Abstract
The indications for subtalar arthrodesis are broad and include arthritis and deformities. Specific problems amenable to management by this method are calcaneus fracture, isolated traumatic subtalar arthritis, middle facet tarsal coalition, and calcaneovalgus deformity, among others. The surgical approach that we use for subtalar arthrodesis depends to some extent on the underlying pathology. Many of these procedures are performed for posttraumatic arthritis secondary to a calcaneus fracture. We generally use a standard incision across the sinus tarsi. In some cases, the patient has undergone multiple surgeries, and the incision is prone to dehiscence unless care is taken with the approach. In cases of a bone block fusion, the use of a vertical posterior incision is preferred to minimize risk of wound complication from distraction of a transverse incision.
Key Words
subtalar, arthrodesis, talocalcaneal, malunion, nonunion, fusion
Overview: Approach and Incisions
The indications for subtalar arthrodesis are broad and include arthritis and deformities. Specific problems amenable to management by this method are calcaneus fracture, isolated traumatic subtalar arthritis, middle facet tarsal coalition, and calcaneovalgus deformity, among others.
The surgical approach that we use for subtalar arthrodesis depends to some extent on the underlying pathology. Many of these procedures are performed for posttraumatic arthritis secondary to a calcaneus fracture. We generally use a standard incision across the sinus tarsi. In some cases, the patient has undergone multiple surgeries, and the incision is prone to dehiscence unless care is taken with the approach ( Fig. 29.1 ). If previous surgery has been performed, one can prefer to reopen the original incision for the open reduction with internal fixation (ORIF) procedure. Although use of the original incision is an option, considerable scarring will be encountered over the lateral calcaneus and peroneal tendons, and it is not as easy to reach the sinus tarsi and the more medial aspect of the subtalar joint through this route ( Fig. 29.2 ). However, the extensile exposure using the original incision has the advantage of good visualization of the lateral wall of the calcaneus, access to removal of hardware, and easy insertion of bone graft. We find that despite the difficulty of raising the flap, the skin heals well unless there has been an infection associated with the original procedure, in which case a small sinus tarsi incision is used ( Fig. 29.3 ). The more limited incision over the sinus tarsi heals well, with no risk for compromise of the intervening skin bridge between the sinus tarsi incision and the original more extensile lateral incision ( Fig. 29.4 ).
Subtalar arthrodesis procedures are of two basic types: (1) fusion performed in situ, without changing the orientation of the hindfoot and (2) a bone block arthrodesis with structural grafting to restore the height of the hindfoot. In addition to these two basic procedures, osteotomies of the calcaneus may be added to correct additional deformity. Beyond correction of the calcaneus and subtalar joint problems, other essential considerations include the condition of the peroneal tendons, which are frequently torn or dislocated, as well as the flexor hallucis longus and the soft tissues on the medial ankle, including the tibial nerve and its branches.
Complete exposure of the peroneal tendons and adequate subfibular decompression in patients with subtalar arthrodesis after calcaneus fracture are essential. Impingement in the subfibular recess is common, and the bone must always be removed regardless of the type of arthrodesis performed ( Fig. 29.5 ). The easiest way to determine that an adequate decompression has been performed is to make sure that the lateral wall of the calcaneus is slightly medial to the undersurface of the overhanging talus. After completion of the procedure, palpate the subfibular recess percutaneously to detect any persistent bone underneath the tip of the fibula.
The incision is made from the tip of the fibula extending distally down over the sinus tarsi toward the calcaneocuboid joint. On the inferior surface of the incision, the peroneal tendon sheath is identified, and more distally in the incision, the terminal branch of the sural nerve should be looked for. The nerve usually lies inferior to the peroneal tendons, but if the dissection extends more distally, the nerve can be at risk for injury ( ).
What incision should be used after a failed ORIF of a calcaneus fracture? Reuse of these extensile incisions for a subsequent elective arthrodesis procedure is typically problematic, and visualization of the entire joint can be limited because of scarring. Provided that 6 months has elapsed since the initial ORIF procedure, a standard sinus tarsi approach is far easier. With fractures treated initially with ORIF for which the hardware is still in place, two outcomes are possible: (1) either failure of the ORIF with widening and collapse of the subtalar joint, or (2) normal hindfoot anatomy with arthritis. In the first case, the hindfoot widens with collapse of the subtalar joint, and the hardware needs to be removed before the lateral wall ostectomy and arthrodesis are performed. In the second case, despite the arthritis, the overall architecture of the hindfoot has been maintained, and the hardware can be left in place. Fixation of the subtalar fusion can be a little more difficult here, but the larger screws for the arthrodesis can be inserted around the plate and original screws, as is done for a primary arthrodesis of the subtalar joint combined with ORIF for an acute fracture.
When the hardware removal is planned as a simultaneous procedure, the plate and screws should be removed percutaneously, assisted by fluoroscopic imaging, alternatively using an extensile approach as demonstrated in Fig. 29.3 . Each screw can be marked with a needle, and then a 2-mm puncture incision is made directly on top of the screw through the skin and then deepened through subcutaneous tissue with a hemostat, to avoid injury to the sural nerve. The plate can then be grasped with needle-nose pliers and then twisted out the front of the incision.
The retinaculum of the undersurface of the peroneal tendon sheath is stripped and elevated off the lateral wall of the calcaneus. Depending on the nature of the underlying disease, the peroneal tendons may be left in position or completely retracted if the lateral calcaneus has widened. After a calcaneus fracture, bone builds up laterally and squeezes the peroneal tendons into the fibula. To address this problem, the lateral wall of the calcaneus is completely exposed proximally toward and then posterior to the fibula, until the impingement against the lateral wall of the calcaneus is visible. A retractor is inserted into the soft tissue to pull the peroneal tendon sheath inferiorly and expose the entire lateral wall of the calcaneus. The peroneal tendons are frequently dislocated, either as a result of the original injury, the release of the retinaculum for exposure of the calcaneus, or impingement from untreated bone along the lateral wall causing subluxation of the tendons. A good example of this is demonstrated in . In general, the tendons will fall into place once the lateral wall ostectomy has been performed and the tissue bone that has built up under the tip of the fibula has been removed ( ). Alternatively, a groove-deepening procedure can be performed with a burr to relocate the tendons. If there is marked ankle instability from the injury or its subsequent treatment, then the split peroneus brevis tendon can be used to perform a modified Chrisman-Snook procedure, which then holds the remaining peroneal tendons in place.
For the lateral wall ostectomy, we use a 2-cm curved osteotome to remove a generous amount of bone to achieve complete exposure of the lateral aspect of the posterior facet of the subtalar joint and also remove the lateral impingement under the tip of the fibula. Slight irregularities are often present in the lateral wall of the calcaneus after this ostectomy, and the surface should be palpated through the skin to identify residual bone, which may be the source of pain. After completion of the ostectomy, the lateral margin of the posterior facet of the calcaneus should be slightly medial to the undersurface of the lateral margin of the talus. We preserve the resected bone and cut it up with a bone cutter into 5-mm fragments for later use as graft material ( Fig. 29.6 ).
The contents of the sinus tarsi are elevated off the floor of the sinus tarsi until the anterior aspect of the posterior facet of the subtalar joint is well visualized. A rongeur can be inserted directly into the posterior facet of the subtalar joint and then twisted around to loosen up the joint. The rongeur can then be pushed more medially to first open up and then debride the interosseous scar, opening up the middle facet. Once the debridement has been performed with the rongeur, a toothed laminar spreader is inserted into the sinus tarsi. With the spreader placed on stretch, the remnant of the interosseous ligament is visualized and is debrided to gain access to the posterior aspect of the subtalar joint and the middle facet. We use a flexible chisel to denude the articular surface of the posterior facet, but minimal bone is removed. The posterior facet is debrided down to bleeding healthy subchondral bone. All of the chondral fragments are removed with the rongeur. Final debridement using a flexible chisel is performed again on the more medial aspect of the subtalar joint, with entry into the middle facet and complete denudation of the articular surface and the undersurface of the talus, as well as the dorsal surface of the middle facet. It is important to debride the medial aspect of the joint, including the middle facet; otherwise, a gap will be present, which may not close, or the heel will tilt into valgus as the posterior and lateral aspect of the joint is compressed. Once we have removed all of the cartilage and chondral fragments, the joint is perforated with a 2- or 2.5-mm drill bit and aggressively punctured or “fish-scaled” using an 8-mm curved osteotome.
The bone graft harvested earlier from the lateral wall of the calcaneus is used to augment the arthrodesis ( Fig. 29.7 ). The graft is now inserted into the sinus tarsi and the recesses in the subtalar joint and packed into place with a bone tamp. It is essential to ensure that no graft spills into the soft tissues, particularly under the peroneal recess laterally and then more posteriorly into the retrocalcaneal space. Over the past few years we have been routinely adding a spun-down concentrate from an iliac crest aspirate to the cancellous bone graft. In patients who are considered to be at higher risk for nonunion, we include use of bone morphogenic protein or an implantable bone stimulator in addition to the arthrodesis.
If we anticipate that copious amounts of bone graft will be needed, the surgical plan includes obtaining either autograft or allograft supplemented with mesenchymal cell aspirate from the iliac crest. If we anticipate that a defect will be present or that elevation of the height of the hindfoot is necessary, then we use a vertical incision. If, however, we have used the standard sinus tarsi incision, then before we complete the procedure, we make sure that the skin can be closed without tension. Removing some of the bulk of the bone graft may be necessary to achieve a tension-free closure. A defect is inevitable if avascular necrosis of the posterior facet is present: as debridement is performed, more bone loss will result. This defect can be filled with either a bulk structural graft or cancellous chips. Before the graft is inserted, a laminar spreader is placed into the sinus tarsi to check the required height, and the tension on the skin is evaluated.
Overview: Approach and Incisions
The indications for subtalar arthrodesis are broad and include arthritis and deformities. Specific problems amenable to management by this method are calcaneus fracture, isolated traumatic subtalar arthritis, middle facet tarsal coalition, and calcaneovalgus deformity, among others.
The surgical approach that we use for subtalar arthrodesis depends to some extent on the underlying pathology. Many of these procedures are performed for posttraumatic arthritis secondary to a calcaneus fracture. We generally use a standard incision across the sinus tarsi. In some cases, the patient has undergone multiple surgeries, and the incision is prone to dehiscence unless care is taken with the approach ( Fig. 29.1 ). If previous surgery has been performed, one can prefer to reopen the original incision for the open reduction with internal fixation (ORIF) procedure. Although use of the original incision is an option, considerable scarring will be encountered over the lateral calcaneus and peroneal tendons, and it is not as easy to reach the sinus tarsi and the more medial aspect of the subtalar joint through this route ( Fig. 29.2 ). However, the extensile exposure using the original incision has the advantage of good visualization of the lateral wall of the calcaneus, access to removal of hardware, and easy insertion of bone graft. We find that despite the difficulty of raising the flap, the skin heals well unless there has been an infection associated with the original procedure, in which case a small sinus tarsi incision is used ( Fig. 29.3 ). The more limited incision over the sinus tarsi heals well, with no risk for compromise of the intervening skin bridge between the sinus tarsi incision and the original more extensile lateral incision ( Fig. 29.4 ).
Subtalar arthrodesis procedures are of two basic types: (1) fusion performed in situ, without changing the orientation of the hindfoot and (2) a bone block arthrodesis with structural grafting to restore the height of the hindfoot. In addition to these two basic procedures, osteotomies of the calcaneus may be added to correct additional deformity. Beyond correction of the calcaneus and subtalar joint problems, other essential considerations include the condition of the peroneal tendons, which are frequently torn or dislocated, as well as the flexor hallucis longus and the soft tissues on the medial ankle, including the tibial nerve and its branches.
Complete exposure of the peroneal tendons and adequate subfibular decompression in patients with subtalar arthrodesis after calcaneus fracture are essential. Impingement in the subfibular recess is common, and the bone must always be removed regardless of the type of arthrodesis performed ( Fig. 29.5 ). The easiest way to determine that an adequate decompression has been performed is to make sure that the lateral wall of the calcaneus is slightly medial to the undersurface of the overhanging talus. After completion of the procedure, palpate the subfibular recess percutaneously to detect any persistent bone underneath the tip of the fibula.
The incision is made from the tip of the fibula extending distally down over the sinus tarsi toward the calcaneocuboid joint. On the inferior surface of the incision, the peroneal tendon sheath is identified, and more distally in the incision, the terminal branch of the sural nerve should be looked for. The nerve usually lies inferior to the peroneal tendons, but if the dissection extends more distally, the nerve can be at risk for injury ( ).
What incision should be used after a failed ORIF of a calcaneus fracture? Reuse of these extensile incisions for a subsequent elective arthrodesis procedure is typically problematic, and visualization of the entire joint can be limited because of scarring. Provided that 6 months has elapsed since the initial ORIF procedure, a standard sinus tarsi approach is far easier. With fractures treated initially with ORIF for which the hardware is still in place, two outcomes are possible: (1) either failure of the ORIF with widening and collapse of the subtalar joint, or (2) normal hindfoot anatomy with arthritis. In the first case, the hindfoot widens with collapse of the subtalar joint, and the hardware needs to be removed before the lateral wall ostectomy and arthrodesis are performed. In the second case, despite the arthritis, the overall architecture of the hindfoot has been maintained, and the hardware can be left in place. Fixation of the subtalar fusion can be a little more difficult here, but the larger screws for the arthrodesis can be inserted around the plate and original screws, as is done for a primary arthrodesis of the subtalar joint combined with ORIF for an acute fracture.
When the hardware removal is planned as a simultaneous procedure, the plate and screws should be removed percutaneously, assisted by fluoroscopic imaging, alternatively using an extensile approach as demonstrated in Fig. 29.3 . Each screw can be marked with a needle, and then a 2-mm puncture incision is made directly on top of the screw through the skin and then deepened through subcutaneous tissue with a hemostat, to avoid injury to the sural nerve. The plate can then be grasped with needle-nose pliers and then twisted out the front of the incision.
The retinaculum of the undersurface of the peroneal tendon sheath is stripped and elevated off the lateral wall of the calcaneus. Depending on the nature of the underlying disease, the peroneal tendons may be left in position or completely retracted if the lateral calcaneus has widened. After a calcaneus fracture, bone builds up laterally and squeezes the peroneal tendons into the fibula. To address this problem, the lateral wall of the calcaneus is completely exposed proximally toward and then posterior to the fibula, until the impingement against the lateral wall of the calcaneus is visible. A retractor is inserted into the soft tissue to pull the peroneal tendon sheath inferiorly and expose the entire lateral wall of the calcaneus. The peroneal tendons are frequently dislocated, either as a result of the original injury, the release of the retinaculum for exposure of the calcaneus, or impingement from untreated bone along the lateral wall causing subluxation of the tendons. A good example of this is demonstrated in . In general, the tendons will fall into place once the lateral wall ostectomy has been performed and the tissue bone that has built up under the tip of the fibula has been removed ( ). Alternatively, a groove-deepening procedure can be performed with a burr to relocate the tendons. If there is marked ankle instability from the injury or its subsequent treatment, then the split peroneus brevis tendon can be used to perform a modified Chrisman-Snook procedure, which then holds the remaining peroneal tendons in place.
For the lateral wall ostectomy, we use a 2-cm curved osteotome to remove a generous amount of bone to achieve complete exposure of the lateral aspect of the posterior facet of the subtalar joint and also remove the lateral impingement under the tip of the fibula. Slight irregularities are often present in the lateral wall of the calcaneus after this ostectomy, and the surface should be palpated through the skin to identify residual bone, which may be the source of pain. After completion of the ostectomy, the lateral margin of the posterior facet of the calcaneus should be slightly medial to the undersurface of the lateral margin of the talus. We preserve the resected bone and cut it up with a bone cutter into 5-mm fragments for later use as graft material ( Fig. 29.6 ).
