Subtalar Arthritis Management Options

Powerpoint presentation on Subtalar Arthritis Management

1. Subtalar Arthritis: Different Management Options
K S Anand MS (Orth.), Dip.SICOT
Consultant, ANAND HOSPITAL, Purnea, Bihar
Associate Professor, MGM Medical College, Kishanganj, Bihar
Executive Committee Member, Indian Foot & Ankle Society
Executive Committee Member, APOA Foot & Ankle Section

4. Subtalar Arthritis: Causes
•Post-traumatic (Most Common in our setting)
•Idiopathic
•Rheumatoid Arthritis, other Inflammatory Arthropathy
•Flat foot
•Neuromuscular Causes
•Talocalcaneal Coalition
•Hindfoot Instability
Subtalar Joint Pathology

5. History & Clinical Examination
•Pain, esp on walking on uneven surface
•Stiffness while moving the foot from side to side
•Deformity
•Tenderness around Sinus Tarsi
•ROM -Significantly Reduced

6. Clinical Examination: Points To Be Noted
•Alignment of Foot & Ankle
•Soft Tissue Conditions
•ROM of Adjacent Joints
•Neurovascular Status of Limb
•Tendoachillies Tightness
•Knee, Hip and Spine Examination

7. Imaging
•Ankle -Standard AP, Lat, Mortise Views
•Foot -Standard AP, Lat Oblique & Med Oblique Views
•Axial Views
•Broden’s View: Excellent visualization of Subtalar Joint
•Weight-bearing view: Saltzmann View
X-ray
CT Scan

8. Saltzmann’s View
For ascertaining Heel Valgus/Varus in weight-bearing position
Tangentialweight-bearingpostero-anteriorviewofthe
hindfootandleg,demonstratingweight-bearing
relationshipofthehindfootwiththeleg.

9. •Patient is supine with knee slightly flexed and
supported by sandbag.
•Foot rests on the film cassette with neutral
dorsiflexion.
•Entire lower leg and foot is internally rotated 45 deg.
•Central beam directed toward the lateral malleolus.
•Films are obtained at 10, 20, 30, and 40 deg. of
cephalic tilt.
Broden’s View

10. Management
•Identify the condition and start
treatment ASAP
•Line of Treatment: Conservative vs
Operative

11. Conservative Management
Limiting the movement and loading of Subtalar Joint:
•Comfortable shoes.
•Hindfoot bracing
•Weight Control
•Activity Modification
However, Generally speaking, surgery is often required!

12. Surgical Management
•Type of Arthritis
•Severity of Disease
•Location of Arthritis
•More than one surgery may be needed
However, in most cases Fusion of the Joint is
done.

13. Subtalar Arthrodesis
In-situ Distraction
Fusion
&
Osteotomy
Loss of Height (Malunited #s of
Calcaneus & Talus
No Deformity
No Height Loss
Associated with
Deformity

14. •Lateral Extensile Approach
•Posterior Approach
•Medial Approach: in severe Valgus, Medial Facet Subtalar Coalition
Subtalar Arthrodesis: Approaches
Lateral Approach

15. Subtalar Arthrodesis: General Consideration
•Broad, Cancellous bleeding surfaces in close approximation
•Rigid Fixation with Compression
•Drilling of Subchondral Bone
•Augmentation of Fixation, if needed, by involving joint proximal &
distal.
As Applicable to any F&A Arthrodesis

16. •Plan Incision as per pathology
•Adequate soft tissue
mobilization
•Respect Soft Tissue: Gentle &
Even Retraction with K-wire
•Avoid Nerves
Subtalar Arthrodesis: General Consideration
Plan Well!

17. Subtalar Arthrodesis
Distraction
Medial/Lateral Graft
Heel Varus:Dwyer Osteotomy
Heel Valgus:Medial Calcaneal Slide Osteotomy
Loss of HeightVarus/Valgus
Posterior Graft
Deformity Correction

18. •0-5 Degree Heel Valgus
•Neutral Mid-tarsal Joints (TN & CC)
•Forefoot -Plantigrade
Subtalar Arthrodesis
Correct Position

19. FHL marks limit
of
medial preparation
Subtalar Arthrodesis

20. Subtalar Arthrodesis
Distraction with lamina spreader
Hintermann’s retractor
Skin closure may be an issue,
as, Post-op Height may
increase.
Adequate Exposure,
Visualization & Closure

21. Subtalar Arthrodesis
Use the excised bone for deformity correction

22. Combine with Osteotomy for Deformity Correction
Subtalar Arthrodesis

23. •Screws from Non-weight Bearing Area of
Heel.
•Screw Heads to be Countersunk
•Use of Anterior Screw for Increased Stability
Subtalar Arthrodesis
Implant Placement

24. Complications?

25. Lag Screws
vs
Fully Threaded Screws
Subtalar Arthrodesis
Implant Placement

26. Take Home
•Good PLANNING is key to success
•Keen eyes on Meticulous Detailing.
•Try to make learning curve as small as possible.
Thank you for your kind attention