Pertinent Insights On The Posterior Approach To Hindfoot Arthrodesis

Jeffrey E. McAlister, DPM, and Christopher F. Hyer, DPM, MS

These authors discuss an innovative approach to a complicated pathology in a 44-year-old patient who had an extensive intraosseous talar cyst with joint involvement.

Tibiotalocalcaneal arthrodesis are often salvage procedures that surgeons utilize for complex Charcot reconstruction, severe post-traumatic arthritis and extensive talar avascular necrosis. Fixation constructs for this procedure have evolved from internal compression screws to retrograde intramedullary nails to a combination of compression screws and plates.

   We present a case report of a 44-year-old male who was referred to our clinic with an eight-year history of a painful right ankle and hindfoot. He said the pain was unrelenting with ambulation, especially when ascending and descending flights of stairs as a local deliveryman. He denied any specific foot and ankle trauma. The patient took only non-steroidal anti-inflammatories (NSAIDs) for the daily pain. The patient also denied any tobacco or ethanol abuse.

   The patient had no significant past medical history of note. Past surgical intervention on the same ankle included a talar cyst filling with a bone graft in 1996. The physical examination demonstrated limited ankle range of motion and tenderness to the anterior joint line. Subtalar joint range of motion was also limited and painful over the sinus tarsi. No gross angular deformity was present at the ankle or subtalar joints.

   Radiographs of the right ankle revealed a large cystic, multi-loculated, dense talar body lesion, occupying over 75 percent of the talus from posterior to anterior and over 50 percent from medial to lateral. Magnetic resonance images (MRI) compared to the aforementioned radiographs demonstrated subchondral irregularities at the posterior subtalar joint and ankle joint. We also noted mild expansion of the talus secondary to intraosseous cystic lesions with fluid-fluid levels that had increased from the last examination in 2005.

   We discussed the complicated nature of this talar cyst with the patient and the involvement of both the ankle and subtalar joints. The ultimate diagnosis of a benign talar body cyst and avascular necrosis with joint extension has led to destruction of the joint surfaces and concomitant arthritis and pain. We counseled the patient on the need for a tibiotalocalcaneal fusion as well as all risks, benefits and possible perioperative complications associated with the case.

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