2011 to January 2015. Six males and five females were enrolled with a mean age of 61 years (41-75). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2±11.6 months. Radiographic examination included a postoperative CT scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed. Results: At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92% and the talonavicular fusion rate was 88%. There was a statistically significant increase in American Orthopedic Foot & Ankle Society ankle/hindfoot score from 25.9 to 74.1 at 12 months post-operatively. Ankle range of motion significantly increased from 10.2° to 30.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.8 to 1.9. Conclusion: TAR and simultaneous subtalar and talonavicular joint fusion are reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopaedic surgeons in determining the degree of successful fusion of subtalar and talonavicular arthrodesis.

Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. Level V, consensus, expert opinion.

Category: Midfoot/Forefoot Introduction/Purpose: A conflicting problem in treating acquired flatfoot deformities is the break-down of the arch at the naviculocuneiform (NC) joints. After having encountered problems with extended triple fusion, in particular increased stiffness of the foot, we established a rational to combine subtalar (ST) fusion with NC I-III fusion while preserving the talonavicular (TN) and calcaneo-cuboidal (CC) joint. Our hypothesis was that the break-down of the arch at the NC joint can be specifically addressed while sparing the Chopart Joint (TN and CC joint). This, in turn, will allow the patient to accommodate better to the ground while walking. The aim of the study was to analyze the radiographic correction and fusion rate, and to determine patient’s satisfaction with this procedure. Methods: Between 2009 and 2015, a consecutive series of 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated by combining a fusion of the subtalar joint with a NC fusion. Both joints were exposed through a medial approach. Two 7.5mm-screws were used for ST fusion, and two 5.5mm-screws were used for NC fusion. In addition an anatomically contoured plate was used as a medio-plantar tension bending support of the NC joint. In 15 patients, an additional medial sliding-osteotomy was done to fully correct valgus misalignment of the hindfoot. The following measures were taken on standard weight-bearing radiographs including hindfoot alignment view preoperatively and at 2 years: the talus-first metatarsal angle, the talocalcaneal angle, the calcaneal pitch, the talonavicular coverage angle, the talus-first metatarsal angle, and calcaneal offset. Bony fusion was confirmed on plain radiographs. If no trabeculation was visible, a CT scan was performed. Results: All radiographic parameters, except the calcaneal pitch, showed a statistically significant improvement (Table 1). Solid fusion at the arthrodesis site was observed between 8 and 12 weeks in all but 2 cases (94.1%). One nonunion occurred at the ST joint and one at the NC joint. No interventions were necessary as both cases were asymptomatic. One patient developed an avascular necrosis of the lateral talus with need for a total ankle replacement after one year. All patients were satisfied with the results of this procedure and stated that they would undergo the surgery again. All patients were able to wear normal shoes without insoles. Conclusion: Our results show that a combined fusion of the subtalar and NC joint is an effective and safe technique in treating the adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. The deformity was corrected in all three planes. Even though the TN joint was not fused, its subluxation was significantly reduced. Although our radiographic results are promising, a clinical follow-up study is necessary to quantify the clinical benefit of this procedure.

Not-only-a-title

A challenge in treating acquired flatfoot deformities is the collapse of the medial arch at the level of the naviculocuneiform (NC) joint. Triple fusions, being a treatment option, may lead to problems such as increased foot stiffness. We thus established a method that combines subtalar (ST) fusion with NC fusion while preserving the Chopart joint. We analyzed the radiographic correction, fusion rate, and patient satisfaction with this procedure. 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated with a ST and NC joint fusion. In 15 cases, a medial sliding-osteotomy was additionally necessary to fully correct hindfoot valgus. The following radiographic parameters were measured on weightbearing radiographs preoperatively and at 2 years: talo-first metatarsal angle, talocalcaneal angle, calcaneal pitch, talonavicular coverage angle and calcaneal offset. Fusion was radiologically confirmed. All parameters, except the calcaneal pitch, showed a significant improvement. Fusion was observed after 1 year in all but 2 cases (94.1%). One nonunion each occurred at the ST and NC joint without needing any subsequent treatment. One patient developed avascular necrosis of the lateral talus with need for total ankle replacement after 1 year. All patients were satisfied with the obtained results. Our data suggest that a combined fusion of the ST and NC joint was effective and safe when treating adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. Although the talonavicular joint was not fused, its subluxation was significantly reduced. Level IV, case series.

The increase of joint contact forces in foot joints with simulated subtalar fusion in healthy subjects

Category: Ankle Arthritis Introduction/Purpose: Patients with arthritis or severe malfunctions involving both the ankle and the subtalar joints can benefit tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. Actually, TTC fusion is considered as a salvage option resulting in a completely stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and surgical techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. Methods: This study includes 25 patients who underwent primary TAR and simultaneous subtalar fusion from May 2011 to November 2014. Sixteen males (64%) and 9 females (36%) were enroled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Radiographic examination included a postoperative CT scan obtained 12 months after surgery. Results: At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopedic Foot & Ankle Society ankle/hindfoot score from 27.9 to 75.1. Range of motion significantly increased from 12 to 32.8 degrees. In addition, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.6 to 2.1. Conclusion: TAR and simultaneous subtalar joint fusion are reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopaedic surgeons in determining the degree of successful fusion of subtalar arthrodesis.

Patients with arthritis or severe dysfunction involving both the ankle and subtalar joints can benefit from tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. TTC fusion is considered by many as a salvage operation resulting in a stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and operative techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. This study included 25 patients who underwent primary TAR and simultaneous subtalar fusion between May 2011 and November 2014. Sixteen males (64%) and 9 females (36%) were enrolled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2 ± 11.6 months. Radiographic examination included a postoperative computed tomographic (CT) scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed. At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopaedic Foot & Ankle Society ankle/hindfoot score from 27.9 to 75.1. Ankle range of motion significantly increased from 12 to 32.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale pain score from 8.6 to 2.1. TAR and simultaneous subtalar joint fusion were reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopedic surgeons in determining the degree of successful fusion of subtalar arthrodesis. Level IV, case series.

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture. We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection. Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001). For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement. IV, Case series.

Category:Hindfoot; Ankle ArthritisIntroduction/ Purpose:Double arthrodesis of the subtalar (ST) and talonavicular (TN) joints, alongwith isolated TN arthrodesis, are commonly performed for hindfootosteoarthritis and rigid hindfoot deformity. Few studies have examined theeffects of the type of ST and TN fixation constructs on nonunion ratefollowing double and isolated TN arthrodesis procedures. This studyevaluates the effect of surgical construct on the union rate and time tofusion in patients undergoing double or isolated TN arthrodesis.Methods:Retrospective chart review identified 52 patients (52 feet) who underwentdouble or isolated TN arthrodesis between 2016 and 2021 by afellowship-trained foot and ankle surgeon with at least six months offollow-up (mean=1.62 years, range=0.50- 4.39 years). Data collected includeddemographics, medical history, surgical indication, surgical constructsused, complications, reoperations, patient-reported outcome measures, andradiographic measures. ST constructs included one (n=4) or two (n=44;parallel=43, divergent=1) cannulated screws, while TN constructs includeddorsal plate (n=2), dorsal plate and screw (n=10), isolated screws (n=3)screw and staple (n=29), or isolated staples (n=13). At the time of theirsurgery, the mean age was 60.39 (range, 17-80) years, mean body mass index(BMI) was 33.89 (range, 20.74-48.41) kg/m2, and most subjects werenon-smokers (94.7%). Mean follow-up duration was 1.62 (range, 0.50-4.39)years.Results:Overall complication and reoperation rates were 26.3% and 12.3%,respectively. Among TN constructs, the time to ST (p=.026) and TN (p=.018)fusion was statistically significantly slower among patients receiving aplate and screw TN construct. Complication rate did not differ by construct,but reoperation rate was significantly higher for the plate and screw TNconstruct (p=.039). Postoperative Foot and Ankle Outcome Score (FAOS)Quality of Life (p=.028) and Total (p=.016) scores were significantly betteramong plate and screw TN constructs.Conclusion:The utilization of a screw and staple or isolated staple construct have astatistically significantly quicker time to fusion and lower reoperationrates than plate and screw constructs for the TN joint. These findings canbe used to guide clinician decision-making while allowing physicians to taketheir personal construct preference into account, as well as serve as auseful starting point to other researchers interested in investigating theimpact of surgical constructs on ST and TN fusions.

What's New in Adult Reconstructive Knee Surgery.

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. The purpose of this study was to examine the role of first tarsometatarsal (1st TMT) fusion combined with subtalar fusion in correcting deformity at this joint.Methods:We retrospectively analyzed 40 patients (41 feet) who underwent 1st TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed six radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1 year follow-up.Results:The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (p <0.01). Overall, patients had statistically significant improvement in all PROMIS domains (p <0.01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes.Conclusion:Our data suggests that when addressing collapse of the medial arch in patients with AAFD, fusion of the 1st TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Based on our findings, deformity through the NC joint does not significantly impact clinical outcomes. In addition, the NCIA was established as a reliable radiographic parameter that can be used to assess NC deformity in the presence of talonavicular and/or 1st TMT fusion.

Category:Ankle; HindfootIntroduction/Purpose:A large variety of hardware can be used for ankle or subtalar (ST) joint arthrodesis, with very little data available to guide which implants might be most effective for these indications. Hardware removal rates in the setting of calcaneal fixation have been shown to vary widely from 9-47%, which can impose an added economic and surgical burden on both the patient and the healthcare system. The purpose of this study was to determine if there was a difference in the outcomes between two different versions of cannulated screws (i.e., headless, variable-pitched; headed), as reflected by patient-reported outcome measures (PROMs), and postoperative complication and reoperation rates.Methods:A retrospective chart review identified 126 patients (135 feet) who underwent ankle or ST arthrodesis with a single fellowship-trained foot and ankle surgeon between December 2015 and February 2021. These patients met the following inclusion criteria: isolated tibiotalar or ST arthrodesis; receipt of a headless, variable-pitched screw made by Acutrak or headed screw made by Orthohelix; and minimum 3 months of postoperative radiographic follow-up. Overall, 76 procedures used headless, variable- pitched screws (ankle=13, ST=63) and 59 used headed (ankle=18, ST=41).Results:Overall, there was a significantly higher rate of complications among headed screws (54.2%), as compared to the headless, variable-pitched screws (35.5%; p=.030). There was no difference in any treatment duration or postoperative PROM between groups. There was a significant difference in reoperation rates between cohorts (headless, variable-pitched=11.8%, headed=32.2%; p=.004), but no difference in nonunion rate (headless, variable-pitched=22.4%, headed=35.6%; p=.090). There were also significantly more screw issues (i.e., break, movement, impingement) with headed screws (headless, variable- pitched=0.0%, headed=5.1%; p=.047). (Table 1) Of the nine patients who underwent a reoperation, headed screws were removed six (66.7%) times, with half attributable to nonunion, whereas headless, variable-pitched hardware was only removed once (1.11%) due to infection.Conclusion:Overall, the use of headed screws in ankle or ST arthrodesis is associated with significantly higher rates of complication and hardware removal, as compared to headless, variable-pitched screws. Even in the examination of the few patients in this cohort who underwent two procedures, headed screws were removed more often. Surgeons should place emphasis on these results when selecting the best hardware to fuse the ankle and ST joints.

There is a lack of literature evaluating outcomes of the ligament-guided approach in medial unicompartmental knee arthroplasty (UKA). An improved comprehension of the distribution of coronal plane alignment of the knee (CPAK) phenotypes and sagittal tibial wear patterns and their associations with patient-reported outcome measures (PROMs) and implant survivorship could provide insights into its further application in daily practice. A registry was reviewed for patients with a minimal 2-year follow-up who underwent robotic-assisted, ligament-guided, medial UKA between 2008 and 2016. Survivorship and postoperative PROMs were collected. CPAK phenotypes and sagittal tibial wear patterns were determined. Survivorship, Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala and patient satisfaction were compared between phenotypes and sagittal tibial wear patterns. A total of 618 knees were included at a mean follow-up of 4.1 [2.0-9.6] years. Four-year conversion to the TKA survival rate was 98.9% [98.4%-99.3%] and 94.3% [93.3%-95.3%] for all-cause revision. Patients with preservation of the CPAK phenotype (84.5 ± 14.9, 81.8 ± 15.5, p = 0.033) and restoration of prearthritic coronal alignment (84.1 ± 14.9, 81.7 ± 15.9, p = 0.045) had a significantly higher Kujala score. No other significant differences in survivorship or PROMs were observed between phenotypes or sagittal tibial wear patterns. Additionally, no difference in survival rates was observed between preserved or altered phenotypes. This study demonstrated that preservation of CPAK phenotype and preservation of prearthritic coronal alignment yielded a significantly higher Kujala score. No other significant differences in PROMs or implant survivorship were observed, suggesting that robotic-assisted, ligament-guided medial UKA provides equal outcomes for all observed phenotypes and sagittal tibial wear patterns in medial compartment OA as long as preoperative CPAK phenotype is preserved postoperatively. Level III.