Search

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.

The exact radiographic assessment of the hindfoot alignment remains challenging. This is reflected in the different measurement methods available. Weightbearing CT (WBCT) has been demonstrated to be more accurate in hindfoot measurements. However, current measurements are still performed in 2D. This study wants to assess the use of computed methods to convert the former uniplanar hindfoot measurements obtained after WBCT towards a 3D setting. Forty-eight patients, mean age of 39.6 ± 13.2 years, with absence of hindfoot pathology were included. A WBCT was obtained, and images were subsequently segmented and analyzed using computer-aided design operations. In addition to the hindfoot angle (HA), other ankle and hindfoot parameters such as the anatomical tibia axis, talocalcaneal axis (TCA), talocrural angle, tibial inclination (TI), talar tilt, and subtalar vertical angle were determined in 2D and 3D. The mean $$\hbox {HA}_{2\mathrm{D}}$$ was $$0.79^{\circ }$$ of valgus ± 3.2 and the $$\hbox {HA}_{\mathrm{3D}}$$ was $$8.08^{\circ }$$ of valgus ± 6.5. These angles differed significantly from each other with a $$P

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.

Background: Triple arthrodesis is traditionally done through a two-incision approach. In certain high-risk patients, it may be desirable to do the procedure through a single medial incision to avoid lateral wound healing problems. Method: A cadaver study was undertaken to determine the percentage of surface area of each hindfoot joint that could be prepared through a single medial incision. Five cadaver legs were assigned to the single-incision group, and one cadaver leg was used as the “standard” two-incision specimen. Results: Through the single-incision approach, 91% of the talonavicular joint, 91% of the subtalar joint, and 90% of the calcaneocuboid joint could be prepared. These results were comparable to the two-incision cadaver specimen results. Conclusions: A single-incision medial approach for triple arthrodesis is a safe and effective technique in the management of hindfoot deformity and arthritis in certain high-risk patients.

Tibiotalocalcaneal arthrodesis is a viable alternative to amputation in severely deformed hindfoot deformity. We report the results of retrospective analysis of single centre, single surgeon operated consecutive 15 cases of tibiotalocalcaneal arthrodesis at our institution. The diagnosis was rheumatoid arthritis in one case, traumatic arthritis in six, degenerative osteoarthritis in five and neuropathic ankle in three cases. Co-morbidity was seen in 13 cases of which six patients were suffering from diabetes. Bony union was observed in 87% of cases, 85% patients were satisfied at the end result achieved. The aim of this study was to determine improvement in pain, function and to determine patients satisfaction achieved. Considering improvement in pain, function, AOFAS score and patient's satisfaction achieved post-operatively, we feel this is good technique with satisfactory outcome. It provides good biomechanical stability thereby minimising the chances of failure.

Tarsal tunnel syndrome is an entrapment neuropathy involving the posterior tibial nerve within the tarsal canal. Typical symptoms include burning pain and paraesthesia along the medial ankle and plantar aspect of the foot. Although potential causes of tarsal tunnel syndrome include trauma, varicosities, tenosynovitis, space-occupying lesions, and hindfoot deformity, in most cases the aetiology is idiopathic. Surgical release of the posterior tibial nerve and its terminal branches is indicated if symptoms persist despite non-operative treatment. In this article, we discuss the pre-operative evaluation of these patients and illustrate in detail our preferred technique for surgical release.

Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients ( 11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.

Category: Ankle, Hindfoot, Imaging, Ankle Instability Introduction/Purpose: Varus hindfoot deformity may increase the risk of chronic ankle instability (CAI).Weightbearing CT (WBCT) semi-automated measurements and built-in databases may contribute to investigate the relationship between clinical and radiographic data. The objective of this study was to analyze hindfoot alignment (HA) in relation with CAI in a series of patients using these new tools. We hypothesized that there would be a positive correlation between a varus morphotype and a history of CAI. Methods: This is a Level 3 retrospective comparative study of a continuous series of 124 feet (63 patients) referred from July to December 2016. and subsequently assessed by WBCT (PedCAT®, CurveBeam LLC). The measurement software (Talas®, Curvebeam LLC), gave HA as a value of Foot and Ankle Offset (FAO). This measures the offset between the center of the ankle joint and the median line of the foot joining the centers of the calcaneus and forefoot weight bearing surfaces. Data was prospectively saved in a database (CubeView®, CurveBeam, PA, USA). The definition of CAI was a history of at least 3 ankle sprains during a 6 months period. Exclusion criteria were medial instability and syndesmotic injuries (2 cases).A univariate analysis was conducted to study CAI against the following variables: gender (Fisher), BMI and FAO (Kurskal-Wallis). The significant variables were subsequently included in a multivariate logistic model. Results: Nineteen feet had CAI, in 12 patients. Gender (p=0.0467 –the proportion of women for patients with CAI was 72.3%, compared to 33.3% without CAI) and FAO (p=0 .0002) were significant in the univariate analysis. The mean FAO was respectively -1.40 (SD: 5.50) and 3.56 (SD: 5.31) with and without a history of CAI. No significant difference of age or BMI was shown. After verification of log-linearity between odds of CAI and FAO, the multivariate logistic regression adjusted for gender demonstrated a 15% increase of odds of CAI per unit increase of varus (adjusted Odds Ratio (CI95%): 0.858 (0.771-0.943) p=0.003), and no more significant effect of gender after adjustment on FAO (Odds ratio (CI95%) Female versus Male: 0.548 (0.185 -1.669) p=0.277). Conclusion: A positive linear relationship was found between Varus Hindfoot Alignment measured using a semi-automatic tool in WBCT and the odds ratio for Chronic Ankle Instability, thus confirming and quantifying previous findings. The recent development of semi-automatic measurements and prospective databases opens future perspectives for big data and multivariate analysis in foot and ankle pathology.