Subtalar Bone Block Research Articles

Subtalar Distraction Bone Block Arthrodesis for Calcaneus Fracture Malunion

Intra-articular calcaneus fractures are associated with a high rate of malunion resulting in hindfoot and ankle impingement, peroneal tendinitis, sural neuritis, arthritis, hindfoot varus or valgus deformity, loss of hindfoot height, and resulting gastrocnemius-soleus complex weakness and gait dysfunction. These issues can arise whether the patient’s injury is treated conservatively with non–weight-bearing precautions, neglected/missed, or treated surgically with open reduction and internal fixation. The sequelae of calcaneal malunions can arise early or late in this process. For patients undergoing subtalar arthrodesis following calcaneus fracture malunion, the use of a bone block wedge can assist with achieving a stable ,well-aligned, pain-free hindfoot. Patient selection, preoperative planning, careful surgical technique, and compliance with postoperative care pathways are critical to optimize patient outcomes and healing of this complex reconstruction. Recent evidence supports the utility of weight-bearing CT to assist with preoperative planning for subtalar arthrodesis. Wedges used in subtalar distraction arthrodesis include bulk autograft (tricortical iliac crest), allograft (pre-fashioned or intraoperatively fashioned wedges from femoral head allograft or other source), and metallic wedges. These wedges are typically secured with screws spanning and compressing the arthrodesis site, which is filled with a mixture of concentrated bone marrow aspirate, bone growth factors, and allograft bone. Concomitant procedures may be indicated to ensure the overall success of the procedure, such as extra-articular, calcaneal osteotomy for additional realignment purposes and/or arthrolysis. A review of the literature shows high rates of union following subtalar bone block arthrodesis with improved functional outcomes. Our preferred technique for a bone block distraction subtalar arthrodesis, described herein, includes the use of an allograft wedge. Ongoing advances, such as the development of novel materials and structures for use in subtalar bone block arthrodesis, but most importantly, the incorporation of weight-bearing CT technology and potential for preoperative CT navigation to make this procedure more predictable, are all important areas for further exploration and future research. Level of Evidence: Level—4.

Subtalar Distraction Arthrodesis for the Treatment of Subtalar Arthritis and Severe Hindfoot Deformity: A Systematic Review

Category:Hindfoot; TraumaIntroduction/Purpose:Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objectives of this study were (1) to conduct a systematic review of clinical outcomes following SDA, (2) to assess the demographics, indications, and surgical technique used, (3) to assess the clinical and radiographic outcomes of this procedure and its role in improving function,(4) to provide treatment recommendations based on the best available literature, and (5) to identify knowledge deficits that require further investigation.Methods:MEDLINE and EMBASE were queried with an end date of January 1, 2018 using the keywords The keywords used for this search included ‘‘subtalar,’’ ‘‘talar,’’ ‘‘talus,’’ ‘‘bone,’’ ‘‘block,’’ ‘distraction,’ ‘arthrodesis,’ ‘fusion,’ ‘arthritis,’ ‘arthrosis,’ ‘calcaneus,’ ‘calcaneal,’ ‘fracture,’ ‘malunion,’ ‘deformity,’ and ‘‘clinical outcome,’’ alone and in various combinations using the Boolean operator ‘‘AND.’’ Data abstraction was performed by two independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least five patients, (4) reporting clinical and/or radiographic outcomes of SDA. Data collected included: demographics, operative techniques, radiographic measures, clinical and functional outcomes, and complications. The level of evidence for each study was assessed according to the method described by Wright et al. Methods followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.Results:Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle hindfoot scores with a weighted average of 33 points of improvement.Conclusion:Subtalar bone block arthrodesis provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. These consistent clinical outcomes throughout the literature, despite different lengths of followup periods, suggest that the functional results do not deteriorate with time.Higher confidence recommendations for SDA require longer follow-up, clear indications and treatment protocols, standardized clinical and radiographic outcome measures, and direct comparison or stratification of results based on graft type and other operative techniques.

Shaped titanium wedges for subtalar distraction arthrodesis: Early clinical and radiological results

BackgroundDisplaced intraarticular calcaneum fractures are associated with late symptomatic hind foot malalignment and painful arthrosis for which distraction subtalar fusion might be considered. During subtalar distraction arthrodesis, a structural graft is often used to fill gaps. Autograft, the current gold standard, is limited in availabilityand is associated with donor-site morbidity and collapse. Allografts have the risk of infectious disease transmission, rejection and failure to integrate. The clinical outcomes and midterm results of subtalar distraction arthrodesis with biofoamtitanium wedges are presented. MethodsA review of 4 patients (3 male and 1 female) undergoing subtalar bone block distraction arthrodesis using biofoam titanium wedges is reported. Results were evaluated clinically and radiologically Mean time from trauma to surgery was 27.5 months and mean follow up was 12 months. ResultsThe mean FAAM ADL score improved from 31.4% preoperatively to 74.2% postoperatively and mean AOFAS score improved from 23.4 preoperatively to 69.6 postoperatively.There was improvement in all radiographic parameters, with 44% improvement in calcaneal pitch, 23% improvement in talocalcaneal angle, 21% increase in talus-first metatarsal angle, and 13.5% correction of talocalcaneal height. VAS Pain scores wasimproved from a pre-operative mean of 8 to a post-operative mean of 2. Mean time to fusion was 13 weeks. Union was achieved in all cases. ConclusionOur data suggest titanium wedges may be used as a structural graft option for subtalar bone block distraction arthrodesis. Fusion rates and time to incorporation are comparable to autogenous bone graft without the associated morbidity.Level IV Case Series.

Idiopathic Congenital Vertical Talus (CVT)

CVT is a rare, severe, important deformity. This case report is to highlight the importance of deformity and early notification. Surgical correction as one stage procedure is probably the best procedure. CVT has no sex prevalence, bilateral in 50% of cases and more than 50% of cases a secondary cause implicated. Pathological anatomy involves dislocation of the talonavicular articulation with the oscalcis. Navicular bone is displaced onto the dorsolateral aspect of the talar head. Diagnostic criteria for CVT were persistent talonavicular dislocation on forced plantar flexion of foot. Talus axis and metatarsal base axis angles (TAMBA) and Calcaneal Axis and metatarsal axis (CAMBA) are introduced. TAMBA and CAMBA enable us to describe the obliquity of the talus and calcaneus, also the severity of the dislocation of the talonavicular joint and the contracture of the tendo Achilli. The current treatment is a one-stage open reduction of the talonavicular dislocation, combined with a posterior release. A subtalar bone block is often imperative to maintain correction. The surgery for (CVT) can lead complications.

Treatment for calcaneal malunion

Pain, limping, and deformity are the most common complications following calcaneal malunion which results from non-operative treatment for calcaneal fractures. To introduce the experience of treating calcaneal fracture malunion. Between December 2009 and April 2011, eleven patients with calcaneal malunion were treated operatively. Age of patients ranged between 23 and 40 years with an average 28.7. All of them were followed up with a mean 13.5 (9-18 months). Eight of them were right-sided and the other three were left-sided. All of them were male. The mechanism of trauma was fall from a height in all patients. All of them were treated non-operatively since the prime trauma. According to Stephens and Sanders classification, all of cases were type II. The extended lateral calcaneal "L" approach was used in all cases. Lateral wall exostectomy and peroneal tendons are decompressed below the tip of the lateral malleolus and in situ subtalar bone block arthrodesis was done. The mean of American Orthopedic Foot and Ankle Society and pain score systems score was improved from 33 (19-44 points) preoperatively to 69 (42-83 points) postoperatively. The reported complications were superficial wound infection in two cases (18.18%) and reflex sympathetic dystrophy in three cases (27.27%). Calcaneal lateral wall exostectomy, peroneal tenolysis and subtalar joint arthrodesis is an efficient method to treat calcaneal malunion type II after calcaneal fracture by reshaping the calcaneal contour and recovering the hind foot function. IV.

Primary Isolated Subtalar Arthrodesis: Outcome after 2 to 5 Years Followup

Favorable to excellent clinical results have been reported for isolated subtalar joint arthrodesis. Pedobarography after subtalar bone-block distraction arthrodesis have demonstrated a more laterally shifted gait line. However pedobarographic measurements after primary in-situ isolated subtalar arthrodesis have not been reported. This is the first study considering this. Physical examination, AOFAS Hindfoot score, full weightbearing anterior/posterior and lateral radiographs were assessed in 15 feet. Peak pressures, ground reaction force and force distribution at foot-flat and push-off were measured. Average AOFAS-Score significantly improved. Subjective satisfaction was high. Non-union was found in 1 foot (7%), screws were removed in 4 of the 15 feet (27%). One new asymptomatic arthritic talonavicular joint was found. The pressure and force distributions under the operated and contralateral foot showed a different pattern compared to a normal foot. Ground reaction force under both the operated and contralateral feet were lower than a normal foot. This study found good clinical, subjective and radiographic results matching that of the reported literature. However, pedobarographic assessment suggests that great functional differences still remain when compared to a normal foot. Subtalar arthrodesis may induce an abnormal gait pattern by preventing compensation of axial rotation of the tibia. This is also reflected in the unaffected side, which may indicate an effort in the general locomotor control to keep a symmetrical gait pattern. This finally alters the pressure and force distribution under both feet. Nevertheless, subtalar arthrodesis is considered a valuable treatment for various isolated subtalar disorders.

Subtalar Distraction Arthrodesis Using Interpositional Frozen Structural Allograft

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. 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. 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. 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 IV, prospective case series.

Factors Associated With Outcome After Subtalar Arthrodesis

To evaluate radiographic and functional outcomes after subtalar arthrodesis and to identify patient factors associated with poor outcome. Retrospective study. Two academic hospitals. Eighty-eight patients with primary or secondary osteoarthritis treated between 1995 and 2002. Primary subtalar arthrodesis. 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). 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. 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.

Intermediate to Long-Term Results of a Treatment Protocol for Calcaneal Fracture Malunions

Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery. Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021). This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.

INTERMEDIATE TO LONG-TERM RESULTS OF A TREATMENT PROTOCOL FOR CALCANEAL FRACTURE MALUNIONS

Background: Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. Methods: Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery. Results: Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021). Conclusions: This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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.

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° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (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.

Varus of the Talus in the Ankle Mortise Secondary to Calcaneus Fracture

Varus displacement of the talus in the ankle mortise secondary to a calcaneus fracture was observed in a 33-year-old man. Similar to the calcaneus fracture-dislocation, the mechanism involved inferior and medial displacement of the talus into the body of the calcaneus. The patient's ankle deformity was not corrected by a lateral ankle ligament reconstruction. Correction required a distraction subtalar bone block fusion. Successful reconstruction of the hindfoot after calcaneus fractures requires a careful analysis of the pathologic lesion. In this unusual case, correction required restoration of lost hindfoot bone structure.

Congenital Vertical Talus and Its Familial Occurrence

Thirty-six patients (57 feet) showing congenital vertical talus were treated at the St. Louis Unit of the Shriners Hospital between 1958 and 1978. A high incidence of congenital hip dislocatiom, arthrogryposis, congenital hypoplasia of tibia and CNA disorders was noted as associated abnormalities. These patients are classified in 3 groups: (I) primary isolated form (16 patients); (II) associated form without neurological deficit (12 patients); (III) associated form with neurological deficit (8 patients). Fifty per cent of the patients with primary isolated form had positive family history of foot deformities in their first degree relatives. Familial incidence of congenital vertical talus was observed in 2 families studied. Genetic factors may play an important role in the etiology of the primary isolated form of congenital vertical talus. The current treatment is a one-stage open reduction of the talonavicular dislocation, combined with a posterior release. A subtalar bone block is often imperative to maintain correction. Cast correction alone has never succeeded as the definitive treatment of this condition.