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Arthroerisis of the subtalar joint.

Arthroerisis of the subtalar joint can be a valuable tool for the foot and ankle surgeon in treating flexible pes planus deformity in adults, as well as in children. Whether by itself, or in conjunction with other procedures, such as Achilles tendon lengthening (to allow dorsiflexion to at least neutral), midfoot or hindfoot osteotomies (to correct significant bony deformities), and posterior tibial tendon advancements (with associated symptomatic accessory navicular), arthroerisis can be helpful to correct deformity. When compared with procedures that involve osteotomy or arthrodesis, there is less morbidity to the patient who undergoes arthoerisis during surgery as well as postoperatively. There is no risk of nonunion, less immobilization is usually required, and arthroerisis is technically easy to perform. As with all surgical procedures, proper patient selection is extremely important.

Adolescent↗

Biomechanical properties of human cadaveric ankle-subtalar joints in quasi-static loading.

The biomechanical properties of human ankle-subtalar joints have been determined in a quasi-static loading condition. The moving center of rotation was determined and approximated by a fixed point. The moment-angle characteristics of the ankle-subtalar joints about the fixed center of rotation have been measured under four basic movements: dorsiflexion, plantarflexion, inversion, and eversion. The method linearly increases rotation of the calcaneus until failure, and measures the moments, forces, and linear and rotational displacements. Failure was identified as the initial drop of moment on plot showing the moment representing gross injury or microfilament damage. In this study, 32 human ankle-subtalar joints have been tested to failure. The center of rotation of the ankle-subtalar joints was determined for a pure dorsiflexion (9 specimens), plantarflexion (7 specimens), inversion (8 specimens), and eversion (8 specimens). Failure in the joints occurred at an average moment of -33.1 +/- 16.5 Nm in dorsiflexion, 40.1 +/- 9.2 Nm in plantarflexion, -34.1 +/- 14.5 Nm in inversion, and 48.1 +/- 12.2 Nm in eversion. The failure angle was also determined in all four motions. Failure was best predicted by an angle of -44.0 +/- 10.9 deg in dorsiflexion, 71.6 +/- 5.7 deg in plantarflexion, -34.3 +/- 7.5 deg in inversion, and 32.4 +/- 7.3 deg in eversion. Injury was identified in every preparation tested in inversion and eversion, while it resulted in five of the nine preparations in dorsiflexion, and in three of the seven in plantarflexion. Injury occurred at -47.0 +/- 5.3 deg and -36.2 +/- 14.8 Nm in dorsiflexion, and at 68.7 +/- 5.9 deg and 36.7 +/- 2.5 Nm in plantarflexion. The results obtained in this study provide basic information of the ankle-subtalar joint kinematics, biomechanics, and injury. The data will be used to form a basis for corridors of the ankle-subtalar joint responses.

Aged↗

Subtalar joint arthrodesis using a single lag screw.

BACKGROUND: This study tested the hypotheses that fusing the subtalar joint with a single lag screw from the posteroinferior calcaneus to the anterior talar neck is an effective technique and that factors affecting the time to fusion can be identified. METHODS: Between October, 1995, and July, 2002, the senior author (RAM) performed 101 isolated subtalar arthrodeses using a technique of single lag-screw fixation from posteroinferior to anterosuperior across the posterior facet of the subtalar joint combined with the application of an autograft taken from the floor of the sinus tarsi and anterior process. The average patient age was 52 (range 17 to 82) years. There were 52 women (53 arthrodeses) and 48 men (48 arthrodeses). Eight of 101 (8%) arthrodeses were revisions. The indications included posttraumatic arthritis (45), posterior tibial tendon dysfunction (18), failed prior ankle joint fusion (14), idiopathic disorders (12), hindfoot coalition (7), rheumatoid arthritis (3), and Charcot-Marie-Tooth disease (2). Fifteen of 101 patients (15%) smoked an average of 0.9 +/- 0.5 pack of cigarettes per day. RESULTS: Two of 101 joints did not fuse, resulting in an overall fusion rate of 98%. The average time to fusion was 12.3 +/- 3.4 weeks. The presence of a prior ankle fusion significantly prolonged the time to fusion of the subtalar joint (11.9 +/- 2.3 vs. 14.9 +/- 7.0, p = .003). Other factors, including smoking, revision surgery, patient age, and patient sex, did not affect time to fusion. The fixation screw was removed in 13 of 101 (13%) joints at an average of 8.8 +/- 0.5 months. CONCLUSIONS: Using a single 7.0-mm lag screw across the posterior facet of the subtalar joint results in fusion of the subtalar joint in 98% of patients. A prior ankle arthrodesis delays the time to fusion of the subtalar joint by 3 weeks. This is a simple and reliable technique for achieving fusion of the subtalar joint.

Adolescent↗

Rotational equilibrium across the subtalar joint axis.

A review of the rotational forces, or moments, acting across the subtalar joint axis during relaxed bipedal stance is presented. The concept of rotational equilibrium about the subtalar joint axis is used to explain some of the biomechanical differences between feet that stand in the neutral and maximally pronated subtalar joint positions. In addition, the mechanical basis of treatment of sinus tarsi syndrome with foot orthoses using the concepts of subtalar joint axis moments rotational equilibrium of the subtalar joint is presented.

Biomechanical Phenomena↗

Determination of subtalar joint axis location by restriction of talocrural joint motion.

The location of the subtalar joint axis is an important determinant of the mechanical function of the foot. The moments of muscle forces and of the ground reaction force about the subtalar joint are dependent upon the location of this joint axis. There is substantial variation in subtalar axis location across subjects, but current methods for determining its location are often invasive or involve expensive imaging protocols. A novel technique for location of the subtalar axis is presented in which the talocrural joint is passively immobilized so that motion of the tibia relative to the calcaneus can be used to estimate the subtalar axis. This paper presents results of cadaver testing in which accuracy of the technique was assessed by comparing helical axes computed from calcaneus-tibia bone motions to axes computed from calcaneus-talus bone motions. Only small motions at the talocrural joint were observed, and good estimates of the subtalar axis (errors less than 15 degrees and 2mm) were achieved in four of six specimens.

Aged↗

Progressive subtalar joint dislocation and limb-length inequality. An unusual case.

Subtalar joint dislocation is a rare entity, accounting for only 1% of all traumatic dislocations. The authors report a case of an adolescent with gradual lateral subluxation of an anatomically abnormal subtalar joint with no history of trauma, an extremely rare presentation. The patient also had a congenitally short limb. The patient underwent llizarov leg lengthening along with multiple surgeries of the subtalar joint. The choice of the Ilizarov technique to lengthen the leg and realign the subtalar joint in this case is discussed.

Abnormalities, Multiple↗

Position of the subtalar joint axis and resistance of the rearfoot to supination.

Determination of the position of the subtalar joint axis is being more widely used clinically to facilitate the prescription of foot orthoses and the understanding of foot function, but clinical determination of the axis has not been widely investigated. The aim of this study was to determine the relationship between clinical determination of the subtalar joint axis and the amount of force needed to supinate the foot. The transverse plane position of the subtalar joint axis was determined in 47 subjects. The sagittal plane orientation of the subtalar joint axis was determined using the relative amounts of forefoot adduction and abduction obtained when the rearfoot was supinated and pronated. The amount of force needed to supinate the foot was measured using a device designed to measure resistance to supination. The only two parameters that were correlated to supination resistance of the rearfoot were body weight (r = 0.52) and the perpendicular distance from the fifth metatarsal head to the subtalar joint axis (r = 0.59). The model on which determination of the subtalar joint axis is based may not be valid, but it might help determine how much force is needed to supinate a foot using foot orthoses.

Adult↗

The association between subtalar joint motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures.

BACKGROUND: There is a paucity of literature on the effect of calcaneal fractures on subtalar joint motion and patient satisfaction. The objective of this study was to determine the relationship between subtalar joint motion and outcome satisfaction in patients who had displaced intraarticular calcaneal fractures. The design of this study was a retrospective analysis from a randomized, controlled clinical trial. The setting was a Level I trauma center. METHODS: Of the 332 displaced intraarticular calcaneal fractures entered into the clinical trial and managed by the senior author, 244 fractures had subtalar joint motion measurements taken at least 12 weeks after fracture, and patient-oriented outcomes were reviewed at 2 years. Nonoperative treatment consisted of ice, elevation, and rest without closed reduction. In the operative group, an extended lateral approach was used with subchondral fixation, plating, and bone grafting when necessary. The Short Form 36 (SF-36), a validated visual analogue scale (VAS), and a gait analogue score measured patient satisfaction. Subtalar joint motion was recorded as percentages of the uninjured limb and grouped into quartiles. RESULTS: The VAS, SF-36 (p <.0001), and the gait satisfaction score (p <.05) all increased significantly with increasing subtalar joint motion. Satisfaction on the VAS and SF-36 was significantly related to subtalar joint motion for men (p <.0001) and in the age groups 30 to 39 (p <.001) and 40 to 49 years (p <0.05). In non-Workman Compensation Board (WCB) clients, higher subtalar joint motion was significantly related to improved satisfaction on VAS and SF-36 (p <.005). Patient satisfaction was significantly related to subtalar joint motion as measured by the VAS when patients reported pre-injury workloads of moderate (p <.05) or heavy (p <.01) regardless of whether they were treated operatively (p <.05) or nonoperatively (p <.0005). CONCLUSIONS: The amount of subtalar joint motion at least 12 weeks after displaced intraarticular calcaneal fracture is significantly related to patient satisfaction at 2 years regardless of the method of treatment.

Adolescent↗

Contact areas and pressure distributions in the subtalar joint.

We investigated how foot position and ankle arthrodesis affect the contact characteristics of the subtalar joint. Nine fresh-frozen specimens of amputated lower legs were used. Pressure-sensitive films were inserted into the anterior and posterior articulation of the subtalar joint. The contact areas and pressure for various foot positions and under axial loads of 600, 1200, and 1800 N were determined based on the gray level of the digitized film. In neutral position and under a 600 N load, the maximum contact pressure in the subtalar joint was 5.13 +/- 1.16 MPa. The contact area (1.18 +/- 0.35 cm2) was only 12.7% of the whole subtalar articulation area (9.31 +/- 0.66 cm2), and the total force (348.5 +/- 41.7 N) transmitted via this contact area was about 58% of the applied load (600 N). Dorsiflexion of the foot increased the contact area and the force transmitted, but decreased the average contact pressure in the subtalar joint, while the reverse occurred in plantar flexion. Eversion increased the subtalar contact stress, whereas inversion up to 10 degrees decreased it. Ankle joint arthrodesis shifted the contact areas in the subtalar joint posteriorly in all inversion/eversion positions. Moreover, total force transmitted through the subtalar joint as well as the contact pressure increased.

Adult↗

Instability of the subtalar joint. Diagnosis by stress tomography in three cases.

Lateral instability in the subtalar joint was documented by a method of stress tomography in three patients. The subtalar inversion angle averaged 38 degrees +/- S.D. 6 degrees in asymptomatic feet and 57 degrees +/- S.D. 5 degrees in those with unstable subtalar joints . Review of the literature suggests that as many as 10 per cent of patients having the Watson-Jones procedure for abnormal talar tilt also have instability in the subtalar joint. It is felt that the subtalar joint should be evaluated in patients seen with the clinical symptom of lateral instability.

Adult↗

Mechanics of the subtalar joint and its function during walking.

Knowledge of the location of the subtalar joint axis in individual patients would permit clinical assessment of the forces and moments that produce frontal-plane foot and ankle deformities. Biomechanical analysis of the subtalar joint is hindered, however, by the inaccessibility of the talus, which makes locating the joint axis difficult, and by the high degree of intersubject anatomic variation. This article discusses work done with cadaver specimens and using invasive methods in vivo that has enhanced our understanding of the mechanics of the subtalar joint and its function during gait. Also reviewed are investigations of the actions of muscles that cross the subtalar joint.

Biomechanical Phenomena↗

Clinical determination of the linear equation for the subtalar joint axis.

The authors present a methodology to measure the frontal plane angular and linear displacement and the transverse plane angular displacement of subtalar joint movement. This method is combined with a modification of the Kirby method for determining the transverse plane projection of the subtalar joint axis onto the plantar foot. A mathematical model is then used to construct the subtalar joint axis into a three-dimensional linear equation. Data are obtained from an in vivo series of 62 feet that indicates that within acceptable clinical errors of measurement the subtalar joint is a ginglymus type of joint that moves around a single fixed axis. Results also indicate that the subtalar joint axis is more superior and lateral to the neutral foot than any previous studies on cadaver feet have shown. Finally, the authors show that once the subtalar joint axis can be accurately located, the torque on the joint axis produced by ground reactive forces and muscular forces can be computed.

Adolescent↗

Assessment of Ankle-Subtalar-Joint-Complex Laxity Using an Instrumented Ankle Arthrometer: An Experimental Cadaveric Investigation.

OBJECTIVE: To show the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity using a portable ankle arthrometer; to assess within and between-tester measurement reliability; and to determine if the ankle arthrometer can detect increased mechanical laxity of the ankle-subtalar-joint-complex after simulated injury of the lateral ankle ligaments. DESIGN AND SETTING: We used linear regression analysis to examine the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity. An intraclass correlation coefficient (2,1) was calculated to determine intratester and intertester reliability for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, 2 separate, one-way, repeated-measures analyses of variance were used to compare instrumented measures of anteroposterior displacement and inversion-eversion rotation among the intact ankles after sectioning the anterior talofibular ligament and both the anterior talofibular and calcaneofibular ligaments. Data were collected in a biomechanics laboratory setting. SUBJECTS: Six fresh-frozen human-cadaver ankle specimens were studied. MEASUREMENTS: Testing involved the concurrent measurement of tibial-calcaneal bone motion and ankle-subtalar-joint-complex motion during the application of external loads. An instrumented ankle arthrometer was used to load the ankle in a controlled manner. Two spatial kinematic linkages measured the 3-dimensional motion of the calcaneus relative to the tibia and the motion of the arthrometer's footplate relative to the tibia. RESULTS: The correlation between tibial-calcaneal bone motion and instrumented measurement for anterior-posterior displacement was.878 (P =.0001). Its linear relationship with bone motion accounted for approximately 77% of the variance of the instrumented measurement. The correlation between tibial-calcaneal bone motion and instrumented measurement for inversion-eversion rotation was.858 (P =.0001), with approximately 74% of the variance of the instrumented measurement accounted for by its linear relationship with bone motion. High intratester and intertester reliability coefficients (ICC [2,1] =.80 to.97) were observed for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, ligamentous sectioning resulted in significantly increased ankle-subtalar-joint-complex laxity. When compared with the intact condition, sectioning both the anterior talofibular and calcaneofibular ligaments produced significant increases in anterior-posterior displacement (P =.0001) and inversion-eversion rotation (P =.002). CONCLUSIONS: We found a strong relationship between tibial-calcaneal bone motion and arthrometric measurements of ankle-subtalar-joint-complex laxity. The instrumented ankle arthrometer may be suitable as a diagnostic tool for the evaluation of lateral ankle-ligament laxity.

Journal Article↗

Effects of simulated genu valgum and genu varum on ground reaction forces and subtalar joint function during gait.

The mechanical effects of genu valgum and varum deformities on the subtalar joint were investigated. First, a theoretical model of the forces within the foot and lower extremity during relaxed bipedal stance was developed predicting the rotational effect on the subtalar joint due to genu valgum and varum deformities. Second, a kinetic gait study was performed involving 15 subjects who walked with simulated genu valgum and genu varum over a force plate and a plantar pressure mat to determine the changes in the ground reaction force vector within the frontal plane and the changes in the center-of-pressure location on the plantar foot. These results predicted that a genu varum deformity would tend to cause a subtalar pronation moment to increase or a supination moment to decrease during the contact and propulsion phases of walking. With genu valgum, it was determined that during the contact phase a subtalar pronation moment would increase, whereas in the early propulsive phase, a subtalar supination moment would increase or a pronation moment would decrease. However, the current inability to track the spatial position of the subtalar joint axis makes it difficult to determine the absolute direction and magnitudes of the subtalar joint moments.

Adolescent↗

Posterior subtalar joint synoviography and corticosteroid injection in rheumatoid arthritis.

Ten posterior subtalar joints of 8 patients with rheumatoid arthritis and 12 posterior subtalar joints of 6 cadavers were studied by contrast synoviography. In the rheumatoid group the abnormalities included posterior capsule distension, filling defects caused by hypertrophic synovitis, limited or irregular filling of the anterior recess of the joint in 5 out of 10, and communication with the ankle joint in 3 out of 10. None of the cadaveric joints showed posterior capsule distension or limited or irregular filling of the anterior recess of the joint, but communication with the ankle was present in 2 joints. The joints of the patients were injected with a 1:1 mixture of sodium iothalamate 70% (Conray 420) and triamcinolone hexacetonide (Lederspan) 20 mg/ml. All patients noticed a decrease in and an improvement in walking beginning 24-48 hours after the examination. Quantitative thermography was done immediately before and 1 after injection in 2 patients who showed an improvement in thermographic index. We conclude that hindfoot inflammatory pain arising from the posterior subtalar joint is caused by distension with hypertrophic synovitis which can be difficult to detect clinically.

Adult↗

Occult osteochondral fractures of the subtalar joint: a review of 10 patients.

Ten patients were treated who had occult osteochondral fractures of the subtalar joint that were not associated with dislocation. Nine osteochondral fractures involved the posterior facet. Seven patients had a stiff and painful subtalar joint, and an arthrodesis was performed. Three patients presented with adequate subtalar joint motion and were treated with physiotherapy. Detection of osteochondral fractures of the subtalar joint is difficult. The "early warning" signs are massive swelling without definitive bone injury on radiographic examination, and a failure to regain subtalar motion after a period of immobilization. Confirmatory evidence is obtained from CT scans or MRI. Initially, aggressive physiotherapy should be considered. Arthrodesis should be used for patients who remain symptomatic.

Adult↗

Closed kinetic chain tarsal mechanics of subtalar joint arthroereisis.

The weightbearing biomechanics of the tarsus with and without subtalar joint arthroereisis was investigated in 11 fresh frozen cadaver specimens using a three-dimensional (3-D) radiowave tracking system. Specimens, consisting of the distal half of the tibia and fibula and the intact ankle and foot, were mounted on a nonmetallic loading frame test system that allowed positioning of the foot to simulate midstance position of gait. The tibia was axially loaded to 756 N (one bodyweight) with 15% of the total load diverted through the fibula. Receiving transducers were attached to the talus, navicular, calcaneus, and cuboid bones. Tarsal movements were monitored as the specimen was loaded with and without subtalar joint arthroereisis. Three-dimensional data sets of osseous positions and orientations were collected and analyzed. Significant rotational differences were detected with and without subtalar joint arthroereisis for all four tarsal bones (p < or = 0.05). Tarsal translational position changes were small and not statistically significant.

Arthrodesis↗