Subtalar arthroscopic arthrodesis: Technique and outcomes
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, adult-acquired 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].
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 cadaveric description 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.
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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 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)
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 30° arthroscope. The posterolateral portal was performed first
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
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
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
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.
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