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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 56-58

Functional outcome of subtalar arthrodesis using double lag screw technique


Department of Orthopaedics, Government Medical College, Kota, Rajasthan, India

Date of Web Publication6-Jun-2014

Correspondence Address:
Dinesh Kumar Meena
KR 251, Civil Lines, Ganwadi, Kota 324 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.134018

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  Abstract 

Background: This study evaluated the functional result of subtalar joint fusion and effectiveness of a technique using double lag screw from posteroinferior calcaneus to talus in post traumatic subtalar arthritis following the calcaneal intra-articular fracture. Materials and Methods: In between January 2012 and August 2013, we performed 10 isolated subtalar arthrodesis by double lag screw technique from posteroinferior calcaneus to talus, across posterior facet of subtalar joint, after denuding the joint cartilage, combined with application of an autograft taken from iliac crest, by open method. The average patient age was 47 (range 35-60) year. There were 7 male and 3 female. The indication was the pain following the post-traumatic arthritis of subtalar joint in intra-articular fracture of posterior facet of calcaneus. Result: All 10 joints were fused except one who undergone delayed fusion because of infection, resulting in an overall fusion rate of above 90%. The average time to fusion was 12.3+/−3.4 weeks. The fixation screw was removed in 2/10 joint at an average of 8.8+/−0.5 month. Conclusion: Using the double lag screws of 6.5mm across the posterior facet of subtalar joint resulted in fusion of joint in above 90% of patients. The relief from pain was obtained in 100% of cases. This is a simple and reliable technique for achieving fusion of subtalar joint.

Keywords: Arthrodesis, bone graft, corticocancellous screw, subtalar joint


How to cite this article:
Meena DK, Sharma SB, Rajawat AS, Tyagi MK, Meena RK, Thalanki SK. Functional outcome of subtalar arthrodesis using double lag screw technique. J Orthop Traumatol Rehabil 2014;7:56-8

How to cite this URL:
Meena DK, Sharma SB, Rajawat AS, Tyagi MK, Meena RK, Thalanki SK. Functional outcome of subtalar arthrodesis using double lag screw technique. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 26];7:56-8. Available from: http://www.jotr.in/text.asp?2014/7/1/56/134018


  Introduction Top


Comminuted and displaced intraarticular fracture of calcaneum when treated by conservative methods or reduced inadequately may result in unfavourable outcomes causing osteoarthritis of subtalar joint. [1],[2],[3],[4],[5],[6] The most common problem that occurs consequently is arthritis causing pain in the hindfoot. Other concerns observed are loss of height of calcaneum, subsequent tibiotalar impingement and flattening of longitudinal arches. Increasing width of calcaneum can cause calcaneofibular abutment and impingement of peroneal tendon as well as axial malalignment of the hindfoot. These features are responsible for the alternation of the distribution of pressure in the adjacent joint and transfer of load to the mid and forefoot which results in a pathological gait and hindfoot pain with swelling. [12],[15] Subtalar arthrodesis eliminates the pain which occurs as a result of residual movement with severe joint incongruity. [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Decompression of the lateral wall of the calcaneum may relieve the impingement of the peroneal tendon and calcaneofibular abutment. Subtalar arthrodesis has been reported to be effective in correcting the malalignment of the hindfoot due to various causes and improve the functional outcome in terms of pain relief. Over the years primary subtalar arthrodesis has proven to be a successful procedure in the management of numerous hindfoot problem. [15],[16],[17]

In this study, we prospectively assessed the function of the foot both clinically and radiographically and the effectiveness of the choosen method of arthrodesis before and after the problem of subtalar arthritis.


  Materials and methods Top


In between January 2012 to August 2013, a total number of 10 isolated subtalar arthrodesis were done using the technique of double lag screw fixation from postero inferior calcaneum to talus across posterior facet of subtalar joint, combined with the application of an autograft taken from iliac crest. The average age of the patient was found to be 47 years (35-60). There were 7 males and 3 females. Primary arthrodesis was done in all the above patients included in the study. We included only post-traumatic unilateral subtalar arthritis in the study [Figure 1]a. Cases with bilateral involvement, degenerative arthritis, and those who refuse to give consent to participate in the study were excluded from the study. All patients had calcaneal height and talar angle within normal limits. All patients had loss of calcaneus height. All patients presented with the complaints of severe hindfoot pain, which was not relieved by conservative measure like analgesics, orthosis, physiotherapy, unisole etc. The preliminary clinical finding was swelling in the hindfoot below medial and lateral malleolus, restricted range of the movement at subtalar joint with mild varus deformity [Figure 1]b. The mean time interval from the injury to subtalar arthrodesis was 17.3 months (10-25 m). All patients were prospectively evaluated clinically, radiographically and functionally.
Figure 1:

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  Surgical technique Top


Surgery was carried out under spinal anesthesia under strict aseptic precautions with single shot of prophylactic antibiotic ΍ hour before the surgery in supine position and tourniquet applied to the thigh after exsanguination. Anterior iliac crest was draped free. The incision was straight in line from antero-lateral corner of calcaneocuboid joint to posterior, ending 1-2 cm anterior to tendo Achillis, with ankle in 90 0 , on lateral side of the foot. Superficial dissection was done protecting the sural nerve and short saphenous vein overlying the combined sheath of peroneal tendon. The inferior peroneal retinaculum was opened on its anterior border where it meets the stem of inferior extensor retinaculum to expose the antero-lateral ridge of the anterior third of calcaneus, which is the lateral border of sinus tarsus. Reflect the origin of extensor digitorum brevis distally. Subtalar joint (posterior facet) was opened and extensive fibrosis was removed from the joint. Lamina spreader was introduced into the joint. Both the articular surface of calcaneus and talus were freed from all residual cartilage and the sclerotic subchondral bone was removed with the help of osteotome. Care was taken not to injure the posterior tibial neurovascular bundle running posterior-medially. With the help of the image intensifier talus, calcaneus realignment had been planned before the operation. Joint was distracted and the bone graft was placed in the posterior facet, in a press fit manner, with heel in slight valgus. [5] Under C-arm two guide wire placed from the posterior-inferior calcaneus to the body of talus across the posterior facet, on which two 6.5 mm cannulated cancellous screw with washer were introduced through the stab incision over the heel [Figure 1]c. Closure over the drains was done in layers. Below the knee POP slab was applied and limb was elevated. Isometric exercises were started on the first postoperative day. Patients were mobilized without weight bearing on crutches. After 10 days stitches were removed and below the knee cast was applied and partial weight bearing was allowed for 10 weeks. At tenth week arthrodesis was assessed with the help of radiograph and full weight bearing allowed in the patient shoe.


  Result Top


All of the 10 patients who underwent fusion, resulting fusion rate was above 90%, except one who developed post-operative infection, but treated conservatively with antibiotic and ultimately fusion occurred. The average time to fusion was 12.3+/−3.4 weeks. Other factors like gender, age, weight (obesity/malnutrition) and smoking did not affect the fusion. The fixation screw removed in 2/10 joints (20%) at an average 8.8+/− months. Complications like non union, wound dehiscence and problems of valgus and varus deformities was not noticed in any of the patients. Problem of hardware during the weight bearing was noted in one patient (10%), but resolved after screw removal. Superficial infection occurred in one patient who was treated with intravenous antibiotics based on the culture sensitivity reports. Swelling persisted in all patients up to 8-12 months during the post operative period. There was complete pain relief in all the patients. For evaluation of arthrodesis in all patients CT scan was done at 4 to 6 months of post operative period. The lag screws were removed after 8 months following the surgery. Follow-up was carried out for a minimum period of 12-16 months; mean follow-up of the patient was 13 months. Surgical scar were sound in all cases. Subjectively 4 patients (40%) rated the result excellent, 2 patients (20%) good, 2 patients (20%) fair and 2 patients (20%) as poor. Before the surgery, all patients rated the result of the conservative treatment of the fracture calcaneum as poor.


  Conclusion Top


Using double screw technique of 6.5 mm CC screws, across the posterior facet of the sub-talar joint with bone graft, resulted in fusion of sub-talar joint in above 90% of the patients. There were few complications. The problem of plantar heel pain because of prominent screw head is well recognized. However, reported rate of screw removal was not high. Normally, eversion/inversion movement of the sub-talar joint allows adaptation of the foot on uneven ground, the loss of this shock absorption mechanism after subtalar fusion provokes the pain beneath the screw head in some patients and heads were not prominent. None of the patients complained of the pain at the subtalar joint after adequate passage of time. Subjectively, patients' satisfaction was 93.6% which points towards a favorable result.

 
  References Top

1.Reich RS. End-result in fracture of the calcaneus. J Am Med Assoc 1923;99:1909-13.  Back to cited text no. 1
    
2.Wilson PD. Tretment of fracture of the os calcis by arthrodesis of the subastragalar joint. A of on 26 cases. J Am Med Assoc 1927;89:1676-83.  Back to cited text no. 2
    
3.Gallie WE. Subtalar arthrodesis in fracture of the os calcis. J Bone Joint Surg Am 1943;25:731-6.  Back to cited text no. 3
    
4.Dennyson WG, Fulford GE. Subtalar arthrodesis by cancellous graft and metallic internal fixation. J Bone Joint Surg Am 1976;58:507-10.  Back to cited text no. 4
    
5.Mann RA, Beaman DN, Horton GA. Isolated subtalar arthrodesis. Foot ankle Int 1988;19:511-9.  Back to cited text no. 5
    
6.Russotti GM, Cass JR, Johnson KA. Isolated talocalcaneal artrodesis. A technique using moldable bone graft. J Bone Joint Surg 1988;70-A;1472-8.  Back to cited text no. 6
    
7.Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorder. Preliminary report. Clin Orthop Relat Res 1988;226:260-5.  Back to cited text no. 7
    
8.Kitaoka HB, Patzer GL. Subtalar arthrodesis for posterior tibial tendon dysfunction and planus. Clin Orthop 1997;345:187-94.  Back to cited text no. 8
    
9.Dahm DL, Kitaoka HB. Subtalar arthrodesis with internail compression for post traumatic arthritis. J Bone Joint Surg Br 1998;80:134-8.  Back to cited text no. 9
    
10.Thermann H, Hufner T, Schratt E, Held C, von Glinski S, Tscherne H. Long- term result of subtalar fusion after operative versus nonoperative treatment of os calcis fracture. Foot Ankle Int 1999;20:408-16.  Back to cited text no. 10
    
11.Sammarco GJ, Tablantc EB. Subtalar arthrodesis. Clin Orthop Relat Res 1999;365:69-73.  Back to cited text no. 11
    
12.Easley ME, Trnkas HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-24.  Back to cited text no. 12
    
13.Flemister AS, Infante AF, Sander RW, Walling AK. Subtalar arthrodesis for complication of intra-articular calcaneal fracture. Foot Ankle Int 2000;21:392-9.  Back to cited text no. 13
    
14.Hanson ST. Functional Reconstruction of the Foot and Ankle. Foot Ankle 2000;1:239-9.  Back to cited text no. 14
    
15.Haskell A, Pfeiff C, Mann R. Subtalar joint arthrodesis using a single lag screw. Foot Ankle Int 2004;25:774-7.  Back to cited text no. 15
    
16.Catanzariti AR, Mendicino RW, Saltrick KR, Orsini RC, Dombeck MF, Lamm BM. Subtalar joint arthrodesis. J Am Podiatr Med Assoc 2005;95:34-41.  Back to cited text no. 16
    
17.Johnson JT, Schuberth JM, Thornton SD, Christensen JC. Joint curettage arthrodesis technique in the foot; a histological analysis. J Foot Ankle Surg 2009;48:558-64.  Back to cited text no. 17
    


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Abstract
Introduction
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Surgical technique
Result
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