A Foot to Last a Lifetime—Is Hindfoot Fusion Ever Appropriate for Pediatric Orthopaedic Conditions?

Abstract

Introduction: Hindfoot deformities in the pediatric population can be painful and result in severe limitations. Although arthrodesis is known to relieve pain, there are concerns over its use because of the risk that adjacent joint degenerative disease could result, leading to a new source of pain, dysfunction, and additional surgical procedures later in life. Methods: A literature review of hindfoot fusions in children focused on articles with the highest levels of evidence and those of particular historical significance. Case examples were obtained by querying the billing records of the local clinic system for Current Procedural Terminology (CPT) codes of hindfoot arthrodeses. Surgery procedures were performed by both fellowship-trained pediatric orthopaedists and fellowship-trained foot and ankle orthopaedic surgeons. Results: The medical literature for this topic generally is divided into 2 main types of articles: those that describe hindfoot fusion procedures for a specific type of deformity or disease process and those that provide the indications and results of a single type of arthrodesis. Long-term follow-up studies are limited. Discussion: The long-term risk of degeneration to adjacent joints has been studied, with mixed results. Other problems, such as recurrent deformity, overcorrection, pseudarthrosis, osteonecrosis, and foot shortening also may be encountered over intermediateterm follow-up. Nevertheless, in properly chosen patients, hindfoot fusion can offer a great improvement over the damaging and destructive deformities of the feet caused by a variety of diseases and traumatic injuries. Hindfoot fusions have been used for the treatment of foot deformities secondary to severe trauma, hemophilia, tarsal coalition, clubfoot, and neurological disease such as polio, static encephalopathy, hereditary motor and sensory neuropathies, and myelodysplasia. Conclusions: Hindfoot fusion in a child or adolescent should be considered only for the most extreme cases when all other options, short of amputation, have been considered or exhausted. While these procedures can offer improvement in the challenging cases, the surgeon should be aware of their long-term implications, including adjacent joint degeneration.

Deformity-Correcting Ankle Fusions With Patient-Specific 3D Operative Planning and 3D-Printed Cut Guides

“…D eformity-correcting fusions of the foot and ankle in adolescence are rare and often complex. They include risks such as shortening of the foot, recurrence of deformity, nonunion, and neurovascular injury [6][7][8] . In extreme cases of severely relapsed clubfoot, there may not be other suitable options 14 .…”

“…Joint sparing procedures are preferred in younger patients; however, in the setting of arthrogryposis, the joints tend to become extremely stiff. When joint motion is already markedly reduced, arthrodesis may be the optimal solution [6][7][8] .…”

“…Joint sparing procedures are preferred in younger patients; however, in the setting of arthrogryposis, the joints tend to become extremely stiff. When joint motion is already markedly reduced, arthrodesis may be the optimal solution [6][7][8] .Deformity-correcting ankle fusions are not commonly performed in pediatric patients. Restoring alignment in children with ankle deformities, such as those seen in arthrogrypotic clubfeet, is challenging because the surgeon must often free-hand bone cuts in multiple planes while avoiding neurovascular structures.To address these complex cases with improved surgical precision and to decrease surgical risks, a new technique of preoperative planning and intraoperative deformity correction was developed using 3D digital modeling and 3D printing of patient-specific cut guides.Others have used 3D guides in orthopaedic surgery, including cut guides for osteotomies of the hindfoot, midfoot, and knee [9][10][11] , and k-wire positioning guides for both arthroscopic ankle fusions 12 and ankle ligament reconstruction 13 .…”

Triple Fusion in Children and Adolescents

“…In the young individual, triple fusion should only be considered after failure of soft tissue releases and other joint-sparing techniques. 7 A relative contraindication of fusion surgery is the insensate foot, and this is a particular feature in spina bifida, where authors have cautioned against fusion where it may result in pressure-related problems, including ulceration. 8…”

Lapidus Procedure for Adolescent Hallux Valgus

“…This is outlined in a recent publication. 7 Therefore, in specific cases of AHV with hypermobility of the first ray and symptomatic hallux valgus refractory to conservative treatment, TMTJ fusion or the Lapidus procedure may be appropriate and can lead to an acceptable, durable correction. 8…”