GLOBUS MEDICAL, INC.
`EXHIBIT 1021
`IPR2015-to be assigned
`(Globus v. Bonutti)
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`Foot &Ank/e/Vol. 12, No. 3/December 1991
`
`ARTHRODESIS OF THE TARSUS
`
`157
`
`was successful at final follow-up or until treatment was
`terminated. They were contacted and examined during
`1990, up until the time of this writing. Due to the inability
`to obtain adequate follow—up for patients who had
`moved, the final patient population for this report con-
`sisted of 41 patients in which 47 arthrodeses had been
`performed.
`The results were graded according to the criteria of
`Angus and Cowell‘ (Table 1). Additionally, the appear-
`ance and size of the operated foot were compared with
`the unoperated foot. The results were graded good,
`fair, or poor. When preoperative deformity was present,
`the anteroposterior talocalcaneal angle of divergence
`and the lateral talocalcaneal angle of convergence were
`measured, comparing them with the postoperative an-
`gles.” The presence of postoperative, adjacent, joint
`arthritis was determined by roentgenograms. Finally,
`the transverse tarsal joint motion was compared with
`the unoperated side in patients in whom isolated talo-
`calcaneal fusions were performed.
`
`OPERATIVE TECHNIQUE
`
`For patients with severe pes valgus, pes cavus, or
`adult talipes equinovarus, three-plane corrections were
`performed. Coronal and sagittal plane corrections were
`incorporated into the arthrodeses, with lateral column
`shortening or lengthening, correcting frontal plane de-
`formity as well. An anterolateral, curvilinear, longitudinal
`incision was made that extended from the anterolateral
`ankle down to the lateral base of the fifth metatarsal
`
`head (Fig. 2). Neurovascular and tendinous structures
`are generally avoided using this approach and the
`disruption of venous drainage is minimized. If encoun-
`tered, the sural or superficial peroneal nerves can be
`protected. The short extensors were reflected distally,
`
`Rating
`
`Good
`
`Fair
`
`Poor
`
`TABLE 1
`
`Criteria for Rating Results‘
`
`Signs and symptoms
`
`No pain or minimal pain after heavy use
`No deformity or minimal deformity
`No callosities
`No pseudarthrosis
`No joint degeneration
`
`Pain after light use
`Moderate deformity
`Single callosity
`Single pseudarthrosis
`Mild joint degeneration
`
`Pain on standing at rest
`Severe deformity
`Multiple callosities
`Multiple pseudarthroses
`Severe joint degeneration
`
`5 By Angus and Cowell.‘
`
`rotation in the sagittal plane was the most important
`aspect of clubfoot surgery.” He challenged orthopae-
`dists to strive for a corrected foot that was as normal
`
`as possible in both appearance and function. The ad-
`dition of this sagittal plane correction to a clubfoot’s
`medial, hind, and forefoot correction represented a
`significant change.
`At the Foot Research Clinic in Pittsburgh, from 1977
`to 1979, and later at the Children’s Orthopedic Hospital
`Foot Clinic in Seattle, a number of patients were seen
`who had poor results from arthrodesis surgery (Fig. 1).
`Reflecting on the principles of frontal, coronal, and
`sagittal correction, the relativity of medial and lateral
`columns, and that normal feet should be left as such, I
`
`began a prospective study of arthrodesis of the major
`joints of the foot. Isolated fusions would be performed
`by iliac-crest-inlay grafting, so as to not disrupt other
`tarsal joint relationships. Symmetry to the opposite foot
`would be sought, except where both feet were severely
`deformed. One-, two-, or three-plane corrections would
`be incorporated into the salvage of planovalgus and
`cavovarus feet. This paper presents the 10-year results
`of this study from 1979 through 1989.
`
`MATERIAL AND METHODS
`
`Fifty patients who had had 56 single or multiple-level
`fusions were treated during the years 1979 through
`1989. They were followed until either the arthrodesis
`
`
`
`Fig. 1. The pre- and postoperative lateral roentgenograms of a
`tarsal coalition patient who underwent a triple arthrodesis in which
`normal talocalcaneal relationships were disrupted.
`
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`158
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`SCRANTON
`
`Foot & Ankle/Vol. 12, No. 3/December 1991
`
`A
`
`Sagittal Derotation
`
`
`
`Fig. 2. The longitudinal, anterolateral approach for a triple arthrod-
`esis in a right foot. The left-hand side is proximal. The hemostat
`points at the talonavicular joint. The subtalar and calcaneocuboid
`joints are above each retractor.
`
`subperiosteally, thereby exposing the calcaneocuboid
`joint. The sinus tarsi was debrided of soft tissue, ex-
`posing the talocaicaneal joint. Further subperiosteal
`exposure, directed medially, exposed the lateral portion
`of the talonavicular joint. The bifurcate, cervical, deep
`components of the inferior retinaculum, interosseous
`talocaicaneal, and calcaneal navicular ligaments may
`be cut to facilitate exposure. A second anteromedial
`incision was made, medial to the anterior tibialis tendon,
`directly over the talonavicular joint. Care was taken to
`sharply strip, subperiostally, the tendinous and ligamen-
`tous structures surrounding the joint, so that the resec-
`tion of cut joint surfaces could be easily accomplished.
`When performing a triple arthrodesis, the first joint to
`be resected is the talocaicaneal joint. In my experience,
`an oscillating saw facilitates these joint resections.
`Once the posterior and middle facet articular surfaces
`had been removed, the talocaicaneal divergence was
`corrected (Fig. 3).
`In patients with severe pes valgus
`and a plantarflexed talus, this would also elevate the
`talar head. The corrected position was held by an
`assistant while the surgeon uses a transfixing, cancel-
`lous, 16-thread, 6.5-mm ankle orthosis screw driven
`
`from the talus down through the calcaneus. Satisfac-
`tory anteroposterior alignment and screw position were
`confirmed with intraoperative roentgenograms.
`If the
`patient has a narrow talocaicaneal AP angle of diver-
`gence, such as is seen in pes cavus or talipes equino-
`varus,
`the talocaicaneal angle can be increased. A
`laterally based wedge taken at the subtalar joint will
`also coronally correct hindfoot varus (Fig. 4). intraoper-
`ative roentgenograms are routine and help confirm
`whether the rotation is correct, as compared with the
`preoperative roentgenogram, and whether screw posi-
`tion and fixation are proper.
`I would also prep the
`
`Pes valgus
`Correction
`
`Pes Cavovarus
`8. Clubfoot
`Correction
`
`E
`
`B
`
`Lateral Talocalcaneal Correction
`
`
`
`Pes Cavovarus
`
`Fig. 3. A, Diagramatic sagittal correction in the anteroposterior plane
`for pes valgus and Cavovarus feet. Talocalcaneal divergence is cor-
`rected by decreasing it in a valgus foot and increasing it in a cavus
`foot. B, The diagramatic effect of sagittal and coronal correction on
`lateral talocaicaneal convergence.
`
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`Foot & Ank/e/Vo/. 12, No. 3/December 1991
`
`opposite foot if asymmetry is present so that clinical
`symmetry can be achieved.
`Residual forefoot deformity in the frontal plane is now
`addressed by the talonavicular and calcaneocuboid
`joint resections (Fig. 5).
`If the forefoot is in valgus, a
`greater degree of joint resection is carried out medially
`and plantarly. This will shorten the medial column and
`the plantar-based wedge will assist in forming an arch.
`If the forefoot is supinated or in adduction, an increased
`lateral articular wedge is taken to create a neutral,
`plantigrade forefoot. These joints may be secured with
`screws, staples, or Steinmann pins, depending on the
`bone stock available and the surgeon’s preference. In
`the end, however, the foot, held in a simulated weight-
`bearing position, should have a neutral or slightly valgus
`hindfoot, an arch, and a neutral plantigrade forefoot.
`lf sagittal plane correction is not necessary, but hind-
`foot valgus is excessive, an iliac crest slot-graft can be
`used across the subtalar joint, levering it into a more
`physiologic position. These same grafts can be used
`across the calcaneocuboid and talonavicular joints. A
`micro-oscillating saw cuts the slots and iliac graft sec-
`tions. The inner joint is burred out with a rotary burr.
`Cancellous bone chips are packed into the defect
`around the slot-graft (Fig. 6).
`
`RESULTS
`
`Forty-one patients in whom 47 arthrodeses had been
`performed were seen in follow-up. There were 17 males
`and 24 females. Their ages ranged from 15 to 80 years,
`with an average age of 46.6 years. The length of follow-
`up ranged from 12 to 120 months, with an average
`follow-up of 67 months.
`Twenty-five patients had triple arthrodeses per-
`formed on 31 feet. Ten patients had 14 feet that were
`diagnosed as having degenerative arthritis, secondary
`to severe pes valgus with a congenital vertical talus.
`One patient had bilateral pes valgus, secondary to
`rheumatoid arthritis. Four patients each had one foot
`with severe posttraumatic multijoint arthritis due to a
`fractured calcaneus. Two patients had three pes valgus
`feet due to spastic cerebral palsy. Two patients had
`three poliomyelitic pes cavus deformities. One patient
`had one Charcot Marie-Tooth pes cavus triple arthrod-
`esis. Three patients had four club feet.
`In 10 of the triple arthrodesis patients who had
`increased talocalcaneal divergence, ranging from 28°
`to 48°, with an average of 34°, the average degree of
`correction was 11 .4°. In this pes valgus population, the
`lateral talocalcaneal angle of convergence preopera-
`tively ranged from 38° to 78° (seven patients greater
`than 50°, with an average of 46°. It was corrected to
`
`ARTHRODESIS OF THE TARSUS
`
`159
`
`Coronal Derotation (Left Foot)
`
`a __
`
`Bone Graft
`
`Pes Valgus
`
`Pes Cavovarus
`
`,
`
`S
`
`Fig. 4. The diagramatic effect of coronal correction on a pes valgus
`and pes cavus left foot as seen from the rear.
`
`an average of 34.4°, for an average correction of 11.6°
`(Fig. 7).
`In six triple arthrodesis patients with a narrow AP
`talocalcaneal angle of divergence, there were three pes
`cavus patients with four feet and three talipes equino-
`varus patients with four feet (Fig. 8). The preoperative
`anteroposterior talocalcaneal divergence ranged from
`6° to 10°.
`It averaged 8°.
`It was corrected to an
`average of 20°. The lateral talocalcaneal convergence
`ranged from 26° to 47° and averaged 34.8°.
`It was
`corrected to an average of 32°.
`If the four talipes
`equinovarus feet were separated from the pes cavus
`feet, the anteroposterior talocalcaneal divergence av-
`eraged 7° preoperatively and 28° postoperatively. The
`number of feet were small and each had had multiple
`operations.
`Seven patients had painful arthroses and a predom-
`inant deformity of hindfoot valgus, ranging from 10° to
`20° on a standing measurement, but talocalcaneal re-
`lationships that were otherwise within normal limits. In
`these seven patients, the triple arthrodesis was per-
`formed by using iliac-crest-inlay grafts for an in situ
`fusion. The valgus os calcis was levered into a more
`neutral position, supplementing the fixation with an A0,
`6.5-mm, cancellous bone screw. Sagittal correction
`was not necessary. The position of valgus was deter-
`mined to be within normal limits on the operating room
`table by examining the foot from behind while holding
`
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`
`T or
`Lengthen Lateral Column
`
`Pes Valgus Correction
`
` Shorten Medial Column
`Correction
`
`Lengthen Medial Column
`
`T or
`Shorten Lateral Column
`
`Pes Cavovarus & Clubfoot
`
`Fig. 5. Dilwyn Evan's principle of frontal plane correction consists
`of either shortening or lengthening the medial or lateral column of the
`foot, depending on the deformity.
`
`it dorsiflexed to neutral in a simulated weightbearing
`position. These seven patients had hindfoot valgus that
`measured at 5° to 7° postoperatively, using a goni-
`ometer.
`
`There were 10 feet in which isolated iliac-crest, inlay,
`talocalcaneal arthrodeses were performed (Table 1).
`Seven were for posttraumatic arthritic calcaneal frac-
`tures, two were for degenerative arthritis of unknown
`origin, and one had a symptomatic subtalar coalition
`that could not be resected. Three of the crushed cal-
`
`caneal fractures had lateral “contouring” to relieve fib-
`ular and peroneal tendon impingement. Two developed
`nonunions that were not initially fixed using AO screws.
`They were successfully arthrodesed at a second oper-
`ation using additional bone graft and A0 screw fixation.
`Another had severe foot and ankle compromise from a
`degloving trimalleolar fracture as well. The initial ar-
`throdesis attempt failed and this patient ultimately had
`a below-knee amputation.
`Four patients had isolated talonavicular fusions with
`iliac-crest-inlay grafts. Two patients had isolated navi-
`culocuneiform arthrodeses (Fig. 9). One of these re-
`
`160
`
`SCRANTON
`
`Foot & Ank/e/Vo/. 12, No. 3/December 1991
`
`Frontal Alignment
`
`quired a refusion for pseudarthrosis, which was suc-
`cessful.
`
`The triple arthrodesis patients were questioned as to
`pain, activity, problems with shoeing, painful calluses,
`and deformity. This information was correlated with
`their follow-up roentgenograms and physical examina-
`tions. The results were then used in the rating system
`of Peter Angus and Henry Cowell. There were no
`pseudarthroses in this group. There was one talar
`avascular necrosis in a pantalar fusion patient who,
`after a second operation, ultimately fused and was
`rated fair. On the basis of the combined clinical and
`
`radiologic evaluation, in the triple arthrodesis population
`there were 15 good, 12 fair, and four poor results. All
`four poor results were in the clubfoot group, in which
`multiple surgeries and adjacent ankle and midtarsal
`arthritides were present.
`The 10 talocalcaneal fusion patients were also rated
`using the Angus-Cowell scale. There were six good
`results, three fair results. and the amputation, of course,
`was a failure. All nine patients had restricted midtarsal
`motion, as compared with the opposite side. All wore
`low heel, soft, cushion-soled shoes with comfort.
`The four talonavicular fusion patients and the two
`naviculocuneiform fusion patients all rated a good re-
`sult. Subtalar motion was present at follow-up in all
`patients, though diminished, compared with the oppo-
`site side.
`
`The accuracy and reproducibility of talocalcaneal
`measurements are hard to determine.
`Ideally, each
`patient should have had standardized, standing roent-
`genograms, taken from the same distance and angle,
`in the anteroposterior and lateral planes. However,
`many patients were referred from a variety of-physicians
`and institutions. There was a significant variation in the
`degree of x-ray penetration, film quality, whether it was
`a copy or an original, angle variations, standing or
`nonweightbearing roentgenograms, and so forth. This
`made accurate and reproducible talocalcaneal meas-
`urements difficult. Additionally, the posterior talus and
`calcaneus tend to disappear into overlapping tibia on
`the anteroposterior projection, making true orientation
`measurements
`difficult
`as well. Morrisey
`and
`associates” showed that inter- and intraviewer error in
`
`measurement reproducibility is at least 5° when meas-
`uring scoliosis films. This series’ measurement of an-
`gles of talocalcaneal divergence and convergence is
`intended to show the results of intentionally altered
`talocalcaneal relationships as measured by one ob-
`server. Talocalcaneal measurements, as a means of
`
`defining normal parameters of the foot and arch, were
`advanced by Lenoir,” Hsu et al.,‘‘ and later by Pirani
`and associates.” Measurements in this study are not
`offered as absolute degrees correction.
`
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`
`ARTHRODESIS OF THE TARSUS
`
`161
`
`Inlay Graft Technique
`
`Micro-Oscillating
`Rotary burr
`
`saw to remove
`removes remaining
`
`5 x 15mm x 10 mm
`inner joint
`
`
`Fig. 6. The diagramatic technique for inlay graft arthrod-
`esis in a talonavicular joint. A triple arthrodesis can be
`performed the same way without disrupting a normal
`arch in an otherwise painful foot.
`
`DISCUSSION
`
`Arthrodesis remains the best means of salvaging
`deformed, unstable, or arthritic joints of the foot. The
`primary goal
`in such a procedure is to eliminate or
`reduce pain and to provide a stable platform for am-
`bulation. A secondary goal is to achieve symmetry of
`the feet and to provide the patient, if possible, with the
`ability to obtain inexpensive, comfortable shoe wear.
`As advocated by Williams, Menelaus, and McKay, the
`surgeon should strive for a corrected foot that is as
`normal as possible in both appearance and function.
`A “normal" foot has a very broad definition.2~‘2"5*2‘5
`Varying degrees of flexible pes valgus, forefoot prona-
`tion, pes cavus, adduction, abduction, ligamentous lax-
`ity, rigidity, and upper limb alignment and rotation affect
`what is regarded as normal. For purposes of simplicity,
`it is reasonable to assume that a person who can walk
`or run symptom-free and who has symmetrical lower
`limbs and feet is normal. Asymmetry is not normal.
`Likewise, a person who experiences pain with or after
`ambulation and who has abnormal talocalcaneal rela-
`
`tions, and secondary arthritis, does not have normal
`feet, even if symmetrical. Therefore, the goal of the
`salvage procedure should be to restore symmetry when
`it is absent, or to correct to within normal limits, dis-
`rupted, painful talocalcaneal relationships. Lenoir de-
`fined these normal relationships as an anteroposterior
`talocalcaneal angle of divergence within 30° to 55° and
`a lateral talocalcaneal angle of convergence between
`25° to 45°.”-‘3
`
`The need for triple arthrodesis procedures has de-
`clined dramatically. The development of polio vaccines
`and better perinatal care and delivery methods has
`
`resulted in a significant decline in the incidence and
`severity of poliomyelitic deformity and spastic cerebral
`palsy. The triple arthrodeses described by Hoke,‘° Re-
`yerson,23 and Lambrinudi” were developed to correct
`profound deformity, muscle imbalance, and dysfunc-
`tion. These authors correctly recognized the interrela-
`tionships among the subtalar, calcaneocuboid, and ta-
`lonavicular joints. Arthrodeses at that time were being
`performed to salvage the deformed foot so that it could
`at least be shod and/or braced. Deformities were major
`and significant bone resection was necessary.
`As the incidence and magnitude of deformity has
`diminished,
`it has become apparent that single-joint
`fusions can be performed. If the entire joint surface and
`subchondral bone are resected and arthrodesed, how-
`
`ever, the interrelationship with the adjacent joints will
`be disrupted and painful, arthritic failure will
`re-
`sult.5~2°’24'23 Mann and Baumgartnerm and Russotti and
`associates“ showed that successful, isolated subtalar
`fusions could be performed without fusing all three
`joints. The important key was to remove only the
`articular cartilaginous surfaces, not
`to resect major
`amounts of bone. Our technique preserves even further
`the three-joint relationships by cutting a trough across
`the joint, burring out the middle articular surface, and
`then inserting cancellous chips and the iliac slot graft.
`This patient series further confirms the concept that
`isolated inlay-graft fusions can be successful, whether
`subtalar, talonavicular, or naviculocuneiform.
`Coronal and frontal plane corrections have been well
`described in the literature as guiding principles in ar-
`throdesis.4‘5'8"3'29 Sagittal correction has been de-
`scribed by McKay, but for clubfoot correction. I believe
`
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`162
`
`SCRANTON
`
`Foot & Ankle/Vo/. 12, No. 3/December 1991
`
`Fig. 7. A, The anteroposterior pre- and postoperative correction of
`excessive talocalcaneal divergence by sagittal plane correction. B,
`The lateral pre- and postoperative correction of an excessive talocal-
`caneal angle of divergence in the same patient. The talar head now
`rests on the subtentaculum tall, and AP and lateral talocalcaneal
`relationships are now within normal limits.
`
`Fig. 8. A, The anteroposterior pre- and postoperative roentgeno-
`grams of a cavovarus patient who had abnormal talocalcaneal diver-
`gence. Increased calcaneocuboid resection assists in forefoot frontal
`plane correction and in talocalcaneal correction. B, The lateral pre-
`and postoperative roentgenogram of the same patient showing cor-
`rection of talocalcaneal convergence.
`
`the principle of sagittal correction is equally important
`in adult, salvage, arthrodesis surgery. Patients with
`symptomatic, arthritic, pes valgus feet requiring a triple
`arthrodesis should have the increased talocalcaneal
`
`angle of divergence corrected. The talar rotation will
`reposition the talar neck upon the subtentaculum tall
`and result in a correction of abnormal lateral talocalca-
`
`neal convergence as well.
`Patients with painful pes cavus and adults with failed
`talipes equinovarus surgery represent different prob-
`lems. The pes cavus patients have an abnormally nar-
`row, anteroposterior, talocalcaneal angle of divergence,
`
`but a large lateral angle of convergence. Talar sagittal
`plane correction can be accompanied at the same time
`as hindfoot coronal correction to valgus. This will dimin-
`ish the abnormal lateral angle of convergence. In talipes
`equinovarus,
`there is anteroposterior “stacking” and
`lateral “parallelism.” The narrow lateral angle of conver-
`gence is due to hindfoot varus and equinus. Thus, the
`triple arthrodesis in these patients must include increas-
`
`ing the anteroposterior talocalcaneal divergence and
`‘correcting os calcis equinovarus.
`In 10 years we saw
`only six patients with narrow talocalcaneal anteropos-
`terior angles of divergence; three had pes cavus and
`
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`
`Foot & Ank/e/Vo/. 12, N0. 3/December 1991
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`ARTHRODESIS OF THE TARSUS
`
`163
`
`pre- Op
`
`
`
`
`
`Fig. 9. The preoperative anteroposterior tomogram of a degenera-
`tive naviculocuneiform joint, and the postoperative roentgenogram
`after successful inlay grafting.
`
`three had clubfeet. The clubfoot patients each had had
`five to seven operations per foot prior to the final
`arthrodesis. Because of the small number of patients,
`from a statistical standpoint, there is no significance in
`this group of the talocalcaneal measurements.
`Four patients in the series developed a pseudar-
`throsis. in three of these, the pseudarthrosis was cor-
`rected by refusion with supplemental screw fixation. In
`the fourth, an amputation was performed. The initial
`incidence of pseudarthrosis in the series was four out
`of 47. This compares very favorably with the pseudar-
`throsis rate of 18% and 23% reported by Patterson et
`al?‘ and Friedenburg.7 It also represents the results of
`arthrodeses in a population in which the incidence of
`polio is declining, and it represents the results of im-
`proved surgical technique, utilizing iliac crest graft and
`internal cancellous screw fixation.
`
`The likelihood of the development of later, adjacent
`joint arthritis is very high.
`in this series, a meaningful
`determination of the subsequent occurrence of joint
`deterioration could not be made.
`In many feet and
`ankles, at the time of definitive triple arthrodesis or
`isolated fusion, some degree of midfoot or ankle arthri-
`tis was already seen. This was particularly true in the
`clubfoot patients, who had degenerative anterior, tibi-
`otalar spurring from limited ankle dorsiflexion. Mann
`and Baumgartner” pointed out that dissipation of en-
`ergy is one of the important functions of the foot, and
`that a rigid foot is less likely to dissipate force than a
`supple one. They found a 50% reduction in transverse
`tarsal motion, as compared with the contralateral side.
`Reduced motion was seen in this series as well. How-
`
`ever, no patient in the series had complaints of pain or
`progressive arthritis that warranted further surgery on
`other joints.
`
`Success in arthrodesis surgery is a relative concept.
`Angus and Cowel|’s rating system gives sufficient al-
`lowance for the salvage nature of this procedure.
`If,
`after arthrodesis, one can achieve a fused, painless, or
`minimally painful foot that allows for normal activity and
`shoe wear, that is clearly a good result. Moderate pain
`with activity, even in the face of a single pseudarthrosis,
`is still compatible with a fair result. A poor result, or
`failure, occurs if further surgery is necessary or if the
`patient has unacceptable pain or limitation of function.
`This series overall had 27 good, 15 fair, and five poor
`results.
`
`One plane of correction which was not attempted in
`this series was that of lateral calcaneal pitch correction
`in the salvage of severely crushed calcanei. Carr and
`associates3 advanced the concept of restoring Bohlers
`angle in the hindfoot by use of distraction and inter-
`posed iliac crest graft. This correction was done in
`addition to varus or valgus, derotation, and relief of
`lateral
`impingement. Patients with severely crushed
`calcanei and a “horizontal talus” with anterior tibiotalar
`
`spurs were not present in this series. However, resto-
`ration of the normal lateral talocalcaneal angle of con-
`vergence is the goal of salvage arthrodesis, and pa-
`tients with significant loss of Bohlers angle should have
`such a correction.
`
`The principles of limb salvage by arthrodesis have
`evolved during this last century. in the foot and ankle,
`the use of internal fixation and supplementary bone
`graft has been shown to greatly enhance the likelihood
`of a successful arthrodesis.” Grice was the first to
`
`recommend screw or pin fixation in difficult cases.
`Russoti and associates and Carr and associates have
`
`also shown the advantages of screw fixation. This
`series confirms these simple principles in the foot.
`Additionally,
`in deformed painful feet, frontal, coronal,
`and sagittal tarsal relationships must be addressed as
`well. Finally, in situ single or triple arthrodeses are quite
`appropriate where no major deformity exists to be
`corrected. This will enable the surgeon to better achieve
`the salvage goal of a painless, stable foot with a normal
`appearance.
`
`REFERENCES
`
`1. Angus, P.D., and Cowell, H.R.: Triple arthrodesis. J. Bone Joint
`Surg., 68:260—265, 1986.
`2. Bordelon, R.L.: Chapter 1. In The Foot Book. Gould, J. (ed.),
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