title: How Do Hindfoot Fusions Affect Ankle Biomechanics: A Cadaver Model.
abstract: BACKGROUND
  While successful subtalar joint arthrodesis provides pain relief, resultant alterations in ankle biomechanics need to be considered, as this procedure may predispose the remaining hindfoot and tibiotalar joint to accelerated degenerative changes. However, the biomechanical consequences of isolated subtalar joint arthrodesis and additive fusions of the Chopart's joints on tibiotalar joint biomechanics remain poorly understood.
  
  
  OBJECTIVE
  We asked: What is the effect of isolated subtalar fusion and sequential Chopart's joint fusions of the talonavicular and calcaneocuboid joints on tibiotalar joint (1) mechanics and (2) kinematics during loading for neutral, inverted, and everted orientations of the foot?
  
  
  METHODS
  We evaluated the total force, contact area, and the magnitude and distribution of the contact stress on the articular surface of the talar dome, while simultaneously tracking the position of the talus relative to the tibia during loading in seven fresh-frozen cadaver feet. Each foot was loaded in the unfused, intact control condition followed by three randomized simulated hindfoot arthrodesis modalities: subtalar, double (subtalar and talonavicular), and triple (subtalar, talonavicular, and calcaneocuboid) arthrodesis. The intact and arthrodesis conditions were tested in three alignments using a metallic wedge insert: neutral (flat), 10° inverted, and 10° everted.
  
  
  RESULTS
  Tibiotalar mechanics (total force and contact area) and kinematics (external rotation) differed owing to hindfoot arthrodeses. After subtalar arthrodesis, there were decreases in total force (445 ± 142 N, 95% CI, 340-550 N, versus 588 ± 118 N, 95% CI, 500-676 N; p < 0.001) and contact area (282 mm(2), 95% CI, 222-342 mm(2), versus 336 ± 96 mm(2), 95% CI, 265-407 mm(2); p < 0.026) detected during loading in the neutral position; these changes also were seen in the everted foot position. Hindfoot arthrodesis also was associated with increased external rotation of the tibiotalar joint during loading: subtalar arthrodesis in the neutral loading position (3.3° ± 1.6°; 95% CI, 2°-4.6°; p = 0.004) and everted loading position (4.8° ± 2.6°; 95% CI, 2.7°-6.8°; p = 0.043); double arthrodesis in neutral (4.4° ± 2°; 95% CI, 2.8°-6°; p = 0.003) and inverted positions (5.8° ± 2.6°; 95% CI, 3.7°-7.9°; p = 0.002), and triple arthrodesis in all loaded orientations including neutral (4.5° ± 1.8°; 95% CI, 3.1°-5.9°; p = 0.002), inverted (6.4° ± 3.5°; 95% CI, 3.6°-9.2°; p = 0.009), and everted (3.6° ± 2°; 95% CI, 2°-5.2°; p = 0.053) positions. Finally, after subtalar arthrodesis, additive fusions at Chopart's joints did not appear to result in additional observed differences in tibiotalar contact mechanics or kinematics with the number of specimens available.
  
  
  CONCLUSIONS
  Using a cadaveric biomechanical model, we identified some predictable trends in ankle biomechanics during loading after hindfoot fusion. In our tested specimens, fusion of the subtalar joint appeared to exert a dominant influence over ankle loading.
  
  
  CONCLUSIONS
  A loss or deficit in function of the subtalar joint may be sufficient to alter ankle loading. These findings warrant consideration in the treatment of the arthritic hindfoot and also toward defining biomechanical goals for ankle arthroplasty in the setting of concomitant hindfoot degeneration or arthrodesis.
authors.affiliation: Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Ian D
authors.initials: ID
authors.lastname: Hutchinson
authors.affiliation: Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Josh R
authors.initials: JR
authors.lastname: Baxter
authors.affiliation: Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Susannah
authors.initials: S
authors.lastname: Gilbert
authors.affiliation: Department of Foot and Ankle Surgery, Hospital for Special Surgery, 523 East 72nd Street, New York, NY, 10021, USA.|Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: MaCalus V
authors.initials: MV
authors.lastname: Hogan
authors.affiliation: Prince of Wales, Sydney Children's Hospitals, Sydney Orthopaedic Specialists Foot and Ankle Institute, Sydney, Australia.
authors.forename: Jeff
authors.initials: J
authors.lastname: Ling
authors.affiliation: Department of Foot and Ankle Surgery, Hospital for Special Surgery, 523 East 72nd Street, New York, NY, 10021, USA.
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Saunders
authors.affiliation: Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Hongsheng
authors.initials: H
authors.lastname: Wang
authors.affiliation: Department of Foot and Ankle Surgery, Hospital for Special Surgery, 523 East 72nd Street, New York, NY, 10021, USA. kennedyj@hss.edu.
authors.forename: John G
authors.initials: JG
authors.lastname: Kennedy
mesh_terms: D000368:Aged; D000843:Ankle Joint / Q000503:physiopathology / Q000601:surgery*; D001174:Arthrodesis / Q000009:adverse effects; D001696:Biomechanical Phenomena; D002102:Cadaver; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology; D013314:Stress, Mechanical; D016474:Weight-Bearing