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Subtalar Joint Arthrodesis

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Subtalar Joint Arthrodesis 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
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