Tibiotalocalcaneal arthrodesis.

The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

Metatarsal osteotomy for primary metatarsalgia: radiographic and pedobarographic study.

The effect of surgical procedures for primary metatarsalgia on the load distribution and bony architecture of the forefoot is poorly understood. A prospective study was performed on 45 feet with this diagnosis treated by dorsal wedge osteotomy and compared with 29 symptom-free contralateral feet. Each foot was evaluated preoperatively and postoperatively with quantitative radiographic analysis, a pedobarographic study, and by physical examination. Following osteotomy there was a 4.5-mm increase in average height from ground and a 7.0 psi decrease in pressure. The symptom-free control group demonstrated no statistically significant changes. Residual pain occurred with an average height increase of less than 3.5 mm and an average pressure decrease of less than 1.5 psi. Transfer lesions developed in three of four patients with a height increase of greater than 4.5 mm. The symptoms of metatarsalgia are altered by changes in height of the metatarsal or the pressure beneath it. It is not possible to predict the surgical elevation of the metatarsal head required to precisely decrease the pressure beneath the metatarsal head, thereby eliminating symptoms.