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1.  Subtalar Coalition: A Case Report 
Malaysian Orthopaedic Journal  2013;7(3):27-29.
Abstract
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
doi:10.5704/MOJ.1311.011
PMCID: PMC4322140  PMID: 25674305
2.  Total hip arthroplasty in a patient with congenital insensitivity to pain: a case report 
Introduction
Congenital insensitivity to pain, a rare neurological entity, is characterized by varying degrees of sensory loss and autonomic dysfunction. Orthopedic manifestations of congenital insensitivity to pain include delayed diagnosis of fractures, nonunions, malunions, Charcot arthropathy, acro-osteolysis, avascular necrosis, osteomyelitis, heterotopic ossification and joint dislocations. We here report the case of a patient with congenital insensitivity to pain who had multiple lower extremity fractures at varying intervals, the most recent being a femoral neck fracture managed by total hip replacement. To the best of our knowledge, this is the first report of cementless hip arthroplasty in such a patient.
Case presentation
A 37-year-old Caucasian woman was admitted to our hospital complaining of painless swellings in her lower limb and limping. She had been diagnosed with multiple lower extremity fractures at different times. On physical examination, we found multiple perioral mucosal ulcers, shortening of her nails and acro-osteolysis, a prematurely aged facial appearance, undersized skeletal structure, Charcot arthropathy of her right ankle, anosmia, insensitivity to temperature differences and evidence of mild intellectual disability. A right subtrochanteric femur fracture was treated with an intramedullary nail. Eighteen months later, she presented with similar symptoms and we diagnosed a right femoral neck fracture. We removed the nail and performed cementless total right hip arthroplasty.
Conclusions
Congenital insensitivity to pain is a rare condition that is associated with severe orthopedic problems. This case report, which will be of particular interest to orthopedic surgeons, presents several difficulties in the management of patients with congenital insensitivity to pain and notes the importance of close follow-up and early recognition of complications. Cementless total hip arthroplasty may be a good therapeutic option for femoral neck fracture in these patients.
doi:10.1186/1752-1947-6-190
PMCID: PMC3419663  PMID: 22776296
3.  Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: a 12.8-year follow-up study 
Purpose
Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus position of the feet and ankles, usually in combination with planovalgus and pronation of the forefoot. The purpose of the study was to evaluate long-term patient satisfaction and clinical effects in ambulating children with lumbosacral myelomeningocele after having performed a Grice arthrodesis of a valgus unstable foot. The clinically most relevant radiographic measurements, such as the frontal and lateral talo-calcaneal angles, were used to evaluate the anatomical effects of the surgery, whereas the main research question was to reveal the patient satisfaction and usefulness of the procedure.
Methods
The modified Grice–Green extraarticular subtalar arthrodesis was performed by the same surgeon on one standing and 22 walking patients (12 female) with lumbosacral myelomeningocele and valgus instability during the period 1985–1999. Twelve patients had bilateral surgery, giving a total of 35 operated feet. The patients attended a thorough check-up at a mean of 12.8 years (standard deviation [SD] ± 3.2, range 7.7–20.2 years) after surgery. The mean age at surgery was 6.6 years (SD ± 1.8) and at follow-up 19.4 years (SD ± 3.8). Functional parameters, such as walking ability, pain and skin problems, and the need for braces and supportive orthopaedic shoes were noted at the follow-up interview. The parents were interviewed along with the patients in order to obtain all of the necessary information. Loaded radiographs in the lateral and frontal planes were taken of both feet and ankles pre-operatively and at follow-up, except for pre-operative radiographs in six patients that were not loaded and, thus, not included, except for the assessment of ankle valgus. Ankle valgus was assessed from lateral and frontal views of the ankle on a scale from grade 0 to grade 3 according to Malhotra. Frontal and lateral talo-calcaneal angles were measured for the assessment of subtalar varus or valgus. Lateral talo-first-metatarsal (Meary’s) angles were measured to investigate the longitudinal arches of the feet.
Results
The mean lateral talo-calcaneal angle was reduced significantly (P < 001) from 55.1° (SD ± 8.9) to 38.8° (SD ± 8.1). The mean frontal talo-calcaneal angle was reduced from 24.7° (SD ± 9.7) pre-operatively to 16.6° (SD ± 6.3) at follow-up (P < 0.001). The mean lateral talo-first-metatarsal angle improved significantly from −16.1° (SD ± 24.7) pre-operatively to 0.9° (SD ± 15.1) at follow-up (P = 0.0015). The calcaneal pitch did not change significantly. In general, ankle valgus worsened during follow-up time, but not significantly (P = 0.113). The visual analogue scale (VAS) score of patient satisfaction improved significantly from 3.7 (SD ± 1.7) prior to surgery to 7.2 (SD ± 1.5) at follow-up (P < 0.005). Nineteen patients (83%) were satisfied with the surgery and would thus recommend the procedure.
Conclusions
Based on the radiological findings and patient satisfaction, the patients participating in this study benefited from having had Grice arthrodeses performed on their valgus unstable feet. The results indicate good long-term correctional effect on valgus deformity after Grice arthrodesis, as the talo-calcaneal and talo-first-metatarsal angles improved significantly. A great majority of the patients were content with the surgery, and none claimed that any residual deformity was the cause for any reduced ability to ambulate.
doi:10.1007/s11832-009-0183-8
PMCID: PMC2726867  PMID: 19533196
Grice arthrodesis; Myelomeningocele; Spina bifida; Valgus deformity; Children
4.  A new approach to the treatment of congenital vertical talus 
Congenital vertical talus is an uncommon foot deformity that is present at birth and results in a rigid flatfoot deformity. Left untreated the deformity can result in pain and disability. Though the exact etiology of vertical talus is unknown, an increasing number of cases have been shown to have a genetic cause. Approximately 50% of all cases of vertical talus are associated with other neuromuscular abnormalities or known genetic syndromes. The remaining 50% of cases were once thought to be idiopathic in nature. However, there is increasing evidence that many of these cases are related to single gene defects. Most patients with vertical talus have been treated with major reconstructive surgeries that are fraught with complications such as wound necrosis, talar necrosis, undercorrection of the deformity, stiffness of the ankle and subtalar joint, and the eventual need for multiple operative procedures. Recently, a new approach to vertical talus that consists of serial casting and minimal surgery has resulted in excellent correction in the short-term. Longer follow-up will be necessary to ensure maintenance of correction with this new technique. A less invasive approach to the correction of vertical talus may provide more favorable long-term outcomes than more extensive surgery as has been shown to be true for clubfoot outcomes.
doi:10.1007/s11832-007-0037-1
PMCID: PMC2656724  PMID: 19308490
Congenital vertical talus; Flatfoot; Treatment; Genetics; Etiology
5.  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.
doi:10.4076/1757-1626-2-8793
PMCID: PMC2769472  PMID: 19918402
6.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4055/cios.2010.2.1.13
PMCID: PMC2824090  PMID: 20190996
Pes planovalgus; Cerebral palsy; Subtalar joint; Arthrodesis; Extraarticular
7.  Minimally invasive ankle arthrodesis with a retrograde locking nail after failed fusion 
Abstract
A retrograde nail with posterior-to-anterior (PA) locking into os calcis, talus and tibia was used to correct deformity and achieve fusion after failed fusion. A variety of methods have been published to achieve union of the ankle and subtalar joint in a failed fusion situation. We have studied a retrograde locking nail technique through a 2.5-cm incision in the non-weightbearing part of the sole of the foot. Remaining cartilage in the ankle joint, where necessary, was percutaneously removed through an anterior approach and the locking nail was inserted after reaming of os calcis, talus and tibia. Locking screw insertion was in the sagittal plane (p.a. direction), in talus os calcis and tibial diaphysis using a nail mounted jig. Ten patients were entered in the study (age 27-60 years). The initial aetiology for attempted fusion was post-traumatic in nine cases and rheumatic in one case. There were 25 previous operations in the cohort not leading to fusion. An additional temporary external fixator was used in four cases to reach and maintain the optimum position for the procedure. The intervention time was 30-75 min. Dynamisation of the nail was performed after four months under local anaesthesia. The mean duration of follow-up was 4 years (3-5.5 years). Radiologically and clinically, fusion was achieved in 16 weeks (range, 12-20 weeks). There was no loosening of the implant or implant failure. A leg length discrepancy was avoided using this technique. There was one complication with varus malunion in a heavy smoker which united after corrective osteotomy, revision nailing and bone grafting. Patient satisfaction was measured on a scale (not visual analogue) of 0 (not satisfied) to 10 (completely satisfied); overall satisfaction averaged 9.5 points (range, 6-10 points). The postoperative ankle-hindfoot score of the American Orthopedic Foot and Ankle Society averaged 73.5 points (range, 61-81 points). Retrograde locked nailing with locking in the sagittal plane is a reliable minimally invasive procedure to achieve fusion of the ankle and the subtalar joint after failed fusion.
doi:10.1007/s11751-007-0018-4
PMCID: PMC2321722  PMID: 18427914
Ankle arthrodesis; Failed fusion; Retrograde nail; Calcaneotalotibial arthrodesis
8.  Minimally invasive ankle arthrodesis with a retrograde locking nail after failed fusion 
Abstract
A retrograde nail with posterior-to-anterior (PA) locking into os calcis, talus and tibia was used to correct deformity and achieve fusion after failed fusion. A variety of methods have been published to achieve union of the ankle and subtalar joint in a failed fusion situation. We have studied a retrograde locking nail technique through a 2.5-cm incision in the non-weightbearing part of the sole of the foot. Remaining cartilage in the ankle joint, where necessary, was percutaneously removed through an anterior approach and the locking nail was inserted after reaming of os calcis, talus and tibia. Locking screw insertion was in the sagittal plane (p.a. direction), in talus os calcis and tibial diaphysis using a nail mounted jig. Ten patients were entered in the study (age 27-60 years). The initial aetiology for attempted fusion was post-traumatic in nine cases and rheumatic in one case. There were 25 previous operations in the cohort not leading to fusion. An additional temporary external fixator was used in four cases to reach and maintain the optimum position for the procedure. The intervention time was 30-75 min. Dynamisation of the nail was performed after four months under local anaesthesia. The mean duration of follow-up was 4 years (3-5.5 years). Radiologically and clinically, fusion was achieved in 16 weeks (range, 12-20 weeks). There was no loosening of the implant or implant failure. A leg length discrepancy was avoided using this technique. There was one complication with varus malunion in a heavy smoker which united after corrective osteotomy, revision nailing and bone grafting. Patient satisfaction was measured on a scale (not visual analogue) of 0 (not satisfied) to 10 (completely satisfied); overall satisfaction averaged 9.5 points (range, 6-10 points). The postoperative ankle-hindfoot score of the American Orthopedic Foot and Ankle Society averaged 73.5 points (range, 61-81 points). Retrograde locked nailing with locking in the sagittal plane is a reliable minimally invasive procedure to achieve fusion of the ankle and the subtalar joint after failed fusion.
doi:10.1007/s11751-007-0018-4
PMCID: PMC2321722  PMID: 18427914
Ankle arthrodesis; Failed fusion; Retrograde nail; Calcaneotalotibial arthrodesis
9.  Closed medial total subtalar joint dislocation without ankle fracture: a case report 
Introduction
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.
Conclusions
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.
doi:10.1186/1752-1947-8-313
PMCID: PMC4178312  PMID: 25240955
Ankle; Dislocation; Subtalar joint
10.  Subtalar dislocation without associated fractures: Case report and review of literature 
World Journal of Orthopedics  2015;6(3):374-379.
Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed.
doi:10.5312/wjo.v6.i3.374
PMCID: PMC4390901  PMID: 25893182
Subtalar; Dislocation; Talus; Calcaneus; Isolated; Medial
11.  Ankle Arthritis in a 6-Year-Old Boy After a Tick Bite – A Case Report 
Background:
Monoarthritis of the ankle is a rare condition in children, and is most often caused by a bacterial infection. Lyme disease is endemic in southern Scandinavia, and diagnosis remains a challenge. The clinical presentation of Lyme disease varies greatly, and often with considerable delay between exposure and presentation.
Case Presentation:
We report a case of ankle arthritis in a boy who presented one year earlier with a tick bite on the dorsum of the foot. He was suboptimally treated with oral antibiotics for one week, and developed in the following months a painless limp. Radiographs revealed a severe arthritis of the right ankle joint with necrosis of the talus and deformation of the talocrural and subtalar joints. There was no history of malaise, fever or other systemic symptoms. He remains seronegative for antibodies against B. burgdorferi.
Conclusions:
The suboptimal oral antibiotic treatment may have hindered the antibody production against B burgdorferi, while not being therapeutic, resulting in severe ankle arthritis due to seronegative Lyme disease.
doi:10.2174/1874325001105010165
PMCID: PMC3096051  PMID: 21594002
Arthritis; children; seronegative Lyme disease; borreliosis.
12.  Neglected surgically intervened bilateral congenital dislocation of knee in an adolescent 
Indian Journal of Orthopaedics  2014;48(1):96-99.
Neglected bilateral congenital dislocation of knee is unusual. A 12 year old boy presented with inability to walk due to buckling of the knee. The symptoms were present since the child learnt walking. He preferred not to walk. Bilateral supracondylar femoral osteotomy was done at the age of 6 years. Patient had a fixed flexion deformity of both knees, 30° in the right (range of flexion from 30° to 45°) and 45° fixed flexion deformity in left knee respectively (range of flexion from 45° to 65°) when presented to us. The radiological examination revealed bilateral congenital dislocation of knee (CDK). No syndromic association was observed. He was planned for staged treatment. In stage I, the knee joints were distracted by Ilizarov ring fixators and this was followed by open reduction of both the knee joints in stage II. A bilateral supracondylar extension osteotomy was done 18 months after the previous surgery (stage III). The final followup visit at 4 years the patient presented with range of motion 5-100° and 5-80° on the right and left knee respectively with good functional outcome. The case is reported in view of lack of treatment guidelines for long standing neglected CDK in an adolescent child.
doi:10.4103/0019-5413.125524
PMCID: PMC3931160  PMID: 24600070
Congenital dislocation of knee; neglected congenital dislocation of knee; surgical treatment
13.  A case of caudal regression syndrome: walking or sitting? 
Caudal regression syndrome (CRS) is a congenital disorder which is seen vertebral anomalies in varying degrees from lower thoracic spineto the level of the coccyx. We present a case of CRS which is not intended operation for orthopedic deformities considering functionality. 2, 5 year-old girl referred to our clinic with complaints about walking disability, knee and foot deformities. Patient's mother with unregulated diabetes did not have a history of drug use, radiation exposure and serious illness during pregnancy. Diagnosis had been put during antenatal follow-ups. On physical examination, her lower extremities were hypoplastic and had no muscle activity. Her hips were flexed and abducted, but did not have contractures. Her knees had 75 degrees of flexion contractures with popliteal webs and feet had equinovarus deformity. Frog belly was present due to abdominal muscles weakness. Also hypoplasic labia majora has been identified. In lumbar MRI, spinal cord was terminated at 6th thoracic (T6) vertebrae and the last solid vertebrae level was at T10. Patient who has been following by urology with clean intermittent catheterization had also severe urological problems including horseshoe kidney, neurologic bladder, vesico-ureteral reflux and grade 2 hydronephrosis. Orthopedic consultation was made for her deformities. They decided that ambulation unexpected patient's knee flexion contractures were helping sitting balance. Because of this operation was not considered. Prognosis, treatment options, strength exercises for upper extremities, skin care were told to parents and patient was taken to follow. CRS is a rare congenital abnormality which is associated with orthopedic deformities, as well as urological, anorectal and cardiac malformations. Treatment requires a multidisciplinary approach. It should not be forgotten that purpose of rehabilitation is not to correct all deformities but increase the functionality of everyday life.
doi:10.11604/pamj.2014.18.92.3683
PMCID: PMC4231316  PMID: 25400859
caudal regression syndrome; sacral agenesis; congenital malformation; maternal diabetes; knee flexion contracture
14.  Delayed debridement of an open total talar dislocation reimplanted in the emergency room 
Open total talar dislocation is a rare but well known injury. Its management is controversial and fraught with complications such as infection, avascular necrosis, and post-traumatic osteoarthritis.
We report the case of a woman sustaining a pure open talar dislocation reduced in the emergency room. Debridement was done three days after the injury in the operating room. There was no infection. One year after surgery she complained of occasional pain. Ambulation was normal. She wore regular shoes. The overall alignment of the ankle, hindfoot, and midfoot was normal. Movements of the tibiotalar and subtalar joints were not impaired. She has resumed her regular activities. Radiographs showed no signs of avascular necrosis. All components of the treatment strategy of open total dislocation should be carried out in emergency. This results in environment close to the original biological state. Good results can be achieved if infection is avoided.
doi:10.1016/j.jcot.2014.04.002
PMCID: PMC4223811  PMID: 25983494
Hindfoot; Open dislocation; Reimplantation; Talar injury
15.  Hormonal and Genetical Assessment of a Japanese Girl with Weaver Syndrome 
We report a case of Japanese girl with a rare disorder of Weaver syndrome, which was characterized by overgrowth with advanced and disharmonic bone age, craniofacial abnormalities, developmental delay, metaphyseal flaring of the long bones and camptodactyly. The patient was delivered at 38 weeks of gestation with a length of 54.2 cm (+ 2.6 SD), a weight of 3805 g (+ 2.5 SD) and an occipitofrontal circumference (OFC) of 35.0 cm (+ 1.1 SD). She manifested hypertonia and flexion contractures in the first few years. She also had submucosal soft cleft palate and difficulty in swallowing and breathing in early infancy. When she was 5 years and 7 months old, her height and weight were 133.3 cm (+ 5.5 SD) and 32.0 kg (+ 5.1 SD), respectively. We could not detect any endocrinological abnormalities for the cause of overgrowth. According to clinical features, Weaver syndrome was suspected and genetical analysis was performed. Fluorescence in situ hybridization (FISH) and direct sequencing analysis showed neither deletion nor point mutation of the nuclear receptor SET-domain-containing protein 1 (NSD1) gene on 5q35, which is responsible for Sotos syndrome. Therefore, we made a diagnosis of Weaver syndrome for this patient and discussed the differential diagnosis in terms of overgrowth syndrome.
doi:10.1297/cpe.13.17
PMCID: PMC4004909  PMID: 24790293
Weaver syndrome; overgrowth; advanced bone age; Sotos syndrome; NSD1 gene
16.  The Effects of Rearfoot Position on Lower Limb Kinematics during Bilateral Squatting in Asymptomatic Individuals with a Pronated Foot Type 
Clinicians frequently assess movement performance during a bilateral squat to observe the biomechanical effects of foot orthotic prescription. However, the effects of rearfoot position on bilateral squat kinematics have not been established objectively to date. This study aims to investigate these effects in a population of healthy adults with a pronated foot type.
Ten healthy participants with a pronated foot type bilaterally (defined as a navicular drop >9mm) performed three squats in each of three conditions: barefoot, standing on 10mm shoe pitch platforms and standing on the platforms with foam wedges supporting the rearfoot in subtalar neutral. Kinematic data was recorded using a 3D motion analysis system. Between-conditions changes in peak joint angles attained were analysed.
Peak ankle dorsiflexion (p=0.0005) and hip abduction (p=0.024) were significantly reduced, while peak knee varus (p=0.028) and flexion (p=0.0005) were significantly increased during squatting in the subtalar neutral position compared to barefoot. Peak subtalar pronation decreased by 5.33° (SD 4.52°) when squatting on the platforms compared to barefoot (p=0.006), but no additional significant effects were noted in subtalar neutral.
Significant changes in lower limb kinematics may be observed during bilateral squatting when rearfoot alignment is altered. Shoe pitch alone may significantly reduce peak pronation during squatting in this population, but additional reductions were not observed in the subtalar neutral position. Further research investigating the effects of footwear and the subtalar neutral position in populations with lower limb pathology is required.
doi:10.2478/v10078-012-0001-0
PMCID: PMC3588658  PMID: 23486735
orthotics; squat; lower limb; kinematics; pronation
17.  Skeletal Muscle Abnormalities and Genetic Factors Related to Vertical Talus 
Background/rationale
Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint and fixed equinus contracture of the hindfoot, causing a rigid deformity recognizable at birth. The etiology and epidemiology of this condition are largely unknown, but some evidence suggests it relates to aberrations of skeletal muscle. Identifying the tissue abnormalities and genetic causes responsible for vertical talus has the potential to lead to improved treatment and preventive strategies.
Questions/purposes
We therefore (1) determined whether skeletal muscle abnormalities are present in patients with vertical talus and (2) identified associated congenital anomalies and genetic abnormalities in these patients.
Methods
We identified associated congenital anomalies and genetic abnormalities present in 61 patients affected with vertical talus. We obtained abductor hallucis muscle biopsy specimens from the affected limbs of 11 of the 61 patients and compared the histopathologic characteristics with those of age-matched control subjects.
Results
All muscle biopsy specimens (n = 11) had abnormalities compared with those from control subjects including combinations of abnormal variation in muscle fiber size (n = 7), type I muscle fiber smallness (n = 6), and abnormal fiber type predominance (n = 5). Isolated vertical talus occurred in 23 of the 61 patients (38%), whereas the remaining 38 patients had associated nervous system, musculoskeletal system, and/or genetic and genomic abnormalities. Ten of the 61 patients (16%) had vertical talus in one foot and clubfoot in the other. Chromosomal abnormalities, all complete or partial trisomies, were identified in three patients with vertical talus who had additional congenital abnormalities.
Conclusions
Vertical talus is a heterogeneous birth defect resulting from many diverse etiologies. Abnormal skeletal muscle biopsies are common in patients with vertical talus although it is unclear whether this is primary or secondary to the joint deformity. Associated anomalies are present in 62% of all cases.
doi:10.1007/s11999-010-1475-5
PMCID: PMC3048242  PMID: 20645034
18.  Destructive post-traumatic chondrolysis of the subtalar joint: a case report and review of the literature 
BMJ Case Reports  2013;2013:bcr2012008472.
Injuries to the subtalar joint are often associated with fractures of the talus or calcaneum. These injuries often lead to degenerative changes resulting in pain, restriction of movement and difficulty in weight bearing. This can cause significant deformity and disability for the patient. Occult injury of the subtalar joint has been described as an isolated event or in association with a subluxation/dislocation of this joint. They are difficult to assess with plain radiography therefore, they are generally diagnosed with advanced imaging like CT scan or MRI scan. We present a case of a 66-year-old man who presented with destructive chondrolysis of the subtalar joint 2 years following conservative treatment of a minimally displaced distal fibular fracture. It was treated by subtalar and talonavicular arthrodesis. Overall, the patient made an excellent recovery and was satisfied with the outcome.
doi:10.1136/bcr-2012-008472
PMCID: PMC3618760  PMID: 23505085
19.  Adjacent tissue involvement of acute inflammatory ankle arthritis on magnetic resonance imaging findings 
International Orthopaedics  2013;37(10):1943-1947.
Purpose
The ankle joint and surrounding subtalar joint have several tendons in close proximity. This study was performed to investigate the concurrent adjacent tissue involvement on MRI findings when the surgical treatment is considered for an acute inflammatory arthritis of the ankle joint.
Methods
Consecutive patients with acute inflammatory ankle arthritis who visited the emergency room and underwent MRI were included. After interobserver reliability testing of MRI findings, adjacent tissue involvement in the acute inflammatory ankle arthritis were evaluated including flexor hallucis longus (FHL), flexor digitorum longus (FDL), tibialis posterior (TP), peroneus longus (PL), peroneus brevis (PB), extensor digitorum longus (EDL), tibialis anterior (Tib Ant), extensor hallucis longus (EHL), subtalar joint, talus, tibia, and calcaneus.
Results
Twenty-five patients (mean age 57.8 years; 16 males and nine females) were included. Of the 25 patients, 23 showed FHL involvement, 21 FDL, 21 TP, 15 PL, 15 PB, three EDL, 21 subtalar joint, six talus, six tibia, and five calcaneus on MR images. No Tib Ant or EHL involvement was observed on MR findings in acute inflammatory ankle arthritis.
Conclusions
Patients with acute inflammatory ankle arthritis showed frequent concomitant surrounding tissue involvement on MRI, which included FHL, FDL, TP, and subtalar joint. This needs to be considered when surgical drainage is planned for acute inflammatory ankle arthritis.
doi:10.1007/s00264-013-1932-3
PMCID: PMC3779583  PMID: 23703539
20.  Neuropathic midfoot deformity: associations with ankle and subtalar joint motion 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1757-1146-6-11
PMCID: PMC3616933  PMID: 23531372
Foot alignment; Deformity; Ankle and foot joint goniometry; Limited joint mobility
21.  Tibiotalar arthrodesis for injuries of the talus 
Indian Journal of Orthopaedics  2008;42(1):87-90.
Background:
Fracture-dislocation of the talus is one of the most severe injuries of the ankle. Opinion varies widely as to the proper treatment of this injury. Since Blair's original description of the tibiotalar fusion in 1943, there is little mention in the literature of his method. The present study reports the results of tibiotalar arthrodesis with modification in Blair's technique.
Materials and Methods:
Eleven cases of modified Blair's tibiotalar arthrodesis were retrospectively studied. The average age was 32.4 years (range, 26-51 years). Six patients had posttraumatic avascular necrosis; five had neglected fracture-dislocation of the talus.
Results:
The mean followup is 8 years (range 3-12 years). Tibiotalar fusion was achieved in all the ankles at an average of 20.5 weeks (range 16-28 weeks). Nine cases having 15°-20° tibiopedal motion had excellent results and two ankles having 10°-15° of tibiopedal motion had good result.
Conclusion:
We achieved good long term results with tibiotalar arthrodesis with modification in Blair technique. The principal modification in the present study is retention of the talar body while performing arthrodesis with anterior sliding graft. The retention of the talar body provides intraoperative stability and in the long term, the retained talar body shares the load transmitted to the anterior and middle subtalar joints thus resulting in improved hind foot function and gait.
doi:10.4103/0019-5413.38588
PMCID: PMC2759590  PMID: 19823662
Anterior tibial sliding graft; arthrodesis; avascular necrosis of talus
22.  A Pediatric Comminuted Talar Fracture Treated by Minimal K-Wire Fixation Without Using a Tourniquet 
The Iowa Orthopaedic Journal  2014;34:175-180.
Background
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
4
PMCID: PMC4127733  PMID: 25328479
talus; fracture healing; tourniquets; avascular; necrosis
23.  Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results 
Background
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.
Results
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.
Conclusions
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.
doi:10.1007/s10195-011-0126-2
PMCID: PMC3052431  PMID: 21308390
Subtalar joint; Dislocations; Ankle; Foot; Rehabilitation
24.  Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results 
Background
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.
Results
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.
Conclusions
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.
doi:10.1007/s10195-011-0126-2
PMCID: PMC3052431  PMID: 21308390
Subtalar joint; Dislocations; Ankle; Foot; Rehabilitation
25.  Congenital vertical talus in Cri du Chat Syndrome: a case report 
BMC Research Notes  2013;6:270.
Background
Congenital vertical talus is a rare deformity of the foot which can cause substantial pain and disability. Its incidence is approximately 1 in 100,000 live births. It has an association with other neuromuscular abnormalities and identified genetic syndromes in 50% of cases [1-5]. This report presents a case of congenital vertical talus in an infant with Cri du Chat Syndrome (CdCS) which - to our knowledge - has not been previously reported.
Case presentation
A 2 week-old Caucasian, male infant was referred for congenital feet abnormalities and a “clicky” hip at the post-natal baby check. The diagnosis was vertical talus of the right foot and oblique talus of the left foot. Treatment involved serial plaster casts in the “reverse-Ponseti” position until surgery 16 weeks later. The correction was maintained and the feet remain in good position at follow-up. General concern over the infant’s development, failing to reach appropriate milestones, prompted paediatric referral. Genetic analysis was finally carried out, giving a diagnosis of Cri du Chat syndrome at two and a half years of age.
Conclusion
In light of other reports of chromosomal anomalies causing congenital vertical talus, the learning point from this case is to investigate early for possible aetiologies, not only spinal/neuromuscular, but also those of a genetic basis.
doi:10.1186/1756-0500-6-270
PMCID: PMC3722027  PMID: 23849392
Congenital vertical talus; Cri du chat syndrome; Flat foot

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