ADULT ACQUIRED FLATFOOT DEFORMITY

10837515/01 $15.00

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POSTERIOR TIBIAL TENDON INSUFFICIENCY

Isolated Fusion of the Talonavicular Joint
Paul T. Fortin, MD

Isolated fusion of the talonavicular joint has been shown to correct the components of atfoot deformity in the clinical setting and in cadaver atfoot models.9, 15 Fusion of the talonavicular joint imparts a signicant restriction of motion on the hindfoot, however, and has the potential consequence of arthrosis of adjacent joints. Isolated fusion of this joint has been reported to have a higher incidence of nonunion than fusion of other joints in the foot.13, 24 Concomitant soft tissue balancing procedures and osteotomies sometimes can be helpful in improving the results of talonavicular fusion. With careful operative technique and appropriate patient selection, talonavicular fusion can be a useful means of producing a painless plantigrade foot in patients with atfoot deformity secondary to posterior tibial tendon dysfunction. ANATOMY AND MECHANICS The talonavicular joint is a ball-and-socket joint. The talar head is covered completely with articular cartilage. The navicular articular surface is biconcave and smaller than the corresponding talar head surface. The navicular bone slides, rolls, and spins on the talar head. The deep socket that receives the talar head is a complex articulation that has been referred to as the acetabulum pedis. It is formed by the navicular bone,

From the William Beaumont Hospital, Royal Oak, Michigan

FOOT AND ANKLE CLINICS

VOLUME 6 NUMBER 1 MARCH 2001

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anterior and middle calcaneal facets, bifurcate ligament, and calcaneonavicular (spring) ligaments. The exibility of the acetabulum pedis allows it to change in form and size to accommodate to displacements of the talar head, calcaneus, and navicular bone. The calcaneonavicular complex can be considered as a functional unit moving around the talus. Any instantaneous motion between the calcaneus and the talus occurs simultaneously at the anterior and posterior talocalcaneal joints and at the talonavicular joint. In other words, there is coupled motion between the hindfoot and forefoot.21 The talonavicular joint has the greatest range of motion of the triple joint complex.1 At heel-strike, the eccentric position of the calcaneus with respect to the talus creates a valgus thrust on the subtalar joint, the axes of the calcaneocuboid and talonavicular joints are parallel or unlocked, and the navicular bone moves laterally on the talar head.3, 17 The posterior tibial tendon passes posterior to the axis of the ankle joint and medial to the axis of the subtalar joint. As a result of this course, the tendon acts to plantar ex the ankle and invert the hindfoot.20 Contraction of the posterior tibial tendon during normal gait inverts the hindfoot, and the axes of the talonavicular and calcaneocuboid joints become nonparallel or locked, creating a rigid lever for forward propulsion of the foot. With posterior tibial tendon dysfunction, the hindfoot remains in valgus, and the navicular bone remains dorsolaterally displaced on the talar head. With normal loading of the foot, there is an increase in the contact area of the talonavicular joint and a uniform distribution of contact across the joint surface. In a simulated atfoot model, Kitaoka et al10 showed a decrease in talonavicular joint contact area and an increase in contact frequency in the dorsal aspect of the joint; this may help explain why patients with long-standing atfoot deformity can develop degenerative changes of the talonavicular joint. OMalley et al15 evaluated the ability of various arthrodesis procedures to correct the components of an experimentally created atfoot deformity. The amount of correction that was obtained with selective hindfoot fusions was measured radiographically. Isolated fusion of the talonavicular joint was shown to correct forefoot abduction, longitudinal midfoot collapse, and hindfoot valgus to the same extent as a triple arthrodesis. In contrast, isolated fusion of the subtalar joint failed to correct forefoot abduction. This study shows the key role that the talonavicular joint has in controlling the triple joint complex. Correction of deformity with talonavicular fusion entails a signicant loss of motion, however. Astion et al1 evaluated the range of motion of the subtalar, calcaneocuboid, and talonavicular joints after various simulated arthrodesis procedures. These authors found that any combination of simulated arthrodeses that included the talonavicular joint severely limited the motion of the remaining joints to about 2 and limited the excursion of the posterior tibial tendon to about 25% of the preoperative value. Talonavicular fusion also decreases ankle range of motion. Harper and Tisdel9 reported an average loss of ankle motion of 10 . Most of the ankle motion lost after fusion was plantar exion.

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PATIENT SELECTION No consensus exists as to which patients with atfoot deformity are suited best for talonavicular fusion. Patient age, severity and exibility of the deformity, and the existence of degenerative changes are important factors in the decision-making process. In younger patients with exible deformity, joint-sparing procedures involving osteotomies and soft tissue balancing have the potential advantage of preserving motion and limiting adjacent joint arthrosis.14 In patients with lower physical demands, loss of hindfoot motion is not likely to have the same functional implications. Older patients with more severe or xed deformity generally are candidates for arthrodesis. Triple arthrodesis is the historical standard for correction of hindfoot deformities and has been reported to be an acceptable method for treatment of late-stage atfoot deformity.7, 8, 19 The decision whether to perform a triple arthrodesis or a more limited fusion, such as a subtalar, double, or isolated talonavicular fusion, is largely a matter of surgeon preference. There are aspects of each deformity, however, that should be taken into account when choosing the appropriate procedure. A mobile subtalar joint that is free of any signicant degenerative changes typically is required for isolated talonavicular joint fusion to be effective. Severe xed hindfoot valgus may not correct adequately with reduction and fusion of the talonavicular joint alone. These patients may be treated best with a triple arthrodesis to correct the deformity. With triple arthrodesis, however, excessive residual heel valgus sometimes can persist and lead to valgus tilt of the ankle and persistent lateral hindfoot pain.8 Adjunctive procedures, such as gastrocnemius-soleus lengthening and medial displacement calcaneal osteotomy, may be necessary in these patients to balance the foot properly. Isolated talonavicular joint fusion and medial displacement calcaneal osteotomy is an alternative to triple arthrodesis in cases of severe planovalgus deformity when the remaining hindfoot joints are free of degenerative changes (Fig. 1). EVALUATION Patients that are candidates for talonavicular fusion have severe painful deformity refractory to orthotic management. Whether the foot is xed or exible is one measure of the severity of a deformity. Degenerative changes and soft tissue contracture can lead to xed peritalar subluxation. If the talonavicular joint can be passively reduced, the position of the heel with the joint reduced should be assessed. This assessment gives an indication of how well isolated fusion of the talonavicular joint would correct the deformity. Commonly, patients with severe deformity have residual heel valgus despite a well-positioned talonavicular joint, and this may require simultaneous correction at the time of talonavicular arthrodesis. This correction can be accomplished by concomitant medial displacement calcaneal osteotomy (see later).

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Figure 1. Preoperative anteroposterior (AP) (A and B) and postoperative lateral (C and D) radiographs of severe acquired atfoot with degenerative changes of the talonavicular joint. Subtalar and calcaneocuboid joints were without signicant degenerative changes. Isolated talonavicular fusion and medial displacement calcaneal osteotomy was used as an alternative to triple arthrodesis with improvement in the radiographic parameters of deformity. Illustration continued on opposite page

Patients often have tightness of the gastrocnemius-soleus complex; this is assessed by testing ankle dorsiexion with the talonavicular joint reduced and the knee exed and extended. Limited ankle dorsiexion only when the knee is extended suggests tightness only in the gastrocnemius, whereas limited ankle dorsiexion with the knee exed suggests that the gastrocnemius and the soleus are tight. Isolated gastrocnemius tightness can be treated by recession of the gastrocnemius muscle, whereas tightness of both should be treated by Achilles tendon lengthening. It is important and sometimes difcult to determine all of the

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Figure 1 (Continued).

components of a deformity when considering surgical intervention for a severe atfoot. Peritalar subluxation seen in patients with acquired atfoot often can be accompanied by signicant abnormality at the ankle, intertarsal, and tarsometatarsal joints that contribute to the deformity and can affect the results of talonavicular fusion. The radiographic parameters of peritalar subluxation have been well described.18 More subtle signs of secondary or concomitant deformity also are important. This deformity may be evidenced by gapping or sagging of the more distal midfoot joints on the standing lateral radiograph. Standing anteroposterior ankle radiographs can show tilting of the talus and lateral tibiotalar joint space wear (Fig. 2). Hindfoot alignment views can be used to assess the calcaneal-tibial axis. These views allow side-by-side comparison with the opposite side and can be helpful to conrm that the heel valgus is not the result of abnormal tibial alignment. Assessment of the deformity should be systematic. The overall lower extremity alignment is important. In patients with concomitant knee deformity, there is no consensus as to whether the foot or knee is corrected rst. Usually the more symptomatic joint is approached rst. Hindfoot fusion that is done without consideration of knee malalignment can lead to a poorly positioned foot when the patient later undergoes total knee replacement or tibial osteotomy. Moving distally, the ankle joint is assessed for stability,

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Figure 2. Standing AP ankle radiograph of patient with severe atfoot deformity reveals attenuation of medial ligamentous support, valgus talar tilt, and lateral tibiotalar joint space wear. Figure 3. Maintaining the normal contour of the talonavicular joint and the use of compression screws maximize the rate of talonavicular union.

deformity, and degenerative changes. Occasionally, patients with longstanding atfoot deformity secondary to posterior tibial tendon insufciency have unstable degenerative ankles as a result of excessive valgus hindfoot alignment, which also may require treatment. Finally, the midfoot and forefoot need to be evaluated. This area can be assessed by examining carefully the position of the forefoot and the amount of sagittal plane motion of the rst metatarsal when the talonavicular joint is held reduced. Instability and collapse of the more distal medial column joints of the foot can be the cause of residual pain and deformity after talonavicular arthrodesis. SURGICAL TECHNIQUE Regardless of the method chosen to correct a atfoot deformity, the mechanics of correction are similar among various procedures. Surgical technique involves restoration of medial column support, correction of the calcaneal tibial axis, and balancing of the soft tissues. In the authors experience, patients best suited for talonavicular arthrodesis are those that have more advanced deformity, typically with severe heel valgus. Although slight residual heel valgus is desirable, excessive residual heel

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valgus after hindfoot fusion can lead to progressive valgus tilt of the tibiotalar joint and lateral joint space wear.4, 7 Because of this concern, medial displacement calcaneal osteotomy is done routinely on patients undergoing talonavicular fusion for atfoot deformity. The patient is placed in a semilateral position to facilitate lateral hindfoot exposure. Once the limb is anesthetized, tightness of the gastrocnemius-soleus complex is assessed. The ankle is dorsiexed with the talonavicular joint held maximally reduced. The knee is exed and extended to determine the need for gastrocnemius recession versus Achilles tendon lengthening. Achilles tendon lengthening is performed percutaneuously using a triple hemisection technique. Gastrocnemius recession is performed through a longitudinal incision made in the middle of the calf. Care is taken to avoid injury to the medial sural cutaneous nerve. The aponeurotic tendon of the gastrocnemius is identied and separated from the underlying soleus muscle. The aponeurotic tendon of the gastrocnemius is divided, leaving the underlying soleus undisturbed. The foot is dorsiexed carefully to allow the appropriate amount of ankle dorsiexion. The lateral wall of the calcaneus is exposed, and the calcaneal tuberosity is osteotomized and displaced medially in the manner described by Koutsogiannis.11 Talonavicular joint arthrodesis for severe atfoot is more technically demanding than fusion in situ, such as with an arthritic hindfoot. Arthrodesis must be performed meticulously to position the foot accurately, avoid shortening of the medial column, and stabilize the fusion adequately. The talonavicular joint is approached through a longitudinal dorsomedial incision just medial to the tibialis anterior tendon. Subcapsular dissection proceeds dorsally to expose the talonavicular joint. Aggressive stripping of the talar neck and navicular bone should be avoided so as to preserve blood supply to the area. Cartilage and subchondral bone are removed with attention to the navicular bone because of its often sclerotic nature. A lamina spreader in the joint facilitates exposure of the lateral most aspect of the talonavicular joint. A power bur is used to contour the navicular surface and remove the dense subchondral bone. Care is taken to maintain the normal contour of the navicular bone and the talus to facilitate reduction of the joint and maximize apposition of the bone surfaces (Fig. 3). Accurate joint reduction is the most difcult and important part of the procedure. In patients with long-standing posterior tibial tendon insufciency with severe peritalar subluxation, the navicular bone rests subluxated on the dorsolateral aspect of the talar head. Mobilizing it from this position constitutes most of the reduction maneuver. A laterally directed force is applied to the talar head, and the navicular bone is swung medially and plantar to cover the talar head. The degree of talonavicular coverage can be veried radiographically. Cancellous bone graft from the iliac crest or calcaneus is used to ll in small areas where there is lack of perfect bone apposition. Once proper position has been established, lag screw xation is used to secure the fusion site. Two screws offer the advantage of better rotational control and are preferable.

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Figure 4. A, Correction of forefoot abduction seen with peritalar subluxation is accomplished by adducting the forefoot and centering the navicular on the talar head. B, The forefoot should be derotated simultaneously in the direction shown (arrow) to correct forefoot varus.

As the navicular bone is swung medially, there is a tendency for the foot to supinate as a result of forefoot varus that often exists in severe planovalgus deformities. Forefoot varus must be corrected by rotating through the arthrodesis site, and the adequacy of this reduction is judged clinically (Fig. 4). In some patients, despite a properly positioned talonavicular fusion site, medial column support may remain inadequate. This inadequacy may be evidenced by hypermobility of the medial tarsometatarsal or naviculocuneiform joints that require extended medial column arthrodesis (Fig. 5). Postoperatively, patients are immobilized in a nonweight-bearing cast for 6 weeks followed by a walking cast for 4 weeks. RESULTS Much of the literature regarding isolated talonavicular fusion has been in patients with rheumatoid arthritis and is of limited value when comparing use of isolated talonavicular fusion in adult atfoot defor-

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Figure 5. A, Preoperative lateral radiograph of patient with severe peritalar subluxation and concomitant instability of the distal midfoot with plantar gapping of the rst metatarsal cuneiform joint. B, Postoperative lateral radiograph after talonavicular arthrodesis, calcaneal osteotomy, and plantar exion fusion of the rst metatarsal cuneiform joint shows restoration of the longitudinal arch. Illustration continued on following page

mity.2, 12 There are no long-term follow-up studies on isolated talonavicular fusion specically for adult atfoot deformity. Intermediate-term follow-up studies of its use for traumatic disorders as well as short-term follow-up of talonavicular fusion for posterior tibial tendon insufciency suggest that results are comparable to other hindfoot fusion techniques.79, 19 Fogel et al5 reported on 11 patients treated with isolated talonavicular arthrodesis for talonavicular arthrosis with follow-up 2.5 to 21 years. None of the patients had arthrosis of the talonavicular joint specically as a result of acquired atfoot deformity. All patients had satisfactory pain relief, but all had some difculty walking on uneven ground secondary to pronounced reduction of subtalar motion. The authors noted diminished terminal stance phase plantar exion. There was one nonunion. Three of the 11 patients developed adjacent joint arthrosis at the subtalar or intertarsal joint after talonavicular fusion. None of the patients were noted to have developed ankle arthrosis after fusion. Scranton22 reported on the results of a series of 41 patients undergoing subtalar, talonavicular, or triple arthrodesis. Good results were obtained in all 4 patients undergoing isolated talonavicular fusions. There

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Figure 5 (Continued). C, Hindfoot alignment view shows severe heel valgus. D, Postoperative hindfoot alignment view shows correction of heel valgus.

were no nonunions using an inlay tricortical iliac crest graft technique. The authors did not specify the type of preoperative deformity or the specic reason for talonavicular fusion. Harper and Tisdel9 reported on 27 patients with posterior tibial tendon insufciency treated with isolated arthrodesis of the talonavicular joint. There was a wide range of patient ages (39 to 74 years) with an average age of 57 years. All patients had an asymmetric planovalgus deformity. The severity of the deformity was not specied clinically or radiographically. Good-to-excellent results were obtained in 24 of 27 patients. Patients were followed for a minimum of 1 year. Progressive adjacent joint arthrosis of the naviculocuneiform or talocalcaeal joint was noted in 4 patients. None of the patients were noted to have progressive ankle arthrosis after the arthrodesis. Fortin and Grant6 reported on isolated talonavicular fusion and calcaneal osteotomy for severe peritalar subluxation secondary to poste-

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rior tibial tendon insufciency. Because of the severity of the heel valgus, medial displacement of the calcaneus was performed in all patients. Fourteen patients were followed for a minimum of 1 year. Patients had pain and deformity for more than 1 year and more advanced deformity with lateral talometatarsal and talonavicular coverage angles of 30 or greater. Bone grafting and compression screw xation were performed in all patients. Twelve of 14 patients were satised without reservation. Thirteen of 14 patients had resolution of pain that was present preoperatively. Lateral midfoot pain has been reported to occur after isolated talonavicular joint fusion for posterior tibial tendon insufciency. Harper and Tisdel9 did not specify the frequency of lateral midfoot pain but stated that it was the most common cause for patient dissatisfaction after isolated talonavicular fusion. Mann and Beaman13 suggested that this problem be addressed by inclusion of the calcaneocuboid joint in the fusion mass (i.e., double arthrodesis).13 Gapping of the lateral aspect of the calcaneocuboid joint can occur once the talonavicular joint is reduced (Fig. 6). Eight of 14 patients undergoing talonavicular fusion and calcaneal osteotomy were noted to have gapping of the lateral calcaneocuboid joint measuring 2 to 5 mm.6 The gapping resolved in some patients, and none of the patients in that series had pain localized to the calcaneocuboid joint at latest follow-up. It is not known whether distraction of this joint that occurs when the talonavicular joint is reduced would lead to accelerated degenerative changes.

Figure 6. Gapping of the calcaneocuboid joint (arrow) seen after talonavicular fusion.

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COMPLICATIONS Malposition Inaccurate reduction of the talonavicular joint at the time of fusion can lead to abnormal weight-bearing transfer and is likely to be tolerated poorly. There is a signicant association between patient satisfaction and postoperative alignment after hindfoot fusion.16 Proper positioning requires intraoperative clinical and radiographic conrmation. Failure to reduce completely the lateral subluxation of the navicular bone on the talar head leaves the heel in valgus and can be associated with persistent lateral hindfoot pain from subbular impingement. In cases of more severe deformity, there may be xed heel valgus that persists despite an adequately reduced talonavicular joint. This problem may be addressed by Achilles tendon lengthening or medial displacement calcaneal osteotomy (or both). Leaving the navicular dorsally displaced fails to restore the longitudinal arch conguration and may lead to excessive weight bearing on the plantar medial midfoot region. Overcorrection can result in varus alignment of the heel and lateral overload of the foot. Probably the most common pitfall in positioning the talonavicular joint is leaving the forefoot in varus or supinated. This pitfall can be prevented by pronating or derotating the forefoot through the talonavicular joint at the time of fusion (see Fig. 4).

Nonunion Higher rates of nonunion have been reported with talonavicular fusion than with fusion of the other hindfoot joints.13, 23, 24 Reported rates of nonunion vary from 0% to 70%.2, 5, 9, 24 In earlier series, methods of xation were variable, or in some cases xation was not used. Traditional techniques often involved the removal of large wedges of bone to effect correction. Compression screw xation, the use of bone graft, and maintaining the normal contour of the joint have diminished the incidence of talonavicular nonunion in hindfoot fusion. Harper and Tisdel9 reported one nonunion in 27 patients who underwent isolated talonavicular fusion using iliac crest graft. In the series reported by Fortin and Grant,6 bone graft and compression screw xation were used in all patients. There was one apparent nonunion that subsequently went on to union without further surgery. The union rate of isolated talonavicular fusion compares favorably with the rate of union of the talonavicular joint when it is fused as a part of a double or triple arthrodesis. Mann and Beaman13 reported a 25% nonunion rate of the talonavicular joint in 16 patients undergoing double arthrodesis for posterior tibial tendon insufciency. Bone graft was not used, and staple xation rather than compression screw xation was used in all of the patients with talonavicular nonunion in this series.

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Adjacent Joint Arthrosis Because of the signicant restriction of motion and alteration of foot mechanics after talonavicular fusion, patients are at risk for the development of progressive arthrosis of adjacent joints. This risk must be considered when contemplating an arthrodesis procedure for correction of adult atfoot deformity. The ankle, subtalar, and remaining midfoot joints all have been reported to have developed arthrosis after talonavicular fusion.5, 6, 9 Degenerative changes after hindfoot fusion are asymptomatic in most patients and do not correlate with patient outcome.5, 9, 16 Commonly, patients with severe peritalar subluxation also have radiographic evidence of more distal midfoot instability and arthrosis that can be seen on preoperative radiographs (Fig. 7). Degenerative changes seen after talonavicular fusion in some of these patients may be the result of unrecognized instability or degeneration of these more distal midfoot joints. Progressive degenerative ankle arthrosis characterized by valgus tilt of the talus and lateral tibiotalar joint space narrowing has been reported to occur after hindfoot fusion for adult atfoot defor-

Figure 7. A, Preoperative radiograph of patient with severe atfoot. Distal midfoot collapse and arthrosis is present in addition to the typical ndings of peritalar subluxation secondary to posterior tibial tendon insufciency. B, Following talonavicular fusion, calcaneal osteotomy, and rst metatarsal cuneiform fusion, the longitudinal arch is restored. A solid fusion is present despite early fatigue failure of one of the talonavicular screws.

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mity.4, 7, 8 Progressive deformity and arthrosis of the ankle in a patient who already has had the hindfoot made rigid with an arthrodesis of the triple joint complex presents a signicant dilemma. Salvage often necessitates pantalar fusion or ankle replacement. Valgus collapse of the ankle joint is believed to occur as a result of residual heel valgus and can occur despite a properly reduced talonavicular joint in patients with severe deformities.7 Because of this concern, the author performs a medial displacement calcaneal osteotomy in all patients undergoing talonavicular fusion for adult acquired atfoot deformity.

References
1. Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 79:241246, 1997 2. Elbaor JE, Thomas WH, Weinfeld MS, et al: Talonavicular arthrodesis for rheumatoid arthritis of the hindfoot. Orthop Clin North Am 7:821826, 1976 3. Elftman H: The transverse tarsal joint and its control. Clin Orthop 16:4145, 1960 4. Fitzgibbons TC: Valgus tilting of the ankle joint after subtalar (hindfoot) fusion: Complication or natural progression of valgus hindfoot deformity. Orthopedics 19:415 423, 1996 5. Fogel GR, Katoh Y, Rand JA, et al: Talonavicular arthrodesis for isolated arthrosis 9.5 year results and gait analysis. Foot Ankle Int 3:105113, 1982 6. Fortin PT, Grant AM: Limited midfoot fusion with calcaneal osteotomy for adult atfoot. Presented at the American Orthopaedic Foot and Ankle Society summer meeting, Monterey, CA, 1997 7. Fortin PT, Walling AK: Triple arthrodesis. Clin Orthop 365:9199, 1999 8. Graves SC, Mann RA, Graves KO: Triple arthrodesis in older patients: Result after long term followup. J Bone Joint Surg Am 75:355362, 1993 9. Harper MC, Tisdel CL: Talonavicular arthrodesis for the painful adult acquired atfoot. Foot Ankle Int 17:658661, 1996 10. Kitaoka HB, Zong PL, Kai-nan A: Contact features of the talonavicular joint of the foot. Clin Orthop 325:290295, 1996 11. Koutsogiannis E: Treatment of mobile at foot by displacement osteotomy of the calcaneus. J Bone Joint Surg Br 53:96100, 1971 12. Ljung P, Kalj J, Knutson K, et al: Talonavicular arthrodesis in the rheumatoid foot. Foot Ankle Int 13:313316, 1992 13. Mann RA, Beaman DN: Double arthrodesis in the adult. Clin Orthop 365:7480, 1999 14. Manoli A, Beals T, Pomeroy G: The role of osteotomies in the treatment of posterior tibial tendon disorders. Foot Ankle Clin 2:309317, 1997 15. OMalley MJ, Deland JT, Lee KT: Selective hindfoot arthrodesis for the treatment of adult acquired atfoot deformity: An in vitro study. Foot Ankle Int 16:411417, 1995 16. Pell RF, Myerson MS, Schon LC: Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am 82:4757, 2000 17. Perry J: Anatomy and biomechanics of the hindfoot. Clin Orthop 177:915, 1983 18. Sangeorzan BJ, Mosca V, Hansen ST: Effect of calcaneal lengthening on relationships among hindfoot, midfoot, and forefoot. Foot Ankle Int 14:136141, 1993 19. Sangeorzan BJ, Smith D, Veith R, et al: Triple arthrodesis using internal xation in treatment of adult foot disorders. Clin Orthop 294:299307, 1993 20. Sarraan SK: Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle Int 8:418, 1987 21. Sarraan SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, JB Lippincott, 1993 22. Scranton PE: Results of arthrodesis of the tarsus: Talocalcaneal, midtarsal, and subtalar. Foot Ankle Int 12:156164, 1991

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23. Schon LC, Bell W: Fusion of the transverse tarsal and midtarsal joints. Foot Ankle Clin 1:93108, 1996 24. Wulker N, Flamme CH, Muller A, et al: 10 years followup of arthrodesis of the hindfoot and upper ankle joint. Z Orthop Ihre Grenzgeb 135:509515, 1997 Address reprint requests to Paul T. Fortin, MD William Beaumont Hospital 30575 Woodward Avenue Royal Oak, MI 48073 e-mail: paulfortn@aol.com