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The Foot 23 (2013) 172–175
Contents lists available at ScienceDirect
The
Foot
j o u r n a l h o m e p a g e :w w w.e l s e v i e r.c o m /l o c a t e /f o o
t
Case
report
Arthroscopic revision of nonunion of calcaneocuboid distraction arthrodesis
Tun Hing Lui ∗
Department of Orthopaedics and Traumatology,North District Hospital,9Po Kin Road,Sheung Shui,NT,Hong Kong SAR,China
a r t i c l e
i n f o
Article history:
Received 3March 2013
Received in revised form 27October 2013Accepted 29October 2013
Keywords:Arthroscopy Flatfoot Revision Arthrodesis Fusion
a b s t r a c t
Calcaneocuboid distraction arthrodesis is one of the common surgical procedures for correction of flatfoot deformity.Nonunion of the arthrodesis site is a significantly well-known complication of this procedure.Revision arthrodesis is indicated especially if the nonunion is symptomatic.Classically,this is performed openly with removal of the implants,refreshment of the fusion sites,bone grafting and revision fixation.We reported,a case of nonunion of the calcaneocuboid arthrodesis,which was successfully treated with arthroscopic revision arthrodesis.Removal of the implant and revision fixation was not needed.
© 2013 Elsevier Ltd. All rights reserved.
1.Introduction
Lateral column lengthening is one of the common surgical procedures for correction of flatfoot deformity [1,2]and usually combines with different medial soft-tissue reconstruction [3,4].It provides triplanar correction of the flatfoot deformity [5].Cal-caneocuboid distraction arthrodesis is one of the lateral column lengthening procedures [6].Either the tricortical autologous bone graft or allograft has been used to fill up the distraction gap.No matter what kind of bone graft is used,nonunion of the arthrode-sis site is the most significant complication of this procedure [7].A case of nonunion of the calcaneocuboid distraction arthrodesis is presented in this case report,and this was successfully treated with arthroscopic revision arthrodesis.
2.Case report
A 15year old boy had right foot arch pain on walking for 3years,which was increasing in severity.Clinically,there was bilateral flexible flatfoot with valgus heel and forefoot abduction and supination,which can be corrected by tiptoeing.There was no definite tenderness.Radiographs showed naviculocuneiform break in the sagittal plane and uncoverage of the talar head and mild calcaneocuboid subluxation in the dorsoplantar view.It did not respond to orthotic treatment.Calcaneocuboid distraction
∗Corresponding author.Tel.:+852********;fax:+852********.E-mail addresses:*******************.uk ,************.hk ,********************
arthrodesis with iliac tricortical autograft,dorsal open wedge osteotomy of the medial cuneiform and gastrocnemius aponeu-rosis recession were performed on 2009.Post-operatively,a short leg cast was put on and he was advised on non-weight bearing walking for 8weeks followed by weight bearing walking with an arch support.The preoperative medial arch pain subsided.However,nonunion of the distal graft-cuboid interface without loosening of the implant developed (Fig.1).He had pain over the operative site on walking or standing with recurrent local swelling since 9months,postoperatively,other areas remained painless.Arthroscopic revision arthrodesis was performed on 2011.
3.Technique
The patient was put in lateral position with a thigh tourniquet to provide a bloodless operative field.Because there was no radi-ological evidence of implant loosening and the correction of the flatfoot deformity was good,the implant was kept in situ.Since the nonunion site was splint by the implant,the nonunion site cannot be accurately identified by palpation or mobility of the nonunion site.The dorsal and plantar portals were identified under fluoroscopy at the dorsal lateral and plantar lateral corners of the nonunion site,respectively.The soft tissue was stripped away from the nonunion site with a small periosteal elevator to provide a working space for the arthroscopic procedure.A 2.7mm arthro-scope was used for this procedure.The nonunion site was pieced by a needle under fluoroscopic guide.It served as a marker of the nonunion site during the arthroscopy.The fibrous tissue at the nonunion site was loosened with an arthroscopic probe and was removed with the arthroscopic shaver.The nonunion surfaces were
0958-2592/$–see front matter © 2013 Elsevier Ltd. All rights reserved./10.1016/j.foot.2013.10.013
T.H.Lui/The Foot23 (2013) 172–175
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teral view showed calcaneocuboid distraction arthrodesis(A),dorsoplantar(B),oblique(C)and lateral(D)views showed nonunion of the calcaneocuboid arthrodesis site without implant loosening.
refreshened with a curette,arthroscopic burr and small arthro-scopic awl.The gap was packed with autologous cancellous bone graft by means of a2.5mm drill guard under arthroscopic guide (Fig.2).Postoperatively,a short leg cast was applied and the patient was advised for non-weight bearing walking for8weeks followed by weight bearing walking with woodened base shoes for another 4weeks.
The lateral foot pain subsided3months after the revision arthrodesis and radiographs showed that the arthrodesis site healed.During the latest follow up,20months after the operation, the patient was symptoms free and no pain over the fusion site. Radiographs showed solid fusion and the implant was not loosened (Fig.3).4.Discussion
Calcaneocuboid distraction arthrodesis can be used to treat stage2posterior tibial tendon dysfunction.Tricortical bone graft, such as iliac crest,is ideal for this procedure because the cortical portion provides excellent structural support and the cancellous portion provides a trellis for osteo-conduction[5].Nonunion,graft resorption,and implant failure are some of the reported complica-tions of this procedure[8].Two different types of nonunion were noted.Thefirst was classic nonunion,which maintained structural integrity of the graft.The second was osteolysis and collapse of the graft accompanying the nonunion[9].Risk factors of nonunion included smoking,inadequate period of protected
immobilization,
Fig.2.The distal(A)and proximal(B)portals were identified underfluoroscopy,the nonunion site was marked with a needle which served as a marker during arthroscopy (C),the nonunion site was refreshened under arthroscopy(D,E),the nonunion site can then be grafted under arthroscopy(F).
174T.H.Lui /The Foot 23 (2013) 172–
175
Fig.3.Dorsoplantar (A),oblique (B)and lateral (C)views showed solid fusion.
unstable fixation and possibly larger deformities requiring Achilles tendon lengthening [6,9].It is still debatable whether the use of allograft will increase the risk of nonunion [4–6,9–11].
Although interpositional arthroplasty with allograft dermal matrix has been suggested,revision arthrodesis is still the stan-dard of treatment in case of symptomatic nonunion.This requires rigid fixation,autogenous cancellous bone grafting,and initial non-weight-bearing immobilization [8,11,12].Open procedure has the potential disadvantage of extensive soft tissue dissection and compromise of the blood supply of the nonunion site.Minimally,invasive approaches including percutaneous and endoscopic bone grafting have been described.Percutaneous bone grafting should be performed under the control of the image intensifier and com-plete debridement of the fibrous tissue and sclerotic bone plates of the nonunion site cannot be sure [13].Endoscopic bone grafting has the advantages of minimal incision,accurate debridement,precise bone grafting,minimal vascular injury to the surrounding tis-sues,fewer complication,minimal hospital stay,and less expense [13,14].Previous reports of this procedures were focused on treat-ment of nonunion or delayed union after fractures of humerus [13,14],femur [13,14],phalanx of finger [15]and scaphoid [16].The only reports of the foot and ankle region were nonunion of fracture of the fifth metatarsal styloid [17].However,there was no implant in that case,and there was freedom of manipulating the nonunion site during endoscopic bone grafting.The implant fixa-tion of this case was still stable and kept the foot in good alignment,it was not removed during the revision and the previous surgical scar was not needed to be reopened.Because the nonunion site was splinted by the plate,the nonunion site needed to be located by intra-operative fluoroscopy.Moreover,the nonunion site can-not be distracted with the plate in situ,the arthroscopic shaver cannot be inserted into the nonunion site.It is useful to loosen the fibrous tissue with a small arthroscopic probe before it can be sucked into the shaver and removed.The lateral part of the nonunion site can be widened with an arthroscopic burr and the deep part of the nonunion site can then be debrided.The gap would finally be filled up with cancellous bone graft under arthroscopic guide [18].The potential risk of this endoscopic procedures include sural nerve injury and the patient should be informed before the surgery.
5.Conclusion
This case demonstrated that endoscopic refreshment of the nonunion site can be effectively done even with the presence of implant.However,because of the limited working space and the technical difficulty of the revision surgery,this should be reserved for the experienced foot and ankle arthroscopists.
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