Surgical Overview
The subtalar joint (STJ), also known as the talocalcaneal joint, is a joint comprising the hindfoot. It is the articulation between the inferior aspect of the talus and the superior aspect of the calcaneus (heel bone). This joint assists with inversion/eversion of the foot (in and out or side to side motion). The subtalar joint has three articulating facets between the talus and the calcaneus, the anterior, middle and posterior facets. The posterior facet is the largest of all the facets. The articulating bones are covered with a thick, smooth material called articular cartilage. Articular cartilage allows the two bones to move/glide against one another and also distribute load across the entire joint surface, thus absorbing shock.
Osteoarthritis is a degenerative joint disease in which the articular cartilage (tough but flexible tissue covering the articulating surfaces of the bones) gradually wears away and breaks down. In most cases, STJ arthritis is related to a previous injury such as a calcaneus fracture and is termed, post-traumatic arthritis. X-rays help determine the severity of the cartilage damage. In a normal XR the articular cartilage creates the appearance of a symmetric joint space between the two bones (picture A). As the articular cartilage wears away the joint space decreases progressing to bone on bone contact (picture B).
Other imaging studies such as a CT scan or MRI also assist the surgeon in determining the amount of joint space narrowing, joint surface positioning and the overall degree of arthritic change to surrounding/adjacent joints.
The main symptom usually associated with osteoarthritis in the subtalar joint is pain. In the early stages of disease, pain is present with movement or activity (walking – especially uneven ground, stairs, or prolonged standing). As the osteoarthritis (OA) progresses, the pain can be present even at rest. Other common symptoms of STJ OA include: joint stiffness, loss of side to side motion, hindfoot swelling, and difficulty walking (or walking with a limp).
Treatment for STJ OA is focused on controlling pain, limiting motion that causes pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (NSAIDs), custom foot orthotics, AFO (ankle-foot orthosis) or other ankle braces to decrease motion, physical therapy, dietary supplements (glucosamine and chondroitin), CBD cream and steroid/PRP injections into the joint.
Once conservative treatment options have been exhausted or the degree of OA is very severe, surgical intervention is usually necessary. The surgical option to treat STJ OA is a subtalar joint arthrodesis (fusion). A STJ fusion is the gold standard treatment for pain relief due to STJ OA (picture below). In some cases this can be performed in a minimally invasive fashion.
Subtalar Fusion
Subtalar arthrodesis (fusion) is a surgical procedure for the treatment of disabling hindfoot arthritis when conservative measures have failed to relieve pain. With this surgery, the joint is permanently stiffened by removing the degenerated cartilage and welding the bones together.
Most patients will walk better, but not normal, after the fusion. You will have some difficulty on uneven ground since you will lose that side to side hindfoot motion. The normal up/down motion of the ankle is not affected.
Yes, you will notice that you will retain your ankle and forefoot motion.
Generally no, but you will be more comfortable in a shoe with a cushioned heel, and many patients walk better with orthotics (custom shoe inserts). High heels can usually still be worn.
With a successful fusion, most patients can walk for distance, ride a bike, perform hiking activities, swim and golf. Doubles tennis with an ankle brace is often possible. Some patients have been able to downhill and cross-country ski. Jogging on flat even surfaces is generally possible. We are still evaluating what diverse activities are available to our patients with fusion.
You will not be able to perform rigorous agility sports such as soccer or basketball.
Obviously the fusion does not restore you to normal. When the hindfoot is fused it does put additional stress on adjacent joints such as the ankle and midfoot. However, and fortunately, most patients do not need additional surgery for this.
Alternatives to fusion include non-surgical treatments such as brace wear, activity modification, nonsteroidal anti-inflammatories (NSAIDs: Advil, Aleve, Motrin.), and cortisone/PRP injections.
Typically, screws are used to hold the bones in position until the fusion is solid. Occasionally, bone graft is necessary if bony defects are present. Your own bone (autograft) or cadaver bone (allograft) may be used.
Your surgery generally takes place at the New England Baptist Outpatient Center and is an outpatient procedure meaning you go home the same day as surgery.
The procedure generally takes about one to two hours.
Usually you will have general anesthesia, but occasionally spinal anesthesia will be recommended by the anesthesia team. Most patients will have a preoperative anesthetic popliteal block performed to the back of the knee immediately before the surgery. This will decrease your requirements for intra-operative anesthesia as well as post-operative pain medication. It is very effective in greatly reducing pain.
Yes. You will get a dose of antibiotic before surgery. Also, due to a length of time being immobilized, patients are started on one 325 mg aspirin once a day for 4 weeks.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read carefully the “What to expect and how to prepare for surgery” handout.
After your surgery you will be placed in a bulky cotton and plaster splint. You will recover in the Post Anesthesia Care Unit or PACU, and then go home. The physical therapist will assist you in the use of crutches, a walker, or a medical scooter.
For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. Keep your surgical foot elevated at the level of your heart when you are not getting up to eat or use the bathroom. You should take the pain medication as directed as necessary. You should take the medication for reducing the chance of blood clots. Keep your splint dry.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (e.g. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
This is an important question because it impacts home and work situations. Typically, it takes about three months to heal the fusion. This will require a period of non-weight-bearing in a cast with crutches, walker or medical scooter for six weeks, followed by a walking boot for an additional six weeks, depending on each individual patient’s ability to heal. After the cast is removed and the walker boot applied, a compression sock obtained from your pharmacy will help with swelling. You will be able to remove the boot for sleep, showers, and physical therapy. After three months, most patients are transitioned into supportive roomy shoes and undergo physical therapy for strengthening and gait training. Expect a limp and some swelling for several months. It may take a full year to recover.
Download the STJ Post Surgical Guidelines PDF for full details.
If your LEFT foot is fused, many patients drive by two weeks when they are off the pain medications. If your RIGHT foot is fused, you may drive after eight weeks. You may also want to apply for a handicap placard.
That depends on what you do. Sedentary desk workers may return as soon as two weeks. On the other end of the spectrum, construction laborers are typically out of work for 4-6 months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
About ten to fifteen percent of patients will have a delayed union or non-union. This can be even greater in patients who have additional medical problems, have poor bone healing factors, or are smokers. To enhance your chances of healing, you should not smoke. For a delayed union you may be prescribed bone healing adjuvants, such as a bone stimulator, and prolonged immobilization. For an established non-union, you may require revision surgery and bone-grafting to try to get the fusion to heal.
Like any surgery, complications can develop. Fortunately, these are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopaedic Foot and Ankle Society website.
