Talonavicular joint fixation using augmenting naviculocalcaneal screw in modified double hindfoot arthrodesis

Comparison of the Acute Postoperative Complications Between Isolated Talonavicular Versus Talonavicular and Subtalar (Double) Arthrodesis in Flatfoot Deformity

BACKGROUND

Both isolated talonavicular arthrodesis and talonavicular and subtalar (such as double) arthrodesis can be effective treatments for adult-acquired flatfoot deformity (AAFD) with good success rates, but double arthrodesis has become more commonly performed in recent years. The purpose of this study is to evaluate whether isolated talonavicular versus talonavicular and subtalar arthrodesis led to significantly different 30-day postoperative complication rates in patients with AAFD.

METHODS

We performed a retrospective review to identify a large cohort of adult patients with the diagnosis of AAFD or posterior tibial tendon deformity (PTTD) who underwent isolated talonavicular or talonavicular and subtalar arthrodesis between 2006 and 2020 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To investigate whether there was a difference in complication rate between the 2 surgical cohorts, we estimated logistic regression models and log-binomial models on each of the outcomes while also adjusting for sex and age.

RESULTS

We found that there was no significant difference in the rate of major complications (P = .567) or readmissions (P = .567) between patients who underwent isolated talonavicular versus talonavicular and subtalar arthrodesis for AAFD. However, there was a significantly higher rate of minor complications in patients who underwent isolated talonavicular arthrodesis when compared with patients who underwent talonavicular and subtalar arthrodesis (P = .009).

CONCLUSION

This study found that there was no increased risk of 30-day postoperative complications or readmissions with talonavicular and subtalar arthrodesis when compared with isolated talonavicular arthrodesis for AAFD. In addition, there was no increased risk of major complications for talonavicular and subtalar arthrodesis when compared with isolated talonavicular arthrodesis, and isolated talonavicular arthrodesis actually carried a higher risk of minor complications for this surgical cohort. This may provide valuable information for surgeons considering surgical treatment for a particular case of AAFD.

LEVEL OF EVIDENCE

Level III.

Double versus Triple Arthrodesis for Flatfoot Deformity: When, Why, and How?

Different types of arthrodesis for flatfoot deformity have a long history in foot and ankle surgery. Arthrodesis of the rearfoot can be a useful tool in helping correct deformity and maintaining that correction with good long-term results. Questions have risen recently however about the necessity of including the calcaneocuboid joint in the traditional rearfoot arthrodesis or triple arthrodesis. The double arthrodesis of the talonavicular and subtalar joints has grown in popularity and this review helps the reader choose with a review of the biomechanics, surgical approaches, fixation techniques and recent literature outcomes of both procedures.

Double and Triple Tarsal Fusions in the Severe Rigid Flatfoot Deformity

A flatfoot deformity is a multiplanar foot deformity characterized by forefoot abduction and supination and hindfoot valgus. With progressive pathology, a rigid deformity may develop. In the setting of a rigid deformity, the appropriate procedure to use is not without controversy. The extent of joints to involve in the arthrodesis depends on the ability to obtain a plantigrade foot. Both double and triple arthrodesis have been suggested. Care must be taken to avoid lateral column shortening and loss of foot reduction when fusing the CC joint. The concerns about lateral skin breakdown led some surgeons to describe a single medial incision for a triple or modified double arthrodesis. The necessity of bone grafting has been controversial. Implant selection is essential to achieve solid stabilization of the arthrodesis sites. To decrease the risk of overcorrection and malunion, the surgeon should be familiar with the hindfoot biomechanics and generate, based on the clinical examination and imaging, a meticulous preoperative plan to address and balance both the soft tissue and bony deformity.

Double Versus Triple Arthrodesis Fusion Rates: A Systematic Review

Hindfoot arthrodesis is often required for end-staged deformities, such as posterior tibial tendon dysfunction, osteoarthritis, or rheumatoid arthritis. Although the need for hindfoot arthrodesis is generally accepted in severe deformities, there is a debate whether a double or triple arthrodesis should be performed. The aim of our systematic review is to review the fusion rates and mean time to fusion in double and triple arthrodesis. A total of 184 articles were identified using the keyword search through the database of articles published from 2005 to 2017. After review by 3 physicians, a total of 13 articles met the eligibility criteria. The reason for double or triple arthrodesis within the studies were posterior tibial tendon dysfunction, tarsal coalition, degenerative joint disease, osteoarthritis, rheumatoid arthritis, Charcot Marie Tooth, Multiple Sclerosis, Polio, neuromuscular disorder, cerebral palsy, acrodystrophic neuropathy, clubfoot, post-traumatic, and seronegative arthropathy (spondyloarthritis). Within these 13 studies, there were a total of 343 (6-95) subjects extremities operated on. The overall fusion rate for double arthrodesis was 91.75% (289/315) compared to 92.86% (26/28) triple arthrodesis fusion rate, p value .8370. The mean time to fusion for double arthrodesis was 17.96 ± 7.96 weeks compared to 16.70 ± 8.18 weeks for triple arthrodesis, p value = .8133. There are risks associated with triple arthrodesis including increased surgical times, lateral wound complications, residual deformity, surgical costs and peri-articular arthritis. Given the benefits of double arthrodesis over triple arthrodesis and the nearly equivalent fusion rates and time to fusion, double arthrodesis is an effective alternative to triple arthrodesis. The authors of this systematic review recommend double arthrodesis as the hindfoot fusion procedure of choice.

Staple-Plate Plus Screw vs Screw Alone in Talonavicular Arthrodesis: A Cadaveric Biomechanical Study

BACKGROUND

This study evaluated whether the addition of a nitinol staple-plate to a single cannulated screw increased the mechanical stability for a talonavicular fixation construct.

METHODS

Twenty matched pairs of cadaveric feet were randomized to fusion with either a single 5.5-mm cannulated screw or a screw and a plate with 2 screws and a slot with an 18-mm nitinol staple. After in situ fusion procedure, the talonavicular joint complex was dissected free and the ends were embedded in epoxy. The specimens were then cyclically loaded on a servohydraulic load frame (1000 cycles at 20 N, increasing at intervals of 20 N until failure), half of them for cantilever bending and the other half for torsion.

RESULTS

In the bending arm of the study, the staple-plate group showed significantly higher stiffness, failure load, and cycles to failure. In the torsion arm of the study, the staple-plate group also had higher cycles to failure, stiffness in external rotation, and torque to failure. No significant difference was noted in stiffness in internal rotation.

CONCLUSION

We found a significant increase in stability of the talonavicular joint when a nitinol staple-plate construct was placed to augment a single cannulated screw for the purpose of a talonavicular fusion.

CLINICAL RELEVANCE

This information may be helpful to surgeons in implant selection for this common arthrodesis procedure.

Structures at Risk During Percutaneous Screw Fixation for Talonavicular Fusion

BACKGROUND:

Talonavicular (TN) fusion using screws dorsomedially and dorsolaterally can cause neurovascular injury. The purpose of our cadaveric study was to evaluate the safety of percutaneous screw insertion in relation to dorsal neurovascular structures.

METHODS:

Ten fresh-frozen cadaver legs were used for this study. Percutaneous cannulated screws were inserted to perform isolated TN arthrodesis. The screws were inserted at 3 consistent sites: a "medial screw" at the dorsomedial navicular where it intersected at the medial plane of the first cuneiform, a "central screw" at the edge of the dorsal navicular between the medial and intermediate cuneiforms, and a "lateral screw" at the edge of the dorsal navicular between the intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and/or tendons.

RESULTS:

The medial screw injured the anterior tibialis tendon in 2 cases (20%), the central screw injured the extensor hallucis longus tendon in 3 cases (30%), and the lateral screw injured the anterior branch of the superior peroneal nerve (SPN), the lateral branch of the SPN, and the medial branch of the distal peroneal nerve (DPN) once each in a total of 3 cases (30%). Despite no direct injury, the central screw indicated a potential risk of neurovascular injury: closest distance to the anterior SPN was 2 mm and to the medial DPN 2 mm.

CONCLUSION:

Although neurovascular injury risk exists for all of these screw placements, TN fusion with a central screw introduced a potentially decreased risk of neurovascular injury at the expense of increased risk of tendon injury compared to the lateral screw.

CLINICAL RELEVANCE:

Based on these results, we recommend a careful dissection be performed prior to percutaneous screw insertion.

Individual headless compression screws fixed with three-dimensional image processing technology improves fusion rates of isolated talonavicular arthrodesis

BACKGROUND

Screw fixation is a typical technique for isolated talonavicular arthrodesis (TNA), however, no consensus has been reached on how to select most suitable inserted position and direction. The study aimed to present a new fixation technique and to evaluate the clinical outcome of individual headless compression screws (HCSs) applied with three-dimensional (3D) image processing technology to isolated TNA.

METHODS

From 2007 to 2014, 69 patients underwent isolated TNA by using double Acutrak HCSs. The preoperative three-dimensional (3D) insertion model of double HCSs was applied by Mimics, Catia, and SolidWorks reconstruction software. One HCS oriented antegradely from the edge of dorsal navicular tail where intersected interspace between the first and the second cuneiform into the talus body along the talus axis, and the other one paralleled the first screw oriented from the dorsal-medial navicular where intersected at the medial plane of the first cuneiform. The anteroposterior and lateral X-ray examinations certified that the double HCSs were placed along the longitudinal axis of the talus. Postoperative assessment included the American Orthopaedic Foot & Ankle Society hindfoot (AOFAS), the visual analogue scale (VAS) score, satisfaction score, imaging assessments, and complications.

RESULTS

At the mean 44-months follow-up, all patients exhibited good articular congruity and solid bone fusion at an average of 11.26 ± 0.85 weeks (range, 10 ~ 13 weeks) without screw loosening, shifting, or breakage. The overall fusion rates were 100%. The average AOFAS score increased from 46.62 ± 4.6 (range, 37 ~ 56) preoperatively to 74.77 ± 5.4 (range, 64-88) at the final follow-up (95% CI: -30.86 ~ -27.34; p < 0.001). The mean VAS score decreased from 7.01 ± 1.2 (range, 4 ~ 9) to 1.93 ± 1.3 (range, 0 ~ 4) (95% CI: 4.69 ~ 5.48; p < 0.001). One cases (1.45%) and three cases (4.35%) experienced wound infection and adjacent arthritis respectively. The postoperative satisfaction score including pain relief, activities of daily living, and return to recreational activities were good to excellent in 62 (89.9%) cases.

CONCLUSIONS

Individual 3D reconstruction of HCSs insertion model can be designed with three-dimensional image processing technology in TNA. The technology is safe, effective, and reliable to isolated TNA method with high bone fusion rates, low incidences of complications.

Increased Failure Rate of Modified Double Arthrodesis Compared With Triple Arthrodesis for Rigid Pes Planovalgus

For rigid pes planovalgus deformities, modified double and triple arthrodeses have had high union rates and subjective outcomes reported. Increased rates of talonavicular nonunions after modified double arthrodesis have led to concern regarding this procedure. A retrospective medical record review was performed of patients who had undergone either a modified double (n = 9) or triple (n = 7) arthrodesis for stage 3 pes planovalgus deformity. Radiographs were reviewed for hindfoot alignment, bony union, and hardware failure. Data from questionnaires, including the Foot and Ankle Ability Measure and the Foot and Ankle Outcome Score, were obtained. No significant differences were found between the cohorts in terms of preoperative radiographic parameters or patient characteristics. The modified double arthrodesis cohort demonstrated a nonunion rate of 44% (4 of 9), but the triple arthrodesis cohort had a 0% (0 of 7) nonunion rate (p = .042). The Foot and Ankle Ability Measure activities of daily living, Foot and Ankle Outcome Score activities of daily living, and Foot and Ankle Outcome Score quality of life scores were significantly worse for the modified double arthrodesis than for the triple arthrodesis group. For patients with stage 3 pes planovalgus, modified double arthrodesis resulted in significantly greater rates of nonunion and incomplete union, with significantly inferior subjective outcome scores compared with triple arthrodesis for the same indication.

Arthroscopic triple and modified double hindfoot arthrodesis

BACKGROUND

Arthroscopic arthrodesis is an accepted technique for the ankle but less commonly reported for multiple hindfoot joints. We present a case series review to establish the feasibility of this surgery.

METHODS

In a consecutive series of 112 arthroscopic hindfoot arthrodeses, 18 involved decortication and fusion of 2 or 3 hindfoot joints. These were reviewed to identify complications, union rates and improvement over preoperative state.

RESULTS

Mean age was 62 (45-78). Mean follow-up was 4.4 (1.75-7.5) years. There were no perioperative complications. The four patients with triple fusions united with good or excellent outcomes. Of 14 patients with subtalar and talonavicular arthrodeses there were three talonavicular non-unions.

CONCLUSIONS

Arthroscopic double and triple arthrodeses appear feasible salvage options for pain and deformity. Decortication of all three joints and rotatory correction of deformity is possible whilst preserving the soft tissue envelope. Late adjacent joint pain and arthrosis can occur.

Calcaneal "Z" osteotomy effect on hindfoot varus after triple arthrodesis in a cadaver model

BACKGROUND

Triple arthrodesis involves subtalar, talonavicular, and calcaneocuboid joint fusion and is performed to relieve pain and correct deformity. Complications include malunion resulting in equinovarus and lateral column overload, which can lead to painful callosities and stress fractures. This study quantified the effectiveness of a closing-wedge calcaneal "Z" osteotomy for correction of the varus condition and reduction of abnormal loading of the lateral border of the foot.

METHODS

Ten fresh-frozen feet were used. Angle meters were attached to the calcaneus and second cuneiform to measure hindfoot and midfoot varus, and pressure sensors were placed under the first and fifth metatarsal heads to document loading of the borders of the foot. Tensile loads were applied to ten extrinsic tendons and the Achilles tendon while an 1187 N axial foot load was applied. Calcaneus and second cuneiform coronal plane angles and medial and lateral plantar pressures were measured initially, after triple fusion-induced varus, and after "Z" osteotomy.

RESULTS

The calcaneal "Z" osteotomy had no significant corrective effect, with hindfoot alignment virtually identical before and after the procedure under the described foot loading conditions. Similarly, second cuneiform inclination, representative of midfoot alignment, showed no change from the osteotomy. Medial and lateral peak plantar pressures after calcaneal "Z" osteotomy did not differ from those measured after varus triple fusion.

CONCLUSION

In this cadaver model of varus malunited triple arthrodesis, the closing-wedge calcaneal "Z" osteotomy was ineffective for correction of bone alignment and lateral forefoot overloading under the tested conditions.

CLINICAL RELEVANCE

The results provide additional information on which to base treatment after triple arthrodesis with varus malunion.

Biomechanical assessment of flexible flatfoot correction: comparison of techniques in a cadaver model

BACKGROUND

Options for surgical correction of acquired flexible flatfoot deformity involve bone and soft-tissue reconstruction. We used an advanced cadaver model to evaluate the ability of key surgical procedures to correct the deformity and to resist subsequent loss of correction.

METHODS

Stage-IIB flatfoot deformity was created in ten cadaver feet through ligament sectioning and repetitive loading. Six corrective procedures were evaluated: (1) lateral column lengthening, (2) medial displacement calcaneal osteotomy with flexor digitorum longus transfer, (3) Treatment 2 plus lateral column lengthening, (4) Treatment 3 plus "pants-over-vest" spring ligament repair, (5) Treatment 3 plus spring ligament repair with use of the distal posterior tibialis stump, and (6) Treatment 3 plus spring ligament repair with suture and anchor. Correction of metatarsal dorsiflexion and of navicular eversion were quantified initially and periodically during postoperative cyclic loading.

RESULTS

Metatarsal dorsiflexion induced by arch flattening was initially corrected by 5.5° to 10.6°, depending on the procedure. Navicular eversion was initially reduced by 2.1° to 7.7°. The correction afforded by Treatments 1, 3, 4, 5, and 6 exceeded that of Treatment 2 initially and throughout postoperative loading. Inclusion of spring ligament repair did not significantly enhance correction.

CONCLUSIONS

Under the tested conditions, medial displacement calcaneal osteotomy with flexor digitorum longus tendon transfer was inferior to the other evaluated treatments for stage-IIB deformity. Procedures incorporating lateral column lengthening provided the most sagittal and coronal midfoot deformity correction. Addition of spring ligament repair to a combination of these three procedures did not substantially improve correction.

CLINICAL RELEVANCE

An understanding of treatment effectiveness is essential for optimizing operative management of symptomatic flatfoot deformity. This study provides empirical evidence of the advantage of lateral column lengthening and novel information on resistance to postoperative loss of correction.

Biomechanical comparison of 4 different lateral plate constructs for distal fibula fractures

BACKGROUND

Displaced lateral malleolar fractures are often treated with reduction and surgical stabilization. However, there has not been a comprehensive laboratory comparison to determine the most appropriate device for treating these patients. This study subjected a range of contemporary lateral fibular plates to a series of mechanical tests designed to reveal performance differences.

METHODS

Forty fresh frozen lower extremities were divided into 4 groups. A Weber B distal fibula fracture was simulated with an osteotomy and stabilized using 1 of 4 plate systems: a standard Synthes one-third tubular plate with interfragmentary lag screw, a Synthes LCP locking plate with lag screw, an Orthohelix MaxLock Extreme low-profile locking plate with lag screw, or a TriMed Sidewinder nonlocking plate. Controlled monotonic bending and cyclic torsional loading were applied and bending stiffness, torsional stiffness, and fracture site motion were quantified. Resistance to cyclic torsional loading was determined by quantifying the number of loads withstood before excessive rotation occurred. Correlation between bone mineral density and each of the mechanical measures was determined.

RESULTS

There was no difference in angulation or bending stiffness between plates. All plates except the LCP showed greater lateral deflection than in the other bending directions. Bending stiffness was lowest in lateral distal fragment deflection for all 4 plates. There was a positive correlation between bone mineral density and bending stiffness for all plate types. There was no difference in fracture site rotation between plate types in internal or external torsion, but internal rotation of the distal fragment consistently exceeded external rotation. Torsional stiffness in external rotation exceeded stiffness in internal rotation in nearly all specimens. LCP plates performed relatively poorly under cyclic torsion.

CONCLUSIONS

Significant differences in plate performance were not demonstrated. The effects of bone quality variability and differences in interfragmentary screw purchase resulted in data dispersion that confounded absolute ranking of plate performance.

CLINICAL RELEVANCE

Identification of an optimal lateral fibular plating system has the potential to improve the clinical outcome of malleolar fracture fixation, particularly when patient conditions are unfavorable.

Single-incision medial approach for double arthrodesis of hindfoot in posterior tibialis tendon dysfunction

BACKGROUND

Triple arthrodesis through a 2-incision approach has been the primary salvage procedure for rigid hindfoot malalignment resulting from posterior tibialis dysfunction. However, complications like calcaneocuboid joint nonunion, lateral wound dehiscence, and adjacent joint arthritis have been reported after triple arthrodesis. Hence we adopted single-incision medial approach arthrodesis of subtalar and talonavicular joints, sparing the uninvolved calcaneocuboid joint and lateral skin.

METHOD

We report the results of a series of 18 feet with posterior tibialis dysfunction that had correction of malalignment by this approach. Mean age at surgery was 65 years. The mean follow-up was 24 months.

RESULTS

There was statistically significant improvement in all the radiological parameters measured. There were no wound-related complications. The union rate was 89%. There were 2 malunions, and 2 feet developed valgus ankle deformity. The overall satisfaction rate among patients was 78%.

CONCLUSION

We present a case series of treatment of posterior tibialis tendon dysfunction by arthrodesis of the subtalar and talonavicular joints through an isolated medial approach. The results were not encouraging enough to recommend adopting this approach as an alternative to triple arthrodesis.

LEVEL OF EVIDENCE

Level IV, retrospective case series.