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Various techniques of reconstruction of deformed Charcot hindfoot using different internal fixation devices have been described in the literature. We present our surgical technique using specific principles that has resulted in improved outcomes to allow correction of deformity, obtain stability and allow progression to weightbearing in orthotic shoes. We describe our preoperative evaluation, planning and surgical timing. We also hope to share some technical pearls and details on the finer points to achieve a satisfactory correction and reduce the learning curve.

Background The purpose of this study was to assess the benefit of using Weight-Bearing CT (WBCT) instead of radiographs (R) and/or CT in a foot and ankle center regarding time spent for image acquisition, radiation dose, and cost effectiveness. Material and Methods All patients who obtained WBCT (PedCAT) from July 1, 2013 until March 15, 2020 were included in the study. Age, sex, primary pathology were analyzed. All parameters were compared between the time period using WBCT (yearly average) with the parameters from 2012, i.e. before availability of WBCT. The time spent for image acquisition (T) and radiation dose (RD) was calculated based on measured values from previous studies. For analysis cost effectiveness, device cost, reimbursement and working time cost of radiology technicians were taken into consideration within the local circumstances. Results 13,156 WBCT scans were obtained in 5,798 patients (5,798 (44%) before treatment; 7,358 (56%) follow-up; mean age, 52.2; 46% male). Primary pathologies were forefoot deformities (n = 1,189 (21%) and ankle instability/cartilage defect (n = 832 (14%)), and hindfoot deformity (n = 765 (13%)). 1,935 WBCT scans were obtained on average yearly, and 10.2 CTs (WBCT group). In 2012, 1,850 R and 254 CTs were obtained (R(+CT) group). Yearly RD was 4.3 uSv for WBCT group and 4.8 uSv for R(+CT) group (difference 0.5 uSv decrease with WBCT 10%, p Conclusions 13,156 WBCT scans in 5,798 patients as substitution of R(+CT) over a 6.8 year period at a foot and ankle center resulted in 10% decreased RD (minus 0.5 uSV on average per patient). Yearly T decreased 380 hours (77%) in total (12.0 minutes per patient). Yearly financial income increased more than 54,000 Euro in total (58 Euro per patient). RD decreased despite higher radiation dose for WBCT than for R alone, based on substitution of a high number of CTs by WBCT. Other centers with low usage of CT might not decrease RD by substituting R alone by WBCT.

Introduction Recent studies suggest that hindfoot deformity should be considered in the surgical treatment of tarsal coalitions. Many authors have used the angle between the talus and the calcaneus (TCA) for decision-making. However, its reliability has not been demonstrated and the measurement technique has not been standardized. The objective of this study was to standardize the TCA measurement technique, and to evaluate the inter and intra-observer reproducibility of the proposed technique. Methods The foot CT scans of a group of 30 patients between 10 and 17 years of age were analysed. Ten patients had talocalcaneal coalitions, ten calcaneonavicular coalitions and ten had no coalitions. The inter and intra-observer reproducibility of the TCA was evaluated by the intraclass correlation coefficient (ICCs). A mixed-effects ANOVA model was used to calculate the ICCs for ICC2 agreement (A, 1). This procedure was applied to the three observers (inter-observer variability), and to the test–retest of observer 1 (intra-observer variability). A two-tailed p value of ≤.05 was considered significant. Results The inter-observer and intra-observer agreements were excellent for the TCA. Inter-observer agreement: ICC2 (A, 1) = .95 (p Conclusion The TCA is a reliable way to evaluate hindfoot alignment. This method of measurement, as described in this study, can be safely used for surgical planning in patients with tarsal coalitions.

Category: Hindfoot; Trauma Introduction/Purpose: Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objectives of this study were (1) to conduct a systematic review of clinical outcomes following SDA, (2) to assess the demographics, indications, and surgical technique used, (3) to assess the clinical and radiographic outcomes of this procedure and its role in improving function, (4) to provide treatment recommendations based on the best available literature, and (5) to identify knowledge deficits that require further investigation. Methods: MEDLINE and EMBASE were queried with an end date of January 1, 2018 using the keywords The keywords used for this search included ‘‘subtalar,’’ ‘‘talar,’’ ‘‘talus,’’ ‘‘bone,’’ ‘‘block,’’ ‘distraction,’ ‘arthrodesis,’ ‘fusion,’ ‘arthritis,’ ‘arthrosis,’ ‘calcaneus,’ ‘calcaneal,’ ‘fracture,’ ‘malunion,’ ‘deformity,’ and ‘‘clinical outcome,’’ alone and in various combinations using the Boolean operator ‘‘AND.’’ Data abstraction was performed by two independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least five patients, (4) reporting clinical and/or radiographic outcomes of SDA. Data collected included: demographics, operative techniques, radiographic measures, clinical and functional outcomes, and complications. The level of evidence for each study was assessed according to the method described by Wright et al. Methods followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle hindfoot scores with a weighted average of 33 points of improvement. Conclusion: Subtalar bone block arthrodesis provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. These consistent clinical outcomes throughout the literature, despite different lengths of followup periods, suggest that the functional results do not deteriorate with time. Higher confidence recommendations for SDA require longer follow-up, clear indications and treatment protocols, standardized clinical and radiographic outcome measures, and direct comparison or stratification of results based on graft type and other operative techniques. [Table: see text]

Category: Hindfoot Introduction/Purpose: Based on a prospective study, a new method of photographing and measuring of hindfoot alignment based on X-ray was proposed, and its reliability is verified, as well as its application in flatfeet. Methods: This study included 28 patients (40 feet) with flatfeet and 20 volunteers (40 feet) from January to December in 2018. The shooting frame, designed by our team, has been used to take the hindfoot alignment view at 10°, 15°, 20°, 25°, 30° respectively. Our modified tibio-hindfoot angles (THA) at standard Saltzman position (shooting at 20°) were evaluated, and the consistency were compared with the van Dijk method and the modified van Dijk method, and compared with weight-bearing CT. The visibility of tibiotalar space were evaluated in all shooting angles. The consistency of the modified THA method at different projection angles were evaluated. The angle of hindfoot valgus of flatfoot patients was measured with use of the modified THA method, and compared in different shooting angles. Results: The mean THA in standard Saltzman view in normal people were significantly differences between the three evaluation methods (P < 0.001). The results of modified THA method were significantly larger than those of Van Dijk method (P < 0.001) and modified Van Dijk method (P < 0.001). There was no significant difference between the results of modified THA method and the weight-bearing CT (P=0.605), and the intra- and inter-group consistency was the best in modified THA group. The tibiotalar space in the normal group were visible in all cases at 10°, 15°, 20°; and visible in some cases at 25°; and invisible in all cases at 30°. In the flatfoot group, the tibiotalar space were visible in all cases at 10°; and in some cases at 15° and 20°; and invisible in all cases at 25° and 30°. In the normal group, the modified THA was 4.84±1.81° at 10°, 4.96±1.77° at 15°, 4.94±2.04° at 20°. No significant difference was found between the three groups (P=0.616). In the flat foot group, the modified THA of 18 feet, which was visible at 10°, 15° and 20°, was 13.58±3.57° at 10°, 13.62±3.83° at 15° and 13.38±4.06° at 20°. There was no significant difference between the three groups (P=0.425). Conclusion: The modified THA evaluation method is simple to use and has high intra- and inter-group consistency. It can be used to evaluate hindfoot alignment. For patients with flatfeet, the 10° position view and modified THA measurement can be used to evaluate the hindfoot valgus conditions.

Limb shortening due to structural bone loss in tibiotalocalcaneal arthrodesis is a concern that can negatively impact the patient’s gait and weight-bearing. To aid in preventing the risk of limb shortening, the use of a femoral head allograft and intramedullary nail in tibiotalocalcaneal arthrodesis has been shown to successfully preserve limb length in patients with structural bone deficits. We present our technique using a femoral head allograft with a cup-and-cone reamer for the treatment of severe ankle and hindfoot deformity., Technique Video Video 1 Intraoperative video and postoperative protocol for a tibiotalocalcaneal arthrodesis with femoral head allograft using a cup-and-cone reamer of the left ankle. The patient is positioned in a partial lateral decubitus position with the surgeon operating through a lateral transfibular approach of the left ankle.

Category: Hindfoot; Ankle; Other Introduction/Purpose: Semi-automatic three-dimensional (3D) biometric weightbearing CT (WBCT) tools have been shown to accurately demonstrate the relationship between the center of the ankle joint and the tripod of the foot. The measurement of the Foot and Ankle Offset (FAO) represents an optimized biomechanical assessment of foot alignment. The objective of this study was to evaluate the correlation between FAO and traditional adult acquired flatfoot deformity (AAFD) markers, measured in different planes. We hypothesized that the FAO would significantly correlate with other radiographic markers of pronounced AAFD. Methods: In this retrospective comparative study, we included 113 patients with stage II AAFD, 43 men and 70 women, mean age of 53.5 (range, 20 to 86) years. Three-dimensional coordinates (X, Y and Z planes) of the foot tripod (most plantar voxel of the first and fifth metatarsal heads, and calcaneal tuberosity) and the center of the ankle joint (most proximal and central voxel of the talar dome) were harvested by two blinded and independent fellowship-trained orthopedic foot and ankle surgeons. The FAO was automatically calculated using the 3D coordinates by dedicated software. Multiple WBCT parameters related to the severity of the deformity in the coronal, sagittal, and transverse plane were manually measured. Results: We found overall good to excellent intra (range, 0.84-0.99) and interobserver reliability (range, 0.71-0.96) for manual AAFD measurements. FAO semi-automatic measurements demonstrated excellent intra (0.99) and interobserver reliabilities (0.98). Hindfoot moment arm (pConclusion: We found that 3D WBCT semi-automatic measurements of Foot and Ankle Offset (FAO) significantly correlated with traditional markers of pronounced AAFD. HMA, subtalar horizontal angle, talonavicular uncoverage angle and forefoot arch angle were found to explain 79% of the variations in FAO measurements. FAO Measurements were also found to be more reliable than the manual measurements. The FAO offers a more complete biomechanical and multiplanar assessment of the AAFD, that that accounts for relative positioning of the foot tripod and the center of the ankle joint, representing in a single measurement the three-dimensional components of the deformity.

Category: Ankle Arthritis; Ankle; Hindfoot; Other Introduction/Purpose: Sinus tarsi and Subfibular impingement are considered the main causes of lateral foot pain in patients with Adult Acquired Flatfoot Deformity (AAFD). They are considered important markers in the spectrum of progressive peritalar subluxation (PTS) in patients with AAFD. Recent literature has also highlighted the use of the Middle Facet of the subtalar joint as a more accurate indicator of PTS. The objective of this study was to assess the relationship between lateral impingement and middle facet PTS. Our hypotheses were that patients with sinus tarsi and subfibular impingement would demonstrate more severe PTS than patients with no impingement, and that subfibular impingement would represent a better indicator of pronounced deformity when compared to sinus tarsi impingement. Methods: In this retrospective comparative Cohort Study, we included 110 AAFD patients that underwent standing weightbearing CT (WBCT) as a standard baseline assessment of their foot deformity. The presence or absence of sinus tarsi and subfibular impingements, as well as the incongruence angle and percentage of subluxation of the middle facet of the subtalar joint, were manually measured on multiplanar reconstruction (MPR) WBCT images by a blinded fellowship-trained foot and ankle surgeon. Descriptive statistics were used to describe the rate of sinus tarsi and subfibular impingement as well as mean values for middle facet incongruence angle and subluxation. Wilcoxon test was used to compare the values of PTS at the middle facet in patients with or without sins tarsi and subfibular impingement. A partition prediction model was used to assess the values of middle facet PTS that would foresee a higher risk for lateral impingement. P-values Results: Seventy-five percent (n=82) of the AAFD patients had sinus tarsi impingement and 64% (n=70) of the AAFD patients had subfibular impingement. The mean value and 95% CI for middle facet incongruence angle and subluxation percentage were respectively 10.5o (CI, 8.7 to 12.2o) and 28.7% (CI, 23.5 to 33.9%). Middle facet subluxation was significantly higher in patients with sinus tarsi and subfibular impingement by respectively 22.6% and 23.9%, both p-values Conclusion: Our results showed significantly increased middle facet subluxation in AAFD patients with sinus tarsi and subfibular impingement. Subfibular impingement was less frequent and associated with more pronounced deformity than sinus tarsi impingement. Measurements of the percentage of subluxation of the middle facet were also found to be the best predictor of impingement, with 29.4% representing an important threshold value above which the risks for both sinus tarsi and subfibular impingement were significantly higher. With that in mind, we would recommend close assessment and follow-up of the amount of middle facet subluxation in the decision-making for the treatment of AAFD patients.

Background: Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objective of this study was to present an overview of outcomes following SDA, focusing on surgical technique as well as clinical and radiographic results. Methods: MEDLINE and EMBASE were queried and data abstraction was performed by 2 independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least 5 patients, and (4) reporting clinical and/or radiographic outcomes of SDA. Results: Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle-hindfoot scores with a weighted average of 33 points of improvement. Conclusion: SDA provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. Higher quality studies are necessary to better assess outcomes between different operative techniques. Level of Evidence: Level III.

Varus hindfoot deformity may increase the risk of chronic lateral ankle instability (CLAI). We retrospectively analyzed hindfoot alignment (HFA) using weight bearing CT (WBCT) by measuring the foot ankle offset (FAO) using dedicated semiautomatic software (TALAS, Curvebeam, Hattfield, PA, USA) in 370 consecutive feet. Multivariable logistic regression adjusted for sex and age demonstrated a 35% increased odds ratio of CLAI per 1% reduction in FAO value (varus) and no significant effect of sex or age after adjustment for FAO.

BACKGROUND: The goals of lower limb reconstruction are to restore alignment, to improve function, and to reduce pain. However, it remains unclear whether alignment of the lower limb and hindfoot are associated because an accurate assessment of hindfoot deformities has been limited by superposition on plain radiography. Consequently, surgeons often overlook hindfoot deformity when planning orthopaedic procedures of the lower limb. Therefore, we used weight-bearing CT to quantify hindfoot deformity related to lower limb alignment in the coronal plane. QUESTIONS/PURPOSES: (1) Is lower-limb alignment different in varus than in valgus hindfoot deformities for patients with and without tibiotalar joint osteoarthritis? (2) Does a hindfoot deformity correlate with lower-limb alignment in patients with and without tibiotalar joint osteoarthritis? (3) Is joint line orientation different in varus than in valgus hindfoot deformities for patients with tibiotalar joint osteoarthritis? (4) Does a hindfoot deformity correlate with joint line orientation in patients with tibiotalar joint osteoarthritis? METHODS: Between January 2015 and December 2017, one foot and ankle surgeon obtained weightbearing CT scans as second-line imaging for 184 patients with ankle and hindfoot disorders. In 69% (127 of 184 patients) of this cohort, a combined weightbearing CT and full-leg radiograph was performed when symptomatic hindfoot deformities were present. Of those, 85% (109 of 127 patients) with a median (range) age of 53 years (23 to 75) were confirmed eligible based on the inclusion and exclusion criteria of this retrospective comparative study. The Takakura classification was used to divide the cohort into patients with (n = 74) and without (n = 35) osteoarthritis of the tibiotalar joint. Lower-limb measurements, obtained from the full-leg radiographs, consisted of the mechanical tibiofemoral angle, mechanical tibia angle, and proximal tibial joint line angle. Weightbearing CT images were used to determine the hindfoot’s alignment (mechanical hindfoot angle), the tibiotalar joint alignment (distal tibial joint line angle and talar tilt angle) and the subtalar joint alignment (subtalar vertical angle). These values were statistically assessed with an ANOVA and a pairwise comparison was subsequently performed with Tukey’s adjustment. A linear regression analysis was performed using the Pearson correlation coefficient (r). A reliability analysis was performed using the intraclass correlation coefficient. RESULTS: Lower limb alignment differed among patients with hindfoot deformity and among patients with or without tibiotalar joint osteoarthritis. In patients with tibiotalar joint osteoarthritis, we found knee valgus in presence of hindfoot varus deformity and knee varus in presence of hindfoot valgus deformity (mechanical tibiofemoral angle 0.3 ± 2.6° versus -1.8 ± 2.1°; p < 0.001; mechanical tibia angle -1.4 ± 2.2° versus -4.3 ± 1.9°; p < 0.001). Patients without tibiotalar joint osteoarthritis demonstrated knee varus in the presence of hindfoot varus deformity compared with knee valgus in presence of hindfoot valgus deformity (mechanical tibiofemoral angle -2.2 ± 2.2° versus 0.9 ± 2.4°; p < 0.001; mechanical tibia angle -1.8 ± 2.1° versus -4.3 ± 1.9°; p < 0.001). Patients with more valgus deformity in the hindfoot tended to have more tibiofemoral varus (r = -0.38) and tibial varus (r = -0.53), when tibiotalar joint osteoarthritis was present (p < 0.001). Conversely, patients with more valgus deformity in the hindfoot tended to have more tibiofemoral valgus (r = 0.4) and tibial valgus (r = 0.46), when tibiotalar joint osteoarthritis was absent (p < 0.001). The proximal joint line of the tibia had greater varus orientation in patients with a hindfoot valgus deformity compared with greater valgus orientation in patients with a hindfoot varus deformity (proximal tibial joint line angle 88.5 ± 2.0° versus 90.6 ± 2.2°; p < 0.05). Patients with more valgus deformity in the hindfoot tended to have more varus angulation of the proximal tibial joint line angle (r = 0.31; p < 0.05). CONCLUSIONS: In patients with osteoarthritis of the tibiotalar joint, varus angulation of the knee was associated with hindfoot valgus deformity and valgus angulation of the knee was associated with hindfoot varus deformity. Patients without tibiotalar joint osteoarthritis exhibited the same deviation at the level of the knee and hindfoot. These distinct radiographic findings were most pronounced in the alignment of the tibia relative to the hindfoot deformity. This suggests a detailed examination of hindfoot alignment before knee deformity correction at the level of the proximal tibia, to avoid postoperative increase of pre-existing hindfoot deformity. Other differences detected between the radiographic parameters were less pronounced and varied within the subgroups. Future research could identify prospectively which of these parameters contain clinical relevance by progressing osteoarthritis or deformity and how they can be altered by corrective treatment. LEVEL OF EVIDENCE: Level III, prognostic study.

Owing to a Publisher error Declaration of Competing Interest statements were not included in the published versions of the following articles, that appeared in the previous issues of Journal of Clinical Orthopaedics and Trauma. The appropriate “Declaration of Competing Interest statements”, provided by the Authors, are included below. 1. “Comprehensive review of surgical approaches to the elbow” (Journal of Clinical Orthopaedics and Trauma, 2021;20: 101482) https://10.1016/j.jcot.2021.101482Declaration of Competing Interest: The Authors have no interests to declare. 2. “Nerve entrapment around elbow” (Journal of Clinical Orthopaedics and Trauma, 2021;19: 209–215) https://10.1016/j.jcot.2021.05.031Declaration of Competing Interest: The Authors have no interests to declare. 3. “Active vs passive haptic feedback technology in virtual reality arthroscopy simulation: Which is most realistic?” (Journal of Clinical Orthopaedics and Trauma, 2021;16: 249–256) https://10.1016/j.jcot.2021.02.014Declaration of Competing Interest: The Authors have no interests to declare. 4. “Risk factors for progression to total knee arthroplasty within two years of presentation for knee osteoarthritis” (Journal of Clinical Orthopaedics and Trauma, 2021;16: 257–263) https://10.1016/j.jcot.2021.02.008Declaration of Competing Interest: The Authors have no interests to declare. 5. “Neglected posterior dislocation of elbow: A review” (Journal of Clinical Orthopaedics and Trauma, 2021;18: 100–104) https://10.1016/j.jcot.2021.04.016Declaration of Competing Interest: The Authors have no interests to declare. 6. “Primary total elbow arthroplasty” (Journal of Clinical Orthopaedics and Trauma, 2021;18: 66–73) https://10.1016/j.jcot.2021.04.015Declaration of Competing Interest: The Authors have no interests to declare. 7. “Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions” (Journal of Clinical Orthopaedics and Trauma, 2021;20: 101496) https://10.1016/j.jcot.2021.101496Declaration of Competing Interest: The Authors have no interests to declare. 8. “Clinical anatomy and biomechanics of the elbow” (Journal of Clinical Orthopaedics and Trauma, 2021;20: 101485) https://10.1016/j.jcot.2021.101485Declaration of Competing Interest: The Authors have no interests to declare. 9. “Dislocations of the elbow †“An instructional review” (Journal of Clinical Orthopaedics and Trauma, 2021;21: 101484) https://10.1016/j.jcot.2021.101484Declaration of Competing Interest: The Authors have no interests to declare. 10. “Global orthopaedic trauma surgeons highlight telenomics during the COVID-19 era: A case for advancing telemedicine in orthopaedics” (Journal of Clinical Orthopaedics and Trauma, 2021;17: 182–185) https://10.1016/j.jcot.2021.03.015Declaration of Competing Interest: The Authors have no interests to declare. 11. “Opportunities and challenges of using augmented reality and heads-up display in orthopaedic surgery: A narrative review” (Journal of Clinical Orthopaedics and Trauma, 2021;18: 209–215) https://10.1016/j.jcot.2021.04.031Declaration of Competing Interest: The Authors have no interests to declare. 12. “Stress fracture of femoral stem of hip resurfacing a cause of sudden onset hip pain- A case report and review of literature” (Journal of Clinical Orthopaedics and Trauma, 2021;19: 50–52) https://10.1016/j.jcot.2021.05.004Declaration of Competing Interest: The Authors have no interests to declare. 13. “Unusual multiloculated serpiginous ganglion of the foot” (Journal of Clinical Orthopaedics and Trauma, 2021;21: 101489) https://10.1016/j.jcot.2021.101489Declaration of Competing Interest: The Authors have no interests to declare. 14. “Injuries associated with arm wrestling: A narrative review” (Journal of Clinical Orthopaedics and Trauma, 2021;18: 30–37) https://10.1016/j.jcot.2021.04.010Declaration of Competing Interest: The Authors have no interests to declare. 15. “Charcot hindfoot deformity reconstruction using a hindfoot na l-surgical technique” (Journal of Clinical Orthopaedics and Trauma, 2021;16: 277–284) https://10.1016/j.jcot.2021.02.007Declaration of Competing Interest: The Authors have no interests to declare. © 2021

Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus. Methods: Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded. Results: Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment. Conclusion: Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.

Category: Basic Sciences/Biologics Introduction/Purpose: Calcaneal displacement osteotomies are frequently utilized procedures to correct hindfoot varus and valgus deformities and are frequently used in conjunction with other procedures to restore normal alignment of the foot. Complications associated with this procedure include overcorrection, undercorrection, iatrogenic fracture, wound dehiscence, and infection. Additionally, neurologic deficit associated with lateralizing calcaneal osteotomy has been documented in the literature. Changes in ankle alignment have been shown to significantly alter tarsal tunnel pressure and volume, and a MRI study by Bruce et. al showed that lateral osteotomy fragment displacement results in significant reduction of tarsal tunnel volume. We hypothesized that a lateral displacement calcaneal osteotomy would result in an increase in tarsal tunnel pressure compared baseline tarsal tunnel pressures or those with a medial displacement calcaneal osteotomy. Methods: We performed cadaveric dissections on five foot and ankle cadavers. The laciniate ligament covering the tarsal tunnel was visualized at 2 cm proximal to the medial malleolus and a nick incision was made to insert the ICP monitoring probe; the tunnel was left intact distally. A 45 degrees lateral incision was made in line with the osteotomy site and a calcaneal osteotomy was performed in line with the incision approximately 1 cm anterior to the attachment of the achilles tendon. A Codman ICP monitoring probe was then used to measure baseline tarsal tunnel pressure measurements prior to calcaneal displacement. The osteotomy was then displaced medially and laterally and fixed in place in place with a K-wire (Figure 1). Tarsal tunnel pressures were measured at 5 mm and 8 mm displacement in both directions. Results: Average tarsal tunnel pressures at baseline were 2.8 mmHg (range, 1-5 mmHg). Average tarsal tunnel pressures with 5 mm and 8 mm of medial calcaneal displacement were 1.0 mmHg (range, 0-4 mmHg) and 0.8 mmHg (range, 0-3 mmHg), and with lateral calcaneal displacement were 7.4 mmHg (range, 3-13 mmHg) and 14.4 mmHg (range, 10-22 mmHg). There was no significant difference in tarsal tunnel pressures with either 5 mm (p=.067) or 8 mm (P=.067) of medial calcaneal displacement compared to baseline. There was, however, a significant increase in tarsal tunnel pressures with both 5 mm (p=.039) and 8 mm (p=.001) of lateral calcaneal displacement compared to tarsal tunnel pressures at baseline and with 5 mm (p=.002) and 8 mm (p=.001) of medial calcaneal displacement. Conclusion: Tibial nerve palsy following lateral displacement calcaneal osteotomy has recently been shown to have an incidence as high as 34%. Osteotomies decreasing volume in the tarsal tunnel could cause iatrogenic compression of the tibial nerve. Based on the results of our study, displacing the calcaneus laterally increases the tarsal tunnel pressures on average five times above baseline tarsal tunnel pressures. Medial displacement, however, does not appear to have any significant effect on pressures within the tunnel. The findings in this study provide further clinical evidence in support of prophylactic tarsal tunnel release prior to performing a lateralizing calcaneal osteotomy.

Category: Diabetes, Hindfoot, Trauma, salvage procedure Introduction/Purpose: Segmental bone loss in the hindfoot hinders the chance of successful outcomes. Tibiotalocalcaneal arthrodesis is a reliable option; however, the risk of nonunion is high. Structural graft is needed to fill the gap, but the use of bone grafts are limited by the availability, risk of collapse, and disease transmission. Three-dimensional (3D) printed titanium implants offer a strong scaffold that can be customized and present similar healing rates. The purpose of the study was to describe the clinical outcomes and the radiologic union rate of a case series of patients with hindfoot arthrodesis, using a retrograde intramedullary nail associated to a 3D printed titanium cage. Methods: After obtaining approval from our institution review board, a retrospective chart review was performed on seven patients undergoing hindfoot arthrodesis, using a retrograde intramedullary nail associated to a custom 3D printed titanium cage from March 2015 to December 2017. Demographic and clinical data were collected. Functional outcomes were assessed using The American Orthopedic Foot and Ankle Score (AOFAS) and the Visual Analog Scale (VAS) for pain. Hindfoot alignment was evaluated using preoperative and postoperative weightbearing radiographs that included anteroposterior, lateral and Saltzman views. Radiographic union was assessed using computed tomography scan at 6 and 12 months postoperatively. Results: All patients had ankle arthritis and six of them (85%) had prior surgery in the compromised hindfoot. The average age at TTC fusion was 57 (range, 29 to 71) years. The mean follow-up time was 21 (range, 12 to 32) months. Six patients had a healed fusion and one patient underwent below knee amputation due to recurrence of chronic osteomyelitis in the ankle. Two additional patients had minor complications. The average AOFAS at pre-op was 35 (range, 20 to 42) points as compared to 68 (range, 53 to 78) points at final follow-up; P=0.004. Preoperative VAS pain was 80.4 (range, 70 to 85) points as compared to 26.8 (range, 6 to 60) points; P=0.002. Conclusion: Tibiotalocalcaneal arthrodesis using customized titanium cages for patients with large bone defects has shown a high rate of union in those at high risk of nonunion. Further research is needed to monitor the development of late complications.

Category: Hindfoot Introduction/Purpose: Patients with a hindfoot deformity pose a particular challenge when performing a total knee arthroplasty (TKA). This could be attributed to the lack of insights concerning hindfoot alignment outcome. Our objective was to perform a systematic review of the literature to investigate the influence of TKA on hindfoot alignment and vice-versa. Methods: This systematic review was performed in accordance to PRISMA guidelines; the original protocol is registered on PROSPERO (ID: 106980). The following electronic databases were searched to identify capable studies: Pubmed, EMBASE, Web of Science, Google Scholar, and Cochrane Library. To ensure the quality of the review, a quality assessment was performed according to the MINORS criteria. The mean MINORS score was 9.5 (range 7-12) and concurred with a good quality of the obtained studies. Results: Sixteen identified articles met the review criteria: six prospective cohort studies, nine retrospective studies, and one case-control study. Five articles reporting on clinical outcomes were identified; a pre-operative hindfoot deformity negatively influenced TKP outcome (N=4) or demonstrated no influence (N=1). Thirteen articles reporting on radiographic outcomes were identified. Five studies reported a significant improvement (P < 0.05) of hindfoot alignment after TKA, two studies demonstrated improvement limited to valgus hindfeet, seven studies observed a significant (P < 0.05) correlation between knee and hindfoot alignment, and two studies reported the association between hindfoot OA in patients undergoing TKA. Two studies reporting biomechanical outcomes were identified; these reported a shift of the weighbearing axis after TKA as a result of the remaining hindfoot deformity. Conclusion: TKA can improve the alignment of valgus hindfeet, but improvement was less pronounced in varus hindfeet. Furthermore, a worse clinical outcome is expected after TKA in patients with concomitant ankle OA. A remaining hindfoot deformity shifts the weightbearing axis, which could shorten the survival of the total knee prosthesis.

Background:Varus hindfoot deformity may increase the risk of chronic lateral ankle instability (CLAI). Our aim was to analyze hindfoot alignment (HFA) in patients with CLAI using weight-bearing cone beam computed tomography (WBCT) to assess this risk.Methods:This retrospective, comparative analysis was carried out using an existing WBCT database (Talas, CurveBeam LLC), including data sets for 370 consecutive feet (189 patients) obtained between July 2016 and October 2018 at a single institution. The software provided semiautomated measurement of HFA, given as foot ankle offset (FAO). Univariate analysis was conducted to compare feet with and without CLAI against sex, age, body mass index, and FAO. Significant variables were included in a multivariable logistic model with random effects to take into account correlation between feet of the same patient.Results:Forty-three feet had CLAI (34 patients). FAO ( P = .0009) was significant for CLAI by univariate analysis. Mean FAO was −2.2% ± 5.5% (varus) and + 2.6% ± 4.7% (valgus) with and without CLAI history, respectively. Multivariable logistic regression adjusted for sex and age demonstrated a 35% increased odds ratio (OR) of CLAI per 1% reduction in FAO value (varus) (adjusted OR=0.64, 95% confidence interval [CI]: 0.49-0.84; P = .001) and no significant effect of sex (adjusted OR=0.52; P = .617) or age (adjusted OR=0.94; P = .165) after adjustment for FAO.Conclusion:A positive relationship was found between varus HFA and the risk to have CLAI. Systematic recording of FAO measurements from WBCT images along with clinical data regarding CLAI history proved successful at quantifying the risk of CLAI.Level of Evidence:Level III, retrospective cohort study.

Severe talar avascular necrosis has many etiologies and can cause bone loss/hindfoot deformity. Tibiotalar calcaneal arthrodesis is a salvage procedure after severe talar avascular necrosis. Large bone voids can present significant challenges. Modest successes have been reported with structural block allograft tibiotalocalcaneal arthrodesis using either plate and screws, intramedullary nail fixation, or a combination. The advent of 3-dimensional printed titanium trusses has given surgeons another option for filling voids and providing structural support to prevent collapse. Although these options expand the armamentarium, treating surgeons must adhere to principles of arthrodesis: stable constructs, thorough joint surface preparation, and correction of deformity.

Category: Hindfoot Introduction/Purpose: The exact relationship between different types of hindfoot deformities and the full leg alignment is currently unclear. Therefore, our aim is to assess hindfoot alignment on a weight-bearing CT (WBCT) and its association with the full leg radiographic alignment. Methods: A retrospective analysis was performed on a study population of 109 patients (mean age of 53 years ± 14.49) with a varus or valgus hindfoot deformity and the presence or absence of ankle osteoarthritis (OA) based on the Takakura classification. The mechanical hindfoot - (mHA) and subtalar vertical angle (SVA) were determined on WBCT, while the mechanical tiba – (mTA) and mechanical tibiofemoral angle (mTFA) were measured on full leg radiographs. Results: In patients with ankle OA, a hindfoot valgus deformity was associated with a significantly higher mean varus alignment of the knee (mTFA = -1.8°±2.1; mTAx= -4.3°±1.9) compared to a valgus alignment of the knee (mTFA = 0.3°±2.6; mTAx= -1.4°±2.2; P 0.05). Conclusion: A valgus hindfoot deformity demonstrated a higher varus alignment of the knee when compared to patients with a hindfoot varus deformity, if ankle OA was present. The subtalar joint did not attain an overall compensatory correction towards the hindfoot deformity as opposed to a compensatory orientation of the tibia alignment. In clinical practice, these findings could improve the current understanding of both joint preserving as well as joint replacing procedures of the hindfoot and the knee.

The two-incision triple arthrodesis is a classic, powerful, and predictable procedure. It can be used for nearly any hindfoot deformity, including varus or valgus deformity, and revision of previous surgery. Surgery is usually started laterally by opening and preparing the subtalar and calcaneocuboid joints. Then attention is directed to a dorsal medial incision for exposure and preparation of the talonavicular joint. Once all joints are prepared, correction of any deformity is performed. Typically, the talonavicular and then subtalar joints are pinned into place and then fixated with cannulated screws. A lateral compression plate is used for the calcaneocuboid joint. Layered closure and then splinting is the initial dressing for the triple arthrodesis. Typical postoperative recovery includes 6–8 weeks non-weight-bearing and then gradual protected weight-bearing and rehabilitation.

Subtalar joint arthrodesis is a commonly performed procedure for the correction of hindfoot deformity and/or the relief of pain related to osteoarthritis. The purpose of the present study was to provide preoperative and intraoperative objective radiographic parameters to improve the accuracy and long-term success of realignment arthrodesis of the subtalar joint. We retrospectively reviewed the data from 16 patients, 11 male (57.9%) and 8 female (42.1%) feet, who had undergone realignment subtalar joint arthrodesis. A total of 19 fusions were performed in 9 (47.4%) right and 10 (52.6%) left feet, with a mean follow-up period of 2 (range 1 to 4.8) years. The mean age at surgery was 54.5 (range 14 to 77) years. Statistically significant improvement in radiographic alignment was found in the anteroposterior talo-first metatarsal angle (p = .002), lateral talo-first metatarsal angle (p < .001), tibial-calcaneal angle (p < .001), and tibial-calcaneal distance (p < .001). A positive correlation was observed between the tibial-calcaneal angle and tibial-calcaneal distance (r = 0.825, p < .001). The statistically significant improvement in tibial-calcaneal alignment, in both angulation and distance, support our conclusions that proper realignment of the calcaneus to vertical and central under the tibia will lead to short-term success and, likely, long-term success of subtalar joint arthrodesis.

Category: Hindfoot; Other Introduction/Purpose: Hindfoot malalignment is a common finding in multiple foot and ankle pathologies. In clinical practice, it is usually quantified through traditional weight bearing radiographs or, more recently, through cone beam weight bearing CT (CB- WBCT), which overcomes issues related to two-dimensional imaging. Interestingly, a few studies have suggested that hindfoot alignment can also be accurately assessed using non-weight bearing magnetic resonance imaging (MRI). The purpose of this study was to compare measurements of hindfoot alignment on non-weight bearing ankle MRI and CB-WBCT and to establish if there was any correlation. Methods: In this Level III retrospective comparative study, a database review identified 51 feet in 47 patients (27 males, 20 females; mean age of 45 (range 13-79)) which had both CB-WBCT and MRI scans on the same day as part of standard care at our specialist tertiary referral Foot and Ankle Unit. Hindfoot alignment was assessed by independent Consultant Musculoskeletal specialists. The foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HA) were assessed on CB-WBCT using dedicated software. The tibiocalcaneal angle (TCA) and calcaneofibular ligament angle (CFLA) were assessed on non-weight bearing MRI. Pearson correlation was used to evaluate the correlation between these measurements. Results: We found a statistically significant positive correlation between TCA on non-weight bearing MRI and each measurement on CB-WBCT (Pearson correlation for TCA and FAO: 0.42, p=0.003; for TCA and CO: 0.46, p=0.001; and for TCA and HA: 0.40, p=0.005).We also demonstrated a moderate-to-low negative but significant correlation between CFLA and CO (Pearson correlation: -0.35; p=0.03). Conversely, the negative correlation between CFL and FAO (Pearson correlation: -0.29; p=0.07) and CFL with HA (Pearson correlation: -0.26; p=0.11) did not reach statistical significance. Conclusion: Weight bearing three-dimensional imaging has shown high degrees of accuracy and reproducibility for hindfoot alignment. The significant correlation between TCA on non-weight bearing MRI and hindfoot alignment measurements on CB- WBCT suggests that TCA should be reported during routine ankle MRI in order to put into context some of the soft-tissue findings. The CFLA shows a less significant negative correlation.

Category: Ankle; Hindfoot Introduction/Purpose: The hindfoot moment arm was first described by Saltzman and el-Khoury to evaluate hindfoot varus and valgus alignment and has been well described and validated in the literature. It is commonly used by surgeons for preoperative planning of various hindfoot reconstructive procedures. The hindfoot alignment angle (the angle formed by the intersection between the tibial axis and the calcaneal axis) is another metric of measuring hindfoot alignment commonly utilized by surgeons. The purpose of this study was to determine if rotation of the hindfoot alters the hindfoot alignment moment arm and hindfoot alignment angle. We hypothesize that slight changes in internal and external rotation of the foot during x-ray positioning will have a large effect on the hindfoot moment arm and hindfoot alignment angle. Methods: We prospectively enrolled 29 patients, totaling 58 lower extremities, presenting to outpatient clinic for evaluation of a foot and ankle complaint. Patients Results: The cohort consisted of 11 (37.9%) males and 18 (62.1%) females, with a mean age of 48.7 (SD=14.7) years and mean body mass index (BMI) of 29.9 (SD=6.6) kg/m2. The mean hindfoot moment arms were 4.6 (SD=6.7) mm, 11.3 (SD=3.4) mm, and -5.4 (SD=6.2) mm in neutral, internal, and external rotation, respectively. The mean hindfoot alignment angles were 4.5 (SD=5.6) degrees, 18.6 (SD=6.8) degrees, and -10.9 (SD=10.6) degrees in neutral, internal, and external rotation, respectively. There was a significant difference in both the hindfoot moment arm (pConclusion: There appears to be significant variability in both the hindfoot moment arm and hindfoot alignment angle with respect to rotation of the patient’s lower extremity. Orthopaedic surgeons should carefully scrutinize limb rotation when making clinical decisions based on the hindfoot moment arm or alignment angle.

Category: Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Recent literature has established the middle facet of the subtalar joint as a reliable and accurate marker of pronounced peritalar subluxation (PTS) in Adult Acquired Flatfoot Deformity (AAFD) patients. The Foot and Ankle Offset (FAO) has also been accepted as a more complete and three-dimensional (3D) measurement of foot collapse and hindfoot valgus. To date, no assessment has been made regarding the relationship between the severity of the AAFD and the amount PTS measured at the middle facet. The objective of this study was to investigate the correlation between these variables. We hypothesized that direct positive linear correlation would be found, with significantly increased middle facet joint incongruence and subluxation in patients with more pronounced hindfoot valgus and foot collapse. Methods: In this IRB-approved retrospective comparative study, we included 76 feet (42 left, 35 right) with symptomatic AAFD who underwent standing weightbearing CT (WBCT) as standard baseline assessment of their foot deformity. One blinded fellowship-trained foot and ankle surgeon with more than 10 years of experience performed measurements using multiplanar reconstruction (MPR) WBCT images. Manual measurements of subluxation and incongruence of the middle facet were performed at the anteroposterior midpoint of the articular facet. Semiautomatic calculation of the FAO was performed after 3D coordinate harvesting of the weightbearing points of the first, fifth metatarsal and calcaneus as well as the center of the ankle. Correlation of FAO severity and subluxation/incongruence of the middle facet was assessed by Spearman’s correlation and bivariate analysis. Paired Wilcoxon was utilized to compare FAO values in congruent (0% subluxation), subluxated (1-99% subluxation) and dislocated middle facets. P-values Results: No significant direct correlation was observed between FAO and Middle Facet Incongruence angle (p=0.12). However, positive linear correlation was found between middle facet subluxation and FAO (Spearman’s 0.54, R2 0.29, p20) (pConclusion: This study is the first to compare and correlate measurements regarding the amount of subluxation of middle facet with the severity of AAFD, when measured by the foot and ankle offset (FAO). We found a significant, positive and linear correlation between the amount of subluxation of the middle facet and FAO measurements. No correlation was found between the incongruence angle of the facet and FAO. Our results support the concept of using the subluxation of the middle facet of the subtalar joint as a key marker of early and progressive deformity in patients with AAFD.

Category: Ankle; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis (fusion) is considered a salvage procedure for patients with severe hindfoot and ankle pathology. Several techniques have been described for TTC fusion, including the use of an intramedullary rod, plate and screw constructs, screws only, and external fixation/frames. Recently, 3D printing technology has allowed for a new technique to treat large hindfoot and ankle osseous defects with a custom three-dimensional (3D) titanium truss implant. These implants are specifically designed based on preoperative patient computed tomography (CT) scans. Early studies have shown promising radiographic and functional results, though these have been limited largely to expert opinions and case reports. The purpose of this study is to evaluate the clinical, radiographic, and functional outcomes of TTC arthrodesis using a custom 3D titanium truss implant. Methods: A retrospective review of patients who have undergone TTC arthrodesis utilizing a custom 3D-printed titanium truss implant (4WEB Medical, Inc., Frisco, TX) with a fellowship-trained orthopaedic foot and ankle surgeon at a single institution was performed. Patients Results: Eighteen patients underwent TTC fusion using custom titanium truss implants and were eligible for follow-up and analysis. Average patient age at the time of surgery was 58.7 years, and average BMI was 30.25 kg/m2. Seven patients (38.9%) were either current or former smokers, and 3 patients (16.7%) were diabetic. On average, patient FAAM ADL scores improved from 33.23 preoperatively to 59.56 (p=0.023), while VAS pain scores decreased from 59.07 to 34.22 (pConclusion: We have shown that custom titanium truss implants are viable and effective for use in TTC fusion. Use of such implants resulted in significant functional improvement among the cohort with low rates of complications and subsequent surgical interventions.

Background: Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury. Methods: A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively. Results: The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group. Conclusion: Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems. Level of Evidence: Level III, comparative series.

Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.

Background: Calcaneal osteotomy is an established technique for correcting hindfoot deformity. Patients traditionally receive an osteotomy through the open lateral approach to the calcaneus. To reduce the rate of wound complications associated with a direct open lateral approach, a minimally invasive surgical (MIS) technique has been adopted. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. We hypothesized that the new MIS calcaneal osteotomy would be a safe alternative to open calcaneal osteotomy while obtaining the same displacement. Methods: The safety of the new MIS technique was investigated with a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre from 2008 to 2014. The primary outcome measure was 30 day postoperative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates, and calcaneal displacement. Eighty-one patients underwent calcaneal osteotomy as part of their corrective surgery, 50 in the Open approach group and 31 in MIS group. The average age was 47.7 years (range 16-77) for the Open group and 50.1 (range 21-77) in the MIS group. Results: A mean calcaneal displacement of 9.4 mm (SD = 1.16, 8 to 11 mm) and 10.2 mm (SD = 1.06, 8 to 13 mm) was achieved through the MIS and Open approaches, respectively. There were significantly fewer wound complications in the MIS group (6.45%) compared to the Open group (28%, P = .022). The MIS group was associated with significantly lower rate of wound infection (3% versus 20%, P = .044). Three patients in the Open group experienced sural peripheral neuropathy. The average length of stay was 3.8 days following MIS and 4.3 days following open calcaneal osteotomy. Nonunion occurred in only 1 patient in the MIS group and none in the open group. Conclusions: MIS calcaneal osteotomy was found to be a safe technique. It was technically as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications. Level of Evidence: Level III, comparative study.

Background: Adult-acquired flatfoot deformity requires a complex operative plan that often utilizes a number of procedures to correct deformity, at both the hindfoot and midfoot. A lateral column lengthening procedure is typically performed to correct abduction deformity across the talonavicular joint; however its effect on hindfoot alignment is not well understood, and overcorrecting the hindfoot deformity can lead to pain and revision surgeries. Therefore, understanding the effect of lateral column lengthening on hindfoot alignment is important for operative planning. The aim of this study was to demonstrate the effect of a lateral column lengthening osteotomy on hindfoot valgus in a simulated flatfoot model. Methods: A flatfoot deformity was created in 12 lower limb cadaveric specimens. A step-cut lateral column lengthening osteotomy was performed and changes in hindfoot and midfoot alignment were measured using a motion capture system. Results: The lateral column lengthening procedure corrected 60% of the hindfoot valgus deformity ( P < .001). In addition, the abduction deformity at the midfoot was completely corrected with the procedure ( P < .001). Conclusion: Our findings suggest that the lateral column lengthening procedure corrects hindfoot valgus, in addition to midfoot abduction, in a flatfoot deformity. Clinical Relevance: Understanding the relative contribution of each operative procedure to the overall deformity correction in flatfoot reconstruction will allow surgeons to accurately correct the foot into a plantigrade position while minimizing the risk of overcorrection.

Background Patients with ankle arthritis often present with concomitant hindfoot deformity, which may involve the tibiotalar and subtalar joints. However, the possible compensatory mechanisms of these two mechanically linked joints are not well known.

Orthopedic complications of intravenous (IV) infiltration are rare, with only a handful of cases reported in the literature. Because of the relatively high rate of IV infiltration in neonates, however, such complications do occur and can include growth arrest, limb length discrepancy, and joint deformities that require surgical intervention. The risk of these complications is highest in preterm neonates. A 7-year-old girl presented to our institution with a severe valgus hindfoot deformity that developed secondary to a neonatal IV infiltration injury. Management consisted of a medial displacement calcaneal osteotomy followed 5 years later by a triple arthrodesis, Strayer procedure, and free flap transfer.

Tibiotalocalcaneal (TTC) fusion and pantalar fusions are salvage procedures for patients with end-stage ankle and hindfoot arthritis or severe malalignment. In many cases, one of these procedures is the only option available to provide patients with a stable, painless, and plantigrade foot. The procedures are technically demanding, requiring operative planning that must take into account the patient’s underlying diagnosis, comorbidities, and malalignment. Various approaches, fixation constructs, and biologic adjuncts may be used in order to obtain fusion. Despite proper surgical technique, complication rates are high across various series given the salvage nature of these procedures. Indications, operative technique, complications, and illustrative cases for TTC and pantalar fusions are reviewed.

Symptomatic hypertrophy of the peroneal tubercle can result in pain, clicking sensation, and limitation of ambulation. Surgical resection is indicated for symptomatic hypertrophied tubercle that is recalcitrant to conservative treatment. The purpose of this Technical Note is to report the details of tendoscopic resection of the hypertrophied peroneal tubercle. This is performed through zone 2 peroneus longus tendoscopy. Any associated hindfoot deformity and peroneal tendon pathology should also be addressed.

Medial column instability is a primary deforming force in the setting of pes planovalgus deformity. Consideration for medial column stabilization only after correction of the hindfoot deformity may result in creating a rigid hindfoot, compromising clinical outcomes. Careful analysis of the lateral radiograph to determine whether the deformity is secondary to the medial column or true peritalar subluxation may allow superior outcomes. Iatrogenic creation of an excessively rigid medial column may lead to significant instability of the remaining joints in the short term and arthrosis in the long term. Medial column arthrodesis should be used selectively to correct gross instability.

Triple (talonavicular, subtalar, and calcaneocuboid) joint arthrodesis and most recently double (talonavicular and subtalar) joint arthrodesis have been well proposed in the literature for surgical repair of the elective, posttraumatic, and/or neuropathic hindfoot deformities. The articulation of the hindfoot with the ankle and midfoot is multiaxial, and arthrodesis of these joints can significantly alter the lower extremity biomechanical manifestations by providing anatomic correction and alignment. This article reviews the indications and preoperative planning for some of the most common procedures to address the hindfoot deformity.

Concomitant hindfoot and midfoot deformity is common. Hindfoot fusion is associated with prolonged recovery and significant disability. Further surgery is often required to obtain a plantigrade foot. Understanding normal structural and kinematic relationships between the midfoot and hindfoot, as well as recognizing common combined patterns of midfoot and hindfoot deformity, can minimize the unanticipated consequences of hindfoot fusion. Treatment of residual or resultant midfoot deformity requires a thorough analysis of the deformity and familiarity with a variety of operative techniques for correction.

Triple arthrodesis is a powerful corrector of hindfoot deformity related to trauma, rheumatoid arthritis, and long-standing peritalar subluxation with posterior tibial tendon dysfunction. To avoid the common postoperative complications related to triple arthrodesis, one must be meticulous in preoperative evaluation as well as surgical technique. Presented are some tips and tricks to avoid the common complications and provide the patient with a plantigrade, stable foot, as well as some salvage options for triple arthrodesis in a malunited position.

Lower limb malalignment is a common cause of disability that increases risk of osteoarthritis (OA). Treatment of OA may require an osteotomy or arthroplasty, which mandate accurate evaluation of mechanical loading on the limbs to achieve optimal alignment and minimal implant wear. Surgical planning uses a conventional method of mechanical axis deviation (MADC) measured from the center of the femoral head to the center of the ankle. This method fails to account for hindfoot deformity distal to the ankle. We used a computer model to compare MADC with the ground mechanical axis deviation (MADG), drawn from the center of the hip to the ground reaction point. Average anatomic measurements were analyzed with a range of knee and hindfoot angle variation in single leg stance, double leg stance, toe off and heel strike. MADG was consistently higher than MADC, suggesting a more complete estimate of weight-bearing axis that considers hindfoot deformity.

Category: Ankle Arthritis, Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis, deformity correction and salvage of failed total ankle replacement. However, union can be difficult to achieve in patients with bulk bone defects. Femoral head allograft is commonly used in the setting of TTC fusion with severe bone loss, but recent studies have reported concerns of arthrodesis rates of 50% or worse and graft collapse in these patients. Retrograde intramedullary nail placement through custom 3D spherical implants is a novel option for these patients. The purpose of this study was to compare fusion rates, graft resorption and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Methods: All patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant or femoral head allograft by the senior author at a single institution from 2013 to 2017 and who had at least one year of follow-up were included in this study. There were 7 patients who received a femoral head allograft and 8 patients who received a 3D printed sphere. Baseline patient and operative characteristics were collected and compared between the 3D sphere and femoral head allograft groups. The rate of successful fusion of the tibia, calcaneus and talar neck to the 3D sphere or femoral head allograft, as determined by radiographs and CT scan, as well as graft resorption and complications were compared between the groups. Results: The rates of union of the tibia (87.5% vs 71.4%), calcaneus (87.5% vs 71.4%), and talar neck (100% vs 42.9%) were higher in the 3D sphere group than in the femoral head allograft group. The rate of union of the talar neck was significantly higher to the 3D sphere implant than to the femoral head allograft (p=0.016). The number of patients achieving successful fusion of all three articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%), although not statistically significant (p=0.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p=0.016).There were no differences between the groups in terms of complications. Conclusion: These data demonstrate that the use of a custom 3D-printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail. The rate of successful fusion of all three tibial, calcaneal and talar neck articulations was higher to the 3D sphere than to the femoral head allograft, although not statistically significant. Union of the talar neck was significantly higher to the 3D sphere implants than it was to the femoral head allograft. Subsidence was significantly higher with the femoral head allograft than the 3D sphere.

Zusammenfassung Rekonstruktive Eingriffe im Bereich des Ruckfuses erfordern haufig eine Knochentransplantation. Die Verwendung des eigenen Beckenkammspans gilt trotz der bekannten Entnahmemorbiditat und langer Rekonvaleszenzzeit bisher als das Mittel der Wahl. Es werden die Ergebnisse nach einer isolierten subtalaren Distraktionsarthrodese mit allogener Knochenspantransplantation uber den posterolateralen Zugang in 19 Fallen prasentiert. Die klinischen und radiologischen Untersuchungen erfolgten praoperativ, acht und 12 Wochen und ein Jahr postoperativ. Der AOFAS Score verbesserte sich von durchschnittlich 35 (31–42) auf 86 (78–90) Punkte 12 Monate postoperativ. Die Punkte in VAS reduzierten sich von durchschnittlich sechs (4–8) praoperativ auf 2 (1–4) 12 Monate postoperativ. Die knocherne Konsolidierung konnte in allen Fallen verzeichnet werden. Die allogene Knochenspantransplantation eignet sich gut fur die subtalare Distraktionsarthrodese. Sie stellt eine hochwertige Alternative zur autogenen Knochentransplantation dar.

Previous hindfoot surgeries present a unique challenge to hindfoot arthrodesis, as the patients may have multiple incisions around the hindfoot. In high-risk patients with compromised soft tissues, a posterior approach can provide an alternative for a fresh soft tissue plane for the surgery. The use of a blade plate construct is widely accepted; however, there are limited data supporting the use of a posterior approach.We asked (1) what proportion of patients treated with this technique achieved osseous union; (2) what complications were observed; (3) were any patient-demographic or health-related factors associated with the likelihood that a patient would have a complication develop?Between December 2001 and July 2014, 42 patients received a posterior blade plate. During the period in question, indications for hindfoot arthrodesis using posterior blade fixation were subtalar osteoarthritis below an ankle fusion, malunion or nonunion, failed tibiotalocalcaneal arthrodesis attributable to nonunion of the tibiotalar and/or subtalar joint; or tibiotalar and subtalar osteoarthritis in patients with impaired bone or soft tissue quality (particularly if the soft tissue problem was anterior). During that period, all patients who met those indications were treated with a posterior blade plate. Forty (95%) were included in this study, and two were lost to followup before the 1-year minimum required by the study. Demographics (age, gender, BMI, smoking status, and comorbidities) and surgical data (indication, previous treatment, and additional procedures) were analyzed. Of the 40 patients included, 27 (68%) were male and 13 (33%) were female, with a median of two previous hindfoot or ankle surgeries (range, 0-9 surgeries). The mean age of the patients was 56 ± 13 years. Followup averaged 47 ± 28 months (range, 14-137 months). Twenty-eight of 40 (70%) patients had a tibiotalocalcaneal arthrodesis as a primary (n = 6), primary staged (n = 10), revision (n = 9), or revision staged (n = 3) procedure. Eleven of 40 patients (28%) underwent ankle arthrodesis (primary n = 7, revision n = 4). One of the 40 patients (3%) underwent tibiotalocalcaneal arthrodesis for a failed total ankle arthroplasty. Weightbearing radiographs were used to assess fusion. Osseous fusion was defined as visible trabecular bridging on the lateral and AP ankle views within 6 postoperative months. Delayed union was defined as osseous fusion occurring between 6 and 12 months. Nonunion was defined as no visible trabecular bridging at the latest followup (longer than 12 months). Clinic and surgery notes were reviewed for complications. Univariate analysis was performed to compare patient groups: patients with solid union versus nonunion, and patients with versus without complications.Twenty-nine of 40 (73%) patients had osseous fusion within 6 postoperative months. Four of 40 (10%) patients had a delayed union between 6 and 12 months, and seven of the 40 (18%) patients had nonunions, which occurred in the ankle (n = 3), subtalar (n = 3), or both (n = 1) joints. There were 26 complications observed: 18 (69%) were considered major and eight (31%) were minor. With the numbers available, we did not identify any demographic or surgical factors associated with complications, delayed union, or nonunion.The proportion of patients treated with a posterior blade plate hindfoot fusion who had delayed union or nonunion is greater than that reported for patients in other series who underwent primary hindfoot arthrodesis with other approaches, and the proportion of patients who had complications develop is high. Further studies are needed to address alternative approaches to achieve hindfoot fusion in patients with complex hindfoot problems.Level IV, therapeutic study.

Background:Hindfoot deformity has been described as a risk factor for poor hallux valgus (HV) surgery outcomes. However, there has been no study that demonstrates it. The purpose of this investigation was to evaluate the influence of hindfoot misalignment in HV surgery results.Methods:All patients operated on for HV during 2010 and 2011 at 3 university hospitals were included. The preoperative and 2-year postoperative radiologic data included the HV and the intermetatarsal (IM) angles, the naviculocuboid overlap (NC), the talonavicular coverage (TN) angle, the talus–first metatarsal (T-1MT) angle, as well as the calcaneal pitch (CP) angle. Additionally, the Short Form–36 questionnaire version 2.0 (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) score, satisfaction and recurrence were also analyzed. A total of 207 met the inclusion criteria. There were 26 patients (12.6%) who could not be assessed at the 2-year follow-up. Patients were allocated to a varus, normal, or a valgus hindfoot tertile using the values for the CP, NC, TN, and T-1MT angles.Results:No significant differences ( P > .05) were found between the groups when the HV or IM angles, AOFAS, SF-36 Mental Composite Scale, SF-36 Physical Composite Scale, or satisfaction were compared. Similarly, no significant and strong correlations were observed ( P > .05, ρ < 0.3) between any of the mentioned hindfoot measures and the outcomes scales.Conclusion:No influence of hindfoot misalignment on HV surgery outcomes was found in the present study in terms of correction, pain, function, satisfaction, or quality of life. Patients with hindfoot misalignment did not obtain worse outcomes in HV surgery.Level of Evidence:Level II, prognostic, comparative study.

Introduction Ankle sprains are one of the most common injuries. Despite appropriate conservative treatment, approximately 20–40% of patients continue to have chronic ankle instability and pain. In 75–80% of cases there is an isolated rupture of the anterior talofibular ligament. Material and method A retrospective observational study was conducted on 21 patients surgically treated for chronic ankle instability by means of an arthroscopic anatomical repair, between May 2012 and January 2013. There were 15 men and 6 women, with a mean age of 30.43 years (range 18–48). The mean follow-up was 29 months (range 25–33). All patients were treated by arthroscopic anatomical repair of anterior talofibular ligament. Four (19%) patients were found to have varus hindfoot deformity. Associated injuries were present in 13 (62%) patients. There were 6 cases of osteochondral lesions, 3 cases of posterior ankle impingement syndrome, and 6 cases of peroneal pathology. All these injuries were surgically treated in the same surgical time. Results A clinical-functional study was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The mean score before surgery was 66.12 (range 60–71), and after surgery it increased up to a mean of 96.95 (range 90–100). All patients were able to return to their previous sport activity within a mean of 21.5 weeks (range 17–28). Complications were found in 3 (14%) patients. Conclusions Arthroscopic anatomical ligament repair technique has excellent clinical-functional results with a low percentage of complications, and enables patients to return to their previous sport activity within a short period of time.

Posttraumatic malalignment after talar neck fractures invariably leads to painful functional impairment. Anatomic reduction and definitive, stable osteosynthesis at the primary surgical intervention is preventative. Secondary anatomic reconstruction with joint preservation should be considered in the absence of arthrosis in the peritalar articulations. Reorientating arthrodeses should be entertained where deformity has resulted in joint incongruity and, ultimately, posttraumatic arthritis. TAA may have a role as a motion-conserving procedure in combination with adjacent subtalar and midtarsal fusions.

Background Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified. Materials and methods A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation. Results The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68–100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36–96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications. Pitfalls The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion. Solutions The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment. Conclusion The review provides practical suggestions to optimize SA-techniques.

Coronal plane hindfoot deformity can be isolated but often exists in combination with other foot deformities. A valgus hindfoot can be the result of osseous malalignment, soft tissue dysfunction, or both. When both are present, correction of either of them alone leads to less satisfying resu

Surgical treatment of varus hindfoot deformity may necessitate bony and soft-tissue corrections, as it is often associated with a cavovarus deformity of the foot. Different procedures have been suggested; most of the authors, however, recommend a calcaneal osteotomy to address the varus deviation of the heel, particularly if a rigid deformity is present. The popular Dwyer osteotomy shortens the heel and allows only limited correction in only 1 plane, and therefore, several modifications of the classic Dwyer osteotomy have been described. This article describes an attractive alternative procedure with a Scarf-like osteotomy, allowing to correct the heel in a frontal and transversal plane.