Systematic Review of Subtalar Distraction Arthrodesis for the Treatment of Subtalar Arthritis

Subtalar Arthrodesis in Patients With Prior Tibiotalar Arthrodesis for Posttraumatic Osteoarthritis

BACKGROUND

The tibiotalar arthrodesis for end-stage ankle osteoarthritis is a surgical procedure that leads to a modification of the kinematics of the adjacent joints and may result in the development of secondary osteoarthritic degeneration of the subtalar joint. It has previously been observed that subtalar arthrodesis in this context shows a lower fusion rate than isolated subtalar arthrodesis. This retrospective study reports the results of subtalar joint arthrodesis with previous ipsilateral tibiotalar arthrodesis and suggests some factors that may compromise the fusion of the joint.

METHODS

Between September 2010 and October 2021, 15 arthrodeses of the subtalar joint with screw fixation were performed in 14 patients, with a fusion of the ipsilateral tibiotalar joint. Fourteen of 15 cases used an open sinus tarsi approach, 13 were augmented with iliac crest bone graft, and 11 had supplemental demineralized bone matrix (DBM). The outcome variables were fusion rate, time to fusion, and revision rate. Fusion was assessed by radiographs and computed tomography scan.

RESULTS

Twelve of the 15 subtalar arthrodeses (80%) fused at the first attempt with an average fusion time of 4.7 months.

CONCLUSION

In this limited retrospective case series, compared to the fusion rate of isolated subtalar arthrodesis reported in the literature, the rate of subtalar fusion in the presence of an ipsilateral tibiotalar arthrodesis was found to be lower.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effect of Arthrodesis Device Type and Trajectory on Subtalar Joint Compression

The use of subtalar arthrodesis procedures has been widely implemented to relieve hindfoot issues after failure of conservative treatments; however, fusion failures persist in some patients with certain risk factors. Currently, surgeons utilize cannulated screws in these arthrodesis procedures to immobilize the subtalar joint. Recent clinical studies have demonstrated improved fusion outcomes in at-risk patients using sustained dynamic compression devices in the tibiotalocalcaneal complex. These devices utilize pseudoelastic nitinol which enables sustained dynamic compression when faced with postoperative bone resorption, joint settling, and bone relaxation. While the clinical success of these devices has been established in the tibiotalocalcaneal complex, the ability of sustained dynamic compression devices to apply joint compression in the subtalar joint has not been quantified. As such, the goals of this study were to (1) compare the ability of static compression devices and sustained dynamic compression devices to apply joint compression and (2) assess the impact of device trajectory on joint compression. A custom mechanical testing fixture was utilized to test the compression applied across the subtalar joint by one sustained dynamic compression device (in anterior and posterior trajectories) as compared to 2 cannulated screws (in both parallel and diverging trajectories). Testing revealed the sustained dynamic compression devices generated 53% greater compression as compared to the static compression devices, despite single versus dual device usage, respectively. Additionally, both types of devices applied joint compression forces in an insertion trajectory-independent manner. These data illustrate the ability of a single SDC device to maintain significantly improved joint compressive forces as compared to 2 static cannulated screws, regardless of insertion trajectory. These SDC devices may be of particular interest for at-risk patients or in revision cases.

Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series

BACKGROUND

The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture.

MATERIAL AND METHODS

We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively.

RESULTS

There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use.

CONCLUSION

Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.

Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BACKGROUND

This study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA).

METHODS

We retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors.

RESULTS

The overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23-10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62-20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28-36.79) were demonstrated as risk factors for nonunion of posttraumatic SA.

CONCLUSION

Patients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.

Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion: a retrospective study

BACKGROUND

This retrospective study aimed to introduce a novel method for simultaneous Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion and to evaluate the feasibility of this method.

METHODS

We retrospectively analysed the clinical and imaging data of 11 patients with calcaneus malunion treated using Y-shape osteotomy and subtalar arthrodesis who were admitted to our hospital from June 2018 to October 2020. The patients included 9 males and 2 females aged from 24 to 69 years old, with an average age of 42.18 years. The clinical and radiological results were assessed with the Visual Analogue Scale (VAS) pain score and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. In addition, functional recovery and general quality of life were evaluated using the 12-Item Short-Form Survey (SF-12).

RESULTS

All radiological parameters were significantly improved at the last follow-up, with increases of 14.37°, 9.18°, and 4.51 mm in the Böhler's angle, calcaneal pitch angle, and talocalcaneal height, respectively, and decreases of 6.39 mm and 6.18° in the calcaneal width and Hindfoot alignment angle (p < 0.05). The mean AOFAS and VAS scores at the last follow-up improved compared with those preoperatively, from 34.18 ± 9.53 to 84.18 ± 11.59 and from 6.90 ± 1.22 to 1.90 ± 1.13, respectively (p < 0.05). The SF-12 physical and mental health scores were 49.65 ± 6.84 and 52.68 ± 7.88, respectively. Furthermore, the early postoperative complications included skin necrosis in one and sural neuralgia in one patient, and the late postoperative complication included ankle pain in one patient. No other complications, such as implant discomforts, malunion, nonunion and re-fracture, were presented.

CONCLUSION

These results indicate that Y-shape osteotomy combined with subtalar arthrodesis is an effective new method for the treatment of calcaneal malunion. Advantages include improvement of the anatomic shape of the calcaneus and union rates for subtalar arthrodesis.

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.

An Umbrella Systematic Review and Meta-Analysis of Systematic Reviews on the Topic of Foot and Ankle Arthrodesis Nonunion Rates

The purpose of this systematic review and meta-analysis was to appraise and combine the available systematic reviews reporting nonunion incidence and prevalence in foot and ankle arthrodesis procedures. The Cochrane Library and MEDLINE were searched for relevant systematic reviews from inception to January 2022. Two independent reviewers selected and reviewed eligible studies. Studies were included if they were systematic reviews or meta-analyses reporting nonunion incidence and prevalence in foot or ankle arthrodesis procedures. Fourteen systematic reviews of 8 types of joint arthrodesis procedures were included for meta-analysis. These reviews comprised 138 studies with 5793 joint arthrodesis procedures. Quality of the included reviews were assessed using the AMSTAR2 checklist. Overall and subgroup meta-analysis of prevalence were performed using random effects model. Publication bias was determined by evaluation of a DOI plot with the Luis Furuya-Kanamori index of asymmetry. The pooled prevalence for foot and ankle nonunion rate was 8.1% (95% confidence interval [CI] 6.5%-9.9%). Overall prevalence of nonunion for single joint foot and ankle joint arthrodesis was 6.1% (95% CI 4.8%-7.6%). Subgroup analysis found that the highest rate of nonunion occurred during tibiotalocalcaneal arthrodesis with 27.1% (95% CI 19.4%-35.2%). We have reported the first meta-analysis of systematic reviews on nonunion rates in foot and ankle arthrodesis procedures. The overall nonunion rate for foot and ankle arthrodesis procedures was 8.1%. For single joint fusion procedures, the nonunion prevalence was 6.1%. Our reported nonunion rates are lower than previously published numbers.

A Direct Posterior Approach for Subtalar Distraction Arthrodesis

Because of soft tissue constraints, definitive management of hindfoot trauma occasionally requires a direct posterior approach via a coronal split of the Achilles tendon. This article and the accompanying video demonstrate a direct posterior approach for subtalar distraction arthrodesis and review treatment decisions involved with management of these complex cases.

Osteosynthesis or primary arthrodesis for displaced intra-articular calcaneus fractures Sanders type IV - A systematic review

BACKGROUND

Displaced intra-articular calcaneus fractures (DIACF) Sanders type IV represent a challenge in its management and questions remain about the best treatment option available. This study aimed to compare the outcomes of primary subtalar arthrodesis (PSTA) and osteosynthesis in these fractures.

METHODS

Studies concerning DIACF Sanders type IV, from 2005 to 2020 were systematically reviewed. Only studies evaluating functional outcomes with American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS) score were admitted allowing for results comparison.

RESULTS

In total, 9 studies met the inclusion criteria. These reported on the results of 142 patients, from which 41 submitted to PSTA and 101 to osteosynthesis, with an average follow-up period over 2 years. We found a significant moderate negative correlation between the reported AOFAS score and the Coleman Methodology Score obtained. Late subtalar arthrodesis was 13.63% of the total osteosynthesis performed.

CONCLUSIONS

Clinical outcomes after PSTA and osteosynthesis, for the treatment of Sanders type IV fractures, do not seem very different, yet careful data interpretation is crucial. Additional powered randomized controlled trials are necessary to assess which surgical strategy is better.

Is There a Borderline Value in the Radiological Findings of Patients With Calcaneal Malunion That May Help to Select an Appropriate Treatment Option?

BACKGROUND

Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning-even fewer have statistically analyzed how these radiological measurements affect clinical outcomes.

METHODS

We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment.

RESULTS

The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively).

CONCLUSION

The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis.

LEVEL OF EVIDENCE

Level III, retrospective cohort study, case series.

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.

Medial approach for subtalar distraction bone block arthrodesis

Subtalar distraction bone block arthrodesis is a useful technique commonly employed in the management of calcaneal and talar fracture malunion. Traditionally it is performed via a posterolateral or extensile lateral approach, however such approaches have been associated with wound complications, particularly secondary to the added stress caused by the subtalar distraction crucial to this technique. Medial approaches to the subtalar joint have been used in other procedures but have not been reported in subtalar distraction bone block arthrodesis. A novel case and technique illustrating the medial approach for subtalar distraction bone block arthrodesis is discussed. LEVEL OF CLINICAL EVIDENCE: Level 4.

Midterm Outcome of Subtalar Joint Revision Arthrodesis

BACKGROUND

The outcomes of revision subtalar arthrodesis have received relatively little focus in research compared with primary subtalar arthrodesis outcomes. This study aimed to assess the midterm clinical and radiologic results of subtalar joint revision arthrodesis and to analyze the risk factors that might influence the outcome of this procedure.

METHODS

We performed a retrospective review of 20 patients after subtalar joint revision arthrodesis for malunion, using interposition of iliac crest bone graft. The mean age was 55.75 years and the average follow-up lasted for 48.93 months. Eighty-five percent of the patients had at least 1 risk factor identified prior to revision. Patients' satisfaction and functional outcomes were evaluated with the American Orthopaedic Foot & Ankle Society Scale (AOFAS), the Foot and Ankle Outcome Score (FAOS), the Foot Function Index (FFI), and dynamic pedobarography.

RESULTS

A fusion rate of 80% was recorded whereas 20% of the cases ended with a painful pseudarthrosis requiring additional surgery. Pedobarographic measurements demonstrated that loading has a propensity toward the lateral column, but no substantial effect on the gait of patients. In this group, the following patient-reported outcomes were observed: 70% of the patients were satisfied, 20% of the patients found the result fair, and 10% were not satisfied with the results. Compared with the preoperative evaluation, postoperative functional scores showed significant improvement on the FOAS, AOFAS, and FFI outcome scales.

CONCLUSION

Revision arthrodesis of the subtalar joint remains a challenging issue with a relatively high rate of nonunion, especially in a population of patients with multiple risk factors.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Subtalar distraction arthrodesis for calcaneal malunion - comparison of structural freeze-dried versus autologous iliac bone graft

BACKGROUND

This study aims to analyze the outcomes of subtalar distraction arthrodesis (SDA) for calcaneal malunion using structural freeze-dried iliac allograft (FDIA) compared to using autologous iliac bone (AIB).

METHODS

We retrospectively evaluated 57 consecutive cases (51 patients) of calcaneal malunion between March 2006 and December 2017. All patients were followed for an average of 22.8 months. All cases were treated by SDA using structural FDIA (17 cases, group 1), or AIB (40 cases, group 2). The outcome measures included the American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, visual analog scale (VAS) pain scores, and radiographic measurements.

RESULTS

The mean postoperative 3, 6, and 12 months of AOFAS scores and VAS pain score were significantly better in group 2 than those in group 1 (p < 0.05, for all). There were 3 cases (17.6%) of nonunion in the group 1, whereas the group 2 had 2 cases (5.0%), which did not shown significant difference between two groups (p = 0.492). Although the mean pre-, postoperative, and final follow-up radiologic parameters in both groups were similar, (p > 0.05, for all) the difference of talocalcaneal height, talocalcaneal angle, and talar declination angle from postoperative to final follow-up were significantly bigger in the group 1. (p < 0.05, for all).

CONCLUSION

Although union rate was not significantly different between the two groups, we obtained more favorable clinical and radiologic outcomes in the autologous iliac bone group. Using FDIA without any orthobiological agent for SDA, there were significant more loss of radiological parameters due to inferior incorporation and biomechanical properties. When considering the SDA for calcaneal malunion, routine use of FDIA without any orthobiological agents as an interpositional graft for SDA is not recommended.