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Performing A Revisional Subtalar Joint Arthrodesis Through A Modified Gallie Approach
These authors present an alternative approach to a revisional subtalar joint arthrodesis in a 50-year-old patient with several comorbidities and previous surgical complications.
Authors have previously described arthrodesis of the subtalar joint with multiple approaches.1-5 Surgeons often favor the lateral approach due to its ability to visualize the posterior and middle facet as well as the calcaneocuboid joint. However, wound healing complications, particularly in smokers, are concerning with this approach.1,2 One may also use the medial approach when access to the talonavicular joint is warranted.3,4 A posterior approach, first described by Gallie in 1943, offers visualization of the subtalar joint through a posterior incision.5 Originally described for restoring calcaneal fractures, this technique provides advantages over the typical lateral approach when one performs a subtalar joint fusion revision.
Understanding the vascular anatomy is vital when performing a revisional surgery on a patient with previous wound dehiscence. Attinger and colleagues describe the posterior tibial artery angiosome as “extending medially between the central raphe of the Achilles tendon to the anteriomedial border of the tibia” while the peroneal artery angiosome extends “laterally between the central raphe of the Achilles tendon to the anterior edge of the lateral compartment.”6 Through the standard lateral approach, one utilizes only the peroneal angiosome during the wound healing process, increasing the likelihood of complications in patients with multiple comorbidities such as smoking and diabetes.7-10 Thus, understanding of vascular anatomy aids the surgeon in understanding potential complications that may arise from performing a subtalar arthrodesis through a single angiosome.
The following describes our surgical technique for performing a subtalar joint arthrodesis revision using a modified Gallie approach in a patient with multiple comorbidities and previous surgical complications.
A Closer Look At The Patient’s Initial Presentation And History
A 50-year-old female patient initially presented in September 2011 with pes planus deformity and subtalar joint arthritis. Her significant past medical history included smoking, hypertension and gastroesophageal reflux disease (GERD). Her medications at that time included hydrochlorothiazide and Nexium. The patient denied any known allergies and smoked five to eight cigarettes per day.
Weightbearing radiographs revealed isolated subtalar joint arthritis. After the patient’s primary care provider cleared her for surgery, the procedure was scheduled and the patient was advised to quit smoking prior to the procedure.
Four weeks later, the patient had an isolated subtalar fusion using a lateral approach. Surgeons utilized percutaneous cannulated screw fixation with two screws measuring 5.0 mm x 75 mm and 7.3 mm x 80 mm. She wore a posterior splint at 90 degrees and was non-weightbearing for two weeks.
At the patient’s first post-op visit two weeks later, the incision site appeared to be healing well. Her only complaint was mild pain and discomfort, which was appropriate for the first post-op visit. The patient had mild edema and erythema with minimal drainage, which was also appropriate at this time. Office radiographs revealed good placement of fixation and healing. The patient received amoxicillin/clavulanate (Augmentin, GlaxoSmithKline) 875/125mg and Vicodin 7.5mg.
One week la
ter, the patient presented with increasing pain and edema at the surgical site. She went to the operating room for evacuation of possible hematoma formation and removal of painful hardware. Initially a small portion of the incision was reopened, however the senior author noted the tissues appeared friable and nonviable in nature. No purulent fluid was present but there was serous and hemorrhagic fluid. An incision and drainage was then performed.
Intraoperatively, the joint site was stable and there were no complications with subsequent removal of one of the previously placed 5.0 mm screws. The senior authors packed the wound open for placement of VAC therapy (KCI) the following day. Normal negative pressure therapy application occurred with subsequent changes three times per week at constant 125 mmHg of pressure. The senior author reminded patient to discontinue smoking and remain non-weight bearing, but she continued smoking.
The following week, the patient presented for a second post-op visit. At this time, the patient continued to have drainage, mild edema and erythema. A week later, the senior author debrided the wound and applied a human skin allograft in the operating room.
Following the procedure, the patient had continued follow up and presented to the office between 2012 and 2014 for unrelated foot and ankle issues to the same extremity including distal phalanx trauma, repetitive ankle sprains, peroneal tendonitis and a second metatarsal base fracture secondary to trauma. At each visit, when radiographs were warranted, no disruptive changes to the subtalar joint arthrodesis site were visible.
In January 2014, the patient presented with painful burning of the left heel. At the time, we determined that the screw was the source of pain. One month later, the other 7.3 mm screw was removed through a posterior percutaneous incision without complications.
In April 2015, the patient presented with severe pain for the past month to her left foot and ankle. Magnetic resonance imaging (MRI) revealed a low evidence of subtalar joint fusion, mild peroneus brevis tendinopathy and mild chronic Achilles tendinopathy. Two months later, the patient presented for a follow up visit and MRI discussion. The patient stated that the pain continued to worsen and the her foot frequently “locked up.” Pain on palpation was present at the lateral aspect of the ankle. At this time, we discussed surgical intervention as well as smoking cessation four weeks prior to surgery. The patient was agreeable to the plan and we selected a revisional subtalar joint fusion through a posterior Gallie approach.
Step-By-St
ep Surgical Pearls
In the OR, after ensuring the patient secured in a prone position with a left thigh tourniquet, a posterior midline incision was made over the Achilles tendon. The incision was straight as there was no true varus or valgus deformities at the subtalar joint. Beginning approximately 8 cm proximal to the Achilles tendon insertion, we started our incision and carried it distally to this level. We subsequently ensured the medial and lateral flares of the tendon were intact. Proximally, we incised through tendon just past the level of the ankle joint for proper landmark visualization and were careful not to disturb the paratenon from the Achilles tendon.
Sharp dissection was made with a scalpel longitudinally through the middle of the Achilles tendon, creating equal full-thickness medial and lateral flaps. The medial and lateral halves of the Achilles tendon with the corresponding skin edges were retracted allowing exposure of the deep posterior fascia of the leg. We proceeded to carefully incise the deep posterior fascia longitudinally, exposing the distal flexor hallucis longus muscle belly on the posterior aspect of the tibia and fibula. A subsequent release of the flexor hallucis longus muscle with medial retraction of the muscle belly helped to protect the neurovascular bundle. This technique allowed excellent exposure of the posterior aspects of the subtalar and ankle joint.
Sharp dissection was then performed deep into and around the posterior facet of the subtalar joint, and all intra-articular and capsular soft tissue structures were released. Use of a lamina spreader and a K-wire distractor facilitated distraction of the posterior facet. Upon distraction, all fibrous, non-viable and necrotic bony tissue was exposed and resected with a rongeur and curettage to good subchondral bone at the talar and calcaneal level was performed. Joint site was was then copiously irrigated with sterile normal saline.
After performing subchondral drilling with a 2.0 drill bit, we packed a mixture of demineralized bone matrix and approximately 10 cc of bone marrow aspirate into the posterior facet of the subtalar joint. With the distractors removed, the demineralized bone matrix/bone marrow aspirate mixture solidified into correct anatomical alignment. We then placed two guide pins from posterior-inferior to distal-anterior under fluoroscopic guidance for placement of two 6.7 mm fully threaded cancellous screws across the fusion site. We used remaining demineralized bone matrix/bone marrow aspirate graft to backfill any voids. Closure was then performed per senior surgeon’s preference utilizing both absorbable and non-absorbable sutures with the later being used for Achilles tendon and skin.
What The Research Says About The Modified Gallie Approach
Researchers have documented the effectiveness of a modified Gallie approach, particularly in patients with multiple comorbidities. Hammitt and coworkers found no wound skin flap necrosis in 33 patients at final follow up.11 However, the authors observed immediate wound healing problems in individuals with diabetes and end-stage renal disease, and severe deformities. Hersh and Flemming presented two case studies and observed wound healing without complications through a posterior approach in patients with Charcot arthropathy, chronic osteomyelitis and tibiocalcaneal dislocation with non-healing wounds.12 Similarly, DeOrio and colleagues noted that all six patients in their study had no wound complications, a complete tibiotalar union and no Achilles tendon disruptions or hardware complications through a posterior approach.13
Several other authors have described similar indications. In a review of 22 cases, Pollard and Schuberth observed five subtalar joint revisions were due to painful hardware, malunion or nonunion.14 Their revisions healed successfully while utilizing a true Gallie posterior lateral incision, observing a 95.5 percent successful union rate with three cases of wound dehiscence among all patients. Also employing the true Gallie posterior lateral incision in 15 cases, Lee and Tallarico observed a union rate of 93.33 percent with two cases of wound dehiscence, identifying the patient as a smoker in both instances.15 In a retrospective study of 88 patients undergoing a subtalar joint fusion, Chahal and colleagues found smokers were 3.8 times more likely to have a nonunion while patients with diabetes were 18.7 times more likely to have a malunion in comparison to the nonsmoking group.1
In Conclusion
In patients with poor wound healing potential due to systemic vascular compromises, such as diabetes and smoking, an alternative approach to avoid complications such as wound dehiscence and infection is necessary. In our opinion, one can best achieve this through a modified Gallie approach in which adequate visualization and exposed surface area of the posterior facet occur through the midline incision of the Achilles tendon while preserving dual angiosome blood supply to promote wound healing.
Dr. Visser is the Director of the Foot and Ankle Surgery Program at SSM DePaul Health in St. Louis.
Dr. Malik is a third-year resident at SSM DePaul Health in St. Louis.
Jesse Wolfe is a fourth-year student at the College of Podiatric Medicine and Surgery at Des Moines University.
Joshua Wolfe is a second-year student at the College of Podiatric Medicine and Surgery at Des Moines University.
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