Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

Background: The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. Methods: A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker’s compensation claims. Plain radiographs were used to characterize injuries and review outcomes. Results: Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker’s compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. Conclusion: In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. Level of Evidence: Level IV, retrospective case series.

Outcomes and Complications of Open vs Posterior Arthroscopic Subtalar Arthrodesis: A Prospective Randomized Controlled Multicenter Study

Background: Open subtalar arthrodesis is the standard treatment for subtalar arthritis. Posterior arthroscopic subtalar arthrodesis (PASTA) has recently gained increasing popularity due to a shorter recovery time and better cosmesis. However, studies comparing outcomes and complications between these 2 techniques are limited. Methods: In total, 56 patients with subtalar joint arthritis were prospectively randomized to 2 parallel groups to receive either PASTA (n = 28 patients) or open subtalar arthrodesis (n = 28 patients). The minimum follow-up period was 12 months. Primary outcome was union rate confirmed on postoperative computed tomography (CT) scan. Secondary outcomes were union time; visual analog scale (VAS), Short Form–36 (SF-36), and Foot and Ankle Ability Measure (FAAM) scores; tourniquet time; and complications. Results: Union time (9.4 vs 12.8 weeks) and recovery time (time to return to activities of daily living [8.4 vs 10.8 weeks], work [10.6 vs 12.9 weeks], and sports [24.9 vs 32.7 weeks]) were significantly shorter with PASTA than with the open technique ( P < .05 all). Both techniques led to significant improvements in all functional outcomes (FAAM, SF-36, and VAS scores; P < .01 all); however, there was no significant difference between the techniques in these outcomes ( P > .05 all). Other outcomes, including tourniquet time (55.8 vs 67.2 min), union rate (96.3% vs 100%), and complication rate, were not significantly different between the techniques. Conclusion: Both open and PASTA techniques led to significant improvements in pain and function in patients with isolated subtalar joint arthritis. Although short-term functional outcomes and complication rates were not significantly different between the techniques, the PASTA technique was better at shortening the union and recovery times. Level of Evidence: Level I, prospective multicenter randomized controlled trial.

Repositional Subtalar Arthrodesis Combined With Supramalleolar Osteotomy for Late-Stage Varus Ankle Arthritis With Hindfoot Valgus

Background: Late-stage varus ankle arthritis is thought to be associated with varus of the tibial plafond and hindfoot. However, some late-stage varus arthritis show hindfoot valgus, which can be explained by subtalar subluxation with opposite directional motion between the talus and calcaneus. We hypothesized that late-stage varus ankle arthritis with hindfoot valgus could improve with repositional subtalar arthrodesis and supramalleolar osteotomy (SMO). The purpose of this study was to investigate the clinical and radiographic results of the repositional subtalar arthrodesis combined with SMO for late-stage varus ankle arthritis with hindfoot valgus. Methods: This study includes 16 consecutive patients (16 ankles) with late-stage varus ankle arthritis of Takakura stage 3-b and hindfoot valgus who were treated using repositional subtalar arthrodesis combined with SMO and followed for a minimum of 2 years. Clinical results were assessed with the visual analog scale (VAS) and the Foot Function Index (FFI). Radiographic results were assessed with standard parameters measured on weightbearing foot and ankle radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up. Results: VAS and FFI significantly improved after surgery. Mean talar tilt angle improved from 12.8 ± 2.8 degrees to 3.9 ± 3.1 degrees ( P < .001). Talus center migration and Meary angle significantly improved after surgery. Medial distal tibial angle, lateral talocalcaneal angle, hindfoot moment arm, and talonavicular coverage angle significantly changed after surgery. Radiographic stage improved in 15 ankles (93.8%) after surgery. Conclusion: In this series with minimum 2-year follow-up, we found that late-stage (Takakura stage 3-b) varus ankle arthritis with hindfoot valgus clinically and radiographically improved with repositional subtalar arthrodesis combined with SMO. Level of Evidence: Level IV, prognostic.

Is There a Borderline Value in the Radiological Findings of Patients With Calcaneal Malunion That May Help to Select an Appropriate Treatment Option?

Background: Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning—even fewer have statistically analyzed how these radiological measurements affect clinical outcomes. Methods: We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment. Results: The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively). Conclusion: The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis. Level of Evidence Level III, retrospective cohort study, case series.

Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet Talocalcaneal Coalition

Background: Medial facet talocalcaneal coalition can be a painful condition. This study aimed to determine clinical and radiographic outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, with a minimal follow-up of 18 months. Methods: Between June 2017 and July 2019, this procedure was performed on 8 feet (8 patients; mean age, 55 [42-70] years; mean BMI, 29.8 [24.4-45.0] kg/m2). Clinical assessment was performed using Visual Analog Scale for Pain (VAS-P), Foot and Ankle Outcome Score (FAOS) and the 36-Item Short-Form Health Survey (SF-36). Patient satisfaction was assessed at the last available follow-up as “very satisfied”, “satisfied” or “unsatisfied”. Radiographic analysis was performed using plain radiography, computed tomography (CT) scan and magnetic resonance imaging (MRI). The primary outcome was to determine both clinical and radiographic outcomes. Results: The mean follow-up was 25.1 (18.2-34.2) months. The authors found statistically significant improvement on all clinical scores (VASP-P, FAOS and SF-36). They registered 6 “very satisfied” patients, 2 “satisfied” patients and no “unsatisfied” patient. Fusion of the subtalar joint was observed in all patients by 12 weeks and in 5 of them as soon as 8 weeks postoperatively (mean, 9.5 [8-12] weeks). There were no cases of delayed fusion or nonunion of the subtalar joint, superficial or deep infection, neurovascular damage, thromboembolic event, screw breakage, need for hardware removal or revision surgery. Conclusion: This study found that PASTA is a safe and reliable technique for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, demonstrating and maintaining clinical improvement at an average follow-up of 2 years. Level of Evidence: Level IV, case series.

OPEN REDUCTION AND INTERNAL FIXATION COMPARED WITH ORIF AND PRIMARY SUBTALAR ARTHRODESIS FOR TREATMENT OF SANDERS TYPE IV CALCANEAL FRACTURES: A RANDOMIZED COMPARATIVE PROSPECTIVE STUDY

Background: The present study was conducted to open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for treatment of sanders type IV calcaneal fractures Methods: Randomized comparative prospective trial conducted on Calcaneum fracture cases attending with orthopaedics department of S.M.S. Medical College and Hospital, Jaipur (Rajasthan, India) Results: SF 36, MFA, AHS and VAS score showed almost same results in both groups at 3 months which showed statistically non significant results. Conclusion: A randomized trial was unable to demonstrate any significant difference between ORIF compared with ORIF + PSTA for the treatment of isolated Sanders type IV fractures with respect to long-term outcome. ORIF + PSTA however, should be considered for patients with Sanders type IV fractures, and the health care system as they heal at a much more rapid rate, and will not require additional surgery. This must be considered as the choice of treatment may have profound economic effects on the patient. More research is needed to find the best solutions for these difficult fractures. Keywords: ORIF, PSTA, Fracture.

Clinical and Radiographic Results of Ankle Joint Preservation Surgery in Posterior Ankle Arthritis

Background: Little information is available about how to manage ankles with eccentric arthritis in the sagittal plane. This study aimed to report clinical and radiographic outcomes following joint preservation surgery for ankles with eccentric arthritis at the posterior tibiotalar joint and a plantarflexed talus in the sagittal plane, which we named posterior ankle arthritis. Methods: Ten ankles with posterior ankle arthritis were treated with realignment surgery between 2017 and 2018. Posterior ankle arthritis was defined as having both (1) eccentric narrowing of the joint space at the posterior aspect of the tibiotalar joint on weightbearing lateral radiographs and (2) coronal talar tilt angle less than 4 degrees on weightbearing anteroposterior radiographs. Flatfoot reconstruction with a hindfoot arthrodesis procedure was performed in all patients (subtalar arthrodesis, n = 9; triple arthrodesis, n = 1), and a supramalleolar osteotomy was added in patients with varus distal tibial alignment (n = 6). Pain, functional outcome (foot function index [FFI]), radiographic arthritis stage (stage I to IV), and 9 radiographic parameters, including lateral talar center migration (LTCM), were evaluated on pre- and postoperative weightbearing radiographs. All patients completed a minimum 2-year follow-up. Results: Preoperative radiographic evaluation demonstrated that ankles with posterior arthritis had a lower medial longitudinal arch, forefoot abduction, and valgus hindfoot alignment. Postoperatively, sagittal tibiotalar alignment was restored, as evidenced by an improved median LTCM from −3.3 to −0.3 mm ( P < .001). The radiographic arthritis stage improved in 7 (70%) patients, whereas 3 (30%) remain unchanged in the same stage. The median score for pain (visual analog scale) decreased significantly from 8 to 2, and the median FFI improved significantly from 67.8 to 23.4 ( P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up. Conclusion: The study results suggest a possible relationship between posterior ankle arthritis and the plantarflexion of the talus, which can be seen in the setting of a flatfoot deformity. Reconstruction of the flatfoot deformity using subtalar arthrodesis restored the tibiotalar relationship in the sagittal plane and resulted in clinical improvements at an average 2.3-year follow-up in this 10-ankle case series. Level of Evidence: Level IV, case series.