Contents

Manuel Monteagudo

Diogo Vieira Cardoso and Andrea Veljkovic

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Ahmed Khalil Attia and Keith A. Heier

Hallux metatarsophalangeal joint (MTPJ) arthrodesis was first described in 1894 by Clutton, who recommended ankylosing the MTPJ to treat painful hallux valgus (HV). He used ivory pegs to stabilize the MTP joint. Surgeons over the last century have modified the procedure and added indications, including hallux rigidus, rheumatoid arthritis, and revision of failed surgeries. This article addresses many common yet challenging clinical scenarios, and a few hot topics, related to hallux MTPJ arthrodesis, including matarsus primus elevatus, severe hallux valgus, avascular necrosis, and infections. The article provides a condensed evidence-based discussion on how to manage these challenges using MTPJ arthrodesis.

Stefan Rammelt and Pablo Andrés Cárdenas Murillo

Chronic injuries at the tarsometatarsal joint represent a wide array of painful malunions ranging from isolated instability to complex three-dimensional deformities with rapid development of posttraumatic arthritis. Deformity correction and arthrodesis of the symptomatic joints leads to significant pain reduction and functional improvement provided that realignment of the anatomic axes is achieved. Arthrodesis should be limited to the first to third tarsometatarsal joints, whereas interposition arthroplasty is preferred for symptomatic arthritis of the fourth to fifth tarsometatarsal joints. For complex deformities and instability, the intercuneiform and naviculocuneiform joints may need to be included into corrective fusion.

James A. Lendrum and Kenneth J. Hunt

Progressive collapsing foot deformity (PCFD; commonly referred to as flatfoot deformity) is a complex condition classically characterized by hindfoot valgus, midfoot abduction, and forefoot varus. Medial column arthrodesis can be used to reliably correct severe, arthritic, and unstable PCFD involving the medial column. Although both naviculocuneiform arthrodesis and talonavicular arthrodesis have their own indications, patient selection and careful radiographic and clinical assessment are crucial for any medial column arthrodesis. Herein, the authors discuss the indications for medial column arthrodesis procedures, outcomes as reported in the literature, and several case examples using medial column arthrodesis in deformity correction.

Benjamin J. Ebben and Mark Myerson

Subtalar joint arthrosis is common following intra-articular calcaneus fractures. The appropriate management of pain secondary to posttraumatic arthritis depends on the status of the remaining posterior facet articular cartilage, the magnitude of any residual joint displacement and distortions in the overall morphology of the calcaneus. In select circumstances, joint-preserving surgical techniques may be considered including lateral wall exostectomy, far lateral posterior facet joint debridement, and intra-articular osteotomies. When the subtalar joint is not salvageable, some form of arthrodesis procedure is pursued. Occasionally, an extra-articular osteotomy may be necessary in combination with arthrodesis to correct deformity.

Naji S. Madi, Amanda N. Fletcher, and Mark E. Easley

A flatfoot deformity is a multiplanar foot deformity characterized by forefoot abduction and supination and hindfoot valgus. With progressive pathology, a rigid deformity may develop. In the setting of a rigid deformity, the appropriate procedure to use is not without controversy. The extent of joints to involve in the arthrodesis depends on the ability to obtain a plantigrade foot. Both double and triple arthrodesis have been suggested. Care must be taken to avoid lateral column shortening and loss of foot reduction when fusing the CC joint. The concerns about lateral skin breakdown led some surgeons to describe a single medial incision for a triple or modified double arthrodesis. The necessity of bone grafting has been controversial. Implant selection is essential to achieve solid stabilization of the arthrodesis sites. To decrease the risk of overcorrection and malunion, the surgeon should be familiar with the hindfoot biomechanics and generate, based on the clinical examination and imaging, a meticulous preoperative plan to address and balance both the soft tissue and bony deformity.

Wolfram Wenz

The cavovarus (cavus) foot is one of the most perplexing and challenging of all foot deformities and may prove to be one of the most difficult conditions to treat. This deformity is characterized by increased plantar flexion of the forefoot and midfoot in relation to the hindfoot resulting in high foot arch. Because cavus foot rarely occurs in an isolated form, the term “cavus foot” rather describes a part of a complex multiplanar foot deformity. Because the underlying disease is mostly neurogenic characterized by muscle imbalance in almost every case a combined bony and soft tissue surgery is inevitable.

Dov Lagus Rosemberg, Rafael Barban Sposeto, and Alexandre Leme Godoy-Santos

Charcot neuroarthropathy (CN) is a systemic disease that causes fractures, dislocations, and deformities involving the foot and ankle, resulting in substantial risk of ulceration, infection, and function loss. Early recognition and prevention of collapsing foot and ankle are still the best options for the management of patients with diabetic CN. For a successful arthrodesis procedure, the principles of adequate joint preparation, deformity correction, and soft tissue protection and care are essentials, associated with robust fixation (internal and/or external), use of different biological graft options in segmental losses, and prolonged off-loading.

Pilar Martínez-de-Albornoz and Manuel Monteagudo

Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies––weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.

Norman Espinosa

The current article provides an algorithm of how to approach crippled ankle by ankle arthrodesis. There is no standard pathology or treatment present, which makes the diagnosis but also surgical correction complex. A surgeon who faces this kind of deformities needs to be skilled and well familiar with the full setting of the foot and ankle armamentarium.

Sagar Chawla and Michael Brage

A triple arthrodesis is comprised of subtalar, talonavicular, and calcaneocuboid joints arthrodesis. A pantalar arthrodesis is triple arthrodesis combined with tibiotalar arthrodesis. The goal of the procedure is to obtain a correction of deformity and achieve a plantigrade, functional, painless, stable, weightbearing foot that can be used to ambulate. This is done by creating an osseous continuity across the ankle, subtalar, and talonavicular, and calcaneocuboid joints. There are several approaches and fixation strategies that result in successful clinical union and should be chosen to match the clinical situation. Modern techniques result in high rates of union and pain relief.