Conservative tibiotalocalcaneal fusion for partial talar avascular necrosis in conjunction with ankle and subtalar joint osteoarthritis in Kashin-Beck disease: A case report

RATIONALE

Kashin-Beck disease (KBD) is known for some typical characters like finger joint enlargement, shortened fingers, and dwarfism. However, Avascular necrosis (AVN) of the talus in KBD has rarely been reported in the literature. Here, we reported on a KBD patient presented with partial AVN of the talus in conjunction with ankle and subtalar arthritis.

PATIENT CONCERNS

A 50-year-old woman presented with severe pain and limited range of motion in her left ankle and subtalar joint while walking for 2 years. She had been walking with the aid of crutches for many years. Conservative treatment with rigid orthosis and activity restriction could not help reduce the pain in the left foot.

DIAGNOSES

Radiographs demonstrated that partial AVN was developed in the body of the talus and arthritis was viewed in the left ankle and subtalar joint. Hence, we established the diagnosis of partial talar AVN in conjunction with ankle and subtalar arthritis.

INTERVENTIONS

A conservative tibiotalocalcaneal fusion attempting to preserve as much viable talar body as possible was performed using a humeral locking plate and 2 cannulated compression screws.

OUTCOMES

Bone union proved by CT scan and a good alignment of the left limb were achieved at 4-month follow-up postoperatively.

LESSONS

Partial AVN of the talus along with ankle and subtalar arthritis in KBD patients has rarely been reported as it is not a common characteristic of KBD in clinical practice. Conservative tibiotalocalcaneal fusion could help preserving much more viable talar body, maintaining most structural integrity of the ankle joint, and achieving a stable and plantigrade foot postoperatively.

Augmented Ligament Reconstruction Partially Restores Hindfoot and Midfoot Kinematics After Lateral Ligament Ruptures

BACKGROUND

Altered kinematics and persisting ankle instability have been associated with degenerative changes and osteochondral lesions.

PURPOSE

To study the effect of ligament reconstruction surgery with suture tape augmentation (isolated anterior talofibular ligament [ATFL] vs combined ATFL and calcaneofibular ligament [CFL]) after lateral ligament ruptures (combined ATFL and CFL) on foot-ankle kinematics during simulated gait.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five fresh-frozen cadaveric specimens were tested in a custom-built gait simulator in 5 different conditions: intact, ATFL rupture, ATFL-CFL rupture, ATFL-CFL reconstruction, and ATFL reconstruction. For each condition, range of motion (ROM) and the average angle (AA) in the hindfoot and midfoot joints were calculated during the stance phase of normal and inverted gait.

RESULTS

Ligament ruptures mainly changed ROM in the hindfoot and the AA in the hindfoot and midfoot and influenced the kinematics in all 3 movement directions. Combined ligament reconstruction was able to restore ROM in inversion-eversion in 4 of the 5 joints and ROM in internal-external rotation and dorsiflexion-plantarflexion in 3 of the 5 joints. It was also able to restore the AA in inversion-eversion in 2 of the 5 joints, the AA in internal-external rotation in all joints, and the AA in dorsiflexion-plantarflexion in 1 of the joints. Isolated ATFL reconstruction was able to restore ROM in inversion-eversion and internal-external rotation in 3 of the 5 joints and ROM in dorsiflexion-plantarflexion in 2 of the 5 joints. Isolated reconstruction was also able to restore the AA in inversion-eversion and dorsiflexion-plantarflexion in 2 of the joints and the AA in internal-external rotation in 3 of the joints. Both isolated reconstruction and combined reconstruction were most successful in restoring motion in the tibiocalcaneal and talonavicular joints and least successful in restoring motion in the talocalcaneal joint. However, combined reconstruction was still better at restoring motion in the talocalcaneal joint than isolated reconstruction (1/3 for ROM and 1/3 for the AA with isolated reconstruction compared to 1/3 for ROM and 2/3 for the AA with combined reconstruction).

CONCLUSION

Combined ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture.

CLINICAL RELEVANCE

This study shows that ligament reconstruction with suture tape augmentation is able to partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, where the classic Broström-Gould technique is followed by augmentation with suture tape, this procedure may protect the repaired ligament during healing by limiting excessive ROM after a ligament rupture.

Ultrasound of Subtalar Joint Synovitis in Patients with Rheumatoid Arthritis: Results of an OMERACT Reliability Exercise Using Consensual Definitions

OBJECTIVE

To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA).

METHODS

Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen's and Light's κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal.

RESULTS

Mean weighted Cohen's κ for SH, PD, and JE were 0.80 (95% CI 0.62-0.98), 0.61 (95% CI 0.48-0.73), and 0.52 (95% CI 0.36-0.67), respectively. Weighted Cohen's κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were -0.04 to 0.79, 0.42-0.95, and 0.28-0.77; 0.31-1, -0.05 to 0.65, and -0.2 to 0.69; 0.66-1, 0.52-1, and 0.42-0.88, respectively. Weighted Light's κ for SH was 0.67 (95% CI 0.58-0.74), 0.46 (95% CI 0.35-0.59) for PD, and 0.16 (95% CI 0.08-0.27) for JE. Weighted Light's κ for SH, PD, and JE were 0.63 (95% CI 0.45-0.82), 0.33 (95% CI 0.19-0.42), and 0.09 (95% CI -0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27-0.64), 0.35 (95% CI 0.27-0.4), and 0.04 (95% CI -0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75-0.89), 0.66 (95% CI 0.56-0.8), and 0.18 (95% CI 0.04-0.34) for posterolateral STJ, respectively.

CONCLUSION

Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Fracture of the Posterior Process of the Talus With Concomitant Subtalar Dislocation

Fracture of the posterior process of the talus with concomitant subtalar dislocation is rare; thus, the mechanism of injury, appropriate treatment, and prognosis are unclear. We report the case of a 50-year-old male with a fracture of the posterior process of the talus with concomitant subtalar dislocation that was recognized early and successfully treated operatively.

Imaging of the subtalar joint

Imaging of the subtalar joint can be challenging because of its complex planar anatomy. This article reviews the anatomy and common anatomic variants as seen with different imaging techniques. Although radiography remains the initial mode of imaging, computed tomography and MRI are frequently needed to better delineate the joint anatomy and improve the sensitivity and the specificity of detection of joint pathology. A short review of arthrographic techniques and various examples of imaging of common pathology involving this joint are also included.

[Tibio-talo-calcaneal arthrodesis with the retrograde intramedullary nail MEDIN]

PURPOSE OF THE STUDY

When the talus and the talocalcaneal joint are both affected, their fusion is the method of treatment. Ankle arthrodesis is carried out using various osteosynthetic materials such as external fixators, screws and plates. One of the options is retrograde nailing. Tibio-talo-calcaneal arthrodesis is frequently indicated in patients with rheumatoid arthritis (RA) in whom both the talus and the subtalar joint are often affected.

MATERIAL AND METHODS

A retrograde nail for tibio-talo-calcaneal arthrodesis was developed at our department in cooperation with MEDIN Company. This is a titanium double-curved nail, with the distal part bent at 8 degrees ventrally and 10 degrees laterally. It is inserted from the transfibular approach.

RESULTS

Sixty-two patients, 35 women and 27 men, were treated at our department from 2005. Since one patient had bilateral surgery, 63 ankles were included. The indications for arthrodesis involved rheumatoid arthritis in 42, post-traumatic arthritis in 10, failed ankle arthrodesis in two and failed total ankle arthroplasty in five ankles; tibial stress fractures close above the ankle in two RA patients, one patient with dermatomyositis and one with lupus erythematodes. The average age at the time of surgery was 64.2 years (range, 30 to 80). The average follow-up was 4.5 years (range, 1 to 9 years), Satisfaction with the treatment outcome and willingness to undergo surgery on the other side were reported by 82% of the patients. The AOFAS score improved from 35 to 74 points. Three (4.8%) patients complained of painful feet due to the fact that exact correction of the calcaneus was not achieved and the heel after arthrodesis remained in a slightly varus position. Of them, two had a failed total ankle arthroplasty. Post-operative complications included early infection managed by antibiotic treatment and early surgical revision with irrigation.in two (3.2%) RA patients, who were undergoing biological therapy. Late infection developed at 2 to 3 years after surgery in three (4.3%) patients (two had RA). The infection was managed by revision surgery with nail removal and irrigation. All patients healed well. Necrosis of the talus and development of a pseudoarthrosis were recorded in four (6.4%) patients, who subsequently underwent nail removal and repeat fusion using an external fixator.

DISCUSSION

Retrograde nailing for tibio-talo-calcaneal arthrodesis is used by many authors. Its complication rate is comparable with the other methods of arthrodesis.

CONCLUSIONS

The use of tibio-talo-calcaneal arthrodesis aims at a painless and stable joint. Arthrodesis of the talus and the subtalar joint using a retrograde nail is an effective surgical treatment of the joints affected. It is especially recommended for RA patients who have severe deviations. Retrograde nailing provides a stable osteosynthesis which does not require plaster cast immobilisation. The double-curved nail allows for its insertion in the solid part of the calcaneus and helps avoiding injury to the neurovascular bundle.

[Surgical treatment of talocalcaneal coalition]

OBJECTIVE

To explore the operative method and effectiveness of talocalcaneal coalition.

METHODS

Between July 2008 and October 2010, 10 patients with talocalcaneal coalition were treated, including 2 cases of congenital talocalcaneal coalition and 8 cases of secondary talocalcaneal coalition. There were 4 males and 6 females, aged 53.5 years on average (range, 16-70 years). Three patients had middle-facet talocalcaneal coalition and 7 had posterior-facet talocalcaneal coalition. The preoperative visual analogue score (VAS) was 9.0 +/- 0.4. According to American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale, the score was 42.4 +/- 1.4. Two cases complicated by subtalar degeneration. Resection of the bone bar and fat packing were performed in 8 cases of simple talocalcaneal coalition, and resection and subtalar arthrodesis in 2 cases of talocalcaneal coalition combined with subtalar degeneration.

RESULTS

Primary healing of incisions was obtained in all patients. Eight patients were followed up 18 months on average (range, 12-36 months). At last follow-up, VAS was 2.0 +/- 0.7, showing siginificant difference when compared with preoperative score (t = 6.425, P = 0.000). AOFAS score was 86.9 +/- 2.3, showing significant difference when compared with preoperative score (t = 7.634, P = 0.000). The X-ray films showed that no recurrence of talocalcaneal coalition was observed in patients underdoing simple removal of bone bar, and bone fusion was observed in patients undergoing arthrodesis.

CONCLUSION

To achieve satisfactory outcomes for talocalcaneal coalition, a reasonable surgical procedure should be chosen according to the specific facet and complication.

Subtalar joint arthroscopy

Subtalar joint arthroscopy can be performed on a wide array of pathology. The procedure has progressed from a diagnostic test to a reconstructive procedure. Although it is not as popular as ankle arthroscopy, it is becoming more commonly discussed in the literature and is part of many arthroscopy courses. Better education along with improved instrumentation will allow more foot and ankle surgeons to treat pathology of the subtalar joint with arthroscopic techniques. This will lead to improved outcomes and lower complication rates in treating that pathology.

A critical evaluation of subtalar joint arthrosis associated with middle facet talocalcaneal coalition in 21 surgically managed patients: a retrospective computed tomography review. Investigations involving middle facet coalitions-part III

Symptomatic middle facet talocalcaneal coalition is frequently associated with rearfoot arthrosis that is often managed surgically with rearfoot fusion. However, no objective method for classifying the extent of subtalar joint arthrosis exists. No study has clearly identified the extent of posterior facet arthrosis present in a large cohort treated surgically for talocalcaneal coalition through preoperative computerized axial tomography. The authors conducted a retrospective review of 21 patients (35 feet) with coalition who were surgically treated over a 12-year period for coalition on at least 1 foot. Using a predefined original staging system, the extent of the arthrosis was categorized into normal or mild (Stage I), moderate (Stage II), and severe (Stage III) arthrosis. The association of stage and age is statistically significant. All of the feet with Stage III arthrosis had fibrous coalitions. No foot with osseous coalition had Stage III arthrosis. The distribution of arthrosis staging differs between fibrous and osseous coalitions. Only fibrous coalitions had the most advanced arthrosis (Stage III), whereas osseous coalitions did not. This suggests that osseous coalitions may have a protective effect in the prevention of severe degeneration of the subtalar joint. Concomitant subtalar joint arthrosis severity progresses with age; surgeons may want to consider earlier surgical intervention to prevent arthrosis progression in patients with symptomatic middle facet talocalcaneal coalition.

Effect of simulated lateral process talus "fracture excision" on its ligamentous attachments

Recent epidemiologic studies highlight lateral talar process fractures as snowboarder's fracture or snowboarder's ankle. Snowboarding is the fastest growing sport worldwide, so lateral talar process fractures are increasing in frequency and mandating a more careful assessment of injury patterns, surrounding tissue involvement, and treatment strategy. In this study, we evaluated the effects of lateral talar process fracture on the footprints of 3 lateral stabilizing ligaments of the ankle and subtalar joint-the lateral talocalcaneal ligament (LTCL), the anterior talofibular ligament (ATFL), and the posterior talofibular ligament (PTFL). The musculotendinous structures from 10 fresh cadaveric limbs were removed and the distal fibula reflected to provide visualization of the lateral talar process and ligamentous attachments. Length and width of the LTCL, ATFL, and PTFL footprints on the lateral process of the talus were measured with calipers before and after removal of a 1-cm(3) simulated fracture fragment. Relative changes in the attachment site areas for the 3 ligaments were determined. Mean pre-excision footprint areas were 80.57 mm(2) (LTCL), 224.38 mm(2) (ATFL), and 394.18 mm(2) (PTFL); mean postexcision footprint areas were 2.10 mm(2) (LTCL), 194.89 mm(2) (ATFL), and 335.18 mm(2) (PTFL); and mean decreases calculated as percentages of the original areas were 97.5% +/- 3.5% (LTCL), 11.7% +/- 13.0% (ATFL), and 14.3% +/- 12.3% (PTFL). Removal of a 1-cm(3) bony fragment from the lateral talar process involves 3 of the major lateral stabilizing ligaments: approximately 100% of LTCL and approximately 10% to 15% of ATFL and PTFL.

Accessory anterolateral talar facet as an etiology of painful talocalcaneal impingement in the rigid flatfoot: a new diagnosis

A retrospective review identified six patients with seven painful rigid flatfeet. In each case, pain was localized laterally to an accessory facet of the anterolateral talus. cross-sectional imaging demonstrated no evidence of tarsal coalition. In five of the six, preoperative magnetic resonance imaging (MRI) was obtained and in each case demonstrated focal abutting bone marrow edema consistent with impingement between the accessory facet and the anterior calcaneus.Seven feet in six patients underwent resection of the accessory facet with additional subtalar joint-sparing reconstructive procedures. At an average follow-up of 11 months, clinical results were graded as four good and two fair.An association between this accessory facet and pain in the rigid flatfoot has not been previously reported. Obesity was universal and may represent a risk factor for facet impingement. At early follow-up, facet resection with subtalar joint-sparing flatfoot reconstruction provided good results with symptomatic and functional improvement in the majority of patients.

[Tarsal osteoarthritis: a rare localisation of tuberculosis]

We report the case of a 39-year-old woman with an uneventful medical history who presented an inflammatory left foot with no notion of trauma or fever. The plain x-ray and magnetic resonance imaging demonstrated talonavicular and subtalar osteoarthritis. A surgical biopsy with excision of inflammatory and necrotic tissue and removal of a fistular tract was performed. Histology revealed the presence of granulomas with caseous central necrosis suggesting tuberculosis of the bone. The diagnosis was confirmed when bacteriology samples grew Mycobacterium tuberculosis. Antituberculosis drugs were administered for twelve months. At 24 months, the patient presents a painful stiff rear foot after the development of secondary talonavicular degeneration. This case illustrates a particular clinical presentation of tuberculosis. This diagnosis should be considered in the presence of atypical bony lesions with a chronic course. Early diagnosis enables proper therapeutic management. Useful diagnostic imaging techniques include plain x-rays, computed tomography, and magnetic resonance imaging. Certain diagnosis is based on bacteriological and histological examinations.

Benefit of fluoroscopically guided intraarticular, long-acting corticosteroid injection for subtalar arthritis in juvenile idiopathic arthritis

BACKGROUND

Children with arthritis may endure a lifetime of disfigurement, dysfunction, and pain if acute inflammation progresses to chronic changes in the joint cartilage and underlying bone. Intraarticular steroids have become an integral component of treatment, but at times are difficult to deliver to joints, such as the subtalar joint, that have complex anatomies.

OBJECTIVE

We describe our technique and outcomes using fluoroscopically guided intraarticular subtalar steroid injection in patients with active symptoms of juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

Fluoroscopically guided subtalar joint injections were performed in 38 children (mean age 6.7 years). Medical records were reviewed retrospectively and improvement was evaluated clinically by the degree of foot movement in eversion and inversion.

RESULTS

Subtalar joint injection was technically successful in 100% of the JIA patients with improvement in physical symptoms in 34/38 (89%). Of the 38 children, 32 were followed up within 13 weeks of the initial injection and, therefore, satisfied the eligibility criteria for resolution of arthritis. Of these 32 children, 14 showed clinical resolution (44%). The mean duration of improvement was 1.2 +/- 0.9 years. Children with a longer interval (>1 year) from diagnosis to treatment had significantly less resolution (P = 0.04). Local subcutaneous atrophy or hypopigmentation were observed in 53% of the children after steroid injection (20/38). These minor complications were associated with a greater volume of steroid injected into the site per child (P = 0.02).

CONCLUSION

Fluoroscopically guided subtalar joint injection is an effective treatment for subtalar arthropathy. Prompt referral for intraarticular steroid treatment in the acute phase improves response. Skin changes often occur at the injection site, and specific precautions should be employed to reduce this risk. Prospective study is indicated to determine the most effective treatment strategy to prevent long-term pain and disability.

Benefit of intraarticular corticosteroid injection under fluoroscopic guidance for subtalar arthritis in juvenile idiopathic arthritis

OBJECTIVE

To determine the demographics of subtalar arthritis, the response to intraarticular corticosteroid injection, and the injection complication rate in a clinic sample of children with juvenile idiopathic arthritis (JIA).

METHODS

A chart review was performed of all patients at a tertiary medical center who underwent subtalar corticosteroid injection during the past 5 years. Injection of 1 ml of triamcinolone hexacetonide or acetonide into the midsubtalar joint was performed using a lateral oblique approach under fluoroscopic guidance. Improvement was defined by enhanced foot inversion and eversion at the following office visit.

RESULTS

Thirty-eight patients underwent 55 subtalar injections during the study period. All 7 JIA subtypes were represented. Thirty-one patients (82%) had subtalar arthritis at time of JIA diagnosis and 32 (84%) had concomitant tibiotalar ankle arthritis. Improvement was observed following 34 (89%) of the initial 38 injections. The mean duration of improvement was 1.2 years (SD +/- 0.9). Twenty patients (53%) developed hypopigmentation or subcutaneous atrophy. This complication was associated with a higher volume of injected corticosteroid per patient weight (p = 0.02) and with less efficacious injections (p = 0.04).

CONCLUSION

Subtalar arthritis in children with JIA is common. Similar to other joints, subtalar arthritis responds to corticosteroid injection in approximately 90% of cases and often remains improved for greater than one year. Hypopigmentation and subcutaneous atrophy are frequent complications and are likely related to the dose of injected corticosteroid and possibly the accuracy of needle placement.

Tarsal tunnel syndrome in athletes

BACKGROUND

The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition.

HYPOTHESIS

Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months.

RESULTS

Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment.

CONCLUSION

Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.

Ankle arthrodesis for failed total ankle replacement

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

Synovial chondromatosis of the subtalar joint and tenosynovial chondromatosis of the posterior ankle

Synovial chondromatosis is a rare, generally benign condition characterized by the formation of multiple cartilaginous nodules in the synovium of joints and occasionally on the tendon sheath or bursae. If the nodules are intra-articular, the condition is referred to as synovial chondromatosis; if extra-articular, tenosynovial chondromatosis. This space-occupying lesion can lead to chronic pain and limit the function of involved joints. We report a case of synovial chondromatosis involving the subtalar joint and tenosynovial chondromatosis involving the posterior ankle and review current definitions of this uncommon lower-extremity condition.

[Limitation in subtalar motion in a patient nine years after treatment for medial subtalar dislocation]

Subtalar dislocations are rare injuries. They may cause serious complications in the long-term. A 27-year-old professional soldier developed medial subtalar dislocation of the right foot due to fall from height and was treated with closed reduction under general anesthesia and below-knee cast fixation for six weeks. At the end of a nine-year follow-up, he began complaining of occasional pain around his ankle. There was minimal loss in subtalar movements. He had no stiffness or instability. The ankle-hindfoot score was 90 according to the American Orthopaedic Foot and Ankle Society clinical rating system. It should be recalled that, following treatment of subtalar dislocations, some degree of loss may occur in subtalar movements.

Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis

Subtalar arthroscopy has become a valuable adjunct to the tools used in lower extremity surgery. For the past 25 years, ankle arthroscopy has been in vogue for treating a variety of conditions. Subtalar arthroscopy has more treatment limitations and is more technically difficult to perform than ankle arthroscopy because of the anatomic confines and structure of the subtalar joint. Most procedures are performed on the posterior aspect of the subtalar joint. The subtalar joint is composed of three articulations (posterior, middle, and anterior facets) and is surrounded by a variety of intra-articular and extra-articular ligaments, whose anatomy must be fully understood before attempting this procedure. Subtalar arthroscopy may be indicated for diagnostic purposes and for débridement of synovial impingement syndromes in the sinus tarsi. It may be used to examine loose bodies or osteochondral lesions, to address fractures of the lateral process of the talus, and to evaluate subtalar instability to determine appropriate stabilization methods. Arthroscopic subtalar arthrodesis also has gained credibility over the past 10 years as an acceptable surgical procedure. Arthroscopic evaluation of subtalar instability is useful in planning the appropriate stabilization. Subtalar arthroscopy is usually performed with the patient in the lateral decubitus position without traction. Anterior and posterior portals as well as an accessory anterior portal are usually necessary to perform all of the above procedures. Because of the limited confines of the joint, care must be taken to prevent any articular cartilage damage. When performing subtalar arthroscopy in conjunction with ankle arthroscopy, the subtalar arthroscopy should be performed first to avoid excessive extravasation from the ankle arthroscopy, which could obscure entry to the subtalar joint. Complications of subtalar arthroscopy are similar to those encountered in ankle arthroscopy, such as damage to the sural and superficial peroneal nerves.

Arthrofibrosis involving the middle facet of the talocalcaneal joint in children and adolescents

BACKGROUND

Pain over the anterolateral aspect of the ankle in a patient with a history of repeated ankle sprains and with restricted subtalar movement may be associated with a tarsal coalition. Nineteen patients presented with such a history, but conventional imaging did not reveal a cartilaginous or osseous coalition. Since symptoms persisted despite nonoperative treatment, the middle facet was explored surgically. The purpose of this study was to discuss the operative findings and to report the results of treatment.

METHODS

Nineteen patients (twenty-three feet) with pain over the anterolateral aspect of the ankle or a history of repeated ankle sprains had restricted subtalar joint motion and inconclusive findings on diagnostic imaging, except for bone-scanning. Their ages ranged from 9.1 to 18.5 years. The middle facet of the subtalar joint was explored surgically through a 3 to 4-cm-long incision centered over the sustentaculum tali. The results at a mean of 5.8 years were classified as good, fair, or poor on the basis of pain, talocalcaneal joint motion, and shoe wear.

RESULTS

Routine radiographs, computed tomography, and magnetic resonance imaging revealed no major abnormality, whereas technetium-99m bone scintigraphy consistently showed slightly increased isotope uptake in the middle facet. Surgical removal of a hypervascular and thickened capsule and synovium in the area of the middle facet of the subtalar joint decreased pain and improved subtalar motion. The final result was good in seventeen patients (twenty feet) and fair in two patients (three feet). There were no poor results.

CONCLUSIONS

A diagnosis of inflammatory arthrofibrosis should be considered when a patient with a painful rigid flatfoot has normal findings on radiographs and hematological studies but increased isotope uptake in the middle facet of the talocalcaneal joint on bone scintigraphy. Excision of the hypervascular capsule and synovium from this area can result in resolution of the symptoms.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions

BACKGROUND

Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions.

METHODS

Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery.

RESULTS

Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021).

CONCLUSIONS

This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.

Minimally-invasive treatment of calcaneal fractures

Percutaneous reduction methods play an important role in the management of calcaneal fractures with severe soft tissue compromise, particularly open fractures, and they offer a treatment alternative in patients with local or systemic contraindication to open reduction. Percutaneous reduction by pin leverage (Westhues or Essex-Lopresti maneuver) followed by minimally invasive screw fixation is a treatment option that yields good to excellent results in tongue-type fractures with posterior facet displacement as a whole (Sanders-type IIC). This method can be applied to selected Sanders-type IIA or IIB fractures if the quality of joint reduction is controlled arthroscopically. Although some authors have expanded the use of percutaneous reduction by traction, leverage, and compression with subsequent K-wire or screw fixation with remarkable results, the uniform application of percutaneous methods to all intra-articular calcaneus fractures is critical. Inadequate joint reduction and redislocation of the fragments in highly unstable fractures may occur in a considerable percentage of cases. Prolonged transfixation of the subtalar and calcaneocuboid joints is strongly discouraged, because functional aftertreatment is an important part of the rehabilitation after calcaneal fractures.

Calcaneal fractures--open reduction and internal fixation (ORIF)

Although pioneers such as Leriche in 1921 [5] and Judet et al in 1954 [4] introduced screw or plate fixation of the broken calcaneus, surgical treatment using open anatomical reduction and stable internal osteosynthesis only commenced at the start of the 1980s. This treatment was made possible by the introduction of new imaging methods such as CT which allowed better detection of the fracture pathology and provided the basis for new surgical strategies. Since the start of the 1990s, various anatomically shaped steel and titanium calcaneal plates have been available. The Foot and Ankle Expert Group of the AO Foundation together with Synthes USA developed an anatomically shaped interlocking calcaneal plate, which has been available in steel since 2002, and a titaniummolybdenum(15%) alloy version (Mathys) since November 2003. The latter is now being tested clinically in our unit.

Talar dislocations

From 1987-2003, 36 patients were treated for talar dislocation, 27 patients for subtalar, six for total talar, and three patients for peritalar dislocation. Luxatio pedis sub talo: We found 19 medial closed, seven lateral closed and one third degree open subtalar dislocations. Our therapeutic concept provides for immediate reduction, which is possible by closed procedure for the majority of medial dislocations. If there is a tendency to redislocation, we perform talonavicular K-wire transfixation. In the case of irreducibility, open reduction via lateral approach is the rule. The lateral dislocation type is often accompanied by additional fractures of the hindfoot and tarsus, frequently requiring primary open procedures via medial approach. 32 patients were followed-up in whom we found 17 excellent results, ten good, three mediocre and two poor results. With two thirds of the patients, low grade arthrosis at least was observed and two thirds showed a reduced amplitude of motion in one or more talar joints. A definite correlation between arthrosis and reduced function was not established. We did not find talar necroses, persisting instabilities, or redislocations. Luxatio tali totalis: We found three lateral and three medial complete dislocations. The therapeutic concept consists of immediate reduction-only possible by open procedure. A tendency to redislocation requires K-wire transfixation. All patients were followed-up. We found two good and four poor results, with two total and three partial necroses. As a secondary treatment, two lower ankle joint(LAJ) and two upper ankle joint (UAJ) arthrodeses were performed. There were no talectomies, amputations, or infections. Luxatio pedis cum talo: We found three anterolateral UAJ dislocations. Our therapeutic concept provides for immediate reduction. The whole capsular ligament apparatus was reconstructed by primary or secondary treatment, depending on the degree of soft tissue damage. Follow-up showed two excellent results

Misdiagnosed iuxta-articular osteoid osteoma of the calcaneus following an injury

The diagnosis of osteoid osteoma, in usual localizations, is generally simple. In iuxta-articular localizations this tumor may be unrecognized and the diagnosis delayed. Injury has been sometimes correlated with the onset of symptoms and this can make the diagnosis even more difficult. We present a case of osteoid osteoma of the calcaneus iuxta-articular to the subtalar joint in a 17-year-old basketball player. He had a history of initial injury, ankle sprain during training, followed by pain and swelling. He was initially treated for lateral ligament lesion of the ankle with unsatisfactory results. After acute trauma the pain changed becoming chronic and mostly nocturnal disappearing when rofecoxib was taken. Standard x-ray didn't show the lesion. Nuclear Magnetic Resonance (NMR) and scintigraphic results were not well interpreted but these clinical changes and Computed Tomography (CT) images supported the diagnosis of osteoid osteoma. The complete resection of the bone lesion resolved all the symptoms and the histological report confirmed the suspected diagnosis.

Primary synovial chondromatosis of the subtalar joint affecting two brothers

Primary synovial chondromatosis is a rare benign condition characterized by the formation of multiple cartilaginous nodules in the synovium of joints and on occasions tendon sheaths or bursae. A case of primary synovial chondromatosis affecting the subtalar joint is reported. The patient's brother developed the same condition affecting the same joint 2 years later. The proposed etiologies are discussed including the presence of the proto-oncogene C-erb B-2.

Posterior tibial tendon and subtalar joint complex in rheumatoid arthritis: magnetic resonance imaging study

OBJECTIVE

To observe by magnetic resonance imaging (MRI) the pathologic changes in the posterior tibial tendon (PTT), subtalar joint complex (STJC), and sinus tarsi in patients with rheumatoid arthritis (RA), and if possible to determine their involvement in the course of the disease.

METHODS

Sixty-seven rheumatoid feet with mid and hindfoot pain underwent MRI with gadolinium injection. Localized enhancement and anatomic lesions were assessed in the 3 sites.

RESULTS

On MRI, PTT involvement was seen to be more frequent than STJC or sinus tarsi. When there was gadolinium enhancement of the PTT there was no sinus tarsi enhancement (p = 0.014). Interosseous talocalcaneal ligament rupture was correlated with disability (p = 0.031).

CONCLUSION

In RA patients with hindfoot pain, PTT synovitis is observed when there is no sinus tarsi synovitis.

Magnetic resonance imaging in the assessment of synovial inflammation of the hindfoot in patients with rheumatoid arthritis and other polyarthritis

OBJECTIVES

To describe the localisation of synovitis and tenosynovitis of the hindfoot observed on magnetic resonance imaging (MRI) in patients with chronic polyarthritis, and to correlate the findings of physical examination and MRI.

METHODS

Patients with chronic polyarthritis, and one or two painful hindfoot were included. On physical examination and on MRI, the tibio-talar, talo-calcaneal, and talo-navicular and calcaneo-cuboidal joints were adjudged to have or not synovitis, and the tibialis anterior and posterior, the peroneus longus and brevis, the flector digitorum and hallucis longus tendons to have or not tenosynovitis. Criteria for synovitis and tenosynovitis were a high signal intensity on T2-weighted images, a low signal intensity on T1-weighted images, and enhancement after Gd-DTPA injection, in the joint area, and around the tendon, respectively. The correlation between the findings of physical examination and those of MRI were evaluated using the Kappa statistics.

RESULTS

12 patients (three men, nine women, mean age of 55.5 years+/-11.4 S.D.) with chronic polyarthritis (rheumatoid arthritis (RA): nine, ankylosing spondylitis: one; psoriatic arthritis: one, unclassified: one) were included. All presented with one (7 patients) or two (5 patients) painful hindfeet (and swelling for 16 out of 17 hindfeet). On physical examination, 25 joints and eight tendons were adjudged to have synovitis and tenosynovitis. MRI showed synovitis in 12 out of 25 of these joints (48%), and tenosynovotis in three out of eight of these tendons (37.5%). Moreover, MRI showed ten and seven clinically unsuspected synovitis and tenosynovitis, respectively. The proportion of agreements between physical examination and MRI were 54.9% (kappa=0.1) and 88.2% (kappa=0.27) for synovitis and tenosynovitis, respectively.

CONCLUSION

A weak correlation was observed between the findings of physical examination and MRI in patients with chronic polyarthritis and a painful hindfoot. MRI might be used to localise synovitis in the area before performing some intra-articular injections. However, other studies are needed to address this question.

[Ankle instability with involvement of the subtalar joint demonstrated by MRI. Results with the Castaing procedure in 45 cases]

The authors report 46 cases of instability of the hindfoot involving the subtalar joint, with or without combined involvement of the tibiotalar ligaments, which were treated using Castaing's technique of ligament plasty between 1988 and 1999. Preoperatively, the patients complained of instability, recurrent sprains and pain. A tarsal sinus syndrome was present in 39%. Forty six patients underwent NMR examination which demonstrated capsuloligamentous lesions in every case. The results were evaluated using Kitaoka's score. With an average follow-up of 5.7 years after operation, instability was no more present in 80% and 63% were painfree. Clinical examination showed a reduction in the range of inversion of the hindfoot in 43%, with values between 50 and 70% of the contralateral foot, but without any significant clinical repercussion. Incipient osteoarthritis was noted on xrays in three patients. The overall results were very good in 82%, fair in 11% and poor in 7%. Eighty seven percent of the patients were satisfied with the result of the operation. The authors found a significant correlation between fair or poor results and a body mass index above 26 kg/m2 or constitutional laxity. Besides, results got worse as the time interval between the first sprain and the operative treatment increased. Comparison of these results with those of other techniques shows that they are essentially similar. Ligament plasty using Castaing's technique is a reliable operation but direct repair of ruptured ligaments at the subtalar joint should be preferred for primary treatment, leaving the possibility for secondary ligament plasty if necessary.

Intra-articular osteoid osteoma: diagnostic imaging in three cases

PURPOSE

To report our experience pertaining to three cases of intra-articular osteoid osteoma assessed by means of integrated imaging and review of literature.

MATERIALS AND METHODS

Medical records, radiologic and nuclear medicine findings pertaining to three cases of intra-articular osteoid osteoma were retrospectively evaluated and compared with those of surgery. All the patients (2 males, one female; age range 8-38 ys) affected by intra-articular osteoid osteoma respectively of the elbow, tibio-talar joint and hip were evaluated by means of radiographic examination and Magnetic Resonance Imaging (MRI). SE T1-w and T2-w, GRE T2*-w, GRE 3D T1-w and STIR pulse sequences were used and axial, coronal and sagittal images were acquired. Two patients underwent CT scan. One patient underwent skeletal scintigraphy. All the patients underwent surgery.

RESULTS

In 2 out of 3 cases plain radiography allowed the radiologist to suspect the presence of the lesion. In the remaining one, plain radiography failed to detect both the nidus and the perilesional osteosclerosis; nevertheless, a small osteochondral erosion of the humeral condyle suggested the presence of joint inflammation, thus leading to further investigation. CT scan well depicted the presence of the nidus and, in one case, the presence of joint effusion. MRI was always able to detect the nidus, which presented as lesion of low to intermediate signal in T1-w images, low signal in the T2-w images in one patient and high signal in the remaining two; in these latter STIR images showed high intensity nidus and edema of neighbouring cancellous bone. Furthermore, in all patients MRI clearly depicted joint effusion. Skeletal scintigraphy demonstrated both the lesion and the inflammatory involvement of neighbouring soft tissue. In all patients histologic specimen confirmed the diagnosis of osteoid osteoma with joint inflammation and synovitis.

CONCLUSIONS

According to our results and literature data the pre-surgical diagnosis of osteoid osteoma is very difficult to achieve. Indeed, only the combination of clinical information and radiologic and nuclear medicine findings enables the radiologist to make the right diagnosis.

Tarsal tunnel syndrome caused by talocalcaneal coalition

Tarsal tunnel syndrome caused by talocalcaneal coalition is uncommon. We presented the ultrasonography (US) and magnetic resonance imaging findings of this disease. This is, to our knowledge, the first case report describing the US findings in tarsal tunnel syndrome caused by talocalcaneal coalition.

Subtalar arthritis as a presenting symptom of Familial Mediterranean fever: case report and literature review

Familial Mediterranean fever (FMF) is an autosomal, recessive disease affecting mainly people of Mediterranean origin. The primary pattern of FMF is acute, self-resolving periodic attacks of high-grade fever, accompanied by either peritonitis, pleuritis, or arthritis and sometimes typical ankle rash that simulates erysipelas. Rare manifestations, such as pericarditis or massive knee effusion, have been reported in the literature as a presenting symptom of FMF. The final diagnosis has recently become more accurate by identification of the gene for FMF. We describe a unique presenting symptom of subtalar arthritis with no former personal or family history of FMF. A genetic evaluation revealed a 694/726 genetic variant that confirmed the diagnosis of FMF. Treatment with daily colchicine, 1 mg/day, resulted in complete resolution of all complaints.

Resection of talocalcaneal middle facet coalition. Interposition with a tensor fascia lata allograft: a case report

Tensor fascia lata is utilized in the management of complex soft-tissue injuries and defects, but has not been described in the literature in the use of tissue interposition with resection of talocalcaneal middle facet coalitions. This article is a case presentation of a resection of a middle facet coalition with interposition of an allograft of tensor fascia lata. At 14 months postoperative follow-up, range of motion of the subtalar joint was noted to be 20 degrees, and without pain or crepitus. There was no radiographic evidence of degenerative changes in Chopart's joint. The patient returned to all routine and sports activities without pain. He was satisfied with the outcome of the procedure.

Congruity of the subtalar joint in tongue fracture of the calcaneus: an anatomical study

STUDY DESIGN

An anatomic study.

OBJECTIVES

To evaluate the effect of displacement of the fractured posterior facet in tongue fracture of the calcaneus on the congruity of the subtalar joint.

METHODS

Eleven feet were used in this study. Seven females and four males with age range from 59 to 78. The specimens were dissected from both the lateral and the medial aspects of the calcaneus to expose these surfaces. A primary fracture line was created first, then a secondary line was engineered to simulate tongue fracture. Displacement of the superio-lateral fragment was done with 5-mm increment. Radiography was performed and the graphs were scanned and studied on specific computer software to explore the effects of displacement on joint congruity.

RESULTS

The anterior end of the fragment of the tongue fracture, when displaced, not only is depressed but also rotated in the sagittal plane in a downward or planterward direction. The articular surface of the posterior facet of the calcaneus and the inferior facet of the talus are maintained in congruence with each other despite the varying degree of displacement and rotation.

CONCLUSION

Congruity of the subtalar joint in tongue fractures is maintained despite different degrees of displacement. This study explains why the non-surgical treatment outcome is comparable to that of the operative treatment in tongue fractures of calcaneus. It also explains why tongue fractures have a good outcome with closed reduction.

Posterior ankle impingement syndrome: MR imaging findings in seven patients

PURPOSE

To report the magnetic resonance (MR) imaging findings in seven patients with posterior ankle impingement (PAI) syndrome.

MATERIALS AND METHODS

Seven patients-three ballet dancers, one badminton player, one soccer player, one hockey player, and one construction worker-who presented with posterior ankle pain were assessed with MR imaging. Their clinical records and imaging studies were reviewed. The MR imaging studies were assessed for the presence of abnormal bone marrow signal intensity, osseous lesions, and soft-tissue abnormalities.

RESULTS

One patient was treated surgically. In all patients, MR imaging demonstrated abnormal bone marrow signal intensity in the os trigonum and/or lateral talar tubercle, consistent with bone contusions. Two patients had a fragmented os trigonum or lateral tubercle, and two had a pseudoarthrosis of the posterolateral talus. Increased signal intensity was seen with distention of the posterior recess of the tibiotalar joint in two patients and with distention of the posterior recess of the subtalar joint in four patients. Three patients had fluid accumulation in the flexor hallucis longus tendon sheath.

CONCLUSION

Bone contusions of the lateral talar tubercle and os trigonum are prevalent MR imaging findings of PAI syndrome. MR imaging clearly depicts the osseous and soft-tissue abnormalities associated with PAI syndrome and is useful in the assessment of this condition.

The effects on subtalar contact and pressure following talonavicular and midtarsal joint arthrodesis

Many clinical studies have demonstrated the effectiveness of both isolated talonavicular and complete midtarsal joint arthrodesis as an alternative to triple arthrodesis. However, in many cases, controversy exists as to which procedure to utilize. Evidence of degenerative radiographic changes and stiffness of the subtalar joint have been reported postoperatively. A cadaveric study at two different loading values, utilizing low-range pressure film transducers and digital scanning, was performed to quantify articular contact effects on the subtalar joint following isolated talonavicular joint arthrodesis and complete midtarsal joint arthrodesis as compared to the intact specimen. Statistically significant differences were found at p < .05 in this study regarding maximum contact pressure and in location of the applied pressures. Results of this study suggest complete midtarsal joint arthrodesis may be favored over isolated talonavicular joint arthrodesis, especially in the setting of a flatfoot deformity.

Arthrography of the foot and ankle. Ankle and subtalar joint

Arthrography is the intra-articular injection of contrast media. This article reviews the normal and pathologic findings of standard arthrography and MR imaging arthrography of the ankle and subtalar joint. Standard arthrography is used primarily after acute ankle sprains, whereas MR imaging arthrography is used for staging and detecting osteochondritis dissecans of the talus, anterolateral soft tissue impingement, and chronic lateral ankle instability.

Arthroscopy of the ankle and subtalar joint

Arthroscopy has become a useful diagnostic and therapeutic tool in foot and ankle surgery. There are a reasonable number of indications for its use in the ankle and a limited number for the subtalar joint. Procedures previously performed as open surgeries typically necessitate a lengthy recovery and were met with higher complication rates. Many of these procedures can now be performed through small incisions with the assistance of arthroscopy. This article reviews the pathologies amenable to arthroscopy as well as describes the indicated procedures and technical aspects of each.

Posteromedial subtalar coalition: imaging appearances in three cases

OBJECTIVE

To define the imaging appearances in three cases of posteromedial subtalar coalition.

DESIGN

Three patients who presented with hindfoot pain were found to have non-osseous coalition involving the posteromedial hindfoot. This entity is distinct from conventional middle facet coalition as the sustentaculum is uninvolved.

RESULTS

Plain radiographs, available in two cases, demonstrated subtle irregularity of the posterior facet. MRI (three cases) demonstrated a mixed bony and cartilaginous mass lying posterior to the sustentaculum. There was trabecular oedema within the mass and adjacent talus, and narrowing of the space between the middle and posterior facets. Prominence and dilatation of the posterior tibial veins with tenosynovitis of the adjacent tibialis posterior tendon was seen. CT demonstrated the bony mass but did not detect the adjacent bony oedema.

CONCLUSION

Posteromedial subtalar coalition may present with hindfoot pain and stiffness. The presence of a pseudarthrosis posterior to a normal middle facet is characteristic. The abnormality can be difficult to detect on plain radiographs.

Neurohistology of the sinus tarsi and sinus tarsi syndrome

The purpose of this study was to clarify the neural anatomy of the sinus tarsi. The nerve endings of the synovium in the sinus tarsi were examined. The synovial membrane in the sinus tarsi was excised in 20 patients with sinus tarsi syndrome (20 feet) and in 2 feet from subjects without symptoms (controls). In 15 of the 20 patients and the two controls, the excised synovial membrane was studied histologically with staining by a modified Gairns gold chloride method. Numerous neural elements were observed in the sinus tarsi in all examined synovium. There were abundant free nerve endings and three types of mechanoreceptors: Pacinian corpuscles, Golgi corpuscles, and Ruffini corpuscles. Macroscopic observation and histological examination, using hematoxylin and eosin, in the other 5 patients revealed chronic synovitis in the sinus tarsi. Our findings suggest that the sinus tarsi is not only a talocalcaneal joint space but a source of nociceptive and proprioceptive information on the movement of the foot and ankle. Sinus tarsi syndrome may result from disorders of nociception and proprioception in the foot.

Cartilage degeneration in talocrural and talocalcaneal joints from Japanese cadaveric donors

In a study human cadavers, degenerative change (DC) was observed more frequently on articular surfaces of the talocrural joint (55. 8%) than on the articular surfaces of the talocalcaneal joint (29. 5%). In the talocrural joint, the anteromedial segments of the tibial plafond, talar dome, and the medial malleolar facet exhibited a high frequency of DC. Moreover, most DCs were found to coexist in multiple segments that often included both the tibial and talar sides. In the talocalcaneal joint, by contrast, DC tended to be distributed diffusely over the articular surfaces. If the DC occurred initially and progressed to a cartilage defect, it tended to be restricted to a certain portion of the talocalcaneal joint. Mirror-image lesions were observed much less frequently than expected in both the talocrural (28.3%) and talocalcaneal joint (25. 0%). Notably, these lesions were not usually observed even if the DC had progressed to a cartilage defect. We considered that the DC tended to advance to the adjacent segment on the same side rather than to the complementary segment on the opposite side. We demonstrated that the more multiple DC lesions were present in the talocrural joint, the more often DC occurred in the talocalcaneal joint. Consequently, we believe than multiplicity of DCs is more critical for the downward joint-to-joint progression of DC than is increased severity.

[Consequences of tibiotalar arthrodesis on the foot. A retrospective study of 36 cases with 8.5 years of followup]

The authors report the results of a retrospective study of 36 cases of tibiotalar arthrodesis performed in 22 men and 14 women with an average age of 32 years. All patients were reviewed with an average of 8.5 years follow-up. The predominating etiologies were ankle osteoarthritis (15 cases) and neurologic deformities of the foot (13 cases). Arthrodesis was performed using the Meary technique in 60% of cases, using the Charnley technique in 20% and the Crawford-Adams technique or with clamps in the other cases. Fusion was obtained in 97% of cases. Long-term results were assessed using Duquennoy et al.'s scoring system. They were very good or good in 58% of cases, fair in 31% and poor in 11%. The study of distal repercussions of tibiotalar arthrodesis shows progressive deterioration of the subtalar joint in 70% of cases and appearance or increase of degenerative changes in 75% of cases. The final results of the procedure depend on this deterioration; the latter is related with the arthrodesis position. Midtalar joint is a compensation joint showing hypermobility in 40% of cases. Degenerative changes were limited and asymptomatic in 80% of cases. Based on the findings in this study and on the literature, we conclude that the foot should be fixed at 90 degrees or with less than 5 degrees of equinus, with 5 degrees of valgus and 10 to 15 degrees of external rotation.

Intra-articular calcaneal fractures: effect of open reduction and internal fixation on the contact characteristics of the subtalar joint

Intra-articular calcaneal fractures are associated with significant long-term morbidity, and considerable controversy exists regarding the optimum method of treating them. The contact characteristics in the intact subtalar joint were determined at known loads and for different positions of the ankle and subtalar joint, using pressure-sensitive film (Super Low; Fuji, Itochu Canada Ltd, Montreal, Quebec). We measured the contact area to joint area ratio (pressure > 5 kg force/cm2 [kgf/cm2]) which normalizes for differences in joint size and the ratio of high pressure zone (>20 kgf/cm2) as a reflection of overall increase in joint pressure. Three simulated fracture patterns were then created and stabilized with either 1 or 2 mm of articular incongruity. Eight specimens were prepared with a primary fracture line through the posterior facet, eight with a joint depression-type fracture, and six with a central joint depression fracture. A measure of 1 to 2 mm of incongruity in the posterior facet for all three fracture patterns produced significant unloading of the depressed fragment, with a redistribution of the overall pattern of pressure distribution to parts of the facet that were previously unloaded.

[Subtalar arthrodesis--minimal resection technique]

INTRODUCTION

This is a prospective clinical and radiological study of the treatment of talocalcaneal deformity or degeneration by a modified technique of isolated talocalcaneal fusion.

METHODS

Thirty-six patients were evaluated with clinical examination, plain dorso-plantar and oblique x-rays and CT-scan or magnetic resonance imaging in a follow-up of 32.5 months (range: 20-62). In 12 cases a posterior tibial tendon rupture with secondary osteoarthritis and in 24 cases a posttraumatic secondary osteoarthritis (18 calcaneal fractures, 3 talar fractures, 2 axial traumas with secondary talar necrosis and 1 rheumatoid arthritis with calcanear and talar fracture) were the indications for arthodesis.

RESULTS

On a visual analog pain scale the patients graded their pain preoperatively at 4.4 and postoperatively at 1.1. The subjective results showed in 12 cases (33.3%) complete satisfaction, in 10 cases (27.7%) satisfaction with minor reservation, in 11 cases (30.5%) satisfaction with major reservation and in 3 cases (8.5%) dissatisfaction. The overall objective results were excellent in 17 (47.2%), good in 11 (30.5%), fair in 6 (16.8%) and poor in 2 (5.5%) cases. A further advantage of this type of talocalcaneal fusion is the remaining range of motion in the neighbouring joints, at the ankle (in 75.7% the same or better ROM than preoperatively) and at Chopart joint (in 69.4% the same or better ROM than preoperatively). The fusion rate was high with 94.5%.

CONCLUSION

The modified isolated talocalcaneal fusion without disruption at the Chopart joint is a simple surgical technique in the hand of the experienced surgeon. The subjective and objective mid-term results of this prospective follow-up study are comparable to other technique described in literature.

Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus

Twenty-one patients (21 feet in 18 women and three men) who were treated with subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus at an average age of 60 years (range, 44-75 years) were studied. Mean duration of symptoms was 3 years. All had realignment of the calcaneus in relation to the talus, and all had screw fixation without supplemental bone graft. Average followup was 3 years (range, 2-5 years). All patients had successful union. The tibiocalcaneal angle averaged 13 degrees +/- 3.1 degrees before operation and 6 degrees +/- 1.9 degrees after operation. The lateral talometatarsal, lateral talocalcaneal, and lateral tibiotalar angles all improved significantly. Arch height (navicular height) increase averaged 5 +/- 2.7 mm. Arch length (calcaneal-metatarsal) decrease averaged 4 +/- 3.2 mm. One complication occurred: delayed wound healing (excellent result). Clinical results were excellent in eight feet, good in eight, fair in four, and poor in one. Patients were satisfied with the operative result in 16 feet, satisfied with reservations in four, and dissatisfied with the operative results in one. Subtalar arthrodesis effectively corrects deformity, does not require bone graft, has a high union rate, and is associated with a low complication rate. However, 11 of the 21 patients continued to have some pain, and in patients with preexisting arthrosis of adjacent joints, symptoms may persist.

Juvenile chronic arthritis: diagnosis and management of tibio-talar and sub-talar disease

The aim of this study was to compare clinical evaluation of the site of hindfoot synovitis with contrast-enhanced magnetic resonance imaging (MRI) findings in children with juvenile chronic arthritis (JCA), and to evaluate the efficacy of selective guided intra-articular steroid injections. Thirteen symptomatic ankles of 11 consecutive JCA patients were examined clinically and with contrast-enhanced MRI. Pannus was demonstrated on MRI in both tibio-talar and sub-talar joints in 10 ankles, in the tibio-talar joint only in one ankle and in neither joint in two ankles. Correlation of clinical and MRI findings was good for the tibio-talar joint with concordance in 11/13 cases. Correlation was poor for the sub-talar joints. Of the 10 sub-talar joints shown to have pannus on MRI, only two were thought to have had definite clinical evidence of synovitis. Guided intra-articular steroid injection resulted in at least 6 months remission in 6/9 ankles compared with 1/10 ankles which had had previous unguided injections. We therefore recommend the use of image guidance for intra-articular triamcinolone hexacetonide injection in children with hindfoot synovitis.