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1.  A Pediatric Comminuted Talar Fracture Treated by Minimal K-Wire Fixation Without Using a Tourniquet 
The Iowa Orthopaedic Journal  2014;34:175-180.
Pediatric comminuted talar fractures are reported to be rare, and treatment options such as minimal internal K-wire fixation without using a tourniquet to prevent avascular necrosis have not previously been investigated.
Case Description
We report a case of a comminuted talar body and a non-displaced neck fracture with dislocation of the tibiotalar, talonavicular and subtalar joints with bimalleolar epiphyseal fractures in an 11-year-old boy due to a fall from height. We present radiological findings, the surgical procedure and clinical outcomes of minimal internal K-wire fixation without using a tourniquet.
Literature Review
Avascular necrosis rates are reported to be between 0 % and 66 % after fractures of the neck of the talus and the talar body in children. The likelihood of developing avascular necrosis increases with the severity of the fracture.
Clinical Relevance
To avoid avascular necrosis in a comminuted talar fracture accompanied by tibiotalar, talonavicular, subtalar dislocations and bimalleolar epiphyseal fractures, a minimal internal K-wire fixation without the use of a tourniquet was performed. The outcome was evaluated by the American Orthopedic Foot and Ankle Society score (AOFAS). A score of 90 (excellent) was found at the end of the second year of follow up. Radiology revealed preservation of the joint with no evidence of avascular necrosis, and clinical findings revealed a favorable functional outcome after two years.
Level of Evidence
PMCID: PMC4127733  PMID: 25328479
talus; fracture healing; tourniquets; avascular; necrosis
2.  Closed subtalar dislocation with non-displaced fractures of talus and navicular: a case report and review of the literature 
Cases Journal  2009;2:8793.
Closed subtalar dislocations associated with talus and navicular fractures are rare injuries. We report on a case of a 43-year-old builder man with medial subtalar dislocation that was further complicated by minimally displaced talar and navicular fractures. Successful closed reduction under general anesthesia was followed by non-weight bearing and ankle immobilization with a below-knee cast for 6 ;weeks. At 3 years post-injury, the subtalar joint was stable, the foot and ankle mobility was in normal limits and the patient could still work as a builder. However, he complained for occasionally mild pain due to the development of post-traumatic arthritis in subtalar and ankle joints. Our search in literature revealed that conservative treatment of all the successfully reduced and minimally displaced subtalar fracture-dislocations has given superior results compared to surgical management. However, even in cases with no or slight fracture displacement, avascular necrosis of the talus or arthritis of the surrounding joints can compromise the final functional outcome.
PMCID: PMC2769472  PMID: 19918402
3.  Anteromedial subtalar dislocation 
BMJ Case Reports  2013;2013:bcr0320123973.
Subtalar dislocation is the simultaneous dislocation of the talocalcaneal and talonavicular joints of the foot, typically caused by falls from heights, twisting leg injuries and motor vehicle accidents. The dislocation can occur medially, lateral, anterior or posterior, but most commonly occurs from inversion injury producing a medial dislocation. These dislocations may be accompanied by fractures. Careful physical examination must be performed to assess for neurovascular compromise. Most subtalar dislocations can be treated with closed reduction under sedation. However, if the dislocation is associated with an open fracture it may require reduction in the operating room. Treatment should include postreduction plain x-ray and CT scan to evaluate for proper alignment and for fractures. This article presents a case of medial subtalar dislocation in a 23-year-old football player.
PMCID: PMC3603425  PMID: 23355551
4.  Closed medial total subtalar joint dislocation without ankle fracture: a case report 
Total subtalar dislocation without fracture of the ankle is a rare clinical entity; it is usually due to a traumatic high-energy mechanism. Standard treatment is successful closed reduction under general anesthesia followed by non-weight bearing and ankle immobilization with a below-knee cast for 6 weeks.
Case presentation
We present the case of a 30-year-old Moroccan woman who was involved in a road traffic accident. She subsequently received a radiological assessment that objectified a total subtalar dislocation without fracture of her ankle. She was immediately admitted to the operating theater where an immediate reduction was performed under sedation, and immobilization in a plaster boot was adopted for 8 weeks. The management of this traumatic lesion is discussed in the light of the literature.
Medial subtalar dislocation is a rare dislocation and is not commonly seen as a sports injury because it requires transfer of a large amount of kinetic energy. The weaker talocalcaneal and talonavicular ligaments often bear the brunt of the energy and are more commonly disrupted, compared to the relatively stronger calcaneonavicular ligament. Urgent reduction is important, and closed reduction under general anesthesia is usually successful, often facilitated by keeping the knee in flexion to relax the gastrocnemius muscle. Long-term sequelae include talar avascular necrosis and osteochondral fracture, as well as chronic instability and pain.
PMCID: PMC4178312  PMID: 25240955
Ankle; Dislocation; Subtalar joint
5.  Neuropathic midfoot deformity: associations with ankle and subtalar joint motion 
Neuropathic deformities impair foot and ankle joint mobility, often leading to abnormal stresses and impact forces. The purpose of our study was to determine differences in radiographic measures of hind foot alignment and ankle joint and subtalar joint motion in participants with and without neuropathic midfoot deformities and to determine the relationships between radiographic measures of hind foot alignment to ankle and subtalar joint motion in participants with and without neuropathic midfoot deformities.
Sixty participants were studied in three groups. Forty participants had diabetes mellitus (DM) and peripheral neuropathy (PN) with 20 participants having neuropathic midfoot deformity due to Charcot neuroarthropathy (CN), while 20 participants did not have deformity. Participants with diabetes and neuropathy with and without deformity were compared to 20 young control participants without DM, PN or deformity. Talar declination and calcaneal inclination angles were assessed on lateral view weight bearing radiograph. Ankle dorsiflexion, plantar flexion and subtalar inversion and eversion were assessed by goniometry.
Talar declination angle averaged 34±9, 26±4 and 23±3 degrees in participants with deformity, without deformity and young control participants, respectively (p< 0.010). Calcaneal inclination angle averaged 11±10, 18±9 and 21±4 degrees, respectively (p< 0.010). Ankle plantar flexion motion averaged 23±11, 38±10 and 47±7 degrees (p<0.010). The association between talar declination and calcaneal inclination angles with ankle plantar flexion range of motion is strongest in participants with neuropathic midfoot deformity. Participants with talonavicular and calcaneocuboid dislocations result in the most severe restrictions in ankle joint plantar flexion and subtalar joint inversion motions.
An increasing talar declination angle and decreasing calcaneal inclination angle is associated with decreases in ankle joint plantar flexion motion in individuals with neuropathic midfoot deformity due to CN that may contribute to excessive stresses and ultimately plantar ulceration of the midfoot.
PMCID: PMC3616933  PMID: 23531372
Foot alignment; Deformity; Ankle and foot joint goniometry; Limited joint mobility
6.  Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction 
The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture.
Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery.
The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case.
Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.
PMCID: PMC2837861  PMID: 20187969
7.  Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia 
Clinics in Orthopedic Surgery  2010;2(1):13-21.
There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft.
Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated.
All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively.
Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.
PMCID: PMC2824090  PMID: 20190996
Pes planovalgus; Cerebral palsy; Subtalar joint; Arthrodesis; Extraarticular
8.  Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results 
Subtalar dislocation is a rare injury, with the medial type occurring in the majority of cases. The period of postreduction immobilization is a matter of controversy. Most studies set the period of immobilization between 4 and 8 weeks. The hypothesis in this study is that a period of 2–3 weeks of immobilization in a cast, followed by early mobilization, could provide better functional results than longer periods of immobilization.
Materials and methods
During a period of 4 years, eight patients (six men, two women) with mean age of 37.2 years and uncomplicated medial subtalar dislocation were treated in our institution. Immediate reduction under sedation and cast immobilization was provided in all cases. Our rehabilitation protocol consisted of two completed weeks of immobilization and thereafter ankle range-of-motion exercises and partial weight-bearing mobilization. Patients were followed up for a mean period of 3 years. Clinical results were evaluated using the AOFAS Ankle–Hindfoot scale.
All patients achieved almost normal ankle range of motion and good clinical outcome (mean AOFAS score 92.25). No radiographic evidence of arthritis or avascular necrosis of the talus was detected. Two patients complained of mild pain of the hindfoot. All patients returned to daily routine activities in about 2 months from injury.
Immediate reduction and early mobilization could be key factors for uneventful recovery of uncomplicated medial subtalar dislocation. Multicenter clinical trials are needed for further validation of our initial results.
Level of evidence
III, prospective clinical series study.
PMCID: PMC3052431  PMID: 21308390
Subtalar joint; Dislocations; Ankle; Foot; Rehabilitation
9.  Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results 
Subtalar dislocation is a rare injury, with the medial type occurring in the majority of cases. The period of postreduction immobilization is a matter of controversy. Most studies set the period of immobilization between 4 and 8 weeks. The hypothesis in this study is that a period of 2–3 weeks of immobilization in a cast, followed by early mobilization, could provide better functional results than longer periods of immobilization.
Materials and methods
During a period of 4 years, eight patients (six men, two women) with mean age of 37.2 years and uncomplicated medial subtalar dislocation were treated in our institution. Immediate reduction under sedation and cast immobilization was provided in all cases. Our rehabilitation protocol consisted of two completed weeks of immobilization and thereafter ankle range-of-motion exercises and partial weight-bearing mobilization. Patients were followed up for a mean period of 3 years. Clinical results were evaluated using the AOFAS Ankle–Hindfoot scale.
All patients achieved almost normal ankle range of motion and good clinical outcome (mean AOFAS score 92.25). No radiographic evidence of arthritis or avascular necrosis of the talus was detected. Two patients complained of mild pain of the hindfoot. All patients returned to daily routine activities in about 2 months from injury.
Immediate reduction and early mobilization could be key factors for uneventful recovery of uncomplicated medial subtalar dislocation. Multicenter clinical trials are needed for further validation of our initial results.
Level of evidence
III, prospective clinical series study.
PMCID: PMC3052431  PMID: 21308390
Subtalar joint; Dislocations; Ankle; Foot; Rehabilitation
10.  Weaver syndrome associated with bilateral congenital hip and unilateral subtalar dislocation 
Hippokratia  2010;14(3):212-214.
Background: Weaver syndrome is a congenital paediatric syndrome characterized by mental, respiratory and musculoskeletal manifestations. The coexisting deformities of the skull, the face, fingers and toes are typical. We report a case of a girl with Weaver syndrome associated with rare bilateral congenital dislocation of the hips associated with congenital hypoplastic talus and subtalar dislocation of her ankle joint.
Case Report: A 3-year old girl was admitted in our department with typical manifestations of Weaver syndrome, associated with congenital dislocation of bilateral hips, hypoplastic talus and subtalar dislocation of her right ankle. She was in pain while standing upright and incapable of independent walking. Both hips were treated operatively with open reduction and bilateral iliac osteotomy. Two years afterwards she had an open reduction of her talus and extraarticular arthrodesis of her subtalar joint in her right ankle. Six years postoperatively after the hip operations and four years after the ankle operation the girl is ambulant with a painless independent and unaided walking with a mild limp and full range of movements in all the operated joints.
Conclusions: We suggest that children with Weaver syndrome and disabling musculosceletal deformities, particularly affecting their ability to stand up and walk should be treated early, before bone maturity, in order to achieve the best potential musculoskeletal as well as developmental outcome.
PMCID: PMC2943362  PMID: 20981173
Weaver Syndrome; congenital dislocation; hip; ankle
11.  Flatfoot in Müller-Weiss syndrome: a case series 
Spontaneous osteonecrosis of the navicular bone in adults is a rare entity, known as Müller-Weiss syndrome. We report here on our experience with six patients with Müller-Weiss syndrome accompanied by flatfoot deformity, but on a literature search found no reports on this phenomenon. Because the natural history and treatment are controversial, an understanding of how to manage this deformity may be helpful for surgeons when choosing the most appropriate operative procedure.
Case presentation
Six patients (five women, one man; average age, 54 years) with flatfoot caused by osteonecrosis of the navicular bone were followed up between January 2005 and December 2008 (mean follow-up period, 23.2 months). Conservative treatment, such as physical therapy, and non-steroidal anti-inflammatory drugs were used, but failed. Physical examinations revealed flattening of the medial arch of the involved foot and mild tenderness at the mid-tarsal joint. Weight-bearing X-rays (anterior-posterior and lateral views), computed tomography, and MRI scans were performed for each case. Talonavicular joint arthrodesis was performed in cases of single talonavicular joint arthritis. Triple arthrodesis was performed in cases of triple joint arthritis to reconstruct the medial arch. Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale; the scores were 63.0 pre-operatively and 89.8 post-operatively. All patients developed bony fusion.
The reason for the development of flatfoot in patients with Müller-Weiss syndrome is unknown. Surgical treatment may achieve favorable outcomes in terms of deformity correction, pain relief, and functional restoration. The choice of operative procedure may differ in patients with both flatfoot and posterior tibial tendon dysfunction.
PMCID: PMC3459784  PMID: 22853553
Flatfoot; Müller-Weiss syndrome; Navicular
12.  Arthrodesis of the talonavicular joint using angle-stable mini-plates: a prospective study 
International Orthopaedics  2012;36(12):2491-2494.
The talonavicular joint is a central connection of the human foot. Symptomatic talonavicular arthritis can be adequately addressed by isolated talonavicular fusion. However, non-union remains a relevant clinical challenge to the orthopaedic surgeon. The aim of this study was to analyse the clinicoradiological outcome of talonavicular fusion using angle-stable mini-plates.
We performed 30 talonavicular fusions in 30 patients (12 male, 18 female) with a mean age of 58.8 years (range, 22–74) between 2005 and 2007. Osseous joint fusion was achieved using mono- and multidirectional angle-stable mini-plates. The patients followed a standardised immobilisation and weight bearing protocol. The mean postoperative follow up was 15.8 months (6.1–23.8).
The American Orthopedic Foot and Ankle Society AOFAS score increased significantly from 31.7 (19–42) to 82.3 points (55–97) (p < 0.001). Neither age at operation nor gender influenced the score results significantly, while the aetiology of talonavicular degeneration showed a significant effect. Mean visual analogue scale (VAS) pain intensity (0–10) reduced from 8.6 to 1.7 (p < 0.001). Good or excellent results were achieved in 26 patients, while two patients reported fair and another two poor results. Complete osseous fusion was observed at a mean of 10.9 weeks (8–13) postoperatively.
For the treatment of talonavicular arthritis, the application of mono- and multidirectional angle-stable mini-plates provided a strong fixation that led to high union rates and good to excellent overall outcome.
PMCID: PMC3508057  PMID: 23052279
13.  Biomechanical and Neuromuscular Effects of Ankle Taping and Bracing 
Journal of Athletic Training  2002;37(4):436-445.
Objective: An extensive review of clinically relevant research is provided to assist clinicians in understanding the underlying mechanisms by which various ankle-support systems may provide beneficial effects. Strategies for management of different types of ankle ligament conditions are also discussed.
Background: Much of the literature pertaining to ankle instability and external support has focused on assessment of inward displacement of the hindfoot within the frontal plane. Some researchers have emphasized the importance of (1) pathologic rotary displacement of the talus within the transverse plane, (2) the frequent presence of subtalar joint ligament lesions, and (3) the interrelated effects of ankle support on deceleration of inversion velocity and facilitation of neuromuscular response.
Description: The traditional method for application of adhesive tape to the ankle primarily restricts inward displacement of the hindfoot within the frontal plane. The biomechanical rationale for a method of ankle taping that restricts lower leg rotation and triplanar displacement of the foot associated with subtalar motion is presented.
Clinical Advantages: The lateral subtalar-sling taping procedure may limit strain on the anterior talofibular ligament associated with subtalar inversion, restrain anterolateral rotary subluxation of the talus in the presence of ligament laxity, and protect the subtalar ligaments from excessive loading. The medial subtalar sling may reduce strain on the anterior-inferior tibiofibular syndesmosis and enhance hindfoot-to-forefoot force transfer during the push-off phase of the gait cycle.
PMCID: PMC164375  PMID: 12937565
ankle instability; subtalar joint injury; ankle dysfunction
14.  Subtalar Coalition: A Case Report 
Malaysian Orthopaedic Journal  2013;7(3):27-29.
Subtalar coalition is an uncommon condition that usually manifests in early adolescence(1). Frequently, this condition is missed. Delayed diagnosis may result in osteoarthritis requiring triple arthrodesis. Here, we report two patients with subtalar coalition. The first patient is a 12 year old boy who presented with right ankle pain for one year and was treated with excision of the coalition and bone wax insertion at the excision site. We followed up the patient for two years and the result was excellent with full range of movement of his right ankle and subtalar joint attained within two months. He returned to athletic activity by six months and was discharged with no complications after two years. The second patient is a 15 year old girl who presented with bilateral ankle pain and swelling for three years and was treated with excision of the coalition and subtalar interpositional arthroplasty bilaterally. She defaulted follow up after seven months as she was very satisfied with the result. We wish to highlight this condition which may be misdiagnosed as flexible flat foot or ankle sprain.
Key Words
Subtalar coalition, excision of coalition, bone wax insertion, subtalar interpositional arthroplasty
PMCID: PMC4322140
15.  Conservative treatment of subtalar dislocations 
International Orthopaedics  2001;26(1):56-60.
Forty-five patients who presented between 1983 and 1998 with acute closed dislocation of the subtalar joint were selected for this study. There were 37 medial and eight lateral dislocations. The mean follow-up was 7.5 years (range: 2–17 years). The mean American Orthopaedic Foot and Ankle Society Hindfoot Score (AOFAS) at follow-up was 84. Subtalar fusion was required in one patient with persistent severe hindfoot instability. There was no significant difference in the AOFAS score between medial and lateral subtalar dislocations. We conclude that pure subtalar dislocation produced by low energy trauma, promptly reduced and immobilised for 4 weeks has a favourable long-term outcome.
PMCID: PMC3620856  PMID: 11954852
16.  Salvage of Diffuse Ankle Osteomyelitis by Single-Stage Resection and Circumferential Frame Compression Arthrodesis 
Salvage of diffuse ankle osteomyelitis, especially in compromised hosts, is a challenging problem. The purpose of this report was to evaluate early complications and results using a standardized salvage protocol. Eight patients with diffuse ankle osteomyelitis were treated by resection of all infected tissue and hybrid-frame compression arthrodesis. At presentation, five had open wounds. According to the Cierny/Mader classification, all had diffuse anatomic involvement and six of eight were compromised hosts. Seven had central distal tibial column involvement and one had primarily talar involvement. Surgical technique involved a two-incision approach, removal of all infected material and application of a compression circumferential frame with five thin wires across the foot, two across the tibia and two half-pins in the tibia. Fusion of eight ankles and four subtalar joints was attempted. All patients received six weeks of intravenous antibiotics. Open wounds were treated with wound vacuum assisted closure (VACs) devices until closure was achieved. Frames were removed at three months and walking casts were applied for one to two more months. Ankle sepsis was eradicated in all patients. Seven of eight ankles fused at an average of 13.5 weeks (range, 10 to 16 weeks). One limb required below-knee amputation (BKA) at five weeks due to nonreconstructible vascular insufficiency. Three of four subtalar joints fused. Fixation problems included two pin-track infections cleared with oral cephalexin and one broken half-pin. Two diabetic Charcot patients required long-term ankle-foot orthosis (AFO) use due to subtalar instability. At average 3.4-year follow-up, none of the seven fused ankles has required further surgery. Use of this standardized salvage treatment protocol for these difficult problems in selected patients was effective with a relatively low associated complication rate.
PMCID: PMC1888789  PMID: 16089072
17.  Successful treatment of bilateral open calcaneal fractures with concomitant lower extremity injuries: A case report 
Cases Journal  2008;1:194.
Open calcaneal fractures are high morbidity injuries and the risk of complications depends on the concomitant injuries, on the size and the position of the traumatic wound. A 53-year-old male patient with bilateral open calcaneal fractures and associated concomitant lower extremity injuries such as subtalar dislocation, talonavicular dislocation and open distal tibial metaphyseal fracture was immediately operated by percutaneous Kirschner wire fixation combined with external fixators. He was able to walk with full weight bearing without any assistance at the end of the first postoperative year. Early aggressive debridement and irrigation followed by fixation with percutaneous Kirschner wires and external fixator can supply bony alignment in open comminuted calcaneal fractures associated with concomitant lower extremity injuries and should be considered for the healthy and active patients before primary arthrodesis.
PMCID: PMC2572042  PMID: 18826629
18.  Treatment of displaced talar neck fractures using delayed procedures of plate fixation through dual approaches 
International Orthopaedics  2013;38(1):149-154.
Treatment of talar neck fractures is challenging. Various surgical approaches and fixation methods have been documented. Clinical outcomes are often dissatisfying due to inadequate reduction and fixation with high rates of complications. Obtaining satisfactory clinical outcomes with minimum complications remains a hard task for orthopaedic surgeons.
In the period from May 2007 to September 2010, a total of 31 cases with closed displaced talar neck fractures were treated surgically in our department. Injuries were classified according to the Hawkins classification modified by Canale and Kelly. Under general anaesthesia with sufficient muscle relaxation, urgent closed reduction was initiated once the patients were admitted; if the procedure failed, open reduction and provisional stabilisation with Kirschner wires through an anteromedial approach with tibiometatarsal external fixation were performed. When the soft tissue had recovered, definitive fixation was performed with plate and screws through dual approaches. The final follow-up examination included radiological analysis, clinical evaluation and functional outcomes which were carried out according to the Ankle-Hindfoot Scale of the American Orthopaedic Foot and Ankle Society (AOFAS), patient satisfaction and SF-36.
Twenty-eight patients were followed up for an average of 25 months (range 18–50 months) after the injury. Only two patients had soft tissue complications, and recovery was satisfactory with conservative treatment. All of the fractures healed anatomically without malunion and nonunion, and the average union time was 14 weeks (range 12–24 weeks). Post-traumatic arthritis developed in ten cases, while six patients suffered from avascular necrosis of the talus. Secondary procedures included three cases of subtalar arthrodesis, one case of ankle arthrodesis and one case of total ankle replacement. The mean AOFAS hindfoot score was 78 (range 65–91). According to the SF-36, the average score of the physical component summary was 68 (range 59–81), and the average score of the mental component summary was 74 (range 63–85).
Talar neck fractures are associated with a high incidence of long-term disability and complications. Urgent reduction of the fracture-dislocation and delayed plate fixation through a dual approach when the soft tissue has recovered may minimise the complications and provide good clinical outcomes.
PMCID: PMC3890131  PMID: 24297608
Ankle; Talar neck fracture; Dual approaches; Internal fixation
19.  Radiography and sonography of clubfoot: A comparative study 
Indian Journal of Orthopaedics  2012;46(2):229-235.
Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.
Materials and Methods:
Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.
MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.
All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.
PMCID: PMC3308667  PMID: 22448064
Clubfoot; congenital talipes equinovarus; pediatric; radiography; sonography
20.  High Union Rates and Function Scores at Midterm Followup With Ankle Arthrodesis Using a Four Screw Technique 
When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8–7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2835613  PMID: 19763726
21.  Understanding acute ankle ligamentous sprain injury in sports 
This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.
PMCID: PMC2724472  PMID: 19640309
22.  Congenital vertical talus: Treatment by reverse ponseti technique 
Indian Journal of Orthopaedics  2008;42(3):347-350.
The surgery for idiopathic congenital vertical talus (CVT) can lead to stiffness, wound complications and under or over correction. There are sporadic literature on costing with mixed results. We describe our early experience of reverse ponseti technique.
Materials and methods:
Four cases (four feet) of idiopathic congenital vertical talus (CVT) which presented one month after birth were treated by serial manipulation and casting, tendoachilles tenotomy and percutaneous pinning of talonavicular joint. An average of 5.2 (range - four to six) plaster cast applications were required to correct the forefoot deformity. Once the talus and navicular were aligned based on the radiographic talus-first metatarsal axis, percutaneous fixation of the talo-navicular joint with a Kirschner wire, and percutaneous tendoachilles tenotomy under anesthesia was performed following which a cast was applied with the foot in slight dorsiflexion.
The mean follow-up period for the four cases was 8.5 months (6-12 months). At the end of the treatment all feet were supple and plantigrade but still using ankle foot orthosis (AFO). The mean talocalcaneal angle was 70 degrees before treatment and this reduced to 31 degrees after casting. The mean talar axis first metatasal base angle (TAMBA) angle was 60° before casting and this improved to 10.5°.
Although our follow-up period is small, we would recommend early casting for idiopathic CVT along the same lines as the Ponseti technique for clubfoot except that the forces applied are in reverse direction. This early casting method can prevent extensive surgery in the future, however, a close vigil is required to detect any early relapse.
PMCID: PMC2739479  PMID: 19753164
Casting; congenital vertical talus; conservative treatment
23.  Nonoperative treatment of closed total talus dislocation without fracture: A case report and literature review 
Complete dislocation of the talus not accompanied by a fracture is a very rare injury. Most cases reported are open talus dislocations; closed dislocations are rarely seen. The functional prognosis is poor due to osteonecrosis of the talus which develops in the majority of cases.
We present a case of lateral dislocation of the left talus in a 29-year-old road accident victim, but no fracture could be detected in the talus and any of malleolus. Reduction of dislocation had been performed in emergency by external manipulation. At 1-year follow-up, the right ankle was pain free and stable. Motion was satisfactory: 15° dorsal flexion, 30° plantar flexion; the talus didn't show subluxation and avascular necrosis could not be detected.
PMCID: PMC4223801
Talus; Dislocation; Closed; Nonoperative treatment
24.  Changes in Chopart joint load following tibiotalar arthrodesis: in vitro analysis of 8 cadaver specimen in a dynamic model 
In the current discussion of surgical treatment of arthroses in the ankle joint, arthrodesis is in competition with artificial joint replacement. Up until now, no valid biomechanical findings have existed on the changes in intraarticular loads following arthrodesis. One argument against tibiotalar arthrodesis is the frequently associated, long-term degeneration of the talonavicular joint, which can be attributed to changes in biomechanical stresses.
We used a dynamic model to determine the changes in intraarticular forces and peak-pressure in the talonavicular joint and in the calcaneocuboid joint on 8 cadaver feet under stress in a simulated stance phase following tibiotalar arthrodesis.
The change seen after arthrodesis was a tendency of relocation of average force and maximum pressure from the lateral onto the medial column of the foot. The average force increased from native 92 N to 100 N upon arthrodesis in the talonavicular joint and decreased in the calcaneocuboid joint from 54 N to 48 N. The peak pressure increased from native 3.9 MPa to 4.4 MPa in the talonavicular joint and in the calcaneocuboid joint from 3.3 MPa to 3.4 MPa. The increase of force and peak pressure on the talonavicular joint and decrease of force on the calcaneocuboid joint is statistically significant.
The increase in imparted force and peak pressure on the medial column of the foot following tibiotalar arthrodesis, as was demonstrated in a dynamic model, biomechanically explains the clinically observed phenomenon of cartilage degeneration on the medial dorsum of the foot in the long term. As a clinical conclusion from the measurements, it would be desirable to reduce the force imparted on the medial column with displacement onto the lateral forefoot, say by suitable shoe adjustment, in order to achieve a more favourable long-term clinical result.
PMCID: PMC2014750  PMID: 17686174
25.  Talocrural Dislocation With Associated Weber Type C Fibular Fracture in a Collegiate Football Player: A Case Report 
Journal of Athletic Training  2008;43(3):319-325.
To present the case of a talocrural dislocation with a Weber type C fibular fracture in a National Collegiate Athletic Association Division I football athlete.
The athlete, while attempting to make a tackle during a game, collided with an opponent, who in turn stepped on the lateral aspect of the athlete's ankle, resulting in forced ankle eversion and external rotation. On-field evaluation showed a laterally displaced talocrural dislocation. Immediate reduction was performed in the athletic training room to maintain skin integrity. Post-reduction radiographs revealed a Weber type C fibular fracture and increased medial joint clear space. A below-knee, fiberglass splint was applied to stabilize the ankle joint complex.
Differential Diagnosis:
Subtalar dislocation, Maisonneuve fracture, malleolar fracture, deltoid ligament rupture, syndesmosis disruption.
The sports medicine staff immediately splinted and transported the athlete to the athletic training room to reduce the dislocation. The athlete then underwent an open reduction and internal fixation procedure to stabilize the injury: 2 syndesmosis screws and a fibular plate were placed to keep the ankle joint in an anatomically reduced position. With the guidance of the athletic training staff, the athlete underwent an accelerated physical rehabilitation protocol in an effort to return to sport as quickly and safely as possible.
Most talocrural dislocations and associated Weber type C fibular fractures are due to motor vehicle accidents or falls. We are the first to describe this injury in a Division I football player and to present a general rehabilitation protocol for a high-level athlete.
Sports medicine practitioners must recognize that this injury can occur in the athletic environment. Prompt reduction, early surgical intervention, sufficient resources, and an accelerated rehabilitation protocol all contributed to a successful outcome in the patient.
PMCID: PMC2386426  PMID: 18523569
ankle dislocations; fibular fractures; syndesmosis injuries; athletic injuries

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