Yearly Archives: 2020

A variant of screwless scarf osteotomy for hallux valgus: Clinical and radiographic outcomes

by Taoufik Cherrad1*, Hicham Bousbaä1, Mohammed Ouahidi2, Hassan Zejjari3, Jamal Louaste3, Larbi Amhajji4

The Foot and Ankle Online Journal 13 (1): 2

Scarf osteotomy is a versatile procedure for the correction of moderate and advanced hallux valgus. This technique has benefited from many improvements to allow translation and angulation correction of the deformity. We describe in our study a scarf variant without osteosynthesis material in which proximal fixation is made by interlocking and distal fixation with nonabsorbable suture. We retrospectively reviewed 33 feet in 30 patients with an average follow-up duration of 35 months (range: 4-60 months). On the latest follow up, 94 % of the patients were satisfied with the result. American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 56/100 to 87/100. The average improvement of HV angle was from 35° to 12°. The intermetatarsal angle improved from 19° to 7°. The DMAA improved from 27° to 8°. Neither delayed union nor osteonecrosis were observed. This variant of screwless scarf technique gives very good results in severe Hallux valgus by safe and large translation authorizing rotation and supination with low iatrogenicity.

Keywords: hallux valgus, scarf osteotomy, screwless

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0002

1 – Orthopaedic surgeon, Military Hospital Moulay Ismail Meknes (HMMIM). Morocco.
2 – Resident in Orthopedic Surgery and Traumatology, HMMIM. Morocco.
3 – Professor in Orthopedic Surgery and Traumatology, HMMIM. Morocco.
4 – Professor Head of the Department of Orthopedic Surgery and Traumatology, HMMIM. Morocco.
* – Corresponding author: taoufikcherrad@gmail.com


Hallux valgus (HV) is the main forefoot deformity. Non-operative treatment may relieve symptoms but the basis of management is surgery. The HV corrective surgery history is marked by various surgical techniques that currently enumerate over 150 procedures [1].

The scarf osteotomy is a powerful and mechanically stable procedure to correct moderate and severe forms of HV. This Z-shaped osteotomy of the first metatarsal was first proposed by Meyer [2]. Weil was the first to use the term ‘Scarf’ [3] and Barouk popularized it in Europe [4]. The scarf osteotomy is very versatile and stable, therefore it allows rotational and translation corrections. Originally this osteotomy was stabilized with two screws. Maestro proposed eliminating the proximal screw by locking the two fragments distally: a notch was created via a medial extension of the cephalic part of the osteotomy, the plantar fragment was displaced laterally, and the distal end of the proximal fragment was then fit into the notch (secondary cut and interlocking joint technique [5]. In 2012, Leemrijse et al optimized this technique to increase the potential range of translation. The procedure consists of distal locking and proximal stabilization without shortening. This was possible by impaction of a corticocancellous bone graft taken from the medial overhanging edge of the proximal fragment [6].

Our study presents the results of a retrospective series involving 33 feet (30 patients) operated for HV according to scarf technique without osteosynthesis material with proximal fixation by interlocking and distal fixation with nonabsorbable suture.

The aim of this study is to evaluate the safety, feasibility, and reproducibility of screwless scarf osteotomy by comparing our clinical and radiographic outcomes to the literature data.

Patients and methods

This is a retrospective study regarding 33 feet of HV from 30 patients treated with Scarf osteotomy without osteosynthesis material and followed in the orthopedic trauma surgery department of the military hospital Moulay Ismail Meknes between January 2014 and December 2018. The average follow-up duration was 35 months (range: 4-60 months). All subjects have given informed consent. Exclusion criteria were; HV treated with other operative techniques than scarf screwless, or a scarf procedure with internal fixation.

Twenty men and ten women had an average age of 37 years (range, 16-65 years) at the time of surgery. Six patients had bilateral HV and only 3 patients have been operated on the two sides by a screwless scarf.   

Pain with irritation at the bunion was present in 29 feet (88%). The unaesthetic deformity was a serious reason for consultation in 14 patients (47%). All of our patients had metatarsalgia and difficulty with shoes wear. Finally, 67% of our feet were Egyptian type (22 cases).

A standardised surgical technique was used in all cases. The foot was positioned on the operative table in spontaneous external rotation position, with a thigh tourniquet inflated to 300 mmHg.

The surgical procedure involves a standard medial incision over the first MTPJ and along the shaft of the first MT. Skin incision is done at the dorsal and plantar skin junction, avoiding to extend too far proximally and stopped distally at about 1 cm from the joint. The dorsal collateral sensitive nerve will be visible and protected. It is normally not necessary to visualise the collateral plantar nerve.

Figure 1 a: The medial capsulotomy with resection of the medial eminence. b: The sesamoid release by medial approach. c: The Z-shaped osteotomy.

After a medial capsulotomy, the medial eminence of the metatarsal head is removed (Figure 1a).

Then, by the same medial approach (Figure 1b). We release and reduce lateral sesamoid according to the Maestro approach; above and under the lateral collateral ligament (LCL) which is respected.

  • Above LCL: to free the extensor hallucis longus (EHL), the fibrous sling is cut.
  • Under LCL: the metatarso-sesamoïd ligament is cut principally with the lateral part of the conjoint ligament close to the base of the phalanx [7] 

The exposure of the plantar aspect of the metatarsal shaft by rugination must respect the soft tissue below the head for blood preservation.

Regarding the scarf osteotomy; the longitudinal section is made along the medial side of M1. The osteotomy begins proximally to 5 mm from the beginning of the proximal plantar exposure and on average at the junction of the dorsal two-thirds and plantar one-third of the shaft. It ends distally at the junction of the dorsal one-third and plantar two-thirds of the head just proximal to the cartilage of the joint (normally approximately 5mm from the joint surface). In the frontal plane, the osteotomy has an oblique direction downwards and outwards. The degree of dorsoplantar slope is chosen to obtain the desired amount of lowering. The saw is directed generally parallel to the metatarsal plantar surface of which has an average inclination from 40° relative to the horizontal; the focus is to respect the lateral beam from the dorsal fragment, which ensures the stability of the osteotomy. The longitudinal cut must be at least 2cm long to eliminate all risk of secondary displacement.

The distal transverse cut is done just behind the dorsal synovial recessus attachment which is respected. This cut is through the distal metaphysis (presence of spongiosa avoids the dorsal fragment to be fit into the distal fragment). The cephalic cut is dorsal and directed from within outward, proximally oblique and angled at 70°or 80° relative to longitudinal limb. If the distal transverse cut is perpendicular to the axis of the second metatarsal, pure translation is achieved and stabilization is required, either via a screw or via interlocking of the two fragments after a secondary cut, which shortens the first metatarsal bone. Finally the position and the obliquity of this distal cut give the osteotomy more stability (Figure 1c). 

The proximal transverse cut is performed, at an angle of 60° relative to the longitudinal limb and perpendicularly to the axis of the second metatarsal bone. A dovetail notch is then created at the proximal part of the plantar fragment to allow interlocking of the proximal plantar part of the osteotomy. This interlocking allows us not to use a proximal screw. This method is mainly used to acquire pure translation without correction of the distal metatarsal articular angle (DMAA). And, as Leemrijse et al recommended, when the DMAA must be corrected, a shorter osteotomy with a greater rotational effect is made and the proximal part of the cut is not impacted, to ensure marked proximal translation. 

After a complete Z cut, we translate easily the lower part of the plantar metatarsal associated with medial rotation which allows to correct the orientation of the metatarsophalangeal cartilage (DMAA).

Figure 2 a: Removal of medial overhanging bone. b: Reshaping and rotation of bony wedge. c: Superior view of screwless scarf osteotomy with a proximal fixation by impaction of bony wedge and distal fixation with nonabsorbable suture through a transosseous tunnel. 

Figure 3 Medial view of first metatarsal showing screwless scarf osteotomy with suture travelling through a transosseous tunnel in distal and proximal stabilisation by interlocking with impaction of the medial overhanging edge.

Once the desired displacement is obtained, the proximal fixation is done by interlocking from the proximal transverse cut, while the distal attachment is held temporarily by a modified Jospin forceps. The 10/10 Kirschner wire is then inserted from top to bottom which will lead the non-resorbable thread N°2 and allows the distal fixation by a transosseous suture under moderate tension avoiding shear of thread in the spongy bone. The medial overhanging wedge of bone is resected and impacted proximally, conferring perfect stability to the construct (Figure 2 and 3). The medial capsulorrhaphy is then performed to center the sesamoid bones which are released by the lateral side.

Figure 4 Postoperative strapping to be kept for 2 weeks.

Primary stability must be compatible with good mobility of the first metatarsophalangeal joint which enables it to maintain satisfying postoperative amplitude. Moreover one patient received an Akin osteotomy of P1 associated with Scarf osteotomy.

Postoperatively, strapping was kept for 2 weeks (Figure 4). Patients were allowed to walk with a Barouk boot for 6 weeks. At week 6, patients were able to walk and stand on the operated foot with full weight bearing.

Patients were assessed preoperatively and postoperatively for clinical and radiological parameters. The clinical evaluation included both subjective and objective assessment with American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological assessment included IMA (angle M1M2), HV angle (HVA: angle M1P1), DMAA (distal metaphyseal articular angle), angle M1M5 and situation of sesamoids. Measurements were taken with radiographs at weight-bearing dorsoplantar and lateral views.

Statistical analysis was performed using the paired z test to analyze the radiological parameters with the P value set at 0.05 to determine statistical differences.

For the situation of the sesamoids, we used the following classification [8]:

  • Grade 0: no dislocation;
  • Grade 1: lateral sesamoid beyond the lateral border of the first metatarsal;
  • Grade 2: the lateral sesamoid is fully apparent in 1st metatarsal space;
  • Grade 3: both sesamoid bones are located in the 1st metatarsal space.

Results

At the time of the latest follow up (mean: 35 months; range: 4-60 months), 94% of the cases were satisfied and very satisfied with the result (64% very satisfied and 30% satisfied), 6% were not satisfied. 

The average preoperative AOFAS score was 55 (range: 36-71), postoperative AOFAS score was 87 (range: 63-95), 

The average preoperative M1P1 angle of 35.06° (range: 24°-46°) improved to 12° (range: 2° to 22°) postoperatively (p < 0.001). The average reduction of M1P1 angle was 23.06 ° (66% from M1P1 angle

The average preoperative M1M2 angle of 19° (range: 12°- 28°) improved to 7.03° postoperatively (range: 4°-16°; p <0.001).The average reduction of the M1M2 angle was 11.96° (63% from M1M2 angle).

The average preoperative DMAA of 27.27 ° (range: 14 °- 32 °) improved to 8.3° postoperatively (range: 3°-16°; p <0.001).The average reduction of the DMAA was 18.96° (70% from DMAA angle).

Preoperatively the average value of the M1M5 angle was 32.51 ° (range: 20 ° to 42 °). While in postoperative, the average value of the angle M1M5 was 20.57 ° (12 ° to 32 °; p <0.001). The average reduction of the M1M5 angle was 11.93° (22% from DMAA angle).

In preoperatively, the grade 2 was predominant with 22 cases (66.67%) followed by grade 3 with 6 cases (18.18%) and finally the grade 1 with 5 cases (15.15%). 

Authors Procedures M1P1 Angle pre-operative M1P1 Angle post-operative M1M2 Angle

pre-operative

M1M2 Angle

post-operative

DMAA

pre-operative

DMAA

post-operative

Jardé [12] (1996) Soft tissue +/- P1 33.3° 24.5° 14.2° 12°   –
Coughlin & Carlson [13] (1999) Double osteotomy 34° 12° 15° 23°
Veri [14] (2001) Proximal osteotomy 37° 13° 16°
Bauer [15] (2010) Reverdin-Isham Percutaneous Osteotomy 30° 15° 14° 11° 15°
Mahadevan et al [16] (2016) Chevron 32.3° 14.3° 15.2 ° 5.8° 16.5° 8.5°
Our series  Screwless scarf osteotomy 35.06° 12° 19° 27°

Table 1 Anatomical results of several series using different techniques.

  Authors  Pre-operative

M1P1

Post-operative

M1P1 

Pre-operative

M1M2

Post-operative

M1M2

Pre-operative

DMAA

Post-operative

DMAA 

Classical

Scarf 

 

Gayet [17] 37° 21° 15° 10°
Crevoisier [18]   32° 17° 16° 10° 13° 10°
Freslon [8]  31.2° 17.5° 12.1° 7.5° 13.3° 11.1°
Lipscombe [19] 31.4° 11° 13°
Law Kin-Wing [9] 37.9° 10° 16.1° 8.4°
Screwless

Scarf

 

Leemrijse [6] 38.5° 10.6° 15.1° 8.7° 15.4° 5.4°
Dries Van Doninck [11] 27,9 ° 4,2° 13.5 ° 4.8°
Our series  35.06° 12° 19° 27°

Table 2 Radiographic outcomes in the Scarf osteotomy series of the literature.

Authors Year Technique Number of feet Follow-up  Satisfaction Preoperative AOFAS score Postoperative AOFAS score
Veri [14] 2001 Proximal metatarsal osteotomy 37 12.2 years 90% 37 92
Schneider[20] 2004 chevron 112 12.7 years 46.5 88.8
Freslon [8] 2005 Scarf 123 4.8 years 84.6%
Bauer [15] 2009 Percutaneous Reverdin-Isham osteotomy 104 2 years 89% 49 87.5
Leemrijse [6] 2012 Screwless scarf 12 7.7 years 100% 80
K.-W. Law [9] 2014 scarf 31 17 months 77% 88
Raymond D. Pollock [21] 2016 Shortening scarf osteotomy 20 25 months 100% 29.2 82.2
Our series 2017 Screwless scarf  33 35.15 months 94% 55 87

Table 3 Comparison of the functional and objectives results of different series.

While in postoperative the grade 0 was found in 18 cases (54%), grade 1 in 13 cases (40%) and grade 2 in 2 patients (6%).

Complications were observed in three patients: Residual pain was reported in two patients (who have been disappointed), while the stiffness of the MP was objectified in one patient. No disorders of consolidation for osteotomy (delayed healing of bone, pseudarthrosis) were noted.

Discussion

Currently, foot surgery requires rapid functional recovery that cannot be conceived without a primary stability and solidity of an osteotomy. Scarf osteotomy is designed to be versatile, authorizing the restoration of multiplanar HV anomaly. It allows horizontal displacement, lengthening, rotation, elevation, and lowering of the MT head [9].

Various modifications of the traditional scarf osteotomy were proposed to improve the biomechanics and to reduce complications. This evolution is motivated by deficiencies and complications of chevron osteotomies, basal osteotomies and Lapidus arthrodesis and by the superiority of scarf osteotomy results compared to these techniques [10] (Table 1).

Many studies have focused on the surgical treatment of hallux valgus by Scarf osteotomy, with or without osteosynthesis material (Table 2). Maestro in 2007 [5] and Leemrijse in 2012 [6] were the first to use the Scarf osteotomy without internal fixation. Leemrijse et al. developed an original technique involving distal locking without shortening and proximal stabilisation by impaction of a cortical-cancellous bone graft [6], whereas in our technique the fixation was ensured  proximally by interlocking and distally by nonabsorbable suture. Compared to other series, our results lead to consider this procedure reliable for correction of the significant hallux valgus (Figure 5 and Tables 1-3).

The screwless scarf osteotomy is a diaphyseal-metaphyseal osteotomy which allows a very wide lateral translation; we don’t need more space for placing a screw which could limit our translation capacity. It also allows sufficient medial rotation to correct the DMAA [5, 6, and 11].

Figure 5 Example of correction of hallux valgus by screwless scarf osteotomy; a: preoperative. b: postoperative.

Figure 6 Scarf osteotomy without internal fixation with 45 days apart, a: preoperative anterior-posterior radiograph. b: Postoperative anterior-posterior radiograph. 

This surgical procedure has clear advantages [6, 11]: 

  • Fewer complications related to screw insertion mostly in porotic bones which can lead to  fragility fracture of  the 1st metatarsal
  • No loss of reduction due to the compressive effect of the screw 
  • Less risk for complications in case of  superficial infection 
  • Less cost because no screw is used

At last, the screwless technique provides high-quality remodeling at the osteotomy site, without stress shielding [6] (Figure 6). The mean follow-up of our series was 35.15 months which is a significant duration for a procedure whose practice is still recent. However, although this period is sufficient to consider the correction for granted, it would be interesting to pursue the follow up of these patients (as in the case of Leemrijse series [6]) to quantify the importance of late recurrence and whether corrections obtained with this procedure are superimposed in terms of efficiency in time to other techniques with an important follow up.

Conclusion

The screwless scarf osteotomy is the favored technique in moderate and severe hallux valgus, on the condition that technique fundamental principles are respected. The absence of screws allows a wide lateral translation and therefore reduces a considerable preoperative metatarsus varus.

Finally in our study, we confirm the efficiency of this recent technique in the treatment of HV with almost 94% excellent and good results in our series. The learning curve of this surgery remains long. Respect and application of various technical artifices is essential for the realization of this economic, reliable and biological procedure.

References

  1. Laffenêtre O, Solofomalala GD, De lavigne C, Bauer THallux valgus : définition, physiopathologie, études clinique et radiographique, principes du traitement. Enc. Med. Chir, 2009 ; 14-1236-A10, 9p. 
  2. Meyer M. Eine neue modifikation der hallux-valgus-operation. Zen Fur Chir. 1926; 53:3265–8.
  3. Weil LS, Borelli AN. Modified Scarf bunionectomy, our experience in more than 1000 cases. J Foot Surg. 1991; 30:609–22.
  4. Barouk LS. Scarf osteotomy for hallux valgus correction: local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000 Sep;5(3):525–58.
  5. Besse JL, Maestro M. Ostéotomie de Scarf du 1er métatarsien. Rev Chir Orthop. 2007; 93:515-23
  6. Leemrijse T, Maestro M, Tribak K, Gombault V, Bevernage BD, Deleu PA. Scarf osteotomy without internal fixation to correct hallux valgus. Orthopaedics & Traumatology: Surgery & Research. 2012 Dec 31; 98(8):921-7.
  7. Maestro M. The ruled lateral release of the metatarsophalangeal and metatarso sesamoïd joint in hallux valgus by the medial approach. Poster EFAS Paris 23-25 octobre 1997.
  8. Freslon M, Gayet LE, Bouche G, Hamcha H, Nebout J. Ostéotomie Scarf  dans le traitement de l’hallux Valgus : à propos de 123 cas avec un recul moyen de 4,8 ans. Rev Chir Orthop. 2005 January; 91:257-266.
  9. Law Kin-Wing, Li Hok-Yin Alwin, Li Pang-Hei, Qunn Jid-Lee, Wai Yuk-Leung. Scarf Osteotomy in Treating Hallux Valgus: Clinical and Radiographical Outcome and Technical Notes. Journal of Orthopaedics, Trauma and Rehabilitation. 2014; 18 (1):22-26. 
  10. Trnka HJ, Mühlbauer M, Zembsch A, Hungerford M, Ritschl P, Salzer M. Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10-to 22-year follow-up. Foot & ankle international. 1999 Mar 1; 20(3):171-7.
  11. Dries Van Doninck et al. Screwless Scarf osteotomy for hallux valgus: evaluation of radiologic correction. Foot and Ankle Surgery. 2017;23 (4): 255–260
  12. Jarde O, Trinquier-lautard JL, Meire P, Gabrion A, Vives P. Hallux valgus traité par ostéotomie de varisation de la première phalange associée à la plastie de l’adducteur. Rev Chir Orthop. 1996; 82:541-548. 
  13. Coughlin MJ, Carlson RE. Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle Int. 1999 Dec; 20(12):762-70.
  14. Veri JP, Pirani SP, Claridge R. Crescentic. Proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study. Foot Ankle Int 2001; 22:817-22.
  15. Bauer T, Biau D, Lortat-Jacob A, Hardy P. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthopaedics & Traumatology: Surgery & Research. 2010; 96(4):407-416.
  16. Mahadevan D, Lines S, Hepple S, Winson I, Harries W. Extended plantar limb (modified) chevron osteotomy versus scarf osteotomy for hallux valgus correction: A randomised controlled trial. Foot and Ankle Surgery. 2016; 22:109–113.
  17. Gayet LE, Vaz S, Muller A, Avedikian J, Pries P, Clarac JP. L’ostéotomie Scarf dans le traitement de l’hallux valgus: à propos de 71 cas. Rev Chir Orthop. 1997; 83(suppl II):81.
  18. Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M. The Scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int. 2001; 22:970-976.
  19. Lipscombe S, Molloy A, Sirikonda S, Hennessy MS. Scarf osteotomy for the correction of hallux valgus: midterm clinical outcome. J Foot Ankle Surg. 2008; 47:273–277. 
  20. Schneider W, Aigner N, Pinggera O, Knahr K. Chevron osteotomy in hallux valgus. Ten-year results of 112 cases. J Bone Joint Surg Br. 2004; 86(7): 1016-20.
  21. Prasad Karpe, Marie C. Killen, Raymond D. Pollock, Rajiv Limaye. Shortening scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome? . The Foot. 2016; 29:45-49.

Arthroscopy of septic ankle and subtalar joints: A case report

by Karl Dunn, DPM, FACFAS1; Jordan Haber2*

The Foot and Ankle Online Journal 13 (1): 1

Infection of the ankle and subtalar joints is a serious and potentially debilitating condition. Of the few reported cases, results have varied. Traditionally open procedures have been performed, some of which even led to amputation. In the case presented, the authors demonstrate a successful result utilizing arthroscopic techniques in combination with intravenous antibiotic therapy. At two-year follow-up the patient has remained infection free.

Keywords: arthroscopy, infection, osteomyelitis, septic joint, pyarthrosis

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0001

1 – Mid-Michigan Orthopaedic Institute, A Division of Compass Healthcare; East Lansing, MI 
2 – Undergraduate Researcher of the Honors College of Michigan State University; East Lansing, MI
* – Corresponding author: haberjor@msu.edu


Joint sepsis is a severe condition with an annual incidence of 2-10 per 100,000 individuals per year [1]. Possible morbidity following joint sepsis includes chronic pain, irreversible joint damage, dysfunction, disability and a mortality rate in 11.5% of cases [2]). The prognosis is directly influenced by the promptness of the diagnosis and initiation of antibiotics [3]. Although administration of culture specific antibiotics with joint decompression are the cornerstones of treatment in a septic joint, debate in the literature exists between open versus arthroscopic approaches.

Larger, over smaller, joints seem to have a predilection, with the hip and knee constituting the majority (60%) of all septic joints [4]. Several risk factors are associated with the development of a septic joint: history of joint prostheses, rheumatoid arthritis, intravenous drug abuse, alcoholism, diabetes, previous intra-articular corticosteroid injection, immunosuppression therapy, among others [5]. 

Interestingly, the false perception is that pyarthrosis is overwhelmingly monoarthritic, as the literature supports polyarticular sepsis 22% of the time [6]. Pyarthrosis has also been reported within the ankle [7,8], metatarsal-phalangeal joints [9], and interphalangeal joints [10]. The presence of joint sepsis in the subtalar joint is extremely rare, as only two other cases have been recorded in the medical literature [5,11]. To the authors’ knowledge, the case presented is the only polyarticular septic arthritis report in which arthroscopic methods were utilized in successful treatment of the subtalar joint.

Case Study

A 68-year-old female presented to the author’s clinic, in May 2016, for evaluation of a tender and swollen left foot and ankle. She reported 9 days prior to arrival, while living in her retirement home in Florida, she suffered a severe and sudden amount of pain to her left foot and ankle while attempting to stand. As a result of the pain, she then fell to the ground. She denied a history of trauma as the inciting event, as the pain occurred prior to her fall. Due to her inability to bear weight, the patient presented to an urgent care clinic, in which radiographs were noted to be negative for fracture. She was placed in a supportive ankle brace and was given non-steroidal anti-inflammatories. She states over the next several days it was difficult to bear weight while her ankle became more edematous. She states she was concerned about her condition and elected to drive back to her permanent residence. Seven days following her first episode of pain she stopped en route to Michigan at a major university hospital in Ohio due to increased pain during her travels. Standard repeat ankle radiographs were negative and she was started on an oral methylprednisolone course. A venous Doppler was negative for deep venous thrombosis.

Upon arrival in the office, the patient was non-diaphoretic, afebrile and in pain. Her past medical history was pertinent for rheumatoid arthritis, treated with bi-weekly injections of adalimumab. Physical examination revealed a mildly edematous foot and ankle, without calor or erythema. Neurovascular status was intact. Range of motion to her ankle and midtarsal joints was severely painful and limited. There was diffuse tenderness of her entire foot and ankle, with maximum tenderness to her lateral foot and posterior ankle. As a result, a lower extremity magnetic resonance image (MRI) was ordered for the patient.

Two days after her MRI, she reported a dramatic increase in pain and presented to her closest emergency department. The patient was afebrile, and her vitals and lab markers revealed no findings of sepsis or leukocytosis. The emergency department physicians’ primary differential diagnosis was continued pain due to ankle sprain. She was discharged from the hospital and was sent directly to our office again as the MRI report was still pending. Upon review of the MRI the radiologist was unable to determine if the large joint effusions were infectious or aseptic due to lack of contrast in the imaging study (Figure 1). There were joint effusions and reactive synovium noted at the ankle, as well as the subtalar joint, with a large expansion noted at the posterior recess (Figure 2). As a result, a joint aspiration was performed from the anterior aspect of the ankle joint. Greater than 3 cc of yellow purulent material was aspirated and the patient was directly admitted to the hospital upon findings of a septic joint. 

Figure 1 Axial MRI T2 weighted image displaying posterior abscess.

Figure 2 Sagittal MRI image which displays reactive bone marrow edema consistent with early osteomyelitis, large posterior fluid collection adjacent to subtalar and ankle joint consistent with abscess.

Upon arrival at the hospital, broad spectrum antibiotics were initiated with previous cultures pending. Infectious disease was consulted for management of antibiotics. Pertinent laboratory findings revealed a white blood count (WBC) of 9,300 WBC/mcL, a C-reactive protein (CRP) of 11.1 mg/L, and an erythrocyte sedimentation rate (ESR) of 47 mm/hr. Except for a small abrasion to her index finger two weeks prior, the patient did not have any other portals of infection. Blood cultures were taken upon presentation and were negative. Due to the patient’s immunosuppression on adalimumab, the medication was stopped indefinitely as this was thought to have predisposed the patient to the infection. She was taken to the operating room the next day for an arthroscopic debridement of the septic joints.

Initial Surgery

After general anesthesia was administered, a well-padded thigh tourniquet was placed. The ipsilateral thigh was placed in a thigh holder and the limb was held in a gravity dependent position. The limb was prepped, draped, and the tourniquet was inflated to 325 mmHg. The subtalar joint was first approached with aspiration to confirm the presence of joint sepsis in this location. An 18-gauge needle was placed on a leur-locked syringe, and the subtalar joint was first accessed for aspiration. The subtalar joint was approached from the sinus tarsi, upon which purulent fluid was aspirated (Figure 3). We traced the distal aspect of the fibula posteriorly, and the 18-gauge needle was placed from posterior to anterior just lateral to the Achilles tendon. Approximately 5 mL of purulent fluid was extracted from the posterior recess of the subtalar joint. Arthroscopic portals were then established, two to the lateral hindfoot at the level of the sinus tarsi, with a third at the posterior recess for an auxiliary suction portal. Upon initial evaluation, the joint was cloudy with purulent material. The joint had elements of infected synovium which was debrided. After establishing a view of the interosseous ligament, the debridement then continued from anterior to posterior and into the posterior facet. There was noted to be loose and degraded cartilage, which exposed the underlying subchondral bone. All loose material was debrided, and the subchondral bone was noted to be firm without obvious signs of infection. After a thorough debridement, 3 liters of fluid was used for irrigation until the joint fluid appeared translucent.

Attention was then directed to the ankle joint for arthroscopy. Anteromedial and anterolateral portals were established and a standard 21-point examination ensued. 

Figure 3 Subtalar joint aspiration with purulence; the accessory portal during arthroscopic irrigation and debridement placed in the same posterior recess.

The joint fluid was initially cloudy, with a lesser degree of loose bodies as the subtalar joint. The ankle cartilage was largely intact, and less irrigation was needed than the subtalar joint to establish a lucent joint and a clear picture with the arthroscopic equipment. Following the thorough irrigation, debridement, and removal of infected synovium, all equipment was removed from the ankle. The portals from the subtalar and ankle joints were left open to allow for joint decompressions and continue to drain.

On postoperative day one, the patient reported an immediate reduction in pain and no postoperative events recorded. The patient remained improved on post-operative day two as well. Culture results from the initial aspiration yielded a Methicillin-resistant Staphylococcus aureus (MRSA) pathogen which was sensitive to vancomycin. She reported a mild increase in pain on postoperative day three and as a result a repeat MRI was ordered with and without contrast to further scrutinize the septic joints. There was noted contrast enhancement of the synovium of the ankle and subtalar joints was noted with joint effusion, with new findings of marrow edema and contrast enhancement of the joint surfaces of the subtalar and ankle joints indicative of acute osteomyelitis. Following a lengthy discussion with the patient regarding possible limb salvage potential with a conversation regarding further arthroscopic versus an open approach, the patient agreed to a second arthroscopic approach to her ankle and subtalar joints.

Second Surgery

The subtalar joint was again approached first with an attempted aspiration. No fluid or purulence was able to be extracted from the sinus tarsi nor the posterior recess of the joint. Arthroscopic equipment was re-introduced in the similar approach, with the posterior drainage portal established as well. There was continued loose cartilage and infected synovium, and an aggressive debridement was performed to the joint. Following copious irrigation, the equipment was removed and the ankle was inspected as well. The joint fluid remained relatively clear, and the cartilage was intact. Following an aggressive synovectomy and irrigation all instrumentation was removed. The portals were again left open to decompress the joint.

Recovery

The patient recovered well following the second arthroscopic procedure, and was prescribed a 6-week course of intravenous vancomycin. Two days following the second procedure, the patient was discharged home with a peripherally inserted central catheter (PICC) line for continued antibiotic administration. Inflammatory lab markers were followed on a weekly basis. Four weeks after discharge, her CRP and ESR normalized and did not re-elevate following her course of antibiotics. Her skin incisions healed without complications by three weeks succeeding the second surgery.

The patient was gradually able to increase her weight bearing status, first with a fixed walking boot for 4 weeks following her hospitalization, and transitioning to an ankle brace thereafter. The patient was sent for extensive physical therapy to aid in her recovery back to full weight bearing. She was eventually able to forego any bracing or assistance 6 months following her hospitalizations with mild pain which was treated with oral NSAIDs. Upon most recent follow-up at fourteen months, she was able to return to all pre-injury activities. No continued signs of infection were noted on clinical exam.

Discussion

The subtalar joint is a highly complex articulation of the talus and calcaneus. There are usually three distinct facets (anterior, middle, posterior) which may differ in the context of a tarsal coalition. There is a degree of variability in the ligamentous contents and joint capsular attachments as well. Arthroscopic evaluation of the subtalar joint remains a lesser utilized procedure, likely due to the complexity of the joint and the relatively small surface area which may be difficult for an unfamiliar arthroscopist to visualize. 

To the authors’ knowledge, no other cases have been reported in the literature in the successful arthroscopic treatment of a septic subtalar joint. Two other cases were identified in the literature but utilized an open approach in combination with antibiotic therapy. A Danish report displayed an isolated septic subtalar joint caused by Neisseria gonorrhoeae [5]. A second, more recent case study depicted an open approach to an infection caused by Mycoplasma hominis [12]. In both cases the infection was rapidly identified, treated, and the patients recovered fully. In the present case, two major risk factors were identified which likely predisposed the patient to her septic joint: rheumatoid arthritis and concomitant immunosuppression therapy. Patients with RA are more likely to develop joint sepsis both due to the disease process itself and due to the immunosuppressive therapy that they receive. Dissimilar to the previous reports is the fact that the patient was successfully treated with an arthroscopic approach, which did not require an open method with antibiotics, to cure the infection.

A joint aspiration of a joint is considered the gold standard in diagnosis of a septic joint, and should be performed with a low threshold when pyarthrosis is considered as a differential diagnosis. Once the diagnosis has been confirmed, rapid initiation of antibiotics should be employed. Arthroscopic and open approaches are useful tools in the irrigation and debridement of the septic joint. Advantages are inherent to an arthroscopic versus open approach: decreased soft tissue damage, which may lead to a shorter hospital stay, possible overall faster patient recovery. Repeat open versus arthroscopic lavage and debridement may be required until the infection has been controlled. This especially holds true when there has been a delay in the diagnosis and initiation of antibiotics from time of initial presentation, such as the case presented.

Conclusion

Due to the proximity of the ankle and subtalar joint, which share a capsular connection, the authors advocate that the subtalar joint may be affected more commonly than previously thought when a septic ankle is encountered. Prognosis of a septic ankle shows probable infection of the subtalar joint, causing a septic subtalar joint. The pyarthrosis of the septic ankle can be polyarthritic [6]. The infection can spread from the septic ankle to the subtalar joint through the sinus tarsi, causing infection of the subtalar joint. Performing a procedure to prevent infection transmission through the sinus tarsi may hinder the ease of the infection to spread; the procedure would counteract the close proximity of the ankle and subtalar joints, preventing a monoarthritis diagnosis from developing into a polyarthritic case.

Given the case encountered, an arthroscopic approach may be beneficial over an open approach when a septic subtalar joint is encountered. An arthroscopic approach is less invasive, leading to a less cumbersome recovery and quicker recovery time for the patient. Arthroscopic aspiration of purulent fluid is more effective in comparison to an open approach. A late diagnosis of a septic subtalar joint is more effectively combated by an arthroscopic approach, as multiple open lavages and debridements are required to accomplish what could be completed by a single arthroscopic approach. Although the literature does not have copious studies regarding open irrigation vs. arthroscopic irrigation, when comparing both methods used during treatment of acute native knee septic arthritis, 71% of the open treatment group required repeat irrigation compared to 50% in the arthroscopic treatment group [12]. Lowered chance of repeated irrigation serves as an assuring factor that an arthroscopic approach would withhold the need of multiple joint irrigations, leading to a quickened overall patient recovery.

The septic subtalar joint cases described in the literature used a combination of an arthroscopic and open procedure to eradicate infection. This is the first described case of a 68-year-old patient with a septic ankle and subtalar joint that was successfully treated with an arthroscopic approach alone. Open procedures are not necessary for proper treatment of septic arthritis. An open procedure combined with antibiotic therapy will likely lead to a more arduous path for patient recovery. Although up to physician preference, research is spreading the belief that arthroscopic procedures are less invasive and more efficient for patient recovery.  

Acknowledgements: None

Funding Declaration: None

Conflict of Interest Declaration: None

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