Subtalar Distraction Arthrodesis Research Articles

Impact of Subtalar Distraction Arthrodesis on Ankle Joint: Radiological Insights from Modified Grice-Green Procedure.

Subtalar distraction arthrodesis (SDA) is a surgical procedure designed to treat hindfoot deformities associated with isolated subtalar joint arthritis. In 1996, Fitzgibbons was the first to observe that, in some cases, hindfoot fusion appeared to be associated with the development of tibiotalar valgus tilt. Since then, few studies have addressed this issue. Given that hindfoot fusion can be performed using various techniques, this study investigated the potential tibiotalar joint frontal or sagittal modifications resulting from the modified Grice-Green technique. All the consecutive patients who underwent the modified Grice-Green procedure were included. The patient records were reviewed to extract demographic data. Weight-bearing foot and ankle radiographs were assessed to measure the talar tilt angle and the tibiotalar ratio on the same picture archiving and communication system by three independent observers. A total of 69 patients met the criteria for inclusion. The mean talar tilt showed no substantial changes, since the increase from 1.46 ± 1.62 preoperatively to 1.93 ± 2.19 at a minimum of 8 months postoperatively was not statistically significant (p = 0.47). The average preoperative tibiotalar ratio significantly increased from 33.4 ± 4.4% to 35 ± 4% postoperatively (p = 0.007), although remaining within the normal range, indicating a possible realignment of the posterior facet of the subtalar joint. In conclusion, this study highlights the effectiveness of the modified Grice-Green procedure in achieving a favorable realignment without impacting the ankle joint, particularly regarding tibiotalar valgus tilt.

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.

A Direct Posterior Approach for Subtalar Distraction Arthrodesis

Because of soft tissue constraints, definitive management of hindfoot trauma occasionally requires a direct posterior approach via a coronal split of the Achilles tendon. This article and the accompanying video demonstrate a direct posterior approach for subtalar distraction arthrodesis and review treatment decisions involved with management of these complex cases.

Subtalar Distraction Arthrodesis.

Subtalar distraction arthrodesis is a hindfoot reconstructive procedure designed to treat posttraumatic sequelae of certain calcaneal fractures. This video demonstrates one method of performing this procedure which resulted in dramatic pain improvement and functional restoration.

Subtalar distraction arthrodesis for calcaneal malunion - comparison of structural freeze-dried versus autologous iliac bone graft.

This study aims to analyze the outcomes of subtalar distraction arthrodesis (SDA) for calcaneal malunion using structural freeze-dried iliac allograft (FDIA) compared to using autologous iliac bone (AIB). We retrospectively evaluated 57 consecutive cases (51 patients) of calcaneal malunion between March 2006 and December 2017. All patients were followed for an average of 22.8 months. All cases were treated by SDA using structural FDIA (17 cases, group 1), or AIB (40 cases, group 2). The outcome measures included the American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, visual analog scale (VAS) pain scores, and radiographic measurements. The mean postoperative 3, 6, and 12 months of AOFAS scores and VAS pain score were significantly better in group 2 than those in group 1 (p < 0.05, for all). There were 3 cases (17.6%) of nonunion in the group 1, whereas the group 2 had 2 cases (5.0%), which did not shown significant difference between two groups (p=0.492). Although the mean pre-, postoperative, and final follow-up radiologic parameters in both groups were similar, (p > 0.05, for all) the difference of talocalcaneal height, talocalcaneal angle, and talar declination angle from postoperative to final follow-up were significantly bigger in the group 1. (p < 0.05, for all). Although union rate was not significantly different between the two groups, we obtained more favorable clinical and radiologic outcomes in the autologous iliac bone group. Using FDIA without any orthobiological agent for SDA, there were significant more loss of radiological parameters due to inferior incorporation and biomechanical properties. When considering the SDA for calcaneal malunion, routine use of FDIA without any orthobiological agents as an interpositional graft for SDA is not recommended.

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.

Systematic Review of Subtalar Distraction Arthrodesis for the Treatment of Subtalar Arthritis

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 objective of this study was to present an overview of outcomes following SDA, focusing on surgical technique as well as clinical and radiographic results. MEDLINE and EMBASE were queried and data abstraction was performed by 2 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 5 patients, and (4) reporting clinical and/or radiographic outcomes of SDA. 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. SDA provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. Higher quality studies are necessary to better assess outcomes between different operative techniques. Level III.

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.

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases. MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments. ResultsThe mean postoperative [TCH] [70.3±1.9mm] was statistically better than the preoperative value [64.7±2.2mm] [p<0.001]. There was a statistically significant decrease in [HVA] [p<0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p<0.001]. ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.

Application and research progress of subtalar distraction bone block arthrodesis in treatment of calcaneus fracture malunion

To review the application and research progress of subtalar distraction bone block arth-rodesis in the treatment of calcaneus fracture malunion. The recent literature concerning the history, surgical technique, postoperative complication, indications, and curative effect of subtalar distraction arthrodesis with bone graft block interposition in the treatment of calcaneus fracture malunion was summarized and analyzed. Subtalar distraction bone block arthrodesis is one of the main ways to treat calcaneus fracture malunion, including a combined surgery with subtalar arthrodesis and realignment surgery for hindfoot deformity using bone block graft. The advantage is on the base of subtalar joint fusion, through one-time retracting subtalar joint, the posterior articular surface of subtalar joint implants bone block can partially restore calcaneal height, thus improving the function of the foot. Compared with other calcaneal malunion treatments, subtalar distraction arthrodesis is effective to correct complications caused by calcaneus fracture malunion, and it can restore the height of talus and calcaneus, correct loss of talocalcaneal angle, and ease pain. Subtalar distraction bone block arthrodesis has made remarkable progress in the treatment of calcaneus fracture malunion, but it has the disadvantages of postoperative nonunion and absorption of bone block, so further study is needed.

Subtalar Distraction Arthrodesis Using Fresh-Frozen Allogeneic Femoral Head Augmented With Local Autograft

Tricortical autograft has been commonly used in subtalar distraction arthrodesis (SDA) for severe calcaneal malunion. Structural allograft enriched with orthobiological agents is an alternative. This study was performed to evaluate the results of SDA using fresh-frozen allogeneic femoral head without the addition of orthobiological agents. We retrospectively reviewed 15 consecutive SDA procedures (13 patients) with allogeneic femoral head augmented with local autograft for the treatment of severe calcaneal malunion. Clinical outcome was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) pain score, Short Form-12 (SF-12), range of motion (ROM) of the ankle joint, and patient satisfaction rate. Radiographic assessment included the talar declination angle (TDA), calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), heel height, calcaneal length, and union time. At a median follow-up of 36.0 months (range, 24-47 months), all 15 feet (100%) achieved union, at a median of 13.0 weeks (range, 12-18 weeks). The AOFAS score and VAS pain score improved significantly, with a satisfaction rate of 93.3%. The TDA, CIA, LTCA, and heel height improved significantly. The median increase in heel height was 8.6 mm (range, 1.9-20.1 mm). There was a significant reduction in calcaneal length. Complications included 1 varus malalignment, 1 complex regional pain syndrome, 1 hardware irritation, and 1 sural neuralgia. This study found that SDA using fresh-frozen femoral head allograft without an orthobiological agent was cost-effective and may have outcomes comparable to those using autograft or allograft enriched with orthobiological agents.

Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?

Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment.Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

Subtalar Fusion After Displaced Intra-Articular Calcaneal Fractures: Does Initial Operative Treatment Matter?

Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment. Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

Subtalar Distraction Arthrodesis through a Posterior Approach

Subtalar arthrodesis is a common procedure for treating subtalar arthrosis. An isolated lateral incision can be used as an approach to subtalar fusion alone. However, it can be a difficult approach for correction of varus or valgus hindfoot deformities through the subtalar joint; especially if it involves distraction to correct calcaneal alignment. Less commonly, two-incision or single-incision medial approaches also have been described, but distraction and angular correction can still be difficult. We present an alternative method, using a posterior Achilles tendon-splitting procedure, that gives excellent subtalar exposure and the ability to obtain distraction with angular correction and bone grafting. Six consecutive patients underwent subtalar fusion with a posterior approach. Both varus and valgus deformities secondary to trauma, tendon insufficiency, or congenital deformities were corrected. Distraction was accomplished with laminar spreaders, and fixation was obtained with two 7.3-mm partially threaded cannulated screws. All patients were followed until fusion, and clinical and radiographic results were recorded. No other concomitant procedures were performed. Fusion was observed radiographically in all patients by 3 months postoperatively. No serious wound complications occurred. Correction to slightly valgus alignment (for varus deformity) or neutral alignment (for valgus deformity) was obtained without collapse of autologous bone graft. Talocalcaneal height and all angular measurements were significantly increased (all p < 0.05). The posterior approach for distraction arthrodesis is an alternative to the standard lateral approach technique. It allows safe exposure with the ability to distract while also correcting varus or valgus deformity of the subtalar joint.

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.

A new perspective on management of open calcaneus fractures

The treatment protocol of closed calcaneal fractures has been described in the literature extensively. However, treatment of open calcaneal fractures has not been discussed in detail. Various treatment alternatives have been suggested including external fixator, primary subtalar distraction arthrodesis, and partial calcanectomy according to the type of fracture. We have retrospectively reviewed 36 adult patients with 39 open calcaneal fractures who were treated with our new philosophy. Average follow-up time was 9.29 years (range, 1.25-28 years). The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used in functional evaluation. The average score was 77.9 (range, 67-92). All of the patients had limited subtalar movement. We propose an algorithm for the management of open calcaneus fractures, although treatment largely depends on the physical status of the patient, type of the fracture, localisation of the open wound and the surgeon's choice.