Aim: To improve our technique of subtalar fusion for the correction of flexible abducto-valgus foot deformities during single event multilevel surgery in children with cerebral palsy, specifically, to decrease operating time, avoid donor site morbidity, improve fusion rates and prevent loss of correction. Methods and Results: The modifications are:. Preparation of the sinus tarsi using hemispherical reamers. Grafting the sinus with a press fit, cortico-cancellous iliac crest allograft, cut with a circular “cookie cutter”. Placing an 8mm titanium cannulated screw parallel to the talo-navicular and calcaneo-cuboid joints. All patients had a preoperative instrumented gait analysis, video recordings of foot position, AP and lateral weight bearing radiographs. Patients were encouraged to weight bear as tolerated in a cast at three weeks. Six weeks postoperatively the casts were replaced with ankle-foot orthoses. Gait laboratory reviews were conducted at 3, 6, 9, 12 and 24 months postoperatively with radiological evaluation of the subtalar fusion at 6, 12 and 24 months postoperatively. Between January 2001 and December 2004, 58 children, mean age 9 years and 4 months underwent bilateral subtalar fusions with the modified technique during multilevel surgery. Fifty-eight patients were reviewed 12 months postoperatively and 54 at 24 months postoperatively. Deformity correction was uniformly satisfactory. All patients had complete graft incorporation on plane radiographs. No patient required a revision procedure. Six patients subsequently had first metatarso-phalangeal joint fusions for symptomatic hallux valgus. Conclusion: The reliability of extra-articular fusion of the subtalar joint improved dramatically using screw fixation and iliac crest graft as described by Dennyson and Fulford. This can be further improved by the use of hemispherical reamers to the sinus tarsi and cannulated screws for fixation of the talus to the os calcis. Allograft is a reliable substitute for autograft and is acceptable to most patients and families

Background. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. Methods. We present the first UK series of 33 arthroscopic subtalar fusions in 32 patients, with a variety of pathologies. Results. There were 14 males and 18 females operated on between March 2004 and February 2009. Patients with previous hindfoot fusions were excluded as were patients who underwent combined arthroscopic hindfoot fusions. All patients had surgery by the senior author and followed an identical post-operative management plan. No patients were lost to follow-up. Successful outcome was taken as clinical and radiological evidence of fusion. We report a 100% union rate with 75.8% [25/33] union by 12 weeks, 97% [32/33] by 16 weeks with a single outlier achieving fusion at 22 weeks. There were no wound breakdowns, deep infections, neuromas or thrombotic events. Two patients required removal of metalwork. One patient developed mild CRPS and a further patient became symptomatic from concomitant calaneo-cuboid and talo-navicular joint arthrosis. Discussion. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. This technique respects the soft tissue envelope and therefore is less traumatic to the hindfoot. Our early results suggest that isolated arthroscopic subtalar fusion is a safe and reliable technique, even in patients with deformity, with an excellent union rate and minimal complications

Introduction: An ideal screw for subtalar fusion would be designed such that screw thread length in the distal bone would be maximised but without distal perforation, whilst having no threads across the fusion site that would inhibit compression. Method: Radiographs and clinical assessment of 100 patients who had undergone subtalar fusion were analysed and correlated with the presence or absence of non-union. In addition, using the characteristics of the inserted screw as a scaleable marker, it was calculated what would have been the optimum length of screw thread in order to maximise screw thread length in the target bone whilst preventing the screw threads being across the fusion site. Results: There is no correlation between the presence of screw threads across the fusion site and non-union. Currently available screws have thread lengths that are either too long (breaching the fusion site) or too short for ideal fixation and we propose a different thread length to those currently available. However, even with current screws, we found no correlation between thread length, thread positioning across the fusion site and non-union

Fusion of the subtalar joint is an accepted method for numerous hindfoot pathologies. Various open techniques have been reported with similar good to excellent results. We designed this prospective analysis to evaluate the efficacy of arthroscopic subtalar fusion to compare the outcome with standard open techniques. Method: 51 adults with a mean age of 42 years (range 21–75) were operated due to persistant pain and impaired function of the hindfoot unresponsive to symptomatic treatment. Patients were excluded if a significant deformity was present. Scoring was done according to the AOFAS ankle-hindfoot scale preoperatively and at each follow-up exam. A summery of the surgical technique is further given. Results: 53 arthroscopic subtalar fusions were performed in 51 patients. At final follow-up (minimum 2 years) the AOFAS score improved from 52 preoperatively to 88 points. Non-unions were not observed. Clinical outcome was good and excellent in over 95% of all cases. Progression of degeneration in adjacent joints was minimal. Through the arthroscopic approach intraoperative visualization and preparation of the fusion site is superior to the open technique. Furthermore the clinical outcome supports the use of the endoscopic technique for the treatment of painful osteoarthritis of the hindfoot

Displaced fractures of the os calcis involving the subtalar joint frequently cause chronic disability due to subsequent osteoarthritis. Early posterior subtalar fusion may prevent this outcome. We have reviewed forty-seven fractures in forty-three patients at an average of seven years after operation. Over 90 per cent of patients had an excellent, good or satisfactory result

A simple modification of Gallie's subtalar fusion is described as a salvage procedure in treating patients with pain from old fractures of the calcaneous involving the subtalar joint. Graft bone for the fusion is taken from the outer half of the calcaneus, thus avoiding disturbance of the tibia or iliac crest. Collapse of the donor site helps to narrow the widened heel present in these patients. The posterior approach allows the peroneal tendons to be freed from any adhesions, and at the same time release of the calcaneo-fibular ligament permits some correction of the valgus of the heel. The early results in six patients have been encouraging

The December 2024 Foot & Ankle Roundup. 360. looks at: Tibiotalar sector and lateral ankle instability; Isolated subtalar fusion and correction of progressive collapsing foot deformity; Diabetic control and postoperative complications following ankle fracture fixation; Are insoles of any benefit for plantar fasciitis?; Postoperative foot shape and patient-reported outcome following surgery for progressing collapsing foot deformity; Calcaneo-stop procedure for symptomatic flexible flatfoot in children

1. Three pantalar, one ankle and subtalar, and three ankle arthrodeses have been performed by a technique, the essential step of which is the insertion of a transarticular graft from below. Union has occurred in four to five months.

2. A method is described of determining the degree of equinus before the operation and securing it during the operation.

3. Pantalar fusion by this technique compares favourably with the methods described so far.

A recognised treatment for severe sub-talar arthritis is joint fusion. This can be performed using a well established open technique or achieved through an arthroscopic approach. The aim of this retrospective study was to investigate the results of arthroscopic sub-talar arthrodesis performed by a single surgeon in our institution.

13 arthroscopic sub-talar joint fusions were performed over a 2 year period in patients presenting with isolated arthritis of the joint in question. All arthrodeses were carried out using two posterolateral portals and one posteromedial portal and fixed with two single 7 mm partially threaded cancellous screws. Outcome measures included the American Foot and Ankle (AFOS) score, time to union and post-operative complications.

No patients were lost to follow-up. 12 out of 13 arthrodeses went onto clinical and radiological fusion. The AFOS score improved from36 (range 32–50) pre-operatively to 75 (range 65–80) at final follow up. Complications included 1 non-union, 1 DVT and 1 superficial wound infection. 3 patients have had metalwork removed secondary to screw irritation.

The results of subtalar arthrodesis performed using an arthroscopic technique is comparable with an open approach and provides high patient satisfaction.

Introduction. Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail. Materials & Methods. A retrospective cohort study was performed based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiological and clinical outcomes, and adverse events. Factors influencing radiological and clinical outcomes were analysed. Results. 47 patients were included, with a mean follow-up of three years. The mean age at time of surgery was 63.6 years. Patients had a median of two previous surgeries. The median LOS was 8.5 days, and median EFT was 237 days. Where simultaneous limb lengthening was performed, the average lengthening was 2.9cm, increasing the EFT by an average of 4 months. Primary and final union rates were 91.5% and 95.7% respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and re-operations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. Conclusions. Complex ankle fusion using circular frames can achieve good outcomes in complicated clinical scenarios, however patients can expect a prolonged time in the frame and high rates of adverse events. Multiple risk factors were identified for poorer outcomes, which should be considered in patient counselling and prognostication

Introduction. AlloStem/Cellular Bone Allograft and autologous bone graft are accepted methods for managing hindfoot degenerative arthritis. The purpose was to evaluate outcomes of AlloStem and autograft in subtalar arthrodesis and compare overall fusion rates. Methods. This study was conducted in IRB compliance. Patients between 18–80 years who qualified for a subtalar fusion were randomized 1:1 to AlloStem or autologous graft. The AOFAS hindfoot ankle scale, FFI-R and SF-12 were collected pre-operatively, 6 weeks, 3 & 6 months, 1 and 2 year. Weight-bearing 3-view ankle X-rays were done at the same intervals. A CT scan was obtained at 6 months. Results. 140 patients were enrolled; 124 patients had surgery(60-AlloStem and 64-Control). Withdrawals included 14 voluntarily before surgery and 2 intra-operative failures. 19 were lost to follow-up. Mean age for AlloStem was 56.69(20.3–79.6) and Autograft was 54.60(20.74–80.07). 59 AlloStem patients completed their 6 month visit and 45 completed 2 years. AOFAS score improved: 40.02 at pre-op to 72.16(6 mo) to 79.51 at 1 year and 80.38 at 2 year. SF-12 improved 58.29 at pre-op to 65.67 at 6 month and 71.59 at 2 year. FFI-R improved 236.88 at pre-op to 203.53 at 6 month 149.93 at 2 year.60 Autograft patients completed their 6 month visit and 51 patients completed their 2 year. AOFAS score improved 42.89 at pre-op to 75.67 (6 mo) to 79.75 at 1 year and 78.62 at 2 year. Autograft SF-12 improved 60.55 at pre-op to 70.40 at 6 month and 75.26 at 2 year. Autograft FFI-R improved 217.16 at pre-op to 166.77 at 6 month and 145.43 at 2 year. AlloStem patients had a mean posterior fusion rate of 28.9% at 6 months whereas the Autograft had 46.3%(p=.049). Non-union rates were AlloStem(9/57)(15.7%) whereas Autograft was 3/60(5%). Conclusion. AlloStem trended to be inferior to Autologous graft

The December 2015 Foot & Ankle Roundup. 360 . looks at: The midfoot fusion bolt: has it had its day?; Ankle arthroplasty: only for the old?; A return to the Keller’s osteotomy for diabetic feet?; Joint sparing surgery for ankle arthritis in the context of deformity?; Beware the subtalar fusion in the ankle arthrodesis patient?; Nonunion in the foot and ankle a predictive score; Cast versus early weight bearing following Achilles tendon repair; Should we plate Lisfranc injuries?

5207 patients treated for a calcaneous fracture in Ontario between 1993–1999 were identified from population datasets and were reviewed to evaluate regional practice variation and complication rates for operatively and non-operatively managed calcaneous fractures. There was considerable geographic variation in treatment. Individuals in some parts of Ontario were almost eight times more likely to receive operative treatment than others. The majority of calcaneous fractures in Ontario are treated non-operatively, however the large observed practice variation suggests that there is disagreement among treating clinicians. Primary subtalar fusion has a high risk of post-operative infection and should therefore be considered very cautiously. The purpose of this study was to evaluate regional practice variation and complication rates for operatively and non-operatively managed calcaneous fractures. The majority of calcaneous fractures in Ontario are treated non-operatively, however the large observed practice variation suggests that there is disagreement among treating clinicians. Primary subtalar fusion has a high risk of post-operative infection and should therefore be considered very cautiously. Given the observed regional variation in management of calcaneous fractures more work needs to be done to address this issue. 5207 fractures of the calcaneous in Ontario between 1993–1999were identified from population datasets. Regional variations in treatment and complication rates were computed. Multiple linear regression was used to identify factors associated with complications. There was considerable geographic variation in treatment. Individuals in some parts of Ontario were almost eight times more likely to receive operative treatment than others. General surgeons or general practitioners definitively treated 30% of patients (almost all closed). Overall rate of complications was low, however there was a 13.4 percent infection rate following immediate subtalar fusion. Infection was 5.3% following ORIF and 0.6% following closed treatment. Infection risk was increased in multiple trauma patients and those with open fractures. Subsequent subtalar fusion rates (within the study period) were higher in multiple trauma patients, but were not associated with treatment (open or closed). Amputation was 22.5 times more likely following open calcaneous fractures but the overall amputation rate was only 0.17%. No relationship between surgeon experience and the rate of complications following operative treatment was identified

There have only been a few studies in the literature which reported on the outcome of ankle arthrodesis in patients with hemophilia, furthermore the number of patients is usually low and the operative technique is not uniform. The aim of this study is to evaluate the outcome of surgery in hemophilic arthropathy of the hindfoot, using internal fixation. From 1983 to 2006, 20 fusions were performed in 13 consecutive patients due to advanced hemophilic arthropathy of the hindfoot. There were 11 ankle fusions, 1 isolated subtalar fusion and 8 ankle and subtalar fusions, 3 of the latter on a second operation. The mean age at operation was 38.7 years and the mean followup was 9.4 years. Preoperativelly the mean modified Mazur score was 47.7. In the majority of cases the ankle fusion was achieved by two crossing screws, while, for the subtalar fusion either staples were used, or the tibiotalar screws were extended to the os calsis. Arthrodesis of the ankle was successful in all but one patient, who was revised and progressed to fusion. The mean postoperative modified Mazur score was 94.9. There was also one painless incomplete union of the subtalar joint which did not need revision. There was no recurrent bleeding, and no deep infection. Arthrodesis with cross screw fixation and staples is a quick, simple and effective method for fusion of the hindfoot in patients with hemophilia

Introduction. The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing. Methods and materials. 33 patients underwent ankle/subtalar arthrodesis at our institute from 2000-2008. The average age of the patients was 69 years and the male: female ratio was 2:1. The minimum follow-up was for one year. Although there were some variations in technique, all the arthrodesis were performed by removal of articular cartilage, bone grafting of any defects and rigid internal fixation. Results. 2/33 patients developed a stress fracture of the distal tibia following successful ankle/subtalar fusion. An angle of ankle/subtalar fusion showed an average of 0 degrees +/− 3 degrees in the sagital plane, except for the two cases that developed the stress fracture. The angles in these cases were 13 and 11 degrees. The stress fractures occurred proximal to the level of the previous arthrodesis internal fixation devices (arthrodesis nail/cancellous screws). Intramedullary and extramedullary devices were utilised to obtain union across the stress fracture sites, without success. Discussion. Equinus of more than 10 degrees following ankle/subtalar arthrodesis is a high risk factor for developing a stress fracture of the distal tibia following ankle/subtalar arthrodesis. Stress fracture following successful ankle/subtalar arthrodesis causes severe morbidity. They are extremely difficult to treat, hence are best avoided if possible

Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. 22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion. All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion. 21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

We reviewed 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean age at operation was 57 years, 2 months (20 to 86 years). The indication for operation was post-traumatic osteoarthritis in 67, primary osteoarthritis in 36, inflammatory arthropathy in 13 and avascular necrosis in two. The mean follow-up was 65 months (18 to 144). Nine patients (10 ankles) died before final review and three were lost to follow-up, leaving 104 patients (105 ankles) who were assessed by a standard telephone interview. The pre-operative talocrural deformity was between 22° valgus and 28° varus, 94 cases were within 10° varus/valgus. The mean time to union was 12 weeks (6 to 20). Nonunion occurred in nine cases (7.6%). Other complications included 22 cases requiring removal of a screw for prominence, three superficial infections, two deep vein thromboses/pulmonary emboli, one revision of fixation, one stress fracture and one deep infection. Six patients had a subtalar fusion at a mean of 48 months after ankle fusion. There were 48 patients with excellent, 35 with good, 10 with fair and 11 with poor clinical results

1. A simple method of subtalar fusion, suitable for use in children, is described. 2. Although it is intended to provide stability for some years until a complete subtalar fusion can be carried out, further operation may not be necessary. 3. Its use is not advocated over the age of eleven or twelve

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV. 97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management. In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure

1 . A small series of fractures of the calcaneum with distortion of the subtalar joint has been reviewed. 2. All were treated by subtalar fusion, in most as part of the primary treatment. 3. In all patients the subtalar joint fused by bone without post-operative plaster immobilisation. 4. Plaster immobilisation is not only unnecessary, it is undesirable. 5. Heavy work, including work on ladders and scaffolding, can be undertaken after subtalar fusion