Safety and efficiency of a 2-portal lateral approach to arthroscopic subtalar arthrodesis: a cadaveric study

Correction of progressive collapsing foot deformity classes after isolated arthroscopic subtalar arthrodesis

INTRODUCTION

Subtalar osteoarthritis in the context of flatfoot (recently renamed Progressive Collapsing Foot Deformity (PCFD)) may be treated through subtalar joint (SJ) arthrodesis with anticipated consequences on three-dimensional bony configuration. This study investigates the correction of PCFD-related deformities achieved after Anterolateral Arthroscopic Subtalar Arthrodesis (ALAPSTA).

METHODS

In this retrospective study, we evaluated pre- and post-operative (at 6 months) weight bearing computed tomography (WBCT) images of patients diagnosed with PCFD with a degenerated SJ (2 A according to PCFD classification) and/or peritalar subluxation (2D) with or without associated flexible midfoot and/or forefoot deformities (1B, 1 C and 1E) which underwent ALAPSTA as a standalone procedure between 2017 and 2020. Multiple measurements were used to assess and compare pre and post-operative PCFD classes.

RESULTS

Thirtythree PCFD (33 patients, median age 62) were included in the study. Preoperative medial facet subluxation was 28.3 % (IQR, 15.1 to 49.3 %). Overall PCFD 3D deformity improved with a reduction of the foot and ankle offset from 9.3 points (IQR, 7.8 to 12) to 4 (IQR, 0.9 to 7) (p < 0.001). Class A-hindfoot valgus (median tibiocalcaneal angle and median calcaneal moment arm improved by 9.4 degrees (p < 0.001) and 11 mm (p < 0.001), respectively), class B-midfoot abduction (median talonavicular coverage angle improved by 20.5 degrees, p < 0.001) and class C-forefoot varus (median sagittal talo-first metatarsal angle improved by 10.2 degrees (p < 0.001)) were significantly corrected after surgery. Class D was difficult to assess due to the fusion procedure. No patient had a pre-operative valgus deformity at the ankle (no class E), and no significant change of the talar tilt was observed (p = 0.12).

CONCLUSION

In this series, ALAPSTA performed as a standalone procedure to treat patients diagnosed with PCFD with a degenerated subtalar joint and/or peritalar subluxation was effective not only at correcting hindfoot alignment but also flexible midfoot abduction and flexible forefoot varus.

LEVEL OF EVIDENCE

Level IV, case series.

Subtalar Joint Arthroscopy

Subtalar arthroscopy is being more commonly utilized by surgeons who perform foot and ankle arthroscopy. The joint can be entered from an anterior lateral or posterior approach. There is unique pathology in the joint that can be repaired through an arthroscopic approach.

Lateral endoscopy of the sinus tarsi: Anatomy, technique and current indications

Numerous pathologies are reported in the lateral mid- and hind-foot. Access to the sinus tarsi is difficult, making lateral endoscopy the preferred approach. The present technical note describes the anatomy, technique and current indications for lateral endoscopy of the sinus tarsi.

Modified Posterior 2-Portal Technique of Arthroscopic Subtalar Joint Arthrodesis: Improved Pain and Functional Outcome at Mean 15 Months Follow-up-A Case Series

INTRODUCTION

Posterior arthroscopic subtalar joint arthrodesis (PASTA) via a posterior 2-portal technique has been described. We modified the surgical technique of creating the portals in the plane of the posterior facet (under fluoroscopy guidance) to enhance the ease of access to the joint, easier and complete removal of articular cartilage along with maintaining the heel height.

METHODS

Patients of post-traumatic subtalar joint arthritis, treated by PASTA during 2016 till 2019 were included in the study. Exclusion criteria: significant height collapse of calcaneum, lateral blow out or heel widening. The confirmation of subtalar joint as the source of pain was done by injection of local anaesthetic inside the joint under the image intensifier, bringing immediate pain relief. The primary outcome variables assessed were the pain and functional scores, assessed using visual analogue scale and AOFAS (American Orthopaedic Foot and Ankle Society) score, respectively.

RESULTS

The total of 16 patients (7 males, 9 females) was included. The average age was 40.68 years (23-58 years). The underlying pathology in all patients was post-traumatic subtalar arthritis secondary to calcaneus fracture malunion in 8 patients (50%), talus fracture malunion in 4 (25%) and ligament injury in 2 patients (12.5%). No bone grafting was done. The mean duration of follow-up was 15.6 months (9-24 months). There was a statistically significant improvement (p < 0.001) in mean VAS score at follow up (2; range 0-4) as compared to the mean preoperative score (7; range 6-9). The AOFAS score also improved significantly (p < 0.001) at the follow up (mean 79; range 68-89) as compared to the preoperative score (mean 18; range 10-25).

CONCLUSION

The posterior arthroscopic fusion of subtalar joint gives good results in terms of pain relief and functional scores when done for carefully selected patients of subtalar joint arthritis. Our slight modification of the original technique improves the ease of removing cartilage from subtalar joint with minimal height loss; thus, precluding any need for bone graft. It also makes the instrument movement easier inside the joint.

Lateral Arthroscopic Subtalar Arthrodesis for Talocalcaneal Coalition: Surgical Technique

Resection of symptomatic talocalcaneal coalitions (TCCs) has been performed for patients with normal tarsal joints and <50% involvement of the subtalar joint. For those with TCCs >50% of subtalar articulation or/and subtalar arthritis, a subtalar arthrodesis is done. The purpose of this Technical Note is to describe the arthroscopic resection of TCC and talocalcaneal arthrodesis during the same procedure by using a 2 lateral portal technique. With the patient in lateral decubitus under general or locoregional anaesthesia, the foot and ankle are extended beyond the edge of the surgical table. A lateral portal is created 1 cm anterior to the tip of the lateral malleolus in which the arthroscope is introduced. The anterolateral portal is created 1 cm inferior and 2 cm anterior to the tip of the lateral malleolus. The posterior subtalar surface is prepared progressively. The TCC resection is completed. The fixation is obtained with 2 cannulated screws. The arthroscopic resection of TCC and subtalar arthrodesis during the same procedure by using 2 lateral portals can be done for correctly selected patients.

Outcomes and Complications of Open vs Posterior Arthroscopic Subtalar Arthrodesis: A Prospective Randomized Controlled Multicenter Study

BACKGROUND

Open subtalar arthrodesis is the standard treatment for subtalar arthritis. Posterior arthroscopic subtalar arthrodesis (PASTA) has recently gained increasing popularity due to a shorter recovery time and better cosmesis. However, studies comparing outcomes and complications between these 2 techniques are limited.

METHODS

In total, 56 patients with subtalar joint arthritis were prospectively randomized to 2 parallel groups to receive either PASTA (n = 28 patients) or open subtalar arthrodesis (n = 28 patients). The minimum follow-up period was 12 months. Primary outcome was union rate confirmed on postoperative computed tomography (CT) scan. Secondary outcomes were union time; visual analog scale (VAS), Short Form-36 (SF-36), and Foot and Ankle Ability Measure (FAAM) scores; tourniquet time; and complications.

RESULTS

Union time (9.4 vs 12.8 weeks) and recovery time (time to return to activities of daily living [8.4 vs 10.8 weeks], work [10.6 vs 12.9 weeks], and sports [24.9 vs 32.7 weeks]) were significantly shorter with PASTA than with the open technique (P < .05 all). Both techniques led to significant improvements in all functional outcomes (FAAM, SF-36, and VAS scores; P < .01 all); however, there was no significant difference between the techniques in these outcomes (P > .05 all). Other outcomes, including tourniquet time (55.8 vs 67.2 min), union rate (96.3% vs 100%), and complication rate, were not significantly different between the techniques.

CONCLUSION

Both open and PASTA techniques led to significant improvements in pain and function in patients with isolated subtalar joint arthritis. Although short-term functional outcomes and complication rates were not significantly different between the techniques, the PASTA technique was better at shortening the union and recovery times.

LEVEL OF EVIDENCE

Level I, prospective multicenter randomized controlled trial.

The comprehensive review of the neurovascular supply of the ankle joint: clinical implications

The rupture of ligament in the lateral part of ankle joint is a common injury and can lead to chronic ankle instability and lead to ankle osteoarthritis. Ankle arthroscopy is considered as a standard option to treat various ankle problems due to the need for only minimal incisions and fewer complications when compared to open surgery. However, there are complications associated with arthroscopic surgery e.g. damage to the anatomical structures around the portal placement areas. The present review provides anatomical knowledge of the superficial and deep neurovascular structures in the ankle region. These structures are important when ankle surgery is performed in order to avoid any intraoperative injury and prevent any complication following surgery.

Do clinical results of arthroscopic subtalar arthrodesis correlate with CT fusion ratio?

BACKGROUND

CT analysis of arthroscopic subtalar arthrodesis rarely finds complete fusion. The aim of the present study was to determine, at 12 months' follow-up of arthroscopic subtalar arthrodesis: (1) CT fusion ratio, (2) functional results, and (3) the correlation between the two.

HYPOTHESIS

Incomplete fusion ratio does not impair the result of arthrodesis.

MATERIALS AND METHODS

A continuous series of 22 arthroscopic subtalar arthrodeses was assessed at 12 months' follow-up. The procedure used a posterior approach without bone graft, with stabilization by 2 compression screws. Clinical assessment comprised of a numerical analog pain scale (NAS, AOFAS and SF12) scores. Satisfaction was assessed on an NAS and on Odom's criteria. CT analysis at 12 months determined the posterior subtalar joint fusion ratio.

RESULTS

At follow-up, 2 patients showed non-union (9.1%). Among the 20 patients with fusion (91%), fusion was complete (>67°) in 16 (72.7%) and partial (34-66%) in 4 (18.2%). Mean fusion ratio at 12 months was 77.7%±14.8 (range, 36-98%). Functional gains (Δ) were: Δ pain NAS 4.8±2 (range, 1-10) and Δ AOFAS score 31.1±14 (range, 10-59). Mean satisfaction score was 8±2.5 (range, 3-10). There were no significant correlations between fusion ratio and any clinical or satisfaction scores.

CONCLUSION

Although clinical gain was systematic, functional and satisfaction scores were independent of whether subtalar fusion ratio was partial or complete.

LEVEL OF EVIDENCE

IV, retrospective study.

Arthroscopic subtalar arthrodesis through the sinus tarsi portal approach: A series of 77 cases

BACKGROUND

Subtalar arthrodesis through an open approach carries significant risk of complications. An arthroscopic approach aims to minimise damage to the soft tissue envelope to improve recovery, union and complication rates. A two portal approach through the sinus tarsi was used.

METHODS

A retrospective review of all patients undergoing isolated arthroscopic arthrodesis was performed.

RESULTS

Seventy-seven procedures were performed. Successful arthrodesis was achieved in 75 (97.4%). Two patients underwent successful revision arthrodesis for aseptic nonunion. There was one (1.3%) superficial infection and one (1.3%) partial sural nerve injury.

CONCLUSIONS

Two-portal sinus tarsi arthroscopic subtalar arthrodesis is safe and effective. Advantages over other arthroscopic approaches are the access to all three facets of the joint, avoidance of a posterolateral portal in order to minimise risk to the sural nerve, and the ability to use the same approach to arthrodese the entire triple hindfoot joint complex. Technical tips and pitfalls are discussed.

Treatment of Malunited Calcaneal Fracture With Posttraumatic Subtalar Osteoarthritis Using Lateral Endoscopic Calcaneoplasty With Posterior Arthroscopic Subtalar Arthrodesis

Malunion of calcaneal fractures is a common complication after improper nonoperative treatment. It may develop into posttraumatic subtalar osteoarthritis, lateral calcaneal wall prominence, and severe foot deformities. This Technical Note reports the technical aspects of lateral endoscopic calcaneoplasty with posterior arthroscopic subtalar arthrodesis for the treatment of malunited calcaneal fracture with lateral calcaneal wall prominence and posttraumatic subtalar osteoarthritis. This technique was chosen because it can reduce the risk of wound complication compared with a conventional lateral extensile approach. This Technical Note describes the use of the technique in a patient with prone position. This offers the advantages of easier access to the lateral surface of the calcaneus and posterior facet of the subtalar joint, and is less invasive to the soft tissue envelope on the lateral side of the foot. Moreover, the concomitant bone void area of the subtalar joint can be dealt with by an arthroscopic procedure.

Anterolateral Arthroscopic Posterior Subtalar Arthrodesis: The Surgical Technique

The effectiveness of subtalar arthrodesis has been well documented in treating degenerative subtalar joint disease. The arthroscopic subtalar approach for arthrodesis has also been proved to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. To date, the main concerns about arthroscopy have regarded incision-related neurologic complications such as lesions of the tibial, fibular, and sural nerves. In this context, we present a 2-portal lateral (anterior and middle) approach to arthroscopic subtalar arthrodesis, recently documented in the literature, that provides similar excellent access to the joint with a lower risk of nerve damage.

Subtalar arthroscopic arthrodesis: Technique and outcomes

PURPOSE

The goal of this study was to describe the surgical technique and our results with arthroscopic posterior subtalar arthrodesis.

MATERIAL AND METHODS

Retrospective case series of 65 patients (38 men and 27 women) averaging 50 years of age (range 21-72 years) undergoing posterior arthroscopic subtalar arthrodesis using one or two percutaneous 6.5-7.3mm screws between May 2004 and February 2011, with a mean follow-up of 57.5 months (range 24-105 months).

RESULTS

We achieved a 95.4% union rate after an average of 12.1 weeks (range 9 to 16 weeks). 12.3% of patients suffered complications, including superficial infection, nonunion and need for hardware removal. The AOFAS score improved from 51.5 points (19-61 points) preoperatively to 81.9 points (60-94 points) in the postoperative period.

CONCLUSIONS

We describe the surgical technique for arthroscopic subtalar arthrodesis, which as proven to be a safe and reliable technique in our experience, with consistent improvements in AOFAS scores.

Arthroscopic subtalar arthrodesis

Arthroscopic subtalar arthrodesis is gaining in popularity based on evidence of bone fusion in over 90% of cases, with a shorter time to healing, a simpler postoperative course, and fewer complication compared to open surgery. Two arthroscopic techniques have been reported: one with the patient in lateral decubitus and lateral portals and the other with the patient prone and posterior portals. The objective of this technical note is to describe these two techniques, with emphasis on the specific characteristics of each.

Arthroscopic Subtalar, Double, and Triple Fusion

Arthroscopic approaches to subtalar, double, and triple arthrodesis allow relative preservation of the soft tissue envelope compared with traditional open approaches. The surgical technique involving the use of a 4.5-mm 30° arthroscope via sinus tarsi portals is described. All 3 joints of the triple joint can be prepared for fusion with motorized burrs. Rigid fixation is achieved with cannulated screws. High union rates and low complication rates have been reported.

Safety and efficiency of posterior arthroscopic ankle arthrodesis

PURPOSE

To study the safety and efficiency of posterior arthroscopic ankle arthrodesis.

METHODS

Ten fresh-frozen human lower leg specimens without evidence of previous surgery to the foot and ankle were selected. Arthroscopic debridement of the tibiotalar joint was performed in all specimens using a standardized protocol. Anatomical dissections were regarded the gold standard for safety analysis. To evaluate the efficacy of the posterior ankle arthroscopic arthrodesis, the debrided articular tibiotalar parts were resected and subsequently analysed using Image-analysis software, Image J (Wayne Rasband, National Institutes of Health, Bethesda, MD).

RESULTS

In none of the specimens, iatrogenic damage was detected during the anatomical dissection following the posterior ankle arthroscopic procedure. A total talar joint surface area of 95 % and total tibial joint surface area of 96 % was addressed during the arthroscopic debridement.

CONCLUSIONS

The posterior ankle arthroscopic arthrodesis can be regarded safe and is also highly effective in the debridement of cartilage, resulting in optimal biology for fusion to occur. Therefore, this new arthroscopic technique potentially will diminish existing non-union rates for the fusion of the ankle joint.

Subtalar joint arthrodesis: open and arthroscopic indications and surgical techniques

Arthrodesis of the subtalar joint can be performed via both open and arthroscopic techniques. Both groups of procedures have their own relative indications and contraindications, as well as complications. Good results have been reported for both general procedures, although some studies suggest superiority with arthroscopic subtalar arthrodesis.

Talocalcaneal coalition combined with flatfoot in children: diagnosis and treatment: a review

Talocalcaneal coalition often leads to a flatfoot deformity in children. Previous reports have uncovered many aspects of tarsal coalition and flatfoot respectively, including the etiology, clinical presentation, and diagnostic imaging, as well as treatment. However, the optimum surgical procedure for talocalcaneal coalition combined with flatfoot has not been definitively determined. The nonconformity of treatment options is due to our incomplete knowledge of biomechanics, diagnosis, and indication of treatment for talocalcaneal coalition with flatfoot. The objectives of this review are to provide an overview of the current knowledge about etiology, biomechanics, classification, diagnosis, and treatment options for talocalcaneal coalitions with flatfoot and highlight its therapies in children.

Arthroscopic triple fusion joint preparation using two lateral portals: a cadaveric study to evaluate efficacy and safety

BACKGROUND

Arthroscopic triple fusion has several advantages over open techniques, but its use has yet to become widespread. Preliminary published techniques use five portals with neurovascular risk. Our aim was to assess the safety and efficacy of an alternative lateral two portal technique.

METHODS

Four cadaveric hindfeet were arthroscopically prepared for a triple fusion using two lateral portals. The distance to relevant subcutaneous nerves was measured as well as the prepared joint surface percentage.

RESULTS

Mean distance from mid-lateral portal to the nearest sural nerve branch was 22.3mm (range 20-24mm) and from the dorsolateral portal to the intermediate branch of the superficial peroneal nerve was 7.8mm (range 4-11mm). Mean percentages of joint preparation were 63% (talar head), 62% (navicular), 75% (calcaneum) and 74% (cuboid).

CONCLUSIONS

Two lateral arthroscopic portals allow adequate joint preparation for triple fusion procedures. The proximity of subcutaneous nerves is important to appreciate when using these portals.