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Subtalar arthroscopic arthrodesis: Technique and outcomes
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FAS-877; No. of Pages 7 Foot and Ankle Surgery xxx (2015) xxx–xxx
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Subtalar arthroscopic arthrodesis: Technique and outcomes Jesu´s Vila´-Rico a,b,*, Marı´a Angeles Mellado-Romero a, Beatriz Bravo-Gime´nez a, Vero´nica Jime´nez-Dı´az a, Cristina Ojeda-Thies a a b
Hospital Universitario Doce de Octubre, Madrid, Spain Department of Surgery. Universidad Complutense, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 May 2015 Received in revised form 16 November 2015 Accepted 26 November 2015
Purpose: The goal of this study was to describe the surgical technique and our results with arthroscopic posterior subtalar arthrodesis. Material and Methods: Retrospective case series of 65 patients (38 men and 27 women) averaging 50 years of age (range 21–72 years) undergoing posterior arthroscopic subtalar arthrodesis using one or two percutaneous 6.5–7.3 mm screws between May 2004 and February 2011, with a mean follow-up of 57.5 months (range 24–105 months). Results: We achieved a 95.4% union rate after an average of 12.1 weeks (range 9 to 16 weeks). 12.3% of patients suffered complications, including superficial infection, nonunion and need for hardware removal. The AOFAS score improved from 51.5 points (19–61 points) preoperatively to 81.9 points (60– 94 points) in the postoperative period. Conclusions: We describe the surgical technique for arthroscopic subtalar arthrodesis, which as proven to be a safe and reliable technique in our experience, with consistent improvements in AOFAS scores. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Subtalar arthroscopic arthrodesis Hindfoot artrhroscopy
1. Introduction Subtalar arthrodesis is the fusion of the talo-calcaneal joint. Initially described by van Stockum [36] in 1912, Gallie later popularized it for the treatment of comminuted calcaneal fractures [16]. This procedure is performed to relieve pain during movement of the subtalar joint, and is indicated in patients suffering from posttraumatic osteoarthritis following fractures of the calcaneus or of the talus, or due to primary subtalar osteoarthritis, adultacquired flatfoot deformity (AAFD) with posterior tibial tendon dysfunction (PTTD), congenital deformities (i.e. tarsal coalitions), neuromuscular dysfunction or inflammatory disease. Open techniques entail the removal of periarticular ligaments and the potential of neurovascular injury and skin breakdown due to surgical dissection. Nonunion rates up to 30% have been reported among some patient subgroups, and bone graft is commonly used in order to improve chances of fusion [6,9,13,15,19,24,34,39].
* Corresponding author at: c/Alcalde Sainz de Baranda 29. 28. 28009 Madrid, Spain. Tel.: +34 619056447; fax: +34 914094413. E-mail address: [email protected] (J. Vila-Rico).
Minimally invasive techniques such as arthroscopic subtalar arthrodesis were developed to improve the results of traditional open methods, with the theoretical advantages of preserving the blood supply to the tarsus, reducing postoperative morbidity, and potentially preserving proprioception. The first cadavericdescription of subtalar joint arthroscopy corresponds to Parisien and Vangness in 1985 [32], and Tasto first described arthroscopic subtalar arthrodesis in 1992 [37]. Few investigators have published mid-term results of this technique, and the published series are limited to a small number of cases [1,2,5,11,14, 17,26,28,35]. The goal of our study was to report our midterm results with posterior arthroscopic subtalar arthrodesis with the patient in the prone position and without addition bone graft, and to compare our results with those previously published in the literature. 2. Material and methods We performed a retrospective review of prospectively captured data on all patients who had undergone posterior arthroscopic subtalar arthrodesis between May 2004 and February 2011. The same surgeon (JVR) performed all the procedures. Inclusion criteria were: (1) patients who underwent arthroscopic arthrodesis
http://dx.doi.org/10.1016/j.fas.2015.11.007 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Vila´-Rico J, et al. Subtalar arthroscopic arthrodesis: Technique and outcomes. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.11.007
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Fig. 1. Arthroscopic images of condral debridement and fixation with a 6.5 mm Synthes canulated screw.
performed by a posterior approach with fixation by means one or two 6.5 mm or 7.3 mm-diameter cannulated screws; (2) with a minimum 24 month clinical and radiological follow-up, and (3) without any other associated surgeries (i.e. calcaneal osteotomy, posterior tibial tendon procedures, etc.). Arthroscopic subtalar arthrodesis is indicated in symptomatic osteoarthritis without significant hindfoot malalignment. When treating sequelae of thalamic calcaneal fractures, if it was also necessary to act on the lateral wall, peroneal tendons, nerve entrapment syndromes or there was a significant articular depression with an increased tibiotalar angle, we opted to perform an open surgery with bone grafting. Sixty-five consecutive patients (38 males and 27 females) were included in this series. The mean age of the patients was 50 years (range 21 to 72 years). The average time elapsed from the onset of symptoms to the surgery was 17.3 months (range 9 to 43 months). 61.5% of the fusions were of the right and the 38.5% of the left hindfoot. The postoperative clinical and radiographic evaluation included union rate, time to union, postoperative complications, as well as the American Orthopedic Foot and Ankle Society (AOFAS) anklehindfoot score [25]. The six points for the subtalar motion were not assigned; the maximal score at final follow-up was 94 points. Criteria for clinical union included absence of pain or crepitation with ambulation, as well as lack of subtalar motion on examination. Radiographic follow-up was performed by lateral, oblique and Saltzman axial radiographic projection to assess mal-alignment in the frontal plane of the hindfoot. Fusion was defined as the appearance of osseous trabeculae across the subtalar arthrodesis area. A CT scan was performed to assess union or lack thereof in patients with persistent pain and lack of radiographic evidence of union. Average follow-up was 57.5 months (range 24 to 105 months). Routine descriptive statistics were used to describe the demographics, clinical characteristics, and functional and radiographic outcomes. When carrying out the bivariate analysis for the rest of variables, parametric and non-parametric tests were applied, depending on the nature of the variables being tested: Wilcoxon’s signed rank and Pearson’s tests or the paired Student’s t-test for continuous variables, and Fisher’s exact and Chi-square test for comparison of proportions. Multivariate analysis was performed using simple linear and multiple regression in order to assess whether any of the variables being studied were independently predictive of differences in AOFAS scores, union rate and complications. Statistical significance was set at an alpha error of p> 0,05. We also performed a literature search in MEDLINE and EMBASE databases, using the keywords ‘‘subtalar’’, ‘‘tarsal’’, ‘‘arthrodesis’’, ‘‘arthroscopy’’ and ‘‘talocalcaneal’’ ‘‘hindfoot’’, to compare our results with and review the most relevant previously published case series.
3. Surgical technique Arthroscopic posterior arthrodesis of the subtalar joint was performed under intradural anesthesia in the prone position, after
applying a pneumatic tourniquet to the thigh, and a small support to the leg, allowing for free movement of the ankle. We did not apply any distraction or previous distension of the joint. The joint was accessed through two posterior endoscopic portals as described by van Dijk [12] [33], using a 4.5 mm 308 arthroscope.The posterolateral portal was performed first through a vertical incision just lateral to the Achilles tendon and in line with a plane parallel to the sole of the foot that crossed the tip of the lateral malleolus. The posteromedial portal was then performed at the medial aspect of the Achilles tendon under direct view through the scope placed in the posterolateral portal, ‘‘travelling’’ a mosquito clamp along the shaft of the scope until reaching the subtalar joint. It is important to create the portals in this standardized fashion in order to avoid injury to the posterior tibial neurovascular bundle. The medial limit of the ‘‘safe area’’ is the flexor halluces longus tendon. The subtalar joint was debrided with a 3.5 mm shaver and burr until it was possible to identify the structures of the sinus tarsi (cervical and interosseous ligaments). Occasionally, a third portal was performed at the sinus tarsi as described by van Dijk [3] in order to improve the view of the anterior margin of the posterior subtalar joint. The structures of the sinus tarsi mark the anterior limit of the posterior subtalar joint. After debriding the joint surfaces until subchondral bone was exposed, we proceeded to fuse the joint using one or two parallel 6.5 mm to 7.3 mm cannulated screws that crossed the most anterior part of the posterior subtalar joint in a calcaneo-talar direction (Fig. 1). It is important to achieve perfect coaptation to ensure joint fusion; joint compression can be visualized directly through the arthroscope as it is retreated while inserting the screws. The type and number of screws were decided by the surgeon, depending on screw purchase during placement and bone quality. Bone graft was not used in any cases. Postoperative management usually comprised three weeks of immobilization in a posterior ankle splint, followed by progressive partial weight-bearing protected by crutches and a walker type ankle-foot orthosis, until allowing complete and unprotected weight-bearing after 8–12 weeks.
4. Results Patient characteristics and results are summarized in Table 1. Most fusions were indicated in patients with posttraumatic arthritis due to sequelae of thalamic fractures of the calcaneus (37 cases, 56.9%). Patients with adult acquired flatfoot deformity with PTTD (24 cases, 36.9%) made up the second largest group. Four patients were treated for primary isolated subtalar osteoarthritis (OA) (6.2%). Patients with posttraumatic arthritis tended to be younger (38.2 years) and predominantly male (97.3%). Twelve of the thirty-seven patients with posttraumatic arthritis had had previous internal fixation of the hindfoot; none of the patients of the other etiologic groups had had prior surgeries. Six patients (9.6%) had a preoperative valgus greater than 108, while the other 59 patients had no preoperative hindfoot malalignment.
Please cite this article in press as: Vila´-Rico J, et al. Subtalar arthroscopic arthrodesis: Technique and outcomes. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.11.007
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Table 1 Patient characteristics and summary of results. Variable
Total group (n = 65)
Age (mean SD) Sex (n, %) Diagnosis (n, %) Primary OA AAFD Posttraumatic AOFAS score (mean SD) Preoperative Postoperative Union (n, %) Time to union (mean SD) Complications (n, %) Superficial infection Hardware issues Nonunion
50.0 15.6 years 38 (58.5%) male 4 (6.2%) 24 (36.9%) 37 (56.9%) 51.5 9.5 points 81.7 9.7 points 62 (95.4%) 11.2 1.5 months 8 (12.3%) 1 (1.5%) 5 (7.0%) 3 (4.6%)
Union was achieved in 62 patients (95.4%) (Fig. 2), after an average of 11.2 weeks (range 9 to 16 weeks). Repeat surgery was necessary in order to achieve fusion in the remaining three patients, arthroscopically in one case and using open technique in the other two cases. No statistic correlation was observed between union rates or time to union and age, indication for surgery, existence of previous internal fixation surgeries, or type of fixation for arthrodesis. AOFAS scores significantly improved from 51.5 points preoperatively (range 19–61) to 81.7 points postoperatively (range 60–94) (p < 0,001) (Fig. 3). Improvement was significantly larger for patients with adult acquired flatfoot deformity than for patients with posttraumatic arthritis (mean improvement in AOFAS scores: 34.9 7.4 points for the AAFD group vs. 27.0 9.1 points for the posttraumatic arthritis group; p < 0.001); multivariate analysis showed that this was regardless of age and gender. However, the scores did not correlate with the presence of
Fig. 3. Box- and whisker plots for the preoperative and postoperative AOFAS scores.
previous surgeries or the type of fixation used for arthrodesis, nor with the degree of preoperative hindfoot valgus. Nine patients (13.8%) suffered complications: 1 patient had a superficial wound infection that resolved with antibiotics, union was not achieved in 3 patients (Fig. 4), and the hardware was removed in another 5 patients due to irritation of the posterior screw heads (4 patients) or tibio-talar joint penetration (1 patient, Fig. 5). No patients in our series suffered deep infection, screw breakage or neuromas, nor any significant postoperative malalignment of the fused joints, as assessed clinically and by plain weightbearing radiographs. Two of the three patients that suffered
Fig. 2. A 57 years female with primary osteoarthritis. Preoperative and postoperative X ray and CT images of the fusion.
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Fig. 4. Screw placed in the tibiotalar joint.
nonunion were smokers. All three nonunions occurred in patients who had suffered a calcaneal fracture. 5. Discussion Posttraumatic arthritis, instability, hindfoot misalignment, inflammatory and congenital disorders can all lead to pain in the subtalar joint. Isolated posterior subtalar arthrodesis is the method of choice for treating this condition, if the other joints are not affected. Its main objective is to eliminate pain and to allow for more mobility and less morbidity than with other procedures, such as a triple arthrodesis [38]. The overall reported results of open subtalar arthrodesis have been satisfactory and are summarized in Table 2. One of the most feared complications of arthrodesis is poor fusion, with many surgeons preferring open approaches to ensure adequate debridement of all the affected joint surfaces. However, large disturbances to the soft tissues pose a high risk in many of these patients, who may have scars from previous surgeries or vascular issues due to underlying issues such as chronic smoking or diabetes. Nonunion rates have been reported to be as high as 30% among smokers [6,13], and
Fig. 5. No consolidation in a sequale of intratalamic calcaneal fracture case.
diabetics were seen to have a significantly higher risk for malunion [6]. Soft tissue problems and infection rates are also relatively common following open surgery; a recent literature review by Tuijdthof reported a 10% weighted rate of damage to neurovascular structures and a 5% wound infection rate [38]. Many authors advocate using bone graft to aid fusion and avoid malunion by increasing bone-to-bone contact surface; though some authors found no differences whether using additional bone graft or not [13], Chahal [6] reported a tendency towards an increased union rate when bone graft was used; however, this tendency was statistically nonsignificant due to insufficient power of the study. Most autografts are harvested from the iliac crest or the proximal tibia, this entails additional surgery and morbidity at the donor site. Currently, there is insufficient evidence to support the need for bone graft, nor regarding the number or configuration of the screws needed to achieve fusion, either [7,18,22]. Recent innovations in surgical techniques have tended towards less invasive approaches, allowing for a quicker recovery and hypothetically better results due to reduced soft tissue injury. Reduced vascular damage to the hindfoot could also promote fusion, reducing the dependency on bone graft to promote union. Regarding union rate and complications, the outcomes of arthroscopic subtalar arthrodesis are excellent (Table 3). Cadaveric studies have proven that the entire posterior subtalar joint is accessible through posterior portals [20,27,31,33], though arthroscopic arthrodesis is technically more demanding than open surgery. There are few comparative studies of open and arthroscopic arthrodesis, but all of them found that the arthroscopic technique achieved a quicker union, with a lower complication rate [35]. When we analyzed the published literature, we found an overall union rate ranging from 91–100% after an average of 7–11 weeks. Postoperative AOFAS scores also tended to be slightly higher among patients treated arthroscopically than with open procedures. In contrast with reports of open subtalar arthrodesis, many of the published series of arthroscopic subtalar arthrodesis did not use bone graft, as was the case in our series. In cases where if it was also necessary to act on the lateral wall or the peroneal tendons, with nerve entrapment syndromes, or if there was a significant articular depression following a malunited thalamic calcaneal fracture, we opted to perform an open surgery with bone grafting. Although it is difficult to accurately determine the exact moment of union, our results are comparable to those published, with a rate of 95.39% after and average of 11.2 weeks (range 9 to 16 weeks), and with an acceptable complication rate; most complications in our series were minor and related to hardware issues (7.7%). Hardware-related issues are a common problem in this procedure, with a weighted incidence of up to 16–18% depending on the surgical indication, according to Tuijthof [38], though some authors had to remove hardware in up to 27% of their patients [11]. A meticulous technique when inserting the screws minimizes the rate of complications and the need for implant removal. Bioabsorbable implants could reduce the need of repeat surgeries for hardware removal, although the fixation achieved may not be as stable as with conventional screws, and union rates could be affected. To our knowledge, this is the largest case series reported so far of arthroscopic subtalar arthrodesis, and it has the longest average follow-up. In our series, we consistently achieved subtalar fusion and improvement in AOFAS scores; patient satisfaction remained high even among patients followed for more than 5 years. Among the strengths of our study is its internal validity, as all cases included were consecutive surgeries performed by a single surgeon (JVR), and data collection was performed in a structured,
Please cite this article in press as: Vila´-Rico J, et al. Subtalar arthroscopic arthrodesis: Technique and outcomes. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.11.007
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Table 2 Reported results of open subtalar arthrodesis NR: Not reported. Preop: Preoperative. Postop: Postoperative. Series
Number of cases
Follow-up, (mean, range)
Bone graft
Fixation
AOFAS score
Results
Russoti (1988) [34] Dahm (1997) [9] (posttraumatic) Mann (1998) [30]
45
57 months (30–96)
45/45 (iliac crest)
Pins/screw
NR
25
4 years (2-6) 59.5 months
10/25 (iliac crest)
1 screw
NR
83/86 (local, iliac crest, allograft) 145/184 (cancellous/ structural autograft/allograft)
2 screws
Postop: 75 (21–94)
97.8% union 4.4% complication 96% union 8% complication 100% union 12.5% complication 96% union 11.6% complication
1 or 2 screws
Preop. 24 (22–69) Postop 70 (41–94)
101/101 (local)
1 screw
NR
48
Postop 89
Flemister (2000) [15] (posttraumatic)
86
Minimum 24 months
Easley (2000) [13]
184
51 months (24–130)
Haskell (2004) [19]
101
Chahal (2006) [6]
88
35.5 months (10–83)
47/88 (local/iliac crest)
1 or 2 screws
NR
Joveniaux (2010) [24]
28
56 months (20-115)
26/28 (iliac crest, substitute, allograft)
1 or 2 staples
76.5 (36–94)
Lo´pez-Oliva (2010) [29] (percutaneous technique) Carranza (2013) [4] (MIS technique)
37
33 months (12–60)
None
VIRA 1 device
75.43 (SD 14.1)
77
50 months (15-108
None
1 or 2 screws
Preop 26.9 (SD 8.6) Postop 74.5 (SD 13.3)
Yavuz (2014) [39] (posttraumatic)
21
43 months (21–83)
11/20 (8 iliac crest/3 allograft)
2 screws
Herrera-Pe´rez (2015) [21]
33
42.7 months (24.5-84.3)
None
2 screws/staples
Preop 61.7 (40– 67) Postop 84.2 (65–94) Preop 54.1 (33– 69) Postop 84.8 (71–91)
prospective manner, without loss of cases due to incomplete data or loss of follow-up. We also recognize several flaws of our study. Nonunion has been seen to be more common among diabetics and smokers [6]. Two of the three patients who suffered nonunion were smokers; data was incomplete regarding the total number of smokers and diabetics in our series, so these variables could not be included for statistical analysis. Patients with several diagnoses were included in the case series; however, we believe our case mix represents most patients treated for subtalar arthritis, and the aim of our study was to analyze our overall results and contrast them with those previously published in the
84% union (73% in smokers, 71% in avascular necrosis and revision surgeries). 96% union rate without associated risk factors. Complications: 20% hardware removal, 9% sural nerve injury, 3% infection, 10% lateral impingement, 6% hindfoot malalignment) 98% union (12.3 weeks) No difference between smokers and nonsmokers. 13% hardware removal 95% with bone graft, 65% without bone graft 90% nonsmokers, 68% smokers 100% union No malalignment 43–65% midfoot arthritis 100% union 31 good/excellent results; 1 reoperation (addition of bone graft) Union 92.2% Hardware protrusion 15.5%
95% union 2 infection, 2 complex regional pain sı´ndrome, 1 hardware removal 87.9% union rate 9.1% need for hardware removal
literature. Furthermore, we based our estimation on achievement of fusion on clinical parameters and standard radiographs during the follow-up visits, as have most of the authors in previously published series [10,13,17,21]. Jones found that plain radiographs could be misleading and believed that a CT scan provided a much more accurate assessment of union [8,23]. It would be ideal to perform a CT scan to confirm union in all patients; however, this would expose a large number of patients to unnecessary expenses and radiation. Consequently, we only performed a CT scan in patients with persistent pain or without evidence of fusion on plain radiographs, as proposed by Davies [10].
Please cite this article in press as: Vila´-Rico J, et al. Subtalar arthroscopic arthrodesis: Technique and outcomes. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.11.007
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Table 3 Reported results of arthroscopic subtalar arthrodesis NR: Not reported. Preop: Preoperative. Postop: Postoperative. Series
Number of cases
Follow-up (months)
Bone graft
Fixation
AOFAS score (points)
Tasto (2003) [37] Glanzmann (2007) [17]
25 41 (85% posttraumatic)
55 months (24–89)
41/41 (proximal tibia)
1 screw
Preop. 53 (22–69) Postop. 84 (41–94)
Amendola (2007) [2]
11
34 months (24–48)
11/11 (cancellous)
2 screws
Carro (2007) [5] Diezi (2008) [11]
4 15
NR
NR
NR
Preop.36 (19–57) Postop. 86 (78–94) NR
El Shazly (2009) [14] Posttraumatic
10
28.4 months (24–32)
None
1 screw
Liu (2009) [28]
38
45 months (21–110)
Lee (2010) [26]
16
30 months (20–46)
NR
2 screws
Albert (2011) [1]
10
21.5 months (12–31)
9/10 (autologous)
1 or 2 screws
Vila´ y Rico (2015) Current series
65
57.54 months (24–105)
None
1 or 2 screws
Preop. 38 Postop 74
Pre 48.3 Post 79.2
6. Conclusion Arthroscopic subtalar arthrodesis has proven to offer at least similar results, and may achieve higher rates of fusion and lower complication rates than open techniques. We prove it is a safe and reliable procedure, provided surgical technique is carefully followed. It provides a high union rate without needing supplementation by bone graft, with an acceptable rate of complications. AOFAS scores improved significantly in all of our patients, and patient satisfaction was high even among patients followed for more than five years. Ethical Approval For this type of study, formal consent is not required. Conflicts of interest The authors have no conflicts of interest to disclose. None of the authors has any conflict of interest to disclose. No benefits in any form have been received or will be received by the authors from a commercial party, directly or indirectly, related to the subject herein. References [1] Albert A, Deleu P-A, Leemrijse T, Maldague P, Devos Bevernage B. Posterior arthroscopic subtalar arthrodesis: Ten cases at one-year follow-up. Orthop Traumatol Surg Res 2011;97:401–5. [2] Amendola A, Lee K-B, Saltzman CL, Suh J-S. Technique and early experience with posterior arthroscopic subtalar arthrodesis. Foot Ankle Int 2007;28: 298–302.
Preop 35 (24–45) Postop 84 (71–94) Preop 47 (22–65) Postop 78 (60–91) Preop. 51.5 (19–61) Postop. 81.7 (60–94)
Results 100% union (8.9 weeks) 100% union (11 weeks (7–36)) Degeneration of neighboring joints (7.31%) 91% union (10 weeks) 100% union (8 weeks) 93.3% union 4/15 (27%) hardware removal; symptomatic talonavicular arthritis Significant improvement of pain and distance walked. Union at 11.44 weeks. 1 painful neuroma anterolaeral portal 92% union (35/38) 2 skin necrosis, 1 Drop foot 94% union (11 weeks) 100% union (6.8 weeks) 2 lateral submalleolar impingement 95.4% union (11.2 weeks) 12.9% complication rate (3/65 nonunion; 5/65 need for hardware removal)
[3] Beimers L, de Leeuw PAJ, van Dijk CN. A 3-portal approach for arthroscopic subtalar arthrodesis. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 2009;17:830–4. [4] Carranza-Bencano A, Tejero-Garcı´a S, Del Castillo-Blanco G, Ferna´ndez-Torres JJ, Alegrete-Parra A. Isolated subtalar arthrodesis through minimal incision surgery. Foot Ankle Int 2013;34:1117–27. [5] Carro LP, Golano´ P, Vega J. Arthroscopic Subtalar Arthrodesis: The Posterior Approach in the Prone Position. Arthrosc J Arthrosc Relat Surg 2007;23: e1-445–4-445. [6] Chahal J, Stephen DJG, Bulmer B, Daniels T, Kreder HJ. Factors associated with outcome after subtalar arthrodesis. J Orthop Trauma 2006;20:555–61. [7] Chuckpaiwong B, Easley ME, Glisson RR. Screw placement in subtalar arthrodesis: a biomechanical study. Foot Ankle Int 2009;30:133–41. [8] Coughlin MJ, Grimes JS, Traughber PD, Jones CP. Comparison of radiographs and CT scans in the prospective evaluation of the fusion of hindfoot arthrodesis. Foot Ankle Int 2006;27:780–7. [9] Dahm DL, Kitaoka HB. Subtalar arthrodesis with internal compression for posttraumatic arthritis. J Bone Joint Surg Br 1998;80:134–8. [10] Davies MB, Rosenfeld PF, Stavrou P, Saxby TS. A comprehensive review of subtalar arthrodesis. Foot Ankle Int 2007;28:295–7. [11] Diezi C, Favre P, Vienne P. Primary isolated subtalar arthrodesis: outcome after 2 to 5 years followup. Foot Ankle Int 2008;29:1195–202. [12] Van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthrosc J Arthrosc Relat Surg 2000;16:871–6. [13] Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613–24. [14] El Shazly O, Nassar W, El Badrawy A. Arthroscopic subtalar fusion for post-traumatic subtalar arthritis. Arthrosc J Arthrosc Relat Surg 2009;25:783–7. [15] Flemister AS, Infante AF, Sanders RW, Walling AK. Subtalar arthrodesis for complications of intra-articular calcaneal fractures. Foot Ankle Int 2000;21:392–9. [16] Gallie WE. Subastragalar arthrodesis in fractures of the os calcis. J Bone Jt Surg 1943;25:731–6. [17] Glanzmann MC, Sanhueza-Hernandez R. Arthroscopic subtalar arthrodesis for symptomatic osteoarthritis of the hindfoot: a prospective study of 41 cases. Foot Ankle Int 2007;28:2–7. [18] Gosch C, Verrette R, Lindsey DP, Beaupre´ GS, Lehnert B. Comparison of initial compression force across the subtalar joint by two different screw fixation techniques. J Foot Ankle Surg 2006;45:168–73.
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FAS-877; No. of Pages 7 J. Vila´-Rico et al. / Foot and Ankle Surgery xxx (2015) xxx–xxx [19] Haskell A, Pfeiff C, Mann R. Subtalar joint arthrodesis using a single lag screw. Foot Ankle Int 2004;25:774–7. [20] Hendrickx RPM, de Leeuw PAJ, Golano P, van Dijk CN, Kerkhoffs GMMJ. Safety and efficiency of posterior arthroscopic ankle arthrodesis Knee Surg. Sports Traumatol. Arthrosc Off J ESSKA; 2014. ˜ uelos C, Barg A, Wiewiorski M, Valderrabano V, [21] Herrera-Pe´rez M, Andarcia-Ban Kapron AL, De Bergua-Domingo JM, Pais-Brito JL. Comparison of cannulated screws versus compression staples for subtalar arthrodesis fixation. Foot Ankle Int 2015;36:203–10. [22] Hintermann B, Valderrabano V, Nigg B. Influence of screw type on obtained contact area and contact force in a cadaveric subtalar arthrodesis model. Foot Ankle Int 2002;23:986–91. [23] Jones CP, Coughlin MJ, Shurnas PS. Prospective CT, scan evaluation of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int 2006;27:229–35. [24] Joveniaux P, Harisboure A, Ohl X, Dehoux E. Long-term results of in situ subtalar arthrodesis. Int Orthop 2010;34:1199–205. [25] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–53. [26] Lee K-B, Park C-H, Seon J-K, Kim M-S. Arthroscopic subtalar arthrodesis using a posterior 2-portal approach in the prone position. Arthrosc J Arthrosc Relat Surg 2010;26:230–8. [27] Lintz F, Guillard C, Colin F, Marchand J-B, Brilhault J. Safety and efficiency of a 2-portal lateral approach to arthroscopic subtalar arthrodesis: a cadaveric study. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2013;29:1217–23. [28] Liu H, Duan S, Liu S, Xie X, Luan T, Li L, Bu J, Zhao X. Trephine arthrodesis of subtalar joints: operative technique and clinical effect. Chin J Traumatol Zhonghua Chuang Shang Za Zhi Chin Med Assoc 2009;12:218–22. [29] Lo´pez-Oliva F, Sa´nchez-Lorente T, Fuentes-Sanz A, Forriol F, Aldomar-Sanz Y. Primary fusion in worker’s compensation intraarticular calcaneus
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Subtalar arthroscopic arthrodesis: Technique and outcomes Jesu´s Vila´-Rico a,b,*, Marı´a Angeles Mellado-Romero a, Beatriz Bravo-Gime´nez a, Vero´nica Jime´nez-Dı´az a, Cristina Ojeda-Thies a a b
Hospital Universitario Doce de Octubre, Madrid, Spain Department of Surgery. Universidad Complutense, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 May 2015 Received in revised form 16 November 2015 Accepted 26 November 2015
Purpose: The goal of this study was to describe the surgical technique and our results with arthroscopic posterior subtalar arthrodesis. Material and Methods: Retrospective case series of 65 patients (38 men and 27 women) averaging 50 years of age (range 21–72 years) undergoing posterior arthroscopic subtalar arthrodesis using one or two percutaneous 6.5–7.3 mm screws between May 2004 and February 2011, with a mean follow-up of 57.5 months (range 24–105 months). Results: We achieved a 95.4% union rate after an average of 12.1 weeks (range 9 to 16 weeks). 12.3% of patients suffered complications, including superficial infection, nonunion and need for hardware removal. The AOFAS score improved from 51.5 points (19–61 points) preoperatively to 81.9 points (60– 94 points) in the postoperative period. Conclusions: We describe the surgical technique for arthroscopic subtalar arthrodesis, which as proven to be a safe and reliable technique in our experience, with consistent improvements in AOFAS scores. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Subtalar arthroscopic arthrodesis Hindfoot artrhroscopy
1. Introduction Subtalar arthrodesis is the fusion of the talo-calcaneal joint. Initially described by van Stockum [36] in 1912, Gallie later popularized it for the treatment of comminuted calcaneal fractures [16]. This procedure is performed to relieve pain during movement of the subtalar joint, and is indicated in patients suffering from posttraumatic osteoarthritis following fractures of the calcaneus or of the talus, or due to primary subtalar osteoarthritis, adultacquired flatfoot deformity (AAFD) with posterior tibial tendon dysfunction (PTTD), congenital deformities (i.e. tarsal coalitions), neuromuscular dysfunction or inflammatory disease. Open techniques entail the removal of periarticular ligaments and the potential of neurovascular injury and skin breakdown due to surgical dissection. Nonunion rates up to 30% have been reported among some patient subgroups, and bone graft is commonly used in order to improve chances of fusion [6,9,13,15,19,24,34,39].
* Corresponding author at: c/Alcalde Sainz de Baranda 29. 28. 28009 Madrid, Spain. Tel.: +34 619056447; fax: +34 914094413. E-mail address: [email protected] (J. Vila-Rico).
Minimally invasive techniques such as arthroscopic subtalar arthrodesis were developed to improve the results of traditional open methods, with the theoretical advantages of preserving the blood supply to the tarsus, reducing postoperative morbidity, and potentially preserving proprioception. The first cadavericdescription of subtalar joint arthroscopy corresponds to Parisien and Vangness in 1985 [32], and Tasto first described arthroscopic subtalar arthrodesis in 1992 [37]. Few investigators have published mid-term results of this technique, and the published series are limited to a small number of cases [1,2,5,11,14, 17,26,28,35]. The goal of our study was to report our midterm results with posterior arthroscopic subtalar arthrodesis with the patient in the prone position and without addition bone graft, and to compare our results with those previously published in the literature. 2. Material and methods We performed a retrospective review of prospectively captured data on all patients who had undergone posterior arthroscopic subtalar arthrodesis between May 2004 and February 2011. The same surgeon (JVR) performed all the procedures. Inclusion criteria were: (1) patients who underwent arthroscopic arthrodesis
http://dx.doi.org/10.1016/j.fas.2015.11.007 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Vila´-Rico J, et al. Subtalar arthroscopic arthrodesis: Technique and outcomes. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.11.007
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Fig. 1. Arthroscopic images of condral debridement and fixation with a 6.5 mm Synthes canulated screw.
performed by a posterior approach with fixation by means one or two 6.5 mm or 7.3 mm-diameter cannulated screws; (2) with a minimum 24 month clinical and radiological follow-up, and (3) without any other associated surgeries (i.e. calcaneal osteotomy, posterior tibial tendon procedures, etc.). Arthroscopic subtalar arthrodesis is indicated in symptomatic osteoarthritis without significant hindfoot malalignment. When treating sequelae of thalamic calcaneal fractures, if it was also necessary to act on the lateral wall, peroneal tendons, nerve entrapment syndromes or there was a significant articular depression with an increased tibiotalar angle, we opted to perform an open surgery with bone grafting. Sixty-five consecutive patients (38 males and 27 females) were included in this series. The mean age of the patients was 50 years (range 21 to 72 years). The average time elapsed from the onset of symptoms to the surgery was 17.3 months (range 9 to 43 months). 61.5% of the fusions were of the right and the 38.5% of the left hindfoot. The postoperative clinical and radiographic evaluation included union rate, time to union, postoperative complications, as well as the American Orthopedic Foot and Ankle Society (AOFAS) anklehindfoot score [25]. The six points for the subtalar motion were not assigned; the maximal score at final follow-up was 94 points. Criteria for clinical union included absence of pain or crepitation with ambulation, as well as lack of subtalar motion on examination. Radiographic follow-up was performed by lateral, oblique and Saltzman axial radiographic projection to assess mal-alignment in the frontal plane of the hindfoot. Fusion was defined as the appearance of osseous trabeculae across the subtalar arthrodesis area. A CT scan was performed to assess union or lack thereof in patients with persistent pain and lack of radiographic evidence of union. Average follow-up was 57.5 months (range 24 to 105 months). Routine descriptive statistics were used to describe the demographics, clinical characteristics, and functional and radiographic outcomes. When carrying out the bivariate analysis for the rest of variables, parametric and non-parametric tests were applied, depending on the nature of the variables being tested: Wilcoxon’s signed rank and Pearson’s tests or the paired Student’s t-test for continuous variables, and Fisher’s exact and Chi-square test for comparison of proportions. Multivariate analysis was performed using simple linear and multiple regression in order to assess whether any of the variables being studied were independently predictive of differences in AOFAS scores, union rate and complications. Statistical significance was set at an alpha error of p> 0,05. We also performed a literature search in MEDLINE and EMBASE databases, using the keywords ‘‘subtalar’’, ‘‘tarsal’’, ‘‘arthrodesis’’, ‘‘arthroscopy’’ and ‘‘talocalcaneal’’ ‘‘hindfoot’’, to compare our results with and review the most relevant previously published case series.
3. Surgical technique Arthroscopic posterior arthrodesis of the subtalar joint was performed under intradural anesthesia in the prone position, after
applying a pneumatic tourniquet to the thigh, and a small support to the leg, allowing for free movement of the ankle. We did not apply any distraction or previous distension of the joint. The joint was accessed through two posterior endoscopic portals as described by van Dijk [12] [33], using a 4.5 mm 308 arthroscope.The posterolateral portal was performed first through a vertical incision just lateral to the Achilles tendon and in line with a plane parallel to the sole of the foot that crossed the tip of the lateral malleolus. The posteromedial portal was then performed at the medial aspect of the Achilles tendon under direct view through the scope placed in the posterolateral portal, ‘‘travelling’’ a mosquito clamp along the shaft of the scope until reaching the subtalar joint. It is important to create the portals in this standardized fashion in order to avoid injury to the posterior tibial neurovascular bundle. The medial limit of the ‘‘safe area’’ is the flexor halluces longus tendon. The subtalar joint was debrided with a 3.5 mm shaver and burr until it was possible to identify the structures of the sinus tarsi (cervical and interosseous ligaments). Occasionally, a third portal was performed at the sinus tarsi as described by van Dijk [3] in order to improve the view of the anterior margin of the posterior subtalar joint. The structures of the sinus tarsi mark the anterior limit of the posterior subtalar joint. After debriding the joint surfaces until subchondral bone was exposed, we proceeded to fuse the joint using one or two parallel 6.5 mm to 7.3 mm cannulated screws that crossed the most anterior part of the posterior subtalar joint in a calcaneo-talar direction (Fig. 1). It is important to achieve perfect coaptation to ensure joint fusion; joint compression can be visualized directly through the arthroscope as it is retreated while inserting the screws. The type and number of screws were decided by the surgeon, depending on screw purchase during placement and bone quality. Bone graft was not used in any cases. Postoperative management usually comprised three weeks of immobilization in a posterior ankle splint, followed by progressive partial weight-bearing protected by crutches and a walker type ankle-foot orthosis, until allowing complete and unprotected weight-bearing after 8–12 weeks.
4. Results Patient characteristics and results are summarized in Table 1. Most fusions were indicated in patients with posttraumatic arthritis due to sequelae of thalamic fractures of the calcaneus (37 cases, 56.9%). Patients with adult acquired flatfoot deformity with PTTD (24 cases, 36.9%) made up the second largest group. Four patients were treated for primary isolated subtalar osteoarthritis (OA) (6.2%). Patients with posttraumatic arthritis tended to be younger (38.2 years) and predominantly male (97.3%). Twelve of the thirty-seven patients with posttraumatic arthritis had had previous internal fixation of the hindfoot; none of the patients of the other etiologic groups had had prior surgeries. Six patients (9.6%) had a preoperative valgus greater than 108, while the other 59 patients had no preoperative hindfoot malalignment.
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Table 1 Patient characteristics and summary of results. Variable
Total group (n = 65)
Age (mean SD) Sex (n, %) Diagnosis (n, %) Primary OA AAFD Posttraumatic AOFAS score (mean SD) Preoperative Postoperative Union (n, %) Time to union (mean SD) Complications (n, %) Superficial infection Hardware issues Nonunion
50.0 15.6 years 38 (58.5%) male 4 (6.2%) 24 (36.9%) 37 (56.9%) 51.5 9.5 points 81.7 9.7 points 62 (95.4%) 11.2 1.5 months 8 (12.3%) 1 (1.5%) 5 (7.0%) 3 (4.6%)
Union was achieved in 62 patients (95.4%) (Fig. 2), after an average of 11.2 weeks (range 9 to 16 weeks). Repeat surgery was necessary in order to achieve fusion in the remaining three patients, arthroscopically in one case and using open technique in the other two cases. No statistic correlation was observed between union rates or time to union and age, indication for surgery, existence of previous internal fixation surgeries, or type of fixation for arthrodesis. AOFAS scores significantly improved from 51.5 points preoperatively (range 19–61) to 81.7 points postoperatively (range 60–94) (p < 0,001) (Fig. 3). Improvement was significantly larger for patients with adult acquired flatfoot deformity than for patients with posttraumatic arthritis (mean improvement in AOFAS scores: 34.9 7.4 points for the AAFD group vs. 27.0 9.1 points for the posttraumatic arthritis group; p < 0.001); multivariate analysis showed that this was regardless of age and gender. However, the scores did not correlate with the presence of
Fig. 3. Box- and whisker plots for the preoperative and postoperative AOFAS scores.
previous surgeries or the type of fixation used for arthrodesis, nor with the degree of preoperative hindfoot valgus. Nine patients (13.8%) suffered complications: 1 patient had a superficial wound infection that resolved with antibiotics, union was not achieved in 3 patients (Fig. 4), and the hardware was removed in another 5 patients due to irritation of the posterior screw heads (4 patients) or tibio-talar joint penetration (1 patient, Fig. 5). No patients in our series suffered deep infection, screw breakage or neuromas, nor any significant postoperative malalignment of the fused joints, as assessed clinically and by plain weightbearing radiographs. Two of the three patients that suffered
Fig. 2. A 57 years female with primary osteoarthritis. Preoperative and postoperative X ray and CT images of the fusion.
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Fig. 4. Screw placed in the tibiotalar joint.
nonunion were smokers. All three nonunions occurred in patients who had suffered a calcaneal fracture. 5. Discussion Posttraumatic arthritis, instability, hindfoot misalignment, inflammatory and congenital disorders can all lead to pain in the subtalar joint. Isolated posterior subtalar arthrodesis is the method of choice for treating this condition, if the other joints are not affected. Its main objective is to eliminate pain and to allow for more mobility and less morbidity than with other procedures, such as a triple arthrodesis [38]. The overall reported results of open subtalar arthrodesis have been satisfactory and are summarized in Table 2. One of the most feared complications of arthrodesis is poor fusion, with many surgeons preferring open approaches to ensure adequate debridement of all the affected joint surfaces. However, large disturbances to the soft tissues pose a high risk in many of these patients, who may have scars from previous surgeries or vascular issues due to underlying issues such as chronic smoking or diabetes. Nonunion rates have been reported to be as high as 30% among smokers [6,13], and
Fig. 5. No consolidation in a sequale of intratalamic calcaneal fracture case.
diabetics were seen to have a significantly higher risk for malunion [6]. Soft tissue problems and infection rates are also relatively common following open surgery; a recent literature review by Tuijdthof reported a 10% weighted rate of damage to neurovascular structures and a 5% wound infection rate [38]. Many authors advocate using bone graft to aid fusion and avoid malunion by increasing bone-to-bone contact surface; though some authors found no differences whether using additional bone graft or not [13], Chahal [6] reported a tendency towards an increased union rate when bone graft was used; however, this tendency was statistically nonsignificant due to insufficient power of the study. Most autografts are harvested from the iliac crest or the proximal tibia, this entails additional surgery and morbidity at the donor site. Currently, there is insufficient evidence to support the need for bone graft, nor regarding the number or configuration of the screws needed to achieve fusion, either [7,18,22]. Recent innovations in surgical techniques have tended towards less invasive approaches, allowing for a quicker recovery and hypothetically better results due to reduced soft tissue injury. Reduced vascular damage to the hindfoot could also promote fusion, reducing the dependency on bone graft to promote union. Regarding union rate and complications, the outcomes of arthroscopic subtalar arthrodesis are excellent (Table 3). Cadaveric studies have proven that the entire posterior subtalar joint is accessible through posterior portals [20,27,31,33], though arthroscopic arthrodesis is technically more demanding than open surgery. There are few comparative studies of open and arthroscopic arthrodesis, but all of them found that the arthroscopic technique achieved a quicker union, with a lower complication rate [35]. When we analyzed the published literature, we found an overall union rate ranging from 91–100% after an average of 7–11 weeks. Postoperative AOFAS scores also tended to be slightly higher among patients treated arthroscopically than with open procedures. In contrast with reports of open subtalar arthrodesis, many of the published series of arthroscopic subtalar arthrodesis did not use bone graft, as was the case in our series. In cases where if it was also necessary to act on the lateral wall or the peroneal tendons, with nerve entrapment syndromes, or if there was a significant articular depression following a malunited thalamic calcaneal fracture, we opted to perform an open surgery with bone grafting. Although it is difficult to accurately determine the exact moment of union, our results are comparable to those published, with a rate of 95.39% after and average of 11.2 weeks (range 9 to 16 weeks), and with an acceptable complication rate; most complications in our series were minor and related to hardware issues (7.7%). Hardware-related issues are a common problem in this procedure, with a weighted incidence of up to 16–18% depending on the surgical indication, according to Tuijthof [38], though some authors had to remove hardware in up to 27% of their patients [11]. A meticulous technique when inserting the screws minimizes the rate of complications and the need for implant removal. Bioabsorbable implants could reduce the need of repeat surgeries for hardware removal, although the fixation achieved may not be as stable as with conventional screws, and union rates could be affected. To our knowledge, this is the largest case series reported so far of arthroscopic subtalar arthrodesis, and it has the longest average follow-up. In our series, we consistently achieved subtalar fusion and improvement in AOFAS scores; patient satisfaction remained high even among patients followed for more than 5 years. Among the strengths of our study is its internal validity, as all cases included were consecutive surgeries performed by a single surgeon (JVR), and data collection was performed in a structured,
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Table 2 Reported results of open subtalar arthrodesis NR: Not reported. Preop: Preoperative. Postop: Postoperative. Series
Number of cases
Follow-up, (mean, range)
Bone graft
Fixation
AOFAS score
Results
Russoti (1988) [34] Dahm (1997) [9] (posttraumatic) Mann (1998) [30]
45
57 months (30–96)
45/45 (iliac crest)
Pins/screw
NR
25
4 years (2-6) 59.5 months
10/25 (iliac crest)
1 screw
NR
83/86 (local, iliac crest, allograft) 145/184 (cancellous/ structural autograft/allograft)
2 screws
Postop: 75 (21–94)
97.8% union 4.4% complication 96% union 8% complication 100% union 12.5% complication 96% union 11.6% complication
1 or 2 screws
Preop. 24 (22–69) Postop 70 (41–94)
101/101 (local)
1 screw
NR
48
Postop 89
Flemister (2000) [15] (posttraumatic)
86
Minimum 24 months
Easley (2000) [13]
184
51 months (24–130)
Haskell (2004) [19]
101
Chahal (2006) [6]
88
35.5 months (10–83)
47/88 (local/iliac crest)
1 or 2 screws
NR
Joveniaux (2010) [24]
28
56 months (20-115)
26/28 (iliac crest, substitute, allograft)
1 or 2 staples
76.5 (36–94)
Lo´pez-Oliva (2010) [29] (percutaneous technique) Carranza (2013) [4] (MIS technique)
37
33 months (12–60)
None
VIRA 1 device
75.43 (SD 14.1)
77
50 months (15-108
None
1 or 2 screws
Preop 26.9 (SD 8.6) Postop 74.5 (SD 13.3)
Yavuz (2014) [39] (posttraumatic)
21
43 months (21–83)
11/20 (8 iliac crest/3 allograft)
2 screws
Herrera-Pe´rez (2015) [21]
33
42.7 months (24.5-84.3)
None
2 screws/staples
Preop 61.7 (40– 67) Postop 84.2 (65–94) Preop 54.1 (33– 69) Postop 84.8 (71–91)
prospective manner, without loss of cases due to incomplete data or loss of follow-up. We also recognize several flaws of our study. Nonunion has been seen to be more common among diabetics and smokers [6]. Two of the three patients who suffered nonunion were smokers; data was incomplete regarding the total number of smokers and diabetics in our series, so these variables could not be included for statistical analysis. Patients with several diagnoses were included in the case series; however, we believe our case mix represents most patients treated for subtalar arthritis, and the aim of our study was to analyze our overall results and contrast them with those previously published in the
84% union (73% in smokers, 71% in avascular necrosis and revision surgeries). 96% union rate without associated risk factors. Complications: 20% hardware removal, 9% sural nerve injury, 3% infection, 10% lateral impingement, 6% hindfoot malalignment) 98% union (12.3 weeks) No difference between smokers and nonsmokers. 13% hardware removal 95% with bone graft, 65% without bone graft 90% nonsmokers, 68% smokers 100% union No malalignment 43–65% midfoot arthritis 100% union 31 good/excellent results; 1 reoperation (addition of bone graft) Union 92.2% Hardware protrusion 15.5%
95% union 2 infection, 2 complex regional pain sı´ndrome, 1 hardware removal 87.9% union rate 9.1% need for hardware removal
literature. Furthermore, we based our estimation on achievement of fusion on clinical parameters and standard radiographs during the follow-up visits, as have most of the authors in previously published series [10,13,17,21]. Jones found that plain radiographs could be misleading and believed that a CT scan provided a much more accurate assessment of union [8,23]. It would be ideal to perform a CT scan to confirm union in all patients; however, this would expose a large number of patients to unnecessary expenses and radiation. Consequently, we only performed a CT scan in patients with persistent pain or without evidence of fusion on plain radiographs, as proposed by Davies [10].
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Table 3 Reported results of arthroscopic subtalar arthrodesis NR: Not reported. Preop: Preoperative. Postop: Postoperative. Series
Number of cases
Follow-up (months)
Bone graft
Fixation
AOFAS score (points)
Tasto (2003) [37] Glanzmann (2007) [17]
25 41 (85% posttraumatic)
55 months (24–89)
41/41 (proximal tibia)
1 screw
Preop. 53 (22–69) Postop. 84 (41–94)
Amendola (2007) [2]
11
34 months (24–48)
11/11 (cancellous)
2 screws
Carro (2007) [5] Diezi (2008) [11]
4 15
NR
NR
NR
Preop.36 (19–57) Postop. 86 (78–94) NR
El Shazly (2009) [14] Posttraumatic
10
28.4 months (24–32)
None
1 screw
Liu (2009) [28]
38
45 months (21–110)
Lee (2010) [26]
16
30 months (20–46)
NR
2 screws
Albert (2011) [1]
10
21.5 months (12–31)
9/10 (autologous)
1 or 2 screws
Vila´ y Rico (2015) Current series
65
57.54 months (24–105)
None
1 or 2 screws
Preop. 38 Postop 74
Pre 48.3 Post 79.2
6. Conclusion Arthroscopic subtalar arthrodesis has proven to offer at least similar results, and may achieve higher rates of fusion and lower complication rates than open techniques. We prove it is a safe and reliable procedure, provided surgical technique is carefully followed. It provides a high union rate without needing supplementation by bone graft, with an acceptable rate of complications. AOFAS scores improved significantly in all of our patients, and patient satisfaction was high even among patients followed for more than five years. Ethical Approval For this type of study, formal consent is not required. Conflicts of interest The authors have no conflicts of interest to disclose. None of the authors has any conflict of interest to disclose. No benefits in any form have been received or will be received by the authors from a commercial party, directly or indirectly, related to the subject herein. References [1] Albert A, Deleu P-A, Leemrijse T, Maldague P, Devos Bevernage B. Posterior arthroscopic subtalar arthrodesis: Ten cases at one-year follow-up. Orthop Traumatol Surg Res 2011;97:401–5. [2] Amendola A, Lee K-B, Saltzman CL, Suh J-S. Technique and early experience with posterior arthroscopic subtalar arthrodesis. Foot Ankle Int 2007;28: 298–302.
Preop 35 (24–45) Postop 84 (71–94) Preop 47 (22–65) Postop 78 (60–91) Preop. 51.5 (19–61) Postop. 81.7 (60–94)
Results 100% union (8.9 weeks) 100% union (11 weeks (7–36)) Degeneration of neighboring joints (7.31%) 91% union (10 weeks) 100% union (8 weeks) 93.3% union 4/15 (27%) hardware removal; symptomatic talonavicular arthritis Significant improvement of pain and distance walked. Union at 11.44 weeks. 1 painful neuroma anterolaeral portal 92% union (35/38) 2 skin necrosis, 1 Drop foot 94% union (11 weeks) 100% union (6.8 weeks) 2 lateral submalleolar impingement 95.4% union (11.2 weeks) 12.9% complication rate (3/65 nonunion; 5/65 need for hardware removal)
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