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

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.

Posterior Arthroscopic Subtalar Joint Arthrodesis (Pasta)

The arthroscopic approach provides a manageable postoperative course in terms of wound healing, pain control, and bone healing when compared with an open procedure. In particular, posterior arthroscopic subtalar joint arthrodesis (PASTA) allows a reproducible and viable alternative to standard lateral-portal subtalar joint (STJ) arthrodesis without violating sinus or canalis tarsi neurovascular structures. Additionally, those patients who have undergone previous total ankle arthroplasty, arthrodesis, or talonavicular joint arthrodesis may be better served with PASTA over open arthrodesis if STJ fusion becomes necessary. This article describes the unique PASTA surgical procedure and its helpful tips and pearls.

Subtalar and talonavicular arthrodesis under lateral arthroscopy

Open hindfoot surgery incurs certain complications: notably, infection and skin problems. Arthroscopic subtalar arthrodesis reduced the complications rate while ensuring >90% fusion. To date, arthroscopy is little used for talonavicular arthrodesis. Here, we describe subtalar and talonavicular arthrodesis under arthroscopy via 2 lateral portals around the sinus tarsi. Level of evidence: IV.

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.

Inconclusive evidence that arthroscopic techniques yield better outcomes than open techniques for subtalar arthrodesis-A systematic review

IMPORTANCE

Open in situ subtalar arthrodesis (ISTA) has been a standard procedure for treating subtalar arthritis for varied etiologies with good outcomes. There has been a paradigm shift from ISTA to arthroscopic subtalar arthrodesis (ASTA) over the past two decades due to increase in number of surgeons performing arthroscopy worldwide. However, there is only limited evidence in the existing literature to substantiate the benefit of this change with regards to patient benefit. To our knowledge, there are also no systematic reviews comparing the results of the two techniques for subtalar arthrodesis (STA).

AIM

Our systematic review aims to determine the superior technique for performing STA by comparing the outcomes, union rates, and complications between open and arthroscopic approach for in situ STA. We hypothesised that both procedures would have similar outcomes, union rates, time to union, and complication rate for in-situ STA.

EVIDENCE REVIEW

Three databases, MEDLINE/PubMed, the Cochrane Library, and Google Scholar, were searched using predefined inclusion and exclusion criteria to compare the two procedures. Risk of bias assessment was done using The Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool for assessing the risk of bias in the included studies. Weighted mean averages were computed for all parameters and tabulated separately for ASTA and ISTA.

FINDINGS

We included a total of 22 studies with a total of 978 (ASTA-310, ISTA-668) patients in the review. The most common indication for both techniques was post traumatic subtalar arthritis due to malunited calcaneal fracture in both groups (54.5%). The American Orthopaedic Foot & Ankle Society score was better in the ASTA group with a weighted average improvement of 43.4, while the weighted average improvement was 31.1 in the ISTA group, respectively. Patients undergoing ASTA had a weighted average union rate of 95.5% (standard deviation [SD]-3.6) with a weighted average time to union of 12.2 weeks (SD-2.4) while the ISTA group reported 90.7% (SD-6) union rate with a weighted average time to union of 15.5 weeks (SD-8.4). The weighted overall average complication rate was 13.1% (SD-8.9) in ASTA group and 20.3% (SD-16.2) in the ISTA group with hardware-related complications being the most common in both the groups.

CONCLUSION

From the existing literature, our review suggests that both ASTA and ISTA techniques are effective procedures for STA. However, there is no conclusive evidence to recommend one technique over another. High quality randomised studies may be further required to clearly define the superiority of one technique over another LEVEL OF EVIDENCE: level III.

Quality of MIS vs Open Joint Preparations of the Foot and Ankle

BACKGROUND

Minimally invasive surgery (MIS) is growing in the field of foot and ankle, and the MIS burr is an emerging tool. Although commonly used to perform osteotomies, the burr can also be used for arthrodesis joint preparation that traditionally would be performed through open incisions. To date, there is no study comparing the quality of joint preparation between using a fluoroscopy-guided MIS technique compared to traditional open techniques. The goal of this cadaveric study is to compare the percentage of joint surfaces prepared between MIS and open techniques for the most common joints that are fused in foot and ankle surgery.

METHODS

Open joint preparation was performed under direct visualization with open incisions. MIS joint preparation was performed percutaneously using fluoroscopic guidance alone, without arthroscopy. After joint preparation, cadaveric samples were disarticulated, and joint surfaces were analyzed for percentage of cartilaginous surface removed. The percentage of joint surface prepared was compared between the open and MIS techniques.

RESULTS

Ten cadaveric samples were used for the MIS technique and 5 samples for the open technique. Percentage of joint surface prepared was similar for all joint surfaces.

CONCLUSION

The MIS technique in the hands of experienced surgeons was found to provide overall similar percentages of surface area prepared compared to traditional open techniques.

CLINICAL RELEVANCE

MIS joint preparation may be useful for specific patient populations. This study suggests that MIS joint preparation is a reasonable, and possibly advantageous, alternative to open preparation in arthrodesis surgery when performed by experienced MIS surgeons.

Persistent Pain After Hindfoot Fusion

One of the most challenging problems facing orthopedic surgeons is persistent pain after surgery and certainly is just as frustrating following hindfoot fusion. The hindfoot joints consist of the subtalar, talonavicular, and calcaneocuboid (CC) joints. These joints are commonly fused for degenerative changes, deformity correction, inflammatory or neuropathic arthropathy, tarsal coalition, or primarily after trauma. Goals of hindfoot fusion are a painless plantigrade foot capable of fitting in shoes without orthotics or a brace. Many believe that deformity correction is achievable without inclusion of the CC joint. Managing patient expectations is important when counseling a patient especially regarding potential complications.

Ankle joint pressure change before and after subtalar joint arthrodesis in varus and valgus malalignment of the tibia

Purpose: The compensation mechanism of subtalar joint in ankle with varus or valgus deformity is controversial and not well established. This biomechanical study aims to investigate how subtalar joint arthrodesis will affect the ankle joint pressure in varus and valgus malalignment of the tibia. Methods: Eight fresh-frozen human cadaver legs were tested in this study. A custom-made fixture was utilized and a total of 600N was applied to simulate weight-bearing. Intra-articular sensors (TeckScan) were inserted in the ankle joint to demonstrate the ankle joint pressure. Conditions include: Neutral, 5°, 10°, 15° and 20° varus, 5°, 10°, 15° and 20° valgus. Results: After the fusion of the subtalar joint, when the tibia is gradually inverted, the inside pressure of the ankle joint gradually increases, and the pressure on the outside of the ankle joint gradually decreases. When the tibia is gradually eversion, the pressure on the outside of the ankle joint gradually increases, and the inside of the ankle joint gradually decreases. Conclusions: After the subtalar joint is fused, the compensatory activity of the subtalar joint disappears, and the regulation of the pressure in the ankle joint will be lost. We hypothesized that the inversion compensation of the subtalar joint is more likely to occur than the eversion compensation.

Arthroscopic Subtalar Joint Arthrodesis: Topical Review

BACKGROUND

Advances in foot and ankle arthroscopy over the last 2 decades have allowed for subtalar joint arthrodesis to be performed arthroscopically. The potential advantages of the arthroscopic technique include higher fusion rates, lower complications, reduced perioperative morbidity, and accelerated rehabilitation. Arthroscopic arthrodesis may, however, not be appropriate in the setting of complex deformity correction or the need for other open procedures.

METHODS

Surgical techniques of arthroscopic subtalar joint arthrodesis are described. Outcomes and complications associated with these procedures are presented, based on a comprehensive literature review. Thirteen Level IV studies of moderate quality were included.

RESULTS AND CONCLUSION

Excellent arthrodesis union rates were achieved (average 96%, range 86%-100%), at a weighted average union time of 8.8 weeks (95% confidence interval 7.9-9.7). The overall complication rate was 21% (87/415 feet; range 10%-36.4%). Metal irritation was the most common complication (11.2%), followed by nerve injury (4.2%) and infection (0.9%). Similar fusion rates have been reported when comparing arthroscopic and open arthrodesis. Complication rates are also similar, excerpt for infection, which may be lower with arthroscopy. Three different approaches were used to access the subtalar joint with similar union and complication rates. There was no evidence that the use of bone graft or more than 1 screw improved outcomes. The superiority of arthroscopic subtalar fusion over open techniques cannot be demonstrated by the available studies.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Isolated Arthroscopic-Assisted Subtalar Fusion: A Systematic Review

BACKGROUND

The subtalar joint has a complex anatomic function that includes inversion and eversion of the hindfoot, assisting in walking on uneven surfaces. Arthritis is the most common pathological condition affecting this joint and can require fusion. The surgery can be performed open or with arthroscopic assistance. This systematic review assesses articles written on the safety and efficacy of isolated arthroscopic subtalar fusion.

METHODS

Using MEDLINE and Embase, we systematically reviewed articles published before May 21, 2020.

RESULTS

Of 395 articles, 17 on a total of 395 patients (409 operations) were included in the review. The average duration of follow-up was 40.0 months (range, 3 to 105 months). Radiographic evidence of union was reported for 95.8% of cases at an average of 11.9 weeks (range, 6 to 56 weeks) postoperatively. Delayed union was reported in 1.0% of patients and nonunion, in 4.3% of patients. In the articles reporting patient satisfaction, including pain relief, 95.4% of patients had positive outcomes. Postoperative complications were reported in 64 patients (16.2%), including 37 (9.4%) with symptomatic implants, 11 (2.8%) with dysesthesia or neuropathic pain, and 3 (0.8%) with postoperative infection.

CONCLUSIONS

Arthroscopic subtalar fusion is a safe and effective alternative to open subtalar arthrodesis, with high patient satisfaction rates, high union rates at similar follow-up intervals, and low complication rates. The aim of future research should be to determine the ideal cases for this approach as well as the most efficient arthroscopic surgical technique and postoperative rehabilitation to optimize function and union as seen on radiographs.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lateral Hind-Foot Endoscopic Anterolateral/Posterolateral (LEAP) Subtalar Arthrodesis: An Effective Minimally Invasive Technique to Achieve Subtalar Fusion and Deformity Correction

Arthrodesis surgery aims to provide relief for chronic joint pain and correct limb alignment by achieving a stable union between articulating bones. The key factors to achieving sound arthrodesis is adequate debridement of arthritic cartilage and creating well-apposed bleeding subchondral bone surfaces without compromising the surrounding soft tissue envelope. Arthroscopic subtalar arthrodesis is technically demanding but provides better visualization of the articular surfaces and is safer for the surrounding soft tissues compared to the open approach. Early published reports of the arthroscopic subtalar arthrodesis from the lateral sinus tarsi approach and posterior approach have shown promising results with high rates of union and less wound healing complications. However, there are concerns about access to all facets of subtalar joint, nerve injury, and deformity correction. In this technique, the article authors describe the lateral endoscopic anterolateral/posterolateral (LEAP) approach for subtalar arthrodesis to improve visualization and access to all facets of the subtalar joint to ensure adequate preparation of apposing surfaces, sound union, and facilitate deformity correction of hind-foot. Strategic portal placement also avoids injury to sural nerve. This is a safe and effective minimally invasive technique for subtalar arthrodesis.

Common Pitfalls in Subtalar Joint Preparation for Arthrodesis via Sinus Tarsi Approach

This cadaveric study assessed factors that could lead to nonunions in subtalar joint arthrodesis. The purpose of this study was to assist surgeons in achieving sufficient joint preparation in hopes to achieve more frequent arthrodesis of the subtalar joint. We evaluated the influence of experience in regard to cartilage preparation of the joint. We also assessed which quadrants of the subtalar joint were more likely to have unprepared cartilage. The subtalar joints in 17 cadaveric limbs were prepared by 17 participants with differing levels of experience. After the cartilage was denuded, the percentage of unprepared cartilage in each subtalar joint was calculated. The medial quadrants were more likely to have unprepared surfaces. There was also a learning curve present with subtalar joint preparation, as seen by the significantly larger percentage of unprepared cartilage in cadavers prepared by first year residents.

Comparison of different bone graft with arthroscopy-assisted arthrodesis for the treatment of traumatic arthritis of the subtalar joint

AIM OF THE STUDY

To compare the clinical outcomes of traumatic arthritis of the subtalar joint treated by arthroscopy-assisted arthrodesis with autologous bone graft, allogenous bone graft, artifical bone graft, and no bone graft .

METHODS

Sixty-two patients (64 ft) with traumatic arthritis of subtalar joint were randomly divided into four groups. The cases treated with arthroscopy-assisted arthrodesis were analyzed retrospectively. The mean follow-up time was about 22 months (18-28 months) in each group. Clinical outcomes were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analog Scale (VAS), and radiographic examination. The post-operative complications in each group were recorded respectively.

RESULTS

All operations were successful, without incision complications. The subtalar joint obtained full osseous fusion in each group. The average time of osseous fusion was about 12 weeks. There was no significant difference in the fusion time with each group (P = 0.991). The AOFAS and VAS scores in each group were improved significantly in the pre-operative vs post-operative evaluation (all P < 0.01). The average operation time in autologous bone graft group was 74.56 ± 11.45 min which significantly different from that of other groups(P < 0.01).

CONCLUSION

Similar clinical outcomes were achieved among each type of bone graft. Therefore, which types of bone graft or not may be not the most important for arthroscopy-assisted subtalar arthrodesis.

Do Patient Positioning and Portal Placement for Arthroscopic Subtalar Arthrodesis Matter?

Background

Arthroscopic subtalar arthrodesis was first described over 2 decades ago and originally performed in the lateral decubitus or supine position using anterolateral and posterolateral portals situated about the fibula. More recently, several authors have advocated for prone positioning utilizing posteromedial and posterolateral portals with an optional accessory lateral portal. To date, a comparison of these techniques has been limited.

Purpose

To determine the effect of patient positioning and portal placement on complication rates after arthroscopic subtalar arthrodesis.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patients were placed into 1 of 3 groups: the lateral group if they were positioned lateral or supine with lateral-based portals; the 2-portal prone group if they were positioned prone with posteromedial and posterolateral portals; or the 3-portal prone group if posteromedial, posterolateral, and accessory lateral portals were utilized in the prone position. Inverse variance-weighted fixed-effects models were used to evaluate pooled estimates.

Results

A total of 20 studies examining 484 feet in 468 patients with a mean follow-up of 36.1 months were included for analysis. Overall, 8 studies examined patients in the prone position with 2 posterior portals (n = 111; 22.9%), 7 articles evaluated lateral portals (n = 182; 37.6%), and 5 studies examined patients in the prone position with 3 portals (n = 191; 39.5%). The total complication rate was similar (P = .620) between the 2-portal prone (18.9%), 3-portal prone (17.8%), and lateral (17.6%) groups. There was no difference observed in the rate of complications secondary to portal placement (P ≥ .334), rate of painful hardware (P ≥ .497), and rate of repeat surgery (P ≥ .304). The 2-portal prone group had a significantly higher rate of nonunion than the lateral group (8.1% vs 1.1%, respectively; P = .020) but not the 3-portal prone group (5.8%; P = .198).

Conclusion

The current study demonstrated a higher rate of nonunion following arthroscopic subtalar arthrodesis with prone patient positioning using posteromedial and posterolateral portals without an accessory lateral portal.