HOSPITAL FOR SPECIAL Grand Rounds from HSS SURGERY MANAGEMENT OF COMPLEX CASES September 2015 | Volume 6 Issue 1 AUTHORS From the Editor Constantine A. Demetracopoulos, MD Edward C. Jones, MD, MA Assistant Attending Orthopaedic Surgeon Assistant Professor of Orthopaedic Surgery Weill Cornell Medical College This volume of Grand Rounds from HSS focuses on foot and Mark C. Drakos, MD ankle surgery. We offer challenging cases presented by HSS Assistant Attending Orthopaedic Surgeon Foot and Ankle specialists; three patients who presented with Assistant Professor of Orthopaedic Surgery malalignment, instability and disabling pain who had previously undergone Weill Cornell Medical College unsuccessful procedures for relatively common conditions. Each case required Scott J. Ellis, MD diagnostic acumen and multifaceted revision surgery in order to restore proper Associate Attending Orthopaedic Surgeon alignment and comfortable function for these very encumbered patients. Associate Professor of Orthopaedic Surgery Weill Cornell Medical College In the first case, Chief of the HSS Foot and Ankle Service,Matthew Roberts, Scott Ellis and Elizabeth Cody revised a failed triple arthrodesis in a 66-year-old Austin T. Fragomen, MD woman with severe flatfoot deformity. Associate Attending Orthopaedic Surgeon Associate Professor of The second case involved a 75-year-old woman who presented with progressive Clinical Orthopaedic Surgery valgus deformity of the ankle along with worsening pain, one year after a Weill Cornell Medical College failed triple arthrodesis and deltoid ligament reconstruction. Scott Ellis and Matthew M. Roberts, MD Constantine Demetracopoulos, assisted by Dylan Soukup, performed Associate Attending Orthopaedic Surgeon total ankle replacement, using a stemmed, fixed-bearing prosthesis. First Chief, Foot and Ankle Service tarsometatarsal fusion was also necessary to achieve neutral forefoot alignment. Associate Professor of Clinical In the final case, Foot and Ankle specialistMark Drakos collaborated with Orthopaedic Surgery Weill Cornell Medical College Limb Lengthening and Complex Reconstruction specialist Austin Fragomen in performing complex, staged revision surgery on a 27-year-old woman after failed cavovarus hindfoot reconstruction. CO-AUTHORS All volumes of this publication also available on www.hss.edu/complexcases, Elizabeth A. Cody, MD where you will find additional images and references as well as links to Orthopaedic Surgery Resident Hospital for Special Surgery related articles. We hope you find these cases to be of interest and the principles presented informative. Comments are always welcome at Dylan Soukup, BS [email protected]. Clinical Research Assistant Orthopaedic Surgery, Foot and Ankle Service Hospital for Special Surgery Edward C. Jones, MD, MA Assistant Attending Orthopaedic Surgeon In This Issue Case 1 Case 2 Case 3 Revision of Failed Total Ankle Staged Revision Triple Arthrodesis Replacement for Surgery for Failed for Flatfoot Valgus Deformity Cavovarus Hindfoot Deformity Correction Following Reconstruction Triple Arthrodesis and Failed Deltoid Ligament Reconstruction Case 1 Case presented by Elizabeth A. Cody, MD, Matthew M. Roberts, MD, and Scott J. Ellis, MD Revision of Failed Triple Arthrodesis for Flatfoot Deformity Case Report: A 66-year-old woman and non-union of the subtalar arthrodesis. bearing. At 10 weeks, all three joints and the presented initially for consultation at Hospital Also noted was persistent forefoot abduc­ calcaneal osteotomy showed radiographic for Special Surgery (HSS) in February 2012 tion and hindfoot valgus (Figure 2). healing. By 6 months, she had minimal symp­ with severe right flatfoot deformity (Figure 1). toms, and examination showed significantly Given significant residual deformity and She had a 6-year history of right foot pain, improved hindfoot and forefoot alignment subtalar nonunion, the decision was made without any history of trauma. Her medical with good ankle range of motion (Figure 3). to perform a revision triple arthrodesis. In history was notable for well-controlled type August 2014, the patient underwent removal Discussion: This is a case of malunited 2 diabetes. Past surgical history was notable of hardware, revision triple arthrodesis, and triple arthrodesis for a severe flatfoot for distal metatarsal osteotomy for hallux concomitant medializing calcaneal osteotomy. deformity, managed with revision triple valgus. In October 2012, the patient elected The nonunited subtalar joint was debrided. arthrodesis and calcaneal osteotomy. to undergo triple arthrodesis for her pes The fused calcaneocuboid joint was oste­ Triple arthrodesis is indicated in cases planovalgus deformity at another hospital. otomized with an oscillating saw. The fused of severe, rigid flatfoot deformity due to She returned to HSS for another consulta­ talonavicular joint was osteotomized with a posterior tibial tendon dysfunction. The tion in 2014 due to persistent deformity, curved osteotome. The talonavicular joint goals are a painless, plantigrade foot with swelling and stiffness, as well as increasing was reduced first to correct the forefoot neutral hindfoot alignment. ankle pain. On examination, she had a severe, abduction. The subtalar joint was then The rate of failure of triple arthrodesis rigid pes planovalgus deformity. Ankle reduced with the aid of a laminar spreader requiring revision surgery is historically fairly range of motion was well-preserved, with placed in the sinus tarsi, which helped low. Mäenpää et al. analyzed 307 arthrod­ no signs of ankle instability. X-rays and translate the joint medially. Given residual eses, of which 21 failed. They found that the computed tomography showed fusion of hindfoot valgus, a medializing calcaneal most common cause of failure was surgical the talonavicular and calcaneocuboid joints osteotomy was performed. All bony work misjudgment, with inadequate correction of was held provisionally with Kirschner wires. A B deformity and resultant malnunion. [1] After excellent correction of the forefoot For failed triple arthrodeses, a midfoot oste­ abduction and hindfoot valgus was otomy can be used as a salvage procedure. confirmed, attention was turned to final Toolan described a biplanar, opening-closing fixation. Two 6.5mm partially threaded osteotomy of the midfoot, with good results screws were placed so as to traverse the reported in five patients. [2] Haddad et al. calcaneal osteotomy as well as the subtalar described using a calcaneal osteotomy in joint. Another 6.5mm partially threaded combination with revision of the transverse screw was placed from the medial navicu­ tarsal arthrodesis, tailored to each patient’s lar into the talus; this was supplemented deformity, also with good results. [3] Given Figure 1 by a claw plate to secure the talonavicular the subtalar nonunion and the severity of joint. The calcaneocuboid osteotomy was hindfoot deformity in the case described secured with a second claw plate. Ten cc of here, a midfoot osteotomy alone would demineralized bone matrix was combined have been insufficient. with autogenous iliac crest bone marrow aspirate and used to augment the fusions In cases such as this, achieving a neutral and osteotomies prior to final fixation. hindfoot is critical, as progressive valgus leads to deltoid insufficiency and ultimately, Postoperatively, the patient was placed in a ankle arthritis. Hyer et al. showed that valgus short leg splint, changed to a short leg cast collapse occurs following triple arthrodesis at 2 weeks. At 6 weeks, she was transitioned if the hindfoot is left in any residual valgus. to a Cam boot and allowed to progress weight Figure 2 Some of the feet did not develop progres­ Figure 1: Initial X-rays from 2012 show severe flatfoot sive valgus, but almost all of these started deformity: (A) greater than 50% uncoverage of the with neutral alignment. [4] As in the case talar head is seen on the AP view; (B) the lateral view shows the plantarflexed talar head and subtalar joint described here, a calcaneal osteotomy can subluxation. be used if necessary for additional correc­ tion. This case illustrates the importance Figure 2: Preoperative X-rays, following triple arthrodesis done at an outside institution, show of a careful, individualized approach to minimal change in alignment. the painful flatfoot deformity, with close attention to correcting forefoot as well as Figure 3: X-rays taken 6 months after revision surgery show healed fusion and osteotomy sites, hindfoot alignment. ■ with marked improvement in forefoot abduction. Figure 3 The ankle joint is well preserved. Continued on page 4 1 | Grand Rounds September 2015 | Volume 6 Issue 1 Case presented by Elizabeth A. Cody, MD, Matthew M. Roberts, MD, and Scott J. Ellis, MD Case 2 Case presented by Dylan Soukup, BS, Constantine A. Demetracopoulos, MD, and Scott J. Ellis, MD Total Ankle Replacement for Valgus Deformity Correction Following Triple Arthrodesis and Failed Deltoid Ligament Reconstruction Case Report: A 75-year-old retired female a long-stem intramedullary implant with Patient selection for TAR is important for a with a history of flatfoot deformity presented a thick polyethylene bearing. Sustained successful outcome. Severe coronal defor­ for evaluation due to significant lateral ankle forefoot supination after implantation of the mity is considered a relative contraindication pain, compromised gait, and severe valgus TAR, along with hypermobility of the first ray for TAR in patients with preoperative