EXTRA-ARTICULAR SUBTALAR ARTHRODESIS. A Review of 286 Operations

Transcription

1 EXTRA-ARTICULAR SUBTALAR ARTHRODESIS A Review of 286 Operations ALFONSO TOHEN, J0AQUIN CARMONA, LEOPOLDO CHOW and JUAN ROSAS, MExico CITY, MEXICO From the Centre for Orthopaedics and Rehabilitation, Mexico City Since Grice (1952) published his report of subtalar extra-articular arthrodesis, and later (1955) described his results in fifty-two cases, this operation has been widely used. In 1957 Westin and Hall published a preliminary report of sixty-two extra-articular arthrodeses in patients from three to twelve years of age with paralytic pes planus and pes calcaneo-valgus. Malvarez (1957) reported his results in eighty-seven cases of children aged from two to six years. Weissman, Torok and Karmosh (1957) reported thirty operations in patients with paralytic pes planovalgus. Baker and Dodelin (1958) published the results of twenty-nine operations on the valgus feet of patients with cerebral palsy aged from three to thirteen years. In 1959 Grice reported his results in a series of 108 cases that included patients with a considerable variety of deformities, including congenital planovalgus foot in cerebral palsy, valgus foot in spina bifida and paralytic calcaneo-valgus foot. He had also treated adult patients with fractures of the calcaneus and with degenerative arthritis and tuberculosis of the subtalar joint. In 1963 Zachariae recorded the results in sixty-six cases of pes planovalgus and calcaneo-valgus in patients from four to twelve years of age. In 1964 Baker and Hill added to TABLE I AGE OF PATIENTS AT THE TIME OF OPERATION Age Number of Per cent (years) patients Age Number of Per cent (years) patients 2 to to to toll to to to to to to to to to Total the arthrodesis an open wedge osteotomy of the calcaneus below its articular surface held open with small bone grafts. In 1964 Rugtveit reported thirty-seven cases in patients aged from five months to nine years. Pollock and Carrell (1964) reported 1 12 cases in patients from three to fourteen years of age. In the years 1958 to 1965 we have done 300 subtalar extra-articular arthrodeses. Eliminating fourteen cases with inadequate follow-up, we have analysed 286 cases in patients from two to fifteen years of age, with pes calcaneo-valgus, pes planovalgus, pes equinovalgus and flail foot. MATERIAL We present a study of 258 patients in whom we have performed 286 subtalar extraarticular arthrodeses. There were 142 boys and 116 girls. The age of the patients at the time of operation ranged from two to fifteen years, but most of the patients were operated upon VOL. 51 B, NO. I, FEBRUARY

2 46 A. TOHEN, J. CARMONA, L. CHOW AND J. ROSAS between the ages of three and nine years with the peak at four to six years (Table I). Two hundred and forty-two of the patients were suffering from the effects of poliomyelitis; twelve had spastic cerebral palsy, two patients had spina bifida, and two had polyradiculoneuritis. TABLE II DEFORMITY OF THE FOOTNumber BEFOREof OPERATION Deformity Per cent Pes calcaneo-valgus Pes planovalgus Flail foot Pes varus I Total TABLE ANALYSIS OF THE MUSCULAR IMBALANCE IN SURGICALLY TREATED FEET III Deformity Number of Per cent Paralysis of anterior and posterior tibialand calf muscles with good peroneal muscle power Paralysis of tibialis posterior with good peroneal and fairto-good anterior tibialpower and good calf power Paralysis of tibialisanterior with weakness of posterior tibialand calf muscles... #{149} #{149} Moderate muscle imbalance with predominance of peroneal function and some weakness of both tibials Muscular imbalance with predominance of tibial function and weakness and paralysis of the peroneal muscles Flail foot Total TABLE IV TENDON TRANSPLANTS DONE AT THE SAME TIME AS ARTHRODESIS Type of transplant Per cent Peroneus longus to calcaneus Peroneus longus and brevis to calcaneus Peroneus brevis to dorsum of foot Other transpositions to dorsum of foot Lengthening of tendo calcaneus Total TABLE V LENGTH OF FOLLOW-UP AFTER OPERATION Duration Number of cases Per cent 2 years years years years More than 6 years Total The right foot was involved in 107 cases, the left foot in 125 cases and both feet in twenty-seven cases. The deformities of the foot for which the operations were done are listed in Table 11. We most commonly encountered calcaneo-valgus deformity secondary to poliomyelitis. Other THE JOURNAL OF BONE AND JOINT SURGERY

3 EXTRA-ARTICULAR SUBTALAR ARTHRODESIS 47 FIG. 1 The Grice technique: two grafts are fastened into a keystone shape and placed in shallow grooves on either side of the sinus tarsi so as to form a strut. FIG. 2 Our modification: a much larger graft also cut in a trapezoid shape but with its upper and lower edges bevelled is driven into slots cut into the talus and calcaneus. FIG. 3 In the treatment of the varus foot we use a long graft that is much narrower on its lateral side than that used in the valgus foot. It reaches right across the sinus tarsi, and is so placed as to open the medial side of the joint while allowing the lateral side of the joint to be closed. VOL. 51 B, NO. 1, FEBRUARY 1969

4 48 A. TOHEN, J. CARMONA, L. CHOW AND J. ROSAS authors have found planovalgus deformity more common, even though we have included in this classification all valgus feet with any equinus whatsoever. We consider a foot to be flail when there is practically no muscular imbalance because of virtually total paralysis of the muscles controlling the foot. In most of the feet studied we encountered muscular imbalance (Table Ill). In 269 of the 286 feet tendon transplants were done in addition to the subtalar arthrodesis. In most of these the transplants were done at the same time as the arthrodesis, but when lengthening of the tendo calcaneus was performed with the arthrodesis the transplants were delayed for six weeks. The type and frequency of the various transplants done are summarised in Table IV. The length of follow-up after operation is shown in Table V. TECHNIQUE OF OPERATION Our technique differs in the following respects from that described by Grice. Firstly, we use only one graft whereas Grice used two. Secondly, our graft is wider and longer than FIGS. 4 TO 7 Case I-Operation for correction of pes planovalgus. Child affected by poliomyelitis at the age of 16 months. Paralysis of tibialis anterior and posterior. Figure 4-Radiograph just before operation; child aged 4 years and 9 months. Pes planovalgus; talocalcaneal angle 55 degrees. Figure 5-Antero-posterior view at same age: talocalcaneal angle 55 degrees. Figure 6-One year after operation. There is solid fusion; the talocalcaneal angle is 30 degrees. Figure 7-Antero-posterior view: talocalcaneal angle 15 degrees. THE JOURNAL OF BONE AND JOINT SURGERY

5 EXTRA-ARTICULAR SUBTALAR ARTHRODESIS 49 that used by Grice, and is varied in its dimensions according to the deformity to be corrected. We use a trapezoid graft, but we do not cut off the corner to make a keystone in the manner described by Grice. Instead, the two sides of the trapezium are sharpened to make a cutting edge (Figs. 1 and 2). Thirdly, in preparing the site for the graft in the sinus tarsi we cut with FIG. 9 FIG. 10 Case 2-Operation for correction of calcaneus deformity. Child affected by poliomyelitis at the age of 13 months. Paralysis of triceps surae. Figure 8-Radiograph just before operation; child aged 4 years. Talocalcaneal angle 55 degrees. Figure 9-Three months after operation, in which arthrodesis was combined with transposition of the peroneus longus to the calcaneus. The graft iswell shown. Figure 10- Two years after operation. There is sound fusion; the talocalcaneal angle is 30 degrees. an osteotome into the lateral cortices and the cancellous bone equally of the talus and the calcaneus, thereby creating a true channel for the graft. In this again we differ from the technique of Grice, who made only a little groove in the two bones in which to prop the grafts. Fourthly, the graft is introduced by pressure into the previously cut channel so as to act as a wedge that can open the sinus tarsi as much as desired to correct the valgus deformities, and can permit it to be closed laterally in cases of varus deformity. Finally, when we are treating a varus foot we use a graft that is likewise trapezoid and has two sharpened edges, but it is longer and narrower than that used for a valgus foot; it extends across the sinus tarsi to the medial side of the calcaneus and talus. When this graft is inserted into the sinus tarsi to correct a varus deformity, we make sure that the lesser base of the trapezium, which is to be medial, can easily open the medial side of the sinus tarsi, and that the lateral or wider base of the trapezium is well within the lateral cortices of the talus and calcaneus and can be impacted into the substances of these two bones, so that the net effect is that of a wedge opening the sinus tarsi medially and allowing it to be closed laterally, thereby restoring the normal valgus relationship. In order to obtain this effect, before inserting the graft we have done capsulotomies of the talocalcaneal joints medially and anteriorly through the sinus tarsi, VOL. 51 B, NO. 1, FEBRUARY 1969 D

6 50 A. TOHEN, J. CARMONA, L. CHOW AND J. ROSAS but if this is not then sufficient to permit the spreading of the joint, we have even made a second incision medially in order to improve these capsulotomies and obtain the passive correction FIGS. 11 TO 15 Case 3-Operation for correction of varus deformity. Child affected by poliomyelitis at the age of 4 years. Figure 11-Radiograph just before operation: child aged 10 years. Note the deformity of the calcaneus. Figure 12-Antero-posterior view at the same age. The talocalcaneal angle is 45 degrees. Figure 13-Three months after operation. Note the shape of the graft as seen in the lateral projection. Figure 14-One year after operation. Fusion of graft. Figure 15-The antero-posterior view shows the length of the graft and the correction of the deformity. of the varus that is necessary before inserting the grafts (Fig. 3). The technique of using a single graft for the valgus foot as we have described was demonstrated to one of us by Dr William T. Green of the Children s Medical Center, Boston, Massachusetts, in THE JOURNAL OF BONE AND JOINT SURGERY

7 EXTRA-ARTICULAR SUBTALAR ARTHRODESIS 51 For immobilisation after operation we use a plaster extending from the groin to the toes and kept on for twelve weeks. Weight-bearing is not permitted during this period. If tendon transplantation is done at the same time as arthrodesis the time of immobilisation is reduced to six weeks, with the object of permitting a start of muscle re-education as soon as possible. Weight-bearing is not permitted until the end of three months. For this purpose we fit a brace to support the foot until the grafts are shown by radiography to have been incorporated into the substance of the talus and the calcaneus. RESULTS Subtalar fusion was obtained in all cases (Figs. 4 to 15). The only complication was soft-tissue infection, which never involved bone. To classify our end-results we use the following criteria : 1 ) follow-up of at least two years; 2) solid clinical and radiographic fusion ; 3) correction of the deformity clinically and radiologically ; 4) aesthetically satisfactory foot ; and 5) no recurrence of the deformity. All these criteria were satisfied in 219 of the 286 feet. In sixty-seven cases there was sufficient residual valgus or varus to fail one of the above tests. Our belief that this series is the largest series reported to date has led us to compare our results with those in the other major reports (Table VI). First, in the series reported by Grice (1955), by Vanderbilt University (Hunt and Brooks 1965) and by the Texas Scottish Rite Hospital (Pollock and Carrell 1964), the results oftreatment for valgus feet only were reported, TABLE VI ANALYSIS OF RESULTS IN COMPARISON WITH THOSE OF OTHER AUTHORS G rice. ChidBoston n s Vanderbilt Hunt and University, Brooks: Texas Pollock Scottish & Carrell: Rite Present series p, Nashville Hospital, Dallas Numberofarthrodeses Length of follow-up after operation.. I to 9 years 2 to 13 years 6 months to S years 2 to 9 years Paralytic pes I calcaneo-valgus; Deformities treated. Paralytic pes valgus Paralytic pes valgus Paralytic pes valgus flail foot paralytic I pes varus; I Number Per cent Number Per cent Number Per cent Percent Associated transplants Without transplants Results Good Bad Varus foot Valgusfoot Failure fusion Reabsorption of graft VOL. 51 B, NO. 1, FEBRUARY 1969

8 52 A. TOHEN, J. CARMONA, L. CHOW AND J. ROSAS whereas we have included the results of treatment of other deformities, especially varus feet. The results in the four series were rather similar, the Texas Scottish Rite Group reporting the largest number of bad results. Failure of fusion and absorption of the grafts is reported in a certain percentage in all three of the other series, but we did not encounter this complication at all. We attribute this to the differences in technique used, feeling that the use of the single graft impacted well into the cancellous bone on both ends and so provided with a good source of blood supply and better stabilisation gives more certainty of fusion. We agree that the bad results, especially over-correction of deformity producing a varus foot, are caused by opening of the lateral aspect of the sinus tarsi too widely. Also, we have noted that when tendon transplants are done simultaneously there is a greater tendency to over-correction. We agree with Grice that correction of equinus should not be done at the time of operation because this tends to produce a varus deformity of the foot. SUMMARY 1. A study is presented of 286 extra-articular subtalar arthrodeses done during the years 1958 to 1965 on 258 patients with pes calcaneo-valgus, pes planovalgus, pes varus or flail foot. 2. Certain changes in the surgical technique originally presented by Grice have been made. We have applied the arthrodesis not only to valgus feet but also to varus feet, and we have described the details of the surgical technique as used on the varus foot. 3. In none of our cases was there failure of fusion or reabsorption of the graft. The unsatisfactory results (239 per cent) were caused by residual varus or valgus deformity of the foot. This paper was translated from the Spanish by Dr Robert W. Milam, M.D., F.A.C.S., of McAlIen, Texas, United States of America. REFERENCES BAKER. L. D., and DODELIN, R. A. (1958): Extra-Articular Arthrodesis ofthe Subtalar Joint (Grice Procedure). Results in Seventeen Patients with Cerebral Palsy. Journal ofthe American Medical Association, 168, BAKER, L. D., and HILL, L. M. (1964): Foot Alignment in the Cerebral Palsy Patient. Journal ofbone and Joint Surgery, 46-A, 1. GRICE, D. S. (1952): An Extra-Articular Arthrodesis of the Subastragalar Joint for Correction of Paralytic Flat Feet in Children. Journal ofbone and Joint Surgery, 34-A, 927. GRICE, D. S. (1955): Further Experience with Extra-Articular Arthrodesis of the Subtalar Joint. Journal of Bone and Joint Surgery, 37-A, 246. GRICE, D. S. (1959): The Role of Subtalar Fusion in the Treatment of Valgus Deformities of the Feet. Instructional Course Lectures, The American Academy oforthopaedic Surgeons, 16, I 27. HUNT, J. C., and BROOKS, A. L. (1965): Subtalar Extra-Articular Arthrodesis for Correction of Paralytic Valgus Deformity of the Foot. Journal ofbone and Joint Surgery, 47-A, MALVAREz, 0. (1957): Arthrodesis Subastragalina Extraarticular en el Pie Valgo Pronado Paralitico. Artrodesis Minima. Estudio de 87 casos. Revista de ortopedia y traumatologia latino-americana, 2, 251. POLLOCK, J. H., and CARRELL, B. (1964): Subtalar Extra-Articular Arthrodesis in the Treatment of Paralytic Valgus Deformities. Journal ofbone and Joint Surgery, 46-A, 533. RUGTVEIT, A. (1964): Extra-Articular Subtalar Arthrodesis, According to Green-Grice, in Flat Feet. Acta Orthopaedica Scandinavica, 34, 367. WEISSMAN, S. L., TOROK. G., and KHARMOSH, 0. (1957): L Arthrod#{234}se Extraarticulaire avec Transplantation Tendineuse Concomitante dans le Traitement du Pied Plat Valgus Paralytique du Jeune Enfant. Revue de Chirurgie Orthop#{233}dique et R#{233}paratrice de L Appareil Moteur, 43, 79. WESTIN, G. W.. and HALL, C. B. (1957): Subtalar Extra-Articular Arthrodesis. A Preliminary Report of a Method of Stabilizing Feet in Children. Journal of Bone and Joint Surgery, 39-A, 501. ZACHARIAE, L. (1963): The Grice Operation for Paralytic Flat Feet in Children. Acta Orthopaedica Scandinavica, 33, 80. THE JOURNAL OF BONE AND JOINT SURGERY