CHAPTER 3I SUBTAIAR JOINT ARTFIRODESIS Alan R, Catanzariti, DPM Robert W Mendicino, DPM Karl Sabrick, DPM Roruan C. Orsini, DPM Michael F. Dombek, DPM Bradley M. Laruru, DPM

ABSTRACT arthrodesis has been recommended as an alternative to triple arthrodesis for pathology confined to the subtalar Forty patients (12 men and 28 women) who were treated joint. Isolated subtalar joint arthrodesis preserves with an isolated subtalar joint arthrodesis were retrospec- approximately 50% of the midtarsal joint motion relative tively reviewed. The average patient age was 50 years to triple arthrodesis.T'to'11 (range 21 rc 76). Preoperative diagnoses included poste- Although isolated subtalar joint arthrodesis is well rior tibial tendon dysfunction, post-traumatic arthritis, documented, most reports neglect to evaluate how the nontraumatic arthritis, and subtalar .ioint middle facet preoperative diagnosis influences Postoperative outcomes coalition. The average follow up period was 15 months and complications. The purpose of this study was to (range 12-74 months). identify the complications and patient satisfaction Subjective postoperative questionnaire results were associated with isolated subtalar joint arthrodesis. In obtained and classified as satisfied (n=32), satisfied with addition, the authors will attempt to correlate these reservations (n=4), or dissatisfied (n=4). Eight-two complications to the preoperative diagnosis. percent the patients (n=33) stated that they would have the procedure performed again. The minor complica- METHODS tions, those complications that resolved with nonoperative treatment, occurred in 55o/o of patients. Forty consecutive patients who underwent isolated However, the major complication rate was only 12.5o/o. subtalar joint arthrodesis from 1994-2000 were This study compared the preoperative diagnosis retrospectively reviewed at the \Testern Pennsylvania with the postoperative outcomes showed no statistical Hospital. Isolated subtalar joint arthrodeses were correlation. In summary, isolated subtalar joint arthrode- performed in patients with a preoperative diagnosis of sis is an effective treatment for pain and deformity of the adult acquired flatfoot secondary to posterior tibial hindfoot. Our results suggest that the prevalence of com- tendon dysfunction, tarsal coalition, and primary and plications is slightly greater than previously reported. posttraumatic subtalar joint osteoarthritis. Patients were Ke),words: isolated subtalar joint arthrodesis, poste- excluded from this study if any additional arthrodesis rior tibial tendon dysfunction, arthritis, coalition, procedures were concomitantly performed. Medical complication. records and radiographs were evaluated. The collected clinical data included sex, age, preoPerative diagnosis, INTRODUCTION occupation, history of systemic illness, previous surgery, type and duration of nonoperative care, concomitant Isolated subtalar joint arthrodesis has been recommended procedures, type of fixation, type of bone graft, time to for posttraumatic arthropathy, neurologic disorders, osseous union, follow up time, time to full weight bear- primary osteoarthritis, talocalcaneal coalition, posterior ing, smoking history, and postoperative comPlications. tibial tendon insufficiency, and inflammatory arthritis. Nonoperative therapy included modification of activities The goals of this procedure are to eliminate pain, restore or occupational status, non-steroidal anti-inflammatory stability, and realign the hindfoot. High patient medication, immobilization, orthoses, ankle-foot satisfaction and low complication rates have been orthoses, various types of braces, physical therapy, and reported with this procedure.'-e Isolated subtalar joint arthrocentesis with corticosteroid. A11 patients in this 152 CHAPTER3l study failed nonoperative care. months postoperatively with the same aforementioned The diagnostic tools utilized to evaluate the subtalar clinical and radioghraphic union characteristics. joint included standard foot and ankle radiographs, Radiographic angles were not analyzed due to the wide advanced imaging (computer tomography (CT) and variery of preoperative foot pathology. Additionally, a post- magnetic resonance imaging (MRI)), and diagnostic operative subjective questionnaire was obtained at the last intra-articular injections. Preoperative and postoperative follow-up visit to determine patient satisfaction. Patients weightbearing anterior-posterior and lateral foot and ankie were questioned about their level of pain, cosmesis, radiographs, and calcaneai axial radiographs were evaluated functional capacities, use of walking aids, and ability to for degenerative joint disease, tarsal coalition, and osseous wear shoes (Thble 1). union of the subtalar joint. Osseous union following This study evaluated minor and major postopera- subtalar joint arthrodesis was recorded when no subtalar tive complications. Minor complications were defined as joint motion was detected on clinical exam and evidence of transient postoperative symptomatology that was resolved trabeculation across the arthrodesis site was observed on with nonoperative treatment. Major complications were plain radiographs (Fig 1A,B). Patients who did not meet defined as continued postoperative symptoms, which these criteria were evaluated with the use of CT. A delayed were recalcitrant to nonoperative treatment or required union was defined as a successful fusion between 6-9 revisional surgery. These rypes of complications were

Thble 1

PAIIENT SAIISFACTION QUESTIONNAIRE

Questions Number Percentage of patients 1. Pain - Over the past month, how has your foot pain limited your daily activities? have no pain with normal activities 5 t2.5 have slight/occasional pain, no compromise in activities 20 50 have moderate pain, slight effect on activities 9 ))5 have pain with serious limitation of activities 5 12.5 have severe pain with total limitation of activities 1 )< 2. Cosmesis - How do you rate the appeirance of your foot? I like it very much 14 35 I mostly like it 12 30 I'm not sure either way (neutral) 9 )) \ I mostly don't like it 5 12.5 I dislike it very much 0 0 3. Functional Capacities - Ability to function on one flight of stairs, inclines, uneven terrain? have no difficulry t4 35 have some difficulty )1 57.5 have significant difficulry 3 7\ 'Walking 4. Aids don't use any 29 72.5 wear a prescription brace above my ankle 2 5 use one cane or one crutch 7 t7.5 use either crutches, a walker or a wheelchair 2 5 5. Shoes can wear normal shoes 23 57.5 am able to wear only walking or athletic shoes L5 37.5 am able to wear only special order, orthopedic or custom shoes 2 5 6. Overall Patient Satisfaction am satisfied with my surgery 32 80 am satisfied wirh reservarions 4 10 am dissatisfied with my surgery 4 10 7.'Would you have this procedure performed again? Yes )) 82.5 No 7 17.5 CIIAPTER 31 153

Figure 1A. Preoperative. Figure 1B. Postoperative radiographs demonstrating a successful subtalar.joint arthrodesis. compared to the type of preoperative diagnoses. prepared with fenestration and scaling. The subtalar joint The procedure was performed with the patients was then positioned and provisional fixation was obtained placed in a supine position utilizing a bump under the with large cannulated guide-pins. This maneuver was ipsilateral hip to gain access to the lateral hindfoot. performed under image intensification. Large-diameter General or spinal anesthesia was administered and a thigh cancellous screws were then delivered over the guide pins. tourniquet was used for hemostasis. An incision was Placement was confirmed with intraoperative imaging. made from the tip of the fibula extending orrer the sinus The dorsal aspect of the calcaneus and undersurface of tarsi toward the fourth metatarsal base with care taken to the talus in the sinus tarsi were then decorticated. Bone identi$, all neurovascular structures. A communicating graft was packed into the sinus tarsi to augment the branch from the intermediate dorsal cutaneous nerve ro primary arthrodesis site. Postoperative management the sural nerve was sometimes encountered. The peroneal included 6-9 weeks in a short leg non-weightbearing cast. tendon sheath was incised just distal to the tip of the Patients were then advanced into weightbearing casts, fibula and the tendons were retracted plantarly. A deep rocker bottom braces, and then standard footgear. fascial incision was made beginning just inferior to the Progression to weightbearing depended on radiographic lateral malleolus and extending distally just inferior to the evidence ofconsolidation at the arthrodesis site. extensor digitorum brevis muscle belly. A vertical deep Descriptive and inferential statistical procedures fascia-periosteal incision was made along the sinus tarsi were used to analyze the resulting data. For each variable extending inferiorly to meet the horizontal incision. All collected, the number and percentages or means and further dissection was subperiosteal. The soft tissue standard deviations were calcuiated. To analyze predictors contents of the sinus tarsi were evacuated. This permitted of complications a chi-square analysis was performed. A visualization of the subtalar joint middle and posterior statistical significance difference was defined as p<=0.05. facets and allowed access to the underlying cortical bone for decortication. The subtalar joint was mobilized and a RESULIS Iamina spreader r,vas placed within the sinus tarsi region. The articular cartilage was debrided from the posterior There were I 2 men (3OVo1 and 28 women (7 0o/o) with an and middle facets. Emphasis was placed on developing a average age of 50 years (range 2l to 76). Preoperative healthy cancellous substrate conducive to primary diagnoses included posterior tibial tendon dysfunction (n arthrodesis while maintaining joint contour and talar = 19), post-traumatic arthritis (" = 11), nontraumatic height. Limited debridement techniques were employed. arthritis (r, = 5), and subtalar joint middle facet coalition This permitted positional realignment without large (" = 4). A total of 77 patients were smokers (42.5o/o) and deficits and prevented lateral fibuiar impingement from 23 patients were non-smokers (57.5oh). There was one excessive loss of talar height. Additionally, maintaining a patient who had a revisional subtalar joint arthrodesis for portion of the subchondral plate enhanced the stiffness of a previous nonunion. One patient had a past medical the fixation construct. The surgical site was irrigated of all history of psoriatic arthritis. The average follow-up cartilaginous debris and the subchondral surface was period was 15 months (range 72 r.o 74 months) and the I54 CHAPTER 31

mean time to full weightbearing was 14 weeks (range 7 to at the time of follow-up was symptomatic, wore a brace 60 weeks). and was on disability (Fig 2a,b,c,d,e). Three of the four Radiographic and clinical assessment demonstrated nonunions (75%o) were patients who smoked. There was that all but 4 feet went on to primary union, which lead a 17.60/o non-union rate for the smoking group and a to an oyerall union rate of 90o/o. The overall time to 4.60/o non-union rate for the non-smoking group. union ranged from 7 to 45 weeks with an average 72.6 Delayed unions only occurred in 3 patients. None of weeks. Two of the nonunions underwent revisional these patients were augmented with bone graft. arthrodesis and went on to successful union. One Bone grafts were udlized in 78 (45o/o) patients to nonunion was lost to follow-up. One patient with a enhance primary union, provide and maintain structural nonunion refused any further surgical intervention, and realignment, or to fill a defect. The bone grafts that were

Figure 2A. Case study of a 40 1,ear old man with non-ttaumatic atthritis of sub- talar joint. Preoperatir.e lateral radiograph (a) ald proton density MRI (b, c) demonstrates ser.ere arthritic changes. CT (d) and a lateral radiograph (e) one ) ea- l)o\roferJr i\ r'l; . onlirmirrg a nonunion.

Figure 2B.

Figure 2D.

Figure 2C. CHAPTER 3] r55

pain management center. One patient with residual post- operative pain related continued mild to moderate pain with activity that was controlled with anti-inflammatory medications. Patients were grouped based on the preoperative diagnosis: posterior tibial tendon dysfunction (PTTD), post-traumatic arthritis, non-traumatic arthritis, and middle facet talocalcaneal coalition. 12 of the 19 patients (630/o) with PTTD had minor complications which included painful internal fixation (n = 3), sural neuritis (n =1), delayed union (n =3), and stress fracture at the tibial graft site (r, = 1), wound dehiscence (., =1), and residual post-operative pain (n =3). Two of the 19 parienrs (10.5o/o) Figure 2E. with PTTD had major complications both of which had non-unions (n = 2). Three of the 11 patients (27o/o) with post-traumatic arthritis had minor complica- tions including painful internal fixation (n = 2), stress implanted included: autogenous anrerior iliac crest grafts,4 fracture of the talus (" = 1), and residual post-operarive autogenous tibial strut grafts3, allogenic cancellous graftst pain (n = 1). Eighteen percent (2 of the 11 patients) with and autogenous cancellous grafts." A total of 7 patients post-traumatic arthritis had major complications received a structural bone graft. Anciilary surgical procedures including, CRPS (n = 1), and non-union (" = 1).Two of that were performed included: achilles tendon lengthening,'' the four patients (50olo) with a middle facet talocalcaneal flexor digitorum longus tendon ilansfer,'3 direct repair of the coalition experienced minor complications including tibialis posterior tendon,' subtalar joint middle facet residual post-operative pain (" =1) and painful internal coalition resection,l and excision of an os tibiale externum.2 fixation h = 2). There were no non-unions or major Large cannulated (7.0mm or 7.3mm) screws were used for complications in the coalition group. Three of the six internal fixation in all patients. Thirty-three patients had patients (5Ooto) with non-traumatic arthritis had minor screws oriented from the plantar proximal calcaneal complications which included painful internal fixation (n tuberosity distal dorsally into the talus while in 7 patients the = 2) and residual post-operative pain (" = 1). A non- screws were directed from the dorsal neck of the talus union (n = 1) was the only major complication recorded plantar posteriorly into the calcaneus. in this grotp (16.70/o) (Thble 3). The overall complication rare for an isolated All 40 patients were evaluated by the use of a subtalar joint fusion was 37.5 o/o (15 of 40 patients). Nine subjective questionnaire at the last follow-up visit. Fifteen of these patients had both minor and major complica- percent of the patients had pain with limitation of tions. The minor complication rate was 55o/o, which activities. Sixty-five percent of the patients were satisfied included: nine painful internal fixation, six residual post- with the resultant appearance of their foot. The ability to operative pain, one sural neuritis, three delayed unions, function on uneven terrain was somewhat difficult in one stress fracture of the taius, stress fracture at the distal 57 .5o/o of the patients. Ninety-five percent of the patients tibial metaphysis, which was the harvest site of a bone were able to wear either normal or athletic shoewear. graft, and one wound dehiscence. The major complica- Thirty-two patients (80o/o) were satisfied with the tion rate was 12.5o/o, which included: one compiex procedure, four patients (10%) were satisfied with regional pain syndrome (CRPS) and four nonunions reservations, and four patients (10%) were dissadsfied (Thble 2). with the results of their surgery. Thirty-three patients The nine patients with painful internal fixation had (82.5%o) responded that they would have the procedure the screws removed, which provided immediate relief of performed again. Seven parienrs (17.5 o/o) stated that they symptoms. A1l other minor complications wenr on ro would not have the procedure performed again (Thble 1). resolve uneventfully with the use of conservative A statistical analysis was performed to compare all treatment consisting of extended periods of non- the above data. No statistical significance was found due weightbearing, anti-inflammatory medications, corticos- to the small sample size. However, the authors discovered teriod injections, and local wound care. The patient with a trend that showed patients who smoked had a greater CRPS failed all treatment options and was referred to a chance ofa non-union. 156 CHAPTER3l

Table2

STJ ARTHRODESIS PAIIENT PROFILE

Diagnosis AS" (1lrr) Smoker F/U (wls) Union Complications Coalition 4l No 68 Yes None Coalition 32 Yes 57 Yes None Coalition 4l Yes 56 Yes Residual pain, Painful fixation Coalition 42 No 61 Yes Painful fixation Non-traumatic DJD 40 No 56 Yes Painful Fxation Non-traumatic DJD 59 Yes 64 Yes None Non-traumatic DJD 37 No 80 Yes Residual pain Non-traumatic DJD 62 yes 48 Yes None Non-traumatic DJD 42 Yes 74 No Non-union, Painful fixation Non-traumatic DJD 47 Yes 48 Yes Nonc Tlaumatic DTD 35 No 66 Yes None Tiaumatic l)TD 35 Yes 53 Yes Nonc Tiaumatic DTD 35 Yes 158 Yes Nonc Ti-aumatic DTD 53 Yes 54 Yes None Ti"aumatic DTD 38 Yes 48 Yes Stress fx talus, Painful fixadon Tiaumatic DTD 49 No 188 No Non-union Tiaumatic DTD 21 Yes 66 Yes Nonc Tiaumatic DTD 49 No 52 Yes None Tiaumatic DTD 6l Yes 44 Yes Residual pain, CRPS, painful fixation taumatic DJD 58 No 78 Yes None Tiaumatic DJD 69 No 44 Yes Nonc PTTD 68 No 64 Yes Nonc PTTD 55 No 66 Yes Dehiscence, Residual pain, Painfirl fixation PTTD 67 No 277 Yes Delayed union, painful fixation PTTD 46 No 136 Yes None PTTD 58 No 42 Yes Delayed union, Residual pain PTTD 56 No 58 Yes None PTTD 56 No 68 Yes Nonc PTTD 57 No 67 Yes None PTTD 42 Yes 6l No Non-Union PTTD 43 Yes 51 No Non-Union PTTD 27 No 47 Yes None PTTD 72 No 48 Yes None PTTD 38 Yes 40 Yes Delayed union, painful fixation, residual pain PTTD 65 No 43 Yes none PTTD 65 yes 55 yes None PTTD 45 Yes 40 Yes Sural neuritis, Stress lx tibia PTTD 76 No 56 Yes None PTTD 59 No 40 Yes None PTTD 60 No 36 Yes None

Coalition = Middle Facet Coalition of Subtalar Joint; DJD = Dcgenerati,e Joint Disease; F/U - Follo*up weeks; PTTD = Posterior Tibial Tendon l)ysfuncrion; fx = Fracture; CRPS = Complex Regional Pain Svndrome.

DISCUSSION etiologies in these series.'' 12 i5 The average patient age of 50 was comparable to Mangone et al.u whose average age There were 12 men (3Oo/o) and 28 women (70olo) in our was 53 years old. However, our Patient population was review. The high female to male ratio was similar to other approximately a decade older than previous studies whose isolated subtalar joint arthrodesis series that had a large preoperative diagnoses included mostly traumatic number of patients with posterior tibial tendon dysfunc- etiologies.T'13 tion.5 Several studies report the opposite, which can be The average follow-up period was 15 months, attributed to the larger number of posttraumatic which is a short follow up period in comparison to other CHAPTER 31 157

Thble 3

COMPLICAIIONS OF STJ ARTHRODESIS IN RELAIION TO DIAGNOSIS

PREO PERATIVE DIAGNOSIS Complications PTTD Thaumatic DJD Non-traumatic DJD Coalition Total Major Non-union 2 1 0 4 CR?S 0 0 0 Minor Stress fx talus 0 0 0 Stress fx tibia 1 0 0 0 Delayed union J 0 0 0 3 Sural neuritis 1 0 0 0 1 Dehiscence 1 0 0 0 1 Painful fixation .) 2 2 2 9 Residual pain :) 1 1 1 6 14 (52o1o1 6 (22o/o) 4 (r5o/o) 3 (llo/o) )'7

PTTD Postcrior'fibial = lendon Dysflnction; DJD = Deeenerarive Joint Diseasei & = Fracturei CoJition = lv{iddle facct Coalition ofsubtrlarJoirt; CRpS = CornpJex Regional pain Syndrome.

studies.''7'8 Due to the short-term follow up, radiographic three delayed unions in our study was a smoker. Cobb et evaluation of angular measures and adjacent joint al." reported that the relative risk of nonunion was arthritis were not analyzed. Adjacent joint arthrosis has increased 3.75 times for the active smoker undergoing been a reported long-term follow up finding after hind- ankle joint arthrodesis. Bednarz et al., reporred that four foot arthrodesis procedures.T.,o of 28 isolated subtalar joint arthrodeses resulted in a Proponents of isolated subtalar joint arthrodesis nonunion, of which all were smokers. Another study agree that this arthrodesis will increase srress on rhe reviewed 184 isolated subtalar joint arthrodeses and adjacent joints, but preserves the majoriry of motion at reported that 73o/o of there 30 nonunions occurred in the midtarsal joint. Thus, the incidence of clinically smokers.'3 Haverstock and Mandracchia.t recommend significant arthrosis at the ankle joint may be less in com- that patients who smoke should seek medical rreatment parison to a triple arthrodesis.rl,,t Thlonavicular joint for nicotine addiction prior to elective foot and ankle motion has been shown to decrease from l3-45o/o in vitro surgery, due to the risk ofdelayed healing and nonunions. and 40o/o in vivo following an isolated subtalar joint Bone grafts were utilized in 45o/o of our patienrs ro to arthrodesis.T Mild to moderate degenerative changes enhance fusion of the arthrodesis site. All seven parienrs within the ankle joint (360/o) and midtarsal joint (4lo/o) treated with structural bone grafts (autogenous anterior has also been demonsrrated following subtalar joint iliac crest grafts and aurogenous tibial strut grafts) went arthrodesis.T It is well known that neither slight varus nor on to primary fusion. This differs from a study by Easley excessive valgus is well-tolerated following hindfoot et a1.," which showed only B3o/o of rhe structural autoge- 10, 17 20 surgical procedures.T, The authors believe that nous grafting cases when on to union. In this same study, positional realignment of the subtalar joint is critical and 40o/o of patienrs thar received structural allograft wenr on may be the most significant factor relative ro ourcome. to a nonunion. In conrrast, none of our patients had a There were 36 feet that went on to primary union, structural allograft utilized. The use of structural allo- therefore our overall union rate was 90%o. The union rates genic bone graft in joint arthrodesis is a relative reported in the literature vary from 84o/o to 100%o.t'8, 13 contraindication.'3 Non-structural, autogenous bone The overall time to union averaged 12.6 weeks, which is grafting in subtalar joint arthrodesis was used in a study comparable ro other studies., The mean time to full of 45 fusions with only one patienr developing a weightbearingwas 14 weeks, which is similar to previous nonunion.n Kitaoka andPatzer5 stated that bone grafting reports of approximately 12 weeks until unprotected is unnecessary when fusing the subtalar joint in patienrs weightbearing.6 with posterior tibial tendon dysfunction. The impact of smoking on arrhrodesis has been Our study revealed a 37.5o/o overall complication rate, r, 13, 2r cleariy shown to impede bone healing. The results of both major and minor complications. Some of the our rerrospective study demonstrated three of four isolated subtalar joint arthrodesis literature indicates high nonunions (75o/o) occurred in smokers. Also, one of the union rates and low complication rates.5,6 However, these r58 CHAPTER 31 studies were only concentrated on correcting flatfoot compare, however the majority of our patrents were deformities. In contrast, Easley et al.'' reported markedly satisfied with their result and would have the procedure higher complication rates for the correction of a variety of performed again. preoperative diagnoses. Our study reflected similar findings. Subtalar joint pathology is variable and includes Our major complications (12.5%) were CRPS and posttraumatic talocalcaneal arthritis, calcaneal fracture, nonunions. CRPS occurred in one patient who had a talocalcaneal arthritis, nontraumatic arthritis, talocal- subtalar .ioint fusion secondary to a traumatic degenera- caneal coalition and posterior tibial tendon dysfunction. tion of the joint. Similarly, Amendola and Lammens" Many studies have reviewed the outcome of isolated reported CRPS as a complication after subtaiar subtalar joint fusions, however most studies fail to arthrodesis following a calcaneal fracture. Delayed unions mention the significance of the preoperative etiology in occurred in two patients with a preoperative diagnosis of determining outcome. Similar to studies by Mann et al.' posterior tendon dysfunction. To the authors knowledge, and Russotti et al.,' our study included a variery of delayed unions have been unreported in the literature and preoperative diagnoses. few studies have mentioned malunion as a post-operative Isolated subtalar joint arthrodesis has been complication.' No malunions were identified in our advocated for traumatic hindfoot arthrosis.ra " Easley et study. Four nonunions occurred in our series, and like al.'3 reviewed 174 subtalar .ioint fusions of which 138 Easley et al.'s'3 study we found that neither the pre- (80o/o) were secondary to a traumatic event. They found operative diagnosis nor the complexiry of the fusion that the majority of these traumatic cases went on to a (bone grafting or revisional arthrodesis) had any relation- successful arthrodesis. Similarly, our Patients with ship to the nonunion rate. Like previous rePorts, our traumatic etiologies had mostly favorable results. study showed that smoking greatly increased the risk of Kitaoka and Patzert looked specificly at subtalar nonunions in subtalar joint fusions. joint arthrodesis in 21 patients with posterior tibial Minor complicadons (55o/o) included the following: tendon dysfunction. Our 19 patients with flatfoot painful internal fixation, sural neuritis, wound dehis- deformities had a higher number of complications cence, stress fractures, and residuai post-operative pain. compared to their results. The authors theorize that the Although stress fractures occurred in rwo patients, Post- increased complication rate may be due to the lack of operatively these healed uneventfully. These minor staging flatfoot deformities in both studies' complications are frequently encountered in any foot and Easley et al." looked at subtalar joint coalitions and ankle surgical procedure and were treated successfully found that only 75o/o went on to union. However, our with conservative care. Although defined as a minor com- study showed all patients with coalitions had primary plication, painful internal fixation can lead to additional union with no major complications. Although the interventions, either operative or advanced imaging. investigators have not had success with subtalar coaliton Similar to our results, Easley et al." and Carr et al.' found resection, some authors favor this method over primary painful fixation or heel pad irritation in approximately arthrodesis.2e' 3o 2Oo/o of their patients. Therefore, the authors of this Our resuits show that complication rates vary manuscript have modified their screw placement to avoid depending on the preoperative subtalar joint etiology. the weightbearing area of the plantar calcaneus, Residual Unfortunately, this study was limited due to the small postoperative pain was common in our study and in sample sizes for each etiology. Therefore, the authors were preoperative diagnosis many other reports.s''' '3 The authors theorize this may be unable to statistically correlate the the result of an unrecognized suprastructural deformity to the rype or rate of postoperative complications. and currentiy utilize a radiographic protocol to evaluate hindfoot alignment to prevent this oversight. CONCLUSION Most manuscripts that discuss subtalar joint arthrodesis use a modified version of the American Isolated subtalar joint arthrodesis with or without an Orthopaedic Foot and Ankle Society ankle-hindfoot adjunctive soft tissue procedure is an effective treatment scoring system.5''' " Easley et al." found that 84o/o of their for pain and deformity of the hindfoot. Our study patients returned to normal daily activities following suggests that complications are not uncommon following arthrodesis. Mangone et a1.6 reported an 82o/o of their isolated subtalar joint arthrodesis and have a greater patients would have the procedure performed again. prevalence than some previous reports. Isolated subtalar Kitaoka and Patzer5 discovered that some of their patients joint arthrodesis should be considered as a salvage had ankle pain when walking on uneven surfaces. The procedure for painful hindfoot pathology. results of our subjective questionnaire are difficult to CHAPTE,R 31 I59

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