Disruption of the blood supply to the talar dome leads to bone infarction that may be segmental or involve the entire dome. There is ischemic death of the cellular constituents in the infarcted area, which leads to osteonecrosis. Histologically, this process is recognized on the basis of the disappearance of osteocytes from within the lacunae. Radiographs give the appearance of osteoporosis of the surrounding bone due to hyperemia, whereas the infarcted bone retains its density. Disruption of the blood supply can be secondary to trauma6,12,14,20, external compression, or intraluminal obstruction1,3. Disruption due to external compression can occur when a space-occupying lesion physically compresses the arterial supply and inhibits blood flow. Intraluminal obstruction occurs when there is an intravascular process that interrupts blood flow. Fat emboli can occlude blood vessels; this has been seen in histological studies performed on specimens of osteonecrotic femoral heads3.
Osteonecrosis of the talus has also been reported in association with several nontraumatic factors, such as exposure to pressurized atmospheric conditions, the use of corticosteroids, alcoholism, sickle-cell disease, chronic pancreatitis, Cushing disease, Addison disease, peripheral vascular disease, and dialysis for chronic renal failure1,3,9,10,13,17. There have also been reports of osteonecrosis of the entire body of the talus after a triple arthrodesis when there has been extensive resection of the talar head and neck4,8,15,18. We report the occurrence of osteonecrosis of the lateral aspect of the talar dome after a triple arthrodesis in three patients who had rheumatoid arthritis and had been taking corticosteroids.
CASE 1. A sixty-eight-year-old man who had seropositive rheumatoid arthritis, diagnosed in 1976, was first seen by us in 1992 because of a six-month history of progressively worsening pain in the left ankle. The pain was aggravated by activity, but the patient could walk without the aid of assistive devices. He had been managed with a variety of medications, including corticosteroids, for problems related to other joints.
The patient had a full, painless range of motion of the ankle and pes planus. On palpation, it was obvious that the posterior tibial tendon had ruptured. The patient had limited and painful subtalar motion and painless motion of the transverse tarsal joints. There was clawing of the lesser four toes with tenderness to palpation over the plantar aspect of the lesser metatarsal heads. The patient also had pain over the first tarsometatarsal joint. The results of the neurological examination were normal, as were the dorsalis pedis and posterior tibial pulses. The skin was thin but intact, and there was no discoloration or mottling. Preoperative radiographs of the ankle, made with the patient standing, revealed normal findings (Fig. 1-A), whereas such radiographs of the foot showed a plantar flexed talus, with uncovering of the talar head, and arthritis of the first tarsometatarsal joint. The radiographic findings were consistent with the clinical findings of subtalar arthritis secondary to dysfunction of the posterior tibial tendon.
As patients with this condition often are, our patient was surprised to hear that the problem was not with his ankle but rather with the adjacent joint. Initially, he was managed nonoperatively with a clamshell ankle-foot orthosis to control the motion of the hindfoot. The patient could not tolerate the brace because of irritation of the skin and osseous prominences; furthermore, the orthosis did not alleviate the symptoms. The patient wished to consider other forms of management. The rupture of the posterior tibial tendon and subtalar arthritis precluded a tendon transfer or a calcaneal osteotomy. The senior one of us (J. A. N.) recommended a triple arthrodesis to realign the hindfoot and to treat the subtalar arthritis and an arthrodesis of the first tarsometatarsal joint to provide a plantigrade and functional foot.
The triple arthrodesis and the arthrodesis of the first metatarsal joint were performed in November 1992. A pneumatic tourniquet, inflated to 350 millimeters of mercury (46.66 kilopascals), was used on the thigh. The talonavicular joint was approached through a medial incision, with careful preservation of the deltoid ligament, and the articular cartilage was removed without resection of the underlying bone. The posterior and middle facets of the subtalar and calcaneocuboid joints, approached through a lateral incision over the sinus tarsi, were denuded of articular cartilage without resection of the underlying bone. The joint surfaces were debrided to bleeding subchondral bone by multiple perforations made with a two-millimeter drill-bit. The talonavicular joint was then reduced and transfixed with a 6.5-millimeter partially threaded cancellous-bone screw placed from the navicular tuberosity into the talar body. A 6.5-millimeter screw was also used to transfix the calcaneocuboid joint5. Bone graft obtained from the iliac crest was packed into the subtalar joint. A small anterior incision was made just lateral to the anterior tibial tendon, and the anterior aspect of the talar neck was exposed by blunt dissection. A guide-pin for a 6.5-millimeter cannulated screw was inserted across the talar neck and into the posterior facet of the calcaneus. The position was checked with fluoroscopy, and a partially threaded 6.5-millimeter screw was passed, from anterior to posterior, over the guide-pin (Fig. 1-B). Through a dorsal incision made medial to the extensor hallucis longus, the arthrodesis of the first tarsometatarsal joint was performed with use of a 3.5-millimeter cannulated lag screw.
For two weeks postoperatively, the patient wore a below-the-knee posterior splint to allow for swelling. During this period, the patient was allowed touch-down weight-bearing with a walker. At two weeks, the sutures and the splint were removed and the ankle was immobilized in a below-the-knee cast. The patient was allowed partial weight-bearing for four weeks. Six weeks after the procedure, the cast was removed and the ankle was supported in a removable ankle-foot orthosis. The patient was permitted to advance to full weight-bearing as tolerated. Radiographs made twelve weeks after the procedure showed a solid fusion of all three joints; at that time, the orthosis was removed and the patient continued full weight-bearing while wearing regular shoes. During these first twelve weeks after the procedure, the patient was able to perform the activities of daily living but was not allowed to drive an automobile. He was functional and able to take care of himself.
The patient returned five months after the operation because of pain over the distal third of the fibula as well as over the screw in the region of the tarsometatarsal fusion. At that time, a stress fracture of the distal aspect of the fibula was suspected. Radiographs did not show any fractures but revealed osteonecrosis of the lateral aspect of the talar dome. There was evidence of osteoporosis of the distal aspects of the tibia and fibula and of the medial half of the talus; the lateral aspect of the talus appeared to be radiodense compared with the surrounding bones. The patient was instructed to limit his activities to walking around the house, to avoid heavy lifting or carrying, and to refrain from weight-bearing activities that caused the pain to become more intense. The patient did not need analgesics at that point. Pain at the tarsometatarsal joint was alleviated by removal of the prominent screw.
The patient was not seen again until he returned twelve months after the operation and reported increasing pain in the ankle and the distal aspect of the fibula. Radiographs made at that time revealed osteoporosis of the distal aspects of the tibia and fibula and a sclerotic line of approximately six to eight centimeters, representing a stress fracture, proximal to the tip of the fibula. The lateral half of the tibiotalar joint was narrowed, and there was a radiolucent line with radiodensity in the lateral half of the talus, which was consistent with osteonecrosis. The radiograph showed two of the screws used in the triple arthrodesis (Fig. 1-C). The fibular stress fracture was treated with an ankle-foot orthosis and limited weight-bearing with the aid of a walker. The fracture healed in two months.
Nevertheless, the patient had persistent pain in the ankle. Nonoperative management included the use of the clamshell ankle-foot orthosis, which provided some pain relief. However, because of increasing valgus deformity of the foot and irritation of the skin and osseous prominences, the patient could not tolerate the orthotic device.
A tibiotalar arthrodesis was performed in February 1994. A transfibular approach to the ankle was used, and the fibula, employed as an onlay graft, was secured with two small screws. The arthrodesis was performed with insertion of three large threaded cancellous-bone screws between the distal part of the tibia and the body of the talus. The procedure was complicated by poor wound-healing, but the wounds eventually healed with topical care and without signs of infection. A solid fusion was obtained three months postoperatively, but the patient had a valgus deformity of the hindfoot. He was fitted with a patellar ligament-bearing orthosis to decrease any residual pain and to transfer some of the stress from the foot to the knee. At the time of the most recent follow-up, four years after the latest operation, the patient could walk around his house without wearing the orthotic device and he did not wear the device when sleeping. He did use the device when walking long distances. He was not taking analgesics.
CASE 2. A sixty-nine-year-old woman with rheumatoid arthritis and systemic lupus erythematosus requiring long-term corticosteroid treatment was first seen by us for the evaluation of pain in both feet. She wore ankle-foot orthoses and molded shoe inserts, prescribed by her rheumatologist, but these devices did not provide pain relief. She was also taking over-the-counter analgesics, but the pain still limited her ability to walk or to carry objects.
The patient had bilateral pes planus. The range of motion of the right ankle was painless and normal; however, motion of the subtalar joint was limited and painful, as was motion of the transverse tarsal joints. The patient also had severe pain with motion of the first tarsometatarsal joint and a painful callosity overlying the joint. Motor strength was normal in both lower extremities, as were responses to sharp and light touch. Peripheral pulses were palpable. Radiographs revealed marked plantar flexion of the talus, uncovering of the talar head, and severe arthritis of the first tarsometatarsal joint with diffuse osteopenia of the surrounding bones. After discussion of the options of continued orthotic management or operative intervention, the patient had a triple arthrodesis and an arthrodesis of the first tarsometatarsal joint on the right side, performed by the senior one of us, in July 1996. The procedure was performed in the same manner as described in Case 1, and the postoperative management was also identical.
Clinical and radiographic evidence of union was noted four months after the operation, at which time the patient was walking without any orthotic devices. Eight months after the operation, she began to have pain in the right ankle. Radiographs made at that time revealed early osteonecrosis of the lateral aspect of the talar dome, but there was no evidence of collapse. The patient was managed with a medial heel-wedge and a molded ankle-foot orthosis. She later had symptoms secondary to a stress fracture of the distal part of the fibula, which healed without complications. At the time of the most recent follow-up, one year and nine months after the operation, the patient was able to perform the activities of daily living while wearing the ankle-foot orthosis, although she could not carry heavy objects. She was not using any analgesics for pain control.
CASE 3. A forty-one-year-old woman with systemic lupus erythematosus, rheumatoid arthritis, and idiopathic thrombocytopenic purpura had been managed with corticosteroids for twenty years. In March 1994, she had a triple arthrodesis on the right side at another institution. The procedure was performed in a manner similar to that used in Cases 1 and 2, but without an arthrodesis of the first tarsometatarsal joint. The patient did very well until one year after the procedure, when she began to have pain in the right ankle. Radiographs made at that time revealed osteonecrosis of the lateral aspect of the talar dome, with slight collapse. She was managed with below-the-knee double-upright braces, but the pain in the ankle worsened progressively. Her primary surgeon recommended an ankle arthrodesis, and she came to the senior one of us for a second opinion.
Physical examination revealed marked crepitus and pain with motion of the ankle; there was no subtalar motion. The hindfoot was in 15 degrees of valgus with the patient standing. Radiographs revealed osteonecrosis of the lateral aspect of the talar dome with collapse of the ankle joint into valgus, a solid fusion at the site of the triple arthrodesis, and diffuse osteopenia of the surrounding bone. Four years after the index operation, she was still able to walk with use of a clamshell ankle-foot orthosis.
Gelberman and Mortensen11 studied the relationship of the intraosseous and extraosseous blood supply of the talus to the prevalence of osteonecrosis after fractures of the talar neck, with and without subtalar dislocation. Their findings, which were generally consistent with the earlier work of Mulfinger and Trueta19, were that the talar dome receives its blood supply primarily from the artery of the tarsal canal, a branch of the posterior tibial artery, and that this artery supplies the middle one-half to two-thirds of the body directly and through the intraosseous anastomoses can supply the rest of the body of the talus. Two important minor vascular sources are the deltoid branches of the posterior tibial artery and the artery of the sinus tarsi, a branch of the peroneal artery. The deltoid branches are the most important secondary source and supply the middle third of the body. The artery of the sinus tarsi supplies the lateral one-eighth to one-half of the talar body. These arteries can supply the rest of the talar body through an internal anastomosis. Other less important sources of blood to the body of the talus are the superior neck vessels from the anterior tibial artery and the posterior tubercle vessels from the peroneal vessels11.
The relationship between trauma and osteonecrosis of the talus has been well described6,12,14,19. The arterial supply to the talus is tenuous and can be disrupted when there is a fracture of the talar neck4,7. Disruption of the blood supply to the talus is more likely with increasing displacement of the fracture and the presence of a subtalar dislocation; therefore, these factors are associated with an increase in the prevalence of osteonecrosis. In one study, the reported prevalence of osteonecrosis after nondisplaced fractures of the talus (type I) was only two of fifteen, whereas it was sixteen of nineteen after fractures associated with subtalar dislocation (type III)6. This increase in prevalence is expected since the subtalar dislocation strips most of the soft-tissue attachments and blood supply of the talus.
The dissection performed during a triple arthrodesis necessarily disrupts the artery of the sinus tarsi when the chondral surface of the talocalcaneal joint is removed. If the talar head and neck are left intact, the artery of the tarsal canal and the deltoid branches should not be disturbed during resection of the talonavicular joint. After a triple arthrodesis, the surgeon must rely on the intraosseous anastomoses and the fused osseous surfaces to provide the blood supply to the lateral aspect of the talar dome. As reported previously by Marek and Schein18 (in a series of sixty-one patients), Wukich and Bowen22 (in a series of thirty-nine patients), Duncan and Lovell8 (in a series of 109 patients), and MacKenzie15 (in a series of 182 patients), when extensive resection of the talar head and neck is required to correct any deformity, the prevalence of total osteonecrosis of the talar body is as high as 24 percent. This is understandable given that the entire primary blood supply to the talus is necessarily disrupted during this dissection. The entire blood supply is less likely to be disrupted when only the articular cartilage and little subchondral bone are resected. Such a technique may decrease the risk of osteonecrosis18-20.
When a triple arthrodesis is performed, the subtalar joint is usually fixed internally with use of a partially threaded 6.5-millimeter cancellous-bone lag screw2,16. This screw can be placed either from anterior to posterior, beginning at the talar neck and entering the body of the calcaneus2, or from posterior to anterior, beginning just proximal to the weight-bearing surface of the calcaneus and proceeding into the talar body17. Manoli et al.17 discussed the advantages and disadvantages of both approaches. The recognized disadvantages of the anterior-to-posterior technique, which constitute advantages of the posterior-to-anterior technique, include (1) a prominent screw head that can impinge on the anterior aspect of the tibia during dorsiflexion of the ankle, (2) creation of a stress-riser in the talar neck, (3) a screw that is not perpendicular to the posterior facet, and (4) possible injury to the deep peroneal artery and nerve. The advantages of the anterior-to-posterior technique, which constitute disadvantages of the posterior-to-anterior technique, include (1) ease of placement from this angle, (2) better purchase of the lag screw because all of the threads cross the arthrodesis site, and (3) avoidance of a prominent screw head on the weight-bearing surface of the calcaneus. Sangeorzan et al.21 also suggested that the talocalcaneal screw be directed upward from the calcaneal tuberosity to avoid disturbing the blood supply of the talus; however, they did not report any instances of osteonecrosis with that technique.
Osteonecrosis of the talus after triple arthrodesis is a recognized complication, and the amount of talus that is involved is proportional to the degree to which the blood supply of the talus is disturbed during the operative procedure. It seems reasonable that individuals who have no comorbid factors are at a lower risk for the development of osteonecrosis after triple arthrodesis than are those who have major comorbid disease, but this hypothesis has not been clinically demonstrated. The assumption is that patients without comorbid conditions, such as alcoholism, the long-term use of steroids, or peripheral vascular disease or other vascular diseases, may have a more competent intraosseous anastomotic network. We hypothesize that injury to the blood supply of the talus in some patients who are at risk can result in partial osteonecrosis of the talus after a triple arthrodesis.
Our three patients had a screw inserted from anterior to posterior across the subtalar joint. The deltoid branches and superior neck vessels were at risk during screw fixation. We believe that placement of the screw from anterior to posterior may have contributed to the development of osteonecrosis. However, there were other risk factors: all three patients had rheumatoid arthritis, and all three patients had been taking corticosteroids and may have had an underlying vasculitis. The senior one of us has modified his operative technique and now places the lag screw from posterior, in the calcaneus, to anterior, in the talus. We hope that this change in technique will prevent osteonecrosis of the talus in the future.
*No benefits in any form have been received or will be received fro+m a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Investigation performed at the Division of Orthopaedic Surgery, Duke University Medical Center, Durham
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