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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 6-9

Functional outcome of subtalar arthrodesis in posttraumatic arthritis


Department of Orthopaedics, Jhalawar Medical College, Jhalawar, Rajasthan, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Nilesh Kumar Jangir
Department of Orthopaedics, Jhalawar Medical College, Jhalawar, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_2_19

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  Abstract 


Introduction: Involvement of the subtalar joint in fracture calcaneus malunion may give rise to chronic pain and permanent functional impairment. This study evaluated the functional result of subtalar joint fusion and effectiveness of a technique using double lag screw from the posteromedial calcaneus to the talus. Materials and Methods: In between April 2015 and April 2017, we performed 12 isolated subtalar arthrodeses by double lag screw technique from posteroinferior calcaneus to talus. The average patient age was 39 (range 28–50) years. There were 9 males and 3 females. Results: Eleven out of 12 joints were fused except one who developed infection, resulting in an overall fusion rate of above 91%. The average time for fusion was 4.5 months (ranging from 3 to 6 months). There was no correlation between the type of accident, the weight of the patient, and the recovery period. Conclusion: Using the double lag screws of 6.5 mm across the posterior facet of subtalar joint resulted in fusion of joint in above 91% of patients. The relief from pain was obtained in 100% of cases. This is a simple and reliable technique for achieving fusion of the subtalar joint.

Keywords: Arthritis, chronic pain, subtalar arthrodesis


How to cite this article:
Jangir NK, Sharma M, Meena M, Jhanwar P. Functional outcome of subtalar arthrodesis in posttraumatic arthritis. J Orthop Traumatol Rehabil 2019;11:6-9

How to cite this URL:
Jangir NK, Sharma M, Meena M, Jhanwar P. Functional outcome of subtalar arthrodesis in posttraumatic arthritis. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Sep 17];11:6-9. Available from: http://www.jotr.in/text.asp?2019/11/1/6/264719




  Introduction Top


Osteoarthritis of the subtalar joint caused due to comminuted or displaced intra-articular fracture of calcaneum which were conservatively managed or reduced inadequately.[1],[2],[3],[4],[5],[6] The single-axis subtalar joint adjusts the forces of ambulation acting on the rest of the skeleton and influences the performance of the more distal foot articulations as well.[7] Intra-articular fractures of the calcaneum, which account for >50% of cases, are caused due to complex injuries with extensive damage to the bone and soft tissue.[8],[9] These cases whether treated surgically or conservatively ultimately present with pain, loss of joint mobility, and functional disability.[10]

The patient most commonly present with pain in the hindfoot due to arthritis. Other concerns are loss of height of calcaneum, soft tissue or tendon impingement, and flattening of longitudinal arches.[11],[12] On performing subtalar arthrodesis, the patient is relieved of pain and has been reported to be effective in correcting the functional disability of the hindfoot due to various causes.[12],[13],[14]

The aim of this study was to evaluate the functional outcome of subtalar arthrodesis using cannulated screws fixation to treat post-traumatic arthritis.


  Materials and Methods Top


In between April 2015 and April 2017, we performed 12 isolated subtalar arthrodeses by double lag screw technique from posteroinferior calcaneum to talus. The initial trauma was a fall from a height in 10 patients and a bike accident in 2. The average patient age was 39 (range 28–50) years. There were 9 males and 3 females.

Inclusion criteria were posttraumatic unilateral subtalar arthritis in the study. Cases with bilateral involvement, degenerative arthritis, and associated comorbidities were excluded from the study.

The indication for operation was severe pain and disability in an incongruent subtalar joint [Figure 1]. The average duration of the presentation of the patient was 16 months (range 12–20 months) after the initial trauma. All patients had calcaneus height and talar angle within normal limits. All patients presented with the complaints of severe hindfoot pain, which was not relieved by conservative measure such as analgesics, orthosis and physiotherapy. All patients were clinically, radiographically, and functionally evaluated.
Figure 1: Preoperative radiograph showing subtalar arthritis

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The clinical rating system of the American Orthopedic Foot and Ankle Society (AOFAS) was used for the clinical evaluation postoperatively. On clinical examination, tenderness was elicited on palpation over the lateral side of the ankle and heel.

Operative procedure

After taking informed and written consent regarding the loss of eversion and inversion movements, the patient is taken in supine position on operating table. Tourniquet was applied in the proximal thigh after exsanguination. Painting and draping were done over the iliac region for harvesting bone graft.

The operation was performed under spinal or general anesthesia. A lateral curvilinear incision was made to approach the talocalcaneal joint. After dissecting the talocalcaneal joint capsule, joint surface is prepared by removing all cartilage. The bone surface is roughened to stimulate bleeding. Bone graft was inserted which was harvested from the autologous iliac crest. Two 6.5 mm partially threaded cannulated screws were inserted from the calcaneum to the talus over the preinserted guide-wire under c-arm [Figure 2] and [Figure 3]. The bleeding allows the two bones to heal together after the joint is fixed with screws.
Figure 2: Guide wire insertion through posteroinferior part of calcaneum

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Figure 3: Intra-operative radiology to ensure screws position

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At the end of the procedure, the tourniquet was released, and thorough wash was done with saline, followed by subcutaneous closure with absorbable suture and skin closure with nonabsorbable suture and below knee slab was applied [Figure 4] and [Figure 5].
Figure 4: Postoperative X-ray with screw fixation – AP view

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Figure 5: Postoperative X-ray with screw fixation – lateral view

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Postoperative strategy

Isometric exercises were started on the 1st postoperative day. Check dress was done on postoperative day 2 or day 3. After 7–10 days stitches were removed and below knee cast were applied. After 4 weeks partial weightbearing was allowed with below knee walking cast. Clinical and radiographic evaluation was done regularly at 4 weeks interval until solid union of arthrodesis was observed and then full weight-bearing was allowed [Figure 6].
Figure 6: Follow up X-ray showing fusion

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  Results Top


Eleven out of 12 joints were fused except one who developed infection, resulting in an overall fusion rate of above 91%. Infection was treated with IV antibiotics and the regular dressing was done. The average time for fusion was 4.5 months (ranging from 3 to 6 months). There was no correlation between the type of accident, the weight of the patient and the recovery period. In 8 (66.66%) patients, there was some residual pain; 4 (33.33%) had no complaints.

During follow-up, complications such as nonunion and wound dehiscence were not noticed in any of the patients. Follow-up was carried out for 20–24 weeks. Surgical scar was sound in all cases.

Foot score

According to AOFAS score [Figure 7], 4 (33.33%) patients had excellentscore, good in 4 (33.33%), fair in 3 (25%), and poor in 1 (8.33%). The talonavicular joint was normal in all feet and two showed degenerative changes in the calcaneocuboid.
Figure 7: Foot score - AOFAS

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Case

40-year-old female with subtalar arthrosis after fracture calcaneum.


  Discussion Top


In the surgical treatment of sequelae of calcaneal fractures, all possible causes of pain should be considered and the anatomy of the hindfoot restored. Mann and Baumgarten[5] reported a 50% loss of forefoot abduction and adduction after an isolated subtalar arthrodesis. These authors have frequently encountered patients after successful subtalar arthrodesis that will have a transient synovitis of the ankle during the first 2–3 months after cessation of postoperative casting. They recommended that most patients should understand that the ankle is also a hinge and that, having the subtalar joint fused, rapid walking with long strides on uneven surfaces may cause the ankle to sustain forces out of its usual plane of motion[11] most cases these radiographic changes of arthrosis do not correlate with clinical symptoms. Screw fixation has become an accepted and reliable fixation method in subtalar arthrodesis, with union rates often exceeding 90%. Screw positioning can be technically demanding due to the orientation of the tarsal bones and the need to place the screws perpendicular to the joint plan for optimal compression. Targeting devices have been developed to improve the accuracy of screw positioning and to reduce intraoperative exposure. With regard to the number of screws, two screws are thought to limit rotational micromotion, which may result in a better union rate.


  Conclusion Top


Isolated subtalar arthrodesis is an effective surgical intervention with significant clinical improvements in some patients with post-traumatic arthritis of the hindfoot. Screw fixation with two cannulated screws can give compression and added stability for fusion of the arthrodesis site. Fusion of joint in above 91% of patients, and the relief from pain was obtained in 100% of cases which favors the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  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. Treatment 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 grafts and metallic internal fixation. J Bone Joint Surg Br 1976;58-B:507-10.  Back to cited text no. 4
    
5.
Mann RA, Beaman DN, Horton GA. Isolated subtalar arthrodesis. Foot Ankle Int 1998;19:511-9.  Back to cited text no. 5
    
6.
Russotti GM, Cass JR, Johnson KA. Isolated talocalcaneal arthrodesis. A technique using moldable bone graft. J Bone Joint Surg Am 1988;70:1472-8.  Back to cited text no. 6
    
7.
Meyer JM, Lagier R. Post-traumatic sinus tarsi syndrome. An anatomical and radiological study. Acta Orthop Scand 1977;48:121-8.  Back to cited text no. 7
    
8.
Johansson JE, Harrison J, Greenwood FA. Subtalar arthrodesis for adult traumatic arthritis. Foot Ankle 1982;2:294-8.  Back to cited text no. 8
    
9.
Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-6.  Back to cited text no. 9
    
10.
Herrera-Pérez M, Andarcia-Bañuelos C, Barg A, Wiewiorski M, Valderrabano V, Kapron AL, et al. Comparison of cannulated screws versus compression staples for subtalar arthrodesis fixation. Foot Ankle Int 2015;36:203-10.  Back to cited text no. 10
    
11.
Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-24.  Back to cited text no. 11
    
12.
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. 12
    
13.
Catanzariti AR, Mendicino RW, Saltrick KR, Orsini RC, Dombek MF, Lamm BM. Subtalar joint arthrodesis. J Am Podiatr Med Assoc 2005;95:34-41.  Back to cited text no. 13
    
14.
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. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Introduction
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