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Background: Planovalgus deformity of the foot is common among cerebral palsy (CP) patients. It is an upcoming topic with debate and controversy that require further studies. Many clinical studies involving arthroereisis have shown acceptable results in short- and mid-term follow-up. The aim of this work was to evaluate the outcome of arthroereisis using a conventional screw placed percutaneously across the talocalcaneal articulation for the treatment of moderate planovalgus deformity in children with CP., Methods: Between 2015 and 2018, a prospective study was conducted including 23 CP patients with bilateral flexible planovalgus deformity with follow-up period ranging from 24 to 40 months (mean of 36.7 months). The radiological and clinical outcomes were assessed. The patient/parent outcome was evaluated using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C)., Results: The results showed statistically significant improvement in both radiological and clinical data as well as patient's symptoms and parent's satisfaction., Conclusion: Results obtained from literature from the past decades after arthroereisis for the correction of moderate planovalgus deformity in CP patients are promising. The few studies reported on that procedure shared the same harmony with our study giving a chance to be a good alternative to joint destructive procedures. Our technique is simple, effective, economical, and minimally invasive if used in selected pediatric CP patients., Levels of Evidence: Therapeutic, Level IV.

Background: Adult acquired flatfoot deformity (AAFD) is a condition affecting approximately 3% of the adult population. It can lead to severe morbidity, and therefore, prompt treatment is of the upmost importance in maintaining and restoring function. Recently, the use of subtalar arthroereisis has become more widespread in the treatment of AAFD. The purpose of this systematic review is to examine the clinical and radiological outcomes of AAFD when treated with subtalar arthroereisis., Methods: Studies involving the use of subtalar arthroereisis for the management of AAFD were reviewed, and appropriate studies selected based on inclusion and exclusion criteria. Studies were reviewed for both clinical and radiological outcomes following the use of subtalar arthroereisis as well as reported complications., Results: Nine studies met our inclusion criteria, with most of these involving stage II AAFD. A total of 190 subtalar arthroereisis procedures were performed with all studies demonstrating improvement in both clinical and radiological scores with a low rate of complications., Conclusion: Subtalar arthroereisis may have benefits when used as an adjunct to treat stage II AAFD. However, more high-quality studies are needed to establish its best use., Levels of Evidence: Level IV: Systematic review .

Background: Tibiotalocalcaneal (TTC) arthrodesis is a salvage reconstructive procedure for ankle and subtalar arthritis and deformity. This study aims to identify fusion rates and complications of TTC arthrodesis procedures performed at our institution using a specific retrograde intramedullary nail. Additionally, we analyzed the subpopulation that sustained an intramedullary nail break., Methods: A retrospective review was conducted of 45 patients who underwent 47 TTC arthrodesis procedures with intramedullary fixation using the Phoenix nail at our institution from October 2010 to September 2017. Patient age, body mass index, sex, smoking status, diabetes diagnosis, peripheral vascular disease, thyroid disease, inflammatory arthritis, steroid use, prior ankle fractures and procedures, fusion rates, nail diameter, time to hardware failure, preoperative coronal plane deformity, and return to work were obtained., Results: Successful fusion was confirmed in 79% of tibiotalar, 70% of subtalar, and 66% of combined tibiotalar and subtalar joints. Eight of 47 (17%) TTC nails suffered nail breakage postoperatively. Although statistical analysis was not performed due to the small population size, patients with nail failure had lower rates of tibiotalar (38% vs 87% of patients without nail failure) and combined tibiotalar/subtalar fusion (25% vs 74%). Ten percent of patients without nail breakage required revision surgery, compared to 75% of patient with nail breakage., Conclusion: This study describes TTC arthrodesis outcomes at our institution. It demonstrates a high complication rate using a specific retrograde intramedullary nail, including nail breakage and non-union. Further analysis and improvement in technique and implant design may decrease revision rates and improve outcomes., Levels of Evidence: Therapeutic, Level IV.

Background . The purpose of this study is to evaluate functional and radiological outcomes of subtalar arthroereisis in the treatment of symptomatic pediatric flexible flatfeet. Methods. A total of 16 patients (26 feet) were treated with a Kalix II as subtalar motion blocker between 2009 and 2014. Calcaneal pitch (CP) and Meary's angle (MA) were measured on radiographs preoperatively, directly postoperatively, and at follow-up 47 ± 17 (range 19-79) months. Patient satisfaction surveys were used to assess functional outcome and patient satisfaction. Results. Surgery was performed mostly for pain, walking problems, or a combination of both at a mean age of 12.5 ± 1.5 (range 10-15) years. Symptoms were relieved in 62.5% of patients in the postoperative phase and increased to 68.75% at follow-up. A statistically significant increase in CP of 2.8° and decrease in MA of 14.0° was observed directly postoperatively, which persisted during the follow-up period irrespective of Kalix removal. Revision surgery was necessary in 6 cases (23%) because of arthroereisis migration. Conclusion. Subtalar Kalix II arthroereisis significantly reduced clinical symptoms and improved the CP and MA directly postoperatively, which persisted during follow-up, irrespective of Kalix removal. Therefore, subtalar arthroereisis is a considerable intervention to reduce symptoms in children with symptomatic flexible flatfeet. Levels of Evidence: Level IV: Case series.

Background . Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for complex hindfoot pathology. Overall union rates range from 50% to 86% but can be even lower in certain populations. A novel retrograde intramedullary nail has recently been developed. The purpose of this study was to report fusion rates, time to weight-bearing, and complications with the use of the A3 Fusion Nail. Methods . All patients 18 years or older who underwent TTC arthrodesis with an A3 Fusion Nail at a single institution from 2010 to 2015 with a minimum 3-month follow-up were included in this study. Rates of successful fusion, time to union, time to weight-bearing, and complications were evaluated. A total of 20 patients with an average age of 58.1 years and an average follow-up of 12.5 months met inclusion criteria. Results . Successful TTC arthrodesis was achieved in 14 of 20 patients (70%) overall. Average time to union was 8.1 months, and average time to weight-bearing was 6.8 weeks. Of 20 patients, 17 (85%) required femoral head allograft for bulk bone defects, and the union rate in this subset of patients was 76.5%. The rates of revision surgery (10%) and complications were low. Conclusion . The A3 Fusion Nail demonstrated a favorable safety profile and achieved TTC arthrodesis at a rate consistent with historical data despite being used in a patient population at high risk for nonunion. In patients with bulk bone defects at high risk for nonunion, the A3 Fusion Nail demonstrated superior rates of fusion (76.5%) to those reported in the literature (50%). Level of Evidence: Level III: Retrospective cohort study.

Introduction . The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods . Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results . No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion . The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence :V, Cadaveric Study.

Background: Hindfoot arthritis or significant deformity involving the ankle and subtalar joint (STJ) is a disabling condition with few salvage options. Many surgeons note a decreased STJ fusion rate compared with ankle union when a retrograde nail construct is used. The purpose of this study was to report the STJ fusion rate of tibiotalocalcaneal (TTC) arthrodesis with retrograde nail., Methods: A chart and radiographic review was performed. TTC fusions performed in patients with osteoarthritis, posttraumatic arthritis, or deformity correction with retrograde nail fixation were included. Exclusion criteria included neuropathy, Charcot arthropathy, and failed total ankle replacement., Results: Ultimately, 66 retrograde TTC fusions (in 63 patients) met inclusion criteria. The average age was 57.0 years. There were 29 female and 34 male patients. Radiographic fusion of the ankle and STJ was demonstrated in 68.2% of the patients. There were 11 cases (16.7%) of ankle arthrodesis with STJ nonunion, 6 cases (9.1%) of STJ fusion but ankle nonunion, and 4 cases (6.1%) of stable radiographic nonunion of both joints. The mean time to subtalar fusion was 112.1 days. One patient required revision surgery and conversion to below-knee amputation. One patient required a CROW walker for assistance with gait., Conclusion: A 22.8% radiographic nonunion rate of the STJ was noted in retrograde TTC fusion. Despite this, patients were stable and pain free., Levels of Evidence: Level IV: Retrospective Case series.

Intra-articular calcaneal osteoid osteoma is a very rare condition and the diagnosis as well as the treatment is extremely challenging. We report a case of a 19-year-old male with intra-articular osteoid osteoma of the calcaneus, initially treated for peroneal tenosynovitis with unsatisfactory results. Thorough diagnostic procedure revealed the superolateral location of a calcaneal osteoid osteoma, near the sinus tarsi. A cherry-red elevated lesion typical of an osteoid osteoma nidus was completely removed arthroscopically using the anterolateral portal and the middle portal for subtalar arthroscopy. Histopathology confirmed the suspected diagnosis. The postoperative clinical course was uneventful with immediate pain relief and full weightbearing and movement allowed soon. The patient had no recurrent pain and normal joint mobility 8 months postoperatively. Considering the accessibility of the lesion, intra-articular osteoid osteoma of the calcaneus can be successfully treated arthroscopically using lateral approach for subtalar arthroscopy., Levels of Evidence: Therapeutic, Level IV: Retrospective, Case report.

Unlabelled: Closed lateral subtalar dislocation is a very rare injury. We report a case of closed lateral subtalar dislocation with entrapment of flexor hallucis longus tendon producing a checkrein deformity. The patient was managed immediately with closed reduction under regional anesthesia and fixated with percutaneous Kirschner wires. Early mobilization and weightbearing was started and there were no complications till the last follow-up visit., Levels of Evidence: Therapeutic, Level IV: Case study., (© 2016 The Author(s).)

Unlabelled: Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures., Levels of Evidence: Therapeutic, Level IV: Case series., (© 2016 The Author(s).)

Unlabelled: Subtalar arthrodesis is considered to be the gold standard surgical solution for end-stage subtalar joint arthrosis. Although subtalar joint fusion rates are high, nonunion has been reported to range from 0% to 43%. Revision subtalar arthrodesis regardless of etiology often requires removal of loose hardware in soft bone. The inability of screw threads to engage bone may result in longer operative time, frustration for the surgeon, and potential negative outcome for the patient. We describe a novel technique in which a cannulated drill bit is used as a tamp to remove subtalar arthrodesis screws. We have found this method to be efficient and safe and transferable to any extremity., Levels of Evidence: Therapeutic, Level V: Expert opinion., (© 2016 The Author(s).)

Unlabelled: Tibiotalocalcaneal (TTC) arthrodesis using an intramedullary hindfoot nail is a common procedure for deformity correction and the treatment of combined tibiotalar and subtalar end-stage arthritis. Nonunion at one or both fusion sites is a difficult complication that can result in reoperation, significant morbidity, and below-knee amputation. There is currently a need for sustained compression across fusion sites using a TTC hindfoot nail with good mechanical stability. The DynaNail TTC Fusion System (MedShape, Inc, Atlanta, GA) uses an internal nitinol compression element to apply sustained compression across the tibiotalar and subtalar joints after surgery. In preliminary clinical cases, we have found that the nail is safe, reliable, and has promising clinical and radiographic results in settings of hindfoot arthritis, complex deformity, Charcot arthropathy, and talar avascular necrosis., Levels of Evidence: Expert opinion, Level V., (© 2015 The Author(s).)

Unlabelled: The role of arthroereises in the treatment of adult acquired flatfoot deformity (AAFD) has been controversial. This study aims to evaluate the outcome of subtalar arthroereisis in treating stage II AAFD. A total of 24 feet with stage II AAFD were treated surgically between 2009 and 2011 using subtalar arthroereisis. The average follow-up was 29.7 months (range = 24 to 35 months). The average postoperative AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 85.6 (compared with 51.7 preoperatively). Average preoperative talar-first metatarsal angle and talonavicular coverage angle were -13.9° and 38.3°, respectively. The average postoperative angles were 1.6° and 11.2°, respectively (P < .01). No deformity recurrences were found at the time of last follow-up, with the exception of 1 case. Subtalar arthroereisis appears to be a reasonable treatment option for stage IIA and IIC AAFD. It can be used alone to correct mild hindfoot valgus, and it can also be performed with a calcaneal osteotomy to gain more correction in severe stage II AAFD., Levels of Evidence: Therapeutic, Level IV: Retrospective Case Series., (© 2014 The Author(s).)

Background: Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA., Methods: Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate)., Results: A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of non-US respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are painful congenital flatfoot, posterior tibial tendon dysfunction, and flatfoot associated with accessory navicular., Conclusion: Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants, commonly for pain. SA is still being performed in the United States and throughout the world., (© 2015 The Author(s).)

Background: The bridle procedure is a tritendon anastomosis between the tibialis posterior, peroneus longus, and tibialis anterior, utilized in the treatment of drop foot. Concerned about the potential for acquired flatfoot deformity following the bridle procedure, the authors hypothesized that placing a sinus tarsi implant would prevent this potential sequela., Materials and Methods: Over a 10-year period, 15 patients (16 feet) were treated with a bridle procedure for drop foot, and 9 of these feet also had a subtalar arthroereisis implanted; 8 patients (9 feet) positively responded to requests for long-term follow-up evaluation and returned for subjective evaluation with the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form (SF)-36 forms and objective clinical and radiographic measurements., Results: At an average follow-up of 61 months, the 8 patients (9 feet) who returned for long-term evaluation maintained a plantigrade foot, were able to dorsiflex above neutral both actively and passively, and did not develop a flatfoot deformity at long-term follow-up. There were no significant differences between those who had a sinus tarsi implant (6 feet) and those who did not (3 feet). Although 7 of the 9 feet evaluated in this study wore a brace preoperatively, none continued to use a brace after surgery. The major complaints were occasional pain at the subtalar arthroereisis site and a feeling that the great toe was dragging., Conclusion: The bridle procedure provided excellent outcomes in patients with drop foot, with patients achieving long-term success in being free from brace wear. The ability to actively dorsiflex the foot during gait was also restored, reestablishing a normal heel-to-toe gait pattern., Levels of Evidence: Therapeutic, Level IV: Case series., (© 2014 The Author(s).)

Bone wax has been used for years by surgeons as a hemostatic agent to prevent bleeding from bone surfaces. Though the effectiveness of bone wax as a hemostatic agent while acting as a tamponade is well known, it is not without its complications. It has been documented in the medical literature that bone wax may remain in the body for many years as a foreign body and in some cases cause a giant cell reaction at various surgical sites. However, to the authors' knowledge, there has not been a reported case of a foreign body giant cell reaction secondary to the use of bone wax in the current podiatric literature. Two case studies are described to bring attention to the fact that bone wax can interfere with bone healing while remaining attached to bone as a foreign body and induce a giant cell reaction and local inflammatory effects in the human foot.

Background: Flatfoot deformities are common in children and are treated using many conservative and surgical approaches. Subtalar extra-articular arthroereisis, in particular, limits talar motion, spares the subtalar joint, and prevents excessive subtalar joint pronation. Addressing the underlying equinus deformity with gastrocnemius recession is an important factor in optimizing outcomes in patients with flatfoot deformity., Methods: This study included 20 children, 4 to 17 years old. The patients presented 34 cases of functional flexible flatfoot, and each was treated with gastrocnemius recession and a subtalar implant insertion of either a resorbable arthroereisis plug constructed of poly-L lactic acid or a threaded titanium alloy plug. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale as well as subjective assessments of pain, function, shoe wear, and overall preoperative and postoperative satisfaction., Results: The average AOFAS Ankle-Hindfoot Scale reading improved by 21.3 points (standard deviation = 8.1; 95% confidence interval = 17.5-25.1), from an average preoperative reading of 67.7 points to an average postoperative reading of 89 points (P < .0001). Subjectively, patients experienced reduced pain and improved function, cosmesis, and shoe wear., Conclusions: Treating equinus deformity with gastrocnemius recession significantly improved patient outcomes when treating flatfoot deformity. Reconstructive flatfoot surgery that combined subtalar arthroereisis with a resorbable arthroereisis plug and gastrocnemius recession resulted in favorable clinical outcomes and patient satisfaction. Symptom improvement and preservation of the subtalar joint were seen with these procedures, which are reasonable and useful options in treating children with symptomatic flexible flatfoot., Levels of Evidence: Therapeutic, Level IV, Retrospective case series.

Subtalar joint arthroereisis is a surgical modality that has been shown to be an effective procedure for flexible flatfoot in both pediatric and adult populations. Despite advances in understanding its mechanics and function, complication and implant removal rates remain as high as 30% to 40%. Analysis was performed to determine the survivability of 2 subtalar joint arthroereisis implants, absorbable and nonabsorbable, used alone and in combination with other procedures in both the adult and pediatric populations. The 95 total arthroereisis procedures were analyzed in several major categories: absorbable implants versus nonabsorbable implants and adult versus pediatric patients. Each major group was then further subdivided to create further subgroups: absorbable isolated procedures, absorbable combined procedures, nonabsorbable isolated procedures, and nonabsorbable combined procedures. The overall survival rates were 83% for absorbable implants and 81% for nonabsorbable implants. A total of 11 (17%) absorbable implants and 6 (19%) nonabsorbable implants were removed, respectively, at an average of 9 months and 23 months postoperatively. When used alone and in combination with other procedures, 36% and 13% of absorbable implants and 18% and 19% of nonabsorbable implants, respectively, were removed. When comparing adult versus pediatric populations, the overall survival rates of the absorbable and nonabsorbable implants were 81% for absorbable implants and 79% for nonabsorbable implants in the adult population and 85% for absorbable implants and 100% for nonabsorbable implants in the pediatric population.

Background: The use of intramedullary nail fixation for tibio-talo-calcaneal fusion is gaining popularity. There is chance of failure of procedure following faulty operative technique specially alignment., Methods: The article describes a useful application of tibial tunnel jig in inserting the calcanio-talo-tibial guide wire., Results: There is precision of few millimeters in the exit point of guide wire on talus., Conclusions: The authors believe that this helps in better positioning of nail and hence better alignment and better operative outcome.

The subtalar joint is complex. With the advent of smaller diameter arthroscopes, subtalar arthroscopy has become an important diagnostic and therapeutic tool for subtalar joint disorders. The objective of this study was to evaluate the outcome of patients who underwent arthroscopy for subtalar joint disorders using a 2.4-mm zero-degree arthroscope. In this prospective study, 6 patients who underwent subtalar arthroscopy from September 2008 to January 2009 in the authors' institution were included. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores were recorded preoperatively and at 3 and 6 months postoperatively. Mean +/- SD age was 45.5 +/- 16.2 years (range, 27.5-63.2). Postoperative diagnosis included arthrofibrosis, osteoarthritis, and osteochondral disease of the subtalar joint. Mean +/- SD AOFAS scores improved from 49.67 +/- 18.83 (range, 22-76) to 67.33 +/- 14.92 (range, 53-91) at 3 months (P = .03) and 75 +/- 19.74 (range, 54-100) at 6 months (P = .004). Subtalar arthroscopy using the 2.4-mm zero-degree arthroscope shows promising results in the diagnosis and treatment of subtalar pathologies. Patients have a significant improvement in their AOFAS hindfoot scores as early as 3 months and continue to improve subsequently. Usage of the zero-degree arthroscope allows the "instrumentation hand" to maneuver more easily in space and perform the operative procedure without getting in the way of the "camera hand." It can also save on inventory costs for centers that already have the zero-degree arthroscope. The role of specialized imaging is still unclear. Diagnosis of sinus tarsi syndrome should be historical with direct visualization of the joint revealing exact etiology.

A philosophical shift toward more joint-sparing procedures has led to increased use of isolated subtalar joint (STJ) versus triple arthrodesis. Union rates for STJ fusion range from 47% to 100%, leading to controversy regarding the optimal type, orientation, and amount of internal fixation. The purpose of this study was to determine if single-screw fixation is a predisposing factor to nonunion. Single-screw fixation is parallel to the STJ axis and may result in motion. It is hypothesized that higher nonunion rates will be observed in single-screw versus 2-screw fusions. Isolated STJ arthrodeses performed in 113 patients were retrospectively reviewed. Single screws were used in 89 (78.8%) fusions; 2 screws were used in 24 (21.2%) fusions. The mean follow-up was 11 months (range, 9-17 months). Nonunion occurred in 13 (14.6%) single-screw and 6 (25.0%) 2-screw fusions. Twenty (22.5%) single-screw and 3 (12.5%) 2-screw fusions required hardware removal. Revision surgery was performed in 6 (6.7%) single-screw and 3 (12.5%) 2-screw fusions. No significant differences in demographics were calculated between single and 2-screw fusions. Furthermore, no significant differences were observed in nonunion rate, postoperative complication incidence, or subsequent surgeries. The results from this study do not support the contention that single-screw fixation predisposes STJ fusions to nonunion. Comparable nonunion and complication incidences were observed between single and 2-screw fusions. These data suggest that the motion occurring from single-screw fixation may not be significant enough to directly affect the rate of union.

A 65-year-old man without significant comorbidities was referred to the senior author (EG) 9 months after an ankle arthrodesis procedure with complaints of pain, swelling, and progressive hindfoot valgus. The patient had elected to have the index surgery because of severe ankle arthritis due to longstanding lateral ankle instability. Physical examination revealed a well-healed anterior, midline ankle incision with normal pulses and sensation. Painful, limited ankle and subtalar range of motion was noted along with 20 degrees of hindfoot valgus and subfibular impingement. Radiographs of the ankle revealed an attempted ankle fusion using a knee arthroplasty trabecular metal augment placed vertically at the tibiotalar joint. There were no screws or other hardware present to provide compression and stability of the fusion. A computed tomography scan showed a tibiotalar nonunion, erosion of the talar body, and severe tibiotalar and subtalar arthritis. Inflammatory markers were within normal range. Based on the findings of a failed fusion and progressive painful hindfoot deformity, it was determined that the patient would benefit from removal of the hardware and revision fusion surgery. Tibiotalocalcaneal (TTC) hindfoot fusion was planned because of the patient's talar collapse and tibiotalar/ subtalar arthritis. The TTC procedure was performed with a retrograde intramedullary nail, femoral head allograft, and morselized fibular autograft enriched with platelet-rich plasma. The femoral head was used as a structural allograft to fill the large bone defect, prevent limb shortening, and assist in correction of the hindfoot deformity. Intraoperative findings revealed severe metallic synovitis of the ankle and subtalar joints, metal debris at the site of the trabecular implant, and segmental defects of the distal tibia and talus. Weight bearing was permitted after 16 weeks when evidence of successful ankle fusion was confirmed radiographically. At 24 months, the patient was pain free and ambulating without difficulty.

The purposes of this study were to evaluate the outcome of pediatric patients who have undergone Maxwell-Brancheau arthroereisis (MBA) subtalar implants for the treatment of painful pediatric flatfoot deformities. In a retrospective study, 39 patients (68 feet) were evaluated clinically and radiographically. The mean age of the patients was 12 years (range, 6-16 years). The mean period of follow-up was 24 months (range, 6-61 months). Statistical evaluation was performed on all radiographic measurements. Additional surgical procedures (gastrocnemius recession, Achilles tendon lengthening, Kidner posterior tibial tendon advancement) were performed in 22 of 68 feet. There were 10 (15%) complications, which consisted of 10 reoperations in 10 feet. Implants were exchanged in 9 feet because of implant migration, undercorrection, and overcorrection. There was 1 reoperation (in 1 foot) for implant removal because of persistent sinus tarsi pain. Radiographic evaluation demonstrated an improvement of all parameters determined. The parameters that were evaluated include talonavicular joint coverage, as well as lateral and anterior-posterior talocalcaneal angles. There were significant changes noted in pre- and postoperative measurements (P < .001). The MBA implant is effective for the correction of painful, flexible flatfoot deformity in children in short-term follow-up. However, this is a multiplanar deformity, and additional procedures may be needed in addition to the MBA.