Osteoid osteoma of the calcaneus misdiagnosed as subtalar sprain.

Osteoid osteoma of foot and ankle account for ten percent of benign bone tumors and commonly involve the talus and metatarsals. Its occurrence in calcaneus is extremely rare and can mimic ankle instability, subtalar arthritis, osteochondritis or plantar fasciitis leading to delay in diagnosis. We present the case of a 17 year old boy with periarticular osteoid osteoma in the calcaneum, who presented following an ankle sprain. He was successfully treated with CT guided percutaneous radiofrequency ablation and we feel that it is a safe, precise and effective treatment option for even periarticular osteoid osteoma in the foot and ankle region.

Conservative tibiotalocalcaneal fusion for partial talar avascular necrosis in conjunction with ankle and subtalar joint osteoarthritis in Kashin-Beck disease: A case report.

RATIONALE: Kashin-Beck disease (KBD) is known for some typical characters like finger joint enlargement, shortened fingers, and dwarfism. However, Avascular necrosis (AVN) of the talus in KBD has rarely been reported in the literature. Here, we reported on a KBD patient presented with partial AVN of the talus in conjunction with ankle and subtalar arthritis. PATIENT CONCERNS: A 50-year-old woman presented with severe pain and limited range of motion in her left ankle and subtalar joint while walking for 2 years. She had been walking with the aid of crutches for many years. Conservative treatment with rigid orthosis and activity restriction could not help reduce the pain in the left foot. DIAGNOSES: Radiographs demonstrated that partial AVN was developed in the body of the talus and arthritis was viewed in the left ankle and subtalar joint. Hence, we established the diagnosis of partial talar AVN in conjunction with ankle and subtalar arthritis. INTERVENTIONS: A conservative tibiotalocalcaneal fusion attempting to preserve as much viable talar body as possible was performed using a humeral locking plate and 2 cannulated compression screws. OUTCOMES: Bone union proved by CT scan and a good alignment of the left limb were achieved at 4-month follow-up postoperatively. LESSONS: Partial AVN of the talus along with ankle and subtalar arthritis in KBD patients has rarely been reported as it is not a common characteristic of KBD in clinical practice. Conservative tibiotalocalcaneal fusion could help preserving much more viable talar body, maintaining most structural integrity of the ankle joint, and achieving a stable and plantigrade foot postoperatively.

Augmented Ligament Reconstruction Partially Restores Hindfoot and Midfoot Kinematics After Lateral Ligament Ruptures.

BACKGROUND: Altered kinematics and persisting ankle instability have been associated with degenerative changes and osteochondral lesions. PURPOSE: To study the effect of ligament reconstruction surgery with suture tape augmentation (isolated anterior talofibular ligament [ATFL] vs combined ATFL and calcaneofibular ligament [CFL]) after lateral ligament ruptures (combined ATFL and CFL) on foot-ankle kinematics during simulated gait. STUDY DESIGN: Controlled laboratory study. METHODS: Five fresh-frozen cadaveric specimens were tested in a custom-built gait simulator in 5 different conditions: intact, ATFL rupture, ATFL-CFL rupture, ATFL-CFL reconstruction, and ATFL reconstruction. For each condition, range of motion (ROM) and the average angle (AA) in the hindfoot and midfoot joints were calculated during the stance phase of normal and inverted gait. RESULTS: Ligament ruptures mainly changed ROM in the hindfoot and the AA in the hindfoot and midfoot and influenced the kinematics in all 3 movement directions. Combined ligament reconstruction was able to restore ROM in inversion-eversion in 4 of the 5 joints and ROM in internal-external rotation and dorsiflexion-plantarflexion in 3 of the 5 joints. It was also able to restore the AA in inversion-eversion in 2 of the 5 joints, the AA in internal-external rotation in all joints, and the AA in dorsiflexion-plantarflexion in 1 of the joints. Isolated ATFL reconstruction was able to restore ROM in inversion-eversion and internal-external rotation in 3 of the 5 joints and ROM in dorsiflexion-plantarflexion in 2 of the 5 joints. Isolated reconstruction was also able to restore the AA in inversion-eversion and dorsiflexion-plantarflexion in 2 of the joints and the AA in internal-external rotation in 3 of the joints. Both isolated reconstruction and combined reconstruction were most successful in restoring motion in the tibiocalcaneal and talonavicular joints and least successful in restoring motion in the talocalcaneal joint. However, combined reconstruction was still better at restoring motion in the talocalcaneal joint than isolated reconstruction (1/3 for ROM and 1/3 for the AA with isolated reconstruction compared to 1/3 for ROM and 2/3 for the AA with combined reconstruction). CONCLUSION: Combined ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture. CLINICAL RELEVANCE: This study shows that ligament reconstruction with suture tape augmentation is able to partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, where the classic Broström-Gould technique is followed by augmentation with suture tape, this procedure may protect the repaired ligament during healing by limiting excessive ROM after a ligament rupture.

Comparison between subtalar joint quantitative kinematic 4-D CT parameters in healthy volunteers and patients with joint stiffness or chronic ankle instability: A preliminary study.

OBJECTIVE: to compare quantitative kinematic 4-D CT parameters between healthy volunteers and pathologic patients (joint stiffness or chronic ankle instability). METHODS: Thirteen healthy volunteers without previous ankle trauma, 18 patients with clinical subtalar joint stiffness and 10 patients with chronic ankle instability diagnosed based on clinical and imaging findings were prospectively evaluated with 4-D CT. This study was approved by the local ethics committee and all patients signed an informed consent. The subtalar joint was evaluated during a prono-supination cycle. Two angles and two distances between the talus and the calcaneus were measured semi-automatically and independently by two readers. Measurement variations were compared in these three different groups. RESULTS: There were statistically significant differences between axial and coronal talocalcaneal angles of healthy volunteers and patients with joint stiffness (p < 0.0001). The best sensitivities and specificities for the identification of subtalar joint stiffness were 92-100% and 74-94%. Mean and maximal posterior calcaneal facet uncovering were significantly lower in patients with chronic ankle instability patients compared to healthy volunteers (p < 0.006) with sensitivities and specificities of 92-95% and 80-92% respectively. CONCLUSION: Quantitative analysis in 4D CT can provide an objective criteria for the differentiation between healthy volunteers and patients with subtalar joint stiffness and chronic ankle instability.

Ultrasound of Subtalar Joint Synovitis in Patients with Rheumatoid Arthritis: Results of an OMERACT Reliability Exercise Using Consensual Definitions.

OBJECTIVE: To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA). METHODS: Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen's and Light's κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal. RESULTS: Mean weighted Cohen's κ for SH, PD, and JE were 0.80 (95% CI 0.62-0.98), 0.61 (95% CI 0.48-0.73), and 0.52 (95% CI 0.36-0.67), respectively. Weighted Cohen's κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were -0.04 to 0.79, 0.42-0.95, and 0.28-0.77; 0.31-1, -0.05 to 0.65, and -0.2 to 0.69; 0.66-1, 0.52-1, and 0.42-0.88, respectively. Weighted Light's κ for SH was 0.67 (95% CI 0.58-0.74), 0.46 (95% CI 0.35-0.59) for PD, and 0.16 (95% CI 0.08-0.27) for JE. Weighted Light's κ for SH, PD, and JE were 0.63 (95% CI 0.45-0.82), 0.33 (95% CI 0.19-0.42), and 0.09 (95% CI -0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27-0.64), 0.35 (95% CI 0.27-0.4), and 0.04 (95% CI -0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75-0.89), 0.66 (95% CI 0.56-0.8), and 0.18 (95% CI 0.04-0.34) for posterolateral STJ, respectively. CONCLUSION: Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Anatomy of the Tarsal Canal and Sinus in Relation to the Subtalar Joint Capsule.

BACKGROUND: Anatomical knowledge of the tarsal canal and sinus is still unclear owing to the complexity of the ligamentous structures within them, particularly the relationship with the capsules of the subtalar joints. The aim of this study was to examine the anatomical relationship between the fibrous tissues of the tarsal canal and sinus and the articular capsules of the subtalar joint. METHODS: We conducted a descriptive anatomical study of 21 embalmed cadaveric ankles. For a macroscopic overview of the subtalar joint, we removed the talus in 18 ankles and separated the fibrous tissues from the surrounding connective tissues to analyze the layered relationship between the inferior extensor retinaculum (IER) and the subtalar joint capsule. Additionally, we histologically analyzed the tarsal canal and the medial and lateral sides of the tarsal sinus using Masson's trichrome staining in 3 ankles. RESULTS: The medial and intermediate roots of the IER and interosseous talocalcaneal ligament (ITCL) were located in the same layer and were connected to each other, between the capsules of the posterior talocalcaneal and talocalcaneonavicular joints. The intermediate root of the IER and the cervical ligament (CL) had adjacent attachments on the tarsal sinus, and synovial tissues originating from the joint capsules filled the remaining area in the tarsal canal and sinus. CONCLUSION: We determined that the tarsal canal and sinus tarsi contained 3 layered structures: the anterior capsule of the posterior talocalcaneal joint, including the anterior capsule ligament; the layer of ITCL and IER; and the posterior capsule of the talocalcaneonavicular joint, including the CL. CLINICAL RELEVANCE: The results of this study may help with the understanding of the pathomechanism of subtalar instability and sinus tarsi syndrome, resulting in better treatment.

Degenerative subtalar joints complicated by medial plantar intraneural cysts : cutting the cystic articular branch prevents recurrence.

AIMS: The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs. PATIENTS AND METHODS: Between 2006 and 2017, five patients with five mICGs were retrospectively reviewed. There were five men with a mean age of 50.2 years (33 to 68) and a mean follow-up of 3.8 years (0.8 to 6). Case history, physical examination, imaging, and intraoperative findings were reviewed. The outcomes of interest were ultrasound and/or MRI features of mICG, as well as the clinical outcomes. RESULTS: The five intraneural cysts followed the principles of the unifying articular theory. Connection to the posterior subtalar joint (pSTJ) was identified or suspected in four patients. Re-evaluation of preoperative MRI demonstrated a degenerative pSTJ and denervation changes in the abductor hallucis in all patients. Cyst excision with resection of the articular branch (four), cyst incision and drainage (one), and percutaneous aspiration/steroid injection (two) were performed. Removing the connection to the pSTJ prevented recurrence of mIGC, whereas medial plantar nerves remained cystic and symptomatic when resection of the communicating articular branch was not performed. CONCLUSION: Our findings support a standardized treatment algorithm for mIGC in the presence of degenerative disease at the pSTJ. By understanding the pathoanatomic mechanism for every cyst, we can improve treatment that must address the articular branch to avoid the recurrence of intraneural ganglion cysts, as well as the degenerative pSTJ to avoid extraneural cyst formation or recurrence. Cite this article: Bone Joint J 2018;100-B:183-9.

Synovial Lipoma of the Subtalar Joint.

Lipomas are benign adipose masses that are rarely associated with synovial membranes. In addition, there are only a few reports describing synovial lipomas in the foot. No reported occurrence of this lesion in the subtalar joint currently exists. This case report documents the presentation, clinical evaluation, advanced imaging, and surgical management of a 45-year-old man with a large synovial lipoma of the subtalar joint.

Subtalar Coalitions: Does the Morphology of the Subtalar Joint Involvement Influence Outcomes After Coalition Excision?

Posteromedial subtalar (PMST) coalitions are a recently described anatomic subtype of tarsal coalitions. We compared with clinical patient-based outcomes of patients with PMST and standard middle facet (MF) coalitions who had undergone surgical excision of their coalition. The included patients had undergone surgical excision of a subtalar tarsal coalition, preoperative computed tomography (CT), and patient-based outcomes measures after surgery (including the American Orthopaedic Foot and Ankle Society [AOFAS] scale and University of California, Los Angeles [UCLA], activity score). Blinded analysis of the preoperative CT scan findings determined the presence of a standard MF versus a PMST coalition. The perioperative factors and postoperative outcomes between the MF and PMST coalitions were compared. A total of 51 feet (36 patients) were included. The mean follow-up duration was 2.6 years after surgery. Of the 51 feet, 15 (29.4%) had a PMST coalition and 36 (70.6%) had an MF coalition. No difference was found in the UCLA activity score; however, the mean AOFAS scale score was higher for patients with PMST (95.7) than for those with MF (86.5; p = .018). Of the patients with a PMST, none had foot pain limiting their activities at the final clinical follow-up visit. However, in the group with an MF subtalar coalition, 10 (27.8%) had ongoing foot pain limiting activity at the final follow-up visit (p = .024). Compared with MF subtalar tarsal coalitions, patients with PMST coalitions showed significantly improved clinical outcomes after excision. Preoperative identification of the facet morphology can improve patient counseling and expectations after surgery.

An investigation into the aetiology of flexible flat feet: the role of subtalar joint morphology.

AIMS: There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture. PATIENTS AND METHODS: A total of 84 children aged between eight and 15 years old were prospectively recruited. The BMI for each child was calculated, flexibility was assessed using the lower limb assessment scale (LLAS) and foot posture was quantified using the arch height index (AHI). Each child underwent a sagittal T1-weighted MRI scan of at least one foot. RESULTS: An absent anterior subtalar articulation (p < 0.001) and increased LLAS (p = 0.001) predicted a low AHI. BMI was not a significant predictive factor (p = 0.566). CONCLUSION: This is the first study to demonstrate the importance of the morphology of the subtalar joint on the underlying foot posture in vivo. TAKE HOME MESSAGE: Flexibility of the lower limb and absence of the anterior facet of the subtalar joint are associated with flexible FF and may influence management of this common condition.

Delineating the Application of Ultrasound in Detecting Synovial Abnormalities of the Subtalar Joint in Juvenile Idiopathic Arthritis.

OBJECTIVE: To investigate the frequency of ultrasound (US)-detectable involvement of the subtalar joint (STJ), to compare clinical versus US assessment of the STJ, and to compare different scanning approaches to the STJ in juvenile idiopathic arthritis (JIA). METHODS: Clinical and US assessments were performed independently in 50 ankles with clinically active JIA. US abnormalities of the STJ were investigated using a lateral, medial, and posterior scanning approach and scored semiquantitatively. Agreement was tested using kappa statistics. A control group of 10 healthy subjects was examined. RESULTS: Clinical and US evaluations detected synovitis in 24 of 50 (48.0%) and 27 of 50 (54.0%) of STJs, respectively. US detected synovitis in 10 of 26 STJs (38.5%) recorded as normal on clinical evaluation, but was negative in 7 of 24 STJs (29.2%) diagnosed as having involvement on clinical examination. Agreement between clinical and US assessments was fair (κ = 0.32). US abnormalities were more frequently detectable using the lateral scanning approach. All patients with US abnormalities in the medial and/or posterior side of the STJ had also US abnormalities on the lateral scanning approach, but the reverse was not true. Intra- and interobserver agreements for the lateral scanning approach were satisfactory for both detecting involvement and scoring US abnormalities. None of the 17 STJs of healthy controls showed US abnormalities. CONCLUSION: US may increase the precision of the evaluation of the STJ in JIA. The observed high frequency of STJ involvement on US suggests to include this joint in US scanning protocols devised for children with JIA. Synovitis is more frequently detected using the lateral scanning approach.

Fracture of the Posterior Process of the Talus With Concomitant Subtalar Dislocation.

Fracture of the posterior process of the talus with concomitant subtalar dislocation is rare; thus, the mechanism of injury, appropriate treatment, and prognosis are unclear. We report the case of a 50-year-old male with a fracture of the posterior process of the talus with concomitant subtalar dislocation that was recognized early and successfully treated operatively.

Imaging of the subtalar joint.

Imaging of the subtalar joint can be challenging because of its complex planar anatomy. This article reviews the anatomy and common anatomic variants as seen with different imaging techniques. Although radiography remains the initial mode of imaging, computed tomography and MRI are frequently needed to better delineate the joint anatomy and improve the sensitivity and the specificity of detection of joint pathology. A short review of arthrographic techniques and various examples of imaging of common pathology involving this joint are also included.

Effects on Subtalar Joint Stress Distribution After Cannulated Screw Insertion at Different Positions and Directions.

We investigated the effects on subtalar joint stress distribution after cannulated screw insertion at different positions and directions. After establishing a 3-dimensional geometric model of a normal subtalar joint, we analyzed the most ideal cannulated screw insertion position and approach for subtalar joint stress distribution and compared the differences in loading stress, antirotary strength, and anti-inversion/eversion strength among lateral-medial antiparallel screw insertion, traditional screw insertion, and ideal cannulated screw insertion. The screw insertion approach allowing the most uniform subtalar joint loading stress distribution was lateral screw insertion near the border of the talar neck plus medial screw insertion close to the ankle joint. For stress distribution uniformity, antirotary strength, and anti-inversion/eversion strength, lateral-medial antiparallel screw insertion was superior to traditional double-screw insertion. Compared with ideal cannulated screw insertion, slightly poorer stress distribution uniformity and better antirotary strength and anti-inversion/eversion strength were observed for lateral-medial antiparallel screw insertion. Traditional single-screw insertion was better than double-screw insertion for stress distribution uniformity but worse for anti-rotary strength and anti-inversion/eversion strength. Lateral-medial antiparallel screw insertion was slightly worse for stress distribution uniformity than was ideal cannulated screw insertion but superior to traditional screw insertion. It was better than both ideal cannulated screw insertion and traditional screw insertion for anti-rotary strength and anti-inversion/eversion strength. Lateral-medial antiparallel screw insertion is an approach with simple localization, convenient operation, and good safety.

Effect of Intraoperative Three-Dimensional Imaging During the Reduction and Fixation of Displaced Calcaneal Fractures on Articular Congruence and Implant Fixation.

BACKGROUND: Operative treatment of displaced calcaneal fractures should restore joint congruence, but conventional fluoroscopy is unable to fully visualize the subtalar joint. We questioned whether intraoperative 3-dimensional (3D) imaging would aid in the reduction of calcaneal fractures, resulting in improved articular congruence and implant positioning. METHOD: Sixty-two displaced calcaneal fractures were operated on using standard fluoroscopic views. When the surgeon had achieved a satisfactory reduction, an intraoperative 3D scan was conducted, malreductions or implant imperfections were revised, the calcaneus was rescanned, and this sequence was repeated until the optimal operative result was achieved. RESULTS: Five fractures underwent 1 intraoperative scan, 39 fractures underwent 2 scans, 13 fractures underwent 3 scans, and 5 fractures underwent 4 scans. The average number of scans was 2.3. Intraoperative scanning led to re-reduction and improvement of reduction in 13 fractures, change of plate position in 1 patient, optimizing of the screw directions in 5 fractures, and shortening of screws that were intra-articular or protruding medially in 6 fractures. The postoperative articular displacement was 0 mm in 69% of the Sanders type 2 fractures and 57% of the Sanders type 3 fractures. Operation duration averaged 118 minutes, and there were no reoperations due to misplaced screws or plates. The average absorbed radiation dose per patient was 288 mGy·cm. CONCLUSION: Intraoperative 3D imaging improved the articular reduction of the posterior facet and secured optimal implant position in displaced calcaneal fractures. Radiation dose to the patient was less than that of a normal foot computed tomography scan. LEVEL OF EVIDENCE: Level IV, case series.

An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an acute ankle sprain: a case report and literature review.

BACKGROUND: The acute ankle sprain is one of the most common injuries seen in trauma departments. Ankle sprains have an incidence of about one injury per 10 000 people a day. In contrast tarsal coalition is a rare condition occurring in not more than one percent of the population. CASE PRESENTATION: We present the case of a 23 year old male patient with pain and local swelling after an acute ankle sprain. Initial clinical and radiological examination showed no pathologies. Due to prolonged pain, swelling and the inability of the patient to weight bear one week after trauma further diagnostics was performed. Imaging studies (MRI and CT) revealed a fracture of a talocalcaneal coalition. To the knowledge of the authors no fracture of a coalition was reported so far. CONCLUSION: This report highlights the presentation of symptomatic coalitions following trauma and furthermore, it points out the difficulties in the diagnosis and treatment of a rare entity after a common injury. A diagnostic algorithm has been developed to ensure not to miss a severe injury.

Large B cell lymphoma of the subtalar and talonavicular joint synovium.

We present the unique case of a 68-year-old man with a background of rheumatoid arthritis, who underwent left subtalar and talonavicular arthrodesis due to degenerative changes and chronic pain. Histology of the synovium demonstrated large B cell lymphoma. The patient subsequently underwent R-CHOP chemotherapy and radiotherapy to the affected area. This is the first described case of a primary large B cell lymphoma of the subtalar and talonavicular joints, without bony involvement.

Natural history and imaging of subtalar and midfoot joint disease in rheumatoid arthritis.

Foot involvement is not uncommon and occurs early in the disease course of rheumatoid arthritis (RA). Inflammation and ongoing synovitis of foot joints lead to joint destruction and instability, tendon dysfunction, and eventually collapse of the medial longitudinal arch and pes planovalgus that contributes to difficulty in walking and gait abnormalities. This article reviews foot-related problems in patients with RA, focusing on the prevalence, natural history and role of imaging in both diagnosis and management of midfoot and subtalar joint disease in RA.

Giant extra-articular synovial osteochondromatosis of the sinus tarsi: a case report.

A 32-year-old male presented with painful swelling of the sinus tarsi that occurred during daily activities. Diagnostic imaging suggested the presence of a large synovial osteochondromatosis that blocked subtalar motion with deformity of the adjacent bone. The large bony mass was excised, and normal subtalar motion was achieved.

[Tibio-talo-calcaneal arthrodesis with the retrograde intramedullary nail MEDIN]. / Tibiotalokalkaneální artrodéza retrográdním hrebem MEDIN.

PURPOSE OF THE STUDY: When the talus and the talocalcaneal joint are both affected, their fusion is the method of treatment. Ankle arthrodesis is carried out using various osteosynthetic materials such as external fixators, screws and plates. One of the options is retrograde nailing. Tibio-talo-calcaneal arthrodesis is frequently indicated in patients with rheumatoid arthritis (RA) in whom both the talus and the subtalar joint are often affected. MATERIAL AND METHODS: A retrograde nail for tibio-talo-calcaneal arthrodesis was developed at our department in cooperation with MEDIN Company. This is a titanium double-curved nail, with the distal part bent at 8 degrees ventrally and 10 degrees laterally. It is inserted from the transfibular approach. RESULTS: Sixty-two patients, 35 women and 27 men, were treated at our department from 2005. Since one patient had bilateral surgery, 63 ankles were included. The indications for arthrodesis involved rheumatoid arthritis in 42, post-traumatic arthritis in 10, failed ankle arthrodesis in two and failed total ankle arthroplasty in five ankles; tibial stress fractures close above the ankle in two RA patients, one patient with dermatomyositis and one with lupus erythematodes. The average age at the time of surgery was 64.2 years (range, 30 to 80). The average follow-up was 4.5 years (range, 1 to 9 years), Satisfaction with the treatment outcome and willingness to undergo surgery on the other side were reported by 82% of the patients. The AOFAS score improved from 35 to 74 points. Three (4.8%) patients complained of painful feet due to the fact that exact correction of the calcaneus was not achieved and the heel after arthrodesis remained in a slightly varus position. Of them, two had a failed total ankle arthroplasty. Post-operative complications included early infection managed by antibiotic treatment and early surgical revision with irrigation.in two (3.2%) RA patients, who were undergoing biological therapy. Late infection developed at 2 to 3 years after surgery in three (4.3%) patients (two had RA). The infection was managed by revision surgery with nail removal and irrigation. All patients healed well. Necrosis of the talus and development of a pseudoarthrosis were recorded in four (6.4%) patients, who subsequently underwent nail removal and repeat fusion using an external fixator. DISCUSSION: Retrograde nailing for tibio-talo-calcaneal arthrodesis is used by many authors. Its complication rate is comparable with the other methods of arthrodesis. CONCLUSIONS: The use of tibio-talo-calcaneal arthrodesis aims at a painless and stable joint. Arthrodesis of the talus and the subtalar joint using a retrograde nail is an effective surgical treatment of the joints affected. It is especially recommended for RA patients who have severe deviations. Retrograde nailing provides a stable osteosynthesis which does not require plaster cast immobilisation. The double-curved nail allows for its insertion in the solid part of the calcaneus and helps avoiding injury to the neurovascular bundle.