Lawrence DiDomenico, DPM, FACFAS reviews arthrodesis in flatfoot deformities, relating the evaluation, indications, procedures, fixation techniques, post-operative care and goals. Dr DiDomenico supports his discussion with multiple case examples.
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Lawrence DiDomenico, DPM
Kent State University College of Podiatric Medicine
Chief Section of Podiatric Medicine & Surgery
St. Elizabeth Health Center
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Male Speaker 1: So, Harold asked me to talk about arthrodesis for flatfoot deformities, wide array of topics. So I’m going to try to stick to some principles and go through a bunch of cases in 20 minutes. So the goal is trying to only fuse non-essential joints. So if you haven’t followed Ted Hansen’s work, I would advise you to follow it. I think it’s tremendous amount of work. He talks about essential joints and non-essential joints. Your patients who have non-essential joint fusions following surgery do much better than ones who have essential joint fusions. Sometimes, you have to sacrifice the essential joint fusions. It’s a much more friendlier long-term outcome for patients. All deformities are triplanar. There’s not a procedure that we do that’s just one or two planes, it’s always a three-plane procedure. And you have to keep that in mind when you try to perform the corrections. So the challenge is, for you young folks in the audience, is to figure out which joints to fuse when you have a flatfoot deformity. Focus on attempting not to fuse the essential joints, as I’ve said, because that will make a much better improvement for your patients, post-operatively. Then the hard problem is to figure out how many joints to fuse. So we have many bones and many joints in the foot, particularly when you’re talking about a PT 10 dysfunction of stage 3, or so, or even 2 for that matter. Which joints do you fuse? And it’s hard to figure out, but you have to figure that out. And you obviously want to fuse as little as you can. And hard to figure out how many, I'm sorry, how to figure how to fuse one, it may affect another one. So if you fuse one, it will have a long-term affect on the others, what I’m about to say on that. So weight bearing, I’m sorry, evaluation of consistent of weight bearing. X-rays, you want AP, AP medial oblique and lateral x-rays of the foot, ankle, as well as calcaneal and posterior alignment is usually what you’d like to get. Clinical exam is very important. Have your patients stand, watch them ambulate. You really need to do that and evaluate the posterior muscle group. And if you’re not a believer in the equinus, I believe the equinus is a huge component of these flatfoot procedures. I really don’t see how you can correct or how one can correct this adequately without adjusting the equinus component of it. And you have to look at your soft tissues. As I’ve said are already gastroc or TALs are, I believe, a large component of it. Particularly, gastroc, I think gastroc is probably 90% of equinus deformities. Do you need it to perform FDL transfer, a kid or Young’s? I will tell you myself, I’ve gotten away from that recently published paper shown for stage 2 PT 10 dysfunction. We don’t find any need to do the soft tissue transfers at all with these procedures. And again, save your patients another incision, another morbidity associated with post-operative care. And I used to do these procedures. I don’t think these are necessary due or anything else along those lines. This is really addressing the boney problems. So, boney procedures, you always want to start proximal and work distal. Treat all three planes as we said. Evaluate each joint in all sort of in a relay sort of like a domino effect. You have to be very cognizant of that and you have to understand how they affect one another, and your column lengths. And you’re going to look at your middle column or lateral column when you look at your AP views, interoperatively as well as preoperatively and postoperatively so that you know, excuse me, that you have the appropriate lengths of your columns. Your joint preparation, to me, this is one area I spend most of my time. So for me, dissection, I’m usually down to my bone and my joint within a minute or two minutes. Really, soft tissue dissections are overrated. You make your skin incision, watch out for your neurovascular bundles and get down to your joint. Leave the periosteum alone, leave everything else alone. Just track in the area you need to focus on which is the joint. And to get down in your joint, spend the time, and I spend most my time preparing the joint, so I don’t get a nonunion. This is where you spend a tremendous amount of your time. The other amount time we spend is preparing our construct. Short of that, you should be really fooling around a whole lot with dissection. And I use curettes, picks, drills, osteotomes, rongeurs every single time. So I make sure I have good bleeding bone before I attempt to do an arthrodesis on these patients. Fixation. The other most important part, as I’ve said, your fixation construct, how you put the screw, what kind of screw, what your host patient look like. Things we talked about the [indecipherable] [04:06]. This is very important. If you’re putting screws and you’re throwing them in there, it doesn’t make sense. You’re just putting cannulated screws in there very easily. Certainly, if you want to keep your patients non-weight bearing in a cast for eight weeks or so, that works fine. But if your goal is to get your people up and moving and get more functional sooner, then really your fixation is very important and your thinking process for your fixation and selection process is very important. Which side do you apply your fixation to? For example, a planar plate is really the most appropriate side to apply fixation to. What is the cost of fixation? You have to be very aware of that today as a cost. You have to keep in mind what the risk and benefits to get people moving versus cost, how much you’re using, what kind of procedures you’re doing, and then how long you mobilized them. Certainly, DVT. PEs are minimal risk than foot and ankle surgery, but they do occur. And then like I said, it’s a numbers game. If you do enough surgery practice, you’re going to have patients with this type of complications.
Postoperative care. Mobilization. How long? How big of a cast? How compliant is your patient. So you have to keep these things in mind when you’re doing these flatfoot procedures. Bandage change. One, I don’t change my post-op bandage for two weeks, maybe sometimes 17 days. I found out and learned this over in Europe, that if you leave that, your natural growth factors in your natural blood. And why disrupt it? Every time you take off that bandage, you’re disrupting those growth factors, disrupting that wound healing process. Unless you have a reason, there’s a compliant by a patient, there’s an odor, or there’s chills, or fever, anything like that, trust your incision, you’re in the most sterile environment when you applied that and that should still be sterile for that time process. So if you’ve handled things appropriately, leave your bandage change, I think you’ll see a better long-term which are bandage change is being and less edema. Prophylaxis. Again do DVT prophylaxis, antibiotic prophylaxis, things to think about in your postoperative course of physical therapy, do perform that. So predictability outcome, reoccurrence, pain and function. Our goal is to reduce pain, improve function. Keep people up and moving as quickly as we can. Failures are when we obtain non-unions, pain and decreased nerve function. That makes for an angry patient or a very unhappy patient in everybody’s office and nobody wants that. So the idea is to correct the deformity, make a plantigrade tripod food. That’s our whole goal. Correct the instability and provide pain relief with arthrosis or any instability that the patient has over a period of time. So I’m going to start and try to work through the foot and so a big topic to cover in another 15 minutes. But really for stage 4 PT 10 dysfunction, these are for the patients who end up with significant valgus deformity of their ankle. So they have all the other affects as you see are going on. They may have a genu valgum that you have to take into consideration as well. You have to look at their hips and knees as well that may be causing this problem. But this is what these patients look like. They got end stage arthritis where you have bone on bone. They have maybe some other peritalar subluxation along. But the tibiotalar joint is the area that’s in valgus. You have middle deltoid insufficiency that occurs with these patients. Stage 1 and 3, as we know, John Strom described them. In stage 4, Myerson described it as ankle valgus with a significant valgus deformity. And here’s the Johnson stroma labeling or I’m sorry [indecipherable] [07:19]. So we’re going to talk about stage 4. What do you do? Valgus talus in early generation of ankle with middle deltoid insufficiency, this patient is starting to break down, right here, is what you see, how do you handle this. And as far as I know, there is not a predictable soft tissue procedure out there that we can get the patients squared away with which is doing soft tissue. If there was, let me know because certainly there’s not one that’s very predictable. Sometimes, you get one to work. Really unfortunately, that’s a bit troublesome. It’s a very complex patient for us to handle in the idea of trying to handle this through soft tissue. Obviously, non-operative care consists of anti-inflammatory drugs, AFOs, different devices like that. One muscle has to oppose your muscle and anything with this in order to get to heal back here at the leg. And eventually, what you don’t want to do is end up with pantalar arthrodesis because there’s nothing worst to do performing a pantalar on a patient who is non-neuropathic because these patients have nowhere to go but more pain eventually. So that’s your goal is not to obtain that. But when you have this middle deltoid insufficiency, you have this valgus rotation of this ankle, really there’s nothing more that I know of than to predictably perform a fusion on these patients. You see this end stage here. These ligaments are gone. We don’t have a way to hold this load of this axial load coming down here through this because the calcaneus slides lateral to the long axis of the tibia. So this is a very difficult patient to handle long term as you can see the joint spaces here. And typically once that happens, you start seeing collapsed around the entire area, and these are the patients, what do you do? And again our goal is to try avoid a pantalar. There’s many different types of fixation techniques. Here, we can see [indecipherable] [08:57] but there’s a number of different things you can use as your options. Here’s another case showing you significant valgus deformity. You see the peritalar subluxation. You can see the change of flatfloot on a lateral x-ray. So in this patient what we try to do is limit the amount of essential joints uninvolved which is a tibiotalar joint. And then, as you can see here, shows some valgus, that much necrosis. So we bone grafted this area. Try to leave the subtalar joint free. We did a calcaneal slide osteotomy, minimally invasive type of approach. And then we perform a talonavicular arthrodesis on her, trying to get the calcaneus more underneath the line of the tibia. And that’s the goal is try to leave some of these essential joints open so the patient can function a little better rather than a pantalar arthrodesis and try to get the alignment reduced to more or the patient has a better outcome of the foot. Here’s another patient. You can see significant valgus forming in the right. You can see bone of the fibula from the significant valgus, peritalar subluxation occurring with it. You can see the TN joint, dislocation occurring here. The whole foot is spun around at talus. Talus really doesn’t move, everything else moves around it below the talus, that is.
And here we perform a tibiotalar in a calcaneal slide. And a TN arthodesis, again, leaving some of the joints free to pick up some micromotion or some motion in the foot. Here’s a significant pathology, patient who had tibial nonunions, patients who had previous wounds, multiple skin disease and most other pathologies, severely ostropenic. You can see the alignment is severe. First patient was below the amputation. She refused. You can see significant arthrosis, previous work done in the fibula. And basically what we do is stage this procedure, did some osmosis fusion, tibiotalar fusion. And you can see by getting the foot underneath the leg, you can see some of the joints open up. Basically, the calcaneal slide and the medial plating column, not the prettiest-looking foot but we got a much better and much more erect, given the fact what we’re working with into alignment. Here, on this patient, the first ray again is elevated, looks long on the first metatarsal. And this patient had a cartilaginous coalition here, the subtalar joint as well as navicular calcaneal form instability. And basically, the subtalar joint fusion, as well as medial column work at the naviculocuneiform form leaving the talonavicular CC joint open as well as the other essential joints in the foot. Here’s another patient with significant arthrosis, subtalar joint as well as the midfoot, same type of approach, subtalar joint and metatarsal joint. One thing that we used to do in the early 2000s was CC joint or distraction arthrodesis. I would tell you not to do those anymore. These are much more difficult, higher rates of nonunion, can be painful if you don’t get it exactly right. I think the Evans procedure provides you much more options. So we try to avoid that when we can. Here’s another patient trying to avoid triple arthrodesis. It may be used in a lateral column lengthening of Evans. As you can see, calcaneal slide use a dual-function screw here, so it’s intramedullary. TN fusion is stabilized in TMT1, getting the Meary’s angle and the calcaneal pitch, you can get your alignments all back there, leaving some of the joints free, trying to avoid as many midfoot arthodesis as we can. And you can see you can achieve that with a lot of different ways. Here, a lot of people were starting to use the medial double approach, pretty significant valgus deformity. The subtalus head is sticking through. You can see significant deformities talonavicular joint as well as the subtalar joint. Here we check the ankle joint is okay, so there’s no PT 10 or there’s no stage 4 involvement. Everything is below the talus which makes it a lot easier for us but a lot to correct yet. And here you can see the bulging of the talar head sticking through when the patient is asleep. It’s just complete instability of this foot. It’s like a loose bag of bones. The talar head pops right out. The foot deviates laterally. So basically, we need to stabilize this whole foot. So basically, we did a medial double, make our medial approach. Subtalar joint fusion, TN joint and TMT1 fusion to stabilize the tripod effect. As you can see, loading the foot, now you can see the foot underneath the leg. If you look back at the pre-op x-rays, the lateral view, the overlapping of the hindfoot and midfoot joints are there. Here, you can see now loading it with a mallet. You can see our alignments here by doing a posterior muscle relief, release being able to get the foot underneath the leg into maintaining alignment into the foot to a much better area. Medial column fusions. One needs to go through and look at each one of these joints, look at adjunctive procedures. Again, the debridement is joint preparation is key. There’s [indecipherable] [13:18] techniques, there’s resection techniques as well, and then your internal fixation, which we very lightly talked about is a technique that we need to know about in your postoperative course changes based on what you’re using. Complication as same as any other. Again, I really have gotten away from doing a lot of these procedures. I really don’t think these really have much role in it. I think they just cause more scar tissue, more potential morbidity for your patients, really sticking to more boney procedures, getting the foot underneath the leg, as you see, significant arthrosis through these patients. So we know the indications for the surgeries. I try to use screw and plate fixation and getting used large long cortical screws. Length is your key. You get more leverage out of these screws and more purchase power on these screws. As you see collapsing feet like this, you need to have visibility in order to hold up this weight over a long term. Here, you can see midfoot sagging. If you’re willing to changing the calcaneal pitch and the Meary’s angle associated with it. And you see the arthrosis. And so the hard part is figuring out which joints to fuse, how much and when to do it. And here you can see patients, again, of flatfoot deformities. And here, we did a calcaneal slide percutaneously, dash like endoscopically. So we’re really stuck with one major incision which makes it a lot easier for us taking out the joint. And here we’re really preparing our joint as we said. We spend a lot of time debriding this, didn’t line up, [indecipherable] [14:36], pin it and use our solid cortical screws through percutaneous incisions in our fixation, where we want to have it there with nice solid cortical screws. And you get your fixation through very, very nicely, and you get the good results. Here’s another gentlemen here with the flatfoot deformities, a more [indecipherable] [14:49] talonavicular joint. NC sag, basically did double calcaneal osteonomy, gastroc and the navicular caneal fusion. Non-essential joints, this people function very well when you don’t affect, don’t know how to find such joints.
But you can see a tremendous change in calcaneal pitch and the Meary’s angle in with the P view. Then you can use some neuropathic patients like, as you can see, with changes in the midfoot, and use a planar plate, works fantastic. It’s a tetra side of the foot and you put a planar plate along the middle aspect of the foot, crossing compression screws outside of the plate, giving you a good fixation through it there. Here’s another patient. As you can see, just using screw technique. Double calcaneal osteonomy, gastroc lengthening, the entire middle column fusion, long shelled cortical screws. As you can see, the changes you can achieve with this. Here, you can see the peritalar subluxation. But leaving the essential joints free and fusing all the non-essential joints here, these patients function much better postoperatively. Here’s another neuropathic patient with significant arthrosis, lesser metatarsal fracture, the area of lesser metatarsals. The calcaneal pitch and Meary’s angle again is off and basically using a homerun screw. A solid cortical screw all the way, homerun screw, all the way down the middle column and supplement with a planar plate in addition in bone graft. And you could see the changes postoperatively, giving you a stable plantigrade osseous union. Here’s another patient, again, with a severely PT 10 dysfunction and you can see the changes throughout the midfoot and hindfoot. And it looks like he needs a triple arthrodesis but oftentimes you can avoid this. Here, we did a gastroc, we did a calcaneal slide with a Gigli saw. We did, I think, an Evans procedure also. So double calcaneal osteotomy, ended up TN fusion and left the subtalar joint and the CC joint alone. And we accomplished our goal with restoring the arch of the foot may give soft tissues mechanical advantage again. Again, I would avoid doing the CC distraction arthrodesis but you can see middle column work being in conjunction with that. Here’s another example of just showing you middle column work done along with the calcaneus, really is done as an isolated procedure. Here’s a patient, flatfoot deformity, peritalar sublaxation. Which joints do you fuse here? It’s a type of thing, interoperatively, you have to check on the table. Going into the side, I was thinking I might have to do a TN fusion here, right? So interoperatively, I realized the TM was stable enough, it was the midfoot. I tested the midfoot, brought it through the range of motion, locked everything up, did my double calcaneal slide, calcaneus. And here, this picture is probably about three years out now. Postoperatively, my subtalar joint, my TN joint, my CC joint are all free. They function much better in a platigrade stable foot. Here, you could see, using a frag compression screw with locking plates over top of it, using Evans, and see fusion with the calcaneal slide. For some of you, this little more, just take you through a bunch more cases. Here’s middle column fusions. Looking plates changing. So it’s really something you have to work your way through, getting through all of these different joints to maintain good alignment so you can get these feet back underneath the ground. Here’s a classic foot. It looks like she will need a triple arthrodesis, significant arthrodesis. But once you get it realigned, you can see the joints up and back up and you can get nice better architecture of these patients. So I think I’m going to face up here, just running through these slides. There’s one more case. This is a neuropathic patient with ulcerations in her foot. For significance, destabilization instability. You can see the way weight-bearing areas of the foot. So you would think this needs a tremendous amount of work. And really, it’s not as bad as you think but it’s really, I say, which joints need to be fixed. And basically, what I want to do is just basically stabilize all this instability, get that posterior muscle lengthening done, and basically what we do, we put an [indecipherable] [18:30] on her, make sure infection was clear, first get bone biopsy cultures, left it on, let this wound healed before we went into the surgery. After we did the surgery, we went and do the calcaneal slide. You can see, and we did a middle column fuse to open down her middle column, took all of the disease bone, shorten the foot. We stabilized the lateral column to lengthen than, got her foot around her talonavicular joint. And here, she looks like post operatively long-term healing both of these wounds on her feet. So it’s a lot to cover a short of period of time, but I’d like to thank Harold for inviting me to come back and speak. Thank you.