Subtalar Motion Research Articles

Differential Distraction for Relapsed Clubfoot Deformity in Children

To evaluate the long-term outcome of clubfoot correction following differential distraction using the Joshi external stabilisation system (JESS). 13 male and 9 female patients aged 1.5 to 5 years with 28 idiopathic clubfeet underwent differential distraction using JESS for relapsed deformity after posteromedial soft-tissue release. They were available for review after a mean of 12 years. Deformities of the feet were rigid and graded as Dimeglio type III or more. Pain, function, and satisfaction were evaluated using a questionnaire. Alignments of the forefoot and hindfoot, subtalar motion, ankle range of movement, muscle power, foot size, calf circumference, and limb length discrepancy were also evaluated. Each foot was rated using the Ponseti scale. In 16 patients with unilateral clubfoot, the abnormal side differed significantly from the normal side in terms of foot size, calf circumference, ankle motion, and Ponseti score. Most affected feet were smaller. The mean Ponseti score for the 28 clubfeet was 80. 20 of the feet had good-to-excellent and 5 had fair scores, whereas 3 had poor scores (because of recurrence of deformity). Most patients were able to perform activities of daily living without any problem. The function of the ankle and subtalar joints was limited. Only 3 feet achieved ankle dorsiflexion of <10 degrees, 15 were beyond neutral to 10 degrees, 7 were neutral, and 3 were less than neutral. Most patients developed pin site infection, but none necessitated premature removal of the assembly or any surgical intervention. Differential distraction using JESS enabled long-term maintenance of correction and good function, despite hindfoot stiffness.

Mobility Characteristics of Total Ankle Replacements

Follow-up studies of the first generation of total ankle replacements indicate failure rates between 52% and 95% at 10 years, mainly attributable to prosthetic loosening linked to compromised subtalar joint motion and excessive intrinsic constraint. Contemporary designs claim to withstand forces across the ankle and minimize loosening by allowing functional motion without excessive constraint. A dynamic testing system was used to measure the anteroposterior, medial-lateral, and internal-external rotational constraints for 4 contemporary total ankle designs under normal gait loads. The force-displacement curves were analyzed for component sliding and tibiotalar surface geometry-generated shear forces. Two designs, with essential soft-tissue load sharing and no mechanical stops on the talar tray, offered the greatest degree of mobility. The others presented substantial differences in mobility due to tibiotalar interface geometry and the locking mechanism of the polyethylene insert.

Minimum incidence of congenital talipes equino-varus (CTEV) and post treatment evaluation of residual deformities in a population in Zimbabwe.

To determine the minimum incidence (MI) of congenital talipes equino-varus (CTEV) in children; evaluate the association between CTEV and other congenital anomalies, and to assess the presence of residual deformities after conservative management at the physiotherapy department of Harare Central Hospital (HCH), Zimbabwe. A three year retrospective study. Physiotherapy Department, HCH, Harare, Zimbabwe. Eighty-two children with CTEV who were assessed and treated at HCH Physiotherapy Department from January 1994 to December 1996. MI of club foot and degree of correction of the club foot after conservative management of the deformity by the physiotherapist. An MI rate of about 0.9 per 1000 was found over a three year period. It was also found that 30.5% of these children had other associated congenital abnormalities. There was no significant association between gender and severity of deformity (P = 0.326). A significant association between the severity of CTEV and the presence of other associated congenital deformities was found (P = 0.013). 91% of the feet were found to have a satisfactory result of treatment using the Wynne Davis scoring system (WDSS). 52% of the patients with residual deformity after discharge from physiotherapy presented with limitation in ankle and sub-talar movements. This study also indicated that children with grade 2 type of deformities were more likely to have other congenital abnormalities than those with grades 1 or 3. The MI of CTEV in the studied population was found to be lower than other countries. The WDSS indicated that a great majority of the feet examined scored above average score.

Operative versus Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures in Elderly Patients

We compared the outcomes of displaced intra-articular calcaneal fractures in 33 patients aged 65 to 75 years, who were treated either operatively (n = 18) or nonsurgically (n = 15), between December 2001 and December 2005. The operative treatment group scored higher on the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and had less pain as measured with the 10-cm visual analog scale than did the nonsurgically treated group, with the differences being statistically significant ( P ≤ .05), suggesting that results can be improved by operative treatment. Böhler's angle, the quality of operative reduction, subtalar joint motion, gender, and the Sanders type of fracture were also analyzed and compared between the treatment groups. The results confirmed that Böhler's angle, the quality of the reduction, and subtalar joint motion were important prognostic factors related to outcome, regardless of treatment; whereas gender and Sanders type had less influence on the results at the 2-year follow-up evaluation. The prevalence of complications observed in the surgically treated group was similar to that reported in prior publications, except for subtalar arthritis (38.9%), which may have been higher because of the age of our patients and the duration of follow-up.

Intra-articular calcaneal fracture: closed reduction and balloon-assisted augmentation with calcium phosphate cement: a case report

IntroductionFor decades, open reduction and internal fixation was the surgical treatment of choice for intra-articular calcaneal fractures, either with or without any augmentation. Delayed weight bearing and wound-related complications are still unresolved. Aiming at a minimally invasive therapy with accelerated mobilization, we applied closed reduction and balloon-assisted augmentation with calcium phosphate cement.Case presentationA 45-years-old Greek man with intra-articular calcaneal fracture was treated with closed reduction and balloon assisted augmentation with calcium phosphate cement. Follow-up was performed using the Maryland foot score, plain radiographs and multidirectional computerized tomography. Early full weight-bearing was performed at the end of the first week postoperatively. There was no need for secondary reconstructive procedures at the 2 year follow-up. The patient had minimal problems regarding the pain, subtalar motion and peroneal impingement. There was no significant further collapse of the subtalar calcaneal articular surface radiologically.ConclusionThe closed reduction and balloon assisted augmentation with calcium phosphate cement of intra-articular calcaneal fractures is a minimally invasive surgical procedure which led to early full weight bearing, good functional patient outcomes and a low complication rate.

A comparison of subtalar joint motion during anticipated medial cutting turns and level walking using a multi-segment foot model

The weight-bearing in-vivo kinematics and kinetics of the talocrural joint, subtalar joint and joints of the foot were quantified using optical motion analysis. Twelve healthy subjects were studied during level walking and anticipated medial turns at self-selected pace. A multi-segment model of the foot using skin-mounted marker triads tracked four foot segments: the hindfoot, midfoot, lateral and medial forefoot. The lower leg and thigh were also tracked. Motion between each of the segments could occur in three degrees of rotational freedom, but only six inter-segmental motions were reported in this study: (1) talocrural dorsi-plantar-flexion, (2) subtalar inversion–eversion, (3) frontal plane hindfoot motion, (4) transverse plane hindfoot motion, (5) forefoot supination–pronation twisting and (6) the height-to-length ratio of the medial longitudinal arch. The motion at the subtalar joint during stance phase of walking (eversion then inversion) was reversed during a turning task (inversion then eversion). The external subtalar joint moment was also changed from a moderate eversion moment during walking to a larger inversion moment during the turn. The kinematics of the talocrural joint and the joints of the foot were similar between these two tasks. During a medial turn, the subtalar joint may act to maintain the motions in the foot and talocrural joint that occur during level walking. This is occurring despite the conspicuously different trajectory of the centre of mass of the body. This may allow the foot complex to maintain its function of energy absorption followed by energy return during stance phase that is best suited to level walking.

The development of a non-invasive, in vivo method of measuring subtalar joint movement during the contact phase of walking

The development of a non-invasive, in vivo method of measuring subtalar joint movement during the contact phase of walking

Effect of Post-traumatic Tibiotalar Osteoarthritis on Kinematics of the Ankle Joint Complex

Knowledge of joint kinematics in the healthy and diseased joint may be useful if surgical techniques and joint replacement designs are to be improved. To date, little is known about the kinematics of the arthritic tibiotalar joint and its effect on the kinematics of the subtalar joint. Kinematics of the ankle joint complex (AJC) were measured in six patients with unilateral post-traumatic tibiotalar osteoarthritis in simulated heel strike, midstance and toe off weight bearing positions using magnetic resonance and dual fluoroscopic imaging techniques. The kinematic data obtained was compared to a normal cohort from a previous study. From heel strike to midstance, the arthritic tibiotalar joint demonstrated 2.2 +/- 5.0 degrees of dorsiflexion while in the healthy controls the tibiotalar joint plantarflexed 9.1 +/- 5.3 degrees (p < 0.01). From midstance to toe off, the subtalar joint in the arthritic group dorsiflexed 3.3 +/- 4.1 degrees whereas in the control group the subtalar joint plantarflexed 8.5 +/- 2.9 degrees (p < 0.01). The subtalar joint in the arthritic group rotated externally 1.2 +/- 1.0 degrees and everted 3.3 +/- 6.1 degrees from midstance to toe off while in the control group 12.3 +/- 8.3 degrees of internal rotation and 10.7 +/- 3.8 degrees eversion (p < 0.01 and p < 0.01, respectively) was measured. The current study suggests that during the stance phase of gait, subtalar joint motion in the sagittal, coronal, and transverse rotational planes tends to occur in an opposite direction in subjects with tibiotalar osteoarthritis when compared to normal ankle controls. This effectively represents a breakdown in the normal motion coupling seen in healthy ankle joints. Knowledge of ankle kinematics of arthritic joints may be helpful when designing prostheses or in assessing the results of treatment interventions.

Calcaneonavicular Coalition

Symptomatic calcaneonavicular coalitions treated with resection and interposition of the extensor digitorum brevis (EDB) muscle often have unpredictable improvement of symptoms. Concerns with regard to skin cosmesis from a bony prominence on the lateral aspect of the foot and inadequate filling of the resection gap potentially causing reossification have motivated us to use fat graft interposition instead. The purpose of this study was to describe our surgical technique and report our clinical and radiographic outcomes for fat graft interposition after resection of a calcaneonavicular coalition. A retrospective review of all pediatric patients surgically treated with a calcaneonavicular coalition resection from January 1999 to December 2006, was performed. Presenting symptoms and examination findings were recorded. Postoperative examinations and imaging studies were evaluated to grade reossification, and functional outcomes were assessed for all patients with minimum 1-year postoperative follow-up. In addition, a cadaveric study was performed to compare the efficacy of EDB and fat graft interposition in terms of filling the postresection gap. Foot pain was the most common presenting complaint, though limitation of activities, stiffness, preoperative hindfoot malalignment, and associated injuries were also frequently observed. One year after resection, 87% of the patients returned to sport or their past activities, whereas 5% had symptomatic regrowth requiring repeat resection. Seventy-four percent had improvement of subtalar motion and 82% had improvement of plantarflexion; which was identified as an additional clinical sign of a calcaneonavicular bar. Preoperative pain averaged 7 of 10, whereas postoperative pain averaged less than 1 of 10 at rest, while walking, and with activities. The cadaveric study showed that the EDB was able to fill on average only 64% of the resected gap, leaving approximately 10 mm of the plantar gap unfilled. Reossification and reoperation rates with fat graft interposition in our series were lower than in most published reports of EDB interposition. Ankle and subtalar motion improved in a vast majority of the patients, and most patients returned to sport without requiring further surgery. Resection of a calcaneonavicular coalition with interposition of fat graft, when meticulously performed, is an effective way to relieve symptoms, restore subtalar motion, and return patients to activities, while preventing reossification.

The impact of rheumatoid foot on disability in Colombian patients with rheumatoid arthritis

BackgroundAlterations in the feet of patients with rheumatoid arthritis (RA) are a cause of disability in this population. The purpose of this research was to evaluate the impact that foot impairment has on the patients' global quality of life (QOL) based on validated scales and its relationship to disease activity.MethodsThis was a cross-sectional study in which 95 patients with RA were enrolled. A complete physical examination, including a full foot assessment, was done. The Spanish versions of the Health Assessment Questionnaire (HAQ) Disability Index and of the Disease Activity Score (DAS 28) were administered. A logistic regression model was used to analyze data and obtain adjusted odds ratios (AORs).ResultsFoot deformities were observed in 78 (82%) of the patients; hallux valgus (65%), medial longitudinal arch flattening (42%), claw toe (lesser toes) (39%), dorsiflexion restriction (tibiotalar) (34%), cock-up toe (lesser toes) (25%), and transverse arch flattening (25%) were the most frequent. In the logistic regression analysis (adjusted for age, gender and duration of disease), forefoot movement pain, subtalar movement pain, tibiotalar movement pain and plantarflexion restriction (tibiotalar) were strongly associated with disease activity and disability. The positive squeeze test was significantly associated with disability risk (AOR = 6,3; 95% CI, 1.28–30.96; P = 0,02); hallux valgus, and dorsiflexion restriction (tibiotalar) were associated with disease activity.ConclusionFoot abnormalities are associated with active joint disease and disability in RA. Foot examinations provide complementary information related to the disability as an indirect measurement of quality of life and activity of disease in daily practice.

Calcaneus fractures, results of the sinus tarsi approach: 4 years of experience

We present the treatment of displaced intra-articular calcaneal fractures using the sinus tarsi approach to reduce the complications described in literature obtaining good clinical and radiographical results. From January 2002 to December 2006, we have treated 39 displaced intra-articular calcaneal fractures (Sanders type II, III, IV). The patients were operated with open reduction and internal fixation through a limited sinus tarsi approach with cannulated screws. The mean follow-up was of 38 months and the Maryland foot score and the podoscopy were used to analyze the results, with an average of 84 points for type III fractures and 60 for type IV. The reduction of the posterior facet, the subtalar movement and the Bohler and Gissane angle resulted good. We have always performed arthrodesis for type IV fractures. In most part of the cases, we have obtained good functional results with great satisfaction of the patients.

A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot

Background Biomechanical models have been used to study stress in the metatarsals, subtalar motion, lateral column lengthening and subtalar arthroereisis. Posterior tibial tendon dysfunction has been associated with increased loads in the arch of the acquired flat foot. We examine whether a 10 millimeter (mm) medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular reduces these increased loads in the flat foot. Methods The response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683 Newton was analyzed using a multi-segment biomechanical model. The distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces were computed. Findings Posterior tibial tendon dysfunction results in increased load on the medial arch, which may cause the foot to flatten. A 10 mm medial displacement calcaneal osteotomy substantially decreases the load on the first metatarsal and the moment at the talo-navicular joint and increases the load on the fifth metatarsal and the calcaneal-cuboid joint. Adding the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy has only a small effect on the flattened foot. Interpretation Our biomechanical analysis illustrates that when the foot becomes flat, the force on the talo-navicular joint increases substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot. This study provides a biomechanical rationale for medial displacement calcaneal osteotomy treatments for posterior tibial tendon dysfunction.

Accuracy of a CT-based bone contour registration method to measure relative bone motions in the hindfoot

For measuring the in-vivo range of motion of the hindfoot, a CT-based bone contour registration method (CT-BCM) was developed to determine the three-dimensional position and orientation of bones. To validate this technique, we hypothesized that the range of motion in the hindfoot is equally, accurately measured by roentgen stereophotogrammetric analysis (RSA) as by the CT-BCM technique. Tantalum bone markers were placed in the distal tibia, talus and calcaneus of one cadaver specimen. With a fixed lower leg, the cadaveric foot was held in neutral and subsequently loaded in eight extreme positions. Immediately after acquiring a CT-scan with the foot in a position, RSA radiographs were made. Bone contour registration and RSA was performed. Helical axis parameters were calculated for talocrural and subtalar joint motion from neutral to extreme positions and between opposite extreme positions. Differences between CT-BCM and RSA were calculated. Compared with RSA, the CT-BCM data registered an overall root mean square difference (RMSd) of 0.21° for rotation about the helical axis, and 0.20 mm translation along the helical axis for the talocrural and subtalar joint and for all motions combined. The RMSd of the position and direction of the helical axes was 3.3 mm and 2.4°, respectively. The latter errors were larger with smaller helical rotations. The differences are similar to those reported for validated RSA and thus are not clinically relevant. Concluding, CT-BCM is an accurate and accessible alternative for studying joint motion, as it does not have the risk of infection and overlapping bone markers.

Roger Mann Award 2008: Sagittal Plane Motion of the Hindfoot Following Ankle Arthrodesis: A Prospective Analysis

The progression of subtalar and midfoot arthritis is well documented following ankle arthrodesis, and gait analysis has suggested that a functional gait pattern following arthrodesis may be due to tarsal hypermobility compensating for lost tibiotalar motion. We present a prospective radiographic study comparing the pre- and postoperative range of motion of the foot following ankle arthrodesis utilizing reliable anatomic landmarks to measure the sagittal range of motion. Between 2002 and 2006, we performed 154 arthrodesis procedures of the ankle. Patients were suitable for inclusion in this study if an isolated arthrodesis of the ankle was performed for post traumatic arthritis only with a minimum of 1-year followup and who had not undergone any prior nor subsequent hindfoot surgery. Standardized pre- and postoperative passive plantar- and dorsiflexion radiographs were obtained, and reproducible anatomic landmarks were then used to measure and compare tibiotalar, subtalar and medial column (talonavicular, naviculo-middle cuneiform and middle cuneiform-first metatarsal) motion. These measurements were repeated at 6, 12, and a mean of 33 months at final followup evaluation. The SF-36, calcaneal pitch, and the presence of radiographic and symptomatic hindfoot arthritis were noted for each patient pre and postoperatively. There were 48 patients who met the inclusion criteria. The mean preoperative sagittal motion (tibiotalar, medial column and subtalar combined) was 37.2 degrees, of which 17.8 degrees was tibiotalar motion. This decreased to a mean of 22.6 degrees postoperatively. The postoperative mean subtalar range of motion increased by 4.1 degrees (from 5.2 degrees to 9.3 degrees) (p < 0.0001), and the medial column motion increased by 2.1 degrees postoperatively (from 14.3 degrees to 16.4 degrees) (p < 0.003). Both of these results were statistically significant. There was a compensatory increase of the combined subtalar and medial column motion after arthrodesis of 10.8%. Using regression analysis, there was a significant correlation between the preoperative tibiotalar motion and the final difference in the subtalar range of motion (p = 0.03) and the combined motion of the medial column and the subtalar joint (p < 0.0001). Quality of life was positively associated with increased compensatory motion of the hindfoot and midfoot after ankle arthrodesis. There was an inverse association between the calcaneal pitch angle and the range of motion postoperatively. This prospective study demonstrated a statistically significant relative hypermobility of the subtalar and medial column joints following ankle arthrodesis, and may account for the functional gait which can be achieved following ankle arthrodesis. The significantly increased subtalar range of movement appeared to cause impingement of the posterior part of the posterior facet of the subtalar joint which may account for the increased incidence of subtalar arthritis following arthrodesis. Preoperative arch height can be used to predict both residual motion and function after ankle arthrodesis.

Foot Segment Kinematics During Normal Walking Using a Multisegment Model of the Foot and Ankle Complex

Gait analysis using optical tracking equipment has been demonstrated to be a clinically useful tool for measuring three-dimensional kinematics and kinetics of the human body. However, in current practice, the foot is treated as a single rigid segment that articulates with the lower leg, meaning the motions of the joints of the foot cannot be measured. A multisegment kinematic model of the foot was developed for use in a gait analysis laboratory. The foot was divided into hindfoot, talus, midfoot, and medial and lateral forefoot segments. Six functional joints were defined: Ankle and subtalar joints, frontal and transverse plane motions of the hindfoot relative to midfoot, supination-pronation twist of the forefoot relative to midfoot, and medial longitudinal arch height-to-length ratio. Twelve asymptomatic subjects were tested during barefoot walking with a six-camera optical stereometric system and passive markers organized in triads. Repeatability of reported motions was tested using coefficients of multiple correlation. Ankle and subtalar joint motions and twisting of the forefoot were most repeatable. Hindfoot motions were least repeatable both within subjects and between subjects. Hindfoot and forefoot pronations in the frontal place were found to coincide with dropping of the medial longitudinal arch between early to midstance, followed by supination and rising of the arch in late stance and swing phase. This multisegment foot model overcomes a major shortcoming in current gait analysis practice-the inability to measure motion within the foot. Such measurements are crucial if gait analysis is to remain relevant in orthopaedic and rehabilitative treatment of the foot and ankle.

Medial swivel dislocation of the talonavicular joint

Medial swivel dislocation, a variant of subtalar dislocation is uncommon. A 35 years old male presented after 6 weeks old injury to left ankle following motor cycle accident. He had pain, swelling around ankle and was unable to bear weight on left foot. Clinical examination revealed diffuse swelling and tenderness in mid foot region. His plain X rays and CT scan showed talonavicular dislocation with compression defect of the head of the talus. He was treated by open reduction and K-wire fixation. At 32 months follow up foot was painless, stable with normal range of ankle and subtalar motion.

In vivo tests of an improved method for functional location of the subtalar joint axis

The subtalar joint is important in frontal plane movement and posture of the hindfoot. Abnormal subtalar joint moments caused by muscle forces and the ground reaction force acting on the foot are thought to play a role in various foot deformities. Calculating joint moments typically requires knowledge of the location of the joint axis; however, location of the subtalar axis from measured movement is difficult because the talus cannot be tracked using skin-mounted markers. The accuracy of a novel technique for locating the subtalar axis was assessed in vivo using magnetic resonance imaging. The method was also tested with skin-mounted markers and video motion analysis. The technique involves applying forces to the foot that cause pure subtalar joint motion (with negligible talocrural joint motion), and then using helical axis decomposition of the resulting tibiocalcaneal motion. The resulting subtalar axis estimates differed by 6° on average from the true best-fit subtalar axes in the MRI tests. Motion was found to have been applied primarily about the subtalar joint with an average of only 3° of talocrural joint motion. The proposed method provides a potential means for obtaining subject-specific subtalar axis estimates which can then be used in inverse dynamic analyses and subject-specific musculoskeletal models.

Subtalar Kinematics Following Resection of Tarsal Coalition

Pain relief and functional improvement in the short term have been demonstrated in the majority of patients with tarsal coalition following resection. Recreation of normal subtalar kinematics is an important goal in these patients as well, and may have long term implications. The purpose of our study was to examine whether kinematic variables of foot motion are normalized following resection of tarsal coalition. This study compared three groups: nine candidates for resection of tarsal coalition, nine patients between 2 and 4 years after bar resection, and nine control subjects. Ankle hindfoot scoring was evaluated according to the AOFAS. Kinematic analysis of subtalar motion in the coronal plane and in the sagittal plane was performed using a computerized gait analysis system. Significantly increased passive subtalar range of motion and AOFAS ankle hindfoot scoring were demonstrated in postoperative subjects relative to preoperative subjects (p = 0.000). However, the kinematic analysis performed during walking, revealed similar, severe restriction of the subtalar eversion-inversion motion in postoperative and preoperative subjects. Angular velocity of the subtalar motion was also similar in both coalition groups, and was significantly increased compared with control. Kinematic analysis of foot motion in the sagittal plain demonstrated improved motion in postoperative subjects, which was comparable with the control group. Foot kinematics are not recreated following tarsal coalition resection, despite the favorable clinical outcome observed. Following resection of a tarsal coalition, patients continue to be subjected to increased loading and torque in their subtalar and adjacent articulations. This may promote further articular deterioration in the long term. Additional operative procedures or rehabilitation protocols should be examined to improve foot kinematics in this population.

Percutaneous fenestration of the anteromedial aspect of the calcaneus for resistant heel pain syndrome

The failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and pain, which mandates a further treatment modality. The presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief of resistant heel pain syndrome. Between September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25-59 years). The average follow-up was 46 months (range, 14-84 months). Clinical evaluation of the intensity of pain (VAS score system), walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular follow-up. The preoperative pain score level was 8.4 (range, 6-10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3-9), at 8 weeks the value was 3.98 (range, 2-7), at 4 months 2.46 (range, 2-5), at 8 months 1.7 (range, 0-3) and at 12 months zero. A clinical improvement was seen in all patients irrespective of the duration of symptoms (p=0.0041). Three heels (7.9%) had partial relief of pain, but after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal nerve that resolved spontaneously after 8 weeks post-surgery. The results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with recalcitrant heel pain syndrome after failed conservative treatment. The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical techniques and warrants further study.

Tibiocalcaneal Arthrodesis Using the Ilizarov Technique in the Presence of Bone Loss and Infection of the Talus

Infected nonunions and extrusions of the talus can often lead to below-knee amputation. Limb-salvage procedures have goals of eradicating infection and creating a painless, stable limb. Often, a tibiocalcaneal fusion is the best option; however, in the presence of infection and bone loss, it can be difficult to achieve a successful outcome using internal fixation. We review the results of circular ring external fixation to obtain a tibiocalcaneal arthrodesis despite these obstacles. A retrospective review of 11 patients who underwent tibiocalcaneal arthrodesis using an Ilizarov external fixator for infected talar nonunions or extrusions was performed. Each patient had a debridement of all nonviable talus. The bony surfaces were prepared for the fusion followed by application of a circular ring fixator. Clinical outcomes were measured using the AOFAS ankle-hindfoot scale. There was a mean followup of 35 months. Nine of the 11 patients had successful fusions. One fused successfully after a revision and the other developed a stable pseudoarthrosis. Eight patients underwent concomitant lengthening with the Ilizarov fixator. Mean AOFAS score at final followup was 65. This was out of a maximum of 86 since the tibiotalar and subtalar joint motion were removed. There were no recurrent deep infections or amputations. Tibiocalcaneal arthrodesis using the Ilizarov technique is a viable alternative to amputation in patients with infected nonunions or large bone loss of the talus.